Week 1-7

Question 1

What factors influence growth and development?

Answer 1

Genetic, temperament,

family, nutrition,

environment, health, culture

Question 2

How do genetic factors influence GD?

Answer 2

genetic factors are hereditary blueprints made when male speak fertilises female ovum

Both sperm and ovum contain 23 chromosomes and combine to form zygote with 46 chromosomes

Genetic material is passed in equal proportions from father and mother

Question 3

How does temperament influence g and d ?

Answer 3

A child’s temperament will affect its behavior

•Of course outside influences impact on a developing fetus

Eg. If the mother smokes, drinks alcohol and takes illicit drugs this will have a profound effect on the baby.

..FASD Fetal alcohol syndrome is shown to have detrimental effects on the growing fetus which effects the child’s health and development throughout the lifespan.

Question 4

What is a temperment?

Answer 4

The temperament is formed in the child’s biology

• It is a set of inborn traits which gives the child its distinctive personality
• Thomas Chess & Birch 1970 coined three temperament types
• Easy , Slow to warm up and difficult  

Question 5

How does family influence growth and development?

Answer 5

When we look at socioeconomic status we clearly see that a child whose parents are lower on the socioeconomic gradient have more health problems and likely to die earlier in life than someone who is high on this gradient

Question 6

How does nutrition influence g and d?

Answer 6

What we eat and drink determines whether we will have a healthy life or not

Type 11 diabetes is a significant health problem across the world

If a mother has a very healthy diet eg fruit and vegetables protein and carbohydrates in balance the baby is going to born healthier and likely to keep to that style of eating

Question 7

How does the environment influence g and d?

Answer 7

Where you live will have a significant impact on your health

We know from Aboriginal Health that people who live remotely will die 11years earlier than their Australian counterparts

IF someone lives remotely in Africa and is drinking poor quality water they are more likely to die sooner than someone who is living in a wealthy city.

Question 8

How does health influence g &d

Answer 8

People who are born to families that have genetically induced cancers and other genetic diseases are more likely to contract those diseases than someone else who is not.

Health is also determined by environment and lifestyle

Someone born in Somalia to poor parents are likely to die earlier than someone born in UK to well off parents

Question 9

How does culture influence g and d

Answer 9

Culture has a huge impact on growth and development.

Language is one of the many ways through which culture affects development.

Parents in different cultures also play an important role in moulding children’s behaviour and thinking patterns.

Cultural differences in interactions between adults and children also influence how a child behaves socially

Question 10

Why is effective communication important

Answer 10

it’s critical to gathering assessment data for nursing diagnoses, to developing understandings of the person receiving care, to instructing and cooperating in care delivery, to teaching, to expressions of caring and com- fort and to collaboration with health colleagues.

Question 11

What makes verbal communication more effective?

Answer 11

effective when the criteria of pace, intonation, simplicity, clarity, brevity, timing, relevance, adaptability and credibility

Question 12

What does non verbal communication do

Answer 12

often reveals more about a person’s thoughts and feelings than verbal communication; it includes personal appearance, posture and gait, facial expressions and gestures.

Question 13

How do you know if communication between 2 has been effective

Answer 13

receiver and sender accurately perceive the meaning of each other’s message.

Question 14

When assessing verbal and non verbal behaviours should a nurse be aware of culture?

Answer 14

Yes. the nurse needs to consider cultural influences and be aware that a single non-verbal expression can indicate any of a variety of feelings and that words can have various meanings.

Question 15

Factors that influence the communication process?

Answer 15

development, gender, culture, values and perceptions, personal space (intimate, personal, social and public distance), territoriality, roles and relationships, environment, congruence and interpersonal attitudes.

Question 16

Techniques that facilitate therapeutic communication?

Answer 16

expressing empathy, prompting, instructing, using silence, probing—using open and closed questions, using touch, restating or paraphrasing, seeking clarification, perception checking or seeking consensual validation, offering self, providing information, encouraging, focusing, reflecting, summarising, confronting and self-disclosure.

Question 17

Techniques that hinder communication

Answer 17

stereotyping, being defensive, testing, rejecting, false reassurance, passing judgement, arguing, patronising, agreeing and dis- agreeing, excessive questioning and giving common advice.

Question 18

4 phases of therapeutic relationship?

Answer 18

pre- interaction phase, the introductory phase, the working phase and the termination phase; each has a specific goal and tasks, with each phase requiring specific skills of the nurse.

Question 19

What to do when a patient experiences deficit in their communication?

Answer 19

careful nursing assessment is needed to identify the deficit and to implement appropriate nursing actions to restore nurse–patient communication.

Question 20

Ways a nurse can help with communication problems?

Answer 20

To help people with communication problems, the nurse manipulates the environment, provides support, employs measures to enhance communication and educates the per- son and support people.

Question 21

How may nurses evaluate their own communication?

Answer 21

• Mentor feedback is used by nurses to evaluate their own communication. Nurses can review both the process and the content of the communication and identify both communication strengths and areas for improvement.

Question 22

Aim of handover?

Answer 22

Its aim is to hand over responsibility for the care of the person to the next nurse/shift and to ensure a safe continuity of care. Use of acronyms such as ISBAR are effective tools in promoting clear communication and maintaining care safety

Question 23

What does assertive communication do

Answer 23

promotes care safety by minimis- ing miscommunication with colleagues. An important char- acteristic of assertive communication is the use of ‘I’ statements.

Question 24

What does non assertive communication do?

Answer 24

includes two types of inter- personal behaviours: submissive and aggressive.

Question 25

What are some members of the interprofessional healthcare team?

Answer 25

``` Student – nursing or midwifery RN EN Midwife NP Healthcare worker Unregulated carer Patient care attendent Technician Medical personnel Pharmacist Social worker Dietitian Psychologist Podiatrist Occupational therapist Speech pathologist Counsellor physiotherapist ```

Question 26

What is a healthcare worker

Answer 26

Various roles undertaken by ealthcare workers. They may function independently or in collaboration wit the interdisciplinary healthcare team. eg. Aboriginal or maori healthcare worker, physioterapy assistant or dietary assitant

Question 27

What is an unregulated worker

Answer 27

A variety of roles exist for people who care for patients without licencing requiremmens . They may undertake activities delegated by the RN or idwife according to their competence eg. Carer, personal care assistants and AINs

Question 28

What is a medical personnel

Answer 28

Several levels of medical personeel. Eg. Resident medical officers like interns, resident medical officers, registars, senior registars also are consultancy medical officers

Question 29

What is a podiatrist

Answer 29

Practitioner of podiatry(chiropody) who deals with the conditions of the feet and their ailments.

Question 30

What is a patient care attendant?

Answer 30

People employed by a facility to support the care requireents of patients. They mmay have functions that involve oving or positioning patients or equipment , attending to the personal needs of patientsor disposing of soiled equipment.

Question 31

What is a technician?

Answer 31

People who work with specialised equipment Eg. Anaesthetic technicians and sterile supply technicians

Question 32

What is an OT

Answer 32

Encourage rehabilitation through performing activities of daily living

Question 33

Factors that can undermine inter-professional communication and collaborative practice

Answer 33

■ Disruptive behaviours and lack of interprofessional respect ■ Passive–aggressive behaviours exerted by health professionals who consider themselves to be disempowered ■ Feeling of ‘being taken for granted’ with work and roles not understood or valued by other team members ■ Different focus and orientation for different professions; for example, ‘care’ as opposed to ‘cure’ ■ Gender differences and power differentials; for example, nursing and allied health being mainly female professions ■ Nurses (and others) unwilling to ‘rock the boat’ by challenging authority ■ The diverse and ever increasing array of health professions, specialities and subcultures, each with its own terminology and norms ■ Different professions training separately leading to misunderstandings and miscommunication.

Question 34

attributes of effective team members?

Answer 34

■ Committedtothegoalsandvaluesoftheteam;forexam- ple, continuum of care for people discharged from the ward. ■ Effective communication skills, including team communication. ■ Enjoy working collaboratively and collectively with others. ■ Use cooperative rather than competitive approaches. ■ Willingly communicate openly with team members. ■ Listen actively to others. ■ Suspend judgment and consider the views of others with- out personal bias. ■ Trust and respect colleagues, team members and them- selves. ■ Expertise that complements team-member expertise. ■ Readiness to applaud the work of others.

Question 35

Features of effective groups/ teams

Answer 35

``` Atmosphere Purpose Leadership and member participation Communication Decision making Cohesion Conflict tolerance Power Problem solving Creativity ```

Question 36

What type of care do nurses provide?

Answer 36

person centered care

Question 37

What forms the family structure

Answer 37

The individual

Question 38

What does assessing family structure allow?

Answer 38

Assessing the family structure enables you to plan your (family centred) care

Question 39

What are the different family unit designs?

Answer 39

``` Traditional family •Nuclear family •Extended family •Dual career family •Single parent family •Adolescent family •Foster family •Blended family •Intragenerational family (matriach/patriach) •Cohabitating family •Gay & lesbian family •Single adults ```

Question 40

So what are we assessing when we are assessing families?

Answer 40

* Family function (or …) * Family interaction/ communication * Family strengths and weaknesses * Health status of family members ``` •Communication styles •Child rearing styles •Health practices and health beliefs Family coping mechanisms Risk of health problems Maturity/ age/ hereditary/ ethnic/ sociological Lifestyle ``` •Literacy/numeracy/education standard

Question 41

What is family structure?

Answer 41

Size and type of family | Age and genders of members

Question 42

What to consider in family roles and functions during assessment?

Answer 42

- Family members working outside the home - household roles and responsibilities + distribution - sharing of child rearing responsibilities - major decision maker and methods of decision making

Question 43

What to consider about physical health status during family assessment?

Answer 43

- current physical health status of each member - perceptions of own and other family members health - preventative health practices ( Eg. Status of immunisations, oral hygiene practices) - routine healthcare, when and why physician last seen

Question 44

What to consider about interaction patterns in family assesment?

Answer 44

- ways of expressing affection, love, sorrow, anger and so on - most significant family member in persons life - openness of communication with all family members

Question 45

What to consider about family values during family assessment?

Answer 45

- cultural and religious orientations; degree to which cultural practices are followed - use of leisure time and whether leisure time is shared with total of family unit - family views of education, teachers and the school system - health values: how much emphasis is put on exersise, diet, preventative health care

Question 46

What to consider about coping resources during family assessment?

Answer 46

- degree of emeotional support offered to one another - availability of support persons and affiliations outside the family ( Eg. Friends, church membership) - sources of stress - methods of handling stressful situations and conflicting goals of family members

Question 47

What is a Genogram

Answer 47

maps out visually gender and lines of birth descent through generations

Question 48

Factors determining the impact of illness on the family?

Answer 48

reatening. ■ The duration of the illness, which ranges from short term to long term. ■ The residual effects of the illness, including none to perma- nent disability. ■ The meaning of the illness to the family and its significance to family systems. ■ The financial impact of the illness, which is influenced by factors such as loss of income and ability of the ill member to return to work. ■ The effect of the illness on future family functioning (e.g. previous patterns may be restored or new patterns may be established).

Question 49

Why are cultural considerations important in Family health assessment?

Answer 49

Cultural safety is effective nursing practice as judged by the person being cared for. •NOTE that this is not just about a person’s race but gender identity/age

Question 50

What are some cultural assessment considerations?

Answer 50

- consider and be respectful of cultural traditions and how important they are - consider spiritual and religious rituals - communication and language ( verbal and non verbal - cultural health practices - view of health and illness - cultural family roles and definitions

Question 51

Intellectual disability ettiquitte is important in family health assessment because?

Answer 51

Etiquette •Offer assistance to a person with a disability if you feel it is appropriate but wait for an answer before you help. •Treat adults like adults. Do not use gestures more suitable for children. •Do not refer to an adult as “cute” or “adorable”. •If someone is a wheelchair user, do not lean on their chair. •Make appropriate physical contact with people with disabilities according to the situation, the same as anyone else.

Question 52

What defines a disability

Answer 52

•The Disability Discrimination Act 1992 (Cth) defines disability as: “ Total or partial loss of the person’s bodily or mental functions •Total or partial loss of a part of the body the presence in the body of organisms causing disease or illness •The malfunction, malformation or disfigurement of a part of the person’s body •A disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction •A disorder, illness or disease that affects a person’s thought processes, perception of reality, emotions or judgment, or that results in disturbed behavior; and includes disability that: •presently exists •previously existed but no longer exists •may exist in the future •is imputed to a person (meaning it is thought or implied that the person has disability but does not).

Question 53

Types of disabilities

Answer 53

* Physical - affects a person's mobility or dexterity * Intellectual - affects a person's abilities to learn * Mental Illness - affects a person's thinking processes * Sensory - affects a person's ability to hear or see * Neurological – affects the person’s brain and central nervous system, * Learning disability * Physical disfigurement or * Immunological - the presence of organisms causing disease in the body

Question 54

What is a physical disability and what is the nursing relevance?

Answer 54

All types and degrees of physical disability •Extend from a person with a broken arm who cannot work •To a person with a permanent spinal injury •To a older person with a hip fracture who cannot go home * Nursing relevance * Sit and listen * Refer to resources

Question 55

What is NDIS?

Answer 55

National Disability Insurance Scheme •This service helps to support families and patients living with a disability •Each service provider will register with NDIS and can deliver the services they offer to the patient •The patient and the family are able to choose from the many service providers who they want to deliver the care •This gives patients more control over what services they are able to have and who delivers those services •Being a nurse in disabilities services is a very rewarding and satisfying career.

Question 56

What is the nursing process?

Answer 56

``` A 5 step framework to formulate care plans to provide individualized nursing care •Assessment •Diagnosis (Nursing) •Planning •Implementation •Evaluation ``` •A•D•P•I•E

Question 57

What is the Assessing part of the nursing process?

