Fundamentals of Nursing Competency Appraisal Flashcards

Comprehensive practice flashcards covering fundamental nursing concepts, vital signs, oxygenation, mechanical ventilation, tube care, and specimen collection based on the lecture transcript.

What is the nursing process and who proposed and refined it?

The nursing process is a systematic and dynamic framework that nurses use in providing individualized and holistic care. It was proposed by Ida Jean Orlando and refined by Lydia Hall.

What are the components and key interventions of the Primary Survey (ABCDE) in Emergency Assessment?

Airway (patency, e.g., Heimlich/intubation for stridor, suctioning for wheezing), Breathing (rate, depth, O2 sat, chest symmetry, breath sounds; e.g., needle decompression for pneumothorax), Circulation (HR, BP, skin color, capillary refill; e.g., blood transfusion for hypovolemic shock), Disability (GCS evaluation; intubate at GCS 8), and Exposure (degree of burn injury assessment).

Based on the Rule of Nines diagram, what percentage of Total Body Surface Area (TBSA) is assigned to the front torso, back torso, each arm, each leg, and the perineum?

Front torso: $18\%$; Back torso: $18\%$; Each arm: $9\%$ ($4.5\%$ each side); Each leg: $18\%$ ($9\%$ each side); Perineum: $1\%$.

What is the Baxter-parkland formula used to calculate fluid resuscitation in burn patients?

$$4\,\text{mL} \times \text{weight (kg)} \times \text{TBSA}$$

What are the four main types of nursing diagnoses?

1. Actual Nursing Diagnosis (problem exists with S/S), 2. Risk Nursing Diagnosis (problem likely to develop, no S/S), 3. Wellness Diagnosis (readiness for health promotion), 4. Syndrome Nursing Diagnosis (cluster of signs and symptoms).

What are the three systems of nursing care defined by Dorothea Orem's Self care Deficit Nursing Theory?

1. Wholly Compensatory (nurse does all care, e.g., comatose patient), 2. Partially Compensatory (both nurse and patient do care, e.g., postoperative patient), 3. Supportive Educative (nurse empowers patient to become independent).

What are the three signs of Cushing's Triad in late-stage increased intracranial pressure (ICP)?

Hypertension, Bradycardia, and Bradypnea (indicates brainstem damage).

How should the pinna be pulled when measuring tympanic temperature or administering otic medications in patients under 3 years old versus 3 years old and older?

Under $3\,\text{years old}$: pull pinna downward and backward. $3\,\text{years old}$ and older: pull pinna upward and backward.

What are the distinguishing characteristics of Intermittent, Remittent, Relapsing, and Constant fever patterns?

Intermittent: fluctuations between normal and abnormal within 24 hours. Remittent: fluctuations within 24 hours but never normalizes. Relapsing: fever lasting in days interspersed with normal temperature. Constant: minimal fluctuations that never normalize.

What is a pulse deficit, and what is its normal value?

Pulse deficit is the difference in heart rate between the apical pulse and peripheral pulse. Normal pulse deficit is $0$.

According to the lecture notes, what are the blood pressure ranges for Normal, Elevated, Stage 1, Stage 2, and Hypertensive Crisis?

Normal: $<120 / <80\,\text{mmHg}$; Elevated: $120\text{--}129 / <80\,\text{mmHg}$; Stage 1: $130\text{--}139 / 80\text{--}89\,\text{mmHg}$; Stage 2: $>140 / >90\,\text{mmHg}$; Hypertensive Crisis: $>180 / >120\,\text{mmHg}$.

What acronym describes the guidelines for blood pressure measurement CARE?

C - Cuff size should be correct (too small = false high, too big = false low); A - Arm at heart level; R - Rest for $5\,\text{minutes}$; E - Evaluate (reassess if right and left arms differ, notify physician and report both).

What management steps correspond to Steps 1, 2, and 3 of the WHO 3 step pain ladder?

Step 1 (Mild Pain 1–3/10): NSAID or Paracetamol; Step 2 (Moderate Pain 4–6/10): Weak Opioids (e.g., Tramadol, Ketorolac) + Metoclopramide for N/V; Step 3 (Severe Pain 7–10/10): Strong Opioids (e.g., Morphine, Fentanyl, Hydromorphone).

Referring to the chest tubes and drainage system shown in the image, what are the three chambers and what indicates an air leak in the water seal chamber?

The three chambers are Suction control, Water seal, and Drainage collection. Continuous bubbling in the water seal chamber indicates an air leak.

What is the emergency protocol for a dislodged chest tube using the SEALED acronym?

S - Seal the site (occlusive sterile petroleum gauze or hand, exhale & hold breath); A - Apply pressure; L - Limit movement; E - Elevate HOB; D - Doctor should be notified.

What is the emergency protocol for a disconnected chest tube using the DIVE acronym?

D - Disconnect (NEVER CLAMP tubing); I - Immerse the tube in sterile water; V - Ventilate the patient; E - Establish reconnection.

What does the DOPE acronym stand for regarding mechanical ventilator high pressure alarms?

D - Displaced Tube; O - Obstruction (secretions, kinked tube); P - Pneumothorax (Pulmonary Barotrauma); E - Equipment failure.

What does the VENT CHECK acronym stand for in mechanical ventilation nursing care?

V - Verify ventilation settings; E - Elevate HOB; N - ok breath sounds, RR, chest symmetry; T - Titrate sedation; I - Inspect ET tube; C - Cuff Pressure monitoring; H - Humidified Oxygen; E - Eye care; C - Communication (Yes/No Board); K - Keep bag-valved mask nearby.

What emergency equipment must be kept at the bedside for a patient with a tracheostomy?

An Obturator, which guides reinsertion of the tracheostomy tube.

What are the proper tube height and residual volume guidelines during NGT or Gastrostomy feeding?

Open clamp slowly at a container height of $12\text{--}18\,\text{inches}$. If aspirated gastric content residual volume is $>100\,\text{mL}$, hold feeding to prevent acid reflux.

What are the characteristics of stool output for Ileostomy, Ascending, Transverse, Descending, and Sigmoid colostomies?

Ileostomy (RLQ): Liquid stool; Ascending (RUQ): Liquid stool; Transverse (Mid Abdomen): Mushy or Semiformed stool; Descending (LUQ): Semi-formed stool; Sigmoid (LLQ): Formed stool.

What patient preparation is required prior to a Fecal Occult Blood Test (FOBT / Guaiac Test) to avoid false positive or false negative results?

To prevent False (+): Avoid dark colored food and red meat for $3\,\text{days}$; avoid $\text{FeSO}_4$, NSAIDs, and Steroids for $7\,\text{days}$. To prevent False (-): Avoid Vitamin C for $7\,\text{days}$; avoid citrus fruits for $3\,\text{days}$.

What instructions should be given to a patient for sputum collection?

Perform oral care (gargle warm water only; NO mouthwash, toothbrush, or toothpaste), perform deep breathing exercises (nebulization/chest physiotherapy to drain sputum), ask the patient to 'hack up' and 'cough out', then perform oral care.