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73 Cards in this Set
- Front
- Back
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14 A Explore how exercise and activity benefit physiological and psychological functioning
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affect: Body alignment/muscle tone body balance coordinated body movement friction ( force that occurs in a direction to oppose movement: e.g. a coma patient has more friction to get out of bed) exercise and activity (activity tolerance: amount of activity a patient can perform) |
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14A Benefits of Activity and Exercise
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Maintains and promotes health essential treatment for chronic illnesses regular physical activity and exercise enhance all functioning of all body systems: cardiopulmondary (endurance), mulsculoskeletal (flexibility, and bone integrity), weight control and maintenance (body image), and psychological well being. |
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14 B assess clients for activity intolerance
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Affected by: physiological, emotional, and developmental factors influence A. tolerance/intolerance 3 categories of exercise: isotonic (contraction e.g., walking, swimming with light resistance) isometric (tightening or tensing muscles to increase strength and muscle tone). This is the ideal exercise for patients that do not tolerate increased activity: eg hemiparalysis |
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14 c Explore interventions for patients with activity intolerance
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Interventions should consider any risk to patient and preexisting health concerns Goals: patient performs activity while maintaining appropriate HR, BP, BR Interventions must be patient centered with set priorities with assistance to prevent injuries and further complications Promote independence with teamwor |
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14c How much should you exercise? |
30 min/day of ADLs 3-5 times/week of moderate intensity activity Acute care: perform passive ROM, medicate 30 min before for pain |
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14 D Identify the effect of clients level of health, age, lifestyle, and environment on oxygenation |
Lung Volume: affected by age, gender, and height. Tidal volume affected by: health status, activity, pregnancy, exercise, obesity, or obstructive/restrictive conditions of the lungs (COPD). Regulation of Respiration: CNS of rate/depth/rhythm (medulla, aortic body, aortic/carotid body) which stimulate ventilation in response to blood gas levels |
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14 D factors that affect oxygenation |
Physiological factors (cardio/pulmonary) Decreased Oxygen Carrying capacity (hemoglobin) Decreased inspired Oxygen Concentration (caused by either environment or obstruction) Hypovolemia (shock or severe dehydration) Increased metabolic rate |
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14E Assess for manifestations of patients who have alterations in oxygenation |
Decreased hemoglobin production/anemia: fatigue, decreased activity tolerance, increased breathlessness, increased HR, pallor Hypoventilation : excessive retention of CO2, leads to respiratory acidosis/arrest. COPD patients: metal status changes, dysrhythmias, convulsions, death Hyperventilation: lungs remove CO2. caused by severe anxiety, infection, drugs or acid-base balance. rapid respirations, sighing breaths, numbness/tingling, lightheadedness, unconsciousness. Hypoxia: inadequate tissue oxygenation, restlessness, inability to concentrate, decreased level of consciousness, dizziness, behavioral changes. fatigued, agitated. increased PR,and rate and depth of respiration. Increased BP. Cyanosis: blue discoloration of the skin cause by desaturated hemoglobin. late sign of hypoxia. |
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14 F Identify interventions for clients with alterations in oxygenation
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goals: patients lungs are clear to auscultation, bilation lung expansion, coughs productivity Priority: maintain patient airway>improving activity intolerance. Pain: control pain facilitates coughing and deep breathing Also: LTCF/community setting: smoking cessation, exercise, or diet modifications. Health Promotion: Vaccines for respiratory illnesses/infections (H1N1) Healthy lifestyle: exercise is a key factor to maintain heart and lungs . Aerobic for lung function Environmental pollutants: avoid exposure to second hand smoke Dyspnea management (shortness of breath) hydration humidification nebulization (adds moisture or medications to inspired air) Postural drainage (chest physiotherapy)- depends on lobe |
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15a examine pathological and physiological influences on body alignment and joint mobility |
Path: postural abnormalities: congenital or acquired: affect body alignment, balance, appearance, pain, mobility Muscle abnormalities: eg. muscular dystrophy damage to CNS (trauma, stroke, bacterial meningitis) Direct Trauma to Musc.skel.system e.g. fracture |
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15b indentify changes in physiological and psychosocial function assoc with mobility and immobility |
Bed Rest: intervention, lose muscle strength 3%/day systemic changes: metabolic (decreases), respiratory (increases risk), cardio ( ortostatic hypertension (increase heart rate), increased cardiac workload, and thrombus formation). Musc. changes: protein breakdown, lost body mass. Skeletal: impaired calcium metabolism eg osteoporosis Urinary: increased UTIs, renal calculi |
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15C assess for correct and impaired body alignment and mobility |
