6676161
Description
Flashcards by Amy Darvill, updated more than 1 year ago
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Created by Amy Darvill
about 8 years ago
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| Question | Answer |
| What is SMART and acronym for | Specific Measurable Achievavle Relevant Time Related |
| Name the five components of the nursing process | Assessment Nursing Diagnosis Planning Implementation Evaluation |
| List the six rights of medical administarion | Right Patient Right Drug Right Dose Right Route Right Time Right DocumentationLit |
| List the 5 p's of medication risk management | The Perscription The Process The People The Place The Patient |
| List the functions of the skin | Protection Sensation Thermoregulation Metabolic synthesis Elimination communication Cosmesis |
| List the three modes of wound healing | Primary intention Secondary Intention Tertiary intention |
| Describe Primary Intention | Tissue edges are approximated and minimal or not tissue loss. Minimal tissue disctuction, granulation and minimal tissue scaring |
| Describe Secondary intention wound healing | considerable tissue loss and edges not approximated. Granulation can occur in infected or necrosed wounds. Cavity fills with a red soft tissue , later forms of connective tissue - some scaring |
| Describe tertiary intention wound healing | Deep wound infected or containing FB's. not sutured early or breakdown or re-sutured 3 -5 days later,deeper or wider scar |
| What are the three phases of wound healing | Inflammatory Proliferation/reconstruction Maturation / Remodelling |
| Describe the Inflammatory phase of wound healing | takes 0-3 days Inflation response causes redness, heat, swelling, pain, functional disturbance Vasoconstruction, platlet response, biochemical response Polymorphonuclear leukocytes and macrophages (defence) polymorphs protect from bacterial invasion and macrophage clear wound infection epithelisation occurs |
| Describe the Proliferation / reconstruction stage of wound healting | Phagocytosis continues and stimulates fibroblastic cells to make collagen. Angiogenesis develops new vascular network seen in the ruddy bumpy granulation tissue. Epithelial cells migrate from wound edges, hair, sweat and sebaceous glands. Ceases once wound covered then mitosis thickens it up to the four layers required. Wound contraction reduces size of the wound and hence required tissue replacement. (e.g. removal of drain) |
| Describe the maturation / remodelling stage of wound healing | Tensile strength increase due to replacement of collagen in a more organised manner vascularity decreases as does scar size |
| Define Haematoma | Localised collection of blood beneath tissue |
| Define Eviseration | Profusion of visceral organs |
| Define Dehisence | wound edges part and are no longer aligned/approximated3 ‐4 days post op: strain/cough, exudate |
| List the stages of a pressure injury | Stage on injury ; Non-Blanchable erythema Stage II pressure injury : partial thickness skin loss Stage III pressure injury : full thickness skin loss Stage IV pressure injury : Full thickness tissue loss |
| What are the interventions to prevent pressure Ulcer | Relieving pressure Positioning the patient pressure relieving devices improving mobility improving sensory perception improving tissue perfusion (avoid massage) Improved nutrition Reduce friction and sheer Minimise irritating moisture promoting pressure ulcer healing |
| List some complications of Naso-gastric tube | Pulmonary aspiration Tube occlusion and displacement Nasopharyngeal trauma and ulceration GIT and metabolic distrubance Preparing and storage of fluid |
| what ‘aseptic technique’ | Aseptic technique protects patients during invasive clinical procedures by employing infection control measures that minimize, as far as practicably possible, the presence of pathogenic microorganisms |
| Define Sterile | Free from micoorganisms |
| Define Asespsos | ‘Freedom from infection or infectious (pathogenic) material’ |
| Define Clean | ‘Free from dirt, marks or stains |
| List the three compontents of sensory process | Reception Perception Reaction |
| Define Pain | an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms of such damage. |
| Explain the 2 componets of reception | External (Five senses) Internal kinaesthetic ( position sense and visceral awareness and internal organs) |
| Define perception | receiving, organising and translation of data by cerebral cortex (when the person receives the stimulation and becomes consecous of the stimuli) |
| Define Reaction | awareness and response to stimuli - controlled by the reticular activating system |
| List some common causes of sensory alterations | Visual Hearing Balance Taste neurological |
| List the states of sensory alterations | Sensory deprivation Sensory overload Sensory deficit |
| List and describe the types of sesosroy deprivation | Reduced input - visual or hearing Elimination of order or meaning from input - e.g exposure to strange environment Restriction of the environments the environment that produces monotony or boredome e.g bed rest |
| What are the effects of sensory deprevation | Cognitive *Decreased learning capacity, to think and problem slove *Poor task performance, disorientated, regression, bizarre thoughts - increased need for socialisation and attention. Affective Bored, restless, increased anxiety, emotional lability , panic - increased need for physical stimulation Perceptual Altered visual and motor coordination interpretation of colour, tactile accuracy, size, shape, spatial and time judgement |
| Define sensory overload AND some of its effects | a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli Effects Behavioural changes (confusion) Disorientation (mood swings or simple disorientation) Racing thoughts Short attention span restlessness anixety |
