Final Flashcards
1
Q
Effects of bedrest
A
Atrophy
Pressure ulcers
Osteoporosis
2
Q
How to prevent bedrest complications
A
Fall risk wristband Non slip socks Ted hose wrinkle free Stress the need for pt to alert nurse when needing to use restroom SCDs
3
Q
Caring for patients with pain
A
Anticipate pain-offer relief/meds
Prevent future pain-long acting relief
Treat pain-a priority-reassess every 2-4 hr
4
Q
Pain relief ladder for chronic pain
A
Non opioid
Opioid for mild to moderate
Opioid for moderate to severe
5
Q
PQRST
A
Pain assessment Provokes Quality Radiates Severity Time
6
Q
OLDCARTS
A
Pain assessment Onset Location Duration Characteristics Alleviates/aggravates Related Treatment Severity
7
Q
Documentation of pain
A
Pain rating scale 1-10 Faces scale (used for children)
8
Q
SS of pain when pt can’t speak
A
Facial expression
Temp or BP increase
Fidgeting or guarding
Circling number on scale
9
Q
Stages of grief/loss
A
Kubler Ross Denial Anger Bargaining Depression Acceptance
10
Q
Types of learning
A
Cognitive: the thinking aspect
Psychomotor: the physical aspect
Affective: the social/emotional/feeling aspect
11
Q
Assessing readiness to learn
A
Make sure they are not in pain
See what motivates them
Assess anxiety-try to decrease stressors
12
Q
Teaching strategies
A
Assessment Incremental approach Appropriate pacing A/V materials and models Establish purposes Repetition Focus on progress Team approach Interactive
13
Q
Assessing wounds
A
Wound size, color, odor Surrounding skin Tissue granulation Drainage Risk assessment-Braden scale
14
Q
Getting wound culture
A
Wound care specialist would obtain culture
Clean with NS
Do not spread bacteria
Gram stain
15
Q
Pressure ulcer
Stage 1
A
Skin is intact
Non blanchable erythema
16
Q
Pressure ulcer
Stage 2
A
Partial skin loss with exposed dermis
Pink/red and moist
No granulation tissue present
17
Q
Pressure ulcer
Stage 3
A
Full thickness loss of skin, adipose tissue visible
Granulation tissue and epibole (rolled wound edges) are usually present
18
Q
Pressure ulcer
Stage 4
A
Full thickness of skin lost
Exposed adipose tissue
Exposed bone/muscle/tendon
Often includes undermining and tunneling
19
Q
Pressure ulcer
Unstageable
A
Full thickness of skin lost
Ulcer is covered by slough and/or eschar
Necrotic tissue-doesn’t necessarily mean wound is infected, but the tissue attracts bacteria and puts pt at risk
20
Q
How often do you check on a pt with restraints
A
every 2 hours
21
Q
Assessment of sleep patterns and problems
A
Sleep history Disorders Meds Rituals or routines Naps, sleep patterns Sleep logs
22
Q
Effects of noise, pain, anxiety, fear, depression
A
Causes sleep disruption
In the hospital: control pain, keep routine, dark room, less noise, cluster night care
23
Q
Purpose of nursing care plan
A
To provide care that is individualized, holistic, effective, and efficient
24
Q
Nursing process steps
A
Assessment Diagnosis Planning Implementation Evaluation
25
Parts of a diagnosis
Problem
Etiology
Defining characteristics
26
Etiology
What is causing or contributing to the problem?
