The Evolution of Health Promotion and the Societal Responsibility for Health, Exams of Nursing

Download The Evolution of Health Promotion and the Societal Responsibility for Health and more Exams Nursing in PDF only on Docsity! Nursing Theory Final Exam QUESTIONS & ANSWERS Self reflection - ANSWER The process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Reflection is necessary for self-evaluation and improvement of nursing practice. CNO Quality Assurance Program -Reflect on Practice Nursing Theory -Reflect on your own Self Concept Critical thinking - ANSWER A process and as a set of skills; an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others. Use of logic and reasoning to make accurate clinical judgements and decisions Purposeful and reflective Examine ideas, beliefs, assumptions, principles etc. Develops over time (experience, knowledge) Nursing Process - ANSWER Assessment, Diagnosis, Planning, Implementation, Evaluation. A problem-solving approach to identifying, diagnosing, and treating the health issues of patients. Systematic approach to delivering nursing care Allows nurses to think critically Best practice guideline - ANSWER are evidence informed and contain recommendations for developing and sustaining collaborative practice models and leadership. Critical Thinking Level 1 - Basic - ANSWER Thinking is concrete and based on rules/guidelines Critical Thinking Level 2 - Complex - ANSWER -Consider other options in addition to the basic -More creative and innovative -Weigh benefits and risks Critical Thinking Level 3 - Commitment - ANSWER -Make choices on your own, take full responsibility -Anticipate needs 5 components of Critical Thinking - ANSWER 1. Specific Knowledge Base: -Education (sciences, theory, humanities, behavioural, nursing sciences) -Important to admit limitations in your knowledge 2. Experience: -Clinical experiences (nursing school and professional employment) -Other work experiences 3. Competencies: -Cognitive processes a) General - Scientific Method, Problem Solving, Decision Making b) Specific-Diagnostic reasoning and Clinical decision making. -Determining health status of patient after you have gathered all important assessments (physical, social, psychological) c) Nursing Process *practice question* The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion, the nurse reviewed the description in his textbook of loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is 1. Experience 2. Problem solving 3. Knowledge application 4. Clinical decision making - ANSWER 3. Knowledge Application: The nurse's knowledge base is an important component of critical thinking. It varies according to a nurse's educational experience, including basic nursing education, continuing education courses, and additional university degrees. In addition, it includes the initiative a nurse shows in reading the nursing literature to remain current in nursing science. *practice question* Focus of data collection - ANSWER Initial Within 24 hours of admission and at the beginning of each shift. Problem Focused Specific areas of concern; arises from the identified nursing diagnoses. Emergency Whenever there is a critical change in the client's condition. Time Lapsed As follow up when client is at facility for long term. Methods of data collection - ANSWER -Interview -Physical examination -Diagnostic and Lab data Nursing Health History - ANSWER Data collected about the client's current level of wellness, including a review of systems (ROS), family and health history, socio-cultural history, spiritual health, and mental and emotional reactions to illness. Includes: Identifying Data Chief Concern or Reason for Visit History of Present Illness or Health Concern Developmental Psychological Spiritual Socio-cultural Physiological - all body systems Cues - ANSWER Are subjective or objective data that can be directly heard or observed by the nurse. Example: What the client says or what the nurse can see, hear, feel, smell, or measure. Inferences - ANSWER Are the nurse's conclusions or interpretations of the cues. Example: A nurse observes the cues that an incision is red, hot and swollen; the nurse makes the inference that the incision is infected. Validation - ANSWER of assessment data is the comparison of data with another source to determine data accuracy. Data analysis - ANSWER involves recognizing patterns or trends in the clustered data, comparing them with standards, and then establishing a reasoned conclusion about the client's responses to a health problem . Patterns of meaning begin to form, enabling you to make inferences about client problems. Verification and Analysis - ANSWER Verification: Double checking or confirming accuracy of your findings. To ensure accuracy, eliminate biases, misperceptions and errors in data collection Analysis: Organize information into 'clusters' -Set of signs and symptoms you group together in a logical way Recognize patterns and trends Improves with knowledge and experience Documentation of data - ANSWER Standards: -Thorough, precise and accurate Objective information: use proper terminology and measurements Subjective information: use quotation marks for a client's statement "Anything heard, seen, felt, or smelled should be reported exactly." Nursing Diagnosis Definition - ANSWER Clinical judgment about individual, family, or community responses to health care problems or life processes that is within the domain of nursing. Medical Diagnosis Definition - ANSWER The identification of a disease condition on the basis of a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests and procedures. *practice question* A nursing diagnosis is 1. The diagnosis and treatment of human responses to health and illness 2. The advancement of the development, testing, and refinement of a common nursing language 3. A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes 4. The identification of a disease condition on the basis of a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests - ANSWER 3. A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes. Diagnosis and treatment of patients' responses describes the entire nursing process; a common nursing language refers to the process of developing nursing diagnoses; identification of a disease refers to evaluation. A nursing diagnosis for an individual patient is the clinical judgement about responses to actual and potential health problems or life processes. *practice question* One of the purposes of the use of standard formal nursing diagnostic statements is to: 1. Evaluate nursing care 2. Gather information on client data 3. Help nurses to focus on the role of nursing in client care 4. Facilitate understanding of client problems among health care providers - ANSWER 4. Facilitate understanding of client problems among health care providers Evaluating nursing care is evaluation, gathering patient information is assessment, and helping nurses focus on their role refers to the entire nursing process *practice question* The nursing diagnosis readiness for enhanced communication is an example of 1. A risk nursing diagnosis 2. An actual nursing diagnosis 3. A potential nursing diagnosis 4. A wellness nursing diagnosis - ANSWER 4. A wellness nursing diagnosis A wellness nursing diagnosis describes levels of wellness in an individual, family, or community that can be enhanced. