Unit 1 Exam Study Guide

Stage 4 pressure ulcer:

Full-thickness skin loss including muscle, bone, and tendons. Extensive destruction, Tissue necrosis

Micro-nutrients?

vitamins and minerals

Culture:

what people in a group have in common, socially transmitted behaviors patterns, arts, beliefs, values, customs

Ulcer tissue: Slough

yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous

Why is genetics important when looking at patient diversity?

Genetics can often be precursors to specific disease, or puts pts at risk for certain types of disease. By recognizing that, we can promote health and give education about them to lessen the risks of acquiring the disease.

Gluconeogenesis:

Glycogen is converted back into glucose

Function of Micro-nutrients:

Help manufacture, repair, and maintain cells

vulnerable populations:

Homeless Poor Mentally ill People with physical disabilities Young Elderly Some ethnic and racial minority groups

Dietary and nursing considerations for wound healing:

INCREASE PROTEIN intake for tissue formation. Ideally want to see redness which means good blood flow.

Enteral nutrition?

(tube feeding) is nutrients that eventually get digested in the GI (intake from PO or jejeunostomys or duodectomies, PEG tubes). Preferred over TPN because less incidence of infection and promote peristalsis. Used for patients in addition to or just tube feeding who can still use GI tract (malnutrition, neurological disorders, long term therapy).

Mrs. G has not been taking her potassium supplements because it upsets her stomach. Which of the following is the BEST nursing intervention? 1: Administer the potassium supplement with an aluminum-based antacid. 2: Administer the potassium with food. 3: Administer the potassium supplement with a magnesium-based antacid. 4: Administer a calcium-based antacid 15 minutes before the potassium.

2: Administer the potassium with food.

What are "never events?"

SERIOUS/COSTLY events resulting in serious consequences that are mostly preventable. Ex. Surgery on the wrong body part, wrong Pt, wrong surgery, DVT (deep vein thrombosis), PE (pulmonary embolism), foreign body in body, infections

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that unless contradicted by her surgeon.

She can drink clear liquids up to 2 hours before surgery

What are supplements?

Supplements are something that completes or enhances something else when added to it

Fats (lipids) function:

Supply essential nutrients for fat-soluble vitamins (DEAK), SECONDARY energy source, flavor and satiety, insulation, cholesterol is a component of every cell in the body/ 9kcal/gram

Function Macronutrients:

Supply the body with energy...1st carbs, 2nd is fat, 3rd is protein. It breaks it down via glycolysis.

A client has a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2mg of morphine sulfate IV by patient controlled analgesia (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse's priority intervention would be:

Take the clients BP

A Japanese patient and his young son arrive at the community hospital where you work. the patient tells you something in japanese and pats his chest. The son speaks english. How should you respond to this patient.

Tell the boy to ask the father whether he can wait for an interpreter to arrive

Malnutrition?

A condition of impaired development function caused by a long-term deficiency, excess, or imbalance in energy and/or nutrient intake.

acculturation:

A person who is acculturated accepts both his own and the new culture, adopting elements of each.

An elderly woman fell at home and fractured her hip. After being admitted to the hospital, the nurse knows that the patient is to be "stabilized" prior to having surgery. This surgery would be classified as a. Urgent b. Elective c. Emergency d. Palliative

A= This patient will most likely have her surgery within the next 48 hr. It must be done to restore joint function.

The nurse is creating a care plan for a postoperative patient. The nursing diagnosis is pain. Which of the following would be an appropriate outcome for this patient with this nursing diagnosis?

Absence of nonverbal signs of discomfort

cultural archetype:

An archetype is an example of a person or thing—something that is recurrent—and it has its basis in facts. Therefore, it becomes a symbol for remembering some of the culture specifics and is usually not negative.

When thinking about diversity, take a trip to the Acronym "BALI":

B-Be aware of own cultural heritage A-Appreciate that your clients' are unique, but not culturally defined L-Learn clients' cultural group I-Incorporate clients' cultural values

The nurse knows the lab result that is the best indicator of a client's nutritional status is the serum albumin. a. True b. False

B= The latest research shows that pre-albumin has a shorter half-life than albumin and is a better indicator of protein stores (and acute changes in those stores).

