240 Exam 2 Flashcards
7 medication rights
right patient
right drug
right route
right time
right dose
right reason
right documentation
3 medication safety checks
When the nurse reaches for the container or unit dose package
After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container
Before giving the unit dose medication to the patient or when replacing the multi-dose container in the drawer or shelf
signs and symptoms of hypoglycemia
signs and symptoms of hyperglycemia
zofran nursing considerations
nurse practice acts (ch 7)
law established to regulate nursing practice
protects the public by broadly defining the legal scope of nursing practice
negligence (ch 7)
performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do
false imprisonment (ch 7)
Unjustified retention or prevention of the movement of another person without proper consent
The indiscriminate and thoughtless use of restraints on a patient can constitute false imprisonment
standards of care (ch 7)
expectation of nurse role
informed consent
informed and voluntary consent is needed for admission, for each specialized diagnostic or treatment procedure
consent must be written, designated for the procedure to be performed, and signed by the patient or person legally responsible for the patient
must be 18 or older
informed consent is not needed in an emergency
scope of practice (ch 7)
legal boundaries of nursing care
clinical reasoning model (ch 13)
use of inductive and deductive reasoning
Thought process that allows HC providers to arrive at a conclusion
clinical judgment model (ch 13)
skill of recognizing cues regarding a clinical situation, generating and weighing hypotheses, taking action, and evaluating outcomes for a satisfactory clinical outcome
tanners clinical judgment model:
Noticing: initial grasp and perceptions of the situation that are impacted by context, the nurse’s practical experience, knowledge of expected versus unexpected data, ethical perspectives, and the nurse–patient relationship
Interpreting: attributing meaning to the data through multiple reasoning patterns
Responding: deciding on an action (or inaction) and monitoring outcomes
Reflecting: in-action and on-action
nursing process (ch13)
ADPIE
used by the nurse to identify the patient’s health care needs and strengths, to establish and carry out a care plan to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes
Nursing assessments focus on
the patient’s response to health problems
Focus on the person, physiological and psychological response to the illness. able to meet basic human needs? perform ADL’s
SMART goals (ch 14)
S: specific
M: measurable
A: Achievable
R: realistic
T: timely
ADPIE (ch 14)
A: assessment
D: diagnosis/ problem identification
P: planning
I: implementation
E: evaluation
Maslows hierarchy (ch 15)
bottom to top:
physiological needs
safety
love/belonging
self esteem
self actualization
ANA standard of practice 1 (ch 15)
Assessment
RN collects comprehensive data r/t the persons health or the situation
Prioritization (ch 16)
ALWAYS THINK OF ABCs
Three helpful guides to determine priority in patient needs include Maslow’s hierarchy of human needs, patient preference, and anticipation of future problems.
High priority: greatest threat to patient well-being
Medium priority: nonthreatening diagnoses
Low priority: diagnoses not specifically related to current health problem
ANA standard of practice 2 (ch 16)
population diagnosis and priorities
analyze assessment data to determine diagnosis
ANA standards of practice 3 and 4 (ch 17)
outcome identification and planning
identify expected outcomes to make a plan
Develops a plan that reflects best practices by identifying strategies, action plans, and alternatives to attain expected outcomes.
ANA delegation of tasks: 5 rights of delegation (ch 18)
right task
right circumference
right person
right directions and communication
right supervision and evaluation
ANA standards of practice 5 (ch 18)
implementation
Implements the identified plan by partnering with others
holistic nursing and natural products (ch 29)
Healing the whole person is its goal.
