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ADN001 Funds > Lecture 1 Exam Review > Flashcards

Lecture 1 Exam Review Flashcards

1
Q

Good spirits brought health, while evil spirts bring sickness and death.

A

Theory of Animism

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2
Q

Nursing role becomes more defined and formal, deaconess made visit to sick.

A

Early Christian Period

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3
Q

In the Ancient Greek Civilization temples were what?

A

Medical Care Centers

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4
Q

In the 16th century a shift occurred from what to what?

A

Religious orientation to an emphasis on warfare, exploration, and expansion of knowledge.

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5
Q

Nursing is based on the beliefs of whom?

A

Florence Nightengale

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6
Q

These reforms changed the roles of nurses and of women in general

A

Social reform.

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7
Q

Who established the first training school for all nurses?

A

Florence Nightengale

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8
Q

Female nurses were under the control of who?

A

Hospital administrators and Physicians

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9
Q

What happened during the World War II era?

A

Large numbers of women worked outside the home and became more independent.

Growth of nursing and technology expanded.

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10
Q

In the 1950s nursing broadened in what areas?

A

Upgrading nursing education.
Practice in variety of healthcare settings.
Developing specific knowledge.
The conduct and publication of nursing research.
Increasing knowledge of nursing and EBP practices

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11
Q

What are the Nursing Aims?

A

Promote Health
Prevent Illness
Restore Health
Facilitate coping with death/ disability.

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12
Q

The 4 Blended competencies?

A

Cognitive
Technical
Interpersonal
Ethical/Legal

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13
Q

What are some roles for nurses?

A

Teacher
Communicator
Counselor
Leader
Researcher
Advocate
Collaborator

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14
Q

QSEN include what?

A

Patient Centered Care
Teamwork
Safety
EBP
Informatics

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15
Q

How can we promote health?

A

Identifying, analyzing, and maximizing each patient’s individual strengths as components of preventing illness, restoring health, and facilitating coping with disability or death.

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16
Q

What are some factors affecting health?

A

Genetics
Education Level
Culture
Sex
Socioeconomic status

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17
Q

What are some Healthy People 2030 Health Promotion Guidelines

A

Attain Healthy, thriving lives and wellbeing, free of preventable disease, disability, injury, and premature death.

Eliminate Health disparities.
Promote Health Development
Encourage Leadership in health settings.

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18
Q

How do nurses prevent illness?

A

By teaching and example

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19
Q

What are some ways to prevent illness?

A

Reducing the risk of illness, promoting good health habits and maintain optimal functioning.
Educational programs.
Health Assessments.
TV, Radio, or Internet Information.

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20
Q

Name ways in Restoring Health

A

Focus on the person with an illness and are considered the nurse’s responsibility.
Performing Assessments
Collaborating with other healthcare members
Planning, teaching, and carrying out rehabilitation for illness.

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21
Q

Ways to facilitate coping with Disability and Death

A

Maximizing person’s strengths and potentials

Providing end of life care.

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22
Q

Well Defined Body of knowledge
Strong service orientation
Code of Ethics
Professional organization that sets standards
Autonomy and Regulations

A

Nursing as a professional Discipline

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23
Q

Nursing educators have a responsibility to form the professional identities of their students. This is known as ?

A

Personal Formation. Graduates will acquire a professional identity with sense of belonging.

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24
Q

Name Professional Nursing Organizations

A

ICN
ANA
NLN

Specialty Practice and Special- Interest Nursing Organizations

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25
Q

Nursing Practice Acts

A

Define the legal scope of nursing practice.
Create a state board of nursing to make and enforce rules and regulations.
Defines scope of practices
Establishes criteria for the educational and licensure of nurses.

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26
Q

What are some guidelines for Nursing Practice?

A

Standards of Nursing Practice
Nurse Practice Acts and Licensure Code of Ethics and Professional Values
Nursing Process and other clinical Judgement Models

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27
Q

What are some NLN trends to watch?

A

Changing demographics and increasing diversity
Globalization
The era of educated consumers and alternative therapies
The cos of healthcare and the challenge of it.
Impact of health policy and regulation.
Growing need for interdisciplinary education.

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28
Q

Self Care

A

Nurse owes the same duties to self as to others

Include promoting health and preserve wholeness of character and integrity in professional and personal growth.

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29
Q

Define resilence

A

Individual’s aptitude for overcoming and adverse life circumstance with hopeful attitude.
Utilizing healthy internal mechanisms

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30
Q

Signs of fatigue in Nursing Profession

A

Compassion Fatigue
Burnout
Fatigue

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31
Q

Knowledge passed down from generation to generation

A

Traditional

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32
Q

Knowledge from an expert?

A

Authorative

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33
Q

Knowledge obtained through the scientific method.

A

Scientific

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34
Q

Theory

A

Group of concepts that describe a pattern of reality.

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35
Q

Abstract impressions organized int symbols of reality, describe objects, properties, and events and relationships among them.

A

Concepts

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36
Q

Group of concepts that follow a pattern

A

Conceptual Framework or model.

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37
Q

The act of making generalized conclusions based of specific scenarios.

A

Inductive Reasoning

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38
Q

The act of backing up a generalized statement with specific scenarios.

A

Deductive reasoning.

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39
Q

Name the common concepts of Nursing

A

The person
The environment
Health
Nursing

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40
Q

Proces that use observable and verifiable information, collected in a systematic manner to explain, describe, or predict events.

A

Scientific Inquiry

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41
Q

Goals of research

A

Develop explanations in theories
Improving care of people in a clinical setting
Study people and the nursing process.

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42
Q

Basic Research

A

Designed to generate and refine theory, findings are often not directly useful in practice.

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43
Q

Applied Research

A

Designed directly to influence or improve clinical practice.

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44
Q

Involves the concepts of basic and applied research

A

Quantitative

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45
Q

Qualitative

A

Conducted to gain insight by discovering meanings
Based on the belief that reality is based on perceptions for each person and change over time.

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46
Q

Evaluating the ethics of clinical research studies

A

Value
Scientific Validity
Fair subject selection
Informed consent
Respect for enrolled subjects

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47
Q

Reading and Critiquing Research Articles

A

Review elements of the article
Level of quality of evidence using a scale
Decide if the study is applicable to your practice

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48
Q

Define PICOT

A

Patent
Intervention
Comparison
Outcome of interest
Time

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49
Q

Problem solving technique to make clinical decisions using the best evidence available.

A

Evidence Based Practice

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50
Q

What are steps in implementing EBP?

A

Formulate clinical questions
Search and collect best evidence
Critically appraise the evidence
Integrate the evidence with clinical expertise and patient/ family for best decision.
Evaluate the outcomes of the practice

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51
Q

Systematic and continuous actions that lead to measurable improvement in health care services and health status of targeted groups.

A

Quality Improvement

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52
Q

What are the IOMs Six Outcomes for New Health for 21st Century

A

Safe
Effective
Efficient
Patient Centered
Timely
Equitable

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53
Q

Access to Healthcare

A

Patient Protection and Affordable Care Act
Health Insurance marketplace
Shortage of providers
Legislation to health care access
Caring for undocumented individuals

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54
Q

One way for affordability for patients is through what group?