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual. An actual nursing diagnosis describes responses to health conditions or life processes that exist in an individual, family, or community. A potential nursing diagnosis is one under consideration during data interpretation. *practice question* The nursing diagnosis hypothermia is an example of 1. A risk nursing diagnosis 2. An actual nursing diagnosis 3. A potential nursing diagnosis 4. A wellness nursing diagnosis - ANSWER 2. An actual nursing diagnosis *practice question* The word impaired in the diagnosis impaired physical mobility is an example of a 1. Descriptor 2. Risk factor 3. Related factor 4. Nursing diagnosis - ANSWER 1. Descriptor Risk factors are evidence considered during assessment; related factors are those contributing to the diagnosis; the complete statement is the nursing diagnosis. *practice question* Nurses use a variety of assessment techniques for data collection. The nurse knows that the first appropriate assessment technique for data collection is: 1. Review client's medical record 2. Interview client 3. Consult health care team 4. Review literature - ANSWER 2. Interview client The patient is the best source of information. *practice question* Priority Setting - ANSWER Clients often have multiple issues happening at the same time (multiple nursing diagnoses) -Ranking of nursing diagnoses or client problems in order of importance -Rank in order of urgency The 'priority nursing diagnosis' is the most pertinent for the client Priority Levels - ANSWER High Priority (do first): Physiological or psychological issues that affect safety, circulation or oxygenation or address basic human needs Intermediate Priority Non emergent, not life threatening Low Priority Not necessarily linked to illness or prognosis Related to client's future well-being Long term health care needs Goal - ANSWER are broad statements about the effects of nursing intervention. A desired outcome or change in client behaviour or physiological responses. Goal attainment is the resolution of the problem as specified in the nursing diagnosis. Expected outcomes - ANSWER More specific, measurable criteria used to evaluate whether the goal has been met. Expected change in response to your nursing care. Goals of Care: - ANSWER Client centered - response that reflects the client's highest level of wellness and independence in function Short-term goal: achieve in a short time, less than a week Long-term goal: achieve over longer period of time, several days, weeks, months SMART GOALS - ANSWER Specific and short (only one behaviour) Measurable and observable Achievable in the proposed time-frame Realistic for the client's capabilities in the time span the objective was designated and for the nurse's level of skill and experience. Time frame for each goal and expected outcome indicates when the expected response should occur. - Divided in weekly, monthly or quarterly segments: After 8 hours or Within 3 months or By May 17 Nursing Interventions - ANSWER A nursing intervention is "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes" Based on reducing or eliminating the related factors (cause/etiology) of the problem. When it is not possible to change the related factors, the nurse chooses interventions to treat the signs an symptoms. Nursing Interventions - direct and indirect - ANSWER Direct Care: Is an intervention performed through interaction with the client. Indirect Care: Is an intervention performed away from, but on behalf of, the client, such as interdisciplinary collaboration. Types of nursing interventions - ANSWER Independent nursing interventions -Nurse initiated -Does not require orders or directives from other health care professionals -Grounded in evidence-informed decision making Examples: Physical Care, ongoing assessment, emotional support, counselling, education, comfort, environmental management, referrals to other health-care professionals Dependent nursing interventions -Physician-initiated -Requires orders or directives from physicians Treating or managing a medical diagnosis Examples: Medications, intravenous therapy, diagnostic tests, treatments, diet, activity *Nurse needs to recognize and question errors* Collaborative interventions -Require combined skill and knowledge of various health acre providers Examples: Consultation with dietician, social worker, physiotherapy etc. *Nurse needs to recognize and question errors* What to consider when selecting interventions: - ANSWER Nursing diagnosis Goals and expected outcomes Evidence and research Feasibility Client preferences Your own competence Benefits and risks of intervention -Determine client's response or progress towards goal by 'asking' and/or 'observing' -Use assessment skills and techniques 3. Interpret and Summarize findings -Compare goal to patient's response/behaviour -Were the measurable desired outcomes achieved? -Was goal met, partially met, not met 4. Document 5. Terminate, continue or revise care plan Nursing Care plan - ANSWER includes nursing diagnoses; goals, expected outcomes, or both; and specific nursing interventions, so that any nurse is able to quickly identify a client's clinical needs and situation. In hospitals and community-based settings, the client often receives care from more than one nurse, physician, or allied health provider. A written nursing care plan makes possible continuity and coordination of nursing care and consultation by a number of health professionals. Consultation - ANSWER involves seeking the expertise of a specialist, such as a nurse educator, registered nurse, or clinical nurse specialist to identify ways of approaching and managing the planning and implementation of therapies. Standard of Care - ANSWER is the minimum level of care acceptable to ensure high quality of care. Standards of care define the types of therapies typically administered to clients with defined problems or needs. Concept Map - ANSWER Visual representation of all of a patient's nursing diagnoses that allows you to diagram interventions for each Group and categorize nursing concepts to give you a holistic view of your patient's health care needs and help you make better clinical decisions in planning care Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information *practice question* Sheila, a nurse, is assigned to a client who has returned from the recovery room after surgery for a colorectal tumour. After an initial assessment, Sheila anticipates the need to monitor the client's abdominal dressing, intravenous infusion, and function of drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. Sheila will have to establish priorities of care in which of the following situations? (Choose all that apply.) 1. The family comes to visit the client. 2. The client expresses concern about pain control. 3. The client's vital signs change, showing a drop in blood pressure. 4. The charge nurse approaches Sheila and requests a report at end of shift. - ANSWER 2. The client expresses concern about pain control. 3. The client's vital signs change, showing a drop in blood pressure. Controlling pain and monitoring vital signs are important direct care priorities for safe and effective care for a patient who has just returned from the recovery room. Family visits and end-of-shift reports are important, but they are not high priorities in the immediate recovery period. *practice question* Sheila's client signals with her call light. Sheila enters the room and finds that the drainage tube is disconnected, the intravenous line has 100 mL of fluid remaining, and the client has asked to be turned. Which of the following should Sheila perform first? 1. Reconnect the drainage tubing. 2. Inspect the condition of the intravenous dressing. 3. Improve the client's comfort and turn her onto her side. 4. Go to the medication room and obtain the next intravenous fluid bag. - ANSWER 1. Reconnect the drainage tubing. Maintaining proper drainage of the wound is a high priority for this patient immediately after surgery. The condition of the intravenous dressing, the patient's comfort, and obtaining more intravenous fluids are important, but they do not have the highest priority in this situation. *practice question* In her nursing care plan, Sheila writes expected outcomes for her client. Which of the following expected outcomes are written correctly? (Choose all that apply.) 