Applied Nursing Skills Flashcards

Flashcards for VNSG 1402 Final Exam Review

Assessment

First step of the nursing process; involves gathering objective and subjective data.

Diagnosis

Second step of the nursing process; involves analyzing assessment data to identify patient problems.

Planning

Third step of the nursing process; involves setting goals and outcomes for patient care.

Implementation

Fourth step of the nursing process; involves carrying out the planned interventions.

Evaluation

Fifth step of the nursing process; involves assessing the effectiveness of interventions and revising the plan as needed.

Role of RN in Nursing Process

The RN leads the full nursing process, including assessment, diagnosis, planning, implementation, and evaluation of care.

Role of LVN/LPN in Nursing Process

LVNs/LPNs support care by collecting data, giving basic care, and reporting to the RN.

Objective Data

Data that can be observed using the five senses.

Subjective Data

Information that the patient or family tells you that you cannot directly observe.

Inspection

A visual examination of the patient's body.

Palpation

Touching or feeling the torso and limbs for pulse, abnormal lumps, temperature, moisture, and vibrations.

Auscultation

Listening for abnormal sounds in the lungs, heart, or bowels.

Percussion

Tapping movements to detect abnormalities of the internal organs.

Fall Prevention in Healthcare Setting

Strategies include placing the patient near the nurses' station and keeping personal items within reach.

RACE

Rescue, Alarm, Confine, Extinguish: Steps to follow in response to a fire.

PASS

Pull, Aim, Squeeze, Sweep: Steps to follow when using a fire extinguisher.

Applying Restraints

Use only if necessary with a provider's order, secure to bed frame, check frequently and document.

PPE for Contact Precautions

Gloves and gown are required when entering the room, along with standard precautions.

PPE for Droplet Precautions

A mask is required when entering the room, along with standard precautions.

PPE for Airborne Precautions

A fit-tested N95 or higher respirator is required when entering the room, along with standard precautions.

Donning PPE Order

Hand hygiene, gown, mask/respirator, goggles/face shield, hair cover, shoe cover, gloves.

Doffing PPE Order

Gloves, goggles/face shield, gown, mask/respirator, hair cover, shoe cover, hand hygiene.

Signs and Symptoms of Fungal Infection

Includes red, itchy, or scaly skin; cracked or peeling skin; white patches in mouth; vaginal itching, discharge, or irritation; discolored, thickened nails.

When to use Eye Protection

Use when there is risk for splashes, sprays, or droplets; when caring for patient with airborne, droplet or body fluid precautions, and when handling hazardous chemicals.

When to wear Gloves

Use when coming in contact with blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or contaminated equipment.

Providing Morning vs. Bedtime Care

AM: toileting, oral hygiene, washing face/hands or full bath, hair care, shaving, dressing, bed making, help with mobility. PM: toileting, oral hygiene, washing face & hands, back rub, change to nightwear, prepare for sleep

Maceration

Softened skin caused by continuous exposure to moisture

Excoriation

Scrapes on the skin that may be caused by scratching.

Mottling

Purplish blotching of the skin that indicates that circulation has slowed greatly.

Bed Bath

For bedridden or weak patients; done in bed.

Therapeutic Bath

For skin conditions; requires a provider's order.

Shower

For mobile, stable patients; promotes independence.

Back Massage: Benefits, Do's, and Don'ts

Includes relaxation, better circulation, pain relief, skin check; use warm lotion, gentle strokes, respect privacy; avoid broken skin, bony areas, or causing discomfort.

ADL Assistance: Do's and Don'ts

Encourage independence, respect preferences, ensure safety; don't rush, ignore input, or do tasks the patient can do.

Signs and Symptoms of Orthostatic Hypotension

Dizzy, pale, clammy, or nauseated; syncope or fainting.

Prevention of Musculoskeletal Injuries/Complications

Reposition often, keep proper body alignment, do ROM exercises, use proper support & alignment ; encourage movement

Prevention of Neurological Complications

Monitor neuro status, use splints, prevent nerve pressure, provide mental stimulation.

Complications of Immobility and Ways to Reduce

Weakness, pressure sores, confusion, pneumonia, clots, depression, constipation, infections. Ways to reduce: ROM, move often, turn, protect skin, stimulate, deep breaths, reposition, leg exercises, compression, fluids, fiber, hydrate, hygiene

Vital Sign Changes in Increased Intracranial Pressure

Decreased BP, increased PR, decreased RR; irregular breathing, widened pulse pressure, possible fever.

Assessing Pulses

Radial, apical, temporal, carotid, brachial, popliteal, femoral, posterior tibialis, dorsalis pedis.

Pulse Deficit

Difference between apical and radial rates; indicates weak heart contractions or poor perfusion.

Pulse Deficit Assessment

Heart beats aren't all reaching the periphery, subtract radial from apical to find deficit.

Cutaneous Pain

Superficial- pertaining to the skins surface & Subcut tissue

Deep Somatic Pain

Bone, ligament, tendon, & blood vessel pain

Neuropathic Pain

a deep ache that occurs when the nerve is compressed ring by pressure

NREM sleep functions

Physical repair and immune support

REM sleep functions

Memory, learning and emotion.

Verbal Evidence of Pain

Scale 1-10

Non-Verbal Evidence of Pain

fidgeting, facial grimacing, rocking back & forth.

Pain Med Administration Protocol

look for other ways to relieve pain, dont give same made at the wrong time

Signs and Symptoms of Chronic Pain

Onset longer than 6 months, few or none, no changes in vital signs, pupils may constrict.

