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2020 Foundations I > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

SMART goals for patients

A
  • specific (singular goal or outcome)
  • measurable
  • attainable
  • realistic
  • timed
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2
Q

When creating goals for patients, always start with …

A

“Patient will …”

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3
Q

What is the Nurse Practice Act, and what does it govern?

A
  • state level regulation of nursing practice
  • serves to
    • approve nursing education programs
    • define practice of professional nursing
    • establish licensing criteria
    • develop rules and regs for nursing practice
    • enforce rules and regs
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4
Q

Discuss the transitions nursing practice has undergone in recent history.

A
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5
Q

Differentiate between legal regulation of practice and practice standards.

A
  • legal regulation: rules and regulations set by the state nursing board or other governing body for the
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6
Q

List the areas of healthcare systems where nursing functions.

A
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7
Q

List the models of nursing care.

A
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8
Q

Identify historical figures in nursing.

A
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9
Q

Identify models of nursing care.

A
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10
Q

profession

A

requires a set of specific skills or qualities

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11
Q

discipline

A

has its own domain of knowledge with theoretical and practical boundaries

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12
Q

occupation

A

technical view of nursing, controlled by an employer

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13
Q

steps of the nursing process (ADPIE)

A
  • assessment
  • diagnosis
  • planning
  • implementation
  • evaluation - ongoing process
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14
Q

How should subjective data be documented?

A

in quotes

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15
Q

objective data

A

observations or measurements of a pt’s health status

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16
Q

subjective data

A

pt’s verbal descriptions of health problems

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17
Q

setting priorities

A
  • use Mazlow’s Hierarchy and ABC most of the time
  • priority framework changes in mass casualty events
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18
Q

List three types of interventions for nurses to carry out.

A
  • independent - no order from another HCT memeber
  • dependent - needs order from MD or other HCT member
  • collaborative - requires combined knowledge, skill, expertise of multiple professionals
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19
Q

What are some considerations when planning an intervention?

A
  • Does the pt agree?
  • Are you competent?
  • Is your intervention evidence-based?
  • What does the Doenges book say?
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20
Q

What must we consider when implementing a care plan?

A
  • good judgment and decision-making
  • pt’s condition can change minute to minute
  • must have knowledge and competency
  • consequences of actions
  • value of the consequence
  • purpose of the intervention
  • steps to perform correctly
  • expected pt response
  • what worked before
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21
Q

important part of documentation

A

be specific and objective

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22
Q

List the stages of wound healing and their expected durations.

A
  • inflammatory: 3-6 days
  • proliferative: 3-24 days
  • maturation/remodeling: about day 21
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23
Q

What happens during the inflammatory stage of wound healing, and what factors are important to nursing interventions?

A
  • hemostasis - vasoconstriction, fibrin, clot formation
  • increased O2 delivery to site
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24
Q

What happens during the proliferative stage?

A
  • granulation of tissue
  • edges pull together
  • generation of new epithelial tissue
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25
Q

What happens during the maturation/remodeling stage of wound healing, and how long does it take?

A
  • strengthening of scar tissue
  • can take up to 1 year
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26
Q

What tool is used to assess risk for skin breakdown?

A
  • Braden Scale
  • completed on admission and at shift assessments
  • provides specific protocols
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27
Q

What do we look for during assessment of wounds?

A
  • size, shape, depth, tunneling
  • color
  • drainage
  • approximation
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28
Q

primary intention

A

wound is closed surgically and well-approximated

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29
Q

secondary intention

A

wound edges are not approximated (such as pressure injuries, etc.), and body must fill in gap

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30
Q

tertiary intention

A

wound left open and closed later

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31
Q

types of acute wounds

A
  • injury
  • surgery
  • procedures
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32
Q

chronic wounds

A
  • any wound that has not healed in the expected time frame (2-4 weeks or longer)
  • pressure ulcers
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33
Q

factors affecting skin integrity and wound healing

A
  • age
  • impaired mobility
  • nutrition, hydration
  • altered sensation
  • impaired circulation
  • meds
  • moisture
  • lifestyle factors
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34
Q

evisceration

A
  • big separation of wound causing internal organs to protrude
  • nursing actions:
    • assess
    • apply pressure
    • position and calm pt
    • cover with sterile saline-soaked gauze
    • notify provider
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35
Q

dehiscence

A
  • separation of wound
  • pts report feeling a “pop” or “tear”
  • nursing actions:
    • assess
    • apply pressure
    • stabilize pt
    • notify provider
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36
Q

What steps should you take when treating a pressure ulcer?

