Semester One - Safety And Protection Flashcards

1
Q

What does the ADPIE nursing process consist of?

A
  • ASSESSMENT: noticing reflecting in action.
  • DIAGNOSIS: interpreting reflecting in action.
  • PLANNING: reflecting in action.
  • IMPLEMENTATION: responding reflection in action.
  • EVALUATION: reflecting on action.
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2
Q

How can a nurse gather clinical information? And from where?

A
  • observations - what you see, hear, smell, touch.
  • interview/Assessment
  • physical examination

This is from the client or secondary sources such as family members, significant others, medical records, diagnostic assessments and procedures.

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3
Q

What is hypersensitivity?

A

Innapropriate excessive immune response.

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4
Q

What is autoimmunity?

A

An innpropriate immune response to self.

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5
Q

What is alloimmunity?

A

An immune response to foreign antigens from the same species. For example, can occur after allograph (transplant of body tissue) or allotransfusion (plasma, immunoglobulin, plasma products)

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6
Q

In manual handling, what does LITE stand for and what does it mean?

A

LOAD: patient charactaristics that can effect handling risk. Age, gender, diagnosis, dependency, neurological status, size, weight, ability to co-operate, fall risk.
INDIVIDUAL: capabilities of the carer. Language, education, physical limitations, stress, fatigue.
TASK: the nature of the task. What, how and when.
ENVIRONMENT: the working environment. Facilities, staff levels, culture, resources.

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7
Q

What is the gauge of the needle?

A

The diameter of the needle.

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8
Q

The bigger the gauge number, the bigger the needle. True or false?

A

False. The smaller the gauge number, the bigger the needle. Eg. 23 gauge needle is smaller than a 16 gauge needle.

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9
Q

What unit are needles measured in?

A

Inches.

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10
Q

Where is a subcutaneous injection administered?

A

Injected beneath the epidermis into fat and connective tissue underlying the dermis.

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11
Q

Why would the intramuscular injection route be used?

A

This route is used when medication is needed quickly. Muscles have rich blood flow meaning rapid absorption of medication.

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12
Q

What are the four sites for IM injections?

A
  • Ventrogluteal site (hip/side/bum) THIS IS THE SAFEST SITE
  • Dorsogluteal site (buttocks)
  • Deltoid site (upper arm)
  • Vastus Lateralis (thigh) this is where babies usually get IM injections.
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13
Q

How much adrenaline would you give to an adult for anaphylaxis? How often can you give this dose?

A

0.5ml . Can repeat this at 5 to 15 minute intervals to a max dose of three doses.

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14
Q

What does lymph fluid contain?

A

Lymphocytes, macrophages, antigens and a collection of excess fluid from the body.

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15
Q

Where are antigens killed when collected by the lymph fluid?

A

The lymph nodes.

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16
Q

Where does lymph fluid go once it leave the lymph node?

A

It leaves the node then travels to the superior vena cava where it empties in to the circulatory system.

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17
Q

Anaphylaxis is an immediate hypersensitive immune response true or false?

A

True.

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18
Q

During anaphylaxis, IgE bind to mast cells and basophils. The mast cells then explode which leads to a release in histamine and heparin. Following this, leukotrienes and prostaglandins are relseased causing what?

A
  • vasodilation
  • increased capillary permeability
  • hives
  • respiratory distress
  • fluid shift
  • vascular collapse, systemic shock and death
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19
Q

What are some symptoms of lymphoedema?

A

Whenever normal lymph drainage is disturbed, swelling may occur.

  • Swelling, weakness, aching and pain in affected arm
  • Feeling of fullness or tightness in limb
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20
Q

During anaphylaxis, what effects should the administration of adrenaline have?

A
  • Prevents (or relieves) – laryngeal oedema, circulatory collapse, release of histamine and other mediators.
  • Provides bronchodilation (SYMPATHETIC)
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21
Q

Which two cells are activated during an autoimmune disease?

A

B or T cells become activated against self-antigens –this is the basis of autoimmune disease.

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22
Q

Which cells are activated during alloimmunity?

A
  • Immune responses are mediated by T lymphocytes

- CD4 (T helper cells) are the main cells in the rejection of transplanted tissue or transfusion.

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23
Q

What are the most common ways for HIV to be aquired?

