ATI fundamentals final set

Proteins

- contribute to the growth and repair of body tissues; - each gram produces 4 kcal; - sources include ground beef, whole milk, and poultry

health promotion (nutrition): preschooler (3-6 yrs)

-consumes about 1/2 the cals of an adult (19800 kcal) -picky eating remains a problem for some, but often by 5 they become more willing to sample different foods -need 13-19 g/day of complete protein in addition to adequate calcium, iron, folate, and vitamins A&C -parents need to ensure child receiving balanced nutrition as outlined by USDA

Individuals who are authorized to grant consent for another person include:

-parent of a minor -legal guardian -court-specified representative -individual who has durable power of attorney for health care -emancipated minors (for themselves)

parental facts / locations

-parenteral - vastus lateralis site <2 years of age >2 can use ventral gluteal up to 2mL or deltoid up to 1mL -tuberculin syringe for solution colunes <0.5 mL

expected psychosocial development (Erikson: intimacy vs isolation): young adult (20-35 yrs)

-pass through two stages of development: intimacy vs isolation -may take on more adult commitments and responsibilities -may make occupational choices characterized by: high goals/dreams and exploration/experimentation

additional safety risks in home/community include:

-passive smoking -carbon monoxide poisoning -food poisoning -bioterrorism

-tympanic membranes should be ___ ___ & ___ -light reflex should be ___ and in a ___-___ ___ ___ -___ & ___ landmarks are readily visible -ear canals are ___ with ___ ___

-pearly gray & intact -visible & well-defined cone shape -umbo & manubrium -pink w/fine hairs

rectal

.5d less than oral ; not with bleeding recautions/ stool , second measure if above 37.2

expected rectal temperatures are usually:

0.5* C (0.9* F) higher than oral temps

What is nociceptive pain?

- pain that arises from damage to or inflammation of tissue other than that of the PNS and CNS; - usually throbbing, aching, localized; - typically responds to opioids and nonopioid medications

What solutions are used for cleansing enemas?

- tap water; - normal saline; - soapsuds solution; - hypertonic solution like Fleet

What do the bronchioles depend on to remain open?

- the bronchioles depend entirely on the elastic recoil of lung to remain open; - elastic recoil decreases with age

DAR (focus charting)

D-ata A-ction R-esponse

DAR

D-data. A-action. R-response.

How far should you insert the rectal tube?

3 to 4 inches

False imprisonment

A person confined or restrained against his will.

Fidelity

Agreement to keep promises

Registered dietitian

Job: assess, plan for, and educate the client reg. nutritional needs; direct care of nutritional aids Refer to when: ex- the client has low nutrient levels and/or experienced a recent unexplained weight loss

Lab tech

Job: obtain specimens of the client's body fluids and perform the necessary diagnostic tests Refer to when: ex- the provider orders a CBC to be performed immediately

Pharmacist

Job: provide & monitor meds for the client as prescribed by the provider; supervises pharm techs in states in which the practice is allowed Refer to when: client concerns over meds; dosage concerns; etc

Nasogastric placement

In an X-ray should end about the pylorus

Stage I Pressure Ulcer

Nonblanchable redness intact skin bony prominence

Malpractice

Nurse gives large dose of meds to a calculation error Client has heart attack and dies

Symptoms of hypocalcemia

Positive Trosseau's sign (carpal spasm induced by inflating blood pressure above systolic pressure for a few minutes) Positive Chvostek's sign (contraction of facial muscles in response to light tap of facial nerve)

Critical thinking incorporates: R___, L___, and I___.

R-eflection L-anguage I-ntuition

airborne

TB-special mask measles varicella private room, negative air pressure exchanged every 6hrs, masks

Assault

The conduct of one person makes another person fearful and apprehensive.

What *SKIN* infections require *contact* precautions?

Think VCHIPS V = varicella zoster (chicken pox); C = cutaneous diphtheria; H = herpes simplex [until lesions crust over] and herpes zoster (shingles); I = impetigo P = pediculosis; S = scabies

What infections require *droplet* precautions?

Think of SPIDERMAN S = scarlet fever, sepsis, streptococcal pharyngitis; P = parvovirus b19, pertussis, pneumonia; I = influenza; D = diphtheria (pharyngeal); E = epiglottitis; R = rubella; M = meningitis, mumps, meningococcal pneumonia, mycoplasma pneumonia AN - adenovirus

thrills are:

a palpable vibration that may be present with murmurs or cardiac malformation

false imprisonment

a person is confined or restrained against his will. ex. a nurse uses restraints on a competent client to prevent his leaving the health care facility.

false imprisonment

a person is confined or restrained against their will restraints, sedatives, etc

tachycardia measuring

assess/ monitor- for other s/s; pain anxiety, restlessness, fatigue, low BP, low 02 stats, for potential side/adverse effects of meds

bradycardia measuring

assess/ monitor: s/s hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental status

capillary refill

after blanching nail bed, color should return to normal withing <3 secs

Beneficence

agreement that the care given is in the best interest of the client; taking positive actions to help others

Fidelity

agreement to keep one's promise to the client about care that was offered

Fidelity

agreement to keep promises

Regulatory Agencies

U.S. Dept of Health and Human Services, U.S. Food and Drug Administration (FDA), State and local public health agencies, State licensing boards (to ensure that HC providers and agencies comply with state regulations), The Joint Commission (to set quality standards for accreditation of HC facilities), Professional Standards Review Organizations, Utilization review committees (to monitor for appropriate diagnosis and tx of hospitalized clients).

report and document ___ incidents per facility policy

all

Nurse licensure compact

allows licensed nurses who reside in a compact state to practice in other compact states under a multi-state license; must provide care in accordance to statutes and rules in state care is being provided

occupational therapist

assesses and plans for pt to regain activities of daily living skills, esp. motor skills of the upper extremities. ex. of when to refer: a pt has difficulties using an eating utensil with her dominant hand following a stroke.

labia

folds of skin on either side of the vaginal orifice

draw sheet

linen item placed under the patient's torso and used to lift and reposition the patient

preauricular lymph node located

in front of ear

radioactive gallium citrate

injected by IV and accumulates in area of inflammation

Dermis

inner layer of skin; strength, mechanical support and protection; restores physical properties to skin

endogenous source

inside the client when part of the client's flora has been altered.

fairness

is objective, nonjudgemental

registered dietitian

assesses, plans, and educates patients on nutrition needs

What are the 5 ethical principles?

autonomy beneficence fidelity justice nonmalificence

older children and adolescents have varying BP based on

body size (larger children have a higher BP)

inflammation

body's local response to injury or infection.

ethnicity

bond or kinship people feel with their country of birth or place of origin, affects culture

certified nurse-midwife (CNM)

collaborates with one or more providers to deliver care to maternal-newborn clients and their families.

CT

computed axial tomography scan

discipline

develops a systematic approach to thinking

sign of botulism

difficulty swallowing

Durable power of attorney for health care

document that designates a health care proxy, who is authorized make health care decisions for a client who is unable

when should a nurse initiate discharge planning?

during the admission process

5 elements to prove negligence

duty breach of duty- not meet standard forseeability of harm breach of duty has potential to cause harm harm

during palpation, the fingertips detect:

pulsation, position, texture, size, and consistency

reporting communicable diseases

reporting allows officials to: -ensure appropriate medical treatment of diseases (TB) -monitor for common-source outbreaks (foodborne - Hep A) -plan and evaluate control and prevention plans (immunizations for preventable diseases) -identify outbreaks and epidemics -determine public

obtunded

require light shaking to respond

Telephone orders (TO) or verbal orders (VO)

should be avoided but may be necessary during emergencies and at unusual times

documentation

should be factual, accurate and concise, complete and current, organized

excoriation

skin abrasion typically resulting from scratching

What should you do if the client reports *cramping*, or if *fluid leaks* around the tube at the anus?

slow the flow of solution by lowering the container

dental caries

tooth decay

what method helps prevent aspiration?

tucking chin when swallowing

atypical symptoms of infection

seen in some older adults; agitation, confusion, incontinence.

direct percussion involves:

striking the body to elicit sounds

ethics

study of conduct and character

romberg test

tell the client to close eyes and stand upright--see if they sway

Loop colostomy

temporary; transverse colon

systemic vascular resistance (SVR) is determined by

the amount of constriction or dilation of the arteries

assault

the conduct of one person makes another person fearful and apprehensive. ex. a nurse threatens to place an NG tube in a client who is refusing to eat.

information security protocols

log off computer before leaving the workstation to ensure that others cant view protected health information on the monitor. never share a user ID or password with anyone. Never leave a medical record or other printed or written PHI where others can access it. shred any printed or written client information for reporting or client care after use.

expected psychosocial development (self-concept): middle adult (35-65 yrs)

may experience issues related to: -menopause -sexuality -depression -irritability -difficulty with sexual identity -job performance and ability to provide support -marital changes with death of a spouse or divorce

Hospital's ethics committee

may meet to discuss/resolve unusual or complex ethical issues; not a legal entity

therapeutic interventions

measures nurses take to minimize risk and to respond to unplanned events, such as an observation of unsafe practice, a change in a status, or the emergency of a life-threatening situation.

smegma

thick, cheesy secretion that accumulates under the labia minora or the male foreskin

What can affect skin integrity?

moisture shearing friction nutritional status increased aging low blood pressure

expectorate

to expel fluid or secretions from the mouth, throat, or lungs by coughing and/or spitting

How should you instruct a client to perform breast self examination [BSE]?

to inspect their breasts in front of a mirror and palpate them during a shower

For *bowel training*, when should you encourage the client to attempt to defecate?

when he/she has the urge; [failure to heed the call to defecate my lead to overdistention of the rectum w/hardening of the stool and subsequent constipation]

flat percussion sounds are expected to be found:

over muscles

dull percussion sounds are expected to be found:

over the liver

resonance from percussion is expected to be found:

over the lungs

postauricular lymph node located

over the mastoid

people allow to consent for others

parent of a minor, legal guardian, court-specified representative, an individual who has durable power of attorney authority for health care, emancipated minors for themselves.

What are the characteristics of the stools of an infant who is *formula fed*?

pasty and brown

When is the incubation stage?

period between when the pathogen enters the body and the first symptom appears

When is the prodromal stage?

period from onset of general symptoms to more distinct symptoms; [the pathogen is multiplying during this time]

When is the convalescence stage?

period when acute symptoms disappear; [total recovery could take days to months]

components of general survey

physical appearance body structure mobility behavior vital signs

what should you do after you prick a patients finger during BG monitoring

wipe away the first drop of blood--it's more serous

Mandatory reporting

abuse communicable diseases (to local or state health department)

5 rights to delegation

task circumstance person communication supervision /evaluation

Hypomagnesemia

-Mg deficit in ECF -serum Mg <1.5mEq/L

fissure

-linear crack -example: tinea pedis

health promotion (nutrition): young adult (20-35 yrs)

-monitor adequate nutrition and proper physical activity -women: monitor calcium intake

pustule

-puss-filled -example: acne

health promotion (health screenings): adolescent (12-20 yrs)

-scoliosis

CN V

-trigeminal -assess the face for strength and sensation

stages of physical examination process

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

for an infant the expected pulse rate range is

120-160 bpm

Sodium

136 to 145

how much space should be left between restraints and skin?

2 finger widths

1+ edema

2 mm that returns rapidly

Calcium Normal Values

8.5-10.5 mEq/L

Chloride

98 to 106

Tort law is

Civil law

Making a clients bed does not require what

Documentation

ABC priority

Greatest risk to client is respiratory compromise due to fluid overload.

What causes Hyponatremia?

Loss of sodium or excess water

Unintentional torts

Malpractice Negligence

Stage II Pressure Ulcer

Partial-thickness skin loss superficial ulcer abrasion, blister or shallow crater

Components of Health Care Systems

Participants, settings, regulatory agencies, and health care financing mechanisms.

What causes Hyperkalemia?

Retention; usually renal failure

Symptoms of Hypokalemia

Similar to hyperkalemia; skeletal muscle weakness/paralysis, muscle cell breakdown, decreased GI motility, altered airway responsiveness, impaired regulation of arterial blood flow, diuresis, hyperglycemia

Heimlich maneuver

The procedure done to relieve a choking individual

equipment should only be used by the nurse after:

a safety inspection and instruction

obese BMI

above 30

submandibular lymph node located

along base of mandible

Nonmaleficence

avoidance of harm or injury

nonmaleficence

avoidance of harm or injury

during the 3rd stage of infection, ___ ___ is replaced by ___ ___.

damaged tissue is replaced by scar tissue

stages of grief

denial, anger, bargaining, depression, acceptance

ethics committees

generally address unusual or complex ethical issues.

alopecia

hair loss

trendelenburg

head below feet, venous return

trendelenburg position

head of bed is lower than foot of bed

federal regulations for nurses

health insurance portability and privacy act (HIPPA) americans with disabilities act (ADA) mental health parity act (MHPA) patient self-determination act (PSDA)

BP classification is based on the

highest reading of either the SBP or DBP (even if either the SBP or DBP falls in a lower classification

Potassium

major intracellular electrolyte

droplet precautions

protect against droplets larger than 5 mcg and travel 3-6 ft from the pt. (streptococcal pharyngitis or pneumonia, haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). precautions require: private room or a room with other clients with the same infectious disease, ensuring each client have their own equipment. masks for providers and visitors.

civil law

protect individual rights i.e. tort laws

advocacy

support of client's health safety and personal rights

Hypermagnesemia

-serum Mg>2.5mEq/L

expected psychosocial development (body-image changes): school-age (6-12 yrs)

-solidification of body image occurs -curiosity about sexuality should be addressed with education regarding sexual development and the reproductive process -are more modest than preschoolers and place more emphasis on privacy issues

CN XI

-spinal accessory -assess the shoulders for strength

health promotion (injury prevention-drowning): adolescent (12-20 yrs)

-teach to swim -teach not to swim alone

asepsis

-the absence of illness-producing micro-organisms -maintained through the use of aseptic technique with hand hygiene as the primary associated behavior

LOC: coma

-there is no response to repeated stimuli -abnormal posturing (decorticate or decerebrate rigidity)

expected physical development (size/growth): school-age (6-12 yrs)

-weight: will gain about 2-4 kg (4.4-8.8 lb) per year -height: will grow about 5 cm (2 in) per year -puberty changes (male): enlargement of testicles with changes in scrotum; appearance of pubic hair -puberty changes (female): budding breasts; appearance of pubic hair; menarche -permanent teeth erupt -visual acuity improves to 20/20 -auditory acuity and sense of touch is fully developed -fine and gross motor skills: coordination continues to develop

nurse responsibilities for informed consent

-witness informed consent -ensure provider gave client necessary info -ensure client understood info and is competent -have client sign document -notify provider if client has questions or does not understand info, provider is responsible for clarification -document questions client has, notify provider, reinforce teaching and use of an interpretator

expected psychosocial development (body-image changes): middle adult (35-65 yrs)

-women: symptoms of menopause may represent loss of reproductive role or femininity and/or new interest in intimacy -men: decreasing strength may be frustrating or frightening -decreased sex drive may occur as a result of declining hormones, chronic disease, or meds -changes in physical appearance may raise concerns about desirability

jaundice

-yellow: orange of skin, sclera, and mucous membranes -indication of liver dysfunction, red blood-cell destruction

if found with an evisceration

-you will see protrusion of organ from wound caused by serosanguineous fluids -call for help -stay with client -position supine -cover with sterile towels/ sterile saline dressings -observe for shock

adherence

...

What are the 3 stages of stress reaction that make up the General Adaptation Syndrome (GAS)?

1) alarm reaction; 2) resistance stage; 3) exhaustion stage

What are the stages of infection?

1) incubation; 2) prodromal; 3) illness; 4) convalescence

grading of pitting edema: 1+: 2+: 3+: 4+:

1+: 2mm/trace, rapid return 2+: 4mm/mild, 10-15 second return 3+: 6mm/moderate, 1-2 min return 4+: 8+mm/severe, 2-5+ min return

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include

Ask the patient in what order she typically performs her morning routine

Six rights of medication administration

1. Right drug- compare to MAR, check expiration date 2. Right dose 3. Right route 4. Right time 5. Right pt-Use 2 identifiers 6. Right documentation

nursing roles in ethical decision making

1. an agent for the client facing an ethical decision. ex. caring for an adolescent client who has to decide whether to undergo an abortion even though her parents think its wrong, discussing options with a parent who has to decide whether to consent to a blood transfusion for a child when his religion prohibits such tx. 2. a decision maker for health care delivery. ex. assigning staff nurses a higher client load than recommended because administration has cut the number of nurses per shift, witnessing a surgeon discuss only surgical options with a client without informing the client about more conservative measures available.

Kubler-Ross five stages of guilt

1. denial 2. anger 3. bargaining 4. depression 5. acceptance

elements necessary to prove negligence (4)

1. duty 2. breach of duty 3. knowledge of harm 4. harm occurs

five elements necessary to prove negligence

1. duty to provide care defined by a standard 2. breach of duty by failure to meet standard 3. foreseeability of harm 4. breach of duty has potential to cause harm 5. harm occurs

Admission process (5)

1. get equipment 2. introduce yourself 3. do assessment 4. inventory items 5. orient patient to room/facility

Magnesium

1.3 to 2.1

Magnesium Normal Levels

1.5-2.5 mEq/L

prehypertension range

120/80 - 139/89

normal HCO3 levels

13 - 30 mEq/L

inflammatory response

3 stages. signs and symptoms during the first stage of the inflammatory response (local infection), second stage microorganisms have been killed. fluid containing dead tissue cells and WBCs accumulate and exudate appears at the site of infection. exudate leaves body by draining into the lymph system. third stage damaged tissue is replaced by scar tissue.

Phosphate

3.0 to 4.5

normal K levels

3.5 - 5.5 mEq/L

Potassium

3.5 to 5.0

Potassium Normal Levels

3.5-5.0 mEq/L

semi-fowler

30 degrees, prevent tube regurgitation & aspiration

expected newborn respiratory rate

30-60 rpm

expected oral temperature ranges:

36* to 38* C (96.8* to 100.4* F) is acceptable. The average is 37* C (98.6* F)

newborns' temperature should be maintained between

36.5* and 37.5* C (97.7* and 99.5* F)

oral

4 + in sunlingual pocket 36-38, no trauma to face, do not use if bite

2+ edema

4 mm that takes 10-15 seconds to return

with menopause, intermittent body temperature may increase by up to

4* C (7.2* F)

fowler

45 degrees, NG, suctioning, vent, abdomen surgery drainage

5% dexterose in water

5g dextrose per 100mL.

normal BUN level

6 -20 mg/dL

3+ edema

6 mm that takes 1-2 minutes to return

expected range for an adult client's pulse is

60-100 bpm at rest

4+ edema

8 mm that takes 2-5 minutes to return

for a child age 12-14 the expected pulse rate range is

80-90 bpm

normal Ca levels

9 - 11 mg/dL

Calcium

9.0 to 10.5

3 Classes of fire extinguishers

A - for paper, wood, upholstery, rags, or other types of trash fires; B - for flammable liquids and gas fires; C - for electrical fires

Nonmaleficence

Avoidance of harm or injury

preventing error in the nursing process

A- Q P I D E

Quasi-intentional torts

Breach of confidentiality Defamation of character

Symptoms of hypophosphatemia

CNS depression (decreased LOC, slow reflexes), confusion, muscle weakness/pain, arrhythmias, cardiomyopathy

blood pressure (BP) is determined by

CO x SVR

pulse strength (amplitude) should be graded on a scale of

*0 to 4* 0 = absent, unable to palpate 1+ = diminished, weaker than expected 2+ = brisk, expected 3+ = increased 4+ = full volume, bounding

main cause of skin tenting

*dehydration* loss of adipose tissue diminished skin elasticity

Dysphagia diet

- pureed food and thickened liquids - also tucking the chin when swallowing helps propel food down the esophagus more easily

What are the modes of transmission for airborne pathogens?

- sneezing; - coughing

Hyponatremia

-Sodium defecit in ECF -loss of sodium or gain of water -serum sodium <135mEq/L -<sodium causes fluid to move by osmosis from ECF to ICF -cells swell

transmission precautions

-airborne -droplet -contact

a murmur sounds like a

-blowing or swishing sound -best heard with bell of steth

Major causes of hypercalcemia

-cancer -hyperparathyroidism

LOC: lethargy

-client is able to open eyes and respond, but is drowsy and falls asleep readily

Effects of hypophosphatemia

-irritability -fatigue -weakness -paresthesias -confusion -seizures -coma

home safety risks for adolescents include:

-motor vehicle/injury -burns

Assessment

Collect information about the clients present health status to identify needs, and to identify additional data to collect based on findings.

Provider's orders

DNR or AND prescriptions that allow death; if not given, then CPR is administered

Hyponatremia

Decreased serum sodium (lower than 135)

Diarrhea occurs when

Feedings are delivered too quickly. Feeding bag should be replaced every 24 hours and it should be washed each time it is refilled.

Federal laws affecting nurse practice

HIPPA ADA MHPS PSDA

Aldosterone

Hormone that retains sodium and water

Symptoms of Hypomagnesemia

Hyperactive deep tissue reflexes, tremors, seizures, cardiac arrhythmia, confusion

Nasogastric tube

If residual volume exceeds 100mL, gastric emptying may be delayed, NG tube is flushed with water to prevent clogging.

Causes of Hypermagensemia

Increased intake/ingestion; renal insufficiency/failure

what should you say to a patient who is angry that you didn't answer their call within 5 minutes?

It must be frustrating. I have a few minutes now. --acknowledge their feelings

Symptoms of Hypermagnesemia

Lethargy, drowsiness, impaired reflexes, somnolence, respiratory and cardiac arrest

Change in body temperature will require

Neurological or cardiovascular check

Steps after client death occurs

Obtain pronouncement of death, remove tubes, clean body, ask family members if they would like to view the body, Place name tag on the body.

Beneficence

Positive actions to help others

Hypokalemic patients should increase what in their diet?

Potassium such as eating avocados

Levels of Health Care

Preventive, primary, secondary, tertiary, restorative, and continuing.

Causes of Hypomagnesemia

Prolonged fasting/starvation, chronic alcoholism, fluid loss

Incentive spirometer

Promotes full lunch re-expansion after surgery and can help prevent pulmonary complications.

What to do with a fire?

RACE = rescue, alarm, contain, extinguish

fire protocol mnemonic

Rescue patients Alarm Contain fire Extinguish

Electrolytes

Sodium, potassium, calcium, chloride, magnesium, and phosphate.

3-Point Gait

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

Battery

Wrongful physical contact

problem as an ethical dilemma

a review of scientific data is not enough to solve it. it involves a conflict between two moral imperatives. the answer will have a profound effect on the situation and the client.

tartar

a sticky film accumulating on the teeth that is formed by and harbors bacteria; also called dental plaque

dental plaque

a sticky film accumulating on the teeth that is formed by and harbors bacteria; also called tartar

criminal laws

a subsection of public law and relates to the relationship of an individual with the government. A nurse who falsifies a record to cover up a serious mistake may be guilty of breaking a this.

callus

a thickening of or a hard thickened area on skin

prone

abdomen, oral / throat surgery drainage

virulence

ability of a pathogen to invade and injure a host.

autonomy

ability of client to make personal decisions, even if they arent in their best interest

Autonomy

ability of client to make personal decisions, even when those decisions may not be in the client's best interest

specific adaptive immunity

allows the body to make antibodies in response to a foreign organisms. this reaction directs against an identifiable microorganism. requires time to react to antigen, provides permanent immunity, involves B and T lymphocytes, produces specific antibodies against specific antigens; called immunoglobulins, IgA, IgD, IgE, IgG, IgM.

anterior cervical lymph node located

along the sternocleidomastoid muscle

percussion of the thorax resulting in hyperresonance is

an abnormal finding and caused by the presence of air; can indicate pneumothorax or emphysema

intentional torts

assault--anything that makes patient fearful or nervous battery--restrain to give injection against patient wishes false imprisonment--restrain against will

occupational therapist

assess and plans for patients to regain ADL's

nursing process

assessment/data collection, analysis/data collection, planning, implementation, evaluation

information to document

assessments, medication administration, tx and responses, client education.

nonmaleficence

avoidance of harm or injury.

nonmalificence

avoidance of harm or pain as much as posiible

Nonmaleficence

avoidance of harm or pain as much as possible when giving treatments

types of pathogens

bacteria, viruses, fungi, prions, and parasites

halitosis

bad breath

Diabetic diet

balanced intake of protein, fats, and carbohydrates of about 1,800 calories

occipital lymph node located

base of skull

levels of critical thinking

basic critical thinking, complex critical thinking, and commitment.

what kind of things can CNA's do for patients?

bathing ambulating toileting vital signs

prior to asepsis

before beginning task HC team must check for latex allergies.

complex critical thinking

begins to express autonomy by analyzing and examining date to determine the best alternative. result from nursing knowledge, experience, intuition, and more flexible attitudes.

bradycardia is

below expected range or slower than 60 bpm

What is plantar flexion?

bending the foot and toes downward

Double-barrel colostomy

bowel surgically cut; both ends brought through abdomen

quasi intentional torts

breach of confidentiality defamation of character

quasi-intentional torts

breach of confidentiality, and defamation of character

exophthalmos

bulging eyes

Prevent I.V. contamination

by inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter. Shaving can increase risk of abrasion which can lead to infection.

board of nursing

can issue and revoke nursing license, set standards for nursing programs and determine scope of practice for nurses

beneficence

care given is in best interest of client

reporting formats

change-of-shift reports, telephone reports, telephone or verbal prescriptions, transfer reports, incident reports.

brown pigmentation of skin

changes with venous insufficiency

Preferred Provider Organizations (PPOs)

client chooses from a list of contracted providers. using non-contracted providers increases the client's out of pocket costs

the 3 domains of learning are:

cognitive, affective, and psychomotor

assault

conduct of one person makes another person fearful and apprehensive (threatening to put in NG tube if client doesn't eat) threats

nurse researcher

conducts research primarily to improve the quality of client care.

Symptoms of Hyponatremia

confusion, nausea, vomiting, seizures, coma

spirituality

connectedness with a higher power, achieve balance in life, maintain health, to seek health care, & to deal with illness & injury as well as give hope , faith, & transcendence

delegatee factors

consider education, training, experience, knowledge, skill to perform the task, level of critical thinking required to complete the task, ability to communicate with others as it pertains to the task, demonstrated competence, facility policies and procedures, licensing legislation.

task factors

consider the predictability of outcome, potential for harm, complexity of care, need for problem solving and innovation, level of interaction with the client.

participants in health care

consumers providers (RN, LPN, APN, medical doctors, pharmacists, etc)

Participants

consumers (patients), providers (licensed providers such as RN, LPN, advanced practice nurses, medical doctors, pharmacists, dentists, dietitians, PT, resp., and occupational therapists. also unlicensed providers such as assistive personnel).

purulent

contains leukocytes and bacteria

sanguineous

contains red blood cells

perseverance

continues to work at a problem until theres a resolution

adaptation

coping behavior that describes how an individual handles demands imposed by the environment

strabismus

crossed eyes

nursing process

cyclical, critical thinking process that consists of five steps to follow in a purposeful, goal-directed, systematic way to achieve optimal client outcomes. its a variation of scientific reasoning that helps nurses organize nursing care and apply the optimal available evidence to care delivery. its dynamic, continuous, client-centered, problem solving and decision making framework that is foundational for practice. provides a framework throughout which nurses can apply knowledge, experience, judgement, and skills as well as established standards of practice to the formulation of a plan of care. 5 steps that are sequential but overlapping include, assessment/ data collection, analysis/data collection, planning, implementation, and evaluation. each step depends on satisfactory completion of the preceding step(s). use of this results in a comprehensive, individualized, client-centered plan of care that nurses can deliver in a timely and reasonable manner. this helps nurses integrate critical thinking creatively to base nursing judgements on reason. promotes the professionalism of nursing while differentiating the practice of nursing from the practice of medicine and that of other health care professionals.

Invasive procedures

cytoscopy, arteriography

DAR (focus charting)

data, action, response

Experience

decision-making ability derived from opportunities to observe, sense, and interact with clients followed by active reflection. The nurse: demonstrates an understanding of clinical situations; recognizes and analyzes cues for relevance; incorporates experience into intuition.

experience

decision-making ability derived from opportunities to observe, sense, and interact with clients followed by active reflection. a nurse demonstrates an understanding of clinical situations, recognizes and analyzes cues for relevance, and incorporates experience into intuition.

Causes of hypocalcemia

decreased production of parathyroid hormone (PTH), acute pancreatitis, multiple blood transfusions, alkalosis, decreased intake

components of health history

demographic info past health history current health status family history psychosocial history health promotion behaviors

position a patient should be in for peripheral IV insertion

dependent position

discharge education

discuss discharge instructions and provide a copy to client, instructions should be clear, concise language that the client will understand.

alchol-based product hand washing

dispense 3-5mL in palm of hand. rub vigorously, covering all areas of both hands and fingers. continue to rub until completely dry.

heat loss- convection is:

dispersion of heat by air currents (wind blowing across exposed skin)

heat loss- evaporation is:

dispersion of heat through water vapor (sweating and diaphoresis)

what should you do after administering a controlled substance

dispose of it no matter how much is left!

durable power of attorney

document that designates a person to make health care decisions for them if they are unable to do so.

advance directive

document that says what the patient wants if they are too ill to make decisions or who they want to give the power of attorney

what client should be told about oxygen safety

don't use nail polish near O2 put "no smoking" sign at door fire extinguisher should always be available

electronic pump math

electronic : ml /hr volume mL/ time Hr = IV flow rate volume mL/ time min = XmL / 60min

Hypernatremia

elevated serum sodium (greater than 145)

surgical asepsis

eliminate all microbes

Primary HC

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. this level is sustained partnership between pt and providers. ex. office or clinic visits and scheduled school-or-work-centered screenings.

Partial thickness wound

epidermis and part of the dermis tape burns, sunburn, blisters, skin tears

scoliosis

exaggerated lateral curvature

neurological system

examination can evaluate the major indicators of neurological function & assist with recognizing dysfunction; integrated with other assessments - LOC & general state of health

muscoskeletal system

examination includes looking at the structure & function of the system, examining each joint & muscle, the surrounding tissues & comparing symmetric parts. inspection & palpation, height, posture spin.e back, ROM, muscle symmetry & strength

vesicular breath sounds

expected sound, soft low-pitched, inspiration three times longer than expiration over most peripheral areas of lung

disenfranchised greif

experienced loss that cannot be publicly shared or os not socially acceptable like suicide

justice

fairness in care delivery and use of resources.

fall risk prevention

fall- risk assessment upon admission; document risks & implement safety measure; -call light/ respond quick -orient to setting -place near nursing station -ensure things are in reach -low bed, rails up if compromised -avoid full bedrails for those who attempt to get up -clutter free, locks, sensors -educate

example of ethical dilemma

family has conflicting feelings about the initiation of enteral tube feeding for their father

sebum

fatty lubricant secreted by the skin's sebaceous glands

sources of laws

federal regulations such as Health Insurance Portability and Accountability Act (HIPAA), Americans with Disabilities Act (ADA), Mental Health Party Act (MHPA), Patient Self-Determination Act (PSDA), and criminal and civil laws

confidence

feels sure of abilities

reverse trendelenburg

feet below head, gastric emptying, esophageal reflux

What is dorsiflexion?

flexing the foot and toes upward

decorticate rigidity

flexion and internal rotation of upper extremity joints and legs

documentation formats

flow charts, narrative documentation, charting by exception, problem-oriented medical records, SOAP, PIE, DAR.

fluid permeation and sterility

fluid permeation of sterile drape contaminates the field --dropping sterile wet supplies on drape would contaminate

avoiding liability for negligence

follow standards of care, give competent care, communicating with other health team members, developing a caring rapport with client, fully documenting assessments, interventions, and evaluations.

expected psychosocial development (self-concept development): young adult (20-35 yrs)

formation of healthy self-concept influenced by: -avoidance of substance abuse -late formation of a family -frequent interactions with family and friends -choosing to behave in an ethical manner

sordes

foul brown crusts or accumulations of food, microorganisms, and epithelial elements on the teeth and lips, usually associated with a febrile or gastrointestinal disorder

macule example

freckle!

nursing interventions for infection

frequently wash hands before and after care, educate pt about required and recommended immunizations and where to obtain them. target group: kids, elderly, those w/ chronic disease, those immunosuppresed and their families and kids. educate the pt and ask for a return demo of good oral hygiene. encourage the client to consume an adequate amount fluids. for immobile pt ensure that pulmonnary hygiene is done q2h or as prescribed. use of aseptic techniques and PPE in the provision of care to all pt prevent unnecessary exposure, teach and use respiratory hygiene/coughing etiquette

What is role strain?

frustration and anxiety that occurs when a person feels inadequate for assuming a role

Resident rights

further protection of rights for residents in nursing facilities that participate in Medicare programs; govern the operation of such facilities

diagnostic procedures to identify infections

gallium scan, radioactive gallium citrate, xrays, ct scan, magnetic resonance imaging (MRI), biopsies to determine the presence of infection, abscesses, and lesions.

homeopathic medicine

giving ill people substances that would produce symptoms of disease state in healthy person

auscultation of the lungs (abnormal or adventitious sound): pleural friction rub

grating sound produced as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration

common infection risks

hand hygiene, compromised health/defenses agianst it , poor asepsis, poor hygiene/nutrition, stress, crowded living environment, older adults, poor lifestyle choices, recent exposure, poor sanitation, mosquito born/ parasite disease, endemic in visited area

receiving a transferred client

have any specialized equip ready, if appropriate inform the client's roommate of the impending admission or transfer. inform other health care team members of the clients arrival and needs, meet with the client and family on arrival to complete the admission process and orient the client and family to the new facility or unit. assess how the client tolerates the transfer, review transfer documentation, implement appropriate nursing interventions in a timely manner.

mandatory reporting

health care providers have a legal obligation to report findings in accordance with state law in the following situations; abuse-report of any suspicion of abuse following facility policy. communicable diseases-nurse must report communicable disease diagnoses to the local or state health dept. reporting allows officials to ensure appropriate tx. monitor for common-source outbreaks, plan and evaluate control and prevention plans, identify outbreaks and epidemics, and determine public health priorities based on trends.

primary care

health promotion, nutrition counseling, and disease control, partnership between patient and provider. example office or clinic, school or work centered screening

vesicle examples

herpes simplex varicella (chicken pox) blisters

secondary care

hospital based care found most places i.e. ER or any clinical unit

secondary care

hospital-based care in ED or on clinical unit

secondary prevention

identifies illness, provides treatment, activities that help prevent worsening --i.e. disease screening

When should an opioid be stopped and naloxone [Narcan] be given?

if respiratory rate is below 8/min and shallow, or the client is difficult to arouse

palliative care

improves quality of life, primarily used when when dying, focus on relief of clinical manifestations

A determination of death must be made:

in accordance with accordance with accepted medical standards

Secondary health care

includes diagnosis and treatment of acute illness and injury ex: hospital settings (inpt, ED), diagnostic centers, and emergent care centers

Secondary health care

includes the diagnosis and treatment of emergency, acute illness, or injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers, or emergent care centers

timing/relevance

knowing when to communicate allows the receiver to be more attentive to the message

susceptible host

must have compromised defense mechanisms that leave host mores susceptible to infections.

stuporous

require painful stimuli to respond

Hydraulic lift

requires 2 staff members. Safest erganomic method to move client from bed to wheelchair

autonomy

right to make one's own decisions even when decision may not be in the person's own best interest

primary care

screening to detect undiagnosed disease at earliest stage

primary care

screening to detect undiagnosed illness

substances that decrease pain transmission

serotonin endorphins

discharge planning

should begin at admission unless at long term care. assess whether or not the pt will be able to return to his previous residence, determine whether or not the pt will need adaptions or specific equip. make a referral to the social worker to arrange for community services, communicate health status and needs to community service providers. provider documents that the client may be discharged. nurse has pt sign the proper papers and provides discharge teaching.

flow charts

show trends in vitals, blood glucose levels, pain level, and other frequent assessments.

ethics

study of conduct and character.

