Week 1-2 Flashcards
Why are observations, documentation important elements of nursing care?
- To identify reasons for admission
- Facilitate communication between health professionals
- Enable effective and ongoing care of patients
- To assess the patients well-being
Why do observations get done in acute patients?
- To ensure patient are keeping stable
- Monitor their health status
- Establish if the patient is deteriorating
Why is it important to know therapeutic limits of vital signs?
- To identify any abnormalities in results
- To determine if further investigation is required
What is the requirement once results are received?
- Received results
- Document finding in patient file/cart
- If urgent pass to the heath professional once documented
what are the main causes of mortality and morbidity?
- Heart disease - associated with lifestyle factors
- Stroke- associated with lifestyle factors
- Cancer
What legality requirements for documentation?
- Use black pen
- Clear/Legible writing
- Correct mistakes appropriately (line through and initial, start again)
- No abbreviations
What is the difference from medical and nursing diagnosis?
- Depending upon medical diagnosis for the direction of appropriate interventions
What is ADPIE?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
What is acute nursing care?
- Involves provision of individualised of chronically ill patients
- Transferrable generalised care through specialised skills
What are some Medical/Surgical acute care patients disorders?
- Respiratory
- Integumentary
- CVA/Neurological conditions
- Immunological
- Pre/Postoperative care
- Musculoskeletal
- Lower/Upper GI
What are the 3 levels of nursing enquiry?
- Critical engagement ie reflection
- Collaborative ongoing evaluation ie clinical audits
- Advanced nursing knowledge i.e. ongoing education/PHD
What is qualitative?
Deeper understanding of patient/health professional experience
What is quantitative?
measurement of specific variables
What are the 3 components of evidence based practice?
- Best practice
- Patient values
- Clinical expertise
What does color Purple mean?
- MET CALL/ CODE BLUE- meets criteria fro this
What does colour Pinky/Red mean?
- Patient requires medical review
What does colour Orange mean?
- Requires Senior nurse review
What does colour Yellow mean?
- Increase patients surveillance/frequent OBS
What is the importance of Integumentary System?
- To protect organs and the bodies function
Why do we use Aseptic Technique?
- To minimise the and protect the body from microorganisms
What are some of Vascular skin lesions?
- Petechiae: round, red, purple molecule 1-2mm
- Ecchymosis: round, black, yellow, green, Irregular macular lesions larger than petechiae.
- Cherry Angioma: round, red/purple- located on trunk/extremities
- Spider Angioma: Red- artery lesions, face,neck, arms, trunk. Associated with liver disease, pregnancy, bit B deficiency.
- Telangiectasia: Spider like/ bluish/red colour
What are the bacterial skin infections?
- Impetigo
What are the 2 types of carcinomas?
- Basal cell
- Squamos cell carcinoma
What are the 3 components or wound healing?
- Haemostasis Phase
- Inflammation Phase
- Reconstruction Phase
- Maturation Phase
What is Basal Cell Carcinoma?
- Uncontrolled growths of in the skins epidermis
- Waxy nodule appearance
- Pearl borders rolled/translucant
What are the differences between primary intention and secondary intention of healing?
Primary intention is a surgical opening and cell and tissue loss is kept to a minimum. The wound is sutured or stapled closed.
Secondary intention is a surgical opening that is left open. Excessive cell and tissue loss occurs, Left open to heal.
What are the types of viral infection?
- Herpes Zoster/simplex
What types of fungal infections are there?
- Tinea
- Ringworm
- Thrush (candida)
What are the types of skin tumours
- Benign
- Malignant
What are the 4 types of melanomas?
- Superficial Spreading
- Nodular Melanoma
- Lentigo-Maligna
- Acral Lentiginous
What is Squamous Cell Carcinoma?
- Involves mucous membranes
- Rough/scaly texture
- Metastasise via blood/lymphatic system
What are 3 types of burns?
- Superficial
- Partial Thickness
- Full thickness
Whats Stage 1 burns?
- Superficial effecting epidermis of skin
- Pressure related alteration
- Skin still intact
Whats Stage 2 burns?
- Partial thickness skin loss involving epidermis & dermis of skin
- Presents as abrasion, blister
Whats Stage 3 burns?
- Full thickness skin loss damage necrosis subcutaneous tissue, muscle/bone
- Presents deep crater
- Exudate presents
What is stage 4 burns?
- Full-thickness skin loss
- Extensive obstruction, tissue necrosis, damage to muscle, bone structures
- Dermis, subcutaneous tissue destroyed
- High risk infection rate
What are the classifications of wounds?
- Acute
- Chronic
- Damage
- Stages
- Color
What are the purpose of dressings?
- Provide protection
- Reduce microorganism
- Reduce patient discomfort
- Improve healing
- Reduce further trauma
What colour is black for a wound?
- Necrotic tissue
What colour is yellow for a wound?
Moist, sloughy wound
What colour is green for a wound?
Moist, sloughy, green discharge (infection)
What colour is red for a wound?
Healthy, granulating wound
What colour is pink for a wound?
Epithelialising wound
What is rule of nines?
- Fast/convenient estimation of total body area
- Divided into areas of 9%
Name types of dressings used for burns?
- Anti-microbial-
- Hydrocoloids
- Alginate dressing- clotter
- Paraffin gauze-
- Silver-
