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Nursing Fundamentals > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

Physical Restraint

A

A manual, physical 🔐, mechanical device or material attached to the pts body, that they cannot easily remove

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2
Q

Medical Restraint

A

A drug or medication 💊 used as restriction to manage the pts behavior

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3
Q

Restrain free environment is the standard of care. However, if needed you can use when…

A

-To ensure physical safety for pt & other pts.

-When less restrictive interventions fail.

-Only w/ a written order from a Provider. 📝

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4
Q

When should a restraint discontinued?

A

Earliest possible time

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5
Q

Restrictions Assessment

A

-Check pt every 15min
-Area checked every hour
-Written orders are limited to 4hrs
-Never prn orders
-Physician must assess prior to new order. 👨🏻‍⚕️
-Restrictions does not solve behavior (calm patient) 🧘🏽‍♀️

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6
Q

Side-rails

A

🚫Do NOT use routinely
Can cause serious falls and injury’s

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7
Q

Define Liability

A

-Person is legally responsible

-Nurses are legally responsible for their own actions. 👩‍⚖️

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8
Q

Malpractice

A

-Legal liability

-Professional failed to act responsible

-Someone is harmed (professional is responsible)

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9
Q

EMTALA
Emergency Medical Treatment & Active Labor Act

A

-ER must screen pt for emergency

-If emergency, must provide treatment (stabilize) before transferring pt to another ER

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10
Q

Patient Self-Determination Act

A

The patients right to make decisions regarding their own healthcare

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11
Q

Living Will

A

Written document for pts wishes in the event of terminal illness
(House, cars, money) 🤑

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12
Q

Durable Power of Attorney
MDPOA

A

Legal document of who can make medical decisions of his own health

(Who can take off life support, CPR) 🫁🧠🫀

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13
Q

Mandatory reporting for

A

Abuse or neglect of a child, at risk elder, or at risk adult 👵🏽👴🏼👧👦

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14
Q

Nurses are covered under the Good Samaritan Law unless….

A

-Performing a procedure outside scope

-Leaving pt w/out handoff to a capable person🦹🏽‍♂️

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15
Q

What happens if you violate the abuse Practice Act?

A

You will receive disciplinary action by the State Board of Nursing 👨🏻‍⚕️

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16
Q

What violates the Nurse Practice Act?

A

-Falsifying documents 📄
-Diverting drugs (pocketing) 👖
-Breech of confidentiality
-Violating code of ethics
-Practice outside of scope

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17
Q

Tort

A

Civil wrong made agains a person or property

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18
Q

Three types of Torts

A

Intentional
Quasi-intentional
Unintentional

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19
Q

Assault

A

Part of Intentional tort

-A threat (no contact) 🗣️📣

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20
Q

Battery

A

Part of intentional tort

  • Touching of body without consent 🥊👊🏽🤜🏽
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21
Q

False Imprisonment

A

Type of intentional tort

-Unjustified restraint of person 🚔

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22
Q

Invasion of Privacy

A

Part of Intentional tort

-unwanted intrusion of privacy
-Posting photos on social media 👙🩲, discussing pt in a public space
-HIPPA violation

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23
Q

Defamation of Character

A

Part of Quasi-intentional Tort

-False statement on person that damage’s reputation
-Slander (verbal) 🗣️
-Libel (written) 📝

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24
Q

Unintentional Tort

A

-Negligence: Failure to provide reasonable care (no harm made)

-Malpractice: Type of negligence (causes harm)

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25
Q

4 criteria points for Nursing Malpractice

A

-Duty (owes legal obligation)

-Breech of duty (fails to meet standard of care)

-Causation (caused by nurse)

-Injury or Damage

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26
Q

In the event of an Occurrence Reporting, document in record what happened (mistake), but…

A

🚫Do not document in the chart that an occurrence report was made

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27
Q

5 Rights of Teaching

A

Right Time (are they ready)
Right context (quiet environment)
Right goal (learning goal)
Right content (learning level)
Right method (strategies)

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28
Q

Cognitive Learning

A

Learn information, understand it, demonstrate it

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29
Q

Affective Learning

A

Learns information then discusses feelings, beliefs and values on topic

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30
Q

Psychomotor Learning

A

Gaining skills mentally and physically. (Using a glucometer)

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31
Q

Age appropriate teaching for

A

🙎🏼‍♂️Adults- written & discussion

👴🏼Elderly- visual aids, large print, good light, short sessions, reposition

32
Q

Since clients do not remember what you tell them, it is important to…

A

Repeat, reinforce, and practice

33
Q

What influences cognition?

