Exam 1 Flashcards
Who develops the code of ethics for nurses, which defines the nurse’s responsibilities and set the standard of nursing practice/scope?
ANA : American nurse association
What does the NLN do?
Conduct nclex and pre entrance testing,
Develops and improve nursing Ed
Provides accreditation
What does the nurse practice act state?
It varies by state
Define legal scope
Establish criteria for Ed and licensure nurses
Who over seed the nurse
The national council of board
What does the joint commission do?
Pt safety goal
Accredits hospital
What’s evidence base practice ?
As evidence changes, so must practice
What are the profession values of nursing ?
Altruism - concern for others
Human dignity
Integrity : acting in accordance
Social justice
What are some examples of bioethics? (5)
Autonomy - pt right to make decison
Nonmaleficence - duty to do no harm
Beneficence- do go, benefit pt
Justice
Fidelity -faithful to agreement /promise
Veracity : telling the truth
List examples of international torts
Assault : threat
Battery: carrying out that threat
Defamation: spoken remarks to reputation
In o privacy : Hipa
False imprisonment : preventing movement form another perosn that’s unjustifiable
Fraud
Examples of unintentional torts
Negligence: did not mean to inflict harm on pt
Malpractice: negligence that’s applied to a profession ( can be a lawsuit )
What are some examples of malpractice ?
Failure to follow standards of care
Use equipment responsible
Assesse and minitor
Communicate
Document
Act as pt advocate
What’s an informed consent?
A voluntary written permission by pt to perform specific test/procedure
( not needed in emergency
Pt much me alert and oriented to sign , has write to refuse
Under what circumstances can’t a pt give consent ( 3 M’s)
Minors ( varies by state
Mentally I’ll
Medicated with certain medication that disrupts thought process
Advance directives
Written directive that gives directions that an individual can act on their behalf either through death or pt not alert and oriented
Living will vs healthcare proxy
Written document by a person for directions on the type of healthcare they would like to recieve in a particular End of life situation
Healthy care proxy; document that states who has the right to malt healthcare proxy in the event that pt can’t give consent
What happens when there’s no living will?
Next of ken ; spouse if not married parents
No next of ken? Ethics committee makes decisions
Molst
Stands for medical order for life sustaining treatment,
Order that stayed pt wishes regarding treatments commonly used in medical crisis
Comorbidity
Joint disease that makes things worse
Roles of the nurse?
Leader, counselor , caregiver advocate, collaborator delegate , educator
Never event vs sentinel event
Unexpected rare medical error that should never happen to a pt
Unexpectedly event involving death or serious physical injury
What is the race accronym
Rescue
Alarm
Confine
Evacuate
What’s is the nursing process?
A systematic method to guide nursing pratice , use to establish health care plan needs and strengthen
Describe the different process of the nursing process
Assemsnt : gather data and review with objective abs subjective data
Diagnose : clinical judgment on situation
Planing: develop goal, desired outcome and action plan
Implement: perform nursing action
Evaluation: we’re Desiree’s outcomes and goals achieved
What does it mean to delegate ?
The transfer of responsibility while attaining accountability for the outcome
What are some things that can not be delegated? ( do not eat )
Inital and ongoing nursing assessments
Determined of nursing diagnosis
Progress in relation to nursing plan
Supervision and education
Evaluate
Access
Teach
What task can be delegated?
Standard , unchanging procedures
Ex height weight, vital signs observing and reporting changes in pt
Therapeutic vs non therapeutic
Shows acknowledgement, Claire, focused, feedback , open questions and reflecting
Asking pt why?
Being defensive
Changing subject
Giving advice
Making judgement
Putting pt feelings on hold
Proving false assurance
How to commmunicate with visually impaired
Acknowledge presence in room
Identify self
Speak in normal tone
Explain reason for touches
Tell pt when conversations ends and when leaving ,
Keep call bell in easy reach
What are some interviewing techniques ?