1. Client will remain a febrile until discharge. 2. Intravenous site will be without phlebitis by the third postoperative day. 3. Provide incentive spirometry for deep breathing every two hours. 4. Client will report pain and turn more freely by the first postoperative day. - ANSWER 1. Client will remain a febrile until discharge. 2. Intravenous site will be without phlebitis by the third postoperative day. The descriptions "afebrile until discharge" and "without phlebitis by the third postoperative day" reflect the actual condition or state of the patient. *practice question* concern for the client includes which of the following? 1. Safety 2. Nurse staffing 3. Confidentiality 4. Adequate pain relief - ANSWER 1. Safety Patient safety always comes first. *practice question* A nurse may use a concept map when implementing a plan of care. What is the purpose and distinction of a concept map? 1. Quality assurance in the health care facility 2. Identification of the relation of client problems and interventions 3. Multidisciplinary communication 4. Provision of a standardized format for client problems - ANSWER 2. Identification of the relation of client problems and interventions. A concept map is a diagram of patient problems and interventions that shows their relations to one another. This process promotes critical thinking and helps the nurse to organize complex patient data and achieve a holistic view of the patient's situation. The purpose is not quality assurance in the health care facility. Multidisciplinary communication is enhanced through the use of critical pathways. Standardized care plans, not concept maps, provide a standardized format for patient problems. CASE STUDY Sally is 14 y/o and has recently been admitted to acute care for appendicitis. She is now post surgery x2 days and is about to be discharged. As her assigned nurse you have been asked to cover post-surgical care with her and her mother prior to discharge. When you ask Sally how she learns best in school she says that she notices she best grasps concepts when her brain Is exercised while physically doing something hands on. A.) Which domain of learning is Sally? B.) Which types of behaviours might you see if you were to observe her learning style? C.) Give examples of how you can get Sally and her Mom to best understand post-op care - ANSWER A) Psychomotor learning B) Adaptation, set, guidance, perception C) Demonstrate, have Sally and her mom demonstrate back to you. Teaching Process - ANSWER Teaching process: *Assessment* Nurses need to assess all factors that influence content, ability to learn, and resources available. -Learning needs -Ability to learn -Motivation to learn -Teaching environment Resources for learning *Nursing Diagnosis* Ineffective health maintenance Health-seeking behaviours Impaired home maintenance Deficient knowledge Ineffective therapeutic regimen management Ineffective community therapeutic regimen management Ineffective family therapeutic regimen management *Planning and Implementation* Determine goals and expected outcomes -Develop learning objectives, set priorities, organize teaching material, select teaching methods and resources, etc. Implement teaching plan by using various approaches and methods -Demonstrations, simulation, one-on-one discussion, role playing, prep instruction Always consider patient abilities (literacy levels, health literacy, culture, language, needs) *Evaluation* Necessary to determine whether the patient has learned the material Helps to reinforce correct behaviour and change an incorrect behaviour Success depends on the patient's performance of expected outcomes Medical Approach to Health - ANSWER Early and mid 1900s Health was compromised due to the presence of physiological risk factors (hypertension, genetic predisposition etc.) Medical interventions restore health Funding for hospitals and remove barriers to receiving medical care Less emphasis on health promotion and disease prevention Behavioural Approach to Health - ANSWER 1974 Lalonde Report ''further improvements in the environment, reductions in self-imposed risks, and a greater knowledge of human biology'' are necessary to improve the health status of Canadians. (Potter & Perry, 2014, p.3) "Prolonged stress, or rather the responses it engenders, are know to have deleterious effects on a number of biological systems and to give rise to a number of illnesses" Robert Evans, 1994 Social Determinants of Health - ANSWER Aboriginal status Gender Disability Housing Early life Income and income distribution Education Race Employment and working conditions Social exclusion Food insecurity Social safety net Health services Unemployment and job security Health Promotion - ANSWER "Activities directed toward increasing the level of well-being and self- actualization. The focus is on enabling people to increase control over and to improve their health." Disease Prevention - ANSWER Action taken to avoid illness or disease. Teaching - ANSWER Interactive process Address needs and desired outcomes Provide information to patient and families to help them achieve desired change Can be learning new skills, changing behaviors, strategies adapting to change Effective teaching depends on effective communication Learning - ANSWER The purposeful acquisition of knowledge, skills, behaviours, and attitudes Occurs in 3 domains: -Cognitive -Affective -Psychomotor Goals of Patient Education - ANSWER Maintaining and promoting health and preventing illness Restoring health Coping with impaired functioning to optimize quality of life Role of the Nurse in Teaching and Learning - ANSWER Ethical responsibility Provide patient information so they can make and 'informed' decision Requires effective communication skills Need to know when to teach, even if patient does not specifically 'ask' for information or help Domains of Learning - ANSWER Cognitive Affective Psychomotor Cognitive Learning - ANSWER -intellectual behaviours -requires thinking Behaviours: -remembering -understanding -applying Examples: -discussion -lecture -independent project Affective Learning - ANSWER -expressions of feelings and acceptance of attitudes/opinions/values Behaviours: -receiving -responding -valuing -organizing Examples: -role play -group discussions Psychomotor Learning - ANSWER -acquiring skills that require integration of mental and muscular activity Behaviours: A.) Cognitive B.) Affective C.) Psychomotor D.) Both A&B - ANSWER B. Affective As the nurse enters a patient's room, she observes that the intravenous line is not infusing at the ordered rate. The nurse checks the flow regulator on the tubing, looks to see whether the patient is lying on the tubing, checks the connection between the tubing and the intravenous catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. She readjusts the flow rate, and the infusion begins at the correct rate. This is an example of 1. Inference 2. Reflection 3. Problem solving 4. Evidence-informed decision making - ANSWER 3. Problem Solving: The nurse notices that the intravenous infusion is not functioning correctly and uses his or her knowledge to solve the problem. *practice question* The nurse sits down to talk with her patient, who lost her sister two weeks ago. The patient reports that she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her clarify the type of trouble, and the patient explains that she cannot concentrate or even solve simple problems. The nurse records the results of her assessment, describing the patient's problem as ineffective coping. This conclusion reflects the nurse's use of 1. Inference 2. Diagnostic reasoning 3. Best practice guidelines 4. Professional practice standards - ANSWER 1. Inference: The nurse makes an inference about how well the patient is coping