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PCC Lecture > Final Exam > Flashcards

Final Exam Flashcards

1
Q

rNCLEX provides the __________ standard for knowledge of practice.

A

minimum

Nursing student graduate is minimally competent

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2
Q

National Nurses Association - ANA

Official professional nursing organization for nurses in the US; establishes standards for profession and tracks legislation on health care and how it impacts nurses

A

American Nurses Association

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3
Q

National Nurses Association - NLN

Sets the standards for nursing education programs; establishes criteria that all schools of nursing must follow

A

National League for Nursing

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4
Q

Roles of Nurse

A

caregiver, educator, leader, advocate, researcher

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5
Q

Inpatient vs outpatient

A

Inpatient = higher acuity and level of care

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6
Q

Maslows hierarchy of needs

A

Physiological (ABC’s)
Safety
Love/Belonging
Esteem
Self actualization

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7
Q

PICO(T)

Evidence based practice

A

Patient/Population
Intervention
Comparison
Outcome
Time (optional)

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8
Q

Decreased mobility = increased risk of

A

falling

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9
Q

Orthostatic hypotension

A

sudden drop in BP at different positions (lying, sitting, and standing)

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10
Q

Transferring Patients According to Dependency Level:

 Mechanical lift with full sling

A

Complete dependence: immobile

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11
Q

Mobility Aids: Canes

A

 Sizing:
* Top of cane should reach top of hip joint
* 30 degrees elbow flexion

 Teaching:
* Hold cane on stronger side
* Distribute weight evenly
* Advance cane and weaker side simultaneously, and then stronger side
* Avoid leaning over

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12
Q

Mobility Aids: Walker

A

 Sizing:
* Top of walker should reach top of hip joint
* 30 degree elbow flexion

 Teaching:
* Pick up walker and advance it as you step ahead
* Do not slide, unless it has wheels

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13
Q

Mobility Aids: Crutches

A

 Sizing:
* Axillary crutch pad should be 3 fingerbreadths below axilla
* Slight flexion of elbows
* Axilla should not rest on crutch pad

 Teaching:
* Tripod position
* Lead with unaffected leg when going up stairs and to lead with affected leg coming down

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14
Q

Intrinsic fall causes

A

 Orthostatic hypotension
 Meds: for new and dose changes
* Psychotropics

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15
Q

Extrinsic fall causes

A

unsafe environment

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16
Q

Guidelines for restraints

A

o Never ordered as needed (PRN)
o Require order within 1 hour
o Must be re-ordered every 24 hours
o Assess and document frequently

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17
Q

What is the #1 way to stop the spread of infection?

A

HAND HYGIENE

Use friction

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18
Q

Stages of infection

A

o Incubation: period of time between invasion of the pathogen and the first signs or symptoms of infection

o Prodromal: most infectious, appear as vague symptoms
 Not all infections have a prodromal phase

o Illness: signs and symptoms present

o Decline: symptoms fade, # of pathogens decline

o Convalescence: tissue repair, return to health

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19
Q

2 Tiers of protection per CDC

A

Tier 1- Standard precautions
Tier 2- Transmission based precautions

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20
Q

Tier 1- Standard Precautions

A

▪ Apply to all patients
▪ Hand hygiene, surgical mask, proper sharp disposal, cover mouth and nose when sneezing/coughing

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21
Q

Tier 2- Transmission based precautions

A

▪ Patients with known or suspected infection or colonization with pathogens

  • Contact precautions: gown and gloves
    o MRSA, CDiff (enhanced)
  • Droplet precautions: gown, gloves, mask, eye protection
    o COVID, pertussis, pneumonia, meningitis, flu
  • Airborne precautions: gown, gloves, N95 mask
    o TB, varicella, measles, SARS
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22
Q

Critical thinking

A

intellectual process

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23
Q

Clinical reasoning

A

the thinking process by which a nurse reaches a clinical judgement. enables you to synthesize, knowledge, experience, and information from various sources to develop an effective plan of care for a client.

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24
Q

Clinical judgement

Contains thinking and reasoning

A

conclusion or outcome for patient scenario

outcomes of thinking, doing, and caring

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25
Q

NCSBN

A

creator of NCLEX

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26
Q

Layers of CJM

A

o Layer 0: clinical decisions
o Layer 1: comprises the outcome = clinical judgement
o Layer 2: form, refine hypotheses; evaluation
o Layer 3: recognize cues, analyze cues, prioritize hypotheses, generate
solutions, take action, evaluate outcomes
▪ Not linear
o Layer 4: context (individual and environmental factors)

