Foundations Exam 1 Flashcards
What is the nursing process?
Assess (history physical, subj, obj) GATHERING DATA, Diagnose, Plan, Implement, Evaluate
*(ADPIE)
What is SBAR?
Communication tool between healthcare professionals: 1. Situation 2. Background 3. Assessment 4. Recommendation
What is critical thinking?
Logical manner to take care of your patient, to reason what is going on with the patient and analyze.
What is IPPA?
- Inspect 2. Percuss 3. Palpate 4. Auscultate
What are the physiological needs in Maslow’s Hierarchy?
- Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure 6. Transportation
What is the nurse’s responsibility?
AAIPM: 1. Administer 2. Assess 3. Implement 4. Provide patient teaching 5. Monitor
What is the most important thing when caring for patient hygiene?
Must be aware of patient’s beliefs, religion, and gender preferences.
What are the guidelines for bathing a patient?
- Privacy 2. Safety 3. Warmth 4. Independence 5. Needs
What are the national patient safety goals?
- Identify patients correctly - 2 factor
- Improve staff communication - SBAR
- Use medicines safely
- Use alarms safely
- Prevent infections
- Identify patient safety risks
- Prevent mistakes in surgery
What must a statement like ‘ineffective airway clearance’ be related to?
Must be related to something, e.g., related to weak cough.
What is the importance of body alignment?
Used for determining physical changes, deviations, posture, trauma, dysfunction, damage, incorrect alignment.
What are 5 safety positions for patients?
- Supported fowlers: angle 45-60 degrees with knees slightly bent and pillows for support 2. Supine: flat on back 3. Prone: flat on belly 4. Side-lying: lateral 5. Sims: legs and arms bent to side
What are the 5 sleep disorders?
- Insomnia; medical condition; trouble falling or staying asleep
- Sleep apnea; medical condition; airway blocked during sleep
- Narcolepsy; sleep paralysis
- Sleep deprivation; emotional stress, meds, environmental
- Parasomnias; sleep walking, night terrors, nocturnal enuresis (bedwetting), nightmares
What is the #1 way to prevent infection?
Hand hygiene.
What are the steps in the chain of infection?
- Infectious agent or pathogen
- Reservoir or source for growth (grow and multiply)
- Portal of exit (blood or skin or mucous membranes or GI tract)
- Mode of transmission
- Portal of entry - to host
- Susceptible host (age, nutritious, immunosuppressant, stress, trauma, smoking)
What is a nosocomial infection?
Hospital acquired infection.
What are the 4 steps of the infectious process?
- Incubation period - entry of pathogen
- Prodromal stage - vague, early symptoms 3. Illness stage - SXS manifest as type of infection
- Convalescence - SXS start to disappear
What are the modes of transmission?
Direct contact: person to person,
Indirect contact: surface to person,
Droplet: up to 3ft, cough and sneeze, Airborne: carried on dust, evaporated droplets.
What is the importance of inflammation in infections?
WBCs diagnose infection, Purulent appearance.
What do purulent, sanguinous, and serous mean?
Purulent - pus
Sanguinous - blood
Serous - clear.
What are the types of healthcare associated infections?
- Iatrogenic - from a procedure
- Exogenous - from microorganisms outside the individual
- Endogenous - patient’s flora becomes altered and overgrowth occurs.
What is hemostasis?
Physiological process stopping bleeding after an injury
Hemostasis is a critical first step in the wound healing process.
What are the steps in wound healing?
- Inflammatory Phase
- Proliferation Phase
- Remodeling (maturation) Phase
Each phase has specific processes vital for proper healing.
What occurs during the inflammatory phase of wound healing?
- Homeostasis
- Histamine and vasodilation
- WBCs move to wound area to inject debris and promote healing
- Pain, swelling, heat
This phase is essential for starting the healing process.
What is the role of albumin in wound healing?
Indicates how much protein is in the body; protein is needed to heal
Adequate protein levels are crucial for effective healing.
What happens during the proliferation phase of wound healing?
New blood cells and capillaries grow; a thin layer of granulation tissue forms
This phase is focused on tissue formation.
What occurs during the remodeling (maturation) phase of wound healing?
Collagen is remodeled and deposited; scar tissue becomes a thin white line
This phase improves the strength and appearance of the healed wound.
What is primary intention in wound healing?
Surgical wound where edges are approximated
This method typically results in minimal scarring.
What is secondary intention in wound healing?
Loss of tissue, such as in burns, pressure ulcers, or lacerations
Healing occurs from the edges inward and may result in more scarring.
What are some complications of wound healing?
- Hemorrhage
- Infection
- Hematoma
- Dehiscence
- Evisceration
Each of these complications can delay healing and worsen outcomes.
What is dehiscence?
Partial or total separation of wound layers
Common in obese patients or after abdominal surgeries.
What is evisceration?
Complete opening of a wound with organs protruding
Requires immediate medical attention.
What defines a fistula?
Abnormal passage from an internal organ to the outside of the body or between organs
Fistulas can complicate healing and require specific management.
What are pressure ulcers?
Found on bony areas of the body; also known as pressure sores, decubitus ulcers, or bed sores
They result from prolonged pressure on the skin.
What does blanchable skin indicate?
Skin turns white and then back to original color when pressure is released
This is a sign of stage 1 pressure ulcer.
What characterizes non-blanchable skin?
If it does not turn back to red, it is a stage 1 pressure ulcer
Non-blanchable redness indicates more severe skin damage.
What factors influence the pathogenesis of pressure ulcers?
- Intensity
- Duration
- Tolerance
Understanding these factors can help prevent pressure ulcers.
What is the Braden Scale used for?
Assessing risk for pressure ulcers; scores range from 6 to 23
It evaluates factors like moisture, friction, sensory perception, activity, mobility, and nutrition.
What does sloughing refer to in wound care?
Unviable tissue that appears yellow, white, or grey
This tissue must be removed for proper healing.
What are the classifications of pressure ulcers?
- Intact skin with non-blanchable redness
- Partial-thickness skin loss involving epidermis, dermis, or both
- Full-thickness tissue loss with visible fat
- Full-thickness tissue loss with exposed bone, muscle, or tendon
- Unstageable; cannot get depth measure
These classifications help guide treatment.
What distinguishes partial thickness wounds?
Shallow in depth, moist, painful, and appears red
These wounds involve the epidermis and part of the dermis.
What distinguishes full thickness wounds?
Extend into the subcutaneous tissue
These wounds require more complex treatment and care.
What factors influence pressure ulcer formation?
- Infection
- Age
- Nutrition
- Tissue perfusion
These factors must be managed to prevent ulcers.
What are the colors associated with wounds?
- Black
- Yellow
- Red
- Mixed
Each color indicates a different stage or type of healing tissue.
What are the nursing implementations for wound care?
- Continuous skin assessment
- Check wounds
- Assess Braden Scale
Ongoing assessment is crucial for preventing complications.
What diagnoses might a patient at risk for wound complications receive?
- Risk for infection
- Imbalanced nutrition
- Acute or chronic pain related to surgical incisions
- Impaired mobility, integrity, perfusion
These diagnoses guide nursing care and interventions.
What are some goals and outcomes for wound care planning?
- Prevent ulcers
- Promote wound healing
Setting clear goals helps measure the effectiveness of interventions.
What interventions might be implemented for wound care?
- Topical skin care
- Changing positioning
- Supportive positions and devices
- Wound cleaning
- Cleaning dressings
These interventions are essential for effective wound management.
What is the importance of evaluating wound care?
Ongoing assessment and evaluation are necessary to ensure effective treatment
Regular evaluation helps adjust care plans as needed.
