Exam 1 Flashcards
(131 cards)
1
Q
SMART goals for patients
A
- specific (singular goal or outcome)
- measurable
- attainable
- realistic
- timed
2
Q
When creating goals for patients, always start with …
A
“Patient will …”
3
Q
What is the Nurse Practice Act, and what does it govern?
A
- state level regulation of nursing practice
- serves to
- approve nursing education programs
- define practice of professional nursing
- establish licensing criteria
- develop rules and regs for nursing practice
- enforce rules and regs
4
Q
Discuss the transitions nursing practice has undergone in recent history.
A
5
Q
Differentiate between legal regulation of practice and practice standards.
A
- legal regulation: rules and regulations set by the state nursing board or other governing body for the
6
Q
List the areas of healthcare systems where nursing functions.
A
7
Q
List the models of nursing care.
A
8
Q
Identify historical figures in nursing.
A
9
Q
Identify models of nursing care.
A
10
Q
profession
A
requires a set of specific skills or qualities
11
Q
discipline
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has its own domain of knowledge with theoretical and practical boundaries
12
Q
occupation
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technical view of nursing, controlled by an employer
13
Q
steps of the nursing process (ADPIE)
A
- assessment
- diagnosis
- planning
- implementation
- evaluation - ongoing process
14
Q
How should subjective data be documented?
A
in quotes
15
Q
objective data
A
observations or measurements of a pt’s health status
16
Q
subjective data
A
pt’s verbal descriptions of health problems
17
Q
setting priorities
A
- use Mazlow’s Hierarchy and ABC most of the time
- priority framework changes in mass casualty events
18
Q
List three types of interventions for nurses to carry out.
A
- independent - no order from another HCT memeber
- dependent - needs order from MD or other HCT member
- collaborative - requires combined knowledge, skill, expertise of multiple professionals
19
Q
What are some considerations when planning an intervention?
A
- Does the pt agree?
- Are you competent?
- Is your intervention evidence-based?
- What does the Doenges book say?
20
Q
What must we consider when implementing a care plan?
A
- good judgment and decision-making
- pt’s condition can change minute to minute
- must have knowledge and competency
- consequences of actions
- value of the consequence
- purpose of the intervention
- steps to perform correctly
- expected pt response
- what worked before
21
Q
important part of documentation
A
be specific and objective
22
Q
List the stages of wound healing and their expected durations.
A
- inflammatory: 3-6 days
- proliferative: 3-24 days
- maturation/remodeling: about day 21
23
Q
What happens during the inflammatory stage of wound healing, and what factors are important to nursing interventions?
A
- hemostasis - vasoconstriction, fibrin, clot formation
- increased O2 delivery to site
24
Q
What happens during the proliferative stage?
A
- granulation of tissue
- edges pull together
- generation of new epithelial tissue
25
What happens during the maturation/remodeling stage of wound healing, and how long does it take?
* strengthening of scar tissue
* can take up to 1 year
26
What tool is used to assess risk for skin breakdown?
* Braden Scale
* completed on admission and at shift assessments
* provides specific protocols
27
What do we look for during assessment of wounds?
* size, shape, depth, tunneling
* color
* drainage
* approximation
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primary intention
wound is closed surgically and well-approximated
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secondary intention
wound edges are not approximated (such as pressure injuries, etc.), and body must fill in gap
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tertiary intention
wound left open and closed later
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types of acute wounds
* injury
* surgery
* procedures
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chronic wounds
* any wound that has not healed in the expected time frame (2-4 weeks or longer)
* pressure ulcers
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factors affecting skin integrity and wound healing
* age
* impaired mobility
* nutrition, hydration
* altered sensation
* impaired circulation
* meds
* moisture
* lifestyle factors
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evisceration
* big separation of wound causing internal organs to protrude
* nursing actions:
* assess
* apply pressure
* position and calm pt
* cover with sterile saline-soaked gauze
* notify provider
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dehiscence
* separation of wound
* pts report feeling a "pop" or "tear"
* nursing actions:
* assess
* apply pressure
* stabilize pt
* notify provider
36
What steps should you take when treating a pressure ulcer?
