Exam 2 Flashcards
What are the 6 factors affecting personal hygiene?
Culture, Socioeconomic class, spiritual practices, developmental level, health state, & Personal preferences
What can hygiene indicate?
Overall health status
What is the largest organ?
Skin
What are the 6 questions for skin nursing history?
How long? Bothersome? Bothersome how? Itich? What makes it better? What makes it worse?
What are the 4 factors to nursing history oral cavity, eyes, ears, and nose?
Identify pt.’s normal, identify risk factors, identify prosthetics, & inquire history of problems
What can dehydration cause in regards to the skin?
Dry skin & lips
What is a big risk factor of poor oral health?
Cardiac risk factors
What are some important aspects to note during a nursing history in regard to hygiene?
The pt. normal, history of problems, and preferences
Why must a nurse be very careful when caring for a diabetic pt.’s feet (ex. Toenails)?
Diabetics have very poor wound healing
When it comes to hair, what can bad circulation cause?
No hair growth
When it comes to hair, what can bad diet cause?
Poor hair health ie. Hair loss & slow growth
When should you incorporate the assessment of the skin when assessing the pt.?
Incorporate assessment of the skin during the assessment of other body systems
When assessing the skin, what should the nurse do regarding the light?
insure they are using a good light source, preferably daylight
When assessing bilateral parts of the body, what should a nurse compare?
Compare the bilateral parts for symmetry
What type of terminology should be used when reporting on the assessment of the skin?
Use standard terminology to report and record findings
What should a nurse allow to direct the skin assessment?
Data from the nursing history
What should be identified during the assessment of the skin?
Any variables known to cause skin problems
What is assessed during the assessment of the oral cavity (7)?
Lips, Buccal mucosa, Color & surface of gums, Teeth, Tongue, Hard and soft palates, & Oropharynx
What does the suffix -itis mean?
Inflamed
What is Cheilosis?
Cracking of the corners of the mouth
What causes Cheilosis?
Vitamin B deficiency
What is halitosis?
Bad breath
What is tartar?
Hardened dental plaque
What is cerumen?
Ear wax
What is pediculosis?
Head lice
What is important to look for when inspecting the fingers?
Clubbing, spoon shape, and any other abnormalities
What accommodations would a nurse make for thick toenails, and why must they be made?
Since capillary refill is not an option, the nurse could push on skin, check pulses, or check the temperature
Why must a nurse be sure to avoid skin on skin folds for their pts.?
It can cause chafing, skin irritation, inflammation, infection, and skin break down
When does early morning hygiene care occur?
Before breakfast
What 4 steps make up early morning hygiene?
Assist pt. with toileting, provide comfort measures, wash face and hands, and provide mouth care
When does morning care occur?
After breakfast
What does morning care encompass (11)?
Toileting, oral care, bathing, back massage, special skin measures, hair care, cosmetics, dressing, positioning for comfort, refreshing/changing bed lines, & tidying up bedside
When does afternoon care occur?
After lunch
What does afternoon care encompass?
Offer assistance with toileting, handwashing, & oral care, straighten bed lines, & help pt. with mobility to reposition self
When does hour of sleep care occur?
Before patient retires to bed (goes to sleep)
What does hour of sleep care encompass(7)?
Offer assistance with toileting, washing, & oral care, offer back massage, change soiled bed linens/clothing, position pt. comfortably, ensure call light and other objects are within reach
How often should a nurse provide oral care to a pt. who can not eat or drink?
Every couple hours
Why should a nurse provide dental care to an intubated pt. so often?
To avoid lung infections
What are some purposes to bathing a pt in the hospital?
Promotes circulation, promotes comfort, reduce infection, strengthens nurse-pt. relationship, etc.
What kind of touch does a bath provide the pt.?
Therapeutic touch
How should a nurse assist a pt. who is able to do some bathing actions?
Let them do as much as they can by themselves
What are the 4 factors of providing perineal & vaginal care?
Assess for problems and related treatments, perform physical assessment, perform perineal care, & cleanse vaginal area with plain soap & water
How should a nurse perform perineal & vaginal care?
