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175 Cards in this Set
- Front
- Back
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Intra-personal Communication
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within the individual- thoughts influence perceptions, behaviors, self-concept
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Inter-personal Communication
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between two persons, allows problem solving, decision making and personal growth
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Public Communication
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interaction with large group, speaking at a lecture
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Referent
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stimulus motivates person to communicate with another
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Sender (Encoder)
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person who initiates interpersonal communication
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Receiver (Decoder)
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person who recieves the message and interprets the message
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Channel
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Means of conveying and recieving messages through any of the senses
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Feedback or response
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the message returned by the receiver, indicates if the meaning or the message was understood
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Interpersonal variables
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factors within both the senderand receiver that influence communication
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Environment
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setting for sender-receiver interaction
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Most important Mode of Communication
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Listening
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Cultural Influence on Communication
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Sociocultural background influence the way we communicate
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Intimate Space
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18 Inch area
Used when giving care |
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Personal Distance
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18 inches to 4 feet
Sitting for an interview Teaching a client |
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Social Distance
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4 feet to 12 feet
Making rounds, support group |
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Public Distance
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more than 4 feet
public speaking |
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Therapeutic Communication is:
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Patient centered
Goal oriented |
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Empathy
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Ability to understand and accept another person's reality
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Sympathy
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expression of one's own feelings about another's predicament
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Autonomy
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An ability to be self-directed
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Mutuality
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Involves sharing with another
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Effects of NG Tube
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Allows removal of gastric secretions
Introduction of solutions into stomach |
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Measure for NG Tube
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Distance from tip of nose to earlobe to xiphoid process
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Purposes of NG Tube
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Decompression
Feeding Compression Lavage |
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Decompression
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Removal of secretions and substances from GI tract
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Common types of Decompression NG Tube
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Salem Sump
Levin Miller-Abbot (most-common) |
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Feeding (gavage)
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Liquid nutritional supplements or feedings into the stomach
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Types of Feeding
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Duo
Dobhoff Levin |
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Length of Use for Feeding Tube
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Less than 1 month
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Compression
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Prevent internal esophageal or GI hemorrhage
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Lavage
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Irrigation of stomach in cases of active bleeding, poisoning or gastric dilation
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Solution for Irrigating NG Tube
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Normal Saline
20-30cc |
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PEG Tube
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Percutaneous Endoscopic Gastrostomy
Surgically insertion into stomach or jejunum |
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Pupose of PEG Tube
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allow for liquid feedings on long term basis
Bettter tolerated than NG tube |
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How do you confirm placement of a PEG tube?
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by x-ray
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Complications of PEG
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Dislodgement
Infection Distention |
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Care of client with PEG tube
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Assess for abdominal complications
Signs of infection at insertion site |
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How do you asses for patency of a PEG tube?
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Flushing with 30cc of water
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If residual is greater than __cc, then ____
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100cc, do not re-infuse and notify MD
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Stop continuos feeding machine how long before?
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30 minutes prior to procedure
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Indications for IV's
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Give meds too irritating for other route
Avoid discomfort of frequent injections Maitain constant blood level of a med Provide fluid and electrolyte replacement |
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Type of Insulin given IV
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Regular Insulin
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Hydrating Solutions
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D/W, D/S, Norm Saline, LR
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Blood Transfusions
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Plasma, RBC's, Whole Blood
Platelets, Albumin |
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Total Parenteral Nutrition
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Solution that provide calories and nutrients
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Important Facts about TPN
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Never stop abruptly (cause hypoglycemia)
Ordered per 24 hrs Never used w/ peripheral IV's |
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Types of Infusions
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Peripheral
Central Continuous Intermittent (Hep-lock) |
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How long are IV tubes good for?
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72 hours
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KVO
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Keep vein open
TKO |
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Infiltration
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IV fluids enter the SQ space around IV site
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S/S of Infiltration
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Swelling
Pallor (decreased circ at site) IV flow rate decreases or stops Coolness and discomfort |
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Treatment of Infiltration
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D/C IV infusion
Re-insert IV into another site Elevate extremity Wrap extremity in warm towel for 20 mins |
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Phlebitis
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Inflammation of the vien
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Risk Factors associated with Phlebitis
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Type of catheter material
Chem irritation from additives Anatomical position of catheter |
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Major Risk associated with Phlebitis
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Developing thrombophlebitis which can become an emboli
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Prevention of Phlebitis
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Removal and rotation of IV sites every 48-72 hours
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S/S of phlebitis
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Pain, Edema, Erythemia
Increased skin temperature Redness traveling along path of vein |
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Treatment of Phlebitis
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D/C IV line
Re-insert IV Apply warm, moist heat |
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Delgation Authority for IVs
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Maybe w/in SOP for LPN
Cannot be delegated to UAP |
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JACHO
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Joint Comm. on Accred. of Health Care
agency that accredits hospitals |
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Client's Record
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Provides a timeline
Establish a baseline Legal document of client's health status |
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Documentation and Reporting must be...
