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Adult Care 1 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

List the 4 components of wellness

A
  1. Capacity to perform to best of ability.
  2. Ability to adjust/adapt to varying situations.
  3. Reported feeling of well-being.
  4. Feeling that “everything is together,” harmonious.
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2
Q

Today, increasing emphasis has been placed on…

A
  1. Health
  2. Wellness
  3. Self-care
  4. Health-Promotion
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3
Q

Describe each tier of the Maslow’s Hierachy of Needs.

A
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4
Q

What are the factors influencing health care delivery?

A
  1. Shifting population demographics (age, culture, changing disease patterns)
  2. Advances in technology and genetics
  3. Economic changes, demand for quality health care
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5
Q

What is managed care?

A

Health care systems where the provider…

  • Recieves pre-negotiated payment rate
  • Fixed-price reimbursement
  • Limited choice of providers
  • Mandatory precertification
  • Utilization review
  • Focus on containing, reducing cost, increasing pt satisfaction, improving health or functional status.
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6
Q

What are the 5 IOM (Institute of Medicine) core competencies? Briefly describe each

A
  1. Provide patient-centered care
  2. Work in interprofessional teams
  3. Employ evidence-based practice
  4. Apply quality improvement
  5. Utilize informatics
  • Patient-centered care - Identify, respect, & care about patients’ differences, values, preferences, & expressed needs; relieve pain & suffering; coordinate continuous care; listen to, clearly inform, communicate with, & educate patients; share decision making & management; & continuously advocate disease prevention, wellness, & promotion of healthy lifestyles, including population health.
  • Work in interprofessional teams - Cooperate, collaborate, communicate, & integrate care in teams to ensure that care is continuous & reliable
  • Employ Evidence-Based Practice - Integrate best research with clinical expertise & patient values for optimum care, & participate in learning & research activities to the extent feasible.
  • Apply quality improvement - Identify errors & hazards in care; understand & implement basic safety design principles; continually understand & measure quality of care in terms of structure, process & outcomes in relation to patient & community needs; & design & test interventions to change processes & systems of care, with the objective of improving quality.
  • Utilize informatics - Communicate, manage knowledge, mitigate error, & support decision making using information technology.
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7
Q

Which role involves actions taken by nurses to meet the health care & nursing needs of individual patients, families, & significant others?

  1. Practitioner
  2. Leadership
  3. Research
A
  1. Practitioner

Rationale: The practitioner role involves those actions taken by nurses to meet the health care & nursing needs of individual patients, their families, & significant others. Nursing leadership role involves 4 components: decision making, relating, influencing, & facilitating. The primary task of nursing research is to contribute to the scientific base of nursing practice. The research role is considered to be a responsibility of all nurses in clinical practice.

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8
Q

Describe the collaborative practice model

A
  • Promotes shared particpation, responsibility, accountability.
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9
Q

________ communication is a
major component of the
nursing profession

A

Effective communication is a
major component of the
nursing profession

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10
Q

What is the nursing process?

A
  1. Assessment
  2. Nursing Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation
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11
Q

What are the levels of communication

A
  • Intrapersonal communication
  • Interpersonal communication
  • Transpersonal communication
  • Small-group communication
  • Public communication
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12
Q

What are the qualities of an effective communicator?

A
  • Critical thinking ability
  • Knowledge of nursing process
  • Knowledge of human behavior
  • Holds no perceptual biases
  • Professional dress & demeanor
  • Must be open to communication & willing to give & receive feedback
  • Courtesy
  • Use of Names
  • Trustworthiness
  • Autonomy & Responsibility
  • Assertiveness (but not aggressive)
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13
Q

List and briefly describe each barrier of communication.

A
  • Incongruent response - when words & actions do not match the inner experience of self &/or are inappropriate to the context
  • Conflict - arises when ideas or beliefs oppose
  • Unclear expectations - ill-defined tasks/duties
  • Gender - men and women may process info differently
  • Culture
  • Anger - irrational responses
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14
Q

What are some of the ineffective communication technique?s

A
  • Asking personal questions
  • Sharing personal opinions
  • Changing the subject (Let pt get closure before changing subj!!)
  • Canned Responses
  • False hope
  • Approval/Disapproval
  • Passive or Aggressive Responses
  • Arguing
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15
Q

What are the therapeutic communication techniques? (SOLER)

A
  • S - sit facing the patient
  • O - observe an open posture
  • L - lean toward the patient
  • E - establish and maintain intermittent eye contact
  • R - relax
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16
Q

What are some non-verbal forms of communication?

