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