NUR 111 - Final Exam - All Modules with correct answers 2024

Pre-interactive phase of a nurse-patient relationship - answer-Begins before the nurse's first contact w/the patient. The nurse's role is self-exploration and gathering data about the patient. Introductory or orientation phase of a nurse-patient relationship - answer-When the nurse & client first meet. The nurse seeks to find out why the client sought help. The tasks during this phase are to establish trust, understanding, acceptance, open communication and formulate a contract with the patient. The working phase of a nurse-patient relationship - answer-Where most of the therapeutic work is carried out. The nurse & patient explore stressors and promote the development of insight in the patient by linking perceptions, thoughts, feelings and actions. Termination phase of a nurse-patient relationship - answer-The most difficult, a summarizing process, discuss termination and allow time for patient adjustment to independence. Also a time to exchange feelings and memories and to mutually evaluate the patients progress and goal attainment. Communication skills needed by a nurse during the working phase of a nurse-patient relationship - answer-Empathetic listening and responding, respect, genuineness, concreteness (holding the patient accountable), reflecting, paraphrasing, clarifying and confronting. Elements of the communication process - answer-Communication involves the sender, aka the source encoder. Encoding involves the selection of signs or symbols to transmit the message, such as which language to use or how to arrange the words. The message is the second component and is conveyed via a channel (i.e. talking face to face or writing a message). The third component is the receiver who must listen or observe. The receiver is also the decoder and must perceive what message the sender intended. The fourth component is the response or feedback which allows the sender to correct or reword a message Verbal communication - answer-Uses the spoken or written word and includes noticing things such as pace of speech, intonation (tone of voice), simplicity, clarity (saying precisely what is meant) and brevity (using the fewest words possible), timing & relevance, adaptability, credibility and humor. Non-verbal communication - answer-Uses other forms such as gestures, facial expression and touch known as body language which is less controlled than verbal behavior because it reinforces or contradicts what is said. Body language requires a systematic assessment of the overall physical appearance, posture, gait (how the patient walks/moves), facial expressions and gestures. Patients with autism have a hard time decoding non-verbal behavior. Patients w/communication problems rely on non-verbal communication such as sign language or reading lips for deaf/hoh, finger taps, eye blinks or object boards for expressive aphasia. Factors that influence the communication process - answer-Development, gender, values & perceptions, personal space, territoriality, roles and relationships, environment, congruence and attitudes. Development - age of the client. Gender - males vs. females communicate in very different ways. Territoriality - patients claiming items in the hospital room as their own. Roles and relationships - nursing student & instructor, client & primary care provider or parent & child. Environment - must be comfortable, temperature extremes or excessive noise can be barriers. Congruence - when the verbal & nonverbal aspects of the communication match. Communicating w/children - answer-For young children, they need plenty of time to be able to verbalize their thoughts. Adults should ask simple questions, provide simple answers and use one-step directions due to the child's short attention span. Avoid sudden or rapid advances, threatening gestures or prolonged eye contact. Communicate through transitional objects such as a stuffed animal. Speak in a quiet, unhurried, confident tone. For school age children, talk to the child at eye level and try to include the child in the conversation if the parents or caretakers are present. Be honest and offer a choice only when one exists. Communicating w/adolescents - answer-Allow time to build rapport. Be honest and offer a choice only when one exists. Use active listening skills and be non-judgmental or non-reactive if the adolescent makes disturbing comments. Communicating w/elderly patients - answer-Ensure the client is using assistive devices like glasses or hearing aids and that they are in working order. Use communication aids such as communication boards, or pictures, when possible. Speak in short, simple sentences and focus on one subject at a time. Always face the client because coming up behind someone can be frightening. Include family & friends in conversation. Reminisce with the client to maintain memory connections, enhance self-identity & self-esteem. When verbal & non-verbal communication is incongruent, believe the non-verbal. Find out what is important and has meaning to the client and try to maintain these things as much as possible. Primary group - answer-Small & intimate. Personal, spontaneous, sentimental, cooperative and inclusive. Communicate primarily face to face. Support each other in times of stress. Secondary groups - answer-Larger and less personal, less sentimental. Once group goal has been achieved the group usually disbands. Members don't have to know each other. Communication is not always face to face. Member expectations administered through impersonal controls & external restraints (i.e. NUR 111 class) Formal groups - answer-Rigidity of purpose, rules & authority comes from above, managers are symbol of authority, power (i.e. corporations) Semi-formal groups - answer-Prestige, status often accrued from membership (i.e. country clubs) Informal groups - answer-Not bound by rules & regulations, ideal testing ground for leadership techniques Functions of groups - answer-• Socialization • Support • Task completion • Camaraderie • Information • Normative function - Boy Scouts, Church groups • Empowerment - support group or education group, AA or NA • Governance - Political Features of an effective group - answer-• Goal accomplishment • Maintaining cohesion • Develop & modify structure to improve effectiveness Physical conditions that influence groups - answer-• Privacy • Comfort of room and seating • Ability of everyone to have eye contact • Environmental noise level • Temperature • Lighting Group dynamics - answer-1. Commitment 2. Decision making ability, effective decisions are made when group listens to members ideas, members satisfied with their participation, problem solving is facilitated, group atmosphere is positive, time is well used, using expertise of members, members committed to decisions and responsible for implementation of decisions 3. Member behavior & their different roles, information givers/seekers, opinion givers, coordinator, initiator-contributor, energizer and evaluator 4. Cohesiveness - the attachment that members feel for each other & the group 5. Power - to encourage cooperation & collaboration in accomplishing a task Roles of group members - answer-• Information givers/seekers • Opinion givers • Coordinators • Initiator - contributor • Energizer • Evaluator Can also be maladaptive roles such as monopolize, recognition seeker, playboy/girl, help seeker, aggressor, groupthink, scapegoat, or blocker. The 5 stages of Tuckman's group development - answer-1) Forming 2) Storming 3) Norming 4) Performing 5) Adjourning If you lose a member of a group, you regress to a lesser stage Forming stage of Tuckman's group development - answer-Infant - task/purpose defined Storming stage of Tuckman's group development - answer-Teenager - important issues