based on the patient's descriptions of how the death of her sister has affected her day-to-day activities (i.e., draws a conclusion based on patterns of behaviour indicative of ineffective coping). *practice question* In observing a new mother breastfeeding her baby, the public health nurse observes that the baby is fussy and is not sucking effectively. The nurse reviews the baby's record and finds that he has lost a considerable amount of weight since birth. The nurse conducts an assessment and notes that the baby has poor skin turgor. The mother reports that he urinates infrequently and sleeps only for very short periods of time between feedings. The nurse concludes that the baby is dehydrated and is at risk of becoming malnourished. This is an example of 1. Inference 2. Problem solving 3. Diagnostic reasoning 4. Applying nursing practice standards - ANSWER 3. Diagnostic Reasoning: Based on an assessment and analysis of the physical signs and symptoms, the nurse diagnoses the patient's health status. Characteristics of the Nursing Process - ANSWER Allows nurses to think critically Not necessarily linear: Cyclic and dynamic For all client systems: Client, families, communities Interpersonal and collaborative Goal and problem-oriented Permits creativity Feedback and evaluation necessary Assessment - nursing process - ANSWER Collect, verify, analyze, and communicate data about a client Purpose to establish a database Information about a client's level of health, health practices, past illnesses, present illnesses, and physical examination combined to serve as the basis for the plan of care Assessment - Types of data - ANSWER Subjective: Clients' perceptions about their health problems. Only clients can give this Symptoms or covert Ex: feelings of anxiety, pain, or mental stress (tells, says) Objective: Observations or measurements made by the data collector. Signs or overt Ex. Assessment of a client's wound , description of client behaviour, observed objective data. (things you see, measure, hear, smell) Sources of Data - ANSWER Primary sources - Client / Caregivers of those who can not communicate ex: infants/critically ill/unconscious Secondary Sources of date - Family or caregivers / other sources. Other sources of data - ANSWER Survey of Client's Environment Medical Records Social Service Records Diagnostic Test Results Health Team Members Nursing Care Conferences Change of Shift Reports, Nursing Rounds Nursing Notes, Progress Notes, Kardex As the nurse enters a patient's room, she observes that the Ex: feelings of anxiety, pain, or mental stress (tells, says) Objective: Observations or measurements made by the data collector. Signs or overt Ex. Assessment of a client's wound , description of client behaviour, observed objective data. (things you see, measure, hear, smell) Sources of Data - ANSWER Primary sources - Client / Caregivers of those who can not communicate ex: infants/critically ill/unconscious Secondary Sources of date - Family or caregivers / other sources. Other sources of data - ANSWER Survey of Client's Environment Medical Records Social Service Records Diagnostic Test Results Health Team Members Nursing Care Conferences Change of Shift Reports, Nursing Rounds Nursing Notes, Progress Notes, Kardex *Practice Question* "Restoring health" is.. A.) A goal of patient education B.) The expected outcome post health promotion strategies C.) The mission statement of the WHO D.) The responsibility of nurses world wide - ANSWER A.) A goal of patient education *Practice Question* In relation to the Transtheoretical Model of Change; "intent upon taking action" is an example of.. A.) Preparation B.) Maintenance C.) Precontemplation D.) Contemplation - ANSWER A.) Preparation alters behaviour in minor ways with the intention to make substantive changes in the immediate future *Practice Question* In relation to the Transtheoretical Model of Change; Action would be defined as... A.) intent upon taking action B.) Sustained change of behaviour C.) Awareness of the problem D.) Modification of behaviour - ANSWER D.) Modification of behaviour Example of Goal Setting with Expected Outcome 1 - ANSWER *Nursing Diagnoses* Acute pain related to pressure on spinal nerves *Goals* Ms. Devine's level of comfort will improve before surgery. *Expected Outcomes* Client will be able to turn without reported discomfort in two hours. Client's self-report of pain will be 3 or less on a scale of 0 to 10 by the time of scheduled surgery. What is the first step in the nursing process? - ANSWER Assessment What does assessment involve? - ANSWER it involves the collection and verification of data and the analysis of all data to establish a database about a client's perceived needs, health problems, and responses to those problems. 7 Practice Nursing Standards - ANSWER accountability continuing competence ethics knowledge knowledge application leadership relationships Sam, a nurse. Walks into her patients room to check Mr. Browns blood sugars after eating his meal. His wife, who just finished assisting Mr. Brown with his meal, told Sam that he ate everything except the porridge. What kind of data is this? - ANSWER Secondary source data To conduct a comprehensive assessment you - ANSWER use a structured database format or a problem- oriented approach Open-ended questions - ANSWER encourage clients to describe their health histories in detail. Closed ended questions - ANSWER present a list of possible choices for the client. Accessing only information which is needed to provide care: Are you in the 'Circle of Care'? Documentation allows for communication between the health care team through: - ANSWER -Records: legal document that has all relevant information about a patient's health status and plan of care. Records are documented by any healthcare professional involved in the plan of care. -Reports: oral, written or audiotaped exchanges of information between caregivers Purpose of records - ANSWER Tool for communication Legal document Defense against any legal claims associated with care Education Funding/ Resource Management Research Auditing and monitoring Guidelines for accurate/factual Documentation - ANSWER Factual -Descriptive, objective information -Subjective information with quotations -Avoid making inferences that are not supported by assessments -Avoid vague terms: appears, seems Accurate -Concise data, clear, exact measurements, correct spelling -Dated, identify author -Use only standard abbreviations*** Guidelines for Documentation and Reporting - ANSWER Complete -Contains all appropriate information Current -Record as soon as possible as to avoid mistakes/omissions and ensure greater communication Organized -Organized, logical order (use agency methods) Compliant with agency, government, CNA and CNO standards Documentation Systems - ANSWER Way in which an agency documents patient information (reflects the philosophy of the unit or agency). Agencies may choose a combination of various systems Systems: -Narrative -Source records -Charting by exception -Case management/ critical pathways -Problem oriented SOAP Notes - ANSWER SOAP or SOAPIE format: -Subjective data, -Objective data, -Assessment (interpretation or conclusions), -Plan -Interventions, Evaluation, Similar to the nursing process This format encourages collaboration, problem lists alert caregivers to clients' needs, and it makes it easier to track the status of the problems. Examples of SOAP - ANSWER 01/19/11 Knowledge deficit regarding surgery at 1630 hrs related to inexperience S: "I'm worried about what it will be like after surgery." O: Patient asking frequent questions about surgery. Has had no previous experience with surgery. Wife present and acting as a support person. A: Knowledge deficit regarding surgery related to inexperience. Patient also expressing anxiety. P: Explain routine