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Nursing 1 > Week 1 > Flashcards

Week 1 Flashcards

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1
Q

You can never delegate a take that the RN must EAT, what does EAT stand for?

A

Evaluate, assess, teach

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2
Q

what is a primary, independent nursing responsibility?

A

Health education

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3
Q

Tips for educating elderly patients:

A 
Treat as they are capable of learning
include in setting goals
ID and accomodate any disability
Gear rate of teaching to person's disability
Break into small parts
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4
Q

Guideslines for developing patient education materials:

A
  1. visuals
  2. 3-5 grade level
  3. short and concise
  4. key points or must know bullets
  5. explain measurements
  6. clearly ID when to call doctor
  7. plan language
  8. teach back
  9. find advocate for someone with low literacy to ensure compliance
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5
Q

Chronic illness:

A

persistent and recurring health problems, non-self limiting, duration of months and years or forever

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6
Q

Trajectory model of chronic illness:

A
  1. pretrajectory
  2. trajectory onset
  3. stable
  4. unstable
  5. acute
  6. crisis
  7. comback
  8. downward
  9. dying
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7
Q

Palliative care

A

Relieve suffering; initiate at any time through patient care; encourage physical support

Hospice is the same BUT is only utilized when the patient is told they have less than 6 months to live

Goal setting in palliative care → comfort vs. aggressive disease focused treatment

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8
Q

hospice care

A

End of life
Focus: QOL
Eligibility criteria
Services covered by CMS

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9
Q

Pre-death what should patient expect and what should nurse do

A

The dying person needs to know what is happening and talked about its reality

be allowed to experience the pain of a feeling bad instead of hiding their feelings

participate in decision-making regarding how they will spend their final days

nurse primary responsibility is to develop a relationship with the dying person

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10
Q

Death

A

primary responsibility is to anticipate problems such as distressing symptoms or family disruptions before they interfere with a dying person’s wishes

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11
Q

Bereavement

A

Time after death, nurse should be in position to listen

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12
Q

Ethical decision making in end of life care

A

nurses must educate patients about possibilities and probabilities regarding their illness and live with the illness

Advanced directives

durable power of attorney for health care

Living Will

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13
Q

Symptom management for end-of-life care

A

physical, psychological, social, spiritual

Pain should be treated; even as death approaches those receiving pain medication should continue as the level of Consciousness changes. even if the patient is unresponsive pain medication should be continued

Anorexia is expected at the end of life; can use appetite stimulants; not important to make sure the dying person is eating if they do not want to eat. educate the family that this is a normal part of the dying process

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14
Q

Cachexia

A

muscle waisting

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15
Q

Measures to manage anorexia in dying patient

A 
Utilize anti-emetics 
Encourage to each when effects of meds subside
modify environment to eliminate odors 
remove items that may decrease appetite
manage anxiety and depression
position to enhace gastric emptying 
assess bowels 
oral care
ensure dentures fit
treat pain
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16
Q

Changes in consciousness and delirium in dying patient:

A

Hypo/hyper active; can treat with benzo’s like ativan; focus on cause

teach family, ensure safety, monitor medications, confusion May mask needs and fears about dying, acknowledge family concern

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17
Q

Dyspnea – end of life

A

treatment varies; subjective and objective should be treated, assess, intervene if needed

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18
Q

Secretions in end of life

A

Related to oropharyngeal relaxation and diminished awareness

suctioning generally does not help

repositioning is most helpful

Oral Care

Atropine (SL/IV/SQ/IM) reduces production of oral secretions

Glycopyrrolate (PO/rectal/SL)

Scopolamine patch

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19
Q

Palliative sedation at end of life

A

Used for people close to death who are not responding to conventional treatment

Goal: reduce symptoms
This is different from euthanasia or PAS as this is to cause death (nurses in iowa can not do this)

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20
Q

Nursing care of patients and families in final hours of life

A

Expected physiological changes

a. s/s of near death, focus on patient, pt. will sleep longer, encourage family to continue to speak to client

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21
Q

After death care

A

body becomes dusky, blood pools, skin waxy

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22
Q

Describe grief mourning and bereavement

A

Grief is a person’s feelings that accompany an anticipated or actual loss

mourning refers to expressions of grief

Bereavement is the period of time that the mourning takes place

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23
Q

Anatomy of skin: Epidermis

A

Keratin (live, continuously dividing cells)
Melanocytes (pigment)
Merkel cells (transmit stimuli to the axon through a chemical synapse
Langerhans cells (play a big role in cutaneous immune system reactions)
Rete ridges (hold epidermis and dermis together and permits the free exchange of essential nutrients between two layers)

