Unit One Flashcards
Two types of body temperature
Core temperature and surface temperature
Hyperthermia
More heat produced than lost Etiology: -Viral infections -Bacterial infections -Tissue breakdown
Hypothermia
More heat lost than produced Etiology: -Impairment of hypothalamus -heat loss greater than heat production -excessive loss of body heat
Thermoregulation
There are more cold receptors than warm receptors
Pyrexia
Body temp is above typical range
Hyper pyrexia
Very elevated body temp (above 105)
Afebrile
Patient does not have a fever
Hypothermia
Core body temperature is below limit of normal temp
Data
- Wellness behaviors
- illness/ signs and symptoms
- strengths and weaknesses
- risk factors
Two types of data
Subjective and objective
Sources of data
Secondary and Primary
Primary Data
Comes from pt
Secondary Data
Comes from support people, client records, healthcare professionals, literature
Types of assessment
Initial
Problem
Emergent
Ongoing
Initial Assessment
Establishes baseline data; problem identification
Problem focused assessment
Determine status of a previously identified problem
Emergent Assessment
During a crisis
Ongoing Assessment
Occurs sometimes after initial assessment; comparison of initial and current data
Methods of Assessment
Inspection
Palpating
Percussion
Auscultation
Method of Assessment should be done in IPPA order unless
You are assessing the abdomen
Profusion
The process of the cardiovascular system providing a continuous supply of oxygenated blood to every cell in the body
What to look at when do ing a Perfusion assessment
Skin color Temp Abnormal pulsation Edema Capillary refill Blood pressure
Evidence based practice (EBP)
- An integration of best evidence available, nursing expertise, and the values and preferences of the individual.
- Serves to bridge the gap between best available evidence and the most appropriate nursing care.
Barriers to EBP
- Work schedule demands
- Client preferences
- Access to technology
- Limited knowledge
- Lack of support from manager
- Lack of access to continuing education
- Attitude of individual nurses
- Resistance to change
Effects of EBR on nursing
Promotes best practice Credibility of nursing as a profession Accountability of nursing practice Cost effective nursing care Generate knowledge, and use current problems
Developing EBP
Step 1: develop a clinical question
Step 2: Retrieve the evidence
Step 3: Evaluate evidence
Step 4: Apply the evidence
Collaboration
Two or more people working towards a common goal by combining skill, knowledge, and resources
Healthy people initiative
Initiatives to make our population as a whole better
Maslow’s Hierarchy of Needs
Physical, Safety, Love and Belongingness, Self Esteem, Self Actualization
Inflammation
The body’s response to help reduce the effects of what the body views as harmful.
Purposes of inflammation
Protection
Encourages healing
Preventative
What is inflammation?
An adaptive response that brings fluid, dissolved substances, and blood cells into that interstitial tissue.
Non-specific
Neutralizes invader, destroyed tissue is removed, and healing begins
Debridement
Debridement
Preparation for wound healing
5 cardinal signs of inflammation
Heat Redness Swelling Pain Loss of fune
How many stages of inflammation are there?
Three
Stage one of inflammation
Vascular and cellular response:
Can cause edema and pain
Vessels constrict and become permeable and fluid leaks out inter interstitial tissue
It’s swollen
Stage two of inflammation
Exudate production:
Helps to dilute any toxins
May have drainage (puss)
Healing is starting to take place
Stage three
Reparative Phase:
Regeneration of the tissue
Things start to return to normal
I’d regeneration is not possible you may end up with fibrous tissue
Inflammation can be _________.
Acute or Chronic
Chronic Inflammation
Lasts longer periods of time
I.E. Lupus
Acute Inflammation
Up to 10 days before duration before symptoms subside and repair starts
I.e. bee sting
ESR
Erythrocytes Sedimentation Rate:
Tells provider that there is inflammation somewhere n the body
CRP
C-reactive Protein; measures how much infection there is
WBC
White blood cell count: its going to tell you that infection is present that is causing the inflammation by how high the WBC is.
