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61 Cards in this Set
- Front
- Back
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Hazards & risk factors to client safety |
Age & development Lifestyle Mobility & health status Sensory perceptual alterations Cognitive awareness Emotional state Ability to communicate Safety awareness Environmental factors |
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Pertinent information when performing a client safety risk assessment |
Nursing hx & physical examination; it can reveal considerable data about the clients safety practices & risks for injury Age & developmental level General health status Mobility status Presence or absence of physiological or perceptual deficits such as olfactory, visual, tactile, taste or other sensory impairment Altered thought processes Substance abuse Indications of abuse or neglect Previous injuries Use risk assessment tools, or Home safety assessment |
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R A C E |
Rescue (protect & evacuate clients) Alarm (pull fire alarm) Confine (contain fire by closing doors) Extinguish (extinguish the fire or evacuate if fire too large) |
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P A S S |
Pull out the extinguishers safety pin Aim hose at base of fire Squeeze or press handle to discharge material on fire Sweep hose from side to side across the base of fire until fire appears to be out |
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3 categories of fire |
Class A: paper, wood, upholstery, rags, ordinary rubbish Class B: flammable liquids & gases Class C: electrical |
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Interventions implemented in case of physical injury |
Restraints (d/c asap) Seclusion |
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An agency record of an accident or unusual occurrence |
Incident report |
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An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof |
Sentinel event (signal the need for immediate investigation and response) |
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The normal body defenses |
Intact skin Mucous membranes Saliva Tears GI tract: stomach acid Urine flow |
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The chain of infection |
Etiologic Agent- pathogens: bacteria, viruses, fungi, parasites Reservoir- humans, animals, environment Portal of Exit- resp. tract, GI tract, urinary tract, reproductive tract, blood, tissue Mode of transmission- direct/indirect contact, droplet, airborne, vector (animal, flying or crawling insect) Portal of Entry Susceptible host- any person at risk for infection |
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The stages of infection |
Incubation period- time between entry of infectious agent in the host & onset of symptoms Prodromal stage- time from onset of non specific symptoms until specific symptoms begin to manifest Full stage of illness- client has specific s&s of an infectious process Convalescent period- from the beginning of the disappearance of acute symptoms until the client returns to the previous state of health |
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Nosocomial infections |
Infections that originate in the hospital. They may develop during clients stay or after discharge |
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The freedom from disease causing microorganisms |
Asepsis |
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What happens to our bodies physiologically when we sleep |
Perception of & reaction to the environment are decreased. There is minimal physical activity, variable levels of consciousness, changes in the body's physiological (functions & activities) processes, & decreased responsiveness to external stimuli |
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PPE DON |
Gown Mask Eyewear/Faceshield Gloves (gloves must be over your cuff) |
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PPE DOFF |
Gloves (wash hands) Eyewear Gown (remove from shoulders) Mask |
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What factors affect our sleep |
Motivation- increases alertness Culture Lifestyle & Habits Physical activity & exercise Dietary habits Environmental factors Psychological stress Illness Medications Stress |
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Nursing interventions to promote normal sleep patterns |
Health teachings about sleep habits Support of bedtime rituals The provision of a restful environment Specific measures to promote comfort & relaxation Appropriate use of hypnotic meds. |
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What is the food guide pyramid and what is it used for |
A graphic aid developed by the USDA as a guide in making daily food choices. The grouping of the foods indicate that activity, moderation, personalization, proportionality, variety, & gradual improvement are the keys to good nutrition |
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6 classes of nutrients |
Carbohydrates- provide energy Protein- build bones, muscles, cartilage, skin, & blood Lipids- fats used as a supply & store of energy Vitamins- accelerate metabolism Minerals- build strong bones, teeth, blood, skin, hair, nerve function, muscle, & metabolic processes Water- essential for proper circulation of nutrients, is the body's transportation system, helps skin regulate body temp through sweating |
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Factors that affect a clients nutritional status |
Age Gender Preferences/Intolerances Food allergies Surgery/injuries Illness/disease Mediations Therapies Overall health Religion Lifestyle Alcohol consumption |
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How gender affects nutrition |
Nutrient requirements are different for men and women because of body composition and reproductive functions |
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How a clients general state of health affect nutritional status |
Weakness Cognitive state Dysphagia Chronic pain Dyspnea Quality and presence of teeth |
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How does use of meds, alcohol abuse, or supplement misuse affect nutritional status |
Changes taste of food Interferes with drug action Interferes with drug metabolism Changes appetite Alcoholic drinks contain large numbers of calories that lead to weight gain |
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Enteral nutrition |
Provided when the client cannot ingest foods or the upper GI tract is impaired & the transport of food to the small intestine is interrupted. Ex: nasogastric, small-bore feeding tubes, gastrostomy (PEG tube) or Jejunostomy (PEG tube) |
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Parenteral nutrition |
