Final Flashcards
The level of promoting health but also preventing illness
Health promotion Health education Immunizations Early detection and treatment Environmental protection
Primary level of health care
The level of diagnosing and treating a patient
Emergency care
Acute and critical care
Elaborate diagnosis and treatment
Secondary level of health care
The level of rehabilitation, health restoration, or palliative care
Rehab
Long term care
Care of the dying
Tertiary level of health care
Nurse is responsible for overseeing the total care of a number of hospitalized patients on a specific unit.
- 24 hours a day, 7 days a week, even if they do not deliver the care personally
- Encompasses teaching, advocacy, decision making, and continuity of care
- Provides comprehensive, individualized, consistent care
- Should work consistently on the nursing unit, challenges include the variable number of part-time nurses
Primary nursing care
Oldest Method –> Private Duty Nursing
Total Patient Care –> Nurse is responsible for total care of the patient during the nurse’s working shift
-Assesses needs, makes nursing plans, formulates nursing diagnosis, implements care, and evaluates the effectiveness of care
-Do not necessarily care for the same patient every time
-Nurse is responsible for several patients
Case method nursing care
Consists of a leader
- An RN leads a team that is composed of other RN’s, LPN’s, and CNA’s.
- Staffing team reports to them
- Has accountability for all of the care
Consists of members
-assigned specific functions or procedures to perform for all clients. (medications, treatments, bedside nurse)
Consists of conferences
-utilized to communicate and develop a plan of care
Team nursing care
Nursing Case Managers responsible for a case load of patients in the hospital
- Assessing patients and their homes/communities
- Coordinating and planning care
- Collaborating with other health professionals
- Monitoring patients progress through follow-ups
- Evaluating patient outcomes
Work with insurance companies to help patient receive the best possible care in the most cost-effective way
Case management nursing care
What are the 5 nursing care methods
Function nursing care Case management nursing care Primary nursing care Case method nursing care Team nursing care
- Leader makes decisions for the group
- Assumption is that the group is externally motivated and incapable of independent decision making
- Very effective in emergency situations & when a project must be completed quickly and efficiently.
- Likened to a dictator: gives orders and directions to the group
- Productivity is usually high, but autonomy and self-motivation low.
- Degree of openness and trust between group & leader is low.
Autocratic (authoritarian) leadership style
- Leader encourages group discussion and decision making
- Assumes individuals are internally motivated and capable of making decisions
- Leader acts as a facilitator towards goals
- Allows more self-motivation and creativity among members (must have cooperation and coordination among members)
- Often very effective in the health care setting
Democratic (participative) leadership style
- Leader assumes group in internally motivated and needs autonomy
- Leader assumes a “hands off” approach and tends to minimize the amount of direction and face time needed
- There may be a lack of cooperation & coordination
- Works well if you have highly trained and motivated group
Laissez-faire (non-directive/permissive) leadership style
- Leader assumes group is externally motivated, but does not trust them to make decisions
- Leader relies on organizational rules and policies – takes an inflexible approach
- Leader motivates through systematic rewards and punishments
- Empowered by the office they hold
Bureaucratic (transactional) leadership style
- The leader adapts the leadership style to the situation
- There is concern for interpersonal relationships and a focus on activities that meet group members’ needs
- Could end up using any of the previously mentioned styles, determined by the group’s needs
Situational leadership style
- No one person is considered to have more knowledge or ability than another in the group
- In essence, all are leaders
Shared leadership style
The transferring of responsibility for the performance of an activity or task to another member of the health care team while retaining accountability for the outcome
Delegation
What are the 5 rights of delegation
The right task The right circumstances The right person The right communication/understanding The right supervision/evaluation
A dynamic, flexible environment that is concerned with the specific needs of an individual patient and/or groups of patients to promote a positive living experience and positive health changes.
A therapeutic environment
Characteristics of a therapeutic environment
- Adequate Comfort (temperature, ventilation, lighting, nonskid surfaces….)