In matter-of-fact & dignified manner according to procedure
What does administering oral hygiene encompass?
Moistening & cleaning the mouth, caring for dentures, toothbrushing, flossing, & using mouthwashes
Should toothpaste be used on dentures?
No, may crack the dentures
How often should a nurse use artificial tears if blink reflex is absent?
Every 4 hours
What should you do after taking a pt.’s hearing aid out?
Open the battery pack
What is one of the most important things for a nurse to do when providing hair care?
Ask the pt. how they want the care done and preform it how the pt. wants to the best of their ability
What should you check for before shaving a pt.?
Check if the pt. is on anticoagulant
If the pt. is on anticoagulants, what accommodation for shaving should be made?
Use an electric razor
What should be done for a diabetic pt. everyday, in regards of nail & foot care?
Wash, lotion, and inspect them every day
What are some ways a nurse ensure bedside safety?
Bed low and locked, call light and controls in reach, side rails up, & pt. in safe comfortable position
When do most falls happen?
At night on the way to the bathroom
When educating the pt., how often should the nurse tell the pt. to use sunscreen?
Everyday
What are some potential problems caused by poor oral hygiene?
Includes dental caries, gingivitis, periodontitis, halitosis, and cheilosis.
What is excoriation?
A condition that appears as a popped blister, often associated with rashes
What is the Patient Outcome Achievement for hygiene?
Focuses on patient participation and management of hygiene and skin treatment.
What are the functions of the skin (8)?
Protection, temperature regulation, psychosocial, sensation, Vit. D production, immunologic, absorption, elimination
What is the body’s first line of defense against infection?
The skin
What factors of skin define against harmful agents?
Unbroken & healthy skin and mucous membranes
What affects the skin’s resistance to injury?
Ages, amount of underlying tissue, and illness
What type of body cells are resistant to injury?
Adequately nourished & hydrated cells
What is necessary to maintain cell life?
Adequate circulation
What is a pressure injury?
A condition that increases the risk of infection and is exacerbated by prolonged pressure on the skin.
What is risk of infection?
An elevated likelihood of contracting an infection due to factors such as pressure injuries.
What is gravity effect?
The force that causes the body’s weight to compress the skin against surfaces like a bed, contributing to pressure injuries.
What is capillary breakdown?
The failure of capillaries that can lead to insufficient blood flow and skin death.
What are pressure points, in regards to pressure injuries?
Specific areas of the body that are more susceptible to pressure injuries
What are some common pressure injury sites?
Sacrum, heels, back of the head, shoulders, elbows, inner knees, and hips
What are some negative factors that come with pressure injuries?
Increased risk of infections, increased hospital stay, lack of insurance reimbursement, capillary breakdown, and cell death
What is the best way to prevent a pt. from acquiring a pressure injury?
Turn the pt. at least every 2 hr.
What are the 4 phases of wound healing?
Hemostasis, Inflammatory, Proliferation, & Maturation
When does the hemostasis phase begin?
Immediately after the initial injury
What do the blood vessels do in the hemostasis phase?
Blood vessels constrict to begin blood clotting
Exudate is formed during hemostasis, what is it and what does it cause?
Cells, such as plasma, platelets, & protein, rushing to the site of injury. It causes swelling & pain
During the hemostasis phase, what does increased perfusion result in?
Heat and redness
What do the platelets do during hemostasis?
Stimulate other cells to migrate to the injury to participate in other phases
When does the inflammatory phase begin and about how long does it last?
After hemostasis and lasts about 2-3 days
What moves to the wound during the inflammatory phase?
White blood cells, predominantly leukocytes and macrophages
What role do the WBCs play in the inflammatory phase?
The cleaners
What do the WBCs do during the inflammatory phases?
Ingest debris & bacteria & release growth factors that attract fibroblasts to fill the wound
What happens to the WBC count during the inflammatory phase?
It increases
What kind of generalized body response occurs during inflammatory?
Pain, fever, etc.
How long does the proliferation phase last?
Several weeks
The proliferation phases is also known as what?
The regeneration phase
What starts to form new tissue in the wound space during proliferation?
