short answers exam 2010 Flashcards
Hospitals and other care institutions have a duty of care to patients (3 Marks)
List three (3) major areas that must be attended to.
Patient and staff safety
Insurance for patients and workers
Reporting of any misconduct
Discuss the principles of good pain management in the care of acute pain? (4 marks)
pain assessment addresses the pain's: Nature Cause Personal context: Psychological Social Spiritual Practical issues Underlying pathophysiology
Use of appropriate interventions
Pharmacologic
Nonpharmacologic
Education of the patient, family, and all caregivers about the plan
Ongoing assessment of treatment outcomes
Regular review of the plan of care
Use of other members of the interdisciplinary team,
Flexibility is essential—successful plans are tailored to the individual patient and family
Willingness to ask for help from colleagues with more expertise when the plan is not effective at controlling the patient’s pain
What are different types of consent nurses gain from patients? (3marks)
verbal, written and implied
When is consent required from a patient and who can consent for a patient?
Consent from a client is required prior to any procedure, it can be given by a parent or legal guardian if the person is under age.
Question 4
Skeletal fractures or soft tissue injury of limbs can result in the development of compartment syndrome. Using the lower leg as an example-
a) Explain what compartment syndrome is at a cellular level, and what factors contribute to the development of compartment syndrome? (4 marks)
Edema and/or bleeding within the confines of the fascial envelope
increase the pressure within the skeletal muscle-compartment.
When the tissue fluid pressure within the compartment exceeds the capillary perfusion pressure to the muscles and nerves in the compartment, these tissues are rendered ischemic.
Factors that can contribute to CS are age, repetitive exercise, overexercise, steroid use.
Causes Fractures, Crush injury. Burns. Infection. Prolonged limb compression, Muscle hypertrophy in athletes
Question 4
Skeletal fractures or soft tissue injury of limbs can result in the development of compartment syndrome. Using the lower leg as an example-
b) Explain the signs and symptoms of compartment syndrome. (3 marks
Aching, burning or cramping pain in the affected limb — usually the lower leg
Tightness in the affected limb
Numbness or tingling in the affected limb
Weakness of the affected limb
Foot drop, in severe cases, if nerves in your legs are affected
Occasionally, swelling or bulging as a result of a muscle hernia
Question 4
Skeletal fractures or soft tissue injury of limbs can result in the development of compartment syndrome. Using the lower leg as an example-
c) What is the rationale of all observations in the early detection of compartment syndrome? (3 marks)
Observations detect early signs of CS and prevent tissue necrosis.
The 5 P’s if 5th occured one achieved it is a late symptom and tissue necrosis has already
Pain
Paresthesia
Pallor
Poikilothermia
paralysis
Neurological observations are an important nursing responsibility; describe what the assessment of the patient will be and how you will conduct this? (4 marks)
Neurological observation is the collection of information on a patient’s central nervous system (consisting of the brain and spinal cord).
It is done using the Glasgow Coma scale to monitor for Motor responses, verbal responses and LOC
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) Describe the features of a person who has decerebrate posturing. (3marks)
Decerebrate posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. The arms and legs are extended and rotated internally.
Neurological observations are an important nursing responsibility. A number of terms exist to describe abnormal findings which nurses are often the first to observe.
b) Describe the features of a person who has decorticate posturing. (3 marks)
Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest.
Question 7
Discuss the differences between ischemic and haemorrhagic stroke? (4 marks)
Ischemia is caused by either blockage of a blood vessel via thrombosis or arterial embolism, or by cerebral hypoperfusion.
Hemorrhagic stroke is caused by bleeding of blood vessels of the brain, either directly into the brain parenchyma or into the subarachnoid space surrounding brain tissue.[
Question 8
Describe the management and nursing care of a patient with a suspected CVA?
- Antithrombolytic therapy
- Hypertension management
- Monitoring for hypotension and other complications of rt-PA therapy, including intracranial hemorrhage, angioedema, bleeding
- Use of intra-arterial thrombolysis
- Use of mechanical thrombolysis
- Oral antiplatelet therapy (aspirin)
- Monitoring for and preventing medical complications of stroke
General supportive care
- Fluid management
- Nutrition management including evaluation and -management of dysphagia
- Monitoring for pneumonia and urinary tract infection
- Bowel and bladder care
- Monitoring for and treatment of deep vein thrombosis and pulmonary embolism
- Performing range of motion exercises to prevent contractures and other orthopedic complications
- Skin care
- Recognition of depression and involuntary emotional expression disorder
- Rehabilitation consultation
- Patient and family education
- Documentation
Question 9
Discuss when a nasogastric tube may be required and the rationale for? (4 marks)
- to decompress the stomach and remove gas and fluid
- to lavage the stomach and remove ingested toxins
- to diagnose disorders of GI motility and other disorders
- to administer meds and feedings
- to treat an obstruction
- to compress a bleeding site
- to aspirate gastric contents for analysis
Question 10
The acronym RICE is used in nursing. Explain what this means and to whom would you apply it?
RICE is a mnemonic for 4 elements used to treat soft tissue injuries which is an acronym for Rest, Ice, Compression and Elevation - first aid treatment
Question 11 Identify five (5) key areas in nursing care where issues of negligence have been highlighted.
Medication administration Ethical care PRIVACY & CONFIDENTIALITY Informed consent Documentation failure to adhere to policies and procedures