A

DRGs

Diagnosis Related Groups

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55
Q

Name the levels of Health Care

A

Primary Health Care Common Health problems

Secondary Health Care Treatment requiring more specialized clinical expertise.

Tertiary Management of rare and complex disorders

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56
Q

Ways of Paying for healthcare

A

Out of pocket
Individual private insurance
Employer based
Government finance: Medicare DRGs

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57
Q

What are some strategies to reduce health care costs?

A

Utilizing quality improvement tools to reduce waste and improve safety.
Improving transitions across settings
Making the delivery of medical services more efficient and less costly.
Elimination unnecessary costs
Improving population health

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58
Q

Name some healthcare settings

A

Hospitals
Ambulatory Care Centers
Home Health Care
Extended Care Services
Specialized Care Centers
Healthcare for ill and dying

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59
Q

Name roles of nurses in Hospitals

A

Direct Care Providers
Manager of other members of health care team
Administrator
Nurse Practioner
Clinical Nurse Specialist
Patient Educator
In service educator
Researcher

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60
Q

What is the most rapidly growing area of healthcare?

A

Home Health
Driven by payment system of reimbursement..

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61
Q

Give examples of extended care facilities

A

Transitional subacute care
Assisted Living
SNFs
Retirment Centers
Residential Institutions for mentally and physically disabled

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62
Q

Specialized Care Centers and Settings

A

Daycare centers
Mental Health
Schools
Industry
Homeless Shelters
Parish Nursing

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63
Q

Name Healthcare Services for seriously Ill and Dying

A

Respite Care
Hospice Services
Palliative Care

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64
Q

Types of Healthcare Agencies

A

Voluntary Agencies
Support groups

Other GOVT> Agencies
Public Health Service
CDC
Public Health Facilities

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65
Q

WHat are some trends to watch in health care delivery?

A

Focus on preventive care.
Knowledgeable and engaged consumers.
Mobile Health
Racial justice and equity

NLN

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66
Q

What are the Nurses’ role in Health Care Reform?

A

Gives opportunity to help shape health care and the future.
Becoming a stronger voice in addressing health related problems in our nation.
Education in nurses is increasing.
The focus of nursing care is providing a holistic care approach.

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67
Q

Define ADPIE

A

Assessment
Diagnosis Nursing
Plan
Implementation
Evaluate

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68
Q

What are some guiding principles of person centered care?

A

All team members are considered caregivers.
Care is based on continuous healing relationships.
Patient safety is priority
Transparency is the rule in the care of the patient.

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69
Q

What is the clinical judgement measurement model?

A

CJMM has new focus that is based on the New Generation NCLEX
Includes layers from 0-4.
Layers 0-2 how clinical judgement informs clinical decisions.
Layers 3-4 expected behaviors of students in specific case scenarios

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70
Q

Clinical Judgment Action model aligns what?

A

Aligns the six cognitive operations from layer 3 of the CJMM with specific situational factors from layer 4.

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71
Q

Mental Model

A

Organized way of thinking that assists in understanding complex situations and guides assessments.

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72
Q

Define the Nursing Process

A

Assessment -Date
Diagnosis -Problem
Plan- Managing the Problem
Implementation-Putting the Plan to Action
Evaluation-Did the plan work?

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73
Q

Systematic and continuous collection, analysis, validation, and communication of PT data.

A

Assessment

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74
Q

Data

A

Reflect how health functioning is enhanced by health promotion or compromised by illness/ injury

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75
Q

Database

A

Includes all the pertinent information collected by the nurse and other health professionals

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76
Q

Name characteristics of nursing assessment

A

Purposeful
Complete
Systematic
Factual
Accurate
Relevant
Recorded in a standard manner

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77
Q

5 Types of Nursing Assessments

A

Initial
Performed by the nurse shortly after admittance to a health care facility to establish a complete database for problem identification and care planning
Focused
May be performed by the nurse during initial assessment or as routine ongoing data collection to gather data about a specific problem already identified, or to identify new or overlooked problems
Quick priority
Short, focused, prioritized assessments completed to gain the most important information needed first; Can flag existing problems and risks
Emergency
Performed by the nurse when a physiologic or psychological crisis presents to identify life-threatening problems
Time-lapsed
Performed to compare a patient’s current status to baseline data obtained earlier, reassess health status and make necessary revisions in care plan, to collect data about current health status of patient
Triage
A screening assessment to determine the extent and severity of patient problems and recommend appropriate follow-up; Can be completed on the phone or in person; Triage nurses need highly specialized nursing knowledge and clinical reasoning and judgment skills
Patient-Centered Assessment Method (PCAM)
Tool used by health care practitioners to assess patient complexity using social determinants of health; Helps ask questions to gain understanding about the patient’s health and well being, social environment, health literacy and communication skills

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78
Q

Ways to establish Assessment Priorities

A

Health Orientation
Developmental Stage
Culture
Need For Nursing

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79
Q

Define Objective Data

A

Observable and measurable data that can be detected with senses.

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80
Q

Subjective Data

A

Information perceived only by affected person.

Example: Pain, dizzy, anxious feeling etc.

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81
Q

Where can I get sources of Data?

A

PT
Family
EHR
Lab studies or diagnostic studies
Other Healthcare professionals

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82
Q

The skill of Nursing Observation

A

Determines the PT current responses
Determines the PTs current ability
Determines the PT current environment and safety
Determines the larger environment and safety

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83
Q

Captures and records the uniqueness of the PT. Examples include: reason for care, health habits, medications, allergies, psychosocial, etc. Obtained by interviewing the PT.

A

Nursing History

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84
Q

What is the purpose of the Nursing Physical Assessment?

A

Appraisal of health status
Identification of health problems
Establishment of a database for nursing interventions

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85
Q

What are the 4 Assessment methods?

A

Inspection
Palpitation
Percussion
Ausculatation

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86
Q

What are some problems related to Data Collection?

A

Inappropriate organization of a database.
Omission of data.
Failure to establish rapport.
Failure to update.

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87
Q

When to verify data?

A

When there is a discrepancy between what the person is saying and what the nurse is observing.

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88
Q

What are the purposes of the diagnosing step?

A

Identify how an individual, group, or community responds to actual health and life processes
Identify factors that contribute to health problem
Identify resources or strengths on which individual can draw to prevent or resolve problems

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89
Q

Diagnostic Reasoning, Clinal Reasoning and Judgement

A

Be familiar with lists of actual and potential problems and needs.
Trust judgement but when needed ask for help
Respect your clinical intuition
Recognize personal bias and keep an open mind.

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90
Q

Steps of Data Interpretation

A

Recognizing significant Data
Recognizing patterns or clusters
Identifying strengths or potential problems
Reaching conclusions
Partner with patient and family

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91
Q

Types of Nursing Diagnosis

A

Problem Focused
Risk
Health Promotion

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92
Q

Formulation of Nursing Diagnosis

A

Problem identifies what is unhealthy about PT
Etiology- Identifies factors maintaining the unhealthy state.
S/S

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93
Q

Validating Nursing Diagnosis

A

Is my PT database sufficient and accurate?
Significant cues?
Subjective and objective data I used t determine the existence of o the current Health problem?
Based on EBP and scientific knowledge?

