Exam 2 1022C Fundamentals of Nursing Keiser University – Flashcards
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Culturally Responsive Care includes
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1.Centering the care around the client (Beliefs and values)
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To deliver care as a nurse
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1. Examine your own beliefs and attitudes, and bias 2. Gain the necessary knowledge and skills 3. create a trusting environment to learn culture
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Subculture
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Identity related to a larger culture group
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Mutliculture
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multiple patterns of identification across cultures, lifestyle, and value sets
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Ethnicity
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Shifts over time - migration, intermarriage
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Nationality
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Citizenship or ethnicity 1. country that you own membership to
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Religion
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System beliefs, practices, ethical values about divine or superhuman worshiped as creator or ruler of the universe
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Enthnocentrism
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belief that their is superiority of ones own culture and lifestyle
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Xenophobia
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the fear or dislike of people different from oneself
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Predjudice
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judgement based on sufficient knowledge - leads to sterotyping
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Racism
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Assumptions , races are inherently unequal or ranked hierarchically
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Discrimination
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Negative treatment on the bias of race, ethnicity, gender, and other groups of membership
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Generalization
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statements about common cultural patterns
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Sterotyping
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an individual that reflects all characteristics associated with being a member of a group
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Acculturation
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changes of ones cultural patterns to those of the host society (Forced to adopt a new culture)
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Assimilation
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Where an individual develops a new cultural identity 1. They lose their culture identity and acquire a new one. (Becoming a member of the dominate culture)
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Health Disparities
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1. Quality and access of care 2. Provider bias 3. Provider communication skills 4. Poor Health literacy
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What causes Health disparities
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Gender social economics employment, education status Available housing Available transportation Food security status
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Culture shock
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Confusion and uncertain of new culture
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Magico-Religious Health Belief
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Health and illness is controlled by the supernatural forces
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Biomedical Health Beliefs
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Manipulated by humans
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Holistic Health Beliefs
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Forces are maintained through balances and harmony (Folk Medicine)
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Translator
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Converts Written Material
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Interpreter
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Transforms the message from the source to the target
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Rights of delegation
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1. Task 2. Circumstances 3. Person 4. Direction and communication 5. Supervision and evalution
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Who can the RN Delegate to
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LPNs UPAs RNs
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What can the Rn delegate to the UPAs
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1. ADLs 2. Bathing 3. Grooming 4. Dressing 5. stable Vitals 6. Ambulating 7. Intake and Output 8. Specimen collection
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What can the Rn Delegate to the LPNs
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1. Admin Feeding 2. Admin Drugs (No IVs) 3. Suctioning 4. NG Petency 5. Insert Cath 6. Reinforcing Teaching
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Authoritarian Leader
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Makes decisions for the group
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Democratic Leader
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Encourages the group to make decisions
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Laissez-Faire Leader
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Permissive, Group need autonomy and self-regulation to be effective
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Bureaucratic Leader
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Follows the Org Rules and Polices and Procedures
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Situational Leader
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Task Orientated (Adapts to the readiness/ ability of the group to perform task)
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Charasmatic Leader
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Emotional Relationships with leader and group
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Transactional Leader
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Relationship based on an exchange of something valued by the follower
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Transformational Leader
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Empowers the Group to Share Organizations Values Ex.Pro. Sho
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1st Level of Management
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charge nurse
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Middle Level of Management
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Nursing Supervisor
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Upper Level (Top) Management
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Director of Nursing
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Authority
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Legit right to direct the work of others
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Accountability
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Assuming the ownership for ones action and accepting consequences
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Responsibility
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Obligation to perform a specific task
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Medical asepsis
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All practices that confine a specific microorganism to a specific are, and limits number, growth and transmission of the microorganism
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Surgical asepsis
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Sterile Free from all (Destroy all microorganism and spores)
