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PN Theory 1 > Test 2 > Flashcards

Test 2 Flashcards

(60 cards)

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1
Q

How does the Need of Safety relate with regards to health promotion?

A
  1. Patient should be in a safe environment
  2. Patient should have a lifestyle that doesn’t risk injury
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2
Q

How does patient safety relate to quality of care?

A

-effective
-safe
-people centred

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3
Q

What is a patient safety incident?

What is a harmful incident?

What is a near miss incident?

What is a no-harm incident?

A

Safety incident - event that could or did harm the patient

Harmful incident - client got harmed

Near miss - harm did not reach patient

No harm incident- incident reached patient but no harm was done

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4
Q

What are nosocomial infections?

A

Infections the patient got from the healthcare facility

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5
Q

What are the changes associated with aging that increases the risk of accidents?

A

Change in vision and hearing
Slow reaction times
Decreased range of motion and strength

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6
Q

What should the nurse use when doing a safety assessment? (4)

A
  1. Knowledge
  2. Standards
  3. Experience
  4. Qualities (response, unbiased, etc.)
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7
Q

What are some interventions to maintain a safe home or healthcare environment?

A

-proper lighting
-no trip hazards
-hand rails in the bathroom
-hand hygene

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8
Q
  1. Discuss the need for collaboration with clients to identify specific health needs/goals that relates to safety
A

patients should have understanding of potential risk factors in their environment

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9
Q

What are the Fall Risk Assessment Tools used?
Schmid
Hendrich II
Timed Up and Go (TUG))

A

schmid - fall risk assessment score

Hendrich - fall assessment tool showing how different factors can increase the chance of falls such as mobility and medication (swiss cheese model)

TUG - Timed Up and Go”
-the person is timed as they get up from a chair, walk 3 meters, and return to the chair

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10
Q

What is the nurse’s role in case of fire?

What does RACE stand for?

A

Identify risks (cigarettes, equipment, etc.)
Know safety regulations

Rescue
Alarm
Contain fire
Extinguish

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11
Q

What are the different types of restraints?

When would we use restraints?

What are some legal considerations with restraints?

What are some alternatives to restraints?

A

Physical, environmental, chemical

To physically or behaviourally control the patient

It should be the last option used
Patients freedom, consent, and emergencys should be considered
Follow least amount of restraint necessary for least amount of time

Alternatives:
Distracting the patient
One-on-one nursing
Walking them somewhere
Get family to sit and visit them

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12
Q

What is the chain of infection? (6)

A
  • An infectious agent (pathogen)
  • A reservoir (source for pathogen growth)
  • A portal of exit from the reservoir
  • A mode of transmission
  • A portal of entry to a host
  • A susceptible host
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13
Q

What are the body’s defense mechanisms against
infections?

A
  1. Normal body flora
  2. Organ systems fight against microorganisms
  3. Immune response
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14
Q

What is local infection?

What is systemic infection?

What is behavioural risk factors?

A

If infection is in one area (e.g., a wound infection)

An infection that affects the entire body instead of just a single organ

Behavioral risk factors include
smoking, poor nutrition, and physical inactivity

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15
Q

What are normal ranges for body temperature across the lifespan?

What are some factors affecting body temperature?

A

Newborns 36.5-37.6 C
Regular 36-38 C
Older Adult - 36 C

Age
Exercise
Hormones
Circadian Rhythm
Stress
Environment
Fever

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16
Q

What is the difference between medical and surgical asepsis?

A

Medical asepsis - clean technique stops the spread of microorganisms (washing hands, etc)

Surgical asepsis -Sterile technique eliminate all microorganisms (wearing sterile gown and gloves)

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17
Q

What can nurses target to control infection specifically in older adults?

A

-immune system response
-skin breakdown
-falls

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18
Q

How does activity an exercise affect the musculoskeletal system and nervous systems?

A

Mobility depends on the nervous and musculoskeletal system

together they maintain body alignment, posture, and movement

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19
Q

Define activity

Define exercise

Define activity tolerance/ intolerance

Define mobility and immobility

A

Activity - any movement requiring energy

Exercise - planned, structured, repetitive

Activity Tolerance/ intolerance - ability to perform activites without getting tired

Mobility/ Immobility - ability to move free and easy

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20
Q

What happens to body
systems when a person experiences immobility?

A

Disease atrophy occurs where cells and tissues decrease in size and function

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21
Q

How can you use proper body mechanics and ergonomics to prevent injuries to the client and nurse?

A

-bed should be raised
-use your legs to lift not your back
-maintain body alignment and posture

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22
Q

What is active and passive range of motion (ROM)?

How do each benefit the client?

A

Active ROM - Client moves their own joints

Passive ROM - you move the patients joints for them

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23
Q

Describe frailty

What is the Frailty Scale range? (7)

A

Frailty - weak and delicate

Scale ranges from:
#1 Very Fit - active, energetic
#2 Well – no active disease but less fit
#3 Well with treated disease – has controlled symptoms
#4 Vulnerable – complains of being slowed down
#5 Mildly Frail – limited dependence on others
#6 Moderately Frail – needs help with Activities
#7 Severely Frail – completely dependent on others

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24
Q

Activity and exercise assessment questions should include:

A

Nature of the problem
Signs and symptoms
Onset and duration
Severity
Barriers to exercise
Patient values
Effect on patient