addressed - conflict surfaces Norming stage of Tuckman's group development - answer-Young adult - group norms are evident, leadership is shared, starting to be productive Performing stage of Tuckman's group development - answer-Middle adulthood - high productivity, flexibility, interdependence, loyalty to group (like a sports team) Adjourning stage of Tuckman's group development - answer-Elderly - task ended, accomplishments recognized, reminisce about past, group breaks up Communication within the healthcare team - answer-• Understanding of anxiety and how it affects communication • Understanding of the process that occurs within groups • Always safety geared & mindful of patient confidentiality • Standard reporting like ISBARR decreases miscommunications Purposes of documentation in healthcare - answer-Communication, planning care, research, education, auditing healthcare agencies, reimbursement, legal documentation & health care analysis The nurse-patient relationship as a basis for communication - answer-Communication with the patient should be all about them and their needs. Keep the focus on the patient, not ourselves, and try to redirect conversations back to the patient for their assessment. Focus 100% of your attention on the patient you're with at the moment. Provide client education (the more they know, the better they can make decisions). Most importantly is help the patient become better at helping themselves. Helpful, goal directed/oriented, unconditional positive regard, confidentiality, integrity, genuineness, empathy. Communication skills needed to develop therapeutic relationships - answer-Active listening, caring, developing trust, respect, showing a genuine interest, confidentiality, advocacy, unconditional positive regard, do not make promises, being truthful (even when it isn't what they want to hear), empathy (putting yourself in someone else's shoes), being aware of cultural differences that may affect meaning and understanding and finally, know your role & your limitations. Various types of documentation reports - answer-Source oriented reporting, problem oriented medical record (POMR) - using SOAP or SOAPIER (subjective, objective, assessment, plan, implement, evaluate, reassess) format, Problems, interventions, evaluation (PIE), focus charting, charting by exception (CBE) - what we use in EPIC, electronic documentation, flow charts Reporting methods used in nursing - answer-Telephone communication, incident of occurrence reports, hands-off communication, change of shift report and the SBAR (situation, background, assessment & recommendation) reporting. ISBARR reporting - answer-• I - Introduction & stating your role in the patient's care • S - Situation describes what is happening at the present time which is prompting you to contact doctor • B - Background includes relevant background info • A - Assessment to provide as much information & content about the patient as possible. • R - Recommendation • R - Repeat the order given by the doctor. Characteristics of quality documentation - answer-(FACTO) Factual, Accurate, Complete, Timely (or Current) and Organized. Evidence-based practice - answer-Made up of clinical expertise, research evidence and patient values & circumstances. A problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician's expertise and patient preference and values in making decisions about the patient's care. It utilizes knowledge that is already known along w/studies completed by others to make a practical decision policy. It requires that the nurse base nursing practice on the best and most applicable evidence from clinical research studies. The nurse should also be alert to clinical issues that warrant investigation and develop a research problem about the issue. Nursing research - answer-A systematic and strict scientific process that test a hypothesis about health-related conditions and the processes of nursing care. It is a way to identify new knowledge, improve professional education and practice, and use resources effectively. Nursing clinical research - answer-Seeks answers to questions that will ultimately improve client care Quantitative research - answer-Uses precise measurement to collect data and to analyze a description of the resulting findings Qualitative research - answer-Investigates a question through narrative data that explores the subjective experiences of human beings Best practice - answer-Nursing practices that are based on the best evidence available from nursing research (YOU DO BETTER WHEN YOU KNOW BETTER) - may be referred to as the standard The role of the ADN nurse in EBP and nursing research - answer-Recognizing problem Collecting data Correlating evidence Categorizing data Documentation Criteria used when evaluating information on the Internet - answer-1) Accuracy - if your page lists the author & institution that published the page & provides a way of contacting them 2) Authority - if your page lists the author credentials and it has a preferred domain (.edu, .gov, .org or .net) 3) Objectivity - accurate info is provided with limited advertising & the info presented is objective 4) Currency - timely, updated regularly, links are also up-to-date 5) Coverage - if you can view the info properly, not limited to fees, technology or software requirements Barriers to evidence-based practice - answer-• Work schedule or demands • Lack of access to technology • Limited knowledge and skills in evaluating evidence • Lack of experience or confidence in promoting EBP • Lack of support from supervisors • Attitudes from staff • Resistance to change The PICOT criteria of developing EBP - answer-P - Population (patients) I - Intervention (for intervention studies only) C - Comparison group O - Outcome of interest T - Time Pain - answer-The most common reason people seek emergency care. It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is perceptual and emotional; a patient can only provide a subjective description of pain. It is a warning of injury, illness or disease. It is described in terms of location, duration, intensity, quality, and etiology. Sleep deprivation - answer-Hinders daily functioning and adversely affects health, contributing to diseases such as diabetes, cardiovascular disease and depression. Mechanisms that regulate sleep - answer-● Biological Rhythms: Daily cycles ● Circadian rhythms - begin to develop at about 6 weeks, by 3-6 months the baby has a regular sleep cycle. Non-REM sleep - answer-Body tissue restoration via · slowed biological functions (decreased HR, RR, BP etc.) · Release of human growth hormone for tissue repair & renewal Divided into four stages. 1.) very light sleep, feeling drowsy and relaxed. Eyes roll from side to side; respiratory and heart rates drop slightly. 2.) light sleep, body processes continue to slow; eyes are generally still. 