A
  • prevent deterioration:
    • assess
    • provide proper care
    • prevent new ulcer formation - hygiene, sterile technique when indicated
  • follow facility protocol
  • wound care consult
  • monitor for infection
    • local - redness, increased drainage
    • systemic - monitor s/s (AMS, VS changes, labs)
    • provide supportive care - fluids, nutrition, antibiotics, wound cultures
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37
Q

preventing skin breakdown

A
  • position changes q 2 hr for bed-bound
  • instruct mobile to shift weight q 15 min while awake
  • ambulate early and often
  • prevent bed slide and lift
  • pressure-reducing devices - bed overlays, offloaders, etc.
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38
Q

community

A
  • “fellowship of common feelings”
  • group of like-minded people
  • group that works together
  • share common language, rituals, customs
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39
Q

Define vulnerable population and list factors that contribute to that status.

A
  • have increased risk for adverse health outcomes
  • factors:
    • limited economic and social resources
    • age
    • chronic disease
    • history of abuse or other trauma
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40
Q

Name the three aproaches to community-based care. Do they overlap?

A
  • approaches
    • community health nursing
    • public health nursing
    • community-oriented nursing
  • yes, they overlap
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41
Q

public health nursing

A
  • concerned with health of community as a whole
  • focus: effect of community health on individuals
  • goals
    • prevent disease
    • promote health for individuals, families, and groups
    • protect health of community
    • promote safety, prevention
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42
Q

community health nursing

A
  • concerned with health of individuals, families, or groups
  • focus: how individual health affects community
  • goals
    • maintain health of population
    • deliver personal health services
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43
Q

community-oriented nursing

A
  • combination of public health and community health nursing approaches
  • more comprehensive approach
  • uses info from individuals to change health on community level
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44
Q

What should be considered when treating the individual pt? For the community as a whole?

A
  • individual
    • communication
    • education
    • patient decision aids
  • community
    • education
    • health policy
    • learning culture, beliefs, and behaviors
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45
Q

List four pioneers of community nursing and their contributions.

A
  • Florence Nightingale
  • Lillian Ward
  • Clara Barton
  • Margaret Sanger
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46
Q

Name five roles of community nurses.

A
  • client advocate
  • educator
  • collaborator
  • counselor
  • case manager
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47
Q

What are some occupations in community-based nursing practice?

A
  • school nurse
  • occupational health
  • parish nursing
  • correctional nursing
  • public health
  • disaster services
  • international nursing
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48
Q

primary interventions in community nursing

A
  • promote health
  • prevent disease
  • educate at-risk clients
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49
Q

secondary interventions in community nursing

A
  • reduce disease impact
  • early detection and treatment
  • health screening
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50
Q

tertiary interventions of community nursing

A
  • halt disease progression
  • restore health where possible
  • treatment
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51
Q

Who receives home health care?

A
  • those with skilled-care needs such as older adults
  • those recuperating from illness or surgery
  • the terminally ill
  • the chronically ill, to avoid hospitalization
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52
Q

What is the goal of home health care?

A

promoting self-care

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53
Q

How do you promote self-care in the home health care setting?

A
  • fostering client independence
  • completing client and family teaching
  • demonstrating skill techniques
  • explaining all aspects of care
54
Q

List some advantages of home health care.

A
  • enables viewing of client’s environment
  • allows inclusion of family members in care
  • increases autonomy of nursing practice
  • teaches flexibility
  • facilitates holistic care
55
Q

Name some disadvantages of home health nursing.

