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N126 Health Assessment II > Test 1 > Flashcards

Flashcards in Test 1 Deck (63)
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1
Q
  1. Know the purposes of patient education.
A

​You will not always be there to control their health and daily activities, you want to educate the patient so they learn how to do things for themselves and take care of themselves effectively so as they can live as healthy and happy as possibly. Include maintenance and promotion of health and illness prevention, restoration of health, and coping with impaired functions.

2
Q
  1. Know what best indicates that learning has occurred 329
A

Having the patient tell you what they have learned, demonstrate procedure back to you, or describe what they are still unclear about

3
Q
  1. Differentiate between the learning domains: Cognitive / Affective / Psychomotor 330-331
A

​Cognitive is the thinking domain. Includes all intellectual behaviors, includes knowledge, comprehension, application, analysis, synthesis, and evaluation. Affective is the feeling domain, and deals with expression of feelings and acceptance of attitudes, opinions, or values. Includes receiving, responding, valuing, organizing, and characterizing. Psychomotor is the skill domain, and involves acquiring skills that require integration of mental and muscular activity. Includes perception, set, guided response, mechanism, complex overt response, adaptation, and origination.

4
Q
  1. Know the different teaching strategies for different stages of development 334 Toddlers and Preschoolers
A

Toddlers and Preschoolers: Keep it brief, let them handle the equipment if possible and safe, look and pay attention to body language.

5
Q
  1. Know the different teaching strategies for different stages of development 334 School age children
A

School age children: Encourage them to express emotions, use coloring books, story books, dolls and puppets, all can be useful for children to learn.

6
Q
  1. Know the different teaching strategies for different stages of development 334 Adolescents
A

Adolescents: Prefer to learn without parents around, identify best with peers, teach to a group can be an effective way to facilitate learning, concerned about appearance.

7
Q
  1. Know the different teaching strategies for different stages of development 334 Young and Middle aged adults
A

Young and Middle aged adults: Not interested in learning about other people’s problems, important to explain how lifestyle has long-term affects on health. Encourage participation in teaching plan by setting mutual goals, encourage independent learning.

8
Q
  1. Know the different teaching strategies for different stages of development 334 Elderly
A

Elderly: Motivated to learn new techniques and procedures that promotes independence and ease, may have decreased manual dexterity, decreased sense of touch, vision, and/or hearing, also may have many chronic conditions such as arthritis or neuropathy. Teach when alert and rested, involve in discussion, focus on wellness and strength, keep lessons short.

9
Q
  1. Know how to determine a patient’s ability to learn? 332-334
A

Developmental capability of patient determines ability to learn. Need to know level of knowledge of patient in order to make an efficient lesson plan, learning is better when new information complements prior knowledge. Be considerate of age as well, as different developmental stages require different abilities to learn. Physical capability also factors in, especially depending upon what is being taught. Physical characteristics such as size, strength, coordination, and sensory acuity factor into psychomotor skills. Any condition that impairs energy and physical level also impairs ability to learn. Lastly, the environment plays a role in whether the patient will have a difficult or pleasant time learning.

10
Q
  1. Know how to determine when the patient is ready to learn 332| 334
A

Readiness to learn is the demonstration of behaviors or cues that reflect the learner’s motivation to learn at a specific time. Attention set, motivation, and self-efficacy factor into the patient’s readiness to learn.

11
Q
  1. Differentiate between the nursing process and the teaching processes 335 Assessment
A

Assessment: Nursing process includes collecting data about physical, psychological, social, cultural, developmental, and spiritual needs from the patient, family, medical records, diagnostic tests, literature, and nursing history. The teaching process includes gathering data about patients learning needs, motivation, ability to learn, and teaching resources from patient, family, learning environment, medical record, nursing history, and literature.

12
Q
  1. Differentiate between the nursing process and the teaching processes 335 Diagnosis/Analysis
A

Nursing Diagnosis: In nursing process, this is identifying appropriate nursing diagnosis based on assessment findings. In teaching process, this is identifying patients learning needs on the basis of the three domains of learning.

13
Q
  1. Differentiate between the nursing process and the teaching processes 335 Planning
A

Planning: Nursing process including developing individualized care plan, set diagnosis priorities based on immediate needs, expected outcomes, and patient-centered goals, as well as collaborating with patient on care plan. In the teaching process, this is establishing learning objectives stated in behavioral terms, identifying priorities regarding learning needs, collaborating with patient about teaching plan, and identifying type of teaching method to use.

