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121 Cards in this Set
- Front
- Back
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What is Spirituality?
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Anything that pertains to a person's relationship with a higher power
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What does faith mean?
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Refers to a confident belief in something for which there is no proof or material evidence
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What is religion?
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An organized system of beliefs about a higher power characterized by set forms of worship,spiritual practices and codes of conduct.
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What are some methods you can use to help meet the patients spiritual needs?
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offering a supportive presence,
encourage:spirituality,forgiveness,love and belonging,pray with your patients. |
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describe standard precautions as described by the CDC
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Use in care of all hospitalized individuals,Treat blood and all bodily secretions as infectious. including respiratory hygiene, use safe injection pratices. sweat is not concidered infectious.
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Describe transmission based precautions as recommended by the CDC-airborn
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Need to have a private room with negative air pressure, wear a mask or respirator.
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Describe transmission based precautions as recommended by the CDC-droplet
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Private room (door may be open) wear PPE, Visitors are kept 3 feet away from infected person
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Describe transmission based precautions as recommended by the CDC-contact
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Private room, wear PPE, avoid sharing patient-care equipment
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What is the main differences between MRSA and C-Diff?
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MRSA is a bacteria,C-Diff is a spore,MRSA is acquired in the community, C-Diff is usually a nosocomial infection.(s/sM) Pimples and boils.(s/s C) watery diarrhea,fever,loss of appetite, nausea, abdominal pain.
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Who is at risk for C-Diff?
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Antibiotic exposure,GI surgery,Long stay in hospital,Serious underlying illness, immunocompromising conditions, Old age.
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Describe transmission based precautions as recommended by the CDC-airborn
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Need to have a private room with negative air pressure, wear a mask or respirator.
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Describe transmission based precautions as recommended by the CDC-droplet
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Private room (door may be open) weare PPE, Visitors are kept 3 feet away from infected person
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Describe transmission based precautions as recommended by the CDC-contact
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Private room, wear PPE, avoid sharing patient-care equipment
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What is the main differences between MRSA and C-Diff?
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MRSA is a bacteria,C-Diff is a spore,MRSA is acquired in the community, C-Diff is usually a nosocomial infection.(s/sM) Pimples and boils.(s/s C) watery diarrhea,fever,loss of appetite, nausea, abdominal pain.
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Who is at risk for C-Diff?
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Antibiotic exposure,GI surgery,Long stay in hospital,Serious underlying illness, immunocompromising conditions, Old age.
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Describe transmission based precautions as recommended by the CDC-airborn
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Need to bave a private roome with negative air pressure, wear a mask or respirator.
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Describe transmission based precautions as recommended by the CDC-droplet
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Private room (door may be open) weare PPE, Visitors are kept 3 feet away from infected person
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Describe transmission based precautions as recommended by the CDC-contact
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Private room, wear PPE, avoid sharing patient-care equipment
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What is the main differences between MRSA and C-Diff?
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MRSA is a bacteria,C-Diff is a spore,MRSA is acquired in the community, C-Diff is usually a nosocomial infection.(s/sM) Pimples and boils.(s/s C) watery diarrhea,fever,loss of appetite, nausea, abdominal pain.
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Who is at risk for C-Diff?
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Antibiotic exposure,GI surgery,Long stay in hospital,Serious underlying illness, immunocompromising conditions, Old age.
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How is C-Diff transmitted?
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Through the feces.
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Describe recommended techniques for medical asepsis.
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Clean technique, good hand hygiene,carry soiled items away from body,Don't put soiled linen on the floor,clean the cleanest areas first, use appropriate containers, pour liquids directly into the drain, and being clean yourself helps to prevent the spread of microorganisms.
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Describe recommended techniques for Surgical asepsis.
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(sterile technique) keep objects free from microorganisms. good hand hygiene,carry soiled items away from body,Don't put soiled linen on the floor,clean the cleanest areas first, use appropriate containers, pour liquids directly into the drain, and being clean yourself helps to prevent the spread of microorganisms.
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What is a nursing diagnosis?
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Identification of patient problems that nurses can treat independently.
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What is a medical diagnosis?
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Identify diseases and prescribe medical treatment.
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What are the four components to a nursing diagnosis?
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Label, Definition,Defining characteristics, Related factors
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(define) and actual nursing diagnosis
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represents a problem that has been validated by the presence of major defining characteristics.
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(define) risk nursing diagnoses
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clinical judgments that an individual,family or community is more vulnerable to develop the problem than others in the same or similar situation.
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(define) possible nursing diagnoses
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statments that describe a suspected problem for which additional data are needed
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(define) wellness diagnoses
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clinical judgments about an individual family or group or community is transition from a specific level of wellnes to a higher level of wellness
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(define) syndrom nursing diagnoses
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comprise of cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation
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Describe the steps in the formation of a nursing diagnosis
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Problem stated as clearly and concisely as possible,
Etiology,and defining characteristics |
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Discuss the major concepts of the transitions framework-types
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Health and illness-Maslow's heirchy of needs,
Developmental-Erickson's developmental stages. Situational-personal transition Organizational-group that goes through changes |
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What is the difference between change and transition?