Identify self, purpose of interview and role
Focus on pt comforbility
Eye contact
Listen attentively
Reflective questions
Open ended questions
Close ended to questions for specific
What do you look for in fall risk safety
Assess for any previous accident
Review meds that could put pt at risk for fall
Assess with pt on immediate environment , stairs use of throw rugs , grab bars
What are some risk factors
Muscle weakness , especially in the legs
Balance and gait, how one walk
Postulate hypotension
Reflexes may be slower
Foot problem that cause painful feet
Measures to prevent fall
Asses the client risk for falling
Print client to sorroundings
Asses client risk for falling
Assess the client frequently
Instruct client to seek assistance when getting up
Use safety devices
Adequate lighting
Eliminate clutter
Setting priorities for nurses
A- airway
B- breathing problems
C- cardiac circulation problems
Vital sign
Lab Val that’s life threatening
Musculoskeletal changes that increase risk for accidents
Strength and function of muscle decrease
Joints becomes less mobile
Postural changes
Nervous system changes
Voluntary and automatic reflexes become slower
Decrease ability to respond to multiple stimuli occurs
Decrease sensitivity to touch occurs
Sensory changes that increase risk accidents
Decrease vision and lens accomdation and cataracts
Delayed transmission of hot and cold impulses
I later hearing develops
Types of restraints
Wrist
Vest
Mitts
Belt
Risk of skin breakdown and contractures
Restrain must have provider order
Points system for restrain
2 points - every 24 h
4 points -every 8 h
Chest/vest every 8h
What must happen when pt is restraint?
Check restraint for circulation every 30min
Release every 2h for rom
Incase of emergency pt must be able to exist bed
Offer fluid if clinically indicated every 2 h
Offer bedpan every 2 h
How do you use fire extinguisher (pass)
Pull the pin
Aim for the base of fire
Squeeze the handle
Sweep from side to side
Remission vs exacerbation
When the disease is present but the person does not experience symptoms
Symptoms of disease reappear
What are some risk factors for illness/injury
Age
Genetic
Physiology
Health habits
Lifestyle
Environment
What are the levels of prevention
Primary - promoting and preventing the development of disease processes ex : diet, weight list exercise immunization, safe sex
Secondary- screening , people at risk for a Health problem , goal is to identify an illness and reverse or reduce severity
Teritiaty ( treatment, people with a health problem)
Eg, medication, surgical treatment, rehab, physical therapy, ot
Isolation precautions /standard
( blood borne)
Must be pratice for All pt in hospital regardless of diagnosis
Hygiene, gloves, mask , eye protection and gown when appropriate
Indication: hiv, hep b and c
Contact precautions
Must be in private rooms or cohort pt with same infectious disease
Gloves and gown
MRS WEE
Multi drug resistant
Respiratory Infections
Skin infection ( v chip)
Chicken pox
C diff, wound infection acute diarrhea
Droplet precautions
Transmit by droplet expelled via coughing sneezing talking
surgical mask with eye shield for all personnel within 3 feet
Private room, pt only
Surgical mask with eye shields ( 3ft)
Gloves for contact with pt and environment
Indication: spider man
Step throat
Influenza
Rubella
Mumps/ meningitis
Pimp: pretisid,influenza, meningitis, pneumonia)
Airborne precautions ( mtv)
Single private room maintained under negative pressure, door remains clues except entering and exiting , room have hepa mask
N95 or higher mask
Surgical mask on pt of leaving room
Ex measles
Chickpox
Herpes zoster
Tb
SARS
( measles tb, vericella )
Types of causative agent
Bacterial- most significant
Virus- smallest of all microorganisms
Fungi- plant like organism
Parasites - organism that lives on host and rely on nourishment
What are some ways to break chain of infection with reservoirs
Change dressings
Appropriate skin and oral hygiene
Dispositions if damp soiled linens
Deposes if feces and urine
Cover all fluid containers
Empty suction and drainage bottle at in of shift
Modes of transmission for infectious agent ?
Direct
Indirect
Ingestion
Inhalation
When should you perform hand hygiene
Before touching pt
Before clean procedure
After body fluid exposure risk
After touching pt
After touching pt surroundings
Donning PPE
Gown
Mask
Googles
Gloves
Removing PPE
Gloves,
Googles
Gown
Mask
Asepsis vs medical
Abscencd of disease producing microorganisms, using method to prevent infection
Break the chain of infection in medical procedures
Reduce # and transfer of pathogens
Surgical a sepsis
Sterile technique
Prevent infection before and after surgery
Pray us that render and keep objects and area free from microorganisms
When is surgical asepsis used?
Dressing changed
Cathertetization
Surgical procedure
When is medical asepsis used?