SOAP

subjective date, objective data, assessment (incudes nursing diagnosis based on assessment), plan

is pain scale subjective or objective?

subjective!

substances the increase pain transmission

substance P prostaglandins bradykinin histamine

what is a seizure?

sudden surge of electrical activity in the brain

advocacy

support of client's health, safety, and personal rights.

Advocacy

support of clients' health, safety, and personal rights

Skin turgor test

tests for adequate hydration especially in elderly

Refusal of Treatment

the Patient Self-Determination Act (PSDA) stipulates that staff must inform clients they admit to a health care facility of their right to accept or refuse care. if client refuses a tx. they sign a document indicating he or she understands the risk involved with refusing and that they have chosen so. when clients decide to leave the facility against medical advice the nurse notifies the provider and discusses with the client the risks to expect when leaving the facility prior to discharge. nurse then ask client to sign an "Against Medical Advice" form and documents the incident.

asepsis

the absence of illness producing micro-organisms

expected findings for the whisper test

the client can hear you whisper softly 30 to 60 cm away

Exclusive Provider Organizations (EPOs)

the client chooses from a list of providers within a contracted organization

assault

the conduct of one person makes another person fearful and apprehensive

Secondary HC

the diagnosis and tx of acute illness and injury. ex. care in hospital settings, diagnostic centers, and emergent care centers.

When performing an emema, what determines the depth of cleansing?

the height of the bag above the rectum

referent

the incentive or motivation for communication to occur between one person and another

sender

the person who initiates the message

providers orders

the provider consults the patient and family prior to administering DNR or AND (allow natural death)

Tertiary HC

the provision of specialized and highly technical care. ex. intensive care, oncology centers, and burn centers.

clarity/bervity

the shortest, simplest communication is usually most effective

diet of patients with dysphagia

thickened liquids pureed food

A nurse is caring for a client with a latex allergy. What steps should the nurse take when initiating an IV line on this client?

• Label client's room as "latex-free" and keep latex-safe supply cart available in client's area • Use latex-safe gloves • Use latex-free equipment and supplies o Latex-safe syringes o Latex-safe IV tubing o Plastic or silk tape o Medications from glass ampules o No rubber injection ports o No medications w/a rubber stopper requiring puncture w/needle • Ensure epi and airway equipment at the ready in case of a reaction

practices to reduce microorganisms

changing linens daily, cleaning floors, bedside stands, separating clean from contaminated materials. use masks, gloves, gowns, and protective eye wear to prevent spread and control contact of micro-organisms. dont place items on floor. cover mouth and nose when coughing, sneezing, using and disposing of facial tissue, and performing hygiene to prevent spraying and spreading droplet infections. dont shake linens, this can spread organisms through the air. keep soiled linens away from clothing. clean the least soiled areas first to prevent moving more contaminants to cleaner areas. use plastic bags for moist, soiled items. put all soiled items directly into the appropriate receptacle. place all lab specimen in biohazard containers or bags for transport or disposal. pour any liquids used for client care directly into drain and avoid splattering to prevent spreading droplets. empty body fluids at water level of toilet to prevent splashing. wash hair frequently, and keep it short or pulled back to prevent contamination of care area. keep natural nails short and clean, remove jewelry from hands and wrists.

ROM head: hyperextention

chin up

axillary

clean / dry with arm over / held down; use under 3m

what is a nurses first action when removing a patient's sutures?

clean the sutures along the incision site

Mechanical soft diet

clear and full liquids + diced or ground foods

Pureed diet

clear and full liquids + food and fluids that have been pureed to a thick liquid form [e.g., pureed meats, fruits, scrambled eggs]

Full liquid diet

clear liquids + liquid dairy products, all juice, strained fruits, vegetables, and cereals

What is the bowel prep for a colonoscopy?

clear liquids only and a bowel cleanser

Implied consent

client adheres to instructions provided by the nurse; ex: the nurse is preparing to administer a TB test and the client holds out his arm for the nurse

when to refer patient to social worker

client who is terminal wants to go home but is no longer able to perform ADLs

expected temporal temperatures are usually:

close to rectal temps, but they are nearly 0.5* C (1* F) higher than oral temps, and 1* C (2* F) higher than axillary temps

auscultation of the lungs (abnormal or adventitious sound): rhonchi

coarse sound heard during either inspiration or expiration resulting from fluid or mucus, may clear with coughing

competence

cognitive processes a nurse uses to make a nursing judgement. general critical thinking including scientific method, problem solving, decision making, diagnostic reasoning and inference, and clinical decision making-collaboration. specific critical thinking in nursing includes the nursing process.

Competence

cognitive processes a nurse uses to make nursing judgments, such as: -general critical thinking: scientific method; problem-solving; decision-making; diagnostic reasoning and inference; clinical decision-making - collaboration -specific critical thinking in nursing: the nursing process

nurse practitioner (NP)

collaborates with one or more providers to deliver nonemergency primary health care in a variety of settings.

subjective data

collected during a nursing hx. include client's feelings, perceptions, and description of health status. client's are the only ones who can describe and verify their own symptoms.

advance directives

communicate a patient's wishes regarding end-of-life care if patient becomes unable to do so.

right direction/communication

communicate in writing, orally, or both. data to collect, method and timeline for reporting, including when to report concerns and assessments findings, specific task(s) to perform; client--specific instructions, expected results, timelines, and expectations for follow-up communication.

right direction/communication

communicate verbally or in writing: -data to collect -method and timeline for reporting -specific tasks to be completed; client specific instructions -expected results, timelines, and expectations for follow-up communication

small group communication

communication w/in a group of people

CAM

complementary alternative medicine

Managed Care Organizations (MCOs)

comprehensive care is overseen by a primary care provider & focuses on prevention and health promotion

problem-oriented medical records

consist of a database, problem list, care plan, and progress notes.

respiratory hygiene and cough etiquette

covering mouth and nose when coughing and sneezing, using facial tissues to contain respiratory secretions, and disposing of them promptly into a hands-free receptacle. wearing a surgical mask when coughing to minimize contaminaiton of the surrounding environment. turning the head when coughing and staying a minimum of 3 ft away from others, especially in common waiting areas, performing hand hygiene after contact with respiratory secretions.

Continuing health care

designed to address long-term or chronic health care needs. examples include hospice, adult day care, and in-home respite care

Pill crushing

destroys enteric coated protection that prevents breakdown in the stomach and decrease the possibility of G.I distress. May cause stomach ache or indigestion.

secondary care

diagnosis and treatment of acute illness and injury. example hospital setting, diagnostic center, emergent care center

naturopathic medicine

diet, exercise, environment, and herbal remedies

pulse deficit

difference between two different pulses --i.e. apical pulse of 60 and radial pulse of 80

primary source of data

directly from patient

state laws

each state has enacted statutes that define the parameters of nursing practice and gives the authority to regulate the practice of nursing to its state board of nursing. board of nursing has the authority to adopt rules and regulations that further regulate practice. boards have the authority to issue and revoke a nursing licensure, they also set standards for nursing programs and further delineate the scope of practice for RNs, LPNs, and APN.

hemorrhagic fevers

ebola yellow fever

fever is the body's response to infectious and/or inflammatory processes but may be blunted in the ___ population

elderly (geriatric)

Primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. is based on a sustained partnership between client and provider. examples include office or clinic visits and scheduled school/work centered screenings (vision, hearing, obesity)

primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control; sustained partnership between clients and provides ex: office/clinic visits and scheduled school-work centered screenings

speech-language pathologist

evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing. teaches techniques and exercises to improve function. Ex. of when to refer: a client is having difficulty swallowing a regular diet after trauma to the head and neck.

respiratory therapist

evaluates patients respiratory status and provides respiratory treatments like O2 and mechanical ventilation

resp. therapist

evaluates resp. status and provides resp. tx. including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation. ex. of when to refer: a pt who has resp. disease is SOB and requests a nebulizer tx.

how often should women above 40 have a mammogram?

every year!

ethical theory

examines principles, ideas, systems, and philosophies that affect judgements about what is right and wrong, and good and bad. Two common types are utilitarianism and deontology.

ethical theory

examines principles, ideas, systems, and philosophies that affect judgments about what is right and wrong ex: utilitarianism, deontology

Malpractice (professional negligence)

example: a nurse administers a large dose of medication due to a calculation error; the client has a cardiac arrest and dies

Battery

example: intentional and wrongful physical contact with a person that involves and injury or offensive contact (restraining a client and administering an injection against her wishes)

Assault

example: the conduct of one person makes another person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat).

bronchial breath sounds

expected sound, loud high-pitched expiration longer than inspiration over trachea

negligence

fails to implement safety measures for a patient at risk

managed care organization (MCO)

focus on prevention and heath promotion --primary care providers oversee

preventative health care

focuses on educating and equipping clients to reduce and control risk factors for disease ex: promote immunizations, stress management, use seat belts

Preventive HC

focuses on educating and equipping pt to reduce and control risk factors for disease. Ex. immunization, stress management, seat belt use.

foreskin

fold of skin covering the glans penis (head) of an uncircumcised penis; also called prepuce

How can a nurse provide negligence

following standards of care giving competent care communicating with other health team members developing a caring rapport with clients fully documenting assessments, interventions, and evaluations

restraint responsibility

food, fluid, safety & comfort assessments performed & documented every 15-30 mins -quick release knot fitting two fingers, pad bony prominences, regularly assess, never leave unattended -document:behaviors, actions causing, when applied/removed, location, type, care, meds, response when removed

Medicare

for clients over age 65 and/or with permanent disabilities. premiums applied as insurance program reimburses providers based on DRGs. Premiums applied as Managed Care Organizations (MCOs) provide enrolled clients with comprehensive care overseen by a primary care provider. Is federally funded.

When should seizure precautions be implemented?

for clients who have a history of seizures that involve the entire body and/or result in unconsciousness

Medicaid

for clients with low income. is federally funded and individual states determine eligibility requirements.

fist percussion is used to assess:

for tenderness over the kidneys, liver, and gallbladder

auscultation of the lungs (abnormal or adventitious sound): wheezes

high-pitched whistling, musical sounds heard as air passes through narrowed or obstructed airways, usually louder on expiration

tertiary care

highly specialized care only found regionally i.e. burn center, cancer center

spirituality

hope, faith, and transcendence

effects of hypochloremia

hyperexcitability of muscles, tetany, hyperactive DTRs, weakness, and muscle cramps

Causes of hypercalcemia

hyperparathyroidism! malignancy, vitamin D, overdose, prolonged immobilization

right task

identify what tasks are appropriate to delegate for each specific client. its repetitive, requires little supervision, and is relatively noninvasive for a certain client. delegate activities to appropriate levels of team members according to professional standards of practice, legal and facility guidelines, and available resources.

secondary prevention

identifying illness, providing treatment, and conducting activities to help prevent worsening of health status. example communicable disease screening, early detection, exercise programs

standards for discharge education

identifying safety concerns at home, reviewing signs and symptoms of potential complications and when to contact either emergency care or provider, providing the phone number of the provider, providing names and phone numbers of community resources that give care at the clients residence, step-by-step instructions for performing continuing tx such as dressing changes, dietary restrictions and guidelines including those that pertain to medication administration. amount and frequency of therapies to perform to support continued independence at home. directions on how to take medications and explanations for why adherence is important.

nursing students and liabilty

if students harm clients as a result of their direct actions or inaction. they shouldnt perform tasks for which they aren't prepared and should have supervision as they learn new procedures. them, the instructor, and the facility share liability for the wrong action or inaction.

preventive care

immunizations or education minimizing risk factors for illness

myopia

impaired far vision

presbyopia

impaired near vision or farsightedness

incident reports

important part of facilities quality improvement plan. ex. of incident are medication errors, falls, and needlesticks. nurses must document the facts without judgement or opinion, nurses must not refer to an incident report in the client's medical record, incident reports contribute to changes that help improve health care quality.

risk of infections

inadequate hand washing, individuals with compromised health or defenses against infection, caregivers using medical and surgical asepsis that doesn't follow established standards, clients who have poor personal hygiene, nutrition, smoke, or consume excessive amounts of alcohol, and those experiencing stress. clients who live in a very crowded environment, older adults clients, individuals who make poor lifestyle choices that put them at risk, client who have recently been exposed to poor sanitation, mosquito-borne or parasitic diseases, diseases endemic to the area visited, but not in the client's home country.

Health Care Systems

incorporate interactions b/w health care providers and pts within constraints of financing mechanisms and regulatory agencies.

health care delivery systems

incorporate interactions between health care providers and clients within the constraints of financing mechanisms and regulatory agencies include individuals who participate, setting, the agencies that regulate health care, and mechanisms that provide financial support challenge to nurses: retain caring values while practicing within a cost-constraining structure

evolution of critical thinking

incorporates reflection, language, and intuition. evolves through three distinct levels as nurses gain knowledge and experience while maturing into a competent nursing professional.

What should you do before treating constipation with laxatives?

increase fiber and water consumption

stages of infection

incubation, prodromal stage, illness stage, convalescence.

nosocomial

infection in hospital from exogenous (outside pt, or endogenous ( altered flora; most commonly UTI; from e.coli or s.aureus or enterococci

chain of infection

infection process: causative agent, reservoir, portal of exit, mode of transmission, portal of entry to host, susceptible host

gingivitis

inflammation of the gums characterized by redness, swelling, and intermittent bleeding

Knowledge

information specific to nursing and acquired through: basic nursing ed; continuing ed courses; advanced degrees and certifications

___ ___ can be used to enhance access to and delivery of knowledge

information technology

knowledge

information thats specific to nursing and comes from basic nursing education, continuing education courses, and advanced degrees and certifications.

patients rights

informed consent, refusal of treatment, advance directives, confidentiality, and information security. patient has the right to understand aspects of are to be active in decision making, accept refuse or request modification of the plan of care, recieve care from competent staff who treat them with respect.

client's rights

informed consent, refusal of tx., advance directives, confidentiality, and information security. these are legal privileges or powers they possess when they receive health care services, clients using the services of a health care institution retain their rights as individuals and citizens. the American Hospital Association identifies pt rights in health care. nursing facilities that participate in medicare programs also follow "resident rights" statutes that govern their operation.

medicaid

insurance for low income people

medicare

insurance for people older than 65

prodromal stage

interval b/w onset of general symptoms to more distinct symptoms. during this time pathogen is multiplying.

incubation

interval b/w the pathogen entering the body and presentation of first symptom.

The client's chart or medical record is the ____ record of care

legal

Living will

legal document that expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues

living will

legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end of life issues

living will

legal document that expresses the client's wishes regarding medical tx in the event the client becomes incapacitated and is facing end-of-life issues. most states laws include provisions that protect health care providers who follow this from liability.

informed consent

legal process by which a client has given written permission for a procedure or tx. consent is informed when a provider explains and the client understands the reason they need the tx or procedure, how the tx or procedure will benefit them, the risks involved if they chose to receive the tx or procedure, and other options to tx the problem, including not txing the problem.

informed consent

legal process by which a lient has given written permission for a procedure or treatment; when a provider explains and the client undersants the reason for it, how the procedure will benefit from it, the risks, other options

Informed consent

legal process by which the client has given written permission for a procedure or treatment to be performed

pediculosis

lice infestation

nursing roles with delegating

licensed nurses are responsible for providing clear directions when delegating a task initially and for periodic reassessment and evaluation of the outcome of the task. RNs can delegate to other RNs, LPNs, and AP. They must delegate tasks so that they can complete higher-level tasks that only RNs can perform. LPNs can delegate to other LPNs and APs.

continuing health care

long-term or chronic care needs. example end-of-life care, palliative care, hospice

auscultation of the lungs (expected sound): bronchial

loud, high-pitched, expiration heard longer than inspiration over the trachea

low residue foods

low in fiber

nurses job regarding informed consent (2)

make sure surgeon receives informed consent witness client's signature on consent form

Causes of hypophosphatemia

malnourishment/malabsorption, alcohol withdrawal

private health care financing organizations (4)

managed care org (MCO) preferred care org (PPO) exclusive provider org (EPO) long-term care insurance

federally funded health care financing organizations (2)

medicare medicaid

auscultation of the lungs (expected sound): bronchovesicular

medium pitch and intensity, equal inspiration and expiration, and heard over the larger airways

causes of hyperchloremia

metabolic acidosis, head trauma, increased perspiration, excess adrenocortical hormone production, and decreased glomerular filtration

channel

method of transmitting and receiving a message (received via sight, hearing, and/or touch)

How does good oral hygiene help prevent infection?

micro-organisms can migrate through breaks in oral mucosa -- good oral hygiene brushes away proteins that attract these micro-organisms

pathogens

micro-organisms or microbes that cause infection

fluid protrusion

midline and flanks

submental lymph node located

midline under the chin

Attitudes

mindsets that affect how a nurse approaches a problem. Attitudes of critical thinkers include: confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility

attitudes

mindsets that affect how a nurse approaches a problem. attitudes of critical thinkers include confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility.

electrolytes

minerals that are present in all body fluids; regulate fluid balance and hormone production, strengthen skeletal structures, act as catalysts, muscle contraction and metabolism of nutrients

Standards

model to which care is compared to determine acceptability, excellence, and appropriateness -intellectual standards ensure the through application of critical thinking. -professional standards include: nursing judgment based on ethical criteria; evaluation that relies on evidence-based practice; demonstration of professional responsibility

standards

models for comparing care to determine acceptability, excellence, and appropriateness. intellectual standards ensure the thorough application of critical thinking, professional standards include nursing judgement based on ethical criteria, evaluation that relies on evidence-based practice, demonstration of professional responsibility.

What type of sedation is given for a colonoscopy?

moderate [aka conscious] sedation

LPN delegation

monitor client findings, reinforce teaching, perform tacheostomy care, suctioning, NG patency check, administer enternal feeding, insert urinary catheter, administer meds

planning

must establish priorities and optimal outcomes of care they can readily measure and evaluate. these direct nurses in selecting interventions. three types of planning. they develop a comprehensive plan of care for clients based on comprehensive assessments they complete. do ongoing planning throughout the provision of care. discharge planning is a process of anticipating and planning for clients needs after discharge. must begin as soon as client is admitted. throughout planning process nurses set priorities, determine client outcomes, and select specific nursing interventions. participate in priority setting when they identify a preferential order of problems. goals/outcomes must be client-centered, singular, observable, measurable, time-limited, mutually agreeable, and reasonable.

nonspecific innate

native immunity restricts entry or immediately responds to a foreign organisms through the activation of phagocytic cells, complement, and inflammation. this occurs with all micro-organisms, regardless of previous exposure. temp. immunity that doesn't have memory of past exposures, intact skin, mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins. inflammatory response to phagocytic cells, the complement system, and interferons localize the invasion and prevent its spread.

decerebrate rigidity

neck and elbow extension, with wrists and fingers flexed

unintentional torts

negligence malpractice (professional negligence)

unintentional torts

negligence, and malpractice (professional negligence)

what side to hold cane

non-injured leg side advance cane, then injured leg, then non-injured leg

immune defense

nonspecific innate, and specific adaptive immunity.

hypotension is classified with a reading below

normal; systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation

pressure ulcer risk lab values

norton below 14 braden below 18 serum below 3.5

NPO

nothing by mouth, derived from the Latin words nil per os

what should you do if you find that a patient has a necklace on before surgery and they are out from anesthesia

notify security for placement of the necklace

gallium scan

nuclear scan that uses a radioactive substance to identify hot spots of WBCs.

example of malpractice

nurse administers too large dose of medication due to calculation error

implementation

nurses base care they provide on assessment data, analyses, and the plan of care they developed in the previous steps. must use problem-solving, clinical judgment, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health. also use interpersonal skills, and technical skills . during this step nurses perform nursing actions, delegate tasks, supervise over health care staff and document the care and client's response.

delegation factors

nurses can delegate only tasks appropriate for the skill and education level of the nurse who is receiving the assignment. RNs cant delegate the nursing process,client education, or tasks that require nursing judgement to LPNs or AP.

information technology

nurses document the care they provided and it should reflect the nursing process. purpose for medical records include communication, legal documentation, financial billing, education, research, and auditing. purpose of reporting is to provide continuity of care among all team members who provide care to the same clients.

laboratory technician

obtains specimen of body fluids, and performs diagnostic tests. ex. of when to refer: a provider needs to see a pts CBC results STAT.

supervision

occurs after delegation, oversees staff's performance of delegated tasks, determine whether completion of tasks is on schedule, performance was at a satisfactory level, delegatee documented and reported unexpected findings, delegatee needed assistance to complete assigned tasks in a timely manner, supervising nurse should reevaluate and possibly change the assignment.

interpersonal communication

occurs between two people, the most common in nursing

infection

occurs when the presence of a pathogen leads to a chain of events. all components of the chain must be present and intact for this to occur.

intrapersonal communication

occurs within an individual, "self-talk"

public communication

occurs within large groups of people

corn

often painful and inflamed circumscribed lesion of thickened skin, usually on the toes and caused by pressure or friction from ill-fitting shoes

sebaceous gland

oil-secreting organ of the skin

expected psychosocial development (Erikson-integrity vs despair): older adult (65+ yrs)

older adults may need to: -adjust to lifestyle changes related to retirement (decreased income, living situation, loss of work role) -adapt to changes in family structure (may be role reversal in later years) -deal with multiple losses (death of a spouse, friends, siblings) -face death

semi-fowler's position

on back with bed inclined 30 degrees

components of the Privacy Rule

only HC team members directly responsible for a client's care may access that client's record. Nurses may not share info with other clients or staff not caring for the client. clients have a right to read and obtain a copy of their medical records. nurses may not photocopy any part of the medical record except for authorized exchange of documents between facilities and providers. staff must keep medical records in a secure area to prevent inappropriate access to the info. they may not use public display boards to list client's names and diagnoses. electronic records are password protected. nurse must not disclose client's info to unauthorized individuals or family members who request it in person or by telephone or email. communication about a client should only take place in a private setting where unauthorized individuals cant overhear it.

flatus protrusion

only the midline abdomen, not the flanks

who can RNs delegate tasks to?

other RNs LPNs AP

secondary hypertension cause

other diseases i.e. kidney disease, diabetes

tympany from percussion is expected to be found:

over a gastric bubble

NG tube

p.H. of stomach contents is measured to confirm or refute placement of the N.G. tube in the stomach.

ingrown nail

painful condition in which the corner or side of a toenail grows into the soft flesh of that toe

individuals who may grant consent of procedure/treatment for patient

parent of minor legal guardian court-specified representative (i.e. power of attorney) emancipated minor (for their own procedure/treatment)

preferred provider organization (PPO)

patients can choose from list of preferred providers and choosing non-preferred provider increases cost

exclusive provider organization (EPO)

patients can only choose from list of preferred providers

bottle caps and sterile surfaces

place bottle cap face up

stereognosis

place something in someones hand and ask them to identify it --place stereo in someones hands and ask them to identify it

indirect percussion involves:

placing a hand flatly on the body, as the striking surface, for sound production

droplet

pneumonia , mumps, pertussis, SF -private / same disease room, masks

semi-Fowler's position

position with the head of the bed raised approximately 30 degrees

radiologic technician

positions pt and performs xrays and other imaging procedures for providers to review for diagnosis of disorders of various body parts. ex. of when to refer: a pt reports severe pain in his hip after a fall, and the provider prescribes an xray of the pt hip.

PIE

problem, intervention, evaluation

Ethical dilemmas are:

problems about which more than one choice can be made and the choice made is influenced by the values and beliefs of the decision makers

contact precautions

protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms. precautions require: private room or a room with other pt with same infection, gloves and gown worn by the caregivers and visitors, disposal of infectious dressing material into a single, nonporous bag without touching the outside of thee bag.

Confidentiality

protection of privacy without diminishing access to high-quality care

confidentiality

protection of privacy without diminishing access to high-quality care

confidentiality

protection of privacy without diminishing access to high-quality care.

Confidentiality

protection of privacy without diminishing access to quality care

prions

protein particles. new variant Creutzfeldt-Jakob disease.

parasites

protozoa. malaria, toxoplasmosis. and helminths. worms, flukes.

admission assessments

provide baseline data to use in the development of the nursing care plan.

spiritual support staff

provide spiritual care i.e. pastors, rabbis, priests

nursing roles in advance directives

provide written info about advance directives, document the client's advance directive status, ensure that the advance directive reflect the client's current decision, inform all members of the health care team of the client's advance directives.

it is the ___'s ___ to assess, report, and document client allergies and to provide client care that avoids exposure to allergens

provider's responsibility

pharmacists

provides and monitors meds. supervises pharmacy techs in states that allow practice. ex. of when to refer: a pt is concerned about a new meds interaction with any of his other meds.

Long-Term Care Insurance

provides for long-term care expenses not covered by Medicare

End colostomy

proximal end forms stoma; distal end removed/sewn closed

reflection

purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event.

Reflection

purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event. -"Why did I say this or do that?" -"Did the original plan of care achieve optimal client outcomes?"

medical asepsis

reduce microbes

expected pulse oximetry ranges are

reference range: 95%-100% acceptable for some clients: 91%-100% some illnesses allow for: 85%-89% abnormal: <85%

pulse rhythm can be

regular or irregular; a premature or late heartbeat can result in an irregular interval and can indicate abnormal electrical activity of the heart

Traditional Insurance

reimburses for services on fee-for-service basis.

necessary loss

related to a change that is part of the cycle of life that is anticipated but still may be deeply felt. can be replaced by something different or better

curiosity

requires more information about clients and problems

Urine culture

requires sterile/clean-voided urine sample; takes 24-48 hours to reveal findings; determines most effective antibiotic

fire - race

rescue alarm contain extinguish A-paper/wood/trash B-flammable liquids / gas C -electrical

normal percussion of the thorax should result in

resonance

bed/client positions

semi-fowler fowler high-fowler prone lateral sims orthopenic trendelenburg reverse trendelenburg

exudate types

serous, sanguineous, purulent

hypochloremia

serum chloride <96 mEq/L

hyperchloremia

serum chloride >106 mEq/L

hyperphosphatemia

serum phosphate >4.5 mg/dL or 2.6 mEq/L

causes of hypochloremia

severe vomiting and diarrhea, drainage of gastric fluid (GI tube), metabolic alkalosis, diuretic therapy, and burns

change-of-shift report

should include significant objective information and patients health problems, be in logical sequence, include no gossip or personal opinion, provide recent changes in medication treatments procedures and the discharge plan.

lateral

side lying, 3 pillows, sleep

change of shift report

significant objective info report is given at the conclusion of each shift by the nurse leave to the nurse assuming responsibility for the client; face to face, audio-taped, presents on rounds

orthopenic

sit, arms on bed table COPD

anterior thorax

sites along midclavicular lines bilaterally

orthopneic position

sits on edge of bed and leans over table covered with pillows --allows chest expansion for COPD patients

Symptoms of Hyperkalemia

skeletal muscles weak/paralyzed, ventricular fibrillation/cardiac standstill, cardiac depolarization impaired, repolarization occurs more quickly, abdominal cramping, diarrhea

expected findings for the Weber test

sound is heard equally in both ears (negative Weber test)

tertiary care

specialized care located regionally such as burn or cancer units

Interprofessional Personnel (non-nursing)

spiritual support staff, registered dietitian, laboratory technician, occupational therapist, pharmacists, PT, provider, radiologic technologist, Resp. Therapist, Social Worker, Speech-Language pathologist.

what stage of sleep does sleepwalking normally occur?

stage 4 (non REM)

ISBAR

standard handoff communication tools such as introduction, background assessment, recommendation to facilitate transfers and discharges.

ethical principles

standards of what is right or wrong with regard to important social values and norms. principles pertaining to the tx of clients include autonomy, beneficence, fidelity, justice, and nonmaleficence.

Ethical principles

standards of what is right/wrong with regard to important social values and norms

pulse equality: peripheral pulse impulses should be

symmetrical in quality and quantity from right side to left

pulse pressure is the difference between

systolic and diastolic pressure readings

what should you tell the patient to do as you insert a suctioning device?

take a deep breath

risk taking

takes calculated chances in finding better solutions to problems

activities of daily living (ADLs)

tasks performed routinely during the course of a typical day, such as walking, eating, bathing, brushing the teeth, and grooming

care after discharge

teach the client about any infection control measures at home, self-administration of medication therapy. complications that need to be needs to immediately.

nurse educator

teaches in schools of nursing, staff development departments in health care facilities, or client education departments.

___ is an interactive process driven by specific client goals

teaching

fever

temp above 39 C / 102 F

hypothermia

temp below 35 heated humidfied o2 warming blanket, warmed fluids cardiac monitoring with emergency resuscitation on stand by

hypothermia

temp below 35 C / 95 F

during palpation, the dorsal surface of the hand detects:

temperature

professional negligence

the failure of a person who has professional training to act in a reasonable and prudent manner.

bioethics

the field that addresses dilemmas that arise from advancing science and technology.

do not place items on the floor in the client's environment (even soiled laundry) because

the floor is considered "grossly" contaminated

perfusion is

the flow of blood to and from the pulmonary capillaries; measure with pulse oximetry

indication for transfer and discharge

the level of care has changed. another setting is required to provide necessary care, the facility doesn't offer the type of care a client now requires, the client no longer need inpt care and is ready to return home.

cuticle

the narrow band of epidermis extending from the nail wall onto the nail surface

respiratory rate is

the number of full inspirations and expirations in 1 min; expected reference range for adults in 12-20 rpm

Symptoms of Hypernatremia

thirst, weakness, fever, tachycardia, increased BP, dry mucous membranes, neurlogical changes

Some patients having a procedure or surgery involving the bowel have an order for an enema to be administered "until clear." This directs you to repeat the enema until the patient passes fluid that is clear of fecal matter. How many enemas can you administer in a row?

to reduce the risk of fluid or electrolyte imbalances, *3 is the max*

Nurse's role in the informed consent process is:

to witness the client's signature on the informed consent form and to ensure the informed consent has been appropriately obtained

Epidermis

top layer of skin; protection and entrance; resurfaces wound and restores barrier

PCA consideration

toxic effect could still result if the client receives more medication that she needs to control pain.

graphesthesia

trace letter in patient's hand and ask them to identify it --draw line graph on their hand and ask them to tell you what it is

things RN can delegate to LPNs

tracheostomy care suctioning checking NG tube enteral feeding

heat loss- radiation is:

transfer of heat from one object to another object without contact between them (heat loss from the body to a cold room)

eversion

turning body part away from midline

inversion

turning body part toward midline

lab values

tylenol max 4 g/day fiber: 25-30 blood glucose: 70-250 potassium 3.5-5 serum sodium 136-145 calcium 9-10.5 mg: 1.3-2.1

what do you expect to hear when auscultating abdomen?

tympany high pitched clicks

iatrogenic infection

type of HAI resulting from a diagnostic or therapeutic procedure.

living will

type of advanced directive, legal document htat expresses patients wishes regarding medical treatment in the event they become incapacitated and is facing end-of-life issues.

discharge documentation

type of discharge, date and time of discharge, who went with the client, and transportation, where the client went, a summary of the client's condition at discharge, a description of any unresolved difficulties and procedures for follow up, disposition of valuables, meds brought from home, and prescriptions, discharge instructions.

hypoallergenic

unlikely to cause an allergic (hypersensitivity) response

complete a fall-risk assessment ___ ___ & at ___ ___ to limit risk of falls

upon admission & at regular intervals

transmission precautions: tier two

use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). airborne precautions require: private room, masks and respiratory protective devices for caregivers and visitors. use an N95 or high-efficiency particulate air (HEPA) respirator if pt is known or suspected to have TB. negative pressure airflow exchange in the room of at least six to 12 exchanges per hr depending on the age of the structure. if splashing or spraying is a possibility, wear full face protection.

evidence-based rationale

used for the selection and implementation of therapeutic interventions.

Barium swallow

used to determine cause of painful swallowing, difficulty swallowing, abdominal pain, bloodstained vomit or unexplained weight loss

telephone reports

useful when contacting the provider or other members of the interprofessional team. important to have all the data ready prior to contacting any member of the interprofessional team, use a professional demeanor, use exact, relevant, and accurate information, document the name of person, time, content of the message, and the instructions or information received during the report.

creativity

uses imagination to find solutions to unique client problems

healing intention

using care, compassion, and empathy with prayer to heal

interpersonal variables

variables that influence communication between the sender and the receiver

Chronic wounds

vascular compromise; chronic inflammation; fails to heal through timely orderly process; continued exposure to insult impedes healing

pronation

ventral surface is facing down

supination

ventral surface is facing up

when to refer patient to dietitian

when patient has abnormal serum nutrient levels and has unexplained weight loss

when to refer patient to occupational therapist

when patient has difficulty using eating utensil after stroke

when to refer patient to respiratory therapist

when patient is short of breath and needs breathing treatment

implied consent

when they adhere to the instructions the nurse provides; ex. sticking out arm for a shot

Responsibility

willingness to respect obligations and follow through on promises

responsibility

willingness to respect obligations and follow through on promises

responsibility

willingness to respect obligations and follow through on promises.

temporal

wipe lens with alcohol; scan / hold against flat forehead moving gently over to temporal artery, touching skin behind ear; release and read

steregnosis

with eyes closed, client can identify a familiar object that is place in his hand

graphesthesia

with eyes closed, client can identify a number drawn on his palm with the blunt end of a pencil

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient

"I'll swab the patient's mouth with diluted hydrogen peroxide."

A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is appropriate by the nurse

"Oral care is still important even though you are not eating."

Provider's orders

"do not resuscitate" (DNR) or "allow natural death" (AND) are orders written by a provider and must be placed in the client's medical record; the provider consults the client and family prior to administering a DNR or AND

intrapersonal communication

"self-talk"

hypophosphatemia

(serum phosphate <2.5 mg/dL or 1.8 mEq/L).

What is the purpose of a tap water enema?

*NOW CONTRAINDICATED PER ATI due to risk for fluid overload* - to stimulate evacuation; - use caution when using tap water because it is a hypotonic solution, thus it pulls electrolytes from the body into the fluid; - should only be performed once - do not repeat

Why does immobility cause pressure ulcers?

*increased pressure* on skin and *decreased circulation* to tissues --- this causes ischemia --- which can lead to pressure ulcers

expected deep tendon reflex response

+2 +4= very brisk with clonus 0= no response

What is the difference between airborne and droplet precautions?

- *airborne* precautions protect against droplet infections *smaller than 5 mcg*; - *droplet* precautions protect against droplets *larger than 5 mcg and travel 3 to 6 ft from the client*

When is the optimal time for a client to perform a breast self-examination?

