Fundamentals Exam 1 Flashcards
Name the 3 levels of health care
Primary
Secondary
Tertiary
This level of health care is preventative with health promotion, focuses of illness prevention, and health care today is more aimed at this level
Primary
This is the health care level of diagnosing and treating an illness
Secondary
This is the health care level that focuses on rehabilitation, health restoration, and palliative or end of life care
Tertiary
What are the 5 frameworks for nursing care
Primary Nursing Case Method Team Nursing Case Management Functional Method
The framework for nursing care when one nurse is responsible for total care for a caseload of clients over time, continuity of care
Primary nursing
The oldest case method in nursing
Private Duty Nursing
The case method in which the nurse is responsible for all the care of the patient, can be responsible for more than one patient at a time, and could care for a different patient every day
Total Patient Care
What are the 3 parts of team nursing
Team leader
Team members
Team conference
The role in team nursing when an RN is accountable for all the care and the rest of the team reports to them
Team leader
The role in team nursing where they are assigned functions or procedures to preform for all clients: meds, treatments, bedside nurse
Team member
The part of the nursing team utilized to communicate and develop a plan of care
Team conference
The framework fo nursing care responsible for a case load of patients in the hospital and follow up after discharge, also work with insurance companies to help patient receive the best possible care in the most cost-effective way
Case Managers
Inspire and motivate, influence others to work together to accomplish goals
Leaders
Employees whom the organization has given authority, power, and responsibility to accomplish the work of the organization. They plan, organize, and coordinate
Managers
This style of leadership makes decisions for the group, assumes the group is incapable, great for emergency situations, productivity is usually high, but autonomy and self-motivation low, degree of openness and trust between group & leader is low
Autocratic (authoritarian)
This style of leadership encourages group discussion and decision making, assumes individuals are internally motivated and capable of making decisions,
allows more self-motivation and creativity among members, very effective in the health care setting
Democratic (participative)
This style of leadership assumes group is internally motivated and needs autonomy, assumes a “hands off” approach and tends to minimize the amount of direction and face time needed, may be a lack of cooperation & coordination, works well if you have highly trained and motivated group
Laissez-faire (non-directive, permissive)
This style of leadership assumes group is externally motivated, but does not trust them to make decisions, relies on organizational rules, rules, rules, rules and policies – inflexible, motivates through systematic rewards and punishments
Bureaucratic (transactional)
This style of leadership adapts the leadership style to the situation, allows certain things to happen depending on the situation, concern for interpersonal relationships and a focus on activities that meet group members’ needs.. Could end up using any of the previously mentioned styles – determined by the group’s needs
Situational
In this style of leadership no one person is considered to have more knowledge or ability than another in the group.. In essence, all are leaders
Shared
The level of management where they manage the work of non-managerial staff and the day-to-day activities of the work group: schedule, room assignments
First level managers
The level of management where they supervise first-level managers and are a liaison between first and upper level managers: problems, evaluation, policy & procedure changes
Middle level managers
The level of management where executives are responsible for establishing goals and plans for the organization: goals, budgeting
Upper level managers
The transferring of responsibility for the performance of an activity or task to another member of the health care team while retaining accountability for the outcome.. huge part of nursing
Delegation
What are the 5 rights of delegation?
Task Circumstances Person Communication Supervision and evaluation
One of the rights of delegation..
Must be in the delegate’s scope of practice and job description
Must be right for the specific client
The right task
This right of delegation considers 4 factors:
stability of the patient’s condition
the potential for harm while performing the task
nurse should be able to problem solve and make decisions
the level of technology in use
The right circumstance
The right of delegation when a clear, complete, and concise description of the task is given, its ongoing and need to be sure the delegate understands the directions
The right communication
The right of delegation when there is appropriate monitoring and feedback is given
The supervision and evaluation
What should you know before delegating..
Policies
How your state board defines these roles
Know the nursing practice act
Think about whether the person has the skills and knowledge to actually do what you asked
Health care delivery skill:
an important first step in developing a caring relationship with your client
involves a focused and complete patient assesment
Clinical decision
Health care delivery skill:
realizing what problems and situations need to be taken care of first
Priority setting
Health care delivery skill:
Being effective and efficient in implementing a plan of care
Effective use of time
Being able to do more than one thing at a time
Having all equipment ready and the client prepared for procedures
Organizational skills
Health care delivery skill:
Helps client care occur more smoothly
Seek assistance when necessary
Know your limitations and seek help from professional colleagues for guidance and support
Communicating with patient and patient’s family
Working together
Health care delivery skill:
essential to remain goal oriented and use this wisely
must learn so that activities of care, as well as client goals, an be achieved
anticipate when care may be interrupted
complete one task before starting another
Time management
Health care delivery skill:
An ongoing process
when you look at effectiveness of therapies
when you look client responses to care
when you help maintain progress towards goals.
