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Ultimate Stack™ Flashcards

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1
Q

*What are some types (6) of elder abuse?

A
  • physical (trauma, bruises, alert: may see multiple providers!!)
  • emotional (do they have outside support network?)
  • financial (ask who controls finances?)
  • neglect (unkempt appearance)
  • sexual
  • abandonment

***first intervention is to ensure client safety, THEN duty to report abuse

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2
Q

*What are some things to keep in mind when communicating with clients with cognitive deficits? (4)

A
  • use simple sentences
  • avoid vague comments
  • repeat words back exactly
  • understand that the client’s reality is distorted
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3
Q

*What are common health problems among older adults? (6)

A
  • heart disease
  • cancer
  • stroke
  • lower respiratory disease
  • diabetes
  • Alzheimer’s/dementia
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4
Q

*What are common challenges for older adults? (3)

A
  • polypharmacy (lots of meds)
  • social isolation
  • adjusting to chronic health problems, loss of independence
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5
Q

*What are the benefits of sleep? (4)

A
  • regulates metabolism
  • improves learning/adaptation
  • reduces stress/anxiety
  • improves immune system
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6
Q

*NREM vs REM sleep?

A

NREM:

  • restful phases (I,II, III)
  • muscles relax
  • body temp and BP decreases
  • delta waves present in phase III

REM:

  • mental&emotional restoration
  • dreaming

***all but NREM I are repeated about 4x/night

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7
Q

*What factors affect sleep? (4)

A
  • Age (older are more prone to sleep disturbances)
  • Lifestyle Factors (exercise, diet high sat fat interferes; animal and dairy products help, caffeine, nicotine, alcohol)
  • Illness (fever, pain, SOB interfere; anxiety)
  • Environmental (light, noise)
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8
Q

*What are the components of good sleep hygiene? (8)

A
  • good sleep habits
  • regular routine
  • restful environment
  • relaxation techniques
  • no tv/computer/cell
  • avoid caffeine, alcohol, nicotine
  • avoid carbs (?)
  • avoid exercise before bed
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9
Q

*What are some common sleep disorders? (8)

A
  • insomnia
  • restless leg syndrome (RLS)
  • sleep apnea
  • narcolepsy
  • parasomnias- sleep walking/talking
  • night terrors
  • bruxism (clenching)
  • nocturnal enuresis (bed wetting)
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10
Q

*What are 3 nonprescription sleep meds?

A
  • melatonin
  • lavender
  • chamomile
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11
Q

*What are nursing responsibilities regarding safe med administration? (5)

A
  • nurses hold full legal responsibility for safe med administration; so abide by institutional policies, state laws, and federal laws
  • practice 3 checks
  • practice 10 rights
  • narcotics must be double locked
  • need witness for “waste”
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12
Q

*What is stress? (definition)

A
  • any disturbance in a person’s balanced state

- a stimulus that the person perceives as a challenge or as physical or emotional stress

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13
Q

*What are the types of stress? (5)

A
  • distress/eustress- threat to health/good stress
  • external/internal- death of family member/anxiety
  • developmental- predictable, middle adults adjust to health changes
  • situational- unpredictable, car accident
  • anticipatory- upcoming exam
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14
Q

*How do people respond to stress?

A

**GAS (General Adaptation Syndrome)- fight or flight stage, adaptation, exhaustion or recovery

**LAS (Local Adaptation Syndrome)- localized body response, inflammatory response, pain response

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15
Q

*What is culture? (definition)

A

-a collection of learned, adaptive, and socially transmitted behaviors, values, beliefs that form the context from which a group interprets the human experience

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16
Q

*What is acculturation? (definition)

A
  • immigrants assume the characteristics of that culture through acculturation
  • a person who is acculturated accepts both their own and their new culture
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17
Q

*What is assimilation? (definition)

A
  • new members gradually learn and take on the essential values, beliefs, and behaviors of the dominant culture
  • complete when the newcomer is fully merged into the dominant cultural group
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18
Q

*How do we provide culturally competent care? (3)

A
  • incorporate beliefs and practices from various cultures into your care and education
  • encourage helpful cultural practices and discourage those that are harmful (suggest alternatives)
  • accommodate cultural dietary practices as possible
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19
Q

*What is cultural awareness? (definition)

A

-ability to objectively examine own beliefs, values, and practices

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20
Q

*Inductive vs Deductive reasoning?

A

Inductive- gathering pieces of info, see pattern, and form generalization

Deductive- general premise and moves to a specific deduction

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21
Q

*What are the essential parts of nursing theory? (4)

A
  • PERSON (needs, fears, etc)
  • (good) ENVIRONMENT
  • (improving) HEALTH
  • NURSING (care I provide)
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22
Q

*Who are some of the important theorists in nursing?

