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NUR 3200 FOUNDATIONS > Final Exam > Flashcards

Final Exam Flashcards

1
Q

Stage 1 of Sleep Cycle

A
  • NREM (non-rapid eye movement)
  • lightest sleep; few minutes
  • Dcrd physiological activity begins w/ gradual fall in vital signs & metabolism
  • Noise can easily arouse; can feel as a daydream has occurred
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2
Q

Stage 2 of Sleep Cycle

A
  • NREM (non-rapid eye movement)
  • Relaxation progresses
  • Arousal still relatively easy
  • Brain & muscle activity continue to slow
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2
Q

Stage 5 of Sleep Cycle

A
  • REM (rapid eye movement)
  • 25% of sleep
  • Vivid, full-color dreaming
  • Begins abt 90 mins after sleep starts
  • Autonomic response of rapidly moving eyes, fluctuating heart & resp rates, incrd/fluctuating BP
  • Loss of skeletal muscle tone
  • Gastric secretions incr
  • Difficult to arouse
  • Duration of REM sleep incrs w/ each cycle & avg 20 mins
  • Facilitates brain cells restoration & improves memory
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3
Q

Stages 3 & 4 of Sleep Cycle

A
  • NREM (non-rapid eye movement)
  • Called slow-wave sleep; deepest stage of sleep
  • Difficult arousal & rarely moves
  • Brain & muscle activity significantly dcrd
  • Vital signs are lower
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3
Q

Hypnotics Effects on Sleep

A

Interfers w/ reaching deep sleep and can cause excess drowsiness, confusion, dcrd energy

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4
Q

Factors Influencing Sleep

A
  • Drugs/substances
  • Lifestyle; night/rotating shifts, college students
  • Unusual sleep patterns due to physical issues; menopause, illness, pain
  • Emotional stress; depression or anxiety
  • Environment; unfamiliar, homelessness, room temp, noise, hosp room
  • Exercise
    >activity incrs REM & NREM; but done w/in 2 hrs before sleep can cause wakefulness
  • Fatigue
  • Food & caloric intake; eating late, weight loss, weight gain, caffeine, sugar, alcohol
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5
Q

Antidepressants & Stimulants Effects on Sleep

A

Suppresses REM sleep & dcrs total sleep time

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6
Q

Alcohol Effects on Sleep

A

Speeds onset of sleep but reduces REM sleep & causes awakening at night

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7
Q

Caffeine Effects on Sleep

A

Interferes w/ falling asleep & REM sleep

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8
Q

Diuretics Effects on Sleep

A

Nighttime awakenings caused by nocturia

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9
Q

Benzodiazepines Effects on Sleep

A

Alters REM sleep, incrs sleep time, & daytime sleepiness

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10
Q

Nicotine Effects on Sleep

A

Dcrs total & REM sleep time & causes awakening from sleep

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11
Q

Opioids Effects on Sleep

A

Suppress REM sleep & cause incrd daytime drowsiness

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12
Q

Respiratory Illness Effects on Sleep

A

Makes it difficult to breathe; chronic lung disease, emphysema, asthma, colds, sleep apnea

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13
Q

Cardiac Illnesses Effects on Sleep

A

Nocturnal angina

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14
Q

Hypertension Effects on Sleep

A

Causes early-morning awakening & fatigue

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15
Q

Hypothyroidism Effects on Sleep

A

Dcrs stage 4 sleep

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16
Q

Pain Effects on Sleep

A

Can affect sleep onset, depth, & duration

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17
Q

GERD & Peptic Ulcer Effects on Sleep

A

Awaken at night due to pain

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18
Q

Planning to Promote Sleep

A
  • Set priority goals & outcomes
  • Include pt
  • Realistic
  • Ex: pt will report waking up less frequently during the night & feeling rested by 4/9/14 at 0800
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19
Q

Implementing to Promote Sleep

A
  • Avoid unnecessary lights & noises
  • Avoid excessively warm or cool temps
  • Uninterrupted periods of rest & sleep
  • Maintain regular bedtime & wake schedule
  • Eliminate or minimize naps; limit to 20 mins or >2x/day
  • Go to bed when sleepy
  • Comfortable positioning
  • Relaxation techniques
  • If unable to sleep in 15-30 mins, engage in low-stimulating then try again
  • Limit alcohol, caffeine, & nicotine in late afternoon & evening
  • Consume carbs or milk before bedtime
  • Dcr fluid intake 2-4 hrs before sleep
  • Elevate HOB or use extra pillows
  • Use analgesics to ease aches & pains
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20
Q

Presbyopia

A
  • Visual deficit
  • Gradual decline to see near objects clearly
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21
Q

