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Fundamentals of Nursing Exam Two - Coggle Diagram
Fundamentals of Nursing Exam Two
Evidence-Based Practice - changing nursing practice based on new evidence
Spirit of Inquiry - desire to understand complex issues through research, the basis of EBP
Why we use EBP
Improves outcomes
increased professional satisfaction
lower cost of healthcare
framework for clinical judgement
EBP Steps
1) Ask a Question (Assess) + Identify a Problem (Diagnose)
Why and How questions mostly
2) Search Credible Sources (Diagnose)
Peer-reviewed articles/Scientific Literature
Hierarchy of Evidence
Level 1 = most reliable, systemic review, meta-analysis, randomized control trials
systemic review -> EBP guidelines
Level 7 = least reliable, expert/authority opinions
Government agencies
Professional and National Associations
Non-scholarly sources are Non-credible
Types of Research
Qualitative
Quantitative
Mixed
Translational - determines how to implement EBP effectively
3) Evaluate Findings Using Table of Evidence (Plan)
4) Implement Recommendations (Intervention)
Theory-Practice Gap - the time between obtainment of knowledge and implementation of knowledge in daily practice
5) Review Effectiveness (Evaluate)
6) Disseminate Results
Clinical Guidelines - statements that outline a plan of care to optimize outcomes, cost effectiveness, and resource allocation
Patient-Centered Care
PCC 101
Being Present (part of Watson's and Swanson's Theories)
Can be physical (like touch)
Can be emotional (AKA: Listening)
Can be spiritual
Patient-Centered Care = client is at the center of care
Caring - the act of nurturing someone you're responsible for
foundational to nursing
holistic approach - physical, emotional, and spiritual
Listening
ask questions
pause
listen
Touch = providing physical presence
Client Preferences
endorsing participation
promote client understanding by sharing information
Cultural Competence - use preferences to care for client
Generational Differences
Silent Generation (1928-1945)
Traditional face to face and written communication
Value loyalty
Baby Boomer (1945-1964)
do not type during appointment
eye contact is valued
Gen x (1965-1980)
Independent
Direct
Comfortable with Technology
Gen Y, Millennial (1981-1997)
Tech savvy
Flexible
Likes feedback
Considered entitled but really they're just brave enough to call people out
Likes to be taught
Gen z (1998-2012)
Prefers text or email
Likes instant feedback and care
Multitaskers
Gen Alpha (2013-Present)
Self-sufficient
Involve the family
Watson's Theory - in order to care for others, nurses must first care for themselves
The 10 Caritas Processes
Human/Altruistic Values
Be authentically present/ enable faith/ honor inner-self
Be sensitive
Develop/Sustain loving and trusting relationship
Allow emotional expression
Creative problem-solving
Transpersonal Teaching/Learning to Approach Patient's Needs
Create Healing Environment
Assist with Basic Needs Like They are Sacred
Remain Spiritually Open-minded
Key Questions
Tell me about your health
What is it like to be you?
How do you perceive yourself?
What are your health priorities
How do you envision your life?
What does healing mean for you
What is the most important thing I can do for you/ that you need right now?