A
  • Florence Nightingale (clean environment)
  • Virginia Henderson (first to define nursing, 14 basic needs)
  • Hildegard Peplau (theorized that communication with the patient helps outcomes)
  • Patricia Benner (primacy of caring theory, novice-expert theory)
  • Madeleine Leininger (cultural competence)
  • Jean Watson (caring theory, interpersonal process)
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23
Q

*What are the rights of research participants? (6)

A
  • informed consent
  • right to not be harmed
  • right to full disclosure
  • right to self-determination
  • right to privacy/confidentiality
  • institutional review boards
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24
Q

*What do experienced nurses strive for?

A

Empowerment!

  • power to solve problems
  • power to take initiatives
  • power to exercise autonomy
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25
*What are necessary leadership skills for nurses? (5)
- schedule - identify goals - set priorities - organize work - delegate
26
*What are (4) leadership styles?
- laizzez-faire (gives followers control in the decision-making process) - autocratic (gives direction, final decisions, bears responsibility of outcomes) - democratic (shares planning, decision making, and responsibility for outcomes. Guidence > control) - scientific (?)
27
*What are some religions and their practices? (4)
- Christianity - Islam - Roman Catholicism (may wish for anointing the sick by a priest, deacon, or minister) - Jehovah's Witnesses (refuse blood transfusion)
28
*What are barriers to spiritual care? (6)
- lack of awareness of spirituality - lack of awareness of your own spiritual belief system - differences between nurse and patient - trying to be all things to all people - fear that your knowledge base is insufficient - fear of where spiritual discussions may lead
29
*What nursing diagnosis' can be applied to spirituality? (7)
- moral distress - impaired religiosity - readiness for enhanced religiosity - readiness for enhanced spiritual well-being - risk for spiritual distress - risk for impaired religiosity - spiritual distress
30
*What are categories of loss? (6)
- actual (death) - perceived (perceived only by the person experiencing) - physical (injury, loss of function) - psychological (loss of hope, faith, or dreams) - external (loss of object) - environmental (loss of familiar) - loss of significant relationships (death or divorce)
31
*What is end-of-life care? (7)
- support of family/caregiver - ensuring continuity of care - ensuring respect for person - ensuring informed decision making - attending to emotional and spiritual concerns - supporting function - managing symptoms
32
*What are the (2) key premises of hospice care?
- the quality of life is as important as the length | - those who are terminally ill should be allowed to face death with dignity
33
*What are the legal and ethical concerns related to death?
- advance directives - DNR/AND - Assisted suicide (ANA prohibits) - Euthanasia (ANA prohibits) - Autopsy (signed permission) - Organ Donation
34
*What are some interventions for family members coping with a loved one's death? (6)
- have family help with care - encourage questions - provide FU for referrals - encourage talk with clergy - provide anticipatory guidance - acknowledge feelings of the family
35
What are the four assessment techniques and which order are they in for most assessments?
- inspection - auscultation - palpation - percussion
36
What is the acronym SPICES used for?
``` Common problems in older adults: S- sleep disorders P- Problems with eating/feeding I- Incontinence C- Confusion E- Evidence of falls S- Skin Breakdown ```
37
During a comprehensive assessment what info do you gather during your general survey?
- vital signs - height/weight - appearance/behavior - dressing/grooming/hygiene - body type/posture - speech - mental state
38
What are each of the cranial nerves? How to test?
I- olfactory- smell- cotton ball II- optic- visual acuity, pupillary reaction to light- PERRLA III- oculomotor- EOMS- follow penlight IV- trochlear- EOMS- follow penlight V- trigeminal- facial sensation, jaw movement- clench teeth, touch with cotton ball VI- abducens- EOMS- follow penlight VII- facial movement, taste- smile for symmetrical movement VIII- auditory- hearing, equilibrium- whisper test IX- glossopharyngeal- swallowing, gag reflex, tongue movement, taste, saliva- ahhh X- vagus- sensation of pharynx/larynx, swallowing, vocal cords, cardiac/respiratory reflexes, peristalsis, digestive secretions- ahhh XI- spinal accessory- head and shoulder movement, speaking- shrug test XII- hypoglossal- tongue movement- light tight dynamite
39
Bronchial vs Bronchovesicular vs Vesicular breath sounds?
Bronchial- loud, high, longer expiration, over trachea Bronchovesicular- medium, equal in/out, over 1st/2nd ICS adjacent to sternum Vesicular- soft, low, breezy longer inspiration, over lung fields
40
What is the order of assessment of the abdomen?
- inspect - auscultate - percuss - palpate
41
What tool can be used to assess level of consciousness?