Cataract

A
  • Visual deficit
  • Cloudy or opaque areas in lens; causes problems w/ glare & blurred vision
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22
Q

Dry Eyes

A
  • Visual deficit
  • Too few tears resulting in itching & burning; can have reduced vision
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23
Q

Glaucoma

A
  • Visual deficit
  • Slowly progressive incr in intraocular pressure against optic nerve; may experience peripheral visual loss, dcrd visual acuity, halo effect around lights, problems seeing in dark
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24
Q

Diabetic Retinopathy

A
  • Visual deficit
  • Retinal blood vessel changes, dcrd vision
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25
Q

Macular Degeneration

A
  • Visual deficit
  • Macula (portion of retina responsible for central vision) function loss, blurring of reading materials, distortion/loss of central vision, distortion of vertical lines
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26
Q

Presbycusis

A
  • Hearing deficit
  • Common progressive hearing loss in older adults
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27
Q

Cerumen Accumulation

A
  • Hearing deficit
  • Build up of earwax causing conduction deafness
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28
Q

Dizziness/Disequilibrium

A
  • Balance deficit
  • Common in older adults from vestibular dysfunction
  • Change in head position provokes episode of vertigo or disequilibrium
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29
Q

Xerostomia

A
  • Taste deficit
  • Dcr in salivary production leads to thicker mucus & dry mouth
  • Often interferes w/ the ability to eat & leads to appetite & nutritional problems
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30
Q

Peripheral Neuropathy

A
  • Neurological deficit
  • Numbness/tingling of affected area
  • Can cause stumbling gait
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31
Q

Stroke

A
  • Neurological deficit
  • CVA caused by clot, hemorrhage, or emboli
  • Disrupts blood flow to brain
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32
Q

Sensory Deprivation

A
  • When a person experiences an inadequate quality or quantity of stimulation
    >reduced sensory input
    >elimination of patterns or meaning from input (strange environments)
    >restrictive environments tht produce monotony & boredom (bedrest/isolation)
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33
Q

Nursing Process - Implementation to Prevent & Control Alterations in Sensory Function

A
  • Modify environment to maximize altered sensory perceptions
  • Education, support, & caring
  • Adjustment to sensory impairment & maximizing sensory function as much as possible
  • Focus on safety
34
Q

Complementary Therapies

A
  • Therapies used in addition to or together w/ conventional treatment recommended by a person’s health care provider
  • Complement conventional treatments
  • herbs/supplements, guided imagery, breathwork, relaxation & massage, art, music, dance, meditation, chiropractic therapy
35
Q

Alternative Therapies

A
  • Include the same intervention as complementary therapies but they become the primary treatment
  • EX: doing yoga over taking medications
36
Q

Safe Herbal Therapies

A
  • Dietary supplements, vitamins, minerals, essential oils, probiotics
  • Herbal medicines are not drugs or regulated by the FDA
  • EX: aloe, chamomile, echinacea, feverfew, garlic, ginger, ginkgo biloba, ginseng, licorice, saw palmetto, valerian
37
Q

Unsafe Herbal Therapies

A
  • Bc they are not regulated, concetrations of active ingredients vary
  • EX: calamus, chaparral, coltsfoot, comfrey, ephedra, life root, pokewood
38
Q

Guidelines for Quality Documentation & Reporting

A
  • Factual: avoid opinions, “appears or seems”, use pt’s exact words in “”
  • Accurate: “360 ml”, correct spelling, no unapproved abbreviations
  • Complete: pertinent data but don’t write a novel
  • Current: timely, chart as soon as intervention is complete
  • Organized: logical order, concise, clear, to the point, ex: head-to-toe assessment
39
Q

Hand-Off Report

A
  • Happens any time one health care provider transfers care of a pt to another (bedside reporting)
  • Provides continuity of care
  • Includes up to date info, required care, treatments, medications, services, any recent or anticipated changes
  • Can be given face-to-face, over the phone, or in writing
  • Efficient & timely; ensures pt’s safety
40
Q

Hand-Off Report Content

A
  • Essential background info
  • Identify pt’s diagnoses or problems
  • Describe observations & responses
  • Continuously review discharge plans
  • Relay significant changes
  • Describes instructions given in teaching plan & pt’s response
  • Evaluate results of nursing or medical care measures
  • Be clear abt priorities for next shift or point of care
  • Share any significant social hx
41
Q

ISBARR

A
  • Identify: yourself & pt
  • Situation: purpose for your communication
  • Background: brief pt’s hx & condition
  • Assessment: findings
  • Recommendation: express pt’s needs or your needs for your pt’s care
  • Read Back: repeat back if an order was received
42
Q

