306 Final Flashcards
Palliative Care
Management of pain, improves quality of life for clients and families, allows dying clients to die with dignity, still able to seek out life-saving measures
Hospice
Diagnosis by a physician as having 6 months or less to live
Physiological signs of death
Dyspnea
Hypotension
Anorexia, Nausea, Dehydration
Restlessness
Pain
DNR
Do not resuscitate
What if family conflicts with client wishes
We advocate for clients wishes
Post Mortem Care
*Clean and prepare the patient
Including removing lines/drains
*Allow for time for family to be with the patient
* Contact donation services (may happen earlier)
OBody bag & Identification
Pain Assessments – components, when to use
PQRST- (Provoke, Quality, Region, Severity, Timing) Adult Pain scale
CRIES (Crying, Requiring O2, Increase in vitals, expression, sleep) Used for infants and newborns
FLACC (Faces, Legs, Arms, Cry, Consolability) 2m-7years or disabled
NVPS (Nonverbal pain Scale) is Used when unable to verbalize pain
Categories of Pain
Nociceptive: Pain in the skin, bones, joints, visceral
Neuropathic: Neurological pain, diabetic neuropathy, phantom limb pain
Cancer: Pain from cancer
Non-verbal signs of pain
Gaurding, Restlessness, Grimicing
Comforting in pain
Pharmaceuticals (Opioids)
Nonpharmacological (TENS, Massage… etc)
Distraction: used for mild pain
Promoting sleep
Go to bed and wake up each time every day, keep naps short and before 3 pm, complete exercise 3 hours before going to bed, remove work items and tv from the bedroom when possible.
Benefits of sleep
Health and Healing, Transfer of memory from short to long term,
The effects of sleep deprivation
Impair judgment, decrease response time, trigger seizure disorders, migraines and tension headaches
Obstructive Sleep Apnea
Related to the recurrent episodes of upper airway collapse and obstruction while sleeping combined with waking from sleep (apnea= no breathing for a minimum of 10 seconds)
Carbohydrates
The main source of energy
Make up 45-65% of total daily calories
Proteins
Found in every cell of the body
The building block of the body
Promotes growth, healing, and overall body maintenance
Builds and repairs tissues
Fats
Storage form of excess energy
Body protection
Facilitates absorption of fat-soluble vitamins
A secondary source of energy
Heart healthy Diet
Omega3
Less plaque buildup in the arteries
Low Sodium Diet
Less salty foods
Fat-soluble vitamins
A, D,E, K
Water soluble vitamins
C, B complex
Signs and symptoms of Malnutrition & Dehydration
Growth failure, compromised immune system, poor wound healing, muscle loss, physical and functional decline
Progression of nutrition following digestive issues – clear to full
Clear liquid- Contains only clear liquids such as broth, gelatin, and water
*Full liquid- Contains fluids, foods that are liquids, and foods that are liquids at room temperature
*Pureed- Consists of food that does not need to be chewed
*Soft Diet- Soft foods that are easy to swallow and digest
*Regular diet- Consists of healthy foods coming from all of the food groups
Dysphagia Definition, assessing for, health professional consult
Difficulty swallowing, Assessment is done by the RN
Evaluation is done by a speech pathologist
Avoid straws and thin liquids at first
Joint Commission role
Perform evaluations of facilities and assess scores of the monthly submissions of hospitals’ safety and quality performance outcomes.
Done 4 times a year
Enteral
Nutrition intake through the GI tract that can be by mouth or GI tube
Near Miss
Potential error or event that could have caused harm but was caught and avoided
Parenteral
Nutrition that is given intravenously through a large vein to clients whose GI tracts don’t work properly
Client Safety Event
An unexpected event that did occur but did not cause harm to the client
Adverse event
Unexpected event that caused harm to the client
Sentinel event
Critical, unexpected event that caused severe physical or psychological harm to a patient including death, dismemberment, or permanent injury.