* prevent deterioration:
* assess
* provide proper care
* prevent new ulcer formation - hygiene, sterile technique when indicated
* follow facility protocol
* wound care consult
* monitor for infection
* local - redness, increased drainage
* systemic - monitor s/s (AMS, VS changes, labs)
* provide supportive care - fluids, nutrition, antibiotics, wound cultures
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preventing skin breakdown
* position changes q 2 hr for bed-bound
* instruct mobile to shift weight q 15 min while awake
* ambulate early and often
* prevent bed slide and lift
* pressure-reducing devices - bed overlays, offloaders, etc.
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community
* "fellowship of common feelings"
* group of like-minded people
* group that works together
* share common language, rituals, customs
39
Define vulnerable population and list factors that contribute to that status.
* have increased risk for adverse health outcomes
* factors:
* limited economic and social resources
* age
* chronic disease
* history of abuse or other trauma
40
Name the three aproaches to community-based care. Do they overlap?
* approaches
* community health nursing
* public health nursing
* community-oriented nursing
* yes, they overlap
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public health nursing
* concerned with health of community as a whole
* focus: effect of community health on individuals
* goals
* prevent disease
* promote health for individuals, families, and groups
* protect health of community
* promote safety, prevention
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community health nursing
* concerned with health of individuals, families, or groups
* focus: how individual health affects community
* goals
* maintain health of population
* deliver personal health services
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community-oriented nursing
* combination of public health and community health nursing approaches
* more comprehensive approach
* uses info from individuals to change health on community level
44
What should be considered when treating the individual pt? For the community as a whole?
* individual
* communication
* education
* patient decision aids
* community
* education
* health policy
* learning culture, beliefs, and behaviors
45
List four pioneers of community nursing and their contributions.
* Florence Nightingale
* Lillian Ward
* Clara Barton
* Margaret Sanger
46
Name five roles of community nurses.
* client advocate
* educator
* collaborator
* counselor
* case manager
47
What are some occupations in community-based nursing practice?
* school nurse
* occupational health
* parish nursing
* correctional nursing
* public health
* disaster services
* international nursing
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primary interventions in community nursing
* promote health
* prevent disease
* educate at-risk clients
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secondary interventions in community nursing
* reduce disease impact
* early detection and treatment
* health screening
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tertiary interventions of community nursing
* halt disease progression
* restore health where possible
* treatment
51
Who receives home health care?
* those with skilled-care needs such as older adults
* those recuperating from illness or surgery
* the terminally ill
* the chronically ill, to avoid hospitalization
52
What is the goal of home health care?
promoting self-care
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How do you promote self-care in the home health care setting?
* fostering client independence
* completing client and family teaching
* demonstrating skill techniques
* explaining all aspects of care
54
List some advantages of home health care.
* enables viewing of client's environment
* allows inclusion of family members in care
* increases autonomy of nursing practice
* teaches flexibility
* facilitates holistic care
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Name some disadvantages of home health nursing.
* uncontrolled environment
* no readily available supplies
* lack of immediate peer assistance
* potential for personal safety issues
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types of home health care agencies
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What are the roles of the home health nurse, and what do they involve?
* direct care provider - performing skilled tasks
* client/family educator - promoting self-care; communication skills needed
* client advocate - supporting client's right to decide
* care coordinator - developing plan of care; accessing correct resources
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What should a nurse be aware of regarding health care reimbursement?
* necessary criteria
* services covered
* documentation needed
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What do you do before a home health visit?
* determine purpose of visit
* gather supplies, materials
* additional information needed from client
* make appointment
* assess area for safety issues
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how to conduct a home health visit
* make intros
* be respectful of home, beliefs, practices, cultural differences
* develop trusting relationship
* verify and, if necessary, complete data collection
* identify barriers to achieving goals of visit
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what to do after a home health visit
* maintain safety precautions
* proceed to safe area to check directions
* complete necessary documentation
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evidence-based practice
use of current best evidence when making decisions in patient care
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levels of evidence for EBP
* single study: observational research; randomized controlled trial
* meta-analysis: statistical analysis that combines the results of multiple scientific studies
* practice guideline: systematically developed statements to guide decisions about health care
* qualitative vs. quantitative
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where to find evidence for EBP
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quantitative research
* data used when research is trying to quantify a problem
* answers question of how many
* involves statistical analysis of numbers
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qualitative research
* data that describes qualities or characteristics
* answers why or how questions
* involves analysis of reoccurring themes
* often from interviews or focus groups
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theory
organized set of related ideas and concepts
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paradigm
* worldview or ideology of a discipline
* medical: views person through lens of disease; compartmentalizes
* nursing: views person through holistic lens
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conceptual framework
set of concepts that form a pattern
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model
visual representation of concepts
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How do nurses use theories?