- 2 or 3 days after menstruation ends; - postmenopausal clients should perform BSE on the same day of each month

Latex allergy

- Must use latex-free gloves; - Schedule surgery first thing in the morning; - Label O.R. as "latex free"; - clients w/latex allergy usually have an allergy to foods such as bananas, kiwis, and avocados

Donning Sterile Gloves

- Use *non-dominant hand* and pick up *dominant-hand glove* by grasping the folded bottom edge of the cuff * (only touching the inside of the glove)*; - Pull dominant glove onto dominant hand; - With sterile dominant-gloved hand, place fingers of dominant hand *inside the cuff* of the non-dominant glove, lifting it off the wrapper, and put non-dominant hand into it

What foods and beverages increase intestinal gas?

- beer, carbonated drinks, dairy products; - broccoli, Brussels sprouts, cabbage, cauliflower, corn, cucumbers, dried beans, mushrooms, onions, peas, radishes, and spinach

What happens during the *alarm reaction*?

- body functions are heightened to respond to stressors; - hormones are released -- which cause elevated BP and heart rate, heightened mental alertness, increased secretion of epinephrine and norepinephrine, and increased blood flow to muscles

What happens during the *exhaustion stage*?

- body functions are no longer able to maintain a response to the stressor; - the end of this stage results in recovery or death

What happens during the *resistance stage*?

- body functions normalize while responding to the stressor; - body attempts to cope w/the stressor and return to homeostatis

What are the *expected* findings upon palpation of a *female* client's breasts?

- breasts firm, dense, elastic, and without lesions or nodules; - breast tissue granular or lumpy bilaterally in some

How do you assess pitting edema?

- by compressing the skin for at least 5 seconds over a bony prominence [like behind the medial malleolus, dorsum of foot, or over the shin] - the depth of pitting reflects the degree of edema; - 2 mm = 1+ [trace edema]; - 4 mm = 2+ [mild edema]; - 6 mm = 3+ [moderate edema]; - 8 mm = 4+ [severe edema];

How does performing pulmonary hygiene every 2 hours decrease the growth of micro-organisms and development of pneumonia for an immobile client?

- by preventing stasis of pulmonary excretions; - stimulating ciliary movement and clearance; - and expanding the lungs

visually impaired client

- call by name before approaching & introduce yourself, staying within visual field -give specific information on location of items in area of building or food on tray leaving -explain interventions before touching -inform client of your departure -appraise clothing & suggest changes if soiled or torn -made a radio, television, compact disc, or digital audio file player available for use

nursing interventions to *maintain or regain body alignment and stability, decrease musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures*

- change position at least every 2 hr; for chair, weight shifts every 15 min; - encourage active or provide passive ROM 2-3 times/day - instruct to perform ROM while bathing, eating, grooming, and dressing; - monitor nutritional intake of calcium; - cluster care to promote a proper sleep-wake cycle. - request PT for clients who have decreased mobility; - use a continuous passive motion device.

What is the Modified Trendelenburg position?

- client remains *flat* w/legs elevated above level of heart; - used to prevent and treat hypovolemia and facilitate venous return

How is the Romberg test performed?

- client stands with eyes closed, arms at side, and feet together; - RN verifies balance if client can stand w/minimal swaying for at least 5 seconds

Minerals

- complete essential biochemical reactions in the body [e.g., calcium, potassium, sodium, iron]

What are the common side effects of opioid analgesics?

- constipation; - orthostatic hypotension; - urinary retention; - nausea/vomiting; - sedation - respiratory depression

What are the therapeutic effects of *cold* applications?

- decrease inflammation; - prevent swelling; - reduce bleeding; - reduce fever; - diminish muscle spasms; - decrease pain by decreasing velocity of nerve conduction

*gastrointestinal changes* due to immobility

- decreased peristalsis; - constipation, then fecal impaction, then diarrhea

metabolic changes due to immobility

- decreased protein resulting in loss of muscle; - alterations in calcium, fluid, and electrolytes; - resorption of calcium from bones; - decreased urinary elimination of calcium --- results in hypercalcemia

What is a role conflict?

- develops when a person must assume opposing roles with incompatible expectations; - conflict may be interpersonal [e.g., when parents expect adolescents to participate in sports and perform household tasks]; or - inter-role [e.g., when a mother wants to stay at home with her infant, but family finances require her to work]

What are some general *crutch* instructions?

- do not alter crutches after fitting; - follow prescribed crutch gait; - support body weight at the hand grips w/elbows flexed at 30°; - position crutches on *unaffected* side when sitting or rising from a chair

What is the Trendelenburg position?

- entire bed is tilted with *head of bed lower* than foot of the bed; - facilitates venous return; can help increase low BP; used for postural drainage

What is the *Reverse* Trendelenburg position?

- entire bed is tilted with the *foot of bed lower* than head of bed; - promotes gastric emptying and prevents esophageal reflux; - *remember*: you use your feet to go in *reverse* and your feet are what tilt down for *reverse* Trendelenburg

What is a sick role?

- expectations of others and society regarding how one should behave when sick [e.g., caring for self and continuing to provide childcare to grandchildren]

What foods should a client with an ostomy avoid to prevent flatus?

- foods that cause odors, such as asparagus, beans, cabbage, eggs, fish, garlic, onions;

What is the purpose of medicated enemas?

- given for the local effect they exert on the rectal mucosa; - e.g., one contains the antibiotic neomycin, which is used to reduce bacteria in the colon before bowel surgery. - can also be given to produce a systemic effect; - e.g., one contains sodium polystyrene sulfonate [Kayexalate], which is administered to treat patients who have dangerously high serum potassium levels

What PPE is required for *contact* precautions?

- gloves + gowns; - private room; [can cohort w/same infection, just as long as each client has their own equipment]

Where does gas exchange take place?

- in lung tissue between the alveoli and lung capillaries; - alveoli are surrounded by lung capillaries; - numerous small alveoli share common walls making a large surface area for gas exchange

nursing interventions to *maintain cardiovascular function, increase activity tolerance, and prevent thrombus formation*

- increase activity ASAP by dangling feet on side of bed or transferring to a chair; - instruct to perform isometric exercises to increase activity tolerance; - change position as often as possible; - instruct to avoid Valsalva maneuver --- give a stool softener to prevent straining; - teach range of motion (ROM) exercises such as ankle pumps and knee flexion; - instruct to avoid placing pillows under knees or lower extremities, crossing the legs, wearing tight clothes around waist or on legs, sitting for long periods of time, and massaging legs; - elastic stockings, sequential compression devices [SCD] or intermittent pneumatic compression [IPC]' - increase fluid intake if no restrictions; - give low-dose heparin prophylactically; - contact HCP immediately if assessment data indicates venous thrombosis

What are the therapeutic effects of *heat* applications?

- increase blood flow; - increase tissue metabolism; - relax muscles; - ease joint stiffness and pain

How do you access skin turgor?

- lifting and releasing a fold of skin on the forearm or chest under the clavicle; - a delay in the skin returning to its usual place is known as "tenting"; - tenting = dehydration or aging and increases the risk for skin breakdown

Clear liquid diet

- liquids that leave little residue - examples: clear fruit juices, gelatin, broth

What PPE is required for *droplet* precautions?

- mask - private room; [can cohort w/same infection, just as long as each client has their own equipment]; - mask on patient for transport

What PPE is required for *airborne* precautions?

- mask [N95 if TB]; - if splashing or spraying is a possible, wear full face protection including eyes, nose, and mouth; - negative pressure room; - private room; - mask on patient for transport

a disaster is a ___ ___ or ___-___ event that overwhelms or interrupts, at least temporarily, the normal flow of services of a hospital and include ___ & ___ emergencies

- mass casualty -intra-facility -internal -external

cardiovascular assessment

- measure orthostatic BP and pulse, and assess for vertigo; - palpate apical and peripheral pulses; - auscultate heart at apex for S3 --- which is an early sign of heart failure; - palpate for edema in the sacrum, legs, and feet; - palpate skin for warmth in peripheral areas to include nose, ear lobes, hands, and feet; - assess for DVT by observing calves for redness and palpating for warmth and tenderness; - measure circumference of both calves and thighs and compare in size

mobility and immobility assessment focuses on:

- mobility; - range of motion (ROM); - gait; - exercise status; - activity tolerance; - body alignment while standing, sitting, and lying

Upon inspection, how should a *healthy* stoma appear?

- moist, shiny, and pink or red; - peristomal area should be intact, and skin should appear healthy

What is role overload?

- more responsibility and roles than are manageable [e.g., assuming the role of student, employee, and parent]

Vitamins

- necessary for metabolism; - fat-soluble vitamins are A, D, E, and K; - water-soluble vitamins include C and B complex

What are the *expected* findings upon palpation of a *male* client's breasts?

- no edema, masses, nodules, or tenderness; - areolas round and darker pigmented

respiratory assessment [complete every 2 hours]

- observe chest wall movement for symmetry; - auscultate breath sounds; - observe for productive cough, and note the *color*, *amount*, and *consistency* of secretions

integumentary assessment [assess at least every 2 hours]

- observe skin for breakdown, warmth, and change in color [Look for pallor or redness in fair-skinned clients, and purple or blue discoloration in dark-skinned clients]; - observe bony prominences; - check skin turgor - use a pressure ulcer risk scale such as Norton or Braden; - observe for urinary or bowel incontinence

What position should the patient be in for an enema?

- on left side in sims position with right knee flexed;

*cardiovascular changes* due to immobility

- orthostatic hypotension; - less fluid volume in circulatory system; - stasis of blood in the legs --- increased risk of thrombus development; - diminished autonomic response; - decreased cardiac output --- leads to poor cardiac effectiveness --- which results in increased cardiac workload; - increased oxygenation requirement

What is neuropathic pain?

- pain that arises from abnormal or damaged pain nerves [e.g., phantom limb pain, pain below the level of a spinal cord injury, diabetic neuropathy]; - usually intense, shooting, burning, or "pins and needles"

What are signs of stomal ischemia?

- pale pink in color; - black or purple in color; - appears dry

What are the modes of transmission for contact pathogens?

- person to person; - object to person (indirect contact w/an inanimate object); - fecal-oral

What are nursing interventions to *maintain intact skin*

- position using corrective devices; - turn every 1 to 2 hr; - teach clients who can to turn at least every 15 min; - provide chair-sitting-clients w/device to decrease pressure, limit chair sitting to < 2 hr, and instruct clients to shift weight every 15 min; - use therapeutic bed or mattress for clients in bed for an extended time; - monitor nutritional intake; - skin and perineal care

*Surgical* asepsis [AKA: "Sterile Technique"]

- practices *to eliminate* all micro-organisms from an object or area to prevent contamination; - Used for: parenteral med admin, insertion of urinary catheters, surgical procedures, sterile dressing changes, etc.

*Medical* asepsis [AKA: "Clean Technique"]

- practices* to reduce* the number, growth, and spread of micro-organisms; - Used for: admin oral meds, managing NG tubes, providing personal hygiene, etc.

What are signs and symptoms of *dehydration* in an *OLDER ADULT*?

- slowed cap refill; - sunken eyes; - oliguria; - poor skin turgor - tenting of skin on chest; [note - do not use back of hand for older adults due to decreased elasticity]

What are the modes of transmission for droplet pathogens?

- sneezing; - coughing; - talking

What foods can alter the results of a fecal occult test?

- some proteins such as red meat, fish, and poultry, also aspirin; - foods high in vitamin C can give false-negative - NSAIDs and anticoagulants should be discontinued 7 days prior to testing

How should stool specimens for serial fecal occult blood be collected?

- specimens should be collected 3 times from 3 different defecations; - stool samples should come from fresh stools that are not contaminated with water or urine

What is the purpose of a low-volume hypertonic enema [*aka Fleet*]?

- to cleanse the bowel; - better for clients who cannot tolerate a large volume of solution

What is the purpose of a return-flow enema and how does it work?

- to expel flatus; - after instilling the solution, lower the container to allow the solution to flow back into the container; - repeat the process several times until patient expels flatus and abdominal distention is relieved

What is included in *pulmonary hygiene*?

- turning; - coughing; - deep breathing; - incentive spirometry

What is the purpose of a normal saline enema?

- volume stimulate peristalsis; - safest solution due to equal osmotic pressure

heart sounds: S2

-"dub" -caused when closure of the aortic and pulmonary valves signals the beginning of ventricular diastole (relaxation) and produces the sound -best heard with the diaphragm of the steth at the aortic area

heart sounds: S1

-"lub" -caused when the closure of the mitral and tricuspid valves signals the beginning of the ventricular systole (contraction) and produces the sound -best heard with the diaphragm of the steth at the apex

Examples of tasks that can be delegated to AP

-ADLS -bathing, grooming, dressing, toileting -ambulating -feeding (w/o swallowing precautions) -positioning -bedmaking -specimen collection and I&Os -VS for stable clients

Triage classes/ categories during mass casualty events

-I- emergent- highest priority; life threatening injuring with high possibility of survival when stabilized - II- Urgent- major injuries, not yet life threatening; can wait 45-60 for treatment - III - Nonurgent- minor injuries, do not need immediate attention -IV- Expectant- not expected to live & will be allowed to die naturally; provide comfort not restorative care

Types of unintentional torts

-Negligence -Malpractice (professional negligence)

Refusal of treatment

-PSDA stipulates all clients have the right to accept and refuse care and must be advised of this right upon admission -if client refuses treatment, will be asked to sign an "Against Medical Advice" form and nurse must document information was provided and provider notified -if client refuses to sign form, nurse must document -if a client decided to leave the facility w/o discharge order, nurse must notify provider and discuss risks of leaving prior to discharge

expected cognitive development: older adult (65+ yrs)

-Piaget: formal operations -many will maintain cognitive function; some decline in speed of cognitive function vs cognitive ability -many factors influence cognitive ability including: overall health, number of stressors present at a given time, client's life-long mental well-being -slowed neurotransmission, imparied vascular circulation, disease states, poor nutrition, and structural brain changes can lead to delirium, dementia, and depression -delirium: acute, temporary, and usually related to other physiologic problems; is often the first symptom of infection (UTI) in older adults -dementia: chronic, progressive, and possibly with an unknown cause (Alzheimer's disease) -depression: chronic, acute, or gradual onset (present for at least 6 weeks)

What is EF (ejection fraction)? What's the normal values?

-Refers to how hard the heart is squeezing -60-75%

smallpox

-S/S: high fever, fatigue, severe headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding -treatment: no cure -supportive care: hydration, pain medication, antipyretics -prevention: vaccine

inhalational anthrax

-S/S: sore throat, fever, muscle aches, severe dyspnea, meningitis, shock -treatment/prevention: IV ciprofloxacin

Ebola

-S/S: sore throat, headache, high temprature, nausea, vomiting, diarrhea, internal and external bleeding, shock -treatment: no cure -supportive care: minimize invasive procedures -prevention: vaccine

-systolic murmurs are heard just after ___ -diastolic murmurs are heard just after ___

-S1 -S2

Specialized license versus nursing CAM therapy intervention

-SL- acupuncture/ pressure, homeopathic meds, naturopathic meds, chiropractic meds, massage therapy, biofeedback, therapuetic touch -nursing- guided imagery/ viualization therapy, healing intention, breath work, humor, mediation, simple touch, music therapy, therapeutic communication

What is SV (stroke volume)? How do you calculate it? What're the normal values?

-The amount of blood ejected from L. ventricle contraction -SV=CO/HR -60-88mL

What is CO (cardiac output)? How do you calculate it? What're the normal values?

-The amount of blood ejected from the L. ventricle in 1 minute. -CO= SV*HR -4-8 L/min

Positioning for postural drainage

-Use high Fowler's position to drain the apical sections of the upper lobes of the lungs. -Place the patient in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs. -Place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung. -Place the patient in the Trendelenburg position to drain the lower lobes of the lungs.

CN VI

-abducens -assess extraocular movements

medical asepsis

-aka "clean technique" -the use of precise practices to reduce the number, growth, and spread of micro-organisms from an object, person, or area -used for administering oral meds, managing NG tubes, providing personal hygiene, and many other common nursing tasks

spider vein

-bluish -spider-shaped or may be linear -up to several inches in size

prolonged exposure to airborne micro-organisms can make sterile items nonsterile. Avoid:

-coughing, sneezing, and talking directly over a sterile field -air movement should be controlled by special ventilation

petechia/purpura

-deep reddish/purple -flat -petechiae = 1 to 3 mm -purpura > 3 mm

expected psychosocial development (Erikson: identity vs role confusion): adolescent (12-20 yrs)

-develops a sense of personal identity influenced by expectations of the family -group identity: may become part of a peer group that greatly influences behavior

hemorrhoids

-dialed BV in rectal wall from straining, can be caused by heart failure, liver disease & pregnancy, itchy, painful, bloody -moist wipes to cleanse, moisture creams/ointments may help

trendelenburg position

-entire bed is tilted with head of bed lower than the foot of the bed -position used during postural drainage, and facilitates venous return

expected psychosocial development (social development): older adult (65+ yrs)

-find ways to remain socially active and to overcome loneliness -maintain sexual health

scale

-flakes of skin that exfoliate -example: dandruff or psoriasis

expected physical development: young adult (20-35 yrs)

-growth has concluded around age 20 -physical senses peak -cardiac output and efficiency peak -muscles function optimally at ages 25-30 -metabolic rate decreases 2%-4% every decade after age 20 -libido higher for men -libido for women peaks during the latter part of this stage -time for childbearing is optimal -pregnancy-related changes occur

the number one measure to reduce the growth and transmission of infectious agents is:

-hand hygiene -hand hygiene refers to both handwashing with an antimicrobial or plain soap and water as well as the use of alcohol-based gels, foams, and rinses

expected psychosocial development (Erikson: autonomy vs shame and doubt): toddler (1-3 yrs)

-independence is paramount for toddler who is attempting to do everything for himself -separation anxiety continues when parent leaves child

lymph nodes should be ___ & ___; normal nodes are ___ ___

-nonpalpable -nontender -not visible

RNs CANNOT delegate

-nursing process -client education -tasks that require nursing judgment to LPNs or AP

expected cognitive development (Piaget: formal operations): young adult (20-35 yrs)

-optimal time for education, both formal and informal -critical thinking skills improve -memory peaks in the 20s -increased ability for creative thought -values/norms of friends (social groups) are relevant

mini-mental exam

-orientation of time & place -attention & calculation of counting backwards by 7 -registration & recalling of objects -laguage, including naming of objects, following commands & ability to write

nodule/tumor

-palpable, circumscribed, 0.5cm or > -example: wart

papule

-palpable, circumscribed, <0.5cm -example: elevated nevus

wheal

-palpable, irregular borders, edematous -example: insect bite

in conjunctiva the ___ is pink and the ___ is transparent

-palpebral -bulbar

expected age-appropriate activities: preschooler (3-6 years)

-parallel play shifts to associative play and is not highly organized -appropriate activities include: playing ball, putting puzzles together, riding trike, pretend and dress-up, role play, painting, sewing cards and beads, reading books

individuals who can grant consent for another person

-parent of a minor -legal guardian -court-specified representative -an individual who has durable power of attorney for health care -emancipated minors for themselves

factors that enhance learning:

-perceived benefit -cognitive and physical ability -health and cultural beliefs -active participation -age/educational level-appropriate methods

sterile procedure steps

-perform hand hygiene -open packaging, slipping package onto center of workspace with top flap opening away from the body -reach around to open top flap -open side flaps, using left hand for left flap and right hand for right flap -grasp last flap and turn it down toward the body -open additional sterile packages and add contents directly to sterile field by dropping contents into place -pour sterile solutions -don sterile gloves

Civil law:

-protect the individual rights of people -one type that relates to the provision of nursing care is tort law

contact precautions

-protect visitors and caregivers against direct client/environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multidrug-resistant organisms) -require a private room or a room with other clients with the same infection, gloves and gowns worn by caregivers and visitors, and disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag

health promotion (injury prevention-pregnancy prevention): adolescent (12-20 yrs)

-provide education

health promotion (injury prevention-STDs): adolescent (12-20 yrs)

-provide education and resources for treatment

health promotion (injury prevention-drowning): school-age (6-12 yrs)

-provide supervision when around pool/near body of water -teach to swim

Nursing role in advanced directives

-provide written information regarding advanced directives -document the client's advanced directives status -ensure that the advanced directives reflect the client's current decisions -inform all members of the health care team of the client's advance directives

baseline data

-provided by the admissions assessment -compared with future assessments to monitor client status and response to treatment

ecchymosis

-purple fading to green or yellow over time -variable in size -flat

expected psychosocial development (self-concept development): school-age (6-12 yrs)

-strive to develop healthy self-respect by finding out in what areas they excel -parents need to encourage regarding educational or extracurricular success

prevention education for risk of poison in preschoolers and school-age children:

-teach about hazards of alcohol, prescription, non-prescription, and illegal drugs -keep potentially dangerous substances out of reach

health promotion (injury prevention-burns): adolescent (12-20 yrs)

-teach fire safety -use sunscreen when outside

only sterile items may be in a sterile field

-the outer wrapping and 1 inch edges are non-sterile -touch sterile materials only with sterile gloves -any object held below the waist or above the chest is considered contaminated -sterile materials may only tough other sterile materials/surfaces; contact with nonsterile materials at any time renders a sterile area contaminated, no matter how short the contact

therapeutic communication is

-the purposeful use of communication to build and maintain helping relationships with the client, families, and significant others -client centered: not social or reciprocal -purposeful, planned, and goal-directed

adequate fluid intake/hydration prevents:

-the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms -the skin from breaking down which will help prevent micro-organisms from entering the body

health promotion (psychosocial interventions to improve self-concept & alleviate social isolation): older adult (65+ yrs)

-therapeutic communication -touch -reality orientation -validation therapy -reminiscence therapy -attending to physical appearance -assistive devices (canes, walkers, hearing aids)

individuals with compromised health or defenses against infection include:

-those who are immunocompromised -those who have had surgery -those with indwelling devices -a break in the skin -those with poor oxygenation -those with impaired circulation -those who have chronic or acute disease

health promotion (injury prevention-burns): preschooler (3-6 yrs)

-turn down thermostat on hot water heater -have working smoke detectors in the home -use sunscreen while outside

passive smoking

-unintentional inhalation of tobacco smoke -exposure can put one at risk for numerous diseases including: cancer, heart disease, and lung infections -low-birth weight, prematurity, stillbirths, and SIDS have been associated with maternal smoking -smoking in presence of children is associated with development of bronchitis, pneumonia, middle ear infections, and an increase in frequency/severity of asthma attacks

health promotion (injury prevention-MVA): infant (birth-1 yr)

-use approved rear-facing car seat in the back seat (pref in middle) -infants in rear facing for 1st year until weighing 9.1 kg (20 lbs) rear-facing recommended till child reaches weight limit -in addition, a 5point harness or T-shield should be a part of the convertible restraint

prevention education for risk of motor vehicle/injury in infants and toddlers:

-use backward facing car seat until yr old and weighs at least 20 lbs -all car seats should be federally approved and be placed in the back seat

Postural drainage

-uses gravity to drain secretions from lungs --2-4 times daily for 20-30 mins -discontinue if patient feels weak or faint -delay for 1-2 hours after meals to avoid vomiting

CN X

-vagus -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech

heart sounds: S3

-ventricular gallop -produced by rapid ventricular filling -can be a normal finding in children and young adults -best heard with bell of steth

expected physical development (size): preschooler (3-6 yrs)

-weight: should gain about 2-3 kg (4.5-6.5 lbs) per year -height: should grow about 6.2-7.5 cm (2.5-3 in) per year

Examples of questions to use to determine need for problem solving and innovation:

-will a judgment need to be made while performing the task? -does it require nursing assessment skills?

What is the proper order for removing PPE?

1) gloves; 2) eyewear; 3) gown; 4) mask; [remember "m" comes last in the list alphabetically]

What is the correct sequence of steps for an abdominal assessment?

1) inspection; 2) auscultation; 3) percussion; 4) palpation

steps to assessing orthostatic BP changes

1) take client's BP and HR in the supine position 2) have client change to sitting or standing position 3) wait 1-5 mins 4) reassess BP and HR 5) client is experiencing orthostatic hypotension if SBP decreases >20 mm Hg and/or DBP decreases >10 mm Hg with a 10%-20% increase in HR

an older client's average body temperature is

36* C (96.8* F)

normal BP range

<120/80

stage II hypertension

>160/100

nursing process mnemonic

A--analysis D--data collection P--planning I--implementation E--evaluation

ADPIE

A= assessment data D= nursing diagnosis P= planning I= implementation of care E= evaluation of care

RN delegation to AP.

ADLs, bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning, bed making, specimen collecting, intake and output, vital signs (for stable pts).

AP delegation

ADLs, bathing, grooming,dressing, toileting, ambulating, feeding without precautions, positioning, bed making, specimen collection, i&o, vital signs for the stable

Ampules

Ampules are glass, single-use containers for liquid injectable medications. To access the medication, snap the top off at the scored neck. You must use a filter needle for withdrawing medication from an ampule to keep any glass particles from entering the syringe. Discard any excess medication into a sink or waste bin.

Intentions torts

Assault Battery False imprisionment

nursing process

Assessment Diagnosis Planning Implementation Evaluation

Ethical principles include

Autonomy, beneficence, fidelity, justice, nonmaleficence

which are health care regulatory agencies: A. ANA B. Jco C.NLN D.FDA

B,C,E

Unstageable Pressure Ulcer

Base of sound cannot be visualized true depth cannot be determined Full thickness tissue loss

A nutritional status measurement can be done using

Body mass index and prealbumin levels.

1. When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A. keep the sterile field at least 6 ft away from the client's bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. keep a box of facial tissues nearby for the client to use during the dressing change.

C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.

Most important factor when delegating tasks to an A.P.

Consider the facility's job description for the A.P.

IV Flow Rate

Determines how rapidly the infusion is delivered to the patient. On an infusion pump, the flow rate is set using using mL/hr. But you will not always have an infusion pump available, in which case you will have to adjust the rate manually in drops per minute. A basic formula for calculating an IV flow rate in drops per minute without medications is: volume (mL)/time (minutes) X drop factor (gtt/mL)= flow rate (gtt/min)

registered nurse (RN)

Edu. Prep: must meet the state board of nursing's requirements for licensure, requires completion of diploma prog, an associate degree, or baccalaureate degree in nursing prior to taking the licensure exam. Roles/Responsibilities: function legally under state nurse practice acts, perform assessments, establish nursing diagnoses, goals, and interventions; and conduct ongoing client evaluations, participate in developing interprofessional plans for client care, share appropriate info among team members; initiate referrals for client assistance, including health edu; and identify community resources.

licensed practical nurse (LPN)

Edu. Prep: must meet the state board of nursing's requirements, requires vocational or community college education prior to taking the licensure exam. Roles/Responsibilities: work under the supervision of RN, collaborate within the nursing process, coordinate the plan of care, consult with other team members, and recognize the needs for referrals to assist with actual or potential problems, possess technical knowledge and skills, and participate in delivery of nursing care, using the nursing process as framework.

unlicensed and licensed assistive personnel

Edu. Prep: must meet the state's formal or informal training requirements. requirement by most states for training and examination to attain CNA status. Roles/Responsibilities: work under the direct supervision of an RN or LPN. position description in the employing facility outlines specific tasks. tasks may include feeding, preparing nutritional supplements, lifting, basic care, measuring and recording vitals, and ambulating clients.

Planning

Establish priorities and optimal outcomes of care to measure and evaluate. Then select the nursing interventions to include in a clients pan of care to promote, maintain, or restore health.

Evaluation

Examine a clients response to nursing interventions and form a clinical judgement about meeting goals and outcomes.

Negligence

Fails to implement safety measures for client at risk of falls

Justice

Fairness in care delivery and use of resources

Dehydration

Fluid intake/retention does not meet body's fluid needs

Stage IV Pressure Ulcer

Full thickness tissue loss exposed bone, tendon or muscle slough/eschar undermining/tunneling

What causes Hypokalemia?

GI losses (vomiting, diarrhea), failure to replace potassium losses, reduced intake, disease, medication

Ethics committee

Generally address unusual or complex ethical issues

Equipment required for MRSA

Gloves, goggles and gown. Especially when spraying of bodily fluid is anticipated during procedure.

Federal regulations- law affecting nursing practice

HIPAA, A D A, M H P A, P S D A

ADH

Hormone that increases water reabsorption

Symptoms of hyperphosphatemia

Hypocalcemia, muscle problems (tetany), calcium-phosphate precipitates in skin, soft tissue, cornea, viscera and blood vessels

What do low phosphate levels indicate?

Impaired kidney function

IV Infiltration

Inflammation and clot formation Problem: The IV site is swollen, red, and warm. Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.) Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue. Prevention: Make sure the medication's concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency's policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.

the correct order for performing abdominal assessment techniques is:

Inspect, Auscultate, Percuss, Palpate

the correct order for completing a physical assessment (with exception to the abdomen):

Inspect, Palpate, Percuss, Auscultate

Selecting the appropriate needle size

Intradermal: 25-27 gauge, 3/8-5/8th ", 5-15 degree angle SubQ: 25-30 gauge, 3/8-5/8th", 45-90 degree angle IM: 18-25 gauge, 5/8-1.5", 90 degree angle

Why should soap not be added to the water in the basin when giving a bed bath

Irritation to the eyes can occur

Right task

Is repetitive, requires little supervision, and is relatively noninvasive for a certain client

medication reconciliation

JCo requires this, Nurse should compile list of current medications ensuring all are included with correct dosages & frequency. Compare list with new medication prescriptions & reconcile to resolve any discrepancies. This list becomes current for administration. This should be done; on admission, when transferring between units/ facilities & at discharge

Physical Therapist

Job: assess and plan for client to increase musculoskeletal functions, esp of lower extremities, to maintain mobility; direct care of physical therapy assistants Refer to when: ex- following a hip replacement, a client requires assistance learning to ambulate and regain strength

Occupational therapist

Job: assess and plan for the client to regain ADLs, esp motor skills of the upper extremities; direct care of occupational therapy assistants Refer to when: ex- client has difficulties using an eating utensil with dominate hand following a stroke

Speech therapist

Job: evaluate and make recommendations regarding the functions of speech, language, and swallowing impacted by various client disorders or injuries; teach client techniques and exercises to improve function when possible Refer to when: ex- a client is having difficulty swallowing a regular diet after trauma to the head and neck

Respiratory therapist

Job: evaluate resp status and provide prescribed resp treatments including O2 therapy, chest physiotherapy, inhalation therapy, and artificial mechanical ventilation Refer to when: ex- client with resp disease experiences SOB and requests nebulizer treatment that is ordered PRN

Rad Tech

Job: position client and perform x-rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts Refer to when: ex- provider orders x-ray of client's hip after a fall

Clergy

Job: provide spiritual care to client (pastors, rabbis, priests) Refer to when: the client requests communication or the family asks for prayer prior to client undergoing a procedure

Hypomagnesemia

Lower than 1.5 mEq/L

A nurse is caring for a patient who is on long-term bed rest and requires frequent linen changes due to excess diaphoresis. Which of the following is the priority rationale for frequent linen changes

Moisture from excessive diaphoresis can cause skin breakdown

LPNs may delegate to

Other LPNs and AP

RNs may delegate to

Other RNs, LPNs, and AP

Hypermagnesemia

Over 2.5 mEq/L

How to use a fire extinguisher

P - *PULL* the pin; A - *AIM* at the base of the fire; S - *SQUEEZE* the levers; S - *SWEEP* extinguisher from side to side, covering area of the fire

PIE

P-roblem I-ntervention E-valuation

to use a fire extinguisher:

PASS -pull the pin -aim at the base of the fire -squeeze the levers -sweep back and forth over the fire

Location of IV in an outpatient procedure

Place I.V. in the dorsal metacarpal vein. Anticubital requires immobilization of elbow. Nurses should choose the most distal vein available in upper extremity, then move up the arm for subsequent I.V. sites in needed.

IV Extravasation

Problem: The tissue around the IV site is pale or discolored and cool to the touch. Possible cause: Inadvertent administration of an irritant solution or medication into the surrounding tissue. Vasoconstrictors, calcium, and chemotherapy drugs are examples of drugs known to cause tissue necrosis with extravasation. The area of tissue damage varies with the concentration of the medication, the quantity of extravasated fluid, and the duration of the extravasation process. Assessment: The pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation and could ultimately become necrosed. Intervention: Extravasation is an emergent situation, as it can cause serious tissue necrosis. Stop the IV infusion and discontinue the IV line. Consult your agency's policy or a pharmacist for specific care of the extravasated tissue or use a medication manual to determine the appropriate care (for example, injection of phentolamine within the extravasation border). Follow your agency's policy for proper documentation. Establish new IV access in the opposite extremity if IV therapy must continue. Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. If central access is available, infuse solutions and medications known to cause tissue necrosis via central venous access.

IV Precipitation during Administration

Problem: While administering an IV bolus (push) medication, cloudiness or precipitation forms in the tubing. Possible cause: The line was not flushed properly with normal saline prior to injecting an incompatible medication. Intervention: Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. Follow your agency's protocol for wasting and crediting medication and prepare another dose to administer. Observe the site for signs of venous irritation. Prevention: Follow proper technique for flushing the IV line with normal saline before and after injecting IV medications.

Whats the best way to provide a client with privacy when assessing

Pull curtain shut in room

What type of edema is associated with fluid excess?

Pulmonary edema

RACE fire mnemonic

R- rescue patient A- alarm--set it off! C- contain E- extinguish

the fire response in the health care setting always follows the ____ sequence

RACE -Rescue: protect and evacuate clients in close proximity to the fire -Alarm: report the fire by setting off the alarm -Contain: close doors and windows as well as turning off any oxygen sources; clients on life support are ventilated with bag-valve mask -Extinguish: extinguish the fire if possible using an appropriate fire extinguisher

Korotkoff phase 2

Sound is a blowing, swishing or whooshing sound.

Korotkoff phase 1

Sound is a sharper thump or tapping that corresponds with the clients systolic blood pressure.

Korotkoff phase 3

Sound is crisp, intense tapping. This phase approximates the midpoint between the clients systolic and diastolic blood pressure.

Korotkoff phase 4

Sounds is soft, blowing, or muffled sound that fades.

Ethical theory

Standards of what is right or wrong with regard to important social values and norms.

Calculating Rate

Step 1: Convert the drug concentration to a like unit of dose measurement. Step 2: Convert the desired flow rate to an hourly rate if necessary. Step 3: Calculate the concentration of the drug in 1 mL of fluid. Step 4: Enter the known and calculated factors into the formula and solve. mg/hr over mg /mL= rate (top and bottom unit must be the same (ex, mg, mcg, kg etc) and always must be concentration of drug in 1 mL of fluid.

who would explain to a patient the risks/benefits of surgery, consequences of not having surgery, and alternatives to surgery?

THE SURGEON

Guaic

Test for hidden microscopic blood in stool. Also a good way to screen for colon cancer.