Root cause analysis
Used to probe potential errors
HAIs
Hospital-acquired infections
CAUTI: Catheter-Associated Urinary Tract Infection
CLABSI: Central Line Associated Blood Systemic Infection
Surgical Site Infection
Correct ID of patients
Two forms of identification
Name, DOB, Phone Number, Social Security
Fall Prevention- Safety in the client’s room, surroundings
Call don’t fall (Use Call light)
De-Clutter
Monitor Mental status
Bedside sitters
Motion alarms
Adequate lighting
Call light in reach
Hourly rounding
At HOME
Throw Rugs
Electrical Cords
Hand Rails
Stair Lift
Standard Precautions
Cautions performed every time in every situation
PPE
Contact precautions: Gown, Gloves, (Everything else as needed)
Droplet: Gown, Mask, Goggles, Gloves
Airbourne: Gown, N95 respirator, Goggles, Gloves
Delegation – Nursing License
Dont delegate what you can EAT
Evaluation, Assessment, Teaching
Basic steps in case of a Fire
R.A.C.E
Rescue
Alarm
Confine
Evacuate
P.A.S.S
*Pull
*Aim
*Squeeze
*Sweep
Restraints
To AVOID restraints
Close to the RN station
Hourly Rounding
Orient to surroundings
Asses if current meds are therapeutic
If restraints ARE ON
Educate the family about why restraints are needed
Passive ROM
Provider Orders every 24 hours
Released and repositioned every 2 hours
ISBAR
I- Identify
S- Situation
B- Background
A- Assessment
R-Recomendations
ADPIE
A-Assessment
D-Diagnosis
P-Planning
I-Interventions
E-Evaluate
Assessment always first!
Vital Signs Normal ranges for adults
BP- 120/80
O2 Sat- 95%+
Pulse- 60-100 BPM
Temp- 97-99 degrees F
RR- 12-20
Illness & Disease
Illness: Personal experience with illness
Disease: Alteration of body function
Modifiable Risks
Risk factors that one can change and prevent.
- obesity
Health Equity/ Equality – Vulnerable Populations
Health equality- Everyone gets the same resources
Health Equity- People who need it more get more resources
Social Determinants of Health
Bad environment, Low income, No insurance. Anything that can deter someone from getting healthcare
Eye Disorders
Cataracts-
A clouding of the lens of the eye that causes vision to be blurry, hazy, or less colorful.
Glaucoma-
An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve.
Open Angle: Tunnel Vision, Gradual loss of vision
Closed Angle: Severe pain, sudden onset of decreased vision
Eye Exams: Increased Ocular pressure
Treatment: Eye drops, Laser eye surgery
Acute Macular Degeneration-
An irreversible degeneration of the macula that leads to a loss of central vision as clients age.
Diabetic Retinopathy-
affects blood vessels in the retina causing blindness.
Astigmatism-
A defect that causes both nearby and faraway objects to appear blurry
Acute Macular Degeneration
An irreversible degeneration of the macula that leads to a loss of central vision as clients age.
Cataracts
A clouding of the lens of the eye that causes vision to be blurry, hazy, or less colorful.
Glaucoma
An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve.
Open Angle: Tunnel Vision, Gradual loss of vision
Closed Angle: Severe pain, sudden onset of decreased vision
Eye Exams: Increased Ocular pressure
Treatment: Eye drops, Laser eye surgery
Diabetic Retinopathy
affects blood vessels in the retina causing blindness.
Astigmatism
A defect that causes both nearby and faraway objects to appear blurry
Eye exams as early as
6 months old
Comprehensive eye exam at
40
With no comorbidities
2-4 years ages 40-54
1-3 years 44-64
1-2 years 65+
Children ages _______ screened at least once
3-5
Eye Safety
Wear goggles or safety glasses in an environment that is dangerous
Hyperopia
Inability to see nearby objects clearly, also referred to as farsightedness.
Myopia
Inability to see faraway objects clearly, also referred to as nearsightedness
Astigmatism
A defect in the eye making objects nearby and faraway look blurry or distorted
Presbyopia
Age-related farsightedness, or a gradual decrease in the ability to clearly see nearby caused by the loss of flexibility of the lens of the eye.
