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63 Cards in this Set
- Front
- Back
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List the three types of transmission precautions |
Airborne (measles, varicella, TB)- Private room, N95 mask, negative pressure, full face protection if splashing/spraying possible Droplet (strept, flu, rubella, pertussis, mumps, pneumonia, sepsis)- Private room, masks Contact ( herpes, scabies, resistant organism infection, etc)- Private room, gloves & gowns, positive airflow, HEPA filtration, Mask for client out of room |
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list some therapeutic communication techniques |
Silence General leads Restating/rephrasing Seeking Clarification Offering Self Providing information Acknowledging Clarifying time or sequence Presenting reality Focusing Reflecting Summarizing/planning Open ended questions Touch |
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In regards to communication what is SBAR? |
S-Situation (what is happening) B-Background (what is the relevant clinical hx) A-Assessment (what do I think the problem is) R-Recommendation (what would I do to correct) R-Response (what is appropriate, what will I do?) |
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List some non-therapeutic communication techniques |
Stereotyping Agreeing/disagreeing Being defensive Challenging Probing ("why...) Testing Giving advice Excess/irrelevant questioning Unwarranted/false reassurance Passing judgment Offering personal opinion Sympathy |
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True or false: It is expected that a newborn will lose 5-10% of birth weight in the first few days and regain it by the second week |
TRUE |
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Describe the basis of Piaget's theory of development and the four stages with appropriate age ranges for each |
Focused in the way which fundamental concepts such as numbers, time, quantity, justice evolve. Sensimotor- infant (2 days-1 year) Preoperational- Toddler/Pre school (1 year-6 years) Concrete operational School aged/adolescent (6 years- 20 years) Formal operational Young adult+ (20+ years) |
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Describe the basis of Erikson's theory of development and the eight stages with appropriate age ranges for each |
Theory of psychosocial development, positive vs negative resolution. Infancy (2d-1 yr)- Trust vs mistrust Early childhood(1-3 yr)- Autonomy vs shame&doubt Late childhood (3-6 yr)- initiative vs guilt School age (6-12 yr)- Industry vs inferiority Adolescence (12-20 yr)- identity vs role confusion Young adult (20-35 yr)- Intimacy vs isolation Middle adulthood (35-65 yr)- generativity vs stagnation Maturity (65+ yr)- integrity vs dispair |
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List some red flags in G+D for infants |
Unable to roll at 6 months or sitalone by age 9 months Unable to transfer objects fromhand to hand by age 1 year Abnormal pincer grip or grasp byage 15 months Unable to walk alone by 18 months Failure to speak recognizable wordsby 2 years. |
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List some red flags in G+D for toddlers |
Can’t walk ( at 18 mos) Doesn’t copy others Doesn’t know what to do with commonthings..Doesn’t have at least 6 words Doesn’t mind when caregivers leavesor returnsLoses skills he once had |
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List some red flags in G+D for preschoolers |
Inability to perform self-caretasks, hand washing simple dressing, daytime toileting Lack of socialization Unable to follow directions duringexam Can’t tell what’s real or makebelieve Doesn’t draw |
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List some red flags in G+D for school age children |
School failure Lack of friends Social isolation Aggressive behavior |
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List some red flags in G+D for young adults |
Notresolving conflict (intimacy vs isolation) Theyoung adult must be willing to be open and committed to another individual. |
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List some age appropriate activities for an infant |
Short attention span, engage in solitary play Appropriate toys/activities that stimulate the senses and encourage development: rattles, mobiles, teething toys, balls, etc |
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List some age appropriate activities for a toddler |
Parallel play, temper tantrums expected-providing consistent age appropriate expectations helps work through frustrations Offer choices such as juice OR milk instead of providing opportunity for yes/no response Toilet training can begin w/ awareness of urge Discipline should be consistent w/ well-defined boundaries |
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List some age appropriate activities for a preschooler |
Parallel play shifts to associative play (playing with others). Appropriate activities include Playing ball puzzles riding tricycles Pretend/dress up activities musical toys painting/drawing/etc roleplaying toys (toy kitchen) illustrated books |
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List some age appropriate activities for school aged children |
Competitive/cooperative play Play board/video/number games hopscotch jumprope bicycles simple models team sports |
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List and describe different routes of med administration |
PO (oral)- Absorbed through GI tract. Affected by gastric pH, food in GI, emptying time, solubility of med Injection (IM, SubQ) Absorbed through capilary wall. Affected by solubility in water, blood perfusion IV- Absorbed through blood stream, fastest ROA, no barriers to absorption Topical (creams) Intradermal Vaginal/rectal sublingual ( under tongue) Inhalation Intranasal Eyes/ears |
