MedSurg1 test1 Flashcards
There are nine key areas where nursing practice can be improved on:
1) ÊMedication administration 2) Clearly communicating patient data and clinical assessments 3) ÊAttentiveness/surveillance of patients 4) ÊClinical reasoning or judgment 5) ÊPrevention of errors or complications 6) ÊIntervention (carrying out nursing actions in an appropriate and timely manner 7) ÊInterpretation of authorized provider order 8) Professional responsibility and patient advocacy 9) ÊMandatory reporting
What are the components of the nursing process?
Assessment, problem identification/diagnosis, planning, implementation, evaluation
This nursing process includes objective/ subjective data, psychological, socio-cultural, spiritual, economic, and lifestyle factors as well
assessment
This nursing process includes Nursing Diagnosis, NANDA, Related to (R/t), As evidenced by (AEB), The nurseÕs clinical judgment about the PtÕs response to actual or potential health conditions or needs. It is the basis for the nurseÕs care plan
problem identification/diagnosis
This nursing process includes: Goals- General
- Outcomes- Specific
- Measurable and achievable short- and long- range goals based on the assessment and diagnosis
Planning
This nursing process includes interventions and nurse to nurse orders
Implementation
This nursing process includes determines if goals are met/outcomes were met, was the problem solved?
Evaluation
What are the goals of QSEN?
Patient- Centered Care, Teamwork and Collaboration, Evidence- Based Practice, Quality Improvement (QI), Safety, Informatics
Essentials to preoperative care; physical exam, lab data, medication history, medical history/general status
physiological
Essential to preoperative care; stress response/level of anxiety, support systems,consider clientÕs cultural aspects
psychosocial
essential to preoperative care: obtain informed consents, operative permits,blood tranfusion (blood type screen), DPA (durable power of attorney)
legal issues
essential to pre-operative care; inform client about what to expect postoperatively, demonstrate use of PCA pump if prescribed, instruct patient in deep breathing technique and coughing technique to prevent pneumonia and atelectasis; Instruct patient on the need to request an opioid for pain management and other techniques to manage pain.
pre-operative teaching
essential to pre-operative care; bowel and skin prep (elimination and surgical site cleansing), food and fluids (NPO status), rings, jewelries, dentures, makeup, hairpins, nail polish, glasses and metals; pre-op meds, and Pre-op checklist completed( allergy band, Id band
pre-operative tasks
This type of nurse provide surgical patient care by assessing, planning, and implementing the nursing care patients receive before, during and after surgery. These activities include patient assessment, creating and maintaining a sterile and safe surgical environment, pre- and post-operative patient education, monitoring the patientÕs physical and emotional well-being, and integrating and coordinating patient care throughout the surgical care
OR Nurse
This type of nurse monitors and minimizes anesthesia efffects
PACU nurse
This type of nurse typically takes care of the patients AFTER surgery
Med-Surg Nurse
Prioritie of post op care are:
airway/ventilation, blood volume, perfusion and circulation, urine output and fluid balance, neurological status, wound status and pain level. Ê
Incentive spirometry should be used how often after surgery?
every hour
After surgery, V.S should be taken how often?
initially every 2 hours, then every 4
What kind of complications should you look out for after surgery?
Neurological: Delirium, stroke; Respiratory: atelactasis, PNA, PE aspiration; CVS: shock, thrombophlebitis; GI: constipation, paralytic ileus, bowel obstruction; GU: acute urine retention, UTI; Wound: INFN, dehiscence, eviseration, delayed hearing, hemorrhage, hematoma; Functional: weakness, fatigue
What kind of assessments would you do after surgery?
LOC, orientation, Auscultate lungs, check blood volume and perfusion/circulation, urine output/fluid balance, wound status, pain status, auscultate abdomen for bowel sounds (may not be present right away)
What kind of symptoms should you look for if a patient is in shock?
tachycardia, tachypnea, hypotension, abnormal CVP (may not be available to measure), urine output will be low, urine specific gravity will be abnormal
What are the symptoms for early shock vs late shock?
early shock-restlessness, warm, vasogenic/late shock-cool clammy skin, change in LOC, lethargy, coma
What kind of interventions would you do after surgery?
Reorient patient, check cap refill, color, temperature of skin-use warm blankets if needed, check for IV fluid orders, monitor I&O, palpate bladder (6-8 hrs after surgery), check the wound for drains, make sure the dressing is intact and dry, medicate for pain, check for nausea and vomiting, check NG tube (if applicable), bowel sounds may be absent for a few days, get patient up and moving as soon as possible
What would you do if your patient is in shock?
Resuscitate the patient from septic shock using supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation, Identify the source of infection and treat with antimicrobial therapy, surgery, or both, Maintain adequate organ system function guided by cardiovascular monitoring and interrupt the pathogenesis of multiple organ dysfunction syndrome (MODS)
Myth or Reality? Pain is an unavoidable part of growing old.
Myth
Myth or Reality? Chronic pain is common after age 65, and painful conditions such as degenerative joint disease (also known as osteoarthritis) increase with age.
