Combo with "fundamentals exam 1 notes" and 5 others

Factors That Increase Infection Risk

-Developmental stage -Breaks in the skin -Illness/injury, chronic disease -Smoking, substance abuse -Multiple sex partners -Medications that inhibit/decrease immune response -Nursing/medical procedures

pre procedure assessment of restraints?

-assess risk for falls -assess need for restraints -appropriate restraint: >least restrictive >does not interfere with care or exacerbate medical condition -does not pose a safety risk to patient

critical aspects of taping a dressing

place patient in a comfortable position that provides easy access to the wound ensure that the skin surrounding the dressing is clean and dry choose a tape that is apprioate to the dressing place the tape parallel to the incision tear strips that extend to 1/2 inch beyond the dressing apply tape without pulling or stretching smooth tape is applied by gently stroking the surface to maximize adhesion

removing sutures and

place patient in comfortable position use the forceps to pick up one end of the suture, slide the small scissors around the suture, and cut near the skin with forceps, gently pull the suture in the direction of the knotted side to remove it

Procedure steps what position is the client placed in for middle or lower lobes

place the bed in the trendelenburg position. Position the patient in Sims position. To drain the left lung, position the patient on his right side. For the right lung, position the patient on his left side

how is it done acupressure

stimulates specfic sites in the body, instead of needles fingertips provide firm gentle pressure over the various pressure point. may have a calming effect and the release of endorphins. patients can be taught this

Common Post-op Discomforts nausea, clinical signs, and interventions

stomach upset or vomiting related to pain, anxiety, anesthesia, medications, or oral intake before peristalsis returns. clinical signs: vomiting,retching, stated nausea. interventions: have pain remain npo until return of bowel sound. advance diet slowly. treat pain.

Pre-existing conditions that increase surgical risk chronic respiratory disorders

such as emphysema, asthma, or bronchitis, decrease pulmonary function, increase the risk of respiratory infection, and may be exacerbated by general anesthesia

Low fiber foods

such as pasta and other simple carbohydrates and meat, slow peristalsis. Foods like broccoli, onion, bean lead to excess gas. spicy foods may also called gas as well as more frequent about you

dorsal recumbent

supine with knees flexed use for abdominal assessment if your client has abnormal or pelvic pain. flexing knees promote relaxation of the abdominal muscles.

interventions for risk for infection

supporting the host defense -adequate nutrition -balanced hygiene -rest/exercise -reducing stress -immunizations*

lifestyle factors that affect skin integrity

tanning, may lead to skin cancer hygiene habits either excessive or insufficient drying of the skin can lead to jeopardizes the skin barrier protection regular exercise improves circulation smoking-compromises the oxygen supply to the tissues making skin more prone to break down and delay wound healing also interferes with vitamin c which is important for collagen body piercings and tattoos: presents a risk for infection and scarring

what does the braden scale include?

the lower the score the more the patient is at risk of developing a pressure ulcer a score or 18 or less indicates a risk. use scale to asses patient on admission and again in 48 to 72 hours . second score more predictive Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear

factors leading to susceptibility

-Developmental stage -Breaks in the skin -Illness/injury, chronic disease -Smoking, substance abuse -Multiple sex partners -Medications that inhibit/decrease immune response -Nursing/medical procedures

reckless behavior is managed through?

remedial action punitive action

Factors That Influence Adaptation Personal factors

Age Developmental level Life experiences

OPD

outpatient department

formal planning

"Formal planning is a conscious, deliberate activity involving decision-making, critical thinking and creativity " (Wilkinson, 2007, p. 262).

subjective data for muscosketetal

"I am so weak and tired, I can barely lift my foot off the bed." "My joints feel so stiff when I try to move them."

subjective data for integumentary

"I feel like I have a rubbed spot on my left heel."

subjective data of metabolic and nutrition

"I feel like I have lost my muscles I had built up doing all my triathlon training."

subjective data psychological

"I feel so down since I haven't' been able to move the way I am used to. Is this normal?"

Denial stages of dying and grief

"Not me". "This cannot be happening. "I don't believe it." Usually the person is in a state of shock. denial is not necessarily negative; it gives the person a chance to prepare psychologically for accepting the news. it is the first stage

subjective date for respiratory

"I get so out of breath just trying to reposition in the bed." "I feel like I got a lot of phlegm in my throat and chest." "I can hear myself rattling in my chest when I breathe."

subjective data for urinary system

"I have trouble using the urinal, especially when lying down." "My urine smells really strong lately."

subjective data for bowels

"I haven't had a bowel movement in three days."

Bargaining stages of , grief and dying

"If only I can live until...""yes me, but..."Usually this takes the form of a bargain with God or a higher power, in which the person asks to live to see a birth, graduation, wedding, and so forth. stage 3

subjective data for cardiovascular

"My heart is racing just lying here in the bed." "My feet have gotten so fat looking since I've been lying around in the bed." "I get so dizzy feeling when they sit me up for my breakfast tray."

Anger, the stages of dying and grief

"Why me?" Why is this happening? " anger can be obvious or subtle. It is the person's response to the feeling that the situation is unfair. The person may take his anger out on people who are safe (e.g. family, spouse) or from whom there will be no reprisals (e.g., nurse's, physician).

pre assessment of hair care

-assess for lesions or infestations -assess self care ability -assess how the patient normally cares for hair

examples of at risk behavior?

>exceeding scope of practice >pre-documentation >minor deviations from established procedure

Providing post mortem care supporting the family, at the moment of death you shouldn't, immediately after death? avoid? if the family wishes to be alone what do you? you want to do what with the patient? never?

- at the moment of death, do not interrupt or intrude on the family. - immediately after death, express sympathy to the family. this is very important. Make a simple statement, such as I'm sorry for your loss. Avoid statements that interpret the situation for the family, such as,"it's God's will." also avoid attempts to mitigate the family members grief, for example, "it will get better in time, "or "you still have your son". - if the family wishes to be alone with the body straighten the bed covers and make the patient look as natural as possible. - be accepting of family members behaviour at this time, no matter how strange it may seem to you. A family member might want to take a picture, or the spouse may lie down beside the deceased person. - if no family members are present, identify the next of kin and be sure the family is informed of the patients death. - if family members arrive after the death, offer them to take them to the bedside. - if family members wish to be involved in post mortem care, encourage them to do so. This can facilitate their grieving process. - take care to present the patient's body in a way that is appropriate for the family (I . e, remove any tubes, iv lines, and so on, according to the institution policy) and have the patient position in a way that appears comforting . viewing the body is useful to many individuals. - ask whether each family member wishes to spend time alone with a deceased person. Never remove the body until the family is ready. - ask, how can I help? What do you need? What would you like for me to do? - locate personal effects and give them to the family/next of kin. If you can't remove a ring, wrap it with a gauze, tape it in place, and tie the gauze to the wrist prevent subsequent loss

Facilitating grief work expressing feelings: you want to encourage? you don't want to appear? expect and accept? avoid what type of comments?

- encourage questions, and respond to them within a reasonable time - sit beside the head of the bed do not appear rush - when you observe the patient or family member expressing feelings, either verbally or non verbally, encourage them to continue. - expect and accept a wide range of feelings, including anger, fear, and loneliness. - ask," how can I help?" "What do you need? " "what would you like for me to do? " - be sure that everyone on the healthcare team understand and follow the care plan. - ask yourself what would you do if this were your family member. - do not compare another person's loss to your own experience. for example, avoid comments such as, "I know how you feel. " instead, say, "tell me how you feel. "

negligence

>failure to perform as a reasonable, prudent person would >failure to follow standards of practice >no intent to harm is present

Level may be decreased in blood urea nitrogen and creatinine due to?

Inadequate protein intake, liver disease, malabsorption syndrome

pre assess of foot care

-assess pulses: dorsalis, pedis, postibial,skin color, warmth, impaired intergrity, edema, condition of nails -assess usual foot wear and self care ability

how is human error managed?

it is managed through changes in >choices >processes >procedures >training >design >environment

meeting physiological needs of the dying provide adequate pain control, provide? assure? respect? administer pain? teach? patients who moan and grunt during near death what does that mean? which symptoms will require medication

- provide education to dispel the myths about pain medication. Effective pain control medications exists and can be administered by various routes. - assure the patient and family that anaglesic will not be addictive in the situation. - respect the patient's informed decision to refuse pain medication. for example, a patient may prefer to endure pain in order to be awake and alert when his family is at the bedside - follow one of the common pain protocol to ensure the pain is control - administer pain medication on a regular schedule instead of waiting until the patient asked PRN, to ensure pain control - teach and perform non pharmacological pain relief measures when you judge they might be helpful. These may include medication, heat or cold therapies, massage, distraction, imagery, deep breathing, and herbal scented lotions. It may be soothing to play soft music, add white noise or turn off the television - patients who are near death may moan or grunt as they breathe; this does not necessarily indicate pain. Be sure that families understand this. When accompanied by agitation and restlessness, these symptoms may indicate terminal delirium , which may require medications for control

Taking care of yourself, what are some interventions for nurses experiencing loss and grieft

- recognize their feelings of grief and loss are normal. - talk with other colleagues about your feelings. Nurses are known for being able to take care of everyone but themselves. Don't be afraid to ask for what you need. - do not be afraid to confront grief. Some nurses feel they have to be strong and tend to deny their feelings. They over work and take care of others. If you use this approach, the feelings will accumulate and begin to wear you down physically and emotionally. - if you wish, it is appropriate for you to attend calling hours or funeral services when one of your patients dies. This helps you to diffuse some of your feelings of loss. And it is very meaningful to the family. - learn how to get support for yourself and how to support your colleagues they experienced the death of the patient. One idea is a nurse support group or grief team, that meets regularly to talk about the feelings - do some nice things for yourself on a regular basis.

Older adults tend to experience the following changes in oxygenation

- reduce lung expansion and less alveolar inflation, especially in the bases of the lung. (1) costal cartilage begins to calcify, reducing chest wall movement during breathing (2) the lungs have less recoil ability (3) the alveoli lose elasticity. - difficulty expelling mucus or foreign material due to a less effective cough reflex, drier mucus, and fewer cilia in the airways - diminished ability to increase ventilation when oxygenation demands increase (e.g., exercise). as diaphragm strength decreases, vital capacity is reduced, so exhalation becomes less efficient, causing progressive air trapping. - declining immune response especially cell mediated immunity, T- cell activity, and the inflammatory response - gastroesophageal reflux creates a risk for aspirating stomach contents into the lungs. This may result in inflammatory response. All these changes put older. Adults at risk t for respiratory infections. Upper respiratory infections can quickly lead to pneumonia in older adults. also making Hypoxemia more likely

Categorizing Loss

-Actual vs. perceived loss -Physical vs. psychological loss -External vs. internal loss -Loss of aspects of self -Environmental loss -Loss of significant relationships

safety hazards in the community pollution and preventive measures

-Air, water, noise, soil -Prevention >>Proper disposal and recycling of solid wastes >>Environmentally safe products >>Car pool, public transport >>Ear plugs

what are my worries of rectal

-"Vagal response" Drop in heart rate -Must be against rectal wall for absorption

Implementing Medical Asepsis, how is it promoted?

-A state of cleanliness that decreases the potential for the spread of infections" -Promoted through >Maintaining a clean environment >Maintaining clean hands/Handwashing/Gloving >Balanced hygiene >Following Centers for Disease Control (CDC) guidelines

Prevent clot formation what is thrombus, embolus. what are my interventions?

-A thrombus is a stationary clot adhering to the wall of the vessel. -An embolus is a clot that travels in the bloodstream. clots can form after injury to vessel, or in response to hypercoagulability. Of course, all the strategies to promote venous return also help prevent clot formation. - turn patients frequently, teach patients to change positions frequently. This prevents vessel injury from prolonged pressure in one's position. - use scrupulous sterile technique when inserting or handling intravenous lines. this prevents infection that can damage the vessel lumens. - be sure intravenous medications are adequately diluted. This prevents chemical irritation of the veins during IV medication therapy. - promote adequate hydration. unless contraindicated, adult fluid intake should be approximately 2000 ml per day to keep urine output around 1500 ml per day. Adequate hydration keeps respiratory secretions thin but also keeps the blood from becoming viscous. viscous blood clots more readily. - promote smoking cessation. Nicotine increases the risk for thrombus formation because of its constricting effects on vessel walls. - patients at particularly high risk for thrombus formation may receive anticoagulant therapy to prevent abnormal clot formation.

Vegetarianism diet all exclude?, semi-vegetarians, ovo-lacto vegetarians, lacto-vegetarians, vegan, fruitarians diets are?

-All vegetarian diet exclude red meat and poultry -Semi-vegetarians are the most inclusive allowing fish, eggs, and dairy products as well as plant based food. -Ovo-lacto vegetarians eat eggs and dairy products but not fish -Lacto-vegetarians consume only dairy and plant based food -Vegan eat only food of plant origin -Fruitarians include only fruit, nuts, honey, and vegetable oil. Soy beans, soy milk, tofu, and process protein products can be used by all except fruitarians to enhance nutritional value of diet

types of baths

-Assist bath >>Bathe areas hard to reach  - Partial bath >>Bathe only those areas absolutely necessary, >>>including perineum -Bed bath >>Complete >>Partial -Towel bath -Bag or packaged bath -Shower - Tub bath - Therapeutic bath

A Focus on the Component of Safety what kind of attitudes should they have?

-Attitudes >Appreciate the cognitive and physical limits of human functioning >Value own role in the reporting of errors >Value vigilance and monitoring (even of own performance of care activities) by patients, families and other members of the health care team

Barriers to Just Culture

-Attitudes >Concerned about being blamed >Concerned about being judged incompetent >Concerned about making colleagues look bad -Reporting systems >Not know how to report >Not know where to report >Too time consuming >Don't think anything will be done with the info -No harm to patient - not understand importance of learning from a near miss***

what should you document?

-Be accurate and nonjudgmental -Adhere to the requirements for reimbursement -Provide details about the client's condition, nursing interventions provided, and client response -Document legibly and as soon as possible -Record significant events or changes in condition -Record any attempts you have made to contact the primary care provider -Chart teaching performed -Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client -Do not chart that you have filled out an occurrence report -Chart any client refusal of treatment or medication -Document any spiritual concerns expressed by the client and your interventions -Always use black or blue ink for handwritten notes -Date, time, and sign all notes -Avoid subjective terms -Use proper spelling and grammar -Use only authorized abbreviations -Document complete data about medications

secondary defenses against infection

-Biochemical processes activated by chemicals released by pathogens >Phagocytosis "seek and destroy" WBCs: phagocytes >Complement cascade proteins that trigger the release of "caustic enzymes" that eat through the protective covering of pathogens >Inflammation "vasodilation" brings in the good stuff >Fever "creates a hostile environment"

Narrative charting most common type, can be used with what? what is the downside?

-Can use with source- or problem-oriented system -"Story" of care in chronological format -Tracks the client's changing status Downside: -Can be lengthy and disorganized -not most efficient

safety hazards in the home : what is carbon monoxide? how is is prevented? how to treat? and how does someone get burns and scalds?

-Carbon Monoxide Poisoning Produced by burning fuel: gas, wood, oil, kerosene Prevention: carbon monoxide detector Treat: 100% humidified oxygen -Scalds and Burns Hot water, grease, sunburn, cigarettes Prevention

what is my after care of MDI

-Care of MDI/Cleaning -Counts to determine replacement timing -Respiratory assessment

what do you for nursing intervention of impaired hearing

-Care of a hearing aid -Closed-caption television -Regular inspection of ear canals -Techniques to improve communication -Promote safety -Assess for social isolation

The Spread of Infection: Six Links mode of transmission

-Contact direct and indirect >Direct - touching, kissing, sexual contact >Indirect - contact with a fomite( is a contamined object liked bred rails, iv pump) Droplet: cough, sneeze (moist) Airborne: via air conditioning, sweeping (dry)

nursing interventions unconscious clients

-Continue orientation to reality -Safety measures Bed in low position/Side rails up -Attend to body systems -Eye care -Range of motion -Skin care/mouth care -Urinary drainage -Bowel management -Nutrition

Culture and Sensitivity, it should be completed when?

-Culture refers to the growing of microorganisms to identify the pathogen. -Culture and sensitivity (C&S) tests are performed to identify both the nature of the invading organisms and their susceptibility to commonly used antibiotics. -ALWAYS completed prior to initiation of antibiotic therapy

what are my worries of optic medication

-Damage to cornea -Contamination of eye dropper

safety hazards in home suffocation and asphyxiation include? who are the highest risk?

-Drowning, choking, smoke/gas inhalation -Children 0-4 years old high risk -Prevention

hygiene schedules

-Early morning care: on awakening - wash face and hands, mouth care -A.M. care: after breakfast - bathing, toileting, hair, skin, bedmaking -P.M. care: afternoon - toileting, hand washing, oral care, readying for visitors -H.S. care: prior to sleep - relaxation activities, readying environment to facilitate sleep

Conversion examples and examples and consequences of overuse

-Emotional conflict is change into physical symptoms that have no physical basis. The symptoms often disappear after the threat is over. -E.g feeling back pain when it is difficult to continue carrying the pressure of life, developing nausea that causes the person to miss a major exam. -Laryngitis, inability to speak on the anniversary of father's death. Continued anxiety can lead to actual physical disorders, such as gastric ulcer.

The Spread of Infection: Six Links portal of entry

-Eye, nares, mouth, vagina, cuts, scrapes -Wounds, surgical sites, IV or drainage tube sites -Bite from a vector

Factors in Moral Decision-Making attitudes

-Feelings toward person, object, idea -Includes thinking and feeling component -What a person thinks

teaching your client about sleep hygiene. they should follow? if they cannot fall asleep in 30 minutes do what? use what to promote sleep? avoid? don't depend on? should use the bedroom for? eat a small amount of?

-Follow a regular routine for bedtime and morning awakening. -Go to bed each night at the same time, even on days you are off work. -If you cannot fall asleep in 30 minutes, get up and do something non stimulating , go back to bed. -Use relaxation methods to promote sleep, read a book, pray or meditate. -Avoid going to bed angry. -Don't depend on sleeping aids, be aware of the potential dangers of your sleeping medications. -Use your bedroom only for sleep, do not turn your bedroom into the family room. -Avoid caffeine, alcohol, smoking, and heavy meals before going to sleep. Remember beverages and foods such as black tea, chocolate, cola, contain caffeine. Alcohol interferes with the transition to deeper phases of sleep. -Eat a small amount of carbohydrates before bed they aid in sleeping Use aromatherapy to relax. If you take prescription drugs, ask your prescriber or pharmacist about the side effects. Use earplugs to block out noise Walk or exercise in the early evening at least 1 hour before going to sleep, doing so will raise your body temperature and tire your muscles. Even 15 minutes a day of exercise will give your body the activity and oxygen it needs to help you relax more and sleep better Take a warm bath just before going to bed. This will raise your body temperature and relax you to help you fall asleep more easily. Avoid naps during the day, unless you are an older adult who take short power naps. daytime napping can lead to night time insomnia. Don't try to catch up on sleep. Rise at your regular time, even if you went to bed later than usual. Try to keep your bedroom as dark as possible. An illuminated bedroom clock is a source of light that can be distracting when trying to fall asleep. Either replace the clock or block the light with something. Close your eyes and visualize something peaceful when trying to fall asleep. imagining your favorite, relaxing place or familiarity can relax you and help you get to sleep. Try progressive relaxation to fall asleep. Follow recorded instructions directing you in a sequence of relaxing certain muscle groups.

Occurrence Reports

-Formal record of unusual occurrence or accident -AKA "incidence report" "report of variance" -Not a part of patient's health record=never -Quality improvement -Perception of Occurrence Reports= tool for hospital

Hand-off ReportChange-of-Shift Report what is the format? what are the components?

-Formats: >>Verbal/Walking Rounds >>Audio-recorded report (not the preferred method) -Components: >>Client demographics, diagnoses & relevant medical history >>Significant assessment findings >>Treatments (e.g., wound care, breathing treatments) >>Upcoming diagnostics or procedures >>Restrictions (e.g., diet, activity, isolation) >>Plan of care for the client >>Concerns

Parasomnias include what?

-Sleepwalking/talking -Bruxism -Night terrors -Enuresis

The Spread of Infection: Six Links

-Infectious Agents >>Pathogens >>Normal flora that become pathogenic -Reservoir >>Where pathogens live and multiply >>>"Carriers" >>May be living >>>Humans, animals, insects >>May be nonliving >>>>Food, floors, equipment, contaminated water Most pathogens prefer a warm, moist dark place to live and thrive

reporting

-Informing other caregivers about the client condition Nurse to nurse; nurse to physician -Passage of vital information related to the client's status/plan of care -Maintenance for the continuity of care

Potential problems of Sims and solution

-Internal rotation and adduction of the upper shoulder and limited respirations: solution is to place a pillow under the upper arm, and comfortably flex the arm at the elbow. -Pressure on the shoulder and axilla of the inferior arm: solution position the lower arm behind and away from the back Internal rotation and adduction of the femur: support the upper leg from groin to foot with pillows. Twisting the spine: align the shoulders with the hips. Foot drop: the solution support the feet and dorsiflexion with sandbags Hyperextension of the neck, solution: place a pillow under the head and neck to provide alignment

Potential problems of supine and

-Internal rotation of the shoulders and extension of the elbows: solution is to position the upper arms next to the body. place pillows under the forearms, and position the wrist and slight pronation. -Flexion of fingers and abduction of the thumb: solution use hand splints is appropriate, or provide a large role in the palm of the hand. -Flexion of the lumbar curvature and hip: solution provider firm mattress, or place a small pillow under the lumbar curvature. -External rotation of the legs: solution place sandbags or rolls alongside the trochanter and upper thighs. -Hyperextension of the knees: solution place a small pillow under the lower legs from the ankles to below the knees. -Foot drop: solution use a footboard or high top sneakers to hold the feet in dorsiflexion.

Nurses as Ethical Agents

-Know the difference between right and wrong -Understand abstract moral principles -Apply moral principles in decision-making Weigh alternatives; plan to achieve goals -Decide and choose freely -Act according to choice

Facilitating therapeutic , perfect your listening skills you want to listen for? be alert for?

-Listen for what is not said as well as what is said - be alert for nonverbal cues

Restitution(undoing) examples and examples and consequences of overuse

-Making amends for behavior when one thinks is unacceptable, to reduce guilt. -E.g Giving a treat to a child who has been punished for wrongdoing -May send double messages. Relieve the person of the responsibility for honesty about the situation

Compensation examples and examples and consequences of overuse

-Making up for perceived inadequacy by developing or emphasizing some other desirable traits -E.g a small boy who wants to be on the football team instead becomes a great singer. -Use of drugs or alcohol to gain courage to enter a social situation

Safety Hazards for Healthcare Workers

-Needlestick injury >>Sharps awareness, proper disposal -Radiation injury >>Radiation precautions -Workplace violence >>Environmental awareness of personal safety -Back injury >>Body mechanics >>Safe transfer/ambulation For nurses and patients!!!

Dissociation examples and examples and consequences of overuse

-Painful events are separated or dissociated from the conscious mind. -E.g a person who was sexually abused as a child describes the events as though they happened to a sibling. -May result in a dissociative disorder such as multiple personality disorder

The Spread of Infection: Six Links susceptible host and what are the 4 determining factors?

-Person with inadequate defense -Four determining factors >Virulence >Organism's ability to survive in the host's environment >Number of organisms >Host's defenses

influencing factors of hygiene?

-Personal preferences - Culture and religion -Economic status -Developmental level -Knowledge level

safety hazards in home causes of falls? prevention of falls?

-Prevalent in those >65 years -Slippery floors, stairs, tubs; low toilet seat; high bed -Prevention: nonskid shoes, tidy clothes, proper lighting, grab bars/rails, no scatter rugs

Health Promotion Activities to reduce stress.

-Promote adequate nutrition -Help client students establish a routine that includes regular exercise -Teach client students importance of getting 7-8 hours of sleep per day -Encourage participation in leisure activities -Help clients students to manage time, balance responsibilities, prioritize tasks -Advise clients students to avoid maladaptive behaviors: excess alcohol, caffeine, sweets, smoking, illicit drugs

standard precautions does what?

-Protects healthcare workers from exposure -Decreases transmission of pathogens -Protects clients from pathogens carried by healthcare workers

what is protective isolation? what are the precautions?

-Protects the client from organisms -Used in special situations with immune-compromised client population -Precautions include >Room with special ventilation and air filters; no carpeting; daily wet-dusting >Avoiding standing water in the room (e.g., humidifier) >Nurse not assigned to other clients with active infection >Standard and transmission-based precautions, plus mask and other PPE (to protect patient)

what are the Factors Affecting Grief?

-Significance of the loss -Amount of support for the bereaved -Conflict existing at the time of death -Circumstances of the loss -Previous loss -Developmental stage -Spiritual and cultural background -Timeliness of death

Factors in Moral Decision-Making what are beliefs?

-Something that one accepts as true -Not always based on fact

what is Sublimation examples and examples and consequences of overuse

-Unacceptable drives, traits, or behaviors ( often sexual or aggressive) unconsciously diverted to socially accepted traits -E.g anger is expressed by aggression when playing sports. A person who chooses to not have children runs a daycare center -The acceptable behavior might reinforce the negative tendencies, and the person may still show signs of the undesirable trait or behavior. For example, a person indulges in child pornography to obtain sexual gratification.

avoidance example and examples and consequences of overuse

-Unconsciously staying away from events or situations that might open feeling of aggression or anxiety -E.g. "I can't go to class reunion tonight. I'm too tired, I have to sleep." -That person become socially isolated because of the tension he feels when around other people.