Answer 57

Collecting, organising, validating and documenting data to establish a database about the persons response to health concerns or illness and the ability to manage health care needs

Question 58

Activities peformed during assessing stage of the nursing process

Answer 58

Establishing a database... - obtaining health history - conduct physical assessment - review persons record - review nursing literature - consult support persons - consult health professionals - updates organise validate and document data

Question 59

What is the diagnosing stage of the nursing process?

Answer 59

Analysing and synthesising data to identify the persons strengths and health problems that may be prevented or resolved by collaborative and independent nursing interventions. Developing a list of nursing and collaborative problems.

Question 60

What activities are peformed during the diagnosing stage of the nursing process ?

Answer 60

- compare data against stabndards - cluster or group data ( generate tentative hypotheses) - identify gaps and inconsistencies - determine persons strengths, risks, diagnoses and problems. - formulate nursing diagnoses and collaborative problem statements. - document nursing diagnoses on the care plan

Question 61

What is the planning stage of the nursing process

Answer 61

Determining how to prevent, reduce or resolve the identified priority patient problems; how to support people’s strengths ; and how to implement nursing interventions in an organised, individualised and goal directed manner to develop an individualised care plan that specifies goals/ desired outcomes, and nursing related interventions

Question 62

What activities are carried out during the planning stage of the nursing process?

Answer 62

- set priorities and goals/ outcomes in collaboration with the person. - write goals/ desired outcomes - select nursing strategies/ interventions - consult other health professionals - write nursing interventions and nursing care plan - communicate care plans to relevant health care providers

Question 63

What is the implementing stage of the nursing process?

Answer 63

Carrying out ( or delegating) and documenting the planned nursing interventions to assist the person to meet desired goals/ outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

Question 64

What activities happen during the implementing stage of the nursing process?

Answer 64

- reassess the person to update the database. - determine the nurses need for assistance - peform planned nursing interventions - communicate what nursing actions were implemented - document care and response to care - give verbal report as necessary

Question 65

What is the evaluating stage of the nursing process?

Answer 65

Measuring the degree to which goals/ outcomes have been achieved and identifying factors that positively or negatively influence goal achievement in order to determine whether to continue, modify or terminate the plan of care

Question 66

What activities are done in the evaluating stage of the nursing process?

Answer 66

- collaborate with the person and collect data related to desired outcomes - Judge whether goals achieved - relate nursing actions to patient outcomes - make decisions about problem status - review and modify the care plan as indicated or terminate nursing care - document achieving or outcomes and modifications of care plan

Question 67

What stages of the nursing process Is critical thinking used + examples

Answer 67

All stages A- making reliable observations, distinguishing relevant and irrelevant data and important from unimportant data D- finding patterns and relationships among cues, making inferences, suspending judgement when lacking data and stating the problem P- forming valid generalisations, transferring knowledge from one situation to another, developing evaluative criteria I- applying knowledge to peform, interventions, testing hypotheses E- making criterion based evaluations, deciding whether hypotheses are correct

Question 68

What are the types of assessment

Answer 68

Initial assessment Problem focused Emergency Time lapsed

Question 69

What is the initial assessment?

Answer 69

Assessment performed within specified time after admission to establish a data base for the prob,em identification, reference and future comparison Eg. Nursing admission assessment

Question 70

What is a problem focused assessment?

Answer 70

Ongoing process integrated within nursing care to determine the status of a specific problem identified in an earlier assessment Eg. Hourly assessment of a persons fluid intake and urinary output in an ICU Assessment of the persons ability to peform self care while assisting them to shower

Question 71

What is an emergency assessment?

Answer 71

Assessment done during any physiological or psychosocial crisis of the person to identify life threatening problems or identify overlooked problems Eg. Rapid assessment of persons airway, breathing status and circulation during cardiac arrest. Assessment of suicidal tendencies or potential for violence

Question 72

What is a time lapsed assessment?

Answer 72

Assessment done several months after the initial assessment to compare the persons current status with the baseline data previously obtained Eg. Reassessment of a persons functional health patterns in a home care or outpatient setting, or in a hospital at shift change

Question 73

Components of a nursing health history?

Answer 73

- biographical data - chief complaint/ reason for visit - history of present illness - family history of illness - lifestyle - social data - psychological data - patterns of healthcare

Question 74

What is subjective data

Answer 74

Something the patient tells us Eg. I feel weak all over when I exert myself, I’m short of breath

Question 75

What is objective data

Answer 75

The testing you do that gives you a number or an answer.

Question 76

What is subjective data

Answer 76

what the patient tells us eg. i feel weak all over when i exert my body, i feel short of breath

Question 77

What is objective data

Answer 77

the testing you do that gives you a number or an answer eg. blood pressure

Question 78

how can you use senses to observe clinical data

Answer 78

vision- overall appearance ( eg. body size general weight, posture, grooming); signs of distress/ discomfort; facial and body gestures; skin colour and lesions; abnormalities of movement; non verbal demeanor (signs of anger or anxiety); religious of cultural artefacts (eg. books, icons, candles, beads) smell- body or breath odours hearing- lung and heart sounds; bowel sounds; ability to initiate conversation; ability to respond when spoken to; orientation to time, person and place; thoughts and feelings about self, other and health status touch- skin temperature and moisture; muscle strength (e.g. hand grip); pulse rate, rhythm and volume; palpatory lesions (e.g. lump, masses, nodules)

Question 79

Advantages of open ended questions

Answer 79

- let the interviewee do the talking - interviewer is able to listen and observe - they are easy to answer and non threatening - they reveal what the interviewee thinks is important - they may reveal the interviewees lack of information, misunderstanding of words, frame of reference, prejudices or stereotypes

Question 80

how to be culturally responsive in terms of personal space

Answer 80

- accepted distance btwn ppl in convos varies with cultural affiliation - men usually require more space than women - anxiety increases need for space - direct eye contact increases need for space - physical contact is used only if for therapeutic purpose

Question 81

advantages of closed questions

Answer 81

- questions and answers can be controlled more effectively - they may require less effort from the interviewee - they may be less threatening, since they do not require explanations or justifications - take less time - information can be asked for sooner than it would be volunteered

Question 82

disadvantages of closed questions

Answer 82

- they may provide too little information and require follow up questions - they may not reveal how the interviewee feels - they do not allow the interviewee to volunteer possibly valuable information - they may inhibit communication and convey lack of interest by the interviewer - the interviewer may dominate the interview with questions

Question 83

how to be culturally responsive in terms of personaal space

Answer 83

- accepted distance btwn ppl in convos varies with cultural affiliation - men usually require more space than women - anxiety increases need for space - direct eye contact increases need for space - physical contact is used only if for therapeutic purpose

Question 84

guidelines for validating assessment data

Answer 84

- compare subjective and objective data to verify the persons statements with your observations. - be sure your data consists of cues and not inferences - double check data that are extremely abnormal - determine the presence of factors that may interfere with accurate measurement - use references (textbook, journals, research reports) to explain phenomena

Question 85

Normal Respiratory Rate for Infants (<1 y)

Answer 85

30-53

Question 86

Normal Respiratory Rate for Toddlers (1-2 y)

Answer 86

22-37

Question 87

Normal Respiratory Rate for Preschoolers (3-5 y)

Answer 87

20-28

Question 88

Normal Respiratory Rate for School-aged children (6-11 y)

Answer 88

18-25

Question 89

Normal Respiratory Rate for Adolescent (12-15 y)

Answer 89

12-20

Question 90

Normal respiratory rate for Adults

Answer 90

12 to 20 breaths per minute

Question 91

What is a respiratory rate

Answer 91

A person's respiratory rate is the number of breaths you take per minute. The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

Question 92

Normal respiratory rates for older patients

Answer 92

12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care.

Question 93

what is Tachypnea

Answer 93

A respiratory rate of 20 breaths per minute (or more than 25 breaths per minute for someone in a nursing home) indicates tachypnea.

Question 94

Normal Pulse Rate for Neonates (<28 d)

Answer 94

Awake Rate: 100-165 | Sleeping Rate: 90-160

Question 95

Normal Pulse Rate for Infants (1 mo-1 y)

Answer 95

Awake Rate: 100-150 | Sleeping Rate: 90-160

Question 96

Normal Pulse Rate for Toddlers (1-2 y)

Answer 96

Awake Rate: 70-110 | Sleeping Rate: 80-120

Question 97

Normal Pulse Rate for Preschoolers (3-5 y)

Answer 97

Awake Rate: 65-110 | Sleeping Rate: 65-100

Question 98

what does a lower heart rate at rest imply?

Answer 98

Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness. For example, a well-trained athlete might have a normal resting heart rate closer to 40 beats a minute.

Question 99

Normal Pulse Rate for Adolescents (12-15 y)

Answer 99

Awake Rate: 55-85 | Sleeping Rate: 50-90

Question 100

A normal resting heart rate for adults

Answer 100

A normal resting heart rate for adults ranges from 60 to 100 beats a minute.

Question 101

Normal Temperature Range by different Methods

Answer 101

Method- Normal Range (oC) Rectal - 36.6-38 Ear- 35.8-38 Oral- 35.5-37.5 Axillary- 36.5-37.5

Question 102

When should we assess vital signs

Answer 102

- On admission to health care facility, to obtain baseline data and monitor patient improvement deterioration - When a person has a change in health status or report symptoms such as chest pain or feeling hot or faint - Before, during and after surgery or an invasive procedure - Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems - before and after any nursing intervention that could affect the vital signs e.g. ambulating a person who has been on bed rest on when a person is receiving a blood transfusion

Question 103

what happens during inspiration

Answer 103

- The diaphragm contracts and pulls downward while - -- Inter costal muscles contract and pull upward. increases the size of the thoracic cavity and decreases the pressure inside

Question 104

what happens during expiration

Answer 104

- The diaphragm relaxes, and the volume of the thoracic cavity decreases, while the pressure within it increases. As a result, the lungs contract and air is forced out.

Question 105

how to assess for breathlessness

Answer 105

- nasal flaring - anxious flailing - neck muscle tensing - cyanosis (bluish discoloration of the skin) - tracheal tug ( A downward pull of the trachea) - use of intercostal muscles- rib retraction - paradoxical breathing- abdomen rises

Question 106

what is tachypnoea

Answer 106

quick, shallow breaths

Question 107

what is bradypnoea

Answer 107

abnormally slow breathing

Question 108

what is apnoea

Answer 108

cessation of breathing

Question 109

what are the different rates of breathing

Answer 109

tachypnoea bradypnoea apnoea

Question 110

terms to describe different breathing sounds

Answer 110

stridor- a shrill, harsh sound heard during inspiration with laryngeal obstruction stertor- snoring or sonorous respiration, usually due to a partial obstruction of the upper airway wheeze- continuous, high pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway. bubbling- gurgling sounds heard as air passes through the moist secretions in the respiratory tract

Question 111

what are the different breathing rhythms

Answer 111

cheyne strokes breathing- waxing and waning of respiration's, from deep to very shallow breathing and temporary apnoea

Question 112

terms to describe different ease and effort of breathing

Answer 112

dyspnoea- difficult and laboured breathing during which there is a persistent, unsatisfied need for air and person feels distressed. orthopnoea- ability to breath only in an upright/ sitting or positions

