nursing foundations study guide - exam 1

8/8/2019 Nursing Foundations Study Guide - Exam 1

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Nursing Foundations

Exam 1 Study Guide

Define:

Health A state of complete physical, mental, and social well-being, not merely the absence of

disease or infirmity.

Wellness State of optimal health within an individual maximizes human potential, moves

toward integration of human functioning, has greater self-awareness and self-satisfaction, andtakes responsibility for health.

y Is a lifestyley A responsibility and choicey A process of living that integrates mind, body, and spirity Calls for awareness in everything done, thought, felt or believed that has an impact on

health

y State of health falls on a continuum from high level wellness to death. Levelsfluctuate daily and the goal is to move toward high level wellness.

Homeostasis Balance or equilibrium among the physiologic, psychological, socio-cultural,

intellectual, and spiritual needs of the body; maintenance of internal environment.

Illness Behaviors Certain behaviors are found to influence the individuals health or illness.

These include:

y Smoking - the most preventable cause of death in the United Statesy Substance abuse - premature death, accidents, crime, and lost productivityy Lack of physical fitnessy Lack of emotional fitnessy Poor nutritional behaviors


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Communication

Communication three parts of the communication process - giving, receiving, and interpreting

of information through any of the five senses by two or more interacting people.

Five components of Effective Communication:

y Sendery Messagey Medium or channely Receivery Interaction

Therapeutic Communication communication that is purposeful and goal-directed, creating a

beneficial outcome for the client. (Helpful and healing for one or more of the participants).

Therapeutic Communication Techniques strategies to encourage clients to express their

thoughts and feelings more effectively.

Barriers to Effective Communication:

y Empty reassurance (ex. Everything is going to be okay)y Changing the subjecty Using clichsy Imposing your ideas or valuesy Disapproving or judging the clienty Voicing personal experiences

Nursing Procedures

Bathing Five types of cleansing baths are shower, tub, self-help or assisted bed bath,

complete bed bath, and partial bath. (pg 734-735)

y Assess the client preferences about bathingy Prepare environmenty Wash hands, apply glovesy Lower side rail on the side closest to you, position client in a comfortable position close

to the side near youy Place bath blanket over top sheet, remove top sheet from under bath blanket, and

remove clients gown

y Fill wash basin 2/3 full and test water temperature, then allow client to test water forcomfort

y Wet washcloth, wring it out, make a bath mitten with the washcloth


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y Wash the face and ask the client about preference for using soap on the face; then use aseparate corner of the washcloth/mitten for each eye, wiping from inner to outer

canthus, then wash neck and ears. Rinse and dry well.

y Wash arms, forearms, and hands; then wash axilla. Rinse and dry well. Apply deodorantor powder if desired.

y Wash chest and abdomen. Place bath towel lengthwise over chest and abdomen, thenfold bath blanket to waist. Lift bath blanket and wash chest in circular motions. Wash

skin fold under the female clients breasts by lifting each breast. Leave chest covered

with dry towel and fold bath blanket down to suprapubic area.Wash abdomen including

the umbilicus and other skin folds carefully. Rinse and dry all skin areas well. Replace

bath blanket over chest and abdomen.

y Wash legs and feet. Rinse leg and dry well. Clean soles, interdigits, and toes. Carefullyexamine the foot and between the digits of a diabetic for pressure sores or ulcerations.

Rinse foot and dry well.

y Change water as needed. Remember to change gloves when emptying water basin.Then apply new gloves.

y Assist client into side-lying or prone position facing away from you.y Wash back and buttocks using long, firm strokes. Rinse and dry well. Give back rub and

apply lotion.

y Perineal care: (pg 738) Assist client to supine position; perform perineal care. Applyclean gown.

y Remove gloves and wash hands.

Ambulating a client (pg 702)

y First assess the strength, endurance, mobility, and orientation of the clienty Assist with client ambulation, gait belts provide client safety when ambulatingy Continually evaluate the clients strength and endurance during the entire ambulation

process.

y Determine the clients most recent activity level and tolerance to evaluate the clientscurrent ambulatory ability.

y Assess the clients current status, including vital signs, fatigue, pain, and medications toidentify conditions that might adversely affect ambulation.

y Evaluate the clients environment for safety. (ex water on the floor, adequate lighting)y Be certain the clients shoes or non-skid slippers are safe to walk in and that he/she has

adequate covering for warmth and privacy.

y While the client is ambulating, assess his/her gait and bearing. Determines how wellhe/she is tolerating the activity and allows detection of hypotension, diaphoresis,

breathlessness, or weakness.

y After ambulation assess the clients ability to recover from the activity, includingexhaustion, energy, and recovery times.


