Ultimate Stack™ Flashcards
*What are some types (6) of elder abuse?
- physical (trauma, bruises, alert: may see multiple providers!!)
- emotional (do they have outside support network?)
- financial (ask who controls finances?)
- neglect (unkempt appearance)
- sexual
- abandonment
***first intervention is to ensure client safety, THEN duty to report abuse
*What are some things to keep in mind when communicating with clients with cognitive deficits? (4)
- use simple sentences
- avoid vague comments
- repeat words back exactly
- understand that the client’s reality is distorted
*What are common health problems among older adults? (6)
- heart disease
- cancer
- stroke
- lower respiratory disease
- diabetes
- Alzheimer’s/dementia
*What are common challenges for older adults? (3)
- polypharmacy (lots of meds)
- social isolation
- adjusting to chronic health problems, loss of independence
*What are the benefits of sleep? (4)
- regulates metabolism
- improves learning/adaptation
- reduces stress/anxiety
- improves immune system
*NREM vs REM sleep?
NREM:
- restful phases (I,II, III)
- muscles relax
- body temp and BP decreases
- delta waves present in phase III
REM:
- mental&emotional restoration
- dreaming
***all but NREM I are repeated about 4x/night
*What factors affect sleep? (4)
- Age (older are more prone to sleep disturbances)
- Lifestyle Factors (exercise, diet high sat fat interferes; animal and dairy products help, caffeine, nicotine, alcohol)
- Illness (fever, pain, SOB interfere; anxiety)
- Environmental (light, noise)
*What are the components of good sleep hygiene? (8)
- good sleep habits
- regular routine
- restful environment
- relaxation techniques
- no tv/computer/cell
- avoid caffeine, alcohol, nicotine
- avoid carbs (?)
- avoid exercise before bed
*What are some common sleep disorders? (8)
- insomnia
- restless leg syndrome (RLS)
- sleep apnea
- narcolepsy
- parasomnias- sleep walking/talking
- night terrors
- bruxism (clenching)
- nocturnal enuresis (bed wetting)
*What are 3 nonprescription sleep meds?
- melatonin
- lavender
- chamomile
*What are nursing responsibilities regarding safe med administration? (5)
- nurses hold full legal responsibility for safe med administration; so abide by institutional policies, state laws, and federal laws
- practice 3 checks
- practice 10 rights
- narcotics must be double locked
- need witness for “waste”
*What is stress? (definition)
- any disturbance in a person’s balanced state
- a stimulus that the person perceives as a challenge or as physical or emotional stress
*What are the types of stress? (5)
- distress/eustress- threat to health/good stress
- external/internal- death of family member/anxiety
- developmental- predictable, middle adults adjust to health changes
- situational- unpredictable, car accident
- anticipatory- upcoming exam
*How do people respond to stress?
**GAS (General Adaptation Syndrome)- fight or flight stage, adaptation, exhaustion or recovery
**LAS (Local Adaptation Syndrome)- localized body response, inflammatory response, pain response
*What is culture? (definition)
-a collection of learned, adaptive, and socially transmitted behaviors, values, beliefs that form the context from which a group interprets the human experience
*What is acculturation? (definition)
- immigrants assume the characteristics of that culture through acculturation
- a person who is acculturated accepts both their own and their new culture
*What is assimilation? (definition)
- new members gradually learn and take on the essential values, beliefs, and behaviors of the dominant culture
- complete when the newcomer is fully merged into the dominant cultural group
*How do we provide culturally competent care? (3)
- incorporate beliefs and practices from various cultures into your care and education
- encourage helpful cultural practices and discourage those that are harmful (suggest alternatives)
- accommodate cultural dietary practices as possible
*What is cultural awareness? (definition)
-ability to objectively examine own beliefs, values, and practices
*Inductive vs Deductive reasoning?
Inductive- gathering pieces of info, see pattern, and form generalization
Deductive- general premise and moves to a specific deduction
*What are the essential parts of nursing theory? (4)
- PERSON (needs, fears, etc)
- (good) ENVIRONMENT
- (improving) HEALTH
- NURSING (care I provide)
*Who are some of the important theorists in nursing?
- Florence Nightingale (clean environment)
- Virginia Henderson (first to define nursing, 14 basic needs)
- Hildegard Peplau (theorized that communication with the patient helps outcomes)
- Patricia Benner (primacy of caring theory, novice-expert theory)
- Madeleine Leininger (cultural competence)
- Jean Watson (caring theory, interpersonal process)
*What are the rights of research participants? (6)
- informed consent
- right to not be harmed
- right to full disclosure
- right to self-determination
- right to privacy/confidentiality
- institutional review boards
*What do experienced nurses strive for?
