Transition study guide (Kaplan) – Flashcards

5 basic levels of needs: physiological, safety, love & belonging, self esteem, self actualization. -Client progresses up the hierarchy when attempting to satisfy needs -Low level needs must be met first

problem solving systematic approach used to meet actual & potential healthcare needs of clients. -Steps: assessment, diagnosis, planning, implementation, evaluation -purpose: to diagnose + treat client's responses to actual/potential health problems -provides common language + step by step process for nurses to care for clients

Extent + limits of medical interventions that healthcare provider may perform

Unlicensed staff; AKA CNA, technicians, etc -Can assist with direct client care activities [bathing, transferring, ambulating, feeding, toileting, obtaining VS, height, weight, I&O, housekeeping, transporting, stocking supplies

listening to and understanding client while promoting clarification and insight Goals: -to understand client's message -to facilitate client's verbalization of feelings -to communicate nurse's understanding + acceptance -to identify problems, goals, + objectives **using silence, using general leads of broad openings, clarification, + reflecting

prevents clients from harming themselves or others by using chemical or physical means -informed consent required -physician's order required specifying duration, + circumstances under which restraints should be used **remove Q2H, assess for redness or excoriation nursing care includes: -assessing + documenting needs for restraints -considering + documenting use of alternative measures

measurement of bp + pulse in supine, and standing positions *positive test when: -client becomes dizzy or loses consciousness -pulse increases by 20bpm -SBP drops by 20mmHg or more 2 mins after changing position from lying to sitting or sitting to standing **indicates hypovolemia or dehydration

visualization of trachea + mainstream bronchi to: -obtain tissue biopsy -apply medication -aspirate secretions for lab exam -aspirate mucous plug causing airway obstruction -remove aspirated foreign objects Nursing responsibilities pre-test: -explain procedure -maintain NPO 6-12hrs -inspect mouth for infection -administer pre medication -remove dentures -prepare for sore throat after procedure Nursing responsibilities post-test: -instruct to sit or lie on side -remain NPO til gag reflex returns -observe for respiratory difficulties

botanical meds, vitamins, + minerals regulated as dietary supplement with statements of how supplement affects structure + function of body -can interact with convention medication -St John's wort: accelerates metabolism of many drugs -Gingko biloba, feverfew, + garlic: suppresses platelet aggregation + increases risk of bleeding when given with anti-coag meds -Ephedra: elevates BP, heart, and CNS **dietary supplements include: echinacea, garlic, ginseng, black cohosh, feverfew, ginger, saw palmetto

state govt agencies responsible for regulation of nursing practice -accredit/approve nursing education programs in schools + universities -develop standards, rules, + regulations **each state has nursing practice act + board's responsibility to enforce nursing practice act includes: -qualification for licensure -nursing titles -scope of practice -outcomes that may happen if nurses dont adhere to practice act

client's agreement to have procedure performed after explanation of risks, benefits, expectations, + alternatives to procedure *can be withdrawn at any time *nurse ensures consent form is signed + attached to chart

loop diuretic that inhibits absorption of sodium + chloride in loop of henle + distal renal tubes -S/E: hypotension, hypokalemia, GI upset, weakness nursing considerations: -monitor BP, pulse rate, I&O, potassium -weight daily -do not give at hour of sleep -encourage potassium containing foods *after oral dose, diuresis can occur within 30 mins

accurate + comprehensive report on any unexpected/unplanned occurrence that affects or can possibly affect a client, family member, or staff person -don't include reference to incident report in charting -don't use words like "error" or "inappropriate", inflammatory words, or judgemental statements needed for: -medication errors -complications from diagnostic or tx procedures -incorrect sponge count in surgery -failure to report change in client's condition -falls -burns -break in aseptic technique -medical/legal incident [client or family refusing tx as ordered, refuses to sign consent] -client or family dissatisfied with care + situation can't be or has not been resolved

where impulse of left ventricle [L 5th intercostal space @ midclavicular line] felt most strongly; point of maximal impulse [aka PMI] -pulse deficit: difference b/t apical + radial pulse ->radial usually slower d/t ineffective contractions failing to send pulse waves to periphery; cardiac dysrhythmia may be present