Question 113

sites for taking pulse

Answer 113

``` temporal- side of head carotid- side of top of neck apical- at the apex of the heart. brachial- inside of arm at the elbow radial pulse- at the wrist femoral- inner thigh popliteal- back of the knee posterior tibial artery- near bony projection on the inside of each ankle dorsalis pedial- arch of the top of the foot between the first and second metatarsal bones ```

Question 114

what words describe the different chest movements

Answer 114

intercostal retraction-in drawing between the ribs substernal retraction- in drawing beneath the breastbone suprasternal retraction- in drawing above the clavicles

Question 115

what terms describe the different breathing secretions and coughs

Answer 115

haemoptysis- presence of blood in sternum productive cough-a cough accompanied by expectorated secretions non productive cough- dry harsh cough without secretions

Question 116

sites for taking pulse

Answer 116

radial pulse- at the wrist, used as it is readily accessible temporal- side of head, used when radial is not readily accessible carotid- side of top of neck, used during cardiac arrest/ shock in adults and to determine circulation to the brain apical- at the apex of the heart. routinely used for infants and children up to 3 yrs, to determine discrepancies with radial pulse, used in conjunction with some medications brachial- inside of arm at the elbow, used to measure blood pressure and during cardac arrest for children femoral- inner thigh, used in cardiac arrest and shock, used to determine circulation to a leg popliteal- back of the knee, used to determine circulation to the lower leg posterior tibial artery- near bony projection on the inside of each ankle, used to determine circulation to the leg dorsalis pedial- arch of the top of the foot between the first and second metatarsal bones, used t determine circulation o the foot

Question 117

Estimated ranges for body temperature during early morning / cold weather oral v rectal

Answer 117

below 36

Question 118

Estimated normal ranges for body temperature oral v rectal

Answer 118

oral- 36-37.5 | rectal-36-37.75

Question 119

Estimated ranges for body temperature when working hard, feeling empootional or for active kids oral v rectal

Answer 119

oral- 37.5-38.5 | rectal- 37.75-38.5

Question 120

Estimated ranges for body temperature during hard exersise rectal

Answer 120

rectal- 38.5-40

Question 121

what times of the day might oral temperature decrease

Answer 121

early mornings and during the night when we are asleep

Question 122

advantages and disadvantages of oral temperature

Answer 122

advantages - accessible, relatively inexpensive and convenient disadvantages - can break if bitten, inaccurate if ingested hot or cold food or has smoked, could injure mouth following oral surgery,

Question 123

advantages and disadvantages of rectum

Answer 123

advantages - reliable measurement disadvantages -inconvenient and more unpleasant, difficult for someone who cannot turn to side, could injure rectum following rectal surgery, presence of stool may affect thermometer placement- if soft the thermometer may be embedded in stool rater than against wall of rectum

Question 124

advantages and disadvantages of axilla temperature measurement

Answer 124

advantages - safe and non invasive disadvantages - thermometer must be left in place 3-5 min to obtain accurate measurement

Question 125

advantages and disadvantages of ear

Answer 125

advantages - readily accessible, reflects the core temperature, very fast disadvantages - can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far, repated measurements may vary - right and left esp if person has been lying on one side, presence of cerumen may affect the reading, impaired accuracy if not calibrated properly

Question 126

advantages and disadvantages of forehead

Answer 126

advantages -safe, non invasive, very fast disadvantages - requires electronic equipment that mmay be expensive or unavailable: variation in technique needed if the person has perspiration on the forehead

Question 127

oral thermometer placement

Answer 127

place bulb on either side of frenulum

Question 128

rectal thermometer placement

Answer 128

- apply clean gloves - instruct the person to take a slow deep breath during insertion - never force thermometer if resistance felt. insert 3.5 cm in adults

Question 129

axillary thermometer placement

Answer 129

- pat axilla dry if very moist | - the bulb is placed in the center of the axilla

Question 130

tympanic thermometer placement

Answer 130

- pill pinna slightly upwards and backwards, - point probe slightly anteriorly towards eardrum, - insert the probe slowly using circular otion until snug

Question 131

temporal artery thermometer placement

Answer 131

- brush hair aside if covering area. with probe flush on centre of the forehead, depress the red button; keep depressed. slowly slide the probe midline across the forehead to the hair line, not down the side of the face. - lift the probe from the forehead and touch on the neck just behind the ear lobe - release the button

Question 132

what is hypothermia

Answer 132

less than 36 degrees Hypothermia involves three mechanisms: excessive heat loss, inadequate heat production by body cells and increas- ing impairment of hypothalamic thermoregulation.

Question 133

what is the average body temperature

Answer 133

36-38 degrees

Question 134

what is pyrexia

Answer 134

raised body temperature; fever. 38-41 degrees

Question 135

what is hyperpyrexia

Answer 135

a very high fever. 41 degrees+

Question 136

3 clinical manifestations/ phases of fever

Answer 136

1) Chill (or cold) phase (onset of fever) - Increased heart rate (tachycardia) - Increased respiratory rate (tachypnoea) and depth - Shivering, Pale, cold skin, Complaints of feeling cold - Cyanotic nail beds, ’Goosebumps’ on the skin, Cessation of sweating. Plateau phase (course of fever) - Absence of chills - Skin that feels warm - Photosensitivity, Glassy-eyed appearance, Tachycardia and tachypnoea, Increased thirst (polydipsia), Mild to severe dehydration - Drowsiness, restlessness, delirium or convulsions - Herpetic lesions of the mouth (i.e. an ulceration of the skin) - Anorexia(persistentlossofappetite)ifthefeverisprolonged - Malaise, lethargy, weakness and aching muscles. Defervescence (or flush) phase (fever abatement) - Skin that appears flushed and feels warm - Sweating (diaphoresis) - Decreased shivering - Possible dehydration.

Question 137

What is heat stroke

Answer 137

When the body’s core temperature rises above 40.58C and its internal systems start to shut down. Heat stroke can be brought on by high environmental temperatures, strenuous physical activity or other conditions that raise a person’s body temperature.

Question 138

Symptoms and treatment of Heatstroke

Answer 138

``` very high body temperature ■ red, hot and dry skin ■ dry swollen tongue ■ rapid pulse, shallow, rapid breathing ■ throbbing headache ■ confusion or ‘strange’ behaviour ■ nausea ■ possible loss of consciousness ``` heat stroke is a life threatening emergency that requires immediate medical treatment to prevent brain damage, organ failure or death.

Question 139

What is heat stress

Answer 139

Heat stress occurs when the body becomes dehydrated and is unable to cool itself enough to maintain a healthy temperature. If left untreated, this can lead to heat stroke, which is a life-threatening medical emergency

Question 140

Children and infants with fever: acute management

Answer 140

- Axillary measurement of temperature is recommended for routine clinical use, but staff should be aware that axillary temperatures are up to 1oC lower than rectal temperatures. - All febrile neonates should have a full septic work-up and be admitted for parenteral antibiotics. -

Question 141

Nursing interventions for adults with fever

Answer 141

Monitor vital signs. ■ Assess skin colour and temperature. ■ Monitor white blood cell count, haematocrit value and other pertinent laboratory reports for indications of infec- tion or dehydration. ■ Remove excess blankets when the person feels warm, but provide extra warmth when the person feels chilled. ■ Provide adequate nutrition and fluids (e.g. 2500–3000 mL per day) to meet the increased metabolic demands and prevent dehydration. ■ Measure fluid intake and output. ■ Reduce physical activity to limit heat production, especially during the defervescent phase. ■ Administer antipyretics (medications that may reduce the signs and symptoms of fever, such as pain, discomfort and elevated body temperature) only as indicated or ordered. This intervention should be considered on the basis of maintaining the person’s level of comfort rather than simply reducing an elevated body temperature. ■ Provide oral hygiene to keep the mucous membranes moist. ■ Provide dry clothing and bed linen.

Question 142

Danger of being inside a locked motor vehicle

Answer 142

Locked motor vehicles are potential death traps, particularly during summer. The temperature inside a motor vehicle during the Australian summer can be 30–408C higher than the outside temperature. Therefore, on a 358C day the temperature inside a motor vehicle can be 65–758C.

Question 143

Clinical manifestations of hypothermia

Answer 143

``` ■ Decreased body temperature and decreased pulse and res- piration rates. ■ Severe shivering (initially). ■ Feelings of cold and chills. ■ Pale, cool, waxy skin. ■ Frostbite (nose, fingers, toes). ■ Hypotension. ■ Decreased urinary output (oliguria). ■ Lack of muscle coordination. ■ Disorientation. ■ Drowsiness progressing to coma. ```

Question 144

Nursing interventions for people with hypothermia

Answer 144

Provide a warm environment. ■ Remove wet clothing and provide dry clothing. ■ Apply warm blankets (a space blanket may also be used). ■ Keep limbs close to body. ■ Cover the person’s scalp with a cap or beanie. ■ Supply warm oral or intravenous fluids. ■ Apply warming pads.

Question 145

clinical manifestations during heat exhaustion

Answer 145

Moderately increased temperature (38.3–38.98C) Paleness Nausea and/or vomiting Dizziness Fainting

Question 146

what is data collection

Answer 146

Data collection is the systematic gathering of data about a patient’s health status.

Question 147

Why do we collect data on the patient?

Answer 147

..

Question 148

data collection basic process

Answer 148

process is basically the same: Patient is admitted The nurse introduces self Asks questions to complete paperwork (subjective data) Conducts vital signs/assesses patient (objective data) Documents and communicates information (as required)

Question 149

What does a pulse oximeter measure?

Answer 149

A pulse oximeter measures the percentage of haemoglobin saturated with oxygen. A normal result is 95% to 100%. may be placed on the finger, toe, nose, earlobe or forehead

Question 150

Factors affecting body temperature include

Answer 150

age, diurnal variations, exercise, hormones, stress and environmental temperatures.

Question 151

Four common types of fever are

Answer 151

intermittent, remittent, relapsing and constant.

Question 152

What happens during a fever

Answer 152

During a fever, the set point of the hypothalamic thermostat changes suddenly from the normal level to a higher than normal level, but several hours elapse before the core tem- perature reaches the new set point.

Question 153

what is documentataion

Answer 153

documentation is anything written or printed relating to the patient Ability to document & communicate competently is a competency requirement of a nurse Nursing documentation is a permanent part of a patient’s records. You are accountable for what you write (or neglect to write)!

Question 154

why is documentation important

Answer 154

Patient care is collaborative and multi team focused so accurate communication through documentation is essential Documentation reflects the quality of care you are giving (or not giving) We live in a litigious society, Documentation (medical and nursing records/”notes”) can be the single most important piece of evidence in legal action. Any of your “notes” could be called for years later in court

Question 155

Why is knowing about growth and development important to you as a nurse?​

Answer 155

Allows appropriate assessment & care planning​ The more you know about psychology and theories and the human mind and body the more knowledge you’ll have as a nurse when carrying out an appropriate assessment and plan your care for that person. Individuals are individuals. - gives us a framework to ‘organise’ humans - gives us what we can see and how we can track it - provides us a sound basis for any reactional actions

Question 156

What does growth relate to in theories of g & d?

Answer 156

Growth relates to physical changes & size increases | ◦Measured quantitatively/ objective data BUT important to think critically

Question 157

What does development relate to in g & d

Answer 157

Development relates to the capacity & skill progression ◦Relates to adaption to environment ◦Behavioural aspect of growth

Question 158

What are some principles of g and d

Answer 158

◦(normally) all follow similar pattern ◦Influenced by maturation/environment/genetics ◦Sequence predictable though individual ◦Certain stages more critical ◦Development starts of simply, becomes more complex

Question 159

Factors influencing G and D

Answer 159

``` ◦Genetic ◦Temperament ◦Family ◦Nutrition ◦Environment ◦Health ◦Culture ```

Question 160

G and D Theories

Answer 160

Biophysical ◦Gesell thought that we have a genetic time table. And though nurture and experience may give children a slight advantage in reaching milestones, the timetable is inborn. Genetic makeup tells you how quickly your going to develop and these milestones will occur anyway in your development Psychosocial ◦Personality development ◦Very many (Eg. Freud/Erikson) Cognitive ◦Thinking/reasoning/language development ◦Piaget thought that the brain develops and children’s experience expands and they move through 5 broad stages Five major phases: • Sensorimotor, Preconceptual, Intuitive, Concrete operations, Formal operations Behaviourism ◦Learning is affected by negative or positive reinforcement ◦Skinner thought that learnt and retained more quickly through consistent, positive reinforcement. Social learning theory -Individuals learn through observation and the behaviour of others -Bandura thought that Individual learns through imitation and practice; self-regulation, self-efficacy are important Ecological - Views the child as interacting with the environment at different levels or systems: • Microsystem, Mesosystem, Exosystem, Macrosystem, Chronosystem Moral theory Spiritual theory -Life meaning theory

Question 161

What may affect psychosocial development

Answer 161

Self concept

Question 162

What is ACE

Answer 162

Adverse childhood events The ACE study= “Adverse Childhood Exposure” This study was carried out in the late 1980s by Dr’s Vincent Feletti and Robert Anda by the center of Disease control It was looking at childhood experience and its impact on health It was completed on 17000 middle class Americans Looked at Category of childhood exposure (Psychological, Physical, Sexual), Household Dysfunction (Substance Abuse, Mental Illness, Mother treated violently , Criminal Behaviour in household ) Believe that you had to have at least four of the ACEs to have an impact on your health.

Question 163

How ACE impacts your health

Answer 163

``` 4+ ACEs more likely to develop... IHD/ heart attack Any Cancer Stroke COPD Diabetes The more ACE the person had the more likely to suffer from one of the above health problem ```

Question 164

Can intergenerational trauma be inherited

Answer 164

Maybe, 2nd generational holocaust survivors do inherent the gene of trauma but it’s still very controversial

Question 165

What are the 7 components of wellness

Answer 165

``` Physical Social Emotional Intellectual Spiritual Occupational ( safe work environment/ free from bullying) Environmental ``` We have to be well in all of these areas in order to say that we are well

Question 166

What is holism

Answer 166

(Greek) - holos - “whole” Holistic – meaning the “whole” Holistic nursing (care) – nursing (caring) for the whole person

Question 167

When you look at you patients what components of wellness are you looking at

Answer 167

``` Physical Spiritual Emotional Social Economic Psyche ``` The whole patient

Question 168

What may a back pain patient be suffering from? Other that the back pain

Answer 168

``` Role play issues Lack of understanding Spiritual distress Sexual issues Partner/carer issues Constipation Body image issues All these different aspects can affect a person’s health/disease worsen or sustain it. A person’s inner beliefs and convictions are powerful resources for healing & wellness ```

Question 169

How can you as a nurse help in all areas of wellness

Answer 169

physical - Essential nursing care/presence Spiritual- Presence/praying/meditating/ referring/respecting emotional- Presence/touch/listening Social- Listening/presence/referring economic- Listening/referring Psyche- Listening/touch/presence/referring

Question 170

What are the Health & Wellness Models

Answer 170

Clinical model The narrowest interpretation of health occurs in the clinical model. People are viewed as physiological systems with related functions and health is identified by the absence of signs and symptoms of disease or injury. The 4+ Model of Wellness consists of the four domains of the inner self—physical, spiritual, emotional and intellectual—plus the elements of the outer systems (environment, culture, nutrition, safety and many other elements).