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24
Q

Anatomy of skin: Dermis

A

Strength and structure in the form of collagen and elastic fibers

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25
Q

Anatomy of skin: hypodermis

A

subcutaneus

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26
Q

What are the 3 types of sweat glands

A

Eccrine: all areas of skin
Apocrine: larger glands and eccrine found in axilla, anus, scrotum and labia majora
Sebaceous glands: sebum on to the space between the hair follice and hair shaft

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27
Q

piloerection

A

tiny hairs standing related to chill or fear

28
Q

Hirsutism

A

abnormal hair growth related to endocrine issue; Cushing increase hair growth; hypothyroidism causes a change in hair texture

29
Q

Alopecia

A

General loss caused from chemotherapy, radiation, or immune disorders

30
Q

petechiae

A

pinpoint spots from blood leaking into skin

31
Q

Striae

A

stetch marks or Cushing’s syndrom sign

32
Q

What may brown/tan spots indicate on the skin

A

endocrine (adrenal) function

33
Q

What should nurse assess for rash

A

border, size, shape, primary/secondary condition, pruritus

34
Q

What should nurse assess for lesions

A

Color, redness/pain/swelling, size, location, pattern of eruption (macule, papular, scaling, oozing, discreet, confluent), distribution, wound bed, edges, size, surrounding skin, vascularity, hydration (turgor)

35
Q

What is the first thing nurse should assess when assessing lesions

A

vascularity (capillary refill around border)

36
Q

Primary vs. secondary lesion

A

What you have (macule, papule, nodule, wheal, pustule, cyst)

Characteristic of the primary; what is on top or within that lesion (erosion, ulcer, fissure, scales, crust, scar, keloid, atrophy, lichenification)

37
Q

What are macules, papules, nodules, vesicles, wheals, pustules, cyst

A 
macule = patch
papule = plaque 
nodule = tumor 
vesicle = bulla 
wheal = evanescent rounded or flat-topped elevation in the skin that is edematous, and often erythematous pustule = containing pus 
cyst = sac-like pocket of membranous tissue that contains fluid, air, or other substances
38
Q

Examples of topical medications

A

Lotion, powder, cream and emulsions, gels, pastes, ointments, sprays and aerosols, corticosteroids, intralesional therapy, systemic medications

It is important for the nurse to consider that penetration of a topical steroid depends on the Skins site, which varies based upon the denseness of the stratum corneum, blood supply and tissue Integrity of the involved area. penetration of topical steroids applied to the eyelids or scrotum is 4 times greater for the forehead and 36 times greater than the palms and Soles. stop Center in less intact skin has a higher absorption and poses a higher risk for side effects

It is important to know what you are putting on a patient’s skin because some topical medications are debriders and they will eat away at the wound; if it is put on the healthy skin it will also eat away at the healthy skin

39
Q

How can nurses care for wounds

A
  1. Dressings
    Primary dressings are usually considered passive and provide protection to the wound, whereas interactive dressings create a moist wound environment and interact with the wound bed components to further enhance wound healing. interactive dressings May reduce colonization count, reduce the level of exudate, improve wound bad moisture retention, improve wound collagen Matrix, remove cellular products, or provide protection for the epithelialing bed
  2. Debridement (getting rid of slough and dead tissue)
  3. Negative pressure wound therapy (wound vac → suction to wound → gets rid of slough and sucks up vascular delivery which increases O2 to that area
  4. Hyperbaric oxygen therapy (increasing O2 to that wound so it can heal)
  5. Pharmacological therapy
40
Q

Braden scale

A

Assessment toolTo determine the risk a patient has for developing pressure ulcers

measures sensory perception, moisture, activity, mobility and friction / shear

should be completed on every patient you take care of

the lower the score the higher the problem / risk for ulcers

41
Q

Describe the stating of ulcers

A

Stage 1: Non blanchable redness; no break in thermos when you push on skin it does not turn white

Stage 2: break in dermis (just the first layer); blister

Stage 3: subcutaneous fat

Stage 4: ligament, tendon, bone
unstageable: covered in eschar or slough; You cannot see under this which means you can’t see how deep the wound goes which means you can’t stage it; requires debridement

42
Q

Staging of pressure ulcer is dependent on what?