code of ethics safeguarding client's right to privacy -client has right of records -info about client can be used only for purposes of diagnosis + tx -info can't be released to others w/o permission

when using nasal canula: -assess patency of nostril -apply water-soluble jelly to nostrils q3-4hrs -perform good mouth care If using face mask: -remove mask q1-2hrs -wash, dry, apply lotion to skin -provide emotional support to decrease feeling of claustrophobia with partial non rebreather mask: -adjust oxygen flow to keep reservoir bag 2/3 full during inspiration

establishing priorities enables nurse to attend to client's most important needs + helps nurse organize care *situations if left untreated, can cause physical harm to clients have highest priority *use maslow's hierarchy of needs to establish priorities

planning + implementing care that's sensitive to the needs of individuals, groups, and families from diverse cultures -requires cultural sensitivity + cultural awareness When nurse from different culture than client interacts with them, include: -their culture, expectations, and beliefs of healthcare -context of interaction -amount of agreement b/t 2 person's set of beliefs and values

1st step of nursing process; establishes database includes: -collection, validation, organization, initial references, + communication of data of client or healthcare situation -subjective data from client's point of view -objective data from nurse's point of view -dynamic process, not ending up with initial contact or impressions

responsibility and authority for performing a task transferred to another individual that accepts responsibility and authority -can delegate only tasks for which nurse is responsible steps include: -defining task to be delegated -determining who should receive delegated task -identifying what the task involves -matching task to individual by assessing their skills and abilities -providing clear communication about expectations regarding task -answering q's

LPN/LVN assist with implementation of defined plans of care -perform procedures according to protocol -differentiate normal from abnormal -care for physiologically stable clients with predictable conditions -has knowledge of asepsis + dressing changes -ability to administer meds varies with educational background + state nurse practice act

person or organizational chart who is above the nurse -nurse reports to this person -is responsible to the person above the nurse **nurse reports variances, problems, + concerns to next person with authority in direct line in their area

unintentional failure of individual to perform act that a reasonable person with same knowledge, experience, + background would or would not perform in similar circumstances -can be acts of omission or commission **failure to act causes injury to client -4 elements of negligence: duty owned, breach of duty or standard care -connection b/t breach of duty + damage

statements reflecting highest level of independence for client -goals are client centered, measurable, and time limited -if goal short term, client expected to achieve in hours up or upto less than a week -long term goals take matters of several days, weeks, or months

patient self determination act + ethical doctrine of autonomy gives patients right to refuse tx -if patient refuses tx, must be informed of harmful consequences of refusal

beliefs, values, attitudes, customs, languages, ceremonies, symbols, behaviors, artifacts shared by group of ppl and passed on from one generation to next -needs to be considered in all health care situations -different cultures have different ways of perceiving, defining, understanding, expressing, responding to, and treating illness *cross cultural difference can be problematic if not understood, accepted, + responded to appropriately

given yearly, preferably in october to november recommended for: -ppl of 65yrs or older -ppl younger than 65 with heart disease, lung disease, DM, immunosuppression, or living in chronic care facility *contraindication: previous anaphylactic reaction to vaccine or eggs

established by american nurses associatio -standards of profession performance include quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, + leadership **include utilization of steps of nursing process [ADPIE] as basis of clinical decision making

assault: threat or attempt to touch a person in a way that's intimidating, insulting, offensive, or harmful battery:actual touching of a person w/o authorization to do so ** any nursing, medical, or surgical procedure performed w/o consent of patient is viewed legally as battery

