NPN-118 Final Review

Stages of Death and Dying

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

Respite

a short period of rest or relief from something difficult or unpleasant; allows caregivers to rest for days to weeks

organ donation

Donating or giving one's organs and/or tissues after death; one may designate specific organs or may donate any needed organs; if patient does not have a designation, you contact organ procurement and they will approach the family

Terminal Illness

an illness or injury for which there is no reasonable expectation of recovery

Chronic Illness

irreversible illness that causes permanent physical impairment and requires long-term health care; gradual onset

Acute Illness

A sudden illness from which a person is expected to recover

Interventions for constipation

1. increase intake of high fiber foods

2. increase fluid intake

3. provide privacy

4. assist patient to a seated or squatting position

5. allow the pt uninterrupted time

6. encourage pt not to ignore the urge

7. assess for complications

8. mineral oil (can affect absorption of fat-soluble vitamins)

Valsalva maneuver

forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with venous blood return to the heart; decreases the pulse rate

Clean-catch urine specimen

a urine specimen obtained by cleaning the genitalia and then capturing a midstream urine sample for laboratory analysis; instruct patient to clean labia by wiping from front to back, hold the labia apart while they urinate first into the toilet then into the cup

Glycosuria

sugar in the urine

Urinary catheters

inserted into the body to allow the passage of fluids into or out of the body; ensure the bag remains below the bladder to prevent reflux

Ways to encourage urination

1. assist patient to the bathroom and allow time to void

2. run water in the sink while patient is sitting on toilet

3. allow patient to drink while sitting on the toilet

Types of incontinence

Urge, stress, overflow, functional, mixed

Urge incontinence (overactive bladder)

Occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage.

stress incontinence

when urine leaks during exercise and certain movements that cause pressure on the bladder

functional incontinence

urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation

mixed incontinence

the combination of stress incontinence and urge incontinence

Power of Attorney (POA)

legal document in which one person appoints another person to act as an agent on his or her behalf; respect the decision of the POA as it is that of the patient

NG tube

nasogastric tube

inserted through nose, past pharynx and esophagus, into stomach

used for feeding and/or administering drugs, or emptying the stomach

measure placement from nose to earlobe to xiphoid process

Cyclic feeding

continuous instillation of liquid nourishment for 8 to 12 hours

Continuous feeding

administration of formula for 10-24 hours daily, using a pump to control the feeding rate

Bolus feeding

instillation of liquid nourishment in less than 30 minutes four to six times a day

Pressure injuries

localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device

Stage I Pressure Injury

intact skin with nonblanchable redness

Stage II Pressure Injury

Skin not intact; Partial thickness skin loss.

Stage III Pressure Injury

full thickness tissue loss with visible fat

Stage IV Pressure Injury

Full-thickness tissue loss with exposed bone, muscle, or tendon

unstageable pressure ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Risk factors for pressure injuries

Immobility

Incontinence

Diaphoresis

Inadequate nutrition

Lowered mental awareness

Excessive diaphoresis

Extreme age

Edema

low body mass index

Military Time

time based on a 24 hour clock

Pedagogy

the art or profession of teaching

Geragogy

the unique techniques that enhance learning among older adults; need to allow time for patient to process information

Cognitive Domain of Learning

includes all intellectual behaviors and requires thinking, reading books and magazines

Affective Domain of Learning

deals with expression of feelings and acceptance of attitudes, opinions, or values

Psychomotor Domains of Learning

demonstration, practice, return demonstration, independent projects, games

Motivation for learning

Determines patients desire to learn what is being taught

Inability to sleep

insomnia; teach patients to keep a sleep schedule, dress in daytime clothes, avoid naps throughout the day, exercise

Communication strategies for stroke patients with aphasia

1. provide an alphabet form for patient to spell words or phrases

2. allow client plenty of time to communicate

3. provide client with a white board to write on

4. provide picture cards

Standard precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious; used with every patient in all aspects of care

Transmission-based precautions

CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions

Airborne precautions

used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei; TB, measles, chicken pox

Droplet precautions

Must be followed for a patient known or suspected to be infected with pathogens transmitted by large-particle droplets expelled during coughing, sneezing, talking, or laughing, influenza

Contact precautions

measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface; c-diff, MRSA

Chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Pay special attention to the exit route with GI and respiratory patients

PPE (personal protective equipment)

a barrier between a person and pathogens; includes gloves, gowns, masks, goggles, and face shields

Don: gown, mask, goggles, gloves

Doff: gloves, goggles, mask, gown

Coping strategies

actions that people can take to master, tolerate, reduce, or minimize the effects of stressors

non therapeutic coping strategies

mind and mood altering substances, hostility and aggression, excessive sleep, avoidance of conflict, and abandonment of social activities

therapeutic coping strategies

help a person to acquire insight, gain confidence to confront reality, and develop emotional maturity

stress-reduction strategies

Providing Information

Processing strong feelings

Developing realistic goals

Priority-setting

Anticipatory guidance

Social support

Helping families reduce health-related stress

Promoting healthy lifestyle

primary care

health care at a basic rather than specialized level for people making an initial approach to a doctor or nurse for treatment.

