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NUR 2115 Exam 2 Study Guide, Study Guides, Projects, Research of Nursing

California Career SchoolNursing

A study guide for Exam 2 of the NUR 2115 course at Rasmussen College. It covers the nursing process, diagnosis, implementation, and evaluation. It also includes NANDA nursing diagnoses for oxygenation and gas exchange, infection, inflammation, and thermoregulation. Additionally, it covers vocabulary related to oxygenation and gas exchange, proper method for auscultation of the lungs, and the importance of coughing. examples and explanations to help students understand the concepts better.

Typology: Study Guides, Projects, Research

2022/2023

Available from 09/10/2022

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NUR 2115 Exam 2 Study Guide Correctly Uploaded
2022/2023(Verified for Your Studies)
NUR 2115 Exam 2 Study Guide
Fundamentals of Nu r sing St udy
Gu i de for Ex a m 2 By M. I o rio
Ra s mussen Colleg e Summe r ‘18
Mo d ule 4 – Clinica l Judge m ent and Nu r sing P r ocess
➢
Th e nursi ng proc e ss cons ists of 5 steps.
1. Ass e ssment if the fi rst ste p. Data is collec ted dur i ng this
st ep so tha t the r e st of the nursin g proces s may b e
ef f icient ly car r ied ou t.
•
Nu rsing a ssessme nts focu s on the p atient ’ s respo nses to
he alth pr o blems , not the data
ba sed fro m the pa t ient’s diagno s is.
•
In itial A ssessme nt – pre f ormed by the nurse s hortly
af ter the patien t is adm itted to a faci lity. T his
as s essme n t typi cally f ollows the gu i deline s set b y the
st andards of the f acili t y and es tablish es a ba s eline
da tabase for the pat ient. A l lows t h e nurs e to gathe r
he alth da ta and identi fy heal th pro b lems t o set
pr ioriti e s for f urther focus e d a ssessme nts.
•
Fo cused A s sessme n t – Nur s e gathe rs data about a proble m
th a t has a lready b een
id e ntifi e d.
✓
Wh at are y our si g ns and s ympto m s?
✓
Wh en did t hey fi r st star t ?
✓
Wh at make s it bet ter/wo r se?
•
Em ergenc y Assess ment – D o ne whe n a psy c hologi cal or
ph ysiolo g ical cr i sis occ urs to ide ntify w hat lif e -
th reateni ng probl ems are occurr i ng.
•
Ti me-Laps e d Asse s sment - This is a sched u led ass essment
to co mpare a patien t’s cur r ent
co n ditio n with th e ir bas eline co ndition . Most r esiden t s
in l o ng-ter m healt h care h ave tim e -lapse d asses s ments
sc h edule d perio d ically .
•
Pr ioriti e s to set d u ring as sessme n t inclu de heal t h
or i entat i on, dev elopme n tal stag e,
cu lture a n d the p a tients need for n ursing .
•
Al w ays va lidate a s sessme nt data before using it for
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2022/2023(Verified for Your Studies)

Fundamentals of Nursing Study

Guide for Exam 2 By M. Iorio

Rasmussen College Summer ‘

Module 4 – Clinical Judgement and Nursing Process ➢ The nursing process consists of 5 steps.

  1. Assessment if the first step. Data is collected during this step so that the rest of the nursing process may be efficiently carried out. - Nursing assessments focus on the patient’s responses to health problems, not the data based from the patient’s diagnosis. - Initial Assessment – preformed by the nurse shortly after the patient is admitted to a facility. This assessment typically follows the guidelines set by the standards of the facility and establishes a baseline database for the patient. Allows the nurse to gather health data and identify health problems to set priorities for further focused assessments. - Focused Assessment – Nurse gathers data about a problem that has already been identified. ✓ What are your signs and symptoms? ✓ When did they first start? ✓ What makes it better/worse? - Emergency Assessment – Done when a psychological or physiological crisis occurs to identify what life- threatening problems are occurring. - Time-Lapsed Assessment - This is a scheduled assessment to compare a patient’s current condition with their baseline condition. Most residents in long-term health care have time-lapsed assessments scheduled periodically. - Priorities to set during assessment include health orientation, developmental stage, culture and the patients need for nursing. - Always validate assessment data before using it for

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diagnosing.

  1. Diagnosis is the second step. Data gathered from the assessment are utilized to form a judgement about the patients’ health. The purposes of diagnosing are: ✓ Identify how a person, group, community, responds to an actual or potential health and life process. ✓ Identify the factors that contribute to or cause the health problems. ✓ Identify resources and strengths that that person or community can draw on to help resolve or prevent the problem.
  • During the diagnosing step of the nursing process the nurse clarifies the exact nature of the patient’s problems and risks that must be addressed to achieve the patient’s outcome of care. Conclusions made during this step affects selected interventions and the entire plan of care.
  • NANDA – North American Nursing Diagnosis Association. ✓ “Nursing diagnosis is a clinical judgement about personal, family or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis of sel ecting nursing interventions to achieve outcomes for which the nurse is accountable.”
  • Nursing diagnoses are written to describe patient problems that the nurse can treat independently.

