Fundamentals: Final Exam (Cumulative)

Flash cards for the fundamentals final exam. Textbook is potter & perry

What is nursing?

Protection, promotion, and optimization of health/abilities
Prevention of illness and injury
Alleviation of suffering through diagnosis and treatment
Advocacy for the individual, family, and populations

Nursing is an...

Artful Science. Nurses...
Deliver care artfully with compassion, caring, and respect
Based on continually changing body of evidence, innovation, and discoveries
Quality of care at a level of excellence that is patient centered

What are some different types of nursing professions?

Advanced practice registered nurses, nurse administrators/managers, nurse educators, nurse researcher, nurse entrepreneurship

Standards of professional performance include...

Ethics, evidenced-based practice/research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource use, environmental health

A BSN prepared graduate is prepared to...

Practice in a holistic, caring framework using EBP
Promotes safe, quality patient care
Use clinical/critical reasoning in caregiving
Assume accountability for one's own and delegated nursing care

Quality and Safety Education for Nurses (QSEN)

Patient-Centered Care
Teamwork & Collaboration
Evidenced-based Practice
Quality Improvement
Safety
Informatics

The Concept of Caring

The heart of a nurse's ability is to work with people
The core of nursing for positive patient outcomes
Demonstrates cultural competence
Follows a code of ethics for decision of making

How is caring achieved?

Providing presence, touch, listening, knowing the patient, remembering the patient's perception of care is #1 importance

What is EBP?

Evidence Based Practice

What is the nursing process? (ADPIE)

Assessment
Diagnosis
Planning
Implementation
Evaluation

What is a SMART goal?

Specific
Measurable
Achievable/Attainable
Realistic
Timely

Direct Care

Care provided face-to-face with a person

Indirect Care

Care provided for a person without face-to-face contact

Assessment (ADPIE)

Collect data, organize data, validate data

Diagnosis (ADPIE)

identification of a disease condition based on a specific evaluation of physical signs and symptoms, patient's medical history, or results of diagnostic test/procedures

Planning (ADPIE)

-Setting priorities
-Establishing goals and outcomes
-Selecting nursing interventions/activities
-Sharing the nursing care plan

Implementation (ADPIE)

Treatments, activites, actions based upon clinical judgment and knowledge

-nurses perform these activities to to ensure quality nursing care and promotion of positive outcomes

Evaluation (ADPIE)

Final phase of nursing process and occurs not only at the end, but throughout the whole nursing process. The process of determining the progress toward attainment of goal and effectiveness of care. Nurse reassesses the patient taking into consideration where the patient was before the planned intervention.

Independent Interventions

Activities that nurses are licensed to initiate based on their knowledge and skill

Dependent Intervention

Activities carried out under the physician's order or supervision or according to specified routines

Collaborative Interventions

Activities with overlapping responsibilities of and partnerships between health personnel

Hygiene

-Patient's comfort safety and well-being are all influenced by this

Activities of Daily Living (ADL)

Bathing, grooming, dressing, eating, toileting, and "being mobile" (walking) are referred to as...

Baths...

Provide general cleanliness and well-being
Decrease the likelihood of infections
Promote effective circulation
Give nurse the opportunity to assess the patient in-depth

Hygiene considerations for patients with diabetes

Poor circulation, podiatrist, cold feet...no heat, do not heal easily

Common Bed Positions

Flat, low-fowlers, semi-fowlers, high-fowlers, trendelenburg, reverse trendelenberg

Common Patient Positions

Fowler's, trendelenburg/reverse, supine, prone, side-lying, sims

Different types of hand hygiene

Waterless antiseptic hand rub, soap and water, surgical scrub

Restraints

Prevents-fall, harm, and therapy interruption. Always needs a physician's order. Follow agency protocol. Try alternatives first.

Active Exercises

When the patient do the exercises by themselves

Passive Exercises

When the nurse does the exercises

Immobility

The inability to move the whole body or a body part

Disuse

A state of decreased or absent use of an organ or a body part

Functions of Sleep

Primary function is unclear
Provides healing and restoration
Important for recovering from illness or surgery
Just as important as diet and exercise E

Evidence does support that poor sleep leads...

poor concentration
impaired judgement
decrease in regular daily activities
increases irritability

Sleep disorders

hypersomnolence, insomnia, sleep apnea, narcolepsy

Normal Sleep Requirements

Neonates (up to 16 hours)
Infants (around 15 hours)
Toddlers (12 hours)
Preschoolers (12 hours)
School-Age Children (9-12 hours)
Adolescents (around 7, need 8-10)
Young Adults (6 to 8.5 hours)
Middle and Older Adults (7 to 9 hours)

Standard Precautions

Hand hygiene
Gloves, gowns, masks, eye protection, face shields

Contact Isolation

-Clean Hands
-Gown
-Gloves
-Use Disposable Equipments

PPE application

Gown, mask, goggles, gloves

PPE removal

Gloves, goggles, gown, mask

The concept of Asepsis in nursing practice...