Stress Reduction Interventions

-Use of specific interventions to relieve anxiety -Anger management -Stress management techniques -Change perception of self -Change perception of stressor -Identify and use support systems -Use of spiritual support -Crisis intervention -Use of proper referrals

Processes for Ethical Practice

-Values clarification -Identify moral dilemmas -Use a decision-making model >>M O R A L -Participate on an ethics committee

types of wound dressings

-Woven gauze dressings - cause little irritation & very absorbent (2x2, 4x4) -Wet to dry (moist) - used in treating wound that requires debridement -Nonadherent gauze dressings (telfa) - used over clean wounds -Self - adhesive - temporary, acts as a second skin, traps the wounds moisture (Acu-derm, Op-site, Tegaderm) -Hydrocolloid (HCD) - complex formulations of colloids, elastomeric and adhesive components (Biofilm, Duoderm, Restore, tegasorb) The wound contact layer forms a gel as fluid is absorbed & maintains a moist healing environment Occlusive & adhesive Useful on shallow to moderately deep dermal ulcers

what should you do when receiving telephone orders

-Write the order only if you heard it yourself -Make sure the verbal orders make sense with the client's status -Repeat the order to confirm accuracy -Spell unfamiliar names; pronounce digits of numbers separately -Directly transcribe the order on the chart >>Date/time >>Text >>To followed by provider's name >>Your signature -Physicians must countersign within 24 hours

pre procedure assessment of denture care

-ask patient about usual oral care routines -assess previous oral problems -assess gag reflex

worries of unresponsive patient and oral care and you should avoid?

-aspiration -avoid use of lemon glycerin or peroxide rinses -care of dentures if present (dentures in unresponsive clients give structure to oral cavity)

worries/ challenges of denture care

-aspiration -irrtitation or lesions -infection -how they fit

when doing oral care for an unresponsive client you want to do what? critical aspects of oral care for unresponsive client

-assess condition of teeth/oral mucosa -assess gag reflex:an intact reflect may decrease incidence of aspiration

doing the nursing diagnosis for risk for infection

-at increased risk of being invaded by pathogenic organisms -risk factors (these are your etiological factors in the two part diagnostic statement) -Inadequate primary defenses** -Inadequate secondary defenses** -Inadequate acquired immunity** -Immunosuppression** -Environmental exposure** ** requires definition to the risk factor for clarification **

when doing bath care the critical aspects of bathing a client

-bath temp 105-110 -wash distal to proximal, clean to dirty -perform hand hygiene when moving from contaminated to clean body part

bathing older patients

-consider a bag bath with no rinse skin cleanser *these help prevent skin dryness -use warm water prevents burns -clean the tub after each use to prevent infection -to avoid skin irritation *pat skin dry; do not rub * apply moisture immediately after drying. wash hands before applying moisture clean the skin immediately after every incident of soliing

Contact precautions

-contact with infection, inanimate object or health care provider may transmit infection -stool incontinence (c.diff), draining wound and or skin lesions that cannot be covered, drainage bads, glown and gown, standard precautions, separate bathroom

when doing denture care what are critcal aspects of denture care

-cool water -line sink with wash cloth -do not use tooth paste

when bathing a client what are the key points to bathing a client

-eyes without soap from inner to outer -privacy for dignity and respect -change water when dirty/cool -bathe head to toe, clean to dirty -encourage self care

how to bathe a dementia patient?

-focus on the pt, not the task: provide choices -distract with food or by playing relax music -use a gentle type of shower head for rinsing *a strong spray may frighten patient -avoid sensory overload: turn down lights, warm the room, play soft music, speak calmly. *people with dementia have trouble processing information. overloading the senses may trigger aggression. -ensure continuity of care. *the pt can build a relationship with the care giver and reduce fear -encourage the pt to wash her own face if able. *makes her feel like an active participant, preserves independence -let the patient know before you touch her or spray her with water. *sudden actions are often frightening to patients with dementia -do not rush *the patient will feel tension and may become agitated.

patient placement and transport of contact precautions

-ideally private room if none place in room with a patient with the same active organism and no other infections. -when transporting ensure the infected area is covered

placement and transport of droplet precautions

-if no private room pt must be placed with pt of different infections, ensure they are physically separated more than 3 feet. -transport should wear a mask . transporter not require to wear a mask

worries of foot care

-impaired bed mobility:protective devices for feet/heels -bed cradle for protection of impaired skin -elderly with diabetes are more prone to foot related complications

when doing foot care the critical aspects of foot care are

-inspect skin intergrity, circulation and edema -clean feet/nails with mild soap, dry well -light application of lotion except between toes

stage 4 pressure ulcer is what?

-involves full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle bone or support structures -exposed tendon/bone is visible or directly palpable -slough or eschar may be present undermining and sinus tracts are common -the depth of ulcer 4 varies by location. they can be shallow on the bridge of the nose because these areas do not have subcutaneous tissues -require a full year to heal. even once healed site remains risk for future injury because the scar is not as strong as the original tissue

ppe of droplet where should supplies be placed? when do you wear a mask?

-keep droplet precaution supplies outside of the patients room on a cart -wear a mask when working within 3 feet of the patient. don mask on entry into the room -change ppe and perform hand hygiene between contact of pts in the same room, regardless of whether one or both patients are droplet precautions.

guidelines for advocacy

-keep the moral principle of patient autonomy always in mind -know the document facts of the case -know the arguments of those who oppose the patient -use role playing to develop a stragety for responding to arguements -have a sound base of support for your actions -form a coalition of allies -intervenue high enough in the hierachy -demonstrate the system -avoid getting into power struggle -be aware of client vulnerability -have alternative actions

key points to deltoid site

-locate the lower edge of the acromion process ( knobby part of shoulder) and go two three finger-breadths down (3 to 5cm) -draw an imaginary line from the anterior axillary crease to the posterior axillary cease. the deltoid site is the resulting inverted triangle -an alternative approach is to place four finger-breadths across the deltoid muscle, with your top on the acromion process. the injection goes three finger-breadths below the process in the midline.

wound assessment size. should be measured in what? and how do you measure wound depth

-measure length and width in centimeters -to measure wound depth gently insert a sterile cotton tip applicator into the deepest part of the wound. then measure applicator from skin level to the tip -possible use photo

when putting restraints what are the key points when using restraints?

-monitor frequently: patient status, circulation, continuing need for use -requires physician order/protocol "quick release" ties ROM of joints each time restraints removed

when providing care for ear and hearing aids you should do what ? critical aspects of ear care/hearing aids?

-never use cotten tipped applicators or other utensils to clean ears-impaction of cerumen or trauma can result -hearing aids:avoid contact with water, hair products, clean external parts with damp cloth only- use wax loop/brush/toothpick to clean canal portion only-do no put anything into the hearing aid

when providing oral care to unresponsive client what are the key points of oral care to unresponsive client

-padded tongue blade/bite block to avoid reflexive bitting -use minimal amount of solution -brush at 45 degree angle, short circular motions -rinse mouth -foam swabs for cleansing mucosa -suction avaliable

what are the events requiring occurrence reports

-patient fall or injury -medication error -incorrect implementation of prescribed treatment -needle stick or other injury to staff -loss a patient belongings -injury of a visitor -unsafe staffing situation -lack of availability of essential patient care supplies -inadequate response to emergency situation

key points to ventrogluteal site

-patient in side lying position with the legs straight, if possible. alternatively, use a supine position -on adults, the site is a triangle formed between your fingers when you place your palm on the head of the trochanter, index finger on the anterior superior iliac spine, and middle finger pointing toward the iliac crest

key points to vastus lateralis site. so what position do you want your client?

-position patient lying supine or sitting. locate the greater trochanter and the lateral femoral condyle -mid lateral thigh on adults : one handbreadth below the head of the trochanter and one handbreadth above the knee. the site is the middle third of the area, slightly lateral to the midline of the anterior thigh

interventions for pressure ulcers

-prevention is the most important nursing intervention - you use the braden or norton is any type of hospital setting to the patient on admission -reassess risk daily -inspect skin daily -manage moisture -lotion and massage except over bony prominces -linens wrinkle free, clean , dry -optimize nutrition and hydration -minimize pressure -rule of 30 -support surfaces

pre procedure assessment of bathing a client? pretty much what do you want to do before bathing a client

-proper body mechanics -asses skin/allergies to care products -assess client self-care abilities - determine the number of personnel needed for task

sterile gloves

-remove all jewelry, rings, watches -place gloves on a clean, dry surface, -open the inner package so that the cuff are closest to you -apply the glove to your dominant hand first, touching only the inside of the gloves folded over cuff with your nondominant hand -apply the second glove by touching only the outer part of the glove with your already gloved hand, keep your sterile thumb well away from bare skin -do not touch gloves to any unsterile items be smart sterile touches sterile and dirty touches dirty

when doing denture care what are the key points to denture care

-remove top denture first, then bottom -gently rub off dentures to clean -make sure patient still cleans mouth -asses oral health

example of nursing diagnosis for risk of infection

-risk for infection r/t altered immune response secondary to corticosteroid therapy -risk for infection r/t impaired skin integrity and poor nutritional status

teaching PCA

-safe and correct use of the PCA pump -the benefits -the pump will only deliver the amount of meds prescribed so you can't overdose. -if pain not relieved tell someone -pump will alarm when emptying, alerting nurse to change alarm -patient the only one who can push it -it is relieve pain not help pt sleep

critical aspects of using bed monitoring devices

-select the correct type of alarm for your patient -explain to the patient and family that a patient monitoring device alerts the staff when trying to get out of bed -apply, or place device; connect the control unit to the sensor pad -connect to the control unit to nurse call, if possible -explain to the patient will need to call for assistance when she wants to get up -disconnect or turn off the alarm before assisting the patient out of the bed or chair -reconnect when putting back in chair or bed - they don't stop falls but are utilize when to improved timeless of staff

pre procdure assessment of oral care unresponsive

-side lying position -gloves/eye protection -waterproof padding -suction set up make sure works -emesis basin under to catch secretions

Airborne precautions

-smaller, airborne pathogen less than 5 microns. - measles, tuberculosis, varicella, localized herpes zoster, disseminated herpes zoster -airborne infection isolation room (aiir) -client face mask if aiir not available -fit tested n95 or higher disposable respirator -standard precautions -you can put with the same infection. -a fit tested n95 is for tb.

how do we administer a intradermal injection and what are the intradermal sites? do not do what?

-the sites are lower inner aspect of arm and upper back . -be aware that intradermal doses are small usually about 0.01 to 0.1 ml -you use a 1ml syringe and a 25-28 gauge. choose a site on the ventral surface of the forearm, upper back, or upper chest -hold the syringe parallel to the skin at a 5 to 15 angle with the bevel up -stretch the skin taut to insert the needle -do not aspirate -inject slowly, and create a wheal or bleb. -do not massage or bandage the site

appearance of wound assessment

-type of wound (open or closed) -if the wound is sutured, examine the closure. are the wounds edges approximated? is there tension on any aspect of the wound? are the stitches intact? -color of wound redness and inflammation for the first 2 to 3 days is normal but erythema or swelling beyond that may indicate infection -condition of wound bed ( in an open wound) a beef red, moist appearance is evidence of healing. a pale or color or dry texture indicates a delay in healing -examine for necrosis, slough, eschar. examine for a tunnel or sinus tract in the wound bed, if there is one inspect and probe it for depth and characteristics -the skin surrounding the wound- skin discoloartion, hematoma, additional injury to surround tissue. examine the edges of the wound for epithelial tissue and contraction

when thinking of putting restraints what are critical aspects of using restraints?

-use least invasive/alternative methods first: >sitters, bed/chair alarms/monitors -use only to protect patient or others from harm (not for connivence) -allow for quick release

what should be done when doing critical aspects of hair care

-water temp 105-110 -protect eyes/ears from soap -use hair products if possible that patient prefers -towel dry hair

when doing foot care on Pt you should know the key points to foot care

-water temp 105-110 -soak 5-20min except for diabetics and those with peripheral circulation prob -trim nails straight across -dry between toes

PPE of contact precautions

-wear clean nonsterile gloves when touching the patient's intact skin. don gloves on entry to the room -wear a clean gown if you anticipate your clothing may contact the patient or any contaminated items in the room - remove ppe and observe hand hygiene before leaving the room. take care that your skin and clothing do not contact environmental surfaces in the way out of the room.

when doing hair care what are the key point to hair care

-wear gloves -assess tolerance to water temp -work from scalp to back of head -rinse hair throughly -tangles removed by working from ends of hair toward the scalp

electroencephalography what is it? How to prepare the patient: what must they avoid? no what? what needs to be wash the day before? , what to expect: what position they are in and how long is it? , what position they are in and how long is it, post procedure expectations, what can go wrong, how will you know, what to do if it does

-what is it: electrical activity of the brain ( frequency, amplitude, characteristics of brain waves) -how to prepare the patient: (explain)- test cannot read their mind wash hair day before no oils, sprays, lotion, no drinks & caffeine -what to expect: supine position electrodes applied to scalp with paste, the length: 45 min --->2 hrs -Post procedure expectations/ routines: shampoo hair (use astringent) -what can go wrong: if sleep EEG-over sedation from hypnotics seizures -how will i know? over sedation: decrease LOC, decrease RR, decrease BP seizures- motor movements -what to do if it does: safety seizure precautions

Assisted suicide

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DNAR: Do not attempt resuscitation ANA Recommendations (Box 15-3) p. 275

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Disturbed Sleep Pattern nursing diagnosis

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Euthanasia: active vs. passive

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Helping families of dying patients help the family to understand the goals of care and solve problems we needed

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Organ donation

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Potential Postoperative Complications:Collaborative Problems wound complications hematoma what is it, clinical signs, interventions

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Promoting normal urination includes privacy, assisting with positioning, facilitating toileting routines, adequate fluid and nutrition, and assisting with hygiene

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Sleep Deprivation nursing diagnosis

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Crisis intervention what do you want to do?

1 assess the situation. 2 ensure the patient safety. 3 defuse the situation. 4 decrease the person's anxiety. 5. Determine the problem. 6 decide on the type of help needed 7 return the person to pre-crisis level of functioning.

Physiological Stages of Dying

1 to 3 months prior to death 1 to 2 weeks prior to death Days to hours prior to death Moments prior to death

Specific gravity of urine

1. 001 to 1.035 this is reflection of the kidneys ability to concentrate urine. specific gravity rises with limited fluid intake or dehydration and also kidney disease. specific gravity decreases as fluid intake increases.

in the event that there is air in the syringe with the medication

1. causes inaccurate doses 2. hold the syringe needle end up 3.tapping 4.gently expel air 5.disposal regulations 6.drips

How to put on compression devices, cleanse? measure? what position? place it where?

1. Cleanse the lower extremities, if necessary. 2. Apply elastic stocking. 3. For thigh high scd sleeves, you must measure the thigh to ensure the sleeves are of proper size. 4. Place the patient in a supine position. 5. Place the compression device pump in a location near an electrical outlet so that the cord will not pose a fall risk.

What's involved in timeout

1. Confirm all team members have introduced themselves by name and role. 2. Surgeon, anesthesia professional and nurse verbally confirm the patient, the site, and Procedure. 3. Anticipated critical events. surgeon reviews what are the critical or unexpected steps, operative duration, anticipated blood loss. anaesthesia team reviews are there any patients specific concerns. Nursing team reviews has sterility been confirmed. Are there equipment issues or any concerned 4. Has antibiotic prophylaxis been given within the last 60 minutes. Is essential imaging displayed. Ppk

example of focus charting using dar what part is what 1. client stated "i'm worried about what it will be like after surgery." client asking frequent questions about surgery. has no previous experience of surgery. wife present acts as support person 2. explained to client normal pre op preps for surgery. demonstrated TCDB exercises provided booklet to client on post op nursing care 3. client demonstrates TCDB exercises correctly. needs review of post op nursing care. client states "i feel better knowing a little bit of what to expect."

1. Data which subjective and objective 2. action 3. response

combining medications from two vials in one syringe ( most common =insulin)

1. check compatibility 2. care must be taken not to contaminate one vial with medication from the other vial 3.mixing insulins a. inject air= dose into the longer acting (NPH) inject air into the air space in the vial so you do not contaminate the needle b. remove needle from NPH, pull up and inject air =dose into the regular insulin, leave the needle in the bottle c. carefully invert the bottle and withdraw the desired dose d. carefully insert the filled syringe into the second vial and carefully with withdraw the desired dose of second medication. BE SURE THAT THERE IS NO INWARD MOTION ON THE PLUNGER e. insulins must be checked by two licensed persons prior to administration

Describe four ways to facilitate the grief work of a grieving or dying person.

1. Help grieving and dying persons express feelings by: ● Encouraging questions and responding to them within a reasonable time. ● Sitting by the head of the bed and not appearing rushed. ● When you observe the patient or family member expressing feelings either verbally or nonverbally, encouraging them to continue. ● Expecting and accepting a wide range of feelings, including anger, fear, and loneliness. ● Asking, "How can I help?" "What do you need?" "What would you like for me to do?" ● Making sure that everyone on the healthcare team understands and follows the care plan. ● Asking yourself what you would do if this were your family member. ● Not comparing another person's loss to your own experience (e.g., avoid comments such as "I know how you feel." Instead, try "Tell me how you feel."). 2. Assist them in recalling memories. For example, by going through photo albums with them and asking questions about the people in the pictures. Also look for objects of sentiment (e.g., a family heirloom) in the environment and have the dying or bereaved person share their significance. 3. Assist them finding meaning in their lives or their past by helping them talk about it. Facilitating life review is one technique to help the patient and family recognize the unique contributions this person has made to family, friends, and society. You can begin by asking about the various aspects of the patient's life, commenting on pictures in the room, or picking up on verbal cues that are expressed. 4. Suggest bibliotherapy and counseling. 5. Provide grief education. Explain the stages of grief and point out that it takes months or even years to resolve. Explain that grief may become more intense on the anniversary of the death (or other loss) and on significant dates (e.g., birthdays). After the death of a loved one, family members may need support for several months. Direct them to educational resources on Web sites, in printed material, and at community forums (e.g., many churches and hospices have groups that meet regularly). Become informed about counseling services and support groups in your community, and refer families to them as needed. 6. Help them to normalize their grief. Recall that once the bereaved person accepts that the loss is real, their feelings may be so intense that they may wonder if they are losing their sanity. The grieving person may be fatigued from not sleeping, may be disoriented or unable to concentrate, and may be concerned about what such symptoms mean. Reassure the person that such responses are expected and that there is no single "right" way to grieve (Egan, 2003). Also assure them that although the grief process takes time, their symptoms won't last forever. 7. Increase your self-awareness: your attitudes and feelings regarding death and dying.

reconstituting powered medications

1. check the label for the correct diluent to use and the desired volume 2.pull air out of the vial that contains the powder equal to the amount of diluent that will be added to reconstitute the powered 3. add the removed air to the diluent bottle so that the desired volume can be withdrawn 4. pull up the desired volume of diluent and add to the bottle with the powdered medication rotate the vial gently to dissolve the powered medication do not shake

How to teach a patient to move in bed, we want the patient in what position?

1. Start with the patient in the supine position, bed rails up. 2. To turn to the left side, bend the right leg, sliding the foot flat along the bed and flexing the knee. 3. reach the right arm across the chest, and grasp the opposite bed rail. It reduces the need to use abdominal muscles for turning, and minimize incision pain. 4. Breathe deeply, and practice splinting any potential abdominal or chest incisions. Assist the patient to practice as needed. 5. pull on the bed rail while pushing off with the right foot. 6. If the patient cannot maintain this position independently, place a folded pillow or blanket along her back for support. 7. change position every 2 hours, repeating the turning process with the opposite arm and leg. You will need to assist a patient who needs pillows place for support.

examples of SOAP state which part it is of the soap method? 1/19/06 deficient knowledge related to inexperience regarding surgery 4:30pm. 1. I'm worried about what it will be like after surgery? 2.client asking frequently questions about surgery. has had no previous experience with surgery. wife present, acts as a support person 3. deficient knowledge regarding surgery related to inexperience. client also expressing anxiety 4. explain routine preoperative preparation. demonstrate and explain rationale for turning, coughing, and deep breathing (TCDB) exercises. Provides explanation and teaching booklet on post of nursing care.

1. Subjective 2. objective 3. assessment 4.plan

Post-op Pain Control

1. assess the type of anesthetic used preoperative medication that the client received, and note whether the client received any pain medication in the post anesthesia period. 2. assess for pain and inquire about the type and location of pain on a scale of 1 to 10, with 10 being the most severe. 3. monitor for objective date related to pain, such as facial expression, body gestures, increased pulse rate, increased bp, and increase respirations. Administration -Preventative Approach >>PRN vs ATC Routes of Administration -Intramuscular -Intravenous >>PCA pump/Epidural lines

assessing for falls morse fall scale

1. does the patient have a history of falling 2. does the patient have more than 1 medical diagnosis 3.does the patient use ambulatory aids, such as crutches or a walker? 4. does the person have an iv line or a heparin lock? 5. is the person gait normal or stooped or otherwise impaired? 6.what is the person mental status?

Canadian nurses association

1. providing safe, compassionate, competent and ethical care. 2.promoting health and well being 3.promoting and respecting informed decision making 4.preserving dignity 5. maintaining privacy and confidentiality 6. promoting justice 7. being accountable

defining characteristics to acute pain

1. verbal or coded report 2.observed evidence 3. antalgic positioning to avoid pain 4. protective gestures 5.guarding behavior 6. facial mask 7. sleep disturbances 8. self focus 9. narrowed focus (altered time perception, impaired thought process, or reduced interaction with people and environment) 10. distraction behavior ( pacing, seeking out other people and/or activities or repetitive activities 11. autonomic responses (diaphoresis, changes in blood pressure, respiration, pulse, pupillary dilation) 12.autonomic change in muscle tone (may span from listless to rigid) 13. expressive behavioral restlistness, moaning, crying, vigilance, irritability, or sighing) 14. changes in appetite or eating

what are the five factors in equipment preparation of medication administration

1.correct syringe for the drug, amount and the site 2. sterility maintained 3.correct needle length and gauge for drug, amount and site 4. careful use of calibration 5. safety precautions when using the equipment and disposal

drawing medication from a vial

1.displacement air 2.air=volume of dosage 3. air displacement problems a too little air b too much air 4 to avoid air in the drawn medicine

defining characteristics of sensory

1.poor concentration 2.auditory distractions 3.changes in usual response to stimuli 4.restlessness 5.reported or measured change in sensory acuity 6.irritability 7.disoriented in time, in place, or with people 8 change in problem solving abilities

example of pie state what part is what 1. deficient knowledge regarding surgery related to inexperience 2.explained to client normal pre op preparations for surgery, demonstrated TCDB exercises. provided booklet to client on post op nursing care 3. client demonstrates TCBD exercises correctly needs review of post nursing care

1.problem 2. intervention 3 evaluation

defining characteristics of chronic pain

1.weight changes 2.verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self focusing, restless, depression 3. atrophy of involved muscle groups 4. changes in sleep pattern 5.fatigue 6. fear of reinjury 7. reduced interaction with people 8.altered ability to continue previous activities 9. sympathetic mediated responses ( temp, cold changes of body position, or hypersenstivity 10. anorexia

how long do you want the patient to remain in the desired position for lung drainage?

10 to 15 minutes if tolerated because it allows adequate drainage of secretions by gravity from the desired lung field.

Hemoglobin

11. 7 to 17.3

what is Hypertonic and what does it do to the colon?

120 to 180 ml of sodium phosphate available as a commercial prepared solution. attracts water into the colon, thereby causing distention. Rapid acting bowel movement 5 to 10 minutes. Adverse effect sodium retention

Pre albumin

12:42

When administering a subcutaneous shot the nurse should use which type of gauge needle?

25 gauge needle

what is defamation of character?

>false >was made to another person or persons >caused the defamed person to experience shame and ridicule and had a negative impact on the person's reputation >was made as a statement of fact of rather than an opinion.

Physiological stress

Affect body: structure/function (e.g., diseases, mobility problems)

Serum albumin

3.4 to 4.8

How far should suppository be placed in the anus

4 inches beyond the internal sphincter

qid

4 times a day

what do you do if you come in contact with bodily fluids or poke your self with a needle?

>immediately flood the area with water and clean any wound with soap and water or skin disinfectant if available. > report the exposure >seek immediate medical attention >complete an incident or injury report >attend counseling session by agency

Hematocrit

43 to 49 men 38 to 44 in menstruating women.

normal range of leukocyte and what tells you about skin breakdown

4500-11,000 wbc may increase when a wound develops; continued evaluation may signal infection. a low wound count may delay wound healing leuokocyets are responsible for an inflammatory response at the wound site, phagocytis of bacteria and cellular debris, and the creation of antibodie

normal range of leukocyte and what tells you about skin breakdown

4500-11,000 wbc may increase when a wound develops; continued evaluation may signal infection. a low wound count may delay wound healing leuokocyets are responsible for an inflammatory response at the wound site, phagocytis of bacteria and cellular debris, and the creation of antibodies

pH of urine

5 to 9 with an average of six a client's pH increases if they eat dairy products or citrus fruits or has a vegetarian diet. the pH decreases if the client eats a high protein diet or consumes cranberry juice

Common Post-op Discomforts diarrhea

At first Diarrhea 9 out of 10 due antibiotics. But a couple of days and you see the diarhhea and then its due to fecal impaction

how much Isotonic solution is used? and what does it do? how long till bowel movement? adverse effects

500 to 1000 ml of normal saline. large volume distends the colon. There by stimulating peristalsis some softening of stool also occurs. 15 minutes till bowel movement. Adverse effects include fluid and electrolyte imbalance especially sodium retention

Hypotonic solution

500 to 1000 ml of tap water. Large volume distended the colon, thereby stimulating peristalsis, water also soften stool. 15 minutes till bowel movements. Adverse effects fluid an electrolyte imbalance especially water intoxication if enema not expelled.

what is the lab values INR international normalized ratio and what is it for

<2.0 for patients not receiving anticoagulation therapy 2.0-3.0 for those receiving coagulation therapy a standardized test to evaluate clotting times, consider the gold standard

Factors That Influence Adaptation Personal perception of stressor

Is understanding of stressor realistic? How successful have previous adaptation attempts been?

Normal blood glucose is what

70 to 100

esr and wound

<50 years old 0-15 mm/hr >50 years old 0-20 in the presence of an inflammatory and necrotic process, blood proteins are altered. this test indicates if the RBCs stick together become heavier and settle at the bottom of a lab tube when held vertically

Calcium levels

8.6 to 10 an increase in calcium is bad for metabolic

Pre procedure for pulse oximetry a normal range, you want to assess for? determine? check for?

