Exam 1 (Focused) Flashcards
What are the 5 HGTC Integrated Concepts?
- Safety 2. Profession Behavior 3. Clinical Decision Making 4. Patient Center Care 5. Teamwork & Collaboration
Give an Example of each Integrated Concepts
Safety: PPE, Med Safety, & Procedure Skills. Prof Beh: Pt. Come First, Good Attitude, Being on Time, Uniform, & Being Prepared. Clin Dec: Quick Decision. Pt. Center Care: All About Patient. Team & Collab: Communication Skills
What are the 4 Aims of Nursing?
- Promote Health 2. Prevent Illness 3. Restore Health 4. Facilitate coping with Disability/Death
Give an Example of each Nursing Aim
Prom Health: Eat right, Exercise, No Smoking. Prevent Illness: Vaccination & Screening. Restore Health: Rehabilitation. Facil Coping: Helping Family & Pt Wishes
What does ADPIE Stand for?
Assessment, Diagnosis, Planning, Interventions, Evaluation
An Exam that Must be Passed for Initial Licensure as a Practical Nurse.
NCLEX-PN
An Examination that Assesses the Knowledge and Skills Required for Nursing Practice.
NCLEX Exam
What are the Standards of Care in Nursing Practice?
What Nurses Can do
What are the Nurses Practice Acts?
How a Nurse Does Tasks (Vary by state)
What is Inductive Reasoning?
Using Multiple Concepts to Reach a Conclusion (2+2=4)
What is Deductive Reasoning?
Working Backwards to Identify a Cause (4=2+2)
What is Qualitative Research?
Gains Insight into Patient Experience “Art of Nursing”
What is Quantitative Research?
Provides Data & Numbers “Science of Nursing”
What does PICOT stand for?
Population, Intervention, Comparison, Outcome, & Time
What is the Gold Standard of Nursing Practice?
Evidence-Based Practice
What is the Normal Adult Temp?
96.4-99.5F or 35.8-37.5C
What is the Normal Adult Pulse?
60-100
What is the Normal Adult Respiration Rate?
12 to 20
What is the Normal Adult Blood Pressure?
120/80
What is the Normal Older Adult Temp?
96.4-98.3F or 35.8-36.8C
What is the Infection Cycle?
Stages involved in the process of infection including: infectious agent, reservoir, portal of exit, means of transmission, portals of entry, and susceptible host.
What is an Infectious Agent?
Pathogens like bacteria, viruses, and fungi that cause infection, such as avian influenza and swine flu Found Everywhere
What are the 5 Moments for Hand Hygiene?
Guidelines for when to perform hand hygiene to reduce infection risk Moment 1: before touching a patient Moment 2: before a clean or aseptic procedure Moment 3: After a body fluid exposure risk Moment 4: After touching a patient Moment 5: After touching patient’s surroundings
What are the Stages of Infection?
Incubation, Prodromal, Full Illness, and Convalescence
Describe the Incubation Stage of Infection?
Infection has entered the body. Little to no symptoms.
Describe the Prodromal Stage of Infection?
Most contagious stage. Some symptoms Know you are sick but not with what
Describe the Full Illness Stage of Infection?
The disease is going to run its course. Sick role is taken on. Time varies”
Describe the Convalescence Stage of Infection?
When we get better. Time depends on many factors. Restored to highest ability of function
Cardinal signs of acute infection/inflammation
Redness, heat, swelling, pain, and loss of function
What are Standard Precautions?
Infection prevention practices used for all hospitalized patients regardless of infection status gloves, gowns, masks, and eyewear Tier 1 precautions The first line of defense This applies to all patient Used when a there is risk of contact with blood, mucus membrane, or body fluids (ex., Giving a shot)
What are Transmission-Based Precautions?
Additional precautions for patients suspected of having infections that can spread by airborne, droplet, or contact routes Tier 2 Protocol provided Standard precautions are still in place as need be Always hand wash, cough etiquette
What are Air Born Precautions?