A
  • Personal Appearance
  • Posture & Gait
  • Facial Expression
  • Eye Contact
  • Gestures
  • Sounds
  • Territoriality & Personal Space
  • Symbolic Communication
  • Metacommunication
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17
Q

List and describe the avenues of communication in the workplace.

A
  • Downward
  • Upward
  • Lateral
  • Diagonal
  • Grapevine
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18
Q

In case of impaired verbal communication, what should the nurse remember?

A
  • Assess communication possibilities
  • Provide interpreters as needed
  • Consider alternatives: writing, letter boards, body movements
  • Keep words/questions simple & closed ended
  • DO NOT assume that patient is unable to communicate
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19
Q

What are the techniques for End-of-Life Communication?

A
  • Assess desired level of knowledge
    • Determine who pt wants to give knowledge to. Provide pt with options. LISTEN to the pt.
  • Initiate family meetings
  • Communication with children based on developmental level
  • Adopt SOLER posture for active listening
  • Take appropriate amount of time to listen & discuss pt/family concerns
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20
Q

How would you break bad news to a patient?

A
  • Reinforce news given by MD
  • Plan what to say if possible
  • Establish rapport
  • Eliminate distractions
  • Assess level of knowledge & desired information
  • Use simple language
  • Be sensitive/respectful of needs, cultures, family process
  • ***It’s okay to cry with the patient.
  • ALWAYS go into the room with a plan
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21
Q

National Patient Safety Goal (NPSG):

Improve the effectiveness of ______ among caregivers.

A

Improve the effectiveness of
communication among caregivers.

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22
Q

Describe NPSG: “Read Back”

A

Person recieving information either via telephone or verbally needs to read back the information.

RBVO

RBTO

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23
Q

Name some abbreviations/rules from NPSG’s “Do-Not-Use” list

A
  • IU (instead use International unit)
  • QD or qd (instead use once daily)
  • QOD or q.o.d (instead use every other day)
  • U or u (instead use unit)
  • Trailing zero after decimal point (e.g. 1.0mg –> 1mg)
  • Naked decimal point (e.g. .5 mg –> 0.5mg)
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24
Q

NPSG: Measure & assess, & if appropriate, take action to improve the timeliness of reporting, & the timeliness of receipt by the responsible licensed caregiver, of critical test results & values.

What is SBAR(R) ?

A
  • Situation
  • Background
  • Assessment
  • Recommendation
  • Repeats back
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25
Q

NPSG: Accurately & completely reconcile medications across the continuum of care.

What is medication reconcilation?

A
  • A complete list of medications is communicated to the next provider when a patient is referred or transferred to another setting, service, practitioner or level of care
  • The complete list of medications provided to the patient on discharge

“The process of comparing the medications that the patient/client/resident has been taking prior to the time of admission or entry to a new setting with the medications that the organization is about to provide”

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26
Q

What are the 5 stages of group development?

A

I Forming: introductions & trust
II Storming: provocations
III Norming: cohesive work begins
IV Performing: cohesion to achieve goals
V Termination: closure & expression of feelings

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27
Q

What are the characteristics of an effective group?

A
  • Clearly defined goals
  • Open, goal directed communication
  • Equally shared power
  • Flexible decision making
  • Controversy considered healthy
  • Diversity encouraged
  • Evident interpersonal problem-solving
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28
Q

What are the characteristics of an ineffective group?

A
  • Goals vague or imposed without discussion
  • Communication guarded
  • Power with leader–not shared
  • Decision making without consultation
  • Controversy & conflict not tolerated
  • Individual resources not utilized
  • Undervalue of member contributions
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29
Q

What is a medical record?

A
  • Written legal confidential account of the client’s:
    • Health history
    • Current health status
    • Treatment (s)
    • Progress
      *
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30
Q

What are the purposes of keeping a medical record?

A
  • Communication
  • Legal Documentation
  • Financial Billing
  • Education/Research
  • Auditing-Monitoring
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31
Q

List the characteristics of charting

A
  • Factual
  • Concise
  • Accurate
  • Complete
  • Organized
  • Current
  • Legible
  • Timely
  • Confidential
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32
Q

Describe the Assessment step of the Nursing Process. What are its 2 stages? What are the sources you can use for this step?

A

The purpose of assessment is to establish a database about the patient’s perceived needs, health problems, and responses to these problems.

