Fundamentals Midterm: Ch. 21, 27, 28, 31, 38, 39, 40, 44, 45, 48, and seizure precautions.

partial seizures

(also called focal seizures) are due to electrical surges in one part of the brain.

thin liquid

(low viscosity) Includes all liquids, Jell-O, sherbet, Italian ice, and ice cream. This consistency is considered non-restrictive. Nothing is added

nectar

(medium viscosity) Apricot or tomato juice, or yogurt smoothies consistency; some liquids will require a thickening agent to reach this consistency.

Restraint

(physical or chemical): reducing the ability of a person to move about freely or manage dangerous behavior.

spoon-thick liquids

(viscosity of pudding) Liquids are spoonable and hold their shape when on a spoon.

oral administration

-easiest and most desirable route -food sometimes affects absorption -aspiration precautions -some medication can be crushed and placed through NG or G tube, others cannot

classification of medications

-effect of medication on the body -symptoms the medication relieves -medication's desired effects

Type I Diabetes Mellitus

-insulin dependent - caused by autoimmune destruction of the beta cells of the pancreas leading to little or no production of insulin - require regular injections of insulin to permit entry of glucose into cells

Type II Diabetes Mellitus

-non-insulin dependent -caused by receptor level resistance to insulin - partially inherited and partially due to environmental factors like obesity -meds can help body more effectively use the insulin it produces

The physician orders penicillin 50,000 units for a client. You have available a vial labeled "100,000 units per ml." How much will you administer?

0.5 mL

1000 ml

1 L

240 ml

1 cup, 8 ounces

15 mL

1 tbsp

5 mL

1 tsp

ambulating with a walker

1) Move walker out 12 inches, 2) Begin walking with affected leg, then strong leg

5 rights of delegation

1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

retinol binding protein

1.6−6.1 mg/dl Retinol plays an important role in growth of body tissues.

pre albumin level

15 to 36 mg/dl (acute illness/week) A more timely & sensitive indicator of protein status

how many calories do woman need?

1600-2400

transferrin

170 to 370 mg/dl (protein in the blood that binds to iron and transports iron throughout the body)

1 L = ?? lbs

2

how far should a rectal suppository be entered into a child?

2 inches

log-rolling (moving patients)

2 on side of bed to which patient will be turned. Move patient as one unit, maintaining proper alignment, in a smooth continuous motion on the count of three. Place pillows along length of patient for him to rest upon.

30 ml

2 tbsp or 1 ounce

ambulating with crutches

2-3 finger widths under axilla. Don't lean forward onto pads; shouldn't touch armpit Adjust hand grips to fit comfortably when angle of elbow is 15-25 degrees.

roller walker

2-4 wheels, patient lacks strength to pick up walker

how many calories do men need?

2000-3000

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slight limited mobility, along with excellent intake of meals and no apparent problem with friction or shear. Which score will the nurse document for this patient?

21

delayed gastric emptying

250 mL or more remains in stomach on 2 assessments (1 hour apart) or a single GRV exceeds 500 mL

urine collection

3 ways (indwelling catheter, in and out catheter, and clean clean/midstream

albumin

3.4 to 5.4 g/dl (chronic illness/month)

low cholesterol diet

300 mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction

how far should a rectal suppository be entered in an adult?

4 inches

low sodium diet

4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no-added-salt to severe sodium restriction (500-mg sodium diet), which requires selective food purchases

Normal WBC count

5,000-10,000

total protein

6 to 8.3 g/dl (measures total amount of the 2 classes of proteins in your blood (albumin and globulin).

Atonic seizure (drop attack)

: causes the patient's muscle to go limp. May slump or fall to the ground.

honey

:(viscosity of honey) Liquids can still be poured, but are very slow. Liquids will require a thickening agent to be added to achieve this consistency.

embolus

A blood clot or other substance in the circulatory system that travels to a blood vessel where it causes a blockage.

Braden Scale

A tool for predicting pressure ulcer risk

toxic effect

Accumulation of medication in the bloodstream

What needs to be documented when it comes to delegation?

Actions that require intervention Risks to the patients Educational opportunities/activities to correct actions Individuals response to education/activities

dry powder inhalers (DPIs)

Activated by patient's breath

priorities with wounds

Acute, traumatic wounds need immediate attention Chronic, stable wounds typically do not need immediate attention Patient's pain management, hygiene, positioning, hydration is a higher priority than wound care.

high fiber diet

Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

buccal medications

Administered by placing the medication between the cheek and gum (i.e. anesthetic benzocaine)

ambulation with a cane

Advance cane first, followed by affected/weak leg, then strong leg.

tips for administering medications to older adults

Advocate for Simple Orders Instructions in large print Memory aids Anticipate dosage adjustments Assist with swallowing if they have difficulty

routine morning care

After breakfast assist by offering a bedpan or urinal to patients confined to bed; provide a bath or shower, including perineal care and oral, foot, nail, and hair care; give a back rub; change the patient's gown or pajamas; change the bed linens; and straighten the patient's bedside unit and room

A in PASS

Aim at the base of the fire

How does a PCA pump work?

Allows patient the power to control their medication Set deliver a small, constant flow of pain medication with additional doses given to the patient as they push the button. Patient cannot give themselves too much Decreases anxiety and leads to decreased medication use

autolytic debridement

Allows the eschar to be self-digested by action of enzymes in wound fluids Transparent film dressings, Hydrocolloid dressings

contact precautions

Always wear gloves and gowns Place patient in the private room, or with roommate with same infection May leave room if infectious area is covered Dedicated blood pressure cuff/stethoscope/thermometer stays in room

dehydration

An abnormally low amount of water in the body.

contact dermatitis

An inflammation of the skin caused by having contact with certain chemicals or substances; many of these substances are used in cosmetology.

vectors

An organism that transmits disease by conveying pathogens from one host to another

nursing diagnoses with medications

Anxiety Ineffective Health Maintenance Deficient Knowledge (Medication Self-Administration) Noncompliance (Medications) Impaired Swallowing Impaired Memory Caregiver Role Strain

Poison

Any substance that can harm the body by altering cell structure or functions.

TENS unit

Applies electrical impulses to the nerve endings and blocks transmission of pain signals.

NPWT/Vacuum-Assisted Closure

Applies localized negative pressure to draw the edges of a wound together, reduce edema, remove fluid, and stimulate growth of new tissue. Covered with a transparent film dressing; must maintain an airtight seal

A nurse strains a back muscle when moving a patient up in bed. Which can the nurse do at home that utilizes the gate-control theory of pain relief to minimize the discomfort?

Apply a cold compress to the site for 20 minutes

Right circumstance

Appropriate patient setting, available resources, and other relevant factors considered

complications of dysphagia

Aspiration pneumonia Dehydration & decreased nutritional status / malnutrition Disability, decreased functional status (increased length of stay, cost of care, long-term care ) Increased mortality

A client is admitted with a diagnosis of terminal cancer and he is experiencing severe pain. The doctor has written an order for pain medication every 3 hours PRN. How will the nurse plan to administer the pain medication?

Assess the client and determine the need for pain medication every 3 hours

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority?

Assess the patient for adverse effects

A patient request pain medication for severe pain. Which should the nurse do first when responding to this patient's request?

Assess the various aspect of the patient's pain

nurse's roles with medications

Assessment of Patient, Medication Administration Record (MAR), allergies (with each med administration), lab results, and drug interactions. Preparation (compare drug label with MAR 3 times) Teaching (Self-administration) Purpose, side-effects Administration Documentation Evaluation Advocate

What cannot be delegated?

Assessment, diagnosis, planning, implementation of advanced nursing skills, evaluation, and patient teaching

how should you prevent abdominal cramping & nausea/vomiting?

Avoid cold formula (room temperature preferred) Decrease rate / volume

eye medication instillation

Avoid instilling meds directly onto the cornea (very sensitive). Avoid touching the eyelids with droppers or tubes to decrease the risk of infection. Use only on the affected eye. Never share medications. If the patient blinks hard and the drop falls on the cheek, place another drop in the eye.

What is the acronym used to remember the 6 ADLs?

BATTED (bathing, ambulating, toileting, transfers, eating, and dressing)

dorsiflexion

Backward flexion, as in bending backward either a hand or foot

perineal care

Bathing or cleaning the area of the body which includes the genitals (external sex organs), groin and rectal areas. Usually called peri-care.

hemorrhage

Bleeding from a wound site Bleeding may be internal or external Hemostatis usually occurs within several minutes Monitor dressing

venous thrombosis

Blood clots in veins because of hypercoaguability of blood and venous stasis. Can apply lotion but don't firmly massage...don't want clot to travel.

plateau (medication)

Blood serum concentration of a medication reached and maintained after repeated fixed doses

pathogens leave on person and enter through

Blood skin, mucous membranes, respiratory tract, GU, GI, and trans-placental sites

vascular responses

Blood vessel dilation Increased vascular permeability and leakage White blood cell adherence to the inner walls of the vessels and migration through the vessels

Standard precautions apply to contact with

Blood, body fluids, non-intact skin, mucous membranes, secretions/excretions (except sweat) Equipment or surfaces contaminated with potentially infectious materials

alterations in bones & minerals

Bone destruction exceeds bone rebuilding. Disuse osteoporosis: lack of active muscle contraction Calcium leaves bones and enters bloodstream (Hypercalcemia). Causes nausea, vomiting, and therefore, dehydration. Renal Calculi (Kidney stones) often occur with urinary stasis.

digestive system

Breaks down food into absorbable units that enter the blood for distribution to body cells.

what goes in a biohazard/infectious waste bag?

