Final Exam Study Guide Flashcards
When should you assess vital signs? (7)
on admission to any health care facility
based on the facility/institutional policy
any time there is a change in patient’s condition
any time there is a loss of consciousness
pre-op/post-op surgical or invasive diagnostic procedure (test)
before and after activity that may increase risk, such as ambulation after surgery
before administering medications that affect cardiovascular and respiratory function
Maslow’s Hierarchy of Needs
physiological needs
safety and security
love and belonging
self-esteem
self-actualization
Something essential to the health and survival of humans; common to all people
Basic Human Needs
Phases of the Helping Relationship (Nurse-Patient Relationship)
orientation: introductions, establishing trust, setting the tone, provide info, establish routine
working: LONGEST PHASE, assisting patient in physical/mental needs, motivate to learn/implement health promotion, caring and providing reassurance throughout day
termination: conclusion, leaving for day, patient going home, review goals, satisfying feeling, introduce new nurses
Assertive vs. Nonassertive vs. Aggressive Communication
assertive: stand up for self or others, using open/honest/direct communication
nonassertive: not stand up for self or others
aggressive: asserting one’s rights in a negative manner that violates the rights of others
Objective understanding of the way in which a patient sees his or her situation, identifying with the way another person feels, putting oneself in another person’s circumstances and imagining what it would be like to share that person’s feelings
Empathy
Feeling of mutual trust experienced by people in a satisfactory relationship
rapport
A stereotyped, trite or pat answer
cliche
Negative, often repetitive, disruptive behavior
Bullying
SBAR - when it’s used, meaning, and rationale
between nurses in other departments in the facility, during nurse to nurse report, or in nurse to physician/HCP discussions
Situation, Background, Assessment, Recommendation
purpose is to eliminate breakdown in communication and potential adverse events
Factors Affecting Health and Illness (7)
basic human needs
human dimensions:
-physical
-emotional
-intellectual
-environmental
-sociocultural
-spiritual
Frequency that a disease occurs
morbidity
Number of deaths
mortality
Modifiable Risk Factors (4)
diet
alcohol
smoking
exercise
Non-Modifiable Risk Factors (5)
age
family history
gender
ethnicity
race
Factors Affecting Safety (9)
developmental considerations
lifestyle
environment
mobility
sensory perception
knowledge
ability to communicate
physical health state
psychosocial health state
An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof
never event
sentinel event
Device used to limit movement or immobilize a patient
restraint
Alternatives to Restraints (5)
3 bed rails
low beds
bed alarm
sitters
distractions/redirection
Infection Cycle - 6 Stages
- Infectious Agents
- Reservoir
- Portal of Exit
- Means of Transmission
- Portal of Entry
- Susceptible Host
Stage 1 of Infection Cycle
infectious agents
pathogens cause infection/disease
-bacteria
-fungi
-virus
-parasites
Stage 2 of Infection Cycle
reservoir
natural habitat of microorganisms
-people/animals
-food/water/milk
-soil
-inanimate objects
Stage 3 of Infection Cycle
portal of exit
point of escape for organisms from the reservoir
-respiratory tract
-gastrointestinal tract
-genitourinary tract
-blood
-tissue
Stage 4 of Infection Cycle
means of transportation
route of an organism takes between transfer from reservoir to susceptible host
-direct: close contact/proximity
-indirect: contact w/ living creature that transmits infectious agent to human or inanimate object
Stage 5 of Infection Cycle
portal of entry
point where organism enters new host
-urinary tract
-respiratory tract
-gastrointestinal tract
-SKIN
Stage 6 of Infection Cycle
susceptible host
source that provides microorganisms with nourishment and shelter
organisms are able to overcome hosts defense systems
Stages of Infection
Incubation Period
Prodromal Stage
Full Stage of Illness
Convalescent Period
Incubation Period
interval between pathogen’s first invasion and the appearance of symptoms
growing and multiplying
Prodromal Stage
most infectious stage
early s&s of disease present, may be mild
continues to be unaware of being contagious
Full Stage of Illness
infection-specific s&s present
acute illness stage
Convalescent Period
recovery from infection
symptoms disappear and person returns to previous health state
Something originating or taking place in the hospital
nosocomial
Process used to destroy microorganisms; destroys all pathogenic organisms except spores
disinfection
Antibacterial agent that kills bacteria or suppresses growth
antimicrobial
Disease state resulting from pathogens in or on the body
infection
Absence of disease-producing microorganisms; using methods to prevent infection
asepsis
The process by which all microorganisms, including spores, are destroyed
Sterilization
Airborne
spread through airborne route when infected host
-coughs
-sneezes
-talks
-becomes attached to dust particles
TB or COVID
Droplet
similar to airborne except pathogens greater than 5 mcm
-common colds
-influenza
-strep
-pneumonia
Contact
direct vs indirect
-HIV/AIDS
-E. coli
-Hepatitis B
Medical Asepsis vs. Surgical Asepsis
Medical: clean technique
Surgical: sterile technique
Precautions that are used regardless of diagnosis or infection status are called
standard precautions
Precautions that are used for patients with suspected infection with pathogens that can be transmitted via airborne, droplet, or contact routes are called
transmission-based precautions
Protection and support of another’s rights
advocacy
Respect for an individual’s right to make their own decision
autonomy
Obligation to do and cause no harm to others
nonmaleficence
Duty to do good to others
beneficence
Distribution of benefits and services fairly
justice
Obligation to tell the truth
Veracity
Following through with a promise
fidelity
Children learn what is of high and low value by observing parents, peers, and significant others
Modeling
Leave children to explore values on their own and to develop a personal value system
Laissez-faire
Children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values
rewards and punishments
Encourage children to explore competing values and to weigh their consequences
responsible choice
developed capacity to respond well to morally distressing experiences and to emerge strong
moral resilience
System dealing with standards of character and behavior related to what is right and wrong
ethics
Set of beliefs that are meaningful in life and that influence relationships with others
Values
Like ethics, concerned with what constitutes right action; more informal and personal than the term ethics
morals
Occurs when you know the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action
moral distress
A report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor
incident report
Intentional Tort Examples (5)
assault and battery
defamation of character
invasion of privacy
false imprisonment
fraud
Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to people or property
fraud
Unintentional Tort Examples (4)
negligence
malpractice
elements of liability
standards of care
Act of negligence as applied to a professional person such as a physician, nurse, or dentist
malpractice
What is the nurse’s most important and best legal safeguard?
