Final Flashcards
Florence Nightingale (4)
- First nurse epidemiologist
- Sanitary/hygiene reform/concerned with the environment of the patient
- “Notes on Nursing: What It Is, and What It Is Not” published in 1859; established the first nursing philosophy based on health maintenance and restoration
- Nicknamed the “lady with the lamp” during the Crimean War
What does ANA set and who does it protect?
Standards of nursing practice and protects nurses
7 Roles of Nurses
Autonomy
Accountability
Caregiver
Advocate
Educator
Communicator
Manager
Autonomy (of nurse)
you can do it!! An essential element of the professional identity of a nurse is that they are able to perform independent nursing interventions (things nurses do to help a patient) without a medical order.
Accountability (2)
- responsible professionally and legally for the type and quality of nursing care provided.
- remain current and competent in nursing and scientific knowledge and technical skills.
Caregiver
help patients and families maintain and regain health, manage diseases and symptoms, and attain max functioning and healing.
You help patients set realistic goals and meet them.
Advocate
you protect your patient’s human and legal rights and provide assistance is asserting these rights. We are the voice of the patient many times when they can’t speak or don’t know what to ask.
Educator
Nurses teach patients and families. We explain disease processes, teach about medications, skills, reinforce learning , evaluate their learning process. Some are formal and planned and some are informal and unplanned.
Communicator
essential to the nurse-patient relationship (know patient’s personality) and your relationship with everyone else you will work with . You will communicate with other nurses, patients, families, and other healthcare professionals
Manager
coordinates the activities of members of their group. As a nurse you will use appropriate leadership styles to talk to patients and other staff in order to coordinate safe, effective care for your patients.
What differentiates APRN and RN? (2)
- APRN have higher clinical knowledge and skills
-APRN has 6-8 years of total education, can be masters or doctorly prepared.
Medical assistant (schooling and role)
- 3-6 months of education in hospital, technical college or community college
- VS, bathe, change linens, serve meals, weigh patient, I and O, etc
LPN/LVN (schooling, role, difference from RN)
- usually 12 months of education at a community college.
- Do treatments (lung care, feeding, oral meds), skills, direct patient care (e.g., observe and report clinical changes, perform wound care, and ADLs), teaching reinforcement
- No initial assessments during the day, no admit and discharge, no initial teaching; under RN
Registered Nurse (schooling, role, difference in levels)
- Associate degree or Bachelors Degree,2-4 years of education.
- All Assessment, Admission and Discharge, IV, skills, Community Focus, Teaching;
- BSN has more health assessment skills, community focus, and leadership
TNA
State board of nursing, Each state has a board of nursing, they are concerned for the public’s safety. They regulate nurse practice acts and licensing
Nurse Practice Acts
Every state has one and it says what a nurse can and can’t do that is different from the accepted national standard of practice for a nurse.
TNA vs ANA
TNA (aka “The State Board”) - concerned about public safety; reprimand you if you do wrong and can take your license
ANA- concerned about nurse safety and advocacy; set professional standards and practice
NSNA
National Student Nurses Association
- interested in your rights as a student
Autonomy in Ethics
- commitment to include patients in decisions about all aspects of their key. It is a key feature of patient-centered care
- freedom from external control, must respect patient independence
Ex. informed consent, patient education, patient advocacy, right to refuse medication
Beneficence
Nurses practice in the best interest of helping others. The agreement to act with beneficence implies that the best interests of the patient remain more important than self interest.
-patient interest> self-interest
Nonmaleficence
Maleficence means to harm or hurt, so nonmaleficence refers to the avoidance of harm or hurt. In nursing practice, we vow to do no harm to the patient.
-balance risks and benefits
Justice
fairness in distribution of resources
Fidelity
faithfulness, agreement to keep promises. Follow through on your promises and actions.
-loyalty
ANA code of ethics describes (3)
- Nurse’s commitment to the patient
- set of guiding principles that all nurses must follow
- duties of nurse to profession and society
5 ANA code of ethics
- Advocacy
- Responsibility
- Accountability
- Confidentiality
- Social Networking
Advocacy
to support of a particular cause. Standing up for the health, safety and patient rights of others is an example.