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patient outcomes, select necessary interventions to achieve these outcomes and communicate the plan of care among the patient, family and other staff involved in the patients care.

  • Initial planning – preformed by the nurse along with the initial assessment. A comprehensive plan that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care.
  • Ongoing planning – This planning is completed each time the nurse interacts with the patient. Data is collected to ensure the plan or care is kept up to date to resolve identified health problems, manage risk factors and promote function. During ongoing planning nursing diagnosis may be clarified or modified and new planning may be implemented.
  • Discharge planning – Ensures that the patient and family outcomes and needs are met as the patient moves from a care setting to home, or from on care setting to another. Education about continuity of care at home or in another health care setting is provided by the nurse upon discharge.
  • Care planning may include standardized templates set on the EHR, concept mapping, ISBARR during patient hand-off, and clinical pathways.
  1. Intervention/Implementation is the fourth step in which the nurse carries out actions that were set for the patient in the planning step of the nursing process.
  • During implementation the nurse carries out the plan, assesses how the patient is responding to it, documents and modifies it to achieve the outcome. Be sure your interventions are supported by evidence-based practice.

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  • Assess, re-asses and record.
  • During implementation determine the patients new/continuing need for nursing, promote their self- care and assist the patient and their family to achieve health outcomes.
  1. Evaluation includes the nurse and the patient and/or their family working together to determine how well the patient outcomes have been achieved. Is there a need for a new plan of care? Continuity of care? Or has the outcome been successfully met?
  • There are five elements to evaluation. ✓ Identify evaluative standards and criteria. ✓ Collect data to determine if the standards and criteria were met. ✓ Interpret and summarize the findings. ✓ Document your nursing judgement. ✓ Terminate, continue or modify your plan of care.
  • There are different outcomes that are set for the patient to meet, these are psychomotor outcomes, cognitive outcomes, affective outcomes, and physiologic outcomes.
  • Evaluative outcomes are documented as: Outcome met/partially met/not met. If the outcome is only partially met plan of care should continue, if the outcome is not at all met the plan of care should be modified.
  • Patient variables (willingness to follow plan of care), nursing variables (burnout) and health care system variables (staffing) all affect how the outcome is met.
  • Quality assurance is a part of the evaluation of the patients care. (HCAHPS) ➢ NANDA nursing diagnoses for oxygenation and gas exchange, infection, inflammation and thermoregulation along with tissue integrity.
  • Impaired gas exchange
  • Risk for/ Ineffective peripheral tissue perfusion
  • Risk for infection
  • Ineffective airway clearance
  • Risk for/ impaired skin integrity
  • Risk for thermal injury
  • Hypothermia
  • Hyperthermia

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  • Bradypnea – A decrease in respiratory rate. Occurs with some pathologic conditions or an increase in IC pressure. Central nervous system depressants such as opioids can cause respiratory depression.
  • Cyanosis – Bluish or grayish discoloration of the skin in response to inadequate oxygenation. (Pg.
  • Anemia – A decrease in the amount of red blood cells. Results in insufficient hemoglobin and hypoxemia.
  • Pallor – Paleness of the skin often resulting from a decrease in the amount of circulating blood or hemoglobin in relation to inadequate oxygenation of the body tissues. (Pg. 639) ➢ A normal respiratory rate is 12-20 breaths per minute. Or one respiration for every four heartbeats. Pulse ox readings should range between 95-100%. Values <90% are considered abnormal and indicate inadequate oxygenation. The patient should be investigated for potential hypoxia. ➢ Proper method for auscultation of the lungs. (Pg. 650)
  • Equipment required is a stethoscope, sphygmomanometer, and a quiet environment.
  • Have patient sitting upright or in semi-fowlers position. (About 30 degrees)
  • Place the warmed diaphragm of the stethoscope over the thoracis landmarks and auscultate breath sounds in a sequential pattern. Ask the patient to breathe slowly and deeply through their open mouth. (NO NOSE)
  • Document breath sounds.

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➢ Types of adventitious lung sounds: (Pg. 652)

  • Crackles – Bubbling, crackling or popping sounds. Opening of deflated small airways; air passing through fluid in the airways.

