Final Exam Flashcards
1
Q
rNCLEX provides the __________ standard for knowledge of practice.
A
minimum
Nursing student graduate is minimally competent
2
Q
National Nurses Association - ANA
Official professional nursing organization for nurses in the US; establishes standards for profession and tracks legislation on health care and how it impacts nurses
A
American Nurses Association
3
Q
National Nurses Association - NLN
Sets the standards for nursing education programs; establishes criteria that all schools of nursing must follow
A
National League for Nursing
4
Q
Roles of Nurse
A
caregiver, educator, leader, advocate, researcher
5
Q
Inpatient vs outpatient
A
Inpatient = higher acuity and level of care
6
Q
Maslows hierarchy of needs
A
Physiological (ABC’s)
Safety
Love/Belonging
Esteem
Self actualization
7
Q
PICO(T)
Evidence based practice
A
Patient/Population
Intervention
Comparison
Outcome
Time (optional)
8
Q
Decreased mobility = increased risk of
A
falling
9
Q
Orthostatic hypotension
A
sudden drop in BP at different positions (lying, sitting, and standing)
10
Q
Transferring Patients According to Dependency Level:
Mechanical lift with full sling
A
Complete dependence: immobile
11
Q
Mobility Aids: Canes
A
Sizing:
* Top of cane should reach top of hip joint
* 30 degrees elbow flexion
Teaching:
* Hold cane on stronger side
* Distribute weight evenly
* Advance cane and weaker side simultaneously, and then stronger side
* Avoid leaning over
12
Q
Mobility Aids: Walker
A
Sizing:
* Top of walker should reach top of hip joint
* 30 degree elbow flexion
Teaching:
* Pick up walker and advance it as you step ahead
* Do not slide, unless it has wheels
13
Q
Mobility Aids: Crutches
A
Sizing:
* Axillary crutch pad should be 3 fingerbreadths below axilla
* Slight flexion of elbows
* Axilla should not rest on crutch pad
Teaching:
* Tripod position
* Lead with unaffected leg when going up stairs and to lead with affected leg coming down
14
Q
Intrinsic fall causes
A
Orthostatic hypotension
Meds: for new and dose changes
* Psychotropics
15
Q
Extrinsic fall causes
A
unsafe environment
16
Q
Guidelines for restraints
A
o Never ordered as needed (PRN)
o Require order within 1 hour
o Must be re-ordered every 24 hours
o Assess and document frequently
17
Q
What is the #1 way to stop the spread of infection?
A
HAND HYGIENE
Use friction
18
Q
Stages of infection
A
o Incubation: period of time between invasion of the pathogen and the first signs or symptoms of infection
o Prodromal: most infectious, appear as vague symptoms
Not all infections have a prodromal phase
o Illness: signs and symptoms present
o Decline: symptoms fade, # of pathogens decline
o Convalescence: tissue repair, return to health
19
Q
2 Tiers of protection per CDC
A
Tier 1- Standard precautions
Tier 2- Transmission based precautions
20
Q
Tier 1- Standard Precautions
A
▪ Apply to all patients
▪ Hand hygiene, surgical mask, proper sharp disposal, cover mouth and nose when sneezing/coughing
21
Q
Tier 2- Transmission based precautions
A
▪ Patients with known or suspected infection or colonization with pathogens
- Contact precautions: gown and gloves
o MRSA, CDiff (enhanced) - Droplet precautions: gown, gloves, mask, eye protection
o COVID, pertussis, pneumonia, meningitis, flu - Airborne precautions: gown, gloves, N95 mask
o TB, varicella, measles, SARS
22
Q
Critical thinking
A
intellectual process
23
Q
Clinical reasoning
A
the thinking process by which a nurse reaches a clinical judgement. enables you to synthesize, knowledge, experience, and information from various sources to develop an effective plan of care for a client.