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Clean
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Absence of almost all microorganism
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Dirty
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Contaminated , microorganisms may be present
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Asepsis
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Free from all disease microorganisms
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Physical assessment for the client with infection
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Body area involved Skin and mucous membrane 1. localized swelling 2. pain and tenderness with palpation 3. loss of function 4. fever (increased pulse and respiration) 5. Malaise 6. Anorexia 7. Nausea and V omitting 8. Enlargement and tenderness of lymph nodes 9. Exudation of various colors
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Inflammatory response
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1. Pain 2. Swelling (Fluid leaking) 3. Redness 4. Heat 5. Heat Impaired Function
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Stages of Imflammation
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1. Vascular and Cellular 2. Drainage (Exudation Production) 3. Reparative
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Vascular and Cellular Stage
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dilation of small blood vessels Histamine is released to injures tissue, increased blood flow
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Drainage (Exudation Production)
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Exudate= dead phagocytic cells. tissue and fluid from blood cells
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Reparative
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Replacement of destroyed cells by identical / similar cells of formations of granulation
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Factors increasing susceptibility to infection
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1. age 2. heredity 3. nature (# and duration) 4. Nutrition 5. Medical Treatments (Radiation) 6. Medication (Steroids) 7. Disease that lesson resistance (COPD)
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Anatomic and physiological barriers for protection against infection
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1. intact skin and moist mucous membrane is the first line of defense. 2. Nasal cilia 3. Alveolar Macrophages 4. Saliva 5. Tears 6. High acid in Stomach 7. Peristalsis 8. low pH in Vag 9. Urine flow through urethra
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Sterile Feild
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All Objects are sterile in the field except skin Prolonged exposure to airborne contaminates Never delegated to a UPA
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Direct Tansmission
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person to person 1. touching 2. biting 3. Sex 4. Sneezing 5. coughing 6. Talking
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Indirect Trasmission
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Vehicle Borne toys, instruments, equipment eating utensils Vector borne Animal Insect
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Airborne Transmission
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evaporated droplets that remain in the air and transported by currents (TB)
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Recommended isolation precautions in hospitals
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1. hand washing 2. avoid tranporting affected clients 3. PPE
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Restraints
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1. to protect/ prevent harm to clients and others
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Physical Restraints
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Any manual, physical or mechanical device attached to any part of the clients body
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Chemical Restraints
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medication to control safety (Larazepam, Haldol, Valium, Ativan)
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Restraints Nursing Considerations
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access very hour need new order ever 24 hours no PRN use
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Restraints only used when
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all possible means have been addressed 1. needs 2. distractions 3. client moved closer to nursing station 4. sitter
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Risk factors and preventive measures for falls (box 32-1)
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1. Infants and eldery 2. orient client to surroundings 3. keep environment sfae and clean and clear 4. use safety monitoring devices (LifeAlert, Bed & Chair Alarms)
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Seizure precautions
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1. Pad bed with blankets Around the head, feet and bed side rails 2. Oral suction equipment and qxygen flow meter and sup O2 in place 3. Assist client to bed or floor in lateral position 4. remove any environmental safety hazards 5. Remain with client 6. Doc- time, duratiom, progression (B4, during and after) 7. Client wear medical id tag
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Phases of diagnostic testing
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1. Pre test 2. Intra test 3. Post Test
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PreTest
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prep of equipment and supplies
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Intratest
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Specimen collection and assiatance 1. Label 2. Store 3. Transport
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Postest
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Appropriate nursing care following up and oberservations
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CBC
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evaluate 3 types of blood cells3 1. Hgb 2. Hct 3. RBS 4. WBC
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CBC with Dif
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evaluate specific #'s of WBCs 5 types 1. Neutrophils 2. Lymphoyctes 3. Mac 4. Eosinophins 5. Basophils
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Basic Metabolic Panel (BMP)
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Glucose. Kidneys, Acid/Base, Electrolytes, Hypotension, Hypokalemia 1. Sodium (Electrotyes) 2. Potassium (Electrotyes) 3. Chloride (Electrotyes) 4. Glucose 5. BUN (K) 6. Creatinine (K) 7 CO2 (acid base)
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Comprehensive Metabolic Panel (CMP)
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14 test 1. Sodium (Electrotyes) 2. Potassium (Electrotyes) 3. Chloride (Electrotyes) 4. Glucose 5. BUN (K) 6. Creatinine (K) 7 CO2 (acid base) 8. Albumin 9. Alkalin 10. ALT 11. AST 12. Bilirubin
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Hgb A1c
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% of hemoglobin carriers O2 (covered with sugar ) -Glycated Elevated Agb A1c = Risk for diabetes
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Cardiac Markers
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CK- Creatine Kinase Myoglogin- Tropin 1 Tropin T
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Tropin Values are
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Critical Test Values
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Specimen collection and Testing prodedures
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Comfort and privacy Note relevant information on the (Requisition Slip) Transport to lab promptly Report abnormal findings to provider 1. Stool 2. Urine 3. Sputum 4. Throat
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Why Collect Stool
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1. Presence if occulated blood 2. Dietary product of digestive secretions 3. Presence of ova (parasites) bacteria, or virsues
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Clean Void
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Done in the Am 10 ml meeded Routine urinalysis UPA CAN