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  • Pursed-lip breathing can assist in reducing dyspnea and feelings of panic. Pursed lip breathing effectively slows and prolongs expiration which is thought to prevent the collapse of small airways.
  • Pursed-lip breathing helps the patient to control the rate and depth of respiration.
  • While sitting up-right the patient inhales through the nose while counting to three, then exhales slowly against pursed lips while counting to seven. ➢ Importance of coughing.
  • Coughing is a cleansing mechanism of the body, it helps clear the airway of secretions and other debris.
  • Phlegm and sputum are respiratory secretions that are expelled by coughing. If these secretions stay in the lungs an infection may occur.
  • Expectorants are drugs that facilitate removal of secretions by reducing their viscosity so that it is easier to expel by coughing.

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  • Teaching a patient to cough voluntarily is an important aspect preoperative and postoperative care.
  • Coughing is more effective when used with deep breathing. ➢ Importance of deep breathing.
  • Deep-breathing exercises can be used to overcome hyperventilation.
  • Instruct the patient to make each breath deep enough to move the bottom ribs inspiring through the nose and expiring though the mouth.
  • Should be done hourly while awake four times daily. ➢ Normal respiratory system regarding gas exchange ➢ Signs and symptoms of respiratory distress
  • Desaturated oxygen (Pg. 1414)
  • Altered mental status
  • Anxiety, hyperventilation
  • Use of accessory muscles ➢ Medications that can cause respiratory depression (<9 breaths/minute)
  • Anesthesia
  • Antibiotic in the mycin group may cause respiratory paralysis when used in conjunction with muscle relaxants.
  • Opioids.
  • Any narcotic or sedative. ➢ Signs and symptoms of hypoxia
  • Dyspnea
  • Elevated blood pressure
  • Increased respiratory and pulse rates
  • Drowsiness Module 6 – Infection, Inflammation and Thermoregulation ➢ Infectious agents are:
  • Bacteria – Can be gram positive, gram negative, aerobic or anaerobic. The treatment is an antibacterial and the type used depends on the classification of the organism.
  • Virus – Not treatable by antibacterial medications. These are the smallest of the microorganisms, antivirals can be given during the prodromal stage of illness to shorten the length of infection.
  • Fungi – are plant-like organisms such as molds and yeasts. Present in the soil, air and water. May be treated with antifungal medications, however many fungi are resistant. These include ringworm, yeast infections and tinea

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➢ Microorganisms typically reside in a host, which is environmentally stable. If the host’s immune resistance is in a weakened state, the microorganism will thrive and result in infection. Hospital patients are susceptible hosts. The susceptibility of the host depends on the integrity of skin and mucous membranes, pH balance, WBCs, age, sex, race, heredity, immunizations, level of fatigue, nutritional status, stress level and use of invasive medical devices. ➢ An organism’s potential to produce disease in a person depends on the organism’s virulence (potential for the organism to cause disease), the persons immunity to that organism, the number of organisms present and the length/ intimacy of contact between that person and the organism. ➢ Stages of infection

  • Incubation period – The interval between the pathogen’s invasion of the body and the appearance of symptoms of infection. Length of this time varies depending on the infectious agent that is present.
  • Prodromal Stage – Stage in which the infected person is considered infectious , early signs and symptoms may be present but are often non -specified. Symptoms that are limited are referred to as localized symptoms. Symptoms manifested throughout entire body are considered systemic symptoms.
  • Full stage of illness – Specific signs and symptoms are present. May be localized or systems, the length of this stage is determined by the infectious agent and the hosts susceptibility.
  • Convalescent period – The period of recovery from the infection, this stage may vary according to the severity of the infection and the patient’s condition. The signs and symptoms disappear, and a normal state of health is returned. ➢ Signs and symptoms of infection are:
  • Redness
  • Heat
  • Swelling
  • Pain
  • Loss of function ➢ Lab data indicative of infection includes:
  • Elevated WBC
  • Elevated temperature ➢ Body temperature may be measured using multiple devices.

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  • Electronic and digital thermometers measure oral, rectal or axillary temperature in 1-60 seconds.
  • Tympanic thermometers detect heat given on by the tympanic membrane. Inserted into the ear with the end pointing towards the nose of the patient. Take 1-3 seconds. Accuracy is debated.
  • Disposable single-use thermometers register temperature within seconds. Eliminate danger of cross-infection.
  • Temporal artery thermometers capture heat emitted over the temporal artery. One of the more accurate choices.
  • Automated monitoring devices measure body temperature, pulse, respirations, and blood pressure all at once. Typically found with patients requiring frequent monitoring. ➢ Methods of obtaining a patient’s temperature vary by route and device used. Routes for collecting data about a patient’s temperature are oral, tympanic, axillary and rectal.
  • When assessing oral temp wait 15-30 minutes if patient has eaten, smoked, is chewing gum or drinking hot or cold fluids. Readings should range from 96.4F- 99.5F
  • When assessing tympanic membrane temperature do not touch the thermometer to the skin. This method should not be used in patients with ear drainage, ear pain of ear infection. The readings are similar to oral temperature readings.
  • When assessing an axillary temperature keep in mind readings are approximately one degree lower than oral.

