Med-Surg Nursing Flashcards
roles in med-surg nursing
direct patient care, education, advocacy, leadership
components of comprehensive assessment
functional capacity assessment, physical assessment, nutritional assessment, cultural assessment
functional capacity assessment
evaluation to determine pt ability to function in various areas to guide treatment and care
physical assessment
evaluating strength, endurance, ROM
mental/emotional evaluation
assessing cognitive and emotional well-being
nutritional assessment
composed of dietary history (intake, preferences, restrictions), anthropometrics (BMI, weight, height), biochemical analysis (lab results), clinical signs (malnutrition or overnutrition)
nursing interventions: nutritional assessment
educate pt on healthy dietary choices, collaborate with dieticians
cultural assessment
assess communication preferences and nonverbal cues, assess health beliefs and practices, assess nutritional practices (restrictions and dietary customs), assess family roles and social support (decision making)
nursing interventions: cultural assessment
show respect and sensitivity to differences, use interpreters, use culturally appropriate educational materials
disability
physical or mental condition that limits a persons movement, senses, or activities
chronic illness
long lasting condition that can be controlled but not cured
physical impact
might affect the physical well-being and daily activities of individuals (limited mobility, chronic pain, fatigue)
emotional/mental impact
coping, stress of long-term management, emotional toll of living with a chronic condition or disability
role of nursing is to
assess, manage, and advocate and support patients
steps of clinical judgment
noticing by recognizing cues and gathering data, interpreting the data, responding by implementation of nursing actions, reflecting on the outcomes for future improvement
physiological changes in older adults
decreased organ function and reserve, changes in skin elasticity and bone density, altered pharmacokinetics affecting metabolism and sensitivity
nursing interventions for physiological changes in older adults
monitoring for signs/complications, adjusting care plans to account for slower healing and reduced mobility, educating pt on fall risk and skin care
visual changes in older adults
cataracts: clouding of the lense, macular degeneration: deterioration of the central portion of the retina (affects detailed vision), glaucoma: increased intraocular pressure causing optic nerve damage and vision loss
nursing interventions: older adult visual changes
ensure adequate lighting, assistive magnifiers, schedule regular eye exams and monitor for changes in vision, educate pt on symptoms that require immediate medical attention
auditory changes in older adults
presbycusis: age related hearing loss (usually to high frequency), tinnitus: ringing/buzzing in ears, earwax accumulation
nursing interventions: hearing loss in older adults
regular hearing checks and cleanings, use of low-pitched clear speech (no shouting), encourage use of hearing aids
normal cognitive changes in older adults
slower processing speed, mild short-term memory changes, decreased multitasking ability
mild cognitive impairment in older adults
in between normal and dementia related cognitive impairment; greater memory problems but maintains ability to perform most daily tasks
nursing interventions: mild cognitive impairment in older adults
encourage regular cognitive exercises and social engagement, monitor progression and involve healthcare providers when needed
dementia
broad term for decline in mental ability severe enough to interfere with daily life (alzhemeirs is most common type)
alzheimer’s disease
characterized by decline in memory, language, problem-solving
nursing interventions: dementia and alzheimers
provide structured environment, use clear communication and visual cues, support families/caregivers with education/resources
delirium
acute sudden change in mental status with confusion, inattention, and fluctuating levels (often reversible)
causes for delirium
infections, medications, surgery, stressors
nursing interventions: delirium
identify/treat underlying cause, maintain calm comfortable environment, reorient often, provide clear information for pt
mental health in elderly
increased depression/anxiety, isolation/loneliness risk, dementia/alzheimer’s
nursing interventions: mental health elderly
regular screening for mental health issues, facilitate social interactions/community engagement, collab with mental health pros
perioperative nursing
preoperative, intraoperative, postoperative; requires thorough assessment and monitoring
perioperative detailed medical history consists of
chronic conditions, meds, allergies, previous surgeries or reactions to anesthesia, pertinent family history
conditions causing high surgical risk
cardiovascular diseases (HTN, HF, arrhythmias), respiratory diseases (COPD, asthma), diabetes mellitus, renal impairment (affects drug clearance and wound healing), liver disease (alters metabolism or drugs and impacts clotting)
medications of concern
anticoagulants (bleeding precautions), antiplatelet (bleeding precautions), diabetic medications (peri-op hypo or hyperglycemia), antihypertensives, herbal supplements
psychosocial assessment
confirm pts understanding and expectations of procedure, discuss pt anxiety and fears of procedure, identify pt support system, acknowledge cultural and spiritual considerations
routine diagnostic testing and labs
cbc, electrolytes, coagulation profile, blood typing/screening
specific assessment diagnostic testing and labs
EKG, chest Xray
risk for infection
identify factors that may increase infection risk such as diabetes of immunosuppression
venous thromboembolism (VTE) risk
assess history of clots, mobility status, and other risk factors
anesthesia risk
identify any factors that may complicate anesthesia such as OSA or difficult airway
surgical consent components
disclosure: explanation of the procedure, alternatives, risks, benefits, potential outcomes; capacity: pt ability to understand the information and make a decision; voluntariness: pt right to make a decision free from coercion
nurse role in consent process
clarify medical jargon and reiterate key points provided by surgeon, ensure pt questions are answered, confirm pt understands information and is voluntarily giving consent, sign as a witness signature
pre-op checklist
ID bracelet, allergy bracelet, verify nutrition and IV status, pre-op checklist complete, appropriate forms completed, PMH, PE, remove accessories/make-up, identify surgical site, admin meds
intraoperative care
aseptic technique: prevent infection by maintaining sterile environment, pt monitoring: continuously monitor vital signs fluid balance and anesthesia effects
post-operative care
promote recovery, prevent complications, ensure safe transition from surgical unit; monitor vitals; monitor pain; monitor incision
post-op nursing interventions
encourage deep breathing, coughing, early mobilization to prevent complications; educate pt and family about potential complications and care instructions
peri-operative complications
surgical site infections (SSIs) are infections at or near surgical site, venous thromboembolism (VTE) are blood clots that can develop and potentially travel to the lungs, anesthesia reactions are unexpected reactions to anesthesia like allergies or respiratory issues
geriatric considerations
low cardiac and respiratory reserves, decreased GI motility, neurological delirium post-op, decreased organ function (hepatic/renal), decreased SC fat, fragile skin (more susceptible to temp changes)
pain management
pharmacological interventions: use of analgesics and monitoring for side effects, non-pharmacological interventions: using techniques like ice, elevation, distraction, relaxation
discharge planning
begins on admission, instructions on home care (wound care/activity restrictions/med management), follow up appts