* clinical practice
* nursing education
* nursing research
72
List three famous nursing theorists.
* Viriginia Henderson: Nature of Nursing
* Hildegard Peplau: Theory of Interpersonal Relations
* Patricia Benner: Novice to Expert
73
Name the levels of Maslow's Hierarchy of Needs, starting with the most basic (base of pyramid).
* physiological
* safety
* love/belonging
* esteem
* self-actualization
74
What does PICO stand for, and what process does it refer to?
* P - population or problem
* I - intervention, treatment, cause, contributing factor
* C - comparison intervention or control
* O - outcome
* PICO is used to identify issues that need improvement and take them through the research process to find better methods
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gait
manner of walking
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kyhosis
* exaggeration or angulation of posterior curve of thoracic spine
* humpback, hunchback, or Pott curvature
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lordosis
* exaggerated anterior convexity of the lumbar spine
* swayback
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scoliosis
* lateral curvature of the spine
* usually consists of two curves: original abnormal and compensatory in the opposite direction
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hypertrophy
increase in the size of an organ, structure, or the body due to growth
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atrophy
decrease in size of an organ or tissue; wasting
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objective data to be gathered when assessing of mobility
* symmetry
* ROM
* strength/weakness
* coordination and motor function
* orientation
* DTR
82
subjective data to gather for mobility issues
* pain and stiffness
* twitching
* falls
* ability to perform ADLs
* exercise habits
* nutrition
* dizziness
* headaches
* seizures
* head injury
* changes in vision, speech, though
* tingling
* weakness
* numbness
83
List the four levels of conciousness.
* alert
* lethargic
* stuporous
* comatose
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alert\*\*\*
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lethargic\*\*\*
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stuporous\*\*\*
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comatose\*\*\*
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decorticate rigidity
flexed
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decerebrate rigidity
extended
90
List four types of immobility.
* temporary - injury, surgery
* permanent - paralysis
* sudden onset - accident, surgery
* slow onset - chronic debilitating diseases (e.g. MS, spinal degeneration)
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basic principles of injury prevention
* body mechanics
* maintain posture
* low center of gravity
* wide stance and straight back
* assessment
* before lifting - assistance needed?
* before moving pt - do they need help?
* maintenance
* regular exercise and activity maintain muscle and coordination
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planning physical activity for pt
* assess pt's baseline before planning
* exercise: activity beyond the pt's baseline
* use resources: PT and OT
* include pt and family during planning
* tailor exercise to pt's ability
93
What exercises and interventions are appropriate for osteopenia and osteoporosis?
* weight-bearing exercise
* calcium and vitamin D supplementation
* avoid smoking
* limit alcohol, caffeine
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osteoporosis
* loss of bone mass throughout the skeleton
* predisposes patients to fractures
* BMD \> 2.5 standard deviations below normal
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osteopenia
* significant decrease in the amount of bone mineral density (BMD) normally found in a population or group
* 1 ≤ BMD ≤ 2.5 standard deviations below normal
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osteomyelitis
* infection of the bone
* can happen after illness or procedures
* very difficult to treat
* very painful
97
List the types of bone and joint injuries.
* osteoporosis and osteopenia
* osteomyelitis
* bone tumor
* trauma: fractures, strains, sprains, tears
98
Fx symptoms
* localized pain
* loss of function
* swelling
* deformity
* discoloration
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compound Fx
when bone protrudes through skin
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nursing actions for Fx
* assess and treat pain
* immobilize site
* frequently assess circulation in dependent areas
* prevent infection
* monitor for complications
* embolism
* infection
* circulatory status
101
rules for handling casts
* keep clean and dry
* NEVER stick objects in cast
* monitor circulation for compartment syndrome
* educate pt and family to notify provider of:
* bad odors
* loosening cast
* tightening cast
* wet cast
* may need sling for arm injuries
102
compartment syndrome
* emergent condition
* swelling of tissue causing altered circulation
* can occur with anything that causes swelling
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nursing actions for compartment syndrome
* assess 5 Ps
* first sign may be pain with movement
* may require fasciotomy
* neurovascular assessment
* pulses - equal?
