Nursing Intervention Review

Flashcards for Nursing Review 2025 focusing on key concepts and clinical guidelines.

Contraindications for BP site/IV insertion site

Infection, wound, AV fistula, mastectomy, lymph node dissection

Contraindications for NG tube

Facial trauma, basilar skull fracture, choanal atresia, esophageal abnormalities; relative contraindications: bleeding disorders

Contraindications for IM/SC site

Infection, wound, AV fistula

Relative contraindications for Urinary catheter

urethral trauma (insert under fluoroscopy), urethral infection, blood at meatus

Patient position for NG tube

Semi-Fowler's

Patient position for Urinary catheter (female)

Dorsal Recumbent

Patient position for Urinary catheter (male)

Supine

Signs and symptoms of Fecal impaction

Hard abdominal mass, fecal seepage, pain, abdominal distension, lack of bowel movements

Risk factors for Fecal impaction

diet, certain medications (anticholinergics, anti-histamines), prolonged constipation or retention

Signs of Rectal mass

Narrow thin stools, rectal bleeding, incomplete bowel emptying, constipation

Definition of Constipation

< three BM/week, dry hard stools

Stoma & Colostomy Care guidelines

Monitor irritation/leakage, avoid creams and use stoma powder, proper seal & fit, empty when half full, change bag every 3–5 days

Enteral Feeding

Via the GI tract: NG, gastrostomy, jejunostomy

Enteral complications

Aspiration, blockage, dislodgement, perforation, weakened swallowing, intolerance to feeds

Parenteral Feeding

IV PPN or TPN

Parenteral complications

Hyper/hypoglycemia, infection, fluid or electrolyte imbalance, liver dysfunction

Inflammatory Phase of Wound Healing (0–6 days)

Hemostasis: Platelets release growth factors (fibrin) that stop the bleeding and start the repair process at the wound location; Phagocytosis: “Eating” of cellular debris by macrophages

Proliferative Phase of Wound Healing (4–21 days)

Epithelialization: development of new epidermis and connective tissue; Angiogenesis: reformation of the blood vessels within the wound; collagen develops to strengthen the wound; contraction: wound contracts in size

Remodeling Phase of Wound Healing (21 days–2 years)

Fibroblasts continue to synthesize collagen, strengthening the wound; leaves a scar

Risk factors measured by Norton/Braden Scales for pressure wound development

Immobility, moisture, nutrition, sensory impairment, friction and shear, activity

Characteristics of Stage 1 Pressure Wound

Non-blanchable redness

Characteristics of Stage 2 Pressure Wound

partial-thickness skin loss involving the epidermis and/or dermis

Characteristics of Stage 3 Pressure Wound

A full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it. Slough or eschar (necrotic tissue) may be visible, and the lesion may be foul-smelling.

Characteristics of Stage 4 Pressure Wound

Full-thickness skin loss extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement.

Characteristics of Unstageable Pressure Wound

The depth is unknown because slough or eschar obscures the extent of tissue damage.

Define Maceration

Maceration: the softening and breakdown of skin tissue due to prolonged exposure to moisture or dressing adherence to healthy tissue

Transient Flora

Microorganisms that temporarily inhabit the body and can be easily removed (hand hygiene)

Resident Flora

Microbiome, our natural flora

Endogenous infections

Caused by a microorganism originating from one’s own body

Exogenous infections

Infection caused from an external organism

Iatrogenic infection

An infection that results from a medical or surgical intervention

Causes of Iatrogenic Infections

Surgical Procedures, Medical Devices, Medication Administration

Infectious Agent

The pathogen (e.g., bacteria, virus, fungus, parasite) that causes the disease

Reservoir

Where the pathogen lives and multiplies. It can be a human, animal, water, surgical tools, surfaces, food.

Portal of Exit

The pathogen leaves the reservoir (e.g., through coughing, sneezing, open wounds, or bodily fluids)

Mode of Transmission

The pathogen travels from the reservoir to a new host. It can be direct (person-to-person contact) or indirect (through contaminated objects or vectors like insects)

Portal of Entry

The pathogen enters the new host. It could be through the mouth, nose, eyes, or broken skin

Susceptible Host

The person or animal that is vulnerable to infection

NREM Sleep

Majority of our sleep: 75-80%. Brain waves are slower, RR, HR are slower. Decreased muscle tone. None or slowed eye movement

REM Sleep

Makes up about 20-25% of our sleep. Brain is active: paradoxical sleep; deep tendon reflexes absent; almost complete muscle paralysis (atonia) except for our eyes: rapid eye movement; our sleep stage of sleep. HR, RR: irregular- may actually increase

Neurotransmitters Involved in Wakefulness

Adrenaline/Noradrenaline, dopamine, serotonin, acetylcholine, histamine

Neurotransmitters Involved in Sleep

Gaba, melatonin, adenosine

Fall Risk Factors

infants, elderly, cognitive, mobility, sensory impairment, previous falls, medications, hypo/hypertension, incontinence, urgency, environment (clutter, lighting, slippery floors), healthcare System Factors:

HAIs (Healthcare-Associated Infections)

Infections associated with healthcare facility stay

Standard Precautions: 7 Principles

Hand hygiene, PPE, cough etiquette, patient cohort/placement, clean surfaces, textile care, sharps disposal

Contact Isolation Precautions

Gloves, gown + standard precautions

Droplet Isolation Precautions

Surgical mask + standard precautions

Airborne Isolation Precautions

N95, goggles + standard precautions

PPE donning order

Gown, mask, googles, gloves

PPE removal order

Gloves, gown, goggles, mask

5 Moments of Hand Hygiene

Before touching a patient, Before a clean/aseptic procedure, After exposure to body fluid, After touching a patient, After touching a patient’s surrounding