Medical Asepsis:
-Reduction of the number and spread of disease causing agents
-Inhibits growth and spread of pathogens
-"Clean Technique"

Surgical Asepsis
-The complete elimination of the disease-causing agents and their spores for the surface of an object
-"Sterile Technique"

Droplet Precautions

Droplets larger than 5 microns
Private room for patient
Patient should wear standard mask if leaving room

(PIMP- Pneumonias, Influenza, Mumps/Meningitis, Pertussis (whooping cough))

Clean hands, wear mask, wear eye protection, gown, and gloves

Airborne Precautions

Droplet less than 5 microns
Private room for the patient
Negative pressure airflow

(MTV- Measles/meningitis, tuberculosis (pulmonary), varicella (chicken pox))

Clean hands, wear fitted N95 mask

Seven Rights of Medicatoin

Dose
Route
Time
Individual
Medication
Indication
Documentation

Safety in medication administration

Medication schedules determined by agencies and institute for safe medication process guidelines

Facilities determine critical and non-critical

Proper medication administration

DRTIMID

Varying routes

Enteral/ Non-parental - Oral, installation, gastric tube, inhalation, irrigation, vaginal/rectal, topical administration

Parenteral- Intradermal, subcutaneous, intramuscular, intravenous

Special considerations

Infants and children (parental help, anatomy consideration)

Older adults (physiological, behavioral, economic factors)

Benefits/purpose to infusion therapy

-Rapid affect
-Appropriate when patient is unable to use other routes
-Rapid reaction
-Timely

-maintain daily body fluid
-restore previous body losses
-replace present body fluid losses

Phlebitis

-Pain, tenderness, erythema, vascular access site warm to touch, edema, induration, purulence, or palpable venous cord

Extravasation/ Infiltration

-Edema or swelling at site or in surrounding tissue, discomfort at the vascular site, decrease in the rate of the infusion or complete stop in flow, failure to obtain blood return

Clotted IV lines

-Blood backing up into the tubing can cause clotting if not cleared

Infection

-Intravenous infections are not readily noticeable at the vascular access site. So be aware that an unexplained rise in temperature and an elevated white blood count in a patient receiving intravenous therapy might be related to IV infection

Ecchymosis

-Avoid bruised areas when starting short peripheral access devices, bruising at insertion site usually means trauma to the vein caused at the time of initiation

Speed Shock

-Caused by rapid infusion of solution

Venous Spasm

-Patient will complain of pain traveling up the extremity caused sometimes when the cannula is small and fluid infusion is fast

Air Embolism

-Caused by air not being cleared from tubing air has entered into the vascular system

Circulatory Overload

-Patient has received too much fluid

Allergic Reactions

-Patient is sensitive to IV solutions or admixtures in solutions

Cannula Shearing

-Can occur if nurse reinserts stylet into cannula

Nerve Injuries

-Avoid areas where nerves are located
-Monitor sites frequently and remove when patient complains of paresthesia-type pain

Documentation of IV complications

Record in client's/patient's record per employing institution's protocol

Special Considerations Infusion Therapy

-Age
-Placement
-Need

Proper Procedure and Care (Blood Transfusion Therapy)

-Chose the appropriate size vascular access device
-Administer in a "y-setup" along with normal saline (0.9%)
-Prime tubing with normal saline first, and then spike blood NOTE: tubing are only good for 4 hours
-Thoroughly check blood prior to administering (involves checking ID number, checking ID band, blood type of patient and blood, expiration date/time). Document per policy
-Inspect blood products dark or purple blood may be contaminated also inspect for gas bubbles
-Blood should be administered as soon as it arrives from the blood bank. It should never be put in a refrigerator.
-Check and record baseline vital signs before starting
-Remain with recipient and monitor vital signs at least fifteen minutes of infusion

Febrile Reaction (Blood)

most common transfusion reaction- usually due to recipient's sensitivity to donor's WBCs

observe for fever, headache, flushed face, chills, changes in vital signs

Allergic Reactions (Blood)

usually due to a hypersensitivity to antibodies or plasma proteins in the donor blood

observe for hives, itching, redness,and wheezing, also flushing hypotension

Circulatory Reactions (Blood)

heart can't handle the amount of fluid being infused

cough, dyspnea, anxiety, increase in vital signs, distended neck veins

Acute Hemolytic Reaction (Blood)

Usually due to ABO incompatibility, recipient receive wrong blood. Antibodies in the recipient's blood react with antigens on donor cells causing agglutination and cell destruction. Mild or DEADLY

increase in vital signs, blood pressure dropping, fever, chills, nausea/vomiting, difficulty breathing, back pain, changes in urinary status, and shock.

