Final Exam Flashcards
1
Q
Stage 1 of Sleep Cycle
A
- NREM (non-rapid eye movement)
- lightest sleep; few minutes
- Dcrd physiological activity begins w/ gradual fall in vital signs & metabolism
- Noise can easily arouse; can feel as a daydream has occurred
2
Q
Stage 2 of Sleep Cycle
A
- NREM (non-rapid eye movement)
- Relaxation progresses
- Arousal still relatively easy
- Brain & muscle activity continue to slow
2
Q
Stage 5 of Sleep Cycle
A
- REM (rapid eye movement)
- 25% of sleep
- Vivid, full-color dreaming
- Begins abt 90 mins after sleep starts
- Autonomic response of rapidly moving eyes, fluctuating heart & resp rates, incrd/fluctuating BP
- Loss of skeletal muscle tone
- Gastric secretions incr
- Difficult to arouse
- Duration of REM sleep incrs w/ each cycle & avg 20 mins
- Facilitates brain cells restoration & improves memory
3
Q
Stages 3 & 4 of Sleep Cycle
A
- NREM (non-rapid eye movement)
- Called slow-wave sleep; deepest stage of sleep
- Difficult arousal & rarely moves
- Brain & muscle activity significantly dcrd
- Vital signs are lower
3
Q
Hypnotics Effects on Sleep
A
Interfers w/ reaching deep sleep and can cause excess drowsiness, confusion, dcrd energy
4
Q
Factors Influencing Sleep
A
- Drugs/substances
- Lifestyle; night/rotating shifts, college students
- Unusual sleep patterns due to physical issues; menopause, illness, pain
- Emotional stress; depression or anxiety
- Environment; unfamiliar, homelessness, room temp, noise, hosp room
- Exercise
>activity incrs REM & NREM; but done w/in 2 hrs before sleep can cause wakefulness - Fatigue
- Food & caloric intake; eating late, weight loss, weight gain, caffeine, sugar, alcohol
5
Q
Antidepressants & Stimulants Effects on Sleep
A
Suppresses REM sleep & dcrs total sleep time
6
Q
Alcohol Effects on Sleep
A
Speeds onset of sleep but reduces REM sleep & causes awakening at night
7
Q
Caffeine Effects on Sleep
A
Interferes w/ falling asleep & REM sleep
8
Q
Diuretics Effects on Sleep
A
Nighttime awakenings caused by nocturia
9
Q
Benzodiazepines Effects on Sleep
A
Alters REM sleep, incrs sleep time, & daytime sleepiness
10
Q
Nicotine Effects on Sleep
A
Dcrs total & REM sleep time & causes awakening from sleep
11
Q
Opioids Effects on Sleep
A
Suppress REM sleep & cause incrd daytime drowsiness
12
Q
Respiratory Illness Effects on Sleep
A
Makes it difficult to breathe; chronic lung disease, emphysema, asthma, colds, sleep apnea
13
Q
Cardiac Illnesses Effects on Sleep
A
Nocturnal angina
14
Q
Hypertension Effects on Sleep
A
Causes early-morning awakening & fatigue
15
Q
Hypothyroidism Effects on Sleep
A
Dcrs stage 4 sleep
16
Q
Pain Effects on Sleep
A
Can affect sleep onset, depth, & duration
17
Q
GERD & Peptic Ulcer Effects on Sleep
A
Awaken at night due to pain
18
Q
Planning to Promote Sleep
A
- Set priority goals & outcomes
- Include pt
- Realistic
- Ex: pt will report waking up less frequently during the night & feeling rested by 4/9/14 at 0800
19
Q
Implementing to Promote Sleep
A
- Avoid unnecessary lights & noises
- Avoid excessively warm or cool temps
- Uninterrupted periods of rest & sleep
- Maintain regular bedtime & wake schedule
- Eliminate or minimize naps; limit to 20 mins or >2x/day
- Go to bed when sleepy
- Comfortable positioning
- Relaxation techniques
- If unable to sleep in 15-30 mins, engage in low-stimulating then try again
- Limit alcohol, caffeine, & nicotine in late afternoon & evening
- Consume carbs or milk before bedtime
- Dcr fluid intake 2-4 hrs before sleep
- Elevate HOB or use extra pillows
- Use analgesics to ease aches & pains
20
Q
Presbyopia
A
- Visual deficit
- Gradual decline to see near objects clearly
21
Q
Cataract
A
- Visual deficit
- Cloudy or opaque areas in lens; causes problems w/ glare & blurred vision
22
Q
Dry Eyes
A
- Visual deficit
- Too few tears resulting in itching & burning; can have reduced vision
23
Glaucoma
- Visual deficit
- Slowly progressive incr in intraocular pressure against optic nerve; may experience peripheral visual loss, dcrd visual acuity, halo effect around lights, problems seeing in dark
24
Diabetic Retinopathy
- Visual deficit
- Retinal blood vessel changes, dcrd vision