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27
Q

Nursing process

A

ADPIE

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28
Q

ADPIE

Assessment

A

Collecting subjective and objective data
▪ Recognize cues

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29
Q

ADPIE

Diagnosis

A

Analyze cues and prioritize hypotheses
* Cues = unexpected findings (abnormal)

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30
Q

ADPIE

Plan

A

Prioritize hypotheses and generate solutions

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31
Q

ADPIE

Implementation

A

Take action
* Doing, delegating, and documenting

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32
Q

ADPIE

Evaluation

A

Evaluate outcomes
* Goal oriented
o Examples:
▪ Inability to walk → ambulate patient
▪ Risk for falls → make sure room is clear of clutter

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33
Q

subjective data

A

what the pt says/tells us

 Primary: obtained directly from patient and/or nurse
 Secondary: received from caregiver or another person on team

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34
Q

objective data

A

what we observe
factual data- vital signs, lab data

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35
Q

Nursing diagnosis- patient problems the nurse can treat independently

A

assessing and analyzing ques/data

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36
Q

Internal respiration

A

oxygen is exchanged to provide oxygen to the tissues (tissue perfusion)

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37
Q

External respiration

A

oxygen is diffused from the alveoli in the pulmonary circulation to the capillary system (CO2 is released from circulation into the alveoli)

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38
Q

Pulse oximetry

A

measures O2 saturation in hemoglobin

does not test for tissue perfusion

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39
Q

Ventilation: mechanical

A

 Movement of air into and out of the lungs

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40
Q

Respiration: chemical

A

 Exchange of the gases in the lungs

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41
Q

Where does diffusion of gases take place (O2 and CO2 exchange)?

A

Alveoli: tiny air spaces with thin walls surrounded by a fine network of capillaries

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42
Q

Oxygen deficiency in body tissues

A

Hypoxia

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43
Q

Oxygen deficiency in the blood

A

Hypoxemia

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44
Q

Nursing intervention to promote oxygenation

A

o Positioning for maximum lung excursion:
▪ High fowlers → best position for patients who have difficulty
breathing

o Pursed lip breathing: exhalation is twice as long as inhalation
▪ COPD patients

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45
Q

Oxygen delivery system: Non-breather

A

AKA mask w/ reservoir bag

delivers 100% oxygen to pt

do not use on copd pts

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46
Q

Minimum urine output

A

30mL/hr

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47
Q

Is urinary incontinence a normal part of aging?

A

no

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48
Q

UTI’s can cause __________ in elderly patients.

A

AMS

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49
Q

Before giving pt’s antibiotics for UTI, what diagnostic test should be completed?

A

Urine culture to determine which bacteria you are treating

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50
Q

Where do you collect urine specimen from when pt has a cath?

A

From specimen port

Not the collection bag

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51
Q

How do you prevent CAUTI?

A

asepsis technique, keep bag below bladder, no kinks in tubing

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52
Q

How to properly obtain clean catch sample?

A

o Wash hands in warm soapy water
o Open contain without touching inside of cup or cover
o Using towelette clean urinary opening
o Begin urinating in toilet and bring container into the stream to collect a clean, mid-stream sample

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53
Q

Process by which the body converts food to energy

A

Metabolism

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54
Q

Nutrition is esp. important for post op patients, why?

A

promotes optimal healing

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55
Q

What macronutrient promotes healing?

A

protein

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56
Q

Constipation

A

increase fluid and fiber intake

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57
Q

Diabetic pts diet

A

low glycemic

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58
Q

Essential for energy supply

A

carbs

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59
Q

Essential for brain and nerve function

A

fats

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60
Q

First step after placing NG tube on pt, before giving any meds or food

A

radiographic (x-ray) verification is the most reliable
method for confirming tube placement and must be
performed before the first feeding is administered

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61
Q

Diets meant for short term use

A

NPO, clear liquid, full liquid

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62
Q

Surgery and diet progression

A

NPO → clear liquid → full liquid → surgical soft → regular diet
o NPO used prior to surgery to prevent aspiration
o Progression used to prevent vomiting —> can cause
incision to open

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63
Q

NPO

A

Nothing by mouth

Used prior to surgery to prevent aspiration

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64
Q

Clear liquid diet

A
  • Clear juices, popsicles, jello, clear broth, tea
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65
Q

Full liquid diet

A
  • All liquids: milk, supplemental drinks, ice cream
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66
Q

Surgical soft diet

A
  • Mashed potato, pureed meats, veggies, pudding
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67
Q

Act of bearing down to defecate

A

Valsalva maneuver

Do not perform on clients with heart disease, glaucoma, increased ICP, or a new surgical wound
▪ Increases risk for cardiac arrythmias

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68
Q

Vagal response

A

Dizziness, ringing ears

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69
Q

Is increased GI motility (peristalsis) a healthy response to intestinal infection?