Glasgow Coma Scale - evaluates eye opening, motor responses, and verbal responses - it does not evaluate brainstem reflexes
42
What is a normal BMI? Overweight? Obesity classes 1-3?
``` normal- 18.5-24.9 overweight- 25-30 obesity (1)- 30-35 obesity (2)- 35-40 obesity (3)- 40+ ```
43
What are the cervical lymph nodes? (12)
- posterior auricular - occipital - superficial - posterior cervical - posterior triangle - superclavicular - deep mandibular - preauricular - tonsillar - submental - anterior triangle - submandibular
44
What are the (5) general health assessment components?
- physical - mental - spiritual - socioeconomic - cultural
45
What are the (2) components of a comprehensive physical examination?
Interview | Head-to-Toe assessment
46
Subjective vs Objective data? Primary vs secondary?
PRIMARY Subjective- what the client tells you Objective- data that you obtain about the client through observation and examination SECONDARY Subjective- what others tell the nurse about client Objective- data the nurse collects from other sources (family, caregivers, med records)
47
What types of things should we avoid when using therapeutic communication? (4)
- medical jargon - giving advice or opinions - ignoring feelings - offering false reassurances
48
What are some good techniques of therapeutic communication? (6)
- open-ended questions - clarifying- specific details - back channeling "tell me more" "go on' - probing "what else would you like to add to that" - closed-ended questions - summarizing
49
What is self-knowledge?
-knowing your own skill and having a willingness to seek help when needed
50
Diaphragm vs Bell of stethoscope?
Diaphragm- high sounds (heat, lung, bowel) Bell- low sounds (unexpected heart sounds, bruits)
51
What are adventitious breath sounds and what do they sound like?
Crackles/Rales- fine bubbly sounds not cleared with coughing Wheezes- high pitched musical sounds Rhonchi- corse, loud, low pitched, can be cleared with coughing Pleural Friction Rub- dry, grating, rubbing sound
52
How do we grade pulse strength?
``` 0 absent 1+ diminished, weaker 2+ brisk, expected 3+ increased, strong 4+ bounding ```
53
What is the expected pulse range?
60-100 bpm
54
What is a pulse deficit?
- the difference between radial and apical pulses
55
What is ventilation?
-the exchange of oxygen and carbon dioxide
56
What is ventilation?
-movement of air air into and out of lungs
57
What are Cheyne-Stokes respirations?
shallow breaths lead to normal breaths lead to increased rate leads to slowing back down leads to apnea period
58
What are Kussmaul respirations?
increased rate, abnormally deep
59
What is the expected range for pulse oximetry?
95-100%
60
What is the expected range for blood pressure?
normal- 120/80 stage I HTN- 130/80 stage II HTN- 140/90
61
What is the pulse pressure?
difference between systolic and diastolic readings
62
How does cuff size affect BP?
- too large- falsely low - too small- falsely high * cuff width=40% of arm circumference * cuff bladder=80% of arm circumference
63
During two-step BP reading how much higher do we go when the pulse is no longer felt?
30 mmHg higher
64
What is a DASH diet?
Dietary Approach to Sop Hypertension - restrict sodium - get enough K, Ca, and Mg - restrict cholesterol and sat fat intake
65
*What is the edema rating scale?
1+ trace- 2mm (rapid refill) 2+ mild- 4mm (10-15 sec) 3+ moderate- 6mm (prolonged) 4+ severe- 8mm (prolonged)
66
What is the ABCD system used for?
``` used to detect possible skin cancer A- asymmetry B- border irregularity C- color variation D- diameter >6mm ```
67
What are the terms to describe joint movement?
Flexion- movement that decreases angle between two bones Extension- movement that increases the angle between two bones Hyperextension- movement of a body part beyond its normal extended position Supination- movement of a body part so that the ventral surface is up Pronation- movement of a body part so that the ventral surface is down Abduction- movement of an extremity away from midline Adduction- movement of an extremity towards midline Dorsiflexion- foot and toes up Plantarflexion- foot and toes down Eversion- turning body part away from midline Inversion- turning body part toward midline External rotation- rotating a joint outward Internal rotation- rotating a joint inward
68
Unexpected spinal curvatures?
Kyphosis- curvature of the thoracic spine Lordosis- curvature of the lumbar spine Scoliosis- exaggerated lateral curvature
69
What are some words we can use to describe a patients level of conciousness?
alert- person, place, time lethargic- can open eyes and respond, drowsy obtunded- responds to shaking, confused, slow stuporous- responds to painful stimuli only comatose- no response
70
Stereognosis vs Graphesthesia?
Stereognosis- familiar object in hand and identify Graphesthesia- trace a number on palm and identify
71
What are the (3) stages of wound healing?
Inflammatory -1-5 days, vasoconstriction, platelets aggregate Proliferative -5-21 days, granulation, fibroblasts make collagen Maturation -2-3 weeks (or more), old collagen is broken down an remodeled
