Fundamentals Exam 1 Flashcards
(128 cards)
1
Q
Name the 3 levels of health care
A
Primary
Secondary
Tertiary
2
Q
This level of health care is preventative with health promotion, focuses of illness prevention, and health care today is more aimed at this level
A
Primary
3
Q
This is the health care level of diagnosing and treating an illness
A
Secondary
4
Q
This is the health care level that focuses on rehabilitation, health restoration, and palliative or end of life care
A
Tertiary
5
Q
What are the 5 frameworks for nursing care
A
Primary Nursing Case Method Team Nursing Case Management Functional Method
6
Q
The framework for nursing care when one nurse is responsible for total care for a caseload of clients over time, continuity of care
A
Primary nursing
7
Q
The oldest case method in nursing
A
Private Duty Nursing
8
Q
The case method in which the nurse is responsible for all the care of the patient, can be responsible for more than one patient at a time, and could care for a different patient every day
A
Total Patient Care
9
Q
What are the 3 parts of team nursing
A
Team leader
Team members
Team conference
10
Q
The role in team nursing when an RN is accountable for all the care and the rest of the team reports to them
A
Team leader
11
Q
The role in team nursing where they are assigned functions or procedures to preform for all clients: meds, treatments, bedside nurse
A
Team member
12
Q
The part of the nursing team utilized to communicate and develop a plan of care
A
Team conference
13
Q
The framework fo nursing care responsible for a case load of patients in the hospital and follow up after discharge, also work with insurance companies to help patient receive the best possible care in the most cost-effective way
A
Case Managers
14
Q
Inspire and motivate, influence others to work together to accomplish goals
A
Leaders
15
Q
Employees whom the organization has given authority, power, and responsibility to accomplish the work of the organization. They plan, organize, and coordinate
A
Managers
16
Q
This style of leadership makes decisions for the group, assumes the group is incapable, great for emergency situations, productivity is usually high, but autonomy and self-motivation low, degree of openness and trust between group & leader is low
A
Autocratic (authoritarian)
17
Q
This style of leadership encourages group discussion and decision making, assumes individuals are internally motivated and capable of making decisions,
allows more self-motivation and creativity among members, very effective in the health care setting
A
Democratic (participative)
18
Q
This style of leadership assumes group is internally motivated and needs autonomy, assumes a “hands off” approach and tends to minimize the amount of direction and face time needed, may be a lack of cooperation & coordination, works well if you have highly trained and motivated group
A
Laissez-faire (non-directive, permissive)
19
Q
This style of leadership assumes group is externally motivated, but does not trust them to make decisions, relies on organizational rules, rules, rules, rules and policies – inflexible, motivates through systematic rewards and punishments
A
Bureaucratic (transactional)
20
Q
This style of leadership adapts the leadership style to the situation, allows certain things to happen depending on the situation, concern for interpersonal relationships and a focus on activities that meet group members’ needs.. Could end up using any of the previously mentioned styles – determined by the group’s needs
A
Situational
21
Q
In this style of leadership no one person is considered to have more knowledge or ability than another in the group.. In essence, all are leaders
A
Shared
22
Q
The level of management where they manage the work of non-managerial staff and the day-to-day activities of the work group: schedule, room assignments
A
First level managers
23
Q
The level of management where they supervise first-level managers and are a liaison between first and upper level managers: problems, evaluation, policy & procedure changes
A
Middle level managers
24
Q
The level of management where executives are responsible for establishing goals and plans for the organization: goals, budgeting
A
Upper level managers
25
The transferring of responsibility for the performance of an activity or task to another member of the health care team while retaining accountability for the outcome.. huge part of nursing
Delegation
26
What are the 5 rights of delegation?
```
Task
Circumstances
Person
Communication
Supervision and evaluation
```
27
One of the rights of delegation..
Must be in the delegate's scope of practice and job description
Must be right for the specific client
The right task
28
This right of delegation considers 4 factors:
stability of the patient's condition
the potential for harm while performing the task
nurse should be able to problem solve and make decisions
the level of technology in use
The right circumstance
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The right of delegation when a clear, complete, and concise description of the task is given, its ongoing and need to be sure the delegate understands the directions
The right communication
30
The right of delegation when there is appropriate monitoring and feedback is given
The supervision and evaluation
31
What should you know before delegating..
