Exam 2: NR410 Flashcards
What is our job as nurses?
- minimize risk or harm
- safe & effective
Safety factors for Infants?
- can’t recognize danger
- tactile explore envt
- dependent
Safety factors for pre-schoolers?
- play outdoors
- more adventruous
- proper attire
- helmet safety
Safety factors for adolescents
- indestructable
- risk taking
- lack adult judgment
- Main cause for injury: drug/alcohol, car accidents. Car accidents are greater risk
Safety factor for adults?
- workplace injury
- lifestyle
- strength/stamina decline
- joint mobility
- slowing reflexes
- sensory loss
Individual factors affecting safety for all
- lifestyle
- cognition
- balance, gait, mobility
- communication
- visual acuity
- emotional helath
- safety awareness
In meeting the saftey needs of the adolescent client, it would be most important for the nurse to focus teaching on?
driver’s education
What are concerns for a child?
- do not leave unattended
- drowning
- taking meds
What are concerns for adult?
- lighting
- handrails
- Kitchen safety (turn stove on/off)
- poisoning
- carbon monoxide (detectors)
- burns
- fires
- falls
- firearms
Safety factors for school-age
- try new activites w/o practice
- stranger danger
- more time outside of home
Whats the biggest safety issue in the home and hospital?
falls
Safety in the Env’t?
- vehicles
- bicycles
- community acquired pathogens
- pollution
- sun exposure
- walking/running- headphones
- toxins
What are problems with CFL’s (compact fluorescent lamp)?
- Mercury exposure - open area on skin
- Fire hazard
Organizations working to make healthcare safer?
- IHI (institue on health improvement)
- Joint Commission
- HCAHPS & CORE
- America Association of Colleges of Nursing
- ANA
How much medical harm occursi annually in the U.S.?
- 40-50 incident for every 100 patients/minute
How many deather per year for medical errors?
98,000
What are impacts of death per year?
- motor vehicle
- breast cancer
- AIDS
How do most hospitals view their quality of care?
Above average
What do you think are major issues in healthcare setting for safety?
- falling
- med errors
- wrong site in surgery
- diagnostic inaccuracy- wrong treatment
- equip failure-iv pump
- transfusion error-wrong blood type
- lab- incorrect labeling
- system failure
- env’t- spills
- communication-documentation important
Who is the last line of defense for meds?
- The Nurse
What percent of falls are accounted for at hosptials
25%
What percent of falls are accounted for deaths in a hospital?
12%
What can you do to reduce falls?
- Identify fall risk, how high?
- Tag patient w/ wristband
- Family Education
- Move closer to Nurse’s station
- Room is free of clutter
- Non-skid booties
- Document everything you did
Who is the highest at risk for falls?
- patients who have fallen in the past 6 months
What are the procedures when a patient falls?
- Focused Assess
- Licensed Independent Practitioner
- Document what you saw
- Interventions
- Occurence/Incident Report
What is the acronym for FIre
R.A.C.E
Race (R) stands for
rescue, alarm, contain, extinguish, relocate
P.A.S.S for fire stands for..
- Pull, Aim, Squeeze, Sweep
What do we do immediately after a patient falls?
ASSESS for injury before getting them up
What are considered a restraint?
- Side rails
- IV arm boards
What facilities do sometimes allow side-rails up?
Long Term Care
Why do we restrain a patient?
- violence
- at risk to themselves or others
- last resort
- pulling out IV
Is restraint a standard of practice?
No
What do you assess for after restraint?
- neurosensory, ever 2 hrs
- basics every 15-30min
- reasses for continued use
For Non-behavioral restraints do you need a physicians order?
Yes
How do you apply a restraint?
- 2 finger breadths
- quick release to bedframe
- document
What restraint can be a hazard for strangulation?
Vests
What are problems that can occur to the patient with restraints?