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94
Q

Documentation of Diagnoses on EHR

A

View the PT ongoing risks and problems that others have identified and documented
Decide and document new PT problems
Facilitate communication of the PT actual problems
Use PT problems to make goals and decisions about mutual goals and PT desires

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95
Q

Goals of the Identification and Planning Step

A

Establish Priorities
Identify and write expected PT outcomes
Select EBP nursing interventions
Communicate the plan of nursing care

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96
Q

What does a formal care plan allow the nurse to do?

A

Individualize care that maximizes outcome achievement
Ste priorities
Communication between other healthcare members
Coordinate Care
Evaluate PT response
Create record for used evaluation, research, and legal reasons.
Promote Nurse Development

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97
Q

Standards to Apply to Outcome Identification And Planning

A

The Law
Specialty professional organizations
The joint comission
The Agency of Healthcare Research and Quality
Your Employer

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98
Q

What are the three elements of comprehensive? planning?

A

Initial- Developed by the nurse who performs the nursing history and assessment. Addresses each problem.

Ongoing- Carried out by nurse who interacts with patients. Keeps everything up to date.

Discharge: Carried out by nurse who works most with PT. Discharge begins on admission.

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99
Q

Maslow’s Hierarchy of Needs

A

Physiologically
Safety/ Security
Love and Belonging
Self- Esteem
Self- Actualization

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100
Q

How can we identify outcomes?

A

Deriving outcomes from nursing problems
Determine PT centered outcomes
Using cognitive, psychomotor, and affective outcomes.
Identifying cultural considerations.

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101
Q

Define SMART

A

S specific
M measurable
A achievable
R relevant
T time-bound

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102
Q

IOMs 6 aims to be met by healthcare include what?

A

Safe
Effective
PT Centered
Timely
Efficient
Equitable

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103
Q

Joint Comission National PT Safety Goals include?

A

Identify PT correctly.
Improve staff communication.
Use medicines safely
Prevent infection.
Identify PT risks.

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104
Q

Common Errors in writing PT Outcomes

A

Expressing PT outcomes as nursing intervention
Vague responses
Including more than one PT behavior

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105
Q

Name 3 types of nursing interventions

A

Nurse initiated- Autonomous action based on scientific rationale that a nurse executes to benefit the PT in a predictable way related to the nursing diagnosis and projected outcomes.

Physician Initiated- Actions initiated by a physician in response to a medical diagnosis but carried out by nurse under doctor’s orders.

Collaborative- treatments intiated by other providers and carried by a nurse.

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106
Q

What are some actions performed in Nurse initiated interventions?

A

Monitor Health status
Reduce Risks
Resolve or prevent a problem. Promote independence.
Promote optimum sense of well- being.

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107
Q

What are purposes of implementation?

A

The nursing aims

Promote Health
Prevent disease and illness.
Restore Health
Facilitate coping with altered functioning.

Scope of Practice

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108
Q

Ways to implement Guidelines.

A

Act with PT and family
Before, reassess the PT.
Approach the PT competently and caringly.
Modify care plan according to the PT. Unique and PT centered.

Check to make sure that the nursing interventions are consistent with the standards of care.

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109
Q

Ways to implement the Plan of Care

A

PT need for assistance
Promote self care
Reassess PT
Use PT whiteboard
Plan ahead
Anticipate unexpected outcomes
Ensure quality and safe care

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110
Q

A way to reassess the PT and reviewing the care plan?

A

Each nursing intervention is supported by EBP.

Consistent with standards of care and safe for the PT.

Clarify anything that is questionable.

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111
Q

What are some variables influencing outcome achievement?

A

PT variables
- Developmental stage
- Psychosocial backgrounds and culture

Nurse Variables
- Resources
- Scope of practice
- Research Findings
- Ethical Legal Guidelines

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112
Q

What are common reasons for noncompliance?`

A

Lack of family support.
Lack of understanding.
Low value attached to outcomes.
Inability to afford treatment.
Limited access to treatment.

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113
Q

Name the 5 rights of Delegation

A

Right:

Task
Circumstance
Person
Directions
Supervision and Evaluation

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114
Q

What is the evaluating step?

A

Nurse and PT measure together how well the PT has achieved the outcomes.

Nurse modifies plan by identifying factors the PT is able to achieve.

Purpose of evaluation is to allow the PT achievements direct future interactions.

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115
Q

What are the 5 classic elements of evaluation?

A

Identifying evaluating criteria and standards

Collecting Data to see if standards are met.

Interpreting and summarizing findings

Documenting judgement

Terminating, continuing, or modifying the plan

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116
Q

Measurable qualities, attributes or characteristics that identify skills, knowledge, or health status.

A

Criteria

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117
Q

Standards

A

Levels of performance accepted by and expected of nursing staff.

Established by authority, custom, or consent.

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118
Q

Name the 4 types of Outcomes

A

Cognitive

Psychomotor

Affective

Physiologic

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119
Q

Evaluation

A

Evaluative Statements

Variables Affecting Outcome Achievement

Actions based on PT response to care plan.

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120
Q

What are the 4 steps crucial to improving performance?

A

Discover a problem

Plan a strategy

Implement a change

Assess the change or plan new strategy

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121
Q

AACN standards for establishing and sustaining Healthy work environments

A

Skilled communication
True collab.
Effective Decision making
Appropriate staffing
Meaningful recognition
Authentic leadership

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122
Q

Name some evaluative programs

A

Quality assurance programs
structure evals
process evals
outcome evals
quality improvement
PT satisfaction
Peer Review
Nursing sensitive quality indicators

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123
Q

Bacteria, Fungi, and Viruses are

A

Infectious agent

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124
Q

Reservoir

A

Natural habitat of the organism

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125
Q

Portal of Exit

A

Point of escape for organism

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126
Q

Means of transmission

A

Direct contact or indirect. Contact. Airborne route.

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127
Q

Point at which organisms enter a new host

A

Portal of Entry

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128
Q

Susceptible Host

A

Must overcome resistance mounted by Host’s defense.

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129
Q

Name the Infection Cycle

A

Infectious Agent
Reservoir
Portal of Exit
Means of Transmission
Portals of Entry
Susceptible Host
Infectious Agent

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130
Q

Most Significant and most prevalent in hospital settings

A

Bacteria

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131
Q

Smallest microorganisms

A

Viruses

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132
Q

Fungi

A

Plant Like organisms present in air, soil, and water

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133
Q

Live on host or in a host and rely on it for nourishment

A

Parasites

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134
Q

How do we classify bacteria?

A

By

Shape
Response to staining
Need for oxygen

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135
Q

What are some factors that affect an organism’s potential to produce disease?

A

Number of organisms
Virulence
Competence of person’s immune system
Length of intimacy of contact between person and microbe

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136
Q

Endemic

A

Occurs with predictability in one specific region or population

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137
Q

Pandemic

A

Global outbreak of new or existing virus.

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138
Q

Name possible reservoirs of microbes

A

people
soil
water and food
animals
inanimate objects

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139
Q

Common Portals of exit include?

