Exam 1 Flashcards
1
Q
the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations.
A
Nursing
2
Q
- To promote health
- Prevent illness
- Restore health
- Coping with death or disability
A
4 broad aims in nursing
3
Q
Assessment
Diagnosis
Planning
Implementation
Evaluation
A
ADPIE
4
Q
- preparing for data collection
- collecting data
- identifying cues and making inferences
- validating data
- clustering related data and identifying patterns
- reporting and recording data
A
Assessing
5
Q
vitals, demographics, family/medication history
A
assessing
6
Q
- initial comprehensive assessment
- focused assessment
- emergency assessment
- time-lapsed assessment
A
types of nursing assessments
7
Q
- Performed shortly after admittance to hospital
- Performed to establish a complete database for problem identification and care planning
- Performed by the nurse to collect data on all aspects of patient’s health
A
initial comprehensive assessment
8
Q
- May be performed during initial assessment or as routine ongoing data collection
- Performed to gather data about a specific problem already identified or to identify new or overlooked problems
- Performed by the nurse to collect data about the specific problem
A
focused assessment
9
Q
- Performed when a physiologic or psychological crisis presents
- Performed to identify life-threatening problems
- Performed by the nurse to gather data about a life-threatening problem
- Ex. Acute respiratory distress, suicidal ideation, severed limb, epilepsy, stroke, MI, chest pain
A
emergency assessment
10
Q
- To compare a patient’s current status to baseline data obtained earlier
- To reassess health status and make necessary revisions in care plan
- By the nurse to collect data about current health status of patient
A
time-lapsed assessment
11
Q
Which one of the following assessments would be performed on a patient to gather data on previously diagnosed liver cancer?
A
focused assessment
12
Q
patient, family/significant others, patient record, nursing and other healthcare literature
A
sources of patient data
13
Q
- nursing observation
- patient interview
- physical assessment
A
methods of data collection
14
Q
inspection, palpation, percussion, auscultation
A
physical assessment
15
Q
- ABC
- Vital signs
- Level of consciousness
A
establishing assessment priorities
16
Q
airway
breathing
circulation
A
ABC
17
Q
blocked (choking or anaphylaxis) or patency
A
airway
18
Q
wheezing, cough, or clear
A
breathing
19
Q
bleeding, clotting
A
circulation
20
Q
temp, pulse, BP, respiratory, pain rating and description
A
vital signs
21
Q
- awake and alert
- lethargic
- stuporous
- comatose
A
level of consciousness
22
Q
- fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands
- Awake: Eyes are open
- Alert: follows directions
- Oriented: know who you are, where you are, and why you are there
- A&O x 4: awake and oriented to person, place, time, and situation
A
awake and alert
23
Q
appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient’s name
A
lethargic
24
Q
unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements
A
stuporous
25
ex. Sternal rubs is very painful and will wake them up and their purposeful movement is their reaction of pain
purposeful movement
26
cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma
comatose
27
- Information perceived only by the affected person
- symptoms
- ex. pain description, gender
subjective data
28
- Observable and measurable data seen, heard, or felt by someone other than the person experiencing them
- AKA signs
- Example: vital signs, BP, height, weight, breath sounds, biological gender
objective data
29
- One of the nurse's primary ethical responsibilities is safeguarding the privacy of patients
- Nurses must be familiar with their institution's policies on privacy and on the requirements of the Health Insurance Portability and Accountability Act (HIPPA)
- American Nurse Association and National Council of State Boards of Nursing united to provide guidelines on social media for nurses
privacy, confidentiality, and professionalism
30
True or false: a patient rates his pain as a "7" on a pain rating scale. This rating is considered to be objective data
False
31
- interpret and analyze patient data
- identify patient strengths and health problems
- formulate and validate nursing diagnosis
- develop a prioritized list of nursing diagnoses
- detect and refer signs and symptoms that may indicate a problem beyond the nurse's experience
Diagnosis
32
- Individualizing patient care
- Defining domain of nursing to health care administrators, legislators, and providers
- Seeking funding for nursing and reimbursement for nursing services
benefit of nursing diagnoses
33
- Describes patient problems nurses can treat independently
- Ex. Deficient fluid volume
nursing diagnoses
34
- Describes problems for which the physician directs the primary treatment
- Ex. Dehydration
medical diagnoses
35
- problem-focused
- risk