Two stages of assessment:

  • Collection and verification of data
  • Analysis of data

Sources of data

  • Patient (interview, observation, physical examination)—the best source of information
  • Family and significant others (obtain patient’s agreement first)
  • Health care team
  • Medical records
  • Scientific literature
  • Nurse’s experience – influences level of critical thinking
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33
Q

What are the comprehensive assessment approaches?

A
  • Use of a structured database format, based on an accepted theoretical framework or practice standard
    • Example: Gordon’s model of functional health patterns
    • Systemic approach, 11 categories
  • Problem-oriented approach
  • Assessment moves from general to specific.
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34
Q

What is a patient-centered interview? List the steps.

A

Definition: An organized conversation with the patient

  1. Set the stage
    • Preparation, environment, greeting
    • Privacy, temperature, etc.
  2. Set an agenda/gather information about patient’s concerns
  3. Collect the assessment or nursing health history; assure the patient of confidentiality.
  4. Terminate the interview - cue the end
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35
Q

What is a nurse’s concept map?

A
  • A visual representation that allows nurses to graphically illustrate the connections between a patient’s health problems
  • Allows nurses to obtain a holistic perspective of health care needs
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36
Q

Compare a medical diagnosis and a nursing diagnosis.

A
  • Medical diagnosis - Identification of a disease condition based on specific evaluation of signs and symptoms
  • Nursing diagnosis - Clinical judgment about the patient in response to an actual or potential health problem
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37
Q

What is the purpose of a nursing diagnostic statement?

A
  • Provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding patients’ needs
  • Allows nurses to communicate what they do among themselves and with other health care professionals and the public
  • Distinguishes the nurse’s role from that of the physician or other health care provider
  • Helps nurses focus on the scope of nursing practice
  • Research can be conducted on outcomes for diagnoses with certain interventions
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38
Q

What are the types of nursing diagnoses?

A
  • Actual nursing diagnosis - Describes human responses to health conditions or life processes
  • Risk nursing diagnosis (potential) - Describes human responses to health conditions/life processes that may develop. DOES NOT HAVE AEB STEP
  • Health Promotion nursing diagnosis (readiness) - A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential
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39
Q

What are the 3 components of a nursing diagnosis?

A
  1. Diagnostic Label (NANDA-1)
  2. Related Factors/Etiology
  3. As Evidenced By
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40
Q

What is the related factor in a nursing diagnosis?

A

a condition, historical factor, or causative event –> gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis.

  • Treatment-related
  • Pathophysiological (biological or psychological)
  • Maturational
  • Situational (environmental or personal)
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41
Q

What data can be used for “As Evidenced By”?

A
  • assessment data
  • subjective and objective data
  • defining characteristics
  • measureable data which can be used to evaluate goals
  • things the patient states
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42
Q

List the Diagnostic Statement Guidelines

A
  1. Identify the patient’s response, not the medical diagnosis
  2. Identify a NANDA-I diagnostic statement rather than the symptom
  3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention
  4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself
  5. Identify the patient response to the equipement rather than the equipment itself
  6. Identify the patient’s problem rather than your problems with nursing care
  7. Identify the patient’s problem rather than the nursing intervention
  8. Identify the patient’s problem rather than the goal of care
  9. Make professional rather than prejudicial judgements
  10. Avoid legally inadvisable statements
  11. Identify the problem and its cause to avoid a circular statement
  12. Identify only one patient problem in the diagnostic statement
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43
Q

Define goals and expected outcomes in critical thinking for nurses

A
  • Goal - A broad statement that describes the desired change in a patient’s condition or behavior. Has an aim, intent, or end
  • Expected outcome - Measurable criteria to evaluate goal achievement
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44
Q

What are the types of goals of care?

A
  • Patient-centered goal: A specific and measurable behavior or response that reflects a patient’s highest possible level of wellness and independence in function
  • Short-term goal: An objective behavior or response expected within hours to a week
  • Long-term goal: An objective behavior or response expected within days, weeks, or months
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45
Q

A nursing-sensitive patient outcome is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

What are the characteristics of a nurses’ expected outcomes?

SMART

A
  • An objective criterion for goal achievement
  • A specific, measurable change in a patient’s status that you expect in response to nursing care
  • Direct nursing care
  • Determine when a specific, patient-centered goal has been met
  • Are written sequentially, with time frames
  • Usually, several are developed for each nursing diagnosis and goal.
  • S - specific
  • M - measurable
  • A - achievable
  • R - relevant
  • T - timing
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46
Q

List the 7 guidelines for writing goals.