- dehydration
- strangulation,
- cutting off circulation
- patient coming out of sedation
NDNQ
for quality indicators
Threats to safe nursing practice
- unfamiliarity
- inadequate time
- poor communication
- underestimating risk
- workflow
Why do nurses make errors?
- accessible
- distractions
- work-arounds “shortcuts”
- limited short term memory
- scheduling
IOM 6 Aims
- Safe
- Timely
- Effective
- Efficient
- Equitable
- Patient-Centered
QSEN
Quality for Safety and Education for Nurses
is it possible to have SHEER without FRICTION?
NO, but it is possible to have friction without sheer
What is cultural awaremess
- an in-depth self-examination of one’s own background, recognizing biases and prejudices and assumptions about other people.
Ethnicity
common sense of identity
How do you develop cultural humility
self assessment
What are barriers in culture?
- langugage
- pre-conceived ideas
- gender
What are the 5 stages social identity theory?
- Naive, no social consciousness
- Acceptance
- Resistance
- Re-definition
- Internalize
What can you do to make them comfortable?
- smile
- touch
- listen
Good Questions to ask?
- What do you think caused your illness?
- Who would you like to be involve
- What have you done to treat your illness?
What can you do in difficult ethic situation?
find resources, get ethics committee
What is communication?
- encoding/sending
- the message
- sensory channels
- decoding/receiving
- feedback- 2ways
Kindness means
- a smile
- eye contact
- active listening
- touch
- generosity
- acknowledge special needs
Communication failure affects
- safety
Components of Communication
- subject matter
- words
- gestures
- substance of the message
- open to interpretation
Principles of Communication
- Verbal/Nonverbal
- Dynamic
- Verbal supports Nonverbal
- Trust
- More than talking/listening
Intrapersonal means?
self-talk, inner dialogue
What is an example of false hope?
“Everything’s going to be okay”
What is the sequence for using a cane
- Put weight on good foot
- Step out with bad foot
- Place cane forward
- Move good foot forward
Define Enculturation?
Socialization into one’s primary culture as a child is known
Define Assimilation
when an individual gradually adopts and incorporates the characteristics of the dominant culture.
What is stereotyping?
unwarranted generalizations about any particular group that prevents further assessment of the individual’s unique characteristics.
What are health disparity populations?
a significant increased incidence or prevalence of disease or that have increased morbidity, mortality, or survival rates compared to the health status of the general population
How do patients suffer cultural pain?
when health care providers disregard values or cultural beliefs
what is feedback
summarizing what the patient said
You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do?
Talk with him about his favorite hobbies
Simple assertive statements include
- referencing the person you are addressing
- the behavior that is a problem
- its effect
If a patient has limited ability to speak or understand English, he or she has legal rights to…
an interpreter
What is therapeutic nurse-client relationship?
- info about health treatment
- wellness
- therapeutic communication
4 Phases of therapuetic relationship
- Pre-orientation- biases?
- Orientation- smile, what does day look like?
- Working Phase-collaborate
- Termination Phase- document, tell patient
What is therapeutic communication?
- patient centered
- goal directed
- strengthens relationship
Communication strategies
- say “I”
- eye contact
- keep promises
- empathy
- touch
- ask permission
Blockers of communication
- false reassurance
- changing the subect
- refer to handout
- close ended questions
- asking “why”?
What percent of negative effects occur because of gaps in communication?
- 85%
SBAR stands for
- Situation
- Background
- Assessment
- Recommendation
HCAHPS
- Hospital Consumer Assessment of Healthcare Provider Systems
- feedback from patient
What statement about nonverbal communication is correct?
- nurses’ verbal communication should be reinforced by nonverbal cues
If a child swallos a toxic substance what is the first action to tell parents
call poison control
A patient with risk of falls is wondering halls, what do you do?
- Leave a night light on in the bathroom
- Provide scheduled toileting during the night shift.
- Keep the pathway from the bed to the bathroom clear.
What is the most important intervention when a patient is having a seizure?
- Clear the area around the child to protect the child from injury.