- health promotion
types of nursing diagnoses
36
- Undesirable human response to a health condition/life process
- Ex: Imbalanced nutrition
problem-focused nursing diagnosis
37
- Vulnerability for developing an undesirable human response to health conditions/life processes
- Ex. Risk for infection
risk nursing diagnosis
38
- Motivation and desire to increase well-being and to actualize human health potential
- Ex: readiness for enhanced self-care
health promotion nursing diagnosis
39
- Phrase as patient problem of altered health state
- Patient problem must precede etiology linked by "related to" (R/T)
- Defining characteristics should follow etiology linked by "as evidenced by" (AEB)
- Write in legally advisable terms
- Use non-judgmental language
- Problem statement states what is unhealthy or what patient wants to enhance
- Reread the diagnosis, ensure problem statement suggests outcomes and etiology directs selection of nursing measures
guidelines for writing a nursing diagnosis
40
identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient's health problem)
problem (nursing diagnosis)
41
suggests the patient outcomes (expectations for change)
purpose of problem (nursing diagnosis)
42
identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors)
etiology (nursing diagnosis)
43
suggests the appropriate nursing measures
purpose of etiology
44
identify the subjective and objective data that signal the existence of the problem (cues that reflect the existence of a problem)
defining characteristics (nursing diagnosis)
45
suggest evaluative criteria
purpose of defining characteristics (nursing diagnosis)
46
Which of the following nursing diagnoses is written correctly?
A) Child abuse related to maternal hostility
B) Breast cancer related to family history
C) Deficient knowledge related to alteration in diet
D) Imbalanced nutrition related to insufficient funds in meal budget
D
47
A nursing is caring for a pt who presents with labored respirations, productive cough, and fever. What would be the appropriate nursing diagnoses for this patient? Select all that apply
A) Bronchial Pneumonia
B) Impaired gas exchange
C) Ineffective airway clearance
D) Infection related to pneumonia
E) Risk for septic shock
B, C, E
48
A nurse makes a clinical judgement that an African American man in a stressful job is more vulnerable to developing hypertension than a white man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis?
Risk
49
- establish priorities
- identify expected patient outcomes
- select evidence-based nursing intervention
- take into consideration patient and nurse capabilities, time, and resources
Outcome identification and planning
50
1. Individualized, patient-centered care (or person-centered care)
2. Prioritization
3. Bias
4. Scope of standards of nursing practice
5. EBP
6. Realistic, specific, and measurable
7. Consider long-term vs. short-term
Keep "big picture) in focus: consider discharge goals
choosing outcomes and interventions
51
- Holistic
- Assess how patient is doing at every encounter
- Partner with patient using shared decision making
- Patient +/- family actively participate in own care
- Open communication with respect and compassion
individualized, patient-centered care
52
- full transparency and fast delivery of information
- mission and values aligned with patient goals
- care is collaborative, coordinate, accessible
- physical comfort and emotional well-being are top priorities
- patient and family viewpoints respected and valued
- patient and family always included in decisions
- family welcoming in care setting
patient-centered care
53
The nurse enters the room of a 32 y/o pt new cancer (CA) dx at 1900. pt scheduled for surgery in AM. Pt observed talking with mother and crying, stating "this is so unfair"; states that she has so many questions. Order in chart: bowel prep enema to be given during night shift. Pre-op checklist to be completed. The nurse establishes priorities for which of the following situations first?
A) Begin enema
B) Talk with patient about past experiences with illness
C) Talk with patient about concerns and acknowledge her sense of unfairness
D) Begin reviewing pre-operative checklist with patient
C
54
- what problems need immediate attention and which ones can wait?
- ABC
- Maslow's hierarchy
- Which problems are your responsibility and which do you need to refer to someone else?
- which problems can be dealt with by using standard plans (e.g. critical paths, standards of care)?
prioritization
55
basic needs
1) physiological needs: food, water, warmth, rest
2) safety needs: security, safety
psychological needs
3) belongingness and love needs: intimate relationships, friends
4) esteem needs: prestige and feeling of accomplishment
self-fulfillment needs
5) self-actualization: achieving one's full potential, including creative activities
Maslow's hierarchy
56
Which nursing diagnosis would most likely to be considered a high priority?