24
Q
Clinical judgement
Contains thinking and reasoning
A
conclusion or outcome for patient scenario
outcomes of thinking, doing, and caring
25
NCSBN
creator of NCLEX
26
Layers of CJM
o Layer 0: clinical decisions
o Layer 1: comprises the outcome = clinical judgement
o Layer 2: form, refine hypotheses; evaluation
o Layer 3: recognize cues, analyze cues, prioritize hypotheses, generate
solutions, take action, evaluate outcomes
▪ Not linear
o Layer 4: context (individual and environmental factors)
27
Nursing process
ADPIE
28
ADPIE
Assessment
Collecting subjective and objective data
▪ Recognize cues
29
ADPIE
Diagnosis
Analyze cues and prioritize hypotheses
* Cues = unexpected findings (abnormal)
30
ADPIE
Plan
Prioritize hypotheses and generate solutions
31
ADPIE
Implementation
Take action
* Doing, delegating, and documenting
32
ADPIE
Evaluation
Evaluate outcomes
* Goal oriented
o Examples:
▪ Inability to walk → ambulate patient
▪ Risk for falls → make sure room is clear of clutter
33
subjective data
what the pt says/tells us
Primary: obtained directly from patient and/or nurse
Secondary: received from caregiver or another person on team
34
objective data
what we observe
factual data- vital signs, lab data
35
Nursing diagnosis- patient problems the nurse can treat independently
assessing and analyzing ques/data
36
Internal respiration
oxygen is exchanged to provide oxygen to the tissues (tissue perfusion)
37
External respiration
oxygen is diffused from the alveoli in the pulmonary circulation to the capillary system (CO2 is released from circulation into the alveoli)
38
Pulse oximetry
measures O2 saturation in hemoglobin
does not test for tissue perfusion
39
Ventilation: mechanical
Movement of air into and out of the lungs
40
Respiration: chemical
Exchange of the gases in the lungs
41
Where does diffusion of gases take place (O2 and CO2 exchange)?
Alveoli: tiny air spaces with thin walls surrounded by a fine network of capillaries
42
Oxygen deficiency in body tissues
Hypoxia
43
Oxygen deficiency in the blood
Hypoxemia
44
Nursing intervention to promote oxygenation
o Positioning for maximum lung excursion:
▪ High fowlers → best position for patients who have difficulty
breathing
o Pursed lip breathing: exhalation is twice as long as inhalation
▪ COPD patients
45
Oxygen delivery system: Non-breather
AKA mask w/ reservoir bag
delivers 100% oxygen to pt
do not use on copd pts
46
Minimum urine output
30mL/hr
47
Is urinary incontinence a normal part of aging?
no
48
UTI's can cause __________ in elderly patients.
AMS
49
Before giving pt's antibiotics for UTI, what diagnostic test should be completed?
Urine culture to determine which bacteria you are treating
50
Where do you collect urine specimen from when pt has a cath?
From specimen port
Not the collection bag
51
How do you prevent CAUTI?
asepsis technique, keep bag below bladder, no kinks in tubing
52
How to properly obtain clean catch sample?
o Wash hands in warm soapy water
o Open contain without touching inside of cup or cover
o Using towelette clean urinary opening
o Begin urinating in toilet and bring container into the stream to collect a clean, mid-stream sample
53
Process by which the body converts food to energy
Metabolism
54
Nutrition is esp. important for post op patients, why?
promotes optimal healing
55
What macronutrient promotes healing?
protein
56
Constipation
increase fluid and fiber intake
57
Diabetic pts diet
low glycemic
58
Essential for energy supply
carbs
59
Essential for brain and nerve function
fats
60
First step after placing NG tube on pt, before giving any meds or food
radiographic (x-ray) verification is the most reliable
method for confirming tube placement and must be
performed before the first feeding is administered
61
Diets meant for short term use
NPO, clear liquid, full liquid
62
Surgery and diet progression
NPO → clear liquid → full liquid → surgical soft → regular diet
o NPO used prior to surgery to prevent aspiration
o Progression used to prevent vomiting —> can cause
incision to open
63
NPO
Nothing by mouth
Used prior to surgery to prevent aspiration
64
Clear liquid diet
* Clear juices, popsicles, jello, clear broth, tea
65
Full liquid diet
* All liquids: milk, supplemental drinks, ice cream
66
Surgical soft diet
* Mashed potato, pureed meats, veggies, pudding
67
Act of bearing down to defecate
Valsalva maneuver
Do not perform on clients with heart disease, glaucoma, increased ICP, or a new surgical wound
▪ Increases risk for cardiac arrythmias
68
Vagal response
Dizziness, ringing ears
69
Is increased GI motility (peristalsis) a healthy response to intestinal infection?