People have a mind, body, emotions, and spirit that are connected and function as a unified whole. A change in any part of the organism will be reflected in other parts
natural products: nutritional and herbal remedies
Functions of the integumentary system (ch 33)
protection, temperature regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination
risk factors for skin alterations (ch 33)
types of wounds (ch 33)
intentional or unintentional
open or closed
acute or chronic
partial thickness, full thickness, complex
etiology of wounds and pressure injuries (ch 33)
surgical (intentional, controlled, sterile),
traumatic (may require additional intervention such as fluid administration or a tetanus shot),
neuropathic or vascular (related to an underlying neurologic and/or circulatory issue), or pressure related
Prevention measures for skin (ch 33)
wound and tissue repair/healing cascade (ch 33)
Hemostasis
Inflammatory
Proliferation
Maturation
staging of pressure injuries (ch 33)
Stage 1: nonblanchable erythema of intact skin
Stage 2: partial-thickness skin loss with exposed dermis
Stage 3: full-thickness skin loss; not involving underlying fascia
Stage 4: full-thickness skin and tissue loss
Unstageable: obscured full-thickness skin and tissue loss
Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration
special population needs for skin care (ch 33)
effects of nutrition on health/wellness/illness/injury (ch 37)
healing wounds require adequate proteins, carbohydrates, fats, vitamins, and minerals
All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional status and fluid imbalance.
BMI- normal and healthy values (ch 37)
18.5-24.9 = healthy
BMI below 18.5 is underweight
BMI of 18.5 to 24.9 is a healthy weight
BMI of 25 to 29.9= overweight person
BMI of 30 to 39.9 indicates Obesity
BMI of 40 or greater indicates extreme obesity.
significance of waist circumference (ch 37)
Waist circumference is a good indicator of abdominal fat
abdominal obesity poses greater risk for cardiovascular disease and diabetes
digestive process (ch 37)
Digestion begins in the mouth where food is taken in, mixes with saliva
pushed into the pharynx by the tongue
continues into the esophagus
Peristalsis moves the food through the esophagus and into the stomach
stomach churns the ingested food, mixing it with substances to break down the food and convert it to a semiliquid mixture
The food leaves the stomach and enters the small intestine
The small intestine secrets enzymes, which, along with secretions from the liver and pancreas, digest the food. The digested nutrients are then transferred into the person’s circulation (absorption), to be transported throughout the body.
clinical indicators of nutritional status (ch 37)
PEG and J tube (ch 37)
A gastrostomy may be used for patients who have impaired chewing and swallowing related to neurologic diseases (stroke, multiple sclerosis) or obstruction of the upper respiratory and/or digestive tract, as in head and neck cancers; patients with oncologic health problems associated with malnutrition; and patients with other health issues that lead to malnutrition, such as chronic renal failure, cystic fibrosis, or Crohn disease
Vitamin A: s/s of low values and how the patient would present
fat-soluble
affects visual acuity, skin and mucous membranes and immune functions
s/s: night blindness
Vitamin D
fat-soluble
provides calcium and phosphorus metabolism and stimulates calcium absorption
Vitamin E
fat soluble
antioxidant that protects Vitamin A
vitamin K
fat soluble
helps the synthesis of certain proteins necessary for blood clotting
urinary testing procedures (ch 38)
Routine urinalysis: checks for protein/blood/glucose/ketones, specific gravity- density of urine
Clean-catch or midstream specimens
Sterile specimens from indwelling catheter
Urine specimen from a urinary diversion
24-hour urine specimens
Point-of-care urine testing
developmental changes in urinary function (ch 38)
children: toilet training 2-5 years old
aging adults: Nocturia, Increased frequency, Urine retention and stasis, Voluntary control affected by physical problems
bladder training (ch 38)
involves biofeedback and muscle training
toileting self-care behaviors (ch 38)
role of the pelvic floor in micturition (ch 38)
Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra
Muscles of perineum and external sphincter relax
Muscle of abdominal wall contracts slightly
Diaphragm lowers, micturition occurs
urinary diversions (ch 38)
Ileal conduit
suprapubic catheter
peristalsis (ch 39)
move waste products along the length of the intestine continuously
laxatives (ch 39)
promote peristalsis
laxatives makes pt go, stool softeners helps the patient go
stool softeners (ch 39)
Agents with surfactant activity that decrease the tension between water and fat and lubricate the stool
iron supplements (ch 39)
chronic vs acute bleeding & s/s (ch 39)
developmental changes in bowel function (ch 39)
constipation is often a chronic problem for older adults (constipation is not a normal part of aging)
decreased peristalsis
post-procedural changes in bowel function and aftercare (ch 39)
Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, causing a condition termed postoperative Paralytic ileus
temporary stoppage of peristalsis normally lasts 3 to 5 days.