- Safe environment
- Individualization of patient care
- An atmosphere that encourages communication
- A feeling of “security” for the patient
- A feeling of self worth for the patient
- Diversional activities
What is the RACE acronym for a fire
R- RESCUE anyone in immediate danger if it does not endanger your own life
A- sound the ALARM
C- CONFINE the fire by closing all doors and windows
E- EXTINGUISH the fire or if the fire is too large, EVACUATE the area
What is the PASS acronym for a fire extinguisher
P- Pull the pin
A- Aim the nozzle at the base of the fire
S- Squeeze the handle
S- Sweep from side to side
What are you going to look for when assessing mobility
- Alignment of the spine while standing and sitting
- scoliosis: C or S curve of the spine
- kyphosis: hunchback - Balance by asking the patient to sit or stand with their eyes closed
- swaying to one side indicates inability to maintain balance - Gait by watching the patient walk
- should be rhythmic and even, symmetric, head is erect, body weight is easily supported - Joints by range of motion
- note limitations
- look for symmetry and discomfort - Muscle strength in the hands (clients squeezes your wrist) in the feet (client pushes foot against your hand)
- grade response of a 0 to 5 scale
What should you consider when ordering restraints
First assess and develop alternative ideas because restraints are only temporary
Next find the least restrictive but one that will still provide safety
Evaluate face to face with patient within one hour or restraints being used
Order must be renewed every 24 hours
Using the restraints correctly
Follow directions
Correct size
Secure restraints to bed frame not bed rails
Continually monitor for circulation, movement, and sensation
Remove them at least every 2 hour for ADLs
Stop when you can
Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.
Pressure ulcer
Contributions to pressure ulcers
Pressure intensity
Pressure duration
Tissue tolerance
An observable skin change
Appears as a defined area of persistent redness in lightly pigmented skin or a red, blue or purple hue in darker skin.
Nonblanchable erythema
There are no open skin areas.
May be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Stage 1 pressure ulcer
There is partial-thickness skin loss involving epidermis and/or dermis
Superficial
Presents as an abrasion, blister or shallow crater with a red/pink wound bed
No slough
Stage 2 pressure ulcer
Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Presents as a deep crater with or without undermining of adjacent tissue
Bone/tendon/muscle is not visible – slough may be present
Depth varies by anatomical location
- Bridge of nose, ear, malleolus do not have subcutaneous tissue and can be shallow
- Areas of significant adiposity can develop deep ulcers
Stage 3 pressure ulcer
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (such as tendons)
Undermining and sinus tracts may also be present.
Depth also varies by anatomical location
Slough or eschar may be present
Stage 4 pressure ulcer
A pressure related injury to subcutaneous tissue under intact skin
Initially, these lesions have the appearance of a deep bruise
May herald the subsequent development of a Stage III-IV pressure ulcer
Mottling may be present.
Document as “unstageable” – DO NOT stage as a Stage I pressure ulcer!
Suspected deep tissue injury
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Unstageable
Wound drainage that is clear and watery
Serous
Wound drainage that is bright red
Sanguineous
Wound drainage that is pale, red, and watery
Serosanguineous
Wound drainage that is thick, yellow, green, tan, or brown
Purulent
Type of healing:
- Tissue surfaces have been closed
- Minimal or no tissue loss
- Example: closed surgical incision
Primary intention
Type of healing:
- When extensive tissue loss occurs
- Edges cannot or should not be closed
- Burns, pressure ulcers, big lacerations
- The wound becomes filled by scar tissue
- Takes longer for wound to heal – chance of infection is greater
- Could be permanent loss of tissue function if scarring is severe
Secondary intention
Type of healing:
Starts healing by secondary intention and then wound is later closed to heal by primary intention.
Tertiary intention
When does wound healing begin?
Immediately upon wounding with vasocontriction
The first phase of wound healing that occurs immediately with the onset of vasoconstriction, platelet aggregation, and clot formation
Hemostasis
This phase of wound healing lasts 3-6 days
It is marked by vasodilation and phagocytosis as the body works to clean the wound to begin the repair process
Inflammatory
The phase of wound healing when capillaries grow across the wound and increase blood supply
Proliferative
The phase of wound healing when the wound is remodeled or contracted
Usually 1 or 2 years after injury
Maturation
What is the RYB color code
Red- protect the wound
Yellow- cleanse the wound
Black- debride the wound
Treat black, then yellow, then red
Important things to remember when applying heat and cold
Heat causes vasodilation and should be kept on no longer than 30 minutes (after this a rebound effect will cause vasoconstriction) and allow 30-60 min before applying it again
Cold causes vasoconstriction and should be kept on no longer than 30 minutes (after this a rebound effect will cause vasodilation) and allow 30-60 minutes before applying cold again
Nurses should consider these things when giving hot and cold therapy
Assessment of the skin.
Assessment of client’s ability to detect temperature changes.