yes
70
Vasovagal syncope
passing out
71
Meconium
dark green to black tarry sticky odorless stool in infants
72
Best position for enema
left lateral Sim's position
73
Florence Nightingale
founder of modern nursing
reduced death rates by improving hygiene
74
Benner's models of novice to expert
novice
advanced beginner
competent
proficient
expert
75
Carbon monoxide poisoning
pt will be bright red in color
76
Ways to prevent pneumonia
early mobilization
upright position
turn, cough, deep breathe
incentive spirometer
77
Nosocomial infection
infection acquired during hospitalization
78
Important w/ inhalers
ask pt to demonstrate inhaler technique, take as prescribed
79
Diagnostic testing for oxygenation status
ABG's
peak flow monitoring
80
What type of finding is a cue?
abnormal finding
81
What does a nurse mean w/ a pt outcome
goals for the pt
82
Chain of infection - 6 components
Infectious agent- pathogen such as bacteria, virus, fungi, parasite.
Reservoir- source of infection
Portal of Exit- most frequent= bodily fluids
mode of transmission ( direct/indirect)
Portal of entry - body openings
Susceptible host- person at risk of infections
83
Contact precautions
gloves and gown
84
First void after cath removal needs to be
measured
85
For IV contrast- its important to check for
iodine allergy
86
Responses to enema are governed by
height of solution container
speed of flow
concentration of the solution
resistance of the rectum
87
Hypertonic enema
fleet: sodium
maintain pressure on bottle until empty
88
Kayexalate enema
Remove excess potassium
89
What do you do if the pt you are administering an enema complains of abdominal cramping
slow the flow
90
Ostomy should be
pink & moist
91
ADPIE matches up with CJM Layer
Layer 3
92
Components of CJM Layer 3
recognize & analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes
93
Absent bowel sounds could indicate
paralytic ileus
94
Impaired peristalsis leading to bowel obstruction can cause
Perforated bowel
95
Occult blood test
blue =
postive
96
Causes of false positive occult blood test
o Hemorrhoids
o Food
o Supplements and medications
o Iron
97
Causes of false negative occult blood test
Vitamin C
98
Promotion of bowel movement
o Exercise, water, fiber, minimize use of laxatives, go when you feel the urge
Increase fluid and fiber consumption: first line of treatment/prevention
99
Overuse of laxative can cause strengthening of the bowels.
True or False
False
Overuse can cause weakening of the bowels leading to chronic constipation
100
Safest form of laxatives
bulk forming
101
Stool softeners
Lubricant action, no effect on peristalsis
102
Osmotics
Drawing water into bowel from surrounding tissue
* Bowel distention
103
Stimulants
Bowel irritants
* Stimulate peristalsis
104
o Increased GI motility (peristalsis) =
healthy response to intestinal infection
105
What do you include in shift report to oncoming nurse?
demographics, relevant med hx, current treatments, pt’s response to interventions, pending labs, procedures, current status, plan of care, concerns
Use I-SBAR-R
106
Assertive communication
SBAR, open, direct, honest, and non-judgmental
107
Passive vs Aggressive communication
Passive- I don’t count, you do.
Aggressive- I count, you don’t.
108
What is the primary purpose of the chart?
Communication
109
The EMR documentation system is problem oriented.
What are the patient issues an interdisciplinary team of professionals work on called?
Collaborative problem
110
Cardinal rule of documentation
If it wasn't documented; it did not happen
111
Documentation guidelines
Be clear and concise
Use correct terminology, spelling, and grammar
Timely
Signature
112
When to document
o Admission
o Transfer
o Discharge
o Ongoing care per policy
o Change in condition
o Communication
113
Potential HIPAA violations
Discussing patients in public areas
Leaving charts out
Not logging off computers
Copying forms
Social media
*Providing report to incoming nurse or to patient’s provider does not break confidentiality —> because they are in charge of patient’s care
114
VORB
o VORB: verbal order read back
*Must be signed by prescriber ASAP
115
TORB
TORB: telephone order read back
*Must be co-signed within 24 hours
*Pronounce digits of numbers separately
* 50mg 5, 0mg
Spell unfamiliar names
Record with date, time, and TORB(V)
116
Read back is used to reduce
errors and any miscommunications --> accuracy
117
What is charting by exception?