95 to 100 percent. Assess the patient's need for the pulse oximetry monitoring, such as heart or pulmonary disease, low hemoglobin level, confusion, decreased level of consciousness, or respiratory distress Assess the patient's respiratory status because assessment findings may suggest a decrease in oxygen saturation and validate oximetry readings determine the optimal location for the oximeter probe sensor, for example, the fingertip, earlobe, forehead, or bridge of the nose. Check the capillary refill and pulse at the pulse closest to the site. Ensure accurate monitoring, choose a site that has adequate circulation, it's free of artificial nails, it contains no moisture - assess for factors that may interfere with pulse oximetry measurements such as hypotension, hypothermia, and tremors. The sensor requires adequate circulation to recognize hemoglobin molecules that absorb the emitted light. Tremors may produce artifact that may be misinterpreted by the oximeter cause a false readings - check patient history for allergy to adhesive because an allergic reaction may occur if an adhesive back disposable probe sensor is used in a patient with a history of allergy to adhesives.

how should we structure Just Culture" in Nursing Education

>>Attitude - a shared accountability model that promotes faculty, student and system(s) learning from mistakes >>Structure - a system of policies and processes to collect and trend data on hazards, errors and near-misses >>Leadership - fully engaged, transparent >>Faculty and students - all working toward safe learning and performance

the purpose of the nursing code of ethics

>inform the public about the professions minimum standards. >demonstrate nursing commitment to the public it serves >outline major ethical considerations of nursing >provide general guidelines for professional behavior >guide the profession's self regulating functions >remind us of the special responsibility we assume in caring for the sick.

General adaptation syndrome what are the stages

>>alarm reaction whether it's good or bad stress fight or flight - stimulation of sympathetic nervous system - increase release of hormones from: hypothalamus (CRH), posterior pituitary (endorphins, ADH), anterior pituitary (ACTH), adrenal cortex (cortisol, aldosterone) adrenal medulla (epinephrine) >>>Resistance or adaptation: -parasympathetic activity balances sympathetic activity. -hormone levels return to normal >>Exhaustion OR Recovery Which Usually Ends IN Disease OR death: - alarm reaction recurs will continue until energy is depleted. The person cannot adapt and subsequently dies.

A Focus on the Component of Safety knowlege include?

>Human factors >Basic design principles >Unsafe practices >Safety-enhancing technology >Error/hazards in care >Factors that create a culture of safety

A Focus on the Component of Safety using skills include?

>Use of technology/standardized practices that support safety >Demonstrate use of strategies to reduce risk of harm to self and others >Communicate concerns related to hazards and errors to patients, families and the health care team

the nurse practice act does what

>credentialing >licensing >discipline

examples of reckless behavior

>nurses leave workplace before completing all assigned patient/client care( and does not report to another nurse) because he has a date waiting >nurses observe patient/client starting to climb over bedrails but walks away without intervening because it was not her assigned patient/client >nurse makes serious medication error, realizes it when client experiences adverse reaction, tells no one, denies any knowledge of reason for change in client condition, and falsifies documentation to conceal error

malpractice and what are the four elements necessary to collect damages

>professional >four elements necessary to collect damages >existence of a duty >breach of the duty >causation >damages

at risk behavior can be managed through?

>removing incentives for at risk behaviors >creating incentives for healthy behaviors >increasing situational awareness

examples of human error?

>single medication error/event (wrong dose, wrong route, wrong patient, or wrong time) >failure to implement a treatment order due to oversight

four-point gait description and uses

slow, safe; right crutch, left foot, left crutch, right foot used when weight bearing is allowed for both legs

Clear liquids

A clear liquid diet provide fluids to prevent dehydration, & supplies some simple carbohydrates to help me energy needs. items in a clear liquid diet include water, tea, coffee, broth, clear juice such as Apple grape or cranberry juice, popsicles carbonated beverages, and gelatin. clear liquid diets do not supply adequate calories, protein, and other nutrients, so timely progression to more nutritious diet is recommended. If clear liquids are required for more than 3 days, commercial clear liquid supplements are usually prescribed.

What is a crisis and what are the five phases of crisis

A crisis exist when an event in a person's life drastically changes the person's routine and he perceives it as a threat to self, and a person usual coping methods are ineffective, resulting in high levels of anxiety and inability to function adequately. Such events are usually sudden and unexpected. the five phases of crisis are pre-crisis, impact, crisis, adaptive, post-crisis

crisis

A crisis exists when (a) an event in a person's life drastically changes his routine and is perceived as a threat to self, and (b) the person's usual coping methods are ineffective, resulting in high levels of anxiety and inability to function adequately. Such events are often sudden and unexpected (e.g., serious illness or death of a loved one, serious financial losses, an automobile accident, rape, or natural disasters).

critical thinking

A combination of Reasoned thinking Openness to alternatives Ability to reflect A desire to seek truth

What is somatoform disorders and examples

A condition characterized by the presence of physical symptoms with no known Organic cause. They are believed to result from unconscious, denial, repression, and displacement of anxiety. examples include hypochondriasis, somatization, pain disorder, malingering.

Factors affecting grief conflicts existing at the time of death may cause?

A conflict left unresolved may cause prolonged grief. For example, if a couple had an argument just before one partner died suddenly, the remaining partners grief may be complicated by guilt.

When is a cough significant? What aspects of a cough should be assessed?

A cough generally becomes significant when it persists, is recurring, or is productive. A persistent or recurring cough is indicative of ongoing or recurring airway irritation. A cough that lasts more than 3 weeks and cannot be explained should be medically evaluated. The following aspects of a cough should be evaluated: ● Type of cough (e.g., dry, productive, hacking) ● Duration of cough ● Timing of cough ● Appearance of sputum (if any) ● Exacerbating factors ● Alleviating factors ● Types of treatments used to date and their effects ● Associated symptoms ● Type, amount, and timing of sputum produced

Constipation

A decrease in a person normal frequency of defecation accompanied by difficult or incomplete passage of stool or passage of excessively hard, dry stool.

Facilitating therapeutic reassure the person that it is not wrong to feel anger, guilt, relief, or other feelings she may believe to be unacceptable. what should you tell the patient?

A dying patient might say," I know it's awful, but I been so angry with God for giving me this disease." or a bereaved spouse might admit, " I shouldn't feel this way, but I'm relieved that it's finally over." - patients need to hear you say their feelings are not wrong or bad and that they are going through a normal process

Color of urine

A freshly voided sample is pale yellow to deep amber

Clarity of urine

A freshly voided samples should be translucent. if the urine sits for a period of time, it will become cloudy. cloudiness in a fresh voided is sample indicates the presence of other constitutes in the urine these may include bacteria, red blood cells, white blood cells, sperm, prostatic fluid, or vaginal discharge.

Full liquid

A full liquid diet contains all the liquids included in the clear liquid diet plus any food items that are liquid at room temperature for example soups, milk, milkshakes, pudding, custard, juices, some hot cereals, and yogurt. it is difficult to obtain a balanced diet on a full liquid plan, so it should be used for short time only. If it is needed for a longer time, it should be planned by professional dietitian. High calories, high protein supplements are often added.

Respiratory effort and dyspnea. what type of questions should you use?

A healthy person breathes effortlessly. A patient experiencing shortness of breath or dyspnea requires a thorough assessment. Use closed questions the patient can answer with yes no, or only a few words. Signs are most easily visible in infants and small children.

Stridor, you can hear it how as well

A high pitch, harsh, crowning, inspiratory sound caused by partial obstruction of the larnyx or trachea. You can hear it without a stethoscope

physiological stages of dying 1 to 2 weeks before death

A host of physical changes indicates the body is beginning to lose its ability to maintain itself. Cardiovascular deterioration brings reduce blood pressure, changes in pulse and skin color (yellowish pallor), and extreme Pallor of the extremities. Temperature fluctuates and perspiration increases. respiratory rate may increase or decrease, during sleep, the dying person may experience brief periods of apnea . congestion may cause a rattling sound and/or a nonproductive cough.

what are the 3 types of behavioral choices just culture company identifies?

A just culture company identifies 3 types of behavioral choices that every person makes and needs to manage Human error "honest mistake" At risk behavior behavioral choice that increases risk, deviation from a standard Reckless behavior disregarding standards, putting own self interest above that of the client, organization or others

Conversational dyspnea

The inability to speak complete sentences without stopping to breathe. the more frequently the patient pauses when speaking, the more severe the dyspnea.

Cognitive function and nutrition

A person with a developmental delay, severe mental illness, confusion, or memory loss may be unable to remember what, when or whether she has eaten.

poor Appetite results in? functional limit of nutrition

A poor appetite result in decreased intake of food and therefore of nutrients. it is a common problem in alcoholism. Almost all oral medications have the potential to cause nausea or vomiting, thereby decreasing appetite.

Adaptation is a possible outcome for? involves? allows for? and influences?

A possible/desired outcome of stress Involves adjusting to the stress/stressor Allows for -Normal growth and development -Effective responses to life's challenges Influences on ability to adapt: -Intensity of the stressor -Effectiveness of coping skills -Personal factors

Pureed diet

A pureed diet is a blended any food item may be eaten, however, the consistency must be altered by blending. Often liquids are added to the food to create a texture that maybe scoop on to serving plate.

Yellow or green sputum

A sign of infection

how can I Facilitate therapeutic response to nonverbal cues to show that I care and concern?

A smile, a gentle touch, sitting with a patient, & eye contact all rely a message of genuine care and concern. You may not need to say very much at all.

Elements of Informatics

Data: unprocessed numbers, symbols, words; no context Information: groupings of processed data Knowledge: meaningful information created by grouping and compiling information Wisdom: appropriate use of knowledge

Factors affecting grief development older adulthood, they experience what types of losses?

A special difficulty for older adults is that day experience so many losses. most deaths occur among older adults, so they are likely to lose friends and siblings in rapid succession. Add to those losses the physical and functional losses and the loss of Independence, and the cumulative effects may be devastating

Exercise program guidelines focuses on?

A well-rounded exercise program focuses on flexibility, resistance training, in aerobic conditioning. factors when designing or evaluating an exercise programs include the following:

how do I administer MDI

Good seal of mouth Inhale/puff at same time, hold breath for 10 sec. Wait at least one minute between puffs of same medicine Wait 5-10 minutes between puffs of different medications

Eustress

Good stress (e.g., passionate kiss)

Pre-existing conditions that increase surgical risk acute conditions acute infection because it

Tax the patient energy and physiological reserves, increasing the risk for various postoperative complications

Assess grief and loss knowledge-based of patient

A. Do the patient and family have the information they need to make informed decisions about health care choices? for example, you might ask the following questions: Tell me what you understand about your illness. Are there any questions about your illness that you like me to answer? What are your options for treatment? Do you know how to reach your provider if you have questions about your care? B. What and how much do the patient and family want to know? the rationale is because some people wish to have all the details of their condition and care. For others, the details cause anxiety.

assessing grief and loss? Perform a cultural and spiritual assessment? assess for? do not assess? you can ask?

A. Assess the patients and families religious beliefs, any spiritual needs they may have(e.g., forgiveness, hope, meaning, love), and cultural influences that may affect the way they cope. B. Do not assume that a person adheres closely to the dominant values of his religion or cultural group. Always assess. For example ask: - to what religious and ethnic groups do you belong? - how closely do you identify with those groups?

Explain what to expect after surgery

A. Explain that the patient will initially be cared for in the post anaesthesia care unit. After a period of observation, he will be transferred to the surgical unit. Notes that some patients may be transferred directly to a critical care unit at the surgery. if this is expected, tell the patient and family about this preoperatively. B. Family may visit after the patient has been admitted and assess on the surgical unit. C. Tell the patient what to expect in terms of dressing, equipment, and monitoring devices. D. Describe the types of assessments that will be perform. E. Explain that pain medication will be given to keep the patient comfortable. If he experience is pain, he should tell the nursing staff. F. Discuss the usual progression of recovery, including activity level, deep breathing, coughing, leg exercise, and dietary intake. G. Discuss the anticipated length of stay. H. Teach the importance of deep breathing and coughing after general anesthesia. Demonstrate how to splint the incision to facilitate deep breathing and coughing. I. Teach the patient how to move into and out of bed after surgery. J. Teach and emphasize the importance of leg exercises to minimize the risk of thrombus formation . if decreased activity or prolonged bed rest is anticipated, explain the use of anti embolism stockings or sequential compression devices.

Explain what to expect before surgery, preoperative testing, skin preparation, medication, actives that will occur before surgery such as, how long do they need to be npo before surgery? what needs to be removed? who will talk to them? give the patient and family what?

A. Explain the plan preoperative testing such as lab test, xray studies, ECG, and so on. B. Discuss skin preparation, including preoperative wash with an antibacterial product if this is included in the treatment plan. C. Discuss prescribed preoperative medications. D. Outline activities that will occur before surgery, such as insertion of an IV, placement of a urinary catheter, or cardiac monitoring. E. Often the patient is to be NPO for at least 8 hours before the plan start of surgery. Some guidelines indicate that most children can drink clear liquids until 2 hours before surgery. F. If the patient is having surgery on the gastrointestinal tract, an additional bowel prep maybe order (e.g low residue diet beginning 1 week before surgery, and a liquid diet for the 48 hours preceding surgery) patients having GI surgery may also have enemas before surgery. H. Explain the need to remove jewelry, makeup, hearing aids, glasses, contact lenses, and any removable Dental prosthesis before being transported to the operating suite. it is best to have family members take valuable belongings home for safekeeping. I. Tell the patient that a member of the anaesthesia team will speak with him about the propose anesthesia before surgery. J. Give the patient and family a tentative schedule for the operative day, including the time to arrive at the hospital or surgery center.

Explain what to expect in the operative suite, inform patient and family what? discuss? describe?

A. Inform the patient and family where relatives may wait during surgery. B. Discuss the preoperative holding area and activities that may occur there. C. Describe the operating room and activities that the patient may anticipate before the surgery. D. Explain that the anesthesiologist or nurse anesthesia will monitor the patient throughout the entire surgery and is responsible for keeping him comfortable with medications throughout the procedure. E. Describe the types of people who may be present in the operative suite. This is particularly important if the patient is not receiving a general anesthetic.

Cheyne Stokes respiration and what is often associated with?

Gradually increase depth of respirations, followed by a gradual decrease and then by period of apnea. Often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

How to put on knee high stockings so measure? how high should the stockings be?

A. Measure the circumference of the calf at the widest section. B. Measure the distance from the base of the heel to the middle of the knee joint. Better use of knee than thigh stockings. Pull up to 2.5 to 5 cm below the knee.

a patient with venous stasis ulcer you should apply?

compression garment. because they apply continous pressure which helps venous return and allows the ulcer to heal

Differentiate between grief and depressive disorder. what are common symptoms of grief and depression, what are symptoms that indicate grief? what are symptoms that indicate depressive disorder?

A. Symptoms common to both grief and depressive disorder include sadness, insomnia, poor appetite, and weight lost. The rationale is feelings of sadness and depression are a normal part of grief, provided the depression does not linger too long. B. Symptoms that indicate grief, but not depression. An example is a "trigger" event. The person may feel relatively better in certain situations, such as when she is with friends and family. However, triggers, such as the deceased person's birthday, and anniversary, or holidays, cause the feelings to resurface more strongly. C. Symptoms that indicate depressive disorder: - depression is more persuasive. That is, the person rarely gets any relief from the symptoms - feelings of guilt not related to the loved one's death. - thoughts about own death or a suicide( other than feelings the person would be better off dead now that the loved one is gone) - preoccupation with own worthlessness - sluggishness - hesitant and confused speech - prolong and mark difficulty in carrying out activities of daily living. - hallucinations, other than thinking he hears the voice of or sees the deceased person

Perform these specific assessment for dying patients, you want to encourage the family and patient to talk about? determine? what happens 1 to 3 months before death, 1 to 2 weeks before death, days to hours before death , and moments before death? and auscultate to determine?

A. When the patient and family are ready, encourage them to talk about what the patient might want for burial or cremation or whether there are task that the person would like taking care of (e.g. giving away valuables, calling family members). B. Determine whether the dying person has a living will or advance directives. C. Discussed with the patient and family the possibility of organ donation if appropriate for the patient circumstances. D. Other for physical changes indicating the approach of death 1 to 3 months before death: increase sleep, decrease appetite, difficulty digesting food 1 to 2 week before death: decrease blood pressure , pulse and respiration changes whether they are a decrease or increase, a yellowish pallor to the skin, extreme pallor of extremities, temperature fluctuations, increase perspiration, brief periods of apnea during sleep, rattling breath sounds, nonproductive cough. Days to hours before death: a brief surge of energy and mental clarity, with a desire to eat and talk with family members - dehydration, difficulty swallowing, decreased blood pressure, weak pulse - sagging of tongue and soft palate, diminished gag reflex, secretions accumulating in the oropharynx and/or bronchi - shallow, rapid, or irregular breathing, Cheyne Stokes respiration, : apnea of 10 to 30 seconds, death rattle - decreased peripheral circulation, clammy skin, extremities cool and mottled, dependent body parts darker than the rest of the body. - decreased urinary output secondary to decreased kidney function - slack facial muscles - retain feces bladder and bowel incontinence. - blurred vision, eyes open but unseeing - restlessness or agitation( check for impacted stool, distended bladder, pain) - decrease communication, quiet, withdrawal Moments before death: does not respond to touch or sound, cannot be awakened. There may be a short series of long space breaths before breathing stops entirely and the heart stops beating. Auscultate to determine whether apical pulse and respirations are absent.

Grief, mourning, bereavement

Grief: Physical, psychological, and spiritual responses to a loss Mourning: Action associated with grief Bereavement: Mourning and adjustment time following a loss

Documentation

The act of recording client assessments and care in written or electronic form Creating a record of client assessments (multidisciplinary), responses to interventions and care Coordination of patient care**

Post crisis

The aftermath of a crisis may have both positive and negative effects on functioning. the person may have developed better ways of coping with stress. Or, she may be critical, hostile, and depressed, and she may use maladaptive strategies to deal with what has happened

Intestinal surface area functional limitation of nutrition

The amount of intestinal surface area may be diminished either by surgery or disease, thereby decreasing absorption of nutrients. This may result in malnutrition despite the fact that patient is consuming adequate calories and protein.

Enzymes secretions and nutrition

Liver, gallbladder, or pancreas problems affecting the secretion of enzymes involved in digesting foods. nearly 50 million Americans lack the enzyme lactase needed to digest milk. up to 80 percent of African Americans, 80 % to 100 % native American, and 90 to 100 % Asian americans are lactose intolerant

for wound assessment you want to know

Location Type Size Undermining/Tunneling Periwound

factors affecting sensory perception

Location of receptor Number of receptors activated Frequency of action potentials Changes in above Past experiences, knowledge and attitude influence perception

Range of motion for the ankle, what type of joint is the ankle?

The ankle is a hinge joint plantarflexion point The toe and foot downward Flexion dorsiflexion pull the toes and foot upward.

Pre-existing conditions that increase surgical risk liver disease

Affect the body's ability to metabolize amino acids carbohydrates, and fat to manufacturer prothrombin for clotting, and to detoxify medications. Therefore, the patient is at risk for increase poor wound healing, hemorrhage, and toxic reaction to anesthetics and medication

Pre-existing conditions that increase surgical risk renal disease

Affects the patient's ability to excrete many medications, including anesthetic agent. it also affects the ability to regulate fluid and electrolytes

Purpose of the Written Record

Communication between providers Educational tool Legal documentation of care Quality improvement Research Reimbursement Education

The Spread of Infection: Six Links portal of exit

through -Bodily fluids -Coughing, sneezing, diarrhea -Seeping wounds -Tubes, IV lines

for drainage you want to know?

Amount - color - odor - consistency Type: Classifications of drainage: Serous - clear, watery plasma Purulent - thick, yellow, green, tan or brown (pus) distinct odor and indicates infection Sanguineous - bright red, indicates active bleeding (bloody) Sero-sanguineous - pale, red, watery; mixture of serous and sanguineous

Emotional grief reactions include?

Anger, sadness, guilt, relief, shock, numbness, loneliness, fear, anxiety, powerlessness, helplessness

Sleep deprivation defining characteristics

Daytime drowsiness, decreased ability to function, agitation, irritability, hallucinations, inability to concentrate, anxiety, apathy, slow reactions, combativesness, fatigue, fleeting nystagmus, hand tremors, heightened sensitivity to pain, lethargy, listlessness, malaise. Perceptual disorders, restlessness, transient paranoia.

How does corticosteroids increase surgical risk

Delayed wound healing and increase risk for infection

Pre-existing conditions that increase surgical risk diabetes mellitus

Delays wound healing and increases the risk of infection and cardiovascular disorders associated with diabetes

List at least three reasons for noncompliance with a medication regimen.

Answer: Reasons for noncompliance with a medication regimen include the following: ● Inability to afford the cost of the medication ● Visual and motor deficits that limit the ability to read labels and manipulate bottle caps, syringes, and so on ● Inability to tolerate side effects ● Forgetfulness ● Impaired mental capacity ● No symptoms of disease

Electronic Health Records (EHRs)

Enables the compilation of electronic health records Improved access to patient data Increased privacy related to records Stored, aggregate data available to researchers Reduces errors in healthcare Increases ability to share critical patient information; e.g., allergies Decreases transcription errors Can prevent medication errors through bar-coding Enables access by multiple providers

interventions to meet the physiological needs of the dying person

Encourage the patient to be as independent as possible, so that she will maintain a sense of control. Monitor the patient's energy level. If she tires easily or lacks the energy to care for herself, you should provide this care. ● Maintain skin integrity by turning the patient frequently, providing massage to increase circulation, assessing for increased diaphoresis and/or incontinence, and maintaining adequate nutrition. During the final hours of life, the goal of these activities changes from preserving skin integrity to providing comfort. Realize that during this time, even excellent skin care may not prevent skin breakdown. ● If the patient is comatose or unconscious, provide special care for the eyes so they do not become too dry. Many agencies use a form of artificial tears for this purpose. ● If the patient is not able to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently with cool water or a prepared product for this (there is some evidence that glycerin swabs dry the mucous membranes and should not be used). You may provide artificial hydration unless the patient has an advance directive requesting "No artificial hydration per nasogastric or IV route." However, IV fluids can cause edema, nausea, and even pain in a patient who is actively dying. ● Dying patients may experience constipation, urinary retention, and incontinence. Pads are helpful, but change them frequently to prevent skin breakdown and, near the end, to promote comfort. Administer laxatives for constipation, and catheterize the patient if he is unable to void and the bladder becomes distended. ● If a "death rattle" occurs from accumulated secretions and if it is distressing to families, turn the patient on his side and elevate the head of the bed. Antispasmodic and anticholinergic medications may also be administered. ● Provide adequate pain control. This can be a major issue for patients and caregivers. Refer to Chapter 30 for more information about pain management. In fact, dying patients are often more concerned about the pain and loss of control than about dying itself. o Provide education as necessary to dispel the myths about pain medication (e.g., addiction, overdose). Effective pain control medications exist and can be administered by various routes. o Assure patient and family that analgesics will not be addictive in this situation. o Respect the patient's informed decision to refuse pain medications. For example, a patient may prefer to endure pain rather than to be sleepy and not alert when his family is at the bedside. o Follow one of the common pain protocols to ensure that pain is controlled. o To ensure pain control, administer pain medication on a regular schedule instead of waiting until the patient asks (PRN). o Teach and perform nonpharmacological pain relief measures when you judge that they can be helpful. These measures might include meditation, heat/cold therapies, massage, distraction, imagery, deep breathing, and herbal-scented lotions. It may be soothing to play soft music, add "white noise," or turn off the television. o Patients who are near death may moan or grunt as they breathe; this does not necessarily indicate pain. Be sure that families understand this. ● Provide medication for other symptoms, such as nausea. ● The patient is usually able to hear even after he can no longer respond to sounds and other stimuli, so continue to talk to him as if he can hear. Do not talk about him to others in his presence.

Endoscopy

Endoscopy the visualization of a body organ or cavity through a scope.

Emerging Pathogens/Diseases

Epidemic vs. Pandemic Emerging infectious diseases Drug Resistant Pathogens (mutants) MRSA (Methicillin-Resistant Staphylococcus) VRE (Vancomycin-Resistant Enterococci) C-diff (Clostridium difficile) Implications for nursing care

Risk for constipation

At risk for decrease in a person normal frequency of defecation accompanied by difficult or incomplete passage of stool or passage of excessively hard dry stool

for assessing grief and loss: Assessing the meaning of the loss or illness be alert for which statements? because it may indicate what?

Be alert for statements such as the following, which may indicate the patient or family is struggling to find meaning - "I'm being punished" - "she doesn't deserve this" - "why is this happening to me" The rationale in trying to make sense of their loss or their dying, people try to attach a meaning to their suffering

Loss of aspects of self: what are the physical losses and psychological losses?

Include physical losses such as body organs, limbs, body function, and or body disfigurement. Psychological and perceived losses in this category include aspects of one's personality, developmental change (as in the aging process), loss of hopes and dreams, and loss of faith.

how to do intermittent bladder irrigation

Establish a sterile field under the specimen removal port or the irrigation port on a three way catheter. Because of the risk of infection catheter never disconnect the draining tubing from the catheter . use a sterile irrigation solution, warm to room temperature. Instill the irrigation solution slowly. Repeat the process as necessary

Elimination Abnormal Findings, what happens in bowel and urinary?

Constipation; fecal impaction - oozing of diarrhea stool may occur Abdominal distention, nausea Urinary stasis Urinary infections - elevated WBC Bladder distention - lower abdominal discomfort, difficulty voiding Kidney stones - pain, blood in uri

Helping families of dying patients provide information, support, & a listening ear and includes?

Include specific facts about the patient's condition and prognosis and whom to call about changes in condition

Supportive interventions for toileting

Focus on helping the patient reach the toilet, urinate independently, and perform toileting self care. Examples include bedside commode and gait and strength training. When Continence cannot be achieve use absorbent products with waterproof coverings are available. under no circumstances should you refer these as diapers.

Full liquid

Includes clear liquid but add smooth texture dairy products, milk, ice cream, custard, refined cook cereals like cream of wheat, peanut butter

Loss of significant relationships includes?

Includes, but is not limited to, actual loss of spouses, siblings, family members, or significant others through death, divorce, or separation (e.g, during war, a move to a foreign country).

Extension

Increase angle joint leg straightening elbow

Types of Assessments

Initial Ongoing Comprehensive Focused Special Needs: -Nutritional -Functional ability -Pain -Cultural -Spiritual health -Psychosocial -Wellness -Family -Community

what is safety and it is a ___?