-consider specific knowledge needed + whether type of learning needed is cognitive, psychomotor, and/or effective -assess motivation, anxiety level, attitudes + beliefs, cultural + environmental influences of patient -best to set realistic goals [preferably with mutual agreement] and priorities -be nonjudgmental and empathetic -supplement verbal w/ nonverbal instruction -use demonstration and return demo for teaching skills -allow for practice periods -give positive feedback -ensure by observation that knowledge has been incorporated

assessed for symmetry, contour, umbilicus, bowel sounds, arteries [aorta, renal, iliac, femoral], peritoneal friction rub, liver + spleen size, inguinal lymph nodes, rebound tenderness, kidneys, abdominal reflexes -done in order of inspection, auscultation, percussion, and palpation -ensures progression from least to most disruptive or invasive technique to prevent bowel sounds from being altered -bowel sounds evaluated for intensity, pitch, + frequency [usually 5-30per minute] **to determine bowel sounds are absent, nurse must listen for total of 5 mins in each quadrant

when hospitalized clients acquire infections as result of hospitalization can be classified as: -iatrogenic infection: c/b diagnostic or therapeutic procedures -exogenous infection: c/b microorganisms outside of client and isn't part of normal flora -endogenous infection: when client's normal flora is altered *common sites: urinary tract, wounds, respiratory tract, bloodstream **standard precautions are primary strategy for nosocomial infection control

uses gravity to facilitate removal of bronchial secretions -client placed in variety of positions to facilitate drainage into larger airways from lungs and bronchi into trachea -secretions may be removed by coughing or suctioning *prevents complication of stasis of respiratory secretions

begin at 18-20yrs of age, examine monthly, 1 week after menstrual period begins or at a routine time [ex: first day of month if non-menstruating] -begins with inspection of breasts in mirror -examine first with arms at sides, second with arms above head, third with hands on hips -while lying down, use finger pads of 3 middle fingers to palpate breasts to detect unusual growths -look for dimpling or retractions -examine nipples for discharge, changes, + swelling

5th VS, whatever person says it is and exists whenever person says it does -can be acute or chronic -cultural and past experiences with pain major factors influencing pain experiences -indications: increased BP + pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprehension + irritability, grimacing, guarding, verbalizations of pain -interventions: establish therapeutic relationship, establish 24 hr pain profile, teach patient about pain + its relief, reduce anxiety + fears, provide comfort measures, administer pain medication, refer to alternative methods of pain relief **with regard to pain medication: use preventive approach, which states if pain is expected to occur throughout most of a 24hr period, a regular schedule is better than prn, usually takes smaller dose to alleviate mild pain or prevent occurence of pain

identifies, coordinates, monitors implementation of services needed to achieve desired outcomes within specified period of time -involves principles of continuous quality improvement -promotes professional practice case manager : ->usually has advanced degree and considerable experience ->doesn't provide direct client care ->supervises care provided by licensed and unlicensed personnel ->coordinates, communicates, collaborates, solves problems ->facilitates client care for group of clients [10-15] ->follows client through system from admission to discharge ->notes variances from expected progress

advance directive that tells healthcare providers of life sustaining tx's [ex: surgery, cpr, respirator, tube feedings] an individual doesn't want initiated or wants if they develop a terminal condition or persistent vegetative state *implemented only if terminal or irreversible state develops

mutual recognition nurse licensure that allows nurse to have one license in state of residency + to practice in other states [both physical + electronic] -subject to each state's practice law and regulation -each state must enact legislation or regulation authorizing the NLC *includes RN's, LN/PN's but doesn't include advance practice nurses

important to establish effective nurse-client relationship before proceeding to actual initial interviewing process -introduce self + purpose, time frame -elicit concerns of client -inform about confidentiality -convey competence + acceptance -use therapeutic communication techniques ->silence ->general leads or broad openings when possible ->reflection ->rephrasing ->clarification ->focusing ->summarizing ->offering info prn **sequence of interview: -greet client -elicit why client seeking healthcare -determine topics of interview -expand + clarify client's story -discuss shared understanding of client's problem -discuss a plan -determine the f/u

herbal supplement used for nausea, vomiting, indigestion, gas, lack of appetite -S/E: minor heartburn, dermatitis -c/i with gallstones -may potentiate antiplatelet + anticoagulation meds, antidiabetic meds, and herbs that increase bleeding time

verifies expertise in specialty areas of clinical practice -most certification programs require clinical experience in related field plus successful completion of written exam -ANA + multiple nursing specialty organizations have exams + procedures for certification in a specialty area *nurse practice act regulates the practice of RN and advance practice nursing

exerted by circulating volume of blood on walls of arteries, veins, & chambers of heart -cover 50% of limb from shoulder to olecranon with cuff -check both arm for comparison, difference of 5-10mmHg normal -difference of 30-40mmHg b/t systolic and diastolic is normal Normals: - newborn: 60 to 80/40 to 50mmHg -child 1-4: 90 to 99/60 to 65mmHg -child 5-12: 100 to 110/56 to 60mmHg -adult: 90 to 140/60 to 90mmHg