Medication
Enemas
Tube feedings
Daily hygiene
Examples of immature immune system
Very young and old pt
Chronic diseases ( diabetes, infection hiv)
Autoimmune disease
Pt on medication that suppress immune system
Stages of infection
Incubation: pathogen invasion
Prodromal : early signs and symptoms
Full stage : specific signs and symptoms
Convalescent- revocery
Nosocomial infections
Hospital acquired ; pt didn’t come in with infection
Common types:
UTI
Cauti
Pneumonia
C diff
Factors that affect mobility
Chronic disease
Disease that affect neuro ( Parkinson’s)
Copd ( impact breathing )
Complications in immobility pt
Nervous: anxiety, isolation confusion and depression
Digestive: decrease appetite, low fluid intake
Skin: pressure ulcers , infections, skin breakdown, poor skin tugor
2 types of blood clots
Deep vein thrombosis ( dvtt): form in one or more of the deep veins in your body usually in the foot,
Embolism : traveling clot
Prevention: rom,
Anticoagulants
Antiemolosim device
Examples of antiembokism device
Scd sequential compression device : method that promotes blood flow to the legs, shape like sleeves that wrap around leg inflated with air 1 at a time
Compression socks/stocking: help to improve blood flow and prevent clot to form in legs
How does immobility affects the respiratory system?
Pneumonia
Decrease respiratory effort
Decrease oxygen of blood
Thickening of respiratory secretion
Respiratory tract infection
How does imobility affect urinary
Reduces kidney function
Urinary incontinence
UTI
Urinary retention
What’s the effects of immobility on the muscular system
Brittle bones
Contracture
Muscle weakness
Atrophy
Oeaterpirisis
Joint stiffness , pain impairs rom
What are the 3 types of exercise
Isotonic : weight lifting , increase muscle tone
Isometric : push ups , muscle length don’t change ( plank)
Isokinetic: resistive exercise ball , walking swimming jogging) rehab
Active rom
Passive rom
Active assistive rom
Pt independently moves joints
Pt unable to move independently, require total assistance
Pt required minimal assistance with rom
Supine /dorsal vs dorsal recumbent
Flat in bed; physical examination
Lying on back, hip and knees forced soles of feet flat on bed
Prone vs high Fowler
Lying on abdomen, head to side , for back massage or im injections
Sitting upright in bed with support , for severe dyspnea
Fowler ava semi Fowler
Head elevated 45-69 degree angle for dyspnea
Head elevated at 30, dyspnea
Chest knee vs lithotomy
Rental exam
Vaginal/rectal exam and treatment, vagina delivery
What is the control system for sleeping and walking?
Hypothalamus
Types of sleep
Nrem: stage 1-2 light sleep,
Stage 3-4 deep sleep/ slow wave sleep , everything decreases
REM: rapid eye movement,
More difficult to wake , dream takes place, brain highly active
What are some sleep disorders
Insomnia : difficultly falling asleep
Narcolepsy : uncontrollable desire to sleep anytime
Hypersomnia : excessive day time sleepiness
Sleep apnea: absence of breathing
Sleep deprivation: prolong lack of sleep , can result in loss of concentration, fatigue
Parasomniss: sleep walking
What are some nursing interventions for sleep ?
Adjust environment
Offer bedtime routine
Perform back rub
Asses pain level
No heavy meals 3 hours prior
Administer medication for sleep
Limit caffeine/smoking in evening
Avoid unnecessary disturbances
What are hypnotics
Drugs that induce unnatural sleep and manage insomnia
2 types
Short acting : induce sleep allow pt to be awaken wake in the Morninf
Intermediate acting: useful for sustaining sleep, maybe isolated with drowsiness
What are sedatives
Drugs used to provide sedation , usually prior to procedure
Zaleplon, ( sonata )
Eszopiclone ( lunesta)
Zolpidem ( ambien)
Are used to treat what?
