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215 Cards in this Set
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Clergy. Example of when to refer
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Provide spiritual care to the clients.
Refer when the client requests communion or the family asks for prayer prior to surgery. |
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Registered Dietitian. Example of when to refer.
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Assess, plan for, and educate the client regarding nutrition needs. Direct care of nutritional aides.
Refer if the pt has low albumin level and has experienced a recent weight loss. |
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Lab tech. Example of when to refer.
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Obtain specimens of the pt's body fluids and performs diagnostic test.
Provider orders a complete blood count (CBC) to be performed. |
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Occupational therapists. Example of when to refer.
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Assess and plan for the client to regain ADLs esp upper extremities.
A client has trouble using an eating utensil with her dominant hand after a stroke. |
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Pharmacist. Example of when to refer.
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Provide and monitor meds for the client as prescribed by the physician. Also supervises pharmacy technicians.
A client is concerned is a med will interact with other meds. |
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Physical therapist. Example of when to refer.
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assess and plan to client to increase musculoskeletal function especially of the lower extremities to maintain mobility.
Following a hip replacement, a client requires assistance learning to ambulate and regain strength. |
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Radiologic tech. Example of when to refer.
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Position and perform x rays and other imaging procedures for providers to review for diagnosis.
Doctor orders x ray. |
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Respiratory therapist. Example of when to refer.
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Evaluate respiratory status and provide prescribed respiratory treatments ie. oxygen therapy, chest physiotherapy, inhalation therapy, and artificial mechanical ventilation.
Pt with respiratory disease is SOB and requests a nebulizer treatment. |
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Social worker. Example of when to refer.
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Coordinate inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and/or discharge.
Py dying of cancer wished to go home but needs special medical equipment. |
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Speech therapist. Example of when to refer.
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Evaluate and make recommendations regarding the functions of speech, lang, and swallowing.
Pt having trouble swallowing a regular diet after trauma to head and neck |
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Provider. Example of when to refer.
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assess diagnose and treat client for disease and or injury. Include doctors, APNS etc.
Pt vital signs change. pt is achy shaking etc. |
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Define APN. Examples
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Have a great deal of autonomy. Usually possess a master's degree in nursing, etc.
Examples NP, Midwife (CNW), Anesthetist (CRNA). Clinical nurse specialist (CNS) |
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Define Ethics.
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Expected behavior of a certain group in relation to what is considered right or wrong. The study of conduct character.
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Define morals
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Values and beliefs held by people that guide their behaviors and decision making.
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Ethical theory.
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Examines the different principles, ideas, systems, and philosophies used to make judgements about what is right and wrong and good and bad.
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What are two common types of ethical theory are...
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utilitarianism and deontology.
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Define utilitarianism.
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Also know as consequentialism.
Evaluation of an action is based on the effect of the outcome ‘greatest good for the greatest number’ Example: “Sustaining life in this situation would only cause great suffering for all.” |
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Deontology.
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Defines actions as right or wrong based on the ‘essential rightness or wrongness’ of the action.
Does NOT consider consequences of the action Emphasis on the principle involved and often interpreted as ‘following the rules’ with focus on duty and obligation |
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Automony.
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The ability of the pt to make personal decisions, even when those decisions may not be in the client's best interest.
Including the pt in the process. |
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Beneficence
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agreement that the care given is in best interest of the client; taking positive action to help others.
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Fidelity
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keeping promises
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Justice
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fair treatment in matters related to physical and psychosocial care and use of resources.
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Nonmaleficence.
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avoidance of harm or pain as much as possible when giving treatments.
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When is a problem an ethical dilemma (3)
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When it cannot be solved solely by a review of scientific data.
When it involves a conflict bt two moral imperatives When the answer will have a profound effect on the situation/client. |
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Steps in determining an ethical dilemma
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1. identify if it is an ethical dilemma
2. state the dilemma 3. List all possible resolutions 4. Select the best resolution 5. Apply the resolution and evaluate the outcome. |
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What are the 4 basic code of ethics.
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Accountability- answer for one's own action.
Advocacy- support pt Responsibility- respect obligations and follow through on promises Confidentiality- protection of privacy without diminishing access to quality care. |
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Uniform Determination of Death Act (UDDA)
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a document that can be used to assist with end of life and organ donor issues.
