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NUR 101 > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

What is the purpose of hygiene care?

A

cleanse body, relax, enhance healing

includes care of skin, hair, nails, mouth/teeth, perineal

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2
Q

why is good hygiene practice important?

A

decreases risk of skin breakdown, infection
provides comfort
increased sense of well-being, body image
improves circulation
assessment/communication opportunity

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3
Q

What are six factors that affect hygiene?

A 
developmental level
culture
socioeconomic class
spiritual beliefs
health state
personal preference
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4
Q

What are developmental concerns for newborns and infants?

A

Supervision is a must.
bathed in basin/tub
special attention to ears, skin folds, neck, back, genitals
frequent urination & stools

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5
Q

What are developmental concerns for toddlers and preschoolers?

A

manages most aspects of bathing & grooming w/ support

potty training w/ assistance is started (bowel & bladder control b/t 2-3 yo

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6
Q

What are developmental concerns for school-age & adolescents?

A

independent, wants privacy
concerned w/ personal appearance
shower more frequently, wears deodorant
may need teaching r/t caring for hormonal changes

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7
Q

What are developmental concerns for older adult care?

A 
Independent
skin drier, thinner
higher risk for infection, periodontal disease
denture fitting, dry mouth
poor nutritional status
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8
Q

How does disease, injury or surgery affect a patient’s hygiene?

A 
decreases ability to perform hygiene
lack of energy 
pain, discomfort
cognitive ability
sensorimotor deficit (vision, hearing)
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9
Q

During the nursing problems, what needs to be assessed for hygiene?

A

client’s need for bathing, other hygiene activities
client’s activity order, note special precautions
client’s ability, level of assistance
client’s preference
ensure room has adequate hygiene supplies and linens

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10
Q

What is the nursing diagnoses formulated after assessing the adequacy of client’s hygiene practices & assessment of body areas?

A 
ex: bating/self-care deficit
dressing/grooming deficit
ineffective health maintenance 
impaired skin integrity 
risk for injury or infection
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11
Q

What are some nursing interventions to assist client to develop/maintain hygiene practices?

A

ex: to decrease the possibility of infection by removing transient bacteria, excessive debris, secretions & perspirations from skin
to eliminate odors & rid body of microorganisms
to promote circulation
to provide comfort for patient
to assess client’s overall status, skin condition, level of mobility

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12
Q

What are the levels of assistance needed to perform hygienic care?

A

self=patient completes all activities on their own; provide supplies & orient to bathroom
assist/partial=patient completes as much of the activities as they can & nurse completes the rest;provide supplies & help w/ hard to reach areas
complete=patient cannot perform any activities on their own; completed by nurse
declined=patient refuses hygienic measures

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13
Q

What are common skin breakdown areas?

A

Supine (back)=head, scapula, elbows, sacrum, heels
prone (stomach)=toes, knees, genitalia, breasts, shoulder, cheek, ears
Lateral (side)=ankle, knee, hip, shoulder, ears, head.
Fowler’s (sitting position)=heels, pelvis, sacrum, vertebrae

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14
Q

what are some variations of lotions and creams?

A

aloe vesta cream=skin protection, chapped dry skin
sensicare=skin barrier
cavilon skin care=foot and dry skin cream
aloe vesta soap=foam soap

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15
Q

What are guidelines for foot care?

A

dry feet thoroughly, do not moisturize between toes.
provide cotton socks, comfortable shoes (avoid restricting circulation)
nail filing/trimming should be done by a podiatrist, especially for patients w/ diabetes/elderly

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16
Q

What are guidelines for fingernail care?

A

assess for cracking, clubbing or any fungus

use an emery board to file nails, caution for cutting (nail cutting may require order or professional)

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17
Q

What are the guidelines for mouth care?

A

gentle brushing & flossing - toothpaste, mouthwash, dental floss
for unconscious pts - use suction and side-lying position

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18
Q

How are dentures cared for?

A

w/ care. use gloves to remove. brush w/ soft brush & denture cleaner, place washcloth at bottom of skin to prevent break if dropped.

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19
Q

What does the oral rating score assess?

A

lips, gingiva/oral mucosa, tongue, teeth, saliva.

determines nursing interventions, what to be performed & how frequently

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20
Q

What is assessed for hair care? why is brushing and combing important?