Policies
How your state board defines these roles
Know the nursing practice act
Think about whether the person has the skills and knowledge to actually do what you asked
32
Health care delivery skill:
an important first step in developing a caring relationship with your client
involves a focused and complete patient assesment
Clinical decision
33
Health care delivery skill:
| realizing what problems and situations need to be taken care of first
Priority setting
34
Health care delivery skill:
Being effective and efficient in implementing a plan of care
Effective use of time
Being able to do more than one thing at a time
Having all equipment ready and the client prepared for procedures
Organizational skills
35
Health care delivery skill:
Helps client care occur more smoothly
Seek assistance when necessary
Know your limitations and seek help from professional colleagues for guidance and support
Communicating with patient and patient’s family
Working together
36
Health care delivery skill:
essential to remain goal oriented and use this wisely
must learn so that activities of care, as well as client goals, an be achieved
anticipate when care may be interrupted
complete one task before starting another
Time management
37
Health care delivery skill:
An ongoing process
when you look at effectiveness of therapies
when you look client responses to care
when you help maintain progress towards goals.
Evaluation
38
Health care delivery skill:
Show respect for one another’s ideas
Share information, Keep one another informed
Treat colleagues with respect and listen to the ideas of other staff members
Team communication
39
A dynamic, flexible environment that is concerned with the specific needs of an individual patient and/or groups of patients to promote a positive living experience and positive health changes... they may need/want family one day but the next day they may not
Therapeutic environment
40
What are the characteristics of a therapeutic environment
1. Adequate Comfort (temperature, ventilation, lighting, nonskid surfaces….)
2. Safe
3. Individualization of patient care
4. An atmosphere that encourages communication
5. A feeling of “security” for the patient
6. A feeling of self worth for the patient
7. Diversional activities
41
Characteristic of a therapeutic environment:
To protect clients and themselves from injury, but a danger free environment is rare
Its a basic need used in the work environment
prevents harm and allows clients to feel secure
allows the client to meet other human needs
age matters
injuries may occur
just be preventative
Safety
42
A type of injury from a fall or a blow:
falling out of bed
slipping on the floor
tripping over cords
Mechanical injury
43
Injury from heat or fire:
hot water bottles
heating pads
lamps
Thermal injury
44
An injury involving strong chemical on the skin, can be internal, such as wrong medications
Chemical injury
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Injury involving burns from faulty wiring, touching electrical connections with wet hands
Electrical injury
46
Injury involving overexposure to xray but can be prevented by using the lead vests
Radiation injury
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Injury caused by disease producing microorganisms
| Patients are usually more susceptible because of their illness.. wash hands and keep things sterile!
Bacteriological injury
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Injury caused by patient’s susceptibility to materials in the environment
Allergens
49
Avoid this injury by preventing sensory deprivation or overload, which can contribute to confusion and hinder the patient’s safety
Psychological injury
50
Name common risks to nurses
Exposure to blood-borne pathogens: needlesticks
Back injuries: moving patients
Exposure to harmful medications: chemotherapy
Threats of violence and assaults from clients and visitors: families can become easily angered
51
The leading cause of unintentional injury among adults
Falls
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R.A.C.E.
R: Rescue anyone in danger if it doesn't endanger you
A: Alarm- sound it
C: Confine by closing all doors and windows
E: Extinguish and Evacuate
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P.A.S.S.
P: Pull
A: Aim
S: Squeeze
S: Sweep
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Any physiologic or psychological factor necessary for a health existence
A need
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Maslow's hierarchy of needs from top to bottom
1. Self actualization needs
2. Esteem needs
3. Love needs
4. Safety needs
5. Psychological needs
56
Guidelines of prioritizing needs
```
Immediate effect on survival
Effect on other needs
Timeframe and available resources
Client’s perception of need
Family’s perception of need
```
57
Behaviors, values, beliefs, and customs that are learned from other people over time..includes language, communication style, traditions, religion, art, music, dress, health beliefs, and health practices
Culture
58
The acute experience of not comprehending the culture in which one is situated..may be expressed as silence, immobility, agitation
Culture shock
59
Factors contributing to the culture of the patient
1. communication
2. space
3. social organization
4. time
5. environment control
6. biological variations
60
Methods for assessing culture
Observe
Interview (therapeutically)
Participate
61
When faced with health care issues, they may begin to question their belief systems and are unable to find support
Spiritual distress
62
JCAHO says a spirituality assessment must be done to assess the patients..
Denomination
Beliefs
Spiritual practice that's important to the patient
63
What a spiritual interview assessment consist of..
Any religious practices important to you?
Will being here interfere with any of those?
Would you look a visit from spiritual counselor?
64
What should you clinically assess about spirituality..