A

Respiratory
GI
GU tracts
Breaks in skin
Blood and tissue

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140
Q

What are some means of transmission?

A

Direct
Indirect
Droplet
Airborne

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141
Q

Name the stages of Infection

A

Incubation Period- organisms growing and multiplying

Prodromal stage- Person is most infectious, vague, and nonspecific signs of disease.

Full stage- presence of specific signs and symptoms of disease.

Convalescent- Recovery from infection.

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142
Q

Vasodilation increases blood flow. Histamine released causes permeability of vessels and protein rich fluid to get to the site of injury

A

Vascular Phase

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143
Q

Cellular Stage

A

Leukocytes/ Neutrophils consume debris; damaged cells are repaired

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144
Q

Inflammatory Response

A

Helps body Neutralize, control, or eliminate the offending agent and prepare the site for repair.

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145
Q

Immune Response

A

Humoral

Cell Mediated

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146
Q

Humoral Immunity

A

Antigen- Foreign material
Antibody- Body response to antigen

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147
Q

Cell Mediated

A

Increase in lymphocytes that destroy or react with cells that the body recognizes as harmful

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148
Q

Factors affecting risk for infection

A

Intact skin and mucous membranes
pH levels
Body’s WBCs
Age, sex, and heriditary factors
Immunization, natural, or acquired
Stress
Use of indwelling medical devices

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149
Q

What Lab values indicate infection?

A

Elevated WBC
Increase in specific types of WBCs
Elevated erthrocyte sedimentation rate
Presence of pathogen in urine, blood, sputum, or draining cultures.

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150
Q

What are some Outcome Identification and Planning infection control

A

Demonstrate Hand Hygiene
Identify signs of infection
Maintain nutritional intake
Proper disposal of soiled articles
Use appropriate cleansing and disinfecting techniques
Proper Immunizations
Demonstrate stress reduction techniques

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151
Q

Medical Asepsis

A

Clean Technique to reduce number of pathogens

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152
Q

Surgical Asepsis

A

Sterile Technique to keep area free from microbes

ex: Indwelling catheter

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153
Q

Transient Flora

A

Attache loosely on skin. Removed with relative ease

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154
Q

Resident Flora

A

Found in folds of skin, requires friction with brush to remove

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155
Q

What are the 7 targeted HAIs

A

CAUTI
SSI
CLABSI
STAPH AUREUS
MRSA
C DIFF or C DIFF infections

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156
Q

Name some Multi- Drug Resistant Organisms

A

MRSA
VRSA
VRE
CDI
Carbapenem Resistant Enterobacteriacae
Acinetobacter Baumannii

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157
Q

What are some factors determining use of sterilization and disinfection methods?

A

Nature of organisms present
Numbe of organisms present
Type of Equipment
Intended use of equipment
Available means for sterilization and disinfection
Time

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158
Q

Used in the care of all hospitalized PTs regardless of diagnosis

A

Standard Precautions:

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159
Q

Name some PT teaching for Medical Asepsis at home

A

Wash Hands before eating foods or preparing
Prepare foods at high temps
Wash Hands and cutting boards before and after meats etc
Wash raw fruits and veggies
Use Pasteurized products
Use Individual care items

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160
Q

What are some ways we can evaluate PT goals

A

Correctly use techniques
Identify health patterns and lifestyle habits
State S/S of infection
Identify unsafe situations in home environments

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161
Q

What are some factors affecting safety?

A

Developmental consideration
PT environments
Functional ability

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162
Q

Developmental Considerations for Neonate and Infant

A

Fetal considerations. Mobility. Car seats.

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163
Q

Developmental safety considerations for school age children

A

Accidents
Child abduction
Bullying

164
Q

Developmental Considerations for toddler and preschooler

A

Poisoning
Child Abuse
Environment
Asphyxiation

165
Q

Developmental Considerations for Older Adults

A

Falls
Motor vehicle accidents
Fire
Polypharmacy
Elder Abuse

166
Q

Adolescent safety considerations include

A

Driving
Piercings
Substance abuse
Social Media
Sex Trafficking

167
Q

Adult safety considerations include ?

A

Drug Use
Intimate Partner violence

168
Q

What are some safety considerations for Adults?

A

Remind them the effects of stress on lifestyle and health
Enroll in defensive driving course
Counsel unsafe habits
Counsel domestic violence

169
Q

What is the safety plan for victims of domestic violence?

A

Safety. Safety. Safety. Safety. Safety. Safety

Leaving a relationship.

170
Q

Name some safety considerations for Older Adults

A

Identify safety hazards in the environment
Modify environment
Encourage vision and hearing tests
Ensure availability assistive healthcare devices
Have operational smoke detectors in place
Objective document and report any signs of elder abuse

171
Q

PT environments include?

A

Work
Social
Home

172
Q

Functional ability includes?

A

Mobility
Sensory Perception
Ability to communicate
Knowledge

173
Q

Health includes?

A

Physical and Psychosocial

174
Q

Ways to Assess falls risk for older adults include?

A

History of falls or accidents
History of falls
History of drug abuse
Obtain knowledge of family support systems and home environments

175
Q

Factors that contribute to falls

A

Poor gait and balance
Strength issues
Visual impairment
Problems with feet
Comorbidities
Use of Medications
Orthostatic hypotension
Hazards in community
Vitamin D deficiency

176
Q

Name safety improvement Strategies

A

Preventing Falls Targeted Solutions Tool
Falls Toolkit
Falls Prevention Training Program
Root Cause Analysis

177
Q

Pt Outcomes for Safety

A

Identify real and potential unsafe situations
Implement safety measurements
Use available resources
Remain free of injury
Preventing falls
Using restraints in health care facilities

178
Q

Physiologic Hazards Associated with Restraints

A

Increased risk of falls
Skin breakdown
Contractures
Depression
Delirium
Anxiety
Death
Aspiration and respiratory difficulties

179
Q

Facility safety includes:

A

Fire safety
Alarm management
Preventing equipment and procedure related accidents
Filing a safety event report

180
Q

What are some procedure related accidents?

A

Transferring PTs
Changing a dressing
Administering meds

181
Q

Safety event reports must be completed when?

A

After any accident or incident in a health care setting
Describe circumstances of the incident
Completed by Nurse
Not part of the medical record

182
Q

Roles of the Skeletal System in Movement

A

Supports soft tissue of body
Protects crucial components of the body
Furnishes surfaces for attachment
Produces blood cells
Provides storage areas for minerals and fat

183
Q

Freely movable joints include:

A

Ball and socket
Condyloid
Gliding
Hinge
Pivot
Saddle

184
Q

Longs bones include:

A

Upper and lower extremities

185
Q

Short Bones include:

A

Wrist and ankle

186
Q

Flat Bones

A

Ribs and skull bones

187
Q

Irregular Bones

A

Spinal column and jaw

188
Q

Name some joint movements

A

Abduction
Adduction
Extension
Flexion
Rotation
Dorsiflexion
Plantar Flexion

189
Q

What are the effects of nervous system on muscle contraction?