Telephone Reports & Orders

A
  • Received from: HCP, lab, radiology, PT, OT, unit to unit, ancillary departments
  • Be clear, accurate, & concise
  • What to document: time of call, who made the call, who was called, to whom info was given, what info was received, verification of info w/ provider
43
Q

Nurse’s Role in Informed Consent

A

To verify consent of medical treatment by signed informed consent

44
Q

Nurse’s Role in Risk Management

A
  • A system of ensuring appropriate nursing care by identifying potential hazards & eliminating them before harm occurs
  • To prevent or mitigate pt injury or potential injury
45
Q

Standard of Care

A

The degree of care a prudent & reasonable person would exercise under the circumstances

46
Q

Delegation

A
  • “Transferring responsibility for performance of an activity or task while retaining accountability for the outcome” American Nurses Association (1995)
  • Results in achievement of quality pt care, improved efficiency, incrd productivity, empowered staff, & development of others
47
Q

5 Rights of Delegation

A
  • The right task
  • Under the right circumstance
  • To the right person
  • With the right directions & communication
  • Under the right supervision & evaluation
48
Q

What Tasks can be Delegated to UAP

A
  • Assisting the client w/ ADLs
  • Measuring & recording fluid I&O
  • Measuring & recording vital signs, height, & weight
  • Nonpharmacological comfort & pain relief interventions
  • Observation & reporting changes in status of client
  • Transport of clients & specimens & other errands & tasks such as stocking supplies
  • Assistance w/ transfers, ROM, feeding, ambulation, making beds, & assisting w/ bowel & bladder functions
49
Q

Nurse’s Role When Caring for Clients Experiencing Loss, Grief, or Death

A
  • Establish a trusting relationship, be honest
  • Explore w/ pt & support system their goals & expectations
  • Explore w/ pt & support system their perceptions abt what is happening
  • Sit down & slow down
  • Respect cultural, spiritual, & personal practices
  • Ensure a good assessment of physical symptoms
50
Q

Maturational

A
  • Normally expected loss from life changes
  • EX: a child moving from home
51
Q

Situational

A
  • Loss from sudden or unpredictable external event
  • EX: loss of a limb from injury
52
Q

Actual vs. Perceived

A
  • Actual: a person can no longer feel, hear, or see a person or object
  • Perceived: uniquely defined by the person and is less obvious
53
Q

Normal Grief

A

Complex emotional, cognitive, social, physical, behavioral, & spiritual response to loss

54
Q

Anticipatory Grief

A

Unconscious process of letting go before the actual loss occurs

55
Q

Disenfranchised Grief

A
  • Marginal or unsupported grief
  • Can occur when the relationship btwn individual is not socially sanctioned
56
Q

Complicated Grief

A
  • Prolonged grief or when there is difficulty moving past the loss
  • More likely to occur when relationships are trained, sudden loss, loss related to violence, or loss of a child
  • 3 Types: exaggerated, delayed, masked
57
Q

Care After Death

A
  • Provide privacy & a peaceful environment: ask if family wants to participate in prep, offer to contact support
  • Validate organ/tissue donation
  • Autopsy if needed
  • Elevate HOB asap to prevent discoloration in face
  • Remove all equipment, tubes, lines; unless autopsy or organ donation
  • Cleanse body thoroughly
  • Cover body w/ clean sheet, leave arms out if possible, close eyes, leave dentures in mouth
  • Deodorize room
  • Offer family to view body
  • Encourage to say goodbyes
  • Determine which belongings will stay w/ body
  • Document
  • Apply identifying tags
58
Q

Caring Through Presence

A
  • Person to person encounter conveying a closeness & sense of caring
  • Need to make a effort to establish
  • Don’t just talk, be there physically
  • Sit down, take time to be w/ pt
59
Q

Caring Through Touch

A
  • Can be used to convey concern & comfort
  • Can be physical contact or eye contact
  • Be aware of cultural or personal boundaries
60
Q

Listening to Pts

A
  • Critical component of caring
  • Should be deliberate
  • Listen w/ openness: non-judgemental, allow pts to share stories
61
Q

Facilitating Spiritual Health

A
  • Establish a trusting relationship
  • Assess pt’s spiritual needs & values
  • Establish a presence
  • Listen
  • Assess support system
  • Support rituals & activities
62
Q

Asepsis

A

Prevention of the transfer of microorganisms & pathogens; hand hygiene, barrier techniques, routine environmental cleaning

63
Q

Contact Precautions

A
  • When in direct or indirect contact w/ pt who has highly transmissible pathogen
  • EX: MRSA, VRE, Cdiff, diarrhea, RSV
  • Private room, gloves, & gown
  • Remove gloves & gown BEFORE exiting room
64
Q