A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task

The AP reuses the patient's blanket and spread

Initiating IV Therapy

The cephalic, basilic, and median cubital veins in the hand and forearm are the veins most often used for initiating intravenous (IV) therapy. This is because they are larger, easier to puncture, and less likely to rupture than the other veins in the hand and arm are Place the patient's extremity in a dependent position and apply a tourniquet around the arm to distend the veins. Place the tourniquet above the antecubital fossa or approximately 4 to 6 inches (10 to 15 centimeters) above the anticipated site. If the patient has fragile skin or a tourniquet is not available, use a blood-pressure cuff instead. When inspecting the patient's hand and arm for an IV site, begin by looking at the most distal part and move proximally. Select a vein that is well-dilated and one that feels soft with palpation and bounces back when you release the pressure. Avoid using veins in an extremity with compromised circulation and those that are distal to previous IV sites. Also avoid sclerosed or hardened veins, bruised areas, and areas where there are valves or bifurcations. If the patient has excessive body hair, do not shave the area; instead, clip the hair with scissors. Shaving can cause microabrasions that increase the risk for infection. Which size IV catheter to use depends on the patient and on the reason for IV therapy. For most adults, a 20- to 22-gauge catheter is adequate for infusing fluids and medication. A 22- to 24-gauge catheter is best for children, older adults, and anyone who has small or fragile veins. If the patient will receive large quantities of fluids at a rapid rate or blood or blood products, use a larger catheter, such as an 18-gauge. In addition to the IV catheter, you will also need a tourniquet or a blood-pressure cuff, an antimicrobial wipe, several small gauze pads, tape, a transparent dressing, and gloves. Some facilities provide all the necessary supplies in an "IV start kit." If your patient will receive a continuous infusion, you'll also need the prescribed bag of fluid and an infusion set (tubing). Before starting the infusion, spike the bag of fluid and prime the tubing. In many situations, a pharmacist will add any prescribed medications, vitamins, or electrolytes to the IV fluid, but if you are adding any of these, be sure to put a label on the bag indicating what you added and the amount, date, and time, plus your initials or signature and any other information your facility's policy requires. Also, put a piece of time tape on the bag to help you monitor the flow rate. If your patient will not have a continuous infusion, initiate a saline lock, also called a heparin lock. A saline lock consists of an IV catheter and a short piece of extension tubing. Since fluids do not infuse continuously through a saline lock to maintain patency of the IV line, you must flush the lock usually with normal saline, 5 to 10 mL, before and after you administer each medication or at regular intervals. Specific procedures for flushing a saline lock vary with the facility, so be sure to familiarize yourself with your facility's policy. Once you have pierced the skin and thread the catheter a short distance into the vein, pull the needle back so that the tip is not extending past the end of the catheter. Then thread the catheter into the vein until the hub of the catheter is resting against the skin at the insertion site. Remove the needle the rest of the way, activate the safety device, and dispose of the needle in the sharps container. Finally, secure the flexible catheter in place for the administration of fluids and medications. Older patients' skin tends to be thinner and their veins more fragile and superficial with a tendency to roll. To avoid bruising or tearing the skin, use a tourniquet sparingly. When inserting the catheter, be sure to pull the skin below the insertion site taut to stabilize the vein. Also, use a lower angle of insertion to avoid puncturing the posterior wall of the vein. When selecting an IV site, try to avoid the veins in the hand and the dominant arm since these sites can make it difficult for an older patient to perform activities of daily living. Use a smaller catheter, such as a 22-gauge. To secure the catheter, use minimal tape to avoid irritating or traumatizing the skin. If possible, use a mesh dressing instead. If your patient is restless or confused, use an arm board or a commercially available protective device to protect the IV site.

Morals

The values and beliefs that guide behavior and decision making

Specialized IV Access devices

These devices include peripherally inserted central catheters (PICCs), implantable venous access devices, and central venous catheters (CVCs). Specialized access devices are most often used for: frequent or recurrent blood sampling for laboratory tests an alternative to poor peripheral venous access delivery of vasoactive medications infusion of total parenteral nutrition (TPN) large-volume or recurrent blood transfusions long-term infusion of medications, such as antibiotics or chemotherapy continuous monitoring of central venous pressure assessment of hypovolemia or hypervolemia placement of a pulmonary artery catheter a transvenous pacemaker

What infections require *contact* precautions?

Think MRS. WEE M = multi-drug resistant organisms [e.g.,MRSA, VRSA]; R = respiratory infections [e.g., RSV]; S = skin infections [e.g., impetigo]; W = wound infections; E = enteric [e.g., c-diff, hep A]; E = eye infections [e.g., conjunctivitis]

What infections require *airborne* precautions?

Think of..."My Chicken Has TB" - Measles; - Chicken pox (varicella zoster); - Herpes zoster (shingles); - TB - also SARS *Note that varicella zoster and herpes zoster also require contact precautions

Nontunneled Catheter "subclavian, percutaneous, acute-care, or short-term catheters"

This type of catheter is usually inserted into the internal jugular or subclavian vein, with the catheter tip resting in the superior vena cava just above the right atrium. Occasionally, the femoral vein is used, with the tip resting in the inferior vena cava. Insertion method is percutaneous venipuncture. Nontunneled catheters most often have dual or triple lumens. Indications for placement of this type of catheter include intravenous therapy, blood sampling, and central venous pressure monitoring. Dwell time (how long the catheter stays in place) for a nontunneled catheter is typically 3 to 4 weeks. Because a nontunneled catheter protrudes externally and because there is no subcutaneous tunneling, the risk for infection is greater than with other central venous access devices. Also, since the vein is punctured directly above the lungs, the risk of pneumothorax is considerable.

Assault

Threat or fear

Administration of Medications via PICC line

To ensure placement of the catheter in the vascular space, assess for venous blood return and patency before beginning any IV infusion. Connect a normal saline-filled 10-mL syringe to the catheter's access port, release the catheter's clamp, and gently aspirate to verify blood return. Flush with up to 10 mL of normal saline using a "push-pause" motion. This technique causes the flush solution to swirl within the catheter, which clears the line and maintains patency. Avoid using syringes with less than a 10-mL volume for flushing or instilling medication. After flushing the line, continue with medication administration or IV infusion. Always cleanse the access port before attaching the infusion tubing or the medication syringe. Adequate flushing after medication administration is the most important factor for preventing the occlusion of a PICC by blood, fibrin, or medication residue. Using a 10-mL syringe filled with normal saline, inject the saline, again using the push-pause motion to create turbulence within the catheter.

Why is it important to perform oral care

To help reduce oral bacteria and keep the oral cavity moist

Providone-Iodine is used for what?

To prepare the skin to invasive procedures. It is not effective for protecting the skin of a client who experiences fecal incontinence.

Footboard

Used to prevent foot drop

How should a bed bath be given

Using long, firm strokes and proceeding from the distal to the proximal areas

Medication from a vial

Vials may be single-use, or, if a preservative has been added to the solution, multidose. 1. Cleanse the top of the vial with alcohol wipe 2.Pressurize the vial (amount of air must equal medication you are withdrawing) 3. Invert vial and withdrawal fluid (needle must be below level of fluid) 4. tap the syringe and get rid of any air bubbles.

leukocytosis

WBCs greater than 10,000

Male perineal cleaning

Wash the patient's upper thighs and inguinal area. Draping a male patient for perineal care involves placing a bath blanket over his abdomen and covering his legs with a sheet or towel. Once you have organized all supplies and you are ready to begin providing care, fold the blanket or towel back to expose the perineal area.

What causes Hypernatremia?

Water loss or sodium gain (severe perspiration; severe watery diarrhea; administration of hypertonic sodium solution; near salt water drowning)

Assessing and managing an IV site

When you begin your assessment of an IV site, start by inspecting it for any redness or swelling. Next, palpate the area around the site and along the vein for any pain, firmness, or swelling. While palpating, be sure to note the skin temperature near the site and along the vein, especially if you note any redness. A peripherally inserted venous catheter is usually replaced every 72 to 96 hours or per your agency's policy. All patients with IV access are at risk for developing IV-related complications, such as phlebitis and infiltration. Those receiving hypertonic, acidic, or irritating fluids or medications; patients with fragile veins; and pediatric patients, however, are at higher risk and require especially frequent assessment. Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. Infiltration results when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by edema, pallor, decreased skin temperature around the site, and pain. Consult your agency's policy for treatment, which usually involves discontinuing the IV line and elevating the extremity. It may also recommend applying a warm compress at the site to help absorb the fluid. Another complication of IV therapy is extravasation. This term is sometimes used interchangeably with infiltration but more accurately describes a situation when an IV catheter becomes dislodged and medication infuses into the tissues. Extravasation is characterized by pain, stinging or burning at the site, swelling, and redness. Follow your agency's policy for treatment, which will likely include discontinuing the IV line and applying a cool compress to the area. If the medication has an antidote, it should be prescribed and administered immediately.

When is a problem an ethical dilemma?

When: - A review of scientific data is not enough to solve it. - It involves a conflict between two moral imperatives. - The answer will have a profound effect on the situation and the client.

open bed

a bed prepared in a hospital room with the top covers folded back to make it easy for the patient to get into the bed

closed bed

a bed prepared in a hospital room with the top sheet, blanket, and bedspread drawn up to the head of the mattress under the pillows

fissure

a break, slit, or tear in soft tissue, often at the junction of skin and mucous membrane

athlete's foot (tinea pedis)

a chronic superficial fungal infection of the skin of the feet, typically between the toes

postural (orthostatic) hypotension is a BP that falls when

a client changes position from lying to sitting or standing; may be caused by peripheral vasodilation, medication side effects, fluid depletion, anemia, prolonged bedrest

Durable Power of Attorney for Health Care

a document in which lcients designate a health care proxy to make health care decisions for them if they are unable to do so; may be any competent adult the client chooses

thrush

a fungal infection in the mouth and/or throat caused by Candida albicans and manifesting as white patches and ulcers

What is flexion?

a movement that *decreases* the angle

What is extension?

a movement that *increases* the angle

pulse oximetry is

a noninvasive, indirect measurement of oxygen saturation of the blood (SaO2)

malpractice

a nurse administers a large dose of meds due to a calculation error. the client has cardiac arrest and dies.

negligence

a nurse fails to implement safety measures for a client at risk of falls.

breach of confidentiality

a nurse releases a client's medical diagnosis to a member of the press.

defamation of character

a nurse tells a coworker that she believes the client has been unfaithful to her spouse.

impaired coworkers

a nurse who suspects a coworker of any behavior that jeopardizes client care or could indicate substance use disorder has a duty to report the coworker to the appropriate manger. each state has laws and regulations that govern the disposition of nurses who have substance use disorders. criminal charges could apply.

false imprisonment

a person confined or restrained against his or her will

false imprisonment

a person is confined or restrained against his will

external emergency readiness includes:

a plan for participation in community-wide emergencies and disasters

ethical decision making

a process that requires striking a balance between science and morality. steps: 1. identify whether the issue is indeed an ethical dilemma. 2. state the ethical dilemma, including all surrounding issues and individuals involved. 3. list and analyze all possible options for resolving the dilemma, and review implications of each option. 4. select the option that is in concert with the ethical principle that applies to this situation, the decision maker's values and beliefs, and the profession's values for client care. 5. apply this decision to the dilemma, and evaluate the outcomes.

Narrative documentation records information as

a sequence of events

plantar wart

a skin lesion on the sole of the foot typically caused by any of the human papillomaviruses

borborygmi

abnormal loud bowel sounds from fast motility

tachycardia is

above expected range or faster than 100 bpm

supraclavicular nodes located

above the clavicles

height that you need to keep sterile things

above your waist

absence

absence of breath sounds from collapsed or surgically removed lobes

situations that have mandatory reporting

abuse communicable disease diagnosis (TB, hep)

humility

acknowledges weaknesses

pustule example

acne

isolation guidelines

actions that include hand hygiene and the use of barrier precautions, which intend to reduce the transmission of infectious organisms. precautions apply to every pt, regardless of diagnosis, and implementation of them must occur whenever there's anticipation of coming into contact with a potentially infectious material. change PPE after contact with each pt, and between procedures with the same pt if in contact with large amounts of blood and body fluids. assist pt and their family to understand the reason for isolation and provide sensory stimulation. standard precautions: tier one, transmission precautions: tier two, droplet precautions, contact precautions.

lunula

active area of nailbed growth at the base of the fingernails and toenails

Continuing health care

addresses long-term or chronic health care needs ex: end-of life care, palliative care, hospice, adult day care, and in home respite care

Continuing HC

addresses long-term or chronic health care needs. ex. end-of-life care, palliative care, hospice, adult day care, and in-home respite care.

transpersonal communication

addresses spiritual needs and provides interventions to meet those needs

responsibility

adheres to standards of practice

adaptation

adjustment to changes in circumstances such as those resulting from illness or disability

electronic health records

advantages include standardization, accuracy, confidentiality, easy access for multiple users, and rapid acquisition and transfer of client's info. challenges include learning the system, knowing how to correct errors, and maintaining security.

basic principles of ethics for nurses (4)

advocacy responsibility accountability confidentiality

basic principles of ethics

advocacy, responsibility, accountability, and confidentiality.

Basic principles of ethics

advocacy, responsibility, accountability, confidentiality.

fidelity

agreement to keep promises

expected findings for the Rinne test

air conduction (AC) greater than bone conduction (BC); 2:1 ration

by weight

amount prescribed * kg weight (mg* kg )= TDD TDD/ #of doses per day = amount per dose ^use this as desired

percussion of the thorax resulting in dullness is

an abnormal finding and caused by fluid or solid tissue; can indicate pneumonia or a tumor

hyperthermia is

an abnormally elevated body temp

hypothermia is

an abnormally low body temp; a body temp below 35* C (below 95* F)

hypertrophy

an enlargement of muscle due to strengthening

extension

an extension of the angle

Intuition

an inner sensing that something is not currently supported with fact. Intuition should spark the nurse to search the data to confirm or disprove the "feeling." The nurse should ponder the following: -"Did the vital signs reflect any changes that would account for the client's present status?" -"When the client's status changed in this way last month, there was a specific reason for it. Is that what is happening here?"

discharge planning

an interprofessional process that starts at admission

dysrhythmia is

an irregular heart rhythm often noted as an irregular radial pulse

during palpation, the fingers and thumb are used to grab:

an organ or mass

independence

analyzes ideas for logical reasoning

tonsillar lymph node located

angle of mandible

vector borne

animals or insects as intermediaries.

What are the modes of transmission for vector borne pathogens?

animals or insects; [e.g., ticks transmit Lyme disease and mosquitoes transmit West Nile and malaria]

treatment for botulism

anti-toxin

stomatitis

any inflammatory disorder of the mouth

perceived loss

any loss defined by the patient that is not obvious or verifiable to others

situational loss

any unanticipated loss caused by an external event

standard precautions: tier one

applies to all body fluids except sweat, nonintact skin, and mucous membranes, implemented for all pt. hand hygiene using an alcohol-based waterless product is recommended after contact with the pt, body fluids, and contaminated equipment and articles, and after removal of gloves. alcohol-based waterless antiseptic is preferred unless the hands are visibly dirty, because alcohol-based product is more effective in removing organisms. clean gloves worn when touching all body fluids, nonintact skin, mucous membranes, and contaminated equipment and articles. remove gloves and complete and hygiene between pt. masks, eye protection, and face shields are required when care may cause splashing or spraying of body fluids, gloves are worn when toughing anything that has the potential to contaminate the hands of the nurse. hand hygiene is required after removal of gown. use a sturdy moisture resistant bag for soiled items, and tie the bag securely in a knot at the top. properly clean equipment for pt care, dispose of one-time use items according to facility policy. bag and handle contaminated laundry to prevent leaking or contamination of clothing or skin. enable safety devices on all equipment and supplies after use; dispose of all sharps in a puncture resistant container. pt doesnt need a private room unless unable to maintain appropriate hygiene practices.

fanfolding

applying the proximal half of a piece of linen in successive layers lengthwise for the purpose of tucking it under the patient and rolling the patient over it while stripping or making an occupied bed

perineum

area between the anus and the posterior portion of the external genitalia

shiny and translucent skin without hair on toes and foot is seen with

arterial insufficiency

what should a nurse do if an orthodox jewish family has a stillborn baby?

ask the family if there is any special rituals that they would like to do

intentional torts

assault, battery, and false imprisonment

absence of breath sounds should:

be noted

legal guidelines

begin each entry with a date and time, record entries legibly, in nonerasble black ink, and dont leave blank spaces in the nurse's notes. dont use correction fluid, erase, scratch out, or blacken out errors in the medical records. make corrections promptly following the facility's procedure for error correction. sign all documentation as the facility requires, generally with name and title. documentation should reflect assessments, interventions, and evaluations, not personal opinions or criticism of others care.

telephone or verbal prescriptions

best to avoid these, but they are sometimes necessary during emergencies and at unusual times. have a second nurse listen to a telephone prescription, repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. question any prescription that may seem inappropriate for the client. make sure the provider signs the prescription in person within the time frame the facility specifies typically 24 hrs.

overweight BMI

between 25 and 30

What is surfactant?

- fatty protein that reduces surface tension in the alveoli; - alveolar walls have cells that secrete surfactant - without surfactant alveolar collapse [aka atelectasis] - this results in decreased gas exchange because of the decreased alveolar surface area

Soft/low-residue diet

- foods that are low in fiber and easy to digest; - dairy products and eggs, such as custard and yogurt,

nursing interventions to *reduce skin injury and maintain metabolism*

- high-calorie and high-protein diet with vitamin B and C supplements; - monitor and evaluate oral intake; - for clients who cannot eat or drink, provide enteral or parenteral nutritional therapy

What is the purpose of an oil-retention enema

- often given to soften stool before digital removal of fecal impaction; - to lubricate the rectum and the colon; - the oil is absorbed by the feces, making them softer and easier to pass; - instruct patients to retain the enema for as long as possible, usually 30 to 60 minutes if possible

How does consuming adequate fluids help prevent infection?

- prevents stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms; - also keeps the skin from breaking down -- intact skin prevents micro-organisms from entering the body

Fats

- provide energy and vitamins; - each gram produces 9 kcal; - no more than 30% of caloric intake should be from fat; - sources include olive oil, salmon, and egg yolks

Carbohydrates

- provide most of the body's energy and fiber; - each gram produces 4 kcal; - sources include whole grain breads, baked potatoes, and brown rice

nurses role in advance directives

- provide written info about AD -document client's AD status -ensure AD reflect client's current decisions -inform all members of health care team of client's AD

What signs and symptoms present during the 1st stage of inflammatory response / local infection?

- redness [from dilation of the arterioles bringing blood to the area]; - warmth of area on palpation; - edema; - pain or tenderness; - loss of use of the affected part

nursing interventions to *maintain airway patency, achieve optimal lung expansion and gas exchange, and mobilize airway secretions*

- reposition every 1 to 2 hr; - instruct to turn, cough, and breathe deeply every 1-2 hr while awake; - instruct to use an incentive spirometer; - remove abdominal binders every 2 hr and replace correctly; - chest physiotherapy -- auscultate lungs to determine effectiveness of chest physiotherapy or other respiratory therapy; - instruct to consume at least 2,000 mL of fluid per day, unless restricted; - monitor ability to expectorate secretions; - suction if unable to expectorate secretions

components of the General Adaptation Syndrome (GAS)

-Alarm reaction: body functions are heightened to respond to stressors -Resistance stage: body functions normalize while responding to the stressor; the body attempts to cope with the stressor -Exhaustion stage: body functions are no longer able to maintain a response to the stressor

Types of intentional torts

-Assault -Battery -False imprisonment

Right circumstance

-Assess the health status and complexity of care required by the client -match complexity of care demands to skill level if team member -consider the workload of the team member

Types of quasi-intentional torts

-Breach of confidentiality -Defamation of character

health promotion (health risks): older adult (65+ yrs)

-CV diseases include: CAD, HTN, stroke -factors affecting mobility include: arthritis, osteoporosis, falls -mental health disorders include: depression, dementia, suicide -other disorders include: diabetes mellitus, cancers, incontinence, abuse and neglect, cataracts, alcoholism, pain

Hypocalcemia

-Ca defecit in ECF -serum Ca <8.9mg/dL, ionized Ca <4.5mg/dL

The 3 classes of fire extinguishers:

-Class A: for paper, wood, upholstery, rags, or other types of trash fires -Class B: for flammable liquids and gas fires -Class C: for electrical fires

What are signs and symptoms of *dehydration*?

-Dry mucous membranes; Dry tongue; Sunken eyeballs; -Hypotension; Tachycardia; Fever; -Poor skin turgor; Decreased urine output; -Confusion; Upper body weakness; Decreased weight

Documentation must be: F___, A___ & C___, C___ & C___, and O___.

-Factual -Accurate & Concise -Complete & Current -Organized

Registered Nurse (RN)

-Functions under state nurse practice laws -Perform assessments; establish nursing diagnoses, goals, and interventions; conducts ongoing client evaluations -Participate in developing interdisciplinary plans for client care -Share best practices; continuing education

Federal laws impacting nursing practice include:

-HIPAA -ADA -the Mental Health Parity Act (MHPA) -the Patient Self-Determination Act (PSDA)

cardiac output (CO) is determined by

-HR -contractility -blood volume -venous return

What is SVR (systemic vascular resistance)? What're the normal values?

-How much resistance the left ventricle pushes against to get blood volume out -900-1600 dynes/sec/cm

Unlicensed Assistive Personnel (UAP)

-Includes CNAs, CMAs, and non-nursing personnel -Work under direct supervision of an RN or LPN -Specific tasks usually outlined in position description -Tasks may including feeding clients, preparing meals, lifting, basic care, measuring & recording vital signs, and ambulating clients

What is PCWP (pulmonary capillary wedge pressure)? What're the normal values?

-Measures *left* ventricular end-diastolic pressure (left ventricle preload) -4-12mmHg

What is CVP (central venous pressure)? What're the normal values? At what numbers are you concerned at?

-Measures rest in the right atrium -2-6 mmHg -10< mmHg and you are not a cardiac patient

Causes of hypomagnesemia

-NG suction -diarrhea -withdrawal from alcohol -admin of tube or parenteral nutrition -sepsis -burns

primary prevention

-addresses the needs of healthy clients to promote health and prevent disease with specific precautions -examples: immunizations programs; child car seat education; nutrition and fitness activities; health education in schools

expected psychosocial development (body-image changes): older adult (65+ yrs)

-adjustments to decreases in physical strength and endurance may be difficult, esp for older adults who are cognitively active and engaged -many feel frustrated that their bodies are limiting what they desire to do

factors that affect the client's ability to protect himself include:

-age, with young and old at greatest risk -mobility cognitive -sensory awareness -emotional state -lifestyle -safety awareness

respiratory rate factors

-age- decreases with age infants- 30-60, school aged 20-40, 12-20 -pain- increases before stabilizing, decreases depth -brainstem injury- decreases rate & rhythm -impaired o2- 95-100 % norm, below 85% abnorm -cherk RR in semifowlers

Nurse's roles in ethical decision making include:

-agent for client facing an ethical decision: adolescent child debating on abortion; parent contemplating blood transfusion even when against religious beliefs -decision maker in regard to nursing practice: increasing staff load due to shift cuts; witnessing a surgeon discussion only surgical options without informing client of more conservative options

tertiary prevention

-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning -examples: prevention of pressure ulcers as complication of a spinal cord injury; promoting independence for the client who has traumatic brain injury

transmission precautions (tier 2) include:

-airborne precautions -droplet precautions -contact precautions

surgical asepsis

-aka "sterile technique" -the use of precise practices to eliminate all micro-organisms from an object or area -used for parenteral med administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures

levels of consciousness

-alert-responsive, fully responds -lethargy- open eyes & respond but is drowsy & falls asleep repeatedly -obstruction- needs to be lightly shaken -stupor- painful stimuli to achieve brief response, sometimes not verbally - coma- 3 on glasgow coma scale, no response, abnormal posturing

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

home safety risks for infants and toddlers include:

-aspiration -suffocation -poisoning -falls -motor vehicle/injury -burns

Right person

-assess and verify the competency of the team member -continually review the performance of the team member & determine competency of care -assess team member performance based on standards & remediate if needed

health promotion (injury prevention-poisoning): preschooler (3-6 yrs)

-avoid exposure to lead paint -keep plants out of reach -place safety locks on cabinets with cleaners and other chemicals -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detector in home

health promotion (injury prevention-poisoning): toddler (1-3 yrs)

-avoid exposure to lead paint -place safety locks on cabinets with household cleaners/chemicals -keep plants out of reach -keep poison control number by phone -keep meds in childproof container and out of reach -have working carbon monoxide detector in home

health promotion (nutrition-weaning): infant (birth-1 yr)

-can be accomplished when infant is able to drink from a cup (sometime after 6 months) -replace 1 feeding with breast milk/formula in a cup -bedtime feeding is last to be replaced

prone position

-client lies flat on abdomen with head to one side -position promotes drainage from the mouth of clients following throat or oral surgery, but inhibits chest expansion

supine or dorsal recumbent position

-client lies on his back with head and shoulders elevated on a pillow; client's forearms may be placed on pillows or placed at side; foot support prevents footdrop and maintains proper alignmentl

sims' or semi-prone position

-client lies on side halfway between lateral and prone positions; weight is on anterior ileum, humerus, and clavicle; lower arm behind client while upper arm is in front; both legs flexed but upper at greater anger than lower at hip and knee -this is a comfortable sleeping position for many clients and promotes oral drainage

indications for transfer and discharge

-client's level of care has changed -another setting is required to provide necessary client care -facility does not offer type of care now required -client no longer needs inpatient care and is ready to return home

expected psychosocial development (moral development): toddler (1-3 yrs)

-closely associated with cognitive development -egocentric: unable to see another's perspective; can only view things from their POV -punishment and obedience orientation begins with sense that good behavior is rewarded and bad behavior is punished

Nurses should be aware that all health care institutions have color-codes designated for emergencies: some examples include:

-code red (fire) -code pink (newborn abduction) -code orange (chemical spill) -code blue (mass casualty incident) -code gray (tornado) **may vary by institution**

bowel

-collect stool specimen for serial fecal occult test (guaiac -fiber requirement 25-30 -foods high: whole grains, fruits, veggies

health promotion (health screenings): preschooler (3-6 yrs)

-vision: myopia and amblyopia can be detected and treated before poor visual acuity impairs the learning environment

expected cognitive development (language): preschooler (3-6 years)

-vocabulary continues to increase -can now speak sentences, is able to identify colors, enjoys talking

expected psychosocial development : adolescent (12-20 yrs)

-vocationally: work habits begin to solidify; plan for future college and career -sexually: increased interest in opposite gender -health perceptions: may view themselves as invincible to bad outcomes of risky behaviors

Social Worker

Job: work with client and client's family by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and/or discharge Refer to when: ex- client dying of cancer wishes to go home but is unable to perform ADLs; the spouse needs med equipment in the home to care for client

What is not appropriate for oral hygiene for a patient that removes moisture from the oral cavity and that damages tooth enamel

Lemon-glycerin swabs

Client with fecel incontinence

Nurse needs to ensure that their clients skin in dried after cleansing. This will decrease the risk of further skin breakdown.

Factors influencing formation and wound healing

Nutrition, tissue perfusion, infection, age, psychosocial

PIE

P-problem. I-intervention. E-evaluation.

Delegating

Process of transferring authority and responsibility to another member of the health care team to complete a task, while retaining accountability

Ethical decision making

Process that requires striking a balance between science and morality

Warm bath

Promotes relaxation and can assist with sleeping problems. Sleeping medication should be last on the priority list of resolutions.

Civil laws

Protect individual rights.

Implementation

Provide care based on assessment data, analysis, and the plan of care.

maturational or developmental loss

any loss normally expected due to developmental processing of life, losses are associated with normal life transitions and help to develop coping skills

actual loss

any loss of a valued person, item, or status, such as a job

neuropathy

any of numerous disturbances or pathologic changes in the peripheral nervous system, most often affecting sensation

right person

assess and verify the competence of the team member, the task must be within the team member's scope of practice and must have the necessary competence and training. continually review the performance of the team member, and determine care competence, assess the team member's performance according to standards, and when necessary, take steps to remediate any failure to meet standards.

right circumstance

assess the health status and complexity of care the client requires, match the complexity of care demands to the skill level of the team member, consider the workload of the team member.

PT

assesses and plans for pt to increase musculoskeletal function, esp. of the lower extremities, to maintain mobility. ex. of when to refer: following hip arthroplasty, a pt requires assistance learning to ambulate and regain strength.

Accountability

ability to answer for one's own actions

accountability

ability to answer for one's own actions

accountability

ability to answer for one's own actions.

hyperthermia

abnormally elevated temperature

antipyretics

acetaminophen and aspirin. used for fever and discomfort as prescribed. considerations: monitor fever to determine effectiveness of medication, graph the pt temp fluctuations on the medical record for trending.

effects of hyperchloremia

achypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, and coma.

certified registered nurse anesthetist (CRNA)

administers anesthesia and provides care during procedures under the supervision of an anesthesiologist.

expanded nursing roles

advanced practice nurse (APN), clinical nurse specialist (CNS), nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), nurse educator, nurse administrator, nurse researcher.

guidelines for cleaning contaminated equipment

always wear gloves and protective eyewear. rinse first with cold water, wash the article with warm water with soap. use a brush or abrasive to clean corners or hard-to-reach areas, rinse well in warm water, dry the article. clean the equipment used in cleaning and the sink. remove gloves and perform hand hygiene.

pulse deficit is

an apical rate faster than the radial rate; with dysrhythmias, the heart may contract ineffectively, resulting in a beat heard at the apical site with no pulsation felt at the radial pulse point

The foundation of ethics is based on:

an expected behavior of a certain group in relation to what is considered right and wrong; it is the study of conduct and character

hyperextension

an extreme extension

intuition

an inner sensing that facts dont currently support something. should spark the nurse to search the data to confirm or disprove the feeling.

provider

assesses, diagnoses, and tx disease and injury. includes medical doctors, doctors of osteopathy, advanced practice nurses, and physician assistants. state regulations vary in their requirements for supervision of APNs and PAs by a physician. ex. of when to refer: a pt has a temp of 39 degree C (102.2 degree F), is achy, shaking, and reports "feeling cold".

registered dietitian

assesses, plans for, and educates regarding nutrition needs. designs special diets, and supervises meal preparation. ex. of when to refer: a pt has a low albumin level and recently had an unexplained weight loss.

Paternalism

assumption that one person can assume responsibility for making the decisions of another person

principles of treatment for patients (5)

autonomy--right to make own decisions beneficence--positive actions to help others fidelity--keeping promises justice--fairness in care delivery nonmaleficence--avoidance of harm/injury

maintaining sterile field

avoid coughing, sneezing, and talking directly over a sterile field. advise pt to avoid sudden movements, refrain from touching supplies. only sterile items may be in sterile field. outer wrappings and 1-inch edges of packages that contains sterile items arent serile. the inner surface of the sterile drape or kit is the sterile field that needs to be avoided. to position field on the table surface, grasp the border before donning sterile gloves, discard any object that comes into contact with the border. touch sterile materials only with sterile gloves, consider any object held below waist or above chest contaminated, sterile materials may touch other sterile surfaces or materials; microbes can move by gravity from a nonsterile item to a sterile item so dont reach across or above a sterile field, dont turn your back on a sterile field, hold items to add to a sterile field at a minimum of 6 inches above field. any sterile, nonwaterproof wrapper that comes into contact with moisture becomes nonsterile by wicking action, keep all surfaces dry, discard any sterile packages that are torn, punctured or wet.

Factors to consider when selecting a delegated

-education, training, and experience -knowledge and skill required to perform the task -level of critical thinking required to complete the task -ability to communicate with others as it pertains to the task -demonstrated competence -agency policies and procedures -licensing legislation (state nurse practice acts)

pulmonary hygiene for immobile clients

-includes turning, coughing, deep breathing, incentive spirometry -done every 2 hrs or as prescribed -decreases growth of micro-organisms and development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance which expands the lungs

adult BP tends to ___ with age and older adults may have a slightly ___ SBP due to ___ elasticity of blood vessels

-increase -elevated -decreased

expected psychosocial development (body-image problems): infant (birth-1 yr)

-infant discovers mouth is a pleasure producer -hands and feet are seen as objects of play -discovers smiling causes others to react

expected age-appropriate activities: infant (birth-1 yr)

-infants have short attention spans and participate in solitary play -appropriate toys and activities: rattles, mobiles, teething toys, nesting toys, pat-a-cake, playing with balls, reading books

expected psychosocial development (Erikson: trust vs mistrust): infant (birth-1 yr)

-infants trust that their feeding, comfort, stimulation, and caring needs will be met -social development initially influenced by infant's reflexive behavior and includes attachment, separation recognition/anxiety, and stranger fear -attachment seen when infant begins to bond with parents; this development occurs w/in 1st month; process is enhanced when the infant and parents are in good health, have positive feeding experiences, and receive adequate rest -separation recognition occurs during the 1st year as learning physical boundaries from that of other people; learning how to respond to people is next phase in development; positive interactions with parents, siblings, and other caregivers help est. trust -separation anxiety develops between 4-8 months; will protest loudly when separated from parents -stranger fear becomes evident between 6-8 months when children are less likely to accept strangers

health promotion (injury prevention-falls): toddler (1-3 yrs)

-keep doors and windows locked -keep crib mattress in lowest position with rails all the way up -use safety gates across stairs

health promotion (injury prevention-bodily harm): school-age (6-12 yrs)

-keep firearms in a locked cabinet or box -assist with identifying "safe" play areas -teach stranger safety -teach to wear helmets and pads when needed

health promotion (injury prevention-bodily harm): adolescent (12-20 yrs)

-keep firearms in locked cabinet or box -teach proper use of sporting equipment prior to use -insist on helmet and/or pads when appropriate -avoid trampolines -be aware of changes in mood and monitor for self-harm in at-risk children (poor school performance, lack of interest in things once interested in, social isolation, disturbances in sleep patterns or appetite, expression of suicidal thoughts)

health promotion (injury prevention-bodily harm): preschooler (3-6 yrs)

-keep firearms in locked cabinet/container -teach stranger safety -wear helmets when riding bike/helmet and pads when participating in physical activity

prevention education for risk of poisoning in infants and toddlers:

-keep house plants and cleaning agents out of reach -place poisons, paint, and gas in locked cabinets -keep medication in child-proof containers and locked up -dispose of meds which are no longer used or out of date

factors leading to bradycardia include:

-long-term physical fitness -hypothermia -medications -changing position from standing/sitting to lying down -chronic pain -hypothyroidism

pallor

-loss of color: best noted in face, conjunctivae, nail beds, palms -indication of anemia or lack of blood flow

internal emergencies include:

-loss of electric power or potable water and -severe damage or casualties w/in the facility related to fire, weather, an explosion, or terrorist act

ulcer

-loss of epidermis and dermis with possible bleeding and scarring -example: venous stasis ulcer or pressure ulcers

erosion

-lost epidermis, moist surface, no bleeding -example: ruptured vesicle

infants have a ___ BP that gradually ___ with age

-low -increases

circadian (diurnal) rhythms affect BP, with BP usually ___ in the early morning hours and ___ during the later part of the afternoon/evening

-lowest -peaking

feedback

-may be verbal and/or nonverbal, positive and/or negative -the message returned to the sender by the receiver that indicates the message was received -an essential component of ongoing communication

Examples of tasks that can be delegated to LPNs

-monitoring client findings -reinforcing client teaching from a standard care plan -trach care -suctioning -checking NG tube patency -admin enteral feedings -inserting urinary cath -admin meds (exc IV in most states)

expected cognitive development (language development): infant (birth-1 yr)

-responds to noises -vocalizes with "ooos" and "aahs" -laughs and squeals -turns head to sound of a rattle -pronounces single-syllable words -begins speaking two and then three-word phrases

measuring BP

-rest 5 min before; no caffine/smoking 30 min before -not on side with IV/ mastectomy or shunt -use arm with higher vascular reading -sit,feet flat, arm at heart level -inflate to 30mmHg above palpated systolic & release at 2/3mmHg per sec -measure standing after initial; 2 min apart

health promotion (injury prevention-MVA): school-age (6-12 yrs)

-restrained in car seat or booster seat until adult seat belt fits correctly (laws vary from state to state) -under 13 are safest in back seat

expected cognitive development (Piaget: sensorimotor stage from birth to 24 month): infant (birth-1 yr)

-separation: when infants learn to separate themselves from other objects in the environment -object permanence: occurs at about 9 months; the process by which an infant knows the object still exists when it is hidden from view -mental representation: recognition of symbols

equipment and sterile fields

-select a clean area in the client's environment to set up the sterile field -check that all sterile packages are dry and have a future expiration date -make sure an appropriate waste receptacle is nearby

the types of exudate appearing at the site of infection during the 2nd stage:

-serous (clear) -sanguineous (contains RBCs) -purulent (contains leukocytes and bacteria)

vesicle

-serous fluid-filled, <1cm -example: blister

Severe hypercalcemia

-serum Ca >17mg/dL -emergency: cardiac arrest may occur

By practicing nursing within the confines of the law, nurses are able to:

-shield oneself from liability -advocate for client's rights -provide care that is within the nurse's scope of practice -discern the responsibilities of nursing in relationship to the responsibilities of other members of the health care team -provide safe, competent care that is consistent with standards of care

basic critical thinking

-the nurse trusts the experts and thinks concretely based on the "rules." -results from limited nursing knowledge and experience, as well as inadequate critical thinking experience

surgical asepsis

the use of precise practices to eliminate all micro-organisms from an object or area and prevent contamination. "sterile technique". it applies to parenteral med administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures.

medical aspesis

the use of precise practices to reduce the number, growth, and spread of micro-organisms. applies to administering oral meds, managing NG tubes, providing personal hygiene, and performing many other common nursing tasks.