Flatus definition and etiology
gas
caused by swallowing more air than usual or eating food that’s difficult to digest
ostomy types (ch 39)
colostomy
urostomy
Ileostomy
empty and change ostomy appliance (ch 39)
ISBAR
I: identify
S: situation
B: Background
A: Assessment
R: recommendation
aim of nursing practice
To promote health
To prevent illness
To restore health
To facilitate coping with disability or death
Recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes are steps included in which model?
A. Clinical Judgment Measurement Model
B. Tanner’s Model
C. The Nursing Process
D. Developing Nurses’ Thinking Model
A. Clinical Judgment Measurement Model
elements of a healthy work environment
Skilled communication
True collaboration
Effective decision making
Appropriate staffing
Meaningful recognition
Authentic leadership
types of nursing interventions
Nurse-initiated: actions performed by a nurse without a physician’s order
Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
Collaborative: treatments initiated by other providers and carried out by a nurse
open wound
inten/uninten= incision or abrasion- road rash
closed wound
car accidents (air bag), fall, skin surface intact- but underlying tissue is damage- ecchymosis, hematoma
acute wound
heal quickly- days to weeks. Edges approximate- go thru the healing cascade without delay/intruption…more on this
chronic wound
4-6 weeks or longer…something has interrupted the healing cascade and has delayed the closure of the wound. Increasing risk for infection
classification of pressure injuries
(1) partial thickness where all or a portion of the dermis is intact
(2) full thickness where the entire dermis, sweat glands, and hair follicles are severed, which can expose bone, tendon, or muscle
(3) unstageable, a full-thickness loss where the true depth cannot be determined
(4) deep pressure-induced tissue damage
hemostasis phase
happens very quickly (minutes)
involved blood vessels constrict and clotting begins (fibrin/scab)
exudate (wound drainage) is formed causing swelling and pain
increased perfusion results in heat and redness
inflammatory phase
duration: 2-3 days
leukocytes and macrophages, move to the wound
24 hr mark- macrophages enter the wound
fibroblasts fill the wound
increase in body temp and WBC
patient feels generalized body response (malaise)
proliferation phase
lasts for several weeks
New tissue is built to fill the wound space through the action of fibroblasts.
new filler tissue is highly vascular
thin layer of epithelial cells forms across the wound
maturation phase
Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years
collagen is remodeled
Vitamins A and C are essential for
epithelialization and collagen synthesis.
Zinc plays a role in
proliferation of cells.
Fluids are necessary for
optimal function of cells
waist to hip ratio
screening tool to identify central obesity
WHR is calculated by dividing the patient’s waist circumference by the hip circumference
men= > 40 inches,
women= >35 inches
folic acid
supplementation prior to conception and during pregnancy reduces the risk of neural tube defects
QSEN competencies
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
Avulsion
tearing of a structure from normal anatomic position
Keloid
excitable tissue formation (when extra tissue is formed)
Atelectacis
complete or partial collapse of the entire lung or area (lobe) of the lung
different types of enemas
Cleansing
Retention:
Oil: lubricate the stool and intestinal mucosa, easing defecation
Carminative: help expel flatus from the rectum
Medicated: provide medications absorbed through the rectal mucosa
Anthelmintic: destroy intestinal parasites
Large volume
Small volume
combination of allopathic and complementary and alternative modalities
integrative health care
to evaluate for hypoxia which test should be ordered
Arterial blood gas (ABG)
saturated vs unsaturated fats
saturated:
raise cholesterol levels
most animal fats
solid at room temp
unsaturated:
lower cholesterol levels
vegetable fats
which type of fat raises cholesterol levels
saturated fats
what vitamin is found only in food made from animals
vitamin B12
a nurse is managing a continuous tube feeding via NG tube. how often should the nurse check for residual
every 4-6 hours
most absorption occurs in the
small intestine
a client on warfarin would be educated to have caution about eating foods containing which nutrient