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What is first pass effect? |
The liver inactivates some medications on their first pass through the liver which decreases bioavailability, thus may require a nonenteral route (sublingual, IV) |
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What can metabolism of meds be affected by? |
Nutritional status- malnourished client may be deficient in factors needed to produce metabolizing enzymes Age- young/old have impaired liver/kidney function Gender Genetics |
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List the rights of medication administration |
Right client Right Med Right dose Right time Right route Right documentation Right allergies, expiration, to refuse |
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List proper lengths/gauges for IM,SubQ, ID injections |
ID- 1/4-1/2" 25-27 gauge SubQ- 3/8-1" (1/2,5/8" most common) 25-30 gauge IM- 5/8-1.5" 18-25 gauge |
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List appropriate sites for IM, SubQ, ID injections, list landmarks, and proper injection angle |
IM- Deltoid (2-3 fingers below acromial process), ventrogluteal (finger spread along illiac crest site between index and middle finger), Vastus lateralis (one hand above patella one hand below grater trochanter divide into thirds, outer middle third). most cases inject@90 degrees, less if insufficient muscle mass SubQ- Outer aspect of upper arm, Abdomen >2 inches from umbilicus, upper ventro/dorso gluteal areas, scapular areas of upper back. Inject@45-90 degrees |
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How should you guide teaching during infancy? |
Teaching directed toward parents Ask for info on child's strengths/limitations, likes/dislikes Provide detailed information to parents |
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How should you guide teaching to toddlers |
Allow play/manipulation of objects Use repetition/imitation of info Respond to simple step by step commands Teaching sessions no longer than 5 mins *Primarily directed to parents* |
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How should you guide teaching to preschoolers |
Use calm approach Build trust Allow manipulation of objects/equipment Use simple drawings/stories Stimulate the senses Use positive reinforcement |
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How should you guide teaching to school aged children? |
Capable of logical reasoning--keep it simple Welcome active participation Teaching sessions can be extended to 30 mins and spread apart for comprehension of large amounts of info Use diagrams/models/pics/vids Clarify scientific/medical jargon Use analogies |
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How should you guide teaching to adolescents |
Need for independence, allow for decision making wherever possible Develop a mutually respectful and trusting relationship Clarify scientific and medical jargon |
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How should you guide teaching to young/middle adults |
Adults are self-directed--they know what they want to know and expect to have voice in the educational process Create a climate of mutual respect Adults have life experience which should be considered and used to promote education Be an active listener Adult learning is usually problem or role centered |
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What are some things to consider when teaching the older adult? |
They have slower processing and reaction times Decreased short term memory Increased test anxiety Altered time perception |
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What are the three types of learners |
Visual Auditory Tactile |
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What are the 3 domains of learning? |
Cognitive- learning through lecture, reading Psychomotor- skill based. learned through imitation, practice, and habit Affective- Talk about how they feel about the skill |
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What is the TEACH acronym? (This will help with some of the more situational test questions) |
T- Tune into the patient E- Edit patient information A- Act on every teaching moment C- Clarify often H- honor the patient as partner in the education process |
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What is polypharmacy? What are some causes? Who suffers most from it? |
Polypharmacy is the overuse of medication. Some causes are multiple providers providing medications to treat side effects from other medications. Older adults suffer most from it. "Any symptom in an elderly patient should be considered a drug side effect until proven otherwise" |
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List and describe the different levels of prevention |
Primary- addresses the needs of healthy clients to promot health and prevent disease with specific protections. Decreases the risk of exposure to individual/community to disease. e.g. Immunization programs, child car seat education, proper nutrition, fitness activities, health education. Essentially all education and vaccination based prevention measures Secondary- Focuses on identifying an existing illness, providing treatment, and conducting activities that help prevent a worsening health status Tertiary- Tertiary prevention aims to prevent the long term consequences of a chronic illness/disability to support optimal functioning |
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List the 5 stages of sleep and describe the sleep cycle |