Fibroblasts
What happens during the proliferation phase?
New tissue is built in the wound space, capillaries grow across the wound, a thin layer of epithelial cells forms across the wound, and granulation tissue forms a foundation for scar tissue to develop
When does the maturation phase begin?
About 3 weeks after the injury
How long can the maturation phase last?
Possibly months or years
What happens durng the maturation phase?
Collagen is remodeled, new collagen tissue is deposited, & scar becomes a flat, thin, white line
The maturation phase is also known as what?
The remolding phase
What type of people are more susceptible to skin injury?
Very thin & very obese
What are some potential causes of skin alterations?
Fluid loss (skin appears loose & flabby), Excessive perspiration, Jaundice, & Skin diseases (ex. Eczema & psoriasis)
What are the 8 factors affecting pressure injury development?
Aging skin, Chronic illnesses, Immobility, Malnutrition, Fecal & urinary incontinence, Altered level of consciousness, Spinal cord & brain injuries, & neuromuscular disorders
What happens when a pt. lacks protein?
They have decreased healing
Why does fecal cause fast skin breakdown?
Fecal is very acidic
What is friction?
Two surfaces rubbing together
What is shearing?
One surface sliding over another (pull pt. across bed)
What are the 6 points of pressure injury assessment?
Risk assessment, Mobility, Nutritional status, Moisture & incontinence, Appearance of existing pressure injury, & Pain assessment
What is the Braden scale?
Risk assessment scale for pressure injury
If a pt. has a history of skin breakdown & wounds, what are they at higher risk for?
Pressure injury
What are the 6 factors of the Braden scale?
Sensory perception, Moisture, Activity, Mobility, Nutrition, & Friction & Shear
What are the 8 topics for home health care teaching?
Supplies (which ones, where to get them), Infection prevention (wash hands, S&S of infection), Wound healing (better? worse? same?), Appearance, activity/mobility, nutrition (enough protein), pain, & elimination
What are the 4 types of wound complications?
Infection, Hemorrhage, Dehiscence & evisceration, & fistula formation
What are some signs of wound infection?
Foul odor, purulent drainage, redness, hot, etc
What is a wet-to-dry dressing?
A type of wound dressing that involves applying a wet material to the wound and allowing it to dry, helping to debris necrotic tissue.
When should wound dressing be changed?
As directed, when wet, and when soiled
What is dehiscence?
An abdominal wound that opens down the middle, exposing the wound bed.
What is evisceration?
An abdominal wound with organs protruding outside the body
What is a fistula?
Tunneling inside the body from an organ to the outside
What is necroses?
Dying flesh impacting wound healing
What are some the things immobility can cause?
Muscle atrophy, weakness, poor circulation, increased skin breakdown, & overall poor health
What is muscle atrophy?
the reduction in size and strength of muscle tissue due to lack of use or a disease
What role does the skeletal system play in movement?
Support, Protect, Surfaces for the attachments, Provides storage, & Produce blood cells
What are the 4 important functions of muscles?
Motion, Maintenance of posture, Support (Abdomen), & Heat Production (increase metabolism)
What are the 7 factors influencing mobility?
Developmental considerations, physical health, mental health, lifestyle, attitude & values, fatigue & stress, & external factors
What are the factors of physical health that influence mobility?
Muscular, Skeletal or Nervous system problems & problems involving other body systems
What are 3 types of exercises?
Isotonic, Isometric, & Isokinetic
What is isotonic exercise? Examples?
Muscle shortening & active movement. Ex: running, swimming, & activities of daily living (ADLs)
What is isometric exercise? Examples?
Muscle contraction without shortening. Ex: yoga, stretching, & planking.
What is isokinetic exercise? Examples?
Muscle contraction with resistance. Ex: weight lifting
What are some protective positioning?
Fowler’s, Protective supine, Protective side-lying or lateral, Protective Sims’, & Protective prone
Where are pillows placed in protective positioning?
Under key bony prominences (heels, sacrum, & elbows)
What does Fowler’s position look like?
