fundamentals exam 1 Flashcards
What is the order of the nursing process and why is it cyclical and not steps?
ADPIE
Assessment: Gathering information about a patient condition
Diagnosis: Identify the patient’s problem
Planning: Set goals of care and desired outcomes and identify appropriate nursing actions. Set priorities.
Implementation: Perform the nursing action identified in the planning
Evaluation: determine if goals and expected outcomes are achieved. You are evaluating the patient’s behavior as well.
The nursing process is cyclical and not steps because it’s an ongoing process
We must continuously be assessing and evaluating our patients and adjusting to their changes.
Describe subjective vs. objective data:
Subjective data is what the patient SAYS
Objective data: observing the patient
Why do we write nursing diagnosis and how does it differ from the medical diagnosis?
We write nursing diagnoses because:
- helps identify priorities and help direct nursing interventions.
- Helps see the patient in a holistic perspective (including them in their care).
- It differs from medical diagnosis because medical diagnosis focuses on disease
What is a SMART goal?
Specific
Measurable
Attainable
Realistic
Timed
What is orthostatic hypotension – what parameters define it and what intervention can the nurse offer to keep the client with orthostatic hypotension safe?
Orthostatic hypotension is where there is a big drop on the patient’s blood pressure when they move from sitting to standing.
A systolic drops at least 20 mm Hg, and diastolic at least 10 mm Hg, within 3 minutes of rising.
Symptoms of dizziness, light-headedness, nauseas, tachycardia, pallor, or fainting
Intervention: drinking enough water, avoid alcohol, elevating head at bed, standing up slowly, fall risk prevention, exercising
What are some common restraints and when are they used?
When to use restraints:
As the last option
Have to have a doctor’s order
Less restrictive as a restraint:
Bed alarms
Chair alarms
What is meant by “fall precautions” as an intervention?
What questions to ask the patient:
Fall prevention includes any action taken to help reduce the number of accidental falls suffered by susceptible individuals
Do you feel unsteady when standing or walking?
Do you have worries about falling?
Have you fallen in the past year? If yes, how many times? Were you injured?
What is the most effective way a nurse can help BREAK the chain of infection?
Hand hygiene
In the chain of infection, what is the mode of transmission?
route or method of transfer by which an infectious microorganism moves from one place to another and enters a new host
It can could be via contact(indirect or direct), droplet, airborne, vehicles, and vector
What is a portal of entry/exit?
Portal of entry: mouth, eye, nose, skin.
Subtitle host (at someone who is at risk of infection) anyone can be it.
Portals of exit: the path by which a pathogen leaves its host
Includes body surface, blood, feces, respiratory, saliva, vomiting, diarrhea
Sites for infections:
Urinary
Wounds
Eyes
Ears
Nose
Respiratory
Systemic infection
More likely to see a fever
How to assess for an infection:
Collect urine, sputum
Culture swap
Culture will tell us the exactly the organism so we know what type of antibiotic to use
Check white blood count - it will be elevated if there is an infection
Interventions that can prevent an infection:
Hand hygiene
PPE
Monitoring
Checking for any signs of infections
Check their temperature
Wound - any redness, swelling, warm, pus, drainage ?
What kind of precautions to take for infections?
PPE:
Airborne - gloves, mask ( TB, chickenpox, measles)
Droplet - gloves, mask ( flu, RSV, common cold)
Contact - gown, mask, gloves, shields ( memory tip -contact covers everything) ( VRE, MRSA, C.Diff)
What type of medication is used to treat bacterial infections and why is this not effective to treat viruses?
Antibiotics are used to treat bacterial infections
Viruses are surrounded by a protective protein coating - that’s why antibiotics do not work
What factors make us most at risk?
Taking multiple antibiotics, weak immune system, older age who had recent hospital or nursing home care, and patients taking immunosuppressants
What is the role of the nurse in teaching clients and families about transmission-based precautions and infection control?
Teach the basic information about an infection, various modes of transmission, and appropriate methods of prevention such as hand hygiene and covering mouth when coughing.
What are the characteristics of impaired physical mobility?
Decreased muscle strength, activity intolerance, stiffness
Limited ROM, assistance device/people, pain
What is activity intolerance and what would you assess that would lead to choosing this nursing diagnosis?
Activity intolerance is lack of physiological or psychological energy to complete daily tasks/activities.
Observing their daily task
What are the types of lifts used to aid patients with imparied transfer mobility?
Stand up lifts - for patients who have some mobility but need assistance getting up from one seat and transferring
Sling lifts: for patients who are diabled or weakened. It will lift patients off the surface of a bed
Hoyer lifts- full body lift
Used for pt after post op, weak/no mobility in lower extremities, unconscious or confused pts
What assisstive devices/ mobility aids are used with mobility needs?
Canes, walkers, crutches, assitives devices, lifts, clothing with velcro clourers
How is joint mobility assessed & what interventions are used to ensure joint mobility is improved or maintained?
joint mobility is assessed by ROM
Interventions: ROM exercises
How is gait assessed & what are some interventions used to ensure that gait is imporved or maintained?
gait is assessed by watching the patient walk
Interventions: ROM exercises in hips, ankles, and feet
Occupational or physical therapy
Assistive devices
What are some special considerations for certain types of care (female perineal & oral care)
ensuring privacy, convery respect, foster a patients independence, safety, and comfort
wiping front to back to prevent any UTI
Who is at most risk for oral care problems?
Older patients
Patients who are physically or cognitive imparied
Patients taking medication
What are some therapeutic communication strategies with patients who refuse to bathe or have poor self-care practices?
Listening, reflecting, and focusing can help promote caring therapeutic relationships when providing hygiene care
Describe the correct order of steps in handwashing:
Turn on warm water to wet hands, keep forearms and hands lower than elbows
Place soap in hands, and rub tgh for 15 secs in circular motions, fraction movement between fingers
Clean under fingernails w/ other hand
Rinse and pat dry w/ towel
Turn off faucet w/ paper towel
If a medication does not seem correct, who should you speak with:
contact the provider; the person who ordered it
What things make clients susceptible to infection?
Age, genetics
nutrition
immunocompromised
pre existing chronic disease
stress
what is multi-resistant and what type of transmission-based precautions are used to prevent the spread of these organisms?
Multi resistant- common bacteria germs that have developed resistance to multiple types of antibiotics
Private rooms, gloves, gown
Clostridium Difficile or C.diff is what type of infection?
What factors put clients at risk for C.diff?
What type of transmission-based precautions are used to prevent the spread of infection?
Bacterial infection
Contact disease, spreads via direct or indirect contact
Risk Factors- taking multiple anti Bs, weak immune system, older age who had recent hospital visit or nursing home care, pt taking immunosuppressants
Precautions- hand washing with soap and water, gloves, mask, eye protection, gowns, N- 95 for airborne and antiseptics
What is deconditioning?
Involves physiological changes after a period of inactivity ( bed rest)
Pt at risk when they are hospitalized and spend most of their time in bed
Could experience muscle weakness and pressure ulcers
What are the range of motion exercises and what can they help to prevent?
ROM- compares and evaluates whether loss in joint mobility has occurred or developing
Active- pts actively moving joints independently
Active assisted- having to provide support for pt who is weak and assist while the pt performs most of joint movement
Passive- literally moving it for them
help prevent stiffness, limited movement of joints, pain, activity intolerance, decrease muscle mass and strength