preoperative preparation. Demonstrate and explain rationale for turning, coughing, and deep breathing (TCDB) exercises. Provide explanation and teaching booklet on postoperative nursing care. S. Lazarus, RPN PIE - ANSWER Problem oriented in nature Groups information into three categories: *Problem, Interventions, and Evaluation of nursing care* Ex: P: Knowledge deficit regarding surgery related to inexperience. I: Explained normal preoperative preparations for surgery to patient. Demonstrated TCDB exercises. Provided booklet on postoperative nursing care to patient. E: Patient demonstrates TCDB exercises correctly. Needs review of postoperative nursing care. S. Lazarus, RPN • A portal of exit from the reservoir • A mode of transmission • A portal of entry to a host • A susceptible host Routine Practices - ANSWER First tier of isolation practices, designed to care for all patients in any setting, regardless of their diagnosis or presumed infectiousness. Routine practices apply when a health care worker is or potentially may be exposed to (1) blood; (2) all body fluids, secretions, and excretions except sweat; (3) non-intact skin; or (4) mucous membranes. Appropriate use of gowns, gloves, masks, eyewear, and other protective devices or clothing. Additional (Isolation) Precautions - ANSWER Second tier of infection control practices. Designed to contain pathogens, prevent spreading. For patients who have a known infection or are symptomatic. Three categories: -Contact -Droplet -Airborne Infectious Diseases - ANSWER Infectious agent: A pathogen that has the potential to cause infection. -Virus, bacteria, fungus, or parasite. -Ex. MRSA, C-Diff, Influenza, TB, aspergillus, candida Infections can be local or systemic. Host can acquire the infectious agent in community or in hospital. Nosocomial infections (or hospital acquired infections) are infections acquired in the hospital that were not present or incubating at the time of hospital admission Complications related to Infections - ANSWER Can progress from local to systemic *Sepsis*: Body's inflammatory response to a local infection becomes overwhelmed and affects entire body. Complications include signs of low perfusion to organs causing low urine output, mental status change, hypotension, shock and death. Fluid loss, dehydration, weight loss Impaired skin integrity Nurses are responsible for the following related to Infectious Disease - ANSWER -Assessing for infectious status in their patients and reporting findings to health care team -Caring for those who already have an infection or are at risk of developing an infection -Provide interventions to meet client goals related to various infections -Prevent the spread of infection Nurses do this by following the 'Nursing Process' Assessment - Infectious Disease - ANSWER The practical nurse needs to assess their patient's: -Status of defence mechanism - primary defenses (ex skin) and secondary defenses (ex immune functioning). -Patient susceptibility - age, nutritional status, stress, disease, medical therapies. -Clinical appearance - local (pain, swelling, redness) systemic (weight loss, pallor, fever, rash) -Laboratory data - culture / specimens, blood work, diagnostic imaging. Infectious Disease Nursing diagnoses - ANSWER Possible nursing diagnoses that may apply: -Risk for infection, injury, social isolation etc. -Imbalanced nutrition (less than requirements) -Risk for impaired skin integrity (or impaired skin integrity) Impaired comfort -Deficient knowledge about the disease, cause of infection, treatment and prevention measures -Risk for imbalanced body temperature (fever) Infectious Disease Planning - ANSWER Goals and outcomes -Prevention of spread of infection -Increased knowledge about the infection and treatment, client follow infection control protocols -Control fever and related discomforts so that client is afebrile and comfortable -Prevent or manage complications -Dehydration -Weight loss -Skin integrity issues -Sepsis Infectious Disease Interventions - ANSWER Independent nursing: -Prevent spread of infection -Provide isolation Diagnosed by: Swab sent for C&S (nasal, rectal, wound) Interventions: -Treatment: Antibiotics Infection Prevention and -Control practices, aseptic procedures, teaching clients about reducing the spread of infection Clostridium Difficile - ANSWER Bacteria, spore forming *Spread by contact* Susceptible population: Those on antibiotic therapy for long term, or high doses, elderly, immunocompromised or chronic conditions, clients admitted in hospital. Signs & Symptoms : watery diarrhea, fever, loss of appetite, nausea, and abdominal pain/tenderness Complications: Dehydration, weight loss, impaired skin integrity Diagnosed by: Symptoms and lab tests (Stool sample sent for C&S) Related Nursing Diagnoses: -Risk for fluid volume deficit -Impaired skin integrity -Risk for infection -Imbalanced nutrition Interventions: Medical treatment: antibiotics, fecal transplantation HH (soap and water to kill spores), PPE, follow antibiotic therapy as prescribed, teaching to clients and families to stop the spread of infection, encourage fluid intake and balanced diet Management of symptoms Dehydration, pain, discomfort, skin breakdown etc. Influenza - ANSWER The 'flu', virus, most common strains are Influenza A + B *Spread by droplet* Susceptible population: Young and elderly, immunocompromised, chronic conditions. Those who are more likely to spread the flu to people at high risk of developing complications: -Those in close contact with susceptible people -Pregnant or caring for newborn during flu season -Health care workers -Child care worker The flu is ranked among the top 10 leading causes of death in Canada. Each year in Canada, it is estimated that the flu causes: -12,200 hospital stays -3,500 deaths Signs & Symptoms : fever, cough, runny nose, muscle aches, chills, fatigue, decreased appetite, sore throat Complications: Dehydration, weight loss, respiratory distress, can be fatal Diagnosed by: Symptoms and lab tests (swab of nasal passages) Related Nursing Diagnoses: -Ineffective Airway Clearance, -Ineffective Breathing Pattern -Fluid volume deficit -Hyperthermia -Acute Pain Interventions: Treatment: antiviral therapy may be an option, oxygen therapy, bronchodilators Encourage rest, sleep, fluids, balanced nutrition, HH, PPE Positioning (fowlers), ambulation Deep breathing and coughing exercises Prevention with influenza vaccine TB: Tuberculosis - ANSWER Bacteria *Spread by airborne* Susceptible population: Traveling to certain countries (Russia, Africa, Eastern Europe, Asia, Latin America, Caribbean Islands), immunocompromised or chronic conditions Signs & Symptoms : -Active: bad cough, blood in sputum, fever, night sweats, weight loss, loss of appetite, chest pain -Latent: no symptoms, can't spread it Complications: respiratory compromised, joint damage, liver/kidney/heart issues, spinal pain Diagnosed by: Symptoms, skin test, X-ray, sputum Related Nursing Diagnoses: -Risk for infection Deficient knowledge about the disease, cause of infection, treatment and prevention measures -Patient explains disease state, recognizes need for medications, and understands treatments. -Patient lists resources that can be used for more information or support after discharge. Risk for imbalanced body temperature (fever) -Pt's temperature will between 97.8-98.6 within 24 hours of hospitalization. -Pt's skin turgor will be less than 5 seconds within 24 hours of hospitalization. Dehydration - ANSWER Dehydration = Fluid volume deficit Excessive loss of water from the body tissues, accompanied by a disturbance of body electrolytes. Fluid output greater than fluid intake Causes: -Lack of fluid intake (I.e. nausea, inability to access fluids) -Vomiting, diarrhea, GI suctioning, excessive sweating -Other: burns, hemorrhage, dementia, meds (diuretics) etc. -Developmental considerations: young and elderly Fluid Balance - ANSWER Possible intake and output measured in hospital or long term care setting includes, but not limited to: Intake: Oral fluids, IV fluids, tube feedings, retained irrigants Output: Urine, wound or tube drainage, vomitus, diarrhea, excess perspiration (sensible losses from sweat glands: fever, high environmental temperature) Positive fluid balance (+) Intake > Output Neutral fluid balance Intake = Output Negative fluid balance (-) Intake < Output Clinical Manifestations of Dehydration - ANSWER Signs and Symptoms: -Acute weight loss -Decreased skin turgor -Concentrated urine -Decreased urine output -Confusion in elderly -Decreased blood pressure, increased heart rate Symptoms can be mild to severe, depending on the level of dehydration. Clinical manifestations (signs and symptoms) may vary depending on the client. Mild: Dry mucous membranes, increased thirst, concentrated urine Moderate: Sunken eyes, loss of skin turgor, dry oral mucous membranes, concentrated urine, decreased urine output, changes in vital signs. Infants may have a sunken fontanel. Severe: Signs of shock (rapid, thready pulse, cyanosis, cold extremities, rapid breathing, lethargy, or coma) Dehydration Nursing Diagnostic Labels - ANSWER Deficient fluid volume Risk of deficient fluid volume Decreased cardiac output Potential complication -Hypovolemic shock Dehydration Nursing Assessments - ANSWER Vital Signs Measure and record intake & output (I & O) Assess urine amount and colour Monitor cardiovascular changes Assess respiratory changes Daily weights Skin assessment, mucous membranes Skin Turgor (Not the best predictor for elderly clients as they have decreased elasticity in their skin) Dehydration Nursing Interventions - ANSWER Offer oral fluids frequently throughout the day Teaching to reduce output Ex. Avoid caffeine, alcohol Frequent mouth care, skin care Monitoring: Daily weights, HR, BP, Temp, Skin turgor and mucous membranes, Labs (blood, urine) Intake and output Q8H or more frequently if needed. Dehydration medical management - ANSWER IV fluids -Amount and electrolyte content determined by physician Anti-emetic therapy Anti-diarrheal agents -Forceful expulsion of stomach contents without nausea Nursing assessment N&V - ANSWER Have basic understanding of those at risk for nausea and vomiting: History of GI disorders, indigestion issues, food allergies, CNS disorders Pregnancy, infection, bulimia, metabolic disorders Recent travel, cancers/chemo, cardiovascular disease, renal disease Recent surgery and exposure to sedation Refer to clinical manifestations including: -Emesis, dry heaves, dry mouth, anorexia -Weakness and fatigue -Abdominal pain or tenderness -Pallor, poor skin turgor, dry mucous membranes -Characteristic of emesis N&V Nursing Diagnoses - ANSWER Nausea Related to nutrition: -Risk for imbalanced nutrition: less than body requirements -imbalanced nutrition: less than body requirements Risk for aspiration Related to dehydration: -Risk of deficient fluid volume or fluid volume deficit -Risk for electrolyte imbalance Patient Outcomes N&V - ANSWER Experience minimal or no nausea Show no signs of dehydration Show no signs of weight loss, or return to baseline body weight Absence of vomiting Patient reports increased comfort Patient achieves neutral fluid balance Nursing interventions N&V - ANSWER Monitor: -Abdominal assessment (bowel sounds) -Presence of nausea -Emesis (ACCO-amount, colour, consistency, odour) -Intake and output, weights -Vital signs -Signs and symptoms of dehydration -Lab values Administer meds, IV fluids as per orders Remove triggers: Maintain quiet, odour-free environment, lights etc. Position client to minimize risk of aspiration Maintain hygiene: Provide oral care, clean clothes, bed bath Encourage fluids and nutrition once patient can tolerate Client teaching Medical Management N&V - ANSWER Choice of medication depends on underlying cause Caution that problem is not masked by medication and be aware of side effects Pharmacotherapy: -*Antiemetics* act on CNS in CTZ to block chemicals that trigger nausea and vomiting. Medications can be given by various routes: Ex. if patient can't tolerate PO, give by IV Example of Antiemetics - ANSWER Dimenhydrinate (Gravol) -Prevention and treatment of nausea, vomiting and dizziness -Commonly used for many types of N&V Ondansetron (Zofran) -Serotonin Receptor Agonist blocks CNS receptors that affect vomiting pathways -Used in chemotherapy related vomiting, post-op N&V Prochlorperazine (Stemetil) -Inhibits vomiting center in brain -Used for short term N&V (I.e. Post-op) Nutritional Management N&V - ANSWER If vomiting is severe: -IV therapy: Fluids, glucose and electrolyte replacement -Nasogastric tube inserted in stomach and suction turned on to decompress stomach Intake once vomiting subsides: -Start with clear fluids at room temperature -Carbonated drinks no longer carbonated, warm tea -Avoid coffee -Start with small amounts of food -Crackers, dry toast, avoid spicy, highly acidic Ambulation Avoid laxatives What is 'normal' Administer medication if ordered Medical Management constipation - ANSWER If pharmaceutical agents are necessary, the following are used: Bulk-forming agents (ex. Metamucil) Need fluids to increase bulk Fecal softeners and lubricants (ex. Docusate sodium) Lubricates tract and softens stools Saline and Osmotic agents (ex. Lactulose) Causes fluid retention in lumen of bowel Stimulants (ex. Dulcolax) Increase peristalsis Nutritional management constipation - ANSWER If pharmaceutical agents are necessary, the following are used: Bulk-forming agents (ex. Metamucil) Need fluids to increase bulk Fecal softeners and lubricants (ex. Docusate sodium) Lubricates tract and softens stools Saline and Osmotic agents (ex. Lactulose) Causes fluid retention in lumen of bowel Stimulants (ex. Dulcolax) Increase peristalsis Clinical manifestations diarrhea - ANSWER Can be explosive (acute) Watery Cramping and abdominal pain, distention Perianal discomfort Fever, nausea, vomiting Weight loss (chronic) Thirst Complications: Dehydration Elderly and young susceptible Electrolyte imbalance Decreased serum potassium Weight loss, malnutrition Bacteremia (if infection enters blood stream) How to diagnose diarrhea - ANSWER Determine underlying cause If the cause of diarrhea is not obvious, the following tests may be performed: Blood tests: Complete blood count (CBC), chemical profile (electrolytes) Stool examinations: Routine Specialized tests- Stool sent for C+S, ova & parasites, toxins, blood, fat etc. Endoscopy, colonoscopy or barium enema Nursing assessment diarrhea - ANSWER Health history: Duration and frequency Medications Stress Dietary history Physical assessment: Refer to clinical manifestations Diarrhea Nursing Diagnostic Labels - ANSWER Deficient fluid volume, dehydration Impaired skin integrity Risk for imbalanced nutrition: less than body requirements or imbalanced nutrition: less than body requirements Situational low self esteem Bowel incontinence Toileting self care deficits Risk for falls Patient outcomes diarrhea - ANSWER Maintains or achieves normal bowel movements No evidence of skin breakdown Show no signs of dehydration Show no signs of weight loss, or return to baseline body weight Nursing Interventions diarrhea - ANSWER Monitor for dehydration, electrolyte imbalance Call bell in reach, commode at bedside Promote hygiene practices Promote skin integrity (washing, dry, barrier cream) Infection control practices (and teach patient) Administer medications, IV fluids as prescribed Medical management diarrhea - ANSWER Primarily focused on controlling symptoms and treating/eliminating underlying causes Certain medications can reduce the severity of diarrhea &/or treat underlying cause: Antibiotics