A) Acute pain
B) Impaired gas exchange
C) Risk for powerlessness
D) Activity intolerance
B
57
Practice in a manner that is congruent with cultural diversity and inclusion principles
bias
58
- Nursing school clinicals
- Employer protocols
- American Nurses Association (ANA): 3rd edition Nursing scope of practice
- State board of nursing
- Agency for healthcare research and quality (AHRQ)
- Quality and Safety Education for Nurses (QSEN)
- Joint Commission on Accreditation of Healthcare Organizations (JACHO)
scope of practice and standards of care
59
- PICO
- MEDLINE and CINAHL
- appraise: valid? important? relevant?
- integrate with clinical expertise and patient preference
evidence-based practice ideal
60
rely on protocols and guidelines
reality of evidence-based practice
61
- Using goals, objectives, and outcomes interchangeably
- Ex) For dx of acute pain "following administration of PRN analgesic, patient will report pain absent or diminished"
specific goals
62
- often means discharge planning that begins at admission and accounts for self-care at home
- Ex) Mrs. Goldstein returns to long-term care facility pain free with her incision healed and her left leg in good alignment
long-term goals
63
- Ex) whenever observed, pt will be lying in bed with legs in correct alignment (abductor pillow in place, if ordered)
- Ex) Before discharge, Mrs. Goldstein's hip incision will show signs of healing (skin surface approximate, free from signs of infection-redness, swelling, heat, purulent drainage)
short-term goal
64
1) expressing pt outcome as nursing intervention
2) using verbs that are not observable or measurable
3) including more than one pt behavior or manifestation in short-term outcomes
4) writing vague outcomes
common errors in writing pt outcomes
65
- carry out the plan
- continue data collection and modify the plan of care as needed
- document care
- taking into consideration developmental age and psychosocial background, ability and willingness to participate, and response to nursing measures and progress toward goal achievement
implementation
66
1) patient variables - developmental stage (ex. Alzheimer's pt) and psychosocial background/culture
2) nursing variables - resources? time? staff?, standards of care, questionable orders, anticipation
factors that could inhibit implementation
67
Which example illustrates a nurse variable influencing patient outcomes?
A) A patient in a SNF refuses to take their medications
B) A family whose monthly income falls below the poverty level is unable to afford formula for their newborn infant
C) A patient with alcoholism is unwilling to participate in AA meetings
D) A victim of sexual assault does not receive counseling in the emergency department because a counselor is not available
D
68
- Low value attached to outcomes
- Lack of understanding about the beliefs
- Lack of social support
- Adverse physical or emotional effects of treatment
- Inability to afford treatment
- Limited access to treatment
factors of patient nonadherance
69
- Assess --> Re-assess --> Revise --> Record
- Know the difference between direct and indirect care interventions
implementation phase
70
both physiological and psychosocial action; laying hands; direct care; interaction with pt
ex) Assisting with ambulating; Administering medication
direct intervention
71
intervention performed away from pt but on behalf of the pt
ex) consultation, calling social worker or case manager, ordering labs, prepping meds/Ivs
indirect intervention
72
- Right task
- Right circumstance
- Right person
- Right directions and communication
- Right supervision and evaluation
considerations when delegating nursing care
73
- clinical assessment
- initial client education
- discharge education
- clinical judgment
- initiating blood transfusion
- psychosocial support
RN scope of practice
74
- monitoring RN findings
- reinforcing education
- routine procedures (catheterization)
- most medication administrations
- ostomy care
- tube latency and enteral feeding
- specific assessments (eg. lung sounds, bowel sounds, neuromuscular checks)
LPN/LVN scope of practice
75
- activities of daily living
- hygiene
- linen change
- routine, stable vitals
- documenting input/output
- positioning
UAP scope of practice
76
The nurse is about to begin implementing care plan for 16 y/o patient with infant born prematurely 12 hours ago. Patient states "we will be fine on our own, I don't need any care right now." What is the nurse's best response?
A) "You know your personal situation better than I do, so I will respect your wishes"
B) "If you don't accept this help, your baby's health might suffer"
C) "Let's take a look at this plan together and see if we can fix it to meet your needs"
D) "I'm going to set a meeting with the social worker to talk to you"
C
77
True or False: When a patient fails to cooperate with the care plan despite the nurse's best efforts, it is time to reassign the patient to another caretaker
False
78
- measure how well the pt has achieved desired outcomes
- identify factors contributing to the patient's success or failure
- modify the plan of care, if indicated
Evaluation
79
1. Interpreting and summarizing findings
2. Collecting data to determine whether evaluate criteria and standards are met
3. Documenting your judgment (evaluative statement)
4. Terminating, continuing, or modifying the plan
5. Identifying evaluate criteria and standards (expected patient outcomes)
elements of evaluation
80
A nurse uses the classic elements of evaluation when care for patients. What is the correct order?