A
  • unprotected sex (including anal and oral sex),
  • contaminated blood transfusions
  • hypodermic needles
  • mother to child during pregnancy, delivery, or breastfeeding
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24
Q

HIV impacts which cells of the immune system?

A

Dendritic cells, T cells, T helper cells (CD4 helper cells).

25
Q

How does HIV cause AIDS?

A
  • Once HIV is in the body it causes a decline in CD4 cells.
  • CD4 cells are important in the body’s immune defence.
  • Without CD4 cells, opportunistic infections and cancer may be the presenting health issue.
26
Q

What are the symptoms of HIV?

A

Flu-like symptoms.

27
Q

How is HIV/AIDS diagnosed?

A

With a blood test counting the CD4 count.

Stage 1 – Blood test - Positive antibodies, CD4 >500 and absence of any clinical evidence

Stage 2 – Blood test – positive antibodies, CD4 200 to 499 and absence of any clinical evidence

Stage 3 – Blood test – positive antibodies, CD4

28
Q

What is HIV treated with and what do they do?

A

ART.
Standard antiretroviral therapy (ART) consists of the combination of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease.

29
Q

What is stress and what are the two types?

A

An internal response to external events.

  1. Ambient /everyday stress
  2. Major life events
30
Q

How is mental illness diagnosed?

A

The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. The current version is the DSM-I, V (fifth edition).

31
Q

To assist with recovery of a mental illness, services should be…?

A
  • Easily accessible
  • Least restrictive and not compulsory
  • Promote autonomy over authority
  • Adapt to the needs of people (not other way round)
32
Q

In relation to mental illness, what is recovery?

A

Active, transformative process towards wellbeing and a satisfying life. Not viewed as returned to a previous state without illness but valuing and respecting the lived experience.

33
Q

What is ‘Let’s Get Real’? What does it consist of?

A

A framework that describes the essential knowledge, skills and attitudes required to deliver effective mental health and addiction services in New Zealand.

Consists of:

  • respect
  • human rights
  • service
  • recovery
  • communities
  • relationships
34
Q

What kind of attitudes are required when working in mental health and addiction treatment services?

A
  • compassion
  • genuine: warm, friendly, fun and have aroha and a sense of humour
  • honest
  • non-judgemental
  • open-minded
  • optimistic
  • patient
  • professional
  • resilient
  • supportive
35
Q

What kind of skills are required when working in mental health and addiction treatment services?

A
  • Working with service users
  • Working with Māori
  • Working within communities
  • Working with family/whanou
  • Challenging stigma and discrimination
  • Law, policy and practice
  • Professional and personal development
36
Q

What are the three layers of the skin and their main function?

A
  • The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone.
  • The dermis, beneath the epidermis, contains tough connective tissue, hair follicles, and sweat glands.
  • The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.
37
Q

What are the main functions of the skin? (There’s five)

A
  • Protection
  • Temperature control
  • Elimination
  • Synthesis
  • Sensation
38
Q

What are the phases of wound healing?

A
  1. Haemostasis: vasoconstriction and clot formation.
  2. Inflammatory phase - neutrophils and macrophages destroy inviders
  3. Proliferation phase - fibroblasts reproduce and secrete glycoprotein and collagen. Epidermal cells migrate from wound edge. Granulation tissue is formed.
  4. Remodeling phase - wound contracts to increase tissue integrity, epidermal cells grow over connective tissue to close wound.
39
Q

What factors can impact wound healing?

A
  • size, depth, location
  • vascular supply
  • radiation
  • foreign bodies
  • local infection
  • wound treatment
40
Q

What is a chronic wound?

A
A wound that has remained unhealed for more than 4 - 6 weeks.
Eg.
Pressure ulcers
Leg ulcers (venous/arterial)
Diabetic foot ulcer
Post op open wounds
41
Q

What is included in a wound bed assessment?

A
  • Identification of cause
  • Type of wound and location
  • Type of healing
  • Clinical appearance – Dimensions, Exudate, Peri wound skin
  • Pain
  • Suffering
42
Q

In relation to wound bed healing, what does TIME stand for?

A

T - tissue: viabitility, deficits
I - infection/inflammation.
M - moisture: exudate type and amount, maceration of peri-wound, dressing decision.
E - edges - advancement of wound edges

43
Q

What does an ideal dressing do?