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Change tends to be abrupt, tends to be external.
Transition is a process that occurs over time, have a sense of flow and movement,an internal processes. |
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What are physiologic stressors-Specific effect?
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an alteration of normal body structure and function
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What are physiologic stressors-General effect?
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Stress response
for example:Chemical agents, infectious agents,hypoxia |
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What are psychosocial stressors ?
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Include real and perceived threats, Responses are continuous and include individualized coping mechanisms for responding to anxiety, guilt fear,frustration and loss. for example accidents, horrors of history,
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Explain LAS as it is related to stress.
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LAS is local adaptation syndrom. It is a localized response of the body to stress. It involves a specific body part instead of the whole body.
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explain the inflammatory response
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local response to injury or infection.
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What is GAS?
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General adaptation syndrom.biochemical model of stress developed by Hans Selye(1979) Describes the body's general response to stress and has three stages.
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What are the three stages to GAS?
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alarm reaction
stage of resistance Stage of exhaustiion |
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Within the alarm reaction of the GAS there is two mechanisms.
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Fight or flight response
and the shock phase |
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what happens in stage two of the GAS phase?
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Vital signs, hormone levels and energy production return to normal
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What happens in stage three of the GAS phase?
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Exhaustion, results when the adaptive mechanism are exhausted.
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What are four types of anxiety in order of least sever?
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Anxiety, moderate anxiety, sever anxiety and panic.
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How can you minimize a clients stress?
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Encourage; exercise, rest and sleep, good nutrition, relaxation, meditation, anticipatory guidance,guided imagery and biofeedback.
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What three things happen during the hemostasis stage of wound healing?
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1 hemostasis occurs immediately after the inital injury. 2 Blood clotting.
3 exudate occurs. |
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Describe the inflammatory phase of wound healing.
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lasts about 4 to 6 days, Leukocyts arrive and ingest bacteria and cellular debris, Macrophages enter the wound area and remain for an exended period and release growth factors. Acute inflammation heat, redness and swelling.
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Describe the proliferation phase of wound healing.
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Fibroblastic
lasts for several weeks new tissue is built to fill the wound space. granulation tissue forms Collagen synthesis and accumulation peak in 5 to 7 days |
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Describe the maturation phase of wound healing
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Final stage of the healing process 3 weeks after the injury, Scar may occure.
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What are four local factors that effect healing?
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Pressure, desiccation, maceration trauma,edema, infection, and necrosis.
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what are systemic effects that effect healing?
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Age, circulation and oxygenation, nutritional status, wound condition, medications and health status.
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What are some complications that may affect wound healing?
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Infection, hemorrage, dehiscence, evisceration, and fistula formation.
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what are some things to look for when performing a wound assessment?
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How does the skin look? activity? nutrition? having any pain? elimination?
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What are the different types and stages of wounds?
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Incision,contusion,abrasion,laceration,puncture, penetrating,avulsion, microbial, chemical, thermal and radiation.
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Describe the four stages of pressure ulcers.
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Stage 1. nonblanchable redness.
Stage 2. partial thickness loss, shallow blister Stage 3. partial thickness tissue loss, through the second layer fat is exposed. Stage 4. full thickness, fat/muscle/bone. often has drainage |
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What is a laceration
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Tearing of skin
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What is avulsion?
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Tearing a structure from normal anatomic position.
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What is a venous ulcer?
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an ulcer caused by poor venous return.
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what is an arterial ulcer?
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an ulcer caused by underlying ischemia.
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Define abduction
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Lateral movement of a body part toward the midline of the body
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Define Circumduction
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Movement of the distal part of the limb to trace a complete circle while the proximal end of the bone remains fixed.
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Define Flexion
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The state of being bent
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Define Extension
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state of being in a straight line
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Define Hyperextension
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state of being in an exaggerated extension
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Define Dorsiflexion
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Backward bending of the hand or foot.
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Define Plantar flexion
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Flexion of the foot
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Define Pronation
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assumption of the prone position
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Define Inversion
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sole of the foot inward
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Define Eversion
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sole of the foot outward.
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Define Isometric exercise
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muscle shortening and active movement
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Define Isometric
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muscle contraction without shortening
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Define Isokinetic exercise
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Muscle contractions with resistance
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Define Fowler's position
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promote cardiac and respiratory functioning. up in a bed at 45 deg
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Define supine
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flat on back
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Define prone position
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lies on the abdomen with the head turned to the side
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what is the effect of immoblility on Cardiovascular
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Increased cardiac workload, orthostatic hypotension, and venous stasis
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what is the effect of immobility on respiratory?
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Decreased ventilator effort, depth and rate of respirataions.
increased respiratory secretions |
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what is the effect of immobility on musculoskeletal?
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decreased muscle size, tone and strength, joint mobility and flexibility, bonedemineralization, limited endurance contractures, disuse osteoporosis
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what is the effect of immobility on the metabolic process?
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Decreased metabolic rate,fluid and electrolyte imbalances, alterations in the exchange of nutrients and gases at the cellular level.