A
  1. Patient-centered
  2. Singular goal or outcome
  3. Measurable
  4. Mutual factors
  5. Observable
  6. Time-limited
  7. Realistic
  • R - realistic
  • U - understandable
  • M - measurable
  • B - behavioral
  • A - achievable
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47
Q

What is a nursing intervention?

A

A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

Interventions include direct and indirect care measures aimed at individuals, families, and/or the community.

48
Q

What are the types of nursing interventions?

A
  • Nurse initiated
    • Independent—Actions that a nurse initiates
  • Physician initiated
    • Dependent—Require an order from a physician or other health care professional
  • Collaborative
    • Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals
49
Q

What are the 6 factors to consider when selecting an intervention?

A
  1. Charateristics of nursing diagnosis
  2. Goals and expected outcomes
  3. Evidence base for interventions
  4. Feasibility of the interventions
  5. Acceptability to the patient
  6. Nurse’s competency
50
Q

What are critical pathways?

A
  • Definition: Patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially.
  • Purpose: To deliver timely care at each phase of the care process for a specific type of patient.
51
Q

What kind of critical thinking steps are involved in implementation?

A
  • Review the set of all possible nursing interventions.
  • Review all possible consequences associated with each possible nursing action.
  • Determine the probability of all possible consequences.
  • Make a judgment of the value of that consequence to the patient.
52
Q

What are the standard nursing interventions?

A
  • Clinical practice guidelines and protocols
    • Systematically developed
      set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health
      care for specific clinical situations
  • Standing orders – PRN orders
    • A preprinted document containing orders for
      the conduct of routine therapies, monitoring guidelines, and/or
      diagnostic procedures for specific patients with identified clinical
      problems
  • NIC interventions
  • ANA Standards of Professional Practice
53
Q

What are some examples of independent nursing interventions
(Select all that apply.)

A. Medication administration
B. Medication teaching
C. Patient positioning
D. Family teaching

A

B. Medication teaching
C. Patient positioning
D. Family teaching

54
Q

Nurse-initiated interventions are
A. Determined by state Nurse Practice Acts.
B. Supervised by the entire health care team.
C. Made in concert with the plan of care initiated by the physician.
D. Developed after interventions for the recent medical diagnoses are evaluated.

A

C. Made in concert with the plan of care initiated by the physician.

55
Q

You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly?
A. The patient will eat 80% of all meals by 6/5.
B. The nursing assistant will set the patient up for a bath every day intervention
C. The patient will have improved airway clearance by June 5.
D. The patient will identify the need to increase dietary intake of fiber by June 5.

A

A. The patient will eat 80% of all meals by 6/5.

56
Q

Compare direct care vs indirect care (nursing intervention)

A
  • Direct care - Treatments performed through interactions with patients
    • ADLs, IADLs, physical care techniques, lifesaving measures, counseling, teaching, controlling for adverse rxns, preventative measures
  • Indirect care - Treatments performed away from the patient but on behalf of the patient or group of patients
    • Communicating nursing interventions
    • Delegating, supervising, and evaluating the work of other health care team members
57
Q

What are the standards of evaluation (nursing process)?

A
  • Resolving actual health problems
  • Preventing potential problems
  • Maintain a healthy state
  • Being systematic
  • Using criterion-based evaluation
    • Physiological, emotional, and behavioral responses that are a patient’s goals and expected outcomes.
  • Collaborating
  • Using ongoing assessment data to revise care plan
  • Communicating results
58
Q

List the steps of an objective evaluation

A
  1. Examine the outcome criteria
  2. Evaluate the patient’s actual response
  3. Compare the established outcome criteria with the actual response
  4. Judge the degree of agreement between the outcome criteria and the response
  5. If no or only partial agreement, what are the barriers?
  6. Goal met, partially met, not met
59
Q

Assessment begins with initial patient contact. Which nursing activity is included during this component of the nursing process?

  1. Interviewing and obtaining a nursing history
  2. Choosing a nursing diagnosis
  3. Establishing expected outcomes
  4. Determining nursing actions
A

Interviewing and obtaining a nursing history

Rationale: Choosing a nursing diagnosis is included during the diagnosis component of the nursing process. Establishing expected outcomes and determining nursing actions are included during the planning component of the nursing process.

60
Q

What is the purpose to patient education?

A
  • To help individuals, families, or communities achieve optimal levels of health
  • Patient education includes:
    • Maintenance and promotion of health and illness prevention
    • Restoration of health
    • Coping with impaired functioning
61
Q

What are the steps to the teaching plan?