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Death. 2 definitions according to the UDDA
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1. Irreversible cessation of circulatory and respiratory functions
2. Irreversible cessation of all functions of the brain, including the brain stem. |
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Coma
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a persistent vegetative state in which The Person maintains basic vital homeostatic functions and therefore is not dead
� |
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What are the 4 Federal Laws that impact nursing practice?
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HIPPA
Americans with Disabilities Act (ADA) Mental Health Parity Act (MHPA) Patient Self-Determination Act (PSDA) |
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Example of a breaking criminal law.
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A nurse who falsifies a record to cover up a serious mistake.
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Civil law. Example of a civil law that relates to nursing?
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Civil laws protect the individual rights of people.
Tort law. |
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Define tort law.
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Laws that offer remedies to individuals harmed by the unreasonable actions of others.
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The core of nursing is regulated by ____________
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state law
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Roles of boards of nursing
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1. issue and revoke a nursing license.
2. set standards for nursing programs and further delineate the scope of practice. |
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In general, nurses need a current license in every state where they practice. What is the exception?
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Nurse licensure compact. It allows nurses who reside in a compact state to practice in other compact states under a multi state license.
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The five elements necessary to prove negligence. pg. 24
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1. Duty to provide care as defined by a standard.
2. Breach of duty by failure to meet standard. 3. Foreseeability of harm 4. Breach of dtuy has potential to cause harm. 5. Harm occurs |
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Client's rights
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Legal guarantees that clients have with regard to their health care.
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What agency identifies pt's rights in health care settings?
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The American Hospital Association (AHA). It is contained in "The Patient Care Partnership"
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Medicare protection of pt rights located...pg. 25
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"Residents Rights" statutes
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Informed consent
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Client has given written consent for a procedure or treatment.
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In order for a pt to give consent pt must understand:
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1. Reason treatment is needed.
2. How treatment will benefit pt. 3. Risks of treatment. 4. Alternatives to treatment. |
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nurse role in informed consent?
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witness signature
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Example of implied consent
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Nurse is about to give TB test and pt holds out arm.
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When is written consent needed?
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invasive procedure or surgery
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Individuals who are authorized to give consent for others include...
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Parent of a minor
Legal guardian Court-specified representative Power of attorney |
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Emancipated minors can
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give consent. Ex. married, pregnant.
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The provider ______ consent. The nurse _____ consent
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obtains, witness
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The Patient Self Determination Act (PSDA) stipulates...
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that on admission all pts must be informed of their right to accept or refuse care.
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A _____ ______ _______ form is used when pt leaves the facility against medical advice.
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against medical advice
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Document if pt refuses to sign form.
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True
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Published standards of care are published by:
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American Nurses Association (ANA), The American Association of Critical Care Nurses (AACN), American Association of Occupational Health Nurses (AAOHN).
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Nurses should refuse to practice beyond the legal scope of practice and/or outside of their areas of competence regardless of reason. (staffing shortage etc)
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True
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Living will
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Pt's wishes regarding medical treatment in the event the pt becomes unstable and is facing end of life,
states what medical treatments a person prefers. Can rule out use of “heroic measures." (pp) |
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Power of attorney
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Makes decisions for pt who is unable.
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Advanced Medical Directive
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combo of living will & durable POA. Spells out end of life wishes.
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Nursing role in Advance medical directive
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Provide written information regarding advance directives.
Document the pt's advance directives status. Ensure that the advance directives reflect the pt's current decisions Inform all members of the team of the advance directives. |
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Mandatory Reporting
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Abuse
Communicable Diseasees |
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Assault
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the conduct of one person makes another person fearful and apprehensive (threatening to place an NG tube in a client who is refusing to eat)
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Battery
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intentional and wrongful physical contact with a person that involves an injury
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False imprisonment
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a person is confined or restrained against his will (ex. using restraints on a competent client to prevent his leaving the health care facility)
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The ____ ___ _____ act requires that all pts admitted to health care facility be asked if they have advance directives.
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Patient Self-Determination Act
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The pt's chart or medical record is...
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the legal record of care
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Who mandates computerized databases?
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The Joint Commission (formerly JCAHO)
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What is the purpose of reporting?
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To provide continuity of care when several nurses provide care to the client.