Responsibility
the respect of one’s professional obligations and to follow through. Every agency that you we will go into in clinical has policies and procedures. Responsibility means that when you are in that agency you follow those policies and procedures. You agree to remain competent.
Confidentiality (2)
health care team’s obligation to respect patient’s privacy from outside sources
- HIPAA( Health Insurance Portablity and Accountability Act of 1996) mandates confidentiality and protections of patient’s personal health information
Purpose of Cultural Assessment (3)
helps nurses gain an understanding of the meaning of the illness to the patient, expectations the patient has regarding treatment and care, and the patient’s perception about the process.
The very first step in becoming culturally competent and providing culturally congruent care is ______.
cultural awareness and acknowledging your own biases
Blue phone in hospital means?
It is for medical interpreter
Social determinants of Health
SDOH are the conditions in which people are born, grow, live, work, and age. This includes conditions within a health care system.
Stereotyping
The process by which people acquire and recall information about others based on race, sex, religion, etc., leads to prejudice; what you say or think
Prejudice
Unjustified negative attitude based on a person’s group membership;
Discrimination
When a person acts on prejudice and denies another person one or more of their fundamental rights (food, sleep, healthcare, happiness)
5 steps to develop cultural competence
1) Cultural awareness
2) Cultural desire
3) Cultural encounters
4) Cultural knowledge
5) Cultural skills
Cultural awareness
An in-depth self-examination of one’s own background, recognizing biases, prejudices, and assumptions about other people
Cultural Encounter
Cross-cultural interactions that provide opportunities to learn about other cultures and develop effective intercultural communication
Nurse’s role in safe medication administration (6 parts)
- Follow 7 rights of drug administration
- Assess patient’s ability to self-administer medications
- Monitor side effects
- Do not delegate any part of the medication administration process to nursing assistive personnel (NAP)
- Educate patient and families about medications
- implement nursing process to integrate medication therapy into patient care
7 rights of medication administration
Right medication Right dose Right patient Right route Right time Right documentation Right indication/reason
6 patient rights
- to be informed about their care
- to make decisions about their care
- to refuse care
- to be listened to by their caregivers
- to receive info in a way that meets their individual needs
- to be informed of errors; transparency
When are side rails not a restraint? (3)
- when they ↑ patient mobility and stability when moving into or out of bed
- if patient can freely exit the bed and move in it
- to prevent sedated patient from falling out
Most common restraint
side rails
When is a medication order required?
for every medications that the nurse will administer to a patient
When to administer “on call” medication?
when the operating room staff members notify you that they are coming to get a patient for surgery.
When to administer STAT? now?
Administer STAT immendiately; now within 90 minutes
When to administer time critical medications?
within 30 minutes before or after the scheduled time
When to administer antibiotics? (time frame)
30 minutes before or after they are scheduled to maintain therapeutic blood levels.
When to administer routinely ordered non time-critical medications?
1 to 2 hours before or after the scheduled time or per agency policy.
5 things that should be on medication order
Drug name
Dose strength
Route
Frequency
If PRN—Indication for use
What counts as a restraint?
any chemical (drugs not to treat patient’s condition), manual method, physical, mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to move freely unless to prevent harm during activity
-THEY ARE TEMPORARY
How often to monitor patient in restraints?