Chart only significant findings/exceptions to norms
Reduces charting time for nurses = more time w/ the pt
Omissions are the biggest problem
118
Are incident reports only for patients?
No. Can be for employees (ex: needle stick)
119
Do you reference incident report in the pt's chart?
No
120
What do you include in incident report?
-Only state facts
-Do not place any blame
-Does not go in pt's chart
121
Adverse event
An event in which care resulted in an undesirable clinical outcome
122
Near miss event
Caught before hand
123
Sentinel event
An event that results in death, permanent harm, or severe temporary harm
124
Examples of sentinel event
-Pt abduction
-Pt suicide
-A foreign body, such as sponge or forceps that was left in a patient after surgery
-A hospital operates on the wrong side of the patient’s body
-Hemolytic transfusion reaction involving major blood group incompatibilities
125
What time should be used when documenting?
The time the assessment/procedure was completed
126
What do you include in hand-off reporting?
Demographics
Relevant medical history
Current treatments and patient’s response
Pending labs, procedures
Current status
* Significant assessment findings
* Significant occurrences over last 24 hours
Plan of care
* Patients progress
* Priority areas to focus
Concerns
127
Best environment for therapeutic communication
quiet, private, comfortable temperature, free of unpleasant smells
128
How to correct an error in the chart
Strikethrough, write “mistaken entry”, date, and initial
Do not use whiteout
129
When can PHI be released?
For payment, treatment, and normal healthcare operations
130
MAR
Medication Administration Record
Comprehensive list of all ordered medications for pt
131
Ways to enhance therapeutic communication
Address the pt, listen actively, establish trust, be assertive, interpret body language, use silence when appropriate, explore issues, validate feelings, clarifying statements, sit at eye level
132
Six Rights of Medication Administration
Right Drug
Right Dose
Right Route
Right Time
Right Patient *Important to preventing errors
Right Documentation *Avoids medication overdose
133
At what points do you triple check medications?
When pulling meds, before leaving med room, and at bedside before pt receives meds
134
Vulnerable populations
Homeless, poor, sexual orientation, mentally ill, physical disabilities, young, elderly, some ethnic and racial minority groups, gender
135
I-SBAR-R
o Intro
o Situation
o Background
o Assessment
o Recommendation
o Read back
136
Appropriate times to use silence
Conveys empathy
* Patient pauses during the conversation
* Discussing heavy or emotional diagnoses
* Patient exhibits emotional distress
137
Barriers to therapeutic communication
o Asking why —> *projects blame and judgement
o Offering advice —> *reframe, allow patient to make their own decisions
o Expressing approval or disapproval
o Changing subject inappropriately
o Asking too many questions
o Fire-hosing information
138
Can you give personal advice/opinion to pt's and their families?
no
139
Process for safe medication administration
-Know your patient history (HX, labs and assess your patient)
-Follow the orders
-Perform the Rights of Safe Med. Administration
-Triple check the medications against the MAR before the patient takes them
-Reassess your patient afterwards and document
140
What is the goal of inter professional education (IPE)?
inter professional practice (IPP)
141
Medication error
is an adverse event unless patient is harmed
142
Stereotype vs archetype
Archetypes- something recurrent, based on facts; usually not negative
Ex: eye or skin color based on region or geographic data
Stereotypes- Widely held unsubstantiated beliefs that have no basis in facts; negative beliefs
Ex: “Naturally athletic” “Naturally intelligent”
143
Discrimination
When a person acts on prejudice (stereotypes) and denies another person one or more of his/her fundamental rights
Ex: Not giving suspected drug user pain meds
144
Universals
values, beliefs, and practices that people from all cultures share
145
Specifics
values, beliefs, and practices that are special/unique to a culture
146
Race is strictly related to
biology
147
How to enhance cultural awareness
Self assessment for bias and prejudices
148
What is needed to deliver culturally competent care?
Cultural awareness and sensitivity
149
What should you tell a trained interpreter before beginning any translations?
