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Nursing 142 Final Flashcards

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1
Q

3 dimensions of fundamental of care framework

A

Context of care - policy level ( governance, financial, quality and safety, regulation and accreditation), system level ( resources, culture, leadership, evaluation, feedback)
Integration of care - psychological patient needs, physical patient needs, relation care giver actions
Relationship - trust, focus, anticipate, know, evaluate

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2
Q

What does a professional intro include

A

Stating name , title, and pronouns

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3
Q

Important factors for patient communication

A

Patient centred, empathetic, inclusive, non-bias, and un gendered language

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4
Q

What are health records used for

A

Legal records, used for knowledge for health care team members, research, data, auditing,monitoring and evaluation

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5
Q

Admission nursing history

A

Completed by nurse upon admission, nursing diagnosis included

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6
Q

Flow sheets/graphic records

A

Includes data from reoccurring assessments eg. Weight, vitals ADL’s (activities if daily living)

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7
Q

Patient care summary/ Kardex

A

Basic and summative information

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8
Q

Standardized care plan:

A

Prepared plan of care, identifies patient goals, nursing diagnosis and nursing orders

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9
Q

Discharge summary forms

A

Includes diet, community resource, medications and follow up care

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10
Q

Safety checks for all patients

A
  • 2 patient identifiers
  • immediate environment
  • risks
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11
Q

What is ISBARR

A

I- Identify: yourself and patient
S- situation: what is happening?
B- background: what circumstances lead up to this?
A- assessment: what is the problem?
R- recommendations: what should be done to correct the problem?
R- response: the patient acknowledges information given and responds

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12
Q

Chain of infection

A
  • Infectious agent ( pathogens, bacteria, virus, etc)
  • reservoir (where it lives eg. people)
  • portal of exit ( droplet, secretion, etc)
  • mode of transmission (airborne, droplet, contact)
  • portal of entry ( openings in body)
  • susceptible host (any person especially those in poor health)
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13
Q

Breaking chain of infection

A

Infectious agent- cleaning, disinfect, diagnosis, treatment
Reservoir- disinfect, clean, sterilize, good health
Portal of entry- hand hygiene, PPE, waste disposal
Mode of transmission- PPE, hand hygiene, isolation precautions, disinfect
Portal of exit- catheter care, wound care, PPE
Susceptible host- immunization, patient education, recognize patients at high risk

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14
Q

Asepsis

A

Absence of pathogens

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15
Q

Aseptic technique

A

A method to make environment, worker and patient as germ free as possible

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16
Q

Hospital acquired infections

A

Infection acquired in a health care facility Eg. C. difficile, CAUTI

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17
Q

Routine practice

A

Used in the care of all patients. Things that are done routinely when caring for patients, can include blood, bodily fluids, secretion, excretion,mucus membranes and non intact skin

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18
Q

Exogenous infection

A

Infection outside organ or part

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19
Q

Endogenous infection

A

Produced or arising from within cell or organism

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20
Q

Point of care risk assessment

A

Access patient, task, environment and reduce transmission of infection

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21
Q

Airborne precaution

A

N95 respirator mask

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22
Q

Droplet precaution

A

Gloves, gown, mask, eye protection

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23
Q

Contact

A

Gloves, gown

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24
Q

Donning and doffing

A

Donning- putting required PPE on
Doffing- taking required PPE off (mask last)