depends on ROM, gait, exercise and activity intolerance, body alignment Alignment: assessed patient standing, sitting, or lying down. determine normal changes, identify deviations , identify trauma, gather info that contribute to incorrect posture: fatigue, malnutrition, psychological problems Looking for symmetry, straight posture, midline |
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15d Explore interventions with impaired body alignment and mobility
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goals: patient skin remains intact. patient is turned every 2 hours prevent work related injuries (lifting weights close to your body) Ambulation ROM exercises |
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15 H examine the impact immobility has on circulation
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orthostatic hypotension (^PR, dec pulse pressure, drop in BP) can lead to faintingThings to prevent: reduce cardiac workload (which is increased by immobility), preventing thrombus formation (hydration, heparin therapy, TEDs/SCDs, proper position, ROM)
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7A examine common misconceptions about pain
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Misconceptions: patients who are addicts overreact to discomforts patients with minor illnesses have less pain that those with severe physical alterations administering analgesics regularly lead to drug addiction the amount of tissue damage in an injury accurate indicates pain intensity health care personnel are the best authorities on the nature of a patients pain psychogenic (psychological in origin) pain is not real chronic pain is psychological patients who are hospitalized will experience pain patients who cannot speak do not feel pain |
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7c identify assessments methods for clients experience pain
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Monitor pain regularly-like a VS ABCDE approach (pg. 970) Ask about pain regularly. assess systematically Believe patient Choose appropriate pain control options Deliver interventions in a timely logical and coordinated fashion empower patients and family/encourage them to control their course as much as possible |
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7D explore guidelines for selecting and individualizing pain interventions that include non-pharm and pharmacological management
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flowchart (pg. 971) Assess preoperative patient assess develop collaborative plan (includes RN, MD, And pain team) Patient (and family) prep and preop interventions A) preop pain B) Analgesia OR No Preoperative Pain then intraoperative anesthesia and analgesia initiate preemptive measure for pain control postop management |
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7C Pain Assessment in a nonverbal patient
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symptoms: hitting, fearful expressions, combativeness, resistance to care If behaviors seem pain related, dose and wait 24 hours to see if improved..most likely pain is the problem (administer nonopiod drugs) if behaviors persist, administer a single low dose short acting opioid (morphine). observe effect |
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7D Nonpharmacological pain interventions
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To be used WITH and no in place of pharmacological measure eg. cognitive behavioral and physical approaches Cog: distraction, prayer, relaxation, guided imagery, music, and biofeedback Phy: provide pain relief , correct physical dysfunction, alter physiological responses, and reduce fears Chriopractic/acupuncture: are examples of physical approaches, also massage |
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7D Acute care pain management |
Eg. surgery or trauma Key to success is ongoing of interventions: pain relief? unacceptable side effects from the meds? |
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7D pharmacological pain relief interventions
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analgesics: most common and effective. 3 classes of analgesics: 1)nonopioids- asprin and nonsteroidal anti-inflammatory drugs 2) opioids-aka narcotics. 3) adjuvants- a variety of meds that enhance analgesics or have analgesic properties that were originally unknown. |
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acetaminophin
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Tylenol. most tolerable and safest of all analgesics. no antifinlammtory effects major adverse effect is hepatotoxicity paired with opioids frequently |
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Aspririn and ibuprofin
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mild to moderate acute intermittent pain for muscle strain or headache |
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Opioids
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prescribed for moderate to severe pain act on higher centers of brain and spinal cord to modify perfections of pain Can cause respiratory depression and sedation |
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7 E evaluate clients response to pain interventions
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Ask patient to obtain: current pain level how far away is pain level from goal Any psychological responses? any side effects from meds any limitations because of uncontrolled pain if pain is altering/limiting rest or sleep |
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8B summarize methods of nutritional assessments
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screening: height, weight, weight change primary diagnosis and presence of other comorbidities Observation of nutritional history: patterns, cultural influences, attitudes and beliefs Anthropometry: measurement system of size and makeup of body. example BMI, and IBW. overweight after 25. medical risk of coronary artery disease, cancer, DM, and HTN Lab/biochemical tests: tests plasma, albumin, transferrin, retinol, hydration Diet and Health History: accurate history with preferences, allergies and relevant info like the patients ability to acquire food. Activity level/illness history Physical Examination Dysphagia (difficulty swallowing)-might be a symptom of a nuero problem, etc. |