The nurse knows that the most important reason for controlling postoperative nausea/vomiting in the PACU is a. To prevent the patient from becoming dehydrated b. To prevent potential airway issues c. To prevent the surgical dressing from becoming soiled d. To prevent the patient from becoming upset

B= The priority nursing intervention for the nurse in PACU is airway management. Controlling nausea and/or vomiting will prevent aspiration and ensure a patent airway.

The nurse notes that the client's grandmother is looked to for input whenever questions arise about the client's care choices. Which cultural specific will guide the nurse's plan of care? a. Communication b. Social organization c. Environmental control d. Biologic variations

B= The social organization of the client's family will influence what treatment will be acceptable to the client.

Preoperative phase-

Before surgery: Begins when the decision to have surgery is made and ends when the client is transferred to the OR table

Intraoperative phase-

Begins when the pt. is transferred to the OR and ends when the pt is admitted to PACU

Postoperative phase-

Begins with the pt. admission to PACU and ends when the healing is complete

Nonessential amino acids:

Body can make them. In total, there are 20 amino acids

Nutrients?

Building blocks for cells and tissues

The charge nurse of a unit tries, as a rule, to admit Hispanic clients to a room at the end of the hall so that "the noise from the family will not disturb others." This nurse is exhibiting a. Racism b. Prejudice c. Discrimination d. Sexism

C= Discrimination is the behavior that results from a prejudice.

Identify the client with the greatest risk for developing protein-calorie malnutrition. a. A client who has multiple sclerosis and is in a wheelchair b. A client weighing 300 lb who has entered the hospital for cardiac bypass surgery c. A client with a broken arm and femur from trauma who is running a fever of 101.5°F (38.6°C). d. A client who is of Native American heritage.

C= This client would have the greatest increase in metabolic demand for "energy"/nutrients and runs the greatest risk for not having those energy demands met.

The postoperative to nursing assessment of a clients ability to swallow fluids before providing oral fluids is based on the type of anethesia given. Which client would NOT have delayed fluid restrictions?

Client who has undergone a repair of carpal tunnel syndrome under local anesthesia

How can culture, beliefs and practices can influence patients and healthcare?

Clients from different cultures have different expectations of healthcare

Complete proteins:

Complete protein foods contain all essential amino acids needed for protein synthesis (animals)

Stage 3 pressure ulcer:

Full thickness skin loss with necrosis to subcutaneous tissue, NO BONE, NO MUSCLE, NO TENDON.. . NOT through facia, Deep crater, Undermining may be present

The most important concept about vulnerable subcultures guiding nursing care is that persons belonging to these groups a. Receive different healthcare b. Have difficulty complying with their therapy c. Never have insurance d. Often have limited access to healthcare

D= Lack of access to healthcare is common to all vulnerable populations for various reasons.

The nurse is completing a preoperative patient assessment. Which finding indicates the greatest risk for the development of a postoperative complication? a. The patient is 60 years old b. The patient's blood pressure is 130/88 mm Hg c. The patient does not understand the surgery d. The patient has early stage Alzheimer's

D= The surgical experience may exacerbate any type of dementia. Even in the early stages, a patient with Alzheimer's may not be able to comprehend written or oral directions related to care. In cases of major surgery, the patient with dementia may pull at dressing, drains, and IV lines and be at increased risk for falls.

Essential amino acids:

Essential because body can not manufacture them, therefore must be obtained via diet.

Ketones:

Fats converted directly into an alternative fuel (diabetes) called ketones, which raise acidity of blood (can lead to acid-base imbalance)

What is "time out" in perioperative care?

Final verification of correct: Client Procedure Site Sterile field Monitor I&O Sponge, sharps, and instrument count Documentation

Incomplete proteins

Incomplete (plants, nuts) must be combined to other incomplete proteins

Who is the nursing theorist known for transcultural nursing?