What interventions are there for Inflammation?
Immobilization Antipyretic Antibiotics Healthy diet Instruct patient to take all medications Change dressings as needed Surgery
Pharmacological interventions for inflammation:
Anti-inflammatory drugs
Corticosteroids for severe inflammation
Chain of infection
Infectious agent>Reservoir>Portal of Exit>Means of Transmission>Portal of Entry>Susceptible Host (repeat)
Where can the chain of infection be broken?
At means of Transmission
How can the chain of infection be broken?
Standard precautions, vaccinations, sterilization, instrument management, hand hygiene
Infectious Agents
Bacteria, fungi, viruses, Protozoa
Reservoirs
People, environment
Portal of exit:
Excretions secretions, skin, droplets
Means of Transmission
Direct contact, ingestion, airborne
Portal of Entry:
Mucus membrane, GI Tract, Respiratory, Broken Skin
Susceptible Host:
Unvaccinated people, immunosuppressant, diabetes, Surgery, burns, cardiopulmonary
What increases the risk for infection?
Age Heredity Stressors Nutrition Cancer Treatments Cancer treatments Medications Anti-inflammatory meds Antibiotics Diseases
Diagnostic tests for Infection?
WBC Procalcitonin (CTpr; Asepsis) C&S Serological Testing X-rays Ultrasounds Lumbar puncture
Antibiotic Peak/Trough
Used to test for infection
Verifies medication is in therapeutic range at all times
Peak
Highest level of a drug in your system; drawn shortly after medicine is given
Trough
Drawn shortly before the next does; measures the lowest level of a drug
Infection is caused by:
An organism
I.e. Bacteria, fungus, etc
Inflammation is _________.
Just the body’s response
Infection leads to ________.
Inflammation
Inflammation and Infection can both be __________ and ___________.
Localized and systemic
Localized
In one area of the body
Redness swelling heat
I.e. Bee sting, ant bite, pink eye.
Systemic
Wide spread throughout the body
Most Common Systemic infection in the hospital:
Sepsis
Nosocomial infections
Hospital acquired infections (HAI)
Does not originate from the patients original diagnosis
Nosocomial infections become evident ____________ hours after hospitalization.
48
Nosocomial Infections lead to
Increased hospital stays
Increased healthcare costs
Decreased reimbursement from insurance
Nosocomial Infections usually occur in _________ and _____________.
Surgical Unit and ICU
Ranked total annual costs for HAI’s
Surgical site infections
Ventilator-associated bloodstream infections
Central-line associated bloodstream infections
C.Diff infections
Catheter associated UTI’s
Infection Prevention Methods:
Hand washing (Best prevention method) Device care Clean nails (no fake nails) Isolation precautions Infection control bundles Identify a risk patients Clean environment Follow Agency Policies MINIMAL invasive equipment and procedures
PPE for Droplet precautions:
Gown
Gloves
Surgical Mask
Is a negative pressure room required for droplet precautions?
No
Patient on droplet precautions must wear _________ when outside their room.
Surgical mask
Common Conditions that require Droplet precautions
Influenza, meningitis, pertussis, rubella
Duration of precautions for influenza:
7 days from admission for respiratory illness.
Duration of precautions for Meningitis:
24 hours after effective therapy has started
Duration of precautions for Pertussis:
5 days after effective therapy has started
Rubella
(German Measles) 7 days after onset rash
PPE for Airborne Precautions
N95 OR PAPR
Gown and gloves
Does Airborne precautions require a negative pressure room?
Yes, door must remain closed at all times
Common conditions on Airborne precautions:
TB
Chicken Pox
Disseminated Herpes Zoster
PPE for contact Precautions Enteric:
Gown and Gloves
Common Conditions that call for contact precautions:
Acute Gastroenteritis
C.Diff
Norovirus
Rotavirus
PPE for Contact precautions
Gown and Gloves to enter room
Common Conditions that call for Contact precautions:
MRSA Multi-drug resistant organisms: -CRE -ESBL -VRE
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
A. The patient states that the Ulcers are very painful
B. The patient has had the heel ulcers for the last 6 months
C. The patient has several old incisions that have formed Keloids
D. The patient takes corticosteroids daily fo rheumatoid arthritis
D.