Airborne Precautions

A
  • <5 particles evaporated droplets
  • EX: measles, chickenpox, varicella zoster, pulmonary or TB, COVID
  • Negative air flow room, respirator mask
65
Q

Droplet Precautions

A
  • > 5 particles expelled in air
  • EX: diptheria, rubella, strep, flu, pneumonia, mumps, meningitis
  • Private room, surgical mask w/ in 3 ft of pt
65
Q

Stage 2 Ulcer

A
  • Partial thickness skin loss
  • Loss of dermis
  • Shallow open ulcer
  • Red/pink wound bed; no slough present
65
Q

Protective Environment

A
  • Pts who undergo transplants & gene therapy
  • Private room, positive airflow
65
Q

Stage 1 Ulcer

A

Non-blanchable redness of intact skin

66
Q

Stage 3 Ulcer

A
  • Full thickness skin/tissue loss
  • Fat visible; includes subcutaneous tissue
  • Some slough may be present
67
Q

Stage 4 Ulcer

A
  • Full thickness tissue loss
  • Muscle, bone, and/or tendon visible
  • Slough and/or eschar present
  • Often includes tunneling or undermining
  • Osteomyelitis can occur
68
Q

Risk Factors of Skin Integrity

A
  • Dcr mobility
  • Dcr sensory perception
  • Moisture
  • Shear & friction
  • Poor nutrition
69
Q

Interventions for Impaired Skin

A
  • Turn q2h
  • Waffle boots
  • Keep HOB < 30 degrees
  • Specialty mattresses
  • Mepilex
  • Barrier creams
  • Lift devices
  • Transfer sheets
  • Incr protein
70
Q

Inserting an NG Tube

A
  • Fowler’s position
  • Measure from tip of nose to earlobe to xiphoid process
  • Mark w/ tape
  • Lubricate end of tube
  • Insert into nare
  • Have pt lean forward and continuously swallow water
  • Secure tube on nose
  • Verify placement: pH 0-4, chest x-ray
71
Q

PEG Tube

A
  • Percutaneous endoscopic gastrostomy tube
  • Takes abt 30 mins
  • Put into stomach through a small opening in skin using endoscope
72
Q

Gastrostomy Tube

A

Placement of a feeding tube through the skin and stomach wall, directly into stomach via surgical procedure

73
Q

Jejunostomy Tube

A
  • Feeding tube placed in jejunum
  • Alternative to gastrostomy when stomach is unsuitable or higher risk for aspiration
  • Surgical procedure
74
Q

Signs of Alterations of Fluid Balance

A
  • When disease processes, medications, or other factors disrupt fluid intake or output
  • Dehydration
  • Dry mucus membranes
  • Excessive urination w/out adequate intake
  • Excessive diarrhea
75
Q

Nursing Process

A
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
76
Q

Interventions for Fall Precautions

A
  • Identify fall risk pt w/ arm band, footwear, signage, & communicate w/ all staff
  • Keep bed as low as possible & locked
  • Orient as needed
  • Keep room free of obstacles
  • Keep all belongings w/in reach
  • Side rails up as appropriate
  • Educate pt & family
  • Observe frequently
  • Regular toileting schedule
  • Use gait belt
  • Bed and/or chair alarms
  • Use of assistive devices
  • PT & OT consults
  • Moving pt location
  • Fall mats
77
Q

General Care for Restraints

A
  • Assess area of application & pad areas if needed before application
  • For limb restraints, ensure tht 2 fingers can be placed btwn pt & restraint
  • Attach straps to bed frame, not to any movable part of bed
  • Secure the straps w/ a quick release buckle
  • Assess & document the continued need for restraints & pt response q2h
  • Assess for signs of injury every 15 mins
  • Evaluate for complications
  • Assess need for toileting, repositioning, & release restraint q2h
78
Q

Effects of Immobility

A
  • Metabolic changes
  • Respiratory changes
  • Cardiovascular changes
  • Musculoskeletal changes
  • Alterations in urinary elimination
  • Integumentary changes
  • Psychosocial changes
79
Q

Assessment of Respiratory Dysfuntion

A
  • SaO2 > 95%
  • SpO2 measures oxygen saturation
80
Q

Interventions to Help with Respiratory Issues

A
  • Halting the pathological process
  • Shortening duration & severity of illness
  • Symptom management
  • Preventing complications from pathological process or treatments
  • Dyspnea management
  • Airway management
  • Secretion management
  • Oxygenation, medications, breathing techniques, positioning, cough & deep breathing suctioning, hydration, humidification,
81
Q
A

NUR 3200 FOUNDATIONS (6 decks)

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