Clinical Exam Flashcards Preview

Adult Health Nursing I > Clinical Exam > Flashcards

Flashcards in Clinical Exam Deck (70):
1

RACE

Rescue
Alarm
Confine the blaze
Extinguish or evaporate

2

PASS

Pull
Aim
Squeeze
Sweep

3

Class A Fires

Wood, paper, cloth, rubber, plastics

Prevented by simple housekeeping

4

Class B Fires

Gases, liquids

Prevented by storing combustible liquids and gases in specific areas away from heat sources

5

Class C Fires

Appliances, air conditioning, heating units, motors, generators

Most common fires in health care

Equipment should be kept clean and maintained properly, extension cords should not exceed 6 feet

6

Class D Fires

Certain metals

7

Licensure

The process of granting permission to a person to engage in a specific occupation

8

Standards of Care

The average degree of skill, care, and diligence exercised by members of the same profession under the same or similar circumstances

9

Negligence

When the standards of care are not met

10

Gross Negligence

Intentional disregard

11

Malpractice

A specific type of professional negligence that occurs when the standard of care that can be reasonably expected is not met

12

Ethics

Rightness or wrongness of an action

Goal is to ensure that individual's rights are protected

13

Ethical Dilemma

Situation that requires a choice between two equally unfavorable alternatives

14

Five Step Process Tool for Helping with Ethical Dilemmas

1. Collect, analyze, and interpret the data

2. State the dilemma

3. Consider the choices of action

4. Analyze the advantages and disadvantages of each course of action

5. Make the decision

15

Code of Ethics

A written list of a professional's values and standards

Framework to help us make decisions

16

Identify areas of the "patient care partnership"

High quality hospital care
Clean and safe environment
Involvement in your care
Protection of your privacy
Help when leaving hospital
Help with your billing claims
Discuss treatment choices
Discuss treatment plan
Provide information about health
Understanding health care goals and values
Understanding who should make decisions

17

Nursing Liability

Can lead to civil judgment, criminal penalties, imprisonment, restrictions on license

18

Nurse Practice Act

Specific statute from the state that defines and regulates nursing practice

Most important legal statute

Safeguards the patients

19

EMTALA

Emergency Medical Treatment and Active Labor Act

Requires that each facility provides appropriate medical screening within their ability

20

Patient cannot be transferred unless:

1. They have had appropriate medical screening

2. They have been stabilized

3. The other facility has been called

21

Reporting Duties for Health Care Professionals

Child abuse
Elder abuse
Communicable diseases
Impaired peers
EMTALA violations

22

Tort

A wrongful act committed by one person against another person

23

Scope of Practice

Determined by Nurse Practice
Act

Defines and limits the scope of nursing practice

24

Common Types of Patient Incidents

Falls
Restraints
Burns
Medication Errors

25

Policy

Directive or regulation

26

Procedure

A way of doing something

27

Describe the purposes for client records

Planning client care, communication, legal documentation, reimbursement, quality assurance monitoring, research, education, accreditation and licensing, statistics

28

SOAP

Subjective, Objective, Assessment, Plan

Used in prisons

29

SOAPIER

Subjective, Objective, Assessment, Plan, Implementation, Evaluation, Revision

30

APIE

Assessment, Plan, Implementation/Intervention, Evaluation

31

PIE

Problem, Intervention, Evaluation

32

DAR

Data, Action (nursing), Response (client)

33

FACT

Factual, Accurate, Consistent and Complete, Timely

34

SBAR

Situation, Background, Assessment, Recommendation

35

Discuss teaching as a major nursing responsibility

Teaching improves patient's health and well-being, is the right of the patient

36

Variables that affect learning abilities

Culture, values, physical readiness, emotional readiness, experiential readiness

37

Specific patient factors that affect learning abilities

Disability, hearing impairment, visual impairment

38

Gerontological Considerations with Learning Abilities

Decreased short term memory, concentration, slow reaction time

Decreased visual acuity

Decreased hearing

39

Methods of preparing for formal and informal clinical teaching situations

Lecture
Group teaching
Demonstration and practice
Teaching aids
Reinforcement and follow-up

40

Why is SBAR needed?