Question 171

Variables that affect health & wellness

Answer 171

Biological -Genetics/gender/age/developmental level Psychological - Mind-body interaction - Self-concept Cognitive (intellectual) - Lifestyle (risky behaviours) - Spiritual External - environment/standard of living/ - culture/family/social support

Question 172

What are some health beliefs models

Answer 172

Locus of control- concept from social learning theory that nurses can use to determine whether individuals are likely to take action regarding health; that is, whether peo- ple believe that their health status is under their own or oth- ers’ control. People who believe that they have a major influence on their own health status—that health is largely self-determined—are called internals. R and B Health Belief model- is based on the assumption that health-related action depends on the simultaneous occur- rence of three factors: (1) sufficient motivation to make health issues be viewed as important, (2) belief that one is vulnerable to a serious health problem or its consequences, and (3) belief that following a particular health recommenda- tion would be beneficial.

Question 173

Factors influencing concordance

Answer 173

■ People’s motivation to become well. ■ Degree of lifestyle change necessary. ■ The use of treatments that are effective in circumstances when they are required. ■ Perceived severity of the health care problem. ■ Value placed on reducing the threat of illness. ■ Difficultyinunderstandingandperformingspecificbehaviours. ■ Degree of inconvenience of the illness itself or of the regimens. ■ Beliefs that the prescribed therapy or regimen will or will not help. ■ Complexity,sideeffectsanddurationoftheproposed therapy. ■ Specific cultural heritage that may make adherence difficult. ■ Degree of satisfaction and quality and type of relationship with the health care providers. ■ Overall cost of prescribed therapy. ■ The development of trust between the individual and the health professional (which limits embarrassment and pro- motes questions and the exercise of choice). ■ Impact of another unrelated illness or disease; for example, depression.

Question 174

What is illness like

Answer 174

It is Highly personal and individual Out of balance Behaviours Individual coping mechanism Influenced by age/gender/socio-economic standard/education/culture/personality/ self-concept

Question 175

What increases likelihood of health promoting behaviour

Answer 175

- modifying variables and perceived benefits and barriers - perceived seriousness, susceptibliy and threat - self efficacy - cues to action

Question 176

Why is Promoting health from conception through to adolescence important for nurses

Answer 176

Allows appropriate assessment & care planning The concepts and theories of G & D from last week Applied to neonates/infant/toddler/preschooler/school-age child/ Basically the age group 0 – 12 years

Question 177

Documentation guidelines

Answer 177

- don’t erase or white out errors, use straight line through mistake, write error and sign it - record all relevant info, factual info not guesses/ judgements - don’t leave blank spaces, if space is left- straight line - sign at end - document your own notes only - accurate, specific, clear info only - start with date and time, Finnish with signature, name and title for contemporaneous and accountable documentation - avoid generalised phrases, such as ‘ had a good day’ or ‘ no change in condition’ indicate more objectively what happened to the patient during the day - black pen, legible - check name on integrated progeress notes before writing in it - late enteries in intergrated progress notes are acceptable. It must be documented as such - students on progress notes at end follow facility guidelines sign....MUNS - accuracy, no unacceptable abbreviations , watch spelling and no slang

Question 178

What type of clock is used in nursing

Answer 178

24hr Clock

Question 179

Most common ways to document patient progress notes

Answer 179

1. ISOBAR •Now WA Health Dept. policy for communication of all types •2. Narrative Traditional, story like/Can be repetitious and time consuming for the reader to find information/still likely to be used in several care facilities •3. SOAP(IE)

Question 180

Explain acronym ISOBAR

Answer 180

I = Identification •(yourself & patient) S = Situation •Current clinical situation/care status O = Observations •Current (how they have changed?) B = Background •Summary of past health history/related issues A = Agreed plan •Document agreed intervention/who you contacted/what was discussed •R = Read back Read over your notes/do they meet facility policy

Question 181

What would you write in I and S (of ISOBAR)

Answer 181

I- Is the patient identified. Is your page in HR 500 identified with an addressograph sticker. Are the notes written, clearly identified as nursing notes /signed/dated/time and printed name/designation S-Brief description of the patients admission so far/ or issue

Question 182

What would you write in O and B (of ISOBAR)

Answer 182

O- Detailed account and findings from your patient Assessment. Reporting all variances in assessment, this must include vital signs that are abnormal. There should be clear documentation listing the abnormal findings. Who they have been reported to and documenting a plan of care to address these. B-Taking into account individual patient and family needs

Question 183

What would you write in A (of ISOBAR)

Answer 183

A- Evaluating the effectiveness of planned care, is planned care progressing the patient towards a timely discharge/intervention/review. Document Interventions required and actioned to progress care. Who you have contacted and what was discussed.

Question 184

What would you do in R(of ISOBAR)

Answer 184

R- Read your notes, are they clear and concise. Have you met the policy criteria for documentation, signed, dated. etc

Question 185

why is Promoting health from conception through to adolescence important for nurses

Answer 185

Allows appropriate assessment & care planning The concepts and theories of G & D from last week Applied to neonates/infant/toddler/preschooler/school-age child/ Basically the age group 0 – 12 years

Question 186

conception & prenatal development Length of gestation​

Answer 186

38-42 weeks, 9 months | Trimesters ​

Question 187

what are we expected to know about conception and prenatal development

Answer 187

``` length of gestation Trimesters ​ Maternal requirements​ Intra-uterine development ​ Oxygen demand​ Nutrition & hydration​ Rest & activity​ Elimination​ Temperature maintenance​ Safety ```

Question 188

Maternal factors that contribute to a higher risk of low birth weight babies

Answer 188

■ Underweight before pregnancy. ■ Less than 9.5 kg gained during pregnancy. ■ Inadequate antenatal care. ■ Age of 16 years or younger, or 35 years or older. ■ Low socioeconomic level. ■ Poor nutrition during pregnancy. ■ Smoking cigarettes during pregnancy. ■ Use of addictive drugs or alcohol during pregnancy. ■ Complications during pregnancy, poor health status, exposure to infections. ■ High stress levels, including physical or emotional abuse.

Question 189

What is the apgar score for newborn assessment

Answer 189

Apgar stands for "muscle tone (flacid/ active movements) , Pulse (absent/100bpm+), colour(pale/pink), reflex irritability(none/cries), and Respiration(absent/ regular rate and crying)" In the test, five things are used to check a baby's health. Each is scored on a scale of 0 to 2, with 2 being the best score If score is below 3- baby is in serious danger

Question 190

when is an apgar test done

Answer 190

1 minute after birth- if emergency treatmment will bbe needed then again 5 minutes after- sometimes babies take a little bit longer to adjust to being out

Question 191

what is a neonate and an infant

Answer 191

Neonate - Birth to one month​, ​they are very vulnerable have newborn reflexes like sucking, blinking and rooting, palm grasp Infant - one month to one year of age​ mum, dad and baby all Require adjustment​

Question 192

how fast does g and d happen in first year

Answer 192

G & D in first year of life rapid​

Question 193

At birth weight, length and head circumference averages​ ​

Answer 193

Weight – Australian average (non-indigenous) – 3.38kg​ Loss of 5 – 10% of birth weight initially​ Length – 50cm but can vary (gender/ethnicity​ Head & chest circumference is important(?) – 35cm​

Question 194

neonate and infant vision development

Answer 194

Vision ​ by 1 month – focus & follow moving figures​ 2 – 4 months recognises parents smile​ 4 months colour vision​

Question 195

neonate and infant hearing development

Answer 195

Hearing ​ Startle reflex at birth​ Recommend a hearing text before hospital discharge​ By 2 – 3 months respond to voices​ Rapidly up to, at 9 – 12 months understands many words​

Question 196

what is importance of Head moulding/fontanelles​

Answer 196

babies have fontanelles which cross over when baby is bornn to allow baby to fit through. once through the move back. fonanelles are a good indicator up to 12 mnths old. if dipped down when babys small= baby not getting enough fluid. if raised and ave a temperature= maybe fuid on brain meningitis. front and back fontanelles dont close until 2 years

Question 197

neonate and infant smell and taste development

Answer 197

Smell & taste ​ Function shortly after birth (smell [turn towards] mother’s milk)​

Question 198

neonate and infant touch development

Answer 198

Touch​ | developed at birth (importance of skin to skin/comfort/temperature maintenance/pain not isolated)​

Question 199

What are some infant reflexes

Answer 199

Sucking reflex: a feeding reflex that occurs when the infant’s lips are touched. The reflex persists throughout infancy. ■ Rooting reflex: a feeding reflex elicited by touching the baby’s cheek, causing the baby’s head to turn to the side that was touched. The reflex usually disappears after 4 months. ■ Moro reflex (startle reflex): often assessed to estimate the maturity of the central nervous system. A loud noise, a sud- den change in position, or an abrupt jarring of the cot elicits this reflex. The infant reacts by extending both arms and legs outwards with the fingers spread, then suddenly retracting the limbs. Often the infant cries at the same time. This reflex disappears after 4 months. ■ Palmar grasp reflex: occurs when a small object is placed against the palm of the hand, causing the fingers to curl around it. This reflex disappears after 3 to 6 months. ■ Plantar reflex: similar to the palmar grasp reflex; an object placed just beneath the toes causes them to curl around it. This reflex disappears after 8 to 10 months. ■ Tonic neck reflex (TNR) or fencing reflex: a postural reflex. When a baby who is lying on its back turns its head to the right side, for example, the left side of the body shows a flex- ing of the left arm and the left leg. This reflex disappears after 4 to 6 months. ■ Stepping reflex (walking or dancing reflex): can be elicited by holding the baby upright so that the feet touch a flat surface. The legs then move up and down as if the baby were walk- ing. This reflex usually disappears at about 2 months. ■ Babinskireflex:whenthesoleofthefootisstroked,thebig toe rises and the other toes fan out. A newborn baby has a positive Babinski. After age 1, the infant exhibits a negative Babinski; that is, the toes curl downwards. A positive Babinski after age 1 can indicate possible upper motor neuron damage.

Question 200

neonate and infant psychosocial development erikson

Answer 200

Psychosocial ​ Erikson (trust v mistrust)​ Developing trust through:​ - Sensitivity to needs​ - Establishing routines​ Meeting these requirements builds trust and attachment​

Question 201

Newborn- 12 months motor development

Answer 201

newborn- Turns head from side to side when in a prone position. Grasps by reflex when object is placed in palm of hand. 4 months- Rolls over. Sits with support, holds head steady when sitting. 6 months- Lifts chest and shoulders when prone, bearing weight on hands. Manipulates small objects. 9 months- Creeps and crawls. Uses pincer grasp with thumb and forefinger. 12 months- Walks alone with help. Uses spoon to feed self.

Question 202

Newborn to 12 months social development

Answer 202

Newborn- Displays displeasure by crying and satisfaction by soft noises. Responds to adult face and voice by eye contact and settling. 4 months- Babbles, laughs and increased response to verbal play. 6 months- Starts to imitate sounds. Says one-syllable sounds: ‘ma ma’, ‘da da’. 9 months- Complies with simple verbal commands. Displays fear of being left alone (e.g. going to bed). Waves ‘bye-bye’. 12 months- Clings to mother in unfamiliar situations. Demonstrates emotions such as anger and affection.

Question 203

Neonate and infant cognitive development?

Answer 203

Piaget 1st phase - sensorimotor 6 stages 3 stages in first 12 months Starting about 4 months with carer recognition to 12 months - concept of space and time(goal achievement)

Question 204

Neonate and infant moral development

Answer 204

Can’t tell right from wrong | Positive v negative reinforcement

Question 205

Neonate and infant health risks

Answer 205

- Failure to thrive – officially dropping below the 3rd percentile could be Organic (something inside) non-organic (carer/parent lazy or other) ``` Outcomes … - Colic - griping abdominal pain (Exact cause unknown) - Scabies - Child abuse ..Global issue ..Physical abuse or neglect/sexual/emotional neglect ...Consequences often catastrophic -SIDS ```

Question 206

Child’s personal health record, completed by:​

Answer 206

``` Child health nurses​ Community health nurses​ GP​ Hospitals​ Allied health staff ​ More in the tutorials​ ```

Question 207

Neonate and infants health examinations

Answer 207

Screening of newborns for hearing loss; follow up at 3 months and early intervention by 6 months if appropriate. ■ At 0–6 weeks, 6–8 weeks, 4, 6, 9 and 12 months.

Question 208

Health promotion Protective measures for infants and neonates

Answer 208

Immunisations Aboriginal and Torres Strait Islander children in high-risk areas and Medically at risk children require a fourth dose of pneumococcal con- jugate

Question 209

Health promotion about nutrition for infants and neonates

Answer 209

- ideally breastfed for first 6 months - breast and bottle feeding techniques - formula preparation if artificial feeding chosen - introduction to solid foods - need for iron supplements 4-6 months

Question 210

Health promotion about neonates and infants in regards to elimination

Answer 210

- Characteristics and frequency of stool and urine elimination. ■ Diarrhoea and its effects - Fluoride supplements if there is inadequate water fluorida- tion (less than 0.5 part per million). Rest/sleep ■ Guthrie test which screens for phenylketonuria (PKU), galac- tosaemia, hypothyroidism and other metabolic conditions. ■ Prompt attention for illnesses. ■ Appropriate skin hygiene and clothing.