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what is the effect of immobility on Gastrointenstinal system
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Disturbances in appetite, altered protein metabolism, poor digestion and decreased food intake
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what is the effect of immobility on urinary system
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Urinary tract infections, kidney stones
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what is the effect of immobility on Skin?
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Skin breakdown
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what is the effect of immobility on Psychosocial outlook
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Decreased self concept, sensory stimulation, feelings of worthlessness, disrupts sleep-wake patterns increased risk for depression.
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What are Florence Nightingale's major contributions?
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Established: standards for hospital management,NSG education,nutrition is related to health,
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Identify themes that are common to all nursing definitions.
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nurses; nurish, protect,promote health and prevent illness.
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Describe nursing as a profession
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nurses focus on the human experiences and responses to birth, health, illness and death within the context of individuals.
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What are the aims of nursing?
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to promote health
to prevent illness to restore health and to facilitate coping with disability or death. |
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Name the different roles nurses have in different types of settings.
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Nurses are: caregiver,communicator,Teacher,counselor,leader,researcher, advocate,and collaborator.
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What is the ANA and what is their role in nursing?
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American Nurses Association
Their role is to be involved in public education, clinical nursing standards and lobbying state and federal lawmakers to advance the profession of nursing. |
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What is the NLN and what is their role in nursing?
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National league for nursing. their role is to foster the development and improvement of all nursing services. the NLN conducts one of the largest testing services in the country.
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What is the AACN and what is their role in nursing?
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Association of Colleges in Nursing. they are responsible for national accreditation for collegiate nursing programs.
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What is the NSNA and what is their role in nursing?
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National Student Nurses' Association. They advocate for student and patient rights.
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*Unit objective* describe evidence based practice in nursing.
(ACCIE) A Crazy Cat Is Everywhere |
needs five steps
1 Ask the clinical question 2 Collect the best evidence 3 Critique the evidence 4 Integrate the evidence 5 Evaluate |
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name the four types of assessment.
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Initial, focused, emergency, and time-lapsed
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what is the purpose of the initial assessment?
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to establish a complete database for problem identification and care planning.
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What is the purpose of a focused assessment?
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to gather data about a specific problem.
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What is the purpose of an emergency assessment?
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to identify life threatening problems.
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What is the purpose of a time-lapsed assessment?
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to compare a patient's current status to baseline data obtained earlier.
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what are two types of data? in regards to an assessment
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Objective and Subjective data.
objective data is data that can be perceived by the senses. may be verified by others. subjective data is perceived only by the affected person |
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When collecting data and documenting nurses should be......? characteristics.(FARPC)
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Factual, Accurate, Relevant, Purposeful, and Complete.
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What are important sources of data collection?
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Patient, family and significant others, patient record
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Narrative Documentation (crono)
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Written in chronological order about the patients status and what interventions have worked and not worked.
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What are some thing you need to include on a narrative documentation?
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Date and time of documentation and the signature of the person that is documenting. don't leave space. bar any spaces that is left over.
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Advantages of Narrative notes.
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Flexible, ability to describe nursing interventions and evaluate patient response to those interventions.
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Disadvantages to narrative notes.
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May become repititious and unnecessarily lengthy. Hard to track problems, interventions and outcomes.
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AIR (Assessment,Intervention,and Response)
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Record your assesment
Summarize interventions Evaluate the patients response to your interventions. |
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What is the purpose of POMR documenting?
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Problem-Oriented medical record concentrates on specific patient problems
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what are the 5 components of a POMR
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1 Assessment
2 Problem list 3 Initial plan 4 Progress notes 5 Discharge summary |
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Advantages of POMR
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Allows for easy-to-understand presentations of information about each patient problem. It inhances consistency of documentation. Facilitates; the documentation of only crucial information, and standardized care plans.
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Disadvantages of POMR
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Numbering problems according to chronology instead of priority may lead to confusion,Charting can be repetitous if similar problem
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Focus documentation
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The emphasis is on patient-specific topics called foci
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What are the advantages of focus documentation?
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Focus charting is flexible and emphasizes the nursing process. informatio is fairly easy to retrieve because the focus statement is in the column that is separate from the progress notes.
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What are the disadvantages?of focus documenting.
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Significant training must be provided for persons new to this system. may become lengthy if the nurse forgets to includeevaluation of the patient's progress
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What is PIE charting?
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Problem Intervention Evaluation. Requires the maintenance of a daily assessment flow sheet.
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What are advantages of PIE charting?
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There is an emphasis on the nursing diagnoses and evaluation. it is a well organized system of charting
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What are the disadvantages of PIE charting?
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Significant training is necessary efore nurses can correctly use this system. Problems need to be reevaluated freuently, PIE is not conducive to multidisciplinary charting.
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what is CBE charting?
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Charting By Exception
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CBE includes what other forms to be used with CBE?
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Flow sheets, Patient education records, Graph forms, Patient discharge documentation.
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What are the advantages of CBE?
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Reduces repetitive charting, eliminates the need to chart routine nursing care, trends are tracked easily
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What are the disadvantages of CBE?
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The development of explicit guideline, policies, and procedures for CBE is time consuming. Lots of different forms can be confusint.
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