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Legal Guidelines for reporting
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Begin each entry with date and time
Record in non erasable black ink Do not leave blank spaces in the nurses' notes. Do not leave white-out Information omitted may be added in the form of a "late entry" Sign and title of person recording data. |
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What are flow charts used for?
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To record and show trends in vital signs, blood glucose levels, pain level etc.
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What is narrative documentation used for?
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To record information as a sequence of events.
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Charting by exception uses...
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Standardized forms that identify normal findings/values and allows selective documentation of abnormal findings.
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What do problem-oriented medical records consist of?
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a database, problem list, care plan, and progress notes.
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What is a DAR?
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an example of focus charting. Data Action Response
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A _____ ___ _____ report is given by the nurse leaving to the nurse assuming responsibility for the client.
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change of shift.
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How can a COS report be given?
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face to face, audiotaped, or during walk arounds in the pts room.
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Telephone Orders (TO) Verbal Orders (VO)
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this type of order should be avoided but may be needed in emergencies and at unusual times.
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How to prevent errors with orders over the phone
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1. Have a second RN/LPN listen.
2. Repeat back the order. (med name, dosage, time and route) 3. Question any order that may seem contraindicated. |
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Transfer reports should include:
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Pt's demographic info
Pt's medical diagnosis and providers An overview of the client's health status Diet All pt information, ETC. |
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What is an incident (report)?
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The occurrence of an accident or an unusual event. (Ex. med errors, falls and needle sticks)
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The incident should not be referred to in the pt's medical record.
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True.
However, it is important to record in the chart an objective description of the incident with any follow-up observations, diagnostic studies and results, and/or related treatment. |
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The _____ _______ requires that the nurse _____ all written and verbal communication about clients
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Privacy Rule; protect.
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Components of the Privacy Rule. pg 39-40
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Only health care members who are involved should access.
Pts have a right to read and obtain a copy of their medical record. Only copy to exchange with othe healthcare facilities. Keep secure Password protect electronic records Cannot give info to unauthorized pts or family members |
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Define supervising.
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The process of directing, monitoring and evaluating the performance tasks by another member of the health care team.
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Examples of licensed personnel
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LPN RN
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Examples of unlicensed personnel
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CNA (nurse) CMA (medical) dialysis techs, monitor techs, phlebotomists
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NAP
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Nursing Assistive Personnel
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Who may RNs delegate to?
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Other RNs, LPNs and AP.
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Who may LPNs delegate to?
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Other LPNs and AP
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What can't RNs delegate?
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The nursing process, client education, unstable pts, readmitted to the floor.
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What 5 things should the nurse consider before delegating?
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Predictability of outcome
potential for harm interaction with the pt complexity of care need for problem solving and innovation |
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What are the 5 rights of delegation?
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What tasks should be delegated? (right task)
Under what circumstances (right circumstance) To whom (right person) What info should be communicated? (right direction/communication) How to supervise (right supervision/evaluation) |
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The RN is responsible for maintaing a PCA pump.
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True.
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What can be delegated to LPNs?
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monitor client findings
reinforce teaching trach care suctioning checking NG tube patency enteral feedings catheter meds (except IV in several states) |
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Can an AP reapply a condom catheter for a client who has urinary incontinence? Why or why not?
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Yes, because it is a noninvasive, routine procedure.
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The nursing process?
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Assess/ Analyze (Data collection)
DPIE |
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Primary source of subjective data
Secondary source of subjective data |
What the pt tells the nurse.
What others tell the nurse based on what the pt has told them. ex. (she told me her head hurts) |
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Primary source of objective data
Secondary source of objective data |
What the nurse obtains through observation and examination.
Data collected from other sources (family, friends, literature review, med records) |
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Nurse initiated interventions vs. physician initiated interventions
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pg. 60
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Types of critical thinking
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Basic Critical Thinking
Complex Critical Thinking Commitment |
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Basic Critical Thinking
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The nurse trusts the experts and thinks based on the rules.
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Complex Critical Thinking
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The nurse begins to express autonomy by analyzing and examining data to determine the best alternative.
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Commitment
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The nurse expects to have to make choices without help from others and fully assumes the responsibility for those choices.
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Components of Critical Thinking
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Knowledge
Experience Competence |
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Medical asepsis
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oral medication administration, managing NG tubes, soiled linens that touched the floor.
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Surgical asepsis
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parenteral medication administration, urinary catheters, surgery, sterile dressing changes (wound care), labor and delivery, trach care.