Urinary tract includes
Kidneys, Ureters, Urinary Bladder, Urethra
Second most most infection in children:
UTI’s
10-15% of patients that have a catheter obtain a ___________.
UTI
Risk Factors for UTI’s in adult females
Increase with sexual activity Spermicidal compounds Pressure from diaphragm Lack of normally protective mucosal enzyme Voluntary Urinary retention
Risk Factors for Adult Males
Prostatic Hypertrophy
Bacterial Prostatitis
Circumcision protective
Anal intercourse
FUO
Fever of Unknown origin
Typical symptoms of a UTI
Dysuria, nocturia
Frequency, Urgency
Foul Odor, Pyuria, Hematuria
Symptoms of UTI’s in older adults:
They are nonspecific “They just don’t feel good” Confusion Behavior change Disorientation
Tests to diagnose a UTI
Urinalysis
Gram Stain
Urine C&S
WBC w/ diff
Recurrent Urinary Tract Infections can lead to
Additional testing
IV pyelography
Voiding Cystourethography
Cystoscopy
IVP (Intravenous Pyelography)
Evaluates the excretory process of your kidneys
Looking for a problem with the structure of the Urinary tract
Pharmacological Treatment for an Uncomplicated lower UTI
Short term antibiotic
UTI Antibiotic is selected based on
Age of client
Sensitivity
Renal Funtion
Clients Signs and symptoms
Nonpharmacologic Treatments for a UTI
Drinking adequate fluids
Drinking Cranberry juiceAvoid fluids that irritate the bladder such as caffeinated beverages, alcohol, citrus juices
What is the Nursing process?
Assessment Diagnosis Planning Implementation Evaluation
MRSA
Methicillin-Resistant Staphylococcus Aureus
MRSA is a
Staph aureus infection that has become resistant to the class of antibiotics.
MRSA is caused by
Unnecessary antibiotic use, antibiotics in food and water, genetic mutations of bacteria
MRSA starts as
Small red bumps that resemble pimples, boils, or spider bites. They turn into deep painful abscesses that may require draining,
Risk Factors for MRSA
Someone with a current or recent hospitalization A resident in a long-term care facility Recent Antibiotic use Young Age Weakened immune system Association with healthcare worker
MRSA can be transmitted through
Contaminated hands
Sharing towels or any personal hygiene items
Close contact sports
Sharing of IV drunk Paraphernalia
How to test for MRSA
MRSA screening
C&S from suspended site
How to treat MRSA
Vancomycin
Cover infected Wounds
Drain infected wounds
Prevention for MRSA
Screening Hand Washing Standard precautions Contact precautions Patient and Family education
A clinical nurse educator is preparing an educational program about transmission of MRSA in hospitalized clients. Which of the following information should the nurse include in the program?
A. Place clients who have MRSA on Airborne precautions
B. MRSA can be effectively treated with an antiviral medication
C. MRSA can live on the hands for 1 hr
D. Bath clients with water and chlorhexidine gluconate
D
Antibiotics for MRSA
Aminglycosides
Cephalosporins
Tetracyclines
Glycyclines
Always Assess for __________ when administering an antibiotic.
Allergies
Do not give Cephalosporins with ______________.
Antacids
Tetracyclines can cause
Liver toxicity, stains teeth, bone damage, photosensitivity
Aminglycosides
Ototoxcity, kidney damage
Do not use ______________ with children, can cause tooth damage.