14
Q
  1. Differentiate between the nursing process and the teaching processes 335 Implementation
A

Implementation: Nursing process includes performing nursing care therapies, include patient as active participant in care, involving family in care when appropriate as well. The teaching process is implementing teaching methods, actively involving patient in learning activities, and including family caregiver as appropriate.

15
Q
  1. Differentiate between the nursing process and the teaching processes 335 Evaluation
A

Evaluation: Nursing process is identifying success in meeting desired outcomes and goals of nursing care, and altering interventions as indicated when goals are not met. Teaching process is determining outcomes of teaching-learning process, measure patient’s achievement of learning objections, and reinforce information as needed.

16
Q
  1. Know the four steps of the teaching process 335
A
  1. Assess learning readiness a. Would you like to know more? I would like to share this with you… 2. Assess what the client knows as a baseline a. Ask what they know about the topic 3. Teach simple to complex 4. Evaluate knowledge learned a. Repeat information b. Return demonstration
17
Q
  1. Know what is needed in defining learning objective/outcome 338
A

In setting goals and outcomes, setting priorities is based on the immediate needs of the patient, as well as what the patient perceives as most important to learn, and his/her readiness to learn. Setting priorities includes timing of teaching and organizing teaching material. Outcomes are the expected knowledge gain the patient will experience, and be able to use and apply to their health care.

18
Q
  1. Know how to assessing the ability to learn 332| 336
A

Determine the patient’s physical and cognitive ability to learn. Health care providers often underestimate patients’ cognitive deficits. Many factors impair the ability to learn, including fatigue, body temperature, electrolyte levels, oxygenation status, and blood glucose level. In any health care setting several of these factors often influence a patient at the same time. Assess the following factors related to the ability to learn:

  • Physical strength, endurance, movement, dexterity, and coordination—Determine the extent to which the patient can perform skills. For example, have the patient manipulate equipment that will be used in self-care at home.
  • Sensory deficits (see Chapter 49) that affect the patient’s ability to understand or follow instruction
  • Patient’s reading level—This is often difficult to assess because patients who are functionally illiterate are often able to conceal it by using excuses such as not having the time or not being able to see. One way to assess a patient’s reading level and level of understanding is to ask the patient to read instructions from an educational handout and then explain their meaning (see the discussion of health literacy, p. 337).
  • Patient’s developmental level—This influences the selection of teaching approaches (see Box 25-3).
  • Patient’s cognitive function, including memory, knowledge, association, and judgment
  • Pain, fatigue, anxiety, or other physical symptoms that interfere with the ability to maintain attention and participate—In acute care settings a patient’s physical condition can easily prevent a patient from learning. (Potter 336)
19
Q
  1. Know safety concerns when administering sub Q injections daily 571-572
A

Risk of introducing infection, medications can be expensive, pain experienced from repeated needle sticks, not best method for patients with bleeding issues, risk of tissue damage, can cause anxiety. Sterile abscesses can form when medication sits under skin.

20
Q
  1. Know what a “Z-track” is and why it may be used 629
A

Holding the skin back when injecting so that the release of the skin upon completion of injection and removal of needle forms a seal that keeps the medication in the desired area, instead of accidently coming back out of the injection site. Used also to minimize local skin irritation.

21
Q
  1. Know how to calculate infuse rates 573-577
A

Simple mathematical calculations to determine how much medication is given to the patient based on the order and the medication disbursement amount. Metric system is used, calculations done for all forms of medication routes. If liquid, make sure to incorporate liquid amount (mL) into calculation, so you know how much medication the patient is receiving per amount of liquid given in order to administer correct amount.

22
Q
  1. Know the about aspiration on IM injections 601-609
A

Aspiration during IM medications indicate whether you are injecting the medicine correctly into the muscle. If blood appears, dispose of needle and medication, redraw up a new dosage.

23
Q
  1. Know the procedure for intra dermal injections 604-605
A

Used for skin testing, injected into dermis. Sites should be lightly pigmented, free of lesions, and relatively hairless. Inner forearm and upper back are ideal locations. Use tuberculin or small hypodermic syringe, at an angle of 5-15 degrees with the bevel of the needle pointing up. As you inject, a small bleb will appear on surface of skin. If bleb does not appear or is site bleeds after needle is removed, there is a good chance you entered sub Q tissue, if this is the case results will not be valid.

