Exam 3 Flashcards
Physical Restraint
A manual, physical 🔐, mechanical device or material attached to the pts body, that they cannot easily remove
Medical Restraint
A drug or medication 💊 used as restriction to manage the pts behavior
Restrain free environment is the standard of care. However, if needed you can use when…
-To ensure physical safety for pt & other pts.
-When less restrictive interventions fail.
-Only w/ a written order from a Provider. 📝
When should a restraint discontinued?
Earliest possible time
Restrictions Assessment
-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) 🧘🏽♀️
Side-rails
🚫Do NOT use routinely
Can cause serious falls and injury’s
Define Liability
-Person is legally responsible
-Nurses are legally responsible for their own actions. 👩⚖️
Malpractice
-Legal liability
-Professional failed to act responsible
-Someone is harmed (professional is responsible)
EMTALA
Emergency Medical Treatment & Active Labor Act
-ER must screen pt for emergency
-If emergency, must provide treatment (stabilize) before transferring pt to another ER
Patient Self-Determination Act
The patients right to make decisions regarding their own healthcare
Living Will
Written document for pts wishes in the event of terminal illness
(House, cars, money) 🤑
Durable Power of Attorney
MDPOA
Legal document of who can make medical decisions of his own health
(Who can take off life support, CPR) 🫁🧠🫀
Mandatory reporting for
Abuse or neglect of a child, at risk elder, or at risk adult 👵🏽👴🏼👧👦
Nurses are covered under the Good Samaritan Law unless….
-Performing a procedure outside scope
-Leaving pt w/out handoff to a capable person🦹🏽♂️
What happens if you violate the abuse Practice Act?
You will receive disciplinary action by the State Board of Nursing 👨🏻⚕️
What violates the Nurse Practice Act?
-Falsifying documents 📄
-Diverting drugs (pocketing) 👖
-Breech of confidentiality
-Violating code of ethics
-Practice outside of scope
Tort
Civil wrong made agains a person or property
Three types of Torts
Intentional
Quasi-intentional
Unintentional
Assault
Part of Intentional tort
-A threat (no contact) 🗣️📣
Battery
Part of intentional tort
- Touching of body without consent 🥊👊🏽🤜🏽
False Imprisonment
Type of intentional tort
-Unjustified restraint of person 🚔
Invasion of Privacy
Part of Intentional tort
-unwanted intrusion of privacy
-Posting photos on social media 👙🩲, discussing pt in a public space
-HIPPA violation
Defamation of Character
Part of Quasi-intentional Tort
-False statement on person that damage’s reputation
-Slander (verbal) 🗣️
-Libel (written) 📝
Unintentional Tort
-Negligence: Failure to provide reasonable care (no harm made)
-Malpractice: Type of negligence (causes harm)
4 criteria points for Nursing Malpractice
-Duty (owes legal obligation)
-Breech of duty (fails to meet standard of care)
-Causation (caused by nurse)
-Injury or Damage
In the event of an Occurrence Reporting, document in record what happened (mistake), but…
🚫Do not document in the chart that an occurrence report was made
5 Rights of Teaching
Right Time (are they ready)
Right context (quiet environment)
Right goal (learning goal)
Right content (learning level)
Right method (strategies)
Cognitive Learning
Learn information, understand it, demonstrate it
Affective Learning
Learns information then discusses feelings, beliefs and values on topic
Psychomotor Learning
Gaining skills mentally and physically. (Using a glucometer)
Age appropriate teaching for
🙎🏼♂️Adults- written & discussion
👴🏼Elderly- visual aids, large print, good light, short sessions, reposition
Since clients do not remember what you tell them, it is important to…
Repeat, reinforce, and practice
What influences cognition?
Infection
ETOH/drugs 🍺
Medications 💊
Hypoxia
Stress
Grief 😭
Sensory deficit & overload
Dementia
-chronic
-1/5 of 70yrs+
-progressive/irreversible
-personality changes, impaired reasoning, memory & social skills
Delirium
-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
Alzheimer’s Disease
-most common in dementia
-irreversable
-first appears in mid 60s, 1 in 10 (65+)
Nonverbal signs of pain
Elevated pulse & BP
Crying
Grimacing
Blinking
Body posture
Stoicism
Depression
NSAIDS are linked to…
Higher risk of cardiovascular events. MI, stroke and heart failure.
Tylenol you should use no more than?
🚫No more than 4g in 24 hours
Adjucant Analgesic Therapy
Corticosteroids (inflammation)
Anti-depressants (neuropathic)
Anti-seizure (neuropathic)
GABA Antagonist- muscle spasm
Anesthetic (neuropathy)
Cannabinoids
Opioid side effects
Constipation
N/V
Sedation
Respiratory Depression
Pruritus
Opioids are more effective/appropriate for?
Visceral pain & acute pain
With Neurologic pain, it can be resistant to opioids
What’s important to remember for Geriatrics with opioids?
