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Nursing 142 > Nursing 142 Final > Flashcards

Nursing 142 Final Flashcards

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1
Q

3 dimensions of fundamental of care framework

A

Context of care - policy level ( governance, financial, quality and safety, regulation and accreditation), system level ( resources, culture, leadership, evaluation, feedback)
Integration of care - psychological patient needs, physical patient needs, relation care giver actions
Relationship - trust, focus, anticipate, know, evaluate

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2
Q

What does a professional intro include

A

Stating name , title, and pronouns

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3
Q

Important factors for patient communication

A

Patient centred, empathetic, inclusive, non-bias, and un gendered language

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4
Q

What are health records used for

A

Legal records, used for knowledge for health care team members, research, data, auditing,monitoring and evaluation

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5
Q

Admission nursing history

A

Completed by nurse upon admission, nursing diagnosis included

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6
Q

Flow sheets/graphic records

A

Includes data from reoccurring assessments eg. Weight, vitals ADL’s (activities if daily living)

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7
Q

Patient care summary/ Kardex

A

Basic and summative information

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8
Q

Standardized care plan:

A

Prepared plan of care, identifies patient goals, nursing diagnosis and nursing orders

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9
Q

Discharge summary forms

A

Includes diet, community resource, medications and follow up care

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10
Q

Safety checks for all patients

A
  • 2 patient identifiers
  • immediate environment
  • risks
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11
Q

What is ISBARR

A

I- Identify: yourself and patient
S- situation: what is happening?
B- background: what circumstances lead up to this?
A- assessment: what is the problem?
R- recommendations: what should be done to correct the problem?
R- response: the patient acknowledges information given and responds

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12
Q

Chain of infection

A
  • Infectious agent ( pathogens, bacteria, virus, etc)
  • reservoir (where it lives eg. people)
  • portal of exit ( droplet, secretion, etc)
  • mode of transmission (airborne, droplet, contact)
  • portal of entry ( openings in body)
  • susceptible host (any person especially those in poor health)
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13
Q

Breaking chain of infection

A

Infectious agent- cleaning, disinfect, diagnosis, treatment
Reservoir- disinfect, clean, sterilize, good health
Portal of entry- hand hygiene, PPE, waste disposal
Mode of transmission- PPE, hand hygiene, isolation precautions, disinfect
Portal of exit- catheter care, wound care, PPE
Susceptible host- immunization, patient education, recognize patients at high risk

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14
Q

Asepsis

A

Absence of pathogens

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15
Q

Aseptic technique

A

A method to make environment, worker and patient as germ free as possible

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16
Q

Hospital acquired infections

A

Infection acquired in a health care facility Eg. C. difficile, CAUTI

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17
Q

Routine practice

A

Used in the care of all patients. Things that are done routinely when caring for patients, can include blood, bodily fluids, secretion, excretion,mucus membranes and non intact skin

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18
Q

Exogenous infection

A

Infection outside organ or part

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19
Q

Endogenous infection

A

Produced or arising from within cell or organism

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20
Q

Point of care risk assessment

A

Access patient, task, environment and reduce transmission of infection

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21
Q

Airborne precaution

A

N95 respirator mask

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22
Q

Droplet precaution

A

Gloves, gown, mask, eye protection

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23
Q

Contact

A

Gloves, gown

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24
Q

Donning and doffing

A

Donning- putting required PPE on
Doffing- taking required PPE off (mask last)

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25
Q

What is MSIP

A

Musculoskeletal injury prevention

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26
Q

What is STABLE?

A
  • maintain natural S curve in spine
  • keep TRUNK aligned
  • keep ARMS close
  • use a wide BASE of support
  • use your LEGS
  • EVALUATE the load, environment and yourself
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27
Q

Principles of body mechanics

A

Decrease work effort and places less strain on musculoskeletal structures

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28
Q

Proper patient positioning

A
  • Maintain body alignment and promote comfort, Prevent injury to musculoskeletal an integumentary system,Provide stimulation
    Sitting- Head erect,Neck and spine in straight line, Thighs parallel, Both feet supported, Patients arms supported, Body weight distributed
    Standing- Head erect and midline,curve spine, knee and ankles slightly flexed
    Laying- Depends on how patient positioned, Should be supported by adequate mattress and without abservable curves in spine
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29
Q

Passive Range of Motion

A

Outside source (Eg nurse) exclusively causes movement to joint

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30
Q

Active range of motion

A

Patient moves part of their body using own muscles

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31
Q

Pre standing safety check

A

Assessing for cognition, ability to follow direction, stability and balance
Includes bridging hips, leaning and lifting legs