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Clean Catch
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Sterile procedure Labia cleaned Discard initial urine and midstream is collected UPA CANNOT
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Time Urine Specimen (24 Hour Test)
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24 hour period of collection Refridge or preserved (Prevent bacteria growth) (if missed or stopped) MUST RESTART
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Sputum collection
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Offer mouth care (b4 ; after) From lungs NOT SPIT breathe deep 15 - 30 ml do not get on outside of container (healthy people do not have sputum) (Label and transport)
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Capillary blood Glucose Spec collection
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Lateral side of fingertip measure blood glucose ca be perform by client
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Anoscopy
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viewing the anal canal (invasive)
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Protoscopy
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Viewing the rectum (invasive)
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Proctosigmoidoscopy
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Viewing of sigmoid colon and rectum (invasive)
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Colonoscopy
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Viewing Large intestine
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Barium Swallow with Xrays
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upper GI tract - small bowel
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Fluoroscopic exam
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Lower GI tract - Enema
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KUB
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kidney , urinary, bladder
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IVP Intravenous Pyelography
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directly in IV or urinary tract
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Renal Ultrasound
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Soundwaves
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Cystoscopy
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Direct visualization of bladder, uretal ofifice and urethra
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Angiography
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Check for coronary disease (Fluoroscopic view)
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Enchocardiagram
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ultrasound to visualize the heart and left ventricle
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V/ Q scan
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looking for clots and ventalation and perfusion of the lungs
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Q scan
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Perfusion of lungs
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V Scan
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Ventilation of the lungs (Breathe in radioactive gasses)
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CT Scan
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3D image distinguish between tissue density
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MRI Magnetic Resonace Imaging
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Imaging of normal and abnormal tissue
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MRI client considerations
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-Pacemaker can stop working or be dislodged -interal metal
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MRI Claustrophobia
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- Educate - Mild sedative (ordered) - Feet first
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Position Emission Tomography PET Scan
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Injection of Radioisotopes to view blood flow and tumor growth
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Lumbar Puncture
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Position Client so provider can access site (Set up equipment)
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Abdominal Paracentesis
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Obtain fluid from the Abdomen (Relive pressure on organs)
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Thoracentesis
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Removal of access fluid or air from lungs Position client for provider and set up equipment - Client sitting with arms above head
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Bone Marrow Biopsy
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Remove specimen from bone marrow for lab study (leukemia)
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Bone Marrow Biopsy sites
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Iliac Crest (preferred) Sternum Iliac spine proximal tibia (child)
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Liver Biopsy
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bedside procedure Apply pressure on site to prevent bleeding Lie client on right side for post op compression
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Clean wound
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not infected minimal inflammation (not inside Respiratory, GI, GU) (Primarily closed)
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Clean contaminated wound
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Surgical wounds (inside Respiratory, GI, GU) show no signs of infection
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Contaminated wound
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Wide open Fresh accident/ surgical wound major sterile break (Large spill in GI tract shows infection
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Dirty or infected wounds
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contain dead tissue and shows signs of infection such as drainage
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Incision wound
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Cause: Sharp (knife scalpel) Open deep shallow
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Contusion wound
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Blow from instrument Closed wound damaged vessels Bruised
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Abrasion wound
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Surface scrape (Knew fall) Open wound
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Puncture wound
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Penetration of the skin and underlying tissue Sharp instrument Open wound
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Laceration wound
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Tissue torn a part Accident (machinery) edges jagged
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Penetrating wound
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Penetration of the skin and underlying tissue Unintentional Bullet Open wound
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Pressure Sore
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due TO ischemia( localized deficiency of blood supply) bed sore
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Blanchable
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press skin turn pale then red again
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Non Blanchable
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does not change in color when touched
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Stage 1 Pressure Ulcers
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non blanchable (Potential Ucleration)
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Stage 2 Pressure Ulcers
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Skin Loss Epidermis Blister Subcutaneous Tissue
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Unstageable Pressure Ulcer
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Full skin or tissue loss- depth unknown
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Stage 3 Pressure Ulcers
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The fat and muscle