Bulk blood or body fluids: Drip able amounts of blood or body fluids Suction canisters IV bags and tubing containing blood Dialysis products Chest tube drainage units Microbiological waste Cultures derived from clinical specimens and discarded lab equipment Human tissue

DO NOT CRUSH LIST

CD: controlled delivery CR: controlled release ER: extended release LA: long acting SR: sustained release XL: extended release XR: extended release TR: time release

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

Call the poison control center

Dysphagia Stages, Thickened Liquids, Pureed

Can include clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy

full liquid diet

Can include clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt

mechanical soft diet

Can include clear, full, liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)

What should you do to prevent diarrhea?

Change type of formula per order; lower rate Deliver continuously in closed container Change bag and tubing every 24 hours Check expiration dates

alterations in lungs

Chest expansion decreases. Alteration in oxygen and carbon dioxide. Turning patient every 1-2 hours helps loosen lung secretions.

toddlers and preschool needs

Choking risks (hot dogs, candy, nuts, grapes, popcorn) Small frequent meals (3 meals + 3 high nutrient dense snacks)

steps to cleansing wound sites

Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin. 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to the most contaminated area

clear liquid diet

Clear fat-free broth, bouillon, coffee (without cream), tea, carbonated beverages, clear fruit juices (pulp free), gelatin, fruit ices, popsicles, ice chips (1 cup or 240 mL of ice chips is 120 mL of intake)

Which is the best goal for the nurse to include in the plan of care related to the problem statement of "acute pain related to strain on muscles with movement?"

Client reports pain of less than 1 on a 0 to 10 scale after pain medication

what are some atypical symptoms that older adults experience with infection:

Confusion Agitation Incontinence General fatigue

C in RACE

Contain the fire

wound healing-infection

Contaminated or traumatic wound. 2nd most common HCAI. May appear in 2-3 days; Surgical wound infection usually does not develop until the 4th or 5th post-op day.

hemostatis

Control bleeding. Allow puncture wounds to bleed a small amount. Do not remove a penetrating object. Pressure & Bandage

warning signs of dysphagia

Coughing / Choking during/after swallowing Facial paralysis / head control / posture Abnormal gag reflex Delayed swallowing Pocketing Drooling

orthostatic hypotension

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

support surfaces with wounds

Decrease the amount of pressure exerted over bony prominences. No specialty bed or overlay mattress eliminates the need for meticulous nursing care!

alterations in gastrointestinal tract

Decreased appetite and constipation are concerns.

signs of vascular insufficency

Decreased hair growth on legs and feet Absent or decreased pulses Infection in the foot Poor wound healing Thickened nails Shiny appearance of the skin Blanching of the skin on elevation

older adults

Decreased immune and inflammatory response. Infection does not always present with typical s/s. May not have an elevated body temperature (fever)

what increases the risk of aspiration?

Decreased level of consciousness (LOC) Lying flat...KEEP HOB ELEVATED A MINUMUM OF 30 DEGREES! 45 DEGREES is better Patient's with dysphagia Confusion, agitation, uncooperative Artificial airways Absent or poor gag reflex

flexion

Decreases the angle of a joint

types of pressure ulcers

Decubitus, pressure sore, and bed sore

Do not crush, cut, or chew

Delayed Release Enteric-coated Effervescent tablet Irritant Mucous Membrane irritant Orally disintegrating tablets Slow Release Sublingual forms of drugs Sustained Release

suspected deep tissue injury

Depth unknown. Damage of underlying soft tissue from pressure and/or shear. May be painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

right indication

Determine if the patient has the actual condition the drug is intended to treat If not, question the drug order

intraocular instillation

Disk resembles a contact lens. Teach patients how to insert and remove the disk. Teach about adverse effects.

preventing med errors

Do not delegate any part of the medication administration process to assistive personnel. Prepare meds for only one patient at a time. Read labels at least 3 times (compare MAR with label on med). First, when removing from storage. Second, before taking to patient's room. Third, at bedside when giving medication. Do not allow any interruptions Double check high-risk medications with another nurse. Question unusually large or small doses.

localized infection

Does NOT affect the whole body Pathogen is contained to one body part or organ Examples: Infected cut, surgical wound, wound site, pressure ulcer, abscess

Older adults & oral cavity problems

Edentulous Periodontal disease could lead to systemic infection Dentures don't always fit properly Enjoyment of food may decrease with dietary changes. Affects nutritional status. Decline in saliva with aging. Some meds cause dry mouth Financial limitations

neutropenic diet

Eliminates raw, unprocessed, and fresh fruits and vegetables, drinking tap water, and emphasize well-cooked foods and appropriate food handling to reduce cross contamination; recommended for prevention of infection in patients who are immunocompromised.

gluten free diet

Eliminates wheat, oats, rye, barley and their derivatives

flat position

Entire bed frame horizontally parallel with floor

chemical debridement

Enzymes digest/dissolve necrotic tissue Dakin's solution (contains bleach)

common bacterial pathogens

Escherichia coli Staphylococcus aureus Streptococcus (group A &B) Nisseria gonorrhoeae Mycobacterium tuberculosis

Schedule II substances

Ex: Dilaudid, Demerol, OxyContin, Percocet, Duragesic, Morphine, Codeine, Adderall, Ritalin.

Schedule IV substances

Ex: Soma, Klonopin, Valium, Ativan, Xanax

schedule III substances

Ex: Vicodin, Tylenol with Codeine.

what are some examples of non-critical items that come in contact with skin?

Examples: bedpans, bedrails, blood pressure cuffs, stethoscopes, bedside trays (should be cleaned and disinfected)

hyperextension

Excessive straightening of a body part

abnormal reactive hyperemia

Excessive vasodilation and induration; skin is bright pink to red; NO blanching with fingertip pressure; can last 1 hour to 2 weeks; Stage I pressure ulcer

Continuous Passive Motion (CPM)

Exercises that are performed by motorized exercise machinery that keeps a joint in constant slow motion

therapeutic effect

Expected or predicted physiological response

how can you prepare a client for sterile procedures?

Explain procedure Tell them how they can help Avoid sudden movements Avoid touching Anticipate problems Pain meds Positioning Bathroom Avoid coughing, sneezing, or talking over sterile field

A neonatal nurse is assessing a 2 week olds pain level following open heart surgery. To assess the pain level using an age appropriate scale, which scales would be appropriate? (Select all that apply)

FLACC scale NIPS

what are some aspiration precautions?

Feed small amounts of food. Seat patient fully upright Do not force feed Provide oral care before and after meals Never put food or fluids in the mouth of a patient who is not fully alert. Crush pills and put them in soft food such as pudding or applesauce

signs/symptoms of systemic infection

Fever Chills Increased HR, RR Deceased BP Increased WBCs (leukocytosis) Body aches Lymph Node enlargement Nausea and/or Vomiting Fatigue, Weakness, Malaise Anorexia Organ failure

Heat is contraindicated:

For areas of active bleeding For an acute localized inflammation Over a large area if a patient has cardiovascular problems

signs/symptoms of localized infection

Foul odor Purulent drainage ("pus") Heat/ warm to touch Pain Swelling Redness Temporary loss of function in affected body part

Pure Food and Drug Act of 1906

Free of impure products. Label standards for packaging. Established the FDA.

how should you clean the eyes?

From inner canthus to outer canthus - using a new part of the washcloth for each stroke

Unstageable/Unclassified Pressure Ulcer

Full-thickness tissue loss; depth is unknown. Cannot stage necrotic tissue. Slough and/or eschar are removed to expose the base of the wound (category/stage III or IV). Exception: Dry, adherent & intact eschar on the heels serves as "the natural (biological) cover of the body."

What does not go in a red bag?

Garbage or recycline Sharps - They need to be a in a sharps container. Batteries Chemotherapy waste Hazardous waste

With the nurse's assistance, a patient quickly gets up out of the bed to go to the bathroom. He walks about 5 feet from the bed, where he stops and states "I feel faint" and starts to fall. What is the priority nursing action?

Gently lower the patient to the floor

A nurse is assessing a patient experiencing chronic pain. Which characteristic is more common with chronic pain than acute pain? (Select all that Apply)

Gradual onset Long duration Psychologically depleting

what is encompassed in dietary and health history?

