Section 1
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pain management
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Date created
Mar 1, 2020
Cards (55)
Section 1
(50 cards)
pain management
5th VS, whatever person says it is and exists whenever a 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, verbalization of pain // Interventions: Establish therapeutic relationship, establish 24 hr pain profile, teach patient about pain + its relief, reduce anxiety + fears, provide comfort measure, administer pain medication, refer to alternative methods of pain relief // Pain Medication: Use preventative approach, which states if pain is expected to occure throughout most of a 24hr period, a regular schedule is better than PRN, usually takes smaller does to alleviate mild pain or prevent occurance of pain.
certification
Verifies expertise in specialty areas of clinical practice // Most certification programs require clinical experiences 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 regulats the practice of RN and advance practive nursing
client goals
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
restraints
Prevents clients from harming themselves or others by using chemical or physical means // Informed consent required // Physician 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
hypertension
An abnormal high blood pressure over 140mmHG systolic and 90mmHG diastolic // Unknown cause = Primary Hypertension Cause Known = Secondary Hypertension // Wide spread problem // Prehypertenion 120-139/80-89 without intervention may develop cardiac disease - Hypertension stage 1 = 140-159/90-99 - Hypertension stage 2 =>160/>100 // Factors associated with HTN include thickening of arterial walls, which reduces size of arterial lumen and inelasticity of arteries as well as lifestyle factors as cigarette smoking, obesity, heavy alvohol comsuption, lack of physical exercise, high blood cholesterol levels and continued exposure to stress. Should have lifestyle changes conducive to lower BP and monitor pressure itself.
delegation
Responsibility and authority for performing a task transferred to another individual that accepts responsibility and authority // Can delegate only tasks for which the nurse is resposible for // Steps include: Defining task, Identifying what the task involves, Matching task to individual by assessing their skills and abilities, provide clear communication about expectations regarding task, answering questions
apical pulse
Where impluse of left ventrical felt most strongly, point of maximal impulse (Left 5th intercostal space at midclavicular line) // Pule deficit: Difference between apical & radial pulse / Radial usually slower due to ineffective contrasctions failing to send pulse waves to periphery; caridac dysrythmia may be present
dementia
Dementia is the loss of cognitive functioning, thinking, remembering and reasoning and behavioral abilites to such an extent that it interferes with a person's daily life and activites. // Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person's functioning to the most severe stage, when a person must depend completely on others for basic activites of daily living. // Doctors use several methos and tools to help determine whether a person who is having memory problems has "possible Alzheimers dementia" (dementia may be due to another cause) or "probably Alzheimers dementia" (no othe cause for dementia can be found) // To diagnose Alzheimers, doctors may: Ask the person and a family member or friend questions about overall health, past medcial problems, ability to carry out daily activities and changes in behavior and personality. Conduct test of memory, problem solving, attention, counting and language. Carry out standard medical test such as blood and urine test to identify other possible causes of the problem, perform brain scans such as CT, MRI PET. The diagnostic test may be repeated to give doctors information about how the person's memory and other cognitive functions are changing over time. Alzheimers disease can be definitely diagnosed only after death, by linking clinical measures with an examination of brain tissue in an autopsy.