25
Macular Degeneration
- Visual deficit
- Macula (portion of retina responsible for central vision) function loss, blurring of reading materials, distortion/loss of central vision, distortion of vertical lines
26
Presbycusis
- Hearing deficit
- Common progressive hearing loss in older adults
27
Cerumen Accumulation
- Hearing deficit
- Build up of earwax causing conduction deafness
28
Dizziness/Disequilibrium
- Balance deficit
- Common in older adults from vestibular dysfunction
- Change in head position provokes episode of vertigo or disequilibrium
29
Xerostomia
- Taste deficit
- Dcr in salivary production leads to thicker mucus & dry mouth
- Often interferes w/ the ability to eat & leads to appetite & nutritional problems
30
Peripheral Neuropathy
- Neurological deficit
- Numbness/tingling of affected area
- Can cause stumbling gait
31
Stroke
- Neurological deficit
- CVA caused by clot, hemorrhage, or emboli
- Disrupts blood flow to brain
32
Sensory Deprivation
- When a person experiences an inadequate quality or quantity of stimulation
>reduced sensory input
>elimination of patterns or meaning from input (strange environments)
>restrictive environments tht produce monotony & boredom (bedrest/isolation)
33
Nursing Process - Implementation to Prevent & Control Alterations in Sensory Function
- Modify environment to maximize altered sensory perceptions
- Education, support, & caring
- Adjustment to sensory impairment & maximizing sensory function as much as possible
- Focus on safety
34
Complementary Therapies
- Therapies used in addition to or together w/ conventional treatment recommended by a person's health care provider
- Complement conventional treatments
- herbs/supplements, guided imagery, breathwork, relaxation & massage, art, music, dance, meditation, chiropractic therapy
35
Alternative Therapies
- Include the same intervention as complementary therapies but they become the primary treatment
- EX: doing yoga over taking medications
36
Safe Herbal Therapies
- Dietary supplements, vitamins, minerals, essential oils, probiotics
- Herbal medicines are not drugs or regulated by the FDA
- EX: aloe, chamomile, echinacea, feverfew, garlic, ginger, ginkgo biloba, ginseng, licorice, saw palmetto, valerian
37
Unsafe Herbal Therapies
- Bc they are not regulated, concetrations of active ingredients vary
- EX: calamus, chaparral, coltsfoot, comfrey, ephedra, life root, pokewood
38
Guidelines for Quality Documentation & Reporting
- Factual: avoid opinions, "appears or seems", use pt's exact words in ""
- Accurate: "360 ml", correct spelling, no unapproved abbreviations
- Complete: pertinent data but don't write a novel
- Current: timely, chart as soon as intervention is complete
- Organized: logical order, concise, clear, to the point, ex: head-to-toe assessment
39
Hand-Off Report
- Happens any time one health care provider transfers care of a pt to another (bedside reporting)
- Provides continuity of care
- Includes up to date info, required care, treatments, medications, services, any recent or anticipated changes
- Can be given face-to-face, over the phone, or in writing
- Efficient & timely; ensures pt's safety
40
Hand-Off Report Content
- Essential background info
- Identify pt's diagnoses or problems
- Describe observations & responses
- Continuously review discharge plans
- Relay significant changes
- Describes instructions given in teaching plan & pt's response
- Evaluate results of nursing or medical care measures
- Be clear abt priorities for next shift or point of care
- Share any significant social hx
41
ISBARR
- Identify: yourself & pt
- Situation: purpose for your communication
- Background: brief pt's hx & condition
- Assessment: findings
- Recommendation: express pt's needs or your needs for your pt's care
- Read Back: repeat back if an order was received
42
Telephone Reports & Orders
- Received from: HCP, lab, radiology, PT, OT, unit to unit, ancillary departments
- Be clear, accurate, & concise
- What to document: time of call, who made the call, who was called, to whom info was given, what info was received, verification of info w/ provider