Reality
Myth or Reality? Residents with dementia are unable to report their pain
Myth
Myth or Reality? Several studies have shown that many people with dementia, even those with moderate to severe dementia, can reliably report pain. Therefore, do not assume that residents canÕt report their pain based on a diagnosis or score on a dementia rating scale.
Reality
Myth or reality? Pain is mostly an emotional or psychological problem.
Myth
Myth or Reality? Pain isnÕt in somebodyÕs head. There are physical reasons for pain.
Reality
Myth or Reality? Doctors are nurses are the experts of pain
Myth
Myth or Reality? Older adults are experts of pain.
Reality
Myth or Reality? It is important to be stoic about pain.
Myth
Myth or Reality? Being stoic about pain often is valued in our society. This tendency may be more common among older persons.
Reality
What are some cultural considerations that affect pain management?
Willingness to report pain, modesty about body issues, religious/social beliefs, language barriers, attitudes/fear of medication, cultural diets
When assessing for pain, you ask about
type and location; how would you rate the pain on a scale of 1-10
If a patient is unable to describe the pain with a numerical scale, what would you ask?
Use a descriptor scale or face scale
What objective data can you use to monitor pain?
facial expressions, body gestures, increased pulse rate, increased bp, and increased RR
The single most reliable indicator of the existence and intensity of pain–and any resultant distress–is
the patient’s self report
Describe categories and guidelines for chemical management of acute pain
Rapid acting opiatesand mild analgesics
Describe categories and guidelines for chemical management of chronic pain
Regular schedule, maintain blood levels, long acting opiates, rapid acting
Describe categories and guidelines for chemical management of chronic cancer pain
Step 1 (mild pain): Non-narcotic, adjuvant drug, (moderate pain): Weak narcotic, non-narcotic, adjuvant drug, (severe pain): Strong narcotic, non-narcotic, adjuvant drug
What are some chemicl non-modalities for pain management?
Transcutaneous electrical nerve stimulation (TENS), application of heat, cold, pressure, therapeutic touch, massage, vibration, PT, ice
What are some other strategies to help with pain?
Distraction, imagery, relaxation techniques, hypnosis, acupuncture
What is the role of the nurse as a patient advocate for a pt with pain?
It is the nurseÕs responsibility to listen to a patient who is in pain, assess the site of pain, and advocate for the patient so the pain can be relieved.
Define stress
event and the response to an event, a change in homeostasis and environment which can be positive or negative.
Define illness
Illness can be a stressor and affect an individualÕs behavior and emotions, role in life, body image, self concept, and family dynamics. Physiologically, stress results in an increase in the sympathetic NS, and cortisol release. ÊIt can lead to a host of physical problems including infection, fatigue, constipation, urine retention, weight gain, blood sugar changes, and pain.
What are the theories of coping?
- Identify the threat, 2. Provide information, 3. Recognize feelings, 4. Reassure patient and engage in reduction activities, 5. Advocate for control, independence
What are some nursing interventions for patient with stress, anxiety, and or coping problems?
Provide information, recognize feelings, engage in reduction activities, and advocate for control, independence
What kind of assessment would you look for in a patient with fluid deficit?
decreased skin turgor, dry mucous membranes, thirst, sudden weight loss of 2% or greater, postural hypotension and/or low B/P, weak, rapid pulse, neck veins flat when client is supine, change in mental status
, elevated BUN and Hct
For a patient with fluid deficit, the nursing dx is r/t:
decreased oral intake associated with anorexia, fatigue, and nausea; increased insensible fluid loss associated with diaphoresis and hyperventilation 3.excessive loss of fluid associated with vomiting and/or diarrhea if present with initial infection or as a side effect of antimicrobial therapy.
What are some interventions to prevent or treat fluid volume deficit?
Reduce nausea and vomiting, control diarrhea, reduce fever,
What kind of assessments would you look for in a patient with fluid excess?
Weight gain, edema, bounding pulses, SOB, orthopena, pulmonary congestion, abnormal breath sounds, intake > output, JVD, oliguria, restlessness, anxiety
For a patient with fluid excess, the nursing dx can be r/t:
excessive fluid/sodium intake, kidney injury/ failure, steroid therapy, liver injury/failure, malnutrition
For a patient with fluid excess, what interventions would you provide?
Monitor location and extent of edema, weight gain, monitor V.S, provie strict sodium diet, administer loop or K+ sparing diuretics
__________________ are functions that nurses can do using their nursing judgment without depending on doctors orders
independent functions
Dependent functions of nurses are:
functions that nurses depend on physicians orders to do.
List at least 4 roles of the med-surg professional nurse
i. Care coordinator
What are the 5 components of the nursing process?
- Assessment 2. Problem Identification 3. Planning 4. Implementation 5. Evaluation
What are the 6 goals of QSEN?
- Patient-centered care 2. Teamwork and collaboration 3. Evidence-based practice 4. Quality Improvement 5. Safety 6. Informatics
What are 5 important areas to address in preoperative care?