Swanson's Theory - 5 Categories
Maintaining belief
Knowing
Being with
Doing for
Enabling
Spiritual Assessment
Sources of strength/support
Existential Concerns
Concerns about relationship with God + others
Loss of faith/spiritual community/practices
Cultural considerations
Hopes/Values/Fear/Meaning/Purpose
Quality of life + afterlife
Life completion/grief/bereavement
Pastoral care is especially important for end-of-life care
Inclusion, Equity, and Diversity
Theory of Culture Care - Madeleine Leininger
Sunrise Enabler - a cultural assessment tool
Developed in 1950's, Published in 1980's
Helps nurses plan culturally appropriate care by stating that as a nurse, you will encounter different cultures
Culture 101
Awareness - willingness to understand that there are different groups and to study them
Diversity - variety within and between cultures
increases chances of miscommunication
Amount of family involvement varies by culture
Competence = appreciation + acceptance + respect + communication
Emic - an insider's perspective
Etic- an outsider's perspective
Equality - evenly splitting resources between everyone
Equity - obtaining highest level for everyone by providing what needed to each person
Notes on using interpreters
use simple non-medical language
be mindful of body language and gestures
document who your interpreter is
Disparities - discrepancies in health outcomes in different populations, particularly with vulnerable populations
How to decrease them
advocate for patient
teachback
interpreters
connect patients to communal resources and case managers
address implicit bias
Culture = behaviors that vary by group
impacts lifestyle and how the perceive/receive healthcare
LGBTQIA+ are at higher risk for depression, obesity, and PTSD
Self-Concept
Self-Concept 101
Self-concept - what a person THINKS of themselves as a whole
Experience can change both self-concept and self-esteem
Self-esteem - what a person FEELS about themselves, stabilizes in adolescence
unique
dynamic
subjective
evolving
shapes identity and relationships
Factors of Influence
Roger's Theory
Self-image - how a person views their physical/genetic traits
Self-concept
Ideal-self
Emotional Intelligence (5 Competencies)
Self-regulation
Motivation
Empathy
Social Skills
Self-awareness = reflection + introspection + objective viewpoint
Self-awareness
Body image
Self-efficacy
Culture
Role Performance/Expectation
Erik Erikson's Theory
Trust vs Mistrust (Birth to 1 yr)
Autonomy vs Shame (1-3yrs)
Initiative vs Guilt (3-6yrs)
Industry vs Inferiority (6-12yrs)
Identity vs Role Confusion (12-19yrs)
Intimacy vs Isolation (20-45yrs)
Generativity vs Stagnation (45-65yrs)
Integrity vs Despair (65+yrs)
Identity
Formation - understanding of oneself within cultural and familial context, a lifelong process
Stressors
Body image
ED's
anxiety
depression
Self-esteen
comparisons
internal criticism
abuse/trauma
unmet expectations
Role performance
challenges
role conflicts
Nursing Role: promote positive self-concept by using a holistic care approach
Stages of Growth
Infancy - birth-1yr, rapid growth + object permanence
Toddlerhood - 1-3yrs, temper tantrums + self-assertion
Childhood - 3-11yrs, social development
Adolescence - 11-19yrs, puberty, social development, identity development
Adulthood - 20+yrs, Early, Middle, + Late
Vital Signs
Vital Signs 101
provide a baseline
identifies trends and changes in client's condition
guides treatment decisions
Order of blood flow
R side of heart
lungs
L side of heart
body
Repeat!
Blood Pressure - measures the force of blood in interior vessel walls
Systolic - max pressure when heart contracts
Diastolic - min pressure when heart relaxes
Stages of Hypertension
Elevated = 120-129/<80
Stage 1 = 130-139/ 80-89
Stage 2 = 140+/90+
Crisis = 180+/ 120+
Interventions
healthy lifestyle = diet + exercise
medications (diuretics and beta blockers)
Hypotension = <90/ <60, causes perfusion of oxygen issues
Symptoms
dizzinesss/fainting
nausea
blurred vision
increased pulse
fatigue
Interventions
increase fluids
lay down
reevaluate meds
client instruction about handling dizziness and safe falls
slow position changes
avoid extreme temperatures
raise legs
Pulse - rhythmic dilation of arteries + pulsation of blood flow upon heart contraction
Normal = 60-100bpm
Factors of Variation
position
age
activity
health
body temperature
Grading Pulses
+2 = normal
+3 = increased/ strong
+1 = weak
+4 = bounding
0 = dead
Tachycardia (bpm > 100)
Causes
Exercise
Anxiety
Medications
Stimulants
Electrical Heart Abnormalities - that's me!!