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Factual, Accurate, Complete, Current, Organized, Confidential, and Legible
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Types of Reports
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Change of shift, Telephone Reports, Transfer reports, Incident reports
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Transfer Reports
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Must talk to RN, not the unit clerk
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Incident Reports
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Any event not consistent w/ routine operations
Don't record in nurses notes Nurse who witnesses event completes report |
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Problem Oriented Medical Record
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Arranged according to problems a client has
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Legal Guidelines for Charting
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Do not chart opinions
Record only facts Record legibly and in ink |
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How do you correct an error on a chart?
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Single line through entry with initials
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Address charting in which direction?
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Head to toe
think logically & systematically |
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Incontinence
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Involuntary loss of urine
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Retention
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unable to void although there is enough urine in bladder
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Suppression
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cannot void b/c bladder is empty
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Diuresis
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Increased urine formation
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Polyuria
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Excessive urine output
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Oliguria
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diminished capacity of urine
100-400cc per day |
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Anuria
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less than 100cc per day
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Gluycosuria
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Glucose in urine
Must be above 180 |
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Cystitis
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inflamed or irritated bladder
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Nocturia
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frequency at night not result of increased intake
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Dysuria
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pain or burning on urination
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Residual Urine
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Retention in bladder after voiding
greater than 100ml <100ml is normal |
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Enuresis
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nighttime wetting after 5 yrs old
prevalent in boys |
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Primary Enuresis
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Never been dry at night
Always wetting the bed |
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Secondary Enuresis
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Aquired after being dry
Result of trauma |
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Hematuria
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Blood in urine
Early sign of bladder infection |
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Capacity of bladder
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600cc
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Retention is ___cc to ___cc
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1000-3000
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Normal Volume of Urine
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60-120 ml/hr
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Polyuria more than ___ ml/day
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2000 ml/day
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Normal Color of Urine
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Straw to Amber
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Causes for Discoloration of Urine
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Dark amber- dehydration
Red or pink- hematuria Meds can discolor urine |
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Cloudy Urine
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Pus from Infection
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Foamy Urine
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May contain protiens
Abnormal finding |
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Sweet Odor of Urine
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Diabetes
Glucose in urine |
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Offensive Odor of Urine
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Pyuria
Caused by bacteria |
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Specific Gravity Testing
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Tells concentration of urine
Normal is 1.010-1.025 |
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Protein in Urine
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Not normally found
May be found after strenous excercise up to 10 mg/ml |
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Blood in Urine
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Up to two RBC's
Seen in truama & menstruating women |
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Complications in Pts with long-term foleys
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Have to re-train bladder
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Peristalsis
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Reduced motility
Part of the aging process |
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Constipation
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Symptom not a disease
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Fecal Impaction
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Results from unresolved constipation
Continuous oozing of diarrhea stools |
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Black Stool
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Blood in upper GI
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Bright Red Stool
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Blood in lower GI
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How does exercise affect bowels?
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Improves GI motility
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Cholinergic drugs
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Increase contraction of bladder and improve emptying
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Anticholinergic Drugs
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Reduce incontinence
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Ways to eliminate constipation
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Prune juice, fresh fruit
Hot meals x 3 days Increase exercise |
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Enema
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Instillation of a solution into rectum and sigmoid colon
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Puposes of Enemas
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Promote defecation by stimulating peristalsis, temp relieve constipation, remove impacted feces
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Types of enemas
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Cleansing
Oil Retention Harris Flush Medicated Enemas |
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Safest type of Cleansing enema
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Normal Saline- same osmotic pressure
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Purpose of Oil Retention Enemas
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lubricate rectum and soften feces
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If order reads "enemas till clear"
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repeat enemas till fluid is clear
Maximum of 3 Check with MD before giving more |
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Teaching is an _____
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Interactive Process
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Learning is the
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acquisition of knowledge
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Learning Need
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Gap b/w the info a client knows and the info necessary to perform a specific function
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Who sets the guidelines for client education?