competent practice
Legal responsibility for one’s actions (and failure to act); includes responsibility for financial restitution of harms = from negligent acts
liability
When a patient believes he or she has been injured because of the negligence of a nurse or other health care professional and pursues legal action
malpractice litigation
Promoting Wound Healing (5)
wash hands before performing wound care
optimal positioning for increased circulation to wound
remove debris from the wound
adequate diet
moisture
Wound Complications (5)
infection
hemorrhage
dehiscence
evisceration
fistula formation
Collection of infected fluid that has not drained
abscess
Cleaning away devitalized tissue and foreign matter from a wound
debridement
splitting (partial/total) of the wound
Dehiscence
complete separation of wound (usually in abdomen)
Evisceration
Thick, leathery scar or dry crust that is necrotic and must be removed for adequate healing to occur
Eschar
abnormal passage from one vessel/organ to another (typically becomes infected with abscess growing in it)
fistula
Deficiency of blood in a particular area
ischemia
when skin is wet too long (excessive moisture)
Maceration
Serous
clear or straw in color
watery consistency
in blister, superficial cut
Sanguineous
contains RBCs
looks like blood
in deep wounds, surgical wounds
Serosanguineous
mixture of serum and RBCs
pink tinged color
thin and watery
sign of healing
Purulent
made up of WBCs, dead tissue debris, dead, and living bacteria
brown, tan, green, yellow
thick, milky consistency
considered abnormal finding (sign of infection)
Decrease in the size of a body structure
atrophy
Decreased muscle tone
flaccidity
Increased muscle tone
spasticity
Absence of strength secondary to nervous impairment
Paralysis
Impaired muscle strength or weakness
Paresis
gas exchange between alveoli and blood in capillaries
respiration
process by which oxygenated blood passes through body tissues
perfusion
exchange of O2 and CO2 between circulating blood and tissues
internal respiration
Positioning to Help with Breathing
Fowler’s: promotes chest expansion
Tripod: increase lung expansion
Prone: opens up lungs (acute pt)
How much fluid is recommended to help with secretions in the lungs?
2-3 quarts
Promoting Proper Breathing (4)
deep breathing
incentive spirometer
pursed-lip breathing
diaphragmatic breathing
Fine, crackling sounds made as air moves through wet secretions in the lungs
Crackles
Continuous high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airways
Wheezes
Low-pitched, continuous sounds with a snoring quality that occur when air passes through secretions
Rhonchi
Adjustment of living with other living things and environmental conditions
Adaptation
Condition in which the human system responds to change in its normal balanced state
Stress
Anything causing a person to experience stress; change in the balanced state
Stressor
Occurs when coping and defense mechanisms are no longer effective, resulting in high levels of anxiety, disorganized behavior, and the inability to function normally
Crisis
cumulative state of frustration with work environment that develops over a long time; behaviors exhibited as the result of prolonged occupational stress
burnout
Vague sense of impending doom or apprehension precipitated by new and unknown experiences
anxiety
Patterns of behavior used to neutralize, deny, or counteract anxiety
coping mechanism
Forms of self-deception; unconscious process the self uses to protect itself from anxiety or threats to self-esteem
Defense mechanism
Physiologic Indicators of Prolonged Stress (13)
backache or stiff neck
chest pain
constipation or diarrhea
decreased sex drive
dilated pupils
dry mouth
headache
increase urination
increase perspiration
increase pulse, bp, and rr
nausea
sleep disturbances
weight gain or loss
Interventions for Managing Stress (7)
exercise
prayer
art therapy
massage
therapeutic touch
relaxation
meditation
General Adaptation Syndrome Phases
alarm
resistance
exhaustion
Alarm Phase of GAS
fight or flight response (sympathetic nervous system)
aka SHOCK phase
Physiologic Changes:
-increase energy levels
-increase oxygen intake
-increase cardiac output
-increase blood pressure
-mental alertness
Resistance Phase of GAS
body attempts to adapt to the stressor
vital signs, hormone levels, and energy production return to normal
Exhaustion Phase of GAS
adaptive mechanisms can no longer provide defense
rest and recover or death
Written, legal record of all pertinent interventions with the patient - ADPIE
documentation
Standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family
Bedside Report
What is the most important purpose of patient records?