or anti-inflammatory agents Anti-diarrheal agents may be used: Loperamide (Imodium) Defining characteristics of incontinence - ANSWER depends on the cause of the incontinence -Transient - ex: UTI, infection -Acquired - stress, reflex etc. How to diagnose urinary incontinence - ANSWER Health history and physical assessment Bladder log or voiding diary Documents timing, amount, leakage, nocturia Urinalysis Rule out other causes, ex. infection, diabetes Post-void residual Patient urinates, then measure remaining urine by catheterization or bladder scan Imaging Nursing assessment urinary incontinence - ANSWER Health history: -Past medical health history (related comorbidities) ex: diabetes, cognitive impairment, Parkinsonism, arthritis, back problems, sensory impairment, visual & hearing impairments -Infectious status (actual UTI, history of UTIs) -Lifestyle factors (smoking, obesity) -Medications:diuretics, morphine, sedatives Fluid intake pattern and type Output pattern and "accidents", urgency, burning, dribbling, including bowel patterns Environment location of bathroom, privacy Functional status: ability to get to bathroom, remove clothes, get on toilet Cognitive status: ability to ask for help, desire Nursing Diagnosis Urinary Incontinence - ANSWER Impaired urinary elimination Overflow, functional, stress urinary incontinence etc. Toileting self care deficit Risk for impaired skin integrity Risk for infection Diagnoses related to stress, self-esteem, personal identity, social isolation Goals and Outcomes Urinary Incontinence - ANSWER The client will achieve continence (or significantly decrease incontinent episodes) The client will maintain optimal dryness Client will not get UTI Client will maintain skin integrity Nursing interventions Urinary Incontinence - ANSWER *depends on type and cause of UI* -Keep a bladder log -Promote and maintain regular voiding patterns -Be available, answer call bells, give patient time to void completely -Modify environment so that it meets functional needs of client -Maintain skin integrity and prevent infection -Perineal care -Incontinence briefs and pads provided, but are a last resort since they do not solve the problem -Change frequently Teaching -Infection prevention -Proper hygiene -Promote skin integrity -Importance of hydration -Avoiding triggers (food/fluids) Introduce schedule voiding patterns Various forms of training: Habit training, bladder training, prompting, Post-residual void > 150ml Nursing assessment Urinary retention - ANSWER Similar to UI assessment Monitor for post-void residuals (PVR) Have patient void Use bladder scanner or intermittent catheterization to measure amount of urine remaining in bladder Notify MD if patient unable to void or incomplete bladder emptying Nursing Diagnosis Urinary retention - ANSWER Urinary retention related to... Impaired comfort Acute pain Risk for infection Goals and outcomes urinary retention - ANSWER Patient will empty bladder completely. Patient will void sufficient quantity with no palpable bladder distension. Patient has a urine volume greater than____ and residual volume less than ____ Patient reports increased comfort Nursing interventions urinary retention - ANSWER Promote complete bladder emptying Scheduled toileting -Every 3-4hrs -Don't rush patient Double voiding -Void, sit on toilet for 3-4 minutes, void again Assist with catheterization if prescribed Medical management urinary retention - ANSWER Chronic: -Post-void residuals of > 100ml should do intermittent catheterizations (take catheter out immediately after urine is evacuated) Acute: -Immediate indwelling or intermittent catheterization required Indwelling: -Catheter remains in bladder for long periods of time -Option if there is an obstruction or if client unwilling or unable to do intermittent catheterizations Indwelling Urinary Catheter - ANSWER Pharmaceutical options urinary retention - ANSWER ⍺-adrenergic antagonists -Reduce urethral sphincter resistance to urinary outflow -Ex. Doxasozin for patients with enlarged prostate 5 ⍺-reducatse inhibitors -Reduces size of prostate -Ex. Finasteride UTI - ANSWER "Second most common bacterial disease the human body is subject to" Women are more susceptible than men More than 50% of women will have had a UTI in their lifetime Accounts for 40% of hospital acquired infections -Due to instrumentation (catheterization) -Bacteria is inevitable within 2 days -100% colonization within 30 days Natural defenses UTI - ANSWER Urinary tract above the urethra is usually sterile Natural defenses to prevent UTIs include: -Normal voiding, complete emptying of bladder, antibacterial capability of the bladder mucosa, function of the ureterovesical junction, peristaltic movement propelling urine, acidic PH of urine -Alteration of these can lead to infections Most infections are caused by gram-negative bacteria -E-coli most common UTI risk factors - ANSWER Diabetes, immunocompromised clients, urinary retention, obstructions, instrumentation, older adults, patients using antibiotics, underlying disease Risk for women: -At greater risk due to shortened urethra and proximity to anal orifice -Sexual activity, pregnancy, diaphragm and spermicide use, pelvic organ prolapse Risk for men: Instrumentation, congenital abnormalities UTI Classification - ANSWER Upper vs. Lower *Upper: kidneys, pelvis, ureters* Nursing Assessment UTI - ANSWER History: -Previous UTI? -Past health history -Medications, antibiotics Physical assessment: -Vital Signs: Presence of fever Symptoms: -Urgency, frequency, dysuria, sense of burning, suprapubic pressure, flank pain Assess urine Nursing Diagnosis UTI's - ANSWER Pain (acute) Impaired urinary elimination Ineffective self-health management At risk for infection Goals and Outcomes UTI - ANSWER Pain Control -Use non-analgesic or analgesics to relieve pain Urinary Elimination Issues -Normal urinary elimination patters -Urine passes without urgency or frequency or burning -Urine free of visible blood -Adequate fluid intake Self care or health management Issues -Verbalizes knowledge of treatment regimen -Expresses intent to carry out treatment regimen Nursing interventions UTI - ANSWER Health Promotion: Prevention is key! Who is at risk? Recognize and act! Routine perineal care and follow proper urinary elimination procedure Answer call bell quickly! Teaching Importance of finishing antibiotic regimen Advise patient about S+S, when to seek help Health promotion techniques Prevention of UTI Nursing interventions - ANSWER Empty bladder regularly and completely Evacuate the bowel Wipe from perineal area to rectum Drink adequate fluid Seek early treatment Avoid irritants to perineal area: powders, scented products, harsh soaps, bubble baths Catheterization Avoid unnecessary catheterization and use sterile technique for catheterizations Proper catheter care Medical Management UTI - ANSWER Antibiotic therapy -Length of therapy depends on classification of UTI -Choice of antibiotic depends on empiric therapy or sensitivity results Common treatments: -Trimethoprim/sulphamethoxazole (TMP/SMX) Used to treat uncomplicated or initial, twice a day -Nitrofurantoin Given 3 or 4 times a day, or twice a day if long acting (Macrobid) -Fluoroquinolones (ex. Cirprofloxacin) Complicated UTIs Nutritional Management UTI - ANSWER Encourage adequate fluid intake Avoid bladder irritants: Caffeine Alcohol Citrus juices Chocolate Spicy foods/drinks Cranberry products May reduce the risk of UTIs Lowers the PH of urine and decreases bacterial adherence to bladder wall Needs to be true cranberry products Care Plans - ANSWER Documentation of 'Plan of Care' for client Includes nursing diagnoses; goals, expected outcomes, or both; & specific nursing interventions Ensures continuity & coordination of nursing care & consultation by a number of health providers. Pain - ANSWER