NUR203 Short Answer Questions Flashcards
- Hospitals and other care institutions have a duty of care. List three (3) major areas that must be attended to.
i) increase health literacy, and partner with patients, families and carers to share decision making about their care
ii) provide care that respects and is sensitive to different cultures
iii) improve continuity of care
iv) use agreed guidelines to reduce inappropriate variation in delivery of care
This is only a few of the examples
- Discuss the principles of good pain management in the care of acute pain.
The goal is to implement pain management with the least amount of potency of medication, and the highest level of patient consciousness.
Discuss; use pain measurement tools, for instance numeric scales, visual analogue scales or behaviour scales, WILDA, PQRST, Pain history, physically exam affected area, positioning regime
- When is consent required from a patient and who can consent for a patient?
At anytime that you will touch, conduct and or enter the patients personal to render treatments, if consent is not gained it is considered assault.
If the patient cannot consciously and verbally give consent, implied consent can be had, otherwise a next of kin, power of attorney or a significant other who has been appointed authority to do so on the patients behalf
- Skeletal fractures or soft tissue injury of limbs can result in the development of compartment syndrome. Using the lower leg as an example
• Explain what compartment syndrome is at a cellular level, and what factors contribute to the development of compartment syndrome?
Compartment Syndrome is where excessive pressure builds up inside an enclosed space in the body especially of the leg or forearm, commonly as a direct result of bleeding or swelling after an injury. This increased pressure results in impeding the flow of blood to and from the damaged tissues, tissue ischaemia and can require emergency surgery to prevent permanent injury
• Explain the signs and symptoms of compartment syndrome.
PAIN: Aching, burning or cramping in the affected limb, due to increased pressure and decreased perfusion
PALLOR: limb maybe pale or dusky colour
PULSELESSNESS: cannot palate pulse, by the time limb has become pulseless emergency orthopaedic surgery is required. The pulse maybe absent or diminished.
PARAESTHESIA: As the nerves become ischaemic paraesthesia may occur in the affected compartment
PARESIS: May report feelings of weakness in limb or the belonging extremeties
• What is the rationale of all observations in the early detection of compartment syndrome?
i) Neurovascular assessment and vital signs to assess the peripheral circulation and neurological integrity of the patient
ii) Appropriate pain management to facilitate a quicker healing process
iii) Early mobilisation promote healing, decrease post-surgical complications
iv) Medication management
Braden or Norton Scale assessment for actual or potential pressure area risk
v) IDC
vi) drains
- Neurological observations are an important nursing responsibility. A number of terms exist to describe abnormal findings which nurses are often the first to observe.
A alert
V responds to voice
P responds to pain
U unresponsive
Deterioration can manifest in many ways, aphasia, dysphasia, dysarthria, increased confusion, unsteady gait, PEARLA, think of the neurological status and deterioration
6..Describe the nursing care of a patient with a bowel obstruction. Where possible provide rationales for your interventions/actions.
Bowel Obstruction
•Review of dietary habits and determine fibre intake,ni creased fibre intake can decrease constipation by providing appropriate amounts of fibre
•Review bowel habits; is the frequency regular, habitual behaviours
•Assess abdomen, for distension, absent bowel sounds, rigid abdominal
•Assess pain: administer analgesia, managing pain adequately can facilitate healing process
•Assess nausea: administer antiemetic to prevent nausea and vomiting that can precipitation electrolyte imbalance and dehydration
•Administer antibiotics if prescribed , to effectively prevent the multiplication of pathogenic microorganisms that maybe present
•Stool chart (aperients as required) documentation is an accurate record of bowel movement in conjunction with Bristol stool chart
•Assess activity tolerance: physio review, activity can facilitate in facilitating normal peristalsis
- Discuss the differences between ischemic and haemorrhagic stroke.
Ischaemic Stroke: a cerebrovascular disorder caused by deprivation of blood flow to an area of the brain, generally as a result of thrombosis, embolism or reduced blood pressure that results in the death of the affected cells
Haemorrhagic Stroke: is either a brain aneurysm that has ruptured or a weakened blood vessel leak, the increased blood results in increased intracranial pressure that damages cells and tissue of the brain
- What is aspiration pneumonia? Why are stroke patients at increased risk? What can be done to reduce the risk of aspiration pneumonia?
Aspiration pneumonia; is an inflammation of the lungs (usually due to infection) and bronchial tubes after foreign matter has been inhaled, such as vomitus, food or liquid.
Stroke patient at increased risk of aspiration pneumonia, because of the neurological deficit, swallowing difficulties, their airway becomes threatened and ineffective, respiratory failure ensues requiring mechanical ventilation and or intubation which can also interfere with normal defense mechanisms, allow way for opportunistic microorganisms
What can be done to reduce the risk? Effectively manage oral hygiene/ care reduces the risk of oral bacteria entering the lungs, coughing exercises (spirometry), maintain a moist oral mucosa, mobility getting out of bed patient is less likely to develop pneumonia
- List 3 indications for the insertion of a urinary catheter.
Diagnosis (monitoring urine output) treatment (urinary obstruction, urinary retention, following childbirth, anaesthesia)
Pre-operatively
- Identify the symptoms of anaphylaxis, paying particular attention to the skin, respiratory and cardiovascular systems.
SYMPTOMS INCLUDE: Chest Tightness Reduced cardiac output Hypotension Acute myocardial ischaemia Cardiac arrhythmias: Asystole, sinus tachycardia, ventricular ectopic’s, Hypotension
Urticaria rash, erythema, pruritis, Warm tingling in axillae and groin, itchy eyes, lips soles of feet and hands, itchy throat
Bronchospasm, wheeze, stridor, Dyspnoea, Shortness of breath, Asthmatic response, Hypoxia
•ARE ALMOST ALWAYS ASSOCIATED WITH
PREVIOUS SENSITISATION
- Discuss the conservative management approach to the management of a bowel obstruction. Why is conservative management a more common treatment option than the surgical approach
Conservative management is a nonsurgical approach to managing bowel obstruction in the first 48 hours if still not resolved surgery maybe precipitated to prevent further complications of ischaemia and or bowel perforation. Following are conservative management strategies:
Abdominal radiography is an effective initial examination in patients with suspected intestinal obstruction.
Computed tomography is warranted when radiography indicates high-grade intestinal obstruction or is inconclusive.
Upper gastrointestinal fluoroscopy with small bowel follow-through can determine the need for surgical intervention in patients with partial obstruction.
Antibiotics can protect against bacterial translocation and subsequent bacteremia in patients with intestinal obstruction.
Clinically stable patients can be treated conservatively with bowel rest, intubation and decompression, and intravenous fluid resuscitation.
Surgery is warranted in patients with intestinal obstruction that does not resolve within 48 hours after conservative therapy is initiated.
12.Name four groups of individuals who may lack the capacity to act in an autonomous matter and whereby the clinician must seek consent from a legal guardian such as a parent, partner or trustee.
Legally under age (children)
Learning disability that may affect sound judgement
Mental capacity compromised to make sound choices
Person who is unconscious
- A patient has a nasogastric tube (NGT) insitu and is receiving a regular regime of bolus feeds. Identify when the nurse is required to check the position of the NGT.
- Aspirate EACH SHIFT
- Verification performed every 4 hours in critical care or when continuous feeding.
- Perform prior to administering anything down the tube
- If the tube has not been used for a time
- If the patient is sick or has coughed violently