Head of the bed is elevated 45-60 degrees, semi-sitting position
What does protective 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 protective 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 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 are some benefits of exercise to the Musculoskeletal system (4)?
Increased muscle efficiency & flexibility, increased coordination, reduced bone loss, increased efficiency of nerve impulse transmission
What are some benefits of exercise to respiratory system(3)?
Improved alveolar ventilation, Decreased work of breathing, & Improved diaphragmatic excursion
What effect can exercise have on the diaphragm?
Allows diaphragm to get stronger
What are some benefits of exercise to the cardiovascular system(5)?
Increased heart efficiency, decreased HR & BP, increased blood flow, increased venous return, & increased circulating fibrinolysin
What is fibrinolysin?
A substance that breaks up small clots
What does PRN order mean?
Give as needed
What does a STAT order mean?
Give immediately (within 30 min)
What are time meds?
Medications given at a specific time
How would an order for a medication given every 6 hours be written?
q6h
What does a daily order mean?
Give every day at the same time
What does AC mean?
Before Meals (ex. Insulin)
What does PC mean?
After Meals
What does HS mean?
Hour of sleep (Insulin)
What does BID mean?
Twice a day (q12h)
What does TID mean?
Three times a day (q8h)
What does QID mean?
Four times a day (q6h)
What are the 7 parts of a medication order?
Pt.’s name & identifier, Date & time, Name of drug, Dosage, Route, Frequency, & Signature of Prescriber
What are the Three Checks of Medication Administration?
Reach for Medication, When actually in Hand, & At Pt. Bedside
What are the 11 Rights of Medication
Right pt., Right medication, Right dose, Right route, Right time, Right documentation, Right reason, Right response, Right education, Right assessment data, & Right to refuse
What is the barrel of a syringe?
The part of the syringe that holds the fluid.
What is the plunger of the syringe?
The part of the syringe that is pushed to draw or expel fluid.
What is the Bevel of a needle?
The slanted edge on the tip of a needle that helps in penetration. (Always pointed up when giving a shot)
What is the needle length for an intramuscular injection into Vastus Lateralis?
5/8 to 1 inch
What is the needle length for an intramuscular injection into the Deltoid?
Child: 5/8 to 1 inch Adult: 5/8 to 1.5 inch
What is the needle length for an intramuscular injection into Ventrogluteal?
1 to 1.5 inch (Adult only)
What is the needle gauge range for intramuscular injections?
Oil-based: 18-25 gauge. Aqueous-Based: 20-25 gauge
What is the medication amount for intramuscular?
Standard: 1-5ml Poorly developed muscle: 1-2ml
How do you find the ventrogluteal injection site?
With thumb pointed in the direction of pt. nose, place index finger toward anterior iliac spine, place middle finger toward the iliac crest, and place palm on the greater trochanter. Inject at the bottom of the V.
How do you find the vastus lateralus injection site?
Dived the thigh into thirds diagonally, and then again horizontally. Inject in the middle outer third.
What is the automical landmark for finding the deltoid injection site?
Acromion process
What is the injection angle for intramuscular injections?
90°
What is the Z track method?
a technique used for intramuscular injections to prevent medication from leaking back into the subcutaneous tissue.
What do the orange caps indcate?
Insulin (Marked in Units)
What do the grey caps indicate?
Used for Heparin and TB test (Marked in ml)
What is the needle length for subcutaneous injections?
3/8 - 5/8 & up to 1 in
What is the needle gauge range for subcutaneous injections?
25-30 gauge
What are the sites for subcutaneous injection?
Upper outer arm, Abdomen (2in from umbilicus), Top of thigh, Upper back, & Upper ventrogluteal
What is the injection angle for subcutaneous injections?
45°(thin pt. & longer needle) -90° (thicker pt. & shorter needle)
What is the order for two insulins in one syringe?
Cloudy, Clear, Clear, Cloudy
What is the difference between NPH Insulin & Regular Insulin?
NPH is long-acting & Regular is short-acting
What is the needle length for an intradermal injection?
1/4- 1/2 inch
What is the needle gauge range for intradermal injection?
25-27 gauge
What is the injection site for intradermal injections?