can be symptomatic or asymptomatic
Bradycardia (bpm < 60)
Causes
Fitness - can be asymptomatic for these people
Congenital Heart Abnormalities
Heart Failure
Heart Muscle Tissue Damage
Hypothyroidism
Symptoms
Dizziness
Fatigue
Shortness of Breath
Chest Pain
Confusion
Pulse deficit = apical - radial
Temperature = heat produced - heat lost
Normal = 96.8 - 100.4, Average 98.6
Hyperthermia
Usually caused by infection
Symptoms
flushed face
diaphoresis
hot to the touch
tachycardia
increased RR
Interventions
fluids
remove excess clothing
antipyretics
antibiotics/antivirals
cool the environment
tepid bath
Causes of Loss/Gain of Body Heat
conduction - direct contact with a surface
convection - air currents
evaporation - sweat
radiation - proximity to a surface
Respiratory Rate (RR)
Normal = 12-20 bpm
Tachypnea (>20 bpm)
Causes
activity
anxiety
pain
health problems
Symptoms
dizziness
tingling in hands
Bradypnea (<12 bpm)
Causes
health conditions
opioids
sedatives
Symptoms
dizziness
fatigue
weakness
confusion
impaired coordination
Oxygen Saturation - estimated amount of oxygen bound to hemoglobin
Normal = 95 - 100%
Causes of hypoxia include health conditions
Symptoms of Hypoxia
decrease in alertness
confusion
Capillary refill should be 2 seconds or less
Pain
Pain 101
Duration
Acute < 6 months
Chronic > 6 months and can be continuous or intermittent
Factors Influencing Perception
culture
family
support systems
gender - women are better at hiding pain
age
environment
past experience
anxiety
health conditions
Client has the right to quality pain control and should be involved at every step
Pain is caused by a stimulus that causes the sensors to release chemicals to excite the PNS, travels through PNS to spine and to brain
Patients with chronic pain might have very specific requests
Types of Pain
Nociceptive
somatic = musculoskeletal
visceral
Neuropathic
Referred
Radiating
Pain Assessment
Subjective
PQRTSU
Chronology
Associated phenomena
Objective
vital signs
initial increase in BP and HR
severe pain shows decrease in BP and HR
tension
pallor
nausea/vomitting
fainting
withdrawal from stimuli
grimacing
restlessness
guarding
Pain Scales
Numeric - rates from 0-10
0 = no pain
1-3 = mild pain
4-7 = moderate pain
8-10 = severe pain
Visual
Wong-Baker FACES - includes six pictures of a face and the patient picks a face
Always subjective
Establish a comfort goal
Use one of the tools to assess
Assessment Steps
1) Pain Scale
2/3) Subjective and Objective Data
Intervention
Nonpharmacological
positioning
cutaneous stimulation/massage/acupuncture/touch/acupressure
heat/cold
hypnosis
Electronic stimulating unit
distraction
Pharmacological
Opioids - first line of treatment moderate to severe pain
morphine
codeine
oxycodone
hydromorphone
methadone
meperidine
Nonopiods - OTC meds like NSAIDS or aceteminophen
Adjuvant Analgesics - drugs that are used for off-label pain treatment
antidepressants
anticonvulsants
corticosteroids
bisphosphonates
Patient-Controlled Analgesia - allows pt to control the when part but not the dose, can provide feedback on treatment effectiveness
Fluid, Electrolyte, and Acid-Base Regulation (Acid-Base Regulation is on the next unit)
Electrolytes - a mineral that conducts electricity
Potassium (normal: 3.5 - 5.0 mEq/L)
Very much INTRACELLULAR
Potassium = HEART bc it's a muscle, and Nerve
Hypokalemia
Causes
not enough dietary potassium
diuretics
penicillin
laxatives/ diarrhea/ vomiting
can lead to metabolic alkalosis
Symptoms
weakness
cardiac arrhythmia
constipation
fatigue
decreased reflexes
Hyperkalemia
Symptoms
cardiac arrhythmia
death
muscle weakness
numbness/tingling
Critical Values
< 3 in adults, < 2.5 pediatrics
NO > 10-20 mEq/hr
Sodium (normal: 136-145 mEq/L)
Nerve and muscle function
BP regulation
Sodium = Neurological + (Fluid Balance = where water goes, sodium follows)
Hyponatremia
Causes
thiazide diuretics
diarrhea/vomiting
excessive water intake
alcohol intake
liver cirrhosis
heart failure
kidney disorders
large burns/wounds
Symptoms
Mild
malaise
nausea
Severe
twitching
seizures
coma + death
decreased LOC
Moderate
lethary
irritable
restlessness
confusion
Hypernatremia
Causes
