Nursing Care Review

Flashcards covering key concepts from lecture notes on patient assessment, safety, communication, and various nursing interventions.

Quantity and Quality of Sleep Assessment

A factor to assess first when a patient reports constant tiredness, forgetfulness, and irritability to identify sleep deprivation or sleep disturbances.

PQRST Model (Time Component)

Addresses the onset, duration, and changes over time related to a patient's pain.

Bullying (Workplace)

Repeated, hostile, and intimidating actions, especially in public, considered as workplace mistreatment.

Active Range of Motion (ROM)

Exercises performed by the patient using their own muscles.

Passive Range of Motion (ROM)

Exercises performed by a nurse or caregiver using external force.

Overall Goal of Discharge Planning

To ensure the patient continues safe and effective care at home or in the next setting, focusing on continuity of care, patient safety, and preventing readmissions.

R.A.C.E.

An acronym for Rescue, Alarm, Contain, Extinguish, used in fire safety protocols.

SBAR

An acronym for Situation, Background, Assessment, Recommendation, used to promote clear, concise, and effective information exchange among healthcare workers.

Expressive Aphasia (Broca's Aphasia)

A condition where a patient understands what is being said but has difficulty speaking or writing, with comprehension relatively preserved.

5 Rights to Delegation

Right task, Right circumstance, Right person, Right direction/communication, and Right supervision/evaluation.

Nursing Interventions to Promote Sleep

Minimizing noise and light, encouraging relaxation techniques, and providing comfortable bedding and positioning.

Trendelenburg Position

A patient position where they lie supine with the head lower than the feet, sometimes used to improve venous return and hypotension.

PQRST Pain Assessment (Quality and Severity)

Components of pain assessment that describe the nature of the pain (e.g., 'burning') and its intensity (e.g., '8 out of 10').

Orthopneic Position

A position beneficial for patients with COPD or dyspnea, where leaning forward improves chest expansion and facilitates breathing.

Fall Prevention Mechanisms

Measures such as non-skid footwear, bed in low position, locked wheels on bed/recliner, adequate lighting, call light within reach, room orientation, and a clutter-free environment.

Language Barrier to Pain Management

A situation where a patient's different first language or inability to speak English leads to underreporting pain, necessitating the use of interpreters like MARTTI.

Macular Degeneration and Ambulation

Patients can often safely ambulate if the environment is kept free of hazards due to retained peripheral vision.

Fall Prevention for Macular Degeneration Patients

A major nursing priority because central vision loss makes it difficult for patients to see hazards directly in front of them, increasing the risk of falls.

Potential Complications of Restraints

Skin breakdown/pressure ulcers, circulatory impairment, muscle atrophy/contractures, and psychological distress/agitation.

Oral Care for Sensory Perception Deficits

Important because impaired taste can decrease appetite and nutrition, as oral health strongly influences taste sensation.

Sims Position

A positioning where the patient lies on their left side with the top leg flexed, required for rectal medication administration or an enema.

Neuropathic Pain

A type of pain (e.g., burning, tingling, numbness in feet) most likely present due to nerve damage, as seen in diabetic neuropathy.

Read-Back Communication

A patient safety strategy that ensures verbal or telephone orders are accurately understood and carried out, reducing medication errors or miscommunication.

Nursing Interventions for Aphasia

Using simple, short sentences; speaking slowly; providing communication boards; allowing time for response; maintaining eye contact; and using gestures to support expression and reduce frustration.

Non-Pharmacological Nursing Interventions

Examples include aromatherapy, massage, repositioning, ice/heat application, padding bony prominences, healing touch, music, and guided imagery.

Objective Indicators of Pain

Observable signs such as vital signs, grimacing, guarding, sweating, crying, or a patient's rating on a pain scale.

Inclusion in Healthcare

Ensures that all patients feel respected, valued, and heard, which improves trust, patient satisfaction, and health outcomes.

Vulnerable Populations

Clients with low income or homelessness, immigrants, children, elderly adults, clients with disabilities, veterans, racial/ethnic minorities, and marginalized sexual groups.

SMART Goal Components

Specific, Measurable, Achievable, Relevant, and Timely.

Symptoms of Sleep Deprivation

Mood changes, increased irritability, unintentionally sleeping long hours, excessive yawning, and feeling down/depressed.

Right Direction/Communication (Delegation)

Ensuring clear instructions with expected outcomes for safe delegation.

PERRLA

An acronym for Pupils equal, round, reactive to light and accommodation.

Visual Change Caused by Cataracts

Cloudy or blurred vision.

Safety Measures for Patient Transfer

Using a gait belt, locking wheelchair or bed brakes, ensuring patient's feet are flat on the floor, and maintaining proper body mechanics when transferring from bed to chair.

Safe Practices with Electrical Devices

Avoiding plugging/unplugging with wet hands, not rolling over electrical cords, unplugging by grasping the plug, avoiding extension cords, and tagging/removing unsafe equipment from service.

Health Equity

Focuses on fairness and addressing disparities, potentially requiring individualized care to meet each patient's unique needs.

Health Equality

Providing the same care to every patient regardless of individual circumstance.

Vertical Violence

Bullying behaviors that occur from a supervisor ('top-down').

Key Elements of a Patient's Discharge Plan

Patient education on medications/procedures, coordination of follow-up appointments/resources, and safety considerations (e.g., fall prevention, mobility support).

Vulnerable Populations Risk for Poor Health Outcomes

Higher risk due to barriers such as poverty, limited healthcare access, low health literacy, chronic illness, discrimination, or social instability.

Reason for Using SMART Goals in Patient Care

To provide clear, measurable, and achievable targets for patient outcomes, guiding nursing interventions and improving patient-centered care.

Sensory Overload

A condition experienced when a patient receives too much sensory input, such as constant alarms, bright lights, and frequent staff interruptions.

Mechanical Restraints

Examples include hand mittens, soft wrist restraints, leather wrist restraints, soft lap belt restraints, and vest restraints.

Read-Back Communication Technique

Requires the receiver to repeat the message exactly as they understood it to confirm accuracy, enhancing patient safety.

Explicit Bias (Nurse)

Demonstrated by actions such as refusing to care for a client based on race/religion, treating patients differently due to gender identity, or making derogatory comments about a client's weight.

Body Systems Affected by Decreased Mobility

Musculoskeletal (muscle atrophy, contractures), Cardiovascular (orthostatic hypotension, DVT), and Respiratory (pneumonia, atelectasis), among others.