Test 2 Flashcards
How does the Need of Safety relate with regards to health promotion?
- Patient should be in a safe environment
- Patient should have a lifestyle that doesn’t risk injury
How does patient safety relate to quality of care?
-effective
-safe
-people centred
What is a patient safety incident?
What is a harmful incident?
What is a near miss incident?
What is a no-harm incident?
Safety incident - event that could or did harm the patient
Harmful incident - client got harmed
Near miss - harm did not reach patient
No harm incident- incident reached patient but no harm was done
What are nosocomial infections?
Infections the patient got from the healthcare facility
What are the changes associated with aging that increases the risk of accidents?
Change in vision and hearing
Slow reaction times
Decreased range of motion and strength
What should the nurse use when doing a safety assessment? (4)
- Knowledge
- Standards
- Experience
- Qualities (response, unbiased, etc.)
What are some interventions to maintain a safe home or healthcare environment?
-proper lighting
-no trip hazards
-hand rails in the bathroom
-hand hygene
- Discuss the need for collaboration with clients to identify specific health needs/goals that relates to safety
patients should have understanding of potential risk factors in their environment
What are the Fall Risk Assessment Tools used?
Schmid
Hendrich II
Timed Up and Go (TUG))
schmid - fall risk assessment score
Hendrich - fall assessment tool showing how different factors can increase the chance of falls such as mobility and medication (swiss cheese model)
TUG - Timed Up and Go”
-the person is timed as they get up from a chair, walk 3 meters, and return to the chair
What is the nurse’s role in case of fire?
What does RACE stand for?
Identify risks (cigarettes, equipment, etc.)
Know safety regulations
Rescue
Alarm
Contain fire
Extinguish
What are the different types of restraints?
When would we use restraints?
What are some legal considerations with restraints?
What are some alternatives to restraints?
Physical, environmental, chemical
To physically or behaviourally control the patient
It should be the last option used
Patients freedom, consent, and emergencys should be considered
Follow least amount of restraint necessary for least amount of time
Alternatives:
Distracting the patient
One-on-one nursing
Walking them somewhere
Get family to sit and visit them
What is the chain of infection? (6)
- An infectious agent (pathogen)
- A reservoir (source for pathogen growth)
- A portal of exit from the reservoir
- A mode of transmission
- A portal of entry to a host
- A susceptible host
What are the body’s defense mechanisms against
infections?
- Normal body flora
- Organ systems fight against microorganisms
- Immune response
What is local infection?
What is systemic infection?
What is behavioural risk factors?
If infection is in one area (e.g., a wound infection)
An infection that affects the entire body instead of just a single organ
Behavioral risk factors include
smoking, poor nutrition, and physical inactivity
What are normal ranges for body temperature across the lifespan?
What are some factors affecting body temperature?
Newborns 36.5-37.6 C
Regular 36-38 C
Older Adult - 36 C
Age
Exercise
Hormones
Circadian Rhythm
Stress
Environment
Fever
What is the difference between medical and surgical asepsis?
Medical asepsis - clean technique stops the spread of microorganisms (washing hands, etc)
Surgical asepsis -Sterile technique eliminate all microorganisms (wearing sterile gown and gloves)
What can nurses target to control infection specifically in older adults?
-immune system response
-skin breakdown
-falls
How does activity an exercise affect the musculoskeletal system and nervous systems?
Mobility depends on the nervous and musculoskeletal system
together they maintain body alignment, posture, and movement
Define activity
Define exercise
Define activity tolerance/ intolerance
Define mobility and immobility
Activity - any movement requiring energy
Exercise - planned, structured, repetitive
Activity Tolerance/ intolerance - ability to perform activites without getting tired
Mobility/ Immobility - ability to move free and easy
What happens to body
systems when a person experiences immobility?
Disease atrophy occurs where cells and tissues decrease in size and function
How can you use proper body mechanics and ergonomics to prevent injuries to the client and nurse?
-bed should be raised
-use your legs to lift not your back
-maintain body alignment and posture
What is active and passive range of motion (ROM)?
How do each benefit the client?
Active ROM - Client moves their own joints
Passive ROM - you move the patients joints for them
Describe frailty
What is the Frailty Scale range? (7)
Frailty - weak and delicate
Scale ranges from:
#1 Very Fit - active, energetic
#2 Well – no active disease but less fit
#3 Well with treated disease – has controlled symptoms
#4 Vulnerable – complains of being slowed down
#5 Mildly Frail – limited dependence on others
#6 Moderately Frail – needs help with Activities
#7 Severely Frail – completely dependent on others
Activity and exercise assessment questions should include:
Nature of the problem
Signs and symptoms
Onset and duration
Severity
Barriers to exercise
Patient values
Effect on patient
What are some nursing diagnosis related to activity and exercise?
-activity intolerance
-impared physical mobility
What 4 components are fundamental to mobility and exercise? BBCJ
- Body Alignment & Posture
- Balance (stability)
- Coordinated Movement
- Joint mobility
What are the different types/categories of exercises and what are the benefits of each? (4)
Isotonic - contracting muscles (walking, swimming, bicycling)
Isometric - tensing without moving (sitting)
Resistive Isometric - increase in resistance and time (planks)
Aerobic - stretching and strength training to bring more oxygen in system
What risk factors contribute to pressure injury formation?
-Unable to change position
-friction and shear
-malnutrition
-age
What needs should you identify about your client when assessing their hygene practices?