Sensorineural Hearing Deficit
Effects inner ear, nerve pathway
Could be associated with tinnitus and vertigo
Age related presbycusis, followed by noise-induced hearing loss
Congenital, genetic or acquired
Noise-induced hearing loss
Associated with prolonged exposure to sounds greeted than 85 dB including loud music
Can be caused by single exposure to intense sound over 120dB
Wear ear protection, avoid loud situations
Warning signs are inability to hear from 3 feet away
Conductive Hearing loss
Loss of hearing at all frequencies
Most common cause: Obstruction of external ear canal
Impacted cerumen
Perforated tympanic membrane
Otosclerosis
Abnormal growth of bone in the middle ear.
Otitis Media
Inflammation in or the accumulation of fluid in the middle ear that can result in conductive hearing loss
Occupational Risks for hearing loss
Machinery, Planes, other loud environments
Presbycusis
Age-related hearing loss.
Hair cells of cochlea ______ With aging
Degenerate
______ pitched tones, conversational speech lost initiaially
High
Conductive Hearing loss
Inability of sound to travel from the outer ear to the eardrum and middle ear.
Blockage in ear canal
Sensorineural hearing loss
Hearing loss that occurs from problems either in the inner ear or on the vestibulocochlear (auditory) nerve (cranial nerve VIII).
Tinnitus
Hearing sound when no external sound is present, such as ringing, buzzing, roaring, clicking, hissing, or humming noises.
Vertigo
a sensation of motion or spinning that is often described as dizziness
TORCH
Toxoplasmosis, Rubella, Cytomegalovirus, Syphilis, Herpes
Idiopathic neuropathy
Neuropathy due to nerve damage of an unknown cause.
Peripheral Neuropathy
Conditions that occur when nerves in the central nervous system become damaged resulting in numbness, pain, and weakness to the extremities.
Diabetic neuropathy
Nerve damage that occurs in clients who have diabetes mellitus due to high blood glucose levels and high levels of triglycerides, which cause damage to the nerves and to the small blood vessels supplying blood to the nerves.
Rinne test
Tuning fork on mastoid bone, when client cannot hear it place it outside auditory canal
Weber Test
Place the tuning fork on the middle of forehead, detect if the client hears the sound equally. Can detect sensorineural issues
Sensory processing disorder
When a client appropriately detects sensory stimuli, but their brain has difficulty interpreting and responding appropriately to the stimuli.
Sensory Deficit
A deficit in the expected function of one or more of the five senses
Sensory Deprivation
A reduction in or absence of stimuli to one or more of the five senses.
Sensory Overload
Receiving stimuli at a rate and intensity beyond the brain’s ability to process the stimuli in a meaningful way.
Ototoxicity
Causing damage to or dysfunction of the cochlea or vestibule.
Aphasia
A disorder that affects a client s ability to articulate and understand speech and written language due to damage in the brain (National Institute on Deafness and Other Communication Disorders).
Tactile Hypersensitivity
Being overly sensitive to tactile stimulilation.
Tactile Defensiveness
A severe sensitivity to touch that most people would find acceptable that often causes physical pain
Tactile Hyposentivity
Under-responsiveness to tactile stimulation.
Gustatory Cells
Taste cells that contain specific receptors that allow for differentiation between sweet, sour, bitter, salty, or savory flavors.
Hypogeusia
A decreased ability to taste.
Dysgusia
A persistent salty, rancid, or metallic taste is said to have dysgeusia.
Aguesia
The inability to taste anything.
Phantom taste perception
A persistent, foul taste when the mouth is empty
Hyposmia
A reduction in the ability to perceive odors.
Anosmia
The inability to smell anything.
Phantosmia
The sensation of an odor that isn’t there.
Parosmia
a distortion in smells, such as when a previously pleasant smell becomes unpleasant.
Vulnerable Populations
Socioeconomic
Different primary language compared to health care site
Sexual Orientation
Sensory Deficits
Demographics
Delirium
confused thinking and reduced awareness of the environment.
Emic knowledge
An insider’s viewpoint of a culture.