A
  • Removes excess exudate
  • Maintains a moist environment
  • Impermeable to invaders
  • Free from irritants
  • Does not shed particles into the wound
  • Does not adhere to skin tissue
  • Performs as a semi permeable membrane
  • Provides thermal insulation
  • Easy to apply, cost effective and evidence based
44
Q

What is the difference between a primary and secondary dressing?

A

Primary comes in contact with the wound. Secondary covers the primary dressing holding it in place.

45
Q

What is the role of an antibiotic?

A
  • Selective toxicity.
  • Kill (or inhibit the growth of) the micro-organism causing disease.
  • Not harm the host cells.
  • To achieve this the drug will target microbial structures or processes different from human cells
46
Q

What is the difference between a bactericidal antibiotic and a bacteriostatic antibiotic?

A
  • bactericidal: kills bacteria

- bacteriostatic: inhibits growth

47
Q

How is bacteria classified?

A

According to the shape.

  • cocci: round
  • bacilli: rod
  • spirilla: spiral
  • staphlo: cluster
  • strepto: chain
48
Q

What do mast cells do during an allergic reaction? How do antihistamines impact this?

A
  • Mast cells release large amount of histamine
  • Immune system mounts response: more histamine released
  • Histamine binds to surface of cells.
  • Antihistamines interrupt this binding
49
Q

What happens during anaphylaxis? (on a cellular level)

A
  1. IgM and IgG recognise and bond to antigen
  2. Activate IgE to produce release of histamine
  3. Mast cells produce even more histamine
  4. Respiratory distress: fluid leaks into alveoli
  5. Increased vascular permeability
  6. Failure of compensatory mechanisms
50
Q

What are some of the key aims of the MHA? (mental health act)

A
  • To define when compulsory assessment and treatment may occur
  • Redefine what a ‘Mental Disorder’ is
  • Set exclusion criteria and recognise cultural beliefs and identity
  • Protect individuals and public from harm
  • Protect patient rights
  • Ensure that assessment and treatment are performed in a safe manner
  • Provide a legal framework for Compulsory Treatment Orders (C.T.O’s) and provision for review and appeals to applications made for compulsory treatment.
  • Promote accountability for actions taken under the MHA
51
Q

What are the four elements of informed consent?

A
  1. Effective communication between the parties (Right 5)
  2. Provision of all necessary information to the consumer (including information about options, risks and benefits) (Right 6)
  3. The consumer’s freely given consent (Right 7)
  4. The consumer’s competence to consent (Right 7)
52
Q

When is written consent required? (there’s 4)

A
  • If the consumer is to participate in any research
  • If the procedure is experimental
  • If the consumer will be under general anaesthetic
  • If there is significant risk of adverse effects to the consumer.
53
Q

In the informed consent process, what four things are looked at when judging competence of a patient to make decisions?

A
  1. Understanding
  2. Appreciation
  3. Reasoning
  4. Communicating a choice

A deficit in any one of the four abilities can mean that decision making capacity is impaired

54
Q

Is informed consent still used under the mental health act?

A

Yes, seeking informed conset should always be practiced with any patient even though the treatment may be authorised under the MHA without the patients consent.

55
Q

Informed consent becomes complicated when dealing with children. Before providing medical treatment for a child when is parental consent required?

A

If under 16 it must be determined whether the child has the understanding and maturity to form a balanced judgement about the proposed treatment.
If so, the child can be treated without obtaining parental consent; if not, parental consent must be secured before treatment is given.

56
Q

How does informed consent work in emergencies?

A

In situations necessary to save life or prevent serious damage to health, consent must be sought.
If the patient is not competent to consent, and no-one is available who is entitled to consent on their behalf, treatment can proceed without consent if it is in the best interests of the patient.

57
Q

What is the difference between a bacteriocidal and bacteriostatic antibiotic?

A

Bacteriocidal - kill the bacteria

Bacteriostatic - prevents the bacteria from reproducing

58
Q

How do beta lactum antibiotics work and what do they usually end with?

A

They use their beta lactum ring to target penecillin binding protein.
This inhibits the cell wall synthesis resulting in destruction of the bacteria.

They usually end in ‘cillin’

59
Q

What are common side effects of antibiotics?

A
  • GI upset
  • Rash
  • Candida
  • Headache