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Before doing asepsis check to _______ allergies
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latex
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_______ ______ is the most important duty in asepsis
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Hand hygiene
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3 components of handwashing
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soap water friction
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When to use soap and water?
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Visibly soiled hands
Blood Bodily fluid |
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When to use alcohol rub (hand sani)?
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Not visibly soiled hands
Before and after direct contact with patient Before donning gloves After removing gloves After contact with inanimate objects |
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When pts are immunocompromised or have infections with multi drug resistant or extremely virulent microorganisms use...
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chlorhexidine, povidone-iodine, or PCMX
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Rules for washing handwashing?
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15 seconds to remove transient flora and up to 2 min when hands are more soiled
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rules for alcohol rub.
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3 to 5 ml. cover surface completely.
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Clean ______ soiled areas first to prevent moving more contaminants into cleaner areas.
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least
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Prolonged exposure to airborne micro-organisms can make sterile items non-sterile.
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True
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Below the waist or above the chest is contaminated.
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true
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Hold items to be added to a sterile at least ____ inches above the field.
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6
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Any sterile, non-waterproof wrapper that comes in contact with moisture becomes ________
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nonsterile
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Setting up a sterile field
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1. hand hygiene
2. open plastic covering per manufacturer's directions 3. reach around to open top flap, grasp the outside flap bt the thumb and index finger 4. unfold top flap AWAY from the body. 5. open side flaps. left hand left flap, right hand, right flap. 6. grab the last flap and turn it down toward the body. |
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How to add additional sterile items to the sterile field.
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1. open NEXT to the sterile field by holding the bottom edge with one hand and pulling back on the top flap.
2. Places packages that are to be used last furthest from the sterile field and open them first. 3. drop into the sterile field (15 cm) 6 in away from sterile field. 4. Once sterile field is set up, don sterile gloves. |
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How to don sterile gloves?
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1. use the left hand to pick up the right glove by grasping the folded bottom edge and lifting it away from the wrapper.
2. Cuff the left glove with the right hand |
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How to pour sterile solutions?
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1. remove cap
2. bottle cap face up on sterile field 3. Hold bottle with label in palm so that solution doesn't run down the side. 4. Pour 1-2ml into a receptacle. pour solution onto dressing or site without touching the bottle to site. |
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In order for an infection to occur...
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all components of the chain must be present and intact.
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What is a HAI
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Health-care Associated Infection formerly called nosocomial infection acquired while in a health care setting.
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"Where" do HAIs come from?
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exogenous source- outside the client
endogenous source- inside the client when part of the the client's flora becomes altered. |
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Where is the most common setting for HAIs? Site?
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Intensive care unit; urinary tract causative agents being Escherichia coli, staphylococcus aureus, and enterococci.
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What is an iatrogenic infection?
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a type of HAI resulting from a diagnostic or therapeutic procedure
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HAIs are not always preventable and are not always latrogenic.
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true
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Signs and symptoms of Systemic Infection
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fever, increased respiratory rate and pulse (in response to the high fever), malaise, anorexia, nausea, and/or vomiting, enlarged lymph nodes, inflammation
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Inflammation. Define.
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The body's local response to injury or infection.
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Describe the 3 stages of inflammatory response.
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1. local infection.
2. killing of micro-organisms (exudate appears at the site) 3. damage tissue replaced by scar tissue. |
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Local infection. Describe.
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Redness (from dilation of arterioles bringing blood to the area)
warmth of the area on palpation edema pain or tenderness Loss of use of the affected area. |
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How does exudate leave the body?
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by draining into the lymph system.
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What are the types of exudate?
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Serous (clear)
Sanguineous (contains red blood cells) Purulent (contains leukocytes and bacteria) |
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What lab results indicate infection?
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Leukocytosis (WBCs > 10,000/ uL)
Elevated erythrocyte sedimentation rate (ESR) Presence or micro-organisms on culture of the specific fluid/area. |
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Components of the chain of infections
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1. Infectious agent (bacteria, virus, fungi, protozoa),
2. Reservoir where the infectious agent grows (wound drainage, food, oxygen tubing) 3. Exit portal (skin, respiratory or gastrointestinal) 4. Means of transmission (droplet, person to person, touching contaminated items) 5. An entry portal to a susceptible host (same as exit) 6. A host that must be susceptible to the infectious agent. |
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How to control infection
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1. Encourage the client to consume an adequate amount of fluids bc this prevents the stasis (passage) of urine by flushing the urinary tract and decreasing the growth of microorganisms.