Every 15 minutes for violent behavior and to tend to needs
Every 2 hours for nonviolent behavior to lossen or remove restraints
When can restraint be used? (4)
Reduce the risk of patient injury from falls
Prevent interruption of medical therapy such as traction, IV infusions, nasogastric (NG) tube feeding, or Foley catheterization
Prevent patients who are confused, disoriented, combative from removing life-support equipment
Reduce the risk of injury to others by the patient
What needs to happen for safe restraint use? (4)
- face-to-face physician order within 24 hrs (60 minutes if violent)
- use all alternatives before restraint —-NO PRN
- use least restrictive alternative
- select alternative based on patient situation
10 things to monitor while patient in restraints
- Vital signs
- Skin integrity
- Nutrition
- Hydration- offer water
- Extremity circulation (2 fingers)
- Range of motion (ensure call light placement in reach)
- Hygiene
- Elimination needs
- Cognitive functioning and Psychological status
- Need for restraint
8 Alternatives to restraints
- de-escalation
- trained sitter (companionship and supervision)
- Move patient closer to nurse’s station
- Distraction
- Frequent observations and attention to needs
- Bed alarms/chair alarms (no slip socks, low bed)
- Family involvement
- discontinue bothersome treatment ASAP
11 pieces for fall prevention
- Fall risk assessment (conducting routinely per agency policy)/ Identify fall risks (Apply yellow color-coded wristbands to identify fall risks; Fall risk wheel on door)
- Hourly/purposeful rounding
- Adaptation of the environment (Remove excess furniture and equipment; Safety bars near toilets; adequate lighiting)
- Reduce the number of psychoactive medications
- Attention to postural hypotension
- Established elimination/toileting schedules
- Call lights and personal belongings within reach
- Bed safety alarms or motion detectors
- Use of assistive devices (walkers, canes, wheelchairs (brake locks), )
- Management of foot problems and footwear (rubber-soled shoes or slippers)
- Assign Physical therapy for balance, strength, gait
How to resolve ethical dilemmas? (3)
- know thyself
- To resolve ethical dilemmas, you must rely on facts instead of beliefs and values
- A strong emotional reaction hints at a belief vs a fact
When to ask about patient allergies?
Immediately ask about and document patient allergies from the moment you start care
Patient Care Hand-Off (2)
*A transfer and acceptance of patient care responsibility using effective communication.
*High-quality hand-off is complex and structured. (a Joint Commission Standard)
I in IPASStheBATON for Handoffs
Introduction (Introduce yourself and your role or job (include patient)); write name on whiteboard
P in IPASStheBATON
Patient (Name, identifiers, age, sex, location)
A(1st) in IPASStheBATON
Assessment (Present chief complaint, vital signs, symptoms, and diagnosis)-new nurse quickly assesses
S (1st) in IPASStheBATON
Situation (Current status or circumstances, including code status, level of (un)certainty, recent changes, and response to treatment)
S (2nd) in IPASStheBATON
SAFETY Concerns (Critical lab values or reports, SES factors, allergies, and alerts (falls, isolation))
What is SBAR? What does it improve? What does it stand for? (3)
- A common language and tool for communicating critical information to healthcare providers in a standardized, structured, and timely manner.
- Improves perception of communication and information about patients between health care professionals.
- Situation, Background, Assessment, and Recommendation
B in IPASStheBATON
Background ( Comorbidities, previous episodes, current medications, and family history)
A(2nd) in IPASStheBATON
Actions (What actions were taken or are required? Provide brief rationale)
T in IPASStheBATON
Timing (Level of urgency and explicit timing and prioritization of actions)
O in IPASStheBATON
Ownership (Who is responsible (person or team) including patient or family?)
N in IPASStheBATON
Next (What will happen next? Are there anticipated changes? What is the plan?
Are there contingency plans?)
What are 4 situations of Interprofessional Collaboration?
-Patient rounding
-Rapid Response Team
-SBAR
-Interprofessional education
S in ISBAR
Situation (concise statement of the problem)
B in ISBAR
Background
- Pertinent and brief information related to the situation.
- Diagnosis and co-morbidities
- Relevant background clinical information (i..e. medications, specialists, procedures)
A in ISBAR
Assessment
- Analysis and considerations of options
- What are your assessment findings?
- What do you think the problem is?
R in ISBAR
Recommendation
- Action requested/recommended
- What do you suggest needs to be done?
- What are you requesting?
- Is everyone clear about what needs to be done?
What is TeamSTEPPS in IPC? What are the 5 principles?