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32
Q

Fowler position

A

Semi siting position; HOB raised 45-60 degrees

33
Q

Semi-Fowler position

A

HOB raised 30 degrees knees can be up 15 degrees

34
Q

Supine position

A

Bed is horizontally parallel to floor

35
Q

Trendelenburg position

A

HOB lowered and foot raise

36
Q

Reverses Trendelenburg position

A

HOB raised and foot is lowered

37
Q

7 factors influencing a patients personal hygiene preference

A

Body image, physical environment, social practices, personal preference,health beliefs, socioeconomic status,motivation

38
Q

What concerns require a nurse to provide hygiene several times a day

A

Incontinence, excess diaphoresis, wound drainage

39
Q

Benefits a patient gets from bathing

A

-circulation
-relax and fresh feeling
-socialization
-removes dirt, sweat, oil

40
Q

Why is skin care important?

A

Skin integrity and prevent pressure injuries

41
Q

That should only receive a bath once or twice a week

A

Infants and older patients

42
Q

What leaves hair oily and unmanageable?

A

Diaphoresis

43
Q

What can radiation therapy and certain chemotherapy medication due to hair?

A

Alopecia

44
Q

Urinary elimination

A

1.2-1.5L over 24hrs (50-70 mL/ hr) concern less than 30ml over 2 hrs or 2L in 24 hrs

45
Q

Toileting options

A

Urinal, bed pan, slipper pan, commode, toilet, brief, catheter

46
Q

ADL’s

A

Eating, bathing, grooming, dressing, toileting, walking

47
Q

IADL’s

A

Shopping, preparing meals, cleaning, transportation,medication, finances

48
Q

ADPIE

A

Assessment
diagnosis
plan
implementation
evaluation

49
Q

FICA

A

Faith
Importance and influence
Community
Action in care

50
Q

3 domains of functional assessment

A

ADL’s, IADL’s, mobility
These are gotten by asking and observing patient

51
Q

Urinalysis

A

Can you be collected during normal voiding or catheter bag

52
Q

Culture and sensitivity

A

Examine presence of bacteria, clean technique/ mid stream to sterile specimen cup or sterile collection port of Catheter bag

53
Q

Dysphagia

A

Difficulty swallowing

54
Q

Risk of aspiration

A

Tachypnea, dyspnea, cough, abnormal gag reflex

55
Q

Normal temperature range

A

36-38

56
Q

Digital removal of stool

A

Done when a patient is unable to pass stool due to severe constipation to empty reflex bowel

57
Q

What to look for when assessing urine

A

Smell, colour, cloudiness, any abnormalities or bacterium

58
Q

Pulse

A

60-100 bpm

59
Q

Respirations

A

12-20 breaths per min

60
Q

Oxygen saturation

A

95-100 %

61
Q

Bradycardia

A

an adults pulse who is less than 60 beats/min

62
Q

Tachycardia

A

an adults pulse who is more than 100 beats/min

63
Q

Hypoxic

A

Low blood oxygen level

64
Q

hypotensive

A

less than 90/60 mm Hg

65
Q

Hypertensive

A

higher than normal blood pressure

66
Q

Bradypnea

A

abnormally slow fewer than 12 breaths per minute

67
Q

Tachypnea

A

abnormally rapid rate of breathing

68
Q

Apnea

A

Respirations seize for several seconds

69
Q

Kussmaul

A

Respirations are abnormally rapid and deep but regular, common in diabetics

70
Q

Cheyene-stokes

A

Respiration rate are irregular pattern, characterized by alternating periods of apnoea and hyperventilation

71
Q

Health assement

A

Evaluation of patients health status by performing a physical exam after taking health history

72
Q

Hyperventilation

A

Rate and depth of respiration increase

73
Q

Hyporespiration ventilation

A

Rate of respiration abnormally low,depth of respiration may be depressed

74
Q

Barriers to oral care

A

Cognition, dexterity, lack of understanding, access

75
Q

Therapeutic diets

A

Clear liquid, full fluid, puréed, dental soft, low residue, etc

76
Q

Suctioning level

A

Regular 100-150

77
Q

What is each vital sign assessing

A

Temperature- Difference between the amount of heat produced by the body and then mount lost in the external environment
Pulse- The ejection of blood from the heart distends the walls of the aorta
Respirations- The exchange of oxygen and carbon dioxide between cells of the body and the atmosphere
Blood pressure- The force exerted by blood against the vessel walls
Oxygen saturation- The percentage to which hemoglobin is filled with oxygen

78
Q

Dyspnea

A

Shortness of breath

Nursing 142 (1 decks)

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