Terms Flashcards
STEEEP
safety, timely, effective, efficiency, equitable, patient-centered
QSEN (6)
patient-centered safety teamwork and collaboration informasx tics quality improvement evidence-based practice
Latent Failure
arises from decision that affect policies, procedures, allocation of resources – “blunt end”
Active Failure
direct contact with the patient – “sharp end”
Organizational system failure
indirect failures related to organizational structure/management, processes, transfer of knowledge
Technical failure
indirect failure of facilities or external resources
Presbycusis
High frequency hearing loss
Iatrogenesis
complications that arise from invasive procedures, nosocomial infections
SPICES
Sleep disorders Problems eating/feeding Incontinence Confusion Evidence of falls Skin Breakdown
Katz
Index of Independence in Activities of Daily Living (ADL)
Frailty
Stage of age-related physiologic vulnerability, resulting from impaired homeostatic reserve and a reduced capacity of the organism to withstand stress.
chronic illness + physiological changes of aging + harmful social/psychological environments
Geriatric Cascade
Phenomenon of rapid decline resulting from frailty, acute illness, and stress of institutional care – domino effect
Components of critical thinking specific to nursing
Specific knowledge base Experience Competencies Attitudes Standards
Nursing Process
Assessment Nursing Diagnosis Planning Implementation Evaluation
Leading cause of death from injury for adults
Falls
How do falls come to the attention of the healthcare team?
Medical hx Physical assessment Mental status Labs and diagnostic results Home safety assessment
Common causes of delirium
Drugs Elimination Liver and other organs Infection Respiratory Injury Unfamiliar environment Metabolic
CAMs test
- acute onset
- inattentiveness
- disorganized thinking OR altered level of consciousness
Hendrich
Fall Risk Model Confusion/disorientation Depression Male Gender Altered elimination Vertigo/dizziness Antiepileptics Benzodiazepines (atvian)
> 5 = high risk
Systemic Effects of Immobility - Metabolic
Negative nitrogen balance
Altered GI function
Fluid and electrolyte balance
Systemic Effects of Immobility -Cardiovascular
Orthostatic hypotension
Thrombus formation
Systemic Effects of Immobility -Urinary
Urinary stasis
Renal calculi
Systemic Effects of Immobility -Respiratory
Atelactasis
Hypostatic pneumonia
Systemic Effects of Immobility -Muscular changes
Loss of endurance and muscle mass
Decreased stability and balance
Loss of muscle mass
Muscle atrophy
Systemic Effects of Immobility -Skeletal effects
Impaired calcium absorption
Joint abnormalities
Systemic Effects of Immobility -Integumentary
Pressure ulcer
Ischemia
Interventions - Metabolic
High protein, high calorie diet
Vitamin B, C, A, D
Interventions - Cardiovascular
Progress from bed to chair to ambulation Sequential compression devices (SCDs) Thrombo-embolic Device (TED) Leg exercises, ROM Anticoagulation therapy (Heparin)
Interventions - Integumentary
Reposition every 1 to 2 hours
Skin care
Interventions - Respiratory
Cough and deep breathe ever 1 to 2 hours
Chest physiotherapy
Interventions - Musculoskeletal
Passive ROM vs Active ROM
Isotonic vs Isometric
Interventions - Elimination
Adequate hydration
Diet rich in fluids, fruits, vegetables, and fiber
Interventions - Psychosocial
Emotional support
Anticipate needs
Pressure Ulcers are a result of…
Pressure or Pressure in combination with shear
- pressure intensity
- pressure duration
- tissue tolerance
Stage I pressure ulcer
non-blanchable redness
Stage II pressure ulcer
Through dermis (no fat involved) no slough
Stage III pressure ulcer
Subcutaneous layer, might see some muscle
presence of slough, possible undermining and tunneling
Stage IV pressure ulcer
Passed fat and into muscle and bone, possible undermining and tunneling
IAD
Incontinence Associated Dermatitis
Exposure to urine
Diffuse in skin folds
Not necrotic
Pain and itch
4 phases of wound healing
- Hemostasis
- Inflammatory phase - protective response to injury
- Proliferative phase - rebuilding of tissue
- Maturation phase - collagen production and organization (ongoing for years)
Assess pressure ulcers for…
Granulation tissue
Slough
Eschar
Exudates (color, odor, consistency)
Braden Risk Assessment (6)
For pressure ulcers Nutrition Mobility Activity Moisture Friction and Shear Sensory Perception
Wound dressing - Hydrocolloids
Clean Stage II or shallow Stage III
Wound dressing - Transparent Film Dressing
Used for autolytic debridement
Wound dressing - Hydrogel
For shallow minimally exuding pressure ulcer (not infected) and are granulating
Wound dressing - Alginate Dressing
For moderate to heavily exudating ulcers
Silver Impregnated Dressings (Silver Sulfadiazine)
Infected wound
Honey Impregnated Dressing
Use of medical-grade honey for stage II and III
Gauze
do NOT use for clean granulating wounds
Pharmacokinetics
Describes how medications are absorbed; distributed; metabolized in cells, tissues, or organs; and how they are excreted
Medication is inactive if…
bound to a protein
Most biotransformation occurs in the…
Liver
Bioavailability
% of what is left after going through the metabolic process