Morals are:

the values and beliefs held by people that guide their behaviors and decision making

Standards of Care

these define and direct the level of care nurses should give, they implicate nurses who dont follow these standards in malpractice lawsuits. nurses should refuse to practice beyond scope of practice or outside of their areas of competence regardless of reason such as staffing shortage, and lack of appropriate personnel.

heat loss- conduction is:

transfer of heat from the body directly to another surface (when the body is immersed in cold water)

IV catheter sizing

trauma- 16 gauge- rapid fluid volume surgical client- 18 gauge- rapid blood -other -22-24 gauge - children /adults

Acute wounds

trauma; surgical incision; heals through timely orderly process; easily cleaned and repaired; clean and intact edges

basic critical thinking

trusts experts and thinks concretely based on rules. limited nursing knowledge and experience

social worker

works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge. Ex. of when to refer: a pt who has terminal Ca wishes to go home but is no longer able to perform many ADL. The spouse needs medical equip. in home to care for the pt.

For an invasive procedure or surgery, the client is required to provide ____ consent.

written

prescription components

client name date & time name of med dosage route frequency signature

Autonomy

client's right to make own personal decisions, even when those decisions might not be in the client's own best interest

culture

collection of learned, adaptive, and socially transmitted behaviors, values, beliefs, and customs that form the context from which a group interprets as the human experience

interpersonal communication

communication between two people

public communication

communication that occurs within large groups of people; community settings

assault

conduct of one person makes another fearful and apprehensive

mode of transmission

contact, droplet, airborne, vector borne.

ptosis

covering of the pupil by the upper eyelid

good oral hygiene and infection

decreases PRO which attracts organisms in the oral cavity, which thereby decreases the growth of organisms that can migrate through breaks in oral mucosa.

good pulmonary hygiene and infection

decreases the growth of organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movements and clearance and expanding lungs. exercises include turning, coughing, deep breathing, incentive spirometry.

complicated greif

difficult progression, prolonged, more severe, may develop suicidal thoughts and guilt, lowered self-esteem

expected psychosocial development (self-concept development): older adult (65+ yrs)

difficulties including: -seeing oneself as an aging person -finding ways to maintain a good quality of life -becoming more dependent on others for ADLs

contact

direct physical contact, indirect contact with an inanimate object, fecal-oral transmission.

Subjective data can be documented as:

direct quote, within quotation marks, or summarized and identified as the client's statement

Clean voided urine specimen

does not contain bacteria from urethral meatus

ROM head: lateral flexion

ear to shoulder bilaterally

Settings

hospitals, homes, skilled-nursing, assisted living, and extended care facilities. community/health departments, adult day care cents, schools, hospices, providers offices, ambulatory care clinics, occupational health clinics, stand alone surgical centers, or urgent care centers.

individuals with compromised health defenses

immunocompromised, had surgery, with indwelling devices, break in the skin, with poor oxygenation, impaired circulation, have chronic or acute diseases such as diabetes mellitus, adrenal insufficiency, renal failure, hepatic failure, or chronic lung disease.

Risk factors for pressure ulcers

impaired sensory perception, impaired mobility, alteration in LOC, shearing forces, friction, moisture

anticipatory greif

implies "letting go" before loss, have the opportunity to start grieving before the actual loss

High-fiber diet

includes: - whole grains such as barley and oats; - raw and dried fruits; - raw and gas-producing vegetables such as cabbage; - legumes such as lentils and black beans

impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in:

increases in the respiratory rate and alterations in rhythm to compensate

battery

intentional and wrongful physical contact with a person that involves an injury or offensive contact

battery

intentional and wrongful physical contact with a person that involves an injury or offensive contact. ex. a nurse restrains a client and administers an injection against her wishes.

Restorative HC

intermediate follow-up care for restoring health. ex. home health care, rehabilitation centers, and skilled nursing facilities.

restorative care

intermediate follow-up care for restoring health. example home health care, rehabilitation center, skilled nursing facility

Nursing diagnosis

interpret or monitor the collected database, reach an appropriate nursing judgement about the clients health status and coping mechanism, and provide direction for nursing care.

critical thinking skills

interpretation, analysis, evaluation, inferance, and explanation used to make clinical judgements. an active, orderly, well thought-out reasoning process that guides nurses in various approaches to making a nursing judgement by applying knowledge and experience, problem-solving, logic, reasoning, and decision-making. critical thinkers prioritize, explores various courses of action, keeps ethics in mind, and determines appropriate outcomes. requires life long learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgement. components: knowledge, experience, critical thinking competencies, attitudes, and intellectual and professional standards.

convalescence

interval when acute symptoms disappear. total recovery could take days to months.

illness stage

interval when symptoms specific to the infection occur.

IVP

intravenous pyelogram

incontinence

involuntary release of urine from the bladder or feces via the anus

assessment/data collection

involves collection of info about client's present health status to identify needs and additional data to collect based on findings. nurses can collect data during initial assessments, focused assessments, or ongoing assessments. methods of data collection include observation, interview, medical hx, comprehensive or focused physical exam, diagnostic and lab reports, and collaboration. to collect data nurses must ask appropriate questions, listen carefully to responses, and have excellent head-to-toe physical assessment skills. must employ clinical judgement and critical thinking in accurately recognizing when to collect assessment data. must recognize the need to collect assessment data prior to intervention. during this the nurse validates, interprets, and cluster data. documentation of assessment data must be thorough, concise and accurate.

culturally responsive nursing

involves delivery of care that transcends cultural boundaries and considers a patients culture

Restorative health care

involves intermediate follow up care for restoring health ex: home health care, rehab, skilled nursing facilities

Restorative health care

involves intermediate follow-up care for restoring health. examples include home health care, rehab centers, and skilled nursing facilities

Tertiary health care

involves the provision of specialized and highly technical care ex: intensive care, oncology, burn centers

Tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

rebound tenderness (Blumberg's sign) is an indication of

irritation or inflammation somewhere in the abdominal cavity

why is carbon monoxide harmful?

it binds with hemoglobin causes hypoxia

what should a nurse recognize with an IM medication

it increases risk of infection

equipment

items to transfer/discharge with client: personal belongings, valuables from the safe, medications, assistive devices, medical records or transfer form.

nystagmus

jerky or tremor-like eye movements

regulatory nursing agencies

joint commission state boards of nursing FDA state and public health agencies professional standards review organizations utilization review committees

auscultatory sites for the heart: tricuspid

just left of the sternum at the fourth ICS

auscultatory sites for the heart: pulmonic

just left of the sternum at the second ICS

auscultatory sites for the heart: erb's point

just left of the sternum at the third ICS

auscultatory sites for the heart: aortic

just right of the sternum at the second ICS

antimicrobial therapy

kills or inhibits the growth of organisms (bacteria, fungi, viruses, protozoans). either kill pathogen or prevent their growth. give antihelmintics for worm infestations. there are currently no tx for prions. considerations: administer antimicrobial therapy as prescribed. monitor for med. effectiveness (reduced fever, and increase in the level of comfort, decreasing WBC count). maintain a med schedule to assure consistent therapeutic blood levels of the antibiotic.

fungi

molds and yeasts. candida albicans, aspergillus

papule example

mole (nevus)

basic critical thinking

nurse trusts the experts and thinks concretely based on the rules. results from limited nursing knowledge and experience as well as inadequate critical thinking experience. ex. pt reports pain 1 hr after receiving pain med. instead of reassessing pt pain, nurse tells client he must wait 2 more hrs before he can get another dose.

mandatory reporting

nurses are require to report the following: abuse, communicable disease to health department

evaluation

nurses evaluate client's response to nursing interventions and form a clinical judgement about the extent to which clients have met the goals and outcomes. this determines whether or not to modify the plan of care. client outcomes in specific, measurable terms are easier to evaluate. factors that can lead to lack of goal achievement include an incomplete database, unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to achieve the outcome.

change-of-shift reports

nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. formats include face to face, audiotaping, or presentation during walking rounds in each client's room. report should include significant objective information about client's health problems, proceed in logical sequence, include no grasp or personal opinion, relate recent changes in medications, treatments, procedures, and the discharge plan.

licensure

nurses must a current one of these in every state they practice in. the state have adopted the nurse licensure compact are exceptions, this allows nurses who reside in a compact state to practice in other compact states under a multistate license. within the compact nurses must practice in accordance with the statutes and rules of the state in which they provide care.

objective data

nurses observe and measure these during a physical exam. they feel, see, hear, and smell them through observation or physical exam of a client.

Language

precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to both the client and other health care team members. The nurse should consider the following: -"Did I use language appropriate for the client?" -"Did I communicate the message clearly to the provider?"

language

precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to clients and other health care team members.

maxillary sinuses are palpated by

pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth

frontal sinuses are palpated by

pressing upward with the thumbs from just below the eyebrows on either side of the bridge of the nose

tertiary prevention

prevent the long-term consequences of chronic illness or disability to support optimal functioning. example prevention of pressure ulcers, promoting independence

tertiary prevention

prevents long term consequences--i.e. cardiac rehabilitation

adequate intake of fluids and infection

prevents the stasis of urine by flushing the urinary tract and decreasing growth of organisms, keeps skin from breaking down.

Primary IV tubing

primary tubing, this long piece of tubing has several components attached: the spike, the drip chamber, the roller clamp, the syringe tip and locking collar, and medication ports. At the top of the tubing is a plastic spike covered with a plastic cap. You'll keep the cap in place until you insert the spike into the bag of fluid. Below the spike is the drip chamber, a clear plastic reservoir that allows you to monitor the flow rate by counting the drops dripping into the chamber. To keep air from entering the tubing and being infused, be sure the drip chamber is at least half full. Gently squeezing the chamber two or three times helps accomplish this. When the roller clamp is in the open position, you can move it along the tubing. When setting the flow rate, it is often helpful to move the roller clamp closer to the drip chamber, as this makes it easier to reach the roller clamp and adjust the flow rate while counting the drops in the drip chamber.

admission process

prior to arrival bring necessary equip into the room. procedure: introduce yourself, explain the roles of other care delivery staff, if in a semiprivate room, introduce the client to his roommate, provide hospital attire and assist as necessary, position the client comfortably, apply the ID bracelet and allergy band if necessary, provide facility-specific brochures and informational material, provide info about advance directives, document the clients advance directives status in medical records. place a copy in there if available. assess and collect data.

ethical dilemmas

problems that involve more than one choice and stem from the different values and beliefs of the decision makers.

ethical dilemmas

problems that involve more than one choice and stem from the different values and beliefs of the decision makers; common in health care problem is an ethical dilemma when a review of scientific data is not enough to solve it, involves a conflict between two moral imperatives, answer will have profound effect on the situation and the pt

supervising

process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team. RNs are responsible for the supervision of client care tasks delegated to assistive personnel and licensed practical nurses.

delegating

process of transferring the authority and responsibility to another member of the health care team to complete a task while retaining the accountability.

heart sounds: S4

produced by a strong atrial contraction -can be normal finding in older and athletic adults and children -best heard with bell of steth

bruits are:

produced by an obstructed peripheral blood flow and are heard as a blowing or swishing sound with the bell of the steth

malpractice

professional negligence - nurse administers large dose of med due to calc error and client dies

time and sterility relationship

prolonged air exposure contaminates sterile field --delayed procedures would cause contamination

primary prevention

promote health and prevent disease --i.e. immunization, heath education, nutrition/fitness

civil laws

protect individual rights. one example is that it relates to the provision of nursing care is a tort law.

nurse administrator

provides leadership to nursing departments within a health care facility.

long-term care insurance

provides long term care expenses that medicare doesn't cover

spiritual support staff

provides spiritual care, pastors, rabbis, priests, ex. of when to refer: a pt requests communion or the family ask for prayer prior to the pt undergoing a procedure.

tertiary care

provision of specialized and highly technical care. example intensive care, oncology center, burn center

Health Care Financing mechanisms

public federally funded programs (medicare-care for the old,medicaid-aid the poor). private plans (traditional insurance reimburses for services on a fee-for-service basis, managed care org., preferred provider org., exclusive provider org., long-term care insurance.).

criminal law

public law that relates to individual and government i.e. nurse falsifying records

to assess inner ear in children <2 years

pull auricle down and back

to assess the inner ear of adults and children >2 years

pull auricle up and back

tympanic

pull ear up & back for adults pull ear down and back for children out ear canal

advance directives

purpose is to communicate a client's wishes regarding end-of-life care should the client become unable to do so. PSDA requires asking clients upon admission to facility whether they have these. types of these: living will, durable power of attorney for health care, and provider's orders.

the International Association for Healthcare Security & Safety (IAHSS) provides:

recommendations for the development of security plans

narrative documentation

records information as a sequence of events in a story like manner

signs and symptoms of local infection

redness from dilation of arterioles bringing blood to area, warmth of the area on palpation, edema, pain or tenderness, loss of use of the affected part.

Symptoms of hypercalcemia

reduced excitability of muscles and nerves-> decreased memory, confusion, disorientation, fatigue

contact

resp viruse, wound, enteric, herpes simplex, private / same disease room, gloves/growns for all, proper disposal

the core of nursing practice is regulated:

state law : can revoke/issue; define practice parameters standards of care , ANA; regulate practice; adopt rules & regulations for this; set standards for nursing programs

discharge instructions

step-by-step instructions for procedures at home, precautions to take when performing procedures or administering medications, signs and symptoms of complications to report, names and numbers of health care providers and community services to contact, plans for follow up care and therapies.

Advocacy

support of the cause of the client regarding health, safety, and personal rights

peridontal

surrounding or near a tooth

five rights of delegation

task to delegate (right task), under what circumstance (right circumstance), to whom (right person), what info to communicate (right direction/communication), how to supervise/evaluate (right supervision/evaluation)

Ishihara test

tests for color vision

effects of hyperphosphatemia

tetany, anorexia, nausea, muscle weakness, and tachycardia

respiratory depth is

the amount of chest wall expansion that occurs with each breath; altered depths are described as deep or shallow

canthus

the angular junction of the eyelids at either corner of the eye

right supervision/evaluation

the delegating nurse must do the following; provide supervision either directly or indirectly (assigning supervision to another licensed nurse), provide clear and understandable expectations of the tasks to perform (time frames, what to report), monitor performance, provide feedback, intervene if necessary (unsafe clinical practice), evaluate the client, and determine client outcome status, evaluate client care tasks, and identify needs for performance improvement activities and additional resources.

expected axillary and tympanic temperatures are usually:

0.5* C (0.9* F) lower than oral temps

message

verbal and/or nonverbal information that is expressed by the sender and intended for the receiver

during palpation, the ulnar surface of the hand and the base of the fingers detect:

vibrations

heel-to-toe walk

-ask client to place heel of one foot in front of toes of the other foot as he walks in a straight line -expected finding: client is able to walk in a straight line without losing balance

Fluid Excess

"overhydration"

Sterile Field

- To open a wrapped-sterile kit: Pull *the top flap* [the one furthest from your body] *away from your body* first; - Outer packaging and 1" border around edges are *NOT* sterile; - Any object below the waist, above the waist, or exposed to moisture should be considered contaminated; - Do *not* reach across or above a sterile field; - Do *not* turn your back on a sterile field; - Hold items to add to a sterile field at least 6" above the field

What *labs* indicate the *presence of infection*?

- WBC > 10,000 [aka leukocytosis]; - increase in specific type of WBCs [e.g., an increase in neutrophils aka left shift]; - ESR > 20 - note that an increased ESR = active inflammatory process or infection; - presence of micro-organisms upon culture of fluid or area

What are the *un*expected findings upon palpation of a *male* client's breasts?

- adolescent boys: unilateral or bilateral [but asymetrical] gynecomastia; - older adult males: bilateral gynecomastia

discharge planning

- an interdisciplinary process started by nurse at time of admission -conducted with both client and client's family for optimal results

nursing interventions to *maintain urinary and bowel elimination*

- at least 2,000 mL of fluid/day unless restricted; - diet including fruits and veggies and high in fiber; - stool softener [consider laxatives only as a last resort]; - perineal care; - teach bladder and bowel training; - to relieve or manage bladder distention - insert a straight or indwelling catheter ; - promote urination by pouring warm water over perineal area

*musculoskeletal changes* due to immobility

- atrophy of muscles, decreased muscle endurance, strength, and mass; - impaired balance, decreased stability; - altered calcium metabolism = osteoporosis; - contractures; - foot drop; - altered joint mobility

What should you teach a client about their diet for the first few weeks after placement of an ileostomy?

- avoid high fiber foods *for first weeks after surgery* [ex. fresh veggies]; [gives small bowel time to adapt to the diversion] - can eat almost any food including high fiber foods *after ostomy heals* -- this will actually be encouraged to help ensure more solid stool to achieve success at irrigation]

*respiratory changes* due to immobility

- decreased respiratory movement --- results in decreased O2 and CO2 exchange; - stasis of secretions and decreased and weakened respiratory muscles --- results in atelectasis and hypostatic pneumonia; - decreased cough response

What should you do if you *feel resistance* or the *patient reports pain* when you are inserting the tube or the tip of the container?

- stop and try asking the patient to take a deep breath and then instilling a small amount of fluid; - this will relax the sphincter or soften the stool enough so that the tube or tip can be inserted and the enema can be administered

What are some physiological responses to *acute* pain?

- tachycardia; - hypertension; - anxiety; - diaphoresis; - muscle tension

What assessment findings would you expect for a client with prolonged diarrhea?

- tachycardia; - hypotension; - fever; - poor skin turgor; [all manifestations caused by dehydration]

What is the purpose of a soap suds enema?

- to act as an irritant *to promote bowel peristalsis*; - use only pure castile soap in tap water or normal saline

*genitourinary changes* due to immobility

- urinary stasis; - change in calcium metabolism w/hypercalcemia ---can result in renal calculi; - decreased fluid intake, poor perineal care, and indwelling urinary catheters = UTIs

What to do *AFTER* a client has a seizure

-*ASSESS* mental status, O2 sat, and vitals; -*EXPLAIN* what happened to client, provide comfort, and a quiet environment for client to recover; -*DOCUMENT* any precipitating behaviors and description of event [i.e., movements, injuries, duration, aura, postictal state], and report it to HCP

what is the difference between a partial seizure and a general seizure?

-*PARTIAL* seizures are due to electrical surges in *one part of* the brain; -*GENERALIZED* seizures involve the *entire* brain

Sequence followed for a fire [RACE]

-*RESCUE* and evacuate clients close to fire. Able clients walk to safety; -Activate *ALARM*; report fire details and location; -*CONTAIN* fire: close doors and windows; turn off sources of O2 and electrical devices. Ventilate life support client w/bag-valve mask; -*EXTINGUISH* fire w/extinguisher

health promotion (immunizations): school-age (6-12 yrs)

--if not given between 4-5, then by 6 years: DTaP, IPV, MMR, varicella -yearly seasonal TIV or LAIV (nasal spray) -11-12 years: Tdap, meningococcal vaccine (MCV4), HPV2 in 3 doses for females and HPV4 may be given to males

expected physical development (fine and gross motor development): infant (birth-1 yr)

-1 month: (g) demonstrates head lag; (f) has a present grasp reflex -2 month: (g) lifts head off mattress; (f) holds hands in an open position -3 month: (g) raises head and shoulders off mattress: (f) no longer has grasp reflex, keeps hands loosely open -4 month: (g) rolls from back to side; (f) places objects in mouth -5 month: (g) rolls from front to back; (f) uses palmer grasp dominantly -6 month: (g) rolls from back to front; (f) holds bottle -7 month: (g) bears full weight on feet; (f) moves objects from hand to hand -8 month: (g) sits unsupported; (f) begins using pincer grasp -9 month: (g) pulls to standing position; (f) has crude pincer grasp -10 month: (g) changes from prone to sitting position; (f) grasps rattle by its handle -11 month: (g) walks while holding on to something; (f) can place objects into container -12 month: (g) sits down from standing position w/o assistance; (f) tries to build two-block tower w/o success

health promotion (immunizations): toddler (1-3 yrs)

-12-15 month: IPV (6-18 month), Hib, PCV, MMR, varicella -12-23 month: Hep A (given in 2 doses at lease 6 months apart) -15-18 month: DTaP -12-36 month: yearly seasonal TIV; at age 2, toddlers can receive the live, attenuated influenza vaccine (LAIV) by nasal spray

expected physical development (fine and gross motor skills): toddler (1-3 yrs)

-15 month: (g) walks w/o help, creeps up stairs; (f) uses cup well, builds two-block tower -18 month: (g) assumes standing position, jumps in place with both feet; (f) manages spoon without rotation, turns pages in book 2-3 at a time -2 year: (g) walks up and down stairs; (f) builds 6-7 block tower -2.5 year: (g) jumps with both feet, stands on 1 foot momentarily; (f) draws circles, has good hand-finger coordination

health promotion (immunizations): preschooler (3-6 yrs)

-4-6 years: DTaP, MMR, varicella, IPV -yearly: TIV or LAIV (nasally)

expected physical development (dentition): infant (birth-1 yr)

-6 to 8 teeth erupt in the infant's mouth by end of 1st yr -teething pain can be eased using cold teething rings, OTC teething gels, acetaminophen and/or ibuprofen; ibuprofen given only to children over 6 months -clean teeth using cool, wet washcloth -bottles should not be given when they are falling asleep; prolonged exposure to milk/juice can cause dental caries

expected cognitive development: middle adult (35-65 yrs)

-Piaget: formal operations -reaction time/speed of performance slows slightly -memory is intact -crystallized intelligence remains (stored knowledge) -fluid intelligence (how one learned and process new info) declines slightly

botulism

-S/S: difficulty swallowing, progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing -treatment/prevention: airway management, antitoxin, elimination of toxin

health promotion (immunizations): young adult (20-35 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -MCV: students entering college and living in dorm if not previously vaccinated -HPV2 or HPV4: 3 doses, recommended for females up to age 26 who were not vaccinated as a child; HPV4 may be given to males up to 26 -seasonal flu vaccine: 1 yearly

specialized license CAM interventions

-acupuncture/pressure- alters body function or produces analgesia -homeopathic medicine- healing remedies -naturopathic med- diet, exercise, environment & herbal promote natural healing -chiropractic med -treated by manipulation of the spine -massage therapy- relaxation/ circulation improved stretching / loosening muscles -biofeedback- increase awareness of body responses to minimize extremes -therapeutic touch- hands to help bring clients energy fields into balance

health promotion (immunizations): middle adult (35-65 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -pneumococcal polysaccharide vaccine (PPV): if not previously vaccinated, vaccinate once at 65 -seasonal flu vaccine: yearly; LAIV (nasal spray) only under 50 and not pregnant or immunocompromised -herpes zoster vaccine: 1 dose over age 60

health promotion (immunizations): older adult (65+ yrs)

-Td booster: every 10 years -varicella vaccine: 2 doses given to those w/o evidence of previous infection; 2nd dose 4-8 weeks after 1st for those who only had 1 previous dose -PPV: if not previously vaccinated, once at age 65 -seasonal flu vaccine: 1 dose annually -herpes zoster vaccine: 1 dose for all adults over 60

Health care regulatory agencies include:

-US Dept of Health and Human Srvcs -US FDA -State and local public health agencies -State licensing boards (to ensure providers & agencies comply with state regulations) -the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities) -Professional Standards Review Organizations (PSROs) -Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized clients)

Licensed Practical Nurse (LPN)

-Works under supervision of the RN -Collaborate with other team members -Possess technical knowledge and skills -Participate in the delivery of nursing care, using the nursing process as a framework

expected psychosocial development (social development): middle adult (35-65 yrs)

-a need to maintain and strengthen intimacy -provide assistance to aging parents, adult children, and grandchildren

expected psychosocial development (Erikson: industry vs inferiority): school-age (6-12 yrs)

-a sense of industry is achieved through advances in learning -motivated by tasks that increase self-worth -fears of ridicule by peer and teachers over school-related issues are common -some manifest nervous behaviors to deal with stress such as nail biting

clubbing of the fingernail

-abnormal curvature of the nail with an angle >160* -can be result of chronic low SaO2, emphysema, chronic bronchitis

mandatory reporting

-abuse suspicion, communicable disease -ensures med treatment -monitors for outbreaks -plan/evaluate control/prevention plan -determine health priorities from trends -identify outbreaks

Mandatory reporting

-abuse: child or elder abuse, domestic violence -communicable diseases (according to CDC) such as hepatitis and TB

CN VIII

-acoustic -assess ears for hearing

the following must occur in order for seclusion or restraint to be used:

-all other less restrictive means have to be exhausted -the treatment must be prescribed by provider in writing based on a face-to-face assessment of the client (exception is in emergency situation where client is a danger to himself or others and providers order must be written asap) -rx must include reason, type, location, how long it may be used, and type of behavior that warranted the restraint -provider must rewrite the rx every 24hrs or as specified by the facility -PRN rx is not allowed

Categories of CAM

-alternative medical philosophy - acupuncture, homeoptahy, chinese meds -biological & botanical therapies- naturopathic therapy, diets, vitamins, minerals, herbal -body manipulation- massage, touch, chiropractic therapy -mind-body therapies- biofeedback, art therapy, mediation, yoga, psychotherapy -energy therapies- reiki, therapeutic touch

other responsibilities of health care providers when dealing with isolation/restraints include:

-always explain need to client and family -obtain signed consent from client or guardian, if required -review manuf. instructions for correct application -remove or replace restraints frequently to ensure good circulation and full ROM of restricted limb -pad bony prominences -use quick-release knot to tie restraints to bed frame -ensure restraint is loose enough for ROM and 2 fingers can fit between device and the client -regularly assess need for continued need -never leave client unattended w/o the restraint

guidelines for cleaning contaminated equipment

-always wear gloves -rinse 1st in cold water -wash the article in hot water with soap -use a brush or abrasive to clean corners or hard-to-reach areas -rinse well in warm or hot water -clean the equipment used in cleaning and the sink (still considered dirty unless a disinfectant is used) -remove gloves and perform hand hygiene

criteria to follow when identifying clients who can be safely discharged in an emergency situation

-ambulatory clients requiring minimal care should be discharged or relocated first -clients requiring assistance should be next and arrangements made for continuation of their care -clients who are unstable and/or require nursing care should not be discharged or relocated unless they are in imminent danger

radiological incidents

-amount of exposure is related to time exposed, distance from source, and amount of shielding -facility treating victims should activate interventions to prevent exposure to treatment areas -staff should wear water-resistant gowns, double glove, and fully cover bodies with caps/shoe covers/masks/goggles -staff should wear radiation or dosimetry badges to monitor amount of exposure -clients should be initially surveyed with radiation meter to determine amount of contamination -decontamination should occur prior to entering the hospital with soap, water, and disposable towels -after decontamination, client should be resurveyed and washed until free of all contamination

Nurses should be aware that security measures include:

-an identification system that identifies authorized personnel -electronic security systems in high-risk areas

health-care associated infections (HAIs)

-an infection acquired while the client is receiving care in a health-care setting -formally called nosocomial infections -can come from exogenous source or endogenous source -most common setting for HAIs is the ICU -best way to prevent HAIs is through frequent and effective hand hygiene -most common site of HAIs is the urinary tract -most common causative agents are Escherichia coli, Staphylococcus aureus, and enterococci -an iatrogenic infection results from a diagnostic or therapeutic procedure -HAIs are not always preventable and not always iatrogenic

components of the chain of infection include:

-an infectious agent (bacteria, virus, fungi, protozoa) -a reservoir where the infectious agent grows (wound drainage, food, oxygen tubing) -an exit portal of the infectious agent (skin, resp or GI tracts) -a means of transmission (droplet, person-to-person contact, touching contaminated items) -an entry portal to a susceptible host (same as exit) -a host that must be susceptible to the infectious agent

According to the UDDA, death is determined by one of two criteria:

-an irreversible cessation of circulatory and respiratory functions -irreversible cessation of all functions of the entire brain, including the brain stem

expected physical development (size): toddler (1-3 yrs)

-anterior fontanel closes by 18 months -weight: should be 4 times birth weight at 24 months -height: grows by 7.5 cm (3 in) per year

obtain specimen for WBC/ESR/electrolytes

-antibiotics from culture -fluids/rest -antipyretics , tylenol/motrin/ aspirin- not children -prevent shivering; head covered oral hygiene

standard precautions (tier 1)

-applies to all body fluids (excluding sweat), non-intact skin, and mucous membranes -hand hygiene recommended after all contact and alcohol-based waterless product is preferred unless hands are visibly dirty; also required after removal of gown -clean gloves are worn when touching all body fluids, non-intact skin, mucous membranes, and contaminated equipment/articles -gloves removed and hand hygiene completed between each client -masks, eye protection, and shields required when splashing or spraying of body fluid may occur -gloves worn whenever touching anything that has potential to contaminate hands of the nurse -sturdy, moisture resistant bag used for soiled items; contaminated laundry to be bagged and handled to prevent leaking; equipment for client care properly cleaned and one time use items disposed of -safety devices on all equipment/supplies enabled after use and sharps disposed of properly -private room not needed unless client is unable to maintain appropriate hygienic practices

expected psychosocial development (body-image changes): toddler (1-3 yrs)

-appreciates the usefulness of various body parts -develop gender identity by age 3

upon admission (but prior to client arrival to room) take necessary equipment into the room including:

-appropriate documentation forms -equipment to obtain vital signs -pulse oximeter -hospital attire for client

Examples of questions to use to determine complexity of care:

-are complex tasks required as part of the client's care? -is the delegatee legally able to perform the task and do they have the skills necessary?

evaluation related to client education includes:

-ask client to explain info in his own words -observe the client demonstrating the learned activity -use written tools to measure accuracy of info -request client's self-evaluation of progress -observe verbal and nonverbal communication -determine client's ability to use info over time but re-evaluate learning during follow-ups -revise care plan as needed

transfers and use of assistive devices

-assess client's ability to help with transfers (balance, muscle strength, endurance) -determine need for additional help or assistive devices (transfer belt, hydraulic lift, sliding board) -assist and monitor the client's proper use of mobility aids (canes, walkers, crutches) -include assistance or mobility aids needed for safe transfers and ambulation in the care plan

hypovolemia care

-assess respiratory status -fluid replacement -SOB , dyspnea -I&O alert under 30 hrs -assess gait -check UA, o2 stat, CBC &electrolytes -IV -measure client weight dailt at same time same scale -Heart rhythm -shock position -back w/legs elevated -vitals -LOC

assessment/data collection related to client education includes:

-assess/monitor the client's learning needs -assess the learning environment -assess/monitor the client's learning style (auditory, visual, kinesthetic) -identify areas of concern -assess/monitor available resources (financial, social, community) -identify the client's developmental stage -determine the client's physical and cognitive ability -identify special needs (visual impairment, decreased manual dexterity) -determine the client's motivation and readiness to learn

included in a chart & why

-assessment; medication administration; treatments given & the client's responses; client education -for: communication, legal documentation, financial billing, education, research monitoring

time requirements for handwashing

-at least 15 seconds to remove transient flora from the hands -up to 2 minutes when hands are more soiled

health promotion (injury prevention): middle adult (35-65 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

health promotion (injury prevention): young adult (20-35 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

health promotion (injury prevention-poisoning): infant (birth-1 yr)

-avoid exposing to lead paint -keep toxins/plants out f -use safety locks on cabinets (esp containing cleaners/chemicals) -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detectors in the home

health promotion (injury prevention-suffocation): toddler (1-3 yrs)

-avoid plastic bags -be sure crib mattress fits tightly -ensure crib slats no further apart than 6 cm (2.4 in) -keep pillows out of crib -remove drawstrings from jackets and other clothing

health promotion (injury prevention-suffocation): infant (birth-1 yr)

-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing

health promotion (injury prevention-aspiration of foreign objects): infant (birth-1 yr)

-avoid small objects (such as grapes, coins and candy) that can become lodged in throat -provide age-appropriate toys -check clothing for safety hazards (loose buttons)

health promotion (injury prevention-aspiration of foreign objects): toddler (1-3 yrs)

-avoid small objects that can become lodged in throat -keep toys with small parts out of reach -provide age-appropriate toys -check clothes for choking hazards -keep balloons out of reach

temperature

-balance between heat lost & heat prodcued. results from basal metabolic rate, muscle activity, thyroxine output, sympathetic stimulation, dehydration, injury / illness-fever response

Levels of critical thinking

-basic critical thinking -complex critical thinking -commitment

discharge education should:

-be clear and concise and also print ed for client to take home -identify safety concerns at home -review s/s of potential complications and when to contact provider -include provider phone number -provide names and numbers of community resources -instructions for continuing treatments -dietary restrictions and guidelines -amount and frequency of therapies -directions and information on medications

The client has the right to:

-be informed about the aspects of care in order to be active in the decision making process -accept, refuse, or request modification to the plan of care -receive care that is delivered by competent individuals who treat the client with respect

Upon admission, orient client and family to room/facility including:

-call light -bed operation -telephone/tv -overhead lighting -smoking policy -restroom locations -waiting areas -meal times -usual times for physician visits -dining/vending services -visiting policies

LOC: alert

-client is responsive and able to fully respond by opening eyes and attending to a normal tone of voice and speech -answers questions spontaneously

general measures to prevent falls includes:

-be sure client knows how to use call light, it is within reach, and encourage its use -respond to call lights in a timely manner -orient client to setting and assistive devices -place clients at risk for falls near nursing station -ensure bedside table and frequently used items are within client's reach -maintain bed in low position -for clients who are sedated, unconscious, or otherwise compromised, bed rails are kept up and bed kept in low position -avoid use of full side bedrails for clients who get out of bed or attempt to get out of bed without assistance -provide nonskid footwear -keep floor free of clutter with a clear path to the bathroom -keep assistive devices nearby after validation of safe use by client and family -educate client and family/caregivers on identified risks and plan of care -lock wheels on beds, wheelchairs, and carts -use chair or bed sensors for clients at risk for getting up unattended

Legal guidelines of documentation

-begin each entry with date & time -legible and in black, non-erasable ink -no white out or blackened out errors -info inadvertently omitted may be added as a "late entry" -signed with signature of person making entry and dated -should reflect assessments, interventions, and evaluations

expected cognitive development (time): preschooler (3-6 years)

-begins to understand the concepts of past, present, and future -by end of preschool years, child may comprehend days of the week

health promotion (immunizations): infant (birth-1 yr)

-birth: Hep B -2 month: DTaP, rotavirus vaccine (RV), inactive poliovirus (IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B -4 month: DTaP, RV, IPV, Hib, PVC -6 month: DTaP, IPV (6-18 months), PVC, Hep B (6-12 months), RotaTeq (alt to RV which required 3 doses completed by 32 weeks) -6-12 month: seasonal flu yearly, trivalent inactivated influenza vaccine (TIV) is available as IM injection

cyanosis

-bluish: best noted in nail beds, lips, mouth, skin -indication of hypoxia or impaired venous return

health promotion (nutrition-feeding alternatives): infant (birth-1 yr)

-breastfeeding provides complete diet during 1st 6 months and is recommended -iron-fortified formula is an acceptable alternative; cow's milk is not recommended

expected psychosocial development (self-concept development): infant (birth-1 yr)

-by end of 1st year will be able to distinguish themselves as being separate from their parents

health promotion (nutrition): school-age (6-12 yrs)

-by end of school-age years is eating adult proportion of food and needs quality nutritious snacks advised parents to: not use food as reward; emphasize physical activity; ensure balanced diet according to USDA recommendations; teach children to make healthy food selections for meals/snacks; avoid frequent meals at fast food; avoid skipping meals -dental health should be encouraged, including: brushing and flossing daily; having regular check-ups and fluoride treatments

disoriented clients

-call by name & identify yourself -maintain eye contact at eye level -one question/1 direction at a time said briefly & slowly with time for response -avoid lengthy conversations -adequate sleep & pain management

power of attorney

-client designates a health care proxy to make health care decisions for them if they are unable to do so -must be a competent adult

health promotion (nutrition-solids): infant (birth-1 yr)

-can be introduced between 4-6 months -indicators for readiness include voluntary control of head and trunk, hunger less than 4 hrs after vigorous nursing or intake of 8 oz of formula, interest of the infant -iron-fortified rice offered 1st -new foods introduced 1 at a time over a 5-7 day period to assess for allergies or intolerance; veggies or fruits introduced between 6-8 months and after both have been introduced, then meats -milk, eggs, wheat, citrus fruits, peanuts, peanut butter, and honey delayed till after 1st year -chopped, cooked, and unseasoned table foods by 9 months -appropriate finger foods include: ripe bananas, toast strips, graham crackers, cheese cubes, noodles, peeled chunks of apples/pears/peaches -breast milk/formula decreased as solid food intake increases -parents encouraged to use iron-enriched foods after 6 months of age

cultural barrier

-can lead to stress disorders or depression -language, communication, culturally inappropriate tests & tools that lead to misdiagnosis & ethic variations in drug metabolism related to genetics -nurses should always accommodate cultural beliefs & valuesexcept in direct conflict w essential health practices

What are some general *cane* instructions?