A patient gets out of bed often, is a fall risk, what is the initial nursing intervention?
Place a bed alarm device on the bed
At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?
prepare for an influx of patients
3 types of documentation
- source oriented
- problem oriented
- electronic computer based
What are the basic principles of documentation
- timely
- accurate
- complete
- legible
- easily retrieved
What does charting by exception mean?
charting what is outside the norms or parameters
What are flow sheets are comprised of?
- vital signs
- intake/output
- pain
SOAPIER stands for
Sub Obj Planning Intervention Evaluation Revision
What is a nursing admission assessment comprised of?
- patient history, allergies
- done several times
- ask the patient who should be present
- baseline
Kardex or Client Care
- “down & dirty”
- demographic, medical diagnosis, allergies, diet, meds, safety, treatments
Occurrence Report is
- unusual or accident
- not a part of patient’s health record
What are sentinel events
- stuff that shouldnt happen under our care
- wrong site surgery
- patient suicide
- op/post-op
- fall
What is elopement
losing a patient
What is effective communication for transition in care and handoff reports?
SBAR
When do you do hand off?
- shift to shift
- transfers
- breaks
- therapist to therapist
- allow questions
Do you take verbal orders only in emergency?
yes
What are the steps for verbal/tele order?
- write, read it back
- clarify spelling
- date, time, providers name, your signature
Evolve:
Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (POST-OP)
- respiratory rate increases.
- The heart rate also increases because the heart is trying to improve oxygen levels.
- crackling
Evolve:
Why do we use stockings after a surgical procedure?
external pressure on the lower extremities and assist in promoting venous return to the heart.
Evolve:
What could being on bed rest be a risk for?
falling
Evolve:
Coffee ground–like aspirate from the feeding tube are a sign of..
bleeding in the GI tract
Evolve:
when patients are immobile and the joint is not exercised through their ROM (range of motion), what can happen?
the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.
Evolve:
Immobilized patients are at risk for impaired skin integrity, what are your interventions?
- An objective assessment scale allows the nurse to assess for pressure ulcer risk over tim
- Using a device to relieve pressure when patient is seated in chair
- Teaching patient how to shift weight at regular intervals while sitting in a chair
- the higher the risk for skin breakdown, the shorter the interval between position changes
Evolve:
When we are helping a patient walk, which side do we want to be on?
the weak side
Evolve:
What part of the body do you want to be holding when assisting a patient to walk?
His waist, not his arm. Using a gait belt to avoid risk of injury.
Name some causes of orthostatic hypotension
- dehydration
- medication
- heart problems
- thyroid/endocrine
- nervous system
Evolve:
Which action(s) are appropriate for the nurse to implement when a patient experiences orthostatic hypotension?
- Allow patient to sit down.
- Take patient’s blood pressure and pulse.
- If patient begins to faint, allow him to slide against the nurse’s leg to the floor
Evolve:
If you can’t lift a patient from bed to chair what can you do?
call the lift team for support
Evolve:
Which is the correct gait when a patient is ascending stairs on crutches?
- modified three-point gait.
- The unaffected leg is advanced between the crutches to the stairs
Evolve:
a patient prescribed bilateral partial weight bearing, which crutch gait is most appropriate for this patient?
The two-point gait requires at least partial weight bearing on each foot
Evolve:
What does a 3 point gait require
- that the patient bear all their weight on one foot,
- For a patient with one injured foot/leg.
Evolve:
Which of the following activities does the nurse delegate to nursing assistive personnel in regard to crutch walking?
- Notify nurse if patient reports pain before, during, or after exercise
- Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise
- Notify nurse of vital sign values.
- Prepare the patient for exercise by assisting in dressing and putting on shoes.
Evolve:
What applies to the proper use of a cane?
- patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs
- The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times.
Evolve:
What are some critical thinking skills?