Question 211

Health promotion in regards to infant safety

Answer 211

Importanceofsupervision(e.g.neverleaveunattendedinbath). ■ Carseat,cot,playarea,bathandhomeenvironmentsafety measures. ■ Feeding measures (e.g. avoid propping bottle). ■ Provide toys with no small parts or sharp edges. ■ Eliminate toxins in the environment (e.g. chemicals, radon, lead, mercury). ■ Use smoke detectors in the home.

Question 212

Heath promotion in regards to infant rest and sleep

Answer 212

■ Establish routine for sleep and rest patterns. | ■ Ensure cot sides are raised to prevent accidental falls.

Question 213

Health promotion guidelines in regards to infant sensory stimulation

Answer 213

■ Touch: holding, cuddling, rocking. ■ Vision: colourful, moving toys. ■ Hearing: soothing voice tones, music, singing. ■ Play: toys appropriate for development.

Question 214

How to Foster a toddler’s psychosocial development

Answer 214

■ Provide toys suitable for the toddler, including some toys challenging enough to motivate but not so difficult that the toddler will fail. (Failure will intensify feelings of self-doubt and shame.) ■ Make positive suggestions rather than commands. Avoid an emotional climate of negativism, blame and punishment. ■ Give the toddler two or three choices, all of which are safe. ■ When the toddler has a temper tantrum, make sure they are safe and then leave. ■ Help the toddler to develop inner control by setting and enforcing consistent, reasonable limits. ■ Praise the toddler’s accomplishments; give random and spontaneous feedback for positive behaviour.

Question 215

Toddler cognitive growth and development

Answer 215

Commences pre-conceptual stage (Piaget) | Cognitive & intellectual skills develop rapidly

Question 216

Toddler moral development

Answer 216

Develop understanding of morals & ethics

Question 217

Toddler health risks

Answer 217

Injuries - A natural curiosity Visual problems (amblyopia)- screening Dental caries (sugar!) Infections

Question 218

how old is an infant

Answer 218

Toddlers (1 – 3 years of age)​

Question 219

what happens during toddler g and d

Answer 219

Develop voluntary control​ - Bowels/bladder/walking & talking(+++)​ Growth Psychosocial ​ - Anal phase (Freud)​ - Autonomy v shame & doubt (Erikson) – “no”​ -Individual and Cultural Differences - Gender - Temperament usually developed - Environment: verbal stimulation characteristics of native language - Language style:

Question 220

Toddler health exams

Answer 220

Health examinations ■ At 18 months and 2.5–3.5 years. ■ Dental visit starting at age 3 or earlier.

Question 221

Toddler Protective measures

Answer 221

■ Immunisations: 18 months: diphtheria, tetanus, acellular per- tussis; measles, mumps, rubella and varicella (MMRV) (Department of Health 2016). ■ Fluoride supplements if there is inadequate water fluorida- tion (less than 0.5 part per million).

Question 222

Toddler safety

Answer 222

■ Importance of constant supervision and teaching child to obey commands. ■ Eliminate toxins in environment (e.g. pesticides, herbicides, mercury, lead, arsenic in playground materials). ■ Use smoke detectors in home. ■ Home environment safety measures (e.g. lock medicine cabi- net, child safety gates). ■ Outdoor safety measures (e.g. close supervision near water, pool fences). ■ Appropriate toys.

Question 223

Toddler Nutrition

Answer 223

Nutrition ■ Importance of nutritious meals and snacks. ■ Teaching simple mealtime manners. ■ Dental care.

Question 224

Toddler elimination

Answer 224

Elimination ■ Toilet training techniques. Rest/sleep ■ Dealing with sleep disturbances.

Question 225

Toddler rest and sleep health promotion

Answer 225

Dealing with sleep distribances

Question 226

Toddlers Play health promotion

Answer 226

■ Providing adequate space and a variety of activities. | ■ Toys that allow role-playing behaviours and provide motor and sensory stimulation.

Question 227

Preschoolers are how old

Answer 227

4 – 5 yrs of age

Question 228

what happens during preschooler growth and development

Answer 228

-Growth slows but coordination of body develops​ ``` -Psychosocial ​ Initiative v guilt (Erikson)​ Phallic – Oedipus/Electra (Freud)​ Major development period of self-concept​ Play well with others​ Need to belong​ Guidance, routine & discipline​ ```

Question 229

preschoolers cognitive development

Answer 229

``` Cognitive ​ -Intuitive thought (Piaget)​ Developing more complex thought processes​ Through trial & error​ -Death​ ```

Question 230

preschooler moral development

Answer 230

Moral​ | - Develop ability to share​

Question 231

preschooler health risks

Answer 231

Similar to toddlerhood ​

Question 232

preschoolers health exams

Answer 232

Health examinations | ■ Healthy Kids Check at 4 years (done with immunisations).

Question 233

preschoolers protective measures

Answer 233

Protective measures ■ Immunisations ■ Medically at risk children should receive pneumococcal polysaccharide (23vPPV) at 4 years (Department of Health 2016). ■ Vision and hearing screening. ■ Regular dental screenings and treatment as recommended.

Question 234

preschooler safety health promotion

Answer 234

Preschooler safety ■ Educating child about simple safety rules (e.g. crossing the street). ■ Teaching child to play safely (e.g. helmet when riding bike). ■ Taking the child to swimming lessons. ■ Educating to prevent poisoning; exposure to toxic materials.

Question 235

preschooler nutrition health promotion guidelines

Answer 235

Nutrition | ■ Importance of nutritious meals and snacks.

Question 236

preschooler elimination health promotion guidelines

Answer 236

Elimination ■ Teaching proper hygiene (e.g. washing hands after going to the toilet).

Question 237

preschooler rest/ sleep health promotion guidelines

Answer 237

Rest/sleep | ■ Dealing with sleep disturbances (e.g. nightmares, sleepwalking, bed wetting).

Question 238

preschooler play health promotion guidelines

Answer 238

Play ■ Providing times to play with their friends. ■ Teaching child simple games that require cooperation and interaction. ■ Providing toys and dress-ups for role playing.

Question 239

what happens during school aged growth and development

Answer 239

6 – 12 years of age​ Pre-pubescent (generally)​ - Significant growth & development​ - Develop coordination and fine motor skills​ Psychosocial ​ - Industry v inferiority (Erikson)​

Question 240

school aged children cognitive development

Answer 240

Cognitive ​ - Concrete operations (Piaget)​ - Developing intellectually ​

Question 241

school aged children moral development

Answer 241

Moral ​ - According to Kohlberg – several stages​ - Act to avoid punishment/act to benefit themselves​ - Well behaved/law & order orientation​ - Less ego-centred​

Question 242

School aged children health risks

Answer 242

Health risks​ - Similar to previous stages​ - Obesity/hypertension/type 2 diabetes​ - Opportunity for education​

Question 243

school aged children health examination guidelines

Answer 243

Health examinations ■ Health check at 10–12 years. ■ Physical examination as recommended.

Question 244

school aged children protective measures

Answer 244

Protective measures ■ Immunisations ■ Periodic vision, speech and hearing screenings. ■ Regular dental screenings and treatment as recommended. ■ Providing accurate information about sexual issues (e.g.puberty and reproduction).

Question 245

health promotion guidelines about safety for school aged children

Answer 245

School-age child safety ■ Using proper equipment when participating in sports and other physical activities (e.g. helmets, pads, mouthguards). ■ Encouraging child to take responsibility for own safety (e.g.participating in bicycle and water safety courses). Nutrition ■ Importance of child not skipping meals and eating a balanced diet. ■ Experiences with food that may lead to an eating disorder (e.g. obesity, anorexia nervosa).

Question 246

health promotion guidelines for school aged children about elimination

Answer 246

Elimination ■ Utilising positive approaches for elimination problems (e.g. enuresis).

Question 247

health promotion guidelines for school aged children about play and social interaction

Answer 247

Play and social interactions ■ Providing opportunities for a variety of organised group activities (e.g. skating and surfing with friends). ■ Accepting realistic expectations of child’s abilities. ■ Acting as role models in acceptance of other people who may be different. ■ Providing a home environment that limits TV viewing, mobile phone usage and computer and internet games, and encourages completion of homework and healthy exercise.

Question 248

steps to completing a skin assessment

Answer 248

- Always confirm your patients identity ​ - Determine the need for the assessment ​ - Be able to demonstrate the ability to validate the skin - - health history through physical assessment ​ - Initiate your communication with the patient​ - Ask the patient what they know about their skin assessment and educate if appropriate ​ - Ensure you do your hand washing ​ - Collect all your equipment ensuring the light is good and you have everything you need to document ​ - Ensure patient privacy and the patient is positioned adequately to complete the assessment ​

Question 249

When inspecting the skin you should palpate looking for ...

Answer 249

- Moisture​ - Temperature​ - General colour ​ - Turgor ​(Skin turgor is the skin's elasticity. It is the ability of skin to change shape and return to normal) - Capillary Refill​ ( time taken for color to return to an external capillary bed after pressure is applied to cause blanching)

Question 250

what are pressure ulcers

Answer 250

- This is an injury to the skin caused through shear friction or pressure ​ - They are found usually over a bony prominence ​ - Shearing forces occur usually as a result of dragging the skin across a support surface eg mattress​ - Friction is the abrasion of the epithelial surface of the skin cause from a rubbing on an abrasive surface ​

Question 251

how many stages are there of pressure ulcer injury

Answer 251

There are 4 stages of pressure ulcer injury ​

Question 252

what are stage one pressure ulcers like

Answer 252

- Stage 1 presents as areas of persistent non blanching redness ​ - The skin around this area may feel boggy, cold, warmer, firm or itchy and painful​

Question 253

what are stage two pressure ulcers like

Answer 253

- This is a partial thickness loss of the dermis ​ - The wound appears shallow with a red or pink wound bed ​ - Could also present as an intact fluid or open blister​ - They are sometimes shiny or dry without any bruising present ​

Question 254

what are stage 3 pressure ulcers like

Answer 254

- These ulcers are full-thickness skin loss​ - Subcutaneous fat may be visible ​ - Thick yellow tissue (slough) may be present​ - There may be undermining of stage 3 ​

Question 255

what are stage 4 pressure ulcers like

Answer 255

- These ulcers are the most severe ​ - They have full thickness tissue loss with exposed bone​ - Thick yellow tissue or necrotic tissue may be present​ - Often has undermining ​ - They can cause osteomyelitis ​(infection of the bone)

Question 256

what are the risks of pressure ulcers

Answer 256

- Alteration in mobility or physical activity​ - Malnutrition and dehydration ​ - Moisture​ - Alteration to sensation and consciousness​ - Other health conditions such as diabetes heart disease. Circulation disorders and a history of smoking ​

Question 257

why do we do skin assesments and what scale do we use

Answer 257

Pressure area development (decubitus ulcers) are a major issue in all health care facilities​ which is why each and every patient is assessed​ - using the Braden/Norton/Waterloo scales or similar​ braden score looks at: moisture,sensory perception, activity, mobility, nutrition, friction and shear

Question 258

interpreting braden score

Answer 258

``` Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23 ``` the lower the no. the higher the risk

Question 259

nursing interventions for pressure ulcers

Answer 259

new mattress barrier creams Positioning and repositioning the patient to minimise shear Provide adequate intake of protein and calories. Maintain current levels of activity, mobility and range of motion.

Question 260

what age is adolecence

Answer 260

12 – 18 yrs of age​

Question 261

what g and d happens during adolecence

Answer 261

- Critical period of development​ - Develops physical maturity​ - develops psychological maturity(!?)​ - Length of this stage determined by culture​ - Puberty commences (though can be earlier)​ ​ Psychosocial (Erikson)​ - Identity formation​ - Role confusion/sexual identity confusion​ - Self-concept formation – see K & E pp. 427-429​

Question 262

adolescence identity vs role confusion

Answer 262

Identity​ - Defining who you are, what you value, and your direction in life​ - Commitments to vocation, relationships, sexual orientation, ethnic group, ideals​ - Exploration, resolution of “identity crisis”​ Role Confusion​ - Lack of direction and self-definition​ - Earlier psychosocial conflicts not resolved​ - Society restricts choices​ - Unprepared for challenges of adulthood​

Question 263

what is the adolescents relationship with self esteem

Answer 263

Continues to gain new dimensions:​ -close friendship​ -romantic appeal​ -job competence​ -Generally rises, but drops temporarily at school transitions​ -Parenting style affects quality and stability of​ self-esteem​

Question 264

adolescent cognitive development

Answer 264

Cognitive​ - Maturing​ - Imaginative & idealistic​...Can lead to conflict & confusion (from others)​

Question 265

adolescent moral development

Answer 265

Moral ​ - Conventional or post-conventional (Piaget)​ - Under parental or peer influence​

Question 266

adolescent spiritual development

Answer 266

Spiritual​ -Beliefs of this age group may be important to nurses​ ​

Question 267

health risks during adolescents

Answer 267

-Risky behaviors​....Accidents/drugs/sexually/​ -Psychological & emotional traumas​ ...Suicides/cutting​ ...Males more common ...Indigenous more common - Bullying​ - Eating disorders​

Question 268

rate of suicide in adolescence

Answer 268

Suicide rate jumps sharply at adolescence​ ``` Related factors:​ gender​ ethnicity​ family environment, high life stress​ sexual orientation​ personality:​intelligent, withdrawn​. antisocial​ triggering negative events ```