| Described as “related to”
27
Defining characteristics
The evidence of the problem
“As evidence by”
“As manifested by”
28
Types of nursing diagnoses
Actual/problem based
Risk
Wellness/health promotion
29
Priority interventions in nursing process
ABCs
Take care of immediate life threatening issues first
Safety issues next
Then pt identified issues
Last nurse identified issues based on holistic care
30
Angina
Chest pain caused by reduced blood flow to the heart
| A symptom of coronary artery disease
31
Ischemia
Decreased blood supply to a body part such as the heart
32
Effects of bedrest
| Circulatory
Increased heart rate
Decreased cardiac reserve
Orthostatic hypotension
Venous thromboembolism
33
Methods to ascertain heart rate
Radial
Antecubutal
Carotid
Apical
34
Measures to promote cardia circulation
Repositioning the patient
Monitoring I&Os
Fluid restriction if necessary
35
Blood flow through the heart
```
Blood from systemic circuit
To vena cava
To right atrium
To right ventricle
To pulmonary trunk
To pulmonary arteries
To lungs
To pulmonary veins
To left atrium
To left ventricle
To aorta
To systemic circuit
```
36
Constipation
Decrease in frequency/amount of stool
Usually accompanied by prolonged or difficult passage
Tends to be hard and dry
Have to strain
May pause pain and hemorrhoids
May cause impact ion or bowel obstruction
Valsalva maneuver
37
Diarrhea
Increase in frequency/amount of stool
Usually informed or liquid
Suggests inappropriate absorption of fluid and nutrients
38
Clear liquids
```
Coffee
Tea
Soda
Bouillon
Clear fruit juice
Popsicles
Jello
```
39
Full liquids
```
Milk
Icecream
Vegetable juices
Yogurt
Strained cereals
```
40
Flatus
Gas in or from the intestines/stomach
41
Reasons for urinary catheterization
```
To relieve discomfort
To obtain a sterile urine specimen
To measure residual urine amounts
To provide continuous bladder drainage
To provide continuous bladder irrigation
To monitor output (icu)
To promote repair to urinary structures after surgery
```
42
Urinary catheter sizes
Adult: 14F to 16F with a 5-10 ml balloon
Child: 5F to 8F younger children
8F to 12F older children
43
Urine sampling techniques
Routine urinalysis
Clean catch / midstream
Sterile
44
Routine urinalysis
Collect urine during normal void, and indwelling catheter, or urinary collection bag
Must be freshly voided using clean cup
45
Clean catch / midstream
Pt cleans area
Voids and discards small amount
Catches 30-60 ml in a sterile cup
Finishes voiding in toilet
46
Sterile urine collection
May be obtained by catheterization
| Or by thawing specimen from already in place indwelling catheter
47
UTI
Burning on urination
Frequency
Urgency
48
Minimally acceptable urine output per hour
30 ml
49
Renin-angiotensin-aldosterone system
Regulates ecf volume by influencing how much sodium and water are excreted in urine
Also contributes to BP
RAAS is increased during hemorrhage or vomiting
50
Atrial natriuretic factor
Regulates ecv by influencing how much sodium and water are excreted in the urine
ANP and ADP contrast
51
Antidiuretic hormone
Regulates osmolarity of body fluids by influencing how much water is excreted in urine
ADH decreases when body fluids are too dilute
ADH increases when body fluids are to concentrated-dehydration, hemorrhage
52
Which organ systems are involved in maintaining homeostasis?
Endocrine and nervous system
53
Which two organs help regulate acid base balance
Lungs: regulate by eliminating/retaining CO2
Kidneys: regulate by selectively excreting/conserving bicarbonate and hydrogen ions slower to respond to change by control overall more powerful and lasting
54
Hyponatremia
Below 135
| CHF, burns, diarrhea, diuretics
55
Sodium
135-145
56
Hypernatremia
Above 145
| Licorice (raises bp), dehydration, higher salt
57
Hypocalcemia
Below 9
| Eating disorders, osteoporosis, renal failure, prolonged vomiting
58
Calcium
9-11
59
Hypercalcemia
Above 11
| Bone disease, parathyroid tumor, renal failure, immobilization
60
Hypokalemia
Below 3.7
| Diarrhea, vomiting, diuretics
61
Potassium
3.7-5.2
62
Hyperkalemia
Impaired renal excretion
| Hemolysis
63
Kussmaul’s breathing
Presence of diabetic acidosis
Respirations are very deep and steady
Fruity sugary breath smell
pH low
64
Cheynes-Stokes
Periods of apnea followed by labored breathing
| Sign of dying
65
Biot’s respirations
Neurological disorder
| Erratic breathing due to damage of the brain stem (medulla)
66
Orthopnea
Breathing patterns that change based on body position
| Associated with pulmonary disease
67
Dyspnea