Signs and Symptoms of Acute Pain

Sudden onset, dramatic effects, less than 6 months

Focused Assessment

Specific body part, after initial assessment or when new symptoms appear, monitors specific issues

Comprehensive Assessment

full body (physical, mental, emotional, cultural, Spiritual) on admission, done by RN,

Initial Assessment

Quick overall check of all systems, start of each shift, establishes baseline to detect Change in condition

Objective Findings

Five senses

Subjective Findings

What patient says

Abdominal Assessment

Inspect, Auscultate, Palpate, Percuss

Aphasia

An inability to speak or understand language.

Dysphasia

Difficulty coordinating or organizing words correctly in a sentence.

Stethoscope Placement for Heart Sound Assessments

Aortic valve, pulmonic valve, erbs, tricuspid, mitral

Lordosis

Lumbar concavity increased

Kyphosis

Convexity of the midthorax is increased.

Scoliosis

Curvature to either the left or right.

Focused cardiovascular assessment

Anorexia. nausea/vomiting, shape or distension, bowel sounds, incontinence flatus, consistency of abdomen. bowel elimination

Signs and Symptoms of Protein Deficiency

Kwashiorkor, severe emaciation, swollen abdomen, enlarged liver, lethargy, failure to grow, skin infections, limitations in mental development.

Laboratory Ranges for Blood Glucose for Diabetics

Normal: 70-105. hypoglycemia: low glucose levels ; hyperglycemia: high blood glucose levels

Nursing Care for Patient Taking Lithium

monitor sodium levels & kidney function, maintain consistent sodium intake, watch for lithium toxicity. Ensure adequate hydration be cautious w/ diuretics.

Nursing Care for Patient Gagging or Coughing During NG Insertion

take out immediately

Nursing Care During Intermittent Tube Feedings

Formula at room temp, check placement initially w/ radiograph, check residual (100mL max), check pH of residual (1-4)

Signs and Symptoms of Anorexia

Brittle nails; dull, dry, brittle hair, Amenorrhea, severe constipation, lethargy or fatigue, below abnormal vital signs, muscle weakness, muscle wasting, anemia.

Inflammatory phase of wound healing

Clotting and clean up, redness, swelling, Pain

Deconstruction phase of wound healing

Tissue grows; red granulation tissue forms

Maturation phase of wound healing

Scar strengthens; may form keloids

Evidence of Wound Infection

Pronounced redness, elevated temperature/heart rate, increased purulent & foul smelling, increased pain, wound edges may open, elevated WBC.

Evisceration nursing interventions

Organs protrude (emergency); Don't push organs back in, cover w/sterile saline soaked dressing, low-fowlers/knees bent, NPO, IV access

Dehiscence Nursing Interventions

Wound opens; lay flat, stay with patient , call provider, get sterile supplies.

Nutrients Necessary for Wound Healing

Protein!

Priority Nursing Interventions Following an Ankle Injury (RICE)

Rest, Ice, Compress, Elevation.

Signs and Symptoms of Complications with an Orthopedic Patient

Redness, purulent drainage (infection), foul odor, no pulse/movement, pain unrelieved ,numbness/tingling, swelling tight cast, pale, cold, blue limb, fever, chills

Crutch gait (2 Point)

Partial weight, move crutch + opposite Foot together

Crutch gait (3 Point)

No weight on affected leg; more both crutches + bael leg, then good leg

Crutch gait (4 Point)

Full weight; move on crutch, opposite foot, then other crutch, other fact.

Crutch gait (Swing Through)

Crutches forward, swing feet past crutches.

Proper Body Alignment for Prevention of Musculoskeletal Complications

Head midline, spine straight, shoulder level, hips aligned feet flat, forward. knees slightly bent

Pin-Site Care

Clean daily w/ sterile solution, use sterile applicators for each pin, monitor for redness, drainage, odor, keep site dry and covered if ordered

Orthopneic Position

Sitting up right 90° or on edge of bed, leaning forward, arms on over bed table for support, used to improve breathing in patients with respiratory issues.

Ways Oxygenation Can Be Altered

Low hemoglobin level (low RBC), talactase, smoking history

Emergency Response to Respiratory Failure: Nursing Priority

Establish airway (ABC).

Signs and Symptoms of Respiratory Distress or Decrease in Proper Oxygenation

Capillary refill, use of accessory muscles cyanosis, retractions

Causes of Fluid Deficit

Vomiting, diarrhea, bleeding, dehydration, sweating

Vital Sign Manifestations During Shock

Low BP, High pulse, high temp

Nursing Interventions for Fluid Deficit

Moniter I&O, vitals, electrolytes, mouth care

Causes of Fluid Excess/Overload

Sodium/ Fluid retention, heart / kidney / liver failure

Symptoms of Fluid Excess/Overload

weight gain, edema, ABD, bouncing pulse, crackels

Nursing Interventions for Fluid Excess

Moniter I&O, weights, vitals; Diuretics, & sodium diet, fluid limits

Sodium Excess Symptoms

Thirst, swelling, confusion, muscle twitching increased BP

Sodium Deficiency Symptoms

Nausea, headache, confusion , muscle cramps Low BP

Potassium Deficiency and Excess Symptoms; Interventions

Priorities normal : 3.5/5.3 mEq/L ; Give K+, moniter ECG

Respiratory alkalosis

PH above 7.45