Evaluation
Health care delivery skill:
Show respect for one another’s ideas
Share information, Keep one another informed
Treat colleagues with respect and listen to the ideas of other staff members
Team communication
A dynamic, flexible environment that is concerned with the specific needs of an individual patient and/or groups of patients to promote a positive living experience and positive health changes… they may need/want family one day but the next day they may not
Therapeutic environment
What are the characteristics of a therapeutic environment
- Adequate Comfort (temperature, ventilation, lighting, nonskid surfaces….)
- Safe
- Individualization of patient care
- An atmosphere that encourages communication
- A feeling of “security” for the patient
- A feeling of self worth for the patient
- Diversional activities
Characteristic of a therapeutic environment:
To protect clients and themselves from injury, but a danger free environment is rare
Its a basic need used in the work environment
prevents harm and allows clients to feel secure
allows the client to meet other human needs
age matters
injuries may occur
just be preventative
Safety
A type of injury from a fall or a blow:
falling out of bed
slipping on the floor
tripping over cords
Mechanical injury
Injury from heat or fire:
hot water bottles
heating pads
lamps
Thermal injury
An injury involving strong chemical on the skin, can be internal, such as wrong medications
Chemical injury
Injury involving burns from faulty wiring, touching electrical connections with wet hands
Electrical injury
Injury involving overexposure to xray but can be prevented by using the lead vests
Radiation injury
Injury caused by disease producing microorganisms
Patients are usually more susceptible because of their illness.. wash hands and keep things sterile!
Bacteriological injury
Injury caused by patient’s susceptibility to materials in the environment
Allergens
Avoid this injury by preventing sensory deprivation or overload, which can contribute to confusion and hinder the patient’s safety
Psychological injury
Name common risks to nurses
Exposure to blood-borne pathogens: needlesticks
Back injuries: moving patients
Exposure to harmful medications: chemotherapy
Threats of violence and assaults from clients and visitors: families can become easily angered
The leading cause of unintentional injury among adults
Falls
R.A.C.E.
R: Rescue anyone in danger if it doesn’t endanger you
A: Alarm- sound it
C: Confine by closing all doors and windows
E: Extinguish and Evacuate
P.A.S.S.
P: Pull
A: Aim
S: Squeeze
S: Sweep
Any physiologic or psychological factor necessary for a health existence
A need
Maslow’s hierarchy of needs from top to bottom
- Self actualization needs
- Esteem needs
- Love needs
- Safety needs
- Psychological needs
Guidelines of prioritizing needs
Immediate effect on survival Effect on other needs Timeframe and available resources Client’s perception of need Family’s perception of need
Behaviors, values, beliefs, and customs that are learned from other people over time..includes language, communication style, traditions, religion, art, music, dress, health beliefs, and health practices
Culture
The acute experience of not comprehending the culture in which one is situated..may be expressed as silence, immobility, agitation
Culture shock
Factors contributing to the culture of the patient
- communication
- space
- social organization
- time
- environment control
- biological variations
Methods for assessing culture
Observe
Interview (therapeutically)
Participate
When faced with health care issues, they may begin to question their belief systems and are unable to find support
Spiritual distress
JCAHO says a spirituality assessment must be done to assess the patients..
Denomination
Beliefs
Spiritual practice that’s important to the patient
What a spiritual interview assessment consist of..
Any religious practices important to you?
Will being here interfere with any of those?
Would you look a visit from spiritual counselor?
What should you clinically assess about spirituality..