Any type of unusual breathing
68
What a nurse can do to promote oxygenation
```
Change in position
Ambulating/exercise
Promote comfort
Deep breathing and coughing
Meds: bronchodilators and expectorants
Incentive spirometer
Postural drainage (head lower than bed)
Oxygen therapy
```
69
Oxygen delivery systems
Nasal cannula
Face tent
Face mask
70
Oxygen in room air
| Each liter
21% oxygen in room air
| Increased 3-4% each liter
71
Methods of infection control
Hand washing
PPE
Isolation
72
Isolation procedures
PPE must be worn
| Minimize delegation
73
Contact vs droplet
Direct: person to person
Indirect: personal contact of host with contaminated inanimate object
Droplet: large particles that travel up to 3 ft during coughing, sneezing, or talking and come into contact with host
74
Types of isolation
Private rooms
Special rooms with positive pressure airflow (used for highly susceptible pt)
Cards are used outside rooms to note level of isolation
75
Nosocomial infection
An infection that originated in the hospital
76
Infectious phases
```
Incubation
Prodromal
Illness
Decline
Convalescence
```
77
Multi drug resistant organism
| MDROs
Have developed resistance to one or more broad spectrum antibiotics
MRSA
VRE
C. Diff
78
Perioperative care
PreOp
IntraOp
PostOp
79
PreOp
May be several hours to several days
Findings and assessments here are important baselines for postOp
Informed consent and teaching
Routine safety checklist
All meds are discontinued until HCP reorders after
80
IntraOp
```
Transport to operating room
Admission to operating room
Looks at skin integrity and mobility
Acute care: prep, allergies, anesthesia, positioning, documentation
Actual surgery
```
81
PostOp
Family is notified: status, results, complications
Handoff report to PACU
monitoring and assessing changes in mental status and level of activity
Aim is prevention
If not, early recognition
82
Anesthesia recovery
```
Looks at activity level, respiratory level, circulation level
Consciousness
Oxygen level
Wound dressing
Pain level
Ambulatory ability
Ability to eat (nausea)
Urine output
```
83
Atelectasis
Partial collapse of the small airways
| One of the most common breathing complications after surgery
84
After surgery
Encourage pt to cough: helps clear lungs and lowers risk of pneumonia and atelectasis
Turn the pt: reduces change of decubiti, bedsores, and muscle loss
85
IV sites
Peripheral or central
Best for blood draw: median cubical, accessory cephalic, antebrachial
Best for IV: dorsal venous network, accessory cephalic
86
IV patency
Make sure the line is free flowing
| To test: may use a syringe of saline solution to limit clothing
87
Infiltration:
Redness, swelling, blanching, pain, tenderness, cool around site
Occurs when the catheter goes through or comes out of the vein
88
Phlebitis
Redness, swelling, warmth, tenderness
Inflammation of the vein
Can be caused by the catheter, the fluids, or an infection
89
Needle gauge for blood admin
18 gauge is standard
90
Safe body mechanics when moving patients or objects
Before lifting, assess weight and determine if assistance is needed
Use pt safe handling equipment if pt is unable to help
Lift teams of two should be used to reduce injury risk
91
Delegation
| Important notes
RN is still accountable for outcome
| Must document! If It wasn’t documented, It wasn’t done
92
Some delegates tasks
```
Vital signs
I&Os
Postmortem care
Bathing/feeding/weighing
CPR
```
93
Tasks you may not delegate
```
Assessment
Data interpretation
Diagnosis
Creating nursing care plan
Education
```
94
Rights of delegation
```
Right task
Circumstance
Person
Communication
Supervisor
```
95
Therapeutic communications
```
Active listening
Empathy
Using touch or silence depending on situation
Clarifying
Paraphrasing
Validating
Summarizing
Asking appropriate questions
```
96
SBAR
```
Situation
Background
Assessment
Recommendation
Able to relay relevant info in a timely manner
```
97
Durable power of attorney
Supersedes legal next of kin in making decisions
| May cause family conflict
98
What constitutes a HIPPA violation?
Disclosing confidential pt info through gossip or discussing in public areas
Assessing info for pt not in your care
Improperly discarding documents that should be shredded
Leaving info visible to unauthorized individuals
Sharing info or photographs on social media
99
What to do if pt refuses treatment
Pt must sign consent form refusing treatment
| Must document that refusal
100
Cardiac output
SV x HR = CO
101
Symptoms of a transfusion reaction
Chills
Tachycardia
Flushing