communication
Nursing Process
Assessment
Diagnose
Planning
Intervention
Evaluation
An autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes
Nurse-initiated interventions
Dependent nursing actions, involving carrying out physician-prescribed orders
physician-initiated interventions
Nursing care provided that is supported by sound scientific rationale
evidence-based practice
A written plan that details the nursing activities to be executed in specific situations
protocol
Document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities
standing order
Group of people with different interests or goals than the primary culture
subculture
Process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different
cultural assimilation
Those feelings, usually negative, a person experiences when placed in a different culture
culture shock
sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns
ethnicity
Division of human beings based on distinct physical characteristics
race
Coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit
cultural diversity
Shared belief system of beliefs, values, and behavioral expectations that provides social structure for daily living
culture
when one assumes that all members of a culture, ethnic group, or race act alike
stereotyping
belief that everyone else should conform to your belief system
cultural imposition
when one ignores differences and proceeds as though they do not exist
cultural blindness
Care delivered with an awareness of the aspects of the patient’s culture
cultural competence
belief that one’s own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one’s cultural norms as the standard to evaluate other’s beliefs
ethnocentrism
Anything that pertains to a person’s relationship with nonmaterial life force or higher power
spirituality
standing in the presence of another consciously believing in (and affirming) his or her capacity for wholeness, empathy/compassion, giving hope, love, religion/transcendence, and touch and healing
presencing
a person who denies the existence of a higher power
atheist
one who holds that nothing can be known about the existence of a higher power
agnostic
an organized system of beliefs about a higher power that often includes set forms of worship, spiritual practices, and codes of conduct
religion
impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself
spiritual distress
5 Stages of Grief/Loss
denial
anger
bargaining
depression
acceptance
when a valued person, object, or situation is changed or becomes inaccessible such that its value is diminished or removed
loss
loss that can be recognized by others as well as by the person sustaining the loss
actual loss
loss that is experienced by the person but is intangible to others
perceived loss
when a person displays loss that has yet to take place
anticipatory loss
an internal emotional reaction to loss
grief
the actions and expressions of grief, including the symbols and ceremonies that make up the outward expressions of grief
mourning
a state of grieving due to a loss of a loved one
bereavement
Written directive that allows people to state in advance what their choices for health care would be if certain circumstances should develop
advanced directive
Mercy killing; the deliberate termination of life of a person
euthanasia
abnormal or distorted, may be unresolved or inhibited grief
dysfunctional grief
Signs of Impending Death (10)
difficulty talking or swallowing
nausea, flatus, abdominal distension
urinary or bowel incontinence or constipation
loss of movement, sensation, and reflexes
decreasing body temp w/ cold and clammy skin
weak, slow, or irregular pulse
decreasing blood pressure
noisy, irregular, or Cheyne-Stokes respirations
restlessness or agitation
cooling, mottling, and cyanosis of extremities and dependent areas
a death that allows a person to die on his or her own terms, relatively free of pain, and with dignity free from distress, pt has a sense of completion of life
good death
an illness in which death is expected within a limited period of time
terminal illness
stands for Physician Order for Life-Sustaining Treatment; a medical order indicating a patient’s wishes regarding treatments commonly used in a medical crisis
POLST form
occurs with severe sensory alterations, especially in critical care/ or intensive care units
ICU psychosis
refers to awareness of positioning of body parts and body movement
kinesthesia
occurs when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless
sensory deprivation
when the body quickly adapts to constant stimuli
adaptation
occurs when a person experiences so much sensory stimuli that the brain is unable to respond or ignore stimuli
sensory overload
impaired or absent functioning in one or more sense
sensory deficit
difficulty in the way the brain takes in, organizes, and uses sensory information
sensory processing disorder
conscious process of selecting, organizing, and interpreting data from the senses into meaningful information
sensory perception
experience of pain where an amputated limb once was
phantom limb pain
process of receiving data about the external or internal environment through the senses
sensory reception
when high-tech devices deliver a bewildering array of assaults on our senses every day
sensory poverty
Extreme drowsiness, but will respond normally to stimuli
somnolence
Can be aroused by extreme and/or repeated stimuli
stupor
Cannot be aroused and does not respond to stimuli
coma
A state in which the individual or group experiences or is at risk for a change in the amount, pattern or interpretation of incoming stimuli
disturbed sensory perception
Condition in which the cortical area of the brain receives and responds appropriately to stimuli
arousal
Description of the sense, usually at a subconscious level, of the movements and position of the body, especially its limbs, independent of vision
proprioception