The condition of being safe from undergoing or causing hurt, injury, or loss Basic human need Nurses attend to safety needs of >>Clients in all healthcare (& care provision)settings >>Healthcare workers, including themselves

initial and ongoing planning

Initial planning -Begins with first client contact -Written as soon as possible after initial assessment -Development of the initial comprehensive care plan Ongoing planning -Changes made in the plan as you evaluate the client's responses to care

NursingProcess: Implementation

Interventions associated with safety Safety Hazards: Patient Focus >>Restraints >>Side rails

Syndactylism

Is the fusion of two or more fingers or toes. most cases involving the hands are treated surgically at an early age to limit effect on fine motor development.

Urge incontinence

Is the involuntary loss of larger amounts of urine accompanied by strong urge to void. It is often referred to as a overactive bladder.

Overflow incontinence

Is the loss of urine in combination with a distended bladder. causes of overflow incontinence include fecal impaction, neurological disorders, & enlarged prostate

Anxiety it may be related to? only make this diagnosis if the client what?

May be mild, moderate, severe, or at a panic level. in the preoperative client, anxiety may be related to the current change in health status or due to concerns about being unable to provide care for loved ones. Make this diagnosis only if the client has symptoms such as restlessness, trembling, increased pulse and so on.

Medicated enemas

May be used to instill antibiotics to treat infections in the rectum or anus or to introduce anthelmintic agent for treatment of intestinal worms and parasites.

High-top sneakers are good for?

May be used to prevent heel drop, but do not reduce heel pressure, they do help and positioning hips and pelvis to prevent hip rotation

Osteomyelitis

May develop after bone injury or surgery.

Classification of Infections by Duration

Acute: rapid onset of short duration (e.g., common cold) Chronic: slow development, long duration (e.g., osteomyelitis) Latent: infection present with no discernible symptoms (e.g., HIV/AIDS)

High fiber

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

soft

Addition of low fiber, easily digested foods, such as pastas, casseroles, moist tender meat, and can cook fruits and vegetables. Desserts, cakes, and cookies without nuts or coconut.

Promote adequate fluid and nutrition for urine, because adequate hydration promotes?

Adequate hydration promotes urinary tract function and flushes the system of waste products. water is the preferred fluid because soda, coffee, and Tea often contain caffeine or additives that may cause diuresis. Drink 8 to 10 ounces glasses of fluid.

Circadian disorders

Abnormality in sleep/wake times. may be caused by rapid time zone changes (jet lag), shift work or a change in total sleep time from day to day. symptoms include decreased vigilance, decreased ability to perform psychomotor task, and short sleep episodes the person is not aware of. people suffering from jet lag need several days to adjust their sleep wake schedule.

Apnea

Absence of breathing due to respiratory arrest requires immediate cardiopulmonary resuscitation

How does personal habits increase the risk of surgical

Abusing alcohol, nicotine, or other substances can increase surgical risk. Smoking affects pulmonary function, long term alcohol use contributes to liver disease, predisposing the patient to bleeding. alcohol and drugs interact with anesthetic agents and medications to create adverse effects. Also, habitual substances abusers may have a cross tolerance to an aesthetic and analgesic agent, causing them to need higher than normal doses

Potential Postoperative Complications:Collaborative Problems urinary retention what is it, clinical signs, interventions

Accumulation of urine in the bladder. May result from poor muscle tone as a result of anesthesia and anti cholinergic medication, handling of tissues during surgery, or inflammation in the pelvic region. Clinical signs : bladder distention, suprapubic pain, diminished urine output or output less than fluid intake, inability to void or small frequent voiding, hypertension, restlessness Interventions : monitor for clinical signs. Provide privacy and adequate time to urinate. Catherize if needed.

Aerobic exercise, it acquires energy from? increases?

Acquires energy from metabolic pathways that use oxygen the amount of oxygen taken into the body meets or exceeds the amount of oxygen required to perform the activity. aerobic exercises uses large muscle groups, can be maintained continuously, and is rhymthic in nature. It increases the heart rate and respiratory rate, thereby providing exercise for the cardiovascular system while simultaneously exercising the skeletal muscles. jogging, brisk walking, and cycling are common forms of aerobic exercise.

Formats for Diagnostic Statements

Actual Problems Nsg Dx Label + Etiology + Symptoms Risk Problems Nsg Dx Label + Etiology/Related Factors Wellness Nsg Dx Label only

what is Actual versus perceived loss

Actual loss includes the death of a loved one or relationship, death, deterioration, destruction, and natural disaster. Actual lost can be identified by others, not just by the person experiencing it (e.g., hair loss during chemotherapy). In contrast, perceived loss is internal, it is identified only by the person experiencing it (e.g., a woman diagnosed with a sexually transmitted infection may perceive herself as having lost her purity).

the types of loss include

Actual, external, physical, perceive, internal, psychological, aspects of self, significant relationships, and environment.

Cognitive nursing diagnosis of stress include?

Acute confusion, disturbed thought Processes, impaired memory

Swallowing functional limitations of nutrition

Acute disorders affecting the throat, such as pharyngitis, make swallowing painful. cancer of the larnyx or esophageal strictures Folsom makes swallowing painful or difficult, and frequently it leads to a avoiding

Nutritive enemas are used for? and commonly in?

Administer fluids and nutrition through the rectum for patients who are dehydrated and frail. They are most commonly used in hospice care as a means to provide hydration for dying patient.

patient prep

Administer pain medication prior to dressing change if needed Describe to client steps of procedure Describe normal signs of healing Answer any questions

what is my assessment/prep/position of otic medication?

Administration ear must be facing up, side lying position Adult: pull ear up and back Child: pull ear down and back gloves

Factors affecting grief development adolescence stage? adolescence is typically a time of? may feel a sense? the lack? which pressures do they face? coping may be more difficult when?

Adolescence is typically a time for dealing with confusion between one identity and ones role. The adolescent struggle to learn who he is as a person as he breaks away from parental control. An adolescent who experiences the loss of parent while "pushing the parent away" may feel a sense of guilt and unfinished business. At the same time, the bereaved teen also faces psychological, physiological, social, and academic pressures. although teens may look mature, they often lack emotional maturity. Teen are often expected to be grown up and support a surviving parent or younger siblings. When they feel this responsibility, they do not have the opportunity, or the permission, to mourn. Coping may be even more difficult for teens if the death comes suddenly and unexpectedly, for example when a teen brother dies in an auto accident.

Factors affecting grief development adulthood. how they respond to loss depends on?

Adults are cognitively able to understand the nature of death, and they usually experience other types of loss by this time. Over time, they perceive loss as a normal part of living. How they respond to loss depends on factors such as the person self esteem and the availability of supports.

advantages of EHR

Advantages Improved efficiency Privacy Accessibility Reduced errors Research and Public Health benefits Planning care Unintended Consequences Decreased efficiency due to lack of coordination with nursing workflow and communication patterns Cost Decreased face-to-face communication

to help with Gastroesophageal reflux tell patients?

Advise clients to not eat just before bedtime and to elevate the head of the bed 30 to 40 degrees. It is also important to avoid overheating, avoid bending over coming and take care prescribe medications. They should also avoid fruit juices, fatty foods, chocolate, alcohol, and smoking all of these stimulate reflux. If overweight, the client with reflex should also lose weight

Factors Affecting Sleep

Age Lifestyle factors -Physical activity -Food and alcohol -Medications -Caffeine -Sleep habits Illness/Disease Environmental factors -Temperature and humidity -Noise and light -Noxious odors -Comfort of bedding

Factors Affecting Sleep

Age Lifestyle factors -Physical activity -Food and alcohol -Medications -Caffeine -Sleep habits Illness/Disease Environmental factors -Temperature and humidity -Noise and light -Noxious odors -Comfort of bedding

factors affecting skin integrity

Age Nutrition/hydration Sensation level Impaired circulation Medications Moisture Fever Infection Lifestyle Mobility

Factors that Influence Illness Behavior

Age Family patterns Culture Nature of the illness Hardiness Intensity, duration, and multiplicity of the disruption

Factors Affecting Wound Healing

Age Hemorrhage Hypovolemia Local Factors Nutritional Deficits Oxygen deficit Drainage Medications Systemic Disorders Wound Stressors: like laughing, coughing, vomiting

airborne precautions

Airborne Precautions Pathogen is spread via air currents Transmission via ventilation systems, shaking sheets, sweeping Precautions include Same as those for contact, with addition of special room, special mask, and mask for patient when transported

lifestyle factor alcohol and sleep

Alcohol disrupts REM and slow wave sleep and may cause spontaneous awakening with difficulty return to sleep. can cause vivid dreams during REM.

pureed

All of clear liquid and full liquid Plus scramble eggs, pureed meats, vegetables, and fruits, mashed potatoes and gravy.

Mechanical soft

All of the above with addition of ground or finely diced meat, flake fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter

Self-care deficit feeding

Allow about 20 to 30 minutes to feed a patient. feeding assistant should be supervised by RN or LPN. Do not interrupt meals with medications. Encourage family members to share meal times. If the patient's condition allows, encourage him to get out of bed for meals. Encourage Residence Inn lonesome care setting to eat meals in the dining room instead of in the bedroom.

facilitating grief work recalling memories, what is one way to encourage recall?

Grieving patient and family members may need to recall memories, both good and difficult. One way to encourage recall is to go through photo albums with them and ask questions about the people in the pictures. Also look for objects of sentiment like a family heirloom. in the environment and ask the dying or beavered person to share their significance.

Inserting a urinary catheter

Allow adequate time for these procedures, experienced nurses need at least 15 minutes. You will need more time if problems arise and even more time if you are a new nurse. take an extra pair of sterile gloves and an extra catheter into the room, be sure that you have good lighting. Work on the right side of the bed if you are right handed and work on the left side if you're left handed. Drape the patient for privacy. Perform perineal care before the procedure, wash your hands, open kit. Don sterile gloves and maintain sterile techniques while manipulating the supplies in the kit and performing the procedure. Once you have touched the patient with your non-dominant hand, do not remove that hand from the patient. for indwelling urinary catheterization, pre testing the balloon by inflating that before insertion is not necessary, especially with silicone catheters. the practice can cause the balloon to form cuffs. Can cause harm to the patient urethra. For class we inflated the balloon. Lubricate the catheter tip before insertion. Insert a catheter 5 to 7.5 centimeters which is 2 to 3 inches for women, 17 to 22.5 centimeters which is 7 to 9 inches for men, until urine flows. drain the bladder, collect needed samples, measure urine, and connect the drainage bag as needed or remove it if catheterization is intermittent.

After performing postural drainage, percussion, vibration

Allow the patient to sit up. Ask her to cough at the end of a deep inspiration. suction the patient if she is unable able to expectorate secretions. treatment should not exceed 60 minutes and provide mouth care.

Managing anxiety in peripheral

Almost everyone who experiences dyspnea or chest pain becomes anxious some, extremely so. It is important to reduce anxiety because anxiety activates the sympathetic nervous system and triggers the stress response. hormone changes occur, including the release of aldosterone, which promotes fluid retention and increases blood pressure. the heart rate and contraction force increases, peripheral and visceral vessels constrict, and the Blood clots more readily. All of these make a cardiac or vascular condition more serious. Prioritize your interventions. You will of course need to intervene first to prevent life threatening situations. But try not to appear rush, and speak calmly and quietly to the patient and to those around you. Do not leave the patient alone. Provide clear factual information and keep the patient and family informed about treatment being given.

what are Return flow enemas?

Also known as Harris flush, maybe order to help a patient expel flatus, and relieved abdominal distention. for adults, approximately 100 to 200 ml of water or saline is instilled into the rectum. the rectal tube and solution container are then lowered below the level of the rectum to encourage return flow of the solution. this process is repeated several times, or until the suspension is relief. If the solution becomes thick, discard it and begin again with new solution.

How does diuretics increase surgical risk

Altered fluid and electrolyte balance especially potassium

Provide privacy

Although urination is a normal physiological process, most people consider it a private matter. Taking a matter-of-fact approach confirmed to patients that you are comfortable with this aspect of care. provide privacy when discussing or providing care related to urination. Excuse visitors from the room, draw the dividing curtains in shared rooms, and close the door. Whenever possible, give the patient time alone to avoid. Do not for example, hover outside the bathroom door asking are you OK or are you finish. However if the client is weak and frail you may need to remain with him.

health care related infection what is exogenous what is endogenous

An infection acquired as a result of healthcare Cost to the healthcare system = $4.5 billion/year Leading cause of death Preventable with use of aseptic principles/techniques Exogenous Healthcare-Related Infection: Pathogen acquired from healthcare environment Endogenous Healthcare-Related Infection: Normal flora multiply and cause infection as a result of treatment

interventions for post op anesthesia

An unconscious client is usual positioned on his side to help maintain an open airway. this decreases the likelihood of aspirating mucus or salvia, by allowing it to drain out instead of the back of the throat. elevating the superior arm on a pillow allows for a good chest expansion so the patient can breathe deeply and expand the lungs fully.

primary defense against infection

Anatomical features, limit pathogen entry >Intact skin >Mucous membranes >Tears >Normal flora in GI tract >Normal flora in urinary tract

Simulating the patients appetite keep the patient's environment neat and clean

And free of unpleasant sites, orders, and medical equipment. These often trigger loss of appetite. For example remove bed pans, urinal the and emesis basin from the room before meal times

Anger management

Anger is a common response to stress, however, clients usually do not openly say I am angry. In fact, they may not even recognize that they are angry. instead they may engage in angry behavior

Grieving defining characteristics

Anger, potential loss of significant object( job status, body function), denial of potential loss, sorrow, guilt, bargaining, altered eating and sleep patterns, changes in activity level or libido, difficulty taking on new roles.

changing perception of stressors or self what should you do to facilitate Positive self talk?

Another method for increasing self esteem. Each time you hear negative self talk stop the client, and ask him to rephrase the statement so that it is positive.

Facilitating grief work finding meaning, what technique can be used?

Another way to facilitate grief work is to help the patient or family find meaning in their lives or in their past. Talking through this meaning is a healthy way to cope. Facilitating life review is one technique to help a patient and your family recognize the unique contributions this person has made his family, friends, and society. You can begin by asking about the various aspects of the patients life, commenting on pictures in the room, or picking up on verbal cues that are expressed.

what should be included in a wound assessment?

Answer: A wound assessment should include the following parameters: The type of wound Location of the wound The color of the wound and surrounding skin The condition of the wound bed and surrounding skin The color, consistency, amount, and odor of exudate or drainage Pain or discomfort related to the wound or wound care

How often is a patient typically assessed after surgery? in the pacu? surgical unit?

Answer: After surgery, a patient is typically assessed at these times: - In the postanesthesia care unit (PACU), every 5 to 15 minutes - In the surgical unit: ● Upon arrival ● Every 15 minutes for the first hour ● Every 30 minutes for the next 2 hours ● Every hour for the next 4 hours ● Then every 4 hours The frequency of vital signs and assessments may be increased if the client condition changes

signs of sensory overload

Answer: Answers may include any of the following manifestations of sensory overload: ● Irritability ● Confusion ● Reduced attention span ● Decreased problem-solving ability ● Drowsiness (due to insomnia) ● Muscle tension ● Anxiety ● Inability to concentrate ● Decreased ability to perform tasks ● Restlessness ● Disorientation Note: Some clinical manifestations of sensory overload overlap with those of sensory deprivation.

Who is responsible for obtaining informed consent for the surgical procedure?

Answer: Before a surgical procedure can be performed, the surgeon is required by law to provide the necessary information and obtain the client's consent.

List the five components of a nursing order.

Answer: Date, subject, action verb, times and limits, signature

What areas should you include in a nursing history for a patient with oxygenation concerns who is undergoing a comprehensive assessment?

Answer: For a patient with oxygenation concerns, six areas need to be assessed: ● Demographic data ● Health history ● Respiratory history ● Cardiovascular history ● Environmental history ● Lifestyle

steps to crisis

Answer: Note: You are asked only to list the steps. However, you may wish to describe and discuss the steps, as well. Step 1. Assess the situation. ● What is the nature of the patient's condition and the severity of the crisis? Step 2. Ensure safety. ● Call for help if you or the patient is in physical danger. ● Do not leave the patient unless you think you are in imminent danger. ● First ensure your own safety; then provide for the patient's safety. Step 3. Defuse the situation. ● Keep in mind that a person in crisis may not be in control of his actions. ● Try to calm the person verbally. ● Maintain an outward appearance of being calm yourself. ● Attempt physical restraint only as a last resort and only when there is enough help to do it safely for staff and patient. Step 4. Decrease the person's anxiety. ● Reassure the patient that he is in a safe place and that you are concerned and want to help. ● Explain gently but firmly that you need his help and cooperation. ● Help the patient to vent feelings of fear, guilt, and anger. ● Use physical contact very cautiously. The patient in turmoil may interpret touch as aggression or sexual innuendo. Step 5. Determine the problem. ● Find out what the patient believes to be the cause of the crisis. ● Remain calm and do not pressure the patient to give reasons. Any tension on your part will create further panic in the patient. Step 6. Decide on the type of help needed. ● You may be able to calm the patient enough for him to understand what just happened, or you may not. Evaluate your ability to calm the patient on your assessment of his coping skills and resources. ● Put in place the help needed to restore the person to a minimal level of functioning. This may require long-term treatment. In that case, make the referrals. Step 7. Return the person to pre-crisis level of functioning. This may involve crisis counseling and/or home crisis visits. ● The goal of crisis counseling is to provide immediate relief, solve the most urgent problems, and give long-term counseling if needed. Crisis centers often rely on telephone counseling ("hotlines"). ● If telephone counseling is not adequate, or if observations of the home environment are needed, home visits may be made.

What are the nursing responsibilities with informed consent?

Answer: Nurses are responsible for verifying that the surgical consent is signed and witnessed. Often you will obtain the signature and document this information on the preoperative checklist. If at any time you believe that the client does not understand the planned surgery or that he is not competent to consent, notify the surgeon and delay sending the client to the operative suite.

List at least three things you should do when providing supervision to an unlicensed caregiver.

Answer: Supervisory activities should include the following: ● Monitor the person's work to be sure it complies with agency policies and procedures and standards of practice. ● Intervene, if necessary. Perhaps demonstrate caregiving activities. ● Obtain and provide feedback from the worker. ● Give positive, as well as negative, feedback often. ● If the NAP's performance was not acceptable, communicate privately with the NAP. ● Evaluate client outcomes. ● Ask the client for input after the care is given. ● Ensure proper documentation.

List the information you should gather in the preoperative nursing history. health history, physical status, allergies, medications, mental status, knowledge and understand of the procedure? cultural and spiritual factors ? access to social resources? coping strategies? use of alcohol and street drugs?

Answer: Ten types of information are gathered in the preoperative assessment: ● Health history. Discuss current and chronic health problems and prior hospitalizations or surgeries. ● Physical status. Identify any mobility concerns, as well as whether hearing aids, glasses, or contact lenses are used to improve sensory perception. ● Allergies. Check allergies to medications, food, tape, soaps, latex, or other substances. ● Medications. Ask about prescribed medications as well as over-the-counter, herbal, and natural remedies. ● Mental status. Note whether the client is able to respond to questions and offer a health history. Is he oriented? Does he appear anxious? ● Knowledge and understanding of the surgery and anesthesia. Ask the client to explain in his own words the planned surgery and postoperative course. Reinforce accurate statements and correct misconceptions. ● Cultural and spiritual factors. Identify any practices or beliefs that bring comfort to the client. Discuss how you can integrate these practices into the client's surgical experience. ● Access to social resources. Identify the client's support network. Who is available to assist the client after surgery? Who does the client rely on? Are the members of the support system aware of the client's upcoming surgery and condition? ● Coping strategies. Have the client identify the strategies he uses to cope with stress. ● Use of alcohol and drugs. Inquire about the amount and frequency of alcohol use. Discuss the use of pain medications and recreational drugs. If the client uses these substances, identify the amount and frequency. Additional assessments may be needed if the client is undergoing outpatient surgery or has a planned short stay after surgery.

For what activities is the circulating nurse responsible in the OR prior to the skin incision?

Answer: The circulating nurse is responsible for the following activities: ● Assessing the client in the holding area ● Developing relevant nursing diagnoses and a plan of care for the intraoperative phase of care ● Prepping the skin ● Positioning the client ● Ensuring client safety

What factors influence behavioral responses to pain?

Answer: The following factors influence behavioral responses to pain: ● Emotions ● Developmental stage ● Sociocultural factors, such as the behavior associated with pain learned through interaction with family and social support groups and the beliefs about the value of expressing pain or minimizing it ● Communication and cognitive impairments

Name three recommended sites for giving intramuscular injections.

Answer: The following sites can be used for giving intramuscular injections: ● Ventrogluteal ● Vastus lateralis ● Deltoid The dorsogluteal and rectus femoris are not recommended.

What are the most common emotional responses to pain?

Answer: The most common emotional responses to pain are fear, guilt, anger, helplessness, hopelessness, isolation, and loneliness. However, pain can also produce confusion and helplessness. Anxiety and depression may also result from injury and pain.

Define the following: ongoing evaluation, intermittent evaluation, terminal evaluation.

Answer: ● Ongoing evaluation is performed while implementing, immediately after an intervention, or at each patient contact. ● Intermittent evaluation is performed at specified times—but it is also ongoing. ● Terminal evaluation describes the patient's health status and progress toward goals at the time of discharge.

Collecting a 24 hour urine specimen

Ask the patient to void. record the time. discard this first voiding. collect all urine voided during the next 24 hours. Apply a label on the storage container, identifying the patient name, date, and the time the test ended. Transport it to the lab after the collection is complete. otherwise, place the urine and refrigerator designated for specimen storage.

Identify three types of laboratory data that may be associated with a delay in wound healing.

Answers may include any three of the following lab data that may be associated with a delay in wound healing: A low WBC count A low serum protein, albumin, or pre-albumin level Prolonged coagulation times Needle aspiration result indicative of infection

Coping Abilities and Support Systems

Anxiety and fears are expressed in many different ways! Previous experiences with surgery may help or hinder the coping abilities Identify the support systems

relieving anxiety

Anxiety is a common response to illness, medical tests, and treatments, you will use anxiety relief interventions everyday of your professional life. for example, when you tell patients what to expect before you perform a procedure or ask them to take deep breaths during a painful treatment, you lessen anxiety.

Psychosocial Responses to Immobility

Anxiety, Depression, Hopelessness, Significant changes in self-concept, role perception, Decreased problem-solving ability, Increased dependency; attention seeking behavior

Emotional nursing diagnosis of stress include

Anxiety, defensive coping, disturbed body image, disturbed personal identity, fear, grieving complicated, ineffective coping, ineffective denial, low self esteem chronic or situational

Psychosocial Assessment

Any surgical procedure evokes an emotional response, regardless of the desire for the surgery The response to surgery is very individualized!

Rusted colored sputum

Associated with pneumococcal pneumonia, tuberculosis, and possibly the presence of blood.

Applying an external condom catheter

Application of a condom catheter is a clean procedure. clean and dry the penis before catheter application. When applying the condom, stabilize the penis with your non-dominant hand. Leave a gap of 2.5 to 5 centimeters which is 1 to 2 inches between the condom and the tip of the penis to prevent skin irritation. use only tape supplied in the application kit to secure the catheter. For condom catheters that contain adhesive material on the inside of the condom, grasp the penis and gently compress the condom on to the shaft. Be certain that the tubing from the end of the catheter to the bedside drainage or leg bag is free from kinks.

Credes maneuver

Apply manual pressure over the bladder to promote emptying

applying a dressing wound care

Apply ointment if ordered Apply sterile dressings Secure dressing (date & time on tape)

Cyclic feedings

Are administered regularly, however, the infusion time is less than 24 hours per day. Nocturnal feedings are form of cyclic feedings. The patient is able to eat meals and participate in activities throughout the day but receives in a infusion of enteral formula at night while at rest. A four hour break allows time for their feeding pump to be disconnected for hygiene and other

Incentive spirometer are designed to encourage patients? usually reserved for which type of patients? incentive spirometer offers? and as the nurse I must evaluate?

Are designed to encourage patients to take deep breaths by reaching a goal directed volume of air. incentive spirometer is usually reserved for patients at risk for developing atelectasis or pneumonia, example, patients who had abdominal, chest, or pelvic surgery, patients on prolonged bed rest, or patients with a history of respiratory problems. incentive spirometer offer various visual cues to show patients whether they are inhaling deeply enough. you must evaluate patients response, airway clearance, and ventilation

Intermittent feedings

Are given to supplement oral intake for for patients who want greater mobility to take part in activities, such as physical therapy. Feedings are given on a regular or periodic basis several times a day, usually 30 to 60 minutes. Periodic feedings are often based on oral intake and are considered to be more physiological similar to normal eating patterns

Trochanter rolls are good?

Are made from tightly roll towels, bath blankets, or foam pads. they are placed snugly adjacent to the hips and thighs to prevent external rotation of the hips.

Foot cradle are used for?

Are metal or plastic devices that are secured at the foot of the bed to hold bedding up off the toes and feet, allowing for free movement.

Vitamin D and calcium

Are needed to form and maintain bone. deficiencies lead to porous bone. in children, prolonged efficiencies can cause the long bones of the leg to become bowed, retard growth, and leads to frequent fractures. nursing responsibilities for patients with bone formation abnormalities include collaborative treatments, providing comfort, lifting and transferring patients safely, and patient education to promote mobility. Education should include teaching patience to consume a balanced diet that meets the minimum recommendations for vitamins and minerals.

tubing missed connections

Are potentially fatal to the patient this is where enteral feedings have been mistakenly connected to IV lines and feeding Solutions has been infused into veins.

Pump control infusions are recommended for who?

Are recommended for jejunal feeding and for gastronomy feeding given by continuous infusion to decrease gastroesophageal reflux. A feeding pump ensures a steady flow rate.

Sandbags

Are small fabric bag filled with sand. they are used in the same manner as pillows and trochanter rolls, however they provide firmer support.

Intermittent feedings. it increases the risk for ? and should never be done with?

Are sometimes given by bolus if the patient can tolerate this method. You use a syringe to deliver 300 to 400 milliliters of formula through the tube over at 5 to 10 minutes. It increases the risk for respiratory aspiration and for stomach distention. Only with gastric tube never with intestinal tubes.

Pillows, foam wedge pillows are good for?

Are the most common devices used to assist with positioning, provide support, and elevate body parts. they help position the patient by molding to the body and expending the weight-bearing area. foam wedge pillows are useful for elevating the upper body when an adjustable bed is not available and for abducting the hips after hip surgery.