3 & 4.) Deepest stage of sleep. Sleeper id difficult to arouse, not disturbed by stimuli, skeletal muscles are relaxed, and reflexes are diminished, snoring is most likely to occur in this stage, swallowing and saliva production are reduced. THIS STAGE is essential for restoring energy and releasing growth hormones. NOTE: number of sleep cycles depends on the total amount of time individual spends sleeping. REM sleep - answer-Usually recurs every 90 minutes and last 5-30 minutes. Most dreams take place during REM sleep. Brain is highly active. Levels of acetylcholine and dopamine increase. Ø Necessary for brain tissue restoration Ø Cognitive restoration - memory storage, learning & filtering info from the day's activities Loss of REM sleep leads to... - answer-· Altered mood, motor performance, memory & equilibrium with prolonged sleep deprivation. · Altered immune function occurs with moderate to severe lack of sleep. · Accidents, lost productivity Co-analgesic drugs - answer-Drugs that are used primarily for another purpose but also have some analgesic properties; used to treat pain alone or in combination with other analgesic drugs -antidepressants, anticonvulsants, corticosteroids Nociceptive pain - answer-Pain resulting from external stimuli on an uninjured, fully functioning nervous system (i.e. sunburn or papercut). It is usually temporary. Somatic: · Results from stimuli in the skin, bone, muscle, connective tissue · Localized · Descriptors: Aching; throbbing, Sharp, stabbing, soreness Visceral: · Due to stretch, distention, or inflammation · Solid or hollow organs such as GI tract · Poorly localized; referred · Descriptors: Deep, crampy, pressure, dull, gnawing, squeezing, spasm Neuropathic pain - answer-Caused by nerve malfunction or injury resulting in trauma, disease, chemicals, infections, and tumors. · Abnormal processing of sensory input · Can be acute or chronic · Opioids are NOT first line of treatment · Central & peripheral · Burning, shooting, pins and needles, electricity, numbness, hot, shooting, sensitivity, tingling · Pain with normal touch Acute pain - answer-Protective, has an identifiable cause, has a short duration (usually 30 days to 6 months). It has limited tissue damage and emotional response. It usually resolves with or without treatment after the injury heals. Unrelieved acute pain can lead to chronic pain. Related to "Fight or Flight". Chronic pain - answer-Lasts longer than 6 months and persists beyond expected periods of healing. It is constant or recurring with a mild-to-severe intensity with a gradual onset. It does NOT always have an identifiable cause. It is usually not life-threatening. Associated symptoms include fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, and anger. There is no objective evidence to confirm the existence of chronic pain. Most CP has a very strong neuropathic component because it represents an error in CNS processing of pain signals. Factors relating to children's experience of pain & rest - answer-· Infants are very sensitive to drugs, response to drugs are often intense and prolonged. Absorption is faster than expected. Dosages excreted from the kidneys need to be reduced. · Children as young as 3 can give a description and location of pain. · Toddlers and preschoolers are unable to explain the pain. · Consideration with children and pain: · Children normally have a higher pulse and respiration and a lower BP. · A normal sympathetic response to pain is not always present in children, changes in vital signs may not be a good indicator in children. Factors relating to adult's experience of pain & rest - answer-· Conditions associated with chronic pain are more prevalent in women than men. · 80-90% of fibromyalgia cases are women. · Women are more likely to develop diseases that cause pain, such as osteoarthritis. · Women have a lower pain threshold, and lower pain tolerance than men. · Men are more likely to experience pain from cluster headaches, coronary heart disease and gout. Factors relating to elderly's experience of pain & rest - answer-· Over 80% of older adults have at least one chronic condition associated with pain. · Have a greater likelihood for developing pathological conditions, which are accompanied by pain. · Potentially reduces mobility, ADLs, social activities, and activity tolerance. · Interpreting pain is complicated due to multiple diseases and vague systems. · With aging, muscle mass decreases, body fat increases, H2O decreases. This increases concentration of water-soluble drugs: volume of fat-soluble drugs increases · Poor nutrition resulting low albumin levels. (Protein Bound) · Lower renal and liver function, decreases metabolism and excretion of drugs. Factors relating to different culture's experience of pain & rest - answer-· Clients from stoic cultures rarely vocalize pain through groans or crying and may avoid showing a reaction to pain. They may tolerate a high level of pain without asking for relief. · Client's with expressive cultures routinely moan and scream when faced with pain. They expect others to care for them and relieve the pain. · Culture may affect how a client describes pain. · Culture can affect the methods of treatment the client is willing to undergo. Some believe that pain is punishment or builds character may refuse treatment. · Some cultures prefer to treat pain with herbal supplements and alternative medications. Different pain scales - answer-1) NPASS (Neonatal Pain Assessment & Sedation Scale) - infants less than 2 months old 2) FLACC (Face, Legs, Activity, Cry, Consolability) - non-verbal children over 2 months of age 3) Wong-Baker Faces Scale - patients older than 6 4) Numeric Rating Scale - patients who are awake, alert, able to verbalize or point to a number, understands number concept 5) OLDCARTS (onset, location, duration, characteristics, aggravating, relieving, treatment, severity) Potential consequences of sleep deprivation - answer-Associated with significant cognitive and health problems. It hinders daily functioning and adversely affects health, contributing to difficulty with concentration and memory and contributes to diseases such as diabetes, cardiovascular disease, and depression. Sleep deprivation decreases the ability to perform tasks requiring speed and accuracy and is also linked to an increased risk for motor vehicle crashes. Sleep is also necessary for immune system repair functioning. Addiction - answer-Neurobiologic disease; genetic, psychosocial and environmental factors; 4 C's: impaired Control, Compulsive, Craving, Continued use despite harm Pseudoaddiction - answer-Behaviors that may occur when pain is undertreated; "Clock-watching", frequent visits to ED, hoarding, misusing, aggressive requests for more drugs (drug-seeking behaviors) Tolerance - answer-State of adaptation in which exposure to a drug results in a decrease in one or more of the drug's effects over time Physical dependence - answer-Adaptation manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist; can develop very quickly Withdrawal syndrome - answer-Response when drug is stopped in person with dependence; nausea & vomiting, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions (autonomic nervous system effects) (Note that health care providers can initiate this as above with the administration of an antagonist.) Adverse effects of unrelieved pain - answer-● Changes in vital signs are not reliable over time as body adapts to pain ● Repeated pain experiences may LOWER the pain threshold and contribute to pain syndromes later in life - especially if pain not well managed ● Anxiety, restlessness, fear, powerlessness, poor concentration, fatigue, immobility, decreased immune response... (Any of these also associated with lack of rest?) ● Can significantly alter the individual's quality of life (as well as impacting family & others) In children, physiological consequences of unrelieved pain may include decreased growth and development, decreased immune function, lack of appetite, hypertension, and increased sensitivity to future pain. In adults, unrelieved pain can dramatically reduce the patient's quality of life, decreasing their ability to perform activities of daily living and increasing their dependence on others. It can cause mood, sleep and appetite disturbances; decreased mobility; falls, slow rehabilitation; and altered cognitive functioning. Decreased mobility can lead to DVT, pulmonary embolism, bone fractures and reduced participation in social activities. Acetaminophen dosing - answer-Pediatric Dosage: 10-15 mg/kg/dose every 4-6 hours. Maximum per day: 60-75 mg/kg for children 50 kg. Children 50 kg take adult doses. Max 4 Gm/day currently; Newer recommendations may be decreasing to 