Insomnia
Pallor vs erythema
Skin appear yellow brown and ashen gray, observed in mucus membrane, lips nails , ( happens when cutaneous vessels are severely constricted , skin have whitish hue
Rely on palpation, feeling for increase warmth on skin , redness cause by vasodilation
Cyanosis vs ecchymosisv
Most difficult to observe, lack of oxygen cause blushes tinge of the skin , inspect lips, tongue, conjunctivae Pam’s soles of feet
Medical term for bruise , blood vessels broken
Petechia vs jaundice
Round pinpoint spots of purplish red color resulting from itradermal bleeding , assess oral mucosa or conjunctivae
Excessive accumulation of bilirubin in the tissue produced a yellow color, check sclera of eye fir yellow discoloration
What are some tips on skin care
Frequent positioning
Avoid friction and sear ( lift don’t drag )
Use pressure relieving surfaces
Use emollient to hydrate dry skin
Protect from excess moisture
Braden scale
System used to check risk for pressure ulcer,
1 being the worst change and 4 having the best chance of not having it
Stages of pressure ulcer
Stage 1: skin intact, non blsnchable redness
Stage 2:
Partial thickness of lord dermis , break in skin
Stage 3: full thickness tissue loss, subq fat may be visible
Stage 4: exposed bone, tendon, muscle slough / dark pigment may be present
What kind of patients at risks for pressure ulcers ?
Older age
Diabetes
Decrease sensory perception
Dry skin, excessive moisture
Altered nutrition
How do we prevent pressure ulcers?
Daily skin assessment
Appropriate positioning
Frequent turning
Good nutrition
Maintain a safe bed
Skin care
Massage
Contusion vs avulsion
Blunt instrument, overlying skin remain intact with injury of underlying soft tissue
Tearing a stractute from Nintendo anatomical position, possibly damage to blood vessels
What’s the difference between open and close wounds
Skin surface is open proving portal of entry, bleeding tissue damage ( incision or abrasion )
Close: from a blow , force or strain cause by trauma such as a cal assault or motor vehicle crash ( evchymosis and hematomas )
Primary intention of wound healing
Well approximate ( skin edges tightly together)
Little tissue loss
Minimal scaring occurs
Most surgical wound heal by first intention healing
Secondary wound healing
Not well approximate
Would allows to granulate
Surgeon may pack wound with guard or use drainage system healing process may be slow
Large open wounds such as burns or major trauma , which require more tissue replacement
Tertiary wound healing intentions
Wound is intuallt cleaned, devreided and observed, typically 4-5 days before closure ,
Would purposely left open to allow Edna to resolve before closing
Types of drainage
Serous :clear and watery
Sanguneous :bright red contain RBC
Serosanguineous : clear light pink
Purulent: Ouse, thick, often with foul odor
Heparin sodium
Hep sq
Inactive thrombin,
Iv or subQ
Rapid onset within minutes
Brief usually for a few hours
Antidote : protamine sulfate
Monitor: aPTT ( activated partial thrombosis)
Side effects:
Low molecular weight
Adverse effect: hematoma anemia bleeding
Coumadin ( warfarin)
Inhibits synthesis of clotting factor
Po
Slow onset within hours
Prolong usually days
Antidote: vitamin K
Monitor : Pt and inr ( prothrombin time, international normalized ratio)
Adverse reaction: bleeding , purple toes muscle pain
Tachypnea vs bradypnea
Greater than 20
Lower than 12
Average ( 12-20)
What is pca
Patient controlled analgesia,
Let’s you decide when you will get a dose of pain medication
Diphenhydramine ( Benadryl)
Antihistamine, use to treat allergies , can be used as sleeping aid
Benzodiazepines Valium
( Ativan)
Sedative hypnotic, can be used for anxiety, general anesthesia, sleeping aid
Adverse effect : sleep walk, drowsiness, headache dizziness, vertigo, lethargy
Antidote:
Lovenox ( enoxaparin)
Used to prevent or treat dvt
What labs are important before warfarin /Coumadin
Heparin:
PT
INR
PTT
What labs are important Benadryl
Benzodiazepines ( Ativan)
Red blood cells
Hgb
Hct
Azithromycin
Pcn, vancomycin
White blood cells : 4500- 11,000
Would culture + sensitivity
What are pt, ptt and inr?