-Health promotion practices and
needs
-Emotional needs
-Health care education needs
What is the Braden scale used for?
What kind of scores are higher risk?
The Braden Scale - bed sores
Lower scores = higher risk
Identify strategies to provide safe oral hygiene to an unconscious client and a client with cognitive impairment
Unconcious client:
turn them on side
Use padded tongue blade
Cognitive impairment:
Talk them through it
What are some body image changes that affect self concept?
What are some role changes that could affect self concept?
Body image changes:
puberty
menopause
aging physical decline
Role changes:
child
parent
student
employee
What can be done in the assessment of a patient to find out their self concept?
- Interview Questions
- Observing behaviours
-any stressors to self concept - Coping patterns
- Significant Other (Family) Observations
- Client’s Expectation
What are some signs you have a healthy self concept?
-You can adapt to challenges
-Better cope with illness
-Can deal with stressful situations
-Choose healthy behaviours for themselves
How can you evaluate the effectiveness of your interventions on a clients self concept?
Questions to ask & what to observe to see :
✓ If goals met, not met or partially met
✓ If nursing orders effective
✓ If nursing diagnosis still needed
What is the Need of Oxygenation?
Cells need oxygen
What 4 factors affect oxygenation the most?
Lifestyle - exercise, occupation, smoking, diet
Environment - altitude, temperature, and pollution affects oxygenation.
Physiological - body changes (pregnancy, obesity)
Developmental - age related changes (babys have smaller airways)
When is comes to oxygenation, what should be in the clients heath history?
How should you physically examine them for oxygenation?
Health History – should focus on the client’s ability to meet O2 demand
Physical Examination:
Position – upright -> greater lung expansion
Blood Pressure – in both arms, norms should be within 10mmHg of each other
Pulse – comparison for strength & if equal, also check for rate, rhythm &
quality
Skin warmth or coolness – indicates circulation
Edema – with decreased blood return
Feet – check for coolness, weak pulses or shiny skin or pitting edema
What is the range for respiratory rate?
What is the range for pulse oximetry?
What is the range for pulse?
What is the range for blood pressure in systolic and diastolic?
Respiratory Rate - 12-20 breaths per minute
Pulse Oximetry - 95-100%
Pulse (Heart Rate, HR) - 60-100 bpm
Blood Pressure (BP):
Systolic: 95-145mmHg
Diastolic: 60-90 mmHg
How can you improve someone’s oxygenation?
-exercise
-quit smoking
-quit drugs and alcohol
-less stress
-leave polluted environments
What should you assess in a patient when looking for oxygenation issues?
History of client
Physical symptoms
Smoking
Lab tests on patient
What is self concept?
What is self esteem?
How a person thinks of themselves
It is subjective and a mixture of concious and unconcious thoughts, attitudes, and perceptions of themselves
Self esteem - our self worth
What are stressors affecting self concept?
-identity stressors (change in physical appearance)
-Body Image Stressors i.e. loss of body parts or function
-Self Esteem Stressors i.e. lack of positive feedback, repeated failures
-Role Performance Stressors
What is the family’s effect on the development of self-concept?
-Children develop a basic sense of who they are from their caregivers
-Parents who respond in a firm, consistent, and warm manner promote positive self esteem
How can a nurse help to support or strengthen a person’s self-concept?
- stress positive thinking rather than negative
- identify & reinforce client’s strengths
- acknowledging goals met
- provide honest & positive feedback
What 4 things make up a persons self concept?
Identity - involves the internal sense of individuality
Body image - is the perception we have of our bodies, including size, appearance, and functioning
Role performance - is the way in which individuals perceive their
ability to carry out significant roles. Common roles include parent, child, spouse, employee, and student
Self esteem - global and specific
How can you check on someone’s hygiene and skin integrity after providing nursing interventions?
-Reassess the condition of the patient’s
skin, hair, nails. and oral cavity
-Patient’s comfort and hygiene have improved
-patient can demonstrate self-care practices
-patients expectations are met
Activity and exercise physical assessments should include:
Pain
Expectations
Body Alignment
Gait
ROM
Capabilities & Limitations
Muscle Strength
Response
Tolerance
Mobility
What are the two most common causes of death in older persons?
Cancer
Heart disease
True or false: hygiene care is never routine
True
True or false: when planning goals for the client they need to be specific
True
True or false: self concept develops throughout the lifetime
True
What influences someone’s self concept?
Parents
Culture
Social interactions
Age
Gender
What are the two types of self esteem?
Global - how you see yourself as a whole
Specific - specific parts of yourself (ex: cooking skills)
When planning goals related to the patients self concept the nurse should try to enhance:
self esteem
Body image
Identity
Body image
What are the three steps in the process of oxygenation?
- Ventilation (gas in and out of lungs)
- Perfusion (heart pumps oxygen to tissues)
- Diffusion (gases go from high to low concentration)
Which two systems does oxygenation include?
Respiratory
Cardiovascular
When priority setting for a patient, what is the most important goal?
Safety (Maslows hierarchy)
What factors affect activity and exercise? (4) BCDE
- Behavioural (knowledge of a&e)
- Cultural influences (fasting)
- Developmental changes (kid becoming a teenager)
- Environmental issues (work)
What is the difference between an actual NANDA diagnosis and a risk diagnosis?
Actual: NANDA (problem) + factors + evidence
Risk: NANDA (problem) + factors
*no evidence because problem doesn’t exist yet