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Stage 4 Pressure Ulcers
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Damage of bone and muscle tissue Necrosis
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Prevention of Pressure Ulcers
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Turn pt q 2 hrs Check skin integrity Clean and dress them Never use alcohol or hydrogen peroxide Client education ROM
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Risk factors for Wounds
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Friction Shearing Immobility Inadequate Nutrition Fecal and Urinary incontinence Excessive body Heat/Sweat Decreased mental Status Advanced Age Diabetes
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Primary Wound Healing
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Formulation of Granulation Tissue not loss Closed wound Ex first Degree burn, surgical incision
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Secondary Wound Healing
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Edges not approximated Repair time longer Scaring greater Ex Pressure Ulcers
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Tertiary Wound Healing
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Initially Left open 3-5 days Edema. Exudate to drain Open abdominal surgery incision
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Inflammatory Phase of Wound Healing
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3-6 days Hemostasis (cessation of bleeding) Phagocytosis (cells ingesting other cells)
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Proliferative Phase of Wound Healing
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4-21 days Collagen (white protein) Granulation Fibroblasts
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Maturation Phase of Wound Healing
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21 days - 2 years Remodeling or contraction Scar Scar never as strong as original tissue
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Dehiscence
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Total or partial rupture of a sutured wound Abdominal wounds
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Evisceration
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Protrusion of internal viscera through incision 4-5 days after surgery
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Serous Exudate
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Mostly serum Watery clear Blister
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Purulent Exudate
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Pus formation (Brown/yellow) Infectious
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Sanguineous Exudate
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Large number or red Blood cells (Damaged Capillaries) Open wound
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Seraosanguineous Exudate
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Clear with blood
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Purosanguineous Exudate
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Pus and Blood
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Wound Assessment for infection UNTREATED
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Location Extent of tissue damage Wound length, width, depth Bleeding Foreign bodies
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Wound Assessment for infection TREATED
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Appearance Size Drainage Presence of swelling Pain Status
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Factors Affecting Wound Healing
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Age Nutrition Lifestyle (exercise and smoking) Medications (steroid)
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Lab Data affecting Wound healing
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Leukocyte count Hemoglobin level Blood coagulation studies Serum protein analysis
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Albumin level
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Nutritional Status
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Nursing Diagnosis for wounds
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Risk for impaired skin integrity Impaired Skin integrity Impaired tissue integrity Risk for infection Acute Pain
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Heat Therapy
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Vasodilation Increased capillary permeability Increased Cellular Metabolism Increased inflammation Sedative effect Indications for heat •joint stiffness from arthritis •Contractures •Low Back pain
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Cold
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Vasoconstriction Decreased capillary permeability Decreased Cellular Metabolism Decreased inflammation Sedative effect Indications for cold •Sprains •Strains •Fractures •Post Injury Swelling ; Bleeding
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Fowlers
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45 degrees angle
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Semi-Fowlers
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30 degrees angle
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High-Fowlers
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90 degree angle
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Prone
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Face Down
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Supine/Dorsal Recumbent
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Face Up
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Isotonic exercise
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Muscles Shorten to produce muscle contraction and active movement
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Isometric
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Muscle contraction without joint movement
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Isokinetic
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Muscle contraction or tension against resistance
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aerobic
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Amount of o2 taken into the body greater than what's used for activity
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Anaerobic
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Muscle cannot draw out enough o2 from the bloodstream
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Proper body mechanics for healthcare providers
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Balancing and maintaining the line of gravity Baseline support
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Passive ROM
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RN assist pt
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Active ROM
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OT do own own
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Effects of musculoskeletal
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Disuse osteoporosis Disuse atrophy Contracture Foot drop Stiffness in joint pain
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Effects of Cardivascular
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Diminished Reserve Orthostatic Hypotension Dependent Edema Thrombus formation
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Effects of Respiratory
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Movement Pooling of secretions Atlelectasis Pneumonia
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Effects of Metabolic Immobility
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Decreased Rate
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Effects of GU Immobility
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Urinary Stasis Renal Calculi Urinary retention UTI
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Effects of GI Immobility
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Constipation
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Effects of integumentary Immobility
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Reduced skin turgor Skin breakdown
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Effects of psychoneurologic Immobility
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Decline in endophins = negative mood and self esteem