Question 269

Sex Differences in​ Adolescent Friendships​

Answer 269

``` girls: Emotional closeness​ Communal concerns​ Get together to​ “just talk”​ Self-disclosure, support​ ``` ``` boys: Shared activities​ Achievement, status​ Competition, conflict​ Androgyny related to increased intimacy​ ```

Question 270

characteristics of sexually active adolescence

Answer 270

personal- early pubertal timing, childhood impulsivity, weak sense of personal control family- step/ single/ large family, little or no religious involvement, weak parental monitoring, disrupted parent-child communication peer- sexually active friends or older siblings educational- poor school performance, low educational goals

Question 271

what is adolescent contraceptive use like

Answer 271

20% of U.S. sexually active teenagers do not use consistently​ Reasons:​ concern about others’ opinions​ unrealistic about consequences​ sexual exploitation​

Question 272

adolescence in the LGBTQI community

Answer 272

``` Impact of heredity:​ -X-linked​ -Prenatal sex hormones​ -Birth order​ Sequence of coming out:​ - Feeling different​(ages 6–12)​ - Confusion (ages 11–15)​ - Self-acceptance (end of adolescence)​ ```

Question 273

adolescence and STI

Answer 273

STI rates highest in adolescence:​ - especially high in United States​ - 1 out of 5 to 6 sexually active teens affected​ AIDS most serious:​ - manifests 8–10 years later​ - often infected during adolescence​ Females more easily infected​ STD education improving​

Question 274

Factors Contributing to Adolescent Parenthood​

Answer 274

``` Low parental warmth,​ abuse​ Repeated parental divorce​ Poor school achievement​ Alcohol, drug use​ Antisocial behavior​ Low SES​ ```

Question 275

Risks for Teenage ​Mothers and Babies​

Answer 275

``` Low educational attainment​ More time as single parent​ Economic difficulties​ Pregnancy and birth complications​ Weak parenting skills​ ```

Question 276

Teen Pregnancy ​ | Prevention and Intervention​

Answer 276

Prevention ​Strategies​ - Better sex education​ - Skills for handling sexual situations​ - Information and access to contraceptives​ - Academic and social competence​ - School involvement​ Intervention​ Strategies​ - Health care​ - Help staying in school​ - Job and life-management training​ - Parenting instruction​ - Adult mentors​ - Affordable child care​ - Father support​

Question 277

Substance Use versus Abuse​

Answer 277

Experimenters​ - Psychologically healthy​ - Sociable ​ - Sensation-seeking​ Abusers​ - Low SES​ - Family mental health problems, substance abuse​ - Child abuse​ - Impulsivity, hostility​ - Drug-taking starts earlier​

Question 278

What do we need to know as nurses about adolescence

Answer 278

Recognize adolescents at risk​ Form therapeutic relationship ​ health education/promotion at the level the person will understand​ Knowledge is power in health​ Guide and help access support systems available ​

Question 279

maslows hierachy of needs order

Answer 279

``` top self actualisation self esteem love/ belonging safety psychological bottom ```

Question 280

why is understanding maslows hierarchy of needs important in adolescent health promotion

Answer 280

Need to know what peoples circumstances are;​ No point in telling someone to eat healthily if they have no money and are homeless ​ People living in refugee camps are not going to be able to “Slip Slap Slop”​ Have to be relevant to the persons plight or no point ​

Question 281

health promotion guidelines for adolescents in regards to health examinations

Answer 281

Health examinations ■ As recommended by the doctor. ■ Immunisations ■ Aboriginal and Torres Strait Islander peoples or at-risk groups are offered influenza (flu) and pneumococcal polysaccharide (23vPPV) at 15 years and over ■ Periodic vision and hearing screenings: every 2–3 years. ■ Yearly dental assessments and treatment as recommended. ■ Obtaining and providing accurate information about sexual issues.

Question 282

health promotion guidelines for adolescents in regards to safety

Answer 282

Adolescent safety ■ Adolescents taking responsibility for using motor vehicles safely (e.g. completing a defensive driving course, wearing a seatbelt and helmet). ■ Making certain that proper precautions are taken during all athletic activities (e.g. medical supervision, proper equipment). ■ Parents keeping lines of communication open to discuss drugs and alcohol usage as well as being alert to signs of substance abuse, the adolescent being bullied (especially via social networking sites and mobile texting) and emotional disturbances in the adolescent

Question 283

health promotion guidelines for adolescents in regards to nutrition and exercise

Answer 283

Nutrition and exercise ■ Importance of healthy snacks and appropriate patterns of food intake and exercise. ■ Factors that may lead to nutritional problems (e.g. obesity, anorexia nervosa, bulimia). ■ Balancing sedentary activities with regular exercise.

Question 284

health promotion guidelines for adolescents in regards to social interactions

Answer 284

Social interactions ■ Encouraging and facilitating adolescent success in school. ■ Encouraging adolescent to establish safe relationships that promote discussion of feelings, concerns and fears. ■ Parents encouraging adolescent peer group activities that promote appropriate moral and spiritual values. ■ Parents acting as role models for appropriate social interactions. ■ Parents providing a comfortable home environment for appropriate adolescent peer group activities. ■ Parents expecting adolescents to participate in and contribute to family activities.

Question 285

nutrition in adolescence

Answer 285

Calorie needs increase​ Poor food choices​ common:​ skipping breakfast​ eating fast foods​ Iron, vitamin–mineral deficiencies​ Family meals associated​ with healthier diet​

Question 286

types of eating disorders adolescence may suffer from

Answer 286

Many types ​ Bulimia​ Anorexia ​ Sugar addition ​ Food addition ​ Loss of control ​

Question 287

where can you use health promotion on adolescence

Answer 287

``` Hospitals​ GP surgeries​ Community health​ Home visiting ​ School ​ Worksite (O H & S)​ ``` With focus on different aspects of health in each​

Question 288

The nurse’s role in health promotion

Answer 288

■ Model healthy lifestyle behaviours and attitudes. ■ Facilitate people’s involvement in the assessment, implementation and evaluation of health goals. ■ Teach people self-care strategies to enhance fitness, improve nutrition, manage stress and enhance relationships. ■ Assist individuals, families and communities to increase their levels of health. ■ Promote a person-centred approach to health by educating and supporting people to be effective health care consumers. ■ Assist individuals, families and communities to develop and choose health-promoting options. ■ Guide people’s development in effective problem solving and decision making. ■ Reinforce people’s personal and family health-promoting behaviours. ■ Advocate in the community for changes that promote a healthy environment. ■ Lobby government and the media for responsible advertising and national health promotion programs.

Question 289

how many stages of wound healing are there and what are they

Answer 289

Wound healing is a complex process​ Tends to follow a defined process in 4 stages​ Each of these stages interlink and are reliant on each other​ Haemostasis ​ Inflammation​ Proliferation​ Maturation ​

Question 290

what happens during haemostasis stage of wound healing

Answer 290

Following injury platelets release a number of growth factors​. These factors draw inflammatory cells to the area . neutrophils initialy, macrophages at late stages Haemostasis occurs (the stopping of a flow of blood.) 3 Components ​of this stage ​1. Vasoconstriction​ 2. Formation of the platelet plug ​ 3. A biomedical response is activated initiating the clotting cascade ​

Question 291

what happens during the inflammation stage of wound healing

Answer 291

Inflammation (0-3 days)​ This phase is a cellular and vascular response ​ Microbes remove the dying tissue ​ Vasodilation occurs with increased capillary permeation ​ Macrophages migrate to the wound ​

Question 292

what happens at the proliferation/ migration stage of wound healing

Answer 292

Proliferation (2-24 days)​ This phase is where the epithelial cells have a huge growth spurt.​ They deposit fibroblasts and collagen fibres ​ This forms the ground substance for growth of the blood vessels ​

Question 293

what happens at the maturation/ remodelling stage of wound healing

Answer 293

Maturation (24 days – 1 year) ​ Fibronectin and collagen forms to promote granulation tissue ​ The remodelling is regulated by growth factors ​ Sometimes this remodelling goes too far and you end up with “Over granulation”​

Question 294

what demographic are skin tears

Answer 294

Most common in elderly people​

Question 295

what are skin tears

Answer 295

tears in the skin caused by friction and/or shear​. | Epidermis is separated from dermis​. i is known as partial thickness wound​.

Question 296

what are wound tears classified by

Answer 296

Classification of wound by STAR Skin Tear Classification System​ To help decide on treatment and management​ There are 5 categorises

Question 297

what do category 1-a skin tears look like

Answer 297

A skin tear where the edges can be realigned. | (the normal anatomical position without undue stretching) and skin or flap colour is not pale, dusky or darkened.

Question 298

what do category 1-b skin tears look like

Answer 298

A skin tear where the edges can be realigned. (the normal anatomical position without undue stretching) and skin or flap colour is pale, dusky or darkened.

Question 299

what do category 2-a skin tears look like

Answer 299

A skin tear where the edges cannot be realigned to the normal anatomically position and the skin of flap tear is not pale dusky or darkened.

Question 300

what do category 2-b skin tears look like

Answer 300

A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap tear is pale, dusky or darkened

Question 301

what do category 3 skin tears look like

Answer 301

a skin tear where the skin flap is completely absent

Question 302

how does decreased sensory perception affect elderly people with skin tears

Answer 302

means that when an elderly person injured their skin they may not be aware they ave been injured

Question 303

when doing a skin assessment what additional information should a nurse seek

Answer 303

- past medical history that may involve skin - medications - exposure to the environment or occupational hazards - substance abuse - psychological or physiological stress - hair, nail and skin care habits - skin self examination - problems with the skin

Question 304

why is the asepsis ANTT approach used

Answer 304

Used to help minimise the onset and spread of infective pathogens​ The aseptic technique reduces the these organisms from becoming in sufficient quantities to infect hands, surfaces and equipment ​ It is a method employed to help prevent contamination of wounds and other susceptible sites.​ ​

Question 305

define aspesis

Answer 305

Asepsis is defined as the absence of pathogens ​

Question 306

when is asepsis ANTT approach used

Answer 306

Nurses use this method at all times when dealing with most invasive procedures

Question 307

what can be placed on the sterile field during ANTT

Answer 307

Only sterile objects may be placed on a sterile field (check all sterile packaging carefully)​ ​A sterile object remains sterile only when touched by another sterile object (sterile cannot touch clean and vice versa)​ Sterile objects/fields are always kept in view and above the waist (can’t turn your back on your trolley or drop your hands below your waist)​ Sterile objects/fields are contaminated if exposed to air too long (prepared immediately before use)​

Question 308

after washing hands how should you position your hands

Answer 308

Fluid flows in the direction of gravity (important with washing your hands and holding your forceps, and wound cleaning)​

Question 309

if you don't use water proof material in your sterile field are you contaminate it

Answer 309

Sterile fields are contaminated by the “wicking” process if waterproof material not used (be aware of moisture seepage)​

Question 310

what parts of the sterile field are conaminated

Answer 310

The edges of sterile field/container are contaminated (2.5cm border all around your working surface is dirty)​

Question 311

can skin be sterilised

Answer 311

​Skin cannot be sterilised (we use hand hygiene, sterile equipment and the non-touch technique)​

Question 312

what do do if asepsis ANTT is breach

Answer 312

Honesty and alertness is required (if asepsis is accidentally breached - report it/start the setup again!)​

Question 313

During wound care what to do pre dressing

Answer 313

Pre-dressing (before you start)​ ``` Explanation given (cooperation is important)​ Obtain verbal consent​ ?Analgesia/?pre-toilet/​ Privacy/? Additional lighting​ No recent cleaning/open windows​ ``` Check wound management plan (WMP)​ Gather equipment​

Question 314

what wounds are suitable to be cleansed with tap water/in the shower

Answer 314

Surgical wounds healing by primary intention​ Lacerations or grazes​ Chronic wounds with no undermining or underlying structures on view​

Question 315

which wounds are NOT to be cleansed in the shower (unless otherwise instructed cleanse with sodium chloride 0.9% - ‘normal saline’)​

Answer 315

Actively bleeding​ Undermined​ If vessel, bone, tendon or underlying structures on view​ If patient is severely immunocompromised​ Venous access devices e.g. invasive lines or catheters​

Question 316

What ages are young adults

Answer 316

0 – 40 years​ Generation X ​ First generation raised by two parents who both worked.​ Generation Y​ Staying at home longer​

Question 317

physical development of young adults

Answer 317

20s ​ - Prime health​ - Risk takers​ Towards 40​ - Chronic health problems can develop ​ - Resulting from poor health behaviours in 20s​

Question 318

young adults psychosocial development

Answer 318

Psychosocial ​ The changes and transitions can be extensive at this stage​ - Consider ​ ...Independence(?)​ ...Many choices to make​ - Variable​ - Multiple roles

Question 319

young adult psychosocial theories

Answer 319

The young adult ■ Is in the genital stage in which energy is directed towards attaining a mature sexual relationship, according to Freud’s theory. ■ Is in the intimacy versus isolation phase of Erikson’s (1963) stages of development. ``` ■ Has the following developmental tasks, according to Havighurst (1972): — selecting a mate — learning to live with a partner — starting a family — rearing children — managing a home — getting started in an occupation — taking on civic responsibility — finding a congenial social group. ``` ``` ■ Has the following characteristics, according to Nelson and Barry (2005): — separation from parents — exploration of new identities for self — personal discovery and self-discovery — high-risk behaviour. ```

Question 320

young adult cognitive development

Answer 320

Piaget’s ‘formal operational’ final stage​ Abstract thought/use of logic/form hypotheses ​

Question 321

young adult moral development

Answer 321

Kohlberg’s ‘post conventional’ stage ​ Form personal moral and ethics​ Individualised behaviour rather then peer-pressured behaviours​

Question 322

young adult spiritual development

Answer 322

How their spirituality fits in with their reality​ Questioning of beliefs inherited from parents​ Accepted, re-defined, rejected​ Generally results in improved quality of life​

Question 323

young adult health risks

Answer 323

Generally a time of health and wellbeing​ Though depends on previous health behaviours:​ Obesity/type 2 diabetes/hypertension/renal failure​ Accidents/suicide/STDs/female abuse(!)/some cancers/drug abuse​

Question 324

young adults health tests and screening

Answer 324

Health tests and screenings ■ Routine physical examination (every 1 to 3 years for females; every 5 years for males). ■ Immunisations ■ Regular dental assessments (every 6–12 months). ■ Yearly to 2-yearly vision and hearing screenings. ■ Professional breast examination every 2 years. ■ Papanicolaou smear annually within 2 years of onset of sexual activity. ■ Testicular examination every year. ■ Screening for cardiovascular disease (e.g. cholesterol test every 5 years if results are normal; blood pressure to detect hypertension; baseline electrocardiogram at age 35). ■ Smoking: history and counselling, if needed.