2.6 Gm per day because of liver damage incidence. Antidote for morphine - answer-Narcan (naloxone - generic name) Side effects of morphine - answer-Constipation, nausea & vomiting, sedation, pruritus (severe itching), hypotension and urinary retention. Of all the side effects associated with opioids, the most life-threatening is severe respiratory depression. Patients on opioids must be carefully monitored for respiratory depression. Normally, sedation precedes respiratory depression. If respiratory rate is less than 8-10 breaths/minute, wake the patient up. If less than 5 breaths/minute, shake the shit out of them! Types of opioids - answer-Oxycodone, Hydrocodone, Codeine, Morphine, Dilaudid, Fentanyl Ibuprofen dosing - answer-5-10 mg/kg/dose q6h NSAIDs - answer-(aspirin, ibuprofen, naproxen and ketorolac) useful for acute inflammation management such as orthopedic trauma or post-op pain (inhibits prostaglandins) and to treat mild to moderate pain. Can also be used with opioids to treat severe pain. They carry a "black box" warning from the FDA highlighting the risk of serious cardiovascular and GI side effects (bleeding). Will interfere with bone healing if treating for inflammation from broken bone. Upper GI bleeds and ulcers (especially elderly pt's); abdominal pain They have a ceiling effect, meaning once the client consumes a specific dosage, consuming more of the drug will not produce a greater analgesic effect but may increase toxic effects. Gate Control Theory - answer-In addition to the physical aspect of pain, there are emotional & cognitive components. It is theorized that pain impulses travel through an open "gate" and impulses are blocked if the gate is closed. Reticular Activating System (RAS) - answer-Responsible for sleep Sympathetic NS response to pain - answer-Tachypnea, tachycardia, peripheral vasoconstriction, increased blood glucose levels, diaphoresis, increased muscle tension, dilation of pupils, decreased GI mobility Parasympathetic NS response to pain - answer-Pallor, muscle tension, decreased HR & BP, rapid, irregular breathing NC Practice Act - answer-Law that governs the practice of nursing in the state of NC & guides the work of the Board of Nursing; it defines competency & protects the public Patricia Benner's 5 levels of proficiency for nurses - answer-1) Novice 2) Advanced beginner 3) Competent 4) Proficient 5) Expert Patricia Benner's novice nurse - answer-No experience; relies on theory, guidelines and policies; lacks discretionary judgment and focuses energy on task performance. Patricia Benner's advanced beginner nurse - answer-Some task and situational experience, but the focus is the task and rules with little ability to take the complexity of the situation into consideration. Patricia Benner's competent nurse - answer-Actions are viewed in terms of long-term goals and feelings of mastery; the speed and flexibility of the proficient nurse are lacking. Patricia Benner's proficient nurse - answer-Perceives the situation as a whole, rather than in parts; decision making is easier with a focus on the most important attributes and the aspects of the problem. Patricia Benner's expert nurse - answer-Has an intuitive grasp of the situation and readily zeros in on the problem and solution without spending much time problem solving. Culture - answer-The patterns of behavior and thinking that people living in social groups learn, develop & share Multi-culturalism - answer-The many subcultures coexisting within a given society in which no one culture dominates. In a multi-cultural society, human differences are accepted and respected. Culturally competent care - answer-• The ability to apply knowledge, skills to provide high quality care to clients of diverse backgrounds. The American Association of Colleges of Nursing has 5 competencies for providing culturally competent care: 1. Apply knowledge of social and cultural factors that affect nursing 2. Use relevant data sources and best evidence 3. Promote achievement of safe, quality outcomes 4. Advocate for social justice 5. Participate in continuous development • One model of cultural competence is called LEARN: 1. L - listen to the patient's perception of the problem 2. E - explain your perception of the problem and of the treatments ordered by the physician 3. A - acknowledge and discuss the differences and similarities between these 2 perceptions 4. R - review the ordered treatments while remembering the patient's cultural parameters 5. N - negotiate treatment Enculturation - answer-Cultural transmission from adults to children Assimilation - answer-The process of adapting to and integrating characteristics of dominant culture Acculturation - answer-Accepting the majority group's culture as one's own Innate characteristics of diversity - answer-Age, gender, ethnicity, physical attributes and some illnesses (such as hemophilia) Acquired characteristics of diversity - answer-Those that are developed throughout your life through your individual life experiences such as education, skills, manner of dress and personal style, religion, improvement of abilities, political views and some illnesses (such as lung COPD due to smoking) Vulnerable populations (to disease) - answer-Elderly, children, homeless & immigrants Diversity - answer-Variety, differences, unlikeness and dissimilarity (i.e. variety) among people. The Joint Commission's Hospital National Patient Safety Goals - answer-1) Identify patients correctly - use 2 identifiers 2) Get important test results to the right person on time 3) Label all medications before a procedure 4) Take extra care w/patients on blood thinners 5) Records & pass along correct info about a patient's medications 6) Ensure that alarms on medical equipment are heard & responded to on time 7) Infection prevention - wash hands, prevent infection that are difficult to treat, prevent infection of blood from central lines, prevent infection after surgery, prevent UTIs from catheter use 8) Assess which patients are most likely to commit suicide 9) Prevent mistakes in surgery - correct surgery on the correct patient on the correct place on the patient's body, mark place on body where surgery will be done, pause before surgery to make sure a mistake is not being made Safety issues associated with patient's environments - answer-Environmental hazards could include clutter, noise or confusion. The transmission of pathogens could include c. Diff, MRSA or blood borne pathogens. Individual factors include age (young children for accidents, elderly for falling, but for children & elderly - adverse drug effects, incorrect dosage calculations, birth complications, surgical errors, diagnostic errors or risk of infection). Risks in the healthcare environment include being in an unfamiliar environment, HAI's or patients without significant others to help them answer questions or assist them after being discharged, a patient not speaking up or not being included as a full partner in their own care, and new medications. Physical hazards include MVA, poisons, falls, fire, disasters or pollution. Standard precautions - answer-Most importantly hand hygiene and the use of PPE when necessary Hand-off communication - answer-Clear communication, accurate, complete & timely Seizure precautions - answer-1) Loosen restrictive clothing, especially around the neck 2) Stay w/patient 3) Protect head w/padding if a fall occurs & turn patient to the side 4) If seated, lower to floor in a side-lying position 5) Do not attempt to open patient's mouth Fire safety - answer-(RACE) R - Rescue A - Alarm/alert C - Contain the fire E - Extinguish Extinguishing a fire - answer-(PASS) P - Pull pin on extinguisher A - Aim low S - Squeeze the handle S - Sweep from side to side Fall prevention - answer-Assess for individual risk factors such as previous fall, elimination needs (incontinent, high frequency), medication use for high risk meds (antihypertensives, diuretics, anticonvulsants, sedatives, laxatives, psychotropics, hypnotics or opioids), equipment use that could impair mobility such as catheter or IV tubing, is patient mobile, gait & balance - what assistance is needed, is the patient alert & oriented. Use of bed alarms, fall precaution sign outside the patient's door, non-skid socks, centralized video-monitoring which talks to a patient if they try to get out of bed. Chasing Zero - answer-The story of Dennis Quaid's twins who were overdosed twice in one day with heparin because the heparin & heplock vials looked the same. As a result of his campaign, the color on the heparin vial was changed for better identification. 