A

Infection
ETOH/drugs 🍺
Medications 💊
Hypoxia
Stress
Grief 😭
Sensory deficit & overload

34
Q

Dementia

A

-chronic
-1/5 of 70yrs+
-progressive/irreversible
-personality changes, impaired reasoning, memory & social skills

35
Q

Delirium

A

-acute (due to infx, Rx, TBI, stress, sleep, hypoxia)
-1 in 3, 70yrs+
-15-25% after surgery
-50% after hip repair and cardiac
-confusion, emotional changes, hallucinations
-report to healthcare provider
-can occur with dementia

36
Q

Alzheimer’s Disease

A

-most common in dementia
-irreversable
-first appears in mid 60s, 1 in 10 (65+)

37
Q

Nonverbal signs of pain

A

Elevated pulse & BP
Crying
Grimacing
Blinking
Body posture
Stoicism
Depression

38
Q

NSAIDS are linked to…

A

Higher risk of cardiovascular events. MI, stroke and heart failure.

39
Q

Tylenol you should use no more than?

A

🚫No more than 4g in 24 hours

40
Q

Adjucant Analgesic Therapy

A

Corticosteroids (inflammation)
Anti-depressants (neuropathic)
Anti-seizure (neuropathic)
GABA Antagonist- muscle spasm
Anesthetic (neuropathy)
Cannabinoids

41
Q

Opioid side effects

A

Constipation
N/V
Sedation
Respiratory Depression
Pruritus

42
Q

Opioids are more effective/appropriate for?

A

Visceral pain & acute pain

With Neurologic pain, it can be resistant to opioids

43
Q

What’s important to remember for Geriatrics with opioids?

A

👵🏽They metabloize drugs more slowly

44
Q

Unrelieved pain symptoms in Endocrine Sytem

A

Weight loss
Fever
Poor appetite

45
Q

Unreleived pain in cardiovascular system

A

Increased HR & BP
O2 demands
Chest pain
MI

46
Q

Unreleived pain on musculoskeletal system

A

Impaired muscle function
Fatigue 😴
Immobility 🩼

47
Q

Unrelieved pain on respiratory system

A

Shallow breathing that can lead to pneumonia and atalectasis

48
Q

Unrelieved pain on Genitourinary system

A

Decreased urine output
Urinary retention
Fluid overload

49
Q

Unrelieved pain on GI system

A

Increased intestinal secretions
Decreased motility

50
Q

After giving opioids you should recheck pt…

A

IV- every 30 min
PO- every hour

51
Q

Documentation Reassessment
COLDSPA stands for

A

Character
Onset
Location
Duration
Severity
Pattern
Associating factors

52
Q

Common Sleep Disorders

A

Insomnia
Circadian disorders (jet lag)
Restless Leg Syndrome
Hypersomnia (excessive sleeping)
Sleep Apnea (10sec of not breathing)
Narcolepsy
Parasomnia (sleep walking)

53
Q

Secondary sleep disorders

A

Depression

Thyroid issues (Hypo-more/Hyper-less sleep)

Pain

54
Q

Disorders provoked by sleep

A

Coronary heart disease (+pulse)
Asthma (bronchospasms)
COPD (+carbon dioxide)
DM (glucose levels)
GI Ulcers (+gastric acid)
Epilepsy (+seizures)

55
Q

Sleep interventions

A

Scheduled sleeping/rituals
Comfort 🛌
Safety 🛟
Foods 🥑
Hygiene 🧽
Medications 💊

56
Q

Circulation

A

Blood flow in the heart and blood vessels
-HR
-Cardiac output
-Heart strength
-Doppler

57
Q

Perfusion

A

Blood flow to capillaries & gives nutrients and oxygen to tissues & organs
-Good BP
-Normal Temp (cold=poor) 🥶
-Urine output

58
Q

Oxygenation

A

Quality of oxygen tocells, tissues, and organs.
-cyanosis 🥶
-pulse ox
-arterial blood gas