* capillary refill
* skin color and temp
* sensation
* motor function
104
traction
* pulling force to maintain alignment
* can be strapped on or internally affixed
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nursing actions for pts in traction
* neurovascular checks
* alignment assessment
* equipment inspection
* pain assessment and treatment
* monitor skin integrity
106
pins
* internal or external
* external huge risk for infection
* provide frequent assessment and pin care
* assess for s/s of infection
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strain
injury to muscle from overuse or exercise stress
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sprain
stretch injury of ligament from tear
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s/s of strains and sprains
* swelling
* pain
* possible discoloration
* sprain usually more severe
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diagnosis of sprains and strains
* assess ROM
* often requires X-ray to rule out Fx
* possibly MRI to visualize soft-tissue injury
* may be diagnosed based on s/s and R/O Fx
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treatment of sprains and strains
* RICE
* rest
* ice
* compression
* elevation
* sometimes requires surgery
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nursing actions for ambulation
* assess:
* gait
* strength
* tolerance
* may need PT
* use assistive devices if indicated
* let pt's legs dangle before standing to prevent hypotension
113
What increases fall risk when ambulating a patient?
* misuse or not using assistive devices
* orthostatic hypotension - let pt dangle legs before ambulation
* prolonged immobility
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how to use a cane
* hold cane on strong side
* advance cane, then weak leg
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how to use a walker
* stand between back legs of walker
* pick up walker and advance with step
* do not slide unless it has wheels
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how to use crutches (basic)
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benefits of heat therapy
* increases blood flow
* increases tissue metabolism
* relaxes muscles
* eases joint stiffness and pain
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benefits of cold therapy
* decreases inflammation
* prevents swelling
* reduces bleeding
* reduces fever
* diminishes muscle spasms
* decreases pain
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nursing considerations for heat therapy
* monitor bony prominences for breakdown
* avoid over implanted parts
* avoid during acute phase of injury
* extreme caution in presence of immobility or impaired sensation
* use in short time intervals
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nursing considerations for cold therapy
* avoid in:
* vascular deficiency
* open wounds
* disorders such as Raynaud disease (vasospastic)
* extreme caution in pts with immobility or decreased sensation
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Raynaud disease
* primary vasospastic disease of small arteries and arterioles
* cause unknown
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How does immobility affect skin integrity, and how do we prevent breakdown?
* increases pressure on skin
* prevention:
* assess q2 hours for early signs: erythema, warmth, Braden scale
* use positioning devices, reduce pressure
* reposition q1-2 hours
* monitor nutrition
* provide good hygiene, especially for the incontinent
123
respiratory infection prevention
* decreased ventilation → decreased O2 sat
* stasis of secretions → atelectasis and infection
* decreased cough response
* assess breathing q2 hours
* reposition and remove secretions q2 hours
* teach TCDB
* turn
* cough
* deep breathe
124
atelectasis
collapsed lung
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preventing stasis of blood in the lower extremities and embolism
* use TEDs and SCD
* anticoagulants
* avoid binding at the knees: pillows, tight clothing, prolonged sitting
* encourage frequent movement
* assess for embolism: one-sided edema, warmth, redness, pain, absent or weak pulse
126
assessing for heart problems in immobile patient
* decreased cardiac output → increased workload long-term
* assess for S3 at apex; could mean heart failure, edema in dependent areas
127
How does immobility affect metabolism?
* decreased basal metabolic rate
* changes in protein, carb, and fat metabolism
* loss of muscle and weight
* fluid and electrolyte imbalance → hypercalcemia
128
nursing actions for immobility-related metabolic changes
* monitor I&O
* assess wound healing (loss of proteins)
* review labs (esp. CMP)
* monitor nutrition: calories, protein, vitamins B and C
* may need parenteral nutrition
129
What elimination issues can arise from immobility?
* urinary stasis → infection
* electrolyte imbalance
* decreased peristalsis → constipation
130
assessment and nursing interventions for bowel issues
* assess bowel sounds
* monitor BMs
* maintain hydration: min. 2L/day unless restricted
* increase fiber
* administer stool softener, laxatives as needed with order
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