Question 325

young adult health promotion safety guidelines

Answer 325

■ Motor vehicle safety reinforcement (e.g. using designated drivers when drinking, maintaining brakes and tyres). ■ Sun protection measures. ■ Workplace safety measures. ■ Water safety reinforcement (e.g. no diving in shallow water).

Question 326

young adult health promotion in regards to nutrition and exersise

Answer 326

Nutrition and exercise ■ Importance of adequate iron intake in diet. ■ Nutritional and exercise factors that may lead to cardiovascular disease (e.g. obesity, cholesterol and fat intake, lack of vigorous exercise).

Question 327

young adult health promotion in regards to social interaction

Answer 327

Social interactions ■ Encouraging personal relationships that promote discussion of feelings, concerns and fears. ■ Setting short- and long-term goals for work and career choices.

Question 328

what are are middle aged adults like

Answer 328

- 40 – 65 years​ - ‘Mature’​ - (generally) years of stability & consolidation​ - Most self-satisfied with life​ - ‘empty nesters’​ - ​Though also see divorce & re-marriage/grand-parenting or late parenting​ - Career changes/financial readjustment​

Question 329

Physical changes of the middle-aged adult (appearance)

Answer 329

Hair begins to thin and grey hair appears. Skin turgor and moisture decrease, subcutaneous fat decreases and wrinkling occurs. Fatty tissue is redistributed, resulting in fat deposits in the abdominal area.

Question 330

Physical changes of the middle-aged adult (Musculoskeletal system )

Answer 330

Skeletal muscle bulk decreases at about age 60. Thinning of the intervertebral discs causes a decrease in height of about 2.5 cm. Calcium loss from bone tissue is more common in postmenopausal women. Muscle growth continues in proportion to use.

Question 331

Physical changes of the middle-aged adult (Cardiovascular system)

Answer 331

Blood vessels lose elasticity and become thicker

Question 332

Physical changes of the middle-aged adult (Sensory perception)

Answer 332

Visual acuity declines, often by the late 40s, especially for near vision (presbyopia). Auditory acuity for high-frequency sounds also decreases (presbycusis), particularly in men. Taste sensations also diminish.

Question 333

Physical changes of the middle-aged adult (Metabolism)

Answer 333

Metabolism slows and may result in weight gain

Question 334

Physical changes of the middle-aged adult (Gastrointestinal system)

Answer 334

Gradual decrease in tone of large intestine may predispose the individual to constipation.

Question 335

Physical changes of the middle-aged adult (Urinary system)

Answer 335

Nephron units are lost during this time and glomerular filtration rate decreases

Question 336

Physical changes of the middle-aged adult (Sexuality)

Answer 336

Hormonal changes take place in both men and women.

Question 337

psychosocial development for middle aged adults according to theories

Answer 337

The middle-aged adult ■ Is in the generativity versus stagnation phase of Erikson’s (1982) stages of development. ■ According to Havighurst (1972), has the following developmental tasks: — achieving adult civic and social responsibility — reaching and maintaining satisfactory performance in one’s occupational career — assisting teenage children to become responsible and happy adults — developing adult leisure-time activities — relating oneself to one’s spouse as a person — accepting and adjusting to the physiological changes of middle age — adjusting to ageing parents. ■ According to Slater (2003), has the additional developmental tasks of: — inclusivity versus exclusivity — pride versus embarrassment (in children, work or creativity) — responsibility versus ambivalence (making choices about commitments) — career productivity versus inadequacy — parenthood versus self-absorption — being needed versus alienation — honesty versus denial (with oneself).

Question 338

middle aged adult cognitive development

Answer 338

Cognitive​ - Little changed from last stage​ - (cognitively at our peak)​ - Though some return to study​

Question 339

middle aged adult moral development

Answer 339

- Little changed from last stage​ | - Though possibly ‘evolved’ to reach the post conventional stage​

Question 340

middle aged adult spiritual development

Answer 340

- More open to other beliefs​ | - Many find comfort in their beliefs​

Question 341

middle aged adult health problems

Answer 341

- Consider by functional age not chronological​ - Injuries due to failing vision/hearing/reaction times​ - Cancer​ - Cardiovascular disease (hypertension)​ - Obesity/diabetes type 2​ - Alcohol consumption​ - Mental health​

Question 342

health promotion for middle aged adults in regards to health screening

Answer 342

■ Physical examination (every 3 to 5 years until age 40, then annually). ■ Immunisations ■ Regular dental assessments (e.g. every 6 to 12 months). ■ Tonometry for signs of glaucoma and other eye diseases every 2 to 3 years or annually if indicated. ■ Breast examination annually by health practitioner. ■ Testicular examination annually by health practitioner. ■ Screenings for cardiovascular disease (e.g. blood pressure measurement, electrocardiogram and cholesterol test as directed by the health practitioner). ■ Screenings for colorectal, breast, cervical, uterine and prostate cancer (see cancer screening guidelines in Chapter 31). ■ Screening for type 2 diabetes. ■ Smoking: history and counselling, if needed.

Question 343

health promotion for middle aged adults in regards to safety

Answer 343

■ Motor vehicle safety reinforcement, especially when driving at night. ■ Workplace safety measures. ■ Home safety measures: keeping hallways and stairways well lit and uncluttered, using smoke detectors, using non-slipmats and handrails in the bathrooms.

Question 344

health promotion for middle aged adults in regards to nutrition and exersise

Answer 344

■ Importance of adequate protein, calcium and vitamin D in diet. ■ Nutritional and exercise factors that may lead to cardiovascular disease (e.g. obesity, cholesterol and fat intake, lack of vigorous exercise). ■ An exercise program that emphasises skill and coordination.

Question 345

health promotion for middle aged adults in regards to social interaction

Answer 345

■ The possibility of a midlife crisis: encourage discussion of feelings, concerns and fears. ■ Providing time to expand and review previous interests. ■ Retirement planning (financial and possible diversional activities), with partner if appropriate.

Question 346

Describe the patient position supine and what is commonly used for ​

Answer 346

lying on his or her back

Question 347

Describe the patient position prone and what is commonly used for ​

Answer 347

lying face down

Question 348

Describe the patient position right lateral recumbent and what is commonly used for ​

Answer 348

RLR means that the patient is lying on their right side

Question 349

Describe the patient position left lateral recumbent and what is commonly used for ​

Answer 349

LLR means that the patient is lying on their left side

Question 350

Describe fowlers position and what is commonly used for ​

Answer 350

a person in the fowler position is sitting straight up or leaning slightly back. their legs may be either straight or bent

Question 351

Describe the trendeleuberg position and what is commonly used for ​

Answer 351

a person in the trendelenberg position is lying supine with their head slightly lower than feet.

Question 352

Describe the patient position abduction

Answer 352

is movement away from the midline or to abduct

Question 353

Describe the patient position adduction

Answer 353

is movement towards the midline, or to add

Question 354

Apart from washing the skin, bathing also:​

Answer 354

- Increases ​circulation​ - Enhances ​muscle tone​ - Promotes ​relaxation & well-being​

Question 355

when bed making what to check first

Answer 355

Brakes (priority +++++++++++++++)​ Height up & down​ Bed rails​

Question 356

why should linen be wrinkle free

Answer 356

to avoid skin tears and pressure wounds

Question 357

when to change bed linen

Answer 357

Linen change frequency – Daily prn (more often as required – why?)​ Diaphoretic/Incontinent/oozy wounds – more often ​ Usually after morning sponge bath/shower​ Straightened and checked during shift​ Minimum (preferably) 2 staff (why?)​ Be organised (know patient requirements & ability to assist/collect linen/have the time/need extra staff)​ Dispose of the dirty linen​

Question 358

categorising the aging adult

Answer 358

older adults 65+ 1. Young-old: 60 to 74 years. 2. Middle-old: 75 to 84 years. 3. Old-old: 85 to 100 years. 4. Centenarians: Over 100 years.

Question 359

characteristics of older adults

Answer 359

Socio-economic​ ..Characteristics are variable​ -Marital status/education​ -Living situation​ Cultural diversity: 1/3 adults born outside of australia​ Health :

Question 360

how does cultural competency affect older adult care

Answer 360

Indigenous Australians​ -Elders are respected role models/wisdom​ Chinese​ - Oldest son expected to care for parents​ - Individual less important than family & society​ Vietnamese ​ - Extended family​ - Respected source of wisdom/tradition ​ Italian​ - Extended family​ - Elderly held in high esteem​ Communication ​ - Culturally appropriate​ - Translating and Interpreting Service (TIS) National (www.tisnational.gov.au)​

Question 361

what is Geriatrics​

Answer 361

Medical care of older adults

Question 362

what is Gerontology​

Answer 362

The study of ageing and older adults​. Gerontological nursing (“aged care nursing”)​ Traditionally undervalued & least preferred area of nursing​ Demands skilful & knowledgeable staff​ Offers opportunity for true person-centred & holistic care​ Promoting quality of life​ In an environment that can be both positive & inspirational​

Question 363

what is Gerontological nursing​

Answer 363

The branch of nursing that cares for older adults​ -Inc. advocacy​

Question 364

Gerontological care settings

Answer 364

``` •Acute care (hospitals) ▫50% of all admission/60% of all bed days •Residential aged care facilities ▫Nursing homes/hostels ▫Provision of care changing •Hospice •Rehabilitation •Community ```

Question 365

Physiological ageing of older adults

Answer 365

Biological theories of ageing Normal physical changes associated with ageing

Question 366

Physiological ageing​ in Older Adults I

Answer 366

Biological theories of ageing​ | eg. Wear-and-tear theories, Endocrine theory, Free-radical theory

Question 367

Normal physical changes associated with ageing (Integumentary)

Answer 367

- Increased skin dryness Decrease in sebaceous gland activity and tissue fluid - Increased skin pallor due to Decreased vascularity - Increased skin fragility due to Reduced thickness and vascularity of the dermis; loss of subcutaneous fat -Progressive wrinkling and sagging of the skin due to Loss of skin elasticity, increased dryness and decreased subcutaneous fat - Brown ‘age spots’ (lentigo senilis) on exposed body parts (e. g. face, hands, arms) - Decreased perspiration - Thinning and greying of scalp, pubic and axillary hair - Slower nail growth and increased thickening with ridges

Question 368

Normal physical changes associated with ageing (Neuromuscular)

Answer 368

- Decreased speed and power of skeletal muscle contractions - Slowed reaction time - Loss of height (stature) - Loss of bone mass - Joint stiffness - Impaired balance - Greater difficulty in complex learning and abstraction

Question 369

Normal physical changes associated with ageing (Sensory/perceptual)

Answer 369

- Loss of visual acuity - Increased sensitivity to glare and decreased ability to adjust to darkness - Partial or complete glossy white circle around the periphery of the cornea (arcus senilis) - Progressive loss of hearing (presbycusis) - Decreased sense of taste, especially the sweet sensations at the tip of the tongue - Decreased sense of smell - Increased threshold for sensations of pain, touch and temperature

Question 370

Normal physical changes associated with ageing (Pulmonary)

Answer 370

- Decreased ability to expel foreign or accumulated matter - Decreased lung expansion, less effective exhalation, reduced vital capacity and increased residual volume - Difficult, short, heavy, rapid breathing (dyspnoea) following intense exercise

Question 371

Normal physical changes associated with ageing (Cardiovascular)

Answer 371

-Reduced cardiac output and stroke volume, particularly during increased activity or unusual demands; may result in shortness of breath on exertion and pooling of blood in the extremities -Reduced elasticity and increased rigidity of arteries -Increase in diastolic and systolic blood pressure -Orthostatic or postural hypotension

Question 372

Normal physical changes associated with ageing (Gastrointestinal)

Answer 372

- Delayed swallowing time | - Increased tendency for indigestion

Question 373

Normal physical changes associated with ageing (Urinary)

Answer 373

- Reduced filtering ability of the kidney and impaired renal function - Less effective concentration of urine - Urinary urgency and urinary frequency - Tendency for nocturnal frequency and retention of residual urine

Question 374

Normal physical changes associated with ageing (Genitals)

Answer 374

- Prostate enlargement (benign) in men - Multiple changes in women (shrinkage and atrophy of the vulva, cervix, uterus, fallopian tubes and ovaries; reduction in secretions; and changes in vaginal flora) - Increased time to sexual arousal - Decreased firmness of erection, increased refractory period (men) - Decreased vaginal lubrication and elasticity (women)

Question 375

Normal physical changes associated with ageing (Immunological)

Answer 375

- Decreased immune response; lowered resistance to infections - Poor response to immunisation - Decreased stress response - Increased insulin resistance - Decreased thyroid function

Question 376

older adults health problems

Answer 376

Numerous​ As a result of the slow breakdown of the body​ ​Commonly ... - Cardiac disease​ - Cancer​ - Cerebro-vascular disease​ - Respiratory diseases​ - Resulting from diabetes mellitus​ Injuries​ - Often as a result of ageing​ - Failing health (vision/balance)​ - Cognitive changes​ Poly-pharmacy​ - Prescribed/ over the counter - interactions/mixing/side-effects​ - (OTC)/complementary​ - Misuse/administration complex in elderly​

Question 377

what are three types of care

Answer 377

Person centred​ Family centred​ Patient centred​

Question 378

what is person centred care

Answer 378

“is collaborative and respectful partnership built on mutual trust and understanding through good communication. Each person is treated as an individual with the aim of respecting people’s ownership of their health information, rights and preferences while protecting their dignity and empowering choice. Person-centred practice recognises the role of family and community with respect to cultural and religious diversity.” ​ pretty much.. The needs & expectations of the patient are heard & listened to​ They are included in all decision making​

Question 379

(bad) Traditional western biomedical care is:​

Answer 379

- Task oriented (just do the job)​ - The needs of the medical practitioner dominate​ - The medical practitioner decides what is best for the patient​ - Health care agendas ​ - Lack of holistic/individualised care​ - Time is money…​ ​

Question 380

process of person centred care

Answer 380

Working with the patients’ beliefs & values​-Getting to know the patient/the individual​, Honouring each persons’ uniqueness​ ​Shared decision making-Getting to know the patient/the individual​, Negotiating decisions and care​,Assisting the patient to make their own educated decision, in their best interest​ ​ ​Engagement (sympathetic presence)​-“connecting with the patient” (but not blindly)​ ​Providing holistic care​-Caring for the “whole” person (not just the illness)​

Question 381

what is spirituality?

Answer 381

Breath or the wind (from the Latin)​ ​Refers to what is at the centre of our lives, or gives meaning or purpose to our lives​ ​Unique to each & everyone of us​ ​Often develops from our own cultures/life-path​ A link exists between mind, body and spirit​ A person’s inner beliefs and convictions are powerful resources for healing

Question 382

what does spirituality affect

Answer 382

psychological, physiological and psysiological approach

Question 383

Health-related information about anglicans, catholics

Answer 383