dehydration
kidney disease
diabetes
Symptoms - see Hyponatremia
confusion
lethargy
Calcium (normal: 9.0-10.5 mg/dL)
Calcium = Bones + Messengers
Nerve and muscle function by acting as a messenger
Hypocalcemia
Causes
Hypoparathyroidsm
hypothyroidism
hydrogen blockers
menopause
vitamin D deficiency
renal disease
sepsis
laxatives
steroids
loop diuretics
multiple blood transfusions
Symptoms
Trousseau's/Chvostek’s sign - involuntary muscle spasms (cramps/leg spasms
numbness/tingling - even in the mouth
confusion
lethargy
personality changes
seizures
depression
How to Assess: Trousseau's/Chvostek’s Sign
Hypercalcemia
Causes
Hyperparathyroidism
Magnesium (normal: 1.3 - 2.1 mg/dL)
Nerve and muscle function
Blood pressure + glucose
Magnesium = GI Symptoms
Hypomagnesemia
Causes
Chron's disease
medications
low dietary intake/poor absorption
Celiac diseases
vomitting/diarrhea
alcohol
Type 2 diabetes
burns
Symptoms
nausea/vomiting
decreased appetite
paralysis
respiratory depression
bradycardia
Bones
Can be replaced orally or with IV
Roles of an Electrolyte
Fluid Balance
pH regulation (pH = 7.35-7.45)
H+ and CO2 = acid
Moving nutrients and Waste
Function of muscles, heart, nerves, and brain
Causes of Imbalance
Dehydration
Overhydration
Medications (like diuretics)
Heart Hx
Kidney Disorders
Liver Disorders
Incorrect IV fluids/feedings
CMP = comprehensive metabolic panel, BMP = basic metabolic panel
Fluid Regulation
Dehydration - lack of WATER only
50-66% water content per human
Symptoms
oliguria or anuria
thirst signal originates in hypothalamus and travels to pituitary gland
a mechanism to conserve water
pituitary gland secretes vasopressin (ADH)
ADH stimulates kidneys to excrete less urine
dry mouth
dry skin
headache
tachycardia
Most water is intracellular
Sensible fluid loss - fluid loss we can measure
Hypovolemia - decreased FLUID or BLOOD in the body
Causes
sweating excessively
large burns
diuretics
inadequate fluid intake
increased urination
Kidney disease
Congestive heart failure
Symptoms (in order)
1) mucosal membrane dryness
2) increased HR and BP
3) Vasoconstriction
4) When Untreated
cyanosis
change in LOC
chest pain/tightness/pressure
palpitations
anuria
tachycardia
tachypnea
decrease BP
weak pulse
5) Hypovolemic Shock - when more than 20% of fluids are lost
0) Regular Dehydration Symptoms
Treatment = fluid replacement (blood or isotonic saline or lactated ringers)
IV Rehydration
Tonicity
Hypertonic - makes H2O move out of the cells
Hypotonic - make H2O move into the cells
Isotonic - does not cause any movement
IV Tips
torniquet
find juicy distal vein
stab!
Techniques
ultrasound
Transillumination - for babies
Central Lines (PICC and CVAD) go into superior vena cava)
tight infection control/SURGICAL ASEPSIS
Used long-term
Peripheral IV (PIV) - short term, 2-4 days
Tunnel cuffed catheter - permanent catheter, no sharps near it!
Embolism
Symptoms
chest pain
shortness of breath
Treatment
reverse Trendelenburg position
Lay on the left
Blood Transfusions
Whole blood = WBC + RBC + platelets + plasma
pRBC's = packed red blood cells, most common, does not increase volume a lot
Plasma = albumin + clotting factors
platelets are used for bleeders
universal donor = O-
universal receiver = AB+
components can be used individually
autologous - giving your own blood to yourself, donated ahead of time
Requirements
stay with the patient for first 15 mins from when blood actually hits the vein
consent
baseline vitals
double check with second nurse as witness (compatibility, order, and volume)
Have 2 IV's ready to go
18-20 gauge bore
document continuous vitals
Adverse RXN Steps
1) stop the transfusion
2) Infuse ONLY 0.9% NaCl
3) Send blood back to blood bank for investigation
Adverse RXN Symptoms
chills/fever
chest/flank/back pain
shortness of breath
change in vital signs
rash
urinary changes
nausea/vomitting
jaundice
urinary changes
Oliguria - Decreased urine
Urine Specific Gravity = 1.005 - 1.030
Hypervolemia = fluid overload
Causes
kidney diseases
end stage liver failure
lung disease
heart conditions
overwhelming amount of fluids
Treatment = diuretics 1st
raise bed, give oxygen, and restrict fluids 2nd