-cane goes on *stronger* side of body; -move *cane* first, then *affected* leg, then *unaffected* leg -maintain 2 points of support on ground at all times; -support body weight on both legs

expected cognitive development (Piaget: formal operations): adolescent (12-20 yrs)

-capable of thinking at an adult level -able to think abstractly and can deal with principles -able to evaluate the quality of own thinking -has longer attention span -highly imaginative and idealistic -makes decisions through logical operations -is future-oriented -capable of deductive reasoning -understands how the actions of an individual influences others

carbon monoxide poisoning

-carbon monoxide binds with hemoglobin and reduces oxygen supply to tissues -cannot be seen. smelled, or tasted -s/s include: nausea, vomiting, headache, weakness, and unconsciousness -death may occur with prolonged exposure -prevention by ensuring proper ventilation when using fuel-burning devices -gas-burning devices should be inspected annually -flues and chimneys should be unobstructed -carbon monoxide detectors should be installed and inspected regularly

older adult health risks

-cardiovascular disease- CAD, HTN, stroke -mobility- arthritis, osteoprosis, falls -mental health- depression, dementia, suicide, DM, cancers, incontinence, abuse/neglect, cataracts, alcoholism, pain

locations to assess bruits include:

-carotid arteries: over carotid pulses -abdominal aorta: just below xiphoid process -renal arteries: MCL above umbilicus on the abdomen -iliac arteries: MCL below the umbilicus on abdomen -femoral arteries: over femoral pulses

Effects of hypernatremia

-cells of CNS especially effected -neurologic impairment -restlessness -weakness -disorientation -delusion -hallucinations -permanent brain damage may occur

health promotion (injury prevention-burns): infant (birth-1 yr)

-check temp of bath water -turn down thermostat on hot water heater -have working smoke detectors in the home -turn handles of pots/pans to back of stove -apply sunscreen when outdoors during daylight hours -cover electrical outlets

health promotion (injury prevention-burns): toddler (1-3 yrs)

-check temp of bath water -turn thermostat down on water heater -have working smoke detectors in the home -turn pot handles to back of stove -cover electrical outlets -use sunscreen when outside

lateral or side-laying position

-client lies on side with most of weight on the dependent hip and shoulder; arms should be flexed in front of the body; pillow placed under head & neck, the upper arm, and under the leg & thigh to maintain body alignment -this is a good sleeping position but the client must be turned regularly to prevent development of pressure ulcers on dependent areas; 30 degree lateral position is recommended for clients at risk for pressure ulcers

semi-fowler's position

-client lies supine with head of bed elevated approx 30 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used to prevent regurgitation of tube feedings and aspiration in clients with difficulty swallowing

fowler's position

-client lies supine with head of bed elevated approx 45 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used during procedures such as NG tube insertion and suctioning; also allows for better chest expansion & ventilation, as well as better dependent drainage, after abdominal surgeries

high-fowler's position

-client lies supine with head of bed elevated approx 90 degrees, and knees may or may not be elevated -position promotes lung expansion by lowering the diaphragm and used for clients experiencing severe dyspnea

LOC: obtundation

-client needs to be lightly shaken to respond, but may be confused and slow to respond

LOC: stupor

-client requires painful stimuli (pinching a tendon or rubbing sternum) to achieve a brief response -client may not be able to respond verbally

orthpneic position

-client sits in the bed or at bedside; pillow placed on over-bed table, which is placed over client's lap; client rests arms on the over-bed table -position allows for chest expansion and is especially beneficial to clients with COPD

Nurse's role in client rights includes:

-client understands their rights -protecting rights of clients under their care

Transfer reports should include

-client's demographic information -client's medical diagnosis and providers -and overview of the client's health status (physical and psychosocial), plan of care, and recent progress -any alterations that might become urgent or emergent situations -directives for assessments or client care essential w/in next few hours -most recent vital signs -meds prescribed and last doses administered (inc PRN) -allergies -diet & activity orders -presence of or need for special equipment or adaptive devices -advance directives and resuscitation status -family involvements in care & health care proxy, if applicable

Advanced directives

-communicate client's end-of-life care wishes for them if they become unable to -PSDA requires all clients be asked if they have advanced directives upon admission -clients with out advanced directives must be provided with written information about their health care rights and how to formulate advanced directives -a health care rep should be available to help with the process

expected age-appropriate activities: school-age (6-12 yrs)

-competitive and cooperative play is predominant -activities for 6-9: simple board and number games, hopscotch, jump rope, collections, riding bike, building simple models, joining organized sports (skill building) -activities for 9-12: making crafts, building models, collections/hobbies, jigsaw puzzles, board and card games, organized competitive sports

normal spine curvatures: -cervical spine: ___ -thoracic spine: ___ -lumbar spine: ___

-concave -convex -concave

expected cognitive development (Piaget: sensorimotor transitions to preoperational): toddler (1-3 yrs)

-concept of object permanence is developed fully -have and demonstrate memories of events that relate to them -domestic mimicry is evident (playing house) -preoperational thought does not allow to understand other viewpoints, but does allow to symbolize objects and people in order to imitate activities seen previously

heat transfer mechanisms

-conduction- heat from body to surface (submerged in cold water; -convection- heat by air currents -evaporation- heat through water vapor ( sweat/ diaphoresis -radiation- one object to another without contact (heat loss to cold room

expected psychosocial development (moral development): preschooler (3-6 years)

-continues in the good-bad orientation of toddler years but begins to understand behaviors in terms of what is socially acceptable

seclusion and/or restraint must never be used for:

-convenience of the staff -punishment for the client -clients who are extremely physically or mentally unstable -clients who cannot tolerate the decreased stimulation of a seclusion room

expected psychosocial development (moral development): adolescent (12-20 yrs)

-conventional law and order: rules are not seen as absolutes; each situation needs to be looked at and maybe rules adjusted -not all adolescents attain this level during these years

components of hygiene/cough etiquette that applies to anyone entering a health care setting includes:

-covering the mouth and nose when coughing and sneezing -using facial tissues to contain respiratory secretions, and disposing of them promptly into a hands-free receptacle -wear surgical mask when coughing to minimize contamination of the surrounding environment -turning head when coughing and staying a min of 3' away from others, especially in common waiting areas -performing hand hygiene after contact with respiratory secretions

implementation related to client education includes:

-create an environment conducive to learning (reduce distractions and interruptions, provide privacy) -use therapeutic communication to develop a trusting relationship that allows client to express concern -review previous knowledge and experiences -explain the therapeutic regimen or procedure -present steps building to more complex tasks -demonstrate psychomotor skills -allow time for return demonstration -provide positive reinforcement

-pain in the chest wall may ___ respiration depth -onset of acute pain may ___ respiration rate -anxiety ___ respiration rate and depth -smoking causes resting respiration rate to ___ -neuro injury to the brainstem ___ respiratory rate and depth

-decrease -increase -increases -increase -decreases

expected physical development: older adult (65+ yrs)

-decrease in skin turgor and subcutaneous fat, which leads to wrinkles and dry skin -loss of subcutaneous fat makes it more difficult to adjust to cold temps -thinning and graying of the hair, as well as more sparse distribution -thickening of finger and toe nails -decrease in chest wall movement, vital capacity, and cilia, which increases risk for respiratory infection -slower reaction time -decrease in touch, smell, and taste sensation -decrease in production of saliva -decline in visual acuity -decreased ability for eyes to adjust from dark to light, leading to night blindness -inability to hear high pitched sounds (presbycusis) -decrease in height due to intervertebral disk changes -decrease in muscle strength and tone -decrease in digestive enzymes -decrease in intestinal motility, which can lead to increased risk of constipation -increase in dental problems -decalcification of bones -degeneration of joints -decrease in bladder capacity -prostate hypertrophy in men -decline in estrogen/testosterone production -decline in tri-iodothyronine T3 production, yet overall function remains effective -decreased sensitivity of tissue cells to insulin -atrophy of breast tissue in women

expected cognitive development (language): school-age (6-12 yrs)

-defines many words and understands rules of grammar -understands that a word can have multiple meanings

coping

-describes how an individual deals with problems and issues -influencing factors include: number, duration, and intensity of stressors; individual past experiences; current support system; available resources (financial)

Objective data should be documented:

-descriptive and should include what the nurse sees, hears, feels, and smells -w/o derogatory words, judgments, or opinions -accurately

blood pressure

-determined by CO; BP = CO x SVR (system vascular resistance d/c) -normal 120/80 prehypertension: S 120-139 d 80-99 stage I hypertension : 140-159 /90-99 stage II hypertension : greater than 160/100 based off highest reading; difference = pulse pressure - infants -low, children/fat-higher, adults increase w/ age; OA -increase systolic due to elasticity; higherin AA; lowest in early morn

expected cognitive development (language): adolescent (12-20 yrs)

-develops jargon within the peer group -able to communicate one way with peer group and another way with parents/teachers -development of communication skills is essential

the second number of the recorded visual acuity is the ___ at which a ___-___ ___ can read the line

-distance -normal-sighted person

health promotion (injury prevention-falls): infant (birth-1 yr)

-keep crib mattress in lowest position with rails all the way up -use restraints in infant seats -place infant seat on ground/floor if used outside of car and do not leave on elevated surfaces unattended -use safety gates across stairs

expected psychosocial development (social development): preschooler (3-6 years)

-do not generally exhibit stranger anxiety and have less separation anxiety; however, prolonged separation (hospitalization) can provoke anxiety but favorite toys and play can help ease fears -pretend play is healthy and allows children to determine the difference between reality and fantasy -sleep disturbances occur frequently and problems range from difficulty going to bed and night terrors -with sleep disturbances, advise parents to: assess if bedtime is too early/late or naps needed (needs about 12 hrs of sleep per day); keep consistent bedtime routine; use a night light; reassure child that is frightened, but avoid having child sleep with them

health promotion (injury prevention-drowning): infant (birth-1 yr)

-do not leave infant unattended in bath tub

health promotion (drowning): preschooler (3-6 yrs)

-do not leave unattended in bathtub -closely supervise while in pool/other body of water -teach how to swim

health promotion (injury prevention-drowning): toddler (1-3 yrs)

-do not leave unattended in bathtub -keep toilet lids closed -closely supervise at pool/other body of water -teach how to swim

microbes can move by gravity from a nonsterile item to a sterile item:

-do not reach across or above a sterile field -do not turn your back on a sterile field -hold items to be added to a sterile field at a min of 6 inches above the field

during a severe thunderstorm or tornado

-draw shades and close drapes to protect against shattering glass -lower beds to lowest position and move away from windows -place blankets over clients confined to bed -close all doors -move as many ambulatory clients as possible into the hallways (away from windows) -do not use elevators -monitor for severe weather warnings using tv, radio, or internet

crust

-dried blood, serum, or pus -example: scab

home safety risks for preschoolers and school-age children include:

-drowning -motor vehicle/injury -burns -poison

expected psychosocial development (moral development): school-age (6-12 yrs)

-early on, may not understand the reasoning behind many rules and try to find a way around them -instrumental exchange is in place ("I'll help you if you help me.") -child wants to make the best deal, and does not really consider elements of loyalty, gratitude, or justice when making decisions -in latter parts of school years, the child moves into a law-and-order orientation with more emphasis placed on justice being administered

home fire safety plan should include:

-emergency numbers near the phone -ensure number and placement of fire extinguishers and smoke alarms are adequate and that they are operable -set specific time to check batteries in alarms and operation of extinguishers -have family plan for evacuation and practice regularly -review "stop, drop, and roll" to extinguish fire of clothing or skin -review oxygen safety measures

categories of triage during mass casualty events

-emergent category (class I): highest priority given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized -urgent category (class II): 2nd highest priority is given to clients who have major injuries that are not yet life threatening and can usually wait 45-60 mins for treatment -nonurgent category (class III): the next highest priority is given to clients who have minor injuries that are not life threatening and do not need immediate attention -expectant category (class IV): the lowest priority is given to clients who are not expected to live and will be allowed to die naturally; comfort measures may be provided, but restorative care will not

health promotion (injury prevention-MVA): adolescent (12-20 yrs)

-encourage attendance in driver's ed -emphasize need for adherence to seat belt use -discourage use of cell phones while driving -teach dangers of combining substance abuse with driving

prevention education for risk of drowning in preschoolers and school-age children:

-ensure child knows how to swim and knows rules of water safety -locked fences around home and neighborhood pools

seizure precautions include:

-ensure rescue equipment is at bedside -inspect client's environment for items that may cause injury in event of seizure -assist client at risk for seizure with ambulation and transferring -advise all caregivers and family not to put anything in client's mouth in event of seizure (with exception of status epilepticus) -advise caregivers and family not to restrain in event of seizure but to lower to bed/floor, protect head, move nearby furniture, provide privacy, put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement -after seizure, explain what happened to client and provide comfort and quiet -document the seizure along with precipitating factors along with description of event and report it to provider

reverse trendelenburg

-entire bed is tilted with the foot of the bed lower than the head -position promotes gastric emptying and prevents esophageal reflux

lordosis

-exaggerated curvature of the lumbar spine -common during toddler years and pregnancy

kyphosis

-exaggerated curvature of the thoracic spine -common in older adults

Hypercalcemia

-excess Ca in ECF -serum Ca >10.1 mg/dL, ionized Ca >5.1mg/dL

hyperkalemia

-excess of potassium in ECF -Serum K>5mEq/L -very dangerous

factors leading to tachycardia include:

-exercise -fever -medications -changing position from lying down to sitting/standing -acute pain -hyperthyroidism -anemia/hypoxemia -stress, anxiety, fear -hypovolemia, shock, heart failure

living will

-expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues

restraints order

-face to face assessment then prescription in writing -emergency: obtain order ASAP -include: reason, type restraint, location, how long to be used, & type of behaviors demonstrated that warrant use & rewrite order every 24hrs

CN VII

-facial -assess mouth for taste -assess the face for symmetrical movement

subcultures

-factors within the culture that may be held differently -based on: age, gender, sexual orientation, maritial status, family structure, income, education level, religious views, life experiences

hypertension

-factors- renal or thyroid disease, meds, contriction of BV, increased fluid, potassium, calcium & magnesium can help lower BP, restrict sodium, carb, & saturated fat intake

Professional negligence

-failure of person with professional training to act in a reasonable and prudent manner -issues that prompt malpractice suits include failure to: follow standards of care, use of equipment in responsible & knowledgeable manner, effectively & thoroughly communicate with the client, document care was provided

barriers to learning:

-fear, anxiety, depression -physical discomfort, pain, fatigue -environmental distractions -health and cultural beliefs -sensory and perceptual deficits -psychomotor deficits

expected psychosocial development (self-concept development): preschooler (3-6 years)

-feels good about self with regard to mastering skills, such as dressing and feeding, that allow independence -during stress, insecurity, or illness, may regress to previous immature behaviors or develop habits like nose picking, bed wetting, or thumb sucking

s/s of generalized or systemic infection

-fever -increased pulse and resp rate (in response to high fever) -malaise -anorexia, nausea, and/or vomiting -enlarged lymph nodes

expected physical development (size/growth): adolescent (12-20 yrs)

-final 20%-25% of height is achieved during puberty -acne may appear -girls may cease to grow about 2-2.5 years after onset of menarche; will grow 5-20 cm (2-8 in) and 7-25 kg (15.5-55 lbs) -in girls, sexual maturation occurs in order of: appearance of breast buds, growth of pubic hair, onset of menstruation -in males, sexual maturation occurs in order of: increased size of testes/scrotum, appearance of pubic hair, rapid growth of genitalia, growth of axillary hair, appearance of downy hair on upper lip, change in voice -changes in sleep habits

shape/contour of abdomen can be described as: -flat: -convex: -concave: -distended:

-flat: lies in horizontal line from the chest to the symphysis pubis -convex: rounded -concave: has sunken appearance -distended: a large protrusion of the abdomen caused by fat, fluid, or flatus that can be differentiated as follows: *fat: client has rolls of fat along sides, and the skin does not look taught *fluid: flanks also protrude, when client turns onto side, the protrusion moves to the dependent side *flatus: protrusion is mainly midline, and the flanks are unchanged *hernias: protrusions through the abdominal muscle wall are visible

Causes of hypernatremia

-fluid deprivation -lack of fluid consumption -diarrhea -hyperventilation or burns

secondary prevention

-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health status -examples: communicable disease screening and case finding; early detection and treatment of diabetes; exercise programs for older adult clients who are frail

health promotion (health screenings): older adult (65+ yrs)

-follow age-related guidelines -DEXA screening for osteoporosis -eye exam for glaucoma every 2-3 years or annually depending on provider -mental health screening for depression

health promotion (health screenings): middle adult (35-65 yrs)

-follow age-related guidelines -dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis -eye exam for glaucoma and other disorders every 2-3 years or annually depending on provider -mental health screening for depression

all health care staff should:

-follow facility protocols for isolation and protection -wash hair frequently and keep it short or pulled back to prevent contamination of care area or client -not wear artificial nails while providing care and keep natural nails short and clean -remove jewelry from hands and wrists to facilitate hand disinfection

Nurses can avoid being liable for negligence by:

-following standards of care -giving competent care -communicating with other health team members -developing a caring rapport with clients -fully documenting assessments, interventions, and evaluations

fun urine control facts

-full bladder control 4-5yrs, prostate enlargement after 40yrs -older; fewer nephrons, loss of bladder muscle tone, inefficient emptying, nocturia -childbirth-kegel exercises pregnancy increases circulatory volume. renal workload up to 50% relaxin-relaxation of sphincter, sodium leads to decrease, spinal cord injury, suppression of the urge with pain, alterations in glomerular flitration rate from anesthesia/opiod analgesics causes decrease , meds

risk factor assessment should assess the following:

-genetics: a predisposition to various illnesses can be attributed to heredity (heart disease, cancer) -gender: some specific diseases are more common in one gender than the other (autoimmune disorders, suicide rates) -physiologic factors: various physiologic states place a client at greater risk for health problems (BMI, pregnancy) -environmental factors: presence of toxic substances and chemicals can affect health where clients work and live; water quality, pesticide exposure, and air pollution should be commonly assessed -lifestyle-risk behaviors: stress, substance abuse, diet deficiencies, lack of exercise, and sun exposure age- early disease detection and intervention is facilitates by following screening guidelines

Change of shift report

-given at the conclusion of each shift by the nurse leaving to the nurse assuming responsibility for the client -can be given face-to-face, audiotaped, or presented during rounds -should include significant objective info, given in logical order, free of gossip and personal opinions, and relate recent changes in meds, treatments/procedures, or discharge plan

The client's responsibility for informed consent:

-giving informed consent -must give consent voluntarily (no coercion), be competent and of legal age (or authorized individual), and receive enough information to make a decision

CN IX

-glossopharyngeal -assess mouth for taste -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech

expected psychosocial development (body-image changes): young adult (20-35 yrs)

-greatly influenced by what young adults eat and how much exercise they get -pregnancy related body changes may also occur

aphasia defecit -speech/language-clients

-greet client & call them by name - speak clearly, slowly & short without shouting -pause between statements to allow understanding -check for comprehension -minimize background noise -ask questions that requires simple answers & allow for time - match verbal with nonverbal -picture charts or other speech therapist measures -writing- may improve communication -acknowledge & frustration expressed

isolation guidelines

-group of actions that include hand hygiene and use of barrier precautions, which are intended to reduce the transmission of infectious organisms -apply to everyone regardless of diagnosis, and must be implemented whenever contact with a potentially infectious material is anticipated -PPE is changed after contact with each client and between procedures with the same client if in contact with large amounts of blood and body fluids

Nursing CAM interventions

-guided imagery/ visualization therapy- healing / relaxation by focusing on images -healing intention- healing through caring, compassion & empathy in prayer -breath work- breathing patterns to reduce stress & increase relaxation -humor- reduce tension & improve mood - coping mechanism -mediation- calm mind & body -simple touch- communicates presence, appreciation & acceptance -music therapy- relaxation with distraction from pain, concentration -therapeutic communication- verbalize/ become aware of emotions and fairs

Board of nursing

-has authority to adopt rules and regs for nursing practice in that state -has authority to both issue and revoke a nursing license -set standards for nursing programs -delineate scope of practice among RNs, LPNs, and APNs

When accepting an order from a provider over the phone or verbally, the nurse should:

-have a second RN/LPN listen to the phone order -repeat back the order given including med name, dosage, time and route -document reading back the order and presence of the second nurse on the telephone -question any order that may seem contraindicated due to a previous order or to the client's condition

responsibilities of the nurse when receiving the transferred client

-have any specialized equipment ready -inform roommate of client's arrival (if applicable) -inform other team members of arrival -meet with client and family to complete admissions/orientation process -assess how client tolerates the transfer -review transfer docs -implement appropriate nursing interventions in a timely manner

the nurse should inform the client who smokes and his/her family about:

-hazards of smoking -available resources for smoking cessation -the effect of visiting or riding in a car with a smoker can have on a non-smoker

expected psychosocial development (self-concept development): adolescent (12-20 yrs)

-healthy self-concept developed by having healthy relationships with peers, family, and teachers -identifying a skill or talent helps maintain healthy self-concept -participation in sports, hobbies, or the community can have a positive outcome

safety prevention education/modifications for older adults includes:

-home hazard evaluation conducted by nurse, physical therapist, occupational therapist if deemed necessary -remove items that could cause client to trip, such as throw rugs and loose carpets -place electrical cords against wall and behind furniture -ensure steps and sidewalks in good repair -place grab bars near toilet and in tub/shower and installing a stool riser -non-skid mat in tub or shower -place shower chair in shower -ensure lighting is adequate inside and outside home

if evacuation of a unit is necessary due to fire:

-horizontal evacuation is done 1st -lateral evacuation is done if client safety cannot be maintained

when dealing with safety, all health care workers must be aware of:

-how to assess for and recognize clients at risk for safety issues -procedural safety guidelines -protocols for responding to dangerous situations -security plans -identification and documentation of the incidents and responses per health care agency policy

external emergencies include:

-hurricanes -floods -volcano eruptions -earthquakes -pandemic flu -industrial accidents -chemical plant explosions -major transportation accidents -building collapse -terrorist acts (including biological and chemical warfare)

CN XII

-hypoglossal -assess the tongue for movement and strength

AHA (american hospital association)

-identifies patient's rights in health care settings

behavior-change strategies nurses can use in health promotion/disease prevention

-identify client's readiness to receive and act upon health info -identify interventions acceptable to the client -help motivate the client to change by setting realistic timelines -reinforce steps the client makes toward change -encourage the client to maintain the change

planning related to client education includes:

-identify mutually agreed upon client outcomes -prioritize the learning objectives with the client's needs in mind -use methods that emphasize the client's learning style -select age-appropriate teaching methods/material -provide electronic educational resources as appropriate -demonstrate use of the internet as in regard to accessing info and support services and how to recognize reliable sources -organize learning activities to move from simple to more complex tasks, and known to unknown concepts -incorporate active participation in the learning process - schedule teaching sessions to coincide with the client's daily activities

Steps in ethical decision making

-identify whether or not the issue is indeed an ethical dilemma -state the ethical dilemma including all surrounding issues and individuals involved -list and analyze all possible options for resolving the dilemma and review implications of each option -select option that is in concert with the ethical principle applicable to this situation, the decision maker's values and beliefs, and the profession's values set forth for client care; justify why chosen over other options -apply this decision to the dilemma and evaluate the outcomes

transporting client in infection control/isolation

-if movement is unavoidable, take precautions to ensure that the environment is not contaminated -for example surgical mask placed on client with airborn or droplet infection and a draining wound is well covered

health promotion (immunizations): adolescent (12-20 yrs)

-if not given during 11-12, then years 12-20: Tdap, MCV4, HPV2 series (females), HPV4 (males), yearly seasonal flu TIV or LAIV (nasal)

causes of hyperphosphatemia

-impaired kidney excretion -hypoparathyroidism

Incident reports (unusual occurrences)

-important part of a facility's quality improvement plan -examples of incidence include med errors, falls, and needle sticks -facts documented without judgment or opinion -should not be referred to in client's medical record

causes of hypocalcemia

-inadequate Ca intake -impaired Ca absorption -excessive Ca loss

risks of infection

-inadequate hand hygiene (client and caregivers) -compromised health or defenses against infection -use of poor medical/surgical asepsis by caregivers -clients who have poor personal hygiene, poor nutrition, and those who are stressed -clients who live in a very crowded environment -older adult clients -clients who used IV drugs and share needles -clients who engage in unprotected sex -clients who have recently been exposed to poor sanitation, mosquito-born/parasitic diseases, or diseases endemic to area visited but not in client's home country

health promotion (injury prevention): older adult (65+ yrs)

-install bath rails, grab bars, and hand rails on stairways -remove throw rugs -eliminate clutter from walkways/hallways -remove extension and phone cords from walkways/hallways -instruct on proper use of ambulation-assistive devices -ensure adequate lighting -remind clients to wear eyeglasses and hearing aids -avoid drugs, including alcohol; prevent substance abuse -avoid taking drugs and/or drinking while driving -wear seat belt when operating a vehicle -wear helmet when riding bike, skiing, snowboarding -install smoke and carbon monoxide detectors in home -secure firearms in safe location

needle sizes, gauge & degree entering

-intradermal-tb/allergy/canver immunotherapy: 3/8 - 5/8 inch 26-27, .01 -.1mL 10-15 degrees -subcutaneous- pinch an inch {heparin/insulin: max 1.5mL: 5/8 - 1/2 in 25-27n, 45-90 degrees -intramuscular- 1- 11/2in, 18-27n, 22-25 gauge, 1-3ml injected -z-track- type of im injection that prevents medication from leaking into subq; stains

When client arrives to room the nurse should:

-intro yourself, explain your role and role of other nursing staff, provide hospital attire, position comfortably, apply ID/allergy bracelets, provide written info and info on advanced directives, document advanced directives in medical record -assess/collect: baselines, reason for seeking care, health history, family history, psychosocial history, nutrition, review of systems, spiritual info, safety assessment, discharge info -inventory personal items brought by client

affective learning

-involves feelings, beliefs, and ideals -example: a client listens to the nurse explain life changes necessary to manage diabetes and then discusses feelings regarding the diagnosis

Criminal law:

-is a subsection of public law -relates to the relationship of an individual with the government -ex: a nurse falsifies a record to cover up a serious mistake may be found guilty of breaking a criminal law

Examples of questions to use to determine potential for harm:

-is there a chance something negative may happen to the client (risk for bleeding, risk for aspiration)? -is the client unstable?

Examples of questions to use to determine level of interaction with the client:

-is there a need to provide psychosocial support or education during the performance of the task?

A problem is an ethical dilemma if:

-it cannot be solved solely by a review of scientific data -it involves a conflict between two moral imperatives -the answer will have a profound effect on the situation/client

sterile fields and moisture

-keep all areas dry -discard any sterile packages that become wet

health promotion (injury prevention-substance abuse/poisoning): school-age (6-12 yrs)

-keep cleaners or chemicals in locked cabinet and out of reach -teach to say "no" to illegal drugs and alcohol

prevention education for risk of falls in infants and toddlers:

-keep crib and playpen rails up -never leave unattended on changing table or other high surface -restrain while in high chair, swing, stroller, etc -place in low bed when toddler starts to climb

prevention education for risk of suffocation in infants and toddlers:

-keep plastic bags out of reach -ensure crib mattress fits snugly and no more than 2 2/3 inches between crib slats -never leave alone in bathtub -remove crib toys, including mobiles, as soon as infant begins to push up -keep latex balloons out of reach -fence swimming pools and use locked gate -begin swimming lessons as soon as developmental status allows -keep toilet lids down and bathroom doors shut

health promotion (injury prevention-bodily harm): toddler (1-3 yrs)

-keep sharp objects out of reach -keep firearms in locked box/cabinet -do not leave unattended with animals -teach stranger safety

health promotion (injury prevention-bodily harm): infant (birth-1 yr)

-keep sharp objects out of reach -keep infant away from heavy objects that can be pulled down onto her -do not leave alone with animals -monitor for shaken baby syndrome

prevention education for risk of aspiration in infants and toddlers:

-keep small objects out of reach -check toys for loose parts -do not feed infant hard candy, peanuts, popcorn, or whole/sliced pieces of hot dog -do not place infant in supine position while feeding or prop the bottle -pacifiers should be constructed of one piece -provide information on prevention of lead poisoning

components of critical thinking

-knowledge -experience -competence -attitudes -standards

expected cognitive development (language development): toddler (1-3 yrs)

-language increases to about 400 words with toddlers speaking in 2-3 word phrases

before beginning any task or procedure that requires aseptic technique, health care team members must check for:

-latex allergies (client and team members) -if there is a known allergy, latex-free gloves, equipment, and supplies must be used

psychomotor learning

-learning how to complete a physical activity or motor skill -example: client practices preparing insulin injections

Client's rights

-legal guarantees that clients have with regard to their health care -situations where nurses have opportunity to protect client's rights include: informed consent, refusal of treatment, advanced directives, confidentiality, and information security

lab results indicating infection include:

-leukocytosis (WBCs > 10,000/uL -increases in the specific types of WBCs on differential (left shift = increase in neutrophils) -elevated erythrocyte sedimentation rate (ESR) -presence of micro-organisms on culture of the specific fluid/area

all staff must be instructed in fire response procedures including:

-location of exits, fire extinguishers, and O2 shut-off valves -evacuation plan for the unit and facility

expected psychosocial development (social changes): young adult (20-35 yrs)

-may leave home early and establish independent living situation -may establish close friendships (intimacy) -may transition from being single to being member of new family -may question their ability to parent -may experience increased anxiety and/or depression, esp. after the birth of a child

expected psychosocial development (moral development): young adult (20-35 yrs)

-may personalize values and beliefs -reasoning may be based on ethical fairness principles, such as justice

expected psychosocial development (Erikson: initiative vs guilt): preschooler (3-6 years)

-may take on new experiences despite not having all physical abilities needed to be successful at everything -guilt may occur when unable to accomplish a task and believe they have misbehaved -guiding to attempt activities within their capabilities while setting limits is appropriate

transfer documentation should include:

-med diagnosis and care providers -client demographic info -overview of health status, plan of care, and recent progress -any alterations that may be of immediate concern -notification of any assessments/client care needed within the next few hrs -most recent vital signs and meds (inc PRNs) -allergies -diet and activity orders -presence of/need for special equipment or adaptive devices -advanced directives & emergency code status -family involvement and health care proxy (if applicable)

What is postural drainage?