Health status Age Allergies Culture, religion, and preferences Prescription meds or over-the-counter supplements Patient's general nutrition knowledge about nutrition Environmental factors (activity level; sedentary lifestyle)

nursing process: assessment

History: chronic diseases, lifestyle, high risk behavior, occupation, travel history, immunizations and vaccinations Physical Assessment findings Signs and symptoms of infection Laboratory findings

Placement of canes

Hold cane on strong side, NOT weak side

TJC National Patient Safety Goals

Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Prevent mistakes in surgery

alterations in kidneys and bladder

If flat or reclining, urine remains in kidneys until they fill and spill over into ureters and bladder. Stasis of urine causes increased bacterial growth. Urinary tract infections are likely.

Cold is contraindicated

If the site of injury is very edematous In the presence of neuropathy If the patient is shivering If the patient has impaired circulation

what are some instances where a patient would be at risk for hygiene problems?

Immobile Unable to perform hygiene Injuries/pain Chemotherapy....ulcerations of the mouth... "stomatitis"

common nursing diagnoses with activity/exercise

Impaired Physical Mobility Activity Intolerance Ineffective Coping Impaired Gas Exchange Risk for Injury Impaired Bed Mobility Acute or Chronic Pain

musculoskeletal system

Improved muscle tone, joint mobility, muscle mass

psychosocial factors

Improved stress tolerance, decrease in illness

soft/low residue diet

Includes all of the above with addition of low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut

alteration in body fluids & circulation

Increase in secretion of urine. Hypovolemia may result. Calcium levels increase in the bloodstream (Hypercalcemia). Diminished circulation and postural (orthostatic) hypotention is a complication with compromised circulation to vital organs.

antianemics

Increase red blood cell production

cardiovascular system

Increased cardiac output, strengthened heart muscle, improved venous return

adolescents developmental needs

Increased energy needs & higher metabolic growth demands (protein, calcium, iron needs) Concerned about body image and appearance

metabolic system

Increased metabolism, gastric motility, and body heat

pulmonary system

Increased respiratory rate and depth

nursing diagnoses with immobility

Ineffective Airway Clearance Ineffective Coping Impaired Physical Mobility Impaired Urinary Elimination Risk for Impaired Skin Integrity Risk for Disuse Syndrome Social Isolation

cheilitis

Inflammation and cracking of the lips and corners of the mouth due to infection, allergies, or nutritional deficiency

school-age developmental needs

Influential years. However, 17% obese.

ear medication instillation

Instill eardrops at room temperature. Use sterile solutions. Check for eardrum rupture if patient has ear drainage. Remove cerumen prior to using eardrops. Place cotton ball in ear and encourage patient to remain on that side for 5 minutes.

ISMP

Institute for Safe Medication Practices

HAI patients at high risk

Insufficient immune system(Immunocompromised) Multiple illnesses (DM, cancer, emphysema, bronchitis) Critical illness (burns, trauma, transplant, AIDS, surgery) Nutritional status (malnutrition) Older adults

peristalsis

Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.

A transcutaneous electrical nerve stimulation (TENS) unit is a battery-operated device that some people use to treat pain. Which is the best explanation of how a TENS unit works?

It sends stimulating pulses through the skin to block the pain signals from reaching the brain

right route

Know the correct route of administration by which the drug should be given

right patient

Know the patient to whom you are administering the medication

HCI additional risk factors

Length of hospitalization increases exposure Number of healthcare workers in direct contact with patient Invasive procedures IV catheters, urinary catheters, diagnostic tests Multi-drug Resistant Organisms (MDROs) Breaks in infection prevention and control

effleurage

Light, continuous-stroking massage movement applied with fingers and palms in a slow and rhythmic manner.

tips for administering medications to children

Liquid best; droppers for infants Mix with small amount of food; not in bottle of formula or milk Use syringe with amounts less than 10mL

hematoma

Localized collection of blood underneath the tissues Appears as swelling, change in color (often bluish discoloration), change in sensation, or warmth

assessment of wounds include:

Location Depth of tissue involvement (staging for pressure ulcer) Type and approximated amount (percentage) of tissue in wound bed Appearance (color) of viable and nonviable tissue Wound dimensions; include sinus tracts and tunneling, if present Character of drainage / exudate description Amount, color, consistency and odor Condition of surrounding skin (peri-wound area) Redness, warmth, signs of maceration, pain, induration

blood and urine cultures

Look for "Positive" Presence of pathogen in culture results Presence of WBCs on gram stain

Schedule V substances

Lower potential for abuse. Ex: Robitussin AC, Gabapentin (Neurotonin), Lyrica.

PPE examples

Mask, Examination gloves, Protective eyewear, Protective (impervious) clothing

Non-pharamacological interventions

Massage therapy; cold and heat applications; relaxation techniques; acupuncture; distraction; music therapy

What are some advanced nursing skills?

Med administration, NG tube placement, wound care, urinary catheter insertion, interpretation of lab values, trach care and suctioning, IV start/IV fluid or med administration

stool collection

Medical aseptic technique is imperative. Hand hygiene, before and after glove use, is essential. Wear disposable gloves. Do not contaminate outside of container with stool. Obtain stool and package, label, and transport according to agency policy.

rectal/vaginal medication installations

Melt alongside rectal wall-Patient can do himself if desired-Rounded end is inserted-Use lubricant

older adults developmental needs

Metabolic rate slows Changes in appetite, taste, smell -> decreased intake of kcals Reduced thirst sensation (->dehydration) Digestive system (decreased peristalsis ->constipation) Difficulty chewing, lack of teeth, dentures, oral health Health affects desire and ability to eat (chronic illnesses) Fixed limited income / transportation Side effects of medications (anorexia, xerostomia) Cognitive impairments (delirium, dementia, depression)

alterations in skin

Moisture leads to infectious organisms. Keep patients clean and dry!!! Important for infection control. Pressure...not just on soles of feet when immobile (Bony prominences) Tissue damage and pressure ulcers occu

abduction

Movement away from the midline of the body

radial deviation

Movement of the wrist towards the radius or lateral side

ulnar deviation

Movement of the wrist towards the ulna or medial side

adduction

Movement toward the midline of the body

alteration in skeletal muscles

Muscle tone is lost and circulation is slowed. Muscle Atrophy occurs/ "Disuse Atrophy" Major complication is a Flexion Contracture where muscles shorten, joints stiffen, alterations in function and deformities occur

Signs of Peripheral Neuropathy

Muscle wasting of lower extremities Absence of deep tendon reflexes Foot deformities Infections Abnormal gait Decreased or absent vibratory sensation

Who needs frequent oral hygiene

NPO patients

elements that should be included in a verbal hour:

Name of patient Age and weight of patient, when appropriate. Drug name (generic and/or brand name) Dosage form (e.g., tablets, capsules, inhalants). Exact strength or concentration. Dose, frequency, and route. Quantity and/or duration. Purpose or indication (unless disclosure is considered inappropriate by the prescriber). Specific instructions for use. Name of prescriber and telephone number when appropriate. Name of individual transmitting the order if different from the prescriber. Repeat the order back to the prescriber to verify accuracy! (speaker phone)

metered-dose inhalers (MDIs)

Need sufficient hand strength for use May be used with a spacer Hold breath for 10 seconds

regular diet

No restrictions unless specified

NPO diet

Nothing by Mouth Patients who are NPO and receive only standard IV fluids for more than 4 to 7 days are at nutritional risk

Parental nutrition

Nutrients are provided intravenously (IV) through an indwelling peripheral or central venous catheter (CVC). Unable to digest or absorb enteral nutrition (nonfunctional GI tract) or very ill.

diabetic diet

Nutrition recommendations by the American Diabetes Association: focus on total energy, nutrient and food distribution; include a balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient's metabolic demands

health-care associated infections (HAI)

Occur as the result of invasive procedures, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities

safety/preventing errors with meds

One patient at a time At least 2 identifiers Avoid interruptions/Be well-rested Verify all calculations and high-risk meds with another licensed nurse (Insulin, narcotics, sedatives, anticoagulants) Don't try to interpret poor handwriting Question unusual dosages Admit errors and report incident Document as soon as meds are given Use bar coding technology Assess allergies and other medications Witness

idiosyncratic reaction

Overreaction or under-reaction or different reaction from normal.

What acronym should you use when using a fire extinguisher?

PASS

systemic infection

Pathogen travels through the bloodstream to the entire body Causes symptoms across the body Can be fatal if untreated Examples: Influenza, Mononucleosis, Cold

surgical debridement

Performed by primary care provider, surgeon

direct contact

Physical contact between reservoir and susceptible host Includes transmission through vectors

Pick the best delegation: Please walk room 201 Please walk room 201 200 feet and if patient c/o fatigue take him back to bed and inform the primary RN

Please walk room 201 200 feet and if patient c/o fatigue take him back to bed and inform the primary RN

signs of hyperglycemia

Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope

sitting position

Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

what are some nursing responsibilties when dealing with infection?