-evidence based team work (increases team awareness and communication; decreases barriers to patient safety)
-Principles: team structure, communication, leadership, situation monitoring, mutual support
CUS Tool in IPC
I am Concerned
I am Uncomfortable
This is a Safety Issue
HIPPA Privacy vs Security rule
Privacy rule: requires disclosures of PHI be limited to specific info required for particular purpose
Security rule: specifies administrative, physical/ and technical safeguards for 18 elements of PHI in electronic form
What did Florence Nightingale say about health informatics?
To Err Is Human: Building a Better Health System: appropriate technologies can help to reduce errors and ensure patient safety
11 legal Guidelines for Documentation
- No retaliatory comments or opinions about HCP or patient
- Correct all errors promptly
- Record facts
- Discuss communication you initiated for orders or clarification
- Document only for yourself
- Avoid generalized statements “status unchanged” or “tolerated well”
- Begin with date and time, end with signature and credentials
- Password protection
- Do not leave blank spaces or lines
- Do not erase or scratch out errors made while recording
- Record all written entries legibly using black ink and not felt tip pen or erasible ink
4 Guidelines for Quality Documentation
- Only include facts
- Write in short sentences
- Use simple, short words
- Avoid the use of jargon or abbreviations
6 standards for Quality Documentation
-Factual (avoid opinions and vague terms; only subjective data should be from patient
-Accurate (avoid irrelevant details)
-Appropriate Usage of Abbreviations
-Current (document right after things occur)
-Organized
-Complete (appropriate and essential info)
5 Error-prone abbreviations
- U, u for unit
- QD or QOD for daily or every other day
- IU for international unit
- trailing and leading zeros
- MS , MSO4, MgSO4 for morphine sulfate and magnesium sulfate
SOAP
-Documentation Method to identify interprofessional problems
Subjective, Objective, Assessment, Plan
What is the Rationale and Correct Action for the following documentation Guideline:
Correct all errors promptly.
Rationale: Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence.
Correct Action: Avoid rushing to complete documentation; be sure that information is correct
What is the Rationale and Correct Action for the following documentation Guideline:
Record all facts.
Rationale: Record must be accurate, factual, and objective.
Correct Action: Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care.
What is the Rationale and Correct Action for the following documentation Guideline:
Document discussions with providers that you initiate to seek clarification regarding an order that is questioned.
Rationale: If you carry out an order that is written incorrectly, you are just as liable for prosecution as the health care provider.
Correct Action: Do not record “physician made error.” Instead document that “Dr. Smith was called to clarify order for analgesic.” Include the date and time of the phone call, with whom you spoke, and the outcome.
What is the Rationale and Correct Action for the following documentation Guideline:
Document only for yourself.
Rationale: You are accountable for information that you enter into a patient’s record.
Correct Action: Never enter documentation for someone else (exception: if professional has went home and forgot to document something)
What is the Rationale and Correct Action for the following documentation Guideline:
Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”
Rationale: This type of documentation is subjective and does not reflect patient assessment.
Correct Action: Use complete, concise descriptions of assessments and care provided so that documentation is objective and factual.”
What is the Rationale and Correct Action for the following documentation Guideline:
Begin each entry with date and time and end with your signature and credentials.”
Rationale: Ensures that the correct sequence of events is recorded; signature documents who is accountable for care delivered.
Correct Action: Do not wait until the end of shift to record important changes that occurred several hours earlier; sign each entry according to agency policy (e.g., M. Marcus, RN).
What is the Rationale and Correct Action for the following documentation Guideline:
Do not erase or scratch out errors made while recording.
Rationale: Charting becomes illegible: it appears as if you were attempting to hide information or deface a written record.
Correct Action: Draw single line through error, write word “error” above it, and sign your name or initials and date it. Then record note correctly.
What is the Rationale and Correct Action for the following documentation Guideline:
Do not leave blank spaces or lines in a written nurse’s progress note.
Rationale: Allows another person to add incorrect information in open space.
Correct Action: Chart consecutively, line by line; if space is left, draw a line horizontally through it and place your signature and credentials at the end.