Forearm (TB test)
What is the bubble formed in a TB test called?
Wheal
What is the degree for intradermal injections?
5°-15°
What is reconstitution?
the process of adding a suitable diluent to a powdered drug to prepare it for administration.
What are controlled substances?
drugs that are regulated by law due to their potential for abuse and addiction
What is a standing order?
An order with no specific time to be given, with & without termination
What is the chemical name of a drug?
The name that reflects the chemical structure of a drug.
What form of drug administration has the fastest absorption rate?
Injectable
What are the 3 types of drug preparations?
Oral, Topical, & Injectable
What is always true about parenteral route drugs?
They are always given by injection
What are some of the types of enteral routes?
Oral, Sublingual, & Rectum
How are sublingual drugs given?
Under the tongue
What are SubQ injections injected into (layer)?
Adipose subcutaneous tissue (fat)
What are intrathecal injections injected into?
The spine
What are the 2 types of drug classifications?
Pharmaceutical & Therapeutic
What are pharmaceutical classification based on?
How the drug works in the body (ex. Beta-blocker)
What are therapeutic classification based on?
What the drug is treating (ex. Antibiotic)
What are the 6 factors affecting absorption of medication?
Route of administration, Lipid solubility, pH, Blood flow, Local conditions at the site of administration, & Drug dosage
What is the first pass effect?
The process where a drug is metabolized in the liver before reaching systemic circulation.
What does liquid solubility mean?
The capability of a drug to dissolve in liquid, facilitating its passage through cell membranes.
What is an emergency anaphylactic reaction?
Angioedema (Tongue swelling)
What is an antagonisitc adverse effects?
When one drug decreases or counteracts the effect of another drug
What is a synergistic adverse effects?
When two drugs work together to produce a greater effect than either drug alone
What is an idiosyncratic adverse effect?
An unusual or atypical reaction to a drug or treatment that is specific to an individual.
What are the 8 factors affecting drug action?
Developmental considerations, weight, gender, genetic & cultural factors, psychological factors, pathology, environment, & timing of administration
What is therapeutic range?
The range of drug concentrations in the bloodstream that achieves the desired effect without toxicity.
What is trough level?
The lowest concentration of a drug in the bloodstream before the next dose is administered.
What is half-life?
The time it takes for the concentration of a drug in the bloodstream to reduce by half.
What are some types of medication errors?
Inappropriate prescribing, wrong dose, wrong pt., wrong route, not within prescribed time, incorrect preparation, improper technique, & deteriorated
What are the 4 steps to reduce medication errors?
Read labels carefully, question admin of multiple, take caution, & use notification system
What are the 4 safety measures for medication admin.?
Double check decimal points, Question abrupt increase or decrease, Check resources, & Do not try to decipher illegible writing
What are the 4 steps to take after a medication error?
Check pt. condition, Notify pcp & nurse manager, write documentation, & Complete form
What should be included in medical record medication documentation?
Name of med, Dosage, Route & time, Name of administer, Site used, Omitted drugs, refused drugs, & Medication errors
What is the overall purpose of patient records?
To provide a comprehensive and accurate documentation of a patient’s medical history and care.
What are the 8 characteristics of effective documentation?
Consistency, Complete, Accurate, Concise, Factual, Organized & Timely, Legally Prudent, & Confidential
When should a nurse document in patients’ records?
Throughout their shift
What are the 5 elements of documentation?
Content, Timing, Format, Accountability, & Confidentiality
What should you never document in a patient’s records?
Your opinion & an action you have not done yet
How should you sign a documentation?
First initial, Last name, & Title (always date & time)
What is HIPAA?
Health Insurance Portability and Accountability Act, a US law that mandates the protection of patient health information.
How should a nurse document time in patient records?
Using military time
What is confidential?
All information about pts. (name, address, treatments, etc.)
T/F A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.
True (A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.)
What is a breach?
An incident where patient information is disclosed improperly.
What is informed consent?
The process of obtaining permission from a patient before sharing their information.
T/F A patient has the right to obtain, review, and revise the patient information in his or her health record.