Perception can be affective, cognitive, behavioural or sensory -Delayed healing time? Threatens recovery, delayed discharge from hospital, delayed rehabilitation Your primary goals: Prevent, effectively manage, relieve so that patient can participate in recovery Nursing assessment of pain - ANSWER Pain is known as the 5th vital sign Routine screening upon: -Admission, change in medical status, before or after a procedure -Self report of pain is considered the "gold standard" -Nurse must initiate pain assessment, can't rely on clients to self report -Be aware of your own beliefs and values -Assess vital signs for possible physiological responses -Assess for behavioural indicators -Assess the characteristics of pain in order to establish potential cause and choose appropriate interventions -Use the OPQRSTUV acronym OPQRSTUV Pain Assessment - ANSWER ONSET PROVOKE/PALLIATE QUALITY REGION/RADIATION SEVERITY TIMING/TREATMENT UNDERSTANDING/IMPACT VALUE/GOAL Pain assessment tools - ANSWER Evidence based tools that have been proven to be reliable and valid uni-dimensional: looking only at one aspect of pain such as intensity Ex. Numerical Rating Scale [NRS 0-10], categorical scale or Faces Pain Scale-Revised) Multidimensional: two or more aspects of pain Ex. Brief Pain Inventory [BPI] or the McGill Pain Questionnaire - Short-Form [MPQ-SF] Nursing diagnoses pain - ANSWER Acute pain Chronic pain Anxiety Ineffective coping Fear Impaired physical mobility Self care deficit Disturbed sleep pattern Pain Management goals - ANSWER "Pain management goals permit the patient to function to the best possible extent" (Potter et. al, 2014, p. 1033) Examples of goals: Achieve satisfactory level of pain Able to participate in ADLs Able to ambulate Identify behaviors that increase pain and then modify those behaviours Use pain relief measures safely A collaborative approach is used to care for clients with pain. Nursing interventions for pain - ANSWER Assess and continue to monitor pain status Support for ADL'S and positioning as needed/for comfort Support for anxiety related to pain Education of patient and family Advocate for pain management for all clients Consult with pain team if available Medical Management of Pain - ANSWER Medications are more effective if given before pain is severe Assessment and education is key! Goal is to keep serum levels of medication constant Variety of medications, routes of administration and dosage ranges used PRN medications may be used for "breakthrough" pain Always assess client status after administration for effectiveness and adverse effects Timing varies depending on treatment Opioids (Narcotics) - ANSWER Used for moderate to severe pain Act on central nervous system Examples: Morphine, codeine, meperidine, oxycodone Monitor for possible side effects: *Respiratory depression (RR<8)* Sedation Nausea and vomiting Constipation Pruritus (itching) May decrease BP Inadequate pain relief from inadequate dose Alternative Management for Pain - ANSWER Relaxation and guided imagery Distraction Biofeedback Acupuncture Refer for physical rehabilitation and/or to support psychological well-being Restraints - ANSWER "A restraint is a physical, chemical, or environmental means on controlling an individual's behaviour or actions" Physical restraints Limits a client's ability to move (bedrail, seat belt) Environmental restraints Control where a client can move to (secure unit, seclusion room) Chemical restraints Psychoactive medication used to stop a behaviour or movement (in this case, the medication is not used to treat illness). Least restraint approach - ANSWER Use of restraints is controversial due to safety issues and negative patient outcomes associated with their use *A 'least-restraint' approach is recommended* Review agency policy prior to any use of restraint RNAO BPG focuses on: -Assessment, Prevention and Alternative -Approaches -De-escalation Interventions and Crisis -Management -Restraint Use Focused on Client Safety alternatives to restraints - ANSWER Supervision, trained sitters, adjust staffing Distraction techniques, diversional activities Assign confused patients a room close to nursing station Remove cues that promote leaving Use calm, simple statements and de-escalate any potential challenging interactions Evaluate all medications Promote relaxation, pain management, Camouflage IV lines, drains, tubes etc. Patients with more support - ANSWER cope better with pain A patient who has been admitted to your unit has been identified as being colonized by (is a carrier of) methicillin-resistant Staphylococcus aureus (MRSA). Which measure should be taken to prevent the spread of MRSA to other patients on the unit? - ANSWER place the patient on contact precautions Which of the following laboratory tests will show elevated results if a bacterial infection is present? - ANSWER white blood cell count For which airborne disease would the nurse be required to use respiratory device when in close contact with the patient? - ANSWER tuberculosis If an infectious disease can be transmitted directly from one person to another, it is called? - ANSWER A communicable disease If an infectious disease is transmitted directly from one person to another, it is a communicable disease. Portals of entry and exit are the mechanisms of disease transmission. A susceptible host is a person who can acquire an infection. A 34-year-old male patient is in hospital rehabilitating from a spinal cord injury. He is incontinent of urine at regular intervals. He is unaware when he is incontinent. This describes which of the following types of incontinence? - ANSWER Reflex incontinence Reflex incontinence is the involuntary loss of urine at regular intervals. The person is unaware that the bladder is filling and does not feel the urge to void. Stress incontinence occurs with activities that increase intra-abdominal pressure, such as coughing and sneezing. Transient incontinence is a temporary incontinence that resolves once its underlying causes are treated, such as dementia or infection. Urge incontinence is associated with a sudden, urgent need to void and often presents with urinary frequency and nocturia. Its causes include nervous system disorders and outflow obstruction To minimize nocturia, when should patients avoid fluids? - ANSWER Patients should avoid fluids for two hours before bedtime to prevent nocturia. A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. What the the probable cause? - ANSWER UTI Hospital-acquired urinary tract infections (UTIs) are often related to - ANSWER Improper catheter care urinary catheterization has the highest potential for causing UTIs, and improper catheter care can increase the chance of these infections. The nurse recognizes that which organism most frequently causes UTIs in women? - ANSWER Escherichia coli Because the female urethra is positioned close to the anus, most UTIs are a result of contamination of the urethra with organisms from the gastrointestinal tract. The organisms in options A, B, and D are not normally found in the gastrointestinal tract and thus are not commonly associated with UTIs. Your 55y/o client has been admitted complaining of the inability to void. They are experiencing an increased urgency of voiding during the night and find that when they use the washroom, only a few drops come at a time, but never feel the relief of urinating. What is the priority NANDA? - ANSWER urinary retention/impaired urinary elimination Incontinence types - ANSWER FUNCTIONAL- aware that they need to urinate but due to mental or physical reasons cannot get to bathroom URGE- sudden need to urinate, involuntary muscular contraction of the bladder walls. Overactive bladder. STRESS- involuntary with pressure - leakage of urine - common amongst women, ie; laughing MIXED- combination of incontinence [urge&stress]