A

Neurons conduct impulses from one part of body to another

Afferent to CNS to Efferent Neurons

190
Q

Name some Postural Reflexes

A

Labyrinthe Sense
Proprioceptor or kinesthetic sense
Visual or optic reflexes

191
Q

Name factors affecting mobility

A

Developmental
Physical Health
Mental Health
Lifestyle
Attitude and Values
Fatigue and Stress
Risks related to exercise

192
Q

Muscle shortening and active movement

A

Isotonic

193
Q

Muscle contraction without shortening

A

Isometric

194
Q

Muscle contraction with resistance

A

Isokinetic

195
Q

Effects of immobility on the body

A

Cardiovascular System
Resp. System
Musco skeletal System
Metabolic Processes
Skin
GI
Urinary System
Psychosocial

196
Q

Health History Includes

A

Daily Activity Level
Endurance
Exercise and fitness
Mobility Problems
External factors affecting mobility
Physical or mental alterations

197
Q

Physical Assessment for Mobility

A

General ease of movement
Gait/ Posture
Alignment
Joint structure
Muscle mass
Endurance

198
Q

Practice of designing equipment and work tasks to confirm to the capability of the worker

A

Ergonnomics

199
Q

Name variables that can lead to PT handeling injuries

A

Uncoordinated Lifts
High exertion
Awkward postures
Manual Lifting
Repetitive movements
Standing for long periods of time

200
Q

Variables leading to Back Injury to Healthcare workers

A

Uncoordinated lifts
Manual lifting
Lifting when fatigued
Transferring PTs
Repetitive movements

201
Q

Name some equipment and assistive devices

A

Gait Belts
Friction Reducing sheets
Transfer chairs
Powered stand and assist
Mechanical lateral assist devices

202
Q

Ways to Position PTs

A

Pillows
Mattresses
Adjustable Beds
Bed side rails
Trapeze Bar

203
Q

Types of Positions

A

Fowlers
Supine/ Dorsal Recumbent
Side Lying
Sims
Prone

204
Q

Name the VS

A

T
RR
HR
BP
SpO2
Pain

205
Q

When do we check or obtain VS

A

On admission
Based on facility policies
Any time change in PT condition
Before and after any surgical or invasive procedure
Before and after activity that may increase risk
Before administering medications that affect CV or Resp. function

206
Q

What is the primary source of metabolism?

A

Temperature

207
Q

When additional heat is required and alter metabolism what is released?

A

Epi and Norepi

208
Q

Axillary range Temperature

A

35.4-36.9 C

209
Q

Oral Temp.

A

35.9-37.5 C

210
Q

Rectal/Bladder Temp

A

36.3- 38.1 C

211
Q

Temporal Artery Temp

A
  1. 3- 38.1 C
212
Q

Tympanic Temp

A

36.8- 38,3

213
Q

Name sources of heat loss

A

Skin
Evaporation of Sweat
Warming and humidifying air
Eliminating urine and feces

214
Q

Without fever

A

afebrile

215
Q

With Fever

A

Pyrexia

216
Q

Intermittent Fever Temp

A

Returns to normal state at least once

217
Q

Regulated by SA node

A

Pulse

218
Q

Decreases HR

A

Parasympathetic

219
Q

Increases HR

A

Sympathetic

220
Q

Pulse Rate

A

Number of contractions over a peripheral artery in a minute

221
Q

Name Assessment Considerations for Pulse

A

Rate
Amplitude
Rhythm
Stroke Volume- Blood ejected with each heart beat

222
Q

Movement of air in and out of lungs

A

Ventiliation

223
Q

Diffusion

A

Exchange of oxygen and CO2 in alveoli and circulating blood

224
Q

Perfusion

A

Exchange of oxygen and CO2 between circulating blood and tissue cells

225
Q

Most powerful Resp stimulant

A

CO2

226
Q

Rate and Depth of breathing

A

Changes in response to tissue demands
Controlled by medulla and pons
Activated by chemoreceptors

227
Q

`Eupnea

A

Normal breathing. One resp/ to 4 heartbeats

228
Q

Dyspnea

A

Difficult or labored breathing

229
Q

Orthopnea

A

Changes in breathing when sitting or standing

230
Q

Difference between Systolic and Diastolic pressure is called

A

Pulse Pressure

231
Q

SHort Term regulation of BP is caused by

A

Nerve or Humoral

232
Q

Heart has what to monitor CV changes?

A

Baroreceptors

233
Q

Name some factors affecting Blood Pressure

A

Age
Race
Circadian Rhythm
Biologic Sex
Food Intake
Exercise
Weight
Emotional State
Body Position
Drugs/ Meds

234
Q

Hypotension

A

Decrease in Blood pressure
Side effect of Meds
Inability of the body to maintain or return pressure back to normal

235
Q

Orthostatic Hypotension

A

Inadequate Physio response to position changes
Occurs when rising to an erect position
Caused by dehydration, blood loss, or problems of the neurologic, CV, or endocrine systems

236
Q

Pulse Oximetry

A

Normal 90-100
Measures Peripheral arterial oxyhemoglobin saturation of arterial blood
Actual oxygen content of hemoglobin and potential max oxygen capacity of Hemoglobin

237
Q

Conduction along pathways A delta to C delta fibers

A

Transmission of Pain

238
Q

Types of Pain

A

Acute
Chronic

Location

Localized
Somatic
Visceral
Cutaneous
Referred

239
Q

Inhibition or modulation of pain

A

Modulation

240
Q

Activation of pain receptors

A

Transduction

241
Q

Pain and nociception are the same?

A

False

242
Q

Rapid onset of pain

A

Acute

243
Q

May be limited, intermittent, or persistent
Lasts beyond normal healing period
Periods of remission

A

Chronic

244
Q

PQRST

A

P- precipitating factors
Q- quality of pain
R- radiation
S- severity
T- timing

245
Q

Terms used to describe pain

A

Quality
Severity
Periodicity

246
Q

What are some basic methods of assessing pain?

A

PT self report
Identify pathologic or procedures causing pain
Report from family or other members close to PT
Nonverbal behaviors
Physiologic measures

247
Q

What pain assessment tools do we use?

A

Numeric Rating Scale
Adult nonverbal scale
Wong Baker Faces

248
Q

Nursing Interventions for Pain

A

Establishing Trusting relationship
Manipulating the Pain
Managing Pharm measures
Ensuring ethical responsibility to relive pain
Understanding Placebo controversy

249
Q

Complementary Health Approaches and Integrative Health Care

A

Distraction
Humor
Music
Imagery
Mindfulness
Acupuncture
Hypnosis
Biofeedback
Cutaneous Simulation

250
Q

Teaching about Pain

A

Should include family members
Explanation about pain scales
Safety
Keep diary of pain
Diet

251
Q

Types of Data

A

Subjective - Based on PT experiences and perceptions

Objective- Measurable and directly observed.

252
Q

Health Assessment includes what?

A

Health History
Physical Assessment

253
Q

Types of Health Assessments

A

Comprehensive

Ongoing partial

Focused

Emergency

254
Q

What are some factors to assess during a health history?