Pink and frothy sputum

Associated with pulmonary edema

Chest percussion and chest vibration. when are they done? chest vibration is also good for what type of patient? what hands do you use for each?

Are used in conjunction with postural drainage. have the patient assume desired position for 10 to 15 minutes. then percuss and vibrate to loosen mobilize secretions. Chest percussion is rhymthic clapping of the chest wall using cupped hands. Chest vibration is the vibration of the chest wall with the palms of the hands. vibration is a gentle procedure, so you can use it in frail patients who cannot tolerate percussion.

Psychological/ psychosocial stressors

Arise from life events (e.g., work pressure, family arguments) are external stressors that arise from work , family dynamics, living situation, social relationships, and other aspects of daily living

Review body system cardiac you want to know problem of

Arrhythmia, edema, cyanosis, chest pain, hypertension, murmur, heart rate, blood pressure

Factors influence oxygenation developmental stage toddler, what remains high?

As a toddler's respiratory and immune systems mature, his risk for frequent and serious infections diminishes. However, the incidence of upper respiratory infections remain high because the tonsils and the adenoids are relatively large, predisposing to tonsillitis and many children are exposed to new infections agents in preschool and daycare - acquiring and transmitting infections through toys and other objects - airway obstruction from aspiration of small objects. The toddler airway is still relatively short and small and may be easily obstructed. - drowning in very small amounts of water around the home

Use the muscles in your legs

As the power for lifting. Bend your knees, keep your back straight, and lift smoothly. repeat the same movements for setting the object down.

Procedure steps what position do you want them in apical areas of the upper lobes? if they can't do that position what is an alternative

Ask the patient sit at the edge of the bed, if possible. If needed, place the pillow at the base of the spine for support. If the patient is not able to sit at the edge of the bed, place him in high Fowler's position

what would be my worries of oral route?

Aspiration Dietary restrictions: NPO, fluid restriction Vomiting Food interactions

Aspiration/Biopsy

Aspiration/Biopsy Aspiration is performed to withdraw fluid that has abnormally collected, or to obtain a specimen. A tissue biopsy (excision of a small amount of tissue) can be obtained during aspiration or with other diagnostic tests.

Interventions for feeding dementia patients

Assess a patient self feeding abilities. assess a patient coming to the limitations in communication abilities. assess for and treat pain. minimize distractions turn off the TV, discourage people from entering the room. Help the patient to a comfortable chair if possible. Assist with oral hygiene and hand hygiene. Remove any unnecessary eating utensils, serve only one food at a time. Remove items that should not be eaten, and hot items that could be spilled. cue the patient verbally to help with self feeding like take a bite, chew, swallow. Do not assist to soon. Do not feed to fast. Feed at a rate that is safe and comfortable for the patient.

Preparation for nutrition, assess

Assess for ritual use before meals. Provide an opportunity for toileting, oral hygiene, and hand washing before meals. Assist the patient to eat and drink only as necessary, encourage independence. Provide privacy during meal times if the patient is embarrassed, to further maintain dignity, use a napkin, not a bib over the patient's clothes. Check for proper fit of dentures. provide music during the meal if the patient wishes.

Delegating Hygiene Care

Assess prior to delegating Instruct NAP regarding Client's limitations Amount of assistance needed Use of assistive devices Presence and care of tubes Observations to make during hygiene care

Get help to move a heavy object or patient

Assess the object or patient you are going to lift. If you have any doubt that you can do it by yourself, get help from a coworker

Pre-procedure assessment of sputum collection, you want to assess for? check when? and if suctioning is required you should do what?

Assess the patient's comprehension of the procedure. Understanding allays anxiety and promotes cooperation. - assess respiratory status, including breath sounds, respiratory rate, depth, and pattern, skin and nail bed color, and tissue perfusion. Because you may need to delay sputum collection if the patient is in respiratory distress. - assess ability to deep breathe, cough, and expectorate, suctioning may be necessary to obtain an adequate sputum specimen. - check when the patient last ate or had a tube feeding, especially for a specimen obtained by suction. Specimen collection should be delayed for 1 to 2 hours after eating because the procedure may cause vomiting, which creates a risk for aspiration of stomach contents. - suctioning is required to obtain the specimen, check for factors such as anticoagulant therapy, bleeding disorders, or low platelet count. these factors place the patient at risk for bleeding when the suction catheter is introduced.

how do you packing a wound and want to assess what

Assess the size, depth and shape of wound Use appropriate material (as ordered by physician) Use "sterile technique" Don't pack too tightly (may cause pressure on wound bed)

Intervention for patient with nausea

Assess why they are nauseous clean mouth and environment. Find out what's pleasurable to them and what is not.

Documentation of posttest care

Assessment data, nursing interventions, and achievement of client expected outcomes. client or family teaching and demonstrated level of understanding. Written instructions given to the client or family members.

What Are the Phases of the Nursing Process ?

Assessment: data gathering Diagnosis: identification of client's health needs Planning outcomes: goals & interventions: strategies to help client achieve goals Implementation: action phase Evaluation: degree of goal attainment

The Nursing Process: Assessment

Assessment: systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community Nursing assessments focus on the RESPONSES to illness

Ambulation Safety

Assisting with ambulation (gait belts) Using assistive devices >>Canes >>Walkers >>Crutches >>>Crutch gaits

Pre-existing conditions that increase surgical risk acute conditions upper respiratory tract infections

Associated with increased risk of postoperative pneumonia, especially if the patient received a general anesthetic

nursing intervention impaired visions

Attend to glasses Sufficient light Protect eyes in sunlight Magnifying lens/large-print books Evaluate -Ability to perform ADLs -Ability to remain safe in the environment -Need for assistance seeing eye dog

2 to 3 years

Autonomy vs. Shame/doubt -success leads to the self control. -parents toilet training - develops a sense of independence without losing self esteem -can I be me? -if not achieve begin to feel inadequate in ability to survive

moral principles what is autonomy and example?

Autonomy: the right to self determination- to choose and act on that choice. Every competent person has the right to decide his own course of action. >>sample professional behavior: plans care in partnerships with patients. Honors the right of patients and families to make decisions about health care. provides information so that patients can make informed choices. informs patients about details of their care (e.g, test results)

what is my after care of nasal medication

Avoid blowing nose

precautions of heat and cold

Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a washcloth, towel, or fitted sleeve. ● Apply hot or cold intermittently, leaving on for no more than 15 minutes at a time in an area. This helps prevent tissue injury (e.g., burns, impaired circulation). It also makes the therapy more effective by preventing rebound phenomenon: At the time the heat or cold reaches maximum therapeutic effect, the opposite effect begins. ● Check the skin frequently for extreme redness, blistering, cyanosis (turning blue), or blanching. When heat or cold is first applied, the thermal receptors react strongly and the person feels the temperature intensely. Over about 30 minutes, the receptors adapt to the new temperature, and the person notices it less. Caution clients not to change the temperature when this occurs because this can cause tissue injury.

Work with smooth and even movements and avoid

Avoid sudden or jerky motions.

erythrocyte RBC sedimentation rate (ESR) or sed rate)

a measure of inflammatory changes. sed rate increases with inflammation. normally it is @15 mm/hr for men and < 20 mm/hr for women.

Teaching Strategies

Group discussion Demonstration Demonstration/return One-to-one instruction and mentoring Audiovisual materials Printed materials Gaming Concept mapping Simulation Role-playing Role-modeling Self-instruction Distance learning List serves, Web sites CAI Other?

what exercises for Range of motion for hands and fingers, and they are what type of joints?

Hand and fingers have condyloid joint, interphalangeal joints are hinges. Flexion bend the fingers into a fist. Extension straighten the fingers Hyperextension bend the finger back Adduction Bring the fingers together Abduction spread the fingers apart

Projection examples and examples and consequences of overuse

Blaming others. Attributing one's own personality traits, mistakes, emotions, motives, and thought to another, finger pointing E.g the clinical instructor makes me nervous, so I cannot do well. I forgot to bake cookies because you did not tell me that cookies were do at school today Person cannot see his own responsibility for a situation, so he cannot make adaptive behaviors. Person criticizes habits in others that are the same as ones own bad habits.

Classification of Infections

By Location Local Occurs in a limited region in the body (e.g., urinary tract infection) Systemic Spread via blood or lymph Affects many regions (e.g., septicemia)

HOH

Hard of Hearing

What Information Is Contained in a Comprehensive Nursing Care Plan

Basic needs and activities of daily living Medical/multidisciplinary treatment Nursing diagnoses and collaborative problems Special discharge needs or teaching needs

Factors That Affect Client Learning

Motivation Readiness to learn -Physical condition -Emotions Timing Active involvement Feedback given Repetition Learning environment Amount and complexity of content Teacher/learner communication Belonging to a special population Developmental stage Culture Health literacy

Removing stool digitally, should be aware that? obtain? determine? monitor?

Be aware that this procedure is both painful and embarrassing to your patient. trim and file your fingernails so they do not extend over the ends of your fingertips. obtain baseline vital signs, and determine whether the patient has a history of cardiac problems or other contraindications. Determine whether the procedure will be accompanied by suppository insertion or enema administration. use only one or two glove fingers, and remove stool in small pieces. allow the patient periods of rest, and monitor for signs of vagal nerve stimulation. teach the patient lifestyle changes necessary to prevent stool retention.

Documenting Client Care includes doing what?

Be familiar with facility forms Chart in the required format Include all aspects of care Be accurate, complete, and consistent

Factors affecting grief development stage childhood. preschool children do not understand death is? what kind of response you may see? what may the child feel?

Because cognitive development is not yet complete, preschool children do not understand death is final. The belief is that death is temporary and reversible is reinforced by cartoon character who die and then come a life. Between ages 5 and 9, children begin to understand that is permanent, but they believe it will never happen to them or anyone they know. During the weeks after a death, a child may feel immediate grief or may continue to believe the person is still alive. Both are normal reactions. A child may display feeling of sadness on and off over a long period of time and often unexpected moments. Young children believe they are the cause of what happens around them. This is known as magical thinking. Such thinking may cause them to feel guilt when there is a death of someone close to them. Other response include regressing to a previous developmental stage: "acting like a baby, " demanding food and attention, becoming incontinent, and talking "baby talk".

facilitating therapeutic your self awareness

Become more conscious of your own attitude and feelings regarding death and dying. If you are comfortable with your perspective, you will be able to hear patients expression of anger, guilt, frustration, fear, and loneliness more comfortably.

Nocturnal enuresis

Bedwetting can persist until age 10 or later. If one parent had nighttime bed wetting as a child, there is a high chance the child will also experience it. most often children outgrow the condition

what are the steps to Measuring specific gravity of urine

Before use, be sure the equipment is calibrated to 1. 000 according to the manufacturer's instructions. use fresh urine, if you cannot perform the test within 1 hour, refrigerate the specimen. place a drop of urine on the glass plate and close the flap. Hold the refractometer up to the light when looking through the eyepiece. read the specific gravity by looking for the point where the contrast line between the dark and light fields crosses the scale. Clean the instrument when finished.

Chronic grief is an example of complicated grief

Begins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal life.

Effects of immobility on the urinary system

Being supine inhibits drainage of urine from the renal pelvis and bladder. urine becomes stagnat which creates an ideal environment for infection and kidney stone formation. Immobility triggers a rise in calcium levels, which also contribute to stone formation. Diminish muscle tone leads to a decrease in bladder tone, and many patients have difficulty voiding in a bed pan or urinal.

Dimensions of Health Along Health and Illness Continuum

Biological factors Nutrition Physical activity Sleep and rest Meaningful work Lifestyle choices Family relationships Culture Religion and spirituality Environmental factors Finances

Potential Postoperative Complications:Collaborative Problems hemorrage what is it, clinical signs, interventions

Bleeding may be internal or external. May be caused by slipped ligature, uncontrolled bleeder, or infection. Clinical signs : if external: dressings saturated with bright red blood; increase output in drains or chest tubes. If internal: increase pain, increasing abdominal girth, ecchymosis or swelling around incision, tachycardia, hypotension. Interventions: frequently monitor vital signs, dressings, and wound drainage.

Potential Postoperative Complications:Collaborative Problems thrombophlebitis what is it, clinical signs, interventions

Blood clot and inflammation of a vein or artery, usually in the legs. Results from increase coagulability and venous stasis due to immobility during and after surgery. Clinical signs : superficial vein is red, hard, and hot to touch. Deep: limb is pale and edematous; aching, cramping in limb; Homan sign (pain in calf when foot is dorsiflex). Interventions : encourage and assist with leg exercises, ambulation, anti embolism stockings, sequential compression devices, hydration. Also position and immobilized the limb, do not massage calves.

Allergic reactions and air quality cardiovascular

Blood vessels dilate in areas affected which increases blood flow to the areas Eosinophils and neutrophils are attracted to the reaction site. Local tissues are damaged by protease Capillaries become more permeable, resulting in fluid leak into tissues. Local smooth muscle cells contact

You should not find what in urine

Blood, sugar, ketones, and protein should not be in urine

Body alignment

Body alignment is an important aspect of body mechanics. Proper posture places the spine in a neutral position. there are four natural curves to the spine. Proper posture maintains these natural curves because it allows movement to occur with less stress and fatigue, the bones are line, and the muscles, joints, and ligaments can work at a peak efficiency. good posture contributes to normal functioning of the nervous system and improve feelings of well-being. most posture problems result from a combination of the following, accident, injuries, and falls. Careless sitting, standing, or sleeping habits, excessive weight, foot problems or improper shoes, negative self image, occupational stress , poor sleep support like a mattress, poorly designed workspace, visual difficulties, and weak muscles or muscle imbalance.

What should the nurse do first to access a ampule

Break the constricted neck using a barrier

Physiological stages of dying days to hours before death, breathing may be? what kind of respirations?

Breathing may be shallow, rapid , or irregular, periods of apnea maybe lengthen to 10 to 30 seconds before breathing resumes. Congestion causes a death rattle that can be quite loud. Cheyne Stokes respirations may occur. This is a cyclic pattern consisting of a 10 to 60 seconds period of apnea and then a gradual increase in depth and rate of respirations. Respiration gradually become slow and shallow, and then the cycle begins again with apnea.

clear liquid diet

Broth, bouillon, coffee, t, carbonated beverages, clear fruit juices, gelatin, popsicles.

Review of body system skin you want to know

Bruising, open sores, rashes, signs of infection, general condition

Blood urea nitrogen Creatinine

Bun 8-20 mg/dl Creatinine 0.5- 1.1 mg/ dl

Blood urea nitrogen and creatinine

Bun 8-20 mg/dl Creatinine 0.5- 1.1 mg/ dl

Transport to Surgery

By stretcher with all requested data and equipment Cover adequately, it's cold! Maintain privacy how would you feel with no teeth, make-up or hair in place?! Accompanied by an attendant at all times: safety & security!

Prone position is good for? should not be used in what patients?

Is the only position that allows full extension of the hips and knees. It also allows secretions to drain freely from the mouth and thus is helpful for an unconscious patient. but it is the most difficult position to move and unconscious or frail patient into. The prone position create a significant lordosis. it should not be used for patients with cervical or lumbar spine problems. it should not be used on patients with cardiac or respiratory difficulties.

Distress what will be an example?

Can threaten health (e.g., continual financial worries)

Objective characteristics of activity intolerance

Changes in heart rate, blood pressure disproportionate to activity, dysthymia or evidence of ischaemia on electrocardiograph, pallor and cynosis with activity

Activity intolerance

Is the state in which a patient has insufficient physical or psychological energy to carry out daily activities

Stages of Grief

Commonalities in the Theories 1. Denial/Numbness 2. Working through the grief -Yearning/searching/making meaning -Intense feelings and emotions/despair/anger Table 15-2: Common Grief Reactions (p. 270 Vol #1) -Maladaptive behaviors: overeating/drinking/working/medicating 3.Accommodation/Adjustment

Pre-existing conditions that increase surgical risk nutritional disorder

Can affect surgical outcome. patients who are malnourished or obese are at risk for the delayed wound healing, infection, and fatigue. Obese clients are also more prone to cardiovascular disorders and impaired pulmonary function

Gravity feedings, increase risk for?

Can also be used, but the rate of delivery is not precise, and they increase the risk of gastroesophageal reflux, diarrhea, and aspiration. You regulate the drip by adjusting a clamp on the tubing, much the same as a adjusting an IV rate.

cardiac assessment data post op, signs for thrombophletis and interventions

Cardiac assessment data: skin color, peripheral pulses, and capillary refill, absence of edema, numbness, and tingling, pulse rate and rhythm, signs for thrombophletis for clients who were in the lithomy position during surgery. heart sounds Leg exercises Avoiding venous stasis ICD/TED hose ambulation

Interpersonal relationships nursing diagnosis of stress include?

Caregiver role strain, compromise or disable family coping, dysfunctional family processes, impaired parenting, impaired social interaction, ineffective community coping, interrupted family processes, post trauma syndrome, relocation stress syndrome, risk a compromised resilient, risk for other directed violence, risk for suicide, social isolation, stress overload

Black sputum is caused by?

Caused by coal dust, smoke, or soot inhalation

Grunting

Caused by involuntary muscle contraction during expiration to help keep a aveoli open and enhance gas exchange

Lifestyle factor nicotine and caffeine effects on sleep?

Central nervous system stimulants such as nicotine and caffeine interfere with sleep. Smokers have more difficulty falling asleep then non smokers.

learning

Change in behavior, knowledge, skills, or attitude Learning occurs as a result of planned or spontaneously occurring situations, events, or exposures Goal-oriented, intended, and deliberate, involving motivation to learn (conscious) Without active participation in the learning process (subconscious) Active process involving more than giving of information

charting by exception is way a health care system is organized cons of

Chart only significant findings or exceptions to norms Streamlines charting and saves time Uses preprinted forms and checklists cons+ Inadvertent omissions are biggest problem

what is the CBE system?

Charting by Exception -Only significant finding or exceptions to standards and norms of care are charted -Based on a set of standards/expectations -Clearly highlights any variations from the plan of care

what is my aftercare of skin medication

Check condition of skin Absorption/maintenance of applied topical medication

what is my assessment/prep/position of nasal medication?

Check for obstruction Tilt head upright for drops and sprays

Nursing considerations of general anesthesia

Check history of sensitization, maintain airway, protect and orient client, monitor vital signs and labs. Prevent aspiration. By elevating head of bed, turning head to side.

Post care assessment, check? assess for?

Check the 'identification band and call the client by name. assess the client closely for signs of airway distress, adverse reactions to anesthesia or other medications, and other signs that may indicate accidental perforation of an organ. Assess body areas where biopsy was performed for bleeding . assess the client's color and skin temperature. Assess vascular access lines or other invasive monitoring devices. Assess the clients ability to expel air if air was instilled during a gastrointestinal test. Assess the client's knowledge of what to expect during the recovery phase.

During the test assessment check, assess

Check the client identification band to ensure the correct client. review the medical record for allergies. Assess the pre-procedure sedatives administer to the client before the administration of anesthesia during the procedure. Assess airway maintenance and gag reflex if a local anesthetic is sprayed into the client's throat. Assess vital signs throughout the procedure and compared with baseline data. Assess the clients ability to maintain and tolerate the prescribed position. Assess the clients comfort level to ensure the effectiveness of the anesthetic agent. Assess for related symptoms indicating complications specific to the procedure.

administering feedings through gastric tubes

Check the medical prescription for the type of formula, rate, route, and frequency of feeding. Check the chart to make sure a confirmation xray of to placement was perform. Confirm tube placement at the bedside before administering the feeding. Elevate the head of the bed at least 30 to 45 degrees while administering the feeding and for an hour after administration. check residual volume before feeding for intermittent feelings. For continuous shooting check the gas should visit you volume at least once every shift. Its residual is 10 percent greater than the formula flow rate for one hour hold the feeding for one hour recheck. Notify the physician if the residual is still not within normal limits. Flush tube with 30 ml of water before and after feeding, and before and after medication administration. Some close continuous feeding systems run sterile water tadem with the tube feeding. change the tube feeding administration set and other supplies a minimum of every 24 hours. continuous eating should be infused by pump.

pre-procedure assessment of performing percussion, vibration, and postural drainage. check for? assess? determine?

Check the patient's chest x-ray results. Because this identifies which lung fields require treatment. Assess the patient's respiratory status including respiratory rate, rhythm depth, breath sounds, color, and pulse oximetry results. Because this determines the need for and effectiveness of percussion, vibration, and postural drainage. Determine when the patient has last eaten. Postural drainage should not be performed for at least 2 hours after meals to prevent nausea, vomiting, and aspiration assess the patient for dysrhythmias, coagulopathy, hypertension, and pain or tenderness in the chest area being treated. if any of these are present, the procedure should be avoided because it might worsen these conditions.

Preparation of the client assessment

Check to be sure the client is wearing an identification band. Review the medical records for herbal supplements, allergies, and previous adverse reactions to dyes and other contrast media period a sign consent form. and the recorded findings of diagnostic test relative to the procedure. assess for presence, location, and characteristics of physical an communicative limitations or pre-existing conditions. Monitor the client's knowledge of why the test is being performed and what to expect during and after the testing. Monitor vital signs for clients schedule for invasive testing to establish baseline data. Assess client outcome measures relatives to the practitioners preferences for pre procedures preparations. Monitor level of hydration and weakness for clients who are NPO especially geriatric and pediatric populations

physiological stressors includem

Chemical-poision, medication, tobacco Physical or mechanical - trauma, cold, joint over use Nutritional - vitamin deficiency, high fat diet Biological-viruses, bacteria Genetic- inborn errors of metabolism Lifestyle - obesity, sedentary lifestyle

Disease processes and functional limitations of nutrition

Chronic diseases like diabetes mellitus and gastrointestinal disorders can alter nutrient intake, digestion, absorption, use, and excretion. Any illness, especially accompanied by fever, increases the need for protein, water, and kilocalories to meet the demands of increase metabolic rate. traumatic injury such as burns and surgery requires extra protein and vitamin C for wound healing and tissue rebuilding. People with long term insufficient calorie intake for example patients with cancer also suffer from protein calorie malnutrition. protein calorie malnutrition is characterized by weight loss and muscle and fat wasting.

Who is responsible for preventing positioning injuries

Circulating nurse. Surgical patient often 3 to 4 hours, or even longer, in the same position. This places them at risk for pressure ulcer formation. Padding the bony prominences is one measure to protect the client during surgery

preparation of client interventions

Clarify with practitioner if regularly scheduled medications are to be administered. The NPO status is determined by the type of test. administer cathartic or laxatives as denoted by the test protocol, however there must be a specific practitioner order to give children and infants laxatives. Instruct client who are weak, to call for assistance to bathroom. Teach relaxation techniques such as deep breathing and imagery. establish intravenous access if necessary for a procedure

basic skin cleansing

Cleanse in a direction from the least contaminated area, such as from the wound or incision to the surrounding skin Use gentle friction when applying solutions When irrigating, allow the solution to flow from the least to the most contaminated area

wound irrigation

Cleanses the wound from exudate and debris Use 100-150 ml NS Sterile technique Never occlude wound with the syringe Flow directly into the wound not over the contaminated area

Preparation and Transfer to the Surgical Suite

Clinical Data Clinical Preparation of the Patient Personal items jewelry, dentures, wigs, nail polish/acrylic nails, gown, id tag IV Fluids ID Band Voiding: LAST THING DONE BEFORE PRE-OP MEDICATIONS ARE GIVEN

Promoting Sleep: Nursing Interventions

Cluster/schedule nursing care to avoid interrupting sleep Create a comfortable/restful environment Promote comfort/relaxation Support bedtime rituals/ Carbohydrates Offer foods that help promote sleep Maintain safety of the client Teach about sleep hygiene Administer/complete client teaching about sleep-inducing medications

three domains of learning

Cognitive (thinking) Storage and recall of information (e.g., facts about a disease) Psychomotor (doing) "Hands-on" skill Requires thinking and doing (self-administration of insulin) Affective (feeling) Changing feelings, beliefs, attitudes, and values (changing a belief about diet)

Intellectualization examples and examples of consequences of overuse

Cognitive reasoning is used to block or avoid feelings about a painful incident. E.g when her husband dies, the wife relief her pain by thinking, "it's better this way, he was in so much pain. " A person says, "I think" rather than, "I feel. " " my husband loves me, so he doesn't like when another man talks to me, that's why he beats me."

Potential Postoperative Complications:Collaborative Problems respiratory atelectasis what is it, clinical signs, interventions

Collapse of alveoli due to hypoventilation, Airways block by mucus plugs, opioid analgesic, and mobility Clinical sign: decreased or absent breath sounds, noisy respirations, decreased o2 saturation, chest asymmetry, sternal retractions, accessory muscle use, trachea deviated from midline, fever, tachypnea, dyspnea, tachycardia, diaphoresis, pleural pain, increased restlessness, anxiety. Interventions: monitor for clinical signs. monitor rate, rhythm, depth, and effort of respirations. Monitor ability to cough effectively. determine need for suctioning by listening for crackles and rhonchi over major airways. suction, as needed. Auscultate lung sounds after suctioning, and other respiratory treatment to determine effectiveness. encourage deep breathing, coughing, moving in bed, ambulation, use of incentive spirometer.

Outcomes and interventions for ineffective airway clearance

Outcomes: respiratory status: airway patency Interventions: airway management, airway suctioning, cough enhancement, respiratory monitoring

what are my Middle-aged stressors

Concerned with career achievement and continuing career challenges. Continuation of child rearing, marriage of the children, grandparenting. Changes in appearance and health due to aging. Dealing with too many responsibilities. empty nest syndrome when the children leave home. Being Sandwich between caring for aging parents as well as children or grandchildren. midlife crisis the person regresses and unrealistically tries to recapture youth, for example, by buying a new sports car that is too small to hold the entire family, making a geographic move, taking an exotic vacation that strains the budget, engaging in an affair, daydreaming excessively about the ideal life in retirement, partying, and overuse of alcohol and illicit drugs, engaging and workaholic behavior, or unhealthy addiction to cosmetic surgery. any of these behaviors does not this necessarily signal midlife crisis, but they are all examples of behaviour someone might use as an escape

nursing intervention confused client

Confused Client Reorient frequently State your name; day, date, time Provide clocks, calendars Visual clues to time Use personal belongings Maintain safe environment Communicate clearly, slowly Respond to feelings Use gestures Limit choices Promote feelings of security Use alternative therapies

Informed Consent

Consent implies that the patient has been provided with the information necessary to understand: nature & reason for the surgery options risks of surgery/anesthesia Nursing Responsibilities

Meeting physiological needs of a dying patient assess and provide interventions for constipation, urinary retention, & incontinence.