Empowerment!
- power to solve problems
- power to take initiatives
- power to exercise autonomy
*What are necessary leadership skills for nurses? (5)
- schedule
- identify goals
- set priorities
- organize work
- delegate
*What are (4) leadership styles?
- laizzez-faire (gives followers control in the decision-making process)
- autocratic (gives direction, final decisions, bears responsibility of outcomes)
- democratic (shares planning, decision making, and responsibility for outcomes. Guidence > control)
- scientific (?)
*What are some religions and their practices? (4)
- Christianity
- Islam
- Roman Catholicism (may wish for anointing the sick by a priest, deacon, or minister)
- Jehovah’s Witnesses (refuse blood transfusion)
*What are barriers to spiritual care? (6)
- lack of awareness of spirituality
- lack of awareness of your own spiritual belief system
- differences between nurse and patient
- trying to be all things to all people
- fear that your knowledge base is insufficient
- fear of where spiritual discussions may lead
*What nursing diagnosis’ can be applied to spirituality? (7)
- moral distress
- impaired religiosity
- readiness for enhanced religiosity
- readiness for enhanced spiritual well-being
- risk for spiritual distress
- risk for impaired religiosity
- spiritual distress
*What are categories of loss? (6)
- actual (death)
- perceived (perceived only by the person experiencing)
- physical (injury, loss of function)
- psychological (loss of hope, faith, or dreams)
- external (loss of object)
- environmental (loss of familiar)
- loss of significant relationships (death or divorce)
*What is end-of-life care? (7)
- support of family/caregiver
- ensuring continuity of care
- ensuring respect for person
- ensuring informed decision making
- attending to emotional and spiritual concerns
- supporting function
- managing symptoms
*What are the (2) key premises of hospice care?
- the quality of life is as important as the length
- those who are terminally ill should be allowed to face death with dignity
*What are the legal and ethical concerns related to death?
- advance directives
- DNR/AND
- Assisted suicide (ANA prohibits)
- Euthanasia (ANA prohibits)
- Autopsy (signed permission)
- Organ Donation
*What are some interventions for family members coping with a loved one’s death? (6)
- have family help with care
- encourage questions
- provide FU for referrals
- encourage talk with clergy
- provide anticipatory guidance
- acknowledge feelings of the family
What are the four assessment techniques and which order are they in for most assessments?
- inspection
- auscultation
- palpation
- percussion
What is the acronym SPICES used for?
Common problems in older adults: S- sleep disorders P- Problems with eating/feeding I- Incontinence C- Confusion E- Evidence of falls S- Skin Breakdown
During a comprehensive assessment what info do you gather during your general survey?
- vital signs
- height/weight
- appearance/behavior
- dressing/grooming/hygiene
- body type/posture
- speech
- mental state
What are each of the cranial nerves? How to test?
I- olfactory- smell- cotton ball
II- optic- visual acuity, pupillary reaction to light- PERRLA
III- oculomotor- EOMS- follow penlight
IV- trochlear- EOMS- follow penlight
V- trigeminal- facial sensation, jaw movement- clench teeth, touch with cotton ball
VI- abducens- EOMS- follow penlight
VII- facial movement, taste- smile for symmetrical movement
VIII- auditory- hearing, equilibrium- whisper test
IX- glossopharyngeal- swallowing, gag reflex, tongue movement, taste, saliva- ahhh
X- vagus- sensation of pharynx/larynx, swallowing, vocal cords, cardiac/respiratory reflexes, peristalsis, digestive secretions- ahhh
XI- spinal accessory- head and shoulder movement, speaking- shrug test
XII- hypoglossal- tongue movement- light tight dynamite
Bronchial vs Bronchovesicular vs Vesicular breath sounds?
Bronchial- loud, high, longer expiration, over trachea
Bronchovesicular- medium, equal in/out, over 1st/2nd ICS adjacent to sternum
Vesicular- soft, low, breezy longer inspiration, over lung fields
What is the order of assessment of the abdomen?
- inspect
- auscultate
- percuss
- palpate
What tool can be used to assess level of consciousness?
Glasgow Coma Scale
- evaluates eye opening, motor responses, and verbal responses
- it does not evaluate brainstem reflexes
What is a normal BMI? Overweight? Obesity classes 1-3?
normal- 18.5-24.9 overweight- 25-30 obesity (1)- 30-35 obesity (2)- 35-40 obesity (3)- 40+
What are the cervical lymph nodes? (12)
- posterior auricular
- occipital
- superficial
- posterior cervical
- posterior triangle
- superclavicular
- deep mandibular
- preauricular
- tonsillar
- submental
- anterior triangle
- submandibular
What are the (5) general health assessment components?