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proliferation. ✓ During this phase the patient has a mildly elevated body temperature and an increase in plasma WBCs.

  • Proliferation phase ✓ Lasts several weeks. Granulation tissue forms the foundation for scar tissue development. ✓ Collagen synthesis and accumulation continue based on the size of the wound. ✓ Connective tissue forms over time. ✓ During this phase adequate nutrition and oxygenation are important patient care considerations.
  • Maturation phase ✓ The final stage of healing begins about 3 weeks after the injury occurrence. ✓ Collagen is remodeled and strengthened. ✓ A scar forms. ➢ Vocabulary to know:
  • Dehiscence – The partial or total separation of wound layers because of excessive stress on wounds that are not healed.
  • Evisceration – A complication of wound dehiscence. The wound completely separates with a protrusion of viscera through the incisional area. ➢ Stages of pressure ulcers

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  • Stage 1 – Skin is intact but reddened and non-blanchable. Localized area typically over a bony prominence. The affected area may be cooler, warmer, painful or soft to the touch.
  • Stage 2 – Partial thickness loss of dermis. Visually a shallow open area.
  • Stage 3 – Full thickness loss of tissue. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. May include undermining or tunneling.
  • Stage 4 – Full thickness loss of tissue with bone, tendon or muscle being visible. Sough or eschar may be present, this wound often includes undermining or tunneling.
  • Unstageable pressure ulcers – The base of the ulcer is covered by slough or eschar in the wound bed and must be removed before the wound can properly be staged. Stable eschar should not be removed. ➢ Know the different types of precautions to take concerning PPE.
  • Protective precaution – Protect patient who are immunocompromised such as neutropenic patients. ✓ Wear a mask, gown and gloves. ✓ Ensure your patient wears a mask ✓ No plants or flowers are allowed in the room ✓ Keep the patient’s door closed ✓ Hand hygiene.
  • Standard precaution – Minimum infection prevention for all patients. ✓ Hand hygiene
  • Isolation precaution – Any patient who is on any precaution other than standard precautions should be isolation to prevent spread of the disease or germs.
  • Droplet precaution – Used for diseases or germs that are spread by coughing or sneezing such as the flu. ✓ Wear a gown, gloves and an appropriate mask. ✓ Hand hygiene
  • Airborne precaution – Used for diseases that are spread through the air such as TB or chickenpox. ✓ Ensure patient is in a negative air pressure room. ✓ Wear a fit tested N-95 mask, gloves and a gown. ✓ Ensure the patient wears a mask. ✓ Hand hygiene
  • Contact precaution – Used for infections, diseases or germs that may be spread by touching the patient or items in the patient’s room. ✓ Wear a gown and gloves

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What are the normal values for a patients vital signs?

  • Blood pressure <120/<
  • Pulse 60-100 bpm
  • Respirations 12-20 per minute
  • Temperature 97.7-99.5 depending on method.
  • Oxygen saturation 95%-100% What are Ericksons Psychosocial Developmental Stages?
  • Trust vs. Mistrust (birth-18mo)
    • Important events include feeding.
    • Caregivers provide care = trust; no care = mistrust.
  • Autonomy vs. Shame and Doubt (2-3yrs)
    • Important events include toilet training.
    • Develop a sense of control and independence. Failure results in shame and doubt.
  • Initiative vs. Guilt (3-5yrs)
    • Important event is exploration.
    • Begin asserting control over the environment. When too much control is exerted disapproval leads to guilt.
  • Industry vs. Inferiority (6-11yrs)
    • Important even is school.
    • Coping with social and academic events. Failure results in inferiority.
  • Identity vs. Role Confusion (12-18yrs)
    • Important event is social relationships
    • Develop a sense of self and personal identity. Failure results in role confusion.
  • Intimacy vs. Isolation (19-40yrs)
    • Important event is relationships.
    • Need to form intimate relationships with others. Failure results in loneliness.
  • Generativity vs. Stagnation (40-65yrs)
    • Important event is work and parenthood.
    • Need to create and nurture. Success results in feelings of accomplishment. Failure results in shallow involvement in the world.
  • Ego Integrity vs. Despair (65yrs-death)
    • Important event is reflection on life.
    • Need to look back on life and feel fulfilled. Success leads to feelings of wisdom. Failure leads to regret and despair. Know that the Braden scale is used for wound risk assessment. Know the difference between types of wounds (i.e primary, secondary, tertiary)