Advise them to translate everything that is said and leave nothing out
Be sure to use interpreter when obtaining consent
150
How to complete a cultural assessment
-Open-ended questions
-Allow patient time to explain
-Listen with respect and remain non-judgmental
Advise pt you want to provide the best care by identifying their cultural practices
151
If patient is unable to swallow —> find same medication, just different form
* *Cut scored pills only (line down middle)
* Crush – if able
o *NOT extended release
* Mix with thickened liquids or pudding/applesauce
* Check to see if drug comes in liquid form FIRST
152
Buccal
inner cheek
153
Sublingual
under tongue
154
Most common adverse effect of meds
abd discomfort
155
Parameters for Nitroglycerin
-Check vitals before and after each dose
-1 SL tab every 5 minutes for a maximum of 3 doses
-Must wear gloves
-Make sure pt doesn't take Cialis/Viagra or any other ED medications
-Warn pt before first dose about wicked headache
-Instruct pt to hold med under tongue, and not to chew-
-If patient’s HR is below 60 or Systolic BP (SBP) is less than 90 hold dose and notify HCP
156
How to administer ear drops for adults and kids
-Use solutions at room temperature – too cold leads to dizziness
-Pull pinna up and back for adults, down and back for children
-Push on tragus to instill meds
157
Should you give food with NSAIDs?
Yes. Upset stomach without it.
158
What should be considered when administering the Albuterol?
-Check vitals before and after administering. Medication raises HR.
-Oral care to reduce risk of thrush
-If pt is unable to use hands, use a spacer.
159
Ampule is a __________ dose only. Use __________ needle when drawing up medication to avoid chards of glass.
single; filter
160
Smaller the needle gauge
Larger the diameter of the needle
161
Insulin injections are
Subcutaneous (subq)
162
General rules for subq injections
-Max. injection is 1 mL
-Sites include upper arm, abdomen, upper back, lower back, and top of thighs
-Rotate sites
-45-90 degree angle
163
How should you draw up insulin?
Inject air into each vial first and then draw up regular (clear) insulin before long acting insulin (cloudy)
Nancy Reagan, RN
164
General rules for intramuscular injections
-Z track method
-Max. injection is 1 mL to 5 mL depending on site
-Deltoid, Vastus Lateralis, and Ventrogluteal
165
Max. injection & landmark for Deltoid is
1 mL
2 fingerbreadths below the acromion process in the middle third of the muscle
166
Max. injection & landmark for Vastus Lateralis is
3 to 5 mL
Between greater trochanter and the lateral femoral condyle - injection site is the middle third of the muscle
167
Max. injection & landmark for Ventrogluteal is
3 to 5 mL
Place your palm on the greater trochanter and thumb towards the groin avoiding the anterior superior iliac spine and iliac crest inject in the muscle
168
General rules for intradermal injections
-Max. injection is 0.1 mL
-5-15 degree angle
-Sites include forearms, upper chest, and upper back
-Ex: TB skin test
169
Culturally competent model of care
ASKED
Awareness- Take an honest look at your own biases
Skills- Ability to conduct a cultural assessment with sensitivity
Knowledge- Information about cultural worldviews
Encounters- Takes practice to become competent
Desire- Must want to be culturally competent
170
What type of needle must be used when drawing up insulin?
Insulin needle (orange) only because it is in units
Must be dual verified by another RN
171
Regulates and defines the scope of nursing practice
* State Nurse Practice Acts
172
Motivated by the desire to increase well-being
health promotion
173
Motivated by the desire to prevent illness
health prevention
174
Primary purpose of incident report
root cause analysis
175
How do you define the pain experience?
* It is what the patient says it is
o Subjective experience
o Can be protective and have purpose
176
How do you manage pain for nonverbal or cognitively impaired patients?
