Exam 1 Flashcards
What are the levels of health care?
- Primary
- Secondary
- Tertiary
Primary level
preventative with health promotion
Secondary level
the diagnosis of an illness
Tertiary level
rehab or the end of life care
What is Palliative care?
Making the patient as comfortable as possible.
ie: if in pain making them feel better, dying; at ease, not worried
Models of Nursing Care Delivery
- Primary
- Total client care
- Team Nursing care
- Modular Nursing care
- Case Management
- Client centered care
Primary Nursing Care
One nurse who is responsible for a whole load of patients 24 hrs
EX: home health aide
Total Client Care
When the nurse is responsible for all care of a patient during a shift
Team Nursing Care
When a group of healthcare workers work together to perform tasks needed for a patient
Modular Nursing
When 2 nurses are responsible for a load of patients
Case manager
Is one who follows up with patient while in a facility and sometimes has to follow up after discharged. Deals with patients well being and insurance information.
Client Centered Care
everything is located in one location
Leadership Styles of Nursing:
- Autocratic
- Democratic
- Laissez Faire
- Bureaucratic
- Situational
Autocratic
Dictator/ makes all decision: works best in emergency situations
Democratic
Group discussion to make a decision
- Very effective except in emergency situations
- Most members are internally motivated
Laissez Faire
Leader lets the people do what they want
- must have strong foundation and trust within the group
Bureaucratic
Strict rules and policies
Management and Delegation
As an RN you are responsible for any deletion (order you give) you make
How often should ROM be completed?
Every 2 hrs
How often to restraints need to be assessed?
every 15 minutes
- Restraints are the last resort for a patient
Levels of space:
- Intimate (0-18 in)
- Personal (18 in. - 3ft.)
- Social/ Public (3- 6 ft.)
Cardiovascular Mobility :
- helps strengthen cardia muscles
- Increases cardiac output
- Decreases resting heart rate
- Increases venous return
Musculoskeletal Mobility:
- Increases joint flexibility & ROM
- Maintains and improves muscle tone strength
- Maintains bone density through weight
GI Mobility:
- Improves appetite
- Increases GI tract tone
- Improves digestion and elimination
Metabolic Mobility:
- Elevates basal metabolic rate
- Reduces triglycerides and cholesterol levels
- Increases glucose
- Increases production of body heat
- Burns excess fat
Urinary System Mobility:
- Promotes excretion of waste
- Prevents urine stasis in the bladder
Activity Tolerance
- Reduces fatigue
- Improves activity tolerance
Psychosocial Factors:
- Improves stress tolerance
- Produces a sense of well being
- Reduces depression
- Improves body image
- Enhances quality of sleep
- Increases energy levels
Semi- Fowlers
30- 45 degrees
Fowlers
60- 90 degrees
Assessment of the abdomen:
Inspect, auscultate, percuss, then palpate
- different from every other part because you don’t want to disrupt the bowel sounds
Assessment
Inspect, palpate, percuss, then auscultate
Eyes: PERRLA
P: Pupils should be clear E: Pupils should be equal in size and between 2-3mm R: Round in shape RL: Reactive to light A: Accommodation
Types of hearing loss:
- Sensory neural
- Conductive
- Presbycusis
Sensoneural:
due to a problem with the inner ear or auditory nerve
Conductive:
due to a problem with the external or middle ear
ex: wax buildup, foreign body, infection
Presbycusis:
hearing loss due to aging
Does ones sense of taste decrease with age?
No it does not
Tonsils: +1
Barely visible
Tonsils: +2
Between entonsillar pillars and uvula
Tonsils: +3
Touching the uvula
Tonsils: +4
Tonsils are touching each other: called kissing tonsils
Objective Data:
- Factual data observed by the nurse
- No conclusions or interpretations made
Subjective Data:
- Information given verbally by the client
- Captures the clients point of view
Objective Data:
- Factual data observed by the nurse
- No conclusions or interpretations made
Subjective Data:
- Information given verbally by the client
- Captures the clients point of view
Myopia
nearsightedness
Hyperopia
farsightedness
Astigmatism
irregularity of the cornea which causes blurred vision
Presbyopia
decreased elasticity of the lens with a decrease in accommodation
If eyeballs appear to be sunken what could you assume is wrong with the patient?
they are dehydrated or emaciated
what is hardness of the eye caused by?
glaucoma
what is softness of the eye caused by?
dehydration
5 rights of delegation
- the right task
- the right circumstance
- the right person
- the right communication
- the right evaluation
Maslow’s Hiearchy of Needs: most important to least important
- Physiological needs:
- need for air, nutrition, water, elimination, rest, and sleep
- Safety Needs:
- Need for shelter and freedom from harm and danger
- Love Needs:
- Need for affection, feeling of belongingness, and meaningful relationships with people
- Esteem Needs:
- Need to be well thought of by oneself as well by others
- Self- Actualization Needs:
- Need to be self- fulfilled, learn, create, understand, and experience ones potential