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Airborne precautions are used to protect against _____ infections smaller than 5mcg. Examples.
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droplet;
measles, varicella/shingles, TB |
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Airborne precautions require...
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A private room (isolation),
N95 masks, negative air pressure room |
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Droplet precautions protect against droplets larger than 5 mcg
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Mumps, pneumonia, scarlet fever, rubella, pertussis, mycoplasma, meningitis, influenza B strep, pharyngitis
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Droplet precautions
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mask
isolation |
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Contact precautions. What do they require?
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protect visitors and caregivers against client/environmental contact infections.
A private room, gloves and gown, |
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Clean contaminated equipment in ____ water first. why?
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Cold, because hot water coagulates proteins, making them adhere (stick).
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Then wash with hot water and soap.
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True
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Why do we report communicable diseases?
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ensure proper medical treatment (TB)
monitor for common source outbreaks (foodborne-hep A) plan and evaluate control and prevention plans (immunizations for prevention) Identify outbreaks and epidemics determine public health priorities based on trends. |
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Falls. If a patient has orthostatic hypotension, instruct patient to....
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avoid getting up too quickly, to sit on the side of the bed for a few seconds b4 getting up, and stand at the side of bed for a secs b4 walking.
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Class A B C fire extinguisher
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A- paper, wood, upholstery, rags, trash fires.
B- flammable liquids and gas fires. C- electrical fires |
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To initiate a plan of care the must do what 4 things.
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1. identify risk factors using a risk assessment tool
2. complete a nursing history 3. a physical exam 4. a home hazard appraisal. |
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To prevent falls in infants and toddlers, keep crib and playpen rails ___
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up.
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Use ______ facing car seat until the infant toddler is 1 or at least 20lbs.
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backward
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Use ____ ______ for children under 4'9" and weigh less than 40. (usually 4-8 years old)
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booster seat
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A decrease in _______ sensitivity may place an older adult at risk for burns.
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tactile
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Risks with maternal smoking
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low birth weights, still birth, prematurity, sudden infant death syndrome.
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Smoking in front of children risks
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bronchitis, pneumonia, middle ear infections
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Why is carbon monoxide dangerous?
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Because it binds with hemoglobin and reduces oxygen supplied in the tissues in the body.
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Primary prevention
Secondary Tertiary |
Primary addresses the needs of healthy clients to promote health and prevent disease. Ex. immunization programs, nutrition and fitness activities
Secondary focuses on early identification of people experiencing illness, providing treatment, and conducting activities. ex STD screening, exercise programs. Tertiary- aims to prevent long term consequences of a chronic illness or disability. Ex. prevention of pressure ulcers as a complication of spinal cord injury. |
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define cognitive learning.
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Obtaining new information, being able to apply the information and being able to evaluate the information.
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define affective learning
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involves feelings, beliefs, and ideals. ex. nurse tells pt the necessary lifestyle changes and pt expresses feelings about the diagnosis.
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define psychomotor learning.
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learning how to complete a physical activity or motor skill. Pt must DEMO.
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The infants posterior fontanel closes by...
Anterior fontanel closes by... |
2-3 months of age.
12 to 18 months. |
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How much weight does the infant gain in the first 6 months?
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150 to 210g (5-7oz) per month.
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Birth weight should ___ by 4 to 6 months and ____by the end of the year.
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double; triple
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Infant head increases about _____ cm per month in the first 6 months and then _____ cm in the next 6-12 months.
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1.25; 0.5cm
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6-8 teeth by the end of the first year
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True.
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How to clean infant's teeth?
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by a cool wet washcloth
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What occurs during Piaget?
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sensorimotor stage (birth to 1 year)
separation, object permanence, and mental representation. |
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Examples:
separation object permanence mental representation |
knows how to separate themselves from the environment
knows object still exists when out of view. recognition of symbols. |
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What is an infant's stage of psychosocial development?
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Trust Vs. mistrust
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When does separation recognition occur?
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During the first year as the infant learns his physical boundaries from that of other people.
Learning how to respond to people in his environment is the next phase |
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When does separation ANXIETY develop? Stranger fear?