``` appreciate receiving Eucharist (Holy Communion), a ritual of ingesting bread and wine (or grape juice) led by clergy or lay leaders to commemorate the death of Jesus. Forehead may be marked by priest with ashes on Ash Wednesday (40 days before Easter); no need to wash off. Lenten season (Ash Wednesday to Easter) may involve some degree of abstention from food. ```

Question 384

Health-related information about buddhists

Answer 384

may be vegetarian. Facilitate meditation (may desire | incense, visual focal point, use breathing or chanting, etc.).

Question 385

Health-related information about christian scientists

Answer 385

typically oppose Western medical interventions, relying instead on lay and professional Christian Science practitioners.

Question 386

Health-related information about hindus

Answer 386

most eat no beef; many are vegetarian. Cleanliness highly | valued. Many food preferences (e.g. foods fresh or cooked in oil).

Question 387

Health-related information about jews

Answer 387

—Some observe kosher diet to varying degrees (e.g. avoid pork and shellfish, do not mix dairy and meat). Sabbath observance varies (e.g. Orthodox Jews avoid travelling in vehicles, writing, turning on electric appliances and lights, etc.)

Question 388

Health-related information about latter day saints/ mormons

Answer 388

avoid alcohol, caffeine. Prefer to | wear temple undergarments. Arrange for priestly blessing if requested.

Question 389

Health-related information about muslims

Answer 389

respect modesty, avoid nakedness. Provide same-gender nurse if possible. Support prayers five times daily (may need to assist with ritual washing and positioning beforehand). Allow for family and imam (religious leader) to follow Islamic guidelines for burial when the person dies. Eat no pork. Children, pregnant women, older adults and the sick are exempt from daytime fast during month of Ramadan.

Question 390

Health-related information about catholics

Answer 390

Sacrament of the Anointing of the Sick (previously known as Last Rites) appropriate for anyone who is ill. Be aware that some may think that the rite means they are dying as it was traditionally previously reserved for such situations.

Question 391

Health-related information about seventh day adventist

Answer 391

avoid unnecessary treatments on Saturday (Sabbath). Sabbath begins Friday sundown and ends Saturday sundown. Adventists prefer restful, spirit-nurturing, family activities on Sabbaths. Likely to be vegetarian and abstain from caffeinated beverages. Do not drink alcohol.

Question 392

Health-related information about catholics

Answer 392

;

Question 393

Health-related information about seventh day adventist

Answer 393

.

Question 394

Health-related information about jehovahs 2itnesses

Answer 394

abstain from most blood products; need to discuss alternative treatments such as blood conservation strategies, autologous techniques, haematopoietic agents, non-blood volume expanders and so on; contact local Jehovah’s Witness hospital liaison committee

Question 395

Opening lines​ for asking about spirituality

Answer 395

Do you have a source of support or help that you look to when life is difficult?​ Would you like to talk to someone about this (offer choice)?​ Would you like to talk about this with me?​ This must be a very difficult time for you …, do you have anything in particular that supports you through this?​ Would you like me to sit with you for a while?

Question 396

how to be respectful of spirituality

Answer 396

Being aware​ ​ Look/listen/be present​ ​ Develop a caring relationship​

Question 397

The majority of older adults now live...​

Answer 397

The majority of older adults now live within the community​

Question 398

why is nutrition essential

Answer 398

-it is a basic component of health ​ ``` -it is essential for: ​ ...normal growth and development​ ...tissue repair and maintenance​ ...cellular metabolism​ ...organ function. ​ ```

Question 399

as nurses we should be aware of what in regards to nutrition

Answer 399

As nurses we need to be aware:​ - of the body’s nutritional requirements necessary to promote health, wellness & healing.​ - that culturally, nutrition can mean different things​ - many patients are unable to take nutrition orally & require it using other methods (you may see this on Prac.)​ - Many patients require nutritional interventions & education​ eg. Diabetics​, Renal patients​, Cancer patients​…​ ​

Question 400

what is BMR

Answer 400

The basal metabolic rate (BMR) is the energy needed to maintain breathing, circulation, heart rate and temperature ​ The fuel to maintain this rate is food (nutrition)​

Question 401

Individual energy/nutritional requirements affected by: ​

Answer 401

age/body mass/gender/fever/starvation/ menstruation/illness /injury/infection/activity/ thyroid function/ pregnancy/lactation/…​

Question 402

what is waist circumference

Answer 402

Waist circumference (WC) is an indicator of health risk associated with excess fat around the waist. A waist circumference of 102 centimeters (40 inches) or more in men, or 88 centimeters (35 inches) or more in women, is associated with health problems such as type 2 diabetes, heart disease and high blood pressure.​ This indicator can be used to educate patients on losing weight ​

Question 403

what are carbohydrates

Answer 403

Main source of energy​ Mainly from plant foods & lactose​

Question 404

what are proteins

Answer 404

Amino acids – essential/non-essential​ Essential for healing & repair​ Mainly from meat/plant foods/milk​ Only source of nitrogen​

Question 405

what are fats

Answer 405

Essential for metabolism​ Mainly from oils/meat/milk products​

Question 406

why is water important in nutrition

Answer 406

60–70% of total body weight​ Essential for metabolism​

Question 407

why are vitamins important for nutrition

Answer 407

Essential for metabolism​ Supply depends on dietary intake

Question 408

why are minerals important for nutrition

Answer 408

Catalysts for biochemical reactions​ Macro- and micronutrients​

Question 409

Nitrogen balance is achieved when?

Answer 409

Nitrogen balance is achieved when:​ Intake = Output​

Question 410

what is a positive nitrogen balance and when would you see it

Answer 410

Intake > Output​ Required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing

Question 411

what is a negative nitrogen balance and when would you see it

Answer 411

Output > Input​ Seen with infection, sepsis, burns, fever, malnutrition, starvation, head injury and trauma​ Demonstrates need for nutritional intervention​, Protein supplementation​

Question 412

where does digestion happen

Answer 412

Begins in the mouth and ends in the large intestine​

Question 413

where does absorption happen

Answer 413

Small intestine is the primary site for absorption of nutrients & water​

Question 414

what is metabolism

Answer 414

Metabolism: all biochemical reactions in body cells​ Anabolism: building of more complex substances​ Catabolism: breakdown into simpler substances​ Nitrogen balance essential

Question 415

how does elimination happen

Answer 415

Peristalsis moves chyme via peristalsis into large intestines becoming faeces​ Faeces is indigestible substances/epithelial GI cells/microbes/water​ Longer it sits in the large intestine the more water is absorbed/firmer it becomes​

Question 416

Importance of Thickening Fluids

Answer 416

Dysphagia the inability to swallow solid foods due to stroke, injury or brain injury ​ For patients to be able to take fluid it has to be thickened ​ If it is not thickened properly then they are at risk of not only choking ​ but also​ Aspiration Pneumonia ​ Thickening improves the ability to control fluid in the mouth and throat.​

Question 417

what is dysphasia

Answer 417

Dysphagia the inability to swallow solid foods due to stroke, injury or brain injury ​

Question 418

when do we thicken fluids

Answer 418

Following evaluation by a speech therapist the doctor will prescribe the necessary thickness of the fluid ​ The 3 common consistencies are nectar-thick, honey-thick and pudding-thick ​ ​

Question 419

what would you do during assessment of nutrition (ADPIE)

Answer 419

``` All part of your patient admission​ -Obtain dietary and health history​ -Anthropometry​ ...Body mass index (BMI)​ (Calculated by weight in kg ÷ height in metres squared)​ ...Bioelectrical impedance analysis (BIA)​ -Laboratory and biochemical tests​ -Clinical observation​ ```

Question 420

importance of nutrition for nurses

Answer 420

As providers of holistic care we are obligated to be aware of patients with nutritional deficiencies​ Educate/refer to dietician​ ​Good knowledge base/critical thinking required​

Question 421

what would you do during assessment of nutrition (ADPIIE)

Answer 421

``` All part of your patient admission​ -Obtain dietary and health history​ -Anthropometry​ ...Body mass index (BMI)​ (Calculated by weight in kg ÷ height in metres squared)​ ...Bioelectrical impedance analysis (BIA)​ -Laboratory and biochemical tests​ -Clinical observation​ ```

Question 422

BMI classes and health consequences

Answer 422

Underweight <18.50 ​- increased ``` Normal range (Healthy)​- average 18.50 - 24.99 ​ ``` Overweight: >25.00 ​- Pre-obese 25.00 - 29.99 ​- increased slightly Obese class 1 30.00 - 34.99 - moderate Obese class 2 35.00 - 39.99 ​- severe Obese class 3 >40.00​- very severe

Question 423

example of a diagnosis in regards to nutrition (adpie)

Answer 423

An example​ ​Altered nutrition: Less than body requirements R/T (related to) unwillingness to eat

Question 424

planning stage of nursing process in regards to nutrition (adpie)

Answer 424

Consider the diagnosis​, What do you think might be a desired (expected) outcome?​ ​eg. Patient will have adequate nutrition as evidenced by ​ Weight gain of 1kg per week​ Patient will weigh within 10% of ideal body weight before discharge - Date - …….​

Question 425

diet progression in hospitalised clients

Answer 425

- clear liquid - full liquid - pureed - mechanical soft - soft - regular

Question 426

nursing process evaluation in regards to nutrition

Answer 426

Goals/expected outcomes should be realistic & achievable​ To measure the effectiveness of nutritional interventions ​ To ascertain if patient has met goals and outcomes​ To amend nursing interventions if required​

Question 427

diet progression in hospitalised clients

Answer 427

..

Question 428

what is/are Parenteral nutrition/lipid emulsions​

Answer 428

Intravenous nutritional supplement​ When unable to take nutrition through the GI tract​ Specialised production & management​ Manufactured according to clinical & laboratory monitoring/individual requirements​

Question 429

what is Enteral Nutrition​

Answer 429

Nutrients given via the GI tract​ - Only possible if GI tract is functioning​ - Via naso-gastric/jejunal/gastric tubes​ - Likely to see this on Aged Care Prac.​ (though can be home managed)​ - It is a required skill to conduct safely​ - Amount/strength set by dietician/nutritionist​ - Altered according to response (“evaluation”)​

Question 430

Common problems of the mouth

Answer 430

Halitosis-Bad breath Glossitis- Inflammation of the tongue Gingivitis- Inflammation of the gums Periodontal disease- Gums appear spongy and bleeding Reddened or excoriated mucosa Excessive dryness of the buccal mucosa Cheilosis-Cracking of lips Dental caries-Teeth have darkened areas, may be painful Sordes -Accumulation of foul matter (food, microorganisms and epithelial elements) on the teeth and on the lips Stomatitis- Inflammation of the oral mucosa Parotitis Inflammation of the parotid salivary glands T