A

yes

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70
Q

Vasovagal syncope

A

passing out

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71
Q

Meconium

A

dark green to black tarry sticky odorless stool in infants

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72
Q

Best position for enema

A

left lateral Sim’s position

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73
Q

Florence Nightingale

A

founder of modern nursing

reduced death rates by improving hygiene

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74
Q

Benner’s models of novice to expert

A

novice
advanced beginner
competent
proficient
expert

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75
Q

Carbon monoxide poisoning

A

pt will be bright red in color

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76
Q

Ways to prevent pneumonia

A

early mobilization
upright position
turn, cough, deep breathe
incentive spirometer

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77
Q

Nosocomial infection

A

infection acquired during hospitalization

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78
Q

Important w/ inhalers

A

ask pt to demonstrate inhaler technique, take as prescribed

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79
Q

Diagnostic testing for oxygenation status

A

ABG’s
peak flow monitoring

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80
Q

What type of finding is a cue?

A

abnormal finding

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81
Q

What does a nurse mean w/ a pt outcome

A

goals for the pt

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82
Q

Chain of infection - 6 components

A

Infectious agent- pathogen such as bacteria, virus, fungi, parasite.

Reservoir- source of infection

Portal of Exit- most frequent= bodily fluids

mode of transmission ( direct/indirect)

Portal of entry - body openings

Susceptible host- person at risk of infections

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83
Q

Contact precautions

A

gloves and gown

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84
Q

First void after cath removal needs to be

A

measured

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85
Q

For IV contrast- its important to check for

A

iodine allergy

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86
Q

Responses to enema are governed by

A

height of solution container

speed of flow

concentration of the solution

resistance of the rectum

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87
Q

Hypertonic enema

A

fleet: sodium

maintain pressure on bottle until empty

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88
Q

Kayexalate enema

A

Remove excess potassium

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89
Q

What do you do if the pt you are administering an enema complains of abdominal cramping

A

slow the flow

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90
Q

Ostomy should be

A

pink & moist

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91
Q

ADPIE matches up with CJM Layer

A

Layer 3

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92
Q

Components of CJM Layer 3

A

recognize & analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes

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93
Q

Absent bowel sounds could indicate

A

paralytic ileus

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94
Q

Impaired peristalsis leading to bowel obstruction can cause

A

Perforated bowel

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95
Q

Occult blood test

blue =

A

postive

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96
Q

Causes of false positive occult blood test

A

o Hemorrhoids
o Food
o Supplements and medications
o Iron

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97
Q

Causes of false negative occult blood test

A

Vitamin C

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98
Q

Promotion of bowel movement

A

o Exercise, water, fiber, minimize use of laxatives, go when you feel the urge

 Increase fluid and fiber consumption: first line of treatment/prevention

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99
Q

Overuse of laxative can cause strengthening of the bowels.

True or False

A

False

Overuse can cause weakening of the bowels leading to chronic constipation

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100
Q

Safest form of laxatives

A

bulk forming

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101
Q

Stool softeners

A

 Lubricant action, no effect on peristalsis

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102
Q

Osmotics

A

 Drawing water into bowel from surrounding tissue
* Bowel distention

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103
Q

Stimulants

A

 Bowel irritants
* Stimulate peristalsis

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104
Q

o Increased GI motility (peristalsis) =

A

healthy response to intestinal infection

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105
Q

What do you include in shift report to oncoming nurse?

A

demographics, relevant med hx, current treatments, pt’s response to interventions, pending labs, procedures, current status, plan of care, concerns

Use I-SBAR-R

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106
Q

Assertive communication

A

SBAR, open, direct, honest, and non-judgmental

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107
Q

Passive vs Aggressive communication

A

Passive- I don’t count, you do.
Aggressive- I count, you don’t.

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108
Q

What is the primary purpose of the chart?

A

Communication

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109
Q

The EMR documentation system is problem oriented.
What are the patient issues an interdisciplinary team of professionals work on called?

A

Collaborative problem

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110
Q

Cardinal rule of documentation

A

If it wasn’t documented; it did not happen

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111
Q

Documentation guidelines

A

Be clear and concise
Use correct terminology, spelling, and grammar
Timely
Signature

112
Q

When to document

A

o Admission
o Transfer
o Discharge
o Ongoing care per policy
o Change in condition
o Communication

113
Q

Potential HIPAA violations

A

 Discussing patients in public areas
 Leaving charts out
 Not logging off computers
 Copying forms
 Social media
 *Providing report to incoming nurse or to patient’s provider does not break confidentiality —> because they are in charge of patient’s care

114
Q

VORB

A

o VORB: verbal order read back
 *Must be signed by prescriber ASAP

115
Q

TORB

A

TORB: telephone order read back
 *Must be co-signed within 24 hours
 *Pronounce digits of numbers separately
* 50mg  5, 0mg
 Spell unfamiliar names
 Record with date, time, and TORB(V)

116
Q

Read back is used to reduce

A

errors and any miscommunications –> accuracy

117
Q

What is charting by exception?