Constipation may be associated with decreased fluid intake, inactivity, weakness, hypercalcemia, hyperkalemia, and lack of privacy. It can contribute to pain, nausea, vomiting, and anorexia, intervention is an important comfort measure. Incontinence may occur because of fatigue and loss of Sphincter control. it can be distressing to patients and family members. - administer laxatives, stool softeners, and lubricants for constipation. - catheterize the patient if he is unable to void and the bladder becomes distended. - use pads for incontinence, but change them frequently to prevent skin breakdown and, near the end, to promote comfort. - use a rectal tube if diarrhea is severe

Physical diagnosis of stress include

Constipation, deficient fluid volume, delayed growth and development, diarrhea, disturbed energy field, disturbed sleep pattern, fatigue, imbalanced nutrition, nausea, pain, risk for injury, sleep deprivation

objective data for bowels

Constipation, hypoactive bowel sounds, abdominal gas (slowed peristalsis)

contact precautions

Contact Precautions Pathogen is spread by direct contact Sources of infection: draining wounds, secretions, supplies Precautions include Possible private room Clean gown and glove use Disposal of contaminated items in room Double-bag linen and mark

Review body systems respiratory you want to know problems of

Cough, shortness of breath, dyspnea, wheezing, orthopnea, orthostasis, diminish sounds, rate, depth

What if the patient had nasal, ophthalmic, or neurological surgery

Coughing and deep breathing exercises are contraindicated. To avoid increasing intracranial pressure.

Sleep

Cyclical states/altered consciousness Decreased motor activity/perception Selective response to external stimuli

Sims position is good for?

Sims position facilitates drainage from the mouth and limits pressure on the trochanter and sacrum. This is an ideal position for administering an enema or perineal procedure

types of anesthesia, general anesthesia causes? regional anesthesia does what and does not cause a? nerve blocks?

General anesthesia causes a loss of consciousness, skeletal muscle relaxation, and amnesia. Regional anesthesia blocks nerve impulses in a particular area of the body and does not cause a loss of consciousness. Local anesthesia is injected subcutaneously and does not cause a loss of consciousness, amnesia, or skeletal muscle relaxation. Nerve blocks are injected into a particular nerve, group of nerves, or surrounding tissue.

25 to 64 middle adulthood

Generativity vs. Stagnation - success in this stage leads to attaining caring and family -their family and work mates -giving back to society with children, work or community activities -can I make my life count? - if this does not occur a feeling of stagnation and being unproductive occurs.

nursing process and pain

Goals and Outcomes: Considerations When managing pain the goal should promote the client's optimal function Mutually acceptable and attainable level of pain Priority setting: Consider the type and severity of pain Effects of pain on body functioning

planning client goals/outcome

Goals: Describe the changes in client health status to be achieved Nursing-sensitive outcomes: Those that can be influenced by nursing interventions Types of Goals: Long-term goal: Global goal that reflects the diagnosis (usu. achieved over a longer period of time) Expected Outcomes: (short term goals) The "steps" achieved towards the global goal and reflect the evidence supporting the diagnosis (usu. achieved within a few hours or days)

what are some Stresses that can lead to burn out?

Dealing with difficult personalities. Working 12 hour shifts with minimal breaks for food, water, rest. Frequent rotating shifts that upset the circadian rhythm of the body and lower the immune system response. Mandatory overtime. Being floated to an unfamiliar in unit. workload low staff ratio. Frustration with patients. need to constantly anticipate patient's needs and cope with the unexpected. feeling helpless against a patient's disease process or lack of healing. Dealing with death and dying. Lack of rewards. Lack of participation in decision making. inability to delegate responsibilities. organizational philosophy that conflicts with personal philosophy.

Chewing functional limitation of nutrition

Decayed or missing teeth and ill fitting dentures make chewing difficult. the person often resorts to eating only soft foods, many of which lack fiber.

Behavior nursing diagnosis of stress include

Decisional conflict, impaired home maintenance, impaired verbal communication, ineffective coping, ineffective health maintenance, ineffective self health management, ineffective therapeutic regimen managment, risk prone health behavior, self neglect

Flexion

Decrease angle of joint like bending elbow

Potential Postoperative Complications:Collaborative Problems hypovolemia what is it, clinical signs, interventions

Decrease blood volume, maybe due to blood loss during and after surgery, dehydration, or excess loss through vomiting, diarrhea, or drains. Clinical signs : hypotension, tachycardia, decreased urine output, fatigue, thirst, dehydration Interventions : monitor vital signs and I&O. Insert urinary catheter, if appropriate. Monitor skin color, temperature, and moistness; central and peripheral cyanosis. Identify possible causes of change in vital signs. Administered iv therapy as prescribed. Promote oral intake when tolerated. Prepare to administer blood products, as prescribed.

objective data of metabolic and nutrition

Decreased arm circumference (decreased muscle mass) Serum glucose abnormalities (decreased glycogen synthesis, glucose intolerance)

Cognition grief reaction

Decreased concentration, forgetfulness, impaired judgement, obsessive thoughts of the deceased or lost objects, preoccupation, confusion, questioning spiritual beliefs, searching for understanding, searching for purpose and meaning

objective data for respiratory

Decreased depth of respirations (decreased strength of pulmonary muscles) Increased secretions (pooling of secretions in the airways) Adventitious breath sounds (secretions, narrowed airways, atelectasis) Decreased oxygen saturation (atelectasis)

what lab values would be a reason to delay surgery

Decreased hematocrit and hemoglobin levels, indicating bleeding or anemia Elevated white blood count, indicating an infection Abnormal urinalysis, indicating infection or fluid imbalances reason to delay surgery

Musculoskeletal Abnormal Findings

Decreased muscle tone and strength Decreased endurance Decreased mobility of joint: ankylosis Disuse osteoporosis Bone demineralization - occurs in 2-3 days Contractures - permanent shortening of muscles covering joints

Ineffective peripheral tissue perfusion, what are some symptoms to look for

Decreasing blood circulation to the periphery that may compromise health . symptoms of ineffective peripheral tissue will be different depending on whether the etiology is arterial or venous. Look for such symptoms as absent or weak pulses, claudication, pale and shiny skin, edema, numbness or pain in the extremity, and delayed wound healing.

Why to teach a patient to deep breathe and cough

Deep breathing and coughing expand the lungs, improve ventilation, promote gas exchange, and help prevent atelectasis and pneumonia. Coughing after deep breathing mobilizes secretions, which keys Airways and aveoli open and provides greater surface area for gas exchange

Teaching deep breathing and coughing, deep breathing promotes, coughing after deep breathing does what?

Deep breathing promotes ventilation and gas exchange. Coughing after deep breathing mobilizes secretions, which keeps airways and alveoli open and provides greater surface area for gas exchange.

what overflow urinary incontinence and defining characteristics and outcomes

Defining Characteristics Continual involuntary loss of urine. over distention of the bladder. 1.bladder distention 2. high post-void residual 3. nocturia 4. observed involuntary leakage of small volumes of urine 5. reports involuntary leakage of small volumes of urine Expected Outcomes Patient remains dry and comfortable. Perineal skin remains intact.

what are the defining characteristics of Stress urinary incontinence

Defining Characteristics Leakage of urine during exercise Leakage of urine during coughing, sneezing, laughing, or lifting urinary frequency every 2 hours urinary urgency Expected Outcome Patient is continent of urine or verbalizes satisfactory management.

What Is the Nursing Process?

Definition A systematic problem-solving process that guides all nursing actions Purpose To help the nurse provide goal-directed,client-centered care

Integumentary Abnormal Findings

Dehydration - poor skin turgor Malnutrition Incontinence Tissue ischemia - redness of skin Decubitus Ulcer Formation Pressure Friction Shearing

Pre-existing conditions that increase surgical risk coagulation disorder because it does what and put the client at increase risk for

Delay clotting And I increase blood loss, placing the client at risk for hemorrhage and hypovolemic shock. In contrast, a hyper coagulation state increases the risk of stroke, embolism, or intravascular clotting.

the psychological stages of dying

Denial, anger, bargaining, depression, acceptance

objective data psychological

Depression, decreased concentration

American Heart association diet

Describe food selection and preparation tips and other behavior modification that can lead to slow, sustained weight loss. Promote a diet that includes a variety of food choices and a balance of nutrients. Encourage physical activity as a cornerstone of weight loss. Emphasize self monitoring, cognitive strategies, and behavior modification

Describe six intraoperative safety measures performed by the circulating nurse. Answer:

Describe six intraoperative safety measures performed by the circulating nurse. Answer: The circulating nurse performs these six intraoperative safety measures: ● Assisting the scrub nurse to prepare and maintain the sterile field ● Providing supplies and materials during surgery ● Monitoring intake and output of the client ● Handling specimens ● Performing sponge, sharp, and instrument counts ● Documenting care and the client's response to care on the surgical record

Assess the history of loss

Determine whether the patient or family has sustained recent loss or major changes (e.g. , death, family, moving, divorce, retirement). Ask such as - have you had any recent changes in your life? - tell me about your family? - are your parents still living? as appropriate - what previous experiences have you had with the loss of someone you love (or with this condition)? -

Placing and removing a bedpan

Determine whether the patient will need to use a regular bed pan or a fracture pan. Put on clean procedure glove. Help the patient to achieve a position on the bed pan that will be most helpful in facilitating urinary or bowel elimination. place the patient in a semi Fowler's position whenever possible. modify the position based on the patient's condition. Provide toilet tissue, clean wash clothes, and towels for the patient to perform personal hygiene when elimination is complete. assist of the patient cannot perform these tasks independently

factors affecting sensory perception

Developmental Culture Illness Medications Stress Personality Lifestyle

Factors That Affect Nutrition

Developmental stage* Educational level* Knowledge of nutrition* Includes concepts of access Ethnicity/Culture/Religious practices* Lifestyle choices Disease Processes Functional limitations

Factors affecting oxygenation and perfusion

Developmental stage, environment, stress, lifestyle which includes occupation pregnancy nutrition obesity exercise smoking substance abuse, medications

Factors affecting mobility

Developmental stage, nutrition, lifestyle, stress, environmental factors, diseases, and physical abnormalities.

assessment Relation to Other Steps

Diagnosis -Data are used to identify the client's actual or potential health problems and strengths Planning outcomes and interventions -Data help you formulate realistic goals and choose the interventions most likely to be acceptable to and effective for the client Implementation -You gather data by observing the client's responses as you perform interventions Evaluation -You assess client responses to interventions; client responses are data

Diarrhea and defining characteristics?

Diarrhea and defining characteristics? Passage of loose, fluid, uniformed stool 1. Hyperactive bowel sounds 2. At least three loose stools per day 3. Urgency 4. Abdominal pain 5. Cramping Outcome will return to usual bowel elimination habits by date

Managing diarrhea

Diarrhea may occur as a result of contaminated food, a viral infection, or dietary change, or as a side effect of the medication. patients with diarrhea are at risk for fluid and electrolyte imbalance. Water and potassium laws are the primary concerns. Infants, young children, and the frail elderly are most vulnerable and may require hospitalization and intravenous fluid replacement therapy. ideally, or liquids replace the lost fluid and potassium.

Posttest care client teaching

Dietary or activity restrictions. Signs and symptoms that should be reported immediately to the practitioner. Medication

What are internal stressors

Diseases, anxiety, nervous anticipation of an event or negative self talk

types of stress include

Distress,eustress, internal, external, developmental, situational, physiological, and psychological

Medication and urine

Diuretics classified as thiazide treat blood pressure, fluid retention, and edema by increasing elimination of urine.

what is my otic medication worries?

Dizziness Nausea Impacted cerumen Contamination of the dropper

Glucose monitoring

Do not display a decimal point. You can only delegate Stable glucose testing. You want to have the patient warm their hands. You use the first drop of blood.

Documenting Data

Document as soon as possible Write legibly without using acronyms Avoid using inferences "just the facts" Use the client's own words Record only pertinent, important, and relevant data

Ineffective denial defining characteristics

Does not admit fear of death, makes dismissive comments when speaking of death/ loss, minimizes the grief/pain, displaces feelings to body (I.e, somatic and psychosomatic symptoms)

vaginal supp assessment,prep, position

Dorsal recumbent Sims gloves Ask if patient prefers self administration

how to do Continuous bladder irrigation

Drape the patient exposing only the irrigation port of the catheter. Using aseptic technique, attach the connecting tube into the irrigation solution container. Prime the tubing. Don clean procedure gloves. pinch the irrigation port of the catheter and connect the irrigation tubing to the port. regulate the flow of the irrigant. Monitor for urine output.

droplet precautions

Droplet Precautions Pathogen is spread via moist droplets Coughing, sneezing, touching contaminated objects Precautions include Same as those for contact Addition of mask and eye protection within 3 ft of client

Amount of exercise, how much should be done?

Duration: is the amount of time one is exercising. To achieve and maintain healthy levels of fitness, the US Department of Health and Human Service recommends two and a half hours a week or more of moderate intensity physical activity coupled with increasing the activity everyday. The frequency of exercise should be 3 to 5 days per week, I'll go the more often and the longer the duration the better. The mode of exercise is a type of activity. Aerobic endurance and muscle strengthening resistance physical activities both promote better health. many people become discouraged because they don't see immediate results from their efforts. However, subtle changes occur long before the person sees changes in weight or shape. some tips to help develop an exercise program.

Use of accessory muscles when will they use it?

During inspiration the patient may use intercostals, abdominal muscles, and muscles of the neck and shoulder when there is an increased demand for oxygen or problems with ventilation.

Monitoring interventions for diarrhea, you should asses, monitor?

During the diarrhea episode assess and monitor the following. monitor stools assess frequency, amount, color, and consistency of stools to determine the severity of the diarrhea. Monitor fluid balance. Monitor intake and output, body weight, and vital signs to assess hydration. Also assess skin turgor and moistness of mucous membranes monitor electrolyte status. Check through electrolyte levels to detect imbalances. monitor skin integrity. assess the perineal area for alterations and skin integrity. Clients with diarrhea may experience perineal irritation and excoriation.

meeting physiological needs of the dying person maintain skin integrity. during the final hours of life the goal changes to? refer to? assess for? and maintain? you should?

During the final hours of life, the goal changes from preserving skin integrity to providing comfort. Realize that during this time even excellent care may not prevent skin breakdown - turn the patient frequently unless contraindicated. Refer to the pain control interventions -assessment for increase diaphoresis and/or incontinence. -maintain adequate nutrition.

Developmental stage infant of bowel

During the first few days of life, the newborn passes meconium through the anus. It's green black, tarry, and sticky and is formed by swallow mucus, hair, and amniotic fluid. It has no odor. Stool transitions to a yellow green color over the next few days. After that the appearance of the feces depends largely on the type of feeding the infant receives. Breastfed babies pass golden yellow stools in formula fed tan stools

QSEN: A Culture of Safety, what is the central role of nurses in patient safety?

Education encompassing the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems within which they work The central role of nurses in patient safety: Surveillance and "rescue" of patients Coordination and integration of care, and services from multiple providers

65 to death

Ego integrity vs. Despair -success in this stage attains the virtue of wisdom -mankind, themselves -life reflection -is it okay to have been me? -dissatisfied with life and develop despair, depression and hopelessness

safety hazards in the community electrical storms

Electrical Storms -Prevention >>During a storm, seek lowest spot possible >>Seek shelter in large building, away from water >>No use of metal objects

Electrodiagnostic Studies

Electrodiagnostic Studies uses devices to measure the electrical activity of the heart, brain, and skeletal muscles

obtaining a sterile urine specimen from a catheter

Empty the drainage tube of urine. put clean gloves, and swab the specimen port with an anti-septic swap. Insert the needleless access device with a 20 or 30 ml syringe into the specimen port, and aspirate to withdraw the amount of urine you need. transfer the specimen into a sterile specimen container. maintain sterility. Transport the specimen to the lab as soon as possible. label the specimen container with the correct patient identification and transported to the lab in a timely manner.

During the testing evaluation, evaluate client what?

Evaluate client's ventilatory status and tolerance to the procedure. Evaluate clients need for assistance. Evaluate client understanding of what was performed during the procedure. evaluate the clients understanding of findings during the procedure.

Preparation of client evaluation

Evaluate clients knowledge of what to expect, anxiety level, level of safety and comfort. Monitor that someone will accompany a child to the department where the test is to be performed and remain with the child during the test if not at risk of harmful exposure.

posttest care evaluation

Evaluate the client's respiratory status to any anesthetic agents. Evaluate the client's tolerance of oral liquid. Evaluate the client understanding of procedural findings or the time frame that written result should be reported to the practitioner. evaluate the client's knowledge of what to expect after discharge.

Effect of mobility on muscle and bone

Even a couple of days in bed can leave you feeling tired and weak, because the musculoskeletal system is one of the first systems affected by immobility. Inactivity causes significant wasting of the gastrocnemius, soleys, and leg muscles that control flexion extension of the hip, knee, and ankle. Confinement to bed leads to 7% to 10 percent loss of muscle strength which is atrophy per week. the strongest muscles, usually the flexors, pull the joints in their direction, leading to contractures, or joint Ankylosis. Immobility affects parathyroid function, calcium metabolism, and therefore bone formation. the result of these changes is osteoporosis, calcium depletion in the joints, and renal calculi due to increased excretion of calcium. these changes place the patient at risk for pathological fractures with minimal trauma.

Assess peripheral circulation

Even if the lungs and heart are functioning well, pathology in the arteries and veins can interfere with tissue perfusion. Palpate the peripheral pulses, assess skin color and temperature, and note the distribution of hair on the extremities. weak pulses, cool feet, lack of hair, and shiny skin on lower legs and feet usually accompany peripheral vascular disease. Look for skin ulcers that often accompany severe venous or arterial disease. Check for edema of the feet and ankles, this is one symptom of heart failure.

what is Cough? what does a persistent or recurrent cough mean? if cough last more than 3 weeks and you can't explain what should you do?

Everyone coughs from time to time,To remove small amounts of mucus and debris from the airways. Coughing is a normal protective response to known respiratory irritant or when food or fluid accidentally gets into the airways. it cost becomes significant if it persist, is recurring, or is productive. A persistent or recurring cost may indicate ongoing or recurring airway irritation. If a cough last more than 3 weeks and cannot be explained seek medical evaluation

Full liquid

Everything of clear liquid Plus smooth texture dairy products, custards, refined cook cereals, vegetable juice, pureed vegetables, and all fruit juices.

what are the Behavior grief reactions?

Forgetfulness, being withdrawn, insomnia or too much sleep, dreaming of the deceased, verbalizing the loss, crying, loss of productivity at work or school

Stress management in the workplace

Examine your expectations, ask for help, support colleagues, be proactive about the things you can change and accept the things that you cannot change. Join a support professional organizations that support or address workplace issues, strive for balance, and obtain counseling.

Hypersomnia what can it be related to?

Excessive sleeping (especially during daytime) Sleep-related or disease-related Can be related to depression

Hyperextension

Excessively increase angle of joint like bending the head backward

Local anesthesia side effects

Excitability, toxic reactions such as respiratory difficulties, vasoconstriction if substance contains epinephrine

Risk for disuse syndrome

Exist when a patient prescribed or unavoidably inactivity creates the rest for deterioration of other body systems.

Family Needs/Coping expectations they have the same what as the client? whose role is it to notify the family

Expectations families have the same hopes/fears/dreams as the client need to assess their expected outcomes of the surgery Surgical Time Time Prognosis Post-op Presentation Facilitator Roles WARNING: If complications occur or a less than satisfactory prognosis is the outcome, it is the surgeon's responsibility and not the nurses to relay this information. Don't assume the family is aware or spoken with the surgeon since surgery!

Nurses' Understanding of Health and Illness

Experiences unique to each individual Illness usually described in terms of how it makes a person feel An illness is a disruption of health Health and illness influenced by client's attitude and lifestyle choices

Five Stages of Illness Behavior

Experiencing symptoms Sick role behavior Seeking professional care Dependence on others Recovery

Preparation of client client teaching

Explain reason for test and what to expect. An estimation of how long the test will take . NPO. Cathartic or laxatives, how much, how often. Sputum: cough deeply, not to clear throat. Urine: voided, clean- catch specimen, time to collect. No objects to obscure xray film. Barium TEST: Taste, consistency, aftereffects ( stools lightly colored for 24- 72 hours, can cause obstruction or impaction. Iodine: metallic test, delayed allergic reaction. Positioning during test. Positioning posttest (e.g angiography) immobile limb. Post test encourage fluids.

During the testing client teaching

Explain what occurred during the procedure. Answer questions and concerns of the client or family member. Explain what to expect during the immediate recovery phase. Explain what to report to the nurse during the immediate recovery phase

for skin medication what do i want to asses, prep, position

Expose area while maintaining privacy Observe char of skin Remove previously applied medication

Adolescence stressors

Exposure to an expanded environment and a wider circle of friends and acceptance by peers. Rapid changes in body appearance. Need for academic achievement, sports performance, or a demonstration of other talents. Peer pressure. Maintaining self-esteem while searching for identity. Decisions about the future in the areas of school, work, and relationships. conflicts between standards for behavior and the sex drive. Decisions about involvement with alcohol and drugs.

External vs internal loss

External losses are actual loss of objects that are important to the person because of their cost or sentimental value (e.g, jewelry, pets, a home). These losses can be brought about by theft, destruction, or disasters such as floods and fire. Internal loss is another term for perceived or psychological loss

Effects of immobility on the integument

External pressure from lying in one position compresses capillaries in the skin, obstructing skin circulation, lack of circulation causes tissue ischemia and possible necrosis.

the spread of infection portal of entry include

Eye, nares, mouth, vagina, cuts, scrapes Wounds, surgical sites, IV or drainage tube sites Bite from a vector

Informatics and Nursing Practice

Facilitates evidenced-based practice New model of decision-making Affords rapid access to most current health information Enables location of best evidence supporting nursing practice

Safety Hazards in the Healthcare Facility prevention of falls

Falls Prevention: >>fall risk assessment, >>environmental safety/clean dry floors >>client education Equipment-related accidents Fires/electrical hazards Mercury poisoning

Helping families of dying patients view the family as your unit of care because

Family members often rate communication with clinicians as one of their most important needs

Subjective characteristics of activity intolerance

Fatigue, weakness, discomfort on exertion, dyspnea, and verbalization of no interest in activity

Anxieties and Fears

Fear of the Unknown Fear of Death Anesthesia Fear of the Outcome diagnosis/prognosis prognosis body image Fear of Pain intensity/duration ability to cope/handle the pain

Managing fecal impaction

Fecal impaction the presence of a hardened fecal mass in the rectum. Impaction often blocks the passage of normal stool and set up a vicious cycle of furthering hardening. Liquid stool may leak, seeping around the hardened mass, and the patient may report feelings of fullness, bloating, constipation, diminish appetite, & a change in bowel habits. You can detect fecal impaction by digital examination of the rectum. To treat a fecal impaction, you will use enemas or Digital removal of stool. once the impaction has been removed, establish a bowel regimen to prevent recurrence of impaction.

safety hazards in home fires prevention

Fires Cooking fires, smoke inhalation, home heating equipment Prevention! >>Smoke alarms >>Caution with cigarettes >>Fire extinguisher >>No candles unattended >>Safety with holiday lights >>Care with electrical cords

Aerobic conditioning, what are the components of it?

Fitness and body composition are improve by aerobic conditioning. components of aerobic conditioning include intensity, duration:, frequency, and mode. Intensity is how hard one is exercising. test used to evaluate exercise intensity include target heart rate method, borg rate of perceived exertion scale, talk test

Psychological Stages of Dying

Five Stages (Dr. Elizabeth Kübler-Ross) Denial Anger Bargaining Depression Acceptance

Range of motion for the trunk

Flexion at the waist, bend forward towards the toes Extension straight in the trunk from the flex position. Hyperextension bend the trunk backward. Lateral flexion bend the trunk to the side. Rotation turn the upper body from side to side like twist at the Weise.

objective data for muscoskeletal

Flexion contractures of hip, knee ankles (wasting of gastrocnemius, slieus and leg muscles) Joint stiffness (ankylosis) Decreased measurement in arm circumference (muscle wasting/atrophy)

sensory deprivation intervention

Focus is prevention Support senses (e.g., glasses, hearing aids) Orientation Calendar; view of environment Provide stimuli Regular contact; touch Television/radio Pet therapy Smells

What equipment is needed for deep breathing and coughing

Folded blanket or pillow if teaching will include splinting of a surgical incision site. And tissues

Testing urine at the bedside

Follow the manufacturer's directions carefully regarding the amount of your needed. Read the kit label to be certain that you are using the correct reagent and that the kit has not passed the expiration date. To ensure accuracy, the reagent strip should be read at the exact time indicated on the label. You would need adequate lighting to evaluate the results. Dipstick testing is considered a preliminary test for screening.

Soft diet

Food easily digestible, low in fiber, crackers

safety hazards in the community community acquired pathogens come from where? and how are they prevented?

Food-borne, vector-borne Prevention: proper storage, cleaning, and cooking of foods; clean cooking surfaces; attention to folk remedies Prevention: drain standing water; insect repellents; protect skin contact with insects; wipe out breeding areas

Lifestyle factor diet and sleep, whats does food do with sleep? which foods should you eat to induce sleep? which promote relaxation?

Foods can either promote or interfere with sleep. a meal high in saturated fat at bedtime may interfere with sleep. Dietary l - tryptophan, an amino acid found in milk and cheese may help to induce sleep, although some studies indicate that the protein in these foods actually increase alertness and concentration. Carbohydrates seem to promote relaxation through their effects on brain serotonin levels. In general, satiation induces sleep, where is many people, especially infants and children, have difficulty falling asleep when they are hungry.

Antigen avoidance diet are for who?

For clients allergic to or intolerance of certain foods such as gluten free diet for clients with celiac disease

Calorie restricted diet

For clients requiring weight reduction

Sodium restricted diet

For clients with blood pressure or fluid balance problems

Mobility, fracture what pan do you use?

For clients with mobility problems, use a bedpan or urinal to collect urine output. use a fracture pan for clients with a fracture of the pelvis, lower back, or legs or for clients who have cast, splints, or braces on their legs. Male clients may void into a urinal while remaining in bed.