Monitor vital signs, treat pathological condition, look for non-verbal cues
177
Health prevention
Primary
Prevent/slow onset of disease
* Education and prevention
178
Health prevention
Secondary
Detect and treat illness in early stages
* Screenings
o Purpose = early diagnosis and early detection
o Examples: BP, mammo, cancer, PSA, glucose, lipid levels
179
Health prevention
Tertiary
Stop disease progression; return to pre-illness state
* Rehab
180
Transtheoretical Model of Change
o Precontemplation
o Contemplation
o Preparation
o Action
o Maintenance
o Termination
181
Precontemplation
no intention to change behavior in the foreseeable future
182
Contemplation
seriously thinking about overcoming a problem
183
Preparation
intending to take action in the next month
184
Action
the plan is implemented
185
Maintenance
working to prevent relapse
Support groups, diet, exercise
186
Termination
changed the behavior
187
Numerical indicator that determines the amount of stress someone is under
Life-Stress Review
188
Purpose of health screenings
early detection
189
Nursing interventions for health promotion
o Role modeling
o Education
o Providing support
190
Health promotion programs
o Disseminating information
o Changing lifestyle and behavior
o Environmental control
o Wellness assessment/health risk appraisal
191
Factors affecting pt learning
o Motivation
o Readiness
o Timing
o Feedback
o Repetition
o Learning environment
192
Barriers to effective learning
o Stress/anxiety
o Pain
o Fatigue
o Nausea
o Emotional distress
o Low literacy
o Communication gap
o Lack of perceived need
193
Can pt teaching be delegated?
No. Should always be done by the RN first.
194
When does d/c planning start?
At time of admission
195
What is the goal of d/c planning?
ensure continuity of care
196
High risk populations that need special arrangements
o Complex conditions – multisystem disease process
o Major surgical procedures
o Chronic or terminal illness
o Elderly
o Emotional or mental instability
o Lack of transportation
o Homeless
o Financial insecurity
o Unsafe home environment
197
Involving pt support system in d/c planning ensures
adherence to discharge plan and patient safety
198
Evidence of effective education
o Adherence to POC
o Verbal explanation
o Demonstration
199
Kubler-Ross 5 stages of grieving
o D: denial
o A: anger
o B: bargaining
o D: depression
o A: acceptance
200
Categories of loss
o Actual: can be identified by others
Death of loved one or relationship, theft, natural disaster
o Perceived: internal, only identified by the person
STD, perceived loss of purity or health
o Physical: any injuries (amputating leg), organ removal, loss of function (paralysis)
o Psychological: areas of control, trust
Losing youth or beauty, body disfigurement (burn victim)
o External: losing objects with sentimental value
o Environmental: change in familiar
18yo moving out, starting a new job
o Loss of significant relationships
201
Uncomplicated grief
natural response to loss, expected
Intense, but gradually diminishes over time
202
Dysfunctional grief
maladaptive, suicidal, depressed
Chronic: unable to rejoin normal life
* Cannot move on
203
Masked grief
expressing grief through other types of behavior
* Excessive shopping
Delayed: busy, not processing emotions
204
Disenfranchised grief
not socially supported or acknowledged/validated
Losing a foster child or mistress
205
Anticipatory grief
experienced before loss occurs
Dementia, heavy diagnoses like cancer
206
Palliative care
Pain control comfort measure
Manage symptoms to increase QOL
207
Hospice care
Terminally ill patient that are anticipated to die in 6mo
208
Nursing role in end-of-life
o Educate patient and families of diagnosis, what to anticipate during dying phase, pain management, consult chaplain, advocate for patient needs
209
Physiological stages of dying
o 1 – 3mo: withdrawal from world and people, excessive sleep, no appetite
o 1 – 2wks: decrease BP, yellowing, changes in pulse rate, agitation/delirium, dyspnea
o Days to hours: surge of energy, Cheyene-Stokes (irregular increase in length and depth following by period of apnea), dehydrated, dysphagia, dry skin, congestion, liver failure, cerebral hypoxia, stool impaction, fatigue
o Moments prior: does not respond to touch or sound, cannot be awakened
Nursing priorities:
* Oxygenation, patient safety, personal hygiene, controlling pain
210
Facilitating grief
o Express feelings
o Recall memories
o Find meaning
211
High risk scenarios for difficult or complicated grieving
o Unexpected, sudden death
o Argumentative grief, unresolved conflict
o Previous or multiple loses
212
Helping families after the death
o Express sympathy
o Acknowledge pain and loss
213
Providing postmortem care
o Rigor mortis: 2 – 4hrs
Close mouth and shut eyes
o Place pillow under head and shoulder to prevent pooling of blood
o Remove tubing, unless going to ME
o Clean and prepare patient for family
214
Classification of pain by origin
Cutaneous/superficial
Deep somatic
Visceral
Radiating/referred
Phantom: surgically removed
Psychogenic: no physical cause identified
215
Classification of pain by cause
Nociceptive: aching
Neuropathic: burning, itching, pins and needles
216
Classification of pain by duration
Acute: up to 6mo, rapid onset
Chronic: 3 – 6mo, interferes with QOL and ADLs
Intractable: chronic that is highly resistant to pain interventions
217
Classification of pain by description
Quality: what does it feel like?