Maslow's hierarchy of needs
5 Basic levels of needs 1. Physiological: airway, respiratory effort, heart rhythym and strength of contraction. Nutrition elimination 2. Safety & Security: protection from injury, promote feeling secure, trust in nurse-client relationship 3. Love & Belonging: maintain support systems, protect from isolation 4. Self Esteem: control, competence, positive regard, acceptance/worthiness 5. Self Actualization: hope, spiritual well being, enhance growth, client progresses up the hierarchy when attempting to satisfy neds, priority needs must be met first
bronchoscopy
Visualization of trachea & mainstream bronchi. Used to: obtain tissue biopsy, apply medication, aspirate secretions for lab exam, aspirate mucous plug causing airway obstruction, remove aspitaed foreign objects // Nursing responsibilites pretest: Explain procedure, maintain NPO 6-12HRS, inspect mouth for infection, administere pre medication, remove dentures, prepare for sire throat after procedure // Nursing respsonsibilites posttest: instruct to sit or lie on side, remain NPO till gag reflex returns, observe for respiratory difficulties
oxygen therapy
When using nasal canula: Assess patency of nostril, apply water soluble jelly to nostrils Q304HRS, perform good mouth care // If using face mask: Remove mask Q1-2hrs, wash and dry, apply lotion to skin, provide emotional support to decrease feeling of claustrophobia // With partian non rebreather mask: Adjust oxygran flow to keep reservoir bag 2/3 full during inspiration
confidentiality
Code of ethics safegaurding client's right to privacy // - Client has right of records - Information about client can be used only for purposes of diagnosis & treatment -Information can't be released w/o permission
battery
Actual touching of a personw ithout authorization to do so // Any nursing, medical or surgical proceudre performed without consent of the patient is viewed legally as battery
living will
Advance directive that tells healthcare providers of life sustaining treatments (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
delegation/Nursing assistant
Unlicensed staff; CAN, technicians, etc. // Can assist with direct client care activities - bathing, transferring, ambulating, feeding, toileting, obtaining VS, height, weight, i&O, housekeeping, transporting and stocking supplies.
postural drainage
Uses gravity to facilitate removal of bronchial secretions // Client is places in variety of positions to facilitate drainage into larger airways from lungs and bronchi into trachea // Secrections may be removed by coughin or suctioning // Prevents complications of statsis of respiratory secretions
postoperative care
Requires full assessment because anesthesia, immobility & surgery can affect any system in the body // Neuropychosocial: Stimulate client postanesthesia & monito LOC // Cardiovascular: Monitor VS Q15 mins x4, then Q30mins x2, then QHR or PRN, check potassium levels, monitor CVP // Respiratory: Check airway & breath sounds, turn, cough & deep breath unless contraindicated such as with brain, spinal or eye surgery, splint wound, offer pain meds, teach to use inceptive spirometer // GI Tract: 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 nausea & vomiting, check abdomen for distention, check for passage of flatus & stool // Genitourinary: Monitor I&O, encourage to void, check for bladder distention, notidy MD if unable to void witin 8HRS, catheterize PRN // Extremities: evaluate & promote circulation // Wounds: evaluate and manage dressing, drains & incision itself // GI Tubes: check placement // Monitor for any complications: Hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infections of wound, dehiscence, evisceration, DVT & psychosis
incentive spirometer
Used to maximize lung expansion by opening closed alveoli & mobilizing secretions // Instruct to breath in and exhale normally, seal lips around mouthpiece, inhale slowly and deeply, hold breath for at least 3 seconds while keeping ball/cylinder elevated, exhale, take several normal breaths & repeat procuder 4-5x // Client should cough after procedure to facilitate secretion removal
nursing process
Problem solving approach based on using very best available evidence from disciplined research findings, used for making clinical judgements & best decisions about client care // Assessment Diagnosis Planning Implementation Evaluation // Purpose: to diagnose and treat client's responses to actual and potential health problems // Provides common language and step by step process for nuses to care for clients
negligence
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 1. Duty owned 2. Breach of duty or standard care 3&4. Connection between breach of duty & damage
culture
Beliefs, values, attitudes, customs, languages, ceremonies, symbols, behaviors, artifacts shared by group of people and passed on from one generatoin to the 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 or responded to appropiately.