100,000 Lives campaign - answer-Began in 2005 with a goal to eliminate HAI's such as ventilator associated pneumonia, central line related blood stream infections, surgical site infections and catheter associated UTI's. The campaign was updated in 2006 to be the 5 million lives campaign. Culture of safety - answer-• acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations • a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment • encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems • organizational commitment of resources to address safety concerns Safety culture has been defined and can be measured, and poor perceived safety culture has been linked to increased error rates. However, achieving sustained improvements in safety culture can be difficult. Specific measures, such as teamwork training, executive walk rounds, and establishing unit-based safety teams, have been associated with improvements in safety culture measurements and have been linked to lower error rates in some studies. Other methods, such as rapid response teams and structured communication methods such as SBAR, are being widely implemented to help address cultural issues such as rigid hierarchies and communication problems, but their effect on overall safety culture and error rates remains unproven. "Just" culture - answer-focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (eg, slips), at-risk behavior (eg, taking shortcuts), and reckless behavior (eg, ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event. For example, reckless behavior such as refusing to perform a "time-out" prior to surgery would merit punitive action, even if patients were not harmed. For human error (inadvertent action, slip, lapse or mistake) the consequences would be to console, encourage reporting, redesign & remediate. For at-risk behavior, consequences would be to coach, remove the incentives for at-risk behavior and create incentives for healthy behavior, increase situational awareness & remediate). For reckless behavior, punishment, disciplinary action & remediation. The use of restraints - answer-Check them every hour & release from restraints Q2H for bathroom & circulation Normal assessment findings related to sensory-perception across the lifespan - answer-During the developmental stage for infants and children, perception of sensation is critical to the intellectual, social and physical development. Infants recognize the face of mom/caregiver, young children respond to music by singing & dancing, older children interpret visual & auditory signals (i.e. traffic signal to cross the street). For older adults, normal physiological changes put them at higher risk for altered sensory function. Hearing starts to change around age 30. As we age, we experience loss of acuity (sharpness) for high-frequency tones, have difficulty understanding speech, and a decreased pitch discrimination. Low pitched sounds are the easiest to hear. For the eyes, there is a decreased accommodation to near/far which causes the need for glasses around the ages of 40 - 50. The cornea is flatter and thicker, causing astigmatism. Reduced visual fields, increased glare sensitivity, impaired night vision and decreased color discrimination. Glaucoma - answer-Normal w/aging - peripheral vision loss, decreased visual acuity, trouble adapting to darkness, halo effect around lights and if not treated, can eventually lead to blindness. Cataracts - answer-Normal w/aging - blurry, hazy, cloudy or foggy vision, changes in color vision including a reduction in color saturation and brightness, increased glare and/or sensitivity to light (especially driving at night), and difficulty seeing in low light levels. Ways to maintain a safe environment for patients with sensory deficits - answer-Maintain patient safety, reduce patient's anxiety, meet patient's basic needs, increase patient's participation in the environment, attempt to focus the patient's attention back to reality, reduce stimuli in the environment, do not convey belief of the misperceived stimuli - let the patient know you do not hear, see or feel what he/she does, but that you understand it is real to her, assist the patient to identify feelings, offer activities that will help the patient focus on reality instead of the false or distorted perception, or biological intervention with antipsychotic medication is almost always indicated to modify biochemical imbalance/changes. Nursing diagnoses relevant to patients with sensory/perceptual alterations - answer-Hearing: • Impaired verbal communication • Risk of injury • Social isolation Vision • Cataracts o Risk of injury related to visual impairments o Risk of ineffective health maintenance o Decisional conflict - cataract removal • Eye injury o Impaired tissue integrity o Acute pain o Anxiety o Ineffective tissue perfusion - retinal Preventing sensory overload - answer-• Minimize unnecessary light, noise and distraction. Provide dark glasses and earplugs as needed. • Control pain • Introduce yourself by name, and call the patient by their name • Provide orienting clues i.e. clocks, calendars • Provide a private room • Limit visitors • Plan care to allow for uninterrupted periods of rest or sleep • Follow a schedule so patient knows what to expect • Provide new information gradually • Explain tests/procedures ahead of time • Reduce noxious odors • Correct misinterpretations as needed • Assist the patient with stress reducing techniques Preventing sensory deprivation - answer-• Encourage the patient to use eyeglasses and hearing aids if normally used • Address the patient by name and touch the patient if that is not culturally offensive. • Communicate frequently with the patient and maintain meaningful interactions. • Provide a telephone, radio, TV, clock, calendar • Provide pictures, murals etc. • Have family and friends bring flowers/plants • Pet therapy • Increase tactile stimulation i.e. massages, hair care, etc. • Group activities • Puzzles, games to stimulate mental function • Encourage environmental changes i.e. walks, outings, sit near nurses station • Encourage patient to sing, whistle, hum (self-stimulation) Self-concept - answer-How an individual perceives himself (personal traits, characteristics, values, beliefs & behavior). Identity - answer-A combination of the ideal self (who we think we should be), the real self (the perceived true self) and the public self (how we wish to be perceived by others) Body image - answer-An individual's mental picture of his physical self Role performance - answer-The demonstration of behaviors or actions associated with a given role Self-esteem - answer-An individual's opinion of himself - the individual's judgments and opinions about the perceived characteristics of the self-concept; whether or not an individual likes the characteristics of himself. Erikson's Theory of Development - answer- Erikson's Trust vs. mistrust - answer-Birth - 18 months; development of basic trust & sense of security