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8 C Identify interventions related to clients with alteration in nutrition
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Goals: physiological, therapeutic, and individualized Nutritional counseling Health promotion: education patient and families for things like meal planning/budgeting/food safety Acute Care: diagnostic testing can disrupt food intake (NPO) advancing diets: acute/chronic patients might need special diets because of being immunocompromised Promoting appetite: offer smaller more frequent meals, certain meds affect taste/smell/nausea, provide oral hygiene |
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8E Summarize the care of clients receive enteral feedings
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Tube feeds: patients are unable to ingest food, but still able to digest and absorb nutrients 3 kinds: Nasogastric: nose surgically (ileum/jejunum) endoscopically (percutaneous endoscopic gastromoy or jejunoscopically placed tubes preferred for long term feeding more than 4 weeks) to reduce the discomfort of the nasal tube. more safe/reliable/easy access. Better for patients with history of aspiration pnuemonia |
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8f Summarize the care of clients undergoing gastric decompression via nasogastric tube
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Get order/assess patientput patient into High Fowlersmeasure tip of nose-xiphoid process-earlobe for tube lengthflush tube prior to insertionuse clean gloves lubricate tube and dip into glass of waterinsert through nose, aiming back and down toward earhave patient flex head toward chest after tube has passed through nasopharynxencourage patient to swallow/eat icechips when tube meets ear, pause and listen for air exchange.continue insertion as patient swallowskeep tube secure as you check gastric PH to verify placement of tube
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6 Nutrient categories
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carbs fats proteins water vitamin mineral |
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Enteral Tube feedings |
Needs an initial X-ray check Remember to turn off NG tube before listening to bowel sounds |
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Preoperative diets
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NPO, Clear liquids, full liquid, soft or general diet. Usually advancing diet afterward. |
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TPN
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Total parental Nutrition, for patients with sepsis, head injury, or burns
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Electrolytes imbalance: NA, Mg, K+, Ca++
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Na: hyper/hyponatremia,too much/too little sodium, affects water, seizure precautions K+: hypo/hyperkalemia sweating, diarrhea, nausea, cardiac irregularities Mg: hypo/hypermagnesia, cardiac issues, respiratory depression Ca:Hyper/hypocalcemia: facial twitching, bones |
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Normal Electrolyte ranges
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Na: 135-145 meq/L K: 3.5-5 Ca: 8,5-10.5 Mg: 1.5-2.5 CL: 95-108 |
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Opioid side effects |
Constipation, Respiratory depression morphine |
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Pharm NSAIDs
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Aspirin, Ibuprofin GI upset |
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Drop equation
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Volumex Gtt factor aka calibration rate/time in minutes eg. 100ml x10gtt/60 minutes: 16.6 ml/min |
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15B Changes physically/physiologically assoc with mobility/immobility
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Immobility can cause: Respiratory: pnuemonia GI: constipation Ur: kidney stones intug: sores psych: social isolation/depression |
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15D interventions for impaired body alignment and mobility
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having people in proper bed/sitting alignment know how to use a walker/cane/crutches... devices are meant to assist regular walking. All four legs down at once. Crutches: NOT under the brachial plexus |
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15F/G safety concerns with mobility
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fall risks/risk of injuries. use proper footwear. gaitbelts. keep weight close to body. lift with legs, not back. using hoyer, keep patient over surface like bed as much as possible |
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15I Summarize nursing interventions for clients experiencing circulatory issues
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blood clots, and deep vein thrombosis (DVT) use scds, ted hose, ambulation if suspected, measure leg/calf circumference |
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15F Correct body mechanics
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watch the center of gravity, use abs, short sets, no twisting. put cane on strong side |
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14B assess clients for activity intolerance
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measure VS before/after activity and how long it takes to stabilize.
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14C Explore interventions for clients with activity intolerance
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Conserve energy with rest period gather supplies let them do what they can.