43
Nurse's Role in Informed Consent
To verify consent of medical treatment by signed informed consent
44
Nurse's Role in Risk Management
- A system of ensuring appropriate nursing care by identifying potential hazards & eliminating them before harm occurs
- To prevent or mitigate pt injury or potential injury
45
Standard of Care
The degree of care a prudent & reasonable person would exercise under the circumstances
46
Delegation
- "Transferring responsibility for performance of an activity or task while retaining accountability for the outcome" American Nurses Association (1995)
- Results in achievement of quality pt care, improved efficiency, incrd productivity, empowered staff, & development of others
47
5 Rights of Delegation
- The right task
- Under the right circumstance
- To the right person
- With the right directions & communication
- Under the right supervision & evaluation
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What Tasks can be Delegated to UAP
- Assisting the client w/ ADLs
- Measuring & recording fluid I&O
- Measuring & recording vital signs, height, & weight
- Nonpharmacological comfort & pain relief interventions
- Observation & reporting changes in status of client
- Transport of clients & specimens & other errands & tasks such as stocking supplies
- Assistance w/ transfers, ROM, feeding, ambulation, making beds, & assisting w/ bowel & bladder functions
49
Nurse's Role When Caring for Clients Experiencing Loss, Grief, or Death
- Establish a trusting relationship, be honest
- Explore w/ pt & support system their goals & expectations
- Explore w/ pt & support system their perceptions abt what is happening
- Sit down & slow down
- Respect cultural, spiritual, & personal practices
- Ensure a good assessment of physical symptoms
50
Maturational
- Normally expected loss from life changes
- EX: a child moving from home
51
Situational
- Loss from sudden or unpredictable external event
- EX: loss of a limb from injury
52
Actual vs. Perceived
- Actual: a person can no longer feel, hear, or see a person or object
- Perceived: uniquely defined by the person and is less obvious
53
Normal Grief
Complex emotional, cognitive, social, physical, behavioral, & spiritual response to loss
54
Anticipatory Grief
Unconscious process of letting go before the actual loss occurs
55
Disenfranchised Grief
- Marginal or unsupported grief
- Can occur when the relationship btwn individual is not socially sanctioned
56
Complicated Grief
- Prolonged grief or when there is difficulty moving past the loss
- More likely to occur when relationships are trained, sudden loss, loss related to violence, or loss of a child
- 3 Types: exaggerated, delayed, masked
57
Care After Death
- Provide privacy & a peaceful environment: ask if family wants to participate in prep, offer to contact support
- Validate organ/tissue donation
- Autopsy if needed
- Elevate HOB asap to prevent discoloration in face
- Remove all equipment, tubes, lines; unless autopsy or organ donation
- Cleanse body thoroughly
- Cover body w/ clean sheet, leave arms out if possible, close eyes, leave dentures in mouth
- Deodorize room
- Offer family to view body
- Encourage to say goodbyes
- Determine which belongings will stay w/ body
- Document
- Apply identifying tags
58
Caring Through Presence
- Person to person encounter conveying a closeness & sense of caring
- Need to make a effort to establish
- Don't just talk, be there physically
- Sit down, take time to be w/ pt
59
Caring Through Touch
- Can be used to convey concern & comfort
- Can be physical contact or eye contact
- Be aware of cultural or personal boundaries
60
Listening to Pts
- Critical component of caring
- Should be deliberate
- Listen w/ openness: non-judgemental, allow pts to share stories
61
Facilitating Spiritual Health
- Establish a trusting relationship
- Assess pt's spiritual needs & values
- Establish a presence
- Listen
- Assess support system
- Support rituals & activities
62
Asepsis
Prevention of the transfer of microorganisms & pathogens; hand hygiene, barrier techniques, routine environmental cleaning
63
Contact Precautions