Precautions used for diseases that spread through the air. M95 or higher mask are used. Goggles if actively coughing. Negative pressure (vented outside), isolation room. Door must be closed. Ex. Chickenpox, smallpox
What are Droplet Precautions?
Used for illness such as Flue, Mumps, COVID. Partials are heavier, if shot out, will hit the ground. Mask are used up close, but not far away. Gloves, goggles, and gown if needed
What are Contact Precautions?
Gloves and gowns. Ex: C.diff & Norovirus
What are Neutropenic Precautions?
Used for no immune system pt (like cancer pt.) You can’t give them something. Gowns, gloves, door closed, & no fresh fruit or flowers
What are Some Common Safety Risk Factors?
Falls, Fires, Poisoning, Suffocation/Choking, & Firearms
What is the Biggest Future Indicator for a Fall?
A Past Fall
What are Some Fall Prevention Strategies?
Methods to reduce the risk of falls, including proper use of side rails, bed and chair locks, bed and chair alarms, shower and non-skid socks
What does R.A.C.E. P.A.S.S. Stand for and What is it Used For?
Rescue Activate Confine Evacuate/Extinguish Pull pin Aim Squeeze Handle Sweeping Motion. Used for Fire Safety
What could Restraints cause?
Increased injury risk, skin injury, depression, anxiety/delirium, aspiration, & death
What are the 6 Vital Signs?
Temperature, Pulse, Respiration, Blood Pressure, Pain, & Oxygen Saturation
When should you assess vital signs (7)?
On admission, Based on policy and procedures, When there is a change, Loss of consciousness, Before and after surgical or invasive procedure, Before and after activity, & Before administering medications
What is the Normal Oxygen Saturation (O2 sat)?
> 95%
What is the Primary Source of Heat in the Body?
Metabolism
What are Some Ways Metabolism is Increased?
Hormones, Muscle Movements, & Exercise
What is the Normal Oral Temperature for an Adult?
37.0C or 98.6F
What is the Normal Rectal Temperature for an Adult?
37.5C or 99.5F
What is the Normal Axillary Temperature for an Adult?
36.5C or 97.7F
What is the Normal Tympanic Temperature for an Adult?
37.4C or 99.5F
What is the Normal Forehead Temperature for an Adult?
34.4C or 94.0F
What are some of the physical effects of fevers?
Muscle aches, fatigue, hr & rr increase, fluid & electrolyte imbalance, loss of appetite, headache, hot &/or dry skin thirst, & seizure &/or confusion
What do seizures and confusion indicate?
Temperature is too High
What are some treatments of fevers?
Comfort, medications, cool baths, increase fluid intake, & simple carbs
What is the Pulse rate?
Number of contractions over a peripheral artery in 1 minute
What HR indicates Tachycardia?
> 100
What HR indicates Bradycardia?
< 60
What is the name for the sounds heard durning BP?
Korotkoff
What is the First sound/Top number heard in BP
Systolic
What is the Change in sound/Bottom number in BP
Diastolic
What arteries are commonly used to take blood pressure?
Brachial artery and popliteal artery
What numbers indicate hypertension?
> 130/90
What happens when the BP cuff is too big?
Decrease blood pressure
What happens when the BP cuff is too small?
Increased blood pressure
What is ventilation?
Movement of air in & out of the lungs
(Inhalation: in Exhalation: out)
What is the term for normal, unlabored respiration 1 resp to 4 heartbeats
Eupnea
What is the term for increased respiratory rate; may occur in response to an increased metabolic rate (>20)?
Tachypnea
What is the term for decreased RR; that occurs in some pathologic conditions (<12)?
Bradypnea
What is the term for period when no breathing occurs?
Apnea
What is the term for difficult or labored breathing?
Dyspnea
What is the term for changes in breathing when sitting or standing?
