Exam 1 Intro

observed outcome of critical thinking and decision making

separates professional nurses from technicians or other assistive personnel (AP)

the ability to think in a systematic anf logical manner with openness to question and reflect on the reasoning process

the knowledge that you are accountable for your decisions, actions, and critical thinking
responsible for correctly performing nursing care activities based on standards of practice

important for you to admit to any limitations in your knowledge and skill
admit what they do not know and try to find the knowledge needed to make proper decisions

beleif in ones self, ones judgement, ones psychomotor skills, and possesion of knowledge

youlearn to consider wide range of ideas and concepts before making a judgement
not limited to what you learn in school but become open-minded to new concepts and interventions

deals with situations justly
do not let bias or prejudice affect your decisions

is desirable, particularly when result is postive outcome
take risks when trying different way to solve problems
willingness to take risks, without causing harm to patient, comes from experience w similar clinical problems

misses few details when assessing a patient, considering care options and resources, or decisions about nursing interventions

determined to find elective soultions to patient care problems
esp important when problems remain unresovled or recur

original thinking
find solutions outside the standard routines of care while stillfollowing standards of practice

ask "why" as you gather and analyze pt information, data patterns appear that are not always clear

question and test their own knowledge and beliefs
builds trust from coworkers

in assessment phase
pt verbal description of their health problems
can come from family memebers, includes pain
includes feelings, perceptions, and self-reported symptoms

in assessment phase
finding results from direct observation
vitals, lab values
apply critical thinking to interpret findings

direct care measures -> in front of pt, ambulation, would care
indirect care measures -> done away from pt, lab work, document
independent nursing interventions -> nurse initiates it, can do without provider orders like pt education, giving bath
dependent interventions (collaborative) -> ordered by helath care provider, collab with someone else, PRN meds, standing orders
other provider interventions

no social media
no financial status
no SSN
no divers license
has to be encrypted!
DO WANT TO KNOW OCCUPATIONAL STATUS

close computer and don't use your phone
follow HIPPA

distract or redirect
sitter
bed alarm
shower wrap over IV

yellow

purple

under bed lighting at night
lock all wheels on bed and pt wheelchairs

dim lighting, area rugs
psychosocial -> do they live alone
hot water heater set above 130 degrees F
medications in pill containter or original container
keep flammable items 3 ft away from space heater
unplug small appliances when not in use
fridge only plugged into outlet

Specific
Meaasurable
Attainable
Realistic
Timing

stay with them
call for help
assess pt
report to health care provider

any plugs that don't have 3 prongs
MUST HAVE 3 prongs

R = resuce and remove pt in immediate danger
A = active the alarm
C = confine fire by closing door and windows
E = extinguish the fire using appropriate extinguisher if possible

no advice
give empathy not sympathy

open-ended

stop

you don't give it to them and you document pt refused meds and why

interview techniques -> different communication techniques
observation -> verbal and nonverbal
open-ended questions -> very pt centered
direct closed-ended questions
leading questions -> "it seems to me it is bothering you a lot. is that correct?
probing
interpreting

includes pt teaching
discharge or with each shift

identify pt with 2 identifiers
3 MAR checks

first STOP med admin
assess pt
contact the provider and fill out SBAR

sublingual = under tongue
buccal = inside cheek

apply topical meds to the skin by painting or spreading the med over an area, applying moist dressings, soaking body part in solution, or giving medicated baths
on skin
hydrocortizone cream or nitroglycern

breath in
if you give pt inhaliation med make sure you clear gunk out with suction b4

blow nose b4 give meds

eye drops

right drug
right dose
right route
right time
right patient
right documentation
right indication

injection

snap off ampule neck
aspirate medication intosyringe using filter needle
replace filter needle with an appropriate size needle or needless device
administer injection
green = filter needle don't inject pt

if dry, use solvent or diluent as needed
inject air into vial
label multidose vials after mixing
refridgerate remaining doses if needed

0.5 - 1.5 mL
5/8ths inch at 45 degree angle or 1/2 inch at 90 degree angle
sites = anterior thigh, 2 inches from umbilicus, outer posterier aspect of upper arms, upper behind

3 mL z-track method
1 inch to 1 1/2 inch at 90 degrees
sites = ventrogluteal, vastus lateralis, and deltoid (max 2mL)

nurse is asking what technique is best for SQ injections
picking the location of an injection

looking up how to dress a wound instead of determining on your own

comprehensive baseline

5/8ths inch at 5-15 degree angle
max 0.5 mL
skin-testing sites = inner forearm and upper back
use tuberculin or small hypodermic syringe

contains objective & subjective data, you’re collecting the data & you always assess first!!!!

this is interpretive data and you are basically figuring out the problems and what could be possible influences

you are creating outcomes based on SMART

ou are carrying out your nursing care plan (examples- ambulating, giving pain meds)

did your patient meet goals? (Example- checking pain 30 mins after giving a pain medication)

use a chemical propellant to. push the medication out of inhaler and require the pt to apply approximately 5-10 lbs of pressure to the top of the canister to administer the medication

comparison of data with another source like primary (patient) or secondary (family or labs)
validation helps determines if more data is needed

IV
IM
SQ
Oral
Topical

patient-centered interview = conducted during a nursing history
periodic assessment = conducted during ongoing contact with patients
physical examination = conducted during a nursing hisotry and at any time a patient presents a symptom

time management = do I have enough time
equipment = do I have all the equipment i need
personnel = do I need help from someone else
environemnt = is it clean and sterile
patient = do they understand or have any questions

reassess

discharge and send home
pt education