A

Chart only significant findings/exceptions to norms
Reduces charting time for nurses = more time w/ the pt
Omissions are the biggest problem

118
Q

Are incident reports only for patients?

A

No. Can be for employees (ex: needle stick)

119
Q

Do you reference incident report in the pt’s chart?

A

No

120
Q

What do you include in incident report?

A

-Only state facts
-Do not place any blame
-Does not go in pt’s chart

121
Q

Adverse event

A

An event in which care resulted in an undesirable clinical outcome

122
Q

Near miss event

A

Caught before hand

123
Q

Sentinel event

A

An event that results in death, permanent harm, or severe temporary harm

124
Q

Examples of sentinel event

A

-Pt abduction
-Pt suicide
-A foreign body, such as sponge or forceps that was left in a patient after surgery
-A hospital operates on the wrong side of the patient’s body
-Hemolytic transfusion reaction involving major blood group incompatibilities

125
Q

What time should be used when documenting?

A

The time the assessment/procedure was completed

126
Q

What do you include in hand-off reporting?

A

 Demographics

 Relevant medical history

 Current treatments and patient’s response

 Pending labs, procedures

 Current status
* Significant assessment findings
* Significant occurrences over last 24 hours

 Plan of care
* Patients progress
* Priority areas to focus

 Concerns

127
Q

Best environment for therapeutic communication

A

quiet, private, comfortable temperature, free of unpleasant smells

128
Q

How to correct an error in the chart

A

Strikethrough, write “mistaken entry”, date, and initial

Do not use whiteout

129
Q

When can PHI be released?

A

For payment, treatment, and normal healthcare operations

130
Q

MAR

A

Medication Administration Record

Comprehensive list of all ordered medications for pt

131
Q

Ways to enhance therapeutic communication

A

Address the pt, listen actively, establish trust, be assertive, interpret body language, use silence when appropriate, explore issues, validate feelings, clarifying statements, sit at eye level

132
Q

Six Rights of Medication Administration

A

Right Drug
Right Dose
Right Route
Right Time
Right Patient *Important to preventing errors
Right Documentation *Avoids medication overdose

133
Q

At what points do you triple check medications?

A

When pulling meds, before leaving med room, and at bedside before pt receives meds

134
Q

Vulnerable populations

A

Homeless, poor, sexual orientation, mentally ill, physical disabilities, young, elderly, some ethnic and racial minority groups, gender

135
Q

I-SBAR-R

A

o Intro
o Situation
o Background
o Assessment
o Recommendation
o Read back

136
Q

Appropriate times to use silence

Conveys empathy

A
  • Patient pauses during the conversation
  • Discussing heavy or emotional diagnoses
  • Patient exhibits emotional distress
137
Q

Barriers to therapeutic communication

A

o Asking why —> *projects blame and judgement
o Offering advice —> *reframe, allow patient to make their own decisions
o Expressing approval or disapproval
o Changing subject inappropriately
o Asking too many questions
o Fire-hosing information

138
Q

Can you give personal advice/opinion to pt’s and their families?

A

no

139
Q

Process for safe medication administration

A

-Know your patient history (HX, labs and assess your patient)
-Follow the orders
-Perform the Rights of Safe Med. Administration
-Triple check the medications against the MAR before the patient takes them
-Reassess your patient afterwards and document

140
Q

What is the goal of inter professional education (IPE)?

A

inter professional practice (IPP)

141
Q

Medication error

A

is an adverse event unless patient is harmed

142
Q

Stereotype vs archetype

A

Archetypes- something recurrent, based on facts; usually not negative
Ex: eye or skin color based on region or geographic data

Stereotypes- Widely held unsubstantiated beliefs that have no basis in facts; negative beliefs
Ex: “Naturally athletic” “Naturally intelligent”

143
Q

Discrimination

A

When a person acts on prejudice (stereotypes) and denies another person one or more of his/her fundamental rights
Ex: Not giving suspected drug user pain meds

144
Q

Universals

A

values, beliefs, and practices that people from all cultures share

145
Q

Specifics

A

values, beliefs, and practices that are special/unique to a culture

146
Q

Race is strictly related to

A

biology

147
Q

How to enhance cultural awareness

A

Self assessment for bias and prejudices

148
Q

What is needed to deliver culturally competent care?

A

Cultural awareness and sensitivity

149
Q

What should you tell a trained interpreter before beginning any translations?