A
  • uncontrolled environment
  • no readily available supplies
  • lack of immediate peer assistance
  • potential for personal safety issues
56
Q

types of home health care agencies

A
57
Q

What are the roles of the home health nurse, and what do they involve?

A
  • direct care provider - performing skilled tasks
  • client/family educator - promoting self-care; communication skills needed
  • client advocate - supporting client’s right to decide
  • care coordinator - developing plan of care; accessing correct resources
58
Q

What should a nurse be aware of regarding health care reimbursement?

A
  • necessary criteria
  • services covered
  • documentation needed
59
Q

What do you do before a home health visit?

A
  • determine purpose of visit
  • gather supplies, materials
  • additional information needed from client
  • make appointment
  • assess area for safety issues
60
Q

how to conduct a home health visit

A
  • make intros
  • be respectful of home, beliefs, practices, cultural differences
  • develop trusting relationship
  • verify and, if necessary, complete data collection
  • identify barriers to achieving goals of visit
61
Q

what to do after a home health visit

A
  • maintain safety precautions
  • proceed to safe area to check directions
  • complete necessary documentation
62
Q

evidence-based practice

A

use of current best evidence when making decisions in patient care

63
Q

levels of evidence for EBP

A
  • single study: observational research; randomized controlled trial
  • meta-analysis: statistical analysis that combines the results of multiple scientific studies
  • practice guideline: systematically developed statements to guide decisions about health care
  • qualitative vs. quantitative
64
Q

where to find evidence for EBP

A
65
Q

quantitative research

A
  • data used when research is trying to quantify a problem
  • answers question of how many
  • involves statistical analysis of numbers
66
Q

qualitative research

A
  • data that describes qualities or characteristics
  • answers why or how questions
  • involves analysis of reoccurring themes
    • often from interviews or focus groups
67
Q

theory

A

organized set of related ideas and concepts

68
Q

paradigm

A
  • worldview or ideology of a discipline
    • medical: views person through lens of disease; compartmentalizes
    • nursing: views person through holistic lens
69
Q

conceptual framework

A

set of concepts that form a pattern

70
Q

model

A

visual representation of concepts

71
Q

How do nurses use theories?

A
  • clinical practice
  • nursing education
  • nursing research
72
Q

List three famous nursing theorists.

A
  • Viriginia Henderson: Nature of Nursing
  • Hildegard Peplau: Theory of Interpersonal Relations
  • Patricia Benner: Novice to Expert
73
Q

Name the levels of Maslow’s Hierarchy of Needs, starting with the most basic (base of pyramid).

A
  • physiological
  • safety
  • love/belonging
  • esteem
  • self-actualization
74
Q

What does PICO stand for, and what process does it refer to?

A
  • P - population or problem
  • I - intervention, treatment, cause, contributing factor
  • C - comparison intervention or control
  • O - outcome
  • PICO is used to identify issues that need improvement and take them through the research process to find better methods
75
Q

gait

A

manner of walking

76
Q

kyhosis

A
  • exaggeration or angulation of posterior curve of thoracic spine
  • humpback, hunchback, or Pott curvature
77
Q

lordosis

A
  • exaggerated anterior convexity of the lumbar spine
  • swayback
78
Q

scoliosis

A
  • lateral curvature of the spine
  • usually consists of two curves: original abnormal and compensatory in the opposite direction
79
Q

hypertrophy

A

increase in the size of an organ, structure, or the body due to growth

80
Q

atrophy

A

decrease in size of an organ or tissue; wasting

81
Q

objective data to be gathered when assessing of mobility

A
  • symmetry
  • ROM
  • strength/weakness
  • coordination and motor function
  • orientation
  • DTR
82
Q

subjective data to gather for mobility issues

A
  • pain and stiffness
  • twitching
  • falls
  • ability to perform ADLs
  • exercise habits
  • nutrition
  • dizziness
  • headaches
  • seizures
  • head injury
  • changes in vision, speech, though
  • tingling
  • weakness
  • numbness
83
Q

List the four levels of conciousness.