evidence-based practice
Problem solving approach based on using very best available evidence from disciplined research findings, used for making clinical judgements & best decisions about client care
interviewing questions
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 fo interview: Great client - Elicit why client seeking healthcare - Determine topics of interview - Exoand & clarify cleint's story - Discuss shared understanding of cleint's problem - Discuss a plan - Determine the follow up
contact precautions
For clients requiring physical skin to skin contact, occurring between nurse & client or client to client. Can occure by contact with contaminated objects in client's environment, private room or with another client with same infection bu no other infection // Wear clean nonsterile gloves when entering room / Change gloves after client contact with fecal material or wound drainage / Remove gloves before leaving client's environment & wahs hands with antimicrobial agent // Wear gown when entering room if clothing has contact with client, environment surfaces, or if client is incontinent, has diarrhea, an ileostomy, colostomy or wound care
health care provider's orders
Orders made for patients that nurses or other qualified personnel fulfill
influenza vaccine
Given yearly, preferably in October to November / Recommended for people 65 years or older , people younger than 65 with heart disease, lung disease, DM, immunosuppresion or living in chronic care facility // Contraindication: Previous anaphylactic reaction to vaccine or eggs
herbal supplements
Botanical meds, vitamins & minerals regulated as dietray supplements with statements of how supplement affects structure & function of body // Can interact with convention medication // St John Wort: Accelerates metabolism of many drugs // Ginko Biloba, Feverfew & Garlic: Suppresses platelet aggregation & increases risk of bleeding when given with anti-coagulation meds // Ephedra: Elevates BO, heart and CNS // Dietary supplements include: Echinacea, Garlic, Ginseng, Black cohosh, feverfew, ginger, saw palmetto
nurse licensure compact
Mutual recognition nurse licensure that allows nurse to have on license in state of residency & to practice in other states (both physical and electronic) // -Subject to each state's practice law and ragulations -Each state must enact legislation or regulation authorizing the NLC // Includes RN's LVN's/PN's but doesn't include advance practice nurses
culturally competent care
Planning & impplementing care that's sensitve to the needs of individuals, groups, and families from diver 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 agreemtn
case management
Identifies, coordinates, monitors implementaiton of services needed to achieve desired outcomes within specified period of time // Involves pronciples 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, sovles problems / Facilitates client through system from admission to discharge / Notes variances from expected progress
right to refuse
Patient self determination act & ethical doctrine of autonomy gives patients right to refuse treatment // -If patient refuses treatment, must be informed of harmful consequences of refusal.
orthostatic vital signs
Measurement of BP & Pulse in supine and standing positions // Positive test: Client becomes dizzy or losses consciousness, pulse increases by 20BPM, standing BP drops by 20 mmHG or more 2 minutes after changing position from lying to sitting or from sitting to standing // Indicates hypovolemia or dehydration
incident report
Accurate & comprehensive report on any unepected/unplanned occurrence that affects or can possible affect a client, family member or staff person // Don't include reference to incident report in charting / Don't use words like "ERROR" or "INAPPROPIATE" inflammtory words or judgemental statements // Needed for: medication errors, complications from diagnostic or treatment procedures, incorrect sponge count in surgery, failure to report change in client's condition, falls, burns, break in aseptic technique, medical or legal incidnet (client or family refusing treatment as ordered, refuses to sign consent) client or family diassatisfied with care & situation can't be or has not been resolved
priorities
Establising priorities enables nurse to attend to client's most important needs & help 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
ginger
Herbal supplement used for nausea, vomiting, indigestion, last of appetite S/E: Minor heartburn, dermatitis // Contraindication: With gallstones, may potentiate antiplatelet + anticoagulant meds, antodiabetic meds and herbs that increase bleeding time.
delegation/LVN
LPN/LVN assist with implementation of defined plans of care // perform procedures according to protocol // Differentiate normal from abnormal // Care for physilogically stable clients with predictable conditions // Has knowledge of asepsis & dressing changes // Ability to administer meds varies with educational background & state nurse practice act
chain of command
Person or organizational chart that a nurse would report variances, problems and concerns to the next person with authority in direct line in their area (your manager - their manager or boss - boss's boss)
abdominal assessment
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 bowels sounds from being altered, bowel sounds evaulated for intensity, pitch, frequency 5-30 mins // To determine bowel sounds are absent, nurse must listen for a total of 5 mins in each quadrant
alzheimer's disease
Disease that invlove progressive dementia, memory loss and inability to care for one's self // Not a normal part of aging // Irregersible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ablility to carry out the simplest tasks. Symptoms first appear in their mid-60's. Estimates vary, but expersta suggest that more than 5 million Americans may have Alzheimers. Most common cause of dementia among older adults.