A
  • Identify Learning Need
  • Develop Teaching Goal
  • Assess Readiness to Learn
  • Expected Outcome (measurable)
  • Specific Content
  • Resources/Method
  • Evaluation of Goal
62
Q

What is the definition of critical thinking?

A
  • Multidimensional skill, cognitive or mental process, set of procedures
  • Critical thinking involves reasoning, purposeful systematic, reflective, rational, outcome–directed thinking based upon body of knowledge, examination of all available information, ideas
63
Q

Define the following terms:

  • Autonomy
  • Beneficence
  • Confidentiality
  • Fidelity
  • Double effect
  • Justice
  • Nonmaleficence
  • Paternalism
  • Respect for persons
  • Sanctity of life
  • Veracity
A
  • Autonomy - self-rule, privacy, choice
  • Beneficence - duty to do good; kindness, charity
  • Confidentiality - info is private
  • Double Effect - justify actions with good/evil
    • The action itself is good
    • The intent is good
    • Good effect not achieved by the evil
    • Favorable balance of good over evil
  • Fidelity - Promise keeping, faithfulness
  • Justice - Distributiion of social benefits/burdens
  • Nonmaleficence - duty to do no harm; prevent & remove harm
  • Paternalism- limitation of another’s autonomy <-NEGAITVE
  • Respect for persons- enable others to have choices
  • Sanctity of life - life is highest good
  • Veracity - tell the truth
64
Q

What is an advanced directive?

A

legal documents specifying a person’s wishes before hospitalization. Can help providers in decision making regarding treatments.

65
Q

Wha are the rules of safe drug administration?

A
  • Verify that you have a clear, written order for each drug administration.
    • When taking a verbal order, READ BACK
  • Avoid distractions when preparing and adminstrating drugs
  • Never administer drugs taken from an unlabeled or illegibly labeled container.
  • Check the MAR against the healthcare providers’ original order to be certain that a transcription error did not occur
  • Carefully check pt’s ID band before adminstering any medication
  • Do not leave meds at the bedside; return any unused drug immediately to the medication area
  • Never return an unused portion of med to a stock bottle b/c potential of returning it to the wrong bottle
  • Do not administer med prepared by someone else
  • Do not prepare med for another person to administer
  • Document all drug administration as soon as you have completed it to prevent accidental reptition of the dose by another caregiver
  • Prepare med for one patient at a time!
66
Q

What should you do when pt refuses a medication?

A
  • Never force a pt to take a medication
  • Try to find out why they are refusing the medication
  • Explain what the medication is and it’s purpose
  • If the pt still refuses, document in chart and notify charge nurse/MD
  • Return medication to medication area or discard (if opened).
67
Q

What are the parts of medication order? (7 parts)

A
  • Clients’ name
  • Date and time the order is written
  • Name of drug to be administered
  • Dosage of the drug
  • Route by which the drug is to be adminstered
  • Frequency of adminstration of the drug
  • SIgnature of person writing the order
68
Q

What are the types of orders? Define each. (6 types)

A
  • Standing order - in effect until discontinued
  • PRN - as needed, per RN
  • Single order - one time order
  • STAT order - one time given immediately
  • Now order - one time and quickly
  • Prescriptions - client fills at pharmacy
69
Q

What is the process of Medication Reconciliation? (4 steps)

A
  1. Verify - current list
  2. Clarify - accuracy
  3. Reconcile - compare
  4. Transmit - communicate updated information to provider
70
Q

What are the 7 rights of Drug Adminstration?

A
  1. Right Drug
  2. Right Dose
  3. Right Client
  4. Right Route
  5. Right Time
  6. Right Documentation
  7. Right Evaluation
71
Q

How many times do you need to check the 7 rights of DA before administering the drug? When do you perform these checks?

A
  1. When the nurse reaches for the container
  2. Immediately prior to pouring the medication
  3. Before returning the container to the drawer or shelf
72
Q

Name the routes for adminstering drugs. List some disadvantages and advantages

A
  • Oral - oral, buccal, sublingual
  • Topical - skin, nasal, eye, ear, (buccal, sublingual)
  • Inhalation - by respiratory tract
  • Injection - subq, IM, intradermal, IV, intraarterial, intracardiac, intraperiotoneal, epidural, intraosseous
  • Table 31-5
73
Q

Can a student nurse adminster meds? Can assistive personnel?

A

Yes, under direct supervision of a RN. / No

74
Q

What should you be assessing during adminstration of oral medications?