Glycyclines
Common side effects of Antimicrobials:
Big 3(Nausea, vomiting, diarrhea)
Allergic reactions (redness, labored breathing)
Miscellaneous (photosensitivity, secondary infections, inflammation)
Toxicity
What is a major side effect of Tetracycline? A. Urinary Retention B. Photosensitivity C. Hepatotoxicity D. Hypersensitivity
B and C
When discharging a patient on tetracycline, the nurse should instruct the patient to:
A. Take medication with food or milk
B. Don;t use NSAIDS concurrently with your antibiotics
C. Limit the time in the sun
D. Discontinue antacids when taking this medication
C
The nurse caring for a newly admitted patient knows that effective use of the nursing process is dependent upon communication that:
A. Is structured and goal-directed
B. Meets the needs of both patient and nurse
C. Is spontaneous and affords mutual self-disclosure
D. Fosters emotional distance between patient and nurse
A
Effective Communication is
Clear/Concise
Professional
Congruent (non-verbal and verbal match)
The communication process
Sender
Message
Receiver
Response
Name the two modes of communication:
Verbal, Nonverbal
Verbal
Spoken or written word
Nonverbal
Gestures, facial expressions, touch
In the healthcare setting we want to use ___________ communication.
Assertive
Sentinel event
An unplanned event that in the end, harms the patient
What is SBAR
Situation, Background, Assessment, Recommendation
Structured to make sure that critical information is communicated between healthcare workers
SBAR: Introduction
Introduce yourself, identify the area you are calling from
SBAR: Situation
Tell the physician what situation has occurred that is concerning
SBAR: Background
Provide information; include why the patient is in the hospital. What is worrying you?
SBAR: Assessment
What do you think is happening?
SBAR: Recommendation
What do you think should be done?
While assessing a postoperative client for pain, the nurse notices the client is holding the surgical site and making facial grimaces. However, the client claims not to be hurting. What part of the communication process needs to be further clarified?
- Sender
- Receiver
- Message
- Feedback
- Message
Document “Do’s”
Chart changes, show follow up, read prior notes, be timely, objective, factual, use patient quotes
What not to do when documenting
Leave blank spaces, chart in advance, use vague terms, chart for others, alter record, record assumptions, include your feelings
What should the nurse know when observing and interpreting a patients nonverbal communication?
A. Patients are usually aware of their nonverbal cues
B. Verbal responses are more important than nonverbal cues
C. Nonverbal cues have obvious meaning and are easily interpreted
D nonverbal cues provide significant information and need to be validated
D.
Which of the following factors has documented negative effects on patient outcomes?
A. Inter professional conflict
B. Ineffective communication between the Neal care personnel
C. Stressful working environment for the nurse
D. All of the above
D
Top safety risks
Falls, improper use of restraints, healthcare associated infections, wrong site surgery, medication errors
Seven rights of Medication Administration
Right assessment Right drug Right does Right client Right route Right time Right documentation
What is a restraint?
Protective devices used to limit physical activity or part of body
Types of restraints
Physical, chemical
Restraints need a __________________
Doctors order.
Hand off communication
Transfer of information during transitions of care across the continuum.
Safety Hazards in the workplace
Blood borne pathogens, needle sticks, latex allergies, musculoskeletal injuries, stress, violence from clients, incident reporting
Which of the first priority in preventing infection when providing care for a client?
A. Hand washing
B. Wearing gloves
C. Using a barrier between client’s furniture and nurse’s bag
D. Wearing gloves and goggles
A.
The nurse is assessing a 70-year-old-client and is determining the clients risk for injury status. The nurse would concentrate a safety on: A. Cognitive awareness B. Unsafe workplace C. Brand of car used D. Number of children in the home
A
Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is: A. Amount of regular exercise B. Illumination of the environment C. The resting pulse rate D. Status of salt intake
B
The nurse is planning interventions to address the National Patient Safety Goal of correct client identification. Which nursing action supports this goal?
A. Writing the clients fist name next to the assigned staff on the assignment sheet
B. Placing the clients name on the room door
C. Matching the name on the clients wrist band with the medical administration record
D. Asking “Are you Betty Jones?”
C
When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things?