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during 4 and 8 months. 6 to 8 months.
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Breastfeeding provides a complete diet and is recommended for the first ___ months.
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6
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What is an alternative to breast milk...
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iron-fortified formula. Cow's milk is not recommended.
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When can solid food be introduced to an infant?
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between 4 and 6 months.
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Milk, eggs, wheat citrus fruits peanuts and honey should be avoided until...
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after the 1st year.
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Toddler's stage of psychosocial development.
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Autonomy vs shame and doubt
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Toddler's develop gender identity by age 3.
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true.
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How much milk per day for a toddler?
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34 to 30 oz and may switch from drinking whole milk to 2% milk at 2 years of age.
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how much juice per day?
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Limit to 4-6 oz per day.
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May have to expose new food __ to ___ times b4 toddler accepts.
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8 to 15 times.
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Where would you hear tympany?
Resonance? Dull Flat |
Abdomen, gastric bubble.
Lungs Liver Muscles |
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You ____ for kidney tenderness
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percuss
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Use ____surface for vibration
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ulnar
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Temp reflects the balance between
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heat produced and lost from the body.
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Respiration is the body'd mechanism for exchanging ___ and ____ ______
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oxygen and carbon dioxide
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Systole
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It measures the amount of pressure that blood exerts on arteries and vessels while the heart is beating.
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Diastolic
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It is the pressure that is exerted on the walls of the various arteries around the body in between heart beats when the heart is RELAXED.
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Core temps
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Rectum, tympanic membrane, bladder
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Surface
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skin mouth axillae
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Normal oral temps
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36-38 C 96.8 to 100.4. Average is 37, 98.6
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REctal and (temporal) _____ than oral
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higher 0.5
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Axillary and tympanic _____ than oral
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lower
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Temporal is 1C (2F) higher than
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axillary
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Heat production causes
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increase in basal metabolic rate
muscle activity thyroxine output sympathetic stimulation |
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Heat loss
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conduction- transfer of heat from the body to another surface (when the body is immersed in cold water)
convection dispersion of heat by air currents Evaporation- dispersion of heat through water vapor Radiation- transfer of heat from one object to another object without contact between them (heat lost from the body to a cold room) |
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Newborns have a large surface to mass ratio: therefore they lose heat rapidly to the environment.
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True
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Newborn temps
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36.5 and 37.5 and 97.7 and 99.5
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Older patients experience a loss in subcutaneous fat that results in lower body temp.
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true
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Temp ______ ovulation and menses. with menopause, body temp may increase by up to ____
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4c 2f
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Define hyperthermia
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Elevated body temp
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Development of hyperthermia can be due to
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exercise, activity and dehydration
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______ is the body's response to
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infection or inflammatory response
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rectal temp and resistance?
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remove immediately.
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When is fever harmful?
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when it exceeds 39C or 102.2
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Medication class for hyperthermia
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antipyretics, aspirin, acetaminophen, ibuprofen etc)
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Do not use aspirin for managing fever in
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kids who may have a viral illness (influenza, chickenpox) due to the risk of Reye syndrome.
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Hypothermia
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temp below 35C/ 95 F
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The ______nervous system controls heart rate.
The ______ nervous system lowers heart rate. The _____ nervous system raises heart rate. |
autonomic
parasympathetic sympathetic |
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Normal pulse
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60-100
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Normal pulse for infants
12-14 |
120-160
80-90 |
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reasons for tachycardia
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excerice
fever meds (epinephrine, levothyroxine, beta-adrenergic agonists, albuterol) laying to sitting or standing acute pain hyperthyroidism anemia, hypoxemia stress, anxiety, fear hypovolemia shock, heart failure |
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reasons for bradycardia
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long term physical fitness
hypothermia meds- digoxin, beta blockers, calcium channel blockers) standing to sitting to lying chronic pain hypothyroidism |
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Chemorecptors in the carotid arteries monitor carbon dioxide levels of the blood.
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True
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If carbon dioxide rises the ...... rises.
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respiratory rate. Increased respiratory rate rids the body of excess CO2.
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The process of respiration includes
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ventilation
diffusion perfusion |
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normal resp. rate
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12-20
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Resp rate in newborns
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30 to 60 min
school age children 20-30 |
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Respiratory rate ____ with age.
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decreases
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