A

Advise them to translate everything that is said and leave nothing out

Be sure to use interpreter when obtaining consent

150
Q

How to complete a cultural assessment

A

-Open-ended questions
-Allow patient time to explain
-Listen with respect and remain non-judgmental

Advise pt you want to provide the best care by identifying their cultural practices

151
Q

If patient is unable to swallow —> find same medication, just different form

A
  • *Cut scored pills only (line down middle)
  • Crush – if able
    o *NOT extended release
  • Mix with thickened liquids or pudding/applesauce
  • Check to see if drug comes in liquid form FIRST
152
Q

Buccal

A

inner cheek

153
Q

Sublingual

A

under tongue

154
Q

Most common adverse effect of meds

A

abd discomfort

155
Q

Parameters for Nitroglycerin

A

-Check vitals before and after each dose
-1 SL tab every 5 minutes for a maximum of 3 doses
-Must wear gloves
-Make sure pt doesn’t take Cialis/Viagra or any other ED medications
-Warn pt before first dose about wicked headache
-Instruct pt to hold med under tongue, and not to chew-
-If patient’s HR is below 60 or Systolic BP (SBP) is less than 90 hold dose and notify HCP

156
Q

How to administer ear drops for adults and kids

A

-Use solutions at room temperature – too cold leads to dizziness
-Pull pinna up and back for adults, down and back for children
-Push on tragus to instill meds

157
Q

Should you give food with NSAIDs?

A

Yes. Upset stomach without it.

158
Q

What should be considered when administering the Albuterol?

A

-Check vitals before and after administering. Medication raises HR.
-Oral care to reduce risk of thrush
-If pt is unable to use hands, use a spacer.

159
Q

Ampule is a __________ dose only. Use __________ needle when drawing up medication to avoid chards of glass.

A

single; filter

160
Q

Smaller the needle gauge

A

Larger the diameter of the needle

161
Q

Insulin injections are

A

Subcutaneous (subq)

162
Q

General rules for subq injections

A

-Max. injection is 1 mL
-Sites include upper arm, abdomen, upper back, lower back, and top of thighs
-Rotate sites
-45-90 degree angle

163
Q

How should you draw up insulin?

A

Inject air into each vial first and then draw up regular (clear) insulin before long acting insulin (cloudy)

Nancy Reagan, RN

164
Q

General rules for intramuscular injections

A

-Z track method
-Max. injection is 1 mL to 5 mL depending on site
-Deltoid, Vastus Lateralis, and Ventrogluteal

165
Q

Max. injection & landmark for Deltoid is

A

1 mL

2 fingerbreadths below the acromion process in the middle third of the muscle

166
Q

Max. injection & landmark for Vastus Lateralis is

A

3 to 5 mL

Between greater trochanter and the lateral femoral condyle - injection site is the middle third of the muscle

167
Q

Max. injection & landmark for Ventrogluteal is

A

3 to 5 mL

Place your palm on the greater trochanter and thumb towards the groin avoiding the anterior superior iliac spine and iliac crest inject in the muscle

168
Q

General rules for intradermal injections

A

-Max. injection is 0.1 mL
-5-15 degree angle
-Sites include forearms, upper chest, and upper back
-Ex: TB skin test

169
Q

Culturally competent model of care

ASKED

A

Awareness- Take an honest look at your own biases
Skills- Ability to conduct a cultural assessment with sensitivity
Knowledge- Information about cultural worldviews
Encounters- Takes practice to become competent
Desire- Must want to be culturally competent

170
Q

What type of needle must be used when drawing up insulin?

A

Insulin needle (orange) only because it is in units

Must be dual verified by another RN

171
Q

Regulates and defines the scope of nursing practice

A
  • State Nurse Practice Acts
172
Q

Motivated by the desire to increase well-being

A

health promotion

173
Q

Motivated by the desire to prevent illness

A

health prevention

174
Q

Primary purpose of incident report

A

root cause analysis

175
Q

How do you define the pain experience?

A
  • It is what the patient says it is
    o Subjective experience
    o Can be protective and have purpose
176
Q

How do you manage pain for nonverbal or cognitively impaired patients?