A
  • Health history / allergy history
  • Diet history
  • Current client condition
  • Know the pt’s ability to swallow oral medications safely
    • What fluids does the pt prefer to take w/ med? Ensure there’s no contraindications btw fluid and med and diet ordered
    • If pt has swallowing difficulty: can crush med (if that’s an option!). can mix med into a small amount of soft food. Don’t mix into large amounts.
    • Consider using liquids and suspension
  • Perception, knowledge, understanding learning needs of medications
75
Q

What are the key points of aspiration prevention?

A
  • Assess swallowing abilities - sit person at 90 degrees, chin to chest
  • Asses pt’s cough and presence of gag reflex
  • Prepare oral meds in form easiest for pt to swallow
  • Unilateral weakness - give medication on the stronger side of mouth
  • Adminster one pill at a time
  • Thicken liquids w/ thickening agents if can’t swallow liquids well
  • Have pt hold and drink cup if possible
  • Time meds to coincide w/ mealtimes or when pt is rested and awake
  • Use anouther med route if risk of aspiration is great
76
Q

How do you adminster meds via NG tube?

A
  1. Confirm placement (pH testing 1-4 for gastric)
  2. Flush (15 mL sterile H20)
  3. Give medicaiton one at a time
  4. Flush (15 mL sterile H20)
  5. Clamp for 30 min
  6. Evaluate (assess for side effects/interactions) and unclamp NGT at 30 min intervals
77
Q

Topical applications are given by placing med on skin or mucous membrane.

What are some forms of adminstration?

A
  • Name soVaginal adminstration
  • Rectal adminstration
  • Sublingual adminstration
    • under tongue
    • ex: nitroglycerin - rapid action to relax blood vessels
  • Buccal adminstration
    • btw gum and cheek
  • Inunction
  • Instillation
78
Q

What are some key points to remember about topical medications?

A
  • Applied to intact skin/mucous membrane
  • Can be lotions, pastes, ointments, patches
  • Can be very powerful medicaitons
  • Wear gloves when adminstrating
  • Before adminstering, cleanse skin thoroughtly by washing area gently w/ soap water
  • Spread evenly over involved skin
79
Q

How do you adminster ear medications?

A
  1. Pt assumes side-lying position w/ treated ear up
  2. Straighten ear canal by pulling auricle down and back for <3 years. Upwards and outward >4 to adults
  3. Instill prescribed drops holding dropper 1/2 inch about ear canal
  4. Pt remains in side-lyin position for 2-3 minutes, then RN massages the tragus
80
Q

Steps to adminstering eye drops

A
  1. Assist pt to a supoine or sitting position
  2. Pt tiles their head back
  3. Pt is instructed to look at ceiling
  • w/ 1 hand, pull down the lower eyelid to expose the conjunctiva. squeeze the prescribed # of drops into the exposed sac
  • Don’t drop med directly into the eyeball
  • don’t touch dropper to the eye or eyelash
  • multiple drops–WAIT at least 5 minutes btw drops
81
Q

What are the advantages/disadvantages of the rectal route?

A
  • advantages
    • safe route for pt who is vomiting, unconcious, unable to swallow
    • doesn’t irritate the upper GI tract
    • avoid destruction of meds by the digestive enzyme of stomach and SI
    • avoids biotransformation in the liver b/c drug absorbed from the lower rectum - bypasses portal system
  • disadvantages
    • uncomfortable or embarassing to pt
    • may result in incomplete drug absorption
    • may stimulate pt’s vagal nerve by stretching anal sphinters. use cautiously in cardiac pts
82
Q

What kind of nursing assement and teching can you do for medications?

A
  • history: pt at risk for adverse effect?
  • allergies: pt at risk for adverse effect?
  • diet: may interfere w/ absorption/action of drug?
  • client’s learnig needs: perceptual or coordination problem or side effects
  • specific requirements: meds given on empty stomach, full stomach, with full glass of water, given at night or early AM only? need to wear gloves? need to assess BP or apical pulse before giving med? KNOW THE PARAMETERS
83
Q

What can you teach the pt to avoid medication errors?