Environment
Behavior
Verbalizations
0-18 inches from the patient
Intimate space
18 inches to 3 feet from the patient
Personal space
3-6 feet from the patient
Public space
Cardiovascular benefits of mobility
Cardiovascular system works more effectively strengthens cardiac muscles increases cardiac output decreasing resting heart rate improves venous return
Musculoskeletal benefits of mobility
Maintains and improves muscle tone and strength
Increases joint flexibility and range of motion
Maintains bone density (through weight bearing)
Respiratory benefits of mobility
Improves alveolar ventilation
Decreases breathing effort
Improves diaphragmatic excursion
O2 intake increases during strenuous exercise
GI benefits of mobility
Improves appetite
Increases GI tract tone, improving digestion
More effective in absorbing nutrients
Metabolic benefits of mobility
Elevates basal metabolic rate Reduces triglycerides and cholesterol levels Increases use of glucose Increases production of body heat Burns excess calories
Urinary benefits of mobility
Promotes effective excretions of waste
Helps prevent urinary stasis in the bladder
Psychological benefits of mobility
Improves stress tolerance Produces a sense of well being Reduces depression Improves body image Enhances quality of sleep Increases energy levels
Effect of immobility
Bone demineralization with calcium loss
Osteoporosis
An effect of immobility
Why you have to use or you lose it
Muscles decrease in size
An effect of immobility causing shortening of the muscles
Contractures
Effects of immobility on the joints
Joint deformity
Arthritis
Stiffness and pain
Frozen joints
Cardiovascular effects of immobility
Diminished cardiac reserve Rapid heart rate Reduced coronary blood flow Orthostatic hypotension Edema: swelling in lower extremities Thrombus: clots and swelling
Respiratory effects of immobility
Pooling of respiratory secretions Inability to cough them up Decreased depth of breathing Atelectasis Pneumonia
Urinary effects of immobility
Urinary stasis: bladder will fill to the point where you cant go to the bathroom and it spills out the ureter leading to infection
Urinary retention
Urinary infection
Renal Calculi
Integumentary effects of immobility
Skin breakdown
Pressure ulcers
Neuropsychological effects of immobility
Low self esteem Frustration Depression Impaired decision making Anxiety
Subjective questions when assessing mobility
Have you noticed any pain in your joints or muscles?
Do you have any weakness or twitching?
Have you had any recent falls?
Are you able to care for yourself?
Do you exercise or participate in sports?
Do you use any assistive devices?
What to look at when assessing mobility
Look at: alignment balance gait joints muscle strength
Stages of pain with musculoskeletal disorders
Early: pain until you rest
Intermediate: pain during work
Advanced: pain even when you’re resting
Symptoms of musculoskeletal disorders
Tingling Numbness Fatigue Weakness Redness Swelling Loss of full or normal joint movement
Factual data observed by the nurse
No conclusions or interpretations are made
Objective data
Information given verbally by the client
Captures the client’s point of view
Always stated in their words with quotations
Subjective data
Type of assessment:
Also referred to as an admission assessment
Performed when patient enters health care facility
Helps evaluate health status and establish comprehensive baseline data
Done by RN
Everyone must have one
Initial assessment
Type of assessment:
Collects data on a certain part of the body instead of the whole head to toe assesment
Collects data about a problem that has already been identified
Determines if problem still exists or if status has changed
Can identify new problems
Focus assessment
Type of assessment:
Takes place after the initial assessment to assess for changes
Not as comprehensive as the initial asses.
Assessing for any kind of change
Usually when substantial periods of time have elapsed (ie between home visits, clinic visits….)
Usually a complete review (not as comprehensive as the initial assessment) of all functional health patterns is done because of the long time interval
Time lapsed assessment
Type of assessment:
Takes place in life-threatening situations
Rapid identification of problems and interventions necessary
Not comprehensive – focuses on problem areas only
Looking for things such as not breathing, distress in the patient
Emergency assessment
Name for the 4 parts of assessment
Observation
Interviewing
Physical Exam
Intuition
Name different observations that can be made during assessment
Sight/vision- how the patient looks (wt., skin, posture)
Sound/hearing- how they talk, breathe, cracking joints
Smell- sweat, urine, feces, breathe
Touch- cold, strong, weak, soft
Also called common sense or a gut feeling, trusting your instincts
Intuition
The first step in the assessment process
Usually carried out during the interview and the physical exam
To detect normal characteristics or significant physical changes
Can do you during the interview or during any other technique
Inspection
Use of touch
Use of fingertips and palms of hands
To detect size, shape, tenderness, temperature, texture, vibration, masses….