A

Intake
Bio data
Reason for care
History
Family history
Functional health

255
Q

How to prepare the PT for physical assessment

A

Consider physio and psycho needs of the PT

Explain the process
Alleviate anxiety
Explain each procedure
Lifespan considerations
Cultural considerations
PT prep
Environmental Prep

256
Q

Sims

A

Assessment of rectum or vagina

257
Q

Prone

A

Assessment of hip joint and posterior thorax

258
Q

Lithotomy

A

Assessment of female genitalia and rectum

259
Q

Knee Chest

A

Assessment of anus and rectum

260
Q

Name techniques used during a Physical Assessment

A

Inspect
Palpate
Percussion
Auscultation

261
Q

Head and Neck assessment includes ?

A

Identify risk factors changes in vision and hearing
History of trauma
Thyroid Gland and Lymph nodes
Inspection and palpitation

262
Q

Respiratory Assessment

A

Identify Risk Factors
Chest Expansion

263
Q

Name some Lung sounds

A

Bronchial
Bronchovesicular
Vesicular

Wheeze
Rhonchi
Crackles
Stridor
Friction Rub

264
Q

What are some common thorax and lung variations in Older adults?

A

Increased AP chest diameter
Increased in spine curve. (kyphosis)
Decreased expansion
Use of accessory muscles to exhale

265
Q

CV Assessment

A

Identify Risk Factors
Inspection, palpitation, and auscultation
Heart Sounds, Pulses, and CArotids

266
Q

Cardiovascular Variations in Older Adults

A

Difficult to palpate apical pulse
Difficult to palpate distal arteries
Varicosities
Increased BP
Widening Pulse Pressure

267
Q

Name the order for Abdominal Assessment

A

Inspection
Auscultation
Percussion
Palpatation

268
Q

Abdominal VAriations in older adults include:

A

Decreased in bowel sounds and abdominal tone
Fat accumulation in abdomen and hips

269
Q

Musculoskeletal Assessment

A

Identify Risk Factors

ex: Trauma
History of pain
Frequency and type of exercise
Diet
Smoking

Inspection and palpation

270
Q

Neurological Assessment

A

Identify risk factors
Health History
Mental Status
Memory
Cognitive abilities
Cranial Nerve Function
Motor and Sensory Relexes

271
Q

Ways to Assess Mental Status

A

LOC

GCS

Memory

Language

272
Q

What are the purposes of documentation of health history and physical assessment?

A

Identify actual and potential problems
Plan care
Evaluate PT response

273
Q

Integrative Health

A

Refers to the combination of complementary health and conventional health approaches in a coordinated way

274
Q

Treatment of symptoms and diseases using drugs, radiation, or surgery

A

Allopathic Medicine

275
Q

Theory and philosophy that focuses on connections and interactions between parts of the whole

A

Holism

276
Q

Practice built on a holistic philosophy and healing the whole person

A

Holistic Nursing

277
Q

Integrative Health Care

A

Combination of allopathic and complementary and alternative modalities.

278
Q

Allopathic Medicine

A

Illness occurs in either the mind or body
Health is absence of disease
Main cause are pathogens
Empahsis is on disease and high technology

279
Q

Holism

A

Focuses on connections of parts of the whole
Body is a dynamic whole

280
Q

Name some Complementary Health Practices

A

Mind Body
ex: Relaxation Meditation

Qi Gong
Acupuncture
Yoga
Ayurveda

281
Q

Hygiene Assessment

A

Hair Nails Feet
Skin
Cultural considerations
developmental levels
Oral Hygiene
Visual
Hearing

282
Q

Assessing the Skin

A

Incorporate with all body systems
Use good lighting
Symmetry
Identify variables known to cause skin problems

283
Q

Name the structure and function of the skin

A

Epidermis - Waterproof layer with no blood vessels

Dermis- Made of collagen made of nerves, hair follicles, glands, and blood vesels

Subcutaneous- Anchors skin layers to underlying tissues

Protection
Body Temperature
Psychosocial
Vitamin D Production
Absorption
Elimination

284
Q

Name some factors affecting the skin

A

Very thin or obese people
Fluid loss in illness causes skin breakdown
Diseases such as eczema may cause lesions that require care
Jaundice- Yellow color of skin

285
Q

As the person ages

A

Maturation of epidermal cells prolonged leading to thin skin

Decreased collagen = decreased elasticity= risk for tissue damage

286
Q

Name some principles of Wound Healing

A

Intact Skin is 1st line of defense

Normal healing is promoted when the wound is free of foreign material

Response of wound is more effective with proper nutrition

287
Q

Local Factors Affecting Wound Care

A

Pressure
Desccation- Dehydration
Maceration- Overhydration
Trauma
Edema
Infection
Infection
Biofilm
Necrosis

288
Q

Systemic Factors Affecting Wound Healing

A

Age
Circulation and Oxygenation
Nutritional Status
Wound Etiology
Health Status
Immunosuppression
Medication Use
Adherence to Treatment of Pain

289
Q

Factors Affecting Pressure Injury Development

A

Aging Skin
Chronic Illnesses
Immobility
Malnutrition
Fecal and Urinary Incontinence
ALOC
Spinal and Brain Injuries
Friction/ Shearing forces
Microclimate

290
Q

Stage 1 Pressure Injury

A

Nonblanchable red intact skin

291
Q

Stage 2 Pressure

A

Partial Thickness skin loss with exposed dermis

292
Q

Stage 3 Pressure

A

Full thickness skin loss not involving the underlying fascia.

293
Q

Stage 4 Pressure

A

Full thickness skin and tissue loss

294
Q

Unstageable Pressure

A

Obscured full thickness skin and tissue loss

295
Q

Deep Tissue Pressure Injury

A

Persistent Non blanchable purple or red discoloration

296
Q

Ways to prevent Pressure Injuries

A

Assess at risk PTs daily
Cleanse skin routinely
Maintain higher humidity
Proper positioning
Nutritional supplements
Improve mobility and activity

297
Q

What are some factors affecting the response to Hot/ Cold therapies?

A

Method and Duration
Degree of heat and cold applied
PT age and condition
Amount of body surfaced covered by application

298
Q

Effects of Applying Heat

A

Dilates peripheral blood vessels
Increase tissue metabolism
Reduces blood viscosity and muscle tension
Helps relieve pain

299
Q

Effecrs of Applying Cold

A

Contricts blood vessels
Reduces Muscle spasms
Promotes comfort

300
Q

Assessment of Oral Cavity

A

Lips
Buccal
Color of gums
teeth
tongue
hard/soft palates
Oropharynx

301
Q

Ways of administering oral hygiene

A

Moistening mouth
Cleaning mouth
Caring for dentures
Toothbrushing and flossing
Using Mouthwashes

302
Q

Early Morning Care includes

A

Assist Pt with toileting
Provide comfort measures
Wash face and hands
Provide mouth care

After morning breakfast nurse completes:

Toileting
Oral care
Bathing
Back massage
Special Skin measure
Hair
Dressing
Refreshing Bed
Tidying bedside

303
Q

Afternoon Care

A

Ensure PT comfort after lunch:
Offer toileting
Straighten bed linens
Help PT with mobility

304
Q

HS Care

A

Offer assistance with toileting, washing, and oral care

Change bed if soiled
Ensure call light and objects in reach
Position comfortably

305
Q

PRN Care

A

Offer hygiene as needed
Oral care when needed
Change bed linens as needed

306
Q

Bath Time does what?