Periodicity: when did it start, is it constant?
Intensity: how bad does the pain feel?
218
Nonpharmacological measures for pain management
Guided imagery
Deep breathing
Acupuncture
219
Pharmacological measures for pain management
Nonopioid:
* NSAIDs: high risk of gastric irritation – avoid prolong use
* Acetaminophen: kills liver
Opioid:
* Drowsiness, n/v, constipation, sedation
220
Increasing dose of medication to achieve desired effects
Tolerance
221
Reasons why a pt may refuse pain meds
Hx of addiction
o Investigate why patient does not want it
222
Non-verbal signs of pain
o Vital signs change
Elevated pulse, BP
o Facial expression
Grimacing, crying, or moaning
o Posture/body position
Guarding, use of accessory muscles
o Behavioral manifestations
Irritable, agitated, use of profanity
*provide medication based on pathologic parameters
223
Assessing pain in adults
o Numeric rating scale: 0 – 10
224
Assessing pain in peds
o Wong-Baker faces
225
Factors affecting skin integrity
Age, Immobility, Malnourishment, Dehydration, Lack of sensation, Medications, Impaired circulation, Excessive exposure to moisture (urinary incontinence) , Fever (find source), Infection. Lifestyle (Tanning, bathing, piercings, tattoos)
226
Any break in the skin increases the risk for
infection
227
Classification of wounds
Open
break in skin or mucous membrane
Abrasion, lacerations, puncture wounds, surgical wounds
228
Classification of wounds
Closed
no break in skin
Bruise, tissue swelling
229
Classification of wounds
Acute
short duration, heal spontaneously
230
Classification of wounds
Chronic
exceed expected length of recovery
Complex, pressure injuries, diabetic ulcers, colonized with bacteria
231
Classification of wounds
Clean
uninfected wounds, minimal inflammation
Surgical incision
232
Classification of wounds
Clean contaminated
surgical incision that is inside GI, respiratory, or GU tract
High risk for infection
233
Classification of wounds
Contaminated
open traumatic wounds or surgical incision where there is a major break and sepsis
Impaled with rusty pipe
234
Classification of wounds
Infected
erythema, swelling, fever, foul odor, sever or increase pain, large amounts of drainage, warmth surrounding soft tissue area
235
Classification of wounds
Superficial
epidermal layer
236
Classification of wounds
Partial thickness
extends to epidermis, but not through dermis
237
Classification of wounds
Full thickness
extends to subcutaneous tissue/fat
238
Classifications of wounds
Penetrating
Wounds of internal organs
239
Priority nursing goal for open wound
wound free from infection throughout healing process
240
At risk populations for wounds
o Paralysis
o Sedated patient
o High risk pregnancy
o Cast or devices
o Altered sensory perception
o Diabetics
o PVD
o Post op
241
__________ patients are at an increased risk for wound healing
o Especially post op, PVD, and diabetics
Malnourished
242
Primary wound intention
o Primary: clean surgical incision
Edges approximated
Minimal scarring
243
Secondary wound intention
o Secondary: heals from inner layer to surface
Remain open
Wound edges not approximated
Tissue loss
244
Tertiary wound intention
o Tertiary: delayed closure of wound edges
Granulating tissue brought together
245
Phases of wound healing
o Inflammatory: 1 – 5days
Hemostasis: stopping of blood
Inflammation: edema, erythema, migration of WBC, elevated temperature, scab formation
o Proliferative: 5 – 21days
Formation of granulation tissue
o Maturation: remodeling phase
Formation of scar tissue strengthens wound
246
Types of exudate
Straw colored
Serous exudate
247
Types of exudate
bloody drainage
Bright red or brown
Sanguineous
248
Types of exudate
mix of bloody and straw-colored fluid
New wounds