neurological assessment
Consist of: Interview, levels of consciousness, pupillary assessment, vital sings, motor function, sensory function and 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, changes in vision, difficulty with swallowing, decreased hearing, altered gait or balance
informed consent
Client's agreement to have procedure performed after explanation of risks, benefits, expectations & alternatives to procedures // Can be withdrawn at any time // Nurse ensures consent form is signed & attached to chart // Obtained by physican performing procedure
blood pressure
Exerted by circulating volume of blood on walls of arteries, veins & chambers of the heart // Covers 50% of limb from shoulder to olecranon with cuff // Check both arms for comparison, differences of 5-10 mmHg normal, differences of 30-40mmHG between systolic and diastolic is normal // Normal ranges: Newborn 60-80/40-50 mmHG / Child 1-4 90-99/60-55 mmHg / Child 5-12 100-110/56-60 mmHG / Adult 90-140/60-90 mmHg
assessment
1st step of nursing process, establishes database // Includes: collection, validation, organizatio, initial references & communication of data of client or healthcare situation // Subjective data from client't point of view // Objective data from nurse point of view // Dynamic process, not ending up with inital contact or impressions
scope of practice
Extent & limits of medical interventions that healthcare providers may perform
assault
Threat ot attempt to touch a person in a way that's intimidating, insulting, offensive or harmful
documentation
Promotes communication / Maintain legal records / Meets requirements of regulatory agencies / Required for 3rd party reimbursement / Is legible, accurate, timely, thorough, concise, well organized, uses proper grammar, spelling & authorized abbreviations
furosemide (Lasix)
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, dialy weight, do not give at HS, encourage potassium containing foods // After oral dose, diuresis can occur within 30 minutes
nursing diagnosis
NANDA official definition of nursing diagnosis "Clinical judgement about individual, family, community responses to actual and potential health problems/life processes. A nursing diagnosis provieds the bases for selection of nursing interventions to achieve outcomes for which the nurse is accountable." // RN's are responsible for making nursing diagnoses, even though other nursing personnel may contribute data to the process of diagnosing and may implement specified nursing care, domain of nursing diagnosis includes only those health states that nurses are educated and livensed to treat, judgement made only after thorough systemic data collection, and describe a continuum of health states deviations from health, presence of risk factors and areas of enhanced personal growth. // Components: Nursing diagnosis, Diagnosis and definition, Related factors and defining characteristics // NANDA related to .. as evidence by .. goals .. interventions .. implementation .. and outcomes
nosocomial infection
When hospitalized clients acquire infections as result of hospitalization can be classified as: -Iatrogenic Infection: Diagnostic or Therapeutic Procedures -Exogenous Infection: 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.
meningitis
Inflammation of meninges of brain or spinal cord. 5 types of meningitis viral bacterial prasitic non infectious fungal 1. 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 ciruses, mumps, herpes, stomach problems etc Bacterial Transmision: Through respirator throat secretions (kissing) - Bacterial Meningitis caused by 3 bacteria with complex code names 1. Haemphilus influenza type B 2.Pneumococcus 3.Meningococcus // Spreads when someone has close contact with an infected person - like real close conversation or kissing. Also through touching infected surfaces, like doorknobs and than touching your mouth or nose. Bacterial meningitis can cause brain damage, hearing loss or learning disabilities // Vaccines and antibiotics are best defense // CDC recommends 11-12 years of age 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
Section 2
(5 cards)