Sepsis (Blood)

Due to contaminated donor unit

high fever, chills, nausea, vomiting, diarrhea, hypotension. Will not develop as rapidly as other types of reactions

Anaphylaxis (Blood)

Rare. Occurs of recipient is IgA deficient. Occurs quickly.

respiratory distress, nausea/vomiting, signs leading to shock and cardiac arrest

Autologous Transfusion (Blood)

person donated his/her own blood some weeks prior to a planned surgical procedure

Autotransfusion (Blood)

special equipment for capturing blood loss at surgery and returning to the patient

Central Line Dressing Change

Only trained personnel who demonstrate competence for insertion and maintenance are allowed to do this.

Central Line Dressing Change

Wash hands, wear mask, remove old dressing, change dressing using aseptic technique, needleless connecters changed per hospital policy

When should you change a central line dressing?

Transparent: 5-7 days
Gauze: 2 days

How often should IV tubing be changed?

96 hours for most
24 hours for parenteral nutrition
12 hours for blood

How often should an IV be changed?

72-96 hours

How often should vascular access sites be monitored?

2-4 hours on adults, hourly for children and elderly

What syringe do you use to flush a central line?

10 mL

Complications from Central Lines

Cardiac arrhythmias, artery puncture, pneumothorax, air embolism, cardiac tamponade, infection, thrombosis

Primary Intention Healing

Edges of the wounds are defined and easily pulled close with sutures. Wounds heal in an orderly and predictable fashion. These wounds heal quickly. Scarring is minimal and risk of infection risk is low.

Secondary Intention Healing

Tissue is lost and therefore wound edges cannot be pulled together. Wound has to be left opened (non-sutured). These wounds heal from the bottom up, filling with granulation. Granulation tissue becomes a scar. New skin will cover the wound.

Tertiary Healing

Delayed primary closure. A wound in which the edges could be pulled together and closed with sutures or staples but is purposely left open for 3-5 days due to excessive drainage, hemorrhage, or infection in

Serous drainage

clear and watery

Serosanguinous

pale red or pink and watery type of drainage

Sanguineous

drainage that is primarily composed of actual bright red blood

Purulent

pus, liquefied necrotic tissue, often indicative of infection

Slough

is loose, stringy, hydrated tissue that is usually yellow "pizza cheese"

is dehydrated, thick, leathery tissue that is usually black

Mechanical Removal

Wet-to-dry dressings, pulsed low-pressure irrigation, whirlpool treatments

Autolytic Debridement

Covers the wound with a dressing that supports moisture at the wound surface. It seals the wound, keeps it moist, and promotes the removal of the dead tissue via lysis of the dead tissue by using the body's natural enzymes and WBCs Ex.Hydrocolloid

Chemical Debridement

Application of a topical enzyme preparation such as Dakin's solution or sterile maggots that either dissolve or digest dead tissue.

Surgical Debridement

Using a scalpel, scissors, or other sharp instrument to cut away dead tissue

Wound healing devices

self-adhesive, transparent film
dry gauze
wet-to-dry dressings
hydrocolloid
hydrogels
foams
alginates
negative pressure wound therapy/wound vac
wound closure: staples/sutures/steri-strips

Nutritional Assessment

Weight changes
Energy levels
Physical signs of malnutrition
Hair, nails, skin
Tongue
Dietary intake history
Weight for height
Fluid status

Fluid Balance Assessment

Rapid, significant weight changes
Intake and Output
Weighing

Enteral Feedings

Delivering liquid nutrients via tube in the GI tract. Patients must be able to digest/absorb nutrients in order to use enteral feedings.

Parental Nutrition

Used for patients who cannot receive digest and absorb nutrients via the GI tract at all. Nutrition is delivered entirely through a vascular access device.

Care of nursing consideration for the patient with a bowel diversion

-Observe stomas constantly, stomas that are not a brick-red color it is a medical emergency

-Skin sealants, stoma powder, and stoma paste can help protect the skin surrounding the stoma

-Bags are reusable, don't clean the inside with hot water to protect the odor control

-Some types of foods are restricted for people. Nuts, raisins, corn, popcorn, and foods with seeds are problematic. Irrigation may be necessary.

-B-12 deficiency is common

-Medications need to be adjusted due to the shortening length of the remaining intestine

-Hydration is important

-Psychological impacts