Erikson's Autonomy vs. shame & doubt - answer-18 months - 3 years; basic awareness of independence, autonomy & self-control Erikson's Initiative vs. guilt - answer-3 - 5 years; emergence of basic sense of self-guidance & self-discipline Erikson's industry vs. inferiority - answer-6 - 12 years; confidence in ability to attain goals, initial formation of identity apart from nuclear family, successful peer group integration Erikson's Identity vs. role confusion - answer-12 - 20 years; formation of strong sense of identity as an individual & as a member of society, identification of personal & occupational goals Erikson's intimacy vs. isolation - answer-18 - 25 years; development of healthy romantic relationships without compromising personal identity Erikson's generativity vs. stagnation - answer-25 - 65 years; productivity & creativity, desire to care for and guide offspring Erikson's integrity vs. despair - answer-65 years - death; sense of peace concerning life experiences, life choices framed within a meaningful context, development of wisdom Factors that influence self-concept - answer-Introversion or extroversion, emotional stability, risk taking behaviors, high or low sense mastery, health status, age, socioeconomic status. Common stressors that affect self-concept & self-esteem - answer-Mobility (immobility have lower self-esteem), family (the ability to fulfill your roles & responsibilities), mood and affect, and ethics (your moral standards and who you are as a person affect how you treat people), and education. Care-giver role strain - answer-The difficulties assuming and functioning in the caregiver role as well as associated alterations in the caregiver's emotional and physical health that can occur when care demands exceed resources. Stresses of being in the sandwich generation...strains can result in decline of health for caregiver, decline of health for care-receiver and dysfunctional or abusive relationships. Piaget's Sensorimotor stage - answer-(birth to 2 years) - infants use motor and sensory capabilities to explore the physical environment. Learning is largely trial & error. Piaget's Pre-operational stage - answer-(2 to 7 years) - young children use symbols (images & language) to explore their environment. Thought is egocentric, and children cannot adopt the perspectives of others yet. Piaget's Concrete operational stage - answer-(7 to 11 years) - older children acquire cognitive operations, or mental activities that are an important part of rational thought. Logical reasoning is possible but limited to concrete (observable) problems. Piaget's formal operational stage - answer-(11 years & beyond) - Adolescents' cognitive operations are organized in a way that permits them to think about thinking. Thought is now systematic & abstract. Expected characteristics of cognitive development across the lifespan - answer-Infants/toddlers develop a sense of "self" and "other" and come to understand object permanence. Require sensory stimulation. Learn by experiencing and manipulating the environment. Young children - egocentric thinking is demonstrated, they participate in imaginative play and begin to recognize that others don't see the world the same way they do. School age children are no longer fooled by appearances. They understand the basic properties of and relations among objects and events, and they are proficient at inferring motives. Logical reasoning is possible but is limited to concrete/observational problems. Adolescents through adults - logical thinking is no longer limited to the concrete or observable. This group engages in systematic, deductive reasoning and they ponder hypothetical issues. Older adults decline in the ability to perform information processing, divide attention between 2 tasks, maintain sustained attention or perform vigilance tasks, filter out irrelevant information, perform word finding, perform abstraction tasks, and maintain mental flexibility. Mental status exam - answer-It is used to gauge a patient's language abilities, orientation, memory, calculation ability, mood, perceptions and thought processes, to obtain a baseline cognitive functioning of the patient. It consists of personal information, appearance, behavior, speech, affect & mood, thought, perceptual disturbances and cognition (level of consciousness, orientation, memory, attention, abstract thinking, insight & judgement). Preparing the client & explaining what will be done, position & observe the client, assess language abilities, assess level of orientation, assess memory, assess computation ability, assess emotions and mood, assess perceptions & thinking abilities to make sure client is aware of reality and that statements are logical, coherent, relevant and complete, and finally assess client's decision making ability. Patients at risk for developing confusion - answer-Children & older adults are at a greater risk. Patients with hypoxia (inadequate oxygenation of the blood), inadequate perfusion (blood circulation to organs or capillary beds), patients on medication, patients with disease, elderly (especially men), patients with dementia, diabetes, undertreated pain, patients who are experiencing the onset of a new illness, patients with a severe chronic illness, patients who are hospitalized, individuals who are depressed or who have other mental illnesses, patients who abuse alcohol or drugs, ictal (post-seizure), injury, immobility, subdural hematoma, underhydrated/undernourished, patients with infection, electrolyte imbalance, emotional stress. Behaviors associated with a confused patient - answer-• Reduced awareness - limited or absent span of attention, highly distracted, difficulty keeping track of what is said, little activity or response to the environment • Impaired thinking skills - impaired memory (especially recent memory), disorganized thought, disorientation to place, time, date and/or person, rambling, incoherent or illogical speech, poor word finding ability, difficulty reading, writing or understanding speech, hallucinations and/or illusions • Changes in behavior - agitation, irritability, restlessness or combative behavior, altered sleep patterns, mood swings and extreme emotions, fear, anxiety and/or depression, withdrawal • Sundowning—confusion that intensifies in the evening or at bedtime Assessment tools for assessing confusion - answer-Obtaining a health history, a physical exam and a mental status exam. To differentiate between delirium (confusion) and dementia, a Confusion Assessment Method (CAM) may be used. This instrument screens for overall cognitive impairment and for traits associated with reversible confusion. History includes onset, duration and baseline mental status, review current medication use, any recent changes in vital signs and O2 saturation, any evidence of infections, labs & x-rays (tests for infection, electrolytes), results of the CAM, results of the mini mental status exam, signs of depression. Nursing interventions for the confused patient - answer-• Maintain safety at all times • Minimize stimuli to decrease anxiety • Arrange the physical environment so that it is clear • Make sure to have clocks and calendars to maximize orientation to time • Keep glasses & hearing aids within reach • Ensure adequate pain management • Keep familiar items in client's environment • Keep room will lit during waking hours • Encourage family to visit if appropriate • Provide clear, concise explanations • Eliminate unnecessary noise • Reinforce reality • Schedule activities consistently • Assign same caregivers if possible • Provide adequate sleep Seven steps to positive approach - answer-1) Come from the front 2) Go SLOWLY! 