Practice hand hygiene Wear clean gloves Maintain standard/isolation precautions Use medical/surgical aseptic technique when appropriate Keep bedside surfaces clean Clean all equipment that is shared between patients Teach patients and caregivers

side effect

Predictable, unavoidable secondary effect

wound irrigation

Primary reason is to remove debris and dead tissue from the wound. The smaller the needle, the greater the pressure. Usually 19 gauge needle and a 35 mL syringe. Mask, goggles, gown, gloves.

what are some things you should provide when performing hygiene for everyone?

Privacy Safety Warmth Promote independence Anticipate needs

When should surgical asepsis be used?

Procedures that require intentional perforation of the patient's skin (injections, insertion of IV catheters) When the integrity of the skin is already broken (trauma, surgical incision, or burns) Procedures that involve insertion of catheters or surgical instruments into sterile body cavities (insertion of a urinary catheter)

acute wounds

Proceeds through an orderly & timely healing process (e.g., trauma, surgical incision). Wound edges are clean & intact. Wound edges are approximated or closed. Risk of infection is low. Quick healing with minimal scar. Usually very painful.

purposes of dressing

Protect a wound from microorganism contamination. Aid in hemostasis. Promote healing by absorbing drainage and debriding a wound. Support or splint the wound site Protect patients from seeing the wound. Promote thermal insulation of the wound surface.

right supervision/evaluation

Provide appropriate monitoring, evaluation, intervention as needed, and feedback. NAP need to feel comfortable asking questions and seeking assistance.

psychological implications of isolation

Psychological implications Loneliness Guilt Feelings of rejection Isolation environment Avoid expressions or actions that convey disgust or frustration

P in PASS

Pull the pin

In the event of a fire, what acronym should you use?

RACE

assessing bowel sounds order

RLQ-> RUQ-> LUQ-> LLU

infant developmental needs

Rapid growth and high protein needs

THE NURSE IS PERFORMING HAND HYGIENE BEFORE ASSITSING A HEALTH CARE PROVIDER WITH INSERTION OF A CHEST TUBE. WHILE WASHING HANDS, THE NURSE TOUCHES THE SINK. WHICH ACTION WILL THE NURSE TAKE.

Repeat handwashing using antiseptic soap

R in RACE

Rescue anyone in immediate danger

trochanter roll

Rolled towel support placed against the hips and upper leg to prevent external rotation of the legs.

external rotation

Rotation of a joint away from the middle of the body.

hemovac

Round drain with springs inside that must be compressed to create a suction

Which skill can be delegated?

Routine vital signs

How should you use alcohol-based hand antiseptics?

Rub hands together for several seconds, until alcohol is completely dry. Allow hands to dry before applying gloves.

priorities in medication administration

STAT Improve breathing analgesics

abrasion

Scrape of the skin due to something abrasive

what should be disinfected?

Semi-critical items that come in contact with mucous membranes or non-intact skin

how are health care workers at risk for exposure?

Sharps Blood, body fluids, feces, urine, wound drainage Contaminated equipment & surfaces Communicable diseases

medication reconcilation frequency

Should be done at every transition of care in which new meds are ordered or existing orders are rewritten.

rash

Small, raised vesicles that are usually reddened; often distributed over entire body

Assessment of the skin (hygiene)

Smooth, warm, supple (opposite of stiff.)...soft, flexible, not easily broken Elastic turgor and quick capillary refill Assess under female breasts and male scrotum Assess perineal tissues Bruising

penrose drain

Soft, flat rubber tubing. A pin or clip is placed through the drain to prevent it from slipping. The drain is pulled or advanced as drainage decreases to permit healing deep within the drain site.

vehicles

Spreading agents and ingredients that carry or deliver other ingredients into the skin and make them more effective.

First S in PASS

Squeeze the handle

droplet isolations diseases

Streptococcal pharyngitis (strep), pertussis (whooping cough), influenza, diptheria, rubella, mumps, scarlet fever, pneumonic plague

right dosage

THE NURSE IS EXPECTED TO KNOW COMMON DOSAGES FOR BOTH ADULTS AND CHILDREN.

postictal phase

The after effects of the seizure; when the person wakes up, they may have sore muscles and be tired or confused. The observer's best course of action is to be assuring and supportive.

location of pain

The area of or location of pain.

trade name

The commercial name given to a drug product by its manufacturer; also called the proprietary name.

Reverse Trendelenburg's position

The head of the bed is raised and the foot of the bed is lowered

functions of skin

The largest organ of the body Protection, sensation, temperature regulation, excretion, and secretion. 1st line of defense against harmful bacteria and viruses.

chemical name

The name that describes the chemical composition and molecular structure of a drug.

lateral recumbent position

The patient is lying on their right or left side.

tonic phase

The person initially stiffens and loses consciousness, causing them to fall to the ground. The person's eyes roll back into their head as the muscles (including those in the chest, arms and legs) contract and the back arches. As the chest muscles tighten, it becomes harder for the person to breathe - the lips and face may take on a bluish hue, and the person may begin to make gargling noises.

nutritional risk

The potential to become malnourished because of primary (inadequate intake of nutrients) or secondary (caused by disease or iatrogenic affects) factors.

medication reconciliation

The process of comparing a patient's medication orders to all of the medications that the patient has been taking."

gate control theory of pain

The theory that pain is a product of both physiological and psychological factors that cause spinal gates to open and relay patterns of intense stimulation to the brain, which perceives them as pain.

quality of pain

The words the patient uses to describe their pain. Such as cramping, burning, pins and needles, sharp, dull or achy, tingling, stabbing and so on

Why can't these aspects be delegated?

These require advanced knowledge, nursing judgment, and critical thinking skills.

duration (medication)

Time during which the medication is present in concentration great enough to produce a response

peak (medication)

Time it takes for a medication to reach its highest effective concentration

medication reconciliation purpose

To avoid med errors such as omissions, duplications, dosing errors, or drug interactions/allergies (use allergy bracelets)

purpose of ROM exercises

To prevent muscle atrophy and joint contractures.

What is the reason for using long firm strokes from distal to proximal while bathing a patient?

To promote venous circulation returning to the heart

health promotion with wounds

Topical skin care and incontinence management Protect bony prominences, skin barriers for incontinence.

antiemetics

Treat nausea and vomiting

True or false: CHG solution is not safe to clean the eyes

True

True or false: Facility schedules or physician/prescriber beliefs should not take priority over the patient's religious or cultural beliefs.

True

True or false: Restraints are utilized only when alternatives have been shown to be unsuccessful, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified.

True

True or false: a patient's self report of pain is the single most reliable indicator of the existence and intensity of pain. (meaning you should medicate patient's based on this report, not their behaviors)

True

True or false: aspiration can lead to pneumonia

True

True or false: cuts do not heal as well due to poor circulation in patients with peripheral vascular disease (vascular insufficency) and/or diabetes mellitus

True

True or false: delegated tasks can be revoked.

True

True or false: do not apply estrogen patch to breasts

True

True or false: do not soak feet in DM patients.

True

True or false: effective delegation requires the use of good communication skills, using the proper display of authority and respect.

True

True or false: elderly skin is paper thin and tears easily

True

True or false: hand hygiene should be performed before and after each patient encounter or treatment & when coming in contact with body fluids or before touching the eyes, nose, or mouth.

True

True or false: if you are exposed to a risk, you should report any exposure immediately.

True

True or false: nitro paste is order in "inches"

True

True or false: oxygen and sparks = bad news.

True

True or false: pain is the fifth vital sign.

True

True or false: pain medications work on pain in different ways (interrupt pathways in different points/ways), so can combine different types for maximal pain relief.

True

True or false: the RN is the leader of the healthcare team.

True

True or false: when choosing an assistive device, choose one that allows for the most independence and maximum amount of safety.

True

True or false: when delegating, make sure to check job description and institutional policies and procedures

True

True or false: when disposing narcotics, you must have a witness

True

True or false: when moving patients, you should tallor the job to the employee, not the employee to the job.

True

True or false: you can grasp the 1 inch border to manuever the sterile field before applying sterile gloves

True

True or false: you should allow as much independence as possible

True

True or false: you should assess the client for usual personal hygiene habits/routine such as products, frequency, time of day, and being bathed by someone of opposite sex

True

True or false: you should hold the label up in palm of hand when pouring a sterile solution.

True

True or false: you should prioritize pain and vomiting.

True

true or false: hand hygiene is the most effective basic technique in preventing and controlling the transmission of infection.

True

true or false: standard precautions apply to all patients because every patient has the potential to transmit infection.

True

true or false: when bracing a fall, you should gently lower the patient to the floor

True

true or false: when you give the wrong medication, assess the patient first

True

True or false: you can give a medication 1 hour before or after the scheduled time.