-method for clearing the lungs by changing position; the Trendelenburg position is commonly used; -allows gravity to help drain mucous from lower and middle portions of lungs to the top of the lungs where it can be removed more easily

expected psychosocial development (Erikson-generativity vs stagnation): middle adult (35-65 yrs)

-middle adults strive for generativity -use life as an opportunity for creativity and productivity -have concerns for others -consider parenting an important task -contribute to well-being of the next generation -strive to do well in one's own environment -adjust to changes in physical appearance and abilities

promote healthy lifestyle behaviors by instructing clients to:

-minimize or reduce stress -get adequate sleep/rest - eat a nutritious diet to achieve and maintain a healthy weight -avoid saturated fats -participate in regular physical activity most days of the week -while outdoors, wear protective clothing, use sunscreen, and avoid sun exposure between 10am and 4pm -wear safety gear while participating in physical activity -avoid substances such as tobacco products, alcohol, and illegal drugs -practice safer sex -seek medical care when necessary, and visit provider for routine screenings

expected psychosocial development (body-image changes): preschooler (3-6 years)

-mistaken perceptions of reality coupled with misconceptions in thinking lead to active fantasies and fears -greatest fear is that of bodily harm, thus fear of the dark and animals -sex-role identification is occurring

health promotion (injury prevention-substance abuse): adolescent (12-20 yrs)

-monitor for s/s of substance abuse in at-risk children -teach to say "no" to drugs and alcohol -present a no tolerance attitude

food poisoning

-most cases caused by bacteria such as E. coli, Listeria monocytogenes, and Salmonella -healthy individuals usually recover in a few days -very young, very old, pregnant, or immunocompromised clients at highest risk for complications -clients who are especially at risk are instructed to follow a low-microbial diet -most cases due to unsanitary food practice -can be prevented by proper hand hygiene, cooking meats/fish to correct temp, handling raw and fresh foods separately to avoid cross-contamination, and proper refrigeration

home safety risks for young and middle age adults include:

-motor vehicle crashes -occupational injury -high alcohol consumption -suicide

effects of hypomagnesemia

-muscle weakness -tremors -tetany -seizures -heart block -change in mental status -hyperactive deep tendon reflexes -respiratory paralysis

Signs of hypokalemia

-muscle weakness and leg cramps -fatigue -parasthesias (tingling/pricking sensation) -dysrhythmias -skeletal muscles are generally first to demonstrate deficiency

nursing responsibilities in regards to isolation/restraints:

-must be identified in the protocol -include how often the client should be: assessed; offered food/fluid; provided for means of hygiene/elimination; monitored for vital signs; offered ROM of extremities

seclusion and restraints

-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min

Effects of hypercalcemia

-nausea -vomiting -constipation -bone pain -excessive urination -thirst -confusion -lethargy -slurred speech

Effects of hypermagnesemia

-nausea -vomiting -weakness -flushing -lethargy -loss of DTRs -respiratory depression -coma -cardiac arrest

effects of hyperkalemia

-nerve conduction and muscle contractility affected -skeletal muscle weakness and paralysis -cardiac irregularities including cardiac arrest

IV guidelines

-never give in bolus if it can cause serious adverse reactions; IV pump, potassium chloride -never admin IV meds through tubing that is infusing blood, blood products or nutritional solutions -fragile veins, anticoagulants, elderly; no tourniquets, use BP cuff, do not slap extremity -edema; digital pressure with alcohol pad over selected vein to displace it -fluids should not hang more than 24hrs

restraints should:

-never interfere with treatment -restrict movement as little as is necessary to ensure safety -fit properly -be easily changed to decrease the chance of injury and to provide for the greatest level of dignity

pulse oximetry

-noninvasive technique that measures SaO2 of arterial blood -A range of 95% to 100% is considered normal SpO2; values ≤90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error

macule

-nonpalpable, skin color change, <1cm -example: freckle

expected age-appropriate activities: adolescent (12-20 yrs)

-nonviolent video games -nonviolent music -sports -caring for a pet -career-training programs -reading -social events (going to movies or school dances)

standards for emergency preparedness mandated by the Joint Commission require procedures be set for:

-notifying and assisting personnel -notifying external authorities of emergencies -managing space and supplies and providing security -isolating and decontaminating radioactive or chemical agents -evacuating and setting up alternative care site when the environment cannot support adequate client care and treatment -performing triage -managing clients during emergencies -interacting with families and news media -identifying backup resources for utilities and communication -orienting and educating personnel participating in emergency preparedness plan -providing crisis support for health care workers -providing performance monitoring and evaluations related to emergency preparedness -conducting 2 emergency preparedness drills each year

the first number of the recorded visual acuity indicates the ___ ___ ___ from the ___ the client is ___

-number of feet -chart -standing

Effects of hypocalcemia

-numbness and tingling of fingers, mouth, or feet -tetany -muscle cramps -seizures

Standards of care

-nurse practice act of each state -ANA, AACN, AAOHN -health care facilities policies and procedures

homes safety

-nurses often collaborate to promote safety -to initiate a plan of care, the nurse must identify risk factors using a risk assessment tool & complete a nursing history, a physical examination & a home hazard appraisal

health promotion (nutrition): adolescent (12-20 yrs)

-nutrient deficiencies tend to be: iron, calcium, and vits A & C -eating disorders commonly develop including: anorexia nervosa, bulimia nervosa, obesity -advise parents: ensure balanced diet according to USDA and teach children to make healthy food choices -encourage dental health including: brushing and flossing daily; having regular check-ups and fluoride treatments

health promotion (alterations in health): middle adult (35-65 yrs)

-obesity and type 2 diabetes mellitus -CV disease -cancer -substance abuse (alcoholism) -psychosocial stressors

health promotion (nutrition): middle adult (35-65 yrs)

-obtain adequate protein intake -increase consumption of whole grains -increase consumption of fresh fruits and veggies -limiting fat and cholesterol -increasing vit D and calcium supplementation (esp for women)

The provider's responsibility for informed consent:

-obtain informed consent -must give complete description of treatment/procedure, description of who will be involved in treatment, description of risks, options for other treatments, and the right to refuse -provide clarification if requested

cognitive learning

-obtaining new info, being able to apply the info, and being able to evaluate the info -example: client is taught s/s of hypoglycemia and then can verbalize when to notify provider

supervision:

-occurs after delegation -oversees a staff's performance of delegated activities -determines if: completion of task is on schedule; performance was satisfactory; abnormal/unexpected findings documented & reported; assistance is needed to complete assigned tasks in a timely manner; assignment should be re-evaluated & possibly changed

CN III

-oculomotor -assess corneal light reflex -assess pupillary reaction to light -assess extraocular movements

seizure precautions

-rescue equipment at bed, remove unsafe items in even, assist ambulation -advise: NPO, do not restrain, lower to floor with space, protect head & flex fwd, body on side, loosen clothes -stay with/call for help -explain/provide comfort

falls

-older adults at increased risk due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception -other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems, and cognitive dysfunction; also side effects of some medications -clients are at greater risk when >1 of the risk factors are present -fall prevention is a major nursing priority

CN I

-olfactory -assess nose for smell

responsibilities of the nurse when transferring/discharging the client:

-on day/time of transfer, confirm they are expecting and have a bed -communicate time client will be arriving -complete documentations -give verbal transfer report in person or over the phone -confirm mode of transportation to complete transfer/discharge -ensure client is dressed appropriately -account for all of client's valuables

CN II

-optic -assess visual acuity -assess visual fields -assess corneal light reflex -assess pupillary reaction to light

expected psychosocial development (social development): school-age (6-12 yrs)

-peer groups play an important part in social development -peer pressure begins to take effect -same-gender friendships begin to form; this is time period when clubs and best friends are popular -children prefer company of same-gender companions -most relationships come from school associations -at this age, may rival same-sex parent -conformity becomes evident

expected psychosocial development (social development): adolescent (12-20 yrs)

-peer relationships develop -these relationships act as support system for the child -best friend relationships are more stable and long-lasting in comparison to previous years -parent-child relationships change to allow a greater source of independence

Items to be transferred/discharged with the client include:

-personal belongings at the bedside -valuables from the safe -medications -assistive devices -medical records or transfer form

causes of hypophosphatemia

-phosphorous deficiency -admin of calories to malnourished patients -alcohol withdrawal -diabetic ketoacidosis -hyperventilation -insulin release -absorption problems -diuretic use

home safety risks for older adults include:

-physical, cognitive and sensory changes -changes in musculoskeletal and logical systems -impaired vision and/or hearing -nocturia and incontinence

health promotion (nutrition): toddler (1-3 yrs)

-picky eaters; repeated requests for favorite foods -consume 24-30 oz of milk/day; may switch from whole milk to 2% at age 2 -limit juice to 4-6 oz/day -food serving size is 1 tbsp for each yr of age -exposure to new food may take 8-15 times before acceptance -if there is a family history of an allergy to a certain food, gradually introduce while monitoring for reactions -finger foods may be preferred due to increasing autonomy -regular meal times and nutritious snacks best meet nutrient needs -avoid snacks/desserts high in sugar, fat, sodium -avoid foods that are potential choking hazards -always provide supervision during snack/mealtimes -cut small bite-size pieces to make them easier to swallow and prevent choking -do not allow drinking/eating during play or while lying down -suggest parents follow USDA nutrition guidelines

expected physical development (size): infant (birth-1 yr)

-posterior fontanel closes by 2-3 months -anterior fontanel closes by 12-18 months -weight: gains 150-210 g (5-7 oz) per month for 1st 6 months; birth weight should double by 4-6 months and triple by the end of the 1st year -height: grows about 2.5 cm (1 in) per month for 1st 6 months; then about 1.25 (0.5 in) per month til the end of 1st yr -head circumference: increases about 1.25 cm (0.5 in) per month for 1st 6 months; then about 0.5 cm (0.2 in)between 6-12 months)

Hypokalemia

-potassium deficit in ECF -serum potassium<3.5mEq/L -potassium leaves cells and creates intracellular K deficiency -Na and H+ are retained by cells to maintain isotonic fluid

What is included in seizure precautions?

-rescue equipment at bedside: O2, oral airway, suction equipment, and padding for bed rails; -remove items from environment that may cause injury to patient if seizure occurs; -assist w/ambulation and transfers; -advise family not to restrain client or put anything in the mouth if a seizure occurs

complete documentation of isolation/restraint use includes a description of:

-precipitating events and behavior prior to seclusion/restraints -alternative actions taken to avoid seclusion/restraint -time restraints applied and removed (if discontinued) -type of restraint and location -client's behavior while restrained -type and frequency of care -client's response when restraint removed -meds administered

expected cognitive development (Piaget: still in preoperational phase>preconceptual though to intuitive thought): preschooler (3-6 years)

-preconceptual thought (2-4 year): make judgments based on visual apperances; misconceptions in thinking include artificialism (everything is made by humans), animism (inanimate objects are alive), and imminent justice (a universal code exists that determines law and order) -intuitive thought (4-7 year): can classify information and become aware of cause-and-effect relationships

Prior to delegating client care, the nurse should consider:

-predictability of outcome -potential for harm -complexity of care -need for problem solving and innovation -level of interaction with the client

catheter irrigation

-prepare sterile syringe -clamp catheter between injection port. extension tubing -cleanse injection port with antiseptic swab/wipe -insert needle of syringe with irrigant into injection port -inject slowly -withdraw & remove clamp; allowing iffigant to drain into draingage bag

nurses legal responsibility to med administration

-preparing administering & evaluating client responses to meds -maintaining up to date knowledge including; uses, mechanisms of action, routes of administration, safe dosage range, side effects, adverse responses, precautions & containdication -determining accuracy of meds orders

expected psychosocial development (self-concept development): toddler (1-3 yrs)

-progressively see themselves as separate from their parents and increase their exploration away from them

droplet precautions

-protect against droplets larger than 5 mcg (streptococcal phryngitis or pnemonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meningococcal pneumonia/sepsis, pneumonic plague) -require a private room or room with clients with the same infectious disease and masks for providers and visitors

purposes of client teaching include:

-providing clients with info and skills to maintain and promote health, and prevent illness (immunizations, lifestyle change, prenatal care) -providing clients with info about how to restore health (teaching how to admin insulin) -providing clients with info about how to adapt to permanent illness or injury (ostomy care, learning swallowing techniques, speech therapy)

hematoma

-raised ecchymosis

steps of mobility assessment

-range of motion -moving from supine to sitting on side of bed -gait -exercise tolerance

pulse

-rate/ rhythm of heart -0-4/ absent to bounding scale; 2 is normal -apical may be faster in pulse deficit then radial and only appear during dysrhythmia- use for irregularities, before cardiac meds, rapid rates & infants -normal 120-160bpm

cherry angioma

-red -1-3 cm -round -can be raised

spider angioma

-red center with radiating red legs -up to 2 cm -can be raised

s/s during 1st stage of the inflammatory response (local infection):

-redness (from dilation of arterioles bringing blood to the area) -warmth of the area on palpation -edema -pain or tenderness -loss of use of the affected part

erythema

-redness: best noted in face, trauma and pressure sore areas -indication of inflammation

prevention education for risk of burns in preschoolers and school-age children:

-reduce setting on water heater to no higher than 120 deg F -teach dangers of playing with matches, fireworks, fire arms, etc -teach school-aged children how to use microwave and other cooking instruments

State laws

-regulate the core of nursing practice -each state has enacted statutes defining parameters of practice and gives authority to regulate to the state board of nursing

expected psychosocial development (moral development): middle adult (35-65 yrs)

-religious maturity -spiritual beliefs and religion may take on added importance -may become more secure in convictions -often have advanced moral development

safety prevention education for young and middle age adults includes:

-remind clients to drive defensively and not to drive after drinking -reinforce teaching about long term effects of high alcohol consumption -monitor for s/s of depression/suicide and refer as appropriate -encourage clients to be proactive about safety in workplace -ensure understanding of hazards of excessive sun exposure and the need to use sun block and protective clothing

causes of hyperkalemia

-renal failure -hypoaldosteronism -heparin, KCl, ACE inhibitors, NSAIDs, K-sparing diuretics

Causes of hypermagnesemia

-renal failure when kidneys fail to extrete Mg or from excessive Mg intake (antacids or laxatives)

advance directives

-required by PSDA -living will: clients wished for treatment if incapacitated or facing end of life issues -durable POA: proxy authorized for decisions when client is unable -Provide Orders: DNR/AND

biological incidents

-take measures to protect self and others -recognize s/s of infection/poisoning and appropriate treatments -incidents include: inhalational anthrax, botulism, smallpox, and ebola

screenings and exams for clients who are asymptomatic

-routine physical: (f) every 1-3 years beginning at 20/annually beginning at 40; 9m) every 5 years starting at 20/annually beginning at 40 -dental assessment: (f&m) every 6 months -blood pressure: (f&m) starting at 20, each routing health care visit, min of every 2 yrs -BMI: (f&m) starting at 20, each routing health care visit -blood cholesterol: (f&m) starting at 20, a min of every 5 yrs -blood glucose: (f&m) starting at 45, min of every 3 yrs -colorectal screening: (f&m) fecal occult blood test annually at 50 AND flexible sigmoidoscopy every 5 yrs or colonoscopy every 10 yrs or double contrast barium enema every 5 yrs -colonoscopy: (f&m) starting at 50, every 1-10 yrs depending on test used -pap test: (f) starting at 21 (or earlier if sexually active) every 1-2 yrs; after 30 every 1-3 yrs depending on provider/test used -clinical breast exam: (f) starting at 20, every 3 yrs; at 40, annually -mammogram: (f) starting at 40, annually -clinical testicular exam: (m) starting at 20, annually -prostate-specific antigen test & digital rectal exam: (m) starting at 50, as indicated by provider

disease prevention tests

-routine starting at age 20 -dental - every 6 months -BP- 2 years starting at age 20 -BMI - each routine - cholesterol - every 5 years starting at age 20 -glucose - every 3 years start at age 45 -Colorectal- FOBT starting at age 50, colonoscopy every 10 years -Pap - every 2 years from 20-30 then 1-3 years -Breast - every 3 years at age 20 yearly at 40 -mammogram at 40 then yearly -testicular- at 20 yearly -prostate / digital rectum - males above 50

types of prescriptions

-routine/standard -regular schedule -single/one time - certain time or as soon as possible -stat- once, immediately -PRN- as needed with clinical judement, prescription says what dosage, what frequency & under what conditions -standing- for specific circumstances/units

internal emergency readiness includes:

-safety and hazardous materials protocols and infection control policies and practices

health promotion (health screenings): school-age (6-12 yrs)

-scoliosis: screening for lateral curve before and during growth spurts; can be at school or provider's office

expected psychosocial development development (body-image changes): adolescent (12-20 yrs)

-seem particularly concerned with body images portrayed by the media -changes during puberty result in comparisons between the child and surrounding peer group -parents also give input as to hair styles, dress, and activity -may require help if depression or eating disorders result due to poor body image

expected cognitive development (Piaget: concrete operations): school-age (6-12 yrs)

-sees weight and volume as unchanging -understands simple analogies -understands time (days/seasons) -classifies more complex information -understands various emotions people experience -becomes self-motivated -is able to solve problems

discharge planning

-should begin when client is admitted (with the exception of LTC) -assess if the client will be able to return home and/or if they will need assistance at home -assess residence to see if adaptations or specific equipment will be necessary -make referral to social worker if needed -communicate client health status and needs to community service providers -if client chooses to leave before discharged, notify provider and have pt sign off

health promotion (health screenings): young adult (20-35 yrs)

-should follow age-related guideline -routine health care visits should include: height, weight, and VS; stress screenings; education related to STDs, substance abuse, and contraception; encouragement of good nutrition and regular physical activity

expected physical development (gross and fine motor skills): preschooler (3-6 yrs)

-should show great improvements in fine motor skills such as copying figures on paper and dressing themselves -3 years: (g) rides tricycle, jumps off bottom step, stands on 1 foot for a few seconds -4 years: (g) skips and hops on 1 foot, throws ball overhead -5 years: (g) jumps rope, capable of walking backward with heel to toe, moves up and down stairs easily

hearing impaired client

-sit & face client without covering mouth while speaking -hearing devices -sign language interpreter id necessary -speak slowly & clearly without shouting, try lowering pitch -brief sentence/simple words, write down if not understood

health promotion (injury prevention-MVA): preschooler (3-6 yrs)

-sit in approved forward-facing car seat in back set away from airbags -can usually sit in seat until 4 yo or 40 lbs -when outgrown, use booster seat in back seat -should be restrained in car seat or booster until adult belt fits correctly (laws vary from state to state)

stress may be:

-situational -developmental -caused by sociocultural -a contributor to illness vulnerability

the three essential components of hand washing include:

-soap -water -friction

expected age-appropriate activities: toddler (1-3 yrs)

-solitary play evolves into parallel play where toddler observes other children and then may engage in activities nearby -appropriate activities include: filling and emptying containers, playing with blocks, looking at books, toys that can be pushed and pulled, tossing a ball -temper tantrums result when frustrated with independence restrictions; providing consistent, age-appropriate expectations helps them work through frustrations -toilet training can begin when it is recognized that child has sensation of needing to urinate/defecate; parents should demonstrate patience and consistency; nighttime control may be last to develop -discipline should be consistent and with well defined boundaries established to develop appropriate social behavior

Patient self determination act

-staff must inform clients of right to refuse treatment -client must sign "against medical advice" document which nurse provides -nurse documents, explains risks, and notifies provider

What to do when a client *IS HAVING* a seizure

-stay with client - call for help; -lower client to floor or bed, protect head, remove nearby furniture, provide privacy, put client on side w/head flexed slightly forward if possible, and loosen clothing; -admin meds as prescribed; -note duration of seizure, sequence and type of movement

discharge instructions should include:

-step-by-step for procedures done at home -precautions to take when performing home procedures and with meds -s/s of complications that should be reported -names and numbers of providers and community services contacts -plans for follow-up care and therapies

health promotion (alterations in health): young adult (20-35 yrs)

-substance abuse -periodontal disease due to poor oral hygiene -unplanned pregnancies (a source of high stress) -STDs -infertility -work-related injuries or exposures

Hypernatremia

-surplus of sodium in ECF -serum sodium>145mEq/L -excess water loss or excess sodium -fluid move from cells b/c of increased extracellular osmotic pressure -cells shrink

Effects of hyponatremia

-swelling of cells -confusion -hypotension -edema -muscle cramps -weakness -dry skin

Systolic BP versus Diastolic BP

-systole- contraction -diastole- relaxtion -systole BP- occurs during ventricular systole of the heart, when ventricles force blood into the aorta & represents the maximum amount of pressure exerted on the arteries -diastole BP- occurs during ventricular diastole of the heart, when the ventricles relax & exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on arteries

hazardous material incidents

-take measures to protect self and avoid contact -approach scene cautiously -try to identify the material and have knowledge of where MSDS manual is located -try to contain material to one area as much as possible until haz-mat team arrives -if individuals are contaminated, decontaminate as much as possible at the scene or as close to the scene as possible

chemical incidents

-take measures to protect yourself and to avoid contact -assess and intervene to maintain the client's ABCs and admin first aid as needed -effectively remove the offending chemical/decontaminate -gather specific history of the injury, if possible -in the event of chemical warfare, have knowledge of which facilities are open to exposed clients and which are open to unexposed clients only -follow facility's emergency ops plans

health promotion (injury prevention-burns): school-age (6-12 yrs)

-teach fire safety and potential burn hazards -have working smoke and carbon monoxide detectors in the home -use sunscreen when outdoors

prevention education for risk of burns in adolescents

-teach to use sunblock and protective clothing -teach dangers of sun bathing and tanning beds -educate on hazards of smoking

prevention education for risk of burns in infants and toddlers:

-test temp of formula and bath water -place pots on back burner and turn handle away from front of stove -supervise use of faucets

Entities with codes of ethics that may be used to guide nursing practice include:

-the American Nurses Association (ANA) -the International Council of Nurses (ICN) -the National Association for Practical Nurse Education and Services, Inc.

bioterrorism

-the dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death -examples include anthrax, variola, Clostridium botulism, and Yersinia pestis

complex critical thinking

-the nurse begins to express autonomy by analyzing and examining data to determine the best alternative -results from increased nursing knowledge, experience, intuition, and more flexible attitudes

commitment

-the nurse expects to have to make more choices without help from others and fully assumes the responsibility for those choices -results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes

Consent considered informed when the client has been provided and understands:

-the reason the treatment or procedure is needed -how the treatment or procedure will benefit the client -risk involved if treatment or procedure is chosen -other options to treat the problem (including no action)

CN IV

-trochlear -assess extraocular movements

discharge documentation should include

-type of discharge -date/time of discharge, how the client was transported out and with who -where discharged to -summary of condition upon discharge -description of any unresolved difficulties and procedures for follow up -deposition of valuables and meds -copy of discharge instructions

prevention education for risk of motor vehicle/injury in preschoolers and school-age children:

-use booster seats for children < 4'9" and <40 lbs -use seat belts properly after booster seats no longer necessary -use protective equipment when participating in sports or riding/passenger on a bike -supervise and teach safe use of equipment -teach to play in safe areas, rules of the road, and what to do if approached by a stranger -begin sex education for school-ages children

oxygen safety measures:

-use/store according to manufacture's recommendations -place a NO SMOKING sign near front door of home and on door of client's bedroom -inform client and family of smoking in presence of oxygen and that smokers should smoke outdoors -ensure electrical equipment is in good repair and well grounded -replace bedding that can generate static electricity (wool, nylon, synthetics) with cotton -keep flammable items (such as heating oil and nail polish remover) away from client when O2 in use -follow general safety measures for fire safety

health promotion (injury prevention-MVA): toddler (1-3 yrs)

-used approved car seat in back seat away from airbags -should be rear facing till reaches 9.1 kg (20 lbs) and is 1 yr old; then can use forward facing seat in back seat-usually until 4 yo old 40 lbs -children who meet weight but not age requirement of 1 yr should remain rear facing and a 5 point harness or T-shield should be a part of convertible harness

airborne precautions

-used to protect against droplet infections smaller than 5mcg (measles, varicella, pulmonary or laryngeal TB) -require a private room, masks/respiratory devices for caregivers and visitors (N95 or HEPA respirator for known/suspected TB), and negative pressure airflow exchange room of at least 6 exchanges per hr

Telephone report

-useful when contacting provider or other members of the interdisciplinary team -important to have all data prepared before calling; use professional demeanor; use exact, relevant, and accurate info; document name of person called, time, content of message, and instructions or information received

5 rights of delegation help decide:

-what task should be delegated (right task) -under what circumstances (right circumstance) -to whom (right person) -what info should be communicated (right direction/communication) -how to supervise/evaluate (right supervision /evaluation)

bomb threat

-when a phone call is received: >lengthen conversation as much as possible >listen for distinctive background noise >be alert for distinguishing voice characteristics >ask where the bomb will explode and at what time >note if the caller indicates knowledge of the facility by his description of the location -if what appears to be a bomb is found, don't touch, clear the area, isolate it, and obtain professional assistance -notify authorities and key personnel -cooperate with police and others -keep elevators available for authorities -remain calm and alert and try not to alarm clients

Examples of questions to use to determine predictability of care:

-will the completion of the task have a predictable outcome? -is it a routine treatment? -is it a new treatment?

steps to donning sterile gloves:

-with cuff side pointing toward the body, use non-dominate had to pick up dominate glove -while picking up edge of the cuff, pull the dominate glove onto the hand -with sterile dominate hand gloved, place fingers of dominate hand inside cuff of left hand, lifting it off the wrapper and put non-dominate hand into it -when both hands are gloved, adjust fingers as needed -during this time, only sterile gloved hand can touch the other sterile gloved hand

The nurse's responsibility for informed consent:

-witness informed consent -must ensure provider provided necessary information, ensure the client understood and is competent to give consent, have the client sign informed consent document, notify provider if more information or clarification needed/requested by client, and document client questions and that the provider was notified (also if interpreter was used)

always count the apical pulse rate for

1 min

What are the 3 types of nociceptive pain?

1) *somatic* - bones, joints, muscles, skin, or connective tissues; 2) *visceral* - internal organs such as the stomach or intestines; can cause referred pain; 3) *cutaneous* - skin or subcutaneous tissue

5 elements necessary to prove negligence

1) duty to provide care as defined by a standard 2) breach of duty by failure to meet standard 3) foreseeability of harm 4) breach of duty has potential to cause harm (combines 2&3) 5) harm occurs

What are the steps for changing a stoma pouch?

1) remove old pouch; 2) inspect stoma; 3) use mild soap and water to cleanse the skin, then dry it gently and completely; 4) apply paste if necessary; 5) measure and draw where to cut the skin barrier, allowing only the stoma to appear through the opening; 6) cut the opening in the skin barrier; 7) if necessary, apply barrier paste to creases; 8) apply skin barrier and pouch; 9) fold bottom of pouch and place closure clamp on the pouch

To clean a surgical instrument prior to sterilization

1) rinse under *cold* water [because hot water coagulates proteins which makes them adhere]; 2) wash with *soap and water*; 3) remove organic materials w/a brush; 4) rinse under *warm water*; 5) dry instrument

patient priority list

1. severe injuries but high chance of survival --i.e. second/third degree burns 2. moderate injuries with higher chance of survival --i.e. major bone fracture 3. mild injury with certain survival --i.e. minor laceration 4. severe injuries with almost certain death

normal Na+ levels

135 - 145 mEq/L

Sodium Normal Levels

135-145 mEq/L

stage I hypertension

140/90 - 159/99

How long should the patient retain the cleansing enema solution?

5 to 10 min

2. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

the line on the Snellen chart for which ___ or ___ letters are missed is recorded as the visual acuity

2 or fewer

client must stand ___ ___ from the Snellen chart

20 feet

expected school-age respiratory rate

20-30 rpm

What is the recommended fiber intake for a normal diet?

25-30 g/day

a diagnosis of hypertension is made is made if readings are elevated on at least

3 separate occasions over several weeks

fever is not usually harmful unless it exceeds

39* C (102.2* F)

high-fowler

90 degrees, lung expansion, severe dyspnea

hypoxemia is an SaO2 below

90%

Needle Gauge (diameter) and length

A needle's gauge reflects the diameter of the needle: the larger the gauge, the narrower or the smaller the diameter of the needle. The length of the needle reflects how long the needle is and is chosen based on intended use. The needle packaging always indicates the needle's gauge and length. For example, this package contains a 25-gauge, 1-inch needle.

Criminal law

A subsection of public law and relates to the relationship of an individual with the government. A nurse who falsifies a record to cover up a serious mistake may be guilty of breaking a criminal law.

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain

A. Role conflict ____________________ A. CORRECT: The client is experiencing role conflict because his career is extremely physical, and he can no longer perform his job duties. However, the client is the primary wage earner in the family. B. INCORRECT: Although the client may feel overloaded and overwhelmed, role overload occurs when the client is trying to juggle too many roles. C. INCORRECT: The client is not experiencing role ambiguity because his job duties and his physical limitations are quite clear. D. INCORRECT: The client is not experiencing role strain. That occurs when one feels inadequate for assuming a role.

Intramuscular (IM) injection

Acceptable sites: deltoid, vastus lateralis, and ventrogluteal For all IM injections use the Z track method (displace skin and subq tissue 1-1.5") with nondominant hand; release immediately after withdrawing needle Insert the needle at a 90º angle for all intramuscular injections. Use a quick, darting motion to insert it. Always aspirate with the plunger of the syringe to check for blood return in the syringe before injecting the medication. Lack of blood on aspiration confirms needle placement in the muscle rather than in a blood vessel. Inject the medication slowly and smoothly, then hold the needle in place for 10 seconds to allow the medication to disperse. Withdraw the needle quickly at the same angle at which you inserted it. Cover the site with dry gauze immediately and apply gentle pressure. Do not massage the site. Deltoid landmarks & needle size: acromion process and the axillary line. Insert the needle at a point two to three finger widths (1 to 2 inches) below the acromion process. average adult or adolescent, give up to 1 mL of medication with a ⅝-inch to 1-inch needle. Do not use the deltoid site for infants and toddlers younger than 3 years. For preschoolers and older children, use a ⅝-inch needle for giving an IM injection in the deltoid. Vastus lateralis landmarks & needle size: the head of the greater trochanter and the knee. Insert the needle into the middle third of the muscle at least one hand width below the greater trochanter and one hand width above the knee in the anterolateral aspect of the leg. average adult or adolescent, give up to 3 mL of medication with a 18- to 25- gauge, 1- to 1½-inch needle for oil based or viscous solutions. Use a 22- to 27-gauge, 1- to 1½-inch needle for aqueous solutions. For infants, give up to 1 mL with a 1-inch needle; for small infants, give up to 0.5 mL with a ⅝-inch needle. This is one of the preferred sites for infants. Ventrogluteal landmarks & needle size: head of the greater trochanter and the anterior superior iliac spine. Place the heel or the palm of your hand on the head of the greater trochanter with your thumb pointing toward the patient's abdomen. Extend your index finger up to the anterior superior iliac spine then spread your other fingers back along the iliac crest. Insert the needle in the "V" formed between your index and third fingers. give up to 3 mL of medication with an 18- to 25-gauge, 1- to 1½-inch needle for oil-based or viscous solutions. Use a 22- to 27- gauge, 1- to 1½-inch needle for aqueous solutions. For infants, give up to 1 mL with a ½- to 1-inch, 21- 25-gauge needle; for small infants, give up to 0.5 mL with a ?-inch, 21- 25-gauge needle. For toddlers, give up to 2 mL with a 1-inch, 21- 25-gauge needle. For children age 3 and older, give up to 2 to 3 mL with a 1-inch, 21- 25-gauge needle. For adolescents, give up to 3 mL with a 1- to 1½-inch, 21- 25-gauge needle. This is the preferred site for administering irritating or oily solutions to patients of any age

Causes of hyperphosphatemia

Acute/chronic renal failure; chemotherapy, excessive ingestion of milk or phosphate containing laxatives, large intakes of vitamin D

Basic principles of ethics

Advocacy, responsibility, accountability, confidentiality

IV Therapy

All IV fluids must be administered carefully, but hypertonic solutions are particularly risky. These solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can result in pulmonary edema, particularly in patients who have cardiac or renal disease. Isotonic solutions have an approximate electrolyte content of 300 mEq/L. This type of solution is infused to replace fluid losses, usually extracellular losses, and to expand the intravascular volume. Most isotonic solutions do not provide calories or free water. Examples of isotonic solutions are 0.9% sodium chloride, commonly called normal saline (NS), and lactated Ringer's (LR). Hypotonic solutions have an electrolyte content of less than 250 mEq/L and are administered to expand the intracellular space. They are commonly infused to dilute extracellular fluid and rehydrate the cells of patients who have hypertonic fluid imbalances and to treat gastric fluid loss and dehydration from excessive diuresis. This type of solution provides free water, sodium, and chloride but does not provide calories or other electrolytes. An example of a hypotonic solution is 0.45% sodium chloride (0.45% NS), commonly called half normal saline. Solutions with an electrolyte content of 375 mEq/L or more are considered hypertonic. Hypertonic solutions are infused to treat patients who have severe hyponatremia. Depending on the type of hypertonic fluid infused, it can provide patients with calories, free water, and some electrolytes. Examples of hypertonic solutions are dextrose 10% in water (D10W) and dextrose 5% in 0.9% sodium chloride (D5NS). Because hypertonic solutions can be extremely irritating to the patient's veins, some must only be infused through a central line.

Care of the Insertion site (CVADs)

Always use surgical asepsis (sterile technique) when changing the dressing and be sure to follow your facility's policy for specific guidelines. CDC recommends changing a dressing when it is damp, loosened, or soiled. The Infusion Nurses Society recommends changing gauze dressings every 48 hours and transparent dressings 3 to 7 days or whenever they are no longer intact. A transparent semipermeable membrane dressing is often preferred as it allows easy visualization of the insertion site. Typically, gauze dressings are not recommended unless there is drainage from the site. Some use alcohol and povidone-iodine (Betadine) and while others use chlorhexidine (ChloraPrep). Age of the patient is also a consideration when choosing an antiseptic. For example, the INS does not recommend using isopropyl alcohol for neonates. Povidone-iodine or chlorhexidine can be used but must be removed completely with sterile water or saline to prevent product absorption. When using alcohol and povidone-iodine, start at the catheter's insertion site and clean in a circular motion, moving from inside the circle near the catheter to the outside. Continue to enlarge the circle, being careful to continue moving outward and to avoid moving inward. Apply it for a minimum of 30 seconds and allow it to dry completely before applying povidone-iodine. When using chlorhexidine, use a back-and-forth motion. Cleanse the site for 30 seconds. With this or povidone-iodine and alcohol, be sure to cleanse the skin well beyond the dressing area. Central venous catheters have a special cap on the end where IV tubing or syringes connect into the line. This cap is called the injection or access cap. Typically, injection caps are changed every 72 to 96 hours for continuous infusions and every 7 days for intermittent infusions, most likely at the same time as a dressing change. Check your facility's policy to determine when to change the caps and, before attaching the new caps, be sure to prime them. In addition to site care and cap changes, your ongoing care includes assessing the insertion site for redness, drainage, inflammation, swelling, tenderness, and warmth.

3. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. The flap farthest from the body Unless the nurse pulls *the top flap [the one furthest from her body]* away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.

Intradermal Injections

Appropriate sites: Inner forearm and the upper back. Use a tuberculin or other small syringe (1 mL or smaller) with a 3/8- to 5/8-inch, 25- to 27-gauge needle for an intradermal injection. Pull the patient's skin so that it is taut and insert the needle at a 5º to 15º angle, almost parallel to the patient's skin and with the bevel facing up. The needle will be visible under the skin; insert it about 1/8 inch. Give the injection slowly while observing the site for blanching and for the appearance of a wheal. After you have injected all of the medication, withdraw the needle slowly and gently apply dry gauze. Do not massage the site. Bleeding or no wheal formation at the injection site indicates that the injection was given incorrectly.

which are federally funded? A.PPO B. medicare C. long-term care insurance D.EPO E. medicaid

B, E

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

B. Autonomy In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy.

5. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B. The nurse *moistens* a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is *delayed* 1 hr because the provider receives an emergency call. D. The nurse *turns* to speak to someone who enters through the door behind the nurse.

4. A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. *A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client.*

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

C. Justice Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources.

Drawing and discarding blood (CVAD)

Central venous access devices can be used to avoid repeated venipunctures for patients who need frequent drawing of blood samples. Depending on its size, you might not be able to obtain a blood sample from a peripherally inserted central catheter (PICC). For example, drawing blood from small-gauge PICC lines (2 or 3 French) can be difficult. Infusion Nurses Society recommends using the distal port of a multi-lumen catheter for blood sampling. The distal port is largest (16-gauge) and has a greater flow rate. Turn off the distal infusions and clamp the tubing for 1 to 5 minutes before obtaining the blood sample. Remember to resume the flow of the solution after you collect the blood sample. Use either the syringe method or the evacuated collection tube system (trade name, Vacutainer) method to collect blood samples. Check to see if your facility's policy requires that you remove the access/injection cap and insert the syringe into the hub of the extension tubing instead of through the injection cap. Drawing blood through the access cap could cause hemolysis. When you use the syringe method, attach a 10-mL syringe to the appropriate port, then slowly aspirate the appropriate amount of blood from the central line. Depending on the volume of blood the laboratory requires for the ordered tests, you might have to fill several syringes. When using just one lumen of a catheter for both blood drawing and for infusions, it is helpful to use a stopcock between the catheter and the IV tubing. The stopcock allows you to draw blood through a side port without opening the system. When you use the evacuated collection tube system, attach a needleless connector to the appropriate port. When you push the evacuated blood tube inside the tube holder, blood will begin to flow into the tube. Fill the number of tubes of the correct color stopper as required by the laboratory for the ordered tests. Some facilities do not allow this method due to the increased pressure this system causes. The purpose of withdrawing fluid/blood before obtaining a blood sample is to clear the catheter of any intravenous fluid or medications that could alter the laboratory test results. Refer to your facility's policy for the recommended volume of blood discard, typically 3 to 6 mL.