72
What are the (3) healing intentions?
Primary Intention -no tissue loss, approximated edges, little scarring Secondary Intention -loss of tissue, unapproximated edges, risk for infection, most scarring Tertiary Intention -deep and unapproximated, closed when free of infection, less scarring than 2ndary
73
What are the types of drainage seen from wounds? (5)
Serous- clear, straw colored Sanguineous- blood, red Serosanguineous- pink, serous and blood Purulent- thick, foul odor, yellow tan green or brown Purosanguienous- pus and blood
74
What are the (3) depths of wounds?
Superficial- epidermal Partial-thickness- through epidermis not dermis Full-thickness- through subcutaneous and beyond
75
*What are the six risk factors related to skin integrity that the Braden scale focuses on? What does it NOT include?
``` sensory perception moisture activity mobility nutrition friction/sheer **does NOT include cognition ```
76
How do we irrigate a wound?
ideal irrigation pressure is 4-15 psi. More than 15 psi has a risk of driving bacteria deeper
77
What are the different types of dressings (5) and what types of wounds to use them on?
Gauze- absorbs exudate Transparent film- IV site or small superficial wounds Hydrocolloid- prevents evaporation, maintains a granulating wound bed (stage 2 pressure) Hydrogel- gel promotes autolytic debridement and cooling for infected or deep wounds (not for heavy drainage) Alginates- non-adherent, absorb exudate, maintains a moist wound bed, packs Collagen- helps stop bleeding and promotes healing
78
What are the stages of pressure injuries?
Stage 1- nonblanchable erythema, intact skin Stage 2- partial thickness skin loss, red-pink wound bed no granulation Stage 3- full-thickness skin loss, visible adipose, possible undermining Stage 4- full-thickness skin and tissue loss, bone or tendon visible, undermining is common Unstageable- eschar or slough obscures the wound bed
79
What are the (7) types of therapeutic diets commonly prescribed? Special recommendations for diabetics and folks with dysphagia?
NPO- nothing by mouth Clear liquid- water, juice, broth, jello Full liquid- clear plus liquid dairy Pureed- clear and full plus pureed meat, fruit, eggs Mechanical soft- clear and full plus diced/ground food Low-residue- dairy products, eggs, ripe bananas High-fiber- whole grain, raw and dried fruits * Diabetic- 1,800 cal/day, watch macros * Dysphagia- pureed and thickened liquids
80
What are the fat-soluble vitamins and what are they used for in the body?
A- immune, skin/mucus mem, visual acuity in dim light D- calcium and phosphorous absorption (strong bones) E- antioxidant that fights toxins K- synthesis of proteins for clotting and bone development (leafy greens, veg, fish, liver, meat, eggs, cereals)
81
What are the water soluble vitamins and what are they used for in the body?
C- immune, wound healing (citrus, tomatoes, potatoes) B- essential
82
What are the (2) most commonly monitored minerals?
Iron- beans/lentils, leafy greens, cereals, whole grains, tofu, cashews Calcium- dairy, leafy greens, breads with fortified flour
83
*What are the normal ranges for electrolytes? (6)
*Sodium- 135-145 *Potassium- 3.5-5.0 *Calcium- 8.5-10.5 Magnesium- 1.6-2.6 Chloride- 95-105 Phosphorous- 3-4.5
84
What are normal BUN and creatinine levels?
BUN- 10-25 | creatinine- 0.5-1.2
85
*What are normal BUN and creatinine levels?
BUN- 10-25 | creatinine- 0.5-1.2
86
What is the range for urine specific gravity?
1.001-1.029
87
What labs to check if client is experiencing hypovolemia? Hypervolemia?
Hypovolemia- urinalysis, CBC, and electrolytes Hypervolemia- ABGs, SaO2, CBC, and chest xray
88
*What are some methods for collecting a urine sample?
Freshly voided- same method as for Intake and Output Clean catch- cleanse genitals, catch midstream Sterile- insert a urinary catheter and withdraw from the bladder 24-hour- void in morning and record the time, collect everything thereafter
89
*What does urinalysis test? (6)
- pH - specific gravity - protein - glucose - ketones - occult blood
90
*What are some of the nursing diagnosis' used to describe incontinence? (5)
- urge incontinence- (involuntary loss of urine with strong urge to void) - stress incontinence (pressure from a sneeze, laugh, cough causes bladder to leak) - overflow incontinence (leakage of urine with distended bladder) - functional incontinence (all GU components work but the person cannot make it to the restroom) - urinary retention (unable to start urination, or if able to start, cannot fully empty) - urinary frequency (need to go many times a day of either a lot or a little urine)
91
*Define the -urias (5)
anuria- no urine (>100ml/24hrs) hematuria- blood in urine (trauma, kidney stone) dysuria- painful/difficult urination (infection, retention) oliguria- small amounts of urine (>400ml/24 hrs) polyuria- large amounts of urine (diabetes, high fluid intake)
92
How much urine is expected from healthy kidneys?
~50-60ml/hour | 1.5L per day
93
*What does CVAT tenderness indicate?
kidney infection
94
What is respiration?
exchange of O2 and CO2 in the lungs
