1
Q
define functional ability
A
the cognitive, social, physical and emotional ability to carry on the normal activities to live
2
Q
what dimensions do we assess for risk recognition?
A
- Developmental
- Physical
- Psychological
- Disease
- Social and cultural factors
- Environment
3
Q
what has research identified as risks for decreased function?
A
- age
- cognitive function
- level of depression
4
Q
what is a sudden onset of functional decline indicative of?
A
acute illness or worsening chronic conditions
5
Q
what are the 12 ADL’s according to the Roper-Logan-Tierney model?
A
- maintaining a safe environment
- breathing
- communication
- mobilizing
- eating and drinking
- toileting
- hygiene and dressing
- maintaining body temperature
- working and playing
- sleeping
- expressing sexuality
- dying
6
Q
what are the 3 major dimensions of concern relative to an individual’s functional ability?
A
- risk recognition
- functional assessment
- planning and delivery of care
7
Q
define instrumental activities of daily living (IADLs)
A
activities necessary for independent living in the community
8
Q
define fundamental care
A
involves actions on the part of the nurse that respect and focus on a person’s essential needs to ensure their physical and psychosocial wellbeing
9
Q
what are the different types of health assessment?
A
- comprehensive
- focused
- urgent
10
Q
when do you complete a HTT assessment?
A
- Beginning of a patient’s hospital stay or care
- Start of each shift
- Whenever there is a significant change in the patient’s condition (post surgery, decline in status)
11
Q
define subjective data
A
data obtained from patient
12
Q
define objective data
A
measurable data collected by nurse
13
Q
what do we assess when doing a self-assessment?
A
- Physical status
- Emotional status
- Training and experience
- Communication
- Workload
14
Q
what do we assess when doing a client-assessment?
A
- Communication
- Cognitive
- Emotional and behavioural
- Medical
- Functional assessment
15
Q
what do we assess when doing an environmental-assessment?
A
- Room and area
- Color and lighting
- Noise and distractions
- Working surfaces
- Equipment
16
Q
what is the functional independance measure (FIM) ?
A
a tool that scores a patient from 1 (completely dependant) to 7 (completely independant) based on self-care, locomotion, social cognition, communication and sphincter control
17
Q
what 6 categories are assessed in the Katz index?
A
- bathing
- dressing
- toileting
- transferring
- continence
- feeding
18
Q
what is the InterRAI?
A
A complex, comprehensive examination looking at multiple factors of mental, physical and social abilities to assess functional ability
19
Q
how often should patients be repositioned?
A
once every two hours
20
Q
what is the Alberta Aids to Daily Living Program?
A
Government program to provide financial support for assistive, medical devices by paying for basic medical equipment and supplies
21
Q
what are the IYM principles of good body mechanics?
A
- 3 at the top
- 3 at the both
- safe effective grip
- comfort zone
- weight transfer
22
Q
fill in the blank: IYM principle states that blank physical effort + blank equipment + blank client participation = no unsafe lift
A
minimum; maximum; maximum
23
Q
what is a hazard assessment?
A
identifying actual or potential hazards we may be exposed to in the worksite
24
Q
what kind of hazards exist in a workplace?
A
- physical
- chemical
- biological
- psychological
25
define posture alignment
relationship between one body part and another along a horizontal or vertical line
26
define gait
manner or style of walking and includes rhythm, cadence and speed
27
what are the two classifications of falls?
- anticipatory
- unanticipated
28
what is the Finding Balance program?
health program that educates and empowers older adults to stay independant and prevent falls through screening tools, also identifies where assistance is needed and what aids may be useful
29
what does the AHS falls risk management policy (PS-58) focus on?
- prevention
- screening and assessment
- intervention
- data collection and measurement
- evaluation
- practice
30
what is the Schmid falls assessment tool?
a tool to identify patients at risk for falls by assessing the criteria: mobility, mentation, elimination, prior fall history, medications
31
define nutrition
the science of optimal cellular metabolism and its impact on health and disease
32
how do we calculate BMI?
weight (kg)/height (m²)
33
what is the normal range of BMI?
18.5-24.9
34
what lab values can we look at to assess nutritional status?
- albumin
- pre-albumin
- BUN
35
define malnutrition
a condition caused by excess or deficient food energy or nutrient intake
36
define calorie
a unit of energy
37
define BMI
ratio of patient’s body weight to height
38
define carbohydrates
compounds comprised of carbon, hydrogen and oxygen and a major source of energy
39
define waist circumference
an indicator of health risk where the waist is measured
40
define nitrogen balance
amount of nitrogen consumed = the amount of nitrogen excreted over a specific period of time
41
define dysphagia
difficulty swallowing defined in terms of impaired oral, pharyngeal or esophageal phases of swallowing
42
what are some possible complications of dysphagia?
- Aspiration
- Respiratory infections
- Dehydration
- Undernutrition/malnutrition
- Decreased quality of life
- Death
43
what is "eating or drinking at risk"
deciding to eat or drink whatever they choose despite risk of aspiration
44
what are risk factors for poor oral health?
- NPO
- dehydration
- malnourishment
- medical treatments or medications
- medical problems
- trauma or surgery in the area
- unconscious
45
what is clinical judgement?
Refers to the decision making process that involves applying knowledge, experience, and expertise to assess patient situations, prioritize needs and choose proper interventions
46
what is the difference between clinical judgement and critical thinking?
Both are interrelated but critical thinking is the foundation and clinical judgement is the practical use of that thinking in clinical settings
47
what are the 4 aspects of Tanner's model?