A

tissues exposed, not depth

43
Q

How do pressure ulcers heal?

A

secondary intention → they granulate (heal) from the inside out and create a large scar

44
Q

Seborrheic Dermatitis

A

Excessive production of sebum

topical steroids can heal this

may develop secondary candidiasis and require topical anti-fungal

anti-dandruff shampoo (zinc-based)

45
Q

Herpes Zoster

A

Viral infection

a. shingles
b. pain management (post herpatic neuralgia)
c. Eyes or close to eye/ ear is emergency (blind or deaf)
d. Common in older people

46
Q

Tinea

A

Viral skin infection

Ringworm, corporis (body), cruris (groin), pedis (foot), ungulum (nails)

47
Q

Scabies

A 
Viral skin infection
Infestation of skin by mite
Usually found in unstandard conditions
Long term care facilities at risk
Warm bath and prescribed lotions 
Burrow under skin and track mark you see is feces
Ammonia based cream
48
Q

Contact dermatitis

A

Viral skin infection

  • Epidermis is damaged by repeated physical and chemical irritation
  • Non allergen or allergen causing
  • Management → avoid trigger, non-fragrant soaps, avoid topical lotions unless prescriber given
  • Usually allergic reaction to whatever caused it
49
Q

Psoriasis

A

Non-infectious inflammatory dermatitis

a. chronic non inflammatory disease
b. overproduction of keratin
c. current research supports immune
d. silver scales called plaque
e. arthritis or erythrodermic psoriasis
f. topical or systemic treatment
g. Non-contagious

50
Q

Exfoliative dermatitis

A

Non-infectious inflammatory dermatitis

- progressive inflammation with erythema and shedding up the skin

51
Q

Pemphigus

A

Blistering disorder

a. Autoimmune illness involving IgG
b. high-dose corticosteroids and or plasmapheresis

52
Q

Bullous pemphogoid

A

Blistering disorder

  • acquired disease of flaccid blisters
  • Corticosteroids
  • common in elderly
  • risk for sepsis and F&E imbalance
53
Q

Toxic epidermal necrolysis & Steven Johnson syndrome

A

Blistering disorder

a. potentially fatal triggered by a medication reaction
b. immunocompromised our most highly affected
c. treatment aimed at F&E, prevent sepsis and
d. ophthalmic complication
e. Skin peels off

54
Q

Cysts

A

Benign skin lesion

contains fluid or solid material

55
Q

Seborrheic keratosis

A

beneign skin lesion

wart-lie lesions, light tan to black in color

56
Q

Actinic Keratosis

A

Benign skin lesion

a. premalignant; similar to seborrheic keratosis

57
Q

Verrucae

A

benign skin lesion

warts - infection by HPV

58
Q

Angioma

A

Benign skin lesion

a. benign vascular tumor of the skin; read and look like spider; vascular tumor but not can

59
Q

Pigmentsed nevi

A

Benign skin lesion

moles - monitor for changing colors or a regular borders; should be removed related to malignancy risk

60
Q

Keloids

A

Benign skin lesion

a. overgrowth of fibrous tissue at the sight of Scar or trauma
b. African-Americans are more prone to this
c. can be removed from surgery

61
Q

Assessing moles ABCDE

A 
asymmetry
border (irregular is bad)
color (variegated)
diameter 
elevation, enlargement, evolution
62
Q

Basal cell

A

Malignant skin tumor

a. face
b. waxy nodule, may have vessel visible, make row and crust

63
Q

Squamous cell

A

Malignant skin tumor

a. arises from epidermis
b. metastesizes into blood and lymphatics
c. need to get rid of lesion with surgery

64
Q

Malignant melanoma

A

Malignant skin tumor

a. atypical melanocytes are present in the epidermis and the dermis; maybe present in subcutaneous cells
b. curable if caught early
c. superficial spreading melanoma
d. lentigo maligna melanoma
e. nodular melanoma
f. Acrall lentiginous melanoma

65
Q

Medical management of melanoma

A

depends on depth and invasion of lesion

skin grafting, Sentinel node, does metastasize to organs, 3% of all cancer deaths

66
Q

kaposi sarcoma

A

malignancy of cells that line the small blood vessels
–> skin, oral cavity, GI tract, and lungs

Immunosuppressed (organ transplant AIDS) → opportunistic cancer

Nursing 1 (6 decks)

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