A

Key points:

  • Maintain a list of prescribed drugs (updated list)
  • Take med list whenever they visit HCP
  • Inform them of where they can find additional meds
  • make sure name of drug and directions for use recieved at the pharmacy are the same as those by the provider
  • teach to review their meds w/ pharmacist
  • request written infor about the med from the pharmacist

Outpatient

  • have the prescriber write down the name of the drug, what it’s for, it’s dosage, and how often to take it, or provide material with this info
  • have prescriber explain how to use it properly
  • ask about drug’s side effects and what to do when you experience a side effect

Inpatient

  • inform pt that they should ask MD/RN what drugs they are taking in the hospital
  • tell pt not to take a drug w/o knowing it’s purpose
  • pt has a right to have a surrogate present whenever they are recieving meds ESPECIALLY if pt is unable to monitor med use themselves
  • prior to surgery, have pt ask whether there are any meds to be stopped pre-op (ie. antibiotics/nsaids)
  • prior to discharge , pt should ask for list of meds. their pcp should review it w/ the pt
84
Q

Effective prevention and control of infection requires _______ of modes of transmission and ways to control them

A

Effective prevention and control of infection requires that the nurse remain aware of modes of transmission and ways to control them.

85
Q

Name all the parts of the chain of infection. .

A
  • Infectious Agent
  • Reservoir
  • Portal of Exit
  • Mode of Transmission
  • Portal of Entry
  • Susceptible Host
86
Q

COI: What can be a resevoir?

A
  • Human body
  • Food
  • Oxygen (aerobic or anaerobic)
  • Insects
  • Inanimate objects
87
Q

COI: What are the modes of transmission?

A
  • Contact - major route is HCP unwashed hands
    • direct
    • indirect- aerolized contaminated environmental suface
  • Droplet: larger than airborne (3-6 foot range) ex: SARS
  • Airborne: small, particles, remains infective over time and distance; TB, measles, chickepox
  • Vehicles: water, medications
  • Vectors: flies, mosquitoes
88
Q

What is the number one intervention a nurse can do at the hospital?

A

HAND WASHING

89
Q

COI: What are some other interventions other than hand washing?

A
  • protective barrers
  • patient hygeine
  • proper disposal of waste
  • cleaning
  • proper med admin
  • client safety
90
Q

Compaire surgical vs medical asepsis

A

surgical : sterile technique, eliminates all m/os

medical: clean technique, reduce # of organisms

91
Q

What are the different types of contact isolation precautions? Describe precaution for each.

A
  • Airborne
  • Droplet
  • Contact
  • Protective
92
Q

Why is safety so important in the hospital?

A
  • Reduces the incidence of injury and illness
  • Shortens legth of treatment and hospitalization
  • Improves outcomes
93
Q

What are some of the environmetal risk factors in the hospital environment?

A
  • Basic needs
    • O2, Nutritiion, Temperature/Humidity!!
  • Physical hazards
    • lighting, obstacles, bathroom, fire, lead, security
  • Pathogens
    • hand hygiene, isolation/biological precautions, immunization
  • Pollution
  • Terrorism
    • noise can distract nurses
  • Biologial
  • Chemical
  • Radiological
    • x-ray, mri’s, gamma therapy
94
Q

List some of the risks based on the age of specific populations (individual risk factors)

A
  • Infants, toddlers, school age - lead, choking
  • school-age kids - outdoor play
  • adolescent - substance abuse
  • adult - lifestyle
  • older adults (greater than 65 years of age)
    • falls
95
Q

Texas Board of Nurse Examiners Rule 217.11 explains the nurses must:

A

Accurately and completely report and document:

  • Pt’s signs, symptoms, response
  • Nursing care rendered
  • MD’s orders
  • Adminstration of medications or treatment
  • Pt’s response
  • Contact with other HCW about significant events
96
Q

Name the nurse-sensitive quality indicators

A
  • pressure ulcers
  • falls w/ or w/o injury
  • nosocomial infection rates (UTI, VAP)
  • pt satisfaction w/ pain
  • pt satisfaction w/ care (overall and nursing)
  • skill mix
  • nurse satisfaction
97
Q

What are the 2012 National Patient Safety Goals?

A
  • Identify pt correctly
  • Improve staff communication
  • Use medication safely
  • Prevent infections
  • Check pt medications
  • Assess pt at risk for suicide
98
Q

How does safety and the nursing process relate?

A
  • Assessment
    • patient centered critical analysis, history, environment, fall/injury risk
  • Nursing Diagnosis
    • analyze clusters of defining characteristics (fall risk, knowledge deficit)
  • Planning
    • goals and outcomes, teamwork, collab
  • Implementation/Intervention
    • developmental or environmental
  • Evaluation
    • actual care based on expected outcomes
99
Q

How do you do a safety assessment?