Madeline Leininger

The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement if made by the nursing student indicates a need for further teaching regarding CAM categories?

Magnetic therapy and massage therapy are a focus of CAM.

Simple carbs:

Monosacaride: fruits, milk, and milk products. They are also found in processed and refined sugars such as candy, table sugar, syrups, and soft drinks.

Nitrogen balance:

Occurs when intake and output of Nitrogen are equal. Nitrogen balance reflects how well body tissues are being maintained.

Insulin:

Pancreatic hormone arising from beta cells of pancreatic islets that allows glucose to be used in body tissue

Stage 2 pressure ulcer:

Partial-thickness involving loss of dermis/epidermis. Skin is no longer intact. May appear as abrasion, blister or shallow crater

Which patient is expected to retain anesthetic agents longest?

Patient who is 5 feet 1 inches tall and weighs 200 lbs.

Why are supplements used?

People use them because they may not be able to obtain the essential nutrients from their diet alone.

What type of tissue do we want to see that is ideal for healing?

Pink to beefy

Dietary fiber is a

Polysaccharide

Complex Carbs:

Polysaccharide: peas, beans, whole grains, and vegetables

Carbs function & measurment:

Primary energy source for muscle and organ function, spare protein, enhance insulin secretion, improves absorption of sodium and calcium/ 4kcal/gram.

Macronutrients?

Protein, lipids- fats, carbohydrate

Stage 1 pressure ulcer:

Redness that doesn't go away, intact skin. Non Blanchable. Tissue consistency is first firm -> soft, boggy•Discoloration remains > 30 minutes after pressure relieved

Why must vitamins be supplied by the foods we eat?.

The body does not make vitamins, so we must obtain them through our diet.

Glycogenolysis:

The breakdown of glycogen to glucose

communication and language considerations

This can involve foreign languages, dialects, regionalisms (words or pronunciation particular to a specific region), street talk, and jargon (words or expressions used by a subculture, including medicine).

Racism

This is a form of prejudice and discrimination based on the belief that race is the principal determining factor of human traits and capabilities and that racial differences produce an inherent superiority (or inferiority).

stereotype

This is a widely held but oversimplified and unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects

sexism

This is the assumption that members of one sex are superior to those of the other sex.

Ethnocentrism:

This is the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened. The tendency to ethnocentrism exists in all groups, not just in the dominant culture.

discrimination

This refers to the behavioral manifestations of that prejudice. For example, before the 1960s many U.S. hospitals refused treatment to African Americans

Protein Function:

Tissue building, metabolism, immune system function, fluid balance (attract h20), tertiary energy source/ 4kcal/gram.

Why is water an essential nutrient?

Water is the basic solvent for the body's chemical processes, it is used for transportation of blood and oxygen, body structure and form, thermoregulation

Cholesterol?

Wax like--not used for energy, helps make bile, vitamin D and steroid hormones (estrogen and testosterone); found in animal products only; dietary fat increases absorption

Lack of knowledge

about the cultural and ethnic values, beliefs, and behaviors of people within their community is not unusual among healthcare providers. It can cause them to misinterpret a client's behaviors

A name-brand ice cream contains the following nutrition information for each serving: 30 g carbohydrates, 19 g fat, 5 g protein. The total number of calories in a serving would be a. 366 b. 311 c. 435 d. 176

b. 311

Ulcer tissue: Necrotic Tissue (Eschar)

black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin.

High fat/high protein diet:

called calorie-protein push---used when there is a need to heal wounds, maintain or increase weight, or promote growth. High in animal meats, nuts, legumes, foods containing high levels of LDLs

- Moderate Sedation

conscious sedation) is the IV delivery of a sedative, hypnotic, and opioid drugs to reduce sensory perception but allow the pt. to maintain a patent airway

What is culturally competent care?

cultural awareness, sensitivity, competence. Delivering care in congruence with pts cultural beliefs.