1. Interpreting and summarizing findings
2. Collecting data to determine whether evaluative criteria and standards are met
3. Documenting your judgment (evaluative statement)
4. Terminating, continuing, or modifying the plan
5. Identifying evaluative criteria and standards (expected patient outcomes)
5,2,1,3,4
81
1) Nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan
2) The nurse identifies factors that contribute to the patient's ability to achieve expected outcomes and when necessary, modifies the care plan. Includes ongoing assessment
Evaluation steps
82
allow the patient's achievement of expected outcomes to direct future nurse-patient interactions
purpose of evaluation
83
A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which statement is written correctly?
A) "outcome not met"
B) "1/21/20 - patient reports no change in diet"
C) "Outcome not met. Patient reports no change in diet or activity level"
D) "1/21/20 - Outcome partially met. Patient reports increased activity since last visit, but no change in diet"
D
84
Assessment - "My husband and I are afraid we won't know what to do with the baby when we get home"
Diagnosis - Nursing Dx: High risk for altered parenting R/T no previous experience in childbearing and fear
Planning - Expected outcome: before discharge, parents will demonstrate confidence in…Holding, diapering, bathing, and feeding baby
Implementation - Nursing interventions: nurse observes mother and infant during initial feeding sessions and offers teaching and support as needed
Evaluation - Evaluative statement: 6/14/22 outcome partially met, both parents correctly demonstrated holding, diapering, and bathing. Mother is still concerned baby is not getting enough milk
Revision - Provide revision if outcome partially met. Continue to spend time with mother and infant during feeding - provide positive reinforcement. Could add items: Schedule appointment with in-hospital lactation consultant
Re-assess: If during following shift mother indicates "she's eating so well". Re-do your assessment of mother and infant and observe improved technique and confidence, without interruption of feeding…outcome met
Result: Care plan terminated bc outcome achieved
ADPIE example
85
What is the number 1 way to break the chain of infection?
hand hygiene
86
- #1 way to break chain of infection
- should be performed before and after ascetic technique
- should be performed after being exposed to fluid
- should be performed after being exposed to pt surroundings
hand hygiene
87
1) hand hygiene
2) PPE
3) Equipment
4) Environmental
5) Linens
6) Needles
7) Resuscitation
8) Placement
9) Respiratory
standard precautions
88
- use soap and water for 20 seconds
- need to do this for C.diff
hand hygiene
89
- consider all body substances potentially infectious
- determined by mode of transmission of disease
- mask, gloves, gown, face shield, respirator
PPE
90
- Wipe it down; Pay attention to which wipes you are using and how long it needs to stay wet
- C.Diff uses specific wipes
- BP machine, glucometer should be wiped down before/after each patient
equipment
91
wiping down side table, rails, disposable curtains
environmental
92
- should be covered
- should have a change as needed (PRN)
linens
93
- Automatic snap to protect healthcare provider from sticks
- Dispose in sharps container
- Never re-cap
needles
94
- No mouth-to-mouth
- Gloves
- Mask
resuscitation
95
- Placement of pt on unit; where is the pt stationed
- If they have a certain disease that is highly contagious where do you place the pt
- If two patients have the same condition they can be placed in the same room; cohorting
placement
96
placing 2 patients in the same room because they have the same disease
cohosting
97
try to teach pt cough etiquette
respiratory
98
includes all activities to prevent or break the chain of infection
2 categories; medical and surgical
asepsis
99
clean technique (standard precautions); regular gloves for tasks such as vitals, glucose reading
medical asepsis
100
sterile technique; sterile gloves for tasks such as placing Foley catheter and tracheostomy care
surgical asepsis
101
can go beyond 6 ft; ex. measles, TB
aerosolized
102
drops in close proximity (3 ft); ex. ebola, flu
droplet
103
- use gloves, wash hands before/after, wiping down equipment, etc.