What is the Rationale and Correct Action for the following documentation Guideline:
Record all written entries legibly using black ink. Do not use pencils, felt-tip pens, or erasable ink.
Rationale: Illegible entries are easily misinterpreted, causing errors and lawsuits; ink from felt-tip pen can smudge or run when wet and may destroy documentation; erasures are not permitted in clinical documentation; black ink is more legible when records are photocopied or scanned.
Correct Action: Write clearly and include appropriate abbreviations using black ink
BUN and Creatinine normal range
BUN-6-24
Creatinine-0.6-1.2
When does BUN increase? What does it mean if BUN and creatinine are high?
BUN increases with dehydration and decreases with ECF excess. If BUN and Creatinine are high, there may be dehydration and kidney failure
Hematocrit and Hemoglobin normal range
Hematocrit (% of RBC in blood)-36-48
Hemoglobin (amount of protein in RBC)—12-16
Hematocrit to Hemoglobin ratios
Normal 3:1
Dehydration/Hypovolemia: >3:1
Fluid Overload: <3:1
Purpose and 2 examples of Isotonic fluids
-increase ECV but do not enter cells; given for dehydrated, hypotensive, or hypovolemic shock
- Normal Saline (0.9%)
- Lactated Ringers-includes Na+, K+, Ca2+, Cl−, and lactate, which liver metabolizes to HCO3−
10 Signs of Hypovolemia/dehydration
- sudden weight loss (overnight)
- decreased skin turgor (elasticity)/tenting
- postural hypotension
- no tears or sweat, dry mucus membranes
- Tachycardia
- Rapid Thready pulse (comes and goes; difficulty finding)
- Flat neck veins
- Restlessness/decreased LOC
- Sunken eyes
- Oliguria (less than 30 mL/hr)
9 signs of hypervolemia/ fluid overload
- Sudden weight gain (overnight)
- Confusion
- Orthopnea (unable to breathe laying down)
- Hypertension
- Tachypnea (fast breathing)
- Crackles/rales in lower bases of lungs
- Bounding pulse (high heart rate)
- Distended neck veins
- Pulmonary edema
Purpose and 5 Examples of Hypertonic fluids
Used to draw water from cells.
- 3% or 5% NS
- D10W (becomes hypotonic in body)
- D5 ½ NS (becomes hypotonic after D5 absorbed)
- D5 NS (becomes isotonic after D5 absorbed)
- D5 LR (becomes isotonic after D5 absorbed)
Purpose and 2 Examples of Hypotonic fluids
§ Used to expand ECV and hydrate cells before surgery
§ 0.225% NS
§ 0.45% NS
Infiltration and Extravasation Assessment Findings (3)
- Skin around catheter site taut, blanched, cool to touch, pitting edema;
- may be painful as infiltration or extravasation increases
- infusion may slow or stop
Infiltration and Extravasation Nursing Intervention (5)
§ Stop infusion (discontinue if not vesicant; if vesicant disconnect and aspirate and give antidote) and call HCP
§ Remove the IV catheter
§ Prop the arm
§ Do not apply heat or cold unless ordered, (can react with substance and cause tissue necrosis)
§ Do not apply pressure (can cause more contact with skin)
Phlebitis (vein inflammation) Assessment Finding
hard, red, painful, hot lump where IV site is ; may or may not have red streak or palpable cord along vein
Phlebitis Nursing Interventions (5)
§ Take out IV and call doctor.
§ Elevate affected extremity
§ Do not apply heat or cold without order.
§ May need IV antibiotics.
§ Start new IV line proximal or in other extremity
Infection of IV site Assessment Finding
Redness, burning ,swelling, weeping or discharge; not hard
Infection of IV site Nursing Intervention (3)
§ Remove catheter and contact HCP
§ Need antibiotics to prevent sepsis
§ Clean skin with alcohol and culture drainage if ordered
Air embolism Nursing Interventions (3)
- Prevent further air from entering the system by clamping or covering the leak.
- Place patient on left side, preferably with head of bed raised, to trap air in the lower portion of the left ventricle.
