Clinical Companion for Fundamentals of Nursing - E-Book , livre ebook

Clinical Companion for Fundamentals of Nursing
Active Learning for Collaborative Practice
First Edition
Barbara L. Yoost, MSN, RN, CNS, CNE, ANEF
Assistant Professor, Division of Nursing, Notre Dame College
Lynne R. Crawford, MSN, RN, MBA, CNE
Retired Faculty, College of Nursing, Kent State University

Subject Matter Expert
Veronica “Ronnie” Peterson, BA RN, BSN, MS
Manager of Clinical Support, University of Wisconsin Medical Foundation
Adjunct Clinical Instructor, University of Wisconsin School of Nursing, Madison, Wisconsin
Table of Contents
Cover image
Contents
Title page
Copyright
Preface
UNIT I: Nursing Basics
Unit I: Nursing Basics
Chapter 1: Nursing and Professional Practice
ANA Code of Ethics
Maslow’s Hierarchy of Needs
The Health Belief Model
Nursing Specialties
Nursing Organizations
ANA Standards of Practice
Nursing Practice Act
The Future of Nursing
National Patient Safety Goals
The Three a s of Health Literacy
Chapter 2: Values, Beliefs, and Caring
Behaviors that Demonstrate Caring
Chapter 3: Communication
Steps in the Communication Process
Reasons We Communicate With Patients
Developing Effective Communication
Develop Your Voice
Developing Good Listening Skills
Special Communication Considerations
Chapter 4: Critical Thinking in Nursing
Critical Thinking Components
Critical Thinking in Nursing Practice
UNIT II: Nursing Process
Unit II: Nursing Process
Chapter 5: Introduction to the Nursing Process
Components of the Nursing Process
Characteristics of the Nursing Process
Chapter 6: Assessment
Methods of Patient Assessment
Interviewing Strategies
The Patient Interview
Functional Assessment
Cultural Assessment
Spiritual Assessment
Physical Assessment
Assessment Techniques
Chapter 7: Nursing Diagnosis
Types of Nursing Diagnoses
The Nursing Diagnostic Process
Chapter 8: Planning
Goal Criteria
Individualizing Patient Care
Development of a Patient Care Plan
Patient Care Plan Components
Prioritization of Patient Needs
Critical Pathways
Chapter 9: Implementation and Evaluation
Direct/Indirect Care
Types of Interventions
The Evaluation Process
Safe Practice Alerts!
UNIT III: Nursing Practice
Unit III: Nursing Practice
Chapter 10: Documentation, Electronic Health Records, and Reporting
Charting
Components of Documentation
Documentation Formats
Documentation Forms
Unacceptable Abbreviations
Prefixes
Suffixes
Body Fluids
Body Substances and Chemicals
Colors
Medical Symbols
Body Regions
Body Cavities
Directions and Planes
Elements of a Good Hand-off Report
Change-of-Shift Report
Chapter 11: Ethical and Legal Considerations
The Patient’s Chart (Paper Chart)
Electronic Medical Record (EMR)
HIPAA Considerations
Professional Nursing Behavior
Informed Consent
Advance Directives
Chapter 12: Leadership and Management
Principles of Delegation
The Five Rights of Delegation
Chapter 13: Health Literacy and Patient Education
Health Literacy
Expected Patient Competencies for Health Literacy: Healthy People 2020
Assessment Questions Related to Patient Education
Chapter 14: Health and Wellness
Levels of Prevention
Safe Practice Alerts!
UNIT IV: Nursing Assessment
UNIT IV: Nursing Assessment
Chapter 15: Human Development
Age and Developmental Stages
Milestones During the First Year
Physical Changes Associated with Normal Aging
Health Considerations by Age Group
Safe Practice Alerts!
Chapter 16: Vital Signs
Situations That Require Vital Sign Assessment
Vital Sign Ranges Across the Life Span
Time Required for Reading Thermometers
Temperature Conversion Calculation
Factors Affecting Temperature
Average Normal Adult Temperature Ranges
Clinical Signs of Fever
Fever Patterns
Thermal Disorders
Hypothermia Stages
Normal Pulse Ranges With Averages
Rhythm
Volume and Amplitude of Peripheral Pulses
Factors Affecting Pulse Rate
Pulse Sites
Heart Sounds
Normal Respiration Ranges
Respiratory Assessment
Abnormal Patterns of Breathing
Adventitious Breath Sounds
Normal Blood Pressure Averages (Systolic/Diastolic)
Hypertension
Orthostatic or Postural Changes
Korotkoff Sounds
Cardiac Terminology
Blood Pressure Cuff
Pain: The Fifth Vital Sign
Pain Assessment
Pain Rating Scales
Nonpharmacologic Treatment of Pain
Chronic Nonmalignant Pain: Nursing Care Guidelines
Cranial Nerves: Function and Assessment
Safe Practice Alerts!
Chapter 17: Ethnicity and Cultural Assessment
Cultural Terminology
Leininger’s Steps for Delivery of Culturally Competent Care
Chapter 18: Spiritual Health
Common Spiritual Beliefs That Affect Health Care
Chapter 19: Public Health, Community-Based, and Home Health Care
Definitions
Vulnerable Populations
Assessment Questions Related to Community Health
Chapter 20: Human Sexuality
Sexual Health Characteristics Across the Life Span
Sexual Health Assessment Questions
Contraception Options
Potential Side Effects of Medications
Terms Related to Gender Identity
Common Sexually Transmitted Diseases
Safe Practice Alert!
