Exam Review Flashcards
- Disease atrophy - the reduction in normal size of muscle fibres after prolonged bed rest, trauma, casting, or local nerve damage
- Cardiovascular changes - orthostatic hypotension
- Skeletal changes
- Organ changes
- Metabolic changes - negative nitrogen balance
- Atelectasis (collapse of alveoli)
- Thrombus
- Embolus
- Joint contractures
- Footdrop
- Urinary elimination changes - urinary stasis
- Pressure injury (changes to integumentary system)
Risks of Immobility
Pneumonia, pressure sores, contractures, etc
Risks of Immobility
Decreased social interaction
Social isolation
Sensory depriavtion
Loss of independence
Role changes
Emotional reactions
Behavioural responses
Sensory alterations
Changes in coping
Sadness
Dejection
Emptiness
Worthlessness
Hopelessness
Psychosocial Effects of Immobility
How do you maintain good skin integrity of an immobile client
Move them every 2 hours
- Impaired sensory perception
- Impaired mobility
- Alteration in level of consciousness
- Shear
- Friction
- Moisture
- Nutrition
- Tissue perfusion
- Infection
- Pain
- Age
Risk factors for pressure injuries
If you are caring for a patient with sensory overload, what can you do as a nurse?
Take to a quiet spot
Constant reorientation, control of excessive stimuli, and, if possible, providing care in blocks of time are important components of the patient’s care. Providing clocks and calendars, dimming of lights, family support, and clear communication can help prevent ____________________ and delirium in patients.
Sensory overload
How do you assess a client with sensory alterations?
What are sensory alterations, the impact and tools to manage.
E..g do you use a hearing aid, do you have trouble feeling (tactile), know if they have glasses (put them on), dentures, all the senses
An alteration in any of the following:
- Visual
- Auditory
- Tactile
olfactory
- Gustatory
- Kinesthetics - enables a person to be aware of the position and movement of body parts without seeing them
- Stereognosis - allows a person to recognize an object’s shape, size, and texture
Sensory alteration
- Infections agent (pathogen)
- Reservoir (source for pathogen growth)
- Portal of exit from the reservoir
- Mode of transmission
- Portal of entry (to a host)
- Susceptible host
The Chain of Infection
What can you do for a hearing deficient?
Hearing aids on, don’t yell
Sensory alterations can cause a feeling of _________
Isolation
At what age do sensory alterations occur
All ages
You have poked a patient for glucose - he is bleeding a lot what do you do?
Apply pressure
Specific
Measurable
Achievable
Relevant
Timely
SMART goals
How do you apply a sterile dressing?
Not reaching over sterile area
Having hands above chest or below waist
Spitting/spilling on dressing
Dropping tools
Putting a non sterile item on the sterile field
Dripping on sterile field
Touching the field with a non sterile object
Things that break sterile technique
How should you position a patient when feeding?
Upright, slightly leaning forward
Assessment
Planning
Implementation
Evaluation
The Nursing Process
Nurses gather information, biographical, sociocultural, environmental, spiritual, and psychological data to create an understanding of the patient’s unique health or illness experience. Organizing the data would enable the nurses to interpret major issues and concerns and produce a nursing diagnosis - the nurse’s perspective on the appropriate focus for the patient
Assessment
Nurses would prioritize the issues raised during assessment in relation to the nursing diagnoses, identify which issues could be supported or assisted by nursing intervention, and create a plan of care.
Planning
The plan of care would be carried out (nursing process step)
Implementation
The plan’s success or failure would be judged both against the plan itself and against the patient’s overall health status; that is, it would be determined whether the intended outcomes had been achieved or whether the nursing intervention strategies required revision
Evaluation
Once you start ___________ - you can change the whole thing you want to, that is when you can change things
Evaluation
What would you say when teaching a patient good sleep hygiene?
Take a nap mid day if you need to nap
How can you prevent falls in your patient?
Fall risk assessment - make sure there’s no rugs around, beds lowest, using walker
- Review home hazard assessment
- List of priorities to modify - assist in installing bathroom safety
- Install lighting
- Educate about normal changes of aging, effects of recent stroke, associated risks for injury
- Encourage vision testing
- Refer to physiotherapist to assess for need for assertive devices for kyphosis, left-sided weakness, and gait
Fall prevention
Describe details on giving a client a bed bath
Clean to dirty
Long firm strokes
Move in a way to promote circulation
What is the cleanest part of the body?
The eyes
Peri care, how would you do that?
Front to back, tip first (pull back foreskin)
Why are you washing front to back?