A

Cleanse skin
Helps relax a person
Promotes circulation
Stimulates respirations
Helps improve self image
Strengthens nurse to PT relationship

307
Q

Perineal and Vaginal Care

A

Cleanse with soap and water
Assess
Perform in a dignified manner according to procedures

308
Q

Care of Eyes

A

Clean from inner to outer
Use artificial tear solution or NS if blink reflex is absent every 4 hours
Care for glasses or contacts

309
Q

Ear and Nose Care

A

Perform hearing aid teaching
Wash ears with wash cloth
Clean nose by having PT blow nose
Remove crusted secretions by applying a warm compress

310
Q

Providing Hair Care

A

Identify PT usual hair and scalp care

History of hair or scalp problems

Treat any infestations

Groom and shampoo

Care for beards

Use electric razor for PT on anticoags

311
Q

Nail and Foot Care

A

Assess Nail for color and shape

Check for History of health related problems

Soak nails and feet and assist with cleaning

Massage feet to promote comfort and relaxation

Provide diabetic foot care if needed

312
Q

How to ensure bed safety

A

Bed in lowest position

Safe for PT

Bed controls are working

Call light in reach

Side rails raised

Wheels are locked

313
Q

PT Outcome Achievement

A

Level of PT participation in hygiene

Elimination of factors affecting PT’s hygiene

Changes related to specific skin problems and independent PT management of prescribed treatment program

314
Q

Rest

A

Refers to a condition in which the body is in a decreased state of activity

315
Q

Define Sleep

A

Sleep is a state of rest accompanied by altered consciousness and relative inactivity.

316
Q

Stages of Sleep

A

Stages 1 to 4

Contains NREM and REM

317
Q

What happens in REM?

A

Everything in body increase except skeletal tone and DTRs.

318
Q

A person passes through consecutively through 4 stages of sleep

A

True. Then the pattern is reversed.

319
Q

What are the effects of ineffective sleep?

A

May affect normal growth.

May increase obesity.

Lowers Leptin levels and increases Ghrelin

320
Q

Name factors affecting sleep

A

Activity/ Exercise
Dietary Habits
Smoking
Stress
Medication effects
Sleep Disorders

321
Q

OSA

A

Obstructive Sleep Apnea

Characterized by at least 5 or more of the following

The absence of breathing
Diminished breathing
Respiratory effort related arousals
Subjective nocturnal Resp disturbances
Gasping for air
Observed apnea and other disorders

322
Q

RLS

A

Restless Leg Syndrome also known as Willis Ekbom disease in middle aged and older adults. 15%

Can’t lie still and report unpleasant creeping

Non Pharm treatments

323
Q

How to obtain Sleep History

A

Nature of problem
Cause of problem
Related Signs and Symptoms
When the problem began
How it affects everyday living
Severity of the problem
How the PT is coping with the problem

324
Q

Screening Tools to Assess Sleep Disturbances

A

Sleep Diary
Sleepiness Scale
Stop Bang Questionaire

325
Q

What are some nursing interventions to promote sleep?

A

Prepare a restful environment
Bedtime rituals
Appropriate snacks and beverages
Promote relaxation and comfort
Use meds
Teach about rest
Schedule care to avoid disturbances

326
Q

Six Classes of Nutrients

A

Nutrients that Supply energy

Carbs, lipids, and Proteins

Nutrients that regulate Body processes

Vitamins, Minerals, and Water

327
Q

Energy Balance

A

Derived from food. From lipids, carbs, and proteins

328
Q

BMR

A

Energy required to fuel involuntary activities of the body at rest after 12 hours. Energy needed to sustain metabolic activities.

Increase BMR: Stress, infection, fever, emotional stress, extreme temps

Decrease BMR:
Aging, Fasting, and sleep

329
Q

BMI

A

Ratio of Kg to HT

Estimate body fat

Provides estimation to relative risk for diseases

May be inaccurate for some groups

330
Q

Vitamins Fat Soluble

A

A D E K

Absorbed through intestinal wall into bloodstream

331
Q

Vitamins

A

Organic compounds needed in small amounts

332
Q

Minerals

A

Organic elements found in all body tissues and fluids

333
Q

Macrominerals

A

Calcium, potassium, phosphorus, sulfur, sodium chloride, magnesium

334
Q

Microminerals

A

Iron, zinc, manganese, copper, fluoride, molybdenum, selenium, iodine

335
Q

Water

A

Two Thirds is intracellular fluid
One third is ECF
Provides fluid medium necessary for all chemical reactions
Acts as a solvent and aids digestion, absorption, circulation, and excretion.

336
Q

Factors affecting nutritional intake

A

Medications
Religion
Culture

Decreased = Anorexia
Increased= Obesity

337
Q

Nursing Interventions for Nutrition

A

Teaching nutritional information
Monitoring nutritional status
Stimulate appetite
Assist with eating
Providing oral nutrition
Providing long term support

338
Q

Types of Diet

A

Therapeutic

Consistent Carb
Fat or sodium restricted
High or Low Fiber
Renal

Modified
Clear liquid
Pureed
Mechanically altered

339
Q

Short Term Nutritional Support

A

Use NG or NI route
Confirm placement
Measurement correctly
CO2 monitoring

340
Q

Long Term Nutritional Support

A

Enterostomal tube is created

341
Q

Comatose preferred route is

A

Gastrostomy

342
Q

Placement of the tube can be done by the surgeon or gastroenterologist via PEG or surgically opened

A

True

343
Q

Enteral vs Parenteral Feeding

A

Highly concentrated hypertonic solutions that contains amino acids, carbs, and lipids

Given through Central line

PPN vs TPN

344
Q

Micturition

A

Process of emptying the bladder

Detrusor muscle contracts, internal sphincter relaxes and urine enters the posterior urethra.

Muscles or perineum and external sphincter relax

Muscle of abdominal wall contracts slightly
Diaphragm lowers and urination occurs

345
Q

Diseases associated with Renal

A

DM
Gout
UTI
Hypertension
Polycystic Kidney Disease

346
Q

Direutics

A

Prevent reabsorption of water and certain electrolytes in tubules

347
Q

Cholinergic

A

Stimulate contraction of detrusor muscles

348
Q

Analgesics

A

Supress CNS and neural reflex

349
Q

Medications that affect Urine

A

Anticoags- red
Direutics- yellow
Pyridium- orange
Antidepressant- Blue
Levodopa- brown

350
Q

Nursing History

A

Usual Patterns of urinary elimination
Recent changes in urinary elimination
Aids to eliminate
Present or past occurrence
Presence or urinary diversion

351
Q

Physical Assessment of Urinary Functioning

A

Kidneys - Palpitation done by advanced practitioner

Urinary Bladder - Palpate and bladder scanner

Urethral Orifice- Signs for infection, discharge, or odor.

Skin- Assess color, texture

Urine -Assess for color, ordor, and temperature.

