Foundations Test 1 Review

Chapter 1: Nursing, Theory, and Professional Practice

 Nursing: define as a holistic profession b/c it addresses physical, mental, emotional,
spiritual, and social needs.
 As a science, nursing relies on knowledge gained through research from nursing and
other disciplines and scientifically testes knowledge applied in the practice setting
 Roles of a nurse (9)
 Care provider: using nursing process to assess pt. data, prioritize nursing
diagnosis, plan the care of the pt, implement the appropriate interventions and
evaluate care.
 Educator: provide pt. with sufficient information about care and related
treatment.
 Advocate: the nurse respects/accepts pts. Decisions and advocates for them.
Speaking up for the pt. at all times
 Leader: people look up to you to for answers
 Change agent: working with staff members, learning new things
 Manager, researcher, collaborator
 Delegator: delegation of certain activities keeping in mind the limits/capabilities
of UAPs
 History of nursing: began in religious and military service, Florence Nightingale(founder
of modern nursing)
 Nursing theories: use to guide practice always involving 4 concepts: nursing, pt. , health,
& enviro.
 Metaparadigm: 1st level. Describes central phenomena of the discipline and
explains the relationship between those concepts.
 Philosophy: 2nd level; beliefs/values of nursing in relation to health. Provides
guidance
 Conceptual framework(model): 3rd level; provides directions for nursing practice
using the 4 concepts
 Nursing theory: 4th level ; can be tested in practice & derived from a previous
conceptual model
 Regardless of which nursing theory is selected, the nurse must use knowledge from
nursing and related sciences, experience , and standards of practice when providing care
 Florence Nightingale’s theory: imbalance between the pt. & the environment decreases
the capacity of health and does not allow for conservation of energy
 Main concepts of nursing ethics are accountability, advocacy, autonomy, beneficence,
confidentially, responsibility, veracity (being truthful)
 Nursing shortage
 QSEN: quality and safety education for nurses; adds safety as a competency
 National patient safety goals
o identify pts. Correctly
o improve staff communication
o use medicines safely
o use alarms safely
o prevent infection
o identify pts w/ safety risk
o prevent mistakes in surgery
 Criteria for a profession in nursing:
 Altruism: patient always comes first
 Body of knowledge : defined skills, abilities , and norms
 Accountability
 Higher education
 Autonomy: making independent decisions about care and responsible for them
 Code of ethics
 Professional organization, licensure, and respect for diversity
 Maslow’s hierarchy of needs
  Practice guidelines
 The Standards of Nursing practice: published by ANA to ensure quality of care
and serve as a legal criteria for adequate pt. care.
 1st part- Six responsibilities: assessment, diagnosis, outcomes
identification, planning, implementation, and evaluation
 2nd part- professional performance: ethics, education, communication,
leadership, collaboration

Chapter 2: Values, beliefs, and caring

 Beliefs
 First order beliefs: never challenge pt.’s first order beliefs
 High order beliefs: Generalizations vs. stereotype vs. prejudice
 A large # of health care errors can be traced back to pt./provider’s beliefs
 Values system: set of somewhat consistent values and measures; each individual may
share values with others but to a certain extend. Values conflict and clarification
 To determine patients values and beliefs the nurse must listen and ask relevant
questions
 Paradigm: how someone views the world.
 Madeline Leininger cultural care theory
 Maintaining the patient’s cultural health practices
 Accommodating, adapting, or adjusting health care practices
 Restructuring some cultural practices as needed
 Behaviors that demonstrate caring in nursing
 Presence: sitting down, touching If appropriate
 Consistency & predictability
 Touch
 task oriented vs. caring touch
 actively listening: listening next to the bed and summarizing the story

Chapter 3: Communication
referent sender message channel receiver feedback
event/ though person who info. that is method of person who response of the
initiating initiates and communicated communication receives and receiver
communication encodes the decodes the
communication communication