5 phases- NREM stages 1-4 (75%) & REM (25%) Stage progression- 1,2,3,4,3,2,REM,2,3,4,3,2,REM |
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List some common sleep disorders/disturbances |
Dyssomnias- difficulty getting to sleep or staying asleep Insomnia, sleep apnea, narcolepsy Parasomnias- waking behaviors that appear during sleep Sleep terrors, sleep talking/walking, nocturnal enuresis |
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What is insomnia? What are some assessment questions? Who is most prone? |
Inability to fall asleep or stay asleep as long as desired. Can be acute or chronic Assessment questions: Are you having difficulty....Falling asleep/staying asleep? Are you...getting refreshing sleep? Stressed? Depressed? Women and older adults most prone |
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What is sleep apnea? What are the different types? Who is affected? Assessment questions? |
Sleep apnea is the cessation of breathing during sleep (decreased arterial saturation levels) Two types: Central--a problem in the CNS that causes breathing to cease, Obstructive--caused by an obstruction of the airways Who is affected? Obese with short/thick necks, enlarged tonsils, adenoids, thyroid Assessment questions: Do you....Snore or gasp? Have apenic episodes (ask partner), wake up with headaches? Have daytime sleepiness? |
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What is narcolepsy? Assessment questions? Nursing concerns? |
Narcolepsy is sudden attacks of sleep or excessive sleepiness during waking hours. Brain does not regulate sleep-wake cycle: Immediate REM Assessment questions: Are you unable to move when first wake? Lose muscle control with strong emotions? Dream with naps? Hallucinations as you fall asleep or wake up? Uncontrolled/instant sleep? Nursing concerns: Can cause high risk for injury in daily activities |
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What is nocturnal enuresis? Different stages/types? Assessment questions? |
Nocturnal enuresis is involuntary urination that happens at night while sleeping after the age when a person should be able to control their bladder Stages/types: Primary-- Never attained dryness, Secondary-- Wetting again after being dry for at least 6 months Assessment questions: Parent history? Primary vs secondary? Affecting self esteem? |
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What are sleep terrors? Treatment? Nursing considerations? |
Sleep terrors are a sleep disruption that seems similar to a nightmare but with more dramatic presentations. During an episode pt might: Sit up in bed, scream, shout, kick, or thrash, sweat, breath heavily, have a racing pulse, can be hard to awaken, can be inconsolable, engage in aggressive behavior. Treatment: Ride it out. Use scheduled awakenings to reduce occurrences, maintain safety by removing hazardous objects from sleep area Nursing considerations- Establish bedtime routine and rituals, limit waking (cluster care), Light carb meal before bed, promote comfort, sleep study referal, teaching/evaluating (proper sleep hygiene, sleep diary), promote OTC sleep aids |
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List five steps of the nursing process |
Assessment/data collection Analysis/connections Planning/outcomes Implementation/Interventions Evaluation |
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List Gordon's functional Patterns |
Cognitive/perceptual Activity/exercise Elimination Nutrition/metabolic Sleep/rest Coping/stress tolerance Health perception/management Self-concept Sexuality Role/relation Value-belief |
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What are some examples of nursing Dx for health perception/management? |
Deficient knowledge Risk-prone health behavior Ineffective health maintenance Noncompliance |
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How are nursing diagnosis' structured? |
NANDA diagnosis R/T (related to) primary causative factor(s) secondary to medical diagnosis (or other factor). The “secondary to” part of a nursing diagnosis is optional ex:IneffectiveAirway Clearance R/T tenacious secretions secondary to pneumonia. |
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What are the three types of exercise? |
Isotonic: Exercise Running , walking, swimming Muscle shortens to produce musclecontraction and active movement. Increase muscle tone, mass, and strength.Maintain joint flexibility and circulation. Heart rate and cardiac outputincrease Isometric: Exercise Squeezing a pillow between kneesMuscle contraction without moving thejoint (muscle length does not change). Involve exerting pressure against asolid object. Isokinetic: Lifting weights. Muscle contraction or tension againstresistance. Can either be isotonic or isometric. Person moves (isotonic) ortenses (isometric) against resistance. An increase in blood pressure and bloodflow to muscles occurs s of the body |
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What are some body system changes that are affected by immobility? (integumentary, respiratory, cardiovascular, elimination) |
Integumentary- increased pressure on skin, decreased circulation to tissue--ischemia, pressure ulcers Respiratory- Decreased oxygenation, CO2 exchange, stasis of secretions, decreased cough response Cardiovascular- othostatic hypotension, LFV, venous stasis, decreased cardiac output, **increased risk for clot development (DVT->PE)** Elimination- Urinary stasis, decreased peristalsis |
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Nursing assessment/interventions for immobility? (integumentary, respiratory, cardiovascular, elimination) |