-promotes communication -maintains legal record -meets requirements of regulatory agencies -required for 3rd party reimbursement -is legible, accurate, timely, thorough, concise, well organized, uses proper grammar, spelling, & authorized abbreviations

used to maximize lung expansion by opening closed alveoli + mobilizing secretions -instruct to breathe in & exhale normally -seal lips around mouthpiece -inhale slowly & deeply -hold breath for at least 3sec while keeping ball/cylinder elevated -exhale -take several normal breaths & repeat procedure 4-5 times **client should cough after procedure to facilitate secretion removal

for clients requiring physical skin to skin contact, occurring b/t nurse + client or 2 clients; can occur by contact w/ contaminated objects in client's environment, private room or w/ another client w/ same infection but no other infection -wear clean nonsterile gloves when entering room -change gloves after client contact w/ fecal material or wound drainage -remove gloves before leaving client's environment + wash hands w/ antimicrobial agent **wear gown when entering room if clothing has contact with client, environmental surfaces, or if client is incontinent, has diarrhea, an ileostomy, colostomy, or wound drae

problem solving approach based on using very best available evidence from disciplined research findings, -used for making clinical judgements, & best decisions about client care

Requires full assessment because anesthesia, immobility, + surgery can affect any system in body -Neuropsychosocial: stimulate client postanesthesia + monitor loc -Cardiovascular: monitor VS q15mins x4, then q30mins x2, then qhr or prn: check potassium levels, monitor CVP -Respiratory: check airway + breath sounds: turn, cough, & deep breathe unless c/I such s with brain, spinal, or eye surgery; splint wound, offer pain meds, teach to use incentive spirometer (hold mouthpiece in mouth, exhale normally, seal lips & inhale slowly + deeply, keep balls or cylinder elevated, exhale + repeat) -GI: check bowel sounds in all 4 quadrants for 5 mins, keep NPO until bowel sounds present, provide good mouth care while NPO, provide antiemetics for n+v, check abdomen for distention, check for passage of flatus + stool -Genitourinary: monitor I&O, encourage to void, check for bladder distention, notify MD if unable to void within 8hrs, catheterize prn -Extremities: evaluate + promote circulation -Wounds: evaluate and manage dressings, drains, + incision itself -GI tubes: check placement -Musculoskeletal: get oob asap, ambulate as much as possible **monitor for complications: hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infections of wound, dehiscence, evisceration, DVT, + psychosis

Inflammation of meninges of brain or spinal cord 5 types of meningitis viral bacterial parasitic non infectious fungal -viral: spreads from person to person through fecal contamination, can occur when changing diaper or using toilet and not properly washing hands after ->caused by common viruses, & mumps, herpes, stomach problems and etc -bacterial transmission: through respirator throat secretions (kissing) ->bacterial meningitis caused by three bacteria with complex code names: 1. Haemophilus influenzae type b 2. Pneumococcus 3. Meningococcus *Spreads when someone has close contact with an infected person—like real close conversation, or kissing. Also thru touching infected surfaces, like a doorknob, and then touching your mouth or nose Bacterial meningitis can cause brain damage, hearing loss, or learning disabilities -vaccines and antibiotic are best defense -CDC recommends 11-12yr olds entering high school to get vaccinated Viral meningitis normally does less damage than bacterial meningitis. -can't be treated with medicine -immune system can usually knock out viral meningitis without any help

consists of: interview, levels of consciousness, pupillary assessment, vital signs, motor function, sensory function, + tone Interview the presence of: -headache -difficulty with speech inability to read or write -alterations in memory -altered consciousness -confusion or change in thinking -disorientation -decreased sensation tingling or pain -motor weakness or decreased strength -decreased sense in smell -changes in vision -difficulty with swallowing -decreased hearing -altered gait or balance

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