UNIT V: Nursing Principles
Unit V: Nursing Principles
Chapter 21: Safety
Life Span Safety Considerations
Poison Safety
Fire Safety
Common Medical Emergencies
Seizure Terminology
Care of the Patient With Seizures
Special Patient Situations
Syncope and Common Causes
Morse Fall Scale Assessment
Fall Prevention at the Hospital
Restraints
How to Tie a Quick-Release (POSEY) Tie
Fall Prevention at Home
Home Safety Assessment
Safe Practice Alerts!
Chapter 22: Asepsis and Infection Control
Terminology
Stages of Infection
The Inflammatory Process
Chain of Infection
Types of Immunity
Antibody Functions
Infection Assessment
Types of Precautions
Prevention of Spread of Resistant Pathogens
Antibiotic-Resistant Pathogens
MRSA and VRE
Common Infectious Diseases
Influenza
Comparison: Cold, Influenza, and Pneumonia
Home Care Considerations to Prevent Infection
Safe Practice Alerts!
Chapter 23: Hygiene and Patient Care
Indications for Hand Hygiene
Reasons for Bathing
Tips on Giving a Bed Bath
A Massage Technique
Contact Lens Care
Safe Practice Alerts!
Chapter 24: Activity, Immobility, and Safe Movement
Effects of Immobility
Assessment Questions Related to Mobility
Exercise
Home Care Assessment
General Principles of Body Mechanics
Joint Movements
Range of Motion
Patient Positioning
Safe Practice Alerts!
Chapter 25: Skin Integrity and Wound Care
Common Integumentary Abnormalities
Common Skin Color Abnormalities
Nail Bed Assessment
Common Foot Problems
Orthopedic Devices
CMS Assessment
Health Assessment Questions
The Healing Process
Phases of Wound Healing
Factors Affecting Wound Healing
Complications of Wound Healing
Classification of Pressure Ulcers
Sites of Pressure Ulcers
Braden Scale
Safe Practice Alerts!
Chapter 26: Nutrition
Types of Diets
Therapeutic Diets
Nutrients
Vitamins
Minerals
Malnutrition
Safe Practice Alerts!
Chapter 27: Cognitive and Sensory Alterations
Sensory Deficits
Sensory Aids and Interventions
Assessing Patient’s Sensory Aids
Comparison of Delirium and Dementia
Depression
Safe Practice Alerts!
Chapter 28: Stress and Coping
Fight-or-Flight Response
Defense Mechanisms
Stress Management Techniques
Safe Practice Alert!
Chapter 29: Sleep
Patient’s Sleep History
Sleep Disorders
Factors Causing Sleep Alterations
Medications That Affect Sleep
Safe Practice Alerts!
UNIT VI: Nursing Care
UNIT VI: Nursing Care
Chapter 30: Diagnostic Testing
Common Diagnostic Tests
Laboratory Values
Blood Collection Tubes
Assessment Questions Related to Diagnostic Tests
Nursing Care for Diagnostic Testing
Home Care Considerations for Diagnostic Testing
Home Care Considerations for Glucose Testing
Chapter 31: Medication Administration
Medication Terminology
Equivalent Measures
Calculating iv drip rates
Medication Safety
Assessment Questions Related to Medications
Home Care Related to Medications
Vitamins and Adverse Effects
Cultural Factors Related to Medications
Chapter 32: Perioperative Nursing Care
Common Surgical Procedures
Nursing Care Before Surgery
Presurgical Checklist
Preoperative Surgical Scrubs
Nursing Care After Surgery
Assessment of Body Systems After Surgery
Cough and Deep Breathing Technique
Pulmonary Emboli
Types of Dressing Changes
Chapter 33: Oxygenation and Tissue Perfusion
Normal Breath Sounds
Signs and Symptoms of Hyperventilation, Hypoventilation, and Hypoxia
Abnormal and Adventitious Sounds
Assessment of Respiratory Status
Tests for Abnormal Breath Sounds
Pulmonary Function Tests
Oxygen Therapy
Abnormal Breathing Patterns
Common Lung Disorders
Assessment Questions Related to Oxygen Therapy
Home Care Related to Breathing
Components of a Smoking Cessation Program
Chapter 34: Fluid, Electrolyte, and Acid-Base Balance
Fluid Volume Deficit
Fluid Volume Excess
Edema Grading Scale
Average Daily Fluid Intake and Output
Common Intravenous Solutions
Red Blood Cell Transfusion
Electrolyte Imbalances
Arterial Blood Gas Results With Acid–Base Imbalances
Acid–Base Imbalances
Chapter 35: Bowel Elimination
Fecal Characteristics
Altered Bowel Elimination Patterns
Foods that Affect Bowel Elimination Patterns
Types of Cathartics
Benefits of Fiber
Antidiarrheal Medications
Types of Enemas
Types of Ostomies
Cultural Factors Related to Bowel Elimination
Disability Factors Related to Bowel Elimination
Assessment Questions Related to Bowel Elimination
Home Care Related to Bowel Function
Chapter 36: Urinary Elimination
Urine Characteristics
Altered Urinary Patterns
Urinary Incontinence
Reasons for Urinary Catheters