Health Disparities
Preventable differences in incidence and prevalence of disease, injury, or violence among populations, based on race, ethnicity, gender, gender identity, LGBT, age, or socioeconomic status
Socioeconomic
Education level
Employment status
Household income
Poverty status
Sexual Orientation
Clients who identify as lesbian, gay, or bisexual, and can also include those clients who are questioning their sexual orientation or sex identity.
Demographics
Age
English language proficiency
Household type
Population density
Race and ethnicity
Sex
Cultural Competence
Being able to incorporate effective nursing care with emic and etic knowledge including appreciating, accepting, and respecting all individual s cultural influences, beliefs, customs, and values.
Etic knowledge
An outsider’s viewpoint of a culture.
Culture
The learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guide their thinking, decisions, and actions in patterned ways.
Cultural Humility
Being aware of power imbalances and biases and respecting other peoples values
Not one culture is better than another
Implicit Bias
The involuntary attitudes or associations that affect our perceptions, actions, decisions, and interactions with others, unconsciously.
Explicit Bias
Bias that’s derived from our conscious thoughts and beliefs that can be reported.
Musculoskeletal system:
Muscular system
Skeletal System
Personal Health Literacy
The extent to which an individual can obtain, process, and comprehend basic health information.
Health Equality
The distribution of the same resources, including opportunities, to all individuals within a population.
Health Equity
Valuing all individuals equally and removing obstacles to optimal health and health care across different populations.
Cultural Health Assessment
Assessments that can be conducted to gather information regarding the client’s culture and how it can affect their health.
Organizational Health literacy
The extent to which organizations equitably assist individuals with understanding, finding, and using information and services to make informed health-related decisions for themselves and others.
Intrapersonal:
“Intrapersonal cultural humility occurs when nurses and nurse faculty are actively engaged in examining and critiquing their beliefs and motives.” (Hughes, et. al. 2020)
Muscular system
Muscles and Tendons, ligaments, cartilage
Interpersonal
Interpersonal humility happens when individuals critically engage in questioning and understanding the values and cultures of their patients, families and colleagues” (Hughes, et. al. 2020)
Skeletal system
Bones, joints of skeletal system
Muscular system and skeletal system work together to…
Support body weight, control movements, provide stability, some provide protection for heart, lungs, and brain.
Ligaments
Connect bones to other bones
Muscle types
Smooth, Cardiac, Skeletal
Tendons
Connects muscles to bones
Cartilage
Flexible connective tissue
Pregnancy complications
Back pain due to weight
Postural fixing, physical therapy to strengthen back muscles
Caution on meds
Acute injury treatment
RICE
Rest, Ice, Compress, Elevate
POLICE
Protection, Optimal, Load, Ice, Compression, Elevation
Alteration in muscles, bones, and joints link a variety of health problems
Arthritis
Fractures
Neurological disorders
Traumatic Injuries
Parkinsons
Spinal cord injuries
Back problems
Multiple sclerosis
Adolescents complication
Most common time to see scoliosis
Childhood complications
Growing pains
Presents as pain in arms and legs
Adult Complications
Back pain
Back Pain – Herniated Disc
Perforation on vertebrae leading to escaping fluid to compress nerve root, extremely painful
Lumbar Herniated Disc
Hip pain, Lower back pain
Herniated Disk interventions
Pharmacologic- Meds
Nonpharmacologic- Accupuncture
Surgery
Cervical Herniated Disc
Upper extremity pain, Shoulder pain, Neck pain
Good body mechanics
Wide Base
Look at patients
Straight back, no bending at the waist
Life with the legs
Effects of Aging on the body
Loss of bone mass
Decrease lean body mass
Increased rigidity in tendons and ligaments
Foot problems
Muscle atrophy
Decreased height
Decreased range of motion
Consequences of immobility
Moving is healing
Hospital acquired pressure injuries, DVTs, pneumonia, Falls, Cognition/Delirium, Readmissions, Length of stay, Discharge disposition, Appropriate rehab utilization
Closer we get to a zero fall environment, the further away we get from a culture of mobility
Clients with Fall Risks
Diagnoses
Abnormal lab values (Potassium)
Vital signs
Cognition
Medication (Pain, diuretics)