A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection

Cleaning the least-soiled areas prior to cleaning the most-soiled areas

2 Mixed meds from a vial

Cleanse both of the tops of the vials with an alcohol wipe 1. Draw up correct amount of air and pressurize vial A 2. Withdrawal the needle and inject the correct amount of air into vial B, invert the vial, and draw up the correct amount of medication B. 3. Withdrawal needle from vial B, insert into vial A, invert vial A and withdraw the correct amount of fluid. *If one vial is a single-use vial, it should be vial A in this scenario, having the medication withdrawn from it last in the sequence. If you are mixing two types of insulin, vial A should be the intermediate or long-acting insulin and vial B the rapid or short-acting insulin.

Ethical dilemmas

Problems that involve more than one choice and stem from the different values and beliefs I the decision makers.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

D. Beneficence Beneficence is taking positive actions to help others. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

D. Nonmaleficence Nonmaleficence is the avoidance of harm or injury. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

Tunneled Catheters- Tunneled Central Venous Access Devices "Hickman, Broviac, Leonard, and Groshong"

Designed for long-term use (months to years). This type of CVAD can be used for administering fluids, chemotherapy, antibiotics, blood, and parenteral nutrition as well as for central venous pressure monitoring and blood sampling. The distal catheter tip is advanced into the vessel and is placed in the superior vena cava, while the proximal end is tunneled subcutaneously to an incisional exit site on the patient's trunk. The usual exit sites allow the patient to care for them conveniently while also making it possible to conceal them under clothing. Made of silicon Hickman and Broviac catheters differ in lumen size. A Hickman catheter has a larger lumen compared with the single-lumen Broviac, which is used primarily for pediatric patients. Because of its small lumen, Broviac catheters are not optimal for blood sampling. A Groshong catheter differs from Hickman and Broviac catheters because of its valve tip. Valve-tip catheters are not heparinized and do not require clamping. A Dacron cuff on tunneled catheters lies within the subcutaneous tunnel, where tissue granulates into the cuff thus effectively anchoring the catheter and acting as a barrier for preventing the spread of organisms along the catheter. You might also find an antimicrobial cuff (trade name, VitaCuff), a type of cuff that sits proximal to the Dacron cuff. The antimicrobial cuff, coated with antibacterial chemicals, substantially reduces the incidence of catheter-related infection in a newly placed line.

Implanted Vascular Access Devices- AKA "Implanted central venous access device" Implanted port or Port-A-Cath

Device placed under the skin without any portion of it exiting the skin. It consists of a single or double injection port with a self-sealing silicone septum covering a metal or plastic reservoir called the body. The catheter connects the port and reservoir to a central vein, typically the superior vena cava. An implanted port can be used to administer medication including chemotherapy, to deliver fluids, and to draw blood samples. cosmetically appealing, they have the lowest risk of infection of all chest-accessed central lines, they allow patients to carry on virtually all activities including bathing and swimming when it is not in use, and they do not require exit-site care. Disadvantage for the patient who has an implanted port is that accessing it can be painful. Most common site for implanted port placement is the anterior chest, just below the clavicle. Other less common sites for implanted port placement include the upper arm, the abdomen, and the back. To access the port, use a noncoring, non-barbed (Huber) needle. Noncoring needles have a deflected point that helps avoid septal injury by slicing through the septum without coring out a tiny piece of it each time the port is accessed. Most facilities' policies allow access to the implanted port with the same needle for 7 days. Implanted ports may be open-ended or valved. Open-ended ports require heparin flushing while valved ports do not require heparin.

I.V pain at insertion site

Discontinue infusion before restarting the I.V. in another location.

Subcutaneous (SubQ) Injections

Favored sites are large areas that are easy for the patient to reach for self-administration. Most commonly selected are the upper outer aspect of the arm, the abdomen (at least 2 inches from the umbilicus), and the anterior thighs. The scapular area and the upper ventrodorsal gluteal area can also be used. For regularly scheduled SubQ injections, rotate injection sites both within each location as well as among sites. Do not administer more than 1 mL with a single SubQ injection. Use a 25- to 30-gauge, ⅜- to ⅝-inch needle. As a general rule, use a needle length equivalent to one half the width of the skinfold you observe when pinching the tissue gently up from the underlying muscle. To inject, grasp or gently pinch an area of the patient's loose fatty tissue with the fingers of your nondominant hand and quickly insert the needle at a 45- to 90-degree angle for an average-sized patient or at a 90-degree angle below the tissue fold for a patient who is obese. Once the needle is inserted, release the pinch and use this hand to stabilize the syringe while administering the medication slowly with your dominant hand. After injecting all of the medication, remove the needle quickly at the same angle at which you inserted it. Cover the site with dry gauze immediately and apply gentle pressure. Do not massage the site.

Discontinuing a Peripheral IV Line

First move the roller clamp on the tubing to the closed position to avoid spilling IV fluid. Then, stabilizing the catheter at all times, pull the transparent dressing and tape toward the insertion site to avoid injuring the vein. Do not apply pressure over the intravenous catheter when removing it, as this can be painful for the patient. Once you have removed the catheter, inspect the catheter's tip to be sure that it is intact. If it is not intact, notify the provider immediately. A catheter that broke off in the vein has the potential to cause an embolus. In addition to inspecting the intravenous catheter, assess the IV site for signs of infection, which include pain, redness, swelling, and drainage. If the site appears to be infected, notify the provider immediately. If cultures are ordered, obtain a specimen for culture from the insertion site. Also, with sterile scissors, cut off the tip of the IV catheter and place it in a sterile container. Send both to the laboratory for culture.

What is the nurse going to do when giving a patient a tub bath

First, nurse will gather all necessary supplies. Second, prepare the room by placing a rubber mat on the rub floor to prevent the patient from slipping and falling. Third, nurse will assist patient into the bathroom and give instructions regarding the use of bars to prevent slipping and falling when entering or exiting the bathtub. Lastly, nurse will instruct patient to remain in tub for no longer than 20 min due to possibility of vasodilation from warm water, which can cause light-headedness or dizziness.

female perineal care

For a female patient, place a bath blanket over her abdomen so that one corner is pointing in the direction of her head and the other corner is covering the perineal area. Secure the lateral corner of the blanket loosely around the patient's legs. When you are ready to begin, fold the corner covering the perineal area back onto the patient's abdomen to expose the area you will bathe. Clean the perineal area from front to back to prevent contamination from the rectal area to the urethra. It is also important to use a separate area of the washcloth for each area or a new washcloth if the one you are using becomes soiled. After you wash and thoroughly rinse each area, pat them dry to prevent skin irritation and breakdown.

Stage III Pressure Ulcer

Full thickness tissue loss SubQ may be visible slough undermining-hollow btwn skin surface and wound bed tunneling-passageway within/beyond wound walls

Oxygen and resuscitation

Giving oxygen is not a form resuscitation. It provides comfort when given by nasal canula.

Ethical decision making process

Identify, state, list and analyze, select then justify, apply and evaluate.

incontinence care

If you are caring for a patient who is incontinent, provide perineal care frequently to help prevent skin breakdown and infection. The procedure is the same as it is for routine perineal care with one difference: After you have washed, rinsed, and dried the perineal area, apply a cream or ointment on the perineum and surrounding skin as prescribed to act as a barrier that will help protect the patient's skin.

Securing an IV-armboard (child)

If your patient is an infant or a young child or is restless or confused, consider using an armboard to protect the IV line. Usually made of a heavy cardboard material that is padded with foam, armboards are available in various lengths. Armboards are usually for single use only; dispose of it after the patient's infusion is discontinued. Avoid using an armboard whenever possible since it can interfere with joint motion. When necessary, use the shortest one that will protect the line so the patient can maintain maximum mobility. To secure the armboard to the patient's arm, wrap gauze loosely around the armboard and the patient's arm. Leave the insertion site uncovered for easy inspection. When you use an armboard, remove it periodically to allow the patient to move the joint and thus prevent stiffness. Assess the extremity at this time for any skin irritation, discomfort, or circulatory impairment.

Supervising

Process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team

IV inflammation and clot formation

Inflammation and clot formation Problem: The IV site is swollen, red, and warm. Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.) Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue. Prevention: Make sure the medication's concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency's policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.

Battery

Intentional and wrongful physical contact with a person that involves an injury or offensive contact.

Provider

Job: assess, diagnose, and treat cllient for disease and/or injury; includes MDs, DOs, APNs, and PAs Refer to when: ex- client experiences change in vital signs

Peripherally Inserted Central Catheter (PICCs)

PICCs are indicated for administering fluids, blood, and medications, as well as for blood sampling (although blood sampling through a PICC can be difficult, especially with smaller PICCs).They are usually intended for patients who require therapy for periods of 1 to 12 weeks, but some PICCs have been known to remain in place for years. PICC can provide central access with fewer and less severe complications than can develop with central venous catheters. The most common complications of a PICC are phlebitis and catheter occlusion. Inserted percutaneously into the cephalic or basilic anticubital fossa, then advanced into the superior vena cava. Single- and double-lumen catheters are the most common, although the newer triple-lumen PICC devices are available in some facilities. Placement of a PICC is contraindicated for patients who have sclerotic veins and in extremities affected by mastectomy or radial artery surgery, a hemodialysis graft, or an arteriovenous fistula. Patients with PICC lines should not have blood-pressure measurements, venipunctures, or injections in the extremity with the PICC. Assess the insertion site and upper extremity at the start of each shift and every 4 to 8 hours or as indicated by the patient's condition. Look for signs and symptoms of phlebitis, thrombophlebitis, venous occlusion, and infiltration: pain along the vein erythema edema at the puncture site ipsilateral (same-side) swelling of the arm, neck, or face a change in arm circumference of more than 0.8 in (2 cm) from baseline Your assessment includes measuring the patient's upper arm circumference to establish baseline data. For standardization, it is best to measure at the level of the top of the axilla. This serves as a reference point to determine with later measurements the presence of swelling or edema. Ongoing care includes a dressing change (usually with a transparent semi-permeable dressing) 24 hours post insertion and then on a weekly basis. Assess the site for redness, drainage, swelling, and pain. Follow your facility's policies for flushing. A typical schedule for flushing is every 12 hours when medications or fluids are not being administered.

what should document if you administered the wrong medication to a patient

Patient given 100 mg insulin at 1600. Provider notified.

Three factors of pressure ulcers

Pressure intensity, pressure duration, tissue tolerance

IV Questionable Reconstitution

Problem: Reconstituting a medication results in cloudiness, discoloration, or precipitation of the diluent. Possible cause: The wrong diluent was selected for reconstitution. It is also possible that the visible change is appropriate for that medication. Intervention: Never inject a questionable IV medication. If the medication has been reconstituted improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper diluent for a medication. Review the package insert or consult a pharmacist to verify the expected appearance of the reconstituted medication.

IV Interrupted Infusion

Problem: The line or pump occlusion alarm sounds. Possible causes: The IV line is not patent, the IV is in a location that occludes when the patient changes position, the tubing is kinked, the IV loop or line is clamped, the roller clamp is in the off position, or the pump was loaded improperly. Intervention: Begin at the patient, correcting each problem: Check for IV patency, tubing patency, and position; open all occluding clamps; and check the infusion pump settings and setup. If the location of the IV causes flow occlusion when the patient moves, consider restarting the IV line at another site.

IV Questionable Solutions

Problem: While administering an IV bolus (push) medication, cloudiness or precipitation forms in the tubing. Possible cause: The line was not flushed properly with normal saline prior to injecting an incompatible medication. Intervention: Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. Follow your agency's protocol for wasting and crediting medication and prepare another dose to administer. Observe the site for signs of venous irritation. Prevention: Follow proper technique for flushing the IV line with normal saline before and after injecting IV medications.

nursing personnel

RNs, LPNs, Unlicensed assistive personnel (UAP), certified nursing assistants (CNA), certified medical assistants (CMA), and non-nursing personnel such as dialysis techs, monitor techs, and phlebotomists. They work together to advocate for and meet needs of the clients within HC delivery system. RN is the lead member, soliciting input from all nursing team members, setting priorities, sharing info with other disciplines, and coordinating client care.

mobility assessment sequence

ROM moving from supine to sitting on the side of the bed gait exercise tolerance

While performing a complete bed bath for a patient, the nurse should

Raise the room temperature

Chlorhexidine

Recommended cleansing agent for I.V. catheter insertion.

Bioethics

Refers to the field that addresses dilemmas that arise from advancing science and technology, such as stem cell research, organ transplant, gender reassignment, and reproductive technologies.

SOAP

S-subjective data. O-objective data. A-assessment. P-plan

SOAPIE

S-ubjective O-bjective A-ssessment (inc nursing diagnosis) P-lan I-ntervention E-valuation

Cognitively impaired client

SHould be placed in a room with a few of their belongings to prevent from any more confusion or distress.

Secondary IV Tubing & "Piggyback" setup

Secondary tubing is a short piece of plastic tubing that connects into the primary IV tubing for administering medications. Because the secondary infusion usually contains a medication, an infusion device is recommended to ensure that it infuses over the prescribed length of time. If an infusion device is not available, use a piggyback setup to infuse the secondary bag of fluid or medication. With a piggyback setup, you'll hang the smaller bag of fluid, the secondary infusion, higher than the larger bag of fluid, the primary infusion. To do this, use the plastic hook, or extension hanger, that is packaged with the secondary tubing. When using the piggyback setup, leave both the primary and the secondary lines open. To regulate the flow rate of the secondary infusion, open the roller clamp on the secondary tubing completely and use the roller clamp on the primary tubing to adjust the flow rate. When the secondary infusion is complete, the primary infusion resumes. If the primary infusion's rate differs from that of the secondary infusion, remember to adjust the rate as soon as possible after the secondary infusion is complete. If your patient will receive subsequent doses of the secondary infusion, leave the bag and tubing hanging. It can be used for 72 to 96 hours, depending on your facility's policy. Of course, discard it immediately if it becomes contaminated.

Hypokalemia

Serum K < 3.5 mEq/L

Hyperkalemia

Serum K > 5 mEq/L

Hypocalcemia

Serum calcium < 8.5 mg/dl

Hypercalcemia

Serum calcium > 10.5 mg/dl

Hospice

Serve clients with terminal cancer.

Full thickness wound

SubQ layer or extends to muscle/bone deep leg ulcers, deep burns, stage III/IV pressure ulcers

Autonomy

The right to make ones own personal decisions even when those decisions might not be in that persons own best interest.

Ethics

The study of conduct and character

Problem-orientated medical records consist of:

a database, problem list, care plan, and progress notes; examples include SOAPIE, PIE, and DAR

atrophy

a decrease in muscle size due to disuse

flexion

a decrease of the angle

durable power of attorney

a document in which client's designate a health care proxy to make health care decisions for them if they are unable to do so. they proxy may be any competent adult they chose.

assessing/ collecting data

baseline data-vitals, ht, wt, allergy status, meds. biographical info. the clients reason for seeking health care, present illness and symptoms, health hx-current illness, current meds, prior illness, chronic diseases, surgeries, previous hospitalizations, other relevant data. family hx. psychosocial assessment-alcohol, tobacco, drug, and caffeine use, hx of mental illness, hx of abuse or homelessness, home situation/significant others. nutrition-current diet, any chewing or swallowing problems, recent wt gain/loss. spiritual health/quality of life concerns-religion, advance directives, living will. review of systems, safety assessments-hx of falls, sensory deficits, use of assistive devices. discharge info-family members in the home, transportation for discharge, any relevant phone numbers, medical equipment needs at home. inventory any personal items-document leaving items at, storing, sending where, and locking up where, discourage keeping valuables at bedside. orient the client and family to the room and facility. share info, including the following-call light operation, electric bed operation, telephone services/television controls,, overhead lighting operation, smoking policy, restroom locations, waiting areas, meal times, usual time for provider's wishes, dining/vending services, visiting policies.

Enema

cleansing, tap water, normal saline, hypertonic solutions, soapsuds, oil retention

serous

clear

prevention education for risk of motor vehicle/injury in adolescents

ensure teen has completed driver's ed -set rules on # of people in car, seat belt use, and to call for ride home if driver is impaired -reinforce teaching on proper use of protective equipment used in sports -be alert to signs of depression -teach about hazards and safety precautions of firearms -teach to check water depth before diving

malpractice

example: a nurse administers a large dose of medication due to calculation error; client has a cardiac arrest, dies

Breach of confidentiality

example: a nurse releases the medical diagnosis of a client to a member of the press

Defamation of character

example: a nurse tells a coworker that she believes the client has been unfaithful to her spouse

Negligence

example: a nurse who fails to implement safety measures for a client who has been identified as at risk for falls

False imprisonment

example: a person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility)

bronchovesicular breath sounds

expected sound, medium pitch and intensity with equal inspiration and expiration times over larger airways

commitment

expects to make choices without help from others and fully assumes responsibility for those choices. results from expert level of knowledge, experience, developed intuition, and reflective flexible attitude

health promotion (nutrition): older adult (65+ yrs)

factors that influence nutrition include: -GI alterations -difficulty getting to and from supermarket to shop for food -low income -impaired mobility -depression or dementia -social isolation (preparing meals for 1 and eating alone) -meds that alter taste or appetite -prescribed diets that are unappealing -incontinence that may cause a person to limit fluid intake -constipation -metabolic rates decline so caloric intake should decline and be pf good nutritional value -nutritional recommendations include: increasing intake of vit D, B6 and calcium; increasing fluid intake to minimize dehydration and prevent constipation; take low-dose multivitamin along with mineral supplementation; follow provider;s recommendation for sodium intake

documentation

factual-subjective and objective data. subjective data should be reported as direct quotes within quotation marks, or summarize and identify the information as the client's statement. objective data should be descriptive and should include what the nurse sees, hears, feels, and smells. document without derogatory words, judgements, or opinions. document client's behavior accurately. ex. "client is agitated." NO write this! "client paced back and forth in room, yelling loudly." accurate and concise. complete and current-never prechart an assessment, intervention or evaluation. organized.

professional negligence

failure of a licensed person to act in a reasonable and prudent manner.

negligence

failure of a person who has professional training to act in a reasonable and prudent manner (generally describe a person who has the average judgement, intelligence, foresight, and skill that a person with a similar training and experience should have)

professional negligence

failure of a person who has professional training to act in a responsible and prudent manner

negligence issues that cause malpractice

failure to follow professional and facility-established standards of care, use of equipment in a responsible and knowledge manner, communicate effectively and thoroughly with clients, and document care the nurse provided.

justice

fair treatment

Justice

fair treatment in matters related to physical and psychosocial care and use of resources

Justice

fairness in care delivery and use of resources

justice

fairness in care delivery and use of resources

signs and symptoms of infections

fever, chills which happen when temp rises, diaphoresis which happens when temp is decreasing, increased pulse and respirations, malaise, fatigue, anorexia, nausea, and vomiting, abdominal cramping, diarrhea, enlarged lymph nodes.

What are the *un*expected findings upon palpation of a *female* client's breasts?

fibrocystic breast disease: tender cysts often more prominent during menstration

auscultation of the lungs (abnormal or adventitious sound): crackles or rales

fine to coarse popping heard as air passes through fluid or re-expands collapsed small airways

Preventive health care

focuses on educating and equipping clients to reduce and control risk factors of disease. Examples include immunizations, stress management programs, and seat belt use

preventative care

focuses on educating and equipping patients to reduce and control risk factors for disease. example promote immunization, stress management

exogenous source

from outside the client

nociceptive pain

from tissue damage or inflammation

social media precautions

know the implications of HIPAA before using social networking sites for school or work-related communication, become familiar with your facility's or schools policies or about using social networking, dont use or view social networking media in clinical setting, dont post info about your school, clinical sites, clinical experiences, clients, and other HC staff on social networking sites.

components of critical thinking

knowledge, experience, competence, attitudes, and standards.

lordosis

large curvature in lumbar spine *L*ordosis-->*L*umbar

kyphosis

large curvature in thoractic spine

chronic pain

last longer than 6 months

Oral care for immobilized patient

lay them on their side.

___ is an intentional gain of new information and represents a change in behavior

learning

auscultatory sites for the heart: apical/mitral

left midclavicular line at the fifth ICS

lab and diagnostic results indicating infection

leukocytes (WBCs) >10,000/nanoL. increases in specific types of WBC on differential (left shift=an increase in neutrophils). elevated erythocytes sedimentation rate (ESR) over 20mm/hr. an increase indicates an active inflammatory process or infection. presence of microorganisms on culture of the specific fluid/area.

information security

mandatory adherence with HIPAA helps to ensure the confidentiality of health information. a major component of HIPAA, the privacy rule, promotes the use of standard methods of maintaining the privacy of protected health info. (PHI). among HC agencies. essential for nurses to be aware of client's rights to privacy and confidentiality. Privacy rule requires that nurses protect all written and verbal communication about clients.

cheilosis

manifestation of vitamin B complex deficiency characterized by reddened lips with fissures at the angles of the mouth

transfer documentation

medical diagnosis and care providers, demographic info, overview of health status, plan of care and recent progress, any alterations that may precipitate an immediate concern, notification of any assessment or care essential within the next few hours, most recent vitals and medications including PRN, allergies, diet and activity orders, special equip or adaptive devices, advance directives and emergency code status, family involvement in care and health care proxy, if applicable.

nursing care for shingles

monitor pain, condition of lesions, presence of fever, neurologic complications, signs of infection. use an air mattress of bed cradle for pain prevention and control of affected areas, isolate the client until the vesicles have crusted over, maintain strict wound care precautions, avoid exposing pt to infants, pregnant who haven't had chickenpox, and pt who are immunocompromised. moisten dressings with cool tap water or 5% aluminum acetate (Burow's solution) and apply to the affected skin for 30-60 min, for to six times per day as prescribed. meds: analgesics (NSAIDs, narcotics) enhance client comfort, antiviral agents, such as acyclovir (zovirax), may shorten the clinical course.

RN delegation to LPNs

monitoring findings as input to RNs ongoing assessment, reinforcing client teaching from a standard care plan, performing a tracheostomy care, suctioning, checking nasogastric tube patency, administrating enteral feedings, inserting urinary catheters, administrating medications excluding IV meds in some states.

primary hypertension cause

most cases people don't know high LDLs

___ influences how much and how quickly a person learns

motivation

ROM head: flexion

movement chin to chest

abduction

movement of extremity away from midline

adduction

movement of extremity toward midline

dorsiflexion

movement toward the dorsum (or top of wrist or foot)

plantar flexion

movement toward the plantar surface (or bottom of the foot)

requirement for fasting blood sugar test

must be taken 8-12 hours after last meal

nursing role in clients rights

must ensure that pt understands their rights and protect their pt rights. regardless of the age, client's nursing needs, or the HC setting, the basic tenets are the same. the client has the right to understand the aspects of care to be active in the decision-making process, accept, refuse or request modification of the plan of care, receive care from competent individuals who treat the client's with respect.

Low sodium diet

no added salt or 1 to 2 g of sodium

Low cholesterol diet

no more than 300 mg/day of dietary cholesterol

KUB

noninvasive urinal examination abdominal roentgenogram kidney, ureter, bladder or flat plate

complex critical thinking

nurse begins to express autonomy by analyzing and examining data to determine the best alternative. results from an increase in nursing knowledge, experience, intuition and more flexible attitudes. ex. nurse realizes pt isnt ambulating as often as prescribed because of fear of missing her daughters phone call. the nurse assures the pt that the staff will listen for and answer her phone when she is out of her room.

commitment

nurse expects to make choices without help from others and fully assumes the responsibility for those choices. results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes. ex. a nurse increases the rate of an IV fluid infusion when the pt blood pressure indicates hypovolemic shock 24 hr after surgery.

complex critical thinking

nurse expresses autonomy and thinks of alternatives

example of negligence

nurse fails to implement safety measures

example of defamation of character

nurse tells coworker she thinks patient has been unfaithful to spouse

basic critical thinking

nurse thinks concretely based on rules

ethical principles

standards of what is right/wrong with regard to important social values and norms include: autonomy, beneficence, fidelity, justice, no maleficence

fowler's position

on back with bed inclined 45 degrees

transferring/discharging a client

on day of transfer confirm that the receiving facility of unit is expecting client, and that the room or bed is available. communicate the time the client will transfer to receiving facility or unit. complete documentation, give verbal transfer report in person or via telephone, confirm the mode of transport the client will use to complete the transfer or discharge, make sure the client is dressed appropriately if going outside the facility, account for all the client's belongings.

Guillotine amputation

open amputation used for patients with severe infection to allow for drainage of infectious material.

temp sites

oral rectal axillary tympanic temporal

treatment for anthrax

oral ciprofloxacin

sims

oral drainage between sims/lateral

viruses

organisms that use the host's genetic machinery to reproduce. HIV, hepatitis, herpes zoster, herpes simplex.

PCA

patient controlled analgesia--i.e. morphine button drip

informed consent

patient's written permission for procedure or treatment

When is the illness stage?

period when symptoms specific to the infection occur

buccal

pertaining to or directed toward the bucca (cheek), the fleshy portion of the side of the face that makes up the lateral wall of the oral cavity

Beneficence

positive actions to help others

beneficence

positive actions to help others

beneficence

positive actions to help others.

posterior cervical lymph node located

posterior to the sternocleidomastoid muscle

complications of shingles

postherpetic neuralgia. tricyclic antidepressants sometimes prescribed. common in adults older than 60.

integrity

practices truthfully and ethically

bacteria

staphylococcus aureus, escherichia coli, mycobacterium tuberculosis.

portal of exits

respiratory tract (droplet, airborne)-mycobacterium tuberculosis and streptococcus pneumoniae. gastrointestinal tract-shigella, salmonella enteritidis, salmonella typhi, hepatitis A. genitourinary tract-escherichia coli, hepatitis A, herpes simplex virus (type 1), HIV. skin, mucous membranes-herpes simplex virus and varicella. blood/body fluids-HIV and hepatitis B and C.

procedure

responsibilities of the nurse, transfer documentation, discharge documentation, discharge instructions.

five rights of delegation

right task right circumstance right person right direction/communication right supervision/evaluation

delegation and supervision

right task, right circumstance, right person, right direction/communication, right supervision

nursing interventions for asepsis

select clean area above waist level in the client's environment to set up. check that all sterile packages are dry and have a future expiration date. any chemical tape must show the appropriate color. make sure an appropriate waste receptacle is near by. wash hands, open covering of package per directions, slipping package onto the center of workspace with top flap opening away from the body. grasp tip of top flap, and with arm positioned away from sterile field unfold flap from body. open side flaps using the right hand for right flap and etc. grasp left flap and turn it down toward body. additional sterile packages open next to sterile field by holding the bottom edge with one hand and pulling back on sterile field and open these first. add them directly to field, lift package from dry surface, holding at 6 in above the field, pulling the two surfaces apart, dropping it onto field. pour sterile solutions by removing bottle cap, placing cap face up on clean nonsterile surface, holding bottle with label in palm so solution doesn't run down the label, first pour a small amount of solution in an available receptacle. pouring solution onto the dressing or site without touching the bottle to the site. once sterile field is set up don sterile gloves.

do not ___ linens because do can spread micro-organisms in the air

shake

preventative care

shots, education to minimize risks

formal chain of command

should be used to verbalize concerns related to assignment in light of current legal scope of practice, job description & area of competence

transfer reports

should include demographic information, medical diagnosis, providers, an overview of health status (physical, psychosocial), plan of care, recent progress, any alterations that might become an urgent or emergent situation, directives for any assessments or client care essential within the next few hrs, most recent vital signs, medications and last doses, allergies, diet, activity, special equipment or adaptive devices, advance directives and resuscitation status, and family involvement in care and health care proxy.

posterior thorax

sites between scapula and vertebra on upper portion of back, below scapula, along right and left scapular lines

high-fowler's position

sitting upright

sign of anthrax (bacteria) poisoning

small lesion that becomes necrotic

airborne

sneezing and coughing

droplet

sneezing, coughing, and talking

auscultation of the lungs (expected sound): vesicular

soft, low-pitched, inspiration three times longer than expiration heard over most of the peripheral areas of the lungs

right supervision/evaluation

the delegating nurse must: -provide supervision (direct or indirect) -provide clear instructions and understandable expectations of the task(s) to be performed -monitor performance -provide feedback -intervene if necessary (unsafe clinical practice) -evaluate the client and determine if client outcomes were met -evaluate client care tasks and identify needs for performance improvement activities and/or additional resources

Ethical theory examines:

the different principles, ideas, systems, and philosophies used to make judgments about what is right/wrong and good/bad

environment

the emotional and physical climate in which the communication takes place

diffusion is

the exchange of O2 and CO2 between the alveoli and the RBCs; measure with pulse oximetry

ventilation is

the exchange of O2 and CO2 in the lungs; measure with respiratory rate, rhythm, and depth

primary prevention

the needs of healthy clients to promote health and prevention of disease with specific protections. example immunization, nutrition and fitness activities, health education in schools

pulse rate is

the number of times per min the pulse is felt or heard

respiratory rhythm is

the observation of breathing intervals; a regular rhythm with an occasional sigh is expected in adults

gingiva

the part of the oral mucosa covering the tooth-bearing border of the jaw; also called gums (plural: gingivae)

receiver

the person to whom the message is aimed at and received by

pacing

the rate of speech can communicate a meaning to the receiver

autonomy

the right to make one's own personal decisions, even when those decisions might not be in that person's own best interest.

palate

the roof of the mouth separating the mouth from the nasal cavity, comprised of the hard palate (in the front of the mouth, separating cavities of the mouth and the nose) and the soft palate (the fleshy portion that separates the mouth from the pharynx)

intonation

the tone of voice can communicate a variety of feelings

expected physical development: middle adult (35-65 yrs)

typically experience decreases in: -skin turgor and moisture -subcutaneous fat -melanin in hair (graying) -hair -visual acuity -auditory acuity -sense of taste -skeletal muscle mass -height -calcium/bone density -blood vessel elasticity -respiratory vital capacity -large intestine muscle tone -gastric secretions -estrogen/testosterone -glucose tolerance

clinical nurse specialist (CNS)

typically specializes in a practice setting or a clinical field.

What is role ambiguity?

uncertainty about what is expected when assuming a role

normal greif

uncomplicated, some acceptance should be evident after 6 months

crackles

unexpected sound, fine to coarse popping as air passes through fluid or re-expands collapsed airways

pleural friction rub

unexpected sound, grating sound as inflamed visceral and parietal pleura rub against each other during inspiration and expiration

wheezes

unexpected sound, high-pitched whistling musical sounds as air passes through narrowed or obstructed airways, usually louder on expiration

provider's orders

unless provider writes a DNR or "allow natural death" (AND) prescription in the client's medical record, the nurse initiates CPR when the client has no pulse or respiration.

hand washing

use an antimicrobial or plain soap and water, using alcohol based products such as gels, foams, and rinses; or performing a surgical scrub. components: soap, running water, friction. HC personnel must perform before and after every client contact, after removing gloves, after contact with body fluids, before eating and after using the restroom. when visibly soiled use soap and water. perform after contact with anything in client's room, contaminated objects, whether gloves were worn or not, and before putting gloves on and after removing them. sometimes between tasks on same client to prevent cross-contamination.

analysis/ data collection

use critical thinking skills to identify clients health status or problems, interprets or monitor the collected database, reach an appropriate nursing judgement about the health status and coping mechanisms, and provide direction for nursing care. requires nurses to look at the data and recognize patterns or trends, compare the data with expected standards or reference ranges, arrive at conclusions to guide nursing care. complete and accurate documentation is essential. it should focus on facts and should be highly descriptive.

delegating and supervision guidelines

use the 5 rights of delegation to decide, use professional judgement and critical thinking skills when delegating, right tasks, right circumstance, right person, right direction/communication, right supervision/evaluation, supervision.

charting by exception

uses standardized forms that identify norms and allows selective documentation of deviations from those norms.

therapeutic touch

using hands to balance energy fields

advanced practice nurse (APN)

usually have a minimum of a master's degree in nursing (or related field), advanced education in pharmacology and physical assessment, and certification in a specialized area of practice including the following roles: CNS, NP, CRNA, and CNM.

morals

values and beliefs that guide behavior and decision making

morals

values and beliefs that guide behavior and decision making.

herpes zoster (shingles)

viral infection. intially produced by chickenpox. usually preceded by a prodromal period of several days, during which pain, tingling, burning may occur along the involved dermatome. can be very painful and debilitating. risk factors: concurrent illness, stress, compromise to immune system, fatigue, poor nutritional status, assess elderly for local or systemic signs of infection. subjective data: paresthesia, pain that is unilateral and extends horizontally along a dermatome. objective data: vesicular, unilateral rash ( the rash and lesions occur on the skin area innervated by the infected nerve), rash the is erythematous, vesicular, pustular, or crushing (depending on the stage), rash the usually resolves in 14 to 21 days, low-grade fever. laboratory tests: cultures provide a definitive diagnosis. occasionally an immunofluorescence assay can be done.

Flow charts are used to record and show trends in:

vital signs, blood glucose levels, pain level, and other frequently performed assessments

manual pump math

volume to be infused/ time Min * drop factor drop factor * volume mL / time hr * 1hr /60 min

water temperature for handwashing

warm NOT hot--removes skin oils

hand washing procedure

wash with warm water and soap. rub hands together vigorously, rinse under running water. wash for at least 15 seconds to remove transient flora and up to 2 min when hands are visibly soiled. dry hands with a clean paper towel before turning off faucet. if sink doesnt have foot or knee pedals for turning off water, use a clean, dry paper towel to turn off faucet.

What are the characteristics of the stools of an infant who is *breast milk fed*?

watery and yellow-brown

secondary sources of data

what others tell the nurse based on what the client has told them. data nurse collects from other sources, physical therapy note in chart indicates client has decreased range of motion in left shoulder.

primary sources of data

what the client tells the nurse. data the nurse obtains through observation and examination. client grimaces when attempting to brush her hair with her left arm.

math dose

what you have of the quantity have over quantity equals desire over x have/quantity = desire/x desired times quantity over have equals amount to be given desire * quantity / have = amount to be given

denotative/connotative meaning

when communicating, participants must share meanings

small group communication

within a group of people, usually working towards a common goal

nursing role in informed consent

witnessing the client's signature on the informed consent form and to ensure that the provider obtained informed consent appropriately.

vocabulary

words used to communicate either a spoken or written message

interprofessional personnel

work collaboratively to provide holistic care to patients each uses a set of skills that are within the scope of practice for the specific profession; some practices overlap ex: spiritual support staff, dietician, lab tech, OT, etc

social worker

work with patient/family to meet psychosocial and environmental needs that are necessary for recovery and discharge