👵🏽They metabloize drugs more slowly
Unrelieved pain symptoms in Endocrine Sytem
Weight loss
Fever
Poor appetite
Unreleived pain in cardiovascular system
Increased HR & BP
O2 demands
Chest pain
MI
Unreleived pain on musculoskeletal system
Impaired muscle function
Fatigue 😴
Immobility 🩼
Unrelieved pain on respiratory system
Shallow breathing that can lead to pneumonia and atalectasis
Unrelieved pain on Genitourinary system
Decreased urine output
Urinary retention
Fluid overload
Unrelieved pain on GI system
Increased intestinal secretions
Decreased motility
After giving opioids you should recheck pt…
IV- every 30 min
PO- every hour
Documentation Reassessment
COLDSPA stands for
Character
Onset
Location
Duration
Severity
Pattern
Associating factors
Common Sleep Disorders
Insomnia
Circadian disorders (jet lag)
Restless Leg Syndrome
Hypersomnia (excessive sleeping)
Sleep Apnea (10sec of not breathing)
Narcolepsy
Parasomnia (sleep walking)
Secondary sleep disorders
Depression
Thyroid issues (Hypo-more/Hyper-less sleep)
Pain
Disorders provoked by sleep
Coronary heart disease (+pulse)
Asthma (bronchospasms)
COPD (+carbon dioxide)
DM (glucose levels)
GI Ulcers (+gastric acid)
Epilepsy (+seizures)
Sleep interventions
Scheduled sleeping/rituals
Comfort 🛌
Safety 🛟
Foods 🥑
Hygiene 🧽
Medications 💊
Circulation
Blood flow in the heart and blood vessels
-HR
-Cardiac output
-Heart strength
-Doppler
Perfusion
Blood flow to capillaries & gives nutrients and oxygen to tissues & organs
-Good BP
-Normal Temp (cold=poor) 🥶
-Urine output
Oxygenation
Quality of oxygen tocells, tissues, and organs.
-cyanosis 🥶
-pulse ox
-arterial blood gas
An organ not adequately perfused will…
Suffer ischemic damage and not be able to perform adequately
Factors that influence circulation & perfusion
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)
Heart Failure
Most common cause is coronary artery disease (reduced blood flow in ♥️)
-reduced cardiac output
-leads to pulmonary edema 🫁, then impairing gas exchange
Left ventricular failure
-low amount of blood to tissue/organs
-blood backs up in pulmonary veins
-+fluid buildup in lungs
-respiratory symptoms 🫁
Right ventricular failure
-low blood pumped into lungs 🫁
-blood backs up into venous circulation
-+ peripheral venous pressure
-systematic symptoms
L- Ventricular Failure S& S
Dyspnea
Orthopnea 🛌🫁
Cough, crackles, wheezing 😷
Tachycardia, tachypnea ♥️🫁
Fatigue
Activity intolerance
R- ventricular Failure S & S
Edema 🦵🦶
Jugular venous destention 🙎
Weight gain
Nausea, bloating 🤰🏽, anorexia
Fatigue 😴
♥️ Failure Interventions
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
Coronary Artery Disease
Plaque in arteries (artherosclerosis)
Reduces blood flow 🩸
Decreased perfusion to ♥️ muscle
Myocardial Infarction
Cardiac Ischemia- when oxygen requirements to the ♥️ are unmet
Prolonged Ischemia- leads to MI, due to ♥️ necrosis 🖤 from lack of oxygen
Long term= ♥️ failure
Dysrhythmias
Alters🫀rate and rhythm
Lower cardiac output
Decrease tissue oxygenation 🫁
Increased risk of stroke
Peripheral Vascular abnormalities
Arterial- low oxygen 🫁 to tissue
(Pallor, pain, weak pulse, - cap refill, 🥶 cool skin
Venous- low🩸 return to 🫀
(Edema💧, brown skin🦵🏾color, ulcers on skin)
Peripheral Artery Disease S&S
Narrow arteries to to plaque
Most common in legs🦵
Artherosclerosis & DM
Most common symptom- leg pain
(Pain goes away with rest)
S & S of peripheral artery disease
Diminished peripheral pulse
Cool extremities 🥶
Smooth shiny dry skin, decreased hair 👩🦲
Prolonged cap refill 👉🏼👈🏽
Ulcers on toes & feet🕳️🦶
Peripheral artery disease interventions
Exercise 🏋🏽♀️
Hydration 💧
Foot and nail care 💅🏼
Injury prevention 🧦👟
Medications 💊
No 🚫
- anti-embolism stocking
-elevating 💺🦶
-smoking 🚬🚭
Chronic venous insufficiency
Relief when legs are elevated 💺🦶
Ulcers are painful 🕳️🦶
Pooled blood🩸 in legs
Brown patches in legs🦵🏾 from breakdown of RBC
Venous return interventions
Elevate legs 🦵🏾 above ♥️
Early & frequent ambulating 🚶🏽
Range of motion 🤸🏽♀️
Apply TED hose 🧦
Avoid 🚫 sitting with legs crossed 🧘🏽♀️
Peripheral Pulses ♥️
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior Tibial
Dorsal Pedis