To prevent infection
Has been used to describe a stimulus, a process, a response, and a state, which often leads to confusion and ambiguity. Fight or flight response.
Stress
Used to describe an event that activates stress response system
Stressor
Behavioural response that have changed over time in order to better manage stress response systems
Adaptation
Stages of stress / general adaption syndrome:
Alarm reaction
Resistance stage
Exhaustion stage
Fight or flight response
Alarm reaction
Organism maintains arousal while the body works to defend against and adapt to the stressor and maintain homeostasis
Resistance stage
When stressors continue for an extended period, organisms use up their finite ability to adapt. Pathological state in which organisms start showing diverse health consequences, which may eventually result in death
Exhaustion stage
Average temperature (range)
36 to 38 C
Average oral/tympanic/temporal
37 C
Average rectal
37.5 C
Average axillary
36.5 C
Pulse
60-100 BPM
Normal respirations
12-20 breaths per min
Systolic
120-139 mm Hg
Diastolic
80-89 mm Hg
Pulse pressure
30-50 mm Hg
Oxygen saturation
95-100%
If a patient has double mastectomy where would you take BP?
Thigh
Where are different places that you can take temps?
Ear, oral, tympanic, axillary
Why might you use the ear for the temperature?
It’s the easiest to get at - quickest it seems
You’re assessing and admitting - so that is why you use the ear
Abnormal vital signs what should you do?
Check again
An important defence mechanism - temperature elevations up to 38C enhance the body’s immune system
White blood cell production is stimulated
Reduces iron in the blood plasma, surpassing the growth of bacteria
Fights viral infections by stimulating production of interferon, the body’s natural virus fighting substance
Cellular metabolism increases and oxygen consumption rises
Heart and respiratory rates increase to meet the increase metabolic needs of the body for nutrients
Increase metabolism entails the use of energy that produces additional heat
What is the role of a fever?
What is a hospital acquired infection called?
Nosocomial infections
How do you promote healing with a client with infection?
Infection control
Healing would be nutrition
Hydration & rest *
When do you wear gloves?
Whenever you may come in contact with bodily fluids
What is normal glucose?
3.5-6.5 - textbook goes from 3-6 ***
How would you care for a client in isolation?
Use isolation precautions - care for them the same you care for anybody else
Apply when a health care worker is or potentially may be exposed to blood, all body fluids, secretions and excretions except sweat, non intact skin, or mucous membranes. Include the appropriate use of gowns, gloves, masks, eyewear, and other protective devices or clothing.
Routine practices
- Hand hygiene
- Dispose of contaminated supplies and equipment in a way that minimizes spread
- Apply knowledge of a disease process and the mode of infection transmission when using protective barriers
- Ensure that all persons who might be exposed during transport of a patient outside the isolation room are protected
Isolation precautions:
How do you remove staples?
With a staple remover
Simply insert the tips of the ________________ under each wire staple. While slowly pressing the ends of the staple remover together, squeeze the centre of the staple with the tips freeing the staple from the skin
Staple remover
Describe the best way to do peri care on male and female?
Clean to dirty
Environmental factors (noise), caffeine, stress - look for the general things
Room is dark, quiet, those sorts of things
No tv before bed
Noise
Uncomfortable bed and pillows
Bright lights
Pathophysiological factos
Pain and discomfort
Use of invasive equipment such as intravenous lines, nasogastric tubes
Stress, worry
Lack of control
Lack of privacy
Anxiety about procedures and outcomes of investigations
What disrupts sleep?
When the patient has dysphagia what is important?
Altered food textures - watch them eat to make sure they swallow
What is it called when doing ROM and clients hand won’t open?
Contracture - stiffened joints
Bringing towards midline of body
Adduction
Taking away from middle of body
Abduction
What promotes good wound healing?
Rest and hydration
Proper nutrition
When is the best time to take a wound culture?
After you’ve cleaned the wound
Describes the amount, colour, consistency, and odour of wound drainage and is part of the wound assessment
Exudate
Excessive exudate usually indicates the presence of an ___________
Infection
Clear, watery plasma
Serous
Thick, yellow, green, tan or brown
Purulent
Pale, red, watery; mixture of clear and red fluid
Serosanguineous
Bright red; indicates active bleeding
Sanguineous
The ________________ condition needs to be included in the assessment - skin surrounding the wound
Periwound
How do you prevent the client from having pain when doing the dressing?
Administer analgesic at least 45 mins prior
Tell me ways to make sure you don’t contaminate sterile field
Not reaching over sterile field
Not coughing or hacking / talking too much over the sterile field