- treat everyone as if they have something
standard precautions
104
Standard precautions PLUS:
- Negative air-pressure room, so door must be kept closed
- N-95 respiratory
- surgical mask on patient if must be transported
airborne precautions (respiratory isolation)
105
- used in airborne precautions
- takes the air and filters it outside of the hospital
negative pressure room
106
Transmission by aerosolized, airborne droplet nuclei; 6 ft
airborne precautions
107
Measles, TB, Covid, Chickenpox (Varicella)
airborne
108
Transmission by close contact with large, particle droplets from respiratory tract; 3 ft
droplet
109
Ebola, Pneumonia (PNA), Flu, Whooping Cough, Bacterial Meningitis
droplet
110
Standard precautions PLUS:
- Surgical mask within 3-6 feet of pt
- Door may remain open
- Isolation preferred, or roommate with similar infection
- Gown if expecting contact with secretions (ex. Suctioning)
droplet precautions
111
Transmission by direct patient contact or contact with items in patient's room
contact
112
C. diff, MRSA
contact
113
Standard precautions PLUS:
- Gown and gloves required
- Patient-dedicated equipment
- Door may remain open and masks are not required
- Isolation preferred, or roommate with similar infection
contact precautions
114
1) Gown
2) mask or respirator
3) goggles/face shield
4) gloves
donning PPE
115
1) gloves
2) goggles/face shield
3) gown with ties in back
4) mask - OUTSIDE ROOM
5) hand hygiene
doffing PPE (method 1)
116
1) gown and gloves
2) goggles/face shield
3) mask - OUTSIDE ROOM
4) hand hygiene
doffing PPE (method 2)
117
what % of older adults living in institutional long-term care settings experience a fall every year
50-75%
118
what % of older adults who fall suffer serious injuries?
20-30%
119
how many patients a year are hospitalized because of a fall injury, most often because a head injury or hip fracture
over 800,000
120
- older age
- history of falls
- gait impairment
- balance disorders
- orthostatic or postural hypotension
- depression
- muscle weakness
- chronic conditions such as dementia, arthritis, Parkinson's disease, orthostatic hypotension
intrinsic risk factors for fall
121
- polypharmacy
- loose carpets
- use of adaptive devices such as cane and wheelchairs
- inadequate lighting and footwear
- use of physical restraints
extrinsic/environmental risk factors for fall
122
- anyone 65 and older
- main cause of injury fatality
- changes in physical strength, sensation, reaction time, and polypharmacy
older adults and falls
123
- lower the bed
- furniture placement
- equipment placement
- slippery floors
- rugs/bedding
- crowding; insufficient space to move walking aids
environmental assessment
124
- completed on admission and throughout stay; after a fall; and transfer to a new unit
- used on all patients regardless of age
- 0 or 25 score; no in-between
morse fall scale
125
- older adults with unsteady gait
- history of falling
- assess mobility status, communication, level of awareness or orientation, sensory perception
continuous mobility assessment
126
is poor lighting (as a fall risk factor) individual or environmental and can you modify it?
environmental; modifiable
127
is orthostatic hypotension (as a fall risk factor) individual or environmental and can you modify it?
individual; modifiable
128
are floor rugs (as a fall risk factor) individual or environmental and can you modify it?
environmental; modifiable
129
is sundowning (as a fall risk factor) individual or environmental and can you modify it?
individual; environmental; modifiable (but hard to)
130
are side effects of psychoactive (as a fall risk factor) individual or environmental and can you modify it?
individual; modfiable
131
is a sensory deficit (as a fall risk factor) individual or environmental and can you modify it?
individual; modifiable
132
is lower body weakness (as a fall risk factor) individual or environmental and can you modify it?
individual; environmental; modifiable
133
risk for falls related to ____(difficulty with gait; A&O x 2); use of restraints; medication side effects) as evidenced by ______ (activity intolerance; risk for injury; impaired physical mobility)
NANDA Fall Risk
134
high risk for falls on fall scale
assess (fall risk nursing process)
135
risk for falls r/t unsteady gait
nursing dx (fall risk nursing process)
136
Outcomes:
- patient will not sustain fall during hospitalization
- patient will demonstrate 3 fall preventive measures before discharge
- patient implements 2 fall prevention strategies at home before next visit
planning (fall risk nursing process)
137
1) Place fall risk leaf on door and/or in chart
2) Place or encourage non-slip footwear
3) Keep call light in reach and bed in lowest position
4) Further assessment of risk factors
5) Education on home strategies, like grab bar
6) Notify OT of patient needs
7) Keep lighting well
8) Wristband
9) Bed in lowest position
10) Bed rails raised
i. At least 2; all 4 are considered a restraint
11) Administer prescribed vitamin D and calcium supplements
12) Assist with establishment of exercise routine (Note: reduce risk of falls 13-40%)
13) Keep wheels on chair locked
14) Leave bedside table within patient's reach
15) Document changes in cognitive status
16) Notify charge nurse of need for sitter
17) Re-assess fall risk using Morse Fall Scale
18) Restraints as last resort
interventions (fall risk nursing process)
138
0700, client was attempting to get out of bed without assistance. Client was re-oriented to room and provided with bedside urinal
implementation (fall risk nursing process)
139
6/1/20, outcome partially met, client was wearing nonskid footwear but began to slip while moving to bedside commode, second assist was necessary to prevent fall
evaluation (fall risk nursing process)
140
have pt lean on you and slide down your body; smooth assist to the floor
assisted fall
141
What should you do if your patient has fallen?