- physical
- mental
- spiritual
- socioeconomic
- cultural
What are the (2) components of a comprehensive physical examination?
Interview
Head-to-Toe assessment
Subjective vs Objective data? Primary vs secondary?
PRIMARY
Subjective- what the client tells you
Objective- data that you obtain about the client through observation and examination
SECONDARY
Subjective- what others tell the nurse about client
Objective- data the nurse collects from other sources (family, caregivers, med records)
What types of things should we avoid when using therapeutic communication? (4)
- medical jargon
- giving advice or opinions
- ignoring feelings
- offering false reassurances
What are some good techniques of therapeutic communication? (6)
- open-ended questions
- clarifying- specific details
- back channeling “tell me more” “go on’
- probing “what else would you like to add to that”
- closed-ended questions
- summarizing
What is self-knowledge?
-knowing your own skill and having a willingness to seek help when needed
Diaphragm vs Bell of stethoscope?
Diaphragm- high sounds (heat, lung, bowel)
Bell- low sounds (unexpected heart sounds, bruits)
What are adventitious breath sounds and what do they sound like?
Crackles/Rales- fine bubbly sounds not cleared with coughing
Wheezes- high pitched musical sounds
Rhonchi- corse, loud, low pitched, can be cleared with coughing
Pleural Friction Rub- dry, grating, rubbing sound
How do we grade pulse strength?
0 absent 1+ diminished, weaker 2+ brisk, expected 3+ increased, strong 4+ bounding
What is the expected pulse range?
60-100 bpm
What is a pulse deficit?
- the difference between radial and apical pulses
What is ventilation?
-the exchange of oxygen and carbon dioxide
What is ventilation?
-movement of air air into and out of lungs
What are Cheyne-Stokes respirations?
shallow breaths lead to normal breaths lead to increased rate leads to slowing back down leads to apnea period
What are Kussmaul respirations?
increased rate, abnormally deep
What is the expected range for pulse oximetry?
95-100%
What is the expected range for blood pressure?
normal- 120/80
stage I HTN- 130/80
stage II HTN- 140/90
What is the pulse pressure?
difference between systolic and diastolic readings
How does cuff size affect BP?
- too large- falsely low
- too small- falsely high
- cuff width=40% of arm circumference
- cuff bladder=80% of arm circumference
During two-step BP reading how much higher do we go when the pulse is no longer felt?
30 mmHg higher
What is a DASH diet?
Dietary Approach to Sop Hypertension
- restrict sodium
- get enough K, Ca, and Mg
- restrict cholesterol and sat fat intake
*What is the edema rating scale?
1+ trace- 2mm (rapid refill)
2+ mild- 4mm (10-15 sec)
3+ moderate- 6mm (prolonged)
4+ severe- 8mm (prolonged)
What is the ABCD system used for?
used to detect possible skin cancer A- asymmetry B- border irregularity C- color variation D- diameter >6mm
What are the terms to describe joint movement?
Flexion- movement that decreases angle between two bones
Extension- movement that increases the angle between two bones
Hyperextension- movement of a body part beyond its normal extended position
Supination- movement of a body part so that the ventral surface is up
Pronation- movement of a body part so that the ventral surface is down
Abduction- movement of an extremity away from midline
Adduction- movement of an extremity towards midline
Dorsiflexion- foot and toes up
Plantarflexion- foot and toes down
Eversion- turning body part away from midline
Inversion- turning body part toward midline
External rotation- rotating a joint outward
Internal rotation- rotating a joint inward
Unexpected spinal curvatures?
Kyphosis- curvature of the thoracic spine
Lordosis- curvature of the lumbar spine
Scoliosis- exaggerated lateral curvature
What are some words we can use to describe a patients level of conciousness?
alert- person, place, time
lethargic- can open eyes and respond, drowsy
obtunded- responds to shaking, confused, slow
stuporous- responds to painful stimuli only
comatose- no response
Stereognosis vs Graphesthesia?
Stereognosis- familiar object in hand and identify
Graphesthesia- trace a number on palm and identify
What are the (3) stages of wound healing?
Inflammatory
-1-5 days, vasoconstriction, platelets aggregate
Proliferative
-5-21 days, granulation, fibroblasts make collagen
Maturation
-2-3 weeks (or more), old collagen is broken down an remodeled