Activated partial theomboplastin: measure time it takes in secs for recalcifies citrates plasma to clot after partial thromboplastin is added to it
Prothrombin time : produce by liver , nescsay for fibrin clot formation , measure the time it takes in seconds for clot formation and used to monitor response to warfarin
International normalized ratio ( if # too bld clot will not be prevented and if too high there’s an increase in risk of bleeding
What are some side effects from warfarin ( Coumadin)
Bleeding from gums
Blood in urine
Bloody dark stool
Vomiting blood
Active immunity
Natural active immunity: antibodies are formed in presence of active infection in the body eg. Measles, mumps and chicken pox ( life long duration)
Artificial active immunity: antigens ( vaccines or toxoids ) stimulate antibody formation
Passive immunity
Natural passive : mother to baby ( 6m to 1yr
Artificial passive immunity:
Occurs when immune serum ( antibody) from an animal or another human is injected ( 2-3 weeks)
Glomerular filtration rates ( gfr)
Less than 15 : kidney failure
20-60: kidney disease
60-120 : normal
Lungs sounds normal
Bronchial : loud pitch heard over treachea/larynx
Bronchovesiculat: medium pitch blowing sounds heard over major bronchi
Vesicular, low pitch soft sound heard over peripheral lung sounds
Adventitious lung sounds
Crackles: air passing through fluid in airways
Wheezes: continues High pitch , produce as air passes through airway constricted by swelling
Ronchi: heard in expiration , cleared by coughing, heard primarily over treachea and bronchi
Pleural friction rub: rubbing or grating sound
Stridor: harsh loud high pitch sound , heard in inspiration
Vital signs (
Bp, hr, rr, oxygen, tempt
120/800
60-100 beats
Respiration 12-20
Oxygen 95-100
97.8-99
Basal metabolic ( BMP)
Sodium
Potassium
Bun
Creatine male and female
Albumin
Glucose
135-145 mEq/L
3.5-5.0
7-20 mg/dl
0.6-1.2mg/dl male 0.5-1.mg female
3.5-5.5g/dl
70-110 mg/dl
Complete blood ct
WBC
RBC
PLT
Hemoglobin
Hematocrit
4.5-11,00
4.5-5.5
140,00-450,000
Female hemo 12-15 male 13.5-16
Female Hemacrit 36-44% male 41-50%
To remember hct multippy hgb by 3
Coags:
Pt
Inr
Pt/inr on Coumadin
APTT ( no iv heparin)
APTT ( on iv heparin )
11-13.5 seconds
0.8-1.1 sec no Coumadin
15.5-30 seconds
30-40 sec
45-100 sec
Hga1c
Gfr
Urine specific gravity
4%-5.6%
90-120 ml/min
1.000-1.030
LDL
HDL
Total cholesterol
Less than 100 mg ( bad)
40mg or higher
125-200 mg /dl
Gen: vancomycin
Trade: firvanq
T;
A:
Treatment: acute otitis media
Check wbc
Adverse effect : hepatotoxicity, c diff, Steven Johnson syndrome , philebitis, leukemia
Gen: diphenhydramine
Trade: Benadryl
T:
A:
Treatment: allergies, cold cough
Adverse effect: dry mouth , dizziness, anorexia, drowsiness
( may decrease skin response)
Coumadin ( warfarin)
Anticoagulant
Prevent thromboem Bolic events
Treatment : venous thrombosis pulmonary embolism
Adverse: cramps , dermanecrosis calciphylaxis bleeding
Asses for tary back stool fall in hematocrit fall in bp
Penicillin: briars spectrum
Ad:
Side effects:
Route
Bacterial antibiotics
Adverse effect: rashes, anemia , anxiety
Side effects : diarrhea sore mouth , vagina itches , white patch on mouth and tongue
IM IV
Tetracycline: broad spectrum
T:
Side:
Ad:
Used to treat Steph throat, std, r infection , acne
Side: photosensitivity, avoid sun, wear sunscreen
Adverse: discoloration of the teeth , fetal retard if taken pregnant
Gen: diazepam
Trade : Valium
Long lasting route iv,po
Treatment: relief of anxiety, sedation, amnesia, decrease seizure activity
Adverse: rash, constipation , hypotension ( iv only )
Ambien
Treatment: sedation
Adverse effect: headaches, vertigo , double vision
Prolong use may lead to dependence (7-10 days)
Route: po
Gen: lorazepam
Trade: Ativan
Intermediate acting sedation
Constipation , diareah fro
Adverse: bradycardia, hypotentis
Iv I’m induce amnesia
Standard precautions ( blood borne )
Hep b,c hiv
3 basic elements of body mechanics
Body alignment
Balance
Coordinated body move