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JACHO
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When teaching infants it is important to
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Asses the learning needs of the parents
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When teaching toddlers
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Include parent participation, simple explanations, pictures
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When teaching preschool age
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use dolls or puppets to demopnstrate
Role playing |
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When teaching school age
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Use different forms of play
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When teaching adolescents
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Use the problem solving method
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Ectomy
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removal of an organ or gland
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Rrhaphy
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suturing or stiching
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Ostomy
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providing an opening
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Plasty
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palstic repair
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Scopy
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looking into
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Urgent surgery
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prompt attention within 24 hours
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Ablative Surgery
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Removal of diseased body part
amputation, tonsils |
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Palliative Surgery
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does not cure, reduce or relieve symptoms
tumor debulking |
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Serum creatinine/BUN blood levels
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indicate renal function
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Incentive Spirometer use
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reduces collapse of alveoli
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Consecutive coughs that help remove mucous more effectively than one forceful cough
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Controlling cough
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Purpose of SCD's and AE hoses
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Promote venous return and prevents circulatory stasis
Reduce risk of thrombi |
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3 Elements of Informed Consent
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Given voluntarily
Given by individual w/ full mental capacities Info provided to allow for informed consent |
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All consents must be signed when?
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prior to administration of sedatives
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If sedatives are given before consent is signed?
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Must wait 4 hours for sedation to wear off
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When the nurse witnesses a client's signature of consent it means what?
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The nurse is stating that this is indeed the signature of the client, not that the client understands the procedure
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If consent can't be obtained by the pt in an emergency
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Consent can be given by next of kin
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For children under 18 years old
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Consent given by parents or legal guardians
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When consent is given over the telephone...
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Need two persons to hear consent
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Reasons for giving pre-op medications
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Reduce client anxiety
Reduce amount of gen anesthesia Reduce risk of nausea/vomiting |
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Benzodiazepines
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Pre-anesthetic agent that reduces anxiety and provides sedation (Versed, Valium, Ativan)
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Barbiturates
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Provide sedation
(Seconal, Nembutal) |
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H2 Blocking Agents
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Promote gastric emptying
(Reglan, Pepsid) |
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Antacids
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Decrease gastric acidity
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Anti-nausea agents
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Reduce probability of aspiration
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Anticholinergics
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Dry secretions and decrease risk of aspiration
(Atropine) |
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Opiods
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Decrease intraoperative anesthesia requirements
(Demerol, Morphine) |
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Principles of OR safety ensured by Nurse
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Preoperative verification process
Marking operative site Time-out before starting procedure |
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3 Classifications of Anethesia
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Concious
Regional General |
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Types of Regional Anesthesia
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Local Anesthesia
Nerve Block Epidural Spinal |
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What type of pts would beneifit from a Nerve Block?
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Pts w/ COPD, lung issues, heart issues
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Pts with which anesthesia can't have HOB elevated after surgery?
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Spinal anesthesia
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3 Stages of General Anesthesia
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Induction
Maintenance Emergence |
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Highest priority of assessment in PACU?
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Respiratory function
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Client needs a score of __ on the Aldrete score before being discharged from PACU
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8 out of 10
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Aldrete Score assess what?
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Activity, Respiratory, Circulation, Consciousness, O2 sat
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Treatment for pts who are shivering
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Oxygen
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Do not remove OPA until...
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Pt's gag reflex returns
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Atelectasis
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collapsed lung
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Treatment for hypopharyngeal obstruction
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jaw thrust
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PARSAP
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Post Anesthesia Recovery Score for Ambulatory Patients
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Early signs of malignant hyperthermia
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tachycardia, tachypnea, jaw muscle rigidity
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For pts post abdominal surgery, keep NPO until when?
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Bowel sounds return
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Reduced glomerular function is what?
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a normal physiological change associated with aging process
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Post operative Complications
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Shock
Thrombophlebitis, Pulm. Emboli Urinary Retention |
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Primary Shock
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Occurs at time of operation
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Intermediate Shock
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First few hours
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Secondary Shock
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Some time after operation
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Steps to reduce risk of Thrombophlebitis or embolus
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Leg exercises, OOB, wlaking, Anti-embolitic stockings, SCDs
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Dehiscense
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partial or complete separation of wound layers
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Evisceration
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Complete separation, intestines protrude
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Most important nursing intervention for pts who are vomiting
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prevent aspiration
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