1) immediately assess pt condition (ABC, injury, orientation)
2) provide appropriate care
3) Notify patient's physician or primary caregiver of incident and your assessment of the patient
4) Ensure prompt follow-through for any test orders (example: CT scan)
5) Evaluate circumstances of the fall and the environment; institute preventive measures
6) Document incident, assessments, and interventions in medical record and complete a safety event report per facility policy
142
The nurse is filling to a safety event report after a confused patient fell when getting out of bed. What action is performed appropriately?
A) The nurse includes suggestions on how to prevent the incident from recurring
B) The nurse provides details to charge nurse to fill out report
C) The nurse discusses the details with the patient before reporting them
D) The nurse records circumstance and effects on patient in safety report
D
143
- Any physical device used to limit patient movement
- Ex. ties, include mitts, bed rails, and geriatric chairs with attached trays
- Medications can be used as chemical forms
- can increase risk of falls, such as slipping through bed rails or trying to climb over them
- should be used as a last resort
- when used, require frequent monitoring
- require an order and communication with patient's family
restraints
144
The nurse is caring for a patient in a long-term care facility. The nurse identifies which patients to be at higher risk for falls? Select all that apply
A) Patient older than 50
B) Patient who has fallen twice before
C) Patient who is taking antibiotics
D) Patient who is experiencing postural hypotension
E) Patient who is experiencing nausea from chemotherapy
F) A 70 y/o patient who transferred from hospital to skilled nursing facility (SNF)
B, C, D, E, F
145
- Assess the patient's skin at least daily and after every episode of incontinence
- Cleanse the skin when indicated, such as when soiled, using a no-rinse, pH-balanced skin cleanser
- Avoid using soap and hot water; avoid excessive friction and scrubbing
- Minimize skin exposure to moisture (incontinence, wound leakage); use a skin barrier product as necessary
- Use skin moisturizers or creams after bathing and as needed
general skin principles
146
- Pressure
- Dessication (dehydration)
- Maceration (overhydration)
- Trauma
- Edema
- Infection
- Excessing bleeding
- Necrosis (death of tissue)
- Presence of biofilm (grouping microorganisms)
local factors affecting wound healing
147
- Age
- Circulation and oxygenation
- Nutritional status
- Wound etiology
- Health status
- Immunosuppression
- Medication use
- Adherence treatment plan
systemic factors affecting wound healing
148
- skin is more easily injured
- skin has less capacity to insulate
- skin wrinkles more easily
- sensation of pressure and pain is reduced
subcutaneous and dermal tissues become thin
149
- skin becomes dryer
- pruritus (itching) may occur
activity of the sebaceous and sweat glands decreases
150
- healing time is delayed
cell renewal is shorter
151
- hair becomes gray-white
- skin may be unevenly pigmented
melanocytes (cells that make the pigment that colors hair and skin) decline in number
152
skin loses elasticity
collage fiber is less organized
153
- subcutaneous and dermal tissues becomes thin
- activity of the sebaceous and sweat glands decreases
- cell renewal is shorter
- melanocytes decline in number
- collagen fiber is less organized
age-related changes in skin
154
- do not apply tape to skin unless necessary
- check skin frequently for any signs of a pressure injury
- pad bony prominences if necessary
- asses pressure tolerance by checking pressure points for redness after 30 minutes
nurse strategies to subcutaneous and dermal tissue thinning
155
- clean perineal area daily but do not bathe full body on a daily basis
