Chapter 5 & 24: Culture & Hospitalized Patient Flashcards
Cast
plaster encasement to help the body heal by holding injured bone or joints in place
Comatose
state of unconsciousness; unable to respond to voices or things around the environment
- won’t reply to any stimuli; even central pain
Decerebrate
abnormal body posture where arms and legs are held straight out, toes pointed downward, and head and neck arches backward with tightened, rigid muscles; indicative of severe damage in brain
External FIxator
device used to immobilize a body part following a fracture or certain orthopedic problems to allow bone healing
Glasgow Coma Scale
international tool used to measure the level of consciousness for traumatically injured patients
Mandibular Pressure
application of pressure on the mandible at the angle of the jaw
Nasal Cannula
small plastic tube connected to two short prongs that are inserted into the nares to supply oxygen directly from a flow meter or through humidified air to the patient
Never Events
errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility
Semicomatose
imprecise term for a state of drowsiness and inaction, in which more than ordinary stimulation may be required to evoke a response, and the response may be delayed or incomplete`
Current Shift Assessment
patient assessment completed at the beginning of each shift to develop a plan of care
Decorticate
abnormal body posture where person is stiff with bent arms, clenched fists, and legs held out straight
- arms bent in toward the body and wrists and fingers are bent and held on the chest
- indicates severe brain damage
Obtunded
state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states
Sequential Compression Devices
mechanical prophylactic(prevention) treatment to reduce the incidence of venous thromboembolism (VTE) by enhancing the blood flow in the deep veins of the leg
Stuporous
not fully conscious
Thrombo Emboli Deterrent Stockings
stockings designed and worn to support the venous and lymphatic drainage of the leg to help stop blood clots from forming
What is culture ?
knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by a person as a member of society
- shared beliefs and values
What is Ethnicity ?
characteristics that a group may share
- language/dialect, race, religious beliefs, geographic orgin, etc
- internal sense of distinctiveness
What is spirituality ?
born out of each person’s unique life experiences and his or her personal effort to find purpose and meaning in life
- life meaning, purpose and connection to others
- nonreligious systems of beliefs and values
- metaphysical or transcendental phenomena
What are some barriers to assessing spiritual needs ?
Personal/Individual Barriers:
- nurses may see the patient’s spiritual needs as a private or family matter and not their responsibility
- Nurse discomfort, embarrassment, or uncertainty of their own spirituality
- Nurse may feel uncomfortable with situations that result in spiritual distress (suffering, grief)
Knowledge Barriers:
- Nurse lack knowledge of spiritual and religious beliefs of others
- Nurse may have minimal education on spiritual assessment
What are some important things to remember about cultural assessment ?
- be sensitive
- ask questions
- gather info specific to the individual patient
- avoid stereotyping
- document your assessment findings so all members of healthcare team have your data from your cultural assessment
What are the components to developing cultural competence ?
- cultural desire
- cultural awareness
- cultural knowledge
- cultural skill
- cultural encounters
What is cultural desire ?
an internal motivation to develop skills interacting with people from other backgrounds
- be respectful of different cultures and let go of your own biases/prejudices
What is cultural awareness ?
a process of self-reflection of one’s own culture and their reactions to people from other backgrounds
- assess your own belief’s and cultural heritage
- this can influence the way you hear and understand others
- identify your feelings gained from experiences from different cultures
- you are aware of your own strengths and weaknesses
What is cultural knowledge ?
a process to intentionally learn about beliefs, customs, traditions of people from other backgrounds
- participate in lifelong learning to appreciate cultural preferences
- helps your provide an insight into the differences and similarities among people
- don’t assume that all people from a particular group are the same
- use your knowledge as a foundation for learning about beliefs, values, and customs of each patient
What is cultural skill ?
the ability to assess and interpret information, adapt communication style, establish relationships
- perform a culturally based health assessment
- interpreter may be necessary
What is cultural encounters ?
the interaction with individuals from diverse cultural backgrounds
- use knowledge of health beliefs, practices and communication patters when interacting with health care consumer
What is FICA ?
spiritual assessment tool
- what is your FAITH tradition ?
- how IMPORTANT is your faith to you ?
- what is your CHURCH or COMMUNITY of faith ?
- how do your religion and spiritual beliefs APPLY to your health ?
- how can we ADDRESS your spiritual needs ?
What do you assess in a patient with a nasal cannula ?
- respiratory effort and O2 sat
- any sputum
- skin of nares and behind of ears for redness and signs of pressure from prongs and tubing
What do you assess in a patient with a oxygen mask ?
- use of accessory muscles to breathe or tripod sitting
- inspect skin of face for redness or indentation from facemask and behind helix of ears for signs of pressure
What do you assess in a patient with a tracheostomy ?
can’t speak since air goes through tube and not vocal cords
- tube held in place with tie around their neck that warms and humidifies the air
- respiratory effort
- amount and color of secretions suctioned from tube
- inspect skin around tube for redness, excoriation, or skin breakdown
What do you assess in a patient with a chest tube ?
tubs work with gravity or suction
- assess pain from surgical site
- dressing around tube should be intact and dry
- don’t remove dressing unless surgeon is ready to remove the tubes
- color and amount of drainage noted
What do you assess in a patient with a gastrostomy tube ?
- inspect oral mucous membranes for moisture
- inspect skin around tube for redness, edema, and drainage
- gingiva and oral mucous membrane should be pink and moist
What do you assess in a patient with a nasogastric tube ?
- inspect skin of nose with tube for redness from pressure
- inspect tape attacking the NG tube to ensure its secure
What do you assess in a patient with a wound drain ?
- assess the site of drain insertion for leakage, redness, or irritation
- is drain is secure with tape or suture
- patency of drain
What do you assess in a patient with a ostomy ?
- inspection of stoma
- inspect skin around stoma
- inspect character of stool and colostomy appliance
- skin around stoma should be red and moist without lesions, irritation, and be intact
What do you assess in a patient with a cast ?
- assess circulation, movement, and sensation of fingers/toes distal to cast
- assess capillary refill
- temp and color of skin
What do you assess in a patient with a external fixator ?
is metal wiring that holds bones in place while they heal
- assess circulation, movement, and sensation of limb
- capillary refill
- inspect insertion site for infection (redness, edema, irritation)
What do you assess in a patient who is unconscious ?
- ensure they are breathing
- use Glasgow Coma test
- assess vital signs