  patient’s verbal and non-verbal communication allows the nurse to interpret

consistency/inconsistency
 Verbal communication
 Written communication
 Electronic communication
 Setting, context + content
 Various types of communications
 Intrapersonal: “I can do this”
 Small-group
 Forming phase: leader must identify mission/goal of group
 Storming: personality conflicts arise, group leader needs to build
cohesion
 Norming: increased trust and openness resulting; leader encourage
participation
 Performing phase: problem solving takes place
 Adjourning: group disperses, having achieved their goals
 Interpersonal: between 2+ people
 Interprofessional: Situation Background Assessment Recommendation
 Ethical implications: know where to discuss certain pt. information
 Nonverbal communication: 93% of most communication ; silence gives the pt. time to
reflect
 Voice inflection: tone, volume, and rate of speech
 Body language (55%)
 Posture, stance, and gait
 Facial expression and eye movements
 Touch, gesture, and symbolic expression
 Intimate space: 0-0.5 ft
 Personal space: 1.5-4 ft
 Social space: 4-12 ft
  Public: 12+ ft
 Voice inflection
 Phases of helping relationship: orientation/introductory phase workingtermination
 Preinteraction activities include: gathering assessments and diagnostic data, organizing
data, identifying areas of concern and planning the interaction helps nurse for initial
contact
 Verbal techniques for initiating and encouraging communication: offering self (ill sit w/
u) , calling the pt by name, sharing observations (you look tense), and giving info. (your
surgery will be in 30 mins) table 3-2 pg 47
 Essential components of professional nursing communication
 Respect
 Assertiveness: ability to express ideas while respecting other’s thoughts
 Collaboration, delegation
 Advocacy
 A nurse during Active listening should: Sit facing the pt. Open stance Lean towards pt.
Eye contact Relax
 Defensive mechanism
 Displacement: putting your stress on someone else
 Introjection: taking on certain characteristics of someone else
 Projection: attributing undesirable feelings to someone else
 Rationalization: denying true motives & using a social acceptable excuse
 Regression: reverting to pass behaviors
 Sublimation: rechanneling unacceptable impulses into social. Acceptable
activities
 Suppression: choosing not to think about unpleasant feelings

Chapter 4: Critical thinking in nursing

 Clinical reasoning: uses critical thinking, knowledge, and experience to develop
solutions to problems and make decisions in a clinical setting
 Reasoning
 Inductive reasoning: signs/symptomsdisease
 Deductive reasoning: diseasesigns/symptoms
 Inferences: involve a conclusion on the basis of something
 Essential critical thinking traits: confidence, thinking independently, fairness,
responsibility/accountability, risk taking, curiosity, integrity, humility, discipline,
perseverance, creativity
 Critical thinking in the nursing process
 Interpretation: Using knowledge of theory and application; effects of meds.
 Analysis: considering advantages/dis. & consequences of all possibilities
 Evaluation: assessing information for credibility
  Inference : making accurate conclusions that are based on sound reasoning
 Explanation: sound rationale for thought and actions
 Self-regulation: “ are my assumptions accurate?”
 Clinical-decision making
 Intellectual standards of critical thinking: breadth, logic, etc.

Chapter 26: asepsis and infection control

 During assessment a history is obtained before observation
 Effects of Infection on the body’s defense system include
 Vital signs: temp. elevates slightly, BP rises, and pulse/respiratory rate increases
 Nutritional assessment: skin, mucous membranes, appearance, and diet
 Risk assessment: ask about chronic diseases, meds. , lack of proper immun.
 Laboratory test: complete blood count (CBC), white blood count (WBC), ESR

 Hand hygiene breaks the chain of infection by interrupting the mode of transmission
 The planning stage of nursing process involves prioritizing nursing diagnoses, evaluating
patient abilities and resource, and setting realistic goals.
 Standard precautions are used with every patient, prevent the spread of infectious
diseases by minimizing the risk of transmission or exposure.
 Transmission precautions (airborne, droplet, and contact) are used in addition to
decrease the transfer of highly transmissible pathogens
 Contact precautions are used when or suspected contagious disease may be
present. Eg: VRE, MRSA, S. aureus, C. diff, scabies, HSV
 Airborne precautions: when a contagious disease can be transmitted by means
of small droplet. Precautions include negative pressure room, used of N95 .
respiratory mask. Eg: varicella, rubeola(measles), Mycobacterium Tuberculosis
 Droplet Precautions: when contagious disease can be spread through large
droplets suspended in air. Eg: German measles rubella , Mumps, and pertussis.
Pneumonias, pneumonic plague, influenza
 Protective isolation: for patients who are immunocompromised(HIV,
chemotherapy, irradiation, bone marrow) . no vegetables, fruits, flesh flowers
 It is important to teach patients and their family members about preventing the spread
of infectious illnesses
 Personal Protective Equipment (PPE): equipment that health care personnel use to
protect against the spread of infection; includes gloves, masks, googles, face shields,
gowns, caps, and shoe coverings.
 Medical asepsis: includes handwashing, wearing gloves, gowning and disinfecting
 Surgical asepsis: is used to prevent the introduction of mo’s from the environment to
the pt. used for wound care and dressing changes
Chapter 27: Hygiene and personal care
 Hygienic practices: includes bathing, oral care, perineal care, foot care, and shaving. They
vary according to personal habits, beliefs, age, ethnic customs, and cultural beliefs
 The nurse assesses patients for signs of infection due to poor hygienic practices during
the initial interview and while giving care
 Diagnoses are done after interview and head to toe assessment are complete