A

stimulates circulation of blood in scalp, distributes oil on scalp, arranges hair
shampooing helps increase patient’s sense of well-being, shampoo trays and caps available for bedridden patients

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21
Q

What are the guidelines for eye care?

A

use cotton ball or clean washcloth or compress moistened with water or normal saline. wipe from inner to outer canthus of eyes. If patient is unable to blink or close lids completely, perform q4hrs. lubricate eyes w/ artificial tears or saline

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22
Q

what are guidelines for perineal care on females?

A

use fresh water and washcloths. position supine w/knees flexed apart, use soap & water, spread labia, move washcloth from pubis to rectum (front to back). use clean section of washcloth for each stroke. cleanse anal area last.

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23
Q

What are guidelines for male perineal care?

A

supine position. clean tip of penis first, using circular motion from meatus outward. wash shaft using downward strokes toward pubis area. if uncircumcised, retract foreskin for cleaning and replace the foreskin (to avoid constriction of penis). wash & rinse scrotum, then anal area last

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24
Q

How is perineal care performed on patients w/ an indwelling foley catheter?

A

wash around meatus, junction of catheter insertion site & along the tube w/ soap & water daily and when soiled. inspect meatus for drainage & note color of urine, keep drainage bag below bladder and unkinked

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25
Q

What is the definition of ergonomics?

A

an applied science concerned w/ designing & arranging things people use so that people & things interact most efficiently & safely

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26
Q

Why are body mechanics important in the care of patients?

A

correct use of body mechanics is part of illness & injury prevention, & health promotion.

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27
Q

How is proper body mechanics achieved?

A

maintaining:
stable center of gravity (back straight, bend at knees, hip)
wide base of support (keep feet apart)
line of gravity (object lifted close to body)
proper body alignment (head up, back flat, weight forward)

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28
Q

How do pressure ulcers and happen?

A

pressure on bony prominences.

lack of muscle use and improper positioning

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29
Q

What are the types of ROM exercises?

A

active=isotonic, client independently moves joints through their full range of motion
active-assist=nurse provides minimal support
passive=client is unable to move independently, nurse moves each joint through its full range of motion

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30
Q

What are indicators for ROM orders?

A

activity intolerance, impaired physical mobility, risk for disuse syndrome, risk of falling, multi-disciplinary team assessment

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31
Q

How do anti embolism stockings work?

A

apply pressure to prevent deep vein thrombosis

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32
Q

What are intermittent compression devices?

A

called venodyne or flowtron. requires physician order. rhythmic inflation simulates normal muscle-pumping action of legs and circulation, remove daily to check skin

33
Q

How is mobility assessed?

A

nursing history, ease of movement/gait, posture/alignment, joint structure/function, muscle mass/tone/strength, endurance

34
Q

Define paralysis and paresis.

A

paralysis=inability to move w/ total absence of muscle strength (hemiplegia, paraplegia, quadriplegia, monoplegia)
paresis=decreased ability to move with decreased muscle strength (hemiparesis, paraparesis, quadriparesis, monoparesis)

35
Q

What are safe ambulation practices?

A

supportive shoes on patient, have “spotter” at first and when needed, explain what you want patient to do, use lots of patience and verbal encouragement

36
Q

What are the three weight bearing statuses?

A

NWB=no weight bearing
PWB=partial weight bearing
FWB=full weight bearing

37
Q

What are descriptions for patient mobility statuses?

A

I=independent, out of bed & ambulates w/ no assistance or supervision
S=Supervised, given safety reminders but no touching client
A=Assistance, touching, steadying, or holding onto client

38
Q

What are transfer devices used to move patients?

A

Sara lift, maxi move

39
Q

Wy is safety important?

A

basic human need, behind physiological needs (Maslow’s)

hospital’s are dangerous, safety is regulated and considered part of quality care

40
Q

What is TJC? And what do they do?

A

The Joint Commission accredits hospital, creates national patient safety goals annually.

41
Q

What were the 2014 National Patient Safety Goals by TJC?

A

ID patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infections, ID patient safety risks, prevent mistakes in surgery

42
Q

What are factors that affect client safety?