Poor communication leads to errors

41

Situation

What is happening at the present time?

Patient name and room number

Patient problem or concern

Why was this patient admitted?

42

Background

What are the circumstances leading up to this situation?

Admit date, surgical day, current medications, lab results, other clinical information

43

Assessment

What you found, what you think

Pertinent objective and subjective data

Assessment of the current situation

44

Recommendation

What do you want?

Include things that need to be done

45

Hepatitis B

1/3 experience no symptoms, 1/3 experience flu-like symptoms, 1/3 experience clinical symptoms of HBV

46

Prevention of Hepatitis B

Universal precautions must be observed

Standard precautions apply to blood, nonintact skin, mucous membranes

Blood is the most common source of infection

47

Preoperative Phase

Begins when decision is made to have surgery and ends when patient is on the operating table

48

Assessment During Preoperative Phase

Health history, physical assessment, medications/herbal supplements/drug use, allergies, alcohol, teeth

Identify health issues that could put a patient at higher risks for complications (COPD)

49

Informed Consent

Means that the patient has been told what the procedure involves, the risks and benefits, potential complications, alternative treatments available

Needed for any surgical and/or invasive procedure

50

Preoperative Teaching

Deep breathing and coughing, incentive spirometer, splinting

Turning and moving, exercises, ambulating early

Pain control, pain scale

51

Preoperative Nursing Interventions

Maintain patient safety

Make sure patient follows NPO orders

Bowel preparation, skin preparation

Helping with preoperative anxiety

52

Nursing Interventions Immediately Prior to Surgery

Remove all jewelry, hair accessories, glasses, dentures, contacts, etc.

Baseline vitals, labs, assessment documentation, physician's H&P

Verify patient, procedure, and site

Preanesthetic medications

53

Intraoperative Phase

Consists of the entire time the patient is on the operating table

54

Surgical Team

Consists of circulating nurse, scrub nurse/tech, surgeon and assistants, and anesthesiologist

55

Circulating Nurse

Helps with getting patient positioned, does further skin preparation, monitors the patient, does all of the documentation, keeps track of time

56

Scrub Nurse

Provides sterilized tools to the physician

57

Unrestricted Area

Area you can go in your street clothes

58

Semi-Restricted Area

Need to be dressed in surgical scrubs

59

Restricted Area

Must be in full surgical garb

60

General Anesthesia

IV, inhalational-volatile gases

Patient becomes fully unresponsive

61

Regional Anesthesia

Epidural, spinal, local conduction blocks

62

Moderate Sedation

"Conscious sedation"

Makes patient loopy but able to follow commands

Amnesia afterwards

63

Complications of Anesthesia

Anesthesia awareness (need to monitor vital signs)

Nausea and vomiting

Anaphylaxis

Hypothermia

Malignant hyperthermia

64

Postoperative Phase

Starts when patient is off operating table and continues until the last follow-up visit

Receive the patient from OR and get their report

Obtain baseline assessment

Reassess every 5-10 minutes

65

Prevention of Postoperative Complications

Prevent atelectasis and pneumonia --> make sure patient is deep breathing and coughing

Prevent DVT --> TED hose, ACE wrap, sequential compression devices, LMWH

Assess surgical site and dressing

Watch for hemorrhage

Assess bowel sounds (do not give anything by mouth until you hear bowel sounds)

66

Outpatient Surgery Discharge

Provide written and verbal instructions

Discuss actions to take if complications occur

Patients are not to drive home or be discharged to home alone

67

Charting

Use facts only, do not summarize, never assign blame

Care plans facilitate the continuity of care

68

Chain of Notification

Student should report concerns to clinical instructor (if present), the clinical preceptor, or designated staff person

Then they will contact the unit supervisor (if necessary), and then the physician

69

Hourly Rounding

"I'm here to round on you."

Explanation

Discuss Pain, Potty, Position, and Possessions

Conduct and Environmental Assessment

Explain Clinical Hourly Rounding Log

Close the Round

70

Normal Fasting Blood Glucose

Less than 100 is considered normal

100 to 125 is considered prediabetes

126 or higher on two test is diabetes