A

Monitor vital signs, treat pathological condition, look for non-verbal cues

177
Q

Health prevention

Primary

A

Prevent/slow onset of disease
* Education and prevention

178
Q

Health prevention

Secondary

A

Detect and treat illness in early stages
* Screenings
o Purpose = early diagnosis and early detection
o Examples: BP, mammo, cancer, PSA, glucose, lipid levels

179
Q

Health prevention

Tertiary

A

Stop disease progression; return to pre-illness state
* Rehab

180
Q

Transtheoretical Model of Change

A

o Precontemplation
o Contemplation
o Preparation
o Action
o Maintenance
o Termination

181
Q

Precontemplation

A

no intention to change behavior in the foreseeable future

182
Q

Contemplation

A

seriously thinking about overcoming a problem

183
Q

Preparation

A

intending to take action in the next month

184
Q

Action

A

the plan is implemented

185
Q

Maintenance

A

working to prevent relapse
 Support groups, diet, exercise

186
Q

Termination

A

changed the behavior

187
Q

Numerical indicator that determines the amount of stress someone is under

A

Life-Stress Review

188
Q

Purpose of health screenings

A

early detection

189
Q

Nursing interventions for health promotion

A

o Role modeling
o Education
o Providing support

190
Q

Health promotion programs

A

o Disseminating information
o Changing lifestyle and behavior
o Environmental control
o Wellness assessment/health risk appraisal

191
Q

Factors affecting pt learning

A

o Motivation
o Readiness
o Timing
o Feedback
o Repetition
o Learning environment

192
Q

Barriers to effective learning

A

o Stress/anxiety
o Pain
o Fatigue
o Nausea
o Emotional distress
o Low literacy
o Communication gap
o Lack of perceived need

193
Q

Can pt teaching be delegated?

A

No. Should always be done by the RN first.

194
Q

When does d/c planning start?

A

At time of admission

195
Q

What is the goal of d/c planning?

A

ensure continuity of care

196
Q

High risk populations that need special arrangements

A

o Complex conditions – multisystem disease process
o Major surgical procedures
o Chronic or terminal illness
o Elderly
o Emotional or mental instability
o Lack of transportation
o Homeless
o Financial insecurity
o Unsafe home environment

197
Q

Involving pt support system in d/c planning ensures

A

adherence to discharge plan and patient safety

198
Q

Evidence of effective education

A

o Adherence to POC
o Verbal explanation
o Demonstration

199
Q

Kubler-Ross 5 stages of grieving

A

o D: denial
o A: anger
o B: bargaining
o D: depression
o A: acceptance

200
Q

Categories of loss

A

o Actual: can be identified by others
 Death of loved one or relationship, theft, natural disaster

o Perceived: internal, only identified by the person
 STD, perceived loss of purity or health

o Physical: any injuries (amputating leg), organ removal, loss of function (paralysis)

o Psychological: areas of control, trust
 Losing youth or beauty, body disfigurement (burn victim)

o External: losing objects with sentimental value

o Environmental: change in familiar
 18yo moving out, starting a new job

o Loss of significant relationships

201
Q

Uncomplicated grief

A

natural response to loss, expected
 Intense, but gradually diminishes over time

202
Q

Dysfunctional grief

A

maladaptive, suicidal, depressed
 Chronic: unable to rejoin normal life
* Cannot move on

203
Q

Masked grief

A

expressing grief through other types of behavior
* Excessive shopping
 Delayed: busy, not processing emotions

204
Q

Disenfranchised grief

A

not socially supported or acknowledged/validated
 Losing a foster child or mistress

205
Q

Anticipatory grief

A

experienced before loss occurs
 Dementia, heavy diagnoses like cancer

206
Q

Palliative care

A

 Pain control comfort measure
 Manage symptoms to increase QOL

207
Q

Hospice care

A

 Terminally ill patient that are anticipated to die in 6mo

208
Q

Nursing role in end-of-life

A

o Educate patient and families of diagnosis, what to anticipate during dying phase, pain management, consult chaplain, advocate for patient needs

209
Q

Physiological stages of dying

A

o 1 – 3mo: withdrawal from world and people, excessive sleep, no appetite

o 1 – 2wks: decrease BP, yellowing, changes in pulse rate, agitation/delirium, dyspnea

o Days to hours: surge of energy, Cheyene-Stokes (irregular increase in length and depth following by period of apnea), dehydrated, dysphagia, dry skin, congestion, liver failure, cerebral hypoxia, stool impaction, fatigue

o Moments prior: does not respond to touch or sound, cannot be awakened

 Nursing priorities:
* Oxygenation, patient safety, personal hygiene, controlling pain

210
Q

Facilitating grief

A

o Express feelings
o Recall memories
o Find meaning

211
Q

High risk scenarios for difficult or complicated grieving

A

o Unexpected, sudden death
o Argumentative grief, unresolved conflict
o Previous or multiple loses

212
Q

Helping families after the death

A

o Express sympathy
o Acknowledge pain and loss

213
Q

Providing postmortem care

A

o Rigor mortis: 2 – 4hrs
 Close mouth and shut eyes

o Place pillow under head and shoulder to prevent pooling of blood

o Remove tubing, unless going to ME

o Clean and prepare patient for family

214
Q

Classification of pain by origin

A

 Cutaneous/superficial
 Deep somatic
 Visceral
 Radiating/referred
 Phantom: surgically removed
 Psychogenic: no physical cause identified

215
Q

Classification of pain by cause

A

 Nociceptive: aching
 Neuropathic: burning, itching, pins and needles

216
Q

Classification of pain by duration

A

 Acute: up to 6mo, rapid onset
 Chronic: 3 – 6mo, interferes with QOL and ADLs
 Intractable: chronic that is highly resistant to pain interventions

217
Q

Classification of pain by description

A

 Quality: what does it feel like?
 Periodicity: when did it start, is it constant?
 Intensity: how bad does the pain feel?