True (check policy though)

positioning with wounds

Turn every 1 to 2 hours as indicated.

inversion

Turning the sole of the foot inward

abscence seizure

Typically appear to stare without moving. Usually lasting less than 15 seconds, absence seizures can occur many times a day and may be mistaken for daydreaming.

clonic phase

Typically following the tonic phase, the clonic phase will start as the muscles begin to spasm and jerk. The elbows, legs and head will flex then relax rapidly at first, but the frequency of the spasms will gradually subside until they cease altogether. As the jerking stops, it is common for the person to let out a deep sigh, after which normal breathing resumes.

adverse effects

Unintended, undesirable, sometimes unpredictable

A nurse is teaching a group of patients about correct body mechanics. Which action reflects teaching about the principle, the greater the base of support, the more stable the body? (Select all that apply)

Use a cane when you walk Seek assistance when you get out of bed

THE NURSE IS CARING FOR A PATIENT ON CONTACT PRECAUTIONS. WHICH ACTION WILL BE MOST APPROPRIATE TO PREVENT THE SPREAD OF DISEASE?

Use a dedicated blood pressure cuff that stay in the room and is used for that patient only.

how to measure wounds?

Use a disposable wound measuring device to obtain measurement of length and width. Measure depth by using a cotton-tipped applicator in the wound bed. Measuring is a good indicator of wound healing. L, W, D

skin applications

Use gloves and applicators; clean skin first. Remove old patch before applying new one. Use caution with discarding Rotate sites

sterile dressing changes

Used when skin integrity is broken as a result of: trauma surgical incision burns

indirect contact

Vehicle transmits pathogen from reservoir to susceptible host

airborne precautions

Wear N95 respirator Place in negative air flow room HEPA (High-efficiency Particulate air) Filter KEEP DOOR CLOSED When a patient has an airborne-transmitted infection, he or she must wear a (regular) mask when leaving the room.

droplet isolations

Wear a gown, surgical mask, and eyewear when within 3 feet When a patient has a droplet-transmitted infection, he or she must wear a (regular) mask when leaving the room

3 point gait

Weight is distributed on both crutches and then on the *unaffected* leg -- then repeat sequence

Input/Output

What is taken in and expelled from the body.

To assess the quality of a client's pain, the nurse asks which question?

What word best describes your pain?

forearm crutches

Wooden or metal crutches with a full or half cuff that fits over a person's forearms and that have a handpiece to grasp; long term use

dehisence

Wound edges "pull apart." Partial or total separation of wound layers Increased risk with abdominal surgeries Prevention strategies: use a pillow to brace/splint incision site when coughing, sneezing or deep breathing

chronic wounds

Wound that fails to proceed through an orderly & timely process. Causes: vascular compromise (diabetes); chronic inflammation; repetitive insults to tissues (impedes wound healing) May not be painful, depending on extent of nerve damage.

complete bed bath

a bath in which all parts of a patient's body are bathed while the patient is confined to bed

Where should your sterile field be?

a clean, dry work surface above waist level

Aura

a distinctive atmosphere that is experienced by a person such as bright light, smell, or taste.

Patient-controlled analgesia (PCA)

a drug delivery system that uses a computerized pump with a button the patient can press to deliver a dose of an analgesic through an intravenous catheter

Food and Drug Administration (FDA)

a federal agency charged with enforcing regulations against selling and distributing adulterated, misbranded, or hazardous food and drug products

pressure ulcer

a localized injury caused to the skin and other underlying tissue related to unrelieved, prolonged pressure or friction usually over bony prominences results in ischemia and damage to the underlying tissue

infectious agent

a pathogen, such as a bacterium or virus that can cause a disease

susceptible host

a person likely to get an infection or disease, usually because body defenses are weak

gait

a person's manner of walking

surgical scrub

a procedure that achieves disinfection of the hands and arms up to the elbows in preparation for donning sterile attire and performing or participating in a sterile procedure

Fowler's position

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees

surgical asepsis priniciples

a sterile object remains only sterile only when touched by another object only sterile objects may be placed on a sterile field a sterile object or field out of the range of vision OR an object held below a person's waist is contaminated a sterile object or field becomes contaminated by prolonged exposure to air When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. Fluid flows in the direction of gravity. The edges (1 inch border) of a sterile field or container are considered to be contaminated.

seizure

a sudden surge of electrical activity in the brain. It can occur at any time due to epilepsy, fever, or a variety of medical problems. Experience a disorderly discharge of neurons in the brain; with sudden, violent, and an involuntary series of muscle contractions.

sitz bath

a warm soak of the perineal area to clean perineal wounds and reduce inflammation and pain

portal of entry

a way for the causative agent to enter a new reservoir or host

mode of transmission

a way that the causative agent can be transmitted to another reservoir or host where it can live

dental caries

abnormal destructive condition in a tooth caused by a complex interaction of food, especially starches and sugars, with bacteria that form dental plaque

NON-OPOID ANALGESICS

acetaminophen (tylenol) nonsteroidal anti-inflammatory drugs (NSAIDs)

A in RACE

activate the smoke/fire alarm

Fall risk is increased when:

advanced age history of falls incontinence, frequency, urgency medications (sedatives, laxatives, diuretics) or a sedated procedure within the past 24 hours Patient care equipment (IV, chest tube, indwelling cath, SCDs) unsteady gait, visual or auditory impairment cognitive impairments; decreased level of consciousness

PC

after meals

risk factors for pressure ulcer development

age alterations in level of consciousness impaired decreased/mobility impaired sensory perception poor nutrition/hydration status moisture (urinary or fecal incontinence) chronic illnesses spinal cord injuries sheering and/or friction

I may rear my ugly head if there is a medication that does not agree with your body. You may see me appear as pruritus (itching), urticaria (skin eruptions), rhinitis (inflammation of the nasal passages), or an ugly rash.

allergic reaction

The nurse is to give a three-year-old child an oral liquid medication. What is the best nursing intervention to facilitate the process?

allow the child to choose whether to take the medication from a spoon or plastic syringe

enteral nutrition

alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula

nutritional assessment

an evaluation used to determine the nutritional status of individuals or groups for the purpose of identifying nutritional needs and planning personal health-care or community programs to meet those needs

bedrest

an intervention that restricts patients to bed for therapeutic reasons (reducing physical activity, oxygen needs, pain, rest, high BP during pregnancy).

I am a cousin to the previously mentioned fellow, although I am much more severe. I cause shortness of breath, wheezing, and pharyngeal edema. If I am not treated, I may even be life-threatening.

anaphylatic reaction

adjuvants/co-analgesics

antidepressants; anticonvuslants

portal of exit

any body opening on an infected person that allows pathogens to leave

chemical restraint

any drug that is used for discipline or convenience and not required to treat medical symptoms

physical restraint

any manual method or physical or mechanical device, material, or equipment attached to or near the person's body that he or she cannot remove easily and that restricts freedom of movement or normal access to one's body

THE SURGICAL MASK THE PERIOPERATIVE NURSE IS WEARING BECOMES MOIST. WHICH ACTION WILL THE PERIOPERATIVE NURSE TAKE?

apply a new mask

Analgesics (pain medications)

are important to prevent unnecessary discomfort/suffering.

non-blanchable erythema

area does not blanch when you apply pressure; deep tissue damage is probable

Ad lib

as desired

prn

as needed

what precautions have the highest priority?

aspiration

What are some things to consider when using restraints?

assess appropriateness of restraint document alternatives attempted use least restrictive restraint possible used timed client monitoring

Nurses not only administer thousands of medications but are also responsible for....

assessing effectiveness and recognizing unfavorable reactions

Nonmalefience

avoidance of harm and hurt

throat specimen

back of throat, do not touch cheeks, gums, teeth

what should you teach a patient before discharge?

basic information about infection perform hand hygiene: how & when how to disinfect equipment/surfaces watch for signs/symptoms of infection; when to contact health care provider how to dispose of old dressings/contaminated sharps

partial bed bath

bath in which only certain body parts are bathed or in which the health care provider bathes those parts of the body that the patient is unable to bathe

Where should restraints be secured?

bed frame (NOT BED RAIL)

AC

before meals

If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent:

before, after and between direct patient contact contact with surfaces in the patient's room before putting on gloves (clean or sterile) after removing gloves

plantar flexion

bending of the sole of the foot by curling the toes toward the ground

lateral flexion

bends vertebral column from side to side

abnormal reactive hyperemia

blanching does not occur with pressure; sign of deep tissue damage

sanguineous

bloody drainage

sanguineous drainage

bloody drainage

Prediction and prevention of pressure ulcers

braden scale

respiratory opioid side effects

bradypnea hypoventilation

What are some medications that improve breathing?

bronchodilators, mucolytics HIGH PRIORITY

aura

can occur before seizure activity begins (metallic taste, sensitivity to lights, smells).

Quad cane

cane that has four rubber-tipped feet and a rectangular base; stronger base of support

intermittent feedings

check residual immediately before each feeding

The patient's blood glucose is 330 mg/dL. What is the priority nursing intervention?

check the medication orders to treat hyperglycemia

implementation-treating wounds: yellow

cleanse characterized by liquid to semiliquid "slough" that is often accompanied by purulent drainage or previous infection. We cleanse yellow wounds to remove nonviable tissue (Debridement required for large amounts of slough).