95
What are some upper respiratory infections and some lower respiratory infections? (3 for each)
Upper: cold, flu, rhinosinusitis, pharyngitis Lower: respiratory syncytial virus, acute bronchitis, tuberculosis
96
What is saO2 vs pO2?
saO2- percentage of hemoglobin carrying O2 pO2- amount of O2 available to combine with hemoglobin
97
What is saO2 vs pO2 vs FiO2?
saO2- percentage of hemoglobin carrying O2 pO2- amount of O2 available to combine with hemoglobin FiO2- percentage of oxygen that the client receives
98
Who is incentive spirometry used for? (3)
- risk for pneumonia and atelectasis - abdominal, chest, or pelvic surgery - prolonged bedrest
99
What are the early signs of hypoxia? (6)
- tachypnea - tachycardia - restlessness, anxiety, confusion - pale skin, mucous membranes - elevated blood pressure - use of accessory muscles
100
What are some low-flow oxygen delivery systems? (4)
- nasal cannula- FiO2 24-44% at a rate of 1-6L/min - simple face mask- FiO2 35-50% at a rate of 6-12L/min - partial rebreather mask- FiO2 60-75% at a rate of 6-11L/min - non-rebreather mask- FiO2 80-95% at a rate of 10-15L/min *delivers highest flow of O2 except for intubation*
101
What are some high-flow oxygen delivery systems?
- venturi mask- FiO2 24-50% at flow rate of 4-12L/min *most precise* - aerosol mask- FiO2 24-100% at a rate of 10L/min
102
Safety measure to take when using oxygen?
- no smoking - cotton clothing not wool - electrical things should be grounded - no alcohol or acetone use
103
What is the best way to obtain a sputum sample?
- in morning - rinse mouth - breath deeply - cough, dont spit
104
What is a fecal occult blood test used for and what can create a false positive?
- used to detect occult blood in stool | - red meat, chicken, raw veg, ASA, and warfarin can create a false positive
105
What is a fecal occult blood test used for and what can create a false positive?
- used to detect occult blood in stool - collect fecal sample 3x from 3 diff defecations - blue color indicates blood - red meat, chicken, raw veg, ASA, and warfarin can create a false positive
106
What is the daily amount of fiber recommended?
25-38g
107
What types of enemas are there? (6) How far to insert? How high to hold bag?
* insert 3-4in for adults * 12-18in above anus tap water (hypotonic)- do not use more than once soapsuds- castile soap irritates and stimulates, be careful with older adults normal saline- safest and volume stimulates low-volume hypotonic- commercially prepared for pts who cannot tolerate high- volume oil-retention- lubricates medicated enema- contains meds to retain for 1-3 hrs
108
What are the (4) components of body mechanics?
- body alignment - balance - coordination - joint mobility
109
List (8) ways to move your body without causing injury?
- proper alignment - wide base of support - avoid bending and twisting - squat to lift - keep objects close - raise beds - push versus lift - get help
110
isometric vs isotonic vs isokinetic exercises
isometric- muscle contraction without motion isotonic- movement of a joint during muscle contraction isokinetic- use of equipment to move a joint during muscle contraction
111
aerobic vs anaerobic exercise
aerobic- oxygen taken in meets needs anaerobic- oxygen taken in does not meet needs
112
What are the s/s of heat exhaustion vs hypothermia?
heat exhaustion- fatigue, loss of concentration, dizzy, nausea, increased RR, abdominal cramps, elevated temp with cold clammy skin hypothermia- fatigue, loss of coordination, confusion
113
*What effects does immobility have on the body?
- joint contractures - muscle atrophy - kidney stones - UTIs - upper respiratory infections (URIs)
114
*What is paresis vs paralysis?
paresis- muscle weakness caused by nerve damage (partial paralysis) paralysis- loss of the ability to move
115
*What are contractures?
ROM of a joint becomes compromised due to muscle, tendon, or ligament tightening
116
How to teach proper cane use?
- cane on strong side of the body - move cane forward 6-10in - move weaker side forward toward the cane - advance strong leg past the cane
117
How to teach proper crutch use?
- elbows flexed 20-30 degrees - 6 in in front of and 15cm from center - hold crutches together when sitting or rising from a chair
118
What is resistance training vs flexibility training?
resistance- for muscle strength and endurance flexibility- maintain mobility
119
How to teach a patient to go up or down stairs?
- lead with the strong leg going up the stairs | - lead with the weak leg coming down the stairs
120
What are the effects of heat vs cold therapy?
heat- increase blood flow, increase tissue metabolism, relaxes muscles, eases joint stiffness and pain cold- decreases inflammation, reduces bleeding, reduces fever, diminished muscle spasms, decreases pain
121
*What types of pain are there? (6)
superficial- subcutaneous pain (burn, papercut) deep somatic- ligaments, tendons, blood vessels, bone (arthritis, fracture) visceral- deep (cramps, labor, bowel, organ cancer) radiating- starts at origin and extends (heartburn all over thorax) referred- arises from area distant to origin (MI pain in jaw or arm) psychogenic- no known origin