218
Q

Nonpharmacological measures for pain management

A

 Guided imagery
 Deep breathing
 Acupuncture

219
Q

Pharmacological measures for pain management

A

 Nonopioid:
* NSAIDs: high risk of gastric irritation – avoid prolong use
* Acetaminophen: kills liver

 Opioid:
* Drowsiness, n/v, constipation, sedation

220
Q

Increasing dose of medication to achieve desired effects

A

Tolerance

221
Q

Reasons why a pt may refuse pain meds

A

Hx of addiction
o Investigate why patient does not want it

222
Q

Non-verbal signs of pain

A

o Vital signs change
 Elevated pulse, BP

o Facial expression
 Grimacing, crying, or moaning

o Posture/body position
 Guarding, use of accessory muscles

o Behavioral manifestations
 Irritable, agitated, use of profanity

*provide medication based on pathologic parameters

223
Q

Assessing pain in adults

A

o Numeric rating scale: 0 – 10

224
Q

Assessing pain in peds

A

o Wong-Baker faces

225
Q

Factors affecting skin integrity

A

Age, Immobility, Malnourishment, Dehydration, Lack of sensation, Medications, Impaired circulation, Excessive exposure to moisture (urinary incontinence) , Fever (find source), Infection. Lifestyle (Tanning, bathing, piercings, tattoos)

226
Q

Any break in the skin increases the risk for

A

infection

227
Q

Classification of wounds

Open

A

break in skin or mucous membrane
 Abrasion, lacerations, puncture wounds, surgical wounds

228
Q

Classification of wounds

Closed

A

no break in skin
 Bruise, tissue swelling

229
Q

Classification of wounds

Acute

A

short duration, heal spontaneously

230
Q

Classification of wounds

Chronic

A

exceed expected length of recovery
 Complex, pressure injuries, diabetic ulcers, colonized with bacteria

231
Q

Classification of wounds

Clean

A

uninfected wounds, minimal inflammation
 Surgical incision

232
Q

Classification of wounds

Clean contaminated

A

surgical incision that is inside GI, respiratory, or GU tract
 High risk for infection

233
Q

Classification of wounds

Contaminated

A

open traumatic wounds or surgical incision where there is a major break and sepsis
 Impaled with rusty pipe

234
Q

Classification of wounds

Infected

A

erythema, swelling, fever, foul odor, sever or increase pain, large amounts of drainage, warmth surrounding soft tissue area

235
Q

Classification of wounds

Superficial

A

epidermal layer

236
Q

Classification of wounds

Partial thickness

A

extends to epidermis, but not through dermis

237
Q

Classification of wounds

Full thickness

A

extends to subcutaneous tissue/fat

238
Q

Classifications of wounds

Penetrating

A

Wounds of internal organs

239
Q

Priority nursing goal for open wound

A

wound free from infection throughout healing process

240
Q

At risk populations for wounds

A

o Paralysis
o Sedated patient
o High risk pregnancy
o Cast or devices
o Altered sensory perception
o Diabetics
o PVD
o Post op

241
Q

__________ patients are at an increased risk for wound healing
o Especially post op, PVD, and diabetics

A

Malnourished

242
Q

Primary wound intention

A

o Primary: clean surgical incision
 Edges approximated
 Minimal scarring

243
Q

Secondary wound intention

A

o Secondary: heals from inner layer to surface
 Remain open
 Wound edges not approximated
 Tissue loss

244
Q

Tertiary wound intention

A

o Tertiary: delayed closure of wound edges
 Granulating tissue brought together

245
Q

Phases of wound healing

A

o Inflammatory: 1 – 5days
 Hemostasis: stopping of blood
 Inflammation: edema, erythema, migration of WBC, elevated temperature, scab formation

o Proliferative: 5 – 21days
 Formation of granulation tissue

o Maturation: remodeling phase
 Formation of scar tissue  strengthens wound

246
Q

Types of exudate

Straw colored

A

Serous exudate

247
Q

Types of exudate

bloody drainage
 Bright red or brown

A

Sanguineous

248
Q

Types of exudate

mix of bloody and straw-colored fluid
 New wounds

A

Serosanguinous

249
Q

Types of exudate

yellow, contains pus
 Thick, malodorous

A

Purulent

250
Q

Types of exudate

contains blood and pus
 Infected wound

A

Purosanguineous

251
Q

Separation or splitting of open layers of a surgical wound
 Apply abdominal binder