Right direction/communication

clear, concise description of the task, including its objective, limits, and expectations

serous

clear, watery plasma

serous drainage

clear, watery plasma

symptomatic

clinical signs and symptoms are present

pulmonary embolism

clot or other material lodges in vessels of the lung

atelectasis

collapsed lung; incomplete expansion of alveoli

shearing force

combination of friction and pressure

jackson pratt drain

constant low pressure (bulb is compressed) empty when 1/2 full decompression before closing to resume suction

gastrointestinal opioid side effects

constipation N/V delayed gastric emptying

CD

controlled delivery

CR

controlled release

What cannot be delegated to an LPN?

critical thinking (assessment, diagnosis, planning, implementation, evaluation) REMEMBER EAT (evaluate, assess, teach)

implementation-treating wounds: black

debride covered with thick necrotic tissue, or eschar. Black wounds require debridement, removal of nonviable tissue from the wound bed before the wound can be staged or heal properly.

activity tolerance

decreased fatigue

Right task

delegate task to appropriate levels of team members based on standards of practice, legal and facility guidelines

Right person

delegating the right task to the right person to be performed on the right person

pressure ulcer staging

describes the pressure ulcer depth at the point of initial assessment ex: pressure ulcers do not progress from a stage III down to Stage I Stage III ulcer demonstrating signs of healing is described as a "healing stage III pressure ulcer"

severity of pain

description of how bad the pain is, often described on a scale of 1 to 10

dysphagia

difficulty swallowing or eating

cold therapy

diminishes swelling and pain vasoconstriction reduced oxygen needs of tissues and promotes blood coagulation at site of injury

A patient is receiving enteral feedings via a nasogastric tube. The patient's gastric residual volume was 250 mL at 0800 and 350 at 0900. What is the priority nursing action at this time?

discard the aspirate, hold the feeding, notify the provider

The nurse considers interventions to include in the plan of care for pain. Before implementing any interventions, what action is most important for the nurse to take?

discuss the plan of care with the client

What is an alternative to using restraints?

diversionary activities such as something to hold is a way to keep the hands busy Assigning a room near the nurses' station or a chair at the desk

Maleficence

doing evil or harm

antipsychotics

drugs used in the treatment of psychotic disorders that help alleviate hallucinations and delusional thinking

antianginals

drugs used to treat chest pain

eschar

dry, tan, brown or black colored dead tissue; remove for wound healing.

xerostomia

dryness of the mouth

BID, TID, and QID medications should be given

during the hours when the patient is awake, not during the night.

dysphagia diets

dysphagia puree, mechanically altered, dysphagia advanced, and regular.

4 point gait

each advancement of crutch or cane as well as LEs indicates a single point, used one at a time.

Goal of palliative care

earn how to live life fully with an incurable condition.

what are some foods and drinks high in protein?

eggs, meat, almonds, oats, cottage cheese, milk, Greek yogurt, broccoli, lentils (a type of legume), peanuts/peanut butter, Brussel sprouts. Increased protein is good for wound healing!

disinfection

eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects.

liquid medications

elixir, extract, syrup, solution, suspension

What are some physiological changes on aging and their effect on patient safety? (older adults)

encourage vision and hearing screenings educate older adults on safe driving tips to avoid automobile accidents demonstrate how to use assistive devices encourage an every 3 hour toileting schedule encourage them to use medication organizers

layers of the skin

epidermis and dermis

clinical signs of infection

erythema; increased amount of wound drainage; change in appearance of wound drainage (purulent: thick, color change, presence of odor); warmth, tenderness, & pain at the wound site; elevated WBCs; fever; edges of wound appear inflamed.

wound A

eschar (black)

What is the most important thing nurses can do when it comes to pain management?

establish a positive culture of pain management is actively listen to patients when they describe their pain

q4d

every 4 hours

continous feedings

every 4-6 hours

q6h

every 6 hours

q8h

every 8 hours

qam

every morning

hirsuitism

excessive growth of hair

Active range of motion exercises

exercises the resident can do without assistance

ER

extended release

XL/XR

extended release

lithotomy

female genitalia and genital tract

characteristics of a good reservior

food, oxygen, moisture, temp, pH, light

instant alcohol-based antiseptic

for use when hands aren't visibily soiled

halitosis

foul-smelling breath

A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught?

four point

QID

four times a day

Safety

freedom from psychological and physical injury

What behavior does a client exhibit that the nurse would document as an objective sign of acute pain?

frequent grimacing

stage III pressure ulcer

full thickness tissue loss (deep crater) tissue loss has extended completely through the epidermis and dermis subcutaneous fat may be visible bone, tendon, and muscle are not exposed slough may be present; may include undermining and tunneling

stage IV pressure ulcer

full thickness tissue loss with exposed bone, tendon, or muscle slough or eschar may be present extensive destruction; may include undermining or tunnelling

What are some ways to prevent falls?

gait belts bracing falls alarms/sensors (bed and chair) hand rails in bathrooms/hallways fall risk assessment (admission and daily) patient-inherent procedure-related, equipment accidents identify appropriate room assignment (close to nurses station)

performing a dressing change

give pain medication 30 minutes before a painful dressing change! hand hygiene before and after wound care wear clean or sterile gloves (depends on type of wound) carefully remove tape toward the wound; stabilize skin with other hand Gently clean the wound Assess wound color, length/width/depth, presence of exudate Assess skin around the wound Pack the wound if ordered Apply prescribed dressing Secure dressing with tape, bandage, or binder Date, time and initial dressing or tape with sharpie Document procedure and assessment findings

sublingual medications

given under the tongue

removing PPE

gloves, goggles, gown, mask

donning PPE

gown, mask, goggles, gloves

wound B

greenish-yellow slough

How should nurses be role-models?

have clean hair & nails no nail polish hair away from face no strong perfumes or lotions clean uniforms and shoes cover tattoos men: wear tee-shirt if lots of chest hair, clean shaven or trimmed beards no piercings except 1 earring in each earlobe shirt under scrubs for warmth needs to be coordinating color

pediculosis capitis

head lice

Schedule I substances

high potential for abuse; examples: LSD, heroin

What qualifications does a NAP have to have?

high school diploma, nurse aide training or on the job training, CPR certification

braden scale: lower score

higher risk

endocrine opioid side effects

hormonal and sexual dysfunction hypoglycemia-reported with tramadol and methadone

relief measures of pain

how patients relieve their pain

common reserviors

humans (unwashed hands) Animals Insects Food Water Organic matter on inanimate surfaces (equipment - BP cuff, stethoscope, bedside commode, bed rails, elevator buttons, handles of sink)

Seizure

hyperexcitation and disorderly discharge of neurons in the brain which leads to sudden involuntary muscle contractions.

Cardiac opioid side effects

hypotension bradycardia peripheral edema

Which of the following medications are non-steroidal anti-inflammatory drugs (NSAIDs) used to reduce inflammation and pain?

ibuprofen/motrin

You will never expect to see me coming because I reverse the intended effects of medications. <-> If a drug is meant to promote sleep, I keep the patient awake all night. If a medication is used to improve memory and attention span, I cause a foggy brain and forgetfulness.

idiosyncratic reaction

When is an incident report filed?

if a fall, injury, or other incident; additionallt, report "near misses" and equipment malfunctions

STAT

immediately

Risk factors for skin impairment?

immobilization reduced sensation nutrition and hydration alterations secretions and excretions on the skin vascular insufficiency external devices broken skin

immunological opioid side effects

immune system impairment possible with chronic use

protective isolations

immunocompromised patients We are protecting the patient from us, and the outside environment...KEEP DOOR CLOSED Place patient in room with positive air flow HEPA (High-efficiency Particulate air) Filter Do not allow potential reservoirs into patient's room (flowers, plants, fruit baskets)

Benefits of delegation

improve efficiency increased productivity empowered staff skill development of others

heat therapy

improves blood flow to injured part. vasodilation reduces muscle tension and pain, improves delivery of leukocytes and antibiotics to wound sites

surgical apepsis (sterile technique)

includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area

afternoon care

includes washing the hands and face, assisting with oral care, offering a bedpan or urinal, and straightening bed linen.

extension

increases the angle of a joint

chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

glossitis

inflamed tongue

thrombophlebitis

inflammation of a vein associated with a clot formation

gingivitus

inflammation of the gums

hypostatic pneumonia

inflammation of the lung from stasis or pooling of secretions

rhinitis

inflammation of the mucous membranes of the nose

stomatitis

inflammation of the oral mucosa

acne

inflammatory disease of the skin involving the sebaceous glands and hair follicles

antivirals

inhibit development of specific viruses

stage I pressure ulcer

intact skin (not broken)-nonblanchable redness over a localized area discoloration of skin, warmer or cooler, edema, hardness, softer pain, color may differ from surrounding skin

three elements of pressure ulcer development

intensity of pressure (tissue ischemia and blanching) duration of pressure tissue intolerance

incubation period

interval between initial infection and first signs and symptoms

illness stage

interval when patient manifests signs and symptoms specific to type of infection

installation into body cavities

intraocular disk, suppository

status epilepticus

is a prolonged seizure and it is a medical emergency; does not regain consciousness between seizures.

