Exam 2 Flashcards

Question

Describe 2 cardiovascular system hazards of immobility

Answer 1

Blood clots, and reduced blood flow

Answer 2

Pneumonia, decreased respiratory effort, and decreased oxygenation of blood

Answer 3

Reduced kidney function, incontinence, urinary tract infections, and urinary retention

Answer 4

Brittle bones, contractures, muscle weakness, atrophy, and footdrop

Answer 5

Abdominal (most common) An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as a patient moves or coughs. Lessens pain in postoperative patients. Enhances recovery of walk performance, controlling pain, and improving patient's experience following major abdominal surgery. Application can be delegated to Assistive Personnel (AP) The nurse performs assessments

Answer 6

Clean around the drain using circular strokes starting NEAR the drain and moving outward and away from insertion site. Do NOT allow swab to wipe back over an area that has already been cleansed!

Answer 7

It drains onto the skin/dressing (safety pin can keep drain from migrating into the incision)

Answer 8

ENSURE ADEQUATE CIRCULATION BEFORE applying compression to an extremity Elevate dependent extremity for 15 minutes BEFORE applying elastic bandage to promote venous return. Make sure that primary dressing over wound is securely in place. Wrap elastic bandage application starting at the DISTAL body part and working to the proximal boundary. Overlapping each layer by one-half to two-thirds the width of the bandage while applying even tension during application. Keep toes or fingertips uncovered and visible for follow-up circulatory assessment, except in cases in which toes or fingers are treated because of wounds. ASSESS circulation (color, temp, cap refill, pulse) AFTER compression application

Answer 9

From the bottom up with hands raised in the air (gown, mask, goggles, gloves)

Answer 10

In alphabetical order (gloves, goggles, gown, mask)

Answer 11

All items within a sterile field must be sterile. A sterile barrier that has been permeated by punctures, tears or moisture must be considered contaminated. Once a sterile package is open, a 1-inch border around the edge is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. Any question or doubt whether an item is sterile, the item is considered unsterile.

Answer 12

Sterile people or items contact only sterile areas; Unsterile people or items contact only unsterile areas. Movement around and in the sterile field must not compromise or contaminate the field. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible.

Answer 13

Medical asepsis: reduces number of pathogens, referred to as "clean techniques" used in administration of medications, enemas, tube feedings, and daily hygiene. Handwashing is the number one method. Surgical asepsis: eliminates all pathogens. Referred to as sterile technique. Used in dressing changes, catheterizations, and surgical procedures.

Answer 14

Assess, diagnose, plan, implement, and evaluate

Answer 15

Assessment is the process of recognizing clues

Answer 16

Diagnosis involves analyzing the cues and prioritize hypotheses

Answer 17

Planning involves generating solutions

Answer 18

Take actions

Answer 19

Evaluation is simply the evaluation of outcomes

Answer 20

Part 1 is the nanda diagnostic label. Part 2 is a list of the risk factors for YOUR patient

Answer 21

Risk diagnosis is something that hasn't happened yet but that we're worried about happening, so we take active steps to look at risk factors and ways to prevent the negative outcome from coming to fruition

Answer 22

Goals are … Individualized or client centered and realistic Therefore… Goals are not copied from a book! For example: It is not realistic to establish a goal for patient to walk 15 feet during an acute hospitalization when the patient has not walked at all in the last year!

Answer 23

Most health care agencies and systems maintain individual patient information using an electronic health record (EHR), which is an electronic version a patient’s traditional paper chart

Answer 24

health information system (HIS) is a group of systems used within a health care organization to support and enhance health care; usually including a clinical and an administrative information system

Answer 25

Documentation provides continuity of care and evaluates patient outcomes.

Answer 26

All information contained in the medical record is confidential and is protected by HIPAA, which protects patients’ right to privacy

Answer 27

EHRs are part of evidence-based practice, allowing improvement in both clinical decision-making and patient outcomes; chronic disease can also be managed more effectively through EHRs.

Answer 28

Quality documentation must be factual, accurate, complete, current, and organized.

Answer 29

Common electronic health record data screens include admission nursing history, flow sheets or graphics, patient education records, patient care summary, acuity records, standardized care plans, critical pathways and discharge summaries

Answer 30

Documentation formats include narrative, charting by exception, and problem- oriented medical records.

Answer 31

Inadequate or incorrect documentation resulting in malpractice suits include failure to document both correct time of events and verbal reports; failure to give a report to oncoming shift; charting in advance; and documenting incorrect data

Answer 32

Charting systems include narrative documentation, problem-oriented, patient database, problem list, plan of care, progress notes, source records, charting by exception, and critical pathways

Answer 33

Structured communication, with health care providers verbally reporting in the SBAR (Situation, Background, Assessment, Recommendation) format, is a concrete approach for framing conversations, especially critical ones that require a nurse’s immediate attention and action.

Answer 34

In addition to written documentation, a nurse provides a verbal change-of-shift report to the next nurse assuming responsibility for patient care. In many clinical settings this hand-off report occurs at a patient’s bedside

Answer 35

Adverse events should be reported and documented whether an injury occurred or not; adverse event reports are an important aspect of quality improvement

Answer 36

Long-term care documentation is interdisciplinary and closely linked with fiscal requirements of outside agencies.

Answer 37

Charting by exception (CBE) is a method of medical notation in which nurses only provide notes if there are deviations from a patient’s norm or baseline. It was designed to reduce the amount of documentation needed on a patient, freeing up nurses to either tend to more pressing tasks or spend more time engaging with the patient.

Answer 38

A nursing narrative note is a type of nursing documentation used to provide clear, detailed information about the patient. A narrative note is written in paragraph form and tells a story

Answer 39

SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way.

Answer 40

The progress notes in the patient record use (P) to define the particular P roblem; (I) to document I ntervention; and (E) to E valuate the patient outcome.

Answer 41

Using Flowsheets, you can, Record and track Patient's health vitals and other custom parameters

Answer 42

U instead write unit. IU, instead write international unit. Any variation of q.d. or q.o.d. instead write daily or every other day. Trailing zero or lack of leading zero. MS instead write morphine sulfate or magnesium sulfate. Don't write MSO4 or MgSO4 as they are confused for one another

Exam 2 Flashcards

(66 cards)