- ethics
- analytics
- self confidence
Evolve:
The pain scale is an example of which intellectual standard?
consistency
Evolve:
What is basic critical thinking?
concrete and based on a set of rules or principles
Evolve:
What is unique to the commitment level of critical thinking?
Anticipates when to make choices without others’ assistance.
What is the difference between negligence & malpractice?
when the patient is involved
Where can you get resources for negligence & malpractice
- standards
- expert opinion
- instiutional policies
- state by state
When delegating, who is responsibile for the action?
the person delegator is liable
What are the 5 rights in delegation
- task
- circumstance
- person (doesn’t have to be a CNA)
- direction
- supervision
What is the delegation process
- communicate, expectations
- monitor
- evaluate
- give feedback
What can a nurse not delegate, even to another nurse?
- assessment
- evaluation
- nursing judgment
What can you delegate?
- Vital signs
- meds
- technical tasks
- procedures
What leaves an RN vulnerable?
poor records
When you delegate to a CNA, can they refuse?
- Yes
Patients Rights
- informed consent
- privacy
- dignity
- to be treated fairely
- safety
Informed Consent
- Nurse, witness patient’s signature
- down to the doctor’s responsibility
If the procedure was not done under informed consent, what could it be considered?
battery
What does informed consent include?
- risks
- patient bill of rights
- nature of health concern
- description of treatment
When does informed consent get overrided?
- emergency
- law presumes they want to be saved
- therapeutic privilege
- when information could harm the pt
How to prevent liability
- follow standards/protocols
- delegate appropriately
- keep up on information
- identify fall risk, decubitis
- safe environment
- document well
When should you question a physicians orders?
- when client questions
- question and record verbal orders
- avoid miscommunication
Causes of negligence?
- patient falls
- equipment injuries
- failure to monitor
- failure to communicate
- medication errors
- medical errors
Intervention errors
- not performing task correctly
- interpret carry out doc’s orders
- pursue the physician
What are the 6F’s
- asses/monitor
- changes
- adequate education
- standards/policies
- document
- failure to act as an advocate
What is the purpose of liability precautions
quality improvement
Be able to determine negligence vs malpractice
Grief?
- physical, psychological, and spiritual responses to loss
Mourning
action associated with grief
Bereavement
mourning/adjustment following loss
What affects grief
- significance of the loss
- amount of support for the bereaved
- developmental stage
- timeliness of death
Hubler Ross 5 Stages of Grief
- denial
- anger
- bargaining
- depression
- acceptance
What are types of grief
- uncomplicated
- complicated
- chronic/masked/delayed
- disenfranchised- miscarriage, society doesnt recognize
- anticipatory- pre-grief
Define Death
- historical definition
- heart-lung death
- whole-brain
- higher-brain
- uniform determination of death act, loss of brain stem fucntion
What are the stages of dying (assessment)
- 1-3mnths prior, withrawn, sleep more, not eating
- 1-2 wks, vitals change, skin color change, apnea, cheyne stokes, death rattle
- days to hours- walk, eat, energy, swallowing diff, dehydration
- moments to hours- unconsciousness
What is palliative care
holistic comfort care
What is hospice care
- doctor order
- 6 months left to live (guess)
- survive on donation
- help family 1 year after death
- must sign a DNR
What does palliative care team look like
- advanced practice nurse
- physician
- chaplain
- case manager
- pharmacist
What are legalities in end of life
- advanced directives
- living will
- POA
- DNR
- Assisted Suicide
- Euthanasia
- Autopsy- unexpected death, dialysis, what if family doesnt want it?
What is our assessment for end of life?
- knowledge
- history
- coping
- meaning of loss
- depression or grief
- physical assessment
- cutlural/spiritual assess
What are NANDA’s for end of life
- powerlessness
- hopelessness
- denial, ineffective
- coping, ineffective
- nutrition imbalance
What does care entail for dying patient
- physiological
- psychological
- spiritual
- cultural
What is a quintessential answer for therapeutic
“tell me more”
Patient Self Determination Act
letting patient know their rights to advanced directive
Post Mordam Care
- comfort dignitiy cooperation
- who validates death?