3) Get to the side 4) Get low - sit down 5) Offer your hand 6) Use the person's preferred name 7) Wait for a response before you start talking or doing! Appraisal - answer-The process by which individuals evaluate and cope with a stressful event Coping - answer-The dynamic process through which the individual applies cognitive and behavioral measures to handle internal and external demands that are perceived by the individual as exceeding his available resources Eustress - answer-"Good" stress which is associated with accomplishment and victory Distress - answer-Stress that is associated with inadequacy, insecurity and loss Hans Selye's General Adaptation Syndrome - answer-The stress response as a 3-stage chain of events; alarm reaction, resistance and exhaustion. Alarm reaction is 2-stage - shock phase where the body prepares for the cascade of physiological reactions to the stressor and the sympathetic nervous system is suppressed and countershock phase where the sympathetic nervous system triggers the body's defenses as fight or flight. This phase is short-lived and lasts anywhere from 1 minute to 24 hours. Resistance is the second stage where the body attempts to move toward restoration of homeostasis while continuing to respond to the stressor. The third stage, exhaustion, if the body cannot maintain its adaptation to the stressor and the stressor overwhelms the individual's ability to cope or mount a continued defense, the result is depletion of energy and resources and an additional susceptibility to disease. Mild anxiety - answer-A positive state of heightened awareness and sharpened senses, allowing the person to learn new behaviors and solve problems. The person can take in all available stimuli (perceptual field) Moderate anxiety - answer-involves a decreased perceptual field (focus on immediate task only); the person can learn new behavior or solve problems only with assistance. Another person can redirect the person to the task. Severe anxiety - answer-Involves feelings of dread and terror. The person cannot be redirected to a task; he or she focuses only on scattered details and has physiologic symptoms of tachycardia, diaphoresis, and chest pain Panic anxiety - answer-Can involve loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. The person may bolt and run aimlessly, often exposing himself or herself to injury Physiological manifestations of anxiety - answer-Increases ventilatory rate and depth of respirations, dilation of bronchioles to facilitate increased oxygenation, increased heart rate & cardiac output to promote transport of oxygen & nutrients throughout the body, increased sweat production to offset increased body temperatures, inhibition of parasympathetic nervous system leads to a decrease in digestion, dry mouth, increased sodium and water retention which leads to decreased urine output and increased blood volume, pupils dilate to allow more light and enhanced visual perception, enhanced awareness and alertness, increased muscular tension, and increase in glucocorticoids and an increase in blood glucose. Psychological manifestations of anxiety - answer-Fear, anxiety, anger, depression and a variety of other responses Behavioral manifestations of anxiety - answer-Changes in problem solving, suppression, diminished or impaired self-control and fantasizing Interventions for mild-moderate anxiety - answer-Acknowledge and validate patient's identification of anxiety and feelings, assist patient to identify the cause of anxiety, assist patient to increase awareness of usual response to anxiety, assist patient to problem solve, encourage safe & comfortable expression of feelings, lead patient through relaxation exercises Interventions for severe-panic anxiety - answer-Label anxiety for patient & intervene immediately , do not explore feelings or cause of anxiety, reduce or place no demands on patient, support/accept safe & comfortable expression of feelings, assess need for anti-anxiety medication, time out, seclusion or restraint after other interventions have been tried Compensation ego mechanism - answer-Covering up weaknesses by emphasizing a more desirable trait or by overachievement in a more comfortable area Displacement - answer-Transferring emotional reactions from one object or person to another Identification ego mechanism - answer-Attempting to manage anxiety by imitating the behavior of someone feared or respected Intellectualization - answer-Evading the emotional response that normally would accompany an uncomfortable or painful incident by using rational explanations that remove from the incident any personal significance and feelings Introjection - answer-A form of identification that allows for the acceptance of others' norms and values into oneself Minimization - answer-Not acknowledging the significance of one's behavior Projection - answer-Blaming others Rationalization - answer-Justifying certain behaviors by faulty logic Reaction formation - answer-A mechanism that causes people to act exactly opposite to the way they feel Repression - answer-An unconscious mechanism where threatening thoughts, feeling and desires are kept from becoming conscious Sublimation - answer-Displacing energy associated with more primitive sexual or aggressive drives into socially acceptable activities Substitution - answer-Replacing a highly valued, unacceptable or unavailable object with a less valuable, acceptable or available object Undoing - answer-Performing an action or using words designed to cancel some disapproved thoughts, impulses where the person relieves guilt by making reparation Watson's theory of human care - answer-Caring is at the core of nursing, positivity impacts health & the healing process Leninger's theory of culture, care, diversity & universality - answer-Culture plays a crucial role in nursing care 3 components of a nursing diagnosis - answer-P - the diagnostic label from NANDA - the problem E - the etiology (where did it come from, what is it r/t?) S - the defining characteristics - the symptoms Concept map - answer-A visual representation of a nursing care plan which can include multiple nursing diagnoses & interventions Nursing care plan - answer-A complete plan of care for ONE nursing diagnosis Direct care interventions - answer-Treatments performed through interactions with the patient Indirect care intervention - answer-Treatments performed away from the patient but on behalf of the patient (i.e. charting) Short-term nursing goal - answer-Hours to less than a week Long-term nursing goal - answer-One week to months... Characteristics of a nursing goal - answer-1) Patient centered 2) Singular goal/outcome 3) Observable 4) Measurable 5) Time-limited 6) Mutual factors - patient & nurse should agree on goals & time frame 7) Realistic Independent nursing intervention - answer-Actions that nurses initiate - do not require a physician's order Dependent nursing intervention - answer-Actions that require an order from a physician Collaborative nursing intervention - answer-Therapies that require combined knowledge, skill & expertise of multiple health care disciplines Cognitive domain of learning - answer-(THINKING DOMAIN) Includes all intellectual behaviors and requires thinking: Includes six intellectual abilities and thinking processes: In the hierarchy of cognitive behaviors the simplest is acquired knowledge, the most complex is evaluation. o Knowing: Learning new facts or information and being able to recall them. o Analyzing: Breaking down information into organized parts. o Comprehending: The ability to understand the learned material. o Synthesizing: The ability to apply knowledge and skills to produce a new whole. o Applying: Using abstract, newly learned ideas in. concrete situation. o Evaluating: A judgement on the worth of the information for a given purpose. Examples: one-on-one or group discussion, lecture, question and answer sessions, role