Exam Review Flashcards by Sydney Coopland

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

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Pneumonia, pressure sores, contractures, etc

Risks of Immobility

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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

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How do you maintain good skin integrity of an immobile client

Move them every 2 hours

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Impaired sensory perception
Impaired mobility
Alteration in level of consciousness
Shear
Friction
Moisture
Nutrition
Tissue perfusion
Infection
Pain
Age

Risk factors for pressure injuries

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If you are caring for a patient with sensory overload, what can you do as a nurse?

Take to a quiet spot

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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

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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

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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

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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

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What can you do for a hearing deficient?

Hearing aids on, don’t yell

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Sensory alterations can cause a feeling of _________

Isolation

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At what age do sensory alterations occur

All ages

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You have poked a patient for glucose - he is bleeding a lot what do you do?

Apply pressure

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Specific
Measurable
Achievable
Relevant
Timely

SMART goals

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How do you apply a sterile dressing?

Not reaching over sterile area

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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

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How should you position a patient when feeding?

Upright, slightly leaning forward

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Assessment
Planning
Implementation
Evaluation

The Nursing Process

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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

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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

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The plan of care would be carried out (nursing process step)

Implementation

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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

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Once you start ___________ - you can change the whole thing you want to, that is when you can change things

Evaluation

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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