- apply lotions and moisturizers as needed
- encourage adequate hydration
- eliminate the use of harsh soaps
nursing strategies for sebaceous and sweat gland decrese
156
perform careful skin assessments, looking for signs of skin breakdown
nursing strategy for shorter cell renewal time
157
assist patient with skin checks, observing for any signs of melanoma and other skin abnormalities
nursing strategy for melanocyte decline
158
check skin frequently for tears, irritation, or breakdown
nursing strategy for less organized collagen fibers
159
- appearance (sight and smell)
- character of drainage (serous; sanguineous; serosanguineous; purulent)
- other things present? (maggots)
- measure (length in cm; width; depth)
- sutures, drains or tubes, and any complications
wound assessment
160
- open systems
- closed systems
- negative pressure wound therapy
types of drainage systems
161
- gauze, iodoform gauze
- penrose drain
open systems
162
- Jackson-pratt (common with breast augmentation)
- hemovac (larger surgeries)
- t-tube
closed systems
163
- infection
- hemorrhage
- dehiscence and evisceration
- fistula formation
wound complications
164
- edema/erythema
- odor
- purulent drainage
infection signs
165
- bleeding too much
- loose sutures/staples
hemorrhage signs
166
suture/staple/glue split open
prevention: hug abdomen to splint wound before coughing/sneezing; prevent pressure from exerting on injury
dehiscence
167
organ pops out; intestine popping out
evisceration
168
Internal vessel popping out of body
fistula
169
* Localized injury to skin; usually caused by pressure
* Risk assessment (Braden scale)
* Mobility
* Nutritional status
* Moisture and incontinence
* Appearance of existing pressure injury
* Pain assessment
* Diagnosing
pressure injury assessment
170
- sensory perception: ability to respond meaningfully to pressure-related discomfort
- moisture: degree to which skin is exposed to moisture
- activity: degree of physical activity
- mobility: ability to change and control body position
- nutrition: usual food intake pattern
- friction and shear
average score at end of assessment
Braden risk assessment
171
- occipital bone; scapula; vertebra; sacrum; coccyx; heel
- frontal bone; mandible; humerus; sternum; tuberosity of pelvis; patella; tibia
- scapula; ribs; hip; lateral knee; ankle
common sites for development of pressure injuries
172
as related to:
- external: chemical injury agent, moisture, pressure over bony prominences, hypothermia/hyperthermia
- internal: alteration in fluid volume, inadequate nutrition, psychogenic factor
as evidenced by...
- acute pain
- bleeding, redness, hematoma
- presence of a pressure injury; destruction of skin layers
- presence of intentional or unintentional wound; disruption of skin surface
impaired skin integrity nursing dx
173
related to:
- alteration in skin integrity
- malnutrition
- obesity
- stasis of body fluid
- associated with chronic illness, immunosuppression, and invasive procedure
as evidenced by...
- acute pain
- bleeding, redness, hematoma
- presence of a pressure injury; destruction of skin layers
- presence of intentional or unintentional wound; disruption of skin surface
risk for infection nursing dx
174
related to:
- alteration in skin integrity
- malnutrition
- obesity
- stasis of body fluid
- associated with chronic illness, immunosuppression, and invasive procedure
as evidenced by:
- expresses desire to enhance choices of daily living for meeting goals
- expresses desire to enhance management of prescribed regimens
- expresses desire to enhance management of risk factors
readiness for enhanced health management nursing dx
175
- Clear and accurate
- Skin and wound assessment tool
- Include
○ Specific location on body
○ Type
§ Surgical, pressure, stab, laceration, etc.