122
What is the physiological pain pathway? (4)
transduction- activation of nociceptors by stimuli (mechanical, thermal, chemical) transmission- conduction of pain message to the spinal cord (via A-delta fibers-fast, via c fibers-slow) pain perception- recognizing and defining pain in the cortex pain modulation- occurs in the spinal cord causing muscles to contract reflexively away from stimuli
123
*What are the characteristics we assess for of pain?
- pain location - quality (sharp/dull, burning, stabbing, aching, throbbing, ripping, searing, tingling) - intensity (pain scale, mild, distracting, moderate, severe, intolerable) - aggravating/alleviating factors (what makes it better/worse) - periodicity (episodic, intermittent, constant)
124
What are adjuvant analgesics?
- reduce the amount of opioid needed - anticonvulsants, antidepressants, local anesthetics, topical agents, psychostimulants, muscle relaxants, neuroleptics, corticosteroids
125
What are (3) models used to describe a person's health?
Health-illness continuum: your position moves with physiological changes, lifestyle choices, results of tx Dunn's health grid: predicts the likelihood that a client will have a change in health status (environment/illness) Neuman's continuum: high energy is associated with wellness and vice versa
126
**What (10) factors disrupt health?
``` disease physical injury mental illness pain loss impending death competing demands the unknown imbalance isolation ```
127
What are the (5) stages of illness behavior?
- experiencing symptoms - sick role behavior - seeking professional care - dependence on others - recovery
128
*What is the difference between primary, secondary, and tertiary levels of prevention?
Primary- PREVENT disease (immunization, child car seat education, nutrition, fitness activities, health education in schools) Secondary- SCREEN (communicable disease screening, early detection, treatment of diabetes, exercise programs for elderly adults) Tertiary- sTOP disease progression (begins after an injury or illness, preventions of pressure ulcers, promoting independence after brain injury, referrals to support groups, rehabilitation)
129
How does change occur in the Transtheoretical Model of Change?
``` Precontemplation- no intent to change Contemplation- decision to change Preparation- baby steps Action- implement plan Maintenance- reinforce behavior Termination- no danger of relapse ```
130
What are the guidelines for screening? (7)
Comprehensive PE- q 3 years until age 40, then q year Dental- q 6 mos Visual- q 3-5yrs (q 2 yrs age 40-64, q 1 years age 65+) Cholesterol- age 20+ q 5 yrs Colon Cancer- beginning at age 50 FOBT or colonoscopy q 10 years OR sigmoidoscopy q 5 years Cervical Cancer- pap q 3 yrs ages 21-65 Breast Cancer- mammogram offered at age 40, def start at age 50, at age 54 can be biannual
131
*What are the three domains of learning?
Cognitive- storage and recall of information Psychomotor- hands on skill Affective- challenging feelings, beliefs, attitudes, and values
132
What is self-efficacy?
a person's perceived ability to successfully perform a task
133
Passive vs Aggressive vs Assertive communication styles?
Passive- avoids conflict, lets others take the lead, apologetic Aggressive- forces others to lose, bossy, manipulative Assertive- "can do" attitude, "I" statements, use negative inquiry, compromises
134
What are the (4) phases of the therapeutic realtionship?
Pre-interaction- gathering info prior to meeting Orientation- build rapport Working- nurse cares, client expresses theirselves Termination- conclusion at end of shift or discharge
135
*What are the (4) key characteristics of therapeutic communication?
Empathy- desire to be sensitive to the client Genuineness- responding honestly Concreteness- clear responses Confrontation- getting clarification from client, being willing to be confronted if unclear
136
What are some "interventions" to enhance therapeutic communication? (10)
- address pt - listen actively - establish trust - be assertive - restate, clarify msg - interpret body language - explore issues - use silence - summarize convo - use recordings
137
What are some barriers to therapeutic communication? (10)
- asking too many questions - fire-hosing info - asking why - changing subject - failing to probe - expressing approval or disapproval - offering advice - false reassurance - stereotyping - using patronizing language
138
What are the (4) components of self-concept?
Body image- cognitive understanding and sensory input affect mental image of self *Role Performance- actions a person takes in fulfilling a role Personal Identity- learned through socialization, doesn't change very much, UNIQUE Self-esteem- how well you like yourself. Difference between ideal self and actual
139
*What is included in a sexual health history?
- reproductive history - cancer screening - history of abuse - sexuality - activity/dysfunction - illness, meds - sexual self-concept - current relationship status - support systems
140