pharmacokinetics

is the study of how a medication enters the body, moves through the body, and ultimately leaves the body.

pruritus

itching

malnutrition

lack of proper nutrition

LA

long-acting

other oral forms

lozenge, aerosol, sustained release

prone position

lying on abdomen, facing downward (head may be turned to one side)

Trendelenburg position

lying on back with body tilted so that the head is lower than the feet

supine position

lying on back, facing upward

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

would specimen collection

make sure that area is cleaned with sterile saline/water first, wash off drainage, use sterile cotton tipped swab to collect drainage/exudate, put in appropriate container and send it to lab

blood specimen collection

make sure when you open that you clean the top with alcohol, clean in a vertical, horizontal, and circular motion; use the first 10 to 15 milliters of blood, , put blood in aerobic bottles first, get 2 sets, 2 separate sites,

Every 4 hours, 6 hours, and every 8 hours..

means around the clock day and night

friction

mechancial force exerted when skin is dragged across a coarse surface

normal flora

microorganisms that reside in the body and maintain a sensitive balance with other microorganism to prevent infect.

trough (medication)

minimum blood serum concentration of medication reached just before the next scheduled dose

musculoskeletal opioid side effects

muscle rigidity and contractions osteoporosis

myoclonic seizure

muscles tense; typically react as if hit by a single jolt of electricity.

generic name

name assigned by the manufacturer who first develops a drug; it is often derived from the chemical name

Opioids

narcotics

culturing a wound

never culture from old drainage; clean with normal saline; apply pressure and moisten tip of cotton sway in culturette; return swab into tube containing a medium for organism growth; label, bad, and deliver to lab

why are bloodborne infections not transmitted through hugging and touching?

no contact with body fluids unless you have open skin

clinical signs of limb ischemia

nonhealing wounds shiny skin loss of hair growth cool skin temperature for one limb but not the other pale or bluish skin reduced capillary fill times pallor on elevation and rubor on dependency

what are some things that can help with ambulation and falling?

nonskid shoes, gait belts, and prevention of orthostatic hypertension/syncope

Chronic pain

not protective in nature; lasts longer than 6 months constant or recurring and does not always have an identifiable cause does not respond to treatment well and leads to problems such as job loss, inability to perform daily activities, sexual dysfunction, and social isolation vital signs are usually unaffected

the potential for microorganisms or parasites to cause disease depends on what

number of microorganisms present virulence susceptibility of the host

NAP

nursing assistive personnel (ex: SRNA)

What are some reliable references for drug administration?

nursing drug reference, epocrates app

A new patient arrives to the unit what can be delegated to the NAP?

obtaining equipment (safest)

Common pressure ulcer sites

occipital bone scapula spinous process elbow iliac crest sacrum ischium achilles tendon heel sole ear shoulder anterior iliac spine trochanter thigh medial knee lateral knee lower leg medial malleolus lateral mallelous lateral edge of foot posterior knee

evening care

offer personal hygiene care that helps patients relax and promotes sleep. Change soiled linens, gowns or pajamas; help patients wash face and hands; provide oral hygiene; give a back massage; offer bedpan or urinal to nonambulatory patients

topical medications

ointment, lotion, paste, transdermal disk or patch

Which group of patients is at most risk for severe injuries related to falls?

older adults

tolerance

over time, increased doses needed to obtain analgesic effect

analgesics

pain relievers

mucositis

painful inflammation of oral mucous membranes

signs of dehydration

pale conjunctival sac, tenting of skin over sternum or forehead, & dry cracked lips.

dermis regions

papillary and reticular

hemiplegia

paralysis of one side of the body

alopecia

partial or complete loss of hair; baldness

stage II pressure ulcer

partial thickness skin loss or open blister superficial tissue loss includes epidermis, and possibly a portion of the dermis shallow open ulcer with a pink wound bed no slough or bruising

absorption

passage of a drug from the administration site into the bloodstream.

knee-chest position

patient is lying face down with the hips bent so that the knees and chest rest on the table

dorsal recumbent position

patient is lying on the back, face up, with the knees bent

examples of immunocompromised patients

patients undergoing stem cell transplants, tissue/organ transplant, cancer treatment

when is log-rolling used?

patients who have experienced cervical spinal injuries/surgery

When is a trochanter roll used?

patients who have muscle weakness or paralysis on one or both sides of the body

prodromal stage

person is most infectious, vague and nonspecific signs of disease

deconditioning

physiological changes following a period of inactivity, bed rest, or sedentary lifestyle.

wound C

pink wound bed

How should you clean the ears of children 3 years or younger?

pinna down and back

How should you clean the ears of an adult and children over 3?

pinna up and back

A nurse observes the nursing assistive personnel (NAP) perform the following interventions for a patient receiving continuous enteral feedings. Which action is incorrect and requires immediate attention?

placing the patient supine while giving a bath

tissue ischemia

point at which tissues receive insufficient oxygen and perfusion

Medical asepsis (clean technique)

practice used to remove or destroy germs and to prevent their spread from one person or place to another person or place

aseptic technique

practices that help reduce the risk for infection

colonization

presence and growth of microorganisms within a host without tissue invasion or damage.

assessing for hyperemia

press a finger over the affected area if blanching (area turns lighter in color) occurs, and erythema returns when you remove your finger, the hyperemia is transient (blanchable hyperemia)

Cultural aspects of care

privacy family participation touch personal space cutting or shaving hair hair/skin care differences toileting practices may not use deodorant

What are some seizure precautions?

privacy provided side rails up loosened clothing pillow under head bed in lowest position patient in side-lying position (immediately postseizure)

metabolism

process by which a drug is altered to a less active form to prepare for excretion.

pharmacodynamics

process in which a medication interacts with the body's cells to produce a biologic response.

phagocytosis

process in which extensions of cytoplasm surround and engulf large particles and take them into the cell

distribution

process of delivering medication to tissues, organs, and the specific site of action.

excretion

process removes the less active drug or its metabolites.

purulent

producing or containing pus; WBCs

Thrombo-Embolic Deterrent Stockings

promote venous return

What is an example of nonmaleficence?

proper assessment of allergies (such as medications, food, latex, environmental allergies) and intervene as needed.

what are the principles of safe patient transfer and positioning?

proper body mechanics get help widen base of support hold objects close to body avoid twisting

main goal of CDC

protect public health and safety through applying disease control & prevention. Focus on improving health, injury prevention and education & health promotion.

implementation treating wounds: red

protect with cover usually developing granulation tissue and need to be protected by gentle cleansing with wound cleanser applied without pressure and a dressing.

Acute pain

protective in nature, sudden onset, short duration, limited tissue damage; emotional response predictive ending and an identifiable cause; treated aggressively; vital signs are elevated

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath?

providing range of motion exercises

PQRST

provocative/palliative, quality, region/radiation, severity, timing

skin opioid side effects

pruritus (itching)

Ocular opioid side effects

pupil constriction

how will assessment findings of tissue injury vary in an individual with dark skin?

purplish hue taut shiny scaly edematous soft and boggy

A nurse is caring for a patient with a moderate problem with balance. Which cane is most appropriate for this patient?

quad cane

uriticaria

raised, irregularly shaped skin eruptions with varying sizes and shapes; eruptions have reddened margins and pale centers

passive range of motion exercises

range of movement through which a joint is moved with assistance

withdrawal syndrome

rapid or sudden cessation or marked does reduction may cause rhinitis, chills, pupil dilation, diarrhea, "gooseflesh"

sputum collection

really deep in lungs

wound D

red with some pale pink or white borders

granulation tissue

red, moist tissue composed of new blood vessels Granulation tissue in the wound bed indicates healing

"normal" reactive hyperemia

reddened skin will blanch (whiten) with pressure, then turn red/pink again when pressure is removed (light-skinned patients)

normal reactive hyperemia

redness-localized vasodilation; blanching w/ fingertip pressure; lasts less than 1 hour

disuse osteoporosis

reductions in skeletal mass routinely accompanying immobility or paralysis

right documentation

requires the nurse to immediately record the appropriate information about the drug administered

standard walker

requires the person to have fair balance and the ability to lift device with upper extremities to advance no wheels

What should you monitor in those using opioids/narcotics?

respiratory rate and depth (patient may develop effect of sedation and respiratory depression)

ischemia

restriction in blood supply resulting in damage to or dysfunction of tissue

Rights of Medication Administration

right medication right dosage right patient right route right time right documentation right indication right to refuse right teaching

nursing diagnosis associated with nutrition

risk for aspiration diarrhea deficient knowledge readiness of enhanced nutrition feeling self-care deficit impaired swallowing imbalance nutrition: less/more body requirements

possible nursing diagnosis for infections

risk for infection imbalanced nutrition: less than/more than body requirements risk for impaired skin integrity impaired skin integrity impaired tissue integrity social isolation

What are some nursing diagnoses associated with safety?

risk for injury impaired home maintenance deficient knowledge risk for poisoning risk for suffocation risk for trauma

generalized seizures

seizures that involve the entire brain

what does braden scale evaluate?

sensory perception moisture activity mobility friction shear

Early morning care

shortly after the patient wakes up, assisting them with toileting and then providing comfort measures to refresh the patient and prepare them for breakfast, including washing the face and hands and providing mouth care.