- Call emergency support team and notify HCP
Listening (3)
- Planned and deliberate act in which the listener is present and fully engages the patient in a nonjudgmental and accepting manner.
- Interpret and understand what the patient is saying
- necessary for meaningful interactions with patient
Knowing the patient(3)
- Knowing means striving to understand an event as it has meaning in the life of the other
- helps to select the most appropriate and effective nursing therapies and interventions (nurse understands how illness, treatment, or rehabilitation affect the patient and family)
- Facilitated by continuity of care and clinical expertise
Causes, Description, and healing of Secondary intention wound
Causes: Stage 2 Pressure ulcers, burns, severe laceration, or surgical wounds that have tissue loss or contamination
Description: Wound edges not approximated
Implications: Wound heals by granulation tissue formation, wound contraction, and epithelization
Providing Presence (and 4 outcomes)
Person to person encounter conveying a closeness and sense of caring; involves being there and being with
Outcomes: relief of suffering, decrease anxiety, decrease in the sense of isolation and vulnerability, and personal growth
Causes, Description, and healing of primary intention wound
Causes: surgical incision (sutures, staples), hematoma (internal bleeding)
Description: Wound that is closed
Implications: Healing occurs by epithelization; heals quickly within minimal scar formation
Causes, Description, and healing of tertiary intention wound
Causes: Wounds that are contaminated and require observation for signs of inflammation
Description: Wound that is left open for several days
Implications: Closure of wound is delayed until risk of infection is resolved; more scaring
Gauze dressing
– most common, absorbent, wick away exudate and can use for packing
Difference between red, yellow, and black wounds
Red: healthy regeneration of tissue, granulation; goal is to keep moist
Yellow: Presence of purulent drainage and slough
Black: Presence of eschar that hinders healing; needs debridement
Self-adhesive, transparent film dressing
– traps moisture, allows viewing, adheres to undamaged skin, does not need secondary dressing
Hydrocolloid dressing (2)
adhesive, occlusive; useful to absorb exudate, maintain wound moisture, slowly liquify necrotic debris; impermeable to bacteria
-used as prevention in high friction area and on IVs
Hydrogel (2)
– hydrates wounds, absorbs small amounts of exudate, debride by softening necrotic tissue; be wary of periwound maceration
—require secondary dressing
Calcium alginate (3)
– highly absorbent, no trauma when removed
– do not use on dry wounds
- require secondary dressing
Negative-pressure wound therapy (3)
§ suction promotes healing, reduces edema and contracture, collects exudate)—good if dehiscence occurs
§ Avoid when necrotic tissue with eschar present; fistulas, malignancy, evisceration or nerves exposes,
§ Express caution if high risk for hemorrhage, MRI, defibrillation
Nursing interventions to prevent pressure ulcers (5)
-turning every 2 hrs in bed
- turning every one hour in chair
-keeping patient dry with clean linen
-keep head at or below 30 degrees to prevent shear and friction
- cover moist areas with zinc oxide
Braden Scale Factors (3)
-RN completes daily
-six measures on sensory perception, moisture, activity, mobility, nutrition, friction and shear
-No risk 18-23; Mild risk: 15-18. Moderate risk: 13-14. High risk: 10-12. Severe risk: less than 9
Patient history factors in Venous Ulcer (5)
-chronic nonhealing ulcer (scaring may be present)
-no claudication (muscle pain when active) or rest pain (or neurologic deficit)
-moderate discomfort
-ankle or leg swelling and full veins
-pulse present
Cause of venous ulcer
Due to improper functioning of the valves in veins causing blood to pool in lower legs b-c can not return to heart
Interventions for Venous Stasis Ulcers (3)
-long term wound care (unna boot, damp-to-dry dressing)
-elevate extremity
-DO NOT encourage prolonged sitting or standing
Arterial Ulcer (description and appearance)
Full-thickness wound on lower leg feet, heels, or toes
“Punched out” appearance-smooth edges, smooth, shiny extremity