- When in direct or indirect contact w/ pt who has highly transmissible pathogen
- EX: MRSA, VRE, Cdiff, diarrhea, RSV
- Private room, gloves, & gown
- Remove gloves & gown BEFORE exiting room
64
Airborne Precautions
- <5 particles evaporated droplets
- EX: measles, chickenpox, varicella zoster, pulmonary or TB, COVID
- Negative air flow room, respirator mask
65
Droplet Precautions
- >5 particles expelled in air
- EX: diptheria, rubella, strep, flu, pneumonia, mumps, meningitis
- Private room, surgical mask w/ in 3 ft of pt
65
Stage 2 Ulcer
- Partial thickness skin loss
- Loss of dermis
- Shallow open ulcer
- Red/pink wound bed; no slough present
65
Protective Environment
- Pts who undergo transplants & gene therapy
- Private room, positive airflow
65
Stage 1 Ulcer
Non-blanchable redness of intact skin
66
Stage 3 Ulcer
- Full thickness skin/tissue loss
- Fat visible; includes subcutaneous tissue
- Some slough may be present
67
Stage 4 Ulcer
- Full thickness tissue loss
- Muscle, bone, and/or tendon visible
- Slough and/or eschar present
- Often includes tunneling or undermining
- Osteomyelitis can occur
68
Risk Factors of Skin Integrity
- Dcr mobility
- Dcr sensory perception
- Moisture
- Shear & friction
- Poor nutrition
69
Interventions for Impaired Skin
- Turn q2h
- Waffle boots
- Keep HOB < 30 degrees
- Specialty mattresses
- Mepilex
- Barrier creams
- Lift devices
- Transfer sheets
- Incr protein
70
Inserting an NG Tube
- Fowler's position
- Measure from tip of nose to earlobe to xiphoid process
- Mark w/ tape
- Lubricate end of tube
- Insert into nare
- Have pt lean forward and continuously swallow water
- Secure tube on nose
- Verify placement: pH 0-4, chest x-ray
71
PEG Tube
- Percutaneous endoscopic gastrostomy tube
- Takes abt 30 mins
- Put into stomach through a small opening in skin using endoscope
72
Gastrostomy Tube
Placement of a feeding tube through the skin and stomach wall, directly into stomach via surgical procedure
73
Jejunostomy Tube
- Feeding tube placed in jejunum
- Alternative to gastrostomy when stomach is unsuitable or higher risk for aspiration
- Surgical procedure
74
Signs of Alterations of Fluid Balance
- When disease processes, medications, or other factors disrupt fluid intake or output
- Dehydration
- Dry mucus membranes
- Excessive urination w/out adequate intake
- Excessive diarrhea
75
Nursing Process
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
76
Interventions for Fall Precautions
- Identify fall risk pt w/ arm band, footwear, signage, & communicate w/ all staff
- Keep bed as low as possible & locked
- Orient as needed
- Keep room free of obstacles
- Keep all belongings w/in reach
- Side rails up as appropriate
- Educate pt & family
- Observe frequently
- Regular toileting schedule
- Use gait belt
- Bed and/or chair alarms
- Use of assistive devices
- PT & OT consults
- Moving pt location
- Fall mats
77
General Care for Restraints
- Assess area of application & pad areas if needed before application
- For limb restraints, ensure tht 2 fingers can be placed btwn pt & restraint
- Attach straps to bed frame, not to any movable part of bed
- Secure the straps w/ a quick release buckle
- Assess & document the continued need for restraints & pt response q2h
- Assess for signs of injury every 15 mins
- Evaluate for complications
- Assess need for toileting, repositioning, & release restraint q2h
78
Effects of Immobility
- Metabolic changes
- Respiratory changes
- Cardiovascular changes
- Musculoskeletal changes
- Alterations in urinary elimination
- Integumentary changes
- Psychosocial changes
79
Assessment of Respiratory Dysfuntion
- SaO2 > 95%
- SpO2 measures oxygen saturation
80
Interventions to Help with Respiratory Issues
- Halting the pathological process
- Shortening duration & severity of illness
- Symptom management
- Preventing complications from pathological process or treatments
- Dyspnea management
- Airway management
- Secretion management
- Oxygenation, medications, breathing techniques, positioning, cough & deep breathing suctioning, hydration, humidification,
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