59
Q

An organ not adequately perfused will…

A

Suffer ischemic damage and not be able to perform adequately

60
Q

Factors that influence circulation & perfusion

A

Developmental: (older- ♥️ loses strength, valves are thicker)

Environment:
-Stress, allergies, altitude, cold, heat

Lifestyle:
-Pregnancy 🤰🏽, nutrition, obesity, tobacco🚬, substance abuse, exercise

Medications:
-ASA (less chance of clot), diuretics (decreased fluid in veins)

61
Q

Heart Failure

A

Most common cause is coronary artery disease (reduced blood flow in ♥️)
-reduced cardiac output
-leads to pulmonary edema 🫁, then impairing gas exchange

62
Q

Left ventricular failure

A

-low amount of blood to tissue/organs
-blood backs up in pulmonary veins
-+fluid buildup in lungs
-respiratory symptoms 🫁

63
Q

Right ventricular failure

A

-low blood pumped into lungs 🫁
-blood backs up into venous circulation
-+ peripheral venous pressure
-systematic symptoms

64
Q

L- Ventricular Failure S& S

A

Dyspnea
Orthopnea 🛌🫁
Cough, crackles, wheezing 😷
Tachycardia, tachypnea ♥️🫁
Fatigue
Activity intolerance

65
Q

R- ventricular Failure S & S

A

Edema 🦵🦶
Jugular venous destention 🙎
Weight gain
Nausea, bloating 🤰🏽, anorexia
Fatigue 😴

66
Q

♥️ Failure Interventions

A

Positioning 🛌💺
Oxygen therapy 🫁
Breathing treatments
Medications 🔃 circulation
Prevent venous stasis
Low sodium diet 🧂
Daily weights
Monitor I&O 🍽️🥃🚽
Fluid restrictions 🚫🍺
Education:
Rest, nutrition, Rx, activity

67
Q

Coronary Artery Disease

A

Plaque in arteries (artherosclerosis)
Reduces blood flow 🩸
Decreased perfusion to ♥️ muscle

68
Q

Myocardial Infarction

A

Cardiac Ischemia- when oxygen requirements to the ♥️ are unmet

Prolonged Ischemia- leads to MI, due to ♥️ necrosis 🖤 from lack of oxygen

Long term= ♥️ failure

69
Q

Dysrhythmias

A

Alters🫀rate and rhythm
Lower cardiac output
Decrease tissue oxygenation 🫁
Increased risk of stroke

70
Q

Peripheral Vascular abnormalities

A

Arterial- low oxygen 🫁 to tissue
(Pallor, pain, weak pulse, - cap refill, 🥶 cool skin

Venous- low🩸 return to 🫀
(Edema💧, brown skin🦵🏾color, ulcers on skin)

71
Q

Peripheral Artery Disease S&S

A

Narrow arteries to to plaque
Most common in legs🦵
Artherosclerosis & DM
Most common symptom- leg pain
(Pain goes away with rest)

72
Q

S & S of peripheral artery disease

A

Diminished peripheral pulse
Cool extremities 🥶
Smooth shiny dry skin, decreased hair 👩‍🦲
Prolonged cap refill 👉🏼👈🏽
Ulcers on toes & feet🕳️🦶

73
Q

Peripheral artery disease interventions

A

Exercise 🏋🏽‍♀️
Hydration 💧
Foot and nail care 💅🏼
Injury prevention 🧦👟
Medications 💊
No 🚫
- anti-embolism stocking
-elevating 💺🦶
-smoking 🚬🚭

74
Q

Chronic venous insufficiency

A

Relief when legs are elevated 💺🦶
Ulcers are painful 🕳️🦶
Pooled blood🩸 in legs
Brown patches in legs🦵🏾 from breakdown of RBC

75
Q

Venous return interventions

A

Elevate legs 🦵🏾 above ♥️
Early & frequent ambulating 🚶🏽
Range of motion 🤸🏽‍♀️
Apply TED hose 🧦

Avoid 🚫 sitting with legs crossed 🧘🏽‍♀️

76
Q

Peripheral Pulses ♥️

A

Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior Tibial
Dorsal Pedis

Nursing Fundamentals (4 decks)

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