Orthopnea
What is the purpose of a health assessment?
Establish relationship, gather data, identify strengths, identify health problems, & establish a base
What is a comprehensive health assessment?
Conducted upon admission to health care facility. Must be done by a RN
What is an ongoing partial health assessment?
Conducted at regular intervals. The 10 min assessment. Snapshot of comprehensive. Track progress. Frequency depends on facility. LPN can help, but RN at least every 24hr
What is a focused health assessment?
Conducted to assess a specific problem/complaint
What is an emergency health assessment?
Conducted to determine life-threatening or unstable conditions
What are the 6 steps to preparing the environment for physical assessment?
Agree on time, Free of pain, Prepare table, Provide gown & drape, Gather supplies & instruments, & Provide a curtain or screen
What are the 6 pieces of equipment used during a physical examination?
Thermometer or sphygmomanometer, scale, flashlight or penlight, stethoscope, metric tape measure and rule, and eye chart
What visualization does a Sitting assessment allow?
Allows visualization of upper body
What does a Supine assessment allow?
Allows relaxation of abdominal muscles
What type of patients are Dorsal recumbent assessments used for?
Used for patients having difficulty maintaining supine position
What does a Sim’s assessment assess?
Assessment of rectum or vagina
What does a Prone assessment assess?
Assessment of hip joint and posterior thorax
What does a Lithotomy assessment assess?
Assessment of female genitalia and rectum
What does a Knee-chest assessment assess?
Assessment of anus and rectum
What does inspections assess?
Assesses size, color, shape, position, and symmetry
What does palpation asses?
Assesses temperature, turgor, texture, moisture, vibrations, and shape
What does percussion assess?
Assesses location, shape, size, and density of tissues
What does auscultation assess?
Assesses the four characteristics of sound, that is pitch, loudness, quality, and duration
What are the 6 characteristics of masses determined by palpation?
Shape, Size, Consistency, Surface, Mobility & Tenderness
What are the 4 characteristics of sound heard during auscultation?
Pitch, Loudness, Quality, & Duration
What are the 4 aspects of a general survey?
General appearance, Vital signs, Height, weight, waist circumference, & Calculating BMI
What are the 4 common thorax & lung variations in older adults?
Increased anteroposterior chest diameter, Increase in the dorsal spinal curve (kyphosis), Decreased thoracic expansion, & Use of accessory muscles to exhale
What are common cardiovascular & peripheral vascular variations in older adults?
Difficult-to-palpate apical pulse and distal arteries, Dilated proximal arteries, More prominent & tortous blood vessels (varicosities common), increased systolic & diastolic bp, & Widening pulse pressure
What is an abdominal variation commonly seen in older adults?
Decreased bowel sound & abdominal tone & Fat accumulation on the abdomen and hips
What does Prone position look like?
The person lies on the abdomen with head turned to the side, the bed is flat
What does Supine (dorsal recumbent) position look like?
The pt. lies flat on the back with head & shoulders slightly elevated w/pillow
What does Fowler’s position look like?
Head of the bed is elevated 45-60 degrees, semi-sitting position
What does Semi-Fowler’s position look like?
Head of the bed is elevated 15-45 degrees
What does Lateral position look like?
Pt. lies on the side with a pillow bt legs, weight on lateral aspect of lower scapula and lower ilium
What does Sims position look like?
Pt. lies on the side with a pillow bt legs, lower arm is behind pt and upper arm is flex at both the shoulder & elbow
What does Trendelenburg position look like?
Pt. is supine on the bed with head decline below their feet at an angle of roughly 16 degrees
What is the order for abdominal assessment?
- Inspect 2. Auscultate 3. Percuss 4. Palpation
What position should the pt be in for an abdominal assessment?
Supine
Why does BP increase in older adults?
Arteriosclerosis
What is arteriosclerosis?
Hardening of blood vessels
What is pulse pressure?
The difference between systolic & diastolic