Integumentary- Observe for skin breakdown, turn every 1-2 hrs, use supportive devices, monitor nutritional/fluid intake, provide skin and perineal care Respiratory- auscultate lung sounds, observe for productive cough, reposition every 1-2 hrs, promote coughing/deep breathing exercises, encourage incentive spirometer, encourage proper fluid consumption to promote secretion movement Cardiovascular- Palpate for edema, assess for DVT,increase activity ASAP, encourage isometric exercises, change positions as much as possible, use antiembolic devices, increase fluid intake Elimination- Assess I&O, auscultate bowels, maintain hydration, provide perineal care |
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Describe the renin-angiotensin-aldosterone cycle and medical interventions related to it |
Kidneys experience decreased blood flow (*hypertension*, blood loss, etc) and start RAA cycle to elevate BP. Kidneys produce renin->converts angiotensinogen from liver to angiotensin I->ACE from lungs converts to angiotensin I to angiotensin II (powerful vasoconstrictor, increases BP) which causes the release of aldosterone which holds onto Na+ and H2O, increasing BP even more Interventions: ACE inhibitors, angiotensin II receptor blockers |
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List and describe the 4 different types of stress |
Internal- Caused by disease, anxiety, nervousness External- Cause by outside events. death of a family member, environmental events Situational- Unpredictable- adjusting to chronic illness, job change, accidents Developmental- Predicted to occur at various stages of life |
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What is local adaptation syndrome? |
Reflex pain response- hand in hot water--automatically pulls back Inflammatory response |
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What are the three stages of general adaptation syndrome? |
Alarm- Stressor upsets homeostasis or cellular balance. SNS activated Resistance- Body fights back by adjusting to stress. Adaptation takes place Exhaustion- Rest permits enhanced adaption and recovery |
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What are the four levels of anxiety? |
Mild- Normal. can have a positive effect, increases alertness and senses. happens daily. Presents as restlessness, increased questioning Moderate- "Butterflies in stomach". Focus shifts to immediate concerns. narrowing of perception, inattention to other details. Presents as quivering voice, tremors, increased muscle tension, RR+HR increase Severe- All behaviors focused on getting relief. Easily distracted, impaired learning and performance. Extreme fear of non-existent danger. interferes with everyday life. Presents as difficulty communicating, increased motor activity, fearful facial expression, headache, nausea, dizziness, tachycardia, hyperventilation Panic- Loss of control, experiencing dread/horror. Presents as loss of logic/rational thought, increased physical activity, distortion of events, severe difficulty communicating. |
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What are some healthy coping mechanisms? |
Healthy ADL's Relaxation/meditation Anticipatory guidance Guided imagery biofeedback |
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What are some altered coping mechanisms? |
Addictive behaviors Physical illness Anxiety and depression Violent behaviors |
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What is a crisis (stress/coping) and what are some interventions? |
A crisis is the temporary state of severe emotional disorganization caused by failure of coping mechanisms/lack of support Interventions- 1- Identify the problem 2- list alternatives 3- choose from alternatives 4- implement the plan 5- evaluate the outcome |
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What are the different types of pain? |
Acute pain- Protective, temporary, has direct cause and resolves with tissue healing. Chronic- lasts >3 months, may/may not have well-defined cause, may be accompanied by depression and fatigue. Noriceptive- Cause by damage to or inflammation of tissues. Presents as throbbing, aching, localized. Three types: Somatic--in bones, muscle,joins,skin. Visceral--pain arising from internal organs. Cutaneous--pain arising from skin or subQ tissues Neuropathic- Caused by abnormal or damaged pain nerves. Presents as intense, shooting, burning. *responds to adjuvant medicines--antidepressants, antispasmotics, muscle relaxers |
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Describe proper pain assessment methods (PQRST) |
P- Provocation Q- Quality/Quantity R- Region/radiation S- Severity scale T- Timing |
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What are appropriate medicines for mild/moderate/severe pain management? |
Mild pain (1-3)- use nonopioids such as acetaminophen Moderate pain (4-6) use weaker opioids like oxycodone/hydrocodone Severe pain (7-10) use strong opioids such as morphine, hydromorphone, fentanyl |
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What are some nursing interventions for pain management? |
Advocate for pain management Avoid labeling/judging Treat pain early Avoid acetaminophen toxicity |
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What are some side effects of pain medications?
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Respiratory depression-- <8 Sedation Nausea/vommiting Constipation Urinary retention Blurred vision Sexual dysfunction |
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What does PERRLA stand for? |
Pupils Equal Round Reactive to Light and Accommodating |
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What are some common NANDA diagnoses for the cognitive pattern? |
Altered thought process Social isolation Risk for injury Acute confusion Chronic confusion |