A
  • alert
  • lethargic
  • stuporous
  • comatose
84
Q

alert***

A
85
Q

lethargic***

A
86
Q

stuporous***

A
87
Q

comatose***

A
88
Q

decorticate rigidity

A

flexed

89
Q

decerebrate rigidity

A

extended

90
Q

List four types of immobility.

A
  • temporary - injury, surgery
  • permanent - paralysis
  • sudden onset - accident, surgery
  • slow onset - chronic debilitating diseases (e.g. MS, spinal degeneration)
91
Q

basic principles of injury prevention

A
  • body mechanics
    • maintain posture
    • low center of gravity
    • wide stance and straight back
  • assessment
    • before lifting - assistance needed?
    • before moving pt - do they need help?
  • maintenance
    • regular exercise and activity maintain muscle and coordination
92
Q

planning physical activity for pt

A
  • assess pt’s baseline before planning
  • exercise: activity beyond the pt’s baseline
  • use resources: PT and OT
  • include pt and family during planning
  • tailor exercise to pt’s ability
93
Q

What exercises and interventions are appropriate for osteopenia and osteoporosis?

A
  • weight-bearing exercise
  • calcium and vitamin D supplementation
  • avoid smoking
  • limit alcohol, caffeine
94
Q

osteoporosis

A
  • loss of bone mass throughout the skeleton
  • predisposes patients to fractures
  • BMD > 2.5 standard deviations below normal
95
Q

osteopenia

A
  • significant decrease in the amount of bone mineral density (BMD) normally found in a population or group
  • 1 ≤ BMD ≤ 2.5 standard deviations below normal
96
Q

osteomyelitis

A
  • infection of the bone
  • can happen after illness or procedures
  • very difficult to treat
  • very painful
97
Q

List the types of bone and joint injuries.

A
  • osteoporosis and osteopenia
  • osteomyelitis
  • bone tumor
  • trauma: fractures, strains, sprains, tears
98
Q

Fx symptoms

A
  • localized pain
  • loss of function
  • swelling
  • deformity
  • discoloration
99
Q

compound Fx

A

when bone protrudes through skin

100
Q

nursing actions for Fx

A
  • assess and treat pain
  • immobilize site
  • frequently assess circulation in dependent areas
  • prevent infection
  • monitor for complications
    • embolism
    • infection
    • circulatory status
101
Q

rules for handling casts

A
  • keep clean and dry
  • NEVER stick objects in cast
  • monitor circulation for compartment syndrome
  • educate pt and family to notify provider of:
    • bad odors
    • loosening cast
    • tightening cast
    • wet cast
  • may need sling for arm injuries
102
Q

compartment syndrome

A
  • emergent condition
  • swelling of tissue causing altered circulation
  • can occur with anything that causes swelling
103
Q

nursing actions for compartment syndrome

A
  • assess 5 Ps
  • first sign may be pain with movement
  • may require fasciotomy
  • neurovascular assessment
    • pulses - equal?
    • capillary refill
    • skin color and temp
    • sensation
    • motor function
104
Q

traction

A
  • pulling force to maintain alignment
  • can be strapped on or internally affixed
105
Q

nursing actions for pts in traction

A
  • neurovascular checks
  • alignment assessment
  • equipment inspection
  • pain assessment and treatment
  • monitor skin integrity
106
Q

pins

A
  • internal or external
  • external huge risk for infection
  • provide frequent assessment and pin care
  • assess for s/s of infection
107
Q

strain

A

injury to muscle from overuse or exercise stress

108
Q

sprain

A

stretch injury of ligament from tear

109
Q

s/s of strains and sprains

A
  • swelling
  • pain
  • possible discoloration
  • sprain usually more severe
110
Q

diagnosis of sprains and strains

A
  • assess ROM
  • often requires X-ray to rule out Fx
    • possibly MRI to visualize soft-tissue injury
    • may be diagnosed based on s/s and R/O Fx
111
Q

treatment of sprains and strains

A
  • RICE
    • rest
    • ice
    • compression
    • elevation
  • sometimes requires surgery
112
Q

nursing actions for ambulation

A
  • assess:
    • gait
    • strength
    • tolerance
  • may need PT
  • use assistive devices if indicated
  • let pt’s legs dangle before standing to prevent hypotension
113
Q

What increases fall risk when ambulating a patient?