The IV infusion of dextrose, water, fat, proteins, electrolytes, vitamins, & trace elements. Also known as Total Parenteral nutrition (TPN) |
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Considerations when caring for clients with enteral nutrition |
Risk for aspiration Check for placement |
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Considerations when caring for clients with parenteral nutrition |
Infections Risk of fluid, electrolyte, & glucose imbalances Frequent evaluation & modification of the TPN mixture Monitor blood glucose because TPN mixture are high in glucose Client must be weaned off to prevent hypoglycemia |
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How we manage clients with altered nutritional status |
Maintain or restore optimal nutritional status Promote healthy nutritional practices Prevent complications associated with malnutrition Decrease weight Regain specified weight |
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3 domains of learning |
Cognitive domain (Thinking) Affective domain (Feeling) Psychomotor domain (Skill) |
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What factors influence learning |
Age & development Motivation Readiness Active involvement Relevance Positive feedback Non-judgmental support Simple to complex learning Repetition Timing Environment |
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Factors that inhibit learning |
Negative feedback Emotions High anxiety level Physiological events (illness, pain) Cultural aspects Psychomotor ability Prognosis (what is likely to come) Age Mental disability |
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What is involved in the nursing management of teaching & learning |
The nursing process. The nurse is in a position to promote healthy lifestyles through the application of health knowledge, the change process, learning theories & the nursing & teaching process when teaching clients & their families |
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Factors that influence self-concept |
Stages of development Family & culture Stressors Resources History of success & failures Illness |
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When an individual experiences changes in the normal balanced state. A stimulus, life event, or a set of circumstances that arouses physiological and/or psychological reactions that may increase the individuals vulnerability to illness |
Stress |
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Physiological indicators of stress |
Diaphoresis (sweating), HR & cardiac output increase, dry mouth, constipation, elevated glucose |
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Psychological indicators of stress |
Anxiety, fear, anger, depression, unconscious ego defense mechanisms |
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Cognitive indicators of stress |
Thinking responses that include problem solving, structuring, self control, self discipline, suppression, & fantasy |
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Defense mechanisms |
Denial Displacement Projection Rationalization Regression Repression |
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Refusing to believe or accept something as it is but rather as one wishes it to be |
Denial |
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Transferring emotion away from the person or situation that incited the emotion to an inappropriate person or object |
Displacement |
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Attributing ones own thoughts, emotions, characteristics, or motives to another |
Projection |
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Concealing the motive for behavior by giving some socially acceptable reason for the action |
Rationalization |
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Return to behaviors more appropriate to an earlier stage of development |
Regression |
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Immersing something in the subconscious or unconscious level of thought |
Repression |
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Dealing with change, successfully or unsuccessfully |
Coping |
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A natural or learned way of responding to a changing environment or specific problem or situation |
Coping strategy |
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Two coping strategies |
Problem focused coping- efforts to improve a situation by making changes or taking action Emotion focused coping- thoughts & actions that relieve emotional distress. It does not improve the situation, but the person often feels better |
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Normal grief response |
Abbreviated or anticipated Stages |
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Complicated grief |
Is unhealthy or pathologic Use of maladaptive coping strategies Long lasting |
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Clinical symptoms of grief |
Crying Talking about it Cannot eat Cannot sleep Denial Guilt Anger Feeling worthless Inability to concentrate Thoughts of suicide Delusions & Hallucinations |
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Clinical indications of death |
Loss of muscle tone Slowing of circulation Changes in respiration Sensory impairment |
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Comfort until the client passes. No labs are drawn, they do not go to the hospital, etc. |
Palliative care (comfort care) |
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A written statement of a person's wishes of what he or she would like done about Healthcare when they have lost capacity to communicate decisions. Ex: a living will |
Advanced directive |
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An order written for clients in a stage of terminal, irreversible illness or expected death. |
DNR |
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When the client deems self as DNR & it cannot be reversed by ANYONE except the client |
DDNR |
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What are comfort measures |
Pain control Personal hygiene measures Relieving respiratory difficulties Assisting with movement Nutrition, hydration, & elimination Providing measures related to sensory changes Providing spiritual support Supporting the family |
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Assisted suicide and Active euthanasia |
ANA states both are a violation of the Code of Ethics for nurses |
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Organ donation |
Nurses may serve as a witness for people consenting to donate organs |
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Death with dignity |
Nurses need to ensure that the client is treated with honor and respect when dying |
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Kubler-Ross stages of grieving |
Denial Anger Bargaining Depression Acceptance |