FLACC Pain Scale

Pain scale for babies, non-verbal and those who don’t understand the concept of numbers: uses facial expressions, leg movement, overall activity, cry and consolability

PAINAD Pain Scale

Pain scale for those with advanced dementia; uses breathing patterns, movement, consolability to measure pain

Transduction (of Pain)

Mediators released

Transmission (of Pain)

Nerves → spinal cord → brain

Perception (of Pain)

Pain felt

Modulation (of Pain)

Body reduces/tries to modify the pain

Nociceptive Pain

Caused by tissue injury or damage (e.g., sprains, fractures, surgery)

Referred Pain

Pain perceived in an area distant from the site of injury (e.g., heart attack pain felt in the arm; Kehr’s sign)

Patient-controlled Analgesia (PCA)

Interactive method of pain management; permits patient to self administer, Most commonly uses opioids

Supine Position

Lying flat on back, face up

Prone Position

Improves oxygenation in ARDS, certain neurosurgeries

Fowler’s Position

Head of bed elevated (45–60°): Easier breathing, feeding, NG tube insertion, reduces aspiration risk

Semi-Fowler’s

HOB elevated ~30–45°: Tube feedings, comfort, minimal aspiration risk, s/p traumatic brain injury.

High Fowler’s

HOB elevated 60–90°: Severe dyspnea, eating, naso-tracheal suctioning.

Trendelenburg

Head lower than feet, bed tilted down: Increased perfusion to head

Reverse Trendelenburg

Head higher than feet, whole bed tilted up: Promotes gastric emptying, prevents reflux (GERD), certain surgeries

Orthopneic/Tripod

Sitting up, leaning forward on table/pillow: Maximizes lung expansion for severe dyspnea

Sim’s

Halfway between lateral & prone: patient on side, opposite knee flexed: Rectal exams, enemas, suppositories

Proper Body Mechanics guidelines

Assess the environment, Plan the move, Widened and stable stance, Stand close to the object being moved, Face the direction of the movement & pivot (don’t twist), When needed, lift with assistance of bed settings and colleagues, Work at waist level to avoid bending, Reduce friction, Keep your back straight and bend knees

Urinalysis measures

leukocytes, blood, glucose, ketones, protein, nitrites, specific gravity, pH, bilirubin, urobilinogen

Urine Culture

isolates the strain of infection

Polyuria

excessive urine production

Oliguria

decreased urine output

Anuria

No urine production

Nocturia

Voiding two or more times at night

Dysuria

pain on urination due to infection or injury

Retention

Difficulty emptying the bladder causing overdistension of bladder

Causes of Incontinence

neurogenic bladder, infection, enlarged prostate, diabetes, diet, pregnancy, neurological disorders, stress urinary incontinence, urgency

Stress urinary incontinence

weak pelvic floor or urethral hypermobility causing urine leakage while laughing, coughing, sneezing

Urgency

sudden, strong desire to urinate can cause urinary incontinence

Indications for Indwelling Urinary Catheter

During and post surgical procedures, urinary retention, monitor output, bladder dysfunction, bladder irrigation due to clots or infection, required immobilization (unstable spine), Incontinence with grade 3 pressure wound in perineal area

Indications for Straight/Intermittent Catheter

Collect urine specimens when urgent or requiring sterile technique in infants, neurogenic bladder, allows patient to be somewhat independent and learn to control bladder again, reduces incidence of UTIs and other complications when compared to foley/indwelling catheter, patients can learn to perform self catheterization, assess residual urine

Urethral complications of Urinary Catheter

trauma of meatus/internal urethra, bleeding, strictures, fistulas

ADPIE

Assess, Diagnose, Plan, Implement, Evaluate

Problem-focused Nursing Diagnosis

utmost priority to treat: ie: deficient fluid volume related to prolonged vomiting as evidenced by decreased urine output/decreased skin turgor/increased HR

Risk Nursing Diagnosis

at risk for infection as evidenced by surgical wound

Health promotion Nursing Diagnosis

Focuses on positive growth. Our goal here is to support and reinforce this positive behavior. “Readiness for Enhanced Breastfeeding as evidenced by desire to increase breastfeeding frequency

Peula Hariga

Procedures that according to the Doctors' Ordinance, were supposed to be performed by a physician only and were then permitted to be performed by non-physicians

Reception (Sensory Processing)

The first part of the sensory process, where we receive data from our nervous system about the internal or external environment through our senses.

Perception (Sensory Processing)

The conscious process of selecting, organizing, and interpreting data from the senses into meaningful and useful information

Reaction (Sensory Processing)

The response that individuals have to a perception of a received stimulus

ADLs

Bathing, dressing, toileting

IADLs

Shopping, finances, cooking

Oral hygiene risk factors

Coordination/Mobility issues, Bed rest patients, Patients receiving oxygen, Lack of knowledge or motivation, Ventilated patients, Feeding issues, Nutritional problems, Inflammatory diseases, Patients receiving chemotherapy or radiotherapy, Certain medications, Alcohol or cigarette use

Foot hygiene risk factors

Diabetes, Uncontrolled blood pressure, Long term use of steroids, Vascular diseases, Certain cancers, Alcohol or smoking, Mobility or cognitive issues, Elderly

5 Rights of Medication Administration

Patient, Drug, Dose, Route, Time

Triple Check for Medication Administration

Bin → Prep → Bedside

Advantages of Oral (PO)/Enteral (NG/PEG) Medication Route

Easiest, convenient, non-invasive, Suitable for self-administration, Cost-effective

Disadvantages of Oral (PO)/Enteral (NG/PEG) Medication Route

Not for vomiting, unconscious, or NPO patients, Slower absorption, First-pass effect, Requires ability to swallow