Modifiable Risk Factors for Alterations of Sensory Perception
- Environment (UV light exposure, loud sounds)
- Lifestyle (stress, smoking)
- Injury
- Medications
Concepts related to mobility
Collaboration, Comfort, Health, Wellness, Injury, Illness, Mood and Affect, Safety, Stress and coping
The 5+ Senses
- Visual
- Olfactory
- Gustatory
-Tactile - Auditory
- Kinesthetic: Position in time and space
- Stereognosis: Use of tactile and memory to identify object
- Visceral: Sensation of knowing something is happening in body
Non-Modifiable Risk Factors for Alterations of Sensory Perception
- Genetics
- Aging
Impacts of Sensory Alteration
- Communication (deaf -> hard to talk/hear)
- Psychosocial (can’t hear, don’t want to do social things)
- Independence (challenges independence, confidence, self-esteem)
Modifiable and Non-Modifiable Risk Factors for Alterations of Sensory Perception
- Disease/Illness
Cataracts
- Lenses get cloudy and yellow
- 60-70yrs old becomes a problem
Refractive Errors
- Presbyopia: Aging of the eye, close objects become blurry
- Myopia: Nearsighted, distant objects appear blurry
- Astigmatism: Blurry/distorted visionNursing Interventions for Visually Impaired
Glaucoma
- Gradual loss of peripheral vision
- Aqueous Humor flow is compromised
- Open Angle: Tunnel vision
- Closed Angle: Severe pain, sudden vision loss
- Treatment: Eye drops, laser eye surgery
Acute Macular Degeneration
- Dark area and distortion
- Treatment: Antioxidants and zinc
Diabetic Retinopathy
- Bleeding in eye and occludes vision
Nursing Interventions for Visually Impaired
- Clear pathways
- Ensure good lighting
- Call light, glasses, assistive devices all in reach
- Prevent Sensory overload
- Print materials in larger font
Tactile Sense
- Access: Touch different texture and temperature objects on patient’s skin with their eyes closed
- Impairment: Decreased mobility, falls, weak grasp, pressure sores
Tactile Impairment Through Lifespan
- Older adults have decreased sensitivity to touch
- Uncontrolled diabetes causing peripheral neuropathy
- Polyneuropathy: Damage to multiple body parts
Symptoms of Peripheral Neuropathy
- Aching, shooting, tingling, burning pain and weakness
Tactile Nursing Care
- Address contributing conditions
- Change position often to avoid sores
- Promote effective coping
Olfactory Sense
Smell
Often not adequately tested
Can use swabs with vanilla
Electro-olfactography
Olfactory and Gustatory Nursing Care
- Danger cleaning with some chemicals
- Gas appliances in good working order
- Inspect food for freshness
- Suggest healthy way to add flavor besides salting
- Maintain good oral care (brush twice, floss once, visit dentist every 6)
Olfactory and gustatory Impairment Through Lifespan
Pregnancy: increase sense of smell, leading to nausea and vomiting or food cravings
- Older adults: senses diminish
- May be affected by cold, flu, coronavirus, sinusitis
- MS and Parkinson’s can affect them as well
Hearing Screenings
- Newborns screened regularly
- Preschool and school age screened at school
- Adults every 10yrs until 50, every 3yrs after 50
Rinne Test
- Place vibrating tuning fork on mastoid bone, remove when can’t hear, place outside ear
- Air conduction should be twice as long as bone conduction
Weber Test
- Place tuning fork on top of head
- Should hear equally in both ears
Auditory Alterations
Hearing Deficits May:
- Be partial or total
- Be congenital or acquired
- Affect one or both ears
- Affect specific frequencies or all frequencies
Conductive Hearing Loss
Equal loss of hearing at all frequencies
Causes
-Obstruction of external ear canal
- Wax buildup
- Perforated ear drum
- Disruption or fixation of ossicles
- Chronic and untreated ear infections
Sensorineural Hearing Loss
-Effects inner ear, auditory nerve pathway
- May be associated with tinnitus and vertigo
- Most common cause is age related presbycusis (degeneration of hair cells of cochlea)
TORCH
T: Toxoplasmosis
O: Other (syphilis, varicella, mumps, parvovirus, HIV)
R: Rubella
C: Cytomegalovirus
H: Herpes simplex
Non-pharmacological Auditory Therapies
-Hearing aids
-Assistive listening devices
-White or pink noise-masking device
-TD/TTY telephones
-Internet accessibility
-Lip Reading
-Flashing/vibrating safety alarms
Pharmacological Auditory Therapies
-Decongestants
-Steroids
-Antibiotics
(Used to treat cause of temporary hearing alterations)
Auditory Health Promotion
- Earplugs
- Use email or text instead of call
- Use written materials
- Closed captions
- ASL or Lip reading classes
What Components Make Up Muscular System?