A. Tie the straps to the side rails
B. Tie the straps to the movable part of the bed frame
C. Tie the straps with a square knot
D. Tie the straps with a quick-release knot
D
In assessing a patient’s readiness to learn, consider:
Physical readiness
Emotional readiness
Cognitive readiness
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is the strongest predictor of health status, according to the American Medical Association. A. Income B. Education C. Health Literacy D. Racial or Educational Background
C
Lifespan Considerations of Children
Establish trust
Educate the caregiver more but still educate the child
Lifespan considerations for adults
How the patients going to learn best
Answer questions
Provide feed back
Lifespan considerations for adults
Medication
Address things that might effect their comprehension
Allow adequate time
Health Literacy means:
A. Able to read and write
B. Able to read and understand health information
C. Able to obtain, process, and understand health information and services needed to make appropriate health decisions
D. The ability to read at the 8th grade level or above
C
Patients quickly forget \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ or medical information given to them by a healthcare provider. A. 10-20% B. 20-30% C. 30-60% D. 40-80%
D.
What is teach-back?
A way to make sure you—the health care provider—explained information clearly; it is not a test or quiz of patients.
Saying: “I want to make sure I explained everything clearly to you. Can you please explain it back to me in your own words?” Is an example of using what?
Teach back tools
While teaching a 32-year-old client about colostomy care, the nurse notes the client has tears in his eyes. The client states, “I cannot believe I have to live with this thing for the rest of my life.” Which nursing response best reflects the nurses understanding of factors that inhibit learning?
A. You’ve been through a lot. As soon as we’re finished I will ask the doctor for a counseling referral.
B. “Let’s reschedule this teaching session for later. I’ll check back with you to pick a time. Right now I’d like to hear more about how you are feeling.”
C. “I’m sorry you have to go through this. Understanding how to take care of yourself should make it a little easier fo you so let’s talk about how to clean your colostomy site.”
D. “I hear you saying that you’re upset. I’ll reschedule your teaching for tomorrow morning. Now please tell me about how you feel.”
B.
Which client behavior may cause a nurse to suspect a literacy problem?
A. The client displays a pattern of compliance
B. The client reads the instructions slowly
C. The client recognizes that he or she does not know the information.
D. The client displays a pattern of making excuses fo not reading instructions
D.
What is an important responsibility of the nurse in client education?
A. Insist that all clients use the internet for medical information for medical information
B. Inform clients of reputable sites for healthcare information
C. Tell clients that if they do not know how to use the internet
D. Tell clients that the Internet is not useful in providing medical advice
B
The nurse is teaching a client about a disease process. The nurse validates that the client understands the teaching by documenting information?
A. A family member’s opinion
B. The responses of the client
C. That the teaching was done
D. That the feedback questionnaires were used
B
What is accountability?
Is being answerable for the outcomes of a task or assignment
Quality and safety education for nurses (QSEN)
Client centered care Teamwork and collaboration Evidence based practice Quality improvement Safety Informatics
Areas of competence
Health and wellness promotion
Illness prevention
Health restoration
Caring for the dying
ANA’a standards for professional practice
Quality of practice Education Professional practice evaluation Collegiality Collaboration Ethics Research Resource Utilization Leadership
Banner’s stages of nursing expertise:
Five levels of proficiency in nursing
Stage I: Novice Stage II: Advance Beginner Stage III: Competent Stage IV: Proficient Stage V: Expert
NC Nurse Practice Act:
Regulates the practice of nursing
Purpose of NC Nursing Act
To protect the public
Nurses are responsible for knowing their state’s practice acts as it governs their practice
*Delegation Tree
The nurse is aware that keeping abreast of changes in the nursing profession through continuing education is the nurses responsibility. What key factors presently drive changes in the field of nursing? A. Supplies and technological advances B. Scientific and technological advances C. Scientific and human responses D. Cardiac and neurological information
B