24
Q
  1. Differentiate between the rates of absorption of different administration methods 567-570
A

Medications on the skin absorb slow due to physical makeup, medications placed on mucous membranes and respiratory airways are absorbed quickly because these tissues contain many blood vessels. IM is a fairly quick method of absorption. Oral administration absorption rates are slow because it passes through the GI tract. IV injection is the most rapid because it immediately enters the systemic circulation.

25
Q
  1. Know what to do when you question about a medication order 584-588
A

Go through the 6 rights, ask a colleague to check your work/calculations, always use critical thinking and be knowledgeable about the medication you are administering. Polly Molly Dolly rode the trolly. Patient, Meds, Dosage, Route, Time, Documentation, Why taking meds Do this check 3 times: before getting meds, at meds cabinet, at patient’s bedside

26
Q
  1. Differentiate between infiltration and phlebitis at an IV site 635
A

Infiltration occurs when an IV catheter becomes dislodged or a vein ruptures and the IV fluids inadvertently enter sub Q tissue around the venipuncture site. IV fluid can contain additives that damage the tissue, which causes extravasation. This causes coolness, paleness, and swelling of the area. Phlebitis is an inflammation of the vein, which results from chemical, mechanical, or bacterial causes. Risk factors include acidic or hypertonic IV solutions, rapid IV rate, certain IV drugs, poorly secured catheter, lack of aseptic technique, and poor hand hygiene. Signs of typical inflammation such as redness, heat, and tenderness form along the vein.

27
Q

Ex: Physician’s order for X oral suspension with concentration of 1 mg / 5 mL, need 80 mcg per kg of patient’s weight, patient is 155 lbs. Systolic blood pressure must be over 90 to give. How much mL of X to give.

A
28
Q
  1. Differentiate between Primary prevention / Secondary prevention / Tertiary prevention. 71
A

Primary: decrease the risk or exposure of the individual or community to disease. Applied to patients physically and emotionally healthy. Aimed at health promotion including health education program, immunizations, and physical and nutritional fitness activities. Includes both specific and general prevention.

Secondary: Identify individuals in an early stage of a disease process and to limit future disability. Activities directed at diagnosis and prompt intervention, in an effort to reduce severity and attempt to return patient to a normal level of health as early as possible. Secondary prevention methods include screenings, treatment of early stages of disease, and delaying consequences of advancing diseases.

Tertiary: Restoration and rehabilitation with the goal of returning the individual to an optimal level of functioning. Defect or disability is permanent and irreversible. Involves minimizing effects of long-term disease by preventing complications and complete deterioration. Activities directed at rehabilitation rather than diagnosis and treatment. Helps patient achieve highest level of functioning as possible.

29
Q

Treatment of Phlebitis

A

Promptly discontinue infusion & remove catheter
Restart infusion proximal to site or in other extremity

Apply warm moist compresses 3-4x/day or as prescribed
Culture site & catheter if drainage present

30
Q

Signs and symptoms of Phlebitis

A

throbbing, burning or pain at site; increased skin temp.; erythema; red line up arm with palpable band at vein site; slowed infusion

31
Q

Prevention of Phlebitis

A

Rotate sites at least every 12hr
Avoid lower extremities
Use hand hygiene
Use surgical aseptic technique

IV cannula smaller than vein

avoid venipuncture over an area of flexion

Change IV (replace) q 48-96 hours (depends on policy)

32
Q

etravasation

A

Leakage; displacement. Related to infiltration where IV extravasation causes the meds go to the tissue instead on the vein

33
Q

Define Infiltration & causes

A

IV complication

The escape of fluid into the subQ tissue.
Dislodged needle
Penetrated vessel wall

34
Q

Swelling/pallor/coldness/pain around infusion site
Significant decrease in the flow rate

A

Sign and symptoms of infiltration

35
Q

Nursing Prevention of Infiltration

A

Flush IV (initially/periodically)
Stabilize IV
Regular assessment

36
Q

Phlebitis Complications

A

clot formation (thrombophlebitis); DVT

37
Q

for a patient who is active or restless, what is the best way to prevent phlebitis?

A

use an armboard or splint as needed on the arm of the IV site

38
Q

if thrombophlebitis occur

A

do not irrigate the IV catheter;

remove IV;

notify the physician;

restart IV in the opposite extremity

39
Q

If there is a seepage of IV fluid out of the vein and into the surrounding interstitial spaces, what are the don’ts of nursing intervention?