A
  • ROS (subj)
    • Allergies (food, med, latex, tape)
    • Medication HX
  • Risk factors
    • falls, hx, polypharmacy
  • Head-to-toe physical assessment (obj)
100
Q

As a nurse, what should you ensure in every shift and at admission of pt?

A
  • ensure proper ID on pt
  • proper markers on/in room/chart to indicate allergies, risks, ID
  • patient and family orientation to room, call light, bed, emergency button, care concerns
101
Q

How do you do a fall risk assessment?

NOTE: THESE ARE REQUIRED UPON HOSPITAL ADMISSION FOR EVERY PATIENT AND ARE NURSE INITIATED.

A

Patient are at higher risk for falls:

  • have a hx of falls
  • has confusion, dementia
  • age >65
  • sensory deficit
  • impaired mobility
  • weakness
  • unfamiliar environment
  • attached equipment
  • pt has impaired vision
  • postural hypotension w/ dizziness
  • medications they’re on (ie. sedatives, diuretics, tranquilizers, analgesics
102
Q

What are some of the reasons on why a pt can fall?

A
  • going to the restroom
  • changing position
  • obtaining a food or drink
  • medications
  • health hx
  • combination of all the above
103
Q

What should you do when a pt falls?

A
  • Check ABC’s
  • Maintain body alignment
  • Notify physician
  • Notify family
  • Re-evaluate current nursing plan
104
Q

What are some of the interventions for fall prevention?

A
  • bed locked, low position, 3 sides up
  • call light in place
  • enviroment clear of hazard/clutter
  • tray w/ water, food w/i reach
  • bed alarms on
  • answer call light immediately or delegate
  • room closest to nurses’ station
  • involve the family
  • HOURLY ROUNDING
105
Q

What are the “must do’s” for pt on restraints?

A
  • MD order for restraints necessary
  • Order renewed every 24 hours
  • Restraints should allow 2 fingers inserted
  • Fasten devices to bed frame, not side rails
  • Assess pt’s circulation every hour
  • Remove restraints every 2 hours - conduct ROM, assess skin
106
Q

What are some of the complications for restraints?

A
  • Altered skin integrity
  • Incontinence
  • Altered nutrition and hydration
  • Risk for isolation
  • Risk for infection
  • Impaired circulation
107
Q

What type of data would support a safety risk nursing diagnosis?

A
  • Risk for fall
  • Injury
  • Poisoning
  • Suffocating
  • Trauma
  • Deficient knowledge
  • Impaired home maintenance
108
Q

List the problems with nutrition during hospitalization

A
  • Malnutrition on admission
  • Increased demands of hospitalization
  • Increased demands of illness
    • Hypermetabolic state
    • Healing needs
109
Q

How do you ensure pt has good nutrititon during hospital stay?

A
  • Provide pt w/ nutrients
  • May required alternate routes
110
Q

Example of a nursing diagnosis for a pt who can’t eat

  1. Altered nutrition: pneumonia
  2. Altered nutriition: less than body requirements
A
  1. Altered nutriition: less than body requirements

(diagnoses r/t complications)

111
Q

2 types of alternate route for feeding. Describe each

A
  • Enteral
    • Use GI tract (best choice)
  • Parenteral
    • Artificial airway
    • Aspiration
112
Q

What are the advantages/disadvantages of a GI tube?

A

Advantages:

  • Promotes satiety
  • Protects GI tract
    • IgA secretion
    • Decreased atrophy of GI/pancreas
    • Decreased Infection
    • Decrease gallbladder sludge/stones
  • Less sepsis/GI problems
  • Better vitamin absorbtion
  • Less expensive/home use

Disvantages:

  • Need GI access w/ tube (tube problems & pt comfort)
  • Risk for aspiration
  • Metabolic problems
113
Q

What are the 3 levels of entry for a GI tube?

A
  • Nasogastric
  • Nasoduodenal
  • Nasojejunal
  • Gastrostomy or PEG
  • Jejunostomy
114
Q

What needs to be on a MD order for feeding tubes?

A
  • Type of formula
  • Type of feeding schedule
  • Amount of formula
  • Rate of adminstration
115
Q

What are some problems that may occur with tube feeding?

A
  • Aspiration
  • Metabolic
    • Glycemic changes
    • Fluid/electrolytes
    • Refeeding syndrome
  • Skin breakdown
  • Gastrointestinal
    • Nausea/vomiting
    • Diarrhea
    • Constipation
  • Tube
    • Migration
    • Cloggin

Adult Care 1 (6 decks)

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