secondary care

health services to which primary caregivers refer clients for consultation and additional testing

tertiary care

highly complex care and therapy services from practitioners in a hospital or overnight facility in which patients must travel long distances to get access to

comprehensive nursing assessment

provides holistic information about the client's overall health status. it includes data about the client's body systems and functional abilities, emotional status, spiritual health, and psychosocial situation, including information about the family and community.

database assessment

initial information about the client's physical, emotional, social, and spiritual health

focused assessment

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

functional assessment

screens the safety of independent living, the need for home health services, and quality of life

Gate-control theory

the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain; ex: giving a back rub

phantom pain

pain felt in a body part that is no longer there

Side effects of opioid narcotics

-GI upset

-constipation

-sedation

-confusion

-agitation

-lower RR and BP

Latex sensitivity

response to latex proteins in gloves and other medical equipment that usually leads to contact dermatitis; also seen in patients with allergies to kiwi, bananas, and other fruits and vegetables

blood transfusion reactions

1. allergic: hives, pruritis, wheezing; antihistamines (allergy to plasma protein)

2. anaphylactic: similar but more sever; seen in IgA deficient people. Dyspnea, bronchospasm, hypotension, shock

3. acute hemolytic transfusion reaction: ABO mismatch; type II hypersensitivity.

chills, difficulty breathing, chest pain (tachypnea, tachycardia, hemoglobinuria/jaundice)

STOP transfusion and notify provider of any reaction

hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

Hypervolemia

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

Colloid solutions

Blood products

Parenteral nutrition (TPN & PPN)

hypertonic solutions

• Used to treat situations of hyponatremia and hypovolemia.

• Administer slowly; can cause intravascular volume overload; carefully monitor serum sodium, lung sounds, and blood pressure.

Solutions.

• Dextrose 5% in 0.45% or half-strength NaCl (normal saline).

• Dextrose 5% in 0.9% NaCl (normal saline).

• Dextrose 5% in Lactated Ringer's.

hypotonic solutions

those with lower solute concentrations and higher water concentrations; cells placed in these solutions gain water; and if they lack a cell wall, may burst

Patient positioning after surgery

+Turn or help the patient turn at least every 2 hours while they are bedridden to prevent complications caused by immobility

Place them in a position that puts the least strain on the wound

Encourage cough and deep breathing to prevent respiratory complications

Patient Discharge Instructions

Guidelines provided to patients upon leaving care; should include information about returning to normal activity, potential adverse effects from medications, signs and symptoms of infection and when to call the physician, information about follow-up appointments

supine position

lying on back, facing upward

prone position

lying on abdomen, facing downward

lithotomy position

lying on back with legs raised and feet in stirrups, hips and knees flexed, thighs abducted and externally rotated; pelvic exam

sim's position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back; enema or colonoscopy

scoliosis

abnormal lateral curvature of the spine

lordosis

abnormal anterior curvature of the lumbar spine (sway-back condition)

kyphosis

excessive outward curvature of the spine, causing hunching of the back.

Apical pulse location

5th intercostal space, midclavicular line; slightly above the left nipple

sterile technique/surgical asepsis

The practices that keep items free of all microbes; sterile technique; everything below the waist is considered non-sterile

hand hygiene

washing hands with either plain or antiseptic soap and water and using alcohol-based hand rubs whenever hands are visibly soiled

Informed consent

An ethical principle requiring that research participants be told enough to enable them to choose whether they wish to participate; discussion of risks, benefits, treatments, etc.

24 hour urine

24 hour collection of urine. Discard first void, but must include the rest

Blood glucose monitoring

The ongoing measurement of blood sugar (glucose). Monitoring can be done at any time using a portable device called a glucometer. Use the sides of the fingers for puncture sites.

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization

Oxygen use in home

1. ensure no smoking or flames around oxygen

2. install smoke detectors, fire alarms and carbon monoxide detectors

3. practice fire escapes from each room in the house

4. avoid electric razors or items that can create a spark

Respiratory distress

increased work of breathing; a sensation of shortness of breath; Raise the HOB!

sentinel event

unexpected occurrence involving death or serious injury

Signs of infection

Redness, sweating, fatigue, fever, change of behavior

RACE

rescue, alarm, contain, extinguish

HIPAA

The Health Insurance Portability and Accountability Act, a federal law protecting the privacy of patient-specific health care information and providing the patient with control over how this information is used and distributed.

Dosage formula

Desired/Have X Quantity