Medical conditions, such as diabetes or circulatory disorders
The very young and very old are more sensitive to temperature changes
Ensuring proper operation of equipment
What is the purpose of the Braden scale and Norton scale
To give a numerical score to rate the patients level of risk for pressure ulcers
The order of Maslows hierarchy of needs
- at the bottom also most important in the pyramid: physiological needs; air, nutrition, water, elimination, rest, sleep, thermoregulation
- safety needs
- love needs
- esteem needs
- self actualization needs
Guidelines for prioritizing needs of the patient
- Immediate effect on survival
- Effect on other needs
- Timeframe and available resources
- Client’s perception of need
- Family’s perception of need
Steps to providing culturally diverse care
- Communication
- Avoid slang words and medical terms
- Speak slowly and respectfully
- Keep making sure they understand
- Use focused, open-ended, nonjudgmental questions
- Recognize whether or not to establish eye contact - Space
- How close to the patient should you be
- Recognize if touching is appropriate - Social organization
- What is important to them; family, religion, organizations - Time
- Do their schedules conflict with med administration, appointments - Environmental control
- Their beliefs about health and illness
- Their culture could affect the way they respond to health activities - Biological variations
- Can affect types of illnesses, their response to treatments
Sacred or holy matters that belong to or relate to a god or church
Spirituality
How to clinically assess for spirituality
- the environment
- prayer books
- bibles
- music - their behavior
- do they pray before meals - their verbalization
- do they mention God
Phases of the nursing process
- Assesment: gathering info about the patients condition
- Nursing diagnosis: identify the patient’s problems
- Planning: set goals of care and desired outcomes and identify appropriate nursing actions
- Implementation: perform the nursing actions identified in planning
- Evaluation: determine if the goals and outcomes were achieved
Describe an independent nursing intervention
Requires no supervision or direction from others
Does not require a physician’s orders or an order from any other professional
Describe a dependent nursing intervention
The nurse carries out the physician’s orders
Not within the scope of the nurses practice to order the intervention, but it is okay for them to carry out the intervention
Describe a collaborative nursing intervention
Carried out in collaboration with another health care professional
A statement that describes the client’s actual, potential or wellness human response to a health problem that the nurse is competent and licensed to treat.
The 2nd phase of the nursing process
Nursing diagnosis
What are the 4 types of diagnoses
Actual (3 part) -impaired skin intergrity Risk for (2 part) -risk for injury Wellness (1 part) -readiness for enhanced family coping Possible -possible social isolation with unknown etiology
The triggering event or stressor initiates the cascade of events (stimulus)
Stimulus based models
Based on Reactive Scope Model:
- Each physiologic system is used to describe the process of the sequence of events and predict outcomes
- Interpretations of stress are as individual as the responses to stress but the physiologic pathway triggered is predominately the same.
Response based models
Assumes the client & environment are inseparable (each affects the other)
Considers individual differences to explain variations among individuals under comparable conditions
Transaction based models
People experience anxiety and increased stress when unprepared to cope with stressful situations.
Adaption model
Stressors due to hospitalization
New roles Different roles than used to Threat to self concept Loss of privacy Financial concerns
Nursing interventions for stress and self concept
Assess the client’s and the family’s coping abilities
Interventions:
-communicate effectively
-encourage appropriate expression of feelings
-encourage self affirmations
-introduce change gradually
-effective teachings
-terminate relationship in a timely manner
Interventions for anxiety and stress
Get exercise, rest, and proper nutrition Relaxation techniques Spirituality Support systems Medications
Nursing interventions with sexual needs
Provide accurate, honest, information in an open environment Empathetic listening Nonjudgemental communication Encourage safe sex practices Referrals such as OB/GYN or therapists
Stage 1 of sleep
- Transition between drowsiness and sleep
- Only lasts a few minutes
- Feels as though daydreaming if awakened during this state
- Heart rate decreases
Stage 2 of sleep
- 40-50% of sleep time
- Can be easily awakened
- Muscles relax
- Body functions slow
Stage 3 of sleep
- Deep sleep
- Body functions continue to slow
- Sleep walking and bed-wetting can occur
- Dreams occur- often realistic
REM (Rapid Eye Movement) stage of sleep
- Both eyes move rapidly
- Low or absent muscle tone
- BP and HR fluctuate
- Oxygen consumption increased
- Dream can occur- vivid, wild, unrealistic