Environment
Behavior
Verbalizations
65
0-18 inches from the patient
Intimate space
66
18 inches to 3 feet from the patient
Personal space
67
3-6 feet from the patient
Public space
68
Cardiovascular benefits of mobility
```
Cardiovascular system works more effectively
strengthens cardiac muscles
increases cardiac output
decreasing resting heart rate
improves venous return
```
69
Musculoskeletal benefits of mobility
Maintains and improves muscle tone and strength
Increases joint flexibility and range of motion
Maintains bone density (through weight bearing)
70
Respiratory benefits of mobility
Improves alveolar ventilation
Decreases breathing effort
Improves diaphragmatic excursion
O2 intake increases during strenuous exercise
71
GI benefits of mobility
Improves appetite
Increases GI tract tone, improving digestion
More effective in absorbing nutrients
72
Metabolic benefits of mobility
```
Elevates basal metabolic rate
Reduces triglycerides and cholesterol levels
Increases use of glucose
Increases production of body heat
Burns excess calories
```
73
Urinary benefits of mobility
Promotes effective excretions of waste
| Helps prevent urinary stasis in the bladder
74
Psychological benefits of mobility
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Improves stress tolerance
Produces a sense of well being
Reduces depression
Improves body image
Enhances quality of sleep
Increases energy levels
```
75
Effect of immobility
| Bone demineralization with calcium loss
Osteoporosis
76
An effect of immobility
| Why you have to use or you lose it
Muscles decrease in size
77
An effect of immobility causing shortening of the muscles
Contractures
78
Effects of immobility on the joints
Joint deformity
Arthritis
Stiffness and pain
Frozen joints
79
Cardiovascular effects of immobility
```
Diminished cardiac reserve
Rapid heart rate
Reduced coronary blood flow
Orthostatic hypotension
Edema: swelling in lower extremities
Thrombus: clots and swelling
```
80
Respiratory effects of immobility
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Pooling of respiratory secretions
Inability to cough them up
Decreased depth of breathing
Atelectasis
Pneumonia
```
81
Urinary effects of immobility
Urinary stasis: bladder will fill to the point where you cant go to the bathroom and it spills out the ureter leading to infection
Urinary retention
Urinary infection
Renal Calculi
82
Integumentary effects of immobility
Skin breakdown
| Pressure ulcers
83
Neuropsychological effects of immobility
```
Low self esteem
Frustration
Depression
Impaired decision making
Anxiety
```
84
Subjective questions when assessing mobility
Have you noticed any pain in your joints or muscles?
Do you have any weakness or twitching?
Have you had any recent falls?
Are you able to care for yourself?
Do you exercise or participate in sports?
Do you use any assistive devices?
85
What to look at when assessing mobility
```
Look at:
alignment
balance
gait
joints
muscle strength
```
86
Stages of pain with musculoskeletal disorders
Early: pain until you rest
Intermediate: pain during work
Advanced: pain even when you're resting
87
Symptoms of musculoskeletal disorders
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Tingling
Numbness
Fatigue
Weakness
Redness
Swelling
Loss of full or normal joint movement
```
88
Factual data observed by the nurse
| No conclusions or interpretations are made
Objective data
89
Information given verbally by the client
Captures the client’s point of view
Always stated in their words with quotations
Subjective data
90
Type of assessment:
Also referred to as an admission assessment
Performed when patient enters health care facility
Helps evaluate health status and establish comprehensive baseline data
Done by RN
Everyone must have one
Initial assessment
91
Type of assessment:
Collects data on a certain part of the body instead of the whole head to toe assesment
Collects data about a problem that has already been identified
Determines if problem still exists or if status has changed
Can identify new problems
Focus assessment
92
Type of assessment:
Takes place after the initial assessment to assess for changes
Not as comprehensive as the initial asses.
Assessing for any kind of change
Usually when substantial periods of time have elapsed (ie between home visits, clinic visits….)
Usually a complete review (not as comprehensive as the initial assessment) of all functional health patterns is done because of the long time interval
Time lapsed assessment
93
Type of assessment:
Takes place in life-threatening situations
Rapid identification of problems and interventions necessary
Not comprehensive – focuses on problem areas only
Looking for things such as not breathing, distress in the patient
Emergency assessment
94
Name for the 4 parts of assessment
Observation
Interviewing
Physical Exam
Intuition
95
Name different observations that can be made during assessment
Sight/vision- how the patient looks (wt., skin, posture)
Sound/hearing- how they talk, breathe, cracking joints
Smell- sweat, urine, feces, breathe
Touch- cold, strong, weak, soft
96
Also called common sense or a gut feeling, trusting your instincts
Intuition
97
The first step in the assessment process
Usually carried out during the interview and the physical exam
To detect normal characteristics or significant physical changes
Can do you during the interview or during any other technique
Inspection
98
Use of touch
Use of fingertips and palms of hands
To detect size, shape, tenderness, temperature, texture, vibration, masses….