- Ligaments
- Tendons
- Cartilage-
- Muscles
What Components Make Up Skeletal System?
- Bones
- Joints
Ligaments
Connect bones to other bones
Tendons
Connects bones to muscles
Types of Musculoskeletal Alterations
-Back problems
-Fractures
-Multiple Sclerosis
-Osteoarthritis
-Parkinson’s
-Spinal Cord Injuries (SCI)
POLICE
P: Protection
O: Optimal
L: Load
I: Ice
C: Compression
E: Elevation
RICE
R: Rest
I: Ice
C: Compress
E: Elevate
Concepts Related to Mobility
-Collaboration
-Comfort
-Health, Wellness, Illness, and Injury
-Mood and Affect
-Safety
-Stress and Coping
Lifespan Considerations: Children
-Massive bone growth
-Growing pains in legs/arms
Lifespan Considerations: Infants
-Flexible
-Unfused cartilaginous joints
Lifespan Considerations: Adolescents
-Injuries from sports
-Continued muscle and bone growth/development
Lifespan Considerations: Pregnancy
-Increase weight
-Increase stress on muscles and bone
Lifespan Considerations: Older Adults
-Compressed Spine
-Decrease muscle mass
-Stiffer joints
Pharmacological Interventions For Back Pain
-Drugs
Herniated Disc Description
-Anulus fibrosis ruptures
-Nucleus pulposus herniates
-Nerve gets compresses
Non-pharmacological Interventions for Back Pain
-Acupuncture
-RICE/POLICE
-Low impact exercise
Fall Risks
-Abnormal lab values (low potassium causes muscle weakness)
-Vitals out of range
-Cognition
-Meds (diuretics make you pee, get up to go to bathroom, fall)
BMAT
-Bedside Motility Assessment Tool
1. Assess use of assistive device
2. Have patient reach across body to shake your hand
2. Stretch foot out and point toe (with at least one leg)
3. Bear weight on leg for 5 seconds
4. March in place
5. Step forward and back with each leg
immobility
An inability to reposition or move self
Synovial Joints
Fluid-filled capsules that connect bones and enable movement.
proprioception
Feedback from sensory receptors to coordinate, balance, and fine-tune body positioning and movement.
Peripheral Nervous System
Nervous system outside of the brain and spinal cord, which regulates the responses of the body to external stimuli.
Ergonomics
Study of body mechanics in relation to the demand and design of the work environment and the equipment used.
Mobility
Moving from one position to another.
Atrophy
Become smaller and weaker often from disuse.
Sarcopenia
Loss of lean muscle caused by immobility.
Foot Drop
A type of joint contracture that results in the foot and toes permanently pointing downward.
Joint Contractures
An abnormal fixation of a joint due to changes in muscles and connective tissue.
Activity Intolerance
Inadequate amount of physical or psychological energy to undergo or complete a necessary activity.
Kyphosis
Excessive outward curvature of the upper area of the spine.
Passive Range of Motion
The movement of a joint by another individual.
Active Range of Motion
Voluntary movement of a joint.
BMAT Stages
Safety Screen.
Level 1 - Sit and Shake Assessment.
Level 2 - Stretch and Point Assessment.
Level 3 - Stand Assessment.
Level 4 - Walk.