I am often times harmless, but nobody likes to see me coming because I can be very annoying. Some people have me and others do not. I might come in the form of gastrointestinal upset, nervousness, cardiovascular changes, or even dermatological changes.

side effect

STAT

signify a single dose of a medication to be given immediately and only once.

activities of daily living (ADLs)

six routine activities that people tend to do every day without needing assistance. Eating, bathing, dressing, toileting, transferring (walking), and continence.

normal flora locations

skin, saliva, oral mucosa, intestinal tract

slough

soft, stringy; yellow, white, tan, gray, green or brown dead tissue; remove for wound healing.

maceration

softening or dissolution of tissue after lengthy exposure to fluid

parental (injections)

solution/powder

nasal medications

sprays and drops

immobility

state of being unable to move

what should you use during a sterile dressing change?

sterile gloves sterile fluids sterile packing and/or dressings

How should you trim nails?

straight across or follow natural curve of nail bed.

layers of epidermis

stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, stratum corneum

purposes of nasogastric tubes

suction of stomach contents instillation of enteral nutrition & medications

SR

sustained release

signs of hypoglycemia

sweating , trembling, tachycardia (cool and clammy you get candy)

Second S in PASS

sweep the extinguisher from side to side

in order for me to function, I need to be accompanied by another drug. Most of the time, I am intended for a certain desirable effect, although I can be negative and unexpected. Oftentimes, physicians use me when a condition cannot be treated with only one drug alone, but instead, need a multi-drug treatment regimen.

synergistic effect

oral medications

tablet, capsule, caplet, enteric-coated tablet

bag bath

technique for bathing that involves the use of 8 to 10 premoistened, warmed, disposable cloths contained in a plastic bag

As the nurse enters the room to administer medications, the client calls out from the bathroom, "Just leave the pills on the bedside table, I'll be out in about ten minutes." What is the best nursing action?

tell the client you will return in a little bit with the pills

therapeutic range

that concentration of drug in the blood serum that produces the desired effect without causing toxicity

Who has the final responsibility of evaluating the NAP's performance of tasks?

the RN

circumduction

the circular movement at the far end of a limb

gestational diabetes mellitus

the form of diabetes that occurs during some pregnancies

convalescence

the gradual recovery of health and strength after illness

Semi-Fowler's Position

the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees

communicable disease

the infectious process transmitted from one person to another.

infection

the invasion of a susceptible host by pathogens or microorganisms.

seclusion

the involuntary confinement of a person in a room or area where the person is physically prevented from leaving

right medication

the medication given was the medication ordered

debridement

the removal of necrotic tissue so that healthy tissue can regenerate.

right time

the time the prescribed dose is ordered to be administered

residual volume

the volume of enteral formula remaining in the stomach

benefits of sitting upright in a chair

therapeutic & way to increase endurance breathe deeper (mobilizes secretions in the lungs)

purulent drainage

thick green, yellow, or brown drainage

serosanguineous drainage

thin, watery drainage that is blood-tinged

Central Nervous System (CNS) toxicity

thought and memory impairment drowsiness, sedation, and sleep disturbance confusion hallucinations, potential for diminished psychomotor performance delirium depression dizziness and seizures

A patient with a right knee replacement is prescribed no weight bearing n the right leg. You reinforce crutch walking knowing that the following crutch gait is most appropriate for this patient?

three point

TID

three times a day

onset (medication)

time it takes for a medication to produce a response

biological half-life (medication)

time it takes for excretion processes to lower the serum medication concentation in half

TR

time release

E in RACE

to extinguish/evacuate

evisceration

total seperation of wound layers with protrusion of visceral organs through the wound opening place damp sterile saline gauze or towels over site; patient NPO; medical emergency; requires surgical repair

opposition

touching the thumb to any other finger

I am most commonly seen in patients who have impaired liver or kidney function. I appear when excess amounts of medication accumulate within the bloodstream.

toxic effects

delegation

transferring responsibility for the performance of an activity or task while retaining accountability for the outcome

True of false: you should use soap and water when exposed to spores such as Clostridium difficile (c-diff)

true

True or false: Absence of BS indicates decreased or absent peristalsis & decreased ability of GI tract to digest or absorb nutrients.

true

True or false: Cleaning, disinfecting or sterilizing depends on the intended use of a contaminated item.

true

True or false: Nurses need to reposition the patient at least every 2 hours while in the bed.

true

True or false: Requires 5 minutes of continuous listening in EACH of the 4 quadrants before determining that bowel sounds are in fact "absent."

true

True or false: you can integrate other activities during hygiene such as assessment, interventions, and teaching

true

true or false: airborne precautions should be used when Pathogens can be transmitted by droplet nuclei (less than 5 microns)

true

true or false: calorie needs depend on age, size, height, lifestyle, overall health, and activity level.

true

true or false: contact precautions should be used when the present pathogen can be transmitted through indirect or direct contact.

true

true or false: droplet isolations should be used when pathogen can be transmitted through large droplets expelled into the air (greater than 5 microns)

true

true or false: the first american law to regulate medications was the Pure Food and Drug Act in 1906

true

Rotation example

turning the head from side to side

pronation

turning the palm downward

supination

turning the palm upward

eversion

turning the sole of the foot outward

BID

twice a day

epilepsy

two or more unprovoked seizure

Pain

unpleasant but protective mechanism of defense serves as a warning related to physical, emotional, cognitive factors subjective & individualized

allergic reaction

unpredictable response to a medication. Ex: medication allergy or anaphylactic reaction.

genitourinary opioid side effects

urinary retention

WHICH NURSING ACTION WILL MOST LIKELY INCREASE A PATIENT'S RISK FOR DEVELOPING A HEALTH CARE-ASSOCIATED INFECTION?

use a clean technique for inserting a urinary catheter

superinfection

use of broad-spectrum antibiotics may eliminate or change normal flora, reducing defenses and allowing disease-producing microorganisms to multiply and cause a second infection.

soap and water

used when hands are visibily soiled

tonic-clonic seizure

usually lasts 2-5 minutes; tonic-clonic muscle jerking; may be unresponsive; incontinent; shallow breathing; cyanosis.

contact precautions diseases

varicella zoster (chickenpox & shingles), scabies, MRSA, Ebola virus, major wound infections, RSV in infants, MDROs (MRSA, VRE), Clostridium difficille

airborne precautions diseases

varicella zoster (chickenpox), disseminated varicella zoster (shingles) tuberculosis (TB), measles (rubeola), smallpox

aggravating or precipitating factors

various factors or conditions conditions precipitate or aggravate pain

What are some interventions that can be delegated?

vital signs bathing, grooming, toileting, dressing/undressing feeding mobility assistance (ambulation, transfers, positioning of motion) hand washing & disposal of contaminated supplies port-mortem care collecting specimens (urine, fecal)

ambulation

walking

what is the most effective way to break the chain of infection?

washing hands

hemiparesis

weakness on one side of the body

mechanical debridement

wet-to-dry saline gauze dressings used to debride a wound (removed dead tissue) so granulation tissue will begin to form used to remove escar and slough

Pain is ______ the experiencing person says it is, occurring ____ whenever they say it does.

whatever; whenever

pregancy and breastfeeding opioid side effects

when at all possible, avoid opioid use during pregnancy to prevent fetal risks

Timing of pain: onset, duration, frequency

when did pain begin? how long has it lasted? does it occur at the same time each day? how often does it occur?

medication interactions

when one medication modifies the action of another. Use caution with vitamins and supplements.

2 point gait

when patient uses 2 crutches or canes. moves left crutch forward while simultaneously advancing rt lower extremity ad vice versa.

hyperemic changes

when pressure is relieved, blood vessels vasodilate to restore blood flow to tissues (hyperemia=redness)

blanching

when the skin becomes pale due to pressure, deep tissue damage is possible if color does not return when pressure is removed

reservior

where pathogens survive, multiply and await transfer to a susceptible host.

when is high level disinfection required?

which is required for some items such as endoscopes, bronchoscopes, respiratory and anesthesia equipment

asymptomatic

without symptoms

edentulous

without teeth

axillary crutches

wooden or aluminum. Hand grips and height are adjustable. For short term use.

secondary intention

wound edges are not approximated loss of tissue pressure ulcers; surgical wounds that have tissue loss or contamination: burn, severe laceration left open until filled with scar tissue wounds heal by granulation tissue formation, would contraction, and epithelization takes longer to heal increased risk of infection

primary intention

wound that is clean; low risk of infection little tissue loss skin edges are approximated, or closed surgical incision; wound that is sutured or stapled healing occurs by epithelization heals quickly with minimal scar formation

teritary intention

wound that is intentionally left open for several days: then, wound edges are approximated cause: monitoring infection or awaiting pathology results

cerumen

yellowish or brownish waxy secretion produced by sweat glands in the external ear