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Hand-washing hygiene hand-washing is the rubbing together of all surfaces and crevices of

the hands using a soap or chemical and water. Hand-washing is a component of all types of

isolation precautions and is the most basic and effective infection-control measure to prevent

and control the transmission of infectious agents.

The three essential elements of hand-washing are soap or chemical, water, and friction. Frictionis the most important element of the trio because it physically removes soil and transient flora.

Hand-washing is performed after arriving at work, before leaving work, between client

contacts, after removing gloves, when hands are visibly soiled, before eating, after excretion of

body waste (urination and defecation), after contact with body fluids, before and after

performing invasive procedures, and after handling contaminated equipment.

The exact duration of time required for hand-washing depends on the circumstances. A

washing time of 10-15 seconds is recommended to remove transient flora from the hands.

High-risk areas, such as nurseries, usually require about a minimum two-minute hand wash.

Soiled hands usually require more time.

y Most basic aspect of standard precautiony Prevents cross-contamination of different body sites on one clienty May be necessary between tasks and procedures on that clienty Friction is most important, then rinsingy Anti-bacterial gels are not effective until your hands are DRY

CPR Review Quick-Study CPRChart.

Question: Why must a dependent patient be turned and repositioned every two hours?

Answer: Clients who cannot reposition themselves must be repositioned at least every two

hours and more frequently if they are uncomfortable, incontinent, or have poor circulation,

fragile skin, decreased cognition, decreased sensation, or poor nutritional status. (pg 713)

Proper turning and positioning allows the health care provider to make clients as comfortable

as possible, prevent contractures and pressure sores, make portions of the clients body

available for treatment or procedures, and allows clients greater access to their environment.

There are three key concepts to remember when positioning a client:

y Pressurey Frictiony Skin shear


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Review: Theory Syllabus

Question: What is included in each level ofMaslows theory?

Answer: Five levels of Human Needs

y Physiologicalo Breathing, food, water, sex, sleep, homeostasis, excretion

y Safety (and security)o Safety needs include both physical and emotional aspectso Security of body, of employment, of resources, of morality, of the family, of

health, of property

y Love and belongingo Friendship, family, and sexual intimacy

y Esteemo Self-esteem, confidence, achievement, respect of others, respect by others

y Self-actualizationo Morality, creativity, spontaneity, problem-solving, lack of prejudice, acceptance

of facts

Question: Explain how Maslows hierarchy of human needs helps prioritize care?

Answer: Many nursing programs use Maslows hierarchy of needs as a basis for planning the

care of clients. This ensures that basic physiological needs as well as the other needs areassessed and addressed in individualized care plans.

Most basic needs (physiological) are met first. Care plans then address issues higher up on the

hierarchy.

Question: What are the ADLs (Activities ofDaily Living)

Answer: ADLs include grooming and hygiene, dressing, eating, mobility, and toileting. IADLs

(Instrumental Activities ofDaily Living) include higher level tasks such as using the telephone,

household and money management, and driving a car.

The goal is to teach clients to manage their own care when there is limited potential for

regaining total independence.


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Question: Why should restraints be a last resort?

Answer: Although restraints are intended to keep clients safe, more people die from restraints

than accidents.

Question: What are common hospital safety hazards?

Answer: Safety is associated with health promotion and illness prevention. Hygiene is a part of

safety in that proper hygiene protects the client against disease.

Environmental hazards in a hospital setting are related to falls, lighting, obstacles, the

bathroom, fire, electricity, radiation, poisoning, and noise pollution.

Accidents in the health care setting include:

y Client behavior accidents clients behavior or actions

y Therapeutic procedure accidents delivery of nursing or medical interventions (ex.wrong patient)

y Equipment accidents malfunction, improper use of medical equipmentMOST ARE TOTALLY PREVENTABLE!

Factors affecting safety:

y Agey Lifestyle and occupationy Sensory and perceptual changes Acronym: M.A.L.E.S.y Mobilityy Emotional state

Question: What can reduce the risk of falls (hospital)?

Answer: Prevent falls by

y Properly supervising clientsy Orienting client to the environmenty Providing ambulatory aids (gait belts)y Keeping personal items in easy reachy Keeping beds in lowest position, side rails upy Using rubber mats in showers and tubsy Having adequate lighting


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Question: How should you identify a client?

Answer:

y Checking the clients ID band ensures that the correct person receives carey C

lient identification is essential before rendering any care

Question: What is the highest priority when providing patient care?

Answer: Safety is the first priority when providing patient care. Yours is first!!

nursing foundations study guide - exam 1

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