1. noticing
2. interpreting
3. responding
4. reflecting
48
what are the 6 steps of the NCSBN model?
1. recognize cues
2. analyze cues
3. prioritize hypotheses
4. generate solutions
5. take action
6. evaluate outcomes
49
what are the components of the alpha prioritization framework?
A-H
- airway
- breathing
- circulation
- disablity
- exposure
- fluids and electrolyes
- goals of care
- history
50
what is documentation?
“Any written or electronically generated information about a client that describes the care or services provided to that client… an essential part of nursing practice”
51
the CRNA states that documentation must be...
- complete
- accurate
- timely
- factual
- and private
52
when is the only time you would not chart for yourself?
in case of an emergency
53
what is the health information act?
Provincial legislation including expectations for the collection, use, disclosure and security of health information
54
what aspects do we mainly observe in a general survey?
- physical appearnce
- behaviour
- mobility
55
the HOB is at ____ degrees in regular Fowler's
45-60º
56
the HOB is at ____ degrees in low Fowler's
30-45º
57
Sim's position is typically used during which procedure?
- rectal exams
- enemas
58
the HOB is at ____ degrees in high Fowler's
60-90º
59
which position prevents pressure injuries on hips and tailbones?
Sims'
60
which position can increase oxygenation?
prone
61
what is a commode chair?
an assistive device that can roll over toilets
62
rate the following assistive devices from least to most support: walker, wheelchair, cane
cane -> walker -> wheelchair
63
T or F: a cane is to be used on the affected side
FALSE
64
what are the levels to the Fundamentals of Care framework?
1. relationship with patient
2. integration of care
3. context of care
65
what does good body alignment look like?
- forward tilt of head
- curving of upper spine
- flattened lumbar spine
- hip and knee flexion
66
what assessment tools can we use to identify falls risk?
- Heindrich II assessment
- Functional gait assessment
- St. Thomas assessment tool
- Schmids Falls assessment tool
67
the schmid's fall assessment tool is used for patients above what age?
≥65
68
T or F: if a patient falls unwitnessed, assume they hit their head
TRUE
69
define fall
“an event that results in a person coming to rest inadvertently on the ground/floor or other lower level, with or without injury”
70
what are the different classifications of falls?
- anticipatory
- unanticipated
- accidental
71
what are some prevention strategies we can use to prevent anticipatory falls?
- Ensure walking paths are clear
- Non-slip footwear
- Good bathroom routine to decrease rushing to bathroom
- Ensuring all equipment is working and patient knows how to use it properly
72
what protocol do we perform following a fall?
- do not move them
- get help
- take vital signs and NVS
- perform a HTT
- continue monitoring
73
what areas do we look at when completing a nutritional assessment?
- food and fluid intake
- dietary restrictions
- appetite
- chewing, swallowing function
- taste or smell sense
- GI assessment
- psychological assessment
- medication review
- anthropometric measurements
- substance use
- past/present self/family history
74
what tools can we use to assess nutrition?
-Food intake records
- Food frequency questionnaires
- Mini nutritional assessment (MNA)
- Mini nutritional assessment short form (MNA SF)
- Malnutrition universal screening tool
75
a pureed diet is restricted for patients who lack the ability to...
bite, chew or swallow solid foods
76
minced foods are restricted to patients who lack the ability to...
bite off pieces of food but have some chewing ability
77
what are some signs of aspiration?
- Coughing
- Change in color
- Respiration effort
- Choking
- Gagging
- Drooling
78
what are some challenges to communication that you may face with a patient?
- sensory deficits
- cognitive deficits
- language barriers
79
where can we document?
- formal chart
- electronic records
- doctors boards
- kardex
80
what is a kardex?
shift to shift communication between nurses
81
T or F: communication via Kardex is considered a legal form of communication
FALSE
82
when do we fill out an incident report?
if anything goes wrong with you or the patient, including near misses
83
T or F: incident reports should be mentioned in patient charting and provided to the legal team
FALSE
84
what are the exceptions to performing a functional assessment on a patient?
* patient is unresponsive
* patient is physically unable
* patient is cognitively unable
85
identify the transfer logo below
independant transfer
86
identify the transfer logo below
minimum assistance
87
identify the transfer logo below
one-person transfer with belt
88
identify the transfer logo below
two person transfer with belt
89
identify the transfer logo below
sit/stand lift
90
identify the transfer logo below
total lift
91
92
identify the transfer logo below
bed rest
93
when is an in-transfer logo used?
in select areas or if client admission is less than 24 hours
94
define minimal assistance
providing verbal or physical cues such as encouragement or guiding touch without bearing any client weight
95
define hands-on assistance
providing directional pressure or additional momentum to assist a client to shift their limb or body weight
96
T or F: repositioning a patient always requires two workers
TRUE
97
98
T or F: the client's body is in constant contact with the surface during repositioning
TRUE
99
what components do we assess during ADL assessment?
* cognition
* physical ability
* executive functioning
* ability to plan
* mobility
* strength
* ROM
100
a higher FIM score indicates what?
higher independence on a specific task
101
what does a higher KATZ score indicate?
higher independance
NURS221
flashcards
Decks in class (9)
# Cards
-
Pre-Midterm Content101
-
Hygiene, Bathing, Pericare and Continence Care31
-
Bedmaking and Minimizing the Complications of Immobility7
-
Infection Control and Safe Environments22
-
Medication Administration22
-
Oxygen Therapy41
-
End of Life Care23
-
Cognitive Impairment27
-
Communicating with Older People4