A

This is a rephrasing of the deinition of infiltration. If this occur, remove the IV immediately; elevate the extremity and apply compress (warm or cool depending on the IV solution that was infusing & the physician’s prescriotion) over the affected area.

40
Q

Check medication order before adm during…

A

1.) before removing the container from the drawer or shelf; 2.) as the amount of medsis removed from the container; 3.) at the patient’s bedside before administering the meds to the patient (585)

41
Q

MAR (Potter 585)

A

Medication Administration Record

42
Q

Medications need to keep in their original labeled containers, separate from other medications, to avoid confusion. (Potter 585)

***note that hospitals rather have nurses administer medications to avoid double dosage by patients

A

For patients with self-administering medications

43
Q

Patient refused narcotics (Potter 585)

A

nurse must follow hospital procedure by having a witness of the “wasted” medication

44
Q

patient questions medications (Potter 585)

A

do not ignore concern

withold the medication

recheck from the prescriber’s order

45
Q

medications can be saved after being refused by the patient if (Potter 585)

A

the medication is not opened

46
Q

If a patient refuses a medication, immediately (Potter 585)

a. ) return it to the container
b. ) leave the medication until the patient swallows it
c. ) discard the medication as hospital procedure
d. ) call the physician and document

A

c.) discard the medication as hospital procedure

47
Q

In performing the right dose which of the following that needs further nurse training? (Potter 585)

a. ) have another qualified nurse check the calculated doses to assure accuracy
b. ) use teaspoons and tablespoons as alternative measurement for home bound patients
c. ) completely clean a crushing device before crushing the tablet
d. ) refer to the “Do not crush list” for medications that are needed tobe absorbed slowly by the body

A

b.) use teaspoons and tablespoons as an alternative measurement for home bound patients

Rationale:

“use kitchen measuring spoons rather than household teaspoons and tablespoons, which vary in volume”

48
Q

One of them is an identifier that hasn higher risk of a medication error (Potter 585)

a. ) telephone numebr
b. ) patient’s hospital number
c. ) name of the patient
d. ) room number

A

d.) room number

49
Q

WRONG Medication Routes (Potter 586)

A

liquid oral meds via parenteral routes;

same syringes for enteral and parenteral routes (usually their syringes are incompatible to each other);

caps still in the oral syringe in administering the meds (can cause aspiration - choking)

50
Q

AC (Skills Lab)

A

before meals

51
Q

PC (Potter 586)

A

after meals

52
Q

tid (Skills Lab)

A

three times daily

53
Q

qd

A

every day

54
Q

q2h (Skills Lab)

A

every 2 hours

55
Q

hs (skills lab)

A

hours of sleep

56
Q

STAT (Potter 586)

A

immediately

57
Q

time critical tolerance (minutes) Potter 586

A

+ or - 30 of scheduled time

58
Q

non time critical medications tolerance (minutes)

A

between + or - 1 hour to

+ or - 2 hours of their sacheduled time (as per agency policy)

59
Q

prn (Potter 586)

A

as needed

60
Q

Prescription Medication cosists of the right… (Lecture

A

Name of client
Date and time of order
Name of medication
Dosage
Route of administration
Time and frequency
Length of time of the order (keep track of the order)
Signature of provider (when transcribed, noted by)
Some abbreviations used

61
Q

Incomplete/unclear info/order of MAR (Potter 587)

A

call the health care provider before adminsitering medication

or if not the nurse, check agency policy of “chain of command” e.g. nurse superviser or superiors to call responsible agency … until the the issues are resolved

62
Q

Nurses’ six rights for Safe Medication Administration (Potter 587)

A

1 The right to a complete and clearly written order

2 The right to have the correct drug route and dose dispensed

3 The right to have access to information

4 The right to have policies on medication administration

5 The right to administer medications safely and identify problems in the system

6 The right to stop, think, and be vigilant when administering medications

From Cook MC: Nurses’ six rights for safe medication administration, Mass Nurse 69(6):8, 1999.

63
Q

Document of Medications (Potter 587)

A

Medications that you have given a medication AFTER you have actually given it.

The name of the medication, the dose, the time of administration, and the route all need to be documented on the MAR.

Also document the site of any injections and the patient’s responses to medications, either positive or negative.

Nurses notify the patient’s health care provider of any negative responses to medications and document the time, date, and name of the health care provider that was notified in the patient’s medical record