A

o Dehiscence

252
Q

Extrusion of viscera or intestine through a surgical wound
 Medical emergency
 Major risk for infection  cover with sterile towels immediately and remain in bed with knees flexed

A

o Evisceration

253
Q

Predicts how likely a pressure ulcer will form

A

Braden scale

254
Q

Braden scale is based on

A

 Sensory perception, moisture, activity, mobility, nutrition, and friction or shear
o Total score less than 18 = at risk

255
Q

Stages of Pressure injuries

A

 Stage 1: non-blanchable erythema (redness) of intact skin
 Stage 2: partial-thickness skin loss involving epidermis, dermis, or both
 Stage 3: full-thickness skin loss damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia
 Stage 4: full-thickness skin loss with exposure of muscle, bone, or supporting structures
 Unstageable: base of wound cannot be seen due to being covered by necrotic tissue, slough, or escar
* Sloth: soft, moist, white or yellow
* Escar: black, dry, thick necrotic tissue

256
Q

Unrelieved pressure to an area, resulting in ischemia cause

A

Pressure injuries

257
Q

Nursing interventions for pressure injuries

A

 Prevention
 Frequent repositioning
 Meticulous skin care and moisture control
 Therapeutic mattress
 Adequate nutrition
 Client/family teaching
 Elevating heels

258
Q

Is stress always negative?

A

No, can be protective or motivating

259
Q

Internal stressors

A

diarrhea, anxiety, negative self-talk

260
Q

External stressors

A

death of family member, natural disaster, financial issues

261
Q

Developmental stressors

A

occur at specific phase in life
 Peer pressure: teens
 Exploring environment and learning rules: toddler
 Navigating parents: young adults

262
Q

Situational stressors

A

car accident, natural disaster, illness, unemployment

263
Q

Psychosocial stressors

A

work, family dynamics, living situation, relationships, daily life

264
Q

Physiological stressors

A

underlying illness, diarrhea

265
Q

General adaptation syndrome

A

o Alarm: fight or flight
 Increase HR, BP, RR, dilated pupils, headaches, nail biting, chest pain, dry mouth, decreased wound healing, increased pain, stiff neck, appetite changes, difficulty sleeping

o Resistance: adaptation (coping mechanisms)

o Exhaustion: illness or death

266
Q

Signs of inflammation

A

o Redness
o Heat
o Swelling
o Pain
o Loss of function

267
Q

Long term stress effects

A

o Sleep difficulties, increased pain, decreased wound healing, HTN, dry mouth, increased RR

268
Q

Metric abbreviations:

A

o cc: cubic centimeters
o mEq: milliequivalent
o mL: milliliter
o mg: milligram
o g: gram
o kg: kilogram
o L: liter
o mcg: microgram
o unit: unit (*do not use ‘U’)

269
Q

Time abbreviations

A

o AC: before meal
o PC: after meal
o QH: every hour
o QHS: at bedtime
o PRN: as needed
o STAT: immediately
o QD: daily
o BID: 2x daily
o TID: 3x daily
o QID: 4x daily

270
Q

Route abbreviations

A

o IV: intravenous
o IVP: intravenous push
o IVPB: intravenous piggyback
o NEB: nebulizer
o MDI: metered-dose inhaler
o S&S: swish and spit/swallow
o SQ: subcutaneous
o IM: intramuscular
o SL: sublingual
o PO: by mouth
o PR: by rectum
o NGT or NG: nasogastric tube

271
Q

Liquid conversions

A

 30 mL = 1 oz
 3 tsp = 1 tbsp
 1 tsp = 5 mL
 1 tbsp = 15 mL
 1 pt = 500 mL
 1 qt = 1 L = 1000 mL

272
Q

Metric conversions

A

 1 gr = 60 mg
 1 kg = 1000 g
 1000 mcg = 1 mg
 1000 mg = 1 g

273
Q

Temp. conversions

A

 C = (F – 32) / 1.8
 F = (C x 1.8) + 32

274
Q

Weight conversions

A

 1 kg = 2.2 lbs
 1 lb = 16 oz

275
Q

Intervention for pt at risk for falls and is not responding to instructions?

A

bed alarms, family at bedside

276
Q

Refusing to give a known drug abuser pain meds is

A

discrimination

PCC Lecture (3 decks)

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