What are the cultures and subcultures of Healthcare?

cultures of healthcare: Indigenous healthcare: folk medicine and traditional healing methods Subcultures of Healthcare: Nursing

Ulcer tissue: Epithelial

for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges oras islands on the ulcer surface.

Subculture:

groups within a larger culture or social system that have characteristics that are different from the dominant culture

General Anesthesia

is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the CNS. This depresses the CNS resulting in analgesia (pain suppression/relief), amnesia (loss of the memory of the surgery), and unconsciousness, with loss of tone and reflexes

Anesthesia

is an induced state of partial or total loss of sensory perception, this may be with or without loss of consciousness.

race:

is associated with biology- example of race is brown, white, or black skin

Parenteral nutrition?

is delivered Intravenously through IV bag. Used for patients with nausea and vomiting, abdominal px that warrants resting GI tract, unable to swallow or impaired airway secondary to injury or disease.

Kwashiorkor

lack of protein, fat normal

Marasmus

low fat, low protein

PUSH tool:

measures length and width, exudate amount, and tissue type involved

Local or Regional Anesthesia

o Local: delivered topically (think the numbing gel put on your gums before the needle stick), and by local infiltration (done with needle stick). o Regional: is a type of local anesthesia that blocks multiple peripheral nerves and reduces sensory perception in a specific body region. (See Page 248, Table 15-3 for Types of Regional Anesthesia).

Preop:

o Notify M.D. of abnormal labs, complete pre-op checklist, assist Pt to understand and mentally prepare for surgery o Obtain consent(surgeon gives information and determines clinical and legal competence. RN responsible for getting signed paper and witnesses it.) o Provide pre-op teaching e.g. what will happen before, during, and after surgery addres common feelings and concerns, how to prevent infections o Maintain temp, Pt fasts, skin prep (shower), bowel prep, urinary elimination, preop meds, routine meds, psotheses, TED stockings

Postop:

o RECOVERY from anesthesia and surgery o Admission to PACU, perform assessment o Position on side (risk for aspiration o Vitals, I&O balance, urinary/bowel movements, mobility and sensation, Level of consciousness o RISKS: ASPIRATION PNEUMONIA, ATELECTASIS, PNEUMONIA, PE, thrombophlebitis, HEMORRHAGE, HYPOVOLEMIA, N&V, CONSTIPATION, URINARY RETENTION, DEHISCENCE, INFECTION o PT TEACHINGS: Incentive spirometry, anti-embolism stockings, diet, dressing changes, exercises,

Intraop:

o Sterile team=surgeon, surgical assistant, scrub person o Clean team= anesthesiologist or CRNA, circulating nurse (looks out for the pt and ensures comfortable and safe environment o Anesthesia administration ▪ General anesthesia: LOC and loss of sensation ▪ Regional anesthesia: Pt is alert, but remains numb to the affected body part ▪ Local anesthesia: loss of pain sensation at the site o RISKS: HYPOTHERMIA,F&E imbalance, hemorrhage, aspiration, vasomotor instability, resp depression cardiovascular compromise o Skin prep, positioning

assimilation:

occurs when the new members gradually learn and take on the essential values, beliefs, and behaviors of the dominant culture. Assimilation is complete when the newcomer is fully merged into the dominant cultural group.

Ulcer tissue: Granulation

pink or beefy red tissue with a shiny, moist, granular appearance

Clear diet:

provides fluids to prevent dehydration and supplies simple cabrs to help meet energy needs, which includes water, tea, coffee, broth, clear juice (apple, grape, or cranberry), popsicles, carbonated beverages, gelatin

ethnicity:

refers to cultural factors, including nationality, regional culture, ancestry, and language. Example of ethnicity is German or Spanish ancestry

prejudice

refers to negative attitudes toward other people based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on

Braden scale:

sensory perception, moisture, activity, mobility, nutrition, friction, and shear

Phospholipids?

similar to triglyceride but have glycerol backbone, 2 fatty acids, and a phosphate; manufactured in the body so not dietary need; components of cell membranes; allows fats...ex. fat soluable viatamins to travel back and forth; dissolve in water and fat.