A

developmental concerns (children, elderly)
Lifestyles (job, social behavior, environment)
Mobility (any limitation is potential safety concern)
Sensory perception (vision, hearing)
Knowledge (client’s understanding & ability)
ability to communicate (ability to send & receive messages)
physical health (acute or chronic illness)
psychosocial health (stress, depression, social isolation

43
Q

What are safety risks for neonates, infants, toddlers and preschool/school-age patients?

A

neonate=infection, falls, SIDS
infant=falls, toys, burns, suffocation, drowning, inhalation/eating foreign bodies
toddlers=same as infants, plus poisons
pre-school/school-age=falls, burns, drowning, broken bones, inhalation, ingestion, guns/weapons, substance abuse

44
Q

What are safety risks for adolescents, adults, and older adults?

A

adolescents=drowning, MVA, guns/weapons, inhalation, & ingestion (drugs)
adult=stress, MVA, DV, occupational injury, drug & alcohol use
older adults= falls, MVA, elder abuse, sensorimotor changes, fires

45
Q

What is meaningful rounding?

A

Checking the four Ps, perform & document:
Pain assessment (may issue meds)
Potty
Position (ensure comfort)
Proximity (ensure all needed items in reach)
*also reassess any abnormal findings

46
Q

How is an incident reported at RHS?

A

Notify manager, complete an incident report, call risk management for serious events such as patient injury (x8256) or anonymous hotline #

47
Q

What is considered a FALL?

A

an unplanned, sudden, descent to the floor. w/ to w/o an injury, can be result of physiological or environmental conditions. an assisted fall is still considered a fall.

48
Q

What are factors that contribute to falls?

A

age (>65), history of falls, impaired vision or balance, altered gait or posture, medications, postural hypotension, slowed reaction time, confusion or disorientation, unfamiliar environment

49
Q

When is the Morse Fall Scale utilized?

A

RN or LPN completes on: admission, every shift, on transfer to another unit, post fall, w/ any significant change in patient’s condition. With high risk score implement the fall prevention plan (low risk=50 or less, high risk=>50)

50
Q

What is assessed to determine the Morse Fall score?

A

History of falls, secondary dx, ambulatory aid use, IV therapy or heparin lock, gait, mental status.

51
Q

What are standard fall prevention interventions used for all patients?

A

adequate lighting, assistive devices, bed position in low, bedside table in reach, brakes on, call bell in reach, minimal clutter, non-skid footwear, phone in reach, side rails in safe position, unobstructed path to bathroom, urinal/bedpan in reach

52
Q

What is the Fall Prevention Protocol for high fall risk patients?

A

yellow fall risk bracelet, yellow fall risk sign outside room, safety checks/meaningful rounding q1hr, place client close to nurses stations, initiate physical therapy consult, never leave patient unattended in bathroom, implement bed/chair alarm, review meds

53
Q

What should you do as an RN when a patient has fallen?

A

assess patient for injuries, perform orthostatic vital signs, pain assessment, evaluate neurological status q2hr x4, q4hr x2 (LOC, orientation, pupils, movement, extremity strength), review meds, notify healthcare provider, reassess morse fall scale, doc facts in EPIC, complete incident report, fall scene investigation

54
Q

What is a sentinel event?

A

unexpected occurrence involving death or serious physical or psychological injury, signals a need for immediate investigation & a response

55
Q

What is a serious event?

A

an event involving patient that results in death or compromises safety & results in injury requiring additional health care services

56
Q

What is a near miss?

A

an event that would have constituted an incident but was intercepted before it reached patient. It did not occur but it was very close to occurring. must also be reported.

57
Q

What is a seizure and the precautions for a patient undergoing a seizure?

A

uncontrolled electrical activity in the brain. assess patient, have rescue equipment at bedside (O2, oral airway, suction equipment, padded side rails), keep environment clear

58
Q

What do you do in the event of a seizure?

A

do not restrain, lower to floor, place on side, protect head, loosen clothing, stay with client, give meds as prescribed, note duration of seizure, sequence and type of movements

59
Q

What is done after seizure?

A

assess mental status, oxygenation, VS. explain what happened to client, provide comfort and quiet environment for recovery, document seizure, note any precipitating behaviors and description of event, report to HCP

60
Q

what is the difference between elopement and wandering?