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25
What are some nursing diagnosis related to activity and exercise?
-activity intolerance -impared physical mobility
26
What 4 components are fundamental to mobility and exercise? BBCJ
1. Body Alignment & Posture 2. Balance (stability) 3. Coordinated Movement 4. Joint mobility
27
What are the different types/categories of exercises and what are the benefits of each? (4)
Isotonic - contracting muscles (walking, swimming, bicycling) Isometric - tensing without moving (sitting) Resistive Isometric - increase in resistance and time (planks) Aerobic - stretching and strength training to bring more oxygen in system
28
What risk factors contribute to pressure injury formation?
-Unable to change position -friction and shear -malnutrition -age
29
What needs should you identify about your client when assessing their hygene practices?
-Health promotion practices and needs -Emotional needs -Health care education needs
30
What is the Braden scale used for? What kind of scores are higher risk?
The Braden Scale - bed sores Lower scores = higher risk
31
Identify strategies to provide safe oral hygiene to an unconscious client and a client with cognitive impairment
Unconcious client: turn them on side Use padded tongue blade Cognitive impairment: Talk them through it
32
What are some body image changes that affect self concept? What are some role changes that could affect self concept?
Body image changes: puberty menopause aging physical decline Role changes: child parent student employee
33
What can be done in the assessment of a patient to find out their self concept?
- Interview Questions - Observing behaviours -any stressors to self concept - Coping patterns - Significant Other (Family) Observations - Client’s Expectation
34
What are some signs you have a healthy self concept?
-You can adapt to challenges -Better cope with illness -Can deal with stressful situations -Choose healthy behaviours for themselves
35
How can you evaluate the effectiveness of your interventions on a clients self concept?
Questions to ask & what to observe to see : ✓ If goals met, not met or partially met ✓ If nursing orders effective ✓ If nursing diagnosis still needed
36
What is the Need of Oxygenation?
Cells need oxygen
37
What 4 factors affect oxygenation the most?
Lifestyle - exercise, occupation, smoking, diet Environment - altitude, temperature, and pollution affects oxygenation. Physiological - body changes (pregnancy, obesity) Developmental - age related changes (babys have smaller airways)
38
When is comes to oxygenation, what should be in the clients heath history? How should you physically examine them for oxygenation?
Health History – should focus on the client's ability to meet O2 demand Physical Examination: Position – upright -> greater lung expansion Blood Pressure – in both arms, norms should be within 10mmHg of each other Pulse – comparison for strength & if equal, also check for rate, rhythm & quality Skin warmth or coolness – indicates circulation Edema – with decreased blood return Feet – check for coolness, weak pulses or shiny skin or pitting edema
39
What is the range for respiratory rate? What is the range for pulse oximetry? What is the range for pulse? What is the range for blood pressure in systolic and diastolic?
Respiratory Rate - 12-20 breaths per minute Pulse Oximetry - 95-100% Pulse (Heart Rate, HR) - 60-100 bpm Blood Pressure (BP): Systolic: 95-145mmHg Diastolic: 60-90 mmHg
40
How can you improve someone’s oxygenation?
-exercise -quit smoking -quit drugs and alcohol -less stress -leave polluted environments
41
What should you assess in a patient when looking for oxygenation issues?
History of client Physical symptoms Smoking Lab tests on patient
42
What is self concept? What is self esteem?
How a person thinks of themselves It is subjective and a mixture of concious and unconcious thoughts, attitudes, and perceptions of themselves Self esteem - our self worth
43
What are stressors affecting self concept?
-identity stressors (change in physical appearance) -Body Image Stressors i.e. loss of body parts or function -Self Esteem Stressors i.e. lack of positive feedback, repeated failures -Role Performance Stressors
44
What is the family’s effect on the development of self-concept?
-Children develop a basic sense of who they are from their caregivers -Parents who respond in a firm, consistent, and warm manner promote positive self esteem
45
How can a nurse help to support or strengthen a person’s self-concept?
- stress positive thinking rather than negative - identify & reinforce client’s strengths - acknowledging goals met - provide honest & positive feedback
46
What 4 things make up a persons self concept?
Identity - involves the internal sense of individuality Body image - is the perception we have of our bodies, including size, appearance, and functioning Role performance - is the way in which individuals perceive their ability to carry out significant roles. Common roles include parent, child, spouse, employee, and student Self esteem - global and specific
47
How can you check on someone’s hygiene and skin integrity after providing nursing interventions?
-Reassess the condition of the patient’s skin, hair, nails. and oral cavity -Patient’s comfort and hygiene have improved -patient can demonstrate self-care practices -patients expectations are met
48
Activity and exercise physical assessments should include:
Pain Expectations Body Alignment Gait ROM Capabilities & Limitations Muscle Strength Response Tolerance Mobility
49
What are the two most common causes of death in older persons?
Cancer Heart disease
50
True or false: hygiene care is never routine
True
51
True or false: when planning goals for the client they need to be specific
True
52
True or false: self concept develops throughout the lifetime
True
53
What influences someone’s self concept?
Parents Culture Social interactions Age Gender
54
What are the two types of self esteem?
Global - how you see yourself as a whole Specific - specific parts of yourself (ex: cooking skills)
55
When planning goals related to the patients self concept the nurse should try to enhance:
self esteem Body image Identity Body image
56
What are the three steps in the process of oxygenation?
1. Ventilation (gas in and out of lungs) 2. Perfusion (heart pumps oxygen to tissues) 3. Diffusion (gases go from high to low concentration)
57
Which two systems does oxygenation include?
Respiratory Cardiovascular
58
When priority setting for a patient, what is the most important goal?
Safety (Maslows hierarchy)
59
What factors affect activity and exercise? (4) BCDE
1. Behavioural (knowledge of a&e) 2. Cultural influences (fasting) 3. Developmental changes (kid becoming a teenager) 4. Environmental issues (work)
60
What is the difference between an actual NANDA diagnosis and a risk diagnosis?
Actual: NANDA (problem) + factors + evidence Risk: NANDA (problem) + factors *no evidence because problem doesn’t exist yet

PN Theory 1 (8 decks)

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