Light (want to do light palpation first)
Deep (go back through with a deeper palpation
Palpation
One or both hands are used to strike the body surface to produce a sound
Helps assess denseness or hollowness of underlying body structures, location and level of organs, tenderness, masses or tumors…
Percussion
Listening to body sounds with the use of a stethoscope
Amplifies sound
Bowel sounds, heart sounds, lung sounds…
Auscultation
Order to preform the physical exam
inspection, palpation, percussion, auscultation
What is the exception in the physical examination order
exception is for bowel sounds (ab. area) : inspect, auscultate, percuss and palpate (to avoid altering bowel sounds)
Awareness of and responsiveness to the surrounding environment
Level of consciousness
What are the 3 levels of consciousness
Highest: completely attentive
Impaired: loss of orientation and inability to follow commands
Lowest: comatose no verbal response
A standardized assessment tool used for measuring consciousness
Nurses are able to detect subtle changes in consciousness by reviewing the scale and looking for deviations from baseline
Glasgow Coma Scale
What to assess for consciousness
Orientation: persons, places, times
Language: speech, aphasia: unable to express or understand
Memory: long term, ask about birthdays, etc.
Nearsightedness
Myopia
Farsightedness
Hyperopia
irregularity of the cornea which causes blurred vision
Astigmatism
decreased elasticity of the lens with a decrease in accommodation
Presbyopia
What should you inspect about the eyes
Eyebrows: symmetrical
Eyelashes: equal distribution, styes
Eyelids: discoloration, edema, blinking
Eyeballs: deep or protrude
Conjunctiva
Pull down gently on the skin just below the eye and observe for inflammation, redness and/or lesions
Sclera
Observed chiefly for color – normally white and clear. Note discolorations.
Cornea and Iris
Cornea normally clear and smooth – cloudiness or opaqueness is abnormal
Note the color of the iris – iris should be round
Pupils
Evaluate for size, shape, accommodation and reaction to light.
Pupil size is measured in millimeters (usually 2-3 mm)
Normally round and of equal size
Normally dilate in a darkened environment and constrict in bright light
PERRLA
P – pupils should be clear E – equal in size and between 3-5 mm R – round in shape RL – reactive to light A – accommodation of the pupils
Types of hearing loss
Sensorineural: due to a problem with the inner ear or the auditory nerve
Conductive: due to a problem with the external or middle ear (wax buildup, foreign body, infection)
Signs of decreased hearing
Behavioral changes Requesting repetition of statements Leaning forward – turning head towards speaker Answering inappropriately Talking loudly
hearing loss due to aging
Presbycusis
Inspection of external ears/auricles
Placement: top of auricles should align with the outer canthus of the eyes
Color: should be the same as the face color
Size: small, moderate, large
Symmetry
Ear canal should be free of foreign bodies or discharge
Wax (cerumen is an expected finding)
Pharynx
uvula should be pink, intact and move with vocalization
tonsils: if visible should be the same color as the surrounding mucosa
Note any redness or swelling
Assessment of the mouth
Lips: should be moist, symmetrical, smooth, no lesions, no tenderness
Gums: should be pink, moist, no lesions
Mucous membranes: pink, moist, no lesions
Teeth: color, cavities, missing teeth, dentures
Tongue: dorsal side should be pink with papillae; underside should be smooth with a symmetrical vascular pattern; moist, free of lesions; should move freely
Inspect hard and soft palates
Assessment of the nose
Symmetry of nose; any deviation of midline
Same color as face
Each nostril should be patent without excess flaring (can occlude one nostril at a time and assess the opposite side for airflow)
Mucosa should be deep pink, moist with no discharge or lesions
Any bleeding?
Inspection of the breast
Females (can be done sitting or standing) Arms at the side Arms above the head Hands on hips, pressing firmly Leaning forward Males (can be done sitting or lying) Arms at the side
Inspecting breasts for..
Size and symmetry Shape Skin color Any lesions, nodules, edema or erythema Round shape of areola Color of areola Direction of nipples (recent inversion is abnormal) Any excoriation under breasts
Documentation of nodules on the breast
Location (using quadrant or clock methods) Size (in centimeters) Shape Consistency (soft, firm or hard) Discreteness (well-defined borders of mass) Tenderness Erythema Dimpling or retraction over the mass Mobility
Expected findings for the breasts
Female
Breasts should be firm, elastic with no lesions or nodules
Breast tissue may feel granular or lumpy in some women
Male
No edema, masses or tenderness
Areolas should be round and darker pigmented
Assessment of scalp and hair
Inspect and Palpate- color, quantity, distribution, texture, hygiene, nodules, and lesions
Hair Color- range from pale blonde to deep black
Moisture- dry, oily
Texture- may be straight, curly, kinky, fine, or coarse
Examine Base of Hair Follicle- pest infestation, dandruff
Alopecia- loss of hair