False (A patient has the right to obtain and review, but not revise the patient information in his or her health record.)
What are the 5 patient rights in documentation?
See & Copy records, Update (biographical info), Get Disclosure List, Request Restriction, & Choose How to Receive Info
What is a way for a nurse to verify the accuracy of an order?
Read back the order
When calling a physician for a telephone order, what are the first steps a nurse needs to take?
Identify self, report concisely & factually, report what has been done, & provide current vitals & clinical symptoms
What should a nurse be sure to have in front of them when receiving a telephone order?
The pt.’s records
T/F One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.
True (One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.)
What are the four purposes of recording data?
Facilitate quality, evidence-based pt. care, financial & legal record, Clinical research, & Support decision analysis
What are the 2 types of personal health records (PHRs)?
Standalone & Tethered
What are standalone personal health records?
Records filled in by pt. in their own words
What are tethered/connected personal health records?
Records linked to a specific facility (review of labs and other values)
What is the source-oriented records method?
A method of documentation where information is organized according to the source of the information.
What is the Problem-oriented medical records method?
A documentation system that organizes patient data around specific problems instead of sources.
What is the PIE charting documenting method?
A documentation method that includes Problem, Intervention, and Evaluation.
What is the Focus charting documentation method?
A documentation approach that emphasizes the patient’s specific problems and needs.
What is the Charting by exception method?
A streamlined documentation method that records only deviations from established norms.
What is the Case management model?
A documentation framework that integrates care coordination for complex patient needs.
What is the Computerized documentation method?
The use of electronic systems to record and manage patient health information.
What are Electronic health records (EHRs)?
Digital versions of patients’ paper charts that provide comprehensive patient data.
Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes?
PIE
What are the 5 major components of Problem-oriented medical records?
Defined database, Problem list, Care plans, Progress notes, & SOAP format
What is the Care Plan?
The plan of action
What are the progress notes?
What you have done to reach the care plan goal
What are the 4 categories of a SOAP note?
Subjective data, Objective data, Assessment data, & Plan
What are flow sheets and graphic records?
Forms used to record ongoing patient data such as vital signs, intake/output, and other assessments.
What are acuity records?
documentation that measures and records the patient’s needs and necessary time for their care. (How much time that pt. takes)
What are the 5 types of flow sheets?
Graphic records, 24-hr fluid balance record, Medication administration record, 24-hr patient care record, & acuity records
What are the four basic components of Resident Assessment Tool?
Minimum Date Set, Triggers, Resident Assessment Protocols, & Utilization Guidelines
What is the minimum data set (Resident Assessment Tool)?
A core component of the Resident Assessment Tool that indicates how well the patient can care for themselves.
What are the triggers (Resident Assessment Tool)?
Alerts staff to risk factors that may affect patient care.
What are the resident assessment protocols (Resident Assessment Tool)?
Protocols that help identify psychologic, social, or medical problems the patient may have.
What are the Utilization guidelines (Resident Assessment Tool)?
Guidelines provided by Medicare that outline the appropriate use of services.
What are the 4 benefits of Resident Assessment Tool?
Individualized care, Effective communication, Increase involvement, & Clearer documentation
What should be included in a hand-off report?
Basic identifying information, Current appraisal(health status), Current orders, Abnormalities, Unfilled orders, Pt./Family questions & concerns, & Reports on transfers/dischargers
What does ISBARR stand for?
Identify/introduce, Situation, Background, Assessment, Recommendation, Read back/response
When is ISBARR used?
When calling the physician
What does SBAR stand for?
Situation, Background, Assessment, & Recommendation
What are purposeful rounds?
Rounds performed every hour that improve overall pt. satisfactory scores
What are the 8 behaviors of purposeful rounding?
Use opening key words, Accomplish scheduled tasks, Address 4 P’s, Address additional needs, Conduct environmental assessment, Ask “anything else”, Tell pt. when you’ll be back, & document round
What are the 4 P’s of purposeful rounding?
Pain, Potty, Position, and Possessions
What is a buccal medication?
A form of medication that is placed between the gums and the inner lining of the cheek for absorption into the bloodstream.