A
  • misuse or not using assistive devices
  • orthostatic hypotension - let pt dangle legs before ambulation
  • prolonged immobility
114
Q

how to use a cane

A
  • hold cane on strong side
  • advance cane, then weak leg
115
Q

how to use a walker

A
  • stand between back legs of walker
  • pick up walker and advance with step
  • do not slide unless it has wheels
116
Q

how to use crutches (basic)

A
117
Q

benefits of heat therapy

A
  • increases blood flow
  • increases tissue metabolism
  • relaxes muscles
  • eases joint stiffness and pain
118
Q

benefits of cold therapy

A
  • decreases inflammation
  • prevents swelling
  • reduces bleeding
  • reduces fever
  • diminishes muscle spasms
  • decreases pain
119
Q

nursing considerations for heat therapy

A
  • monitor bony prominences for breakdown
  • avoid over implanted parts
  • avoid during acute phase of injury
  • extreme caution in presence of immobility or impaired sensation
  • use in short time intervals
120
Q

nursing considerations for cold therapy

A
  • avoid in:
    • vascular deficiency
    • open wounds
    • disorders such as Raynaud disease (vasospastic)
  • extreme caution in pts with immobility or decreased sensation
121
Q

Raynaud disease

A
  • primary vasospastic disease of small arteries and arterioles
  • cause unknown
122
Q

How does immobility affect skin integrity, and how do we prevent breakdown?

A
  • increases pressure on skin
  • prevention:
    • assess q2 hours for early signs: erythema, warmth, Braden scale
    • use positioning devices, reduce pressure
    • reposition q1-2 hours
    • monitor nutrition
    • provide good hygiene, especially for the incontinent
123
Q

respiratory infection prevention

A
  • decreased ventilation → decreased O2 sat
  • stasis of secretions → atelectasis and infection
  • decreased cough response
  • assess breathing q2 hours
  • reposition and remove secretions q2 hours
  • teach TCDB
    • turn
    • cough
    • deep breathe
124
Q

atelectasis

A

collapsed lung

125
Q

preventing stasis of blood in the lower extremities and embolism

A
  • use TEDs and SCD
  • anticoagulants
  • avoid binding at the knees: pillows, tight clothing, prolonged sitting
  • encourage frequent movement
  • assess for embolism: one-sided edema, warmth, redness, pain, absent or weak pulse
126
Q

assessing for heart problems in immobile patient

A
  • decreased cardiac output → increased workload long-term
  • assess for S3 at apex; could mean heart failure, edema in dependent areas
127
Q

How does immobility affect metabolism?

A
  • decreased basal metabolic rate
  • changes in protein, carb, and fat metabolism
  • loss of muscle and weight
  • fluid and electrolyte imbalance → hypercalcemia
128
Q

nursing actions for immobility-related metabolic changes

A
  • monitor I&O
  • assess wound healing (loss of proteins)
  • review labs (esp. CMP)
  • monitor nutrition: calories, protein, vitamins B and C
    • may need parenteral nutrition
129
Q

What elimination issues can arise from immobility?

A
  • urinary stasis → infection
  • electrolyte imbalance
  • decreased peristalsis → constipation
130
Q

assessment and nursing interventions for bowel issues

A
  • assess bowel sounds
  • monitor BMs
  • maintain hydration: min. 2L/day unless restricted
  • increase fiber
  • administer stool softener, laxatives as needed with order
131
Q
A

2020 Foundations I (4 decks)

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