Mechanical soft diet

For patients who have trouble chewing, cottage cheese, small dice meat

Strategies to increase patients fluid intake

For patients with limited mobility, keep water or other liquids in easy reach. You may need to remind young children or patience with cognitive or psychiatric disorders to drink fluids. For patients who have increased fluid needs, provide goals for intake, and frequently remind them to drink. Many foods have a high fluid content. If the patient requires additional food for hydration, consider adding soup and watery foods, such as watermelon, to the diet. In contrast, if the patient requires fluid restriction, you'll have to have account for these foods into the fluid balance. Try offering liquids with a straw. Patients tend to drink more this way. chill drinks might be more appealing, particularly if the patients mouth is dry. offer beverages with ice if they are to be served cold. Provide good enough care. Patient will often drink more readily if their mouth feels fresh

objective data for urine

Foul smelling urine with sediment and crystals (supine positioning inhibits drainage of urine from the renal pelves and bladder causing stagnation of urine and potential kidney stones.

Balanced Hygiene

Good hygiene techniques promote the normal structure and function of body tissues Physical hygiene is necessary for comfort, safety, and well-being. Promotes comfort Improves self-image Decreases infection and disease Hygiene care is never routine

To assist with stimulating a patient's appetite you should provide

Frequent oral hygiene, provide a pleasant eating environment, serve food attractively, position the person comfortable for mealtime, control pain around the clock and avoid painful treatments before meals. you should encourage family and friends to bring food from home. if the patient receives a nutritional supplement, delay the meal for at least an hour afterward. provide nutrient dense foods like adding ice cream to appropriate beverages and foods. Lastly arrange for a home health aide to shop and prepare meals for those who are unable to leave home for groceries or arrange meals on wheels

Examples of high fiber foods

Fresh fruits and berries, dried fruit, vegetables, whole grain cereal products, flaxseed, popcorn, and dried beans, peas, and legumes

odor of normal urine, bacteria? sweet syrup odor?

Fresh urine is aromatic. bacteria will give urine an ammonia like odor. Sweet syrup odor may indicate a congenital metabolic disorder.

Functional urinary incontinence

Functional urinary incontinence Defining Characteristics Recognizes need to urinate, but is unable to access toileting facility. 1. may be only incontinent in early morning 2. senses need to void 3. amount of time required to reach toilet exceeds length of time between sensing urge and uncontrolled voiding 4. loss of urine before reaching toilet 5. able to empty bladder completely Expected Outcome Patient experiences fewer episodes (or no episodes) of incontinence.

Long-term feeding tubes include? how are they placed?

G tube, PEG tube, J tube, pej, g button. they are place surgically or laparoscopically through the skin and the abdominal wall into the stomach or jejunum. They can also be placed endoscopically.

wound care applying a dressing

Gather equipment & wash hands Close door or curtain Position client and drape Put disposable bag within reach Put on clean gloves Remove dressing, pull tape toward suture line. Low and slow Observe appearance of dressing & wound Discard dressing and gloves Wash hands Open/set up sterile dressing tray/field Open cleansing solution - pour on gauze Put on sterile gloves Cleanse wound

Nursing Diagnostic Label (NANDA) drives what

General Goal = Positive "mirror" of the NANDA label

Administering an enema

Generously lubricate and gently insert the rectal tube. instill warm solution at a slow rate. For best results be sure that the patient is properly position. instruct her to attend the solution for 3 to 15 minutes, depending on the type of enema. Assist the patient in a sitting or squatting position to promote defecation. before leaving the bedside, implement fall prevention measures that are appropriate for your patient. Using nursing judgment to modify the procedure based on the patient's mobility and ability to follow your instructions.

Cleansing Wounds

Gentle cleansing essential Clean with normal saline (unless otherwise ordered by physician)

> 50% but < 75 %

Give 200 ml of formula after each meal

> 25% but < 50%

Give 300 ml of formula after each meal

0 to 25 percent of the ordered diet

Give 400 ml of formula

> 75 % but < 90%

Give a hundred ml of formula after each meal

6 rights an examples

Give an example of each one. Answer: These are some examples of the rights of medication: ● The right medication/drug—giving the patient the medication ordered on the MAR and checking the label three times before giving the drug ● The right patient—identifying the patient through the identification band the patient wears and asking for the patient's name so the medication is not given to the wrong patient ● The right time—giving the medication at the time prescribed, within the 1-hour window (30 minutes before to 30 minutes after the scheduled time) ● The right dose—giving the correct amount of the medication (this includes giving the prescribed amount, as well as being certain that this amount makes sense in light of the patient's weight or other condition) ● The right route—giving the medication by the prescribed route (e.g., oral, intramuscular, IV) and questioning the order/prescription if the drug is not available in the form needed for the prescribed route or if the patient's status requires a route different from what is prescribed (e.g., an oral med is ordered, but the patient is vomiting) ● The right documentation—the medication is charted on the MAR, and there's additional documentation in the narrative notes if the medication is ordered PRN, if the patient had a reaction to the medicine, or if the patient refused the medicine

if the client consumes 90% to a hundred percent of the order diet

Give no additional feeding

how do i administer skin medication

Gloves if contact with med Lotions in direction of hair Patches: rotate sites, date/time/initial patch Hold for 10 seconds to ensure adhesion

Goal of caring for a patient with an indwelling catheter

Goal one prevent urinary tract infection. Maintain the free flow of urine. goal 3 prevent transmission of infection. goal 4 promote normal urine production. goal 5 maintain skin and mucosal integrity

evaluation of skin

Goals Expected Outcomes Revision of the plan of care biggest is time

Biofeedback

Has been advocated by some women. Electrodes attached to the skin on the perineum provide feedback to the patient about the perineal contraction.

How to teach a patient to deep breath and cough when they are too weak

Have the patient inhale deeply, bend forward slightly, and perform 3 or 4 huffs against an open glottis to move secretions forward

Review of body system neurologic you want to know problem of

Headaches, dizziness, ringing in ears, gait reflexes, muscle strength, emotions

inflammatory response healing

Healing is a replacement of tissue by regeneration or repair. Regeneration is replacement of the damaged cells with identical or similar cells. However, not all cells can regenerate. Most injuries heal by repair, wherein scar tissue replaces the original position. the inflammatory respond is adaptive in that it protects from infection and promotes healing. However Chronic inflammation As IN Arthritis Is Itself A Stressor.

interventions of pain

Health Promotion Holistic health approach Teaching and self-care Non-pharmacological Interventions used with, not in place of medications Actions: decreases the pain stimulus or pain perception

HMO

Health maintenance organization

Adaptive

Healthy choices Directly reduce negative effects of stress Examples: change in lifestyle; problem-solving

how long should heat and cold therapy

Heat or cold should be applied intermittently, leaving on for no more than 15 minutes at a time to avoid tissue injury.

Critical aspects of performing percussion, vibration, and postural drainage? how long should the patient be kept in the position? use what type of hands, how long do you perform percussion? then what do you do? the entire treatment should not exceed? and perform?

Help the patient assume the appropriate position based on the lung field that requires drainage. Keep the patient in the desired position for 10 to 15 minutes Using cup hands, perform percussion over the affected lung area for 1 to 3 minutes while the patient is in the desired drainage position. Next perform vibration Assist the patient to sit up. Ask him to cough at the end of a deep inspiration to clear the air ways of secretions. Repeat postural drainage, percussion, and vibration for each lung fields are required for treatment. the entire treatment should not exceed 60 minutes. Provide mouth care.

After the meal

Help the patient to wash hands or use the restroom after the meal. Record amount of food and fluid the patient consume. Document feeding behaviour. Document changes in nutritional status. Document staffing and staff education, and availability of a supported inter disciplinary team.

Nursing Measures to Promote Activity and Exercise

Helping the Client Out of Bed Use of transfer board Mechanical lift Transfer belt Assisting with Ambulation May require conditioning exercises Obtain appropriate assistive devices

A cleansing enema maybe given high or low

High enema attempts to clear as much of the large intestine as possible. with a high enema the client receives initial instillation of the fluid in the left lateral position. the client then moves to the dorsal recumbent position and then the right lateral position for the remainder of the installation. This turning process allows the fluid to follow the shape of the large intestine

what is my position/prep/ assessment for optic medication

High fowlers, Head tilted back, Tissues for excess, Gloves

Focus/Dar charting and highlights what?

Highlights the client's concerns, problems, or strengths in three columns Column 1: Time and date Column 2: Focus or problem being addressed Column 3: Charting in a DAR format: Data, Action, Response

what exercise for Range of motion for toes, what kind of joint is the toe?

Hinge. Except intertarsal joint, which are gliding joint Flexion curl the toes downward Extension straighten the toes Abduction spread the toes apart Adduction Bring the toes together

tertiary line of defense

Humoral immunity B-cell production of antibodies in response to an antigen Cell-mediated immunity Direct destruction of infected cells by T cells

H&P

History and physical

Hospice care:

Holistic care of dying clients -Usually a prognosis of < 6 months to live -Support for death with dignitiy and surrounded by the comfort of their homes and family

what is hospice care?

Holistic care of dying clients Usually a prognosis of < 6 months to live Support for death with dignitiy and surrounded by the comfort of their homes and family

Palliative care:

Holistic comfort care Long term care for clients who have reached a stage in their illness where cure is no longer possible

pallivate care

Holistic comfort care Long term care for clients who have reached a stage in their illness where cure is no longer possible

Fluid/Nutritional Status monitor what

Hydration status data Drainage amts vital signs daily weights!( best measurement of fluid volume) NPO status Progression of diet check bowel sounds

hydrogel dressing

Hydrogel dressings - water or glycerin based (Nu-Gel, ClearSite, IntraSite) Used on partial or full thickness wounds, deep wounds with exudate, necrotic wounds, burns and radiation burns Are soothing, reducing pain in the wound Debride the wound by softening necrotic tissue

The psychological interventions of dying include

Honesty, therapeutic communication, spiritual and cultural support.

Spiritual domain nursing diagnosis associated with stress

Hopelessness, spiritual distress, impaired religiosity

Potential problems of prone and solution

Hyperextension of the lumbar curvature, pressure on the breasts in women or genitals in the men, impaired respiration, solution: place a small pillow under the abdomen. Foot drop, move the patient down in bed so that the feet extend over the edge of the mattress, or place a small pillow under the shins so that the toes do not touch the bed. Lateral flexion of the neck, place a pillow under the head and neck to provide alignment, unless drainage from the mouth is desired.

Potential problems of the Fowlers position

Hyperextension of the neck you use a small pillow under the head and neck. posterior flexion of the lumber curvature you use a firm mattress or you position the patient so that the angle of elevation begins at the hip. Dislocation of the shoulders you position a pillow under the forearms to prevent pull on the shoulders. Flexion contracture of the wrist and edema of the hands you support the hands on pillows in alignment with the forearms. flexion contracture of the fingers and abduction of the thumbs use hand splints if appropriate or provide a large roll in the palm of the hand. External rotation of the legs you play sand bags or roll along side the trochanter and upper thighs. Hyperextension of the knees you place a small pillow under the lower legs from the ankles to below the knees. do this for short periods only, avoid pressure on the politeal area. Foot drop use a footboard or high top sneakers to hold the feet in dorsiflexion.

Pre-existing conditions that increase surgical risk cardiovascular disease

Hypertension, congestive heart failure, and myocardial infarction, affect the ability of the heart to work as an efficient pump. If these disorders are well controlled, risk is limited

hypochondriasis and what may trigger the physical sensations?

Hypochondriasis. The person is preoccupied with the idea that he is or will become seriously ill. The person is abnormally concerned with his health and interprets his real or imagined symptoms unrealistically, fearing that they will get worse or become incurable. The person is not "faking it"; anxiety about her health may trigger the physical sensations.

Spinal anesthesia side effects

Hypotension, headache

Epidural side effects

Hypotension, respiratory depression

Cleansing enemas solutions include

Hypotonic solution which has saline, tap water, and soap you introduce a large volume 500 to 1000 ml for adults of fluid into the rectum. the volume causes intestinal distention and leads to rapid evacuation of stool. large volume solutions may be contraindicated in patients who have weakened intestinal wall. Hypertonic solutions are usually in smaller volume 70 to 120ml it attract water into the colon, causing distention and stimulating peristalsis and defecation it is contraindicated in renal failure and congestive heart failure

what are the identification of behaviors? Nursing Education

Identification of Behaviors Examples in the educational setting: >>Human Error >>At-risk >>Reckless

Analyzing Data

Identify significant data Cluster cues Identify data gaps and inconsistencies Draw conclusions about health status* Make inferences* Identify problem etiologies Verify problems with the patient

13 to 18

Identity vs. Role Confusion -success in this stage will lead to a coherent sense of self and future. -peers social relationship -explore possibilities and begin to form their own identity -who am I? -if unsuccessful they can be hindered, which results in a sense of confusion about themselves and their role in the world.

documentation do's and don'ts if a client refuses medication

If a client refuses medication Record on the medication administration record in narrative form; chart the reason given Do not leave blank lines If you make a mistake, draw a single line through the entry and place your initials next to the change Sign all your charting entries

nursing intervention for impaired smell, impaired taste, impaired tactile sense

Impaired Smell Importance to the ability to taste Safety measures Home safety (smoke, gas, spoiled food) Impaired Taste Frequent mouth care Varying the flavors/spice and color of foods Impaired Tactile Sense Safety teaching Stimulation Therapeutic touch (individually driven)

Functional incontinence

Is the untimely loss of urine when no urinary or neurological cause is involved. This type of incontinence occurs because of physical disability, immobility, pain, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet. Nanda defines functional incontinence as the inability as a usually continent person to reach the toilet it in time to avoid unintentional loss of urine. etiology include confusion, disorientation, or mobility problems.

physiological responses to stress. what questions should you ask? observe for what? examples of physiological responses are?

If coping is successful, clinical signs and symptoms may not occur. The following are examples of questions you should ask: ● What do you do to stay healthy? ● Tell me about your health habits. ● How often do you have a checkup? ● What are your health concerns? Observations. A check of vital signs for elevations in pulse, respiration, and blood pressure will indicate whether the fight-or-flight response is present. In your general survey, or overview, of the patient you should note hygiene, grooming, facial expression, and ability to make eye contact.summarizes other physiological responses you might see: ● Dilated pupils ● Muscle tension ● Stiff neck ● Headaches ● Nail biting ● Skin pallor ● Skin lesions (e.g., eczema) ● Diaphoresis, sweaty palms ● Dry mouth ● Nausea ● Weight or appetite changes ● Increased blood glucose ● Increased heart rate ● Cardiac dysrhythmias ● Hyperventilation ● Chest pain ● Water retention ● Increased urinary frequency or decreased urinary output ● Diarrhea or constipation ● Flatulence

Helping families of dying patients teach the family what to expect with regard to medications, treatments, and signs of approaching death, why is this done?

If family members know what is normal, they will be less likely to panic or fear the inevitable

meeting physiological name for the dying patient intervene for death rattling? what do you do?

If it occurs and if it is just distressing to the family - turn the patient on his side, and elevate the head of the bed. - administer antispasmodic and anticholinergic drugs if necessary.

Lifestyle factor , how does exercise affect sleep?

If it occurs at least two hours before bedtime, exercise promotes sleep. however, the more tired a person is, the shorter the first period of REM sleep.

Assisting the patient in feeding

If the patient must eat in bed, place to head of the bed at the highest tolerable level, and adjust the overbed table to be an easy reach. If the patient can feed himself, prepare the food on the tray for him peel an orange, open the milk and butter containers. If the client is visually impaired, identify the locations of the meal on the tray base on a clock face

Factors affecting grief previous loss, it makes the grieving process what?

If the person has sustained more than one loss in a short period of time, the grieving process can become more complicated. In the hospital, you will frequently care for patients experiencing multiple losses. For example, consider a patient who has suffered a stroke and loss of mobility and then has to move out of his home of many years to a nursing home. The patient's loss of Health and functioning is compounded by the loss of his independence and familiar surroundings.

Impact a stage in the crisis

If the usual strategies are not effective, anxiety and confusion increase. A person may have trouble organizing her personal life. The person may feel the stress but minimize its severity.

Do not stand on tiptoes to reach an object

If you must use a ladder or step stool to reach an object, make sure it is stable and adequate to position your body close to the object.

b lymphocytes make what and what are they?

IgM: just met IgG: got it forever or tells you had for a long time IgE: means allergic response

inflammatory response vascular response

Immediately after injury, blood vessels at the site constrict (narrow) to control bleeding. after the injury cells release histamine, the vessels dilate, increasing blood flow to the area hyperemia. Under the influence of kinins by the dying cells, the capillaries become more permeable, allowing movement of fluid from capillaries into tissue spaces. tissue becomes edematous. After leukocytes move into the area, localized as blood flow again decreases, to keep them in the area to fight infection.

Effect of a immobility on the heart and vessels

Immobility increases the workload of the heart and promotes venous stasis. When you are active, the skeletal muscles of the legs help pump blood back to the heart. Recall that the veins are thin walled vessels with valves. Muscle activity propels blood toward the right side of the heart, and the valves prevent back flow of blood. To compensate for Immobility, heart rate and stroke volume increase to maintain blood pressure. But with a immobility, cardiac reserves are lessen, which means the heart is less able to respond to the demands above baseline. Without muscle activity, the force of gravity causes blood to pool in the periphery, which leads to edema. Fluid in the tissue is more prone to pressure injury. In addition to venous pooling, immobility leads to compression and injury of the small vessels in the legs and decreased clearance of coagulation factors, causing blood to clot faster. These three changes stasis, activation of clotting, and vessel injury make up what is known as Virchow triad, a trilogy of symptoms associated with a greater chance of DVT. An immobile person is also more prone to orthostatic hypertension. Prolonged bed rest and activates the baroreceptors involved with construction and dilation of the blood vessels. As a result, when a person who has been immobilized changes position, he is less able to maintain his blood pressure. The patient complains of feeling dizzy and lightheaded and may be unable to support his own weight

Posttest care interventions, position, monitor, enforce?

Implement the practitioners orders regarding the post procedure care of the client. Institute standard precautions or surgical asespis as appropriate to the client care needs. Position the client for comfort and accessibility ability to perform nursing measures. Monitor vital signs according the frequency required for the specific test. observe the insertion site for a hematoma or blood loss, replace pressure dressing as needing. monitor the client urinary output and drainage from other devices. Enforce activity restrictions appropriate to the test. Schedule client appointments as directed by the practitioner

Benefits of Exercise

Improves cardiovascular health, Increases muscle tone and flexibility, Enhances immune system, Promotes weight loss, Decreases stress/increases overall feeling of well-being

diminish or absent breath sounds in a patient experiencing dyspnea means

In a patient experiencing dyspnea these are signs of worsening ventilation and oxygenation. Oxygen therapy and measures to restore adequate ventilation maybe required.

Medications and nutrition

In addition to the direct effects of disease and disorders, nutrition may be affected by the drug therapies used to treat them. For example chemotherapy and radiation therapy may cause oral ulcers intestinal bleeding, or diarrhea which interfere with eating and absorbing nutrients from food. Certain drugs alter nutri metabolism, and others increase or decrease nutrient excretion. Some drugs affect specific nutrients. For example aspirin decreases folate levels increases excretion of vitamin C, laxatives may cause calcium and potassium depletion, and thiazide dyer edit decrease the absorption of vitamin b 12.

Factors affecting oxygenation development to adolescence

In adolescence, the lungs develop adult characteristics. The average adolescent is developmentally at little risk for lung disease. They may begin smoking and they do not see health care as often and do not receive the recommended influenza vaccines. exercise induced asthma is still a problem in this age group.

what happens in Pre crisis

In response to the event and anxiety, the person uses her usual coping strategies. A person has no symptoms, denies any stress, and may even report a feeling of well-being

Alter the stressor type of coping strategy

In some situations, a person takes actions to remove or change the stressor.

In the alarm stage of the GAS, what are the effects of the sympathetic nervous system on each of the following: heart, brain, glycogen stores, and skeletal muscle?

In the GAS alarm stage, the sympathetic nervous system produces a fight-or-flight response that: ● Increases heart rate and strength of contractions, increasing cardiac output ● Increases mental alertness ● Causes the release of glycogen stores and increases in blood glucose levels ● Increases muscle strength (ability to contract)

When do you apply them elastic stockings

In the morning before the client arises

Somatization

In this disorder, anxiety and emotional turnmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. The patient is unable to control the symptoms and behaviors, and complaints are vague or exaggerated.

Maintain competency

In using all assistive and transfer devices.

Effect of immobility on the lungs

Inability the creases the strength of all muscles, including those involved in chest wall expansion, which also affects ventilation. When a patient is in bed, tHe depth of respiration decreases, and secretions pool in the airways. the ability to effectively cough and expectorate secretions diminishes as muscle tone of the abdomen and chest decrease. As a result, pool secretions block air passages and alveoli, decreased oxygen and carbon dioxide exchange, and often lead to atelectasis, for ammonia. even a sedentary lifestyle affects the capacity to increase ventilation in response to exercise

Insomnia

Inability to fall or remain asleep or go back to sleep

Effects of immobility on metabolism

Inactivity increases the level of serum lactic acid and decreases ATP concentrations. As ATP concentrations decrease, so do the body's energy reserves. In response, metabolic rate drops, protein and glycogen synthesis decrease, and fat stores increase. Together, these cause glucose intolerance and reduce muscle mass. in mobility also triggers the release of epinephrine, norepinephrine, thyroid hormones, ACTH hormone from the pituitary gland, and aldosterone from the kidneys. These changes in hormones are the same as occur in the stress response, so as you can see immobility can be a stressor in itself

what is Decreased cardiac output? what are the symptoms?

Inadequate blood pump by the heart to meet metabolic demands of the body . symptoms vary depending on whether the problem is one of preload or afterload , but are likely to include changes in heart rate and rhythm, palpitations, ECG changes, anxiety, fluid retention, oliguria, weak peripheral pulses, hypotension, adventitious lung sounds, symptoms of hypoxia and hypoxemia.

Lifestyle modification

Increase daily or foods 8 to 10 glasses or 3000 ml as tolerated. Limit daily caffeine intake to less than 100 mg. This is about one cup of coffee or two 12 ounce cans of cola. Caffeine is a diuretic and a bladder stimulant. try limiting the intake of alcohol, artificial sweeteners, spicy foods, and citrus fruits because they are thought to irritate the bladder. stop smoking, lose weight, smoking has been linked to stress ui and urge urinary incontinence among women, and to urge urinary incontinence men. Take prescribed diuretics early in the morning. Avoid constipation. be aware that high impact exercise is associated with increase stress urinary incontinence.

Managing Constipation

Increase intake of high-fiber foods Increase fluid intake Increase activity/exercise Provide privacy/Allow uninterrupted time Help client to a position that facilitates defecation Laxatives when lifestyle changes are ineffective

How do anticoagulants affect surgical risk

Increase risk of bleeding

Interventions for constipation

Increase the intake of high fiber foods if intake is inadequate. increase fluid intake. increased physical activity. Provide privacy for using the toilet. assist a patient to a seated or squatting position whenever possible. a semi Fowler's position is preferred for a client on bedrest. Allow the patient uninterrupted time to use the toilet, when mass peristalsis occur. Assess for complications such as impaction and hemorrhoids

How does medications effec surgical risk

Increase the risk for cardiac dysrhythmias secondary to potassium loss. interfere with metabolism of anesthetics because of their effects on the liver. increase the potential for excessive bleeding. Decrease cerebral blood flow. Cause hypertension. Increase the effects of opioids and sympathetic nervous system stimulant.

How do antihypertensives increase surgical risk

Increase the risk for hypotension during surgery, may interact with anesthetic agent to cause bradycardia and impaired circulation

How does opioids increase surgical risk

Increase the risk of respiratory depression

How does tranquilizers increase surgical risk

Increase the risk of respiratory depression

Indications of pain include

Increased blood pressure, pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, verbalizations of pain

Cardiovascular Abnormal Findings

Increased cardiac workload Decreased oxygen supply Thrombophlebitis blood clots in legs due to impaired venous return: bedrest can reduce the venous return in the legs by at least 50% Orthostatic hypotension: decrease in BP resulting from sudden position change

Altitude in cardiovascular causes

Increased production of red blood cells Increased vascularity body tissues Increased ability of tissue cells to use oxygen even when atmospheric oxygen pressure is low

How do aspirin increase surgical risk

Increased risk for bleeding

Benefits of Sleep

Increases mental performance -Improves learning -Helps the storage of long-term memory Restores energy Improves ability to cope Strengthens the immune system

Preparation of client support of data

Increasing the client's knowledge promote cooperation, enhances the quality of testing, and decreases the time required to perform to study with an outcome of increase cost-effectiveness. Proper physical preparation prevents delays

Post care support of data

Increasing the client's participation and knowledge of expected outcome measures after a diagnostic test. proper post-procedure care and client teaching alert the client to what signs and symptoms need to be reported to the practitioner

Stages of Infection

Incubation: from time of infection until manifestation of symptoms; can infect others Prodromal: appearance of vague symptoms; not all diseases have this stage Illness: specific signs and symptoms present Decline: number of pathogens decline Convalescence: tissue repair, return to health

stages of infection list the stages and what they are?

Incubation: from time of infection until manifestation of symptoms; can infect others Prodromal: appearance of vague symptoms; not all diseases have this stage Illness: specific signs and symptoms present Decline: number of pathogens decline Convalescence: tissue repair, return to health

Preparation of client level

Independent

Restraints

Indications >>Legal and ethical issues "What you should know about using restraints" Clinical insight 21-1 (p. 373 Vol. #2) Avoiding restraints Bed monitoring devices Using Restraints >>Procedure 21-2

6 to 12

Industry vs. Inferiority -success in this stage will lead to competence -school sports/extracurricular - if children are encouraged and reinforced for their initiative, they begin to feel industrious. -can I make it in the world of others? -if they cannot develop the specific skill they feel society is demanding then they may develop a sense of inferiority

Potential Postoperative Complications:Collaborative Problems wound complications wound infection what is it, clinical signs, interventions

Inflammation or drainage from a wound due to grow of microorganisms secondary to poor aseptic technique or pathogen already present in surgical area. Clinical signs : localized swelling, redness, heat, pain, fever (> 100 . 4 or 38 c), foul smelling drainage, or a change in the color of the drainage. Interventions: effective skin prep in preoperative period. Surgical scrub according guidelines in the intraoperative period. Monitor for systemic and localized sign and symptoms of infection. Inspect incision and drain area for redness and extreme warmth. Inspect surgical dressings for drainage and odor. Monitor vital signs especially temperature. Assess vulnerability to infection. Maintain aseptic non touch technique with surgical dressings change. Use and teach good hand hygiene. Use sterile saline for wound cleansing up to 48 hours post op. Limit visitors, as appropriate. Obtain cultures as needed. Encourage sufficient nutritional and fluid intake. Teach client about signs of infection.

informal planning

Informal planning is the making of mental notes and plans

informatics and nursing informatics

Informatics Managing and processing information necessary to make decisions Nursing informatics Managing and processing information applying to nursing practice, education, and research

Helping families of dying patients communicate medical updates daily because it can?