Light (want to do light palpation first)
Deep (go back through with a deeper palpation
Palpation
99
One or both hands are used to strike the body surface to produce a sound
Helps assess denseness or hollowness of underlying body structures, location and level of organs, tenderness, masses or tumors…
Percussion
100
Listening to body sounds with the use of a stethoscope
Amplifies sound
Bowel sounds, heart sounds, lung sounds…
Auscultation
101
Order to preform the physical exam
inspection, palpation, percussion, auscultation
102
What is the exception in the physical examination order
exception is for bowel sounds (ab. area) : inspect, auscultate, percuss and palpate (to avoid altering bowel sounds)
103
Awareness of and responsiveness to the surrounding environment
Level of consciousness
104
What are the 3 levels of consciousness
Highest: completely attentive
Impaired: loss of orientation and inability to follow commands
Lowest: comatose no verbal response
105
A standardized assessment tool used for measuring consciousness
Nurses are able to detect subtle changes in consciousness by reviewing the scale and looking for deviations from baseline
Glasgow Coma Scale
106
What to assess for consciousness
Orientation: persons, places, times
Language: speech, aphasia: unable to express or understand
Memory: long term, ask about birthdays, etc.
107
Nearsightedness
Myopia
108
Farsightedness
Hyperopia
109
irregularity of the cornea which causes blurred vision
Astigmatism
110
decreased elasticity of the lens with a decrease in accommodation
Presbyopia
111
What should you inspect about the eyes
Eyebrows: symmetrical
Eyelashes: equal distribution, styes
Eyelids: discoloration, edema, blinking
Eyeballs: deep or protrude
112
Conjunctiva
Pull down gently on the skin just below the eye and observe for inflammation, redness and/or lesions
113
Sclera
Observed chiefly for color – normally white and clear. Note discolorations.
114
Cornea and Iris
Cornea normally clear and smooth – cloudiness or opaqueness is abnormal
Note the color of the iris – iris should be round
115
Pupils
Evaluate for size, shape, accommodation and reaction to light.
Pupil size is measured in millimeters (usually 2-3 mm)
Normally round and of equal size
Normally dilate in a darkened environment and constrict in bright light
116
PERRLA
```
P – pupils should be clear
E – equal in size and between 3-5 mm
R – round in shape
RL – reactive to light
A – accommodation of the pupils
```
117
Types of hearing loss
Sensorineural: due to a problem with the inner ear or the auditory nerve
Conductive: due to a problem with the external or middle ear (wax buildup, foreign body, infection)
118
Signs of decreased hearing
```
Behavioral changes
Requesting repetition of statements
Leaning forward – turning head towards speaker
Answering inappropriately
Talking loudly
```
119
hearing loss due to aging
Presbycusis
120
Inspection of external ears/auricles
Placement: top of auricles should align with the outer canthus of the eyes
Color: should be the same as the face color
Size: small, moderate, large
Symmetry
Ear canal should be free of foreign bodies or discharge
Wax (cerumen is an expected finding)
121
Pharynx
uvula should be pink, intact and move with vocalization
tonsils: if visible should be the same color as the surrounding mucosa
Note any redness or swelling
122
Assessment of the mouth
Lips: should be moist, symmetrical, smooth, no lesions, no tenderness
Gums: should be pink, moist, no lesions
Mucous membranes: pink, moist, no lesions
Teeth: color, cavities, missing teeth, dentures
Tongue: dorsal side should be pink with papillae; underside should be smooth with a symmetrical vascular pattern; moist, free of lesions; should move freely
Inspect hard and soft palates
123
Assessment of the nose
Symmetry of nose; any deviation of midline
Same color as face
Each nostril should be patent without excess flaring (can occlude one nostril at a time and assess the opposite side for airflow)
Mucosa should be deep pink, moist with no discharge or lesions
Any bleeding?
124
Inspection of the breast
```
Females (can be done sitting or standing)
Arms at the side
Arms above the head
Hands on hips, pressing firmly
Leaning forward
Males (can be done sitting or lying)
Arms at the side
```
125
Inspecting breasts for..
```
Size and symmetry
Shape
Skin color
Any lesions, nodules, edema or erythema
Round shape of areola
Color of areola
Direction of nipples (recent inversion is abnormal)
Any excoriation under breasts
```
126
Documentation of nodules on the breast
```
Location (using quadrant or clock methods)
Size (in centimeters)
Shape
Consistency (soft, firm or hard)
Discreteness (well-defined borders of mass)
Tenderness
Erythema
Dimpling or retraction over the mass
Mobility
```
127
Expected findings for the breasts
Female
Breasts should be firm, elastic with no lesions or nodules
Breast tissue may feel granular or lumpy in some women
Male
No edema, masses or tenderness
Areolas should be round and darker pigmented
128
Assessment of scalp and hair
Inspect and Palpate- color, quantity, distribution, texture, hygiene, nodules, and lesions
Hair Color- range from pale blonde to deep black
Moisture- dry, oily
Texture- may be straight, curly, kinky, fine, or coarse
Examine Base of Hair Follicle- pest infestation, dandruff
Alopecia- loss of hair
