quality improvement

teamwork/collaboration

patient-centered care

informatics

evidence-based practice

safety

find problem in health setting

plan to improve

evaluate

Nurse is continually w/ pt.

DR. is not.

Have to have opinions & recommendations

focus on pt.

cultures, values, etc.

Must take into consideration what they want.

Technology

xrays, computer systems, etc etc.

What do pts base their rating of hospital on?

(not intentionally)

PAIN.

If pain in managed/manageable, pt is more likely to respond positively to their treatment.

12 Basic Human needs

In order!

Oxygenation

Fluid/Electrolytes

Safety

Elimination

Nutrition

Rest & Activity

Sensory

Comfort

Sexuality

Spirituality

Human Interaction

Learning

12 basic human needs

pneumonic

OFSENRSCSSHL

Our fellow students enter nursing realizing some classes sound simple; how laughable.

FALSE.

Oxygenation also includes proper circulation in pts.

What is included in electrolytes?

Provide examples.

Na

Cl

Ca

Mg

K

-examples provided in class: Na= v8 juice, chips. K=banana

both bowel & bladder.

Biophysical.

Rest & Activity

-what's involved?

rest- good mood.

activity- work on weight bearing activities. build muscle/reinforce bones. water activities, etc.

allow for periods of rest and recovery

Older adults ADAPT TO DISFUNCTIONS.

They set the problem as a norm b/c they don't want to be a bother.

Ex. hearing- they attribute their hearing loss to old age and will not acknowledge it to a health professional.

Older adults (as well as any other age) need to be able to tell the difference between hot/cold, sharp/dull, etc.

This avoids possible injuries (burns, cuts, etc.)

acute- pain needs to be resolved

chronic- long term. Happy when pain is at 3 or less. (on pain numbers scale)

FALSE.

Older adults are at more of a risk because they are new to the "dating scene" (spouses dying). Not accustomed to using condoms (raised on idea of only having "relations" with one person). Also more of a risk of UTIs.

Continue to maintain values, habits, & behavior in old age.

*Assess normal habits before stating there is a problem.

FALSE.

Don't have cognitive decline. May take longer but do not lose function. Must be motivated to learn!

motivation

 relevance

 environment

readiness

 feedback (+)

involvement

support

Assess

Diagnose

Plan

Implement

Evaluate

What do we do with data during assessment?

(4 things)

collect

organize

validate

document

Signs- objective. What we can see; tangible; can't interpret.

Symptoms- subjective. Pt reports. Ex. nausea, headache.

Can't measure.

Which step are interventions in?

nursing process

Planning.

FALSE.

Interventions should be pt centered.

Develop individualized care plan.

Prioritization of Human Needs

(levels)

Level 1: Oxygenation

2: fluid & electrolytes, nutrition, safety, elimination

3: rest & activity, sensory, comfort

4: learning, human interaction, sexuality, spirituality

to present new problem, to prevent worsening of existing problem.

INDIVIDUALIZE!

SMART

what does it stand for and what does it relate to?

Specific

Measurable

Attainable

Reasonable

Timed

--Used as guidelines for GOALS.

short term: completed during shift that day

long term: 7 days or more. done by discharge (ex.)

FALSE.

Care plans are fluid. They are constantly modified because the situation is always changing.

Basic needs & ADL's

Teaching

@ least 1 med

Evalutation

Did pt meet goals and to what extent? Continue, modify, or terminate plan of care?

speech

mood

cleanliness

ambulation

obvious abnormalities

Color (cyanosis, jaundice, erythema)

Moist/dry

Edema

Lesions

Integrity

+1: up to 1/4"

+2: 1/4" to 1/2"

+3: 1/2" to 1"

+4: ≥ 1"

Extremeties- feet, hands.

if laying flat, butt.

Bath is a good time to inspect/assess.

Symmetrical moles

Malignant will be uneven and discolored.

Temperature

texture

moisture

turgor

cleanliness

equal distribution

quantity

quality

Color

shape

thickness

texture

lesions

Nails: Color

what to assess for

blanch test

check capillary refill-- <3sec.

Nails: Shape

What to assess for

clubbing (result of chronic hypoxia)

-> greater than 180 ° angle.

caused by long term lack of O2

Nails: Thickness

what to assess for

fungal infection?

Aging, trauma, bloodflow?

pallor-- oral mucosa (needs to be pink & moist)

yello/brown or ash gray skin indicated decreased blood flow

Hx disorders, vision loss, trauma/surgery

difficulty w/ vision

glasses or contact lenses

last vision check

Squinting, head tilting, moving to see object better

Abnormalities: cloudiness, lack of red reflex, strabismus, drainage (chronic tearing), redness, yellow sclera

past accidents, injuries (especially head), or surgeries

Diet deficiencies (vit. A deficiency can cause eye dryness, keratomalacia, and blindness)

Environmental exposures: computer overuse (screen), allergen exposure

Ear & Hearing: Assessment

Hx hearing disorders/hearing loss, trauma/surgery

exposure to environmental noise

earaches or infections

vertigo (dizzy)

feeling of fullness in ear

hearing aid use

method of cleaning ears

Conductive: physical obstruction of sound wave transmission

Sensorneural: cochlear defect, 8th cranial nerve, brain abnormality, or from loud noises/music

Mixed: profound hearing loss

Nose & Sinus: Assessment

Hx of disorders or trauma/surgery

discharge (color, etc)

frequent &/or severe colds

sinus pain

nasal obstruction

nosebleeds (amt & frequency)

allergies/hay fever

Changes in sense of smell

assess for deformities, tumors, nasal flaring, redness, drainage, bleeding, polyps

Hx disorders or trauma/surgery

pain

frequent sore throats

bleeding gums

toothache

lesions in mouth or on tongue

dysphagia

horseness or voice changes

altered taste

dentures/ prosthetics

last dental checkup