play, discovery, independent project and field experience. Psychomotor domain of learning - answer-(SKILLS DOMAIN) Involves acquiring motor skills, such as fine motor skills, that require integration of mental and muscular activity. The simplest behavior in the hierarchy is perception, whereas the most complex is origination. Psychomotor learning includes: o Perception: Being aware of objects or qualities through the use of senses. o Set: a readiness to take a particular action. o Mechanism: the performance of an act under the guidance of an instructor. o Complex overt response: smoothly and accurately performing a motor skill. o Adaptation: the ability to change a motor response unexpectedly. o Origination: Using existing motor skills to perform a complex motor act. o MOTOR SKILLS Examples: demonstration, practice, return demonstration, independent projects and games. Affective domain of learning - answer-(FEELING DOMAIN) Deals with expression of feelings and acceptance of attitudes, opinions or values. o Feelings o Emotions o Interests o Attitudes Examples: role play, discussion, one-on-one or group discussion. Factors that facilitate learning - answer-• Motivation of the learner • Readiness of the learner • Active involvement of the learner • Relevance of the content of the learner • Feedback that is meaningful to the learner • Nonjudgmental support: • Simple to complex: material organized from simple to complex. • Address early any area that is causing anxiety • Repetition • Timing: people retain information and skills when there is a short time between learning and using. • Good environment (well lit, good ventilation, private, quiet, etc) Core measures - answer-Developed by the JC; national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Compliance shows how often a hospital provides each recommended treatment for certain medical conditions. The 6 aims of quality improvement in healthcare - answer-(SEPTEE) S - Safe E - Effective P - Patient centered T - Timely E - Efficient E - Equitable for all Sentinel event - answer-An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Most commonly occurring sentinel events - answer-Unintended retention of a foreign object Falls Performing procedures on the wrong patient Loss of limb or functions Team Nursing - answer-• RN leads team of other RNs, LPNs, and assistive personnel • LPNs provide direct patient care under supervision of RN, physician or other licensed practitioner • Team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. • There is hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. • NA's assume delegated aspects of basic client care Total patient care aka client focused care - answer-One nurse assigned to comprehensive care (all tasks) of clients during an 8 or 12 hour shift (i.e. ICU) Primary nursing - answer-One primary RN assumes responsibility for a caseload of patients (24/7) even if the nurse does not deliver all the care personally (i.e. home health care) Case management - answer-An approach that coordinates and links healthcare services to patients and their families while streamlining costs and maintaining quality. Case managers coordinate patient's acute care in the hospital & follows up with the patient after discharge home. Fueled by insurance. Includes nurses & social workers. Shared governance - answer-Using a pool of knowledge - shared responsibilities & decision making Tasks that an RN can delegate to an LPN - answer-• Monitoring findings (as input to the RN's ongoing assessment) • Reinforcing client teaching from a standard care plan • Performing tracheostomy care • Suctioning • Checking nasogastric tube patency • Administering enteral feedings • Inserting a urinary catheter • Administering medication (excluding IV medications in some states) Factors affecting urination: - answer-Age Diet/fluid balance psycholgical factors pregnancy Disease conditions medications (laxatives/ Cathartics) socioeconomic factors personal habits common symptoms of urinary Alterations - answer-Urgency Frequency Retention Dysuria Nocturia Urinary Hesitancy Neurogenic Bladder dysuria - answer-pain in urination urinary hesitancy - answer-trouble voiding neurogenic bladder - answer-a urinary problem caused by interference with the normal nerve pathways associated with urination Nocturia - answer-Urination at night oliguria - answer-scanty urine (100-400 mL/24h) polyuria - answer-frequent urination (2000 mL/day) Polydipsia - answer-Excessive thirst. Associated with polyuria diuresis - answer-increased formation and secretion of urine cause for concern - answer- 60 mL per 2 hours anuria - answer-absence of urine (100 mL/day) alterations in urinary retention - answer-Retention Urinary incontinence UTI retention - answer-an accumulation of urine due to the inability of the bladder to empty. Small amount of urine voided 2-3 times per hour. UTI - answer-the presence of microorganisms in the urinary tract, causing pain, burning fever, chills, n/v, frequent urge sensation. urinary incontinence - answer-inability to control urination urinary diversion - answer-diversion of urine to external source nephrostomy tubes - answer-small tubes tunneled through the skin into the renal pelvis Physical assessment of elimination - answer-SKIN- hydration, KIDNEYS- flank pain with infection or inflammation, URETHRAL MEATUS- discharge, BLADDER- distended bladder. Types of urinary incontinence (FOURST) - answer-Functional Overflow Urge Reflex Stress Transient Functional incontinence - answer-loss of urine r/t functional deficits such as: altered mobility, cognitive impairment, environmental barriers, and caregivers not responding in time to assist• Who- frail elderly people, LTC residents, dementia patients • Characteristics: o Toilet access limited by problems with: Sensory issues Mobility issues Cognitive issues Manual dexterity Environmental barriers Overflow Incontinence - answer-(associated with chronic retention of urine) • Definition- involuntary loss of urine caused by over-distended bladder r/t bladder outlet obstruction or poor bladder emptying because of weak/absent bladder contractions • Who- men with enlarged prostate, people with DM • Characteristics: o Distended bladder on palpation o High PVR o Frequency o Nocturia o Involuntary leakage of small volumes of urine urge incontinence - answer-• Definition- involuntary loss of urine associated with strong, sudden urgency r/t overactive bladder caused by: bladder inflammation, neurological problems, bladder outlet obstruction • Who- all ages, older adults with physical and cognitive decline • Characteristics: o Sudden urgency o Frequent urination o Difficulty holding urine once urge felt o Leaks on the way to bathroom o Strong leaks when one hears water, drinks fluids reflex incontinence - answer-• Definition- involuntary loss of urine occurring at somewhat predictable intervals when pt. reaches specific bladder volume r/t spinal cord damage between C1 to S2 • Who- older adults, patients with spinal cord dysfunction • Characteristics: o Diminished awareness of bladder filling, the urge to void and leakage of urine o May not completely empty bladder o Caution: At risk for developing autonomic dysreflexia (life-threatening; causes severe elevation in BP/HR with diaphoresis) stress incontinence - answer-• Definition- involuntary leakage of small volumes of urine associated with increased abdominal pressure and weakened external sphincter/pelvic support • Who- Women 60 • Characteristics: o Loss of urine when coughing, laughing, bending, exercising Transient incontinence - answer-• Definition- Incontinence caused by medical conditions that may be treated or reversed • Characteristics: o Delirium/acute confusion o UTI o Medications o Excessive urination o Impaired mobility o Fecal impaction o