Serosanguinous
249
Types of exudate
yellow, contains pus
Thick, malodorous
Purulent
250
Types of exudate
contains blood and pus
Infected wound
Purosanguineous
251
Separation or splitting of open layers of a surgical wound
Apply abdominal binder
o Dehiscence
252
Extrusion of viscera or intestine through a surgical wound
Medical emergency
Major risk for infection cover with sterile towels immediately and remain in bed with knees flexed
o Evisceration
253
Predicts how likely a pressure ulcer will form
Braden scale
254
Braden scale is based on
Sensory perception, moisture, activity, mobility, nutrition, and friction or shear
o Total score less than 18 = at risk
255
Stages of Pressure injuries
Stage 1: non-blanchable erythema (redness) of intact skin
Stage 2: partial-thickness skin loss involving epidermis, dermis, or both
Stage 3: full-thickness skin loss damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia
Stage 4: full-thickness skin loss with exposure of muscle, bone, or supporting structures
Unstageable: base of wound cannot be seen due to being covered by necrotic tissue, slough, or escar
* Sloth: soft, moist, white or yellow
* Escar: black, dry, thick necrotic tissue
256
Unrelieved pressure to an area, resulting in ischemia cause
Pressure injuries
257
Nursing interventions for pressure injuries
Prevention
Frequent repositioning
Meticulous skin care and moisture control
Therapeutic mattress
Adequate nutrition
Client/family teaching
Elevating heels
258
Is stress always negative?
No, can be protective or motivating
259
Internal stressors
diarrhea, anxiety, negative self-talk
260
External stressors
death of family member, natural disaster, financial issues
261
Developmental stressors
occur at specific phase in life
Peer pressure: teens
Exploring environment and learning rules: toddler
Navigating parents: young adults
262
Situational stressors
car accident, natural disaster, illness, unemployment
263
Psychosocial stressors
work, family dynamics, living situation, relationships, daily life
264
Physiological stressors
underlying illness, diarrhea
265
General adaptation syndrome
o Alarm: fight or flight
Increase HR, BP, RR, dilated pupils, headaches, nail biting, chest pain, dry mouth, decreased wound healing, increased pain, stiff neck, appetite changes, difficulty sleeping
o Resistance: adaptation (coping mechanisms)
o Exhaustion: illness or death
266
Signs of inflammation
o Redness
o Heat
o Swelling
o Pain
o Loss of function
267
Long term stress effects
o Sleep difficulties, increased pain, decreased wound healing, HTN, dry mouth, increased RR
268
Metric abbreviations:
o cc: cubic centimeters
o mEq: milliequivalent
o mL: milliliter
o mg: milligram
o g: gram
o kg: kilogram
o L: liter
o mcg: microgram
o unit: unit (*do not use ‘U’)
269
Time abbreviations
o AC: before meal
o PC: after meal
o QH: every hour
o QHS: at bedtime
o PRN: as needed
o STAT: immediately
o QD: daily
o BID: 2x daily
o TID: 3x daily
o QID: 4x daily
270
Route abbreviations
o IV: intravenous
o IVP: intravenous push
o IVPB: intravenous piggyback
o NEB: nebulizer
o MDI: metered-dose inhaler
o S&S: swish and spit/swallow
o SQ: subcutaneous
o IM: intramuscular
o SL: sublingual
o PO: by mouth
o PR: by rectum
o NGT or NG: nasogastric tube
271
Liquid conversions
30 mL = 1 oz
3 tsp = 1 tbsp
1 tsp = 5 mL
1 tbsp = 15 mL
1 pt = 500 mL
1 qt = 1 L = 1000 mL
272
Metric conversions
1 gr = 60 mg
1 kg = 1000 g
1000 mcg = 1 mg
1000 mg = 1 g
273
Temp. conversions
C = (F – 32) / 1.8
F = (C x 1.8) + 32
274
Weight conversions
1 kg = 2.2 lbs
1 lb = 16 oz
275
Intervention for pt at risk for falls and is not responding to instructions?
bed alarms, family at bedside
276
Refusing to give a known drug abuser pain meds is
discrimination