A

elopement=any patient who comes in for care then leaves without authorization
wandering=any patient wh comes in for care, then leaves assigned clinical area, but not entire environment (hospital, rehab facility)

61
Q

How are elopement risks assessed?

A 
evidence & history of substance abuse
cognitive impairment
complex social situation
verbalized intent/desire to leave
elopement history
(highest risk are patients under influence of drugs/alcohol and those who verbalized desire to leave)
62
Q

What are elopement interventions?

A

consider patient room/unit location related to need for supervision, physician consultation (medical management of specific complaints/concerns), family involvement, “CODE PURPLE” when elopement occurs

63
Q

What is the MAT team and Code BLUE used for?

A

Medical Assessment Treatment Team=rapid response teams for patient emergencies. Code Blue=called when patient stops breathing or heart stops

64
Q

What are the codes pink or orange used for?

A

pink=child abducted

orange=violent patient, guest

65
Q

What are the fire codes?

A

Red=fire, evacuate
yellow=fire, under control
green=all clear

66
Q

What does RACE stand for in fire safety?

A

Rescue
Activate alarm
Confine fire, close windows, doors
Evacuate patients to a safe area (patients that can walk first, patients in wheelchairs next, bed bound patients third)

67
Q

What does PASS stand for in fire safety?

A

Pull the pin
Aim at base of fire
Squeeze handle
Sweep across fire

68
Q

What are the classes of fire extinguishers?

A

A=regular combustibles, wood, paper, cardboard
B=flammable liquids, gas, kerosene, oil
C=electrical fires

69
Q

How is the need for restraints assessed? what is important to keep in mind?

A

assessment for restraint alternatives, use least restrictive interventions as possible. assess for physical causes of behavioral change: pain, low oxygen levels, alterations in VS, blood glucose, fluid or electrolytes, urinary retention/constipation, meds/anesthesia, sleep deprivation, sensory deficits

70
Q

What are physical restraints?

A

any manual method that immobilizes or reduces the ability of the patient to move body parts freely. ex: hand mitts, limb restraints, chest vest, geriatric chairs, side rails. alternative methods must be used first, restraints are a last resort

71
Q

What are the dangers of using restraints?

A

suffocation, impaired circulation, skin and nerve damage, fractured bones, altered nutrition/hydration, urine/fecal incontinence, psychological trauma

72
Q

What are the nursing interventions when a patient is in restraints?

A

q1hr reassess patient for safety, comfort, cleanliness, readiness for removal of restraints. q2hr check skin and circulation, provide ROM, offer food, fluids and toileting. Need for continued restraint assessed q4hr for adults, q2hrs for ages 9-17, q1hr for children under 9.

73
Q

What are the differences when using violent restraints?

A

They are much more restrictive requirements, original orders renewed every q4hrs for adults, q2hr for 9-17yo, q1hr <9. Physician or psych RN must complete face-to-face evaluation w/in 1 hour of restraint application, uninterrupted observation of patient by trained staff member

74
Q

What is nutrition and why is it important?

A

study of how food nourishes the body. nutrients are used by the body for growth, development, activity, health, and recovery from illness or injury. they work better together. needs are changed in response to development, sickness, injury.

75
Q

What are the six essential nutrients?

A

macronutrients/energy nutrients=carbohydrates, protein, lipids
micronutrients/regulatory nutrients=water, vitamins, minerals

76
Q

What are the types of carbohydrates and how much is recommended?

A

carbs provide energy, prevents protein from being used for energy.
Simple and complex: sugars and starches/fibers
sources: fruits, veggies, grains, milk

77
Q

Why is protein important? What are the types?

A

protein is required for proper growth and development, needed for tissue building and maintenance, balance of nitrogen and water, backup energy, support of metabolic processes and immune system. insufficient protein leads to atrophy and wasting of muscle tissue
it may be complete=high quality, from animal sources. incomplete=low quality, from plants. complementary=other food sources eaten together.

78
Q

Why are lipids important? What are the types of lipids?

A

lipids supply energy and vitamins. from animal products, egg yolks, organ meats, butter, cheese, oils.

NUR 101 (3 decks)

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