Measuring Output- Continent PT, Incontinent PT, Indwelling catheter

Routine Urinalysis-
Clean catch or midstream
Sterile Specimen
Urinary Diversion
24 Hour Specimen

352
Q

Measuring Urine Output

A

Ask the PT to void into the bedpan or bathroom or urinal
Put on gloves
Read at eye level in proper device
Document and record
Discard urine unless specimen is needed

353
Q

Ways to promote urinary elimination

A

Maintaining regular voiding habits
Promoting fluid intake
Strengthens muscle tone
Assisting with toileting

354
Q

Planned PT goals for Urinary

A

Fluid and electrolyte balance
Empty bladder regularly
Ease of voiding
Maintain skin integrity
Equal input and output

355
Q

PTs risk for UTIs

A

Sexually active people with female genetalia
Postmenopausal
PT with indwelling catheter
People with DM
Older adults

356
Q

Transient

A

Appears suddenly and lasts 6 months or less

357
Q

Mixed

A

Urine loss with features of two or more types of incontinence

358
Q

Overflo

A

Overdistention and overflow of bladder

359
Q

Functional is caused by outside factors.

A

True.

360
Q

Reflex

A

Emptying bladder without sensation of need to void

361
Q

Total

A

Continuous unpredictable loss of urine

362
Q

Stress

A

Involuntary loss of urine related to an increase of abdominal pressure.

363
Q

Urine Collection Devices

A

External
Internal
Absorbent Products

Consider functional disability, type and severity, gender, PT preference

364
Q

Process of Peristalsis

A

Under control of nervous system
Contractions occur every 3to12 minutes

Mass Peristalsis sweeps occur 1-4 times in a 24 hour period

1/3rd to 1/2 is exerted in stool within 24 hours

365
Q

Name some variables influencing Bowel Elimination

A

Developmental considerations
Daily Patterns
Food and Fluid
Actvity and muscle tone
Lifestyle
Psychological Variables
Pathologic conditions
Meds
Surgery and Anesthesia

366
Q

Older Adult and BM

A

Constipation is chronic

Diarhhea or fecal incontenence may result from physiologic or lifestyle changes

367
Q

Sequence for abdominal assessment

A

Inspect
Auscl
Percussion
Palpatation

368
Q

Physical Assessment of Anus and Rectum

A

Inspection and palpatation

Lesions, ulcers, and fissures

Ask PT to bear down as having a BM

Inspect perineal area.

369
Q

Stool Collection

A

Medical A sceptic technique
Hand hygiene
Wear disposable gloves
Do not contaminate
Label and transport accordingly

370
Q

Stool Characteristics

A

Volume
Color
Odor
Consistency
Shape
Constituents

371
Q

Bowel Habits

A

Timing Positioning
Privacy
Hygiene
Nutrition
Exercise

372
Q

Direct Visualization Studies :

A

EGD
Colonoscopy
Sigmoidoscopy
Wireless Video Capsule

373
Q

Indirect Visualization Studies

A

UGI
Small Bowle Series
Barium Enema
Abd. Ultrasound
MRI
CT scan of Abd.

374
Q

PT Outcomes for normal BMs

A

Soft and formed w/out discomfort
Able to explain the relationship between BM and dietary fiber, fluid intake, and exercise.
Skin integrity and notify HCP if anything of stool changes

375
Q

Name Individuals at High Risk for Constipation

A

PT on bedrest or immobility
PT taking constipating meds
PT with reduced fluids
PT that is depressed
PT with CNS diease or local lesions that cause pain while defecating

376
Q

Nursing Measures for PT with Diarrhea

A

Answer Immediately
Remove cause
Risk for impaction hold antidiarrheal meds
Give special care to anus region

377
Q

Ways to Prevent Food Poisoning

A

Take item refrigerate immediately
Wash hands and surfaces
Use separate cutting boards
Wash all fruits and Veggies
Never use raw eggs Do not eat seafood raw or undercooked
Use food thermometer
Keep food hot after cooking

378
Q

Methods of emptying the colon of feces

A

Enemas - Cleansing and retention

Hypertonic large and small volumes
Rectal Suppositories
Oral intestinal Lavage
Digital removal

379
Q

Managing Bowel Incontinence

A

Note when it likely to occur
Keep the skin Clean and Dry
Change bed and clothing
Bowel training programs
Indwelling rectal tube
External anal pouch —————

380
Q

Bowel Training Programs

A

Manipulate factors within PT control
Plan bowel program w PT and family
Set regular time for BM
Monitor
Ensure privacy and adequate fluid and diet
Stimulate BMs

381
Q

Alternatives

A

NG tubes
Ostomies

382
Q

Functions of Water in the Body

A

Transporting nutrients and wastes from cells

Facilitating cellular metabolism

Acting as solvent

Maintains body temperature

Acting as tissue lubricant

383
Q

ICF

A

70% fluid in cells

384
Q

ECF

A

intravascular and interstitial

30%

385
Q

Fluid Loss

A

Kidneys- Urine
Intestinal- Feces
Skin- Perspiration
Insensible water loss

386
Q

Hypovolemia

A

Deficiency in amount of water and electrolytes in ECF with near normal limits

387
Q

Interstitial to plasma shift

A

Movement of fluid from space surrounding cells to blood

388
Q

Sodium

A

Controls and regulates volume of body fluids

389
Q

Potassium

A

Chief regulator of cellular enzyme activity and water content

390
Q

Calcium

A

Nerve impulse
Blood clotting
Muscle contraction
b12

391
Q

Magnesium

A

Metabolism of carbs and proteins
Vital actions of enzymes

392
Q

Chloride

A

Maintains osmotic pressure in blood and produces HCI

393
Q

BICARB

A

Body’s primary buffer system

394
Q

Phosphate

A

Involved in important chemical reactions in the body, cell division, and hereditary traits

395
Q

Osmolarity of Solutions

A

Isotonic- Same concentration as plasma

Hypo- Lesser than plasma

Hyper- Greater than plasma

396
Q

Capillary Filtration

A

Passage of fluid through permeable membrane from high to low pressure

397
Q

ACID

A

Substance containing hydrogen ions that can be liberated or released

398
Q

Base

A

Substance that traps Hydrogen ions

399
Q

Acidosis

A

Excess Hydrogen ions

400
Q

Alkalosis

A

Loss of hydrogen ions

401
Q

RF for Imbalances

A

Patho of acute or chronic illnesses
Abnormal losses of body fluids
Burns
Trauma
Surgery Therapies that disrupt fluid imbalances

402
Q

Physical Assessment

A

Skin and tongue turgor
Moisture of oral cavity
Tearing and salivation
Appearance and Temp of skin
Facial Appearance
Edema
VS

403
Q

Expected Outcomes

A

Maintain appropriate fluid intake and output balance

Urine specific gravity 1.010- 1.035

Imbalance occurs:
Report relief of symptoms
Exhibit S/S of restored balance
Identify S/S of recurrence

404
Q

Implementation of Electrolyte Imbalances

A

Preventing them
Developing diet plan
Modifying Fluid intake
Administering Meds
Administering IV fluid therapy

405
Q

Nurses Role In Diagnostic Procedures

A

Assist before, during, and after
Complete Testing
Witness PT consent
Schedule Test
Prepare the PT physically and emotionally
Provide care and teaching after the test
Dispose used equipment
Transport specimens

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