- donor?
- autoposy? (everything stays in)
- making them presentable
What is rigor mortis?
- put in dentures before
- muscles stiffen up
Evolve:
The nurse asks a patient, “Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a patient-centered interview?
Collecting Assessment
Evolve:
What technique(s) best encourage(s) a patient to tell his or her full story?
- Active listening
- Back channeling
- Use of open-ended questions
Evolve:
What is validating?
comparing data with another ?source
Evolve:
What is probing?
encourages a full description without trying to control the direction of the patient’s story
Evolve:
Is a chest x-ray considered a nursing assessment?
NO
Evolve:
A patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient?
- Lean forward when interacting with the patient
- Acknowledge the patient’s answers through head nodding
Evolve:
What is the related factor or risk?
a condition for which the nurse can implement preventive measures
Evolve:
What does a nurse do when reviewing data?
the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data
Evolve:
A risk diagnosis does not have defining characteristics, instead what does it have?
Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem
Evolve:
Time Frame what it is & what it is NOT
- IS:
- when you expect a response to your nursing interventions
- helps to organize nursing priorities
- IS NOT
- which problem is most important
- a nurses work schedule
Evolve:
What must an outcome have to be a precise measurement?
- quality
- quantitly
- frequency
- length or weight
Evolve:
When does implementation begin as the fourth step of the nursing process?
After the plan of care has been developed
Evolve:
When interpreting findings you…
compare the patient’s behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation.
Evolve:
A goal specifies the expected behavior or response that indicates
Resolution of a nursing diagnosis or maintenance of a healthy state
Evolve:
The evaluation of interventions examines two factors:
- the appropriateness of the interventions selected
- the correct application of the intervention
Evolve:
An evaluative measure determines a
a patients response
Evolve:
What criteria would you recommend in choosing a nursing center?
- clean look like patient’s home
- adequate staffing on all shifts
- Meals should be high quality with options for what to eat and when it is served.
- active family involvement
Evolve:
blurred vision, sensitivity to glare, and gradual loss of vision
cataracts
Evolve:
eye condition resulting in a person having difficulty adjusting to near and far vision
presbyopia
Evolve:
Who makes the request for organ and tissue donation at the time of death?
Specially educated personnel make requests
Evolve:
How do you start the conversation about the goals of care at the end of life?
asking the patient to identify his or her beliefs about the goals of care while the family member is present
Evolve:
What action honors cultural beliefs at the end of life?
Giving people options in caregiving (i.e. family members)
Evolve:
Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient?
Older adults have usually sustained many losses in life, which influence the current loss
Evolve:
A nurse stops to help in an emergency at the scene of an accident, injured party files a law suit
The Good Samaritan law holds the health care provider immune from liability as long as he or she functions within the scope of his or her expertise
Evolve:
When is a living will invoked?
when the patient has a terminal condition or is in a persistent vegetative state.
Evolve:
What can posting medical information about the patient on a message board in the patient’s room cause?
information being accessed by persons who are not involved in the patient’s treatment. Violation of hippa
Evolve:
Who are mandated reporters of suspected child abuse
nurses
Evolve:
What type of communication is used during the orientation phase of a relationship
unrelated small talk
Evolve:
What do you include in a hand off report
- patient’s name, age, and admitting diagnosis
- allergies
- patient pain raiting
Evolve:
A patient newly diagnosed with type 2 diabetes says, “My blood sugar was just a little high. I don’t have diabetes.” The nurse responds:
with silence, gives patients time to process their thoughts.
What is the purpose of NCLEX
To determine if it’s safe for you to begin practice as an entry-level nurse
What are topic of the NCLEX
- Safe care environment
- Health promotion/maintenance
- psychosocial
- physiological
- nursing process
- communication, documentation, teaching
what organization developed the NCLEX testing system
National Council of State Boards of Nursing
What are the 4 recommendations of the IOM?