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25
What is MSIP
Musculoskeletal injury prevention
26
What is STABLE?
- maintain natural S curve in spine - keep TRUNK aligned - keep ARMS close - use a wide BASE of support - use your LEGS - EVALUATE the load, environment and yourself
27
Principles of body mechanics
Decrease work effort and places less strain on musculoskeletal structures
28
Proper patient positioning
- Maintain body alignment and promote comfort, Prevent injury to musculoskeletal an integumentary system,Provide stimulation Sitting- Head erect,Neck and spine in straight line, Thighs parallel, Both feet supported, Patients arms supported, Body weight distributed Standing- Head erect and midline,curve spine, knee and ankles slightly flexed Laying- Depends on how patient positioned, Should be supported by adequate mattress and without abservable curves in spine
29
Passive Range of Motion
Outside source (Eg nurse) exclusively causes movement to joint
30
Active range of motion
Patient moves part of their body using own muscles
31
Pre standing safety check
Assessing for cognition, ability to follow direction, stability and balance Includes bridging hips, leaning and lifting legs
32
Fowler position
Semi siting position; HOB raised 45-60 degrees
33
Semi-Fowler position
HOB raised 30 degrees knees can be up 15 degrees
34
Supine position
Bed is horizontally parallel to floor
35
Trendelenburg position
HOB lowered and foot raise
36
Reverses Trendelenburg position
HOB raised and foot is lowered
37
7 factors influencing a patients personal hygiene preference
Body image, physical environment, social practices, personal preference,health beliefs, socioeconomic status,motivation
38
What concerns require a nurse to provide hygiene several times a day
Incontinence, excess diaphoresis, wound drainage
39
Benefits a patient gets from bathing
-circulation -relax and fresh feeling -socialization -removes dirt, sweat, oil
40
Why is skin care important?
Skin integrity and prevent pressure injuries
41
That should only receive a bath once or twice a week
Infants and older patients
42
What leaves hair oily and unmanageable?
Diaphoresis
43
What can radiation therapy and certain chemotherapy medication due to hair?
Alopecia
44
Urinary elimination
1.2-1.5L over 24hrs (50-70 mL/ hr) concern less than 30ml over 2 hrs or 2L in 24 hrs
45
Toileting options
Urinal, bed pan, slipper pan, commode, toilet, brief, catheter
46
ADL’s
Eating, bathing, grooming, dressing, toileting, walking
47
IADL’s
Shopping, preparing meals, cleaning, transportation,medication, finances
48
ADPIE
Assessment diagnosis plan implementation evaluation
49
FICA
Faith Importance and influence Community Action in care
50
3 domains of functional assessment
ADL’s, IADL’s, mobility These are gotten by asking and observing patient
51
Urinalysis
Can you be collected during normal voiding or catheter bag
52
Culture and sensitivity
Examine presence of bacteria, clean technique/ mid stream to sterile specimen cup or sterile collection port of Catheter bag
53
Dysphagia
Difficulty swallowing
54
Risk of aspiration
Tachypnea, dyspnea, cough, abnormal gag reflex
55
Normal temperature range
36-38
56
Digital removal of stool
Done when a patient is unable to pass stool due to severe constipation to empty reflex bowel
57
What to look for when assessing urine
Smell, colour, cloudiness, any abnormalities or bacterium
58
Pulse
60-100 bpm
59
Respirations
12-20 breaths per min
60
Oxygen saturation
95-100 %
61
Bradycardia
an adults pulse who is less than 60 beats/min
62
Tachycardia
an adults pulse who is more than 100 beats/min
63
Hypoxic
Low blood oxygen level
64
hypotensive
less than 90/60 mm Hg
65
Hypertensive
higher than normal blood pressure
66
Bradypnea
abnormally slow fewer than 12 breaths per minute
67
Tachypnea
abnormally rapid rate of breathing
68
Apnea
Respirations seize for several seconds
69
Kussmaul
Respirations are abnormally rapid and deep but regular, common in diabetics
70
Cheyene-stokes
Respiration rate are irregular pattern, characterized by alternating periods of apnoea and hyperventilation
71
Health assement
Evaluation of patients health status by performing a physical exam after taking health history
72
Hyperventilation
Rate and depth of respiration increase
73
Hyporespiration ventilation
Rate of respiration abnormally low,depth of respiration may be depressed
74
Barriers to oral care
Cognition, dexterity, lack of understanding, access
75
Therapeutic diets
Clear liquid, full fluid, puréed, dental soft, low residue, etc
76
Suctioning level
Regular 100-150
77
What is each vital sign assessing
Temperature- Difference between the amount of heat produced by the body and then mount lost in the external environment Pulse- The ejection of blood from the heart distends the walls of the aorta Respirations- The exchange of oxygen and carbon dioxide between cells of the body and the atmosphere Blood pressure- The force exerted by blood against the vessel walls Oxygen saturation- The percentage to which hemoglobin is filled with oxygen
78
Dyspnea
Shortness of breath

Nursing 142 (1 decks)

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