What medications could affect sexual functioning?
Diuretics- decrease vaginal lubrication, ED, and low libido Antidepressants- ED and low libido
141
*What are the five routes of med administration?
- PO (oral) - enteral (NG tube, G tube, J tube) - parenteral (IV, injections) - sublingual (under tongue) - buccal (cheek) *used to absorb into mucous membranes rather than GI tract - topical (lotion, cream, ointment, transdermal patch, inhalations, eye, ear, nasal, rectum, vagina)
142
*Pharmacokinetics vs Pharmacodynamics?
Pharmacokinetics- absorption, distribution, metabolism, and excretion Pharmacodynamics- primary and secondary effects of the drug
143
What are the (6) components of a med prescription?
- full name - date and time - name of med - dosage size, freq, number of doses - route of admin - signature of provider
144
*What are the three checks?
- before you pour - after you prepare med - at the bedside * *checking against MAR
145
*What are the (12) rights?
- right patient - right drug - right dose - right route - right time - right documentation - right reason - right to know - right to refuse
146
Where are ___ given? What are ___ used for? Angle of injection? (Intradermal, Subcutaneous, Intramuscular)
Intradermal: - nondominant forearm (or chest/upper back) - TB or allergy test - 5-15 degrees Subcutaneous: - abdomen and triceps (fast absorption) anterior thigh and upper buttocks - insulin, immunization - not closer than 5cm to belly button, 45-90 degrees Intramuscular: - deltoid, vastus lateralis, ventrogluteal (site of choice) **AVOID DORSOGLUTEAL - iron, anything really - 90 degrees
147
*What factors affect absorption, distribution, metabolism, and excretion?
Absorption: - route of admin - drug solubility - PH ionization - blood flow Distribution: - membrane permeability - protein binding capacity - local blood flow Metabolism: - liver function - first pass effect - health/disease status Excretion: -kidney function
148
What are the (6) ethical principles for client care?
Beneficence- do good Nonmaleficience- do no harm Autonomy- right to make one's own decisions Fidelity- fulfillment on promises Justice- fairness Veracity- tell the truth
149
What are the (3) types of torts?
Unintentional: - negligence- failure to use safety measures for a fall risk patient - malpractice- med error resulting in death Quasi-intentional: - breach of confidentiality - defamation of character Intentional: - assault- threat - battery- physical - false imprisonment- restraining a client against their will
150
What does the Patient Self-Determination Act stipulate?
staff must inform clients they admit of their right to refuse or accept care
151
What is the chain of infection?
Infectious Agent- bacteria, virus, fungi, prion, parasite Reservoir- human, animal, food, water, soil, insects, surfaces Portal of Exit- respiratory tract, GI tract, transplacental Mode of Transmission- contact, droplet, airborne, vector Portal of Entry- break in skin, sexual contact Susceptible Host- compromised immune system
152
What are the (4) stages of infection?
Incubation- pathogen enters the body and first symptoms Prodromal- symptoms rise Illness- findings specific to the infection occur Convalescence- symptoms disappear
153
What (2) lab values would indicate an infection?
WBC- greater than 10.000 | ESR- over 20mm/hr
154
What are standard precautions?
- applies for all patients - hand hygiene after contact with the client, after removing gloves - mask, eye protection, and face shields when their could be splashing or spraying of bodily fluid
155
What are transmission precautions (4)?
Airborne: - measles, varicella, TB - private room - N95 - negative pressure airflow exchange - client should wear a mask when outside of room Droplet: - strep, pneumonia, flu, scarlet fever, rubella, pertussis, mumps - private room (or same dx) - masks for HCP and visitors - client should wear a mask when outside of room Contact: - RSV, shigella, wound infections, herpes, impetigo, scabies, MDROs, cdif - private room (or same dx) - gloves and gown worn by HCP and visitors - disposal of infectious material in its own bag Protective: - private room - positive airflow - HEPA filtration for incoming air - mask for client when out of the room
156
What are the guidelines for use of restraints?
- provider must assess client face-to-face - choose the restraint that is least restrictive - 4hrs max for an adult, can be renewed for up to 24 hours - signed consent from patient - assess restraints every 2 hours, should be able to fit 2 fingers under them NEVER USE FOR: convenience, punishment, clients who are extremely mentally of physically unstable
157
What is the acronym RACE used for?
``` Fire response: R: rescue A: alarm C: contain E: extinguish ```
158
*What are some of the considerations for a Catholic patient?
- clients may wish to anoint a client who is ill or near death - clients might fast during lent - might practice Holy Communion or have clergy come visit
159
*What are some of the considerations for a Muslim patient?