- Physiological 2. Psychosocial 3. Legal issues 4. Pre-op teaching 5. pre-op tasks
T or F: All rings, jewelries, dentures, makeup, hairpins, nail polish, glasses and metals must be removed before surgery.
TRUE
This type of nurse provides surgical patient care by assessing, planning, and implementing the nursing care patients receive before, during and after surgery.
OR nurse
This nurse’s job is to create and maintain a sterile and safe surgical environment
OR nurse
The PACU nurse is responsible for checking these 6 things after surgery:
- airway, reflexes (gag, cough)
The __________________ is typically the nurse that cares for patients after surgery
medical-surgical nurse
__________________ are registered nurses (RNs) who care for adult patients in many settings, including hospitals, clinics, HMOs, ambulatory care units, home health care, long-term care, skilled nursing homes, urgent care centers, surgical centers and universities
medical-surgical nurse
What are the 7 nursing priorities of post operative nursing care?
airway/ventilation, blood volume, perfusion/circulation, urine output/fluid balance, neurological status, wound status and pain level
After surgery, initially vital signs should be checked how often?
every 2 hours
After the immediate post-op period how often are vital signs assessed?
every 4 hours
What temperature-related problem could occur in a post-op patient?
hyperthermia
T or F: The bladder should be palpated 4 hours after surgery.
FALSE. The bladder should be palpated 6-8 hours after surgery
T or F: Medication should not be offered after surgery, only given if the patient asks for it.
FALSE. Medication should be offered as soon as possible after surgery
Why should medication be given in post-op?
For pain relief, but also to make getting up and moving around less painful-movement after surgery is critical
List 2 serious neuro. Surgery complications:
Delirium, stroke
List 4 serious respiratory complications after surgery:
Atelectasis, pneumonia, pulmonary embolism, aspiration
List 2 serious cardiovascular complications after surgery:
Shock, thrombophlebitis
T or F: constipation, paralytic ileus, bowel obstruction are three things that can occur post-op.
TRUE
What are two urinary issues that can occur after surgery?
acute urine retention, urinary tract infection
List 6 wound-specific issues that can occur after surgery:
Infection, dehiscence, eviseration, delayed healing, hemorrhage, hematoma
tachycardia, tachypnea, hypotension, abnormal CVP (may not be available to measure), urine output will be low, urine specific gravity abnormal are all signs of:
shock
T or F: A patient in early shock will have a change in LOC and be lethargic.
FALSE. These symptoms are for a person in late shock. Early shock present with restlessness
How would one resuscitate a patient in septic shock?
use supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation.
__________________ provides patients with a legal cause of action if they are not adequately informed about the nature and consequences of a particular medical treatment or procedure
informed consent
Informed consent has three essential ingredients:
decisional capacity (competency), adequate information, and voluntariness (freedom from coercion)
What two situations are exempt from informed consent?
1.emergency treatment is necessary to save a life or prevent imminent serious harm and it is impossible to obtain consent from the patient or an authorized surrogate 2. when a patient lacks sufficient mental capacity to give consent or is legally incompetent.
T or F: Treatment without any consent or against a patient’s wishes may constitute assault and battery
TRUE
T or F: Pain is an unavoidable part of growing old.
FALSE. Although pain is more common in people over 65, it does not have to be tolerated, and there are successful treatments for relieving pain
T or F: Residents with dementia can reliably report their pain
TRUE
T or F: Pain is mostly an emotional or psychological problem.
FALSE. Pain is a physical problem that may be made worse by psychological issues, so both should be addressed.
T or F: Doctors and nurses are the experts about a patient’s pain.
FALSE. The patient is an expert in their own pain
What are 4 different ways an RN could assess for pain?
Use 0-10 pain scale, use pain descriptors scale, use faces scale, monitor objective pain data
What 2 categories for meds should be used for acute pain?
Rapid acting opiates
What should be used for chronic pain?
Regular schedule medications
What three levels should be used for chronic cancer pain?
Step 1 (mild pain): Non-narcotic, adjuvant drug
List at least 4 alternative (not medication) PHYSICAL MEASURES that can be done to relive pain:
Transcutaneous electrical nerve stimulation (TENS)
List 4 COGNITIVE/BEHAVIORAL strategies that can be used to aliviate pain:
Distraction
What are 4 steps in developing good nursing interventions for patients with stress or anxiety?
- Provide information
Normal serum Na level:
125-145 mEq
Normal serum OSM:
280-300
normal BUN/creatinine:
10-20mg/ .5-1.2mg
Normal intake:
2-3 L
Normal output:
2-3 L
1 lb= ?ml?
500ml
1 kg=liters?
1 liter
What is a normal specific grarvity?
1.005-1.025
What could cause a low specific gravity?
diabetes insipidus, nephrogenic diabetes insipidus, acute tubular necrosis, or pyelonephritis.
What can cause a specific gravity that never changes nomatter the fluid intake?
chronic glomerulonephritis with severe renal damage.
What causes a high specific gravity?
nephrotic syndrome, dehydration, acute glomerulonephritis, heart failure, liver failure, or shock.