vitamin k
dehiscence
“I feel like something just popped”
separation of wound layers
function of large intestine and colon
absorption of water
formation of feces
expulsion of feces from the body
black stools caused by
iron salts, pepto
upper GI bleeds have which characteristics
black, tarry, coffee ground emesis
when administering an enema lay the patient on which side
left side
Acupunture
Acupuncture either increases or decreases the flow of qi along the meridian, restoring the balance of yin and yang
1st stool passed is the start of the collection period
nasogastric (NG) tube
tube is inserted and used to decompress or drain the stomach of fluid or unwanted stomach contents
Anuria
less than 50 mL in 24 hours
24 urine collection is started
after the patient urinates and that sample is discarded
stress incontinence
involuntary loss of urine elated to increased intra-abdominal pressure
medications that affect urine production
Diuretics: prevent reabsorption of water and certain electrolytes in tubules
Lasix- HCTZ-common in txmt of htn, HF
Cholinergic medications: stimulate contraction of detrusor muscle, producing urination
Analgesics and tranquilizers: suppress CNS, diminish effectiveness of neural reflex
furosemide
diuretics
lasix
increase urine production and common in the treatment of hypertension and heart failure
Transient incontinence
appears suddenly and is usually caused by an illness or temporary problem that is short-lived or treatable
It is usually caused by treatable factors, such as confusion secondary to acute illness or infection or as a result of medical treatment, such as the use of diuretics or intravenous fluid administration
Ileal Conduit
attaches ureters to the bowel
suprapubic catheter
Long term continuous drainage- spinal cord injury, prostate /obstruction/ cancer
Less risk for contamination
trans fats
Trans fats are a form of dietary fat that raise LDL (“bad”) cholesterol and lower HDL (“good”) cholesterol
Naturally occurring trans fats are produced by some animals and small amounts of these trans fats are present in some meat (e.g., beef, lamb) and dairy products (e.g., milk)
water percent of total weight
Accounts for between 50% and 60% of adult’s total weight
Anticoagulants may cause Hematuria (blood in the urine), leading to a pink or red color.
Diuretics can lighten the color of urine to pale yellow.
Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine.
The antidepressant amitriptyline or B-complex vitamins can turn urine green or blue-green.
Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine.
Irritable bowel disease (IBD)
crohns and ulcerative colitis
irritable bowel syndrome (IBS)
malpractice is a _____ law
common law
nurse practice acts fall under which laws
statutory laws
The state nurse practice act is the most important law affecting nursing practice. Each nurse practice act protects the public by broadly defining the legal scope of nursing practice.
four components of a diagnosis
Label
Definition
Defining characteristics
Related factor
implementation step involves
- Determining how to implement the planned interventions
- Delegating
- Communicating
- Teaching others
Cholinergic medications on urine production
stimulate contraction of detrusor muscle, producing urination
diagnosis step involves
how an individual, group, or community responds to actual or potential health and life processes
etiology
strengths and weaknesses
planning step involves
Establish priorities.
Identify and write expected patient outcomes. (“the pt will…”)
Select evidence-based nursing interventions.
Communicate the care plan.
types of urinary incontinence
Transient: appears suddenly and lasts 6 months or less
Overflow/chronic retention: overdistention and overflow of bladder
Functional: caused by factors outside the urinary tract
Reflex: emptying of the bladder without sensation of need to void, spinal cord injuries- no urge to void
Stress: involuntary loss of urine related to an increase in intra-abdominal pressure (laughing, sneezing, coughing)
Mixed: urine loss with features of two or more types of incontinence
Total: continuous, unpredictable loss of urine
what two things must be present for pressure injuries to occur
unrelieved pressure
mobility limitation
scheduling diagnostic tests for stool
1: fecal occult blood test
2: barium studies (should precede UGI)
3: endoscopic examinations