 Alterations in structure and function that affect hygienic care

 Ulcers,incisions, and wounds
 Excoriations: red,scaly areas with surface loss of skin tissue, occurs in
patients whose skin is exposed to bodily fluids such as stool,urine, or
gastric juices, seen in areas where skin rest on skin(boobs/axilla
 Decreased sensation
 Alopecia: when hair follicles completely die ;
 Pediculosis
 Nails: any cut in the skin can lead to an ulcer in pt. w/ poor circul.
 Oral cavity
 Gingivitis: inflammation of the gums
 Halitosis: unpleasant breath odor
 Assessment
1. Assess skin, hair, nails and oral cavity
 Assessment of the skin occurs before and during hygienic care
 Poor hygienic practices are indicated by oily ,matted, or tangled hair
 Assess nails for thickness, color, cracking, odor
 Assess mouth for broken or missing teeth
 Bathing and skin care
 after the bath, the nurse should document the type of care performed,
date and time, skin assessment, the pt’s current position, ability to assist,
and response to bathing
 Complete Bed bath
 Partial bed bath
 Sink bath
 Shower & chair shower
Chapter 5: Introduction to the Nursing process
 Nursing process: the systematic method of critical thinking used by professional nurses
to develop individualized plans of care and provide care for patients.
 All patients are required to have unique, patient-centered plans of care to meet their
specific needs.
 Characteristics of the nursing process
 Analytical: is the data collection accurate? Are outcomes specific?
 Dynamic: the nurse can always go back and change the care plan during pt. care
 Organized: following the steps of nursing process ensure pt. care is thorough
 Outcome oriented: short term and long term goals
 Collaborative
 Adaptable: could be use in a community setting

 Steps Of Nursing process

Planning Diagnosis
Assessment
eg: imbalanced nutrion
prioritize diagnoses Data Collection
diarrhea
set goals w/ specific outcomes Contributing factors
Putting a diagnosis to it
Rate of incidence
risk factors
Head to toe info

Evaluation implementation
are goals met? initianing nursing intervations
effectiveness of intervations Independent, dependent,
collaborative

 Types of diagnosis
 Actual diagnosis (3 Parts): Diarrhea r/t increase intake of milk products
aeb 4-6 loose stools
 1)Pt. identified need or problem; eg:diarrhea; NANDA label
 2)The etiology or underlying cause
 3)Signs and symptoms
 Risk-diagnosis (2 parts) : pt. identified need or problem , and risk factors; eg:
risk for electrolyte imbalance r/t diarrhea
  Health Promotion: The nursing diagnostic label and defining characteristic, eg:
readiness for knowledge deficit [lactose free diet] aeb increased intake of milk
products
 Protocols: written plans that can be generalized to groups of pts. With the same or
similar clinical needs that do not require a physician’s order.
 Standing orders: written order by physicians and list specific actions to be taken by a
nurse

Chapter 7: Nursing diagnosis

 Identification of correct nursing diagnosis depends on
 Accurate collection
 Accurate validation
 Accurate analysis
 Accurate clustering of pt. data
 Every 24 hours RN needs to look at plan care to make sure it is up to date
 Nursing diagnosis have a more holistic care of plan compared to medical diagnosis;
medical diagnosis only focuses on physical/psychological illness
 All patient information should be considered as potentially contributing to the
identification of diagnostic labels.
 Physical assessment data includes subjective and objective data
 Interview of the pt. and family members
 Laboratory/diagnostic imaging test results
 Physician’s orders
 Documentation from health care providers
 Clustering: organizing pt. assessment data w/ similar underlying causes
 Write the statement to address the highest-priority needs of pt. (physiological needs);
statement should be written according to pt.’s assessment
 Avoiding problems in the diagnostic process
 Data clustering: clustering unrelated data can be avoided w/ more info.
 Accurate data collection: caused by errors in data collection, incomplete
understanding/knowledge of assessment techniques, or pt.’s condition
 Formulating related factors: the underlying etiology, or cause of pt.’s concern
should be used as r/t factor
 Identifying the correct cause: data listed as characteristic of etiology.
 Focusing on one problem at a time
According to the NANDA-I guidelines, the second part of the nursing diagnosis consists of
related factors (for actual nursing diagnoses) and risk factors (for risk nursing diagnoses).
Related factors are the underlying cause or etiology of a patient’s problem. Risk factors are
environmental, physical, psychological, or situational concerns that increase a patient’s
vulnerability to a potential problem or concern. In this case, the acute pain is being caused by
pressure on the lumbar spinal nerves.