- may avoid conversations about death - might withdraw life-support services but continue hydration and oral feedings - avoid organ transplantation - may decline porcine-derived-medications - fast during Ramadan - should be faced toward Mecca and pray 5x a day
160
*What are some of the considerations for Jehovah's Witness?
- refuse blood transfusions | - dont observe holidays
161
*What are some of the considerations for Judaism?
- might refuse treatment on Sunday - life support may be discouraged - Kosher diet - death care is often performed by Jewish Burial Society and buried within 24 hours
162
What is the Kubler-Ross Model?
Grief follows a pattern: - denial - anger - bargaining - depression - acceptance
163
How to provide post-mortem care?
- elevate the HOB - remove tubes - remove personal belongings - clean the body, keep dentures in - fresh linens - brush the client's hair - remove supplies - apply ID tages post-viewing * if an autopsy is being performed tubes should stay in place
164
*What should we do to promote teaching?
- consider the patients learning style, language, education level - teach concepts simple to complex
165
*How to obtain a sexual history?
-provide privacy
166
*Rest vs Sleep?
Rest- the body is inactive and relaxed Sleep- altered consciousness
167
*What does a lack of REM sleep do to the body?
* REM sleep is necessary for mental and emotional restoration - a person deprived of REM sleep for several nights in a row may experience REM rebound which means they will have more REM sleep on successive nights - sleep deprivation in general causes drowsiness, difficulty performing tasks, difficulty with cognitive functions, restlessness, perceptual disorders, slowed reaction time, irritability, reduced immune system defenses
168
*What are the s/sx of fluid volume deficit and fluid volume overload?
FVD: - thirst - HR and BP up - hypovolemic shock: HR up, weak pulse, orthostatic hypotension, elevated temp, dry skin/turgor, fatigue, decreased urine output FVO: - high BP - bounding pulse - increased shallow resp - cool, pale skin - distended neck veins - edema
169
*What needs to be present in a nursing theory?
- nurse - patient - environment - health
170
*What are some interventions for altered sensory function?
Hearing loss: - sit and face client - hearing aids - speak slowly and clearly - short sentences - lower pitch before increasing volume - minimize background noise * do not shout Vision loss: - call client by name when approaching, let them know when you leave - stay in client's visual field if they have some vision - explain interventions before touching them - describe arrangement of food as if a clock Aphasia (difficulty speaking or understanding speach): - call pt by name - clear and slow speech - pause between statements - check for comprehension - tell client when you do not understand them - ask Q's that have simple A's - picture chart may help - ackowldge frustration Disoriented: - call client by name - maintain eye contact - brief simple sentences - one Q at a time - directions one step at a time - allow time to respond
171
*What is SBAR?
``` handoff report S- Situation B- Background A- Assessment R- Recommendation ```
172
*What is Erikson's theory?
Psychosocial Development Theory: | individuals must master 8 stages as they progress through life (may move back or forward based on life events)
173
*What are some common myths about older adults that are not true?
- that they are all incontinent - that they cant have sex - that they can't learn new things
174
*What are some common age-related changes?
- decreased bladder capacity - dry skin, low skin turgor - increased BP - decreased muscle tone - decreased saliva production and GI motility - decreased sensation - vision or hearing changes
175
*How to prevent a catheter associated urinary tract infection?
- maintain a closed system - keep insertion site clean - empty bag every 8 hrs - dont let the bag touch the floor
176
*What do you know about Tylenol (acetaminophen)?
Class: Antipyretic (fever reducer), non-opioid analgesic Side Effects: SJS, TENecrolysis, fatigue, insomnia, anxiety, N&V, dyspnea, constipation Contraindications: kidney or liver disease, taking with warfarin, NSAIDS, or alcohol Client Education: avoid alcohol, check for rash, don't take for longer than 10 days
177
*What do you know about ibuprofen?
Class: Non-steroidal Anti-Inflammatory Agents Side Effects: heart complications, exfoliative dermatitis, SJS, TENecrolysis, GI bleed, constipation, N&V, dizziness, drowsiness, burred vision, tinnitus, renal failure Contraindications: ulcers, heart problems, renal problems, active GI bleed Client Education: avoid driving, don't take for more than 10 days, avoid alcohol, observe for rash or cardiac symptoms
178
*What do you know about Oxycodone?
Class: opioid analgesics Side Effects: confusion, sedation, respiratory depression, constipation, dizziness, blurred vision, headache Contraindications: severe respiratory depression, asthma, paralytic ilieus Client Education: avoid driving, protect med from theft, don't crush ER tablets, avoid alcohol
NUR120
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