○ Measurement in mm or cm
§ Length, width, depth, tunneling (depth, direction)
○ Description
§ Odor, color, wound edges, wound bed, character of drainage if present, wound stage if pressure injury)
wound documentation
176
non-blanchable erythema of intact skin (when you depress skin, the color remains red)
stage 1
177
partial-thickness skin loss with exposed dermis
stage 2
178
- full-thickness skin loss; not involving underlying fascia
- Fat visible; no bone, tendon
- Tunneling may begin; describe it as oriented to a clock
stage 3
179
- full-thickness skin and tissue loss
- Muscles, bone, ligaments visible
stage 4
180
- obscured full-thickness skin and tissue loss
- Obscured by necrotic skin or slough (eschar)
- Needs to be debrided via Chemical through ointment or Mechanical when physician carves away at skin until bleeding
unstageable
181
- aka DTI, persistent non-blanchable deep red, maroon, or purple discoloration
- may feel cool to touch
- feels like bad tomato
- often at the heel of foot
deep tissue pressure injury
182
flat on back
supine
183
flat on stomach
prone
184
laterally on side
sim's position
185
sitting at 90 degrees
fowler
186
sitting at 35-50 degrees
semi-fowlers
187
- head towards the floor
- feet towards ceiling
trendelenburg
188
- head to ceiling
- feet to floor
reverse trendelenburg
189
Effects of applying heat
----- Dilates peripheral blood vessel
----- Increases tissue metabolism
----- Reduces blood viscosity and increases capillary permeability
effects of applying cold
- constricts peripheral blood vessel
hot and cold treatments
190
- Use of proper body movement in daily activities
- The prevention and correction of problems associated with posture
- The enhancement of coordination and endurance
proper body mechanics
191
* Uncoordinated lifts
* Manual lifting and transferring of patients without assistive devices
* Lifting when fatigued or after recent back injury recovery
* Repetitive movements such as lifting transferring, and repositioning patients
* Standing for long periods of time
* Transferring patients
* Repetitive tasks
* Transferring/repositioning uncooperative or confused patients
variables leading to back injury in health care workers
192
- dangling
- 1 person nurse assist
- 2 person nurse assist
ways to ambulate a patient
193
- never allow anyone else to use their log-in
- computer system should time out when not in use
- log off system when leaving workspace
- printouts must be discarded appropriately
legal implications in nursing
194
ensures that patients have the following rights:
- To see and copy their health record
- To update their health record
- To request correction of any mistakes
- To get a list of the disclosures a health care institution has made independent of disclosures made for the purpose of treatment, payment, and health care operations
- To request a restriction on certain uses or disclosures
- To choose how to receive health information
health insurance portability and accountability act (HIPAA)
195
What to expect during your hospital stay
- High-quality hospital care
- A clean and safe environment
- Involvement in your care
- Protection of your privacy
- Help preparing you and your family for when you leave the hospital
- Help with your bill and filing insurance claims
patient bill of rights
196
what time is nursing documenting?
military clock
197
- complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document
- content
- timing
- format
- accountability
- confidentiality
- The law presumes that if something was not documented, it was not done
documentation aim
198
- computerized on EHR
- SOAP
- Care plans
- MARs
methods of documentation
199
- subjective
- objective
- assessment
- plan
Typhon note
SOAP
200
- Formal record of the patient's problems or diagnoses, related goals, outcomes, and interventions
- Multidisciplinary: provider, nurse, therapists, social workers, discharge planners, etc.
care plan
201
- Nurse who administered drug
- Drug name, dose, route, time, indication, effectiveness
medication administration records (MARs)
202
nurses are legally responsible for carrying out the orders of a provider unless a reasonable person would anticipate the order would lead to injury
questioning an order
203
- ambiguous or uses unapproved abbreviations
- contraindicated by normal practice, e.g. an abnormally high dose
- contraindicated by patient's present condition
when to question an order
204
- what you taught (topic)
- how was it taught (format of delivery, e.g. verbal, written material, video)
- evaluation of patient's understanding (verbalized understanding, teach back method, or return demonstration of a task to be completed upon discharge)
documenting patient education
205
- how to document a pt situation when providers are not responding to calls for assistance
- document the facts of the incident, avoid incriminatory statements
- document time the health care provider was called, time of response, or lack of response, and subsequent nursing response
documentation of urgent/emergent situations
206
- aka variance or occurrent reports
- used for quality improvement or identifying high-risk patterns in the care of patients
incident reports
207
- unexpected occurrence --> death or serious physical or psychological injury
- ex: wrong-side surgery, suicide, operative/postoperative complications
sentinel events
208
- include a complete account of what happened in the patient's record as well as in the incident report
- documentation in patient record, however should not include that fact that the incident report was filed
incident reports and sentinel events
209
- Hemostasis (immediate) → blood vessels constrict, blood clotting exudate
- Inflammatory (2-3 days) → WBC’s migrate to wound, pain, heat, redness, swelling, mildly elevated temp
- Proliferation (several weeks) → granulation tissue, WBC’s leave the wound, adequate nutrition and O2 needed
- Maturation (~3wks-months/years) → collagen remodeled, scar develops, healing times vary
stages of wound healing