- practice to the full extent of their education and
training - achieve higher levels of education and training through an improved education system that promotes seamless academic progression
- full partners, w/ physicians and other health care
professionals, in redesigning health care in the United States. - Effective workforce planning and policy making require better data collection and an improved
information infrastructure.
What is the reasonable man standard?
a hypothetical person in society who exercises average care, skill, and judgment in conduct and who serves as a comparative standard for determining liability.
What are common examples of malpractice
- Doing or Saying Nothing When Action Is Required
- Injuring a Patient With Equipment
- Improper Administration of Medication
What is EMTALA
- no patient with an emergency medical condition, unable to pay may be treated differently than patients who are covered by health insurance
- Emergency Medical Treatment and Active Labor Act
What is the bill of rights for nursing?
nurse’s rights in the workforce
What are 4 elements that must exist for malpractice
- Duty
- Breach of Duty
- Causation
- Harm/Injury
What 2 components are mandatroy to report?
- communicable disease
- abuse
Intentional Torts Relevant to Nursing
- Confidentiality
- False imprisonment
- Assault and battery
- Fraud
- Invasion of privacy
This is a term for a published false statement that is damaging to a person’s reputation
Libel/Slander
What is flexion?
bending
What is extension?
the straightening of a part
What is abduction?
away from midline
Pronation is?
inward roll of the foot
supination
outward roll of the foot
What are the steps for formulating a nursing diagnosis
- identify problem
- write diag statement
- validate
What is a diagnostic label?
world/phrase represents a pattern of related cues. Describes the problem or wellness response
What does ANA define in standards of Nursing?
ADOPIE
What is the Colorado Nurse Practice Act?
evaluating health status thru the collection and asessment of health data
What do you do if you make a mistake?
- follow the policy/procedure of the facility
- Never obliterate an entry or use white out
It is important for nurses working with patients with a diagnosis of dementia to
adopt a common approach of care because these patients have consistency and sameness in their environment
What is delirium?
- An acute condition that have altered brain functioning
- Reduction in cerebral functioning
- sudden disturbance in consciousness or cognition
What is dementia?
A clinical syndrome involving reduced intellectual functions with impairment in memory, language, visiospacial skills and cognition.
- chronic/irreversible
What is caregiver burden?
increased morbidity & mortality of caregivers and increased risk of LTC placement
What are causes of delirium?
- Fever
- Infection
- Allergic reaction
- Vitamin deficiency
- Drug toxicity
- Malnutrition
- Electrolytes
- hypoxia
- hypoglycemia
Types of dementia?
- Alzheimer’s Disease
- Lewy body disease-hallucination, get worse w/meds
- Parkinson’s disease
- Subdural hematoma-bloodclot in brain, stroke
- Normal pressure hydrocephalus
- Focal brain atrophy syndrome
- Creutzfeldt Jakob disease-mad cow
What tools can be used to measure dementia?
Blessed Scale and Clock Drawing tests
What are nursing interventions for a dementia patient?
- evaluate environmental and placement choices
- Maintain safe environment
- driving and occupational safety
- long term financial and legal planning
What would the prudent nurse
- high level
- picks up on subtle changes
What is an intervention for delirium
take labs!
What is the common cause of delirium for the elderly?
UTI
NANDA for delirium
acute confusion, disturbed throught processes, interrupted family processes, risk for infection, acute pain, ineffecting coping,
What is a common cause for alzheimers (dementia) of death?
aspirations pneumonia
What are the steps for transferring a patient?
- high fowlers position, dizziness
- place a gait belt on the patient
- bring the patient to the edge of the bed and dangle their legs
- assist the patient to a standing position and transfer to the chair
What does a “problem” suggest”
Client Goals
What does etiology suggest?
interventions
What do cue clusters suggest?
- whether the correct nursing diagnosis has been identified
What is focus charting?
Clients Concerns & Strengths