| List the factors that influence sensory function | Age medications environments elderly living alone pre existing illness culture smoking |
| What assessments are corrected during an FNO | Glascow coma scale Observation of vital signs Observation of the following neuro signs Pupil size and reaction to light Upper limb motor function Lower limb function |
| What are the stages of sleep | Pre sleep / s;eepiness NREM stage one NREM stage two NREM stage three NREM stage four NREM Stage two REM SLEEP NREM Stage two REPEAT |
| Describe NREM Stage one | - Light sleep and only lasts a few minutes -Decreased physical activity, gradual fall in vital signs and metabolism -Easily aroused by sensory stimuli - If awakened, feels as though daydreaming has occurred |
| Describe NREM Stage two | - Sound asleep 10-20 Mins -Relaxation progresses -Body function continues to slow |
| Describe NONREM Stage 3 | -Involves initial stages of deep sleep -Lasts 15-30 minutes -Sleeper difficult to rouse and rarely moves -Vital signs decline but remain regular |
| Describe NOREM stage 4 | - Deepest stage of sleep -Lasts 15-30 mins -Very difficult to rouse sleeper -vital signs significantly lower -Sleep walking and enuresis way occur |
| Describe REM Sleep | Starts 90mins after sleep has begun -Autonomic Response -Rapidly moving eyes -Fluctuating HR and RR and increased or fluctuating BP Loss of skeletal muscle tone increased gastric secretions Brain highly active Active dreaming (Full color, remembered) INCREASES with every sleep cycle and averages 20 minutes |
| Why is NREM sleep required | Slow biological functions Release HGH Repair and renewal of cells and devision Conserve energy |
| What is the function of REM sleep | Cognitive restoration -Increased cerebral blood flow -increased cortical activity increased oxygen and epineprine release increased memory storage and learning |
| Describe intrinsic sleep disorders | Intrinsic (disorders of initiating and maintaining sleep) Psychological insomnia Narcolepsy and obstructive sleep apnoea syndromes |
| Describe extrinsic sleep disorders | Inadequate sleep syndrome -Insufficient sleep syndrome _Hypnotic-dependant sleep disorders - alcohol-dependant sleep disorders Time zone changes and shift work sleep disorders |
| Describe parasomnias | Undesired behaviours that occur predominantly during sleep AROUSAL Disorders: Sleep walking, sleep terrors SLEEP WAK TRANSITION DISORDERS Sleep talking, nocturnal leg cramps, includes parasomnias associated with REM sleep; nightmares, sleep paralysis Other _Teeth grinding, sleep enuresis, SIDS Medical/psychiatric disorders: Psychiatric, neurological and others Proposed sleep disorders Pregnancy, menstruation, sleep choking syndrome |
| Describe Sleep Apnoea | A lack of airflow via nose or mouth for period greater than 10 secs Can be obstructive , Central or mixed. |
| What does assessment of saftey include | Nursing History Physical examination -Body alignment -Gait -Appearance and movement of joints -Capabilities and limitations of movement - Muscle mass and strength -Activity tolerance - Problems related to immobility |
| List and describe the types of restraints | Physical - device used to immobilise a patient or extremity and to restrict freedom of movement eg. vests, mittens Environmental - to restrict movement: bed rails, recliners, locked doors Chemical - Medications to control individuals thoughts or behaviours that may not be related to medical treatment Emotional - Verbal, non-verbal and physical intimidation. To actively encourage or discourage particular behaviour. |
| What are some risks in a health care setting | Falls Patient-inherent accidents Procedure related accidents Equipment related accidents |
| What does normal body movement depend on | Intact musculoskeletal system CNS -Cerebrum (initiates) -Cerebellum (Coordinates) -Basal ganglia (Inhibits unwanted muscular activity) Inner Ear (vestibule and semilunar canal) |
| Define Isotonic (dynamic) Exercise | Exercise when a contracting muscle shortens against a constant load e.g lifting a weight |
| Define Isometric (Static) exercise | Isometric (static) contractions of a particular muscle or group of muscle e.g pushing against a static object |
| Define Isokinetic (resistive) exercise | Increase muscular strength, power, and endurance based on resistance a constant speed |
| Active exercise | Initiated and maintained by the patient |
| Passive exercise | the nurse exerts force on the patient to complete an action |
| Define abduction | the movement of a limb or other part away from the midline of the body, or from another part. |
| Define Adduction | Movement of a body part toward the median plane (of the body, in the case of limbs; of the hand or foot, in the case of digits) or midline of the body |
| Define Extension | movement increasing angle between two adjoining bones |
| Define Flexion | movement and decreasing angle between two adjoining bones – bending of l limbs |
| Define Hyerextension | movement of body part beyond its normal resting extended position |
| Define Circumduction | a conical movement of a limb extending from the joint (e.g. shoulder or hip) at which the movement is controlled |
| Medial Rotation | a turning towards the midline of the body |
| Lateral rotation | A Turing away from the midline of the body |
| Define Eversion | Turing the body part away from the midline |
| Define Inversion | Turing of body part towards midline |
| Define Pronation | Movement of body part so that the front or ventral surface is downwards |
| Define Supination | Movement of body parts so that the front or ventral surface faces upwards |
| What are the psychosocial factors associated with altered mobility | -Growth/development/age -Medications, narcotics, antihypertensive, antidepressants -Nutrition; over or under -Personal values -External factors -Rest in Bed (Rin) tractions, plaster cast (POP) |
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