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14E Assess for physical manifestations that occur with alterations in oxygenation
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Altered LOC change in VS P02 decreases HR goes up RR up cyanosis diminished lung sounds |
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14F identify interventions for clients with alterations in oxygenation
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conserve energy, no smoking, no friction toys, no wool (static), monitor flow 2L |
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7A Examine common misconception of pain
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personal or cultural: don't want to appear weak entirely subjective |
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7C identify assessment methods for clients experiencing pain
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slide scale: baker wong 0-3 acceptable 4-6 moderate pain 7-10 severe reassess pain 30-40 minutes after administering |
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7D explore guidelines for selecting and individualizing pain interventions that include nonpharm and pharm managment
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steroids and nonsteroids (NSAIDS) opioids Round the clock meds, to prevent breakthrough pain (escalated pain) |
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7E evaluate clients response to pain interventions
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scaling pain: from an 8 to a 4 |
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8B summarize methods of nutritional assessment
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HT WT dietary labs protein albumin hemoglobin BMI |
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8C enteral feeds
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Tube feedings dysphagia : keep patient upright use strong side of mouth, tuck chin Perioperative: advancing the diet after surgery. clear liquids to general diet |
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8e Summarize the care of clients receiving enteral feedings
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residuals checked every 6 hours, HOB elevated Slow feeding to prevent cramping testing PH for placement formula is prescribed in rate/flow |
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8F summarize the care of patients with NG tube
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monitor electrolytes listen for sounds, check for distension |
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8G common fluid and electrolyte imbalances
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hyperatremia: seizure precautions hyper/hypokalemia: cardiac irreg hypomagnesia": cardiac and respiratory depression |
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9F summarize the nursing process for clients with alterations in urinary elimination
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Its a catheter question.
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16A Explore ways nurse practice acts credentialing standards of care and agency policies and procedures affect the scope of nursing practice
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Summarize the nurse legal responsibilities with selected aspects of nursing practice
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HIPAA-Confidentiality. advocacy- advocate for patients health, safety, and rights. responsibility- respect professional obligations, and follow through on promises Accountability- answering for ones action |
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16F Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values
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values: personal belief about the worth of a given idea, attitude, custom, or object that sets the standards that influence behaviors. Value Formation: begin in childhood. shaped by experiences values clarification: to resolve ethical dilemmas, need to differentiate between values, facts and opinions. |
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16H Examine the advocacy role of the nurse
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A nurse has a relationship with patients that provides knowledge that is specific to the nursing role, and as such provides the opportunity to see the patients POV.
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17 D contrast therapeutic communication techniques that facilitate communication and focus on client concerns
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verbal: nonverbal: symbolic communication: using art and music to promote understanding and healing |
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17e Differentiate barriers to communication
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-language barriers special needs people who have issues expressing needs have difficulties seeing/hearing confused or disoriented demanding and expect others to meet demands |
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17F examine how nurses use communication skills in each phase of the nursing process
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preinteraction phase: review available data talk to other caregivers about patient anticipate health concerns or issues identify a suitable location plan enough time for the interaction Orientation phase: set a warm tone recognize the initial relationship starts out superficially expect the patient to test you begin to observe patient and make inferences and form judgements from patients messages and behaviors clarify the patients and your roles Working Phase: the patient and nurse work together to solve problems and accomplish goals. encourage the patient to express self and provide information use therapeutic communication skills to facitlitate successful interations Termination phase: ending the relationship evaluate goal achievement reminisce separate from patient by relinquishing responsibilty provide transition for patient |
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17G identify the following disruptive behaviors and how they affect the HC environment and client safety: incivility, lateral violence, and bullying
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17H distinguish effective communication pattersn between the nurse and other health care team members
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communicating with: critical thinking creative inquiry focused self awareness and awareness of others purposeful analysis control of perceptual biases |
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18B identify the three learning domains
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cognitive learning: understanding, knowledge (acquiring new facts), comphrehension, applications, analysis affective: attitudes, the expression of feelings and acceptance of attitudes, opinions, and values. active listening and participation Psychomotor learning: acquiring skills that require mental and muscular ability. ie. learning to walk or use a spoon. |
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18C factors that affect learning
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motivation to learn ability to learn (developmental capability) Learning environment- comfortable, well lit, number of people, ventilation, need for privacy |
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18D examine the learning needs of learners and the learning environment
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comfortable environment Infant: keep routines, estab trust toddler: use play to teach preschool: use play, use simple words and questions, use pictures school age: teach psychomotor skills offer opportunities to discuss health problems adolescent: encourage learning about feelingins and self expression, use teaching as a collaborative function, use problem solving to help adoescents to make choices Young/middle adult: encourage participating by setting mutual goals, offer information Older adult: teach when patient is alert and rested involve adult in discussion and activity keep sessions short assess: learning needs, motivation to learn, resources, teaching environment, and learning environment |
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18 .F Identify nursing diagnosis outcomes and interventions that reflect the learning needs of the clients
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Having a quiet, comfortable well ventilated space free of distractions for patient limit sensory stimulus physical status affects learning: pain, fatigue, anxiety interfere reading level affects understanding |
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18G identify the essential aspects of a teaching plan
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18h examine guidelines for effective teaching
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18I identify methods to evaluate learning
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patient goals and outcomes of them. Did the patient value the info provided?what barriers preventing learning?is patient able to perform the behavior or skill?how well is patient able to answer questions?
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