Information can relieve anxiety and is useful to the family when making decisions

Knowledge Deficit

Informed Consent Dietary Restrictions Skin Preparation Equipment Exercises/Post-op Routines

How does NSAIDs increase surgical risk

Inhibit platelet aggregation, increase the risk for bleeding

3 to 5 years

Initiative vs. Guilt -success in this stage learn limit -family exploration - give them the opportunity to initiate play and make up games children develop a sense of initiative -feel safe asking questions - can I trust those around me? -if unsuccessful child slow to interact with other and may inhibit their creativity. Allow the child to explore and create. Creative opportunity

The technique of intradermal injection

Inserting THE Needle With THE Bevel up

insomnia

Insomnia Inability to fall or remain asleep or go back to sleep

Assessment techniques and abnormal findings of the skin

Inspection and palpation will show breaking the skin integrity

Assessment techniques and abnormal findings of muscoskeletal

Inspection and palpation will show decrease range of motion, erythema, increase diameter and calf or thigh. Palpation will show joint contracture. inspection will show activity intolerance muscle atrophy, joint contractures.

Assessment techniques for metabolic and abnormal findings

Inspection for slow wound healing, abnormal laboratory data. inspection for muscle atrophy. Anthropometric measurements and you'll see decreased amount of subcutaneous fat. palpation and you will see generalized edema.

Assessment techniques and abnormal findings elimination

Inspection will show decreased urine output, cloudy or concentrated urine, decrease frequency of bowel movements. palpation distended bladder and abdomen. auscultation decreased bowel sounds.

Assessment techniques and abnormal findings for respiratory

Inspection you will see asymmetrical chest wall movement, dyspnea, increase respiratory rate. auscultation you hear crackles and wheezes. behavior change.

how to do Oil retention enemas? and used for?

Instill 90 to 120 ml of oil into the rectum to soften stool and lubricate the rectum. This type of enema may be used to assist a client to pass hard stool or before digital removal of stool. It may also be used in conjunction with a cleansing enema at least one hour before the cleansing enema

During the testing interventions report? remain with the client during? keep what available and maintain?

Institute standard precautions or appropriate aseptic technique for the specific test. report to all personnel involved with the test any known client allergies. Place the client in the correct position, drape,and monitor to ensure that breathing is not compromised. Remain with the client during the administration of anesthesia. If the procedure requires the administration of a dye ensure the client is not allergic to the dye, perform the skin allergy test.. Maintain the airway and keep resuscitated equipment available. Assist a client to relax during insertion of the instrument by telling the client to breathe through the mouth and to concentrate on relaxing the involved muscles. Explain what the practitioner is doing so that the client will know what to expect. label and handle the specimen according to the type of materials obtained and the testing to be done. Report to the practitioner any symptoms of complications. secure client transport from the diagnostic area. post test in the diagnostic area: assist client to a comfortable, safe position. Provide oral hygiene and water to clients who were NPO for the test if they are alert and able to swallow. remain with the client awaiting transport to another area

Advance directives

Instructions stating a person's wishes relative to healthcare if incapacitated to make those choices Living Will: specific directions regarding the kinds of health care Durable power of attorney (health care proxy) specific directions and power given to another to implement them if needed all of these can be changed at any time

During the test level

Interdependent

Posttest care level

Interdependent

Circadian rhythm, affects

Internal clock 24-hour day-night sleep/wake pattern Affects overall level of functioning

What is "Just Culture" in Health Care?

Traditionally, health care's culture has held individuals accountable for all errors or mishaps that befall patients under their care • A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control.

20 to 25 young adulthood

Intimacy vs. Isolation -success in this stage will lead to fidelity -relationship romantic -share themselves more intimately with others -can I love? -difficulties can lead to isolation, loneliness, and sometimes depression.

what are the benefits of Enteral feedings? and what are the risk?

Introduction of liquid nutrition into the upper intestinal tract. preferred over intravenous because of lower incidence of sepsis, maintains integrity of intestinal structure and function. Risk of enteral feeding includes aspiration, diarrhea, nausea, vomiting, tubing misconnections.

Isometric exercises involve?, how long is each position held for and repeated for? it is effective for?

Involve muscle contraction without motion. They are usually perform against an immovable surface or object, for example, pressing the hand against a wall. the muscles of the arm contract, but the wall does not moved. Each position is held for 6 to 8 seconds and repeated five to ten times. isometric training is effective for developing total strength of a particular muscle or group of muscles. it is often used for rehabilitation because the exact area of muscle weakness can be isolated and strengthening can be administered at the proper joint angle. This kind of training requires no special equipment, and there is little chance of injury. patients who are bed bound can use this form of exercise to maintain or regain muscle strength.

Environmental loss involves? what are examples?

Involves a change in the familiar, even if the change is perceived as positive. Examples include moving to a new home, getting a new job, and going to college. These losses can be perceived or actual.

Biots respirations

Irregular respirations of variable depth usually shallow, alternating with periods of apnea. Often associated with damage to the medullary respiratory center or high intercranial pressure due to brain injury.

vaginal worries

Irritation

Range of motion for the hip, what type of joint is it?

Is a ball and socket joint. Flexion move the leg forward And up Extension move the leg back down beside the other. HyperExtension move the leg back behind the body. Abduction move the leg laterally Adduction sweep the leg inward across the midline. Circumduction circle the leg, Keeping the knee straight Internal rotation turn the foot and leg inward toward the other leg. External rotation turn the foot and leg outward, pointing the toes as far as possible away from the other leg.

Ankylosing spondylitis

Is a chronic inflammatory joint disease characterized by stiffening and fusion of the spine and sacroiliac joints. the inflammation occurs where the ligament, tendon, and joint capsule insert into the bone.

Mixed apnea

Is a combination of obstructive sleep apnea and central sleep apnea

Mixed incontinence

Is a combination of urge and stress incontinence

Osteogenesis imperfecta

Is a congenital disorder of bone and connective tissue that is characterized by brittle bones that fracture easily. Infants with OI are often born with fractures and continue to fracture with minimal trauma or even spontaneously. Prompt recognition and treatment of fractures help prevent deformities.

Facilitating grief work bibliotherapy, what does it use?

Is a counseling technique used when grief therapy is indicated. It uses guided reading of self-help or fiction literature to increase client awareness and understanding and promote healing. poems, novels, and essays can help reduce new insights, either as the client retells the story or is guided to discuss his feelings and thoughts about the characters in the story

Osteoporosis

Is a decrease in total bone density, which occurs when osteoclast activity outpaces that of the osteoblast. The best treatment is prevention. Teacher adolescence to eat a diet high in calcium, fluoride, and other minerals, and to start exercise program they can continue throughout their lives. Advise old woman that weight bearing exercise can help decrease the rate of bone loss, and advise them to ask their provider about medications to reduce bone mineral loss

Peristalsis, functional limitations of nutrition

Is the wavelike action that propels food through the intestinal tract. bowel inflammation or infection, diverticula or tumors may increase peristalsis thereby decreasing absorption of nutrients. in addition high stress levels may either speed or slow transit time. If peristalsis is slow, the stomach may not empty properly. This can lead to early satiety, nausea, vomiting and affect nutrient intake. This is not unusual in patients with diabetes.

Schedule voiding is?

Is a form of bladder training involving time voiding and habit retraining. The patient must be mentally and physically capable of self toileting. Assisted patient to the toilet, commode, or bedpan on a time schedule. initially this maybe every 2 hours or even more often. As a pattern develops and the person gains greater control, the length of time between voiding may be increase. Schedule voiding is usually combined with other techniques, including lifestyle adjustments and pelvic muscle exercises. ask the patient to keep a daily record of her adherence to the schedule and number of incontinence episodes. If the patient can adhere to the schedule without frequent changes due to urgency, avoiding interval can be increased by 15 to 30 minutes each week.

Scoliosis

Is a lateral curvature of the spine. scoliosis can result from congenital bone disorders, neuromuscular impairment, or trauma, but approximately two-thirds of cases have no known cause and are term idiopathic scoliosis. idiopathic scoliosis is classified as infantile, juvenile, or adolescent depending on the age at onset. nursing responsibilities for all of these this order includes early detection and referral for additional treatment, parent counseling, and careful attention to positioning and transfers.

Role of scrub nurse

Is a member of the sterile team. he can be an RN, LVN/LPN, or a surgical technician. The scrub nurse sets up the sterile field, prepares the surgical instruments, assist with the sterile draping of the patient, anticipates and respond to the surgeon's needs, and maintains the integrity of the sterile field.

Pagets disease

Is a metabolic bone disease in which increase bone loss results in pain, pathological fractures, and deformities. this disorder usually affects the skull, vertebrae, femur, and pelvis.

A bier intravenous block

Is a nerve block technique in which the anaesthesia places a tourniquet on an arm or leg, and then inject a local anesthetic agent intravenously below the level of the tourniquet. the tourniquet is maintained at a pressure that limit venous return but continue to allow aterial circulation. Advantages are it decreases bleeding during the surgical procedure and prevent systemic absorption of the local anesthetic. however, when the procedure is finished, the tourniquet is deflated, and there is potential for systemic absorption of the anesthetic. To prevent tissue damage, the tourniquet , must not be left in place for more than 2 hours.

Closed feeding system

Is a pre fill system that functions much like IV fluid. Close decrease risk of contamination. A pre filled closed system container can safely hang for 24 to 48 hours if you use sterile techniques.

Carminative enemas

Is a procedure in which 60 to 180 ml of solution are instilled into the rectum to help expel flats and relieve bloating and distention. this procedure is used after abdominal or pelvic surgery when peristalsis is slow to return and the client experiences pressure from gas. solutions may be commercially prepared or prepared on the unit. a mixture of magnesium sulfate glycerine, and water in a ratio of 123

Malignant hyperthermia

Is a rare, often fatal, metabolic condition that can occur during the use of muscle relaxants and inhaled anesthesia. metabolism increases in the skeletal muscle, and they become rigid. The temperature rises rapidly. predisposition to this condition is inherited.

what is Transient incontinent? what are the causes?

Is a short-term incontinence that is expected to resolve spontaneously. causes include UTI and medications, especially diuretics.

Rheumatoid arthritis

Is a systemic autoimmune disease involving chronic inflammation of the joints and surrounding connective tissue. rheumatoid arthritis causes joint pain, deformity, and loss of function, patients may also experience fevers, fatigue, weakness, and weight loss. It occurs more frequently in the fingers, wrists, elbows, ankles, and knees. the illness usually begins in mid life, but person in any age group can be affected. pain is most intense when the person arises from bed. Pain and joint deformities may so severely affect mobility that patients cannot care for themselves

Trapeze bar is good for?

Is a triangular shaped device that is attached to an overhead bed frame. the patient can use the base of the triangle as a grip bar to move up in the bed, turn, and pull up in preparation for getting out of the bed or getting on and off the bedpan. they can use this to move about in the bed and to exercise their upper extremities. Frail patient may not be able to use because of the amount of effort it requires.

RNFA

Is an RN with additional Education and training in surgical technique and it's also part of the sterile team. Serves as an assistant to the surgeon, a role that has historically been filled by physician. They work with the surgeon to perform the surgical procedure.

Conscious sedation

Is an alternative form of anesthesia that provides intravenous sedation and analgesia without producing unconsciousness. The patient is aware of his surroundings and consult with the surgical team during the procedure. They may sleepy but are easily aroused by touch and speech. Blood pressure, heart rate, respiratory rate, oxygen saturation are monitored, and the patient usually receive oxygen through nasal canal during procedure. they may forget the procedure.

Urinary retention

Is an inability to empty the bladder completely. It can be due to obstruction, inflammation and swelling, neurological problems, medications, and anxiety.

Gout

Is an inflammatory response to high levels of uric acid. Crystals form in the synovial fluid, and small white nodules, form in the subcutaneous tissues. Gout produces painful joints and severely limit activity during acute flare up. Nursing activity for patients with joint mobility problems focuses on assisting with movement, providing comfort, and teaching about medications. Its mobility is severely restricted, you will also assist patients with adl

Stress incontinence

Is an involuntary loss of small amounts of urine with increase intra abdominal pressure. Nanda specifies loss of less than 50 ml of urine in the absence of an overactive bladder. etiological factors include pregnancy, childbirth, obesity, chronic constipation, and straining at stool. Activities that produce leakage of urine also include exercise, laughing, sneezing, coughing, and lifting

Vaginal weight training

Is another form of pelvic muscles training however this method has not been shown to produce better outcomes then Kegel exercises

Obstructive sleep apnea is caused by

Is caused by airway occlusion usually by the tongue or palate during sleep, but the person continues to try to breathe.

Paralytic ileus

Is cessation of bowel peristalsis. The bowel still continues to produce secretions.

central sleep apnea

Is complete suspension of breathing resulting from the dysfunction in central respiratory control

Malingering

Is different from the other this one is because it is conscious effort to escape unpleasant situation. The patient merely pretends to have the symptoms for personal or tangible gain (e.g calling in sick because the person does not want to go to work).

Complicated grief how is it distinguish from uncomplicated grief? what are the responses? prolong complicated grief has been associated with?

Is distinguished from uncomplicated grief by length of time and intensity of emotion. the person's responses are maladaptive, dysfunctional, unusually prolong, or overwhelming. For example, the beavered May become severely depressed, violent, or suicidal, they become a workaholic, become socially isolated, or demonstrate addictive behavior. or, after several years, the person may still be experiencing as much pain and disruption as in the first months after the loss. prolong or complicated grief has been associated with depression, suicidal ideation, and hypertension. risk factors for complicated grief include sudden death of a significant other, emotional instability, and lack of social support.

Pursed lip breathing why is it done and how to do it?

Is done to prevent air trapping . as air is pushed against the small opening between the lips, the resistance created goes backwards and through the airways and pushes them open throughout expiration, pursing the lips also prolongs the exhalation, all this result in a delay of airway compression, or collapse, allowing more air to escape and to prevent air trapping, and pursed lip breathing, the patient breathe in deeply through the nose, hold it in for a moment, and then exhale slowly through lips that are almost closed or purse as if patient we're going to whistle, exhalation should be at least twice as long as inhalation.

Anticipatory grief and what is the potential negative outcome

Is experienced before a loss occurs. a wife caring for her husband through a long illness may grieve as she sees the vibrant man she once knew change before her eyes and as she anticipates his death. Family members caring for a loved one with Alzheimer's disease common experience anticipatory grief, realizing that as mental capacity diminishes, the person they once knew will become ever more removed from them. The potential negative outcome of anticipatory grief is that the survivor may detached from a dying person too early in the dying process, leaving the person without emotional support that period. This does not always happen, of course.

Delayed grief is an example of complicated grief

Is grief that is put off until a later time (e.g. I'll think about it later. Right now, I'm busy trying to keep a roof over our heads and care for my children. ")

Nerve block

Is injection of anesthetic into and around a nerve or group of nerves. For example the facial nerve, the brachial plexus

how is Spinal anesthesia done? how does it work? what does it allow the patient to be? how to prevent respiratory paralysis

Is injection of anesthetic into the cerebrospinal fluid in the subarachnoid space. This injection block sensation in movement below the level of the injection. spinal anesthesia it's often use for surgical procedures in the lower abdomen, pelvis, and lower extremities. This technique allows the patient to remain conscious during the procedure and usually does not depress respirations. placing the patient in Fowler's position may prevent respiratory paralysis.

Impaired physical mobility

Is limitation of independent purposeful movement of the body. Impaired physical mobility is a broad, general diagnosis. Using the following more descriptive diagnosis when the patient has specific deficits such as in impaired bed mobility, impaired walking, impaired wheelchair mobility, and impaired transfer ability

what is a Ne tube? and use for patients at risk for?

Is longer than a NG tube, extending through the nose down into the duodenum or jejunum. if it extends to jejunum it's call a NJ tube. a NE tube may be use instead of an NG tube for patient at risk for aspiration. This includes patients who have decreased level of consciousness, absent or diminished gag reflex, or severe gastroesophageal reflux.

Reflex incontinence

Is loss of urine when the person does not realize the bladder is full and has no urge to void. central nervous system disorders and multi system problems are common causes. Nanda defines reflex urinary incontinence as the involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reach. tissue damage from radiation, cystitis, bladder inflammation, or radical pelvic surgery can also trigger reflex incontinence.

B 12 and vegetarianism

Is only found in animal products, such as eggs and milk. Vegan must eat food fortified with b 12 or take b 12 supplements. B 12 deficiency can lead to severe and irreversible neurological impairment

Isokinetic exercise

Is perform with specialized appartus that provide variable resistance to movement. isokinetic exercise combines the best features of both isometric and weight training by providing resistance at a constant, presets speed while the muscle moves through the full range of motion. specialized machines available at health club in physical therapy department are used for this form of exercise.

Isol

Isolation

Lateral position creates pressure on? but release pressure from?

It creates pressure on the lower scapula, ilium, and trochanter but release pressure from the heels and sacrum

adapting to the stressor type of coping strategy

It is not always possible to remove or change a stressor. Adapting involves changing one's thought or behaviour related to the stressor

Helping families of dying patients follow up with other healthcare team members promptly because the family may

It the family has questions that are outside your scope of practice

Lateral position potential problem and solution

Lateral flexion of the neck: place a pillow under the head and neck to provide alignment. Internal rotation and adduction of the upper shoulders and limited respirations: place a pillow under the upper arm, and comfortably flex the lower arm. Internal rotation and adduction of the femur: support the upper leg from groin 2 foot with pillows Twisting of the spine you should align the shoulders with the hips Flexion of the cervical spine: place a pillow under the head and neck to provide alignment, unless drainage from the mouth is desired.

Patient assist with limited mobility

Transfer belt or gait belt

Procedure steps what is the position for posterior lower lobes

Keeping the bed flat, position the patient prone with a pillow under her stomach.

Displacement examples and examples and consequences of overuse

Kick the dog. Transferring emotions, ideas, or wishes from one original object or situation to a substitute inappropriate person or object that is perceived to be less powerful or threatening E.g husband loses his job, go home, and yells at his wife. (This mechanism is rarely adaptive). In extreme situations, this mechanism leads to verbal and physical abuse.

The kidneys produced how much urine and at what rate in per day

Kidneys produce urine urine at a rate of about 50 to 60 ml per hour, or 1500 ml per day. However, output may fluctuate by 1000 ml to 2000 ml.

Ethnic, cultural, and religious practice of nutrition

Language barrier may make it difficult for a client to understand nutritional information. For those patients, simple visual aids may be useful. Ethnic/cultural food choices often reflect the food that were plentiful of origin. ( fish in coastal communities, coffee n cocoa bean n equatorial regions as well as foods that were readily grown in the native soil like rice and warm wetland and potatoes in colder climates Other diet choices reflect a concern for food preservatives for instance people from various Geographic regions eat salted meats and dried fruits and cook with fiery spices to combat microbes Certain religions may require fasting or abstaining from certain foods for example Roman Catholics fast on Ash Wednesday and Good Friday, kosher shell fish The burden of childhood obesity is not spread equally across the US population. for example, obesity has been increasing faster among Mexican American and African American children cultural beliefs, perception, and attitudes about weight issues may often not match those of health Providers. For example, some parents may perceive their children as cute and healthy even though their BMI indicates they are obese. a slim body is not the ideal in all cultures. traditional diets of many cultures are healthful and should not be discouraged, infact contemporary adaptations made to these diets may compromise their nutritional quality. examples of adapted traditional diets are the Asian, Latin, an Mediterranean diet pyramids. the Mediterranean diet which includes a glass of red wine and is rich in fish, vegetables, and nuts and low in dairy foods, saturated fats, and red meat, has been linked to decrease risk of death from all causes, including death due to cancer an cardiovascular disease in a u.s population.

Components of a Teaching Plan

Learning Outcomes/Objectives: what is to be learned Teaching strategies: method used to present content Content: all information needed to reach the learning outcomes Scheduling and sequencing: how to organize and sequence information Instructional material: materials/tools used to present Evaluation

Components of a Learning Assessment

Learning needs/knowledge level Health beliefs and practices Physical and emotional readiness Ability to learn Literacy level Health literacy Ability to see, feel, hear, grasp Learning style Time constraints Available resources

Why do we teach leg exercises

Leg exercises flex an extended leg muscles to increase peripheral circulation and help prevent thrombus formation.

What if the patient has had knee, hip, or back surgery

Legs exercises may be contraindicated in patients having knee, hip, or back surgery.

Individual Factors Affecting Safety

Lifestyle Cognition Balance, gait, and mobility Ability to communicate Visual acuity Emotional health Safety awareness

what are some Factors that influence cardiovascular function developmental young and middle adults

Lifestyle in young and middle adults can create cardiac risk factors. Family history of cardiovascular disease. some adults become too busy to prepare and eat nourishing foods, or more often simply prefer the taste of high fat, high sugar foods. A sedentary lifestyle, lack of aerobic exercise, and tobacco use

Respiratory Abnormal Findings

Limited chest expansion - lungs work best upright! Stasis of respiratory secretions, ineffective cough Shallow, rapid breathing Lung sounds diminished, crackles, rhonchi, wheezing Restlessness, confusion

Objective characteristics of impaired physical mobility

Limited range of motion, limitations in fine or gross motor Movement, lack of coordination with movement, unstable gait, decrease reaction time, postural instability, slow movement, and difficulty performing ADL

for assessing loss and grief Perform a physical assessment

Look for signs of increased stress, such as tension, forgetfulness, distraction, increase or decrease appetite and sleep, weight gain or loss, fatigue, and decrease self care (e.g. ,deficient hygiene) the rationale A thorough physical examination add data to help you determine how well the patient is coping with the loss or illness

exaggeration of anterior convex curve of lumbar spine.

Lordosis

Physical grief reactions

Loss of appetite, weight loss or gain, fatigue, decreased libido, decreased immune system response, decreased energy, possible physical symptoms such as headache or stomach pain

Older adults stressors

Loss of family and friends due to illness or death, resulting in loneliness and isolation, changes in physical appearance and functional abilities, including mobility. Major life changes. Health problems with accompanying discomfort or pain. The cost of healthcare. learning to live on a fixed, perhaps inadequate, income. adjusting to loss of independence. Reduction in social status. substance and alcohol misuse.

Potential Postoperative Complications:Collaborative Problems intestinal obstruction Illeus what is it, clinical signs, interventions

Loss of the forward flow of intestinal content due to decreased peristalsis secondary to anesthesia, handling of the intestine during surgery, electrolyte imbalance, infection, or ischemic bowel. Clinical signs : dead bowel 3-5 days post op, pt complaining of fullness, abd pain, abd distention. May get bowels, then hyperactive, then stop. Hyperactive bowel sounds are not normal after post op. If they stay obstructed, eventually vomit stool. Interventions : if they anticipates it put a nasogastric tube in. Observe for symptoms and notify the surgeon.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) uses radiowaves and a strong magnetic field to make continuous cross-section images of the body.

vaginal supp aftercare

Maintain position for 5-15 minutes Provide peri-pad if ambulatory

maintaining a clean environment

Maintaining a Clean Environment Clean spills and dirty surfaces promptly Remove pathogens through chemical means (disinfect) Remove clutter Consider supplies brought to the client room as contaminated Consider items from the client's home as contaminated Beds/Bedmaking

Middle age and older adults sleep they may experience what because of? what declines in later life?

May experience insomnia because of depression, anxiety, and tension that result from the stress of career demands, the need to care for a parent, marital discord, worried about teenage children, or financial problems. a physiological example would be menopause women may be weakened by hormonal fluctuations. many older adults suffer from sleep disturbances do to nocturia the side effects of medications and discomfort or pain. Also the levels of melatonin the natural hormone that controls sleep decline in the later decades of life.

How do antidysrhythmics increase surgical risk

May impair cardiac function during anesthesia

Helping families of dying patients listen actively to the patient's and families concerned. you should?

Make eye contact, classify when you don't understand. This helps you avoid misinterpreting the families concerns and needs

malingering

Malingering is different from the other disorders because it is a conscious effort to escape unpleasant situations. The patient merely pretends to have the symptoms for personal or tangible gain (e.g., calling in sick because the person does not want to go to work).

Personal, socio cultural, and environmental factors of urine

Many people put a voiding while they are working, watching TV, or busy with other test. Delaying urination promotes urinary stasis can lead to bladder infections.

Vitamin d and vegetarianism

May be inadequately supplied by vegetarian diet, so vitamin d fortified foods like soy and dairy milk are usually in vitamin d fortified should be included. Adequate sun exposure also helps to compensate for lack of dietary intake

Protein and vegetarianism

May be inadequately, especially in vegan children who don't care for the taste of soy milk, tofu, and other soy-based meat substitute

How do antibiotics affect surgical risk

May potentiate the action of anesthetic agents

NPO

Means no food or fluids including water by mouth. this may be order before surgery or an invasive procedure to limit the risk of aspiration. Common examples are NPO after midnight or NPO 8 hours prior to procedure. Most well Nourish, well hydrated patients easily tolerate short term NPO status. However, no one can tolerate long periods of NPO. Intravenous fluid may be given to provide hydration, and client who must remain nPO for lengthy period need enteral or parenteral nutrition to prevent malnutrition.

How to put on thigh high stockings stocking, what happens if too tight? measure? launder stockings? cannot be applied if what?

Measurement of lower extremity. Too tight may compress the veins and impair circulation to skin. A. Measure the circumference of the thigh at the widest section. Cannot be applied if exceed 25 inches. B. Measure the calf circumference at the widest section. C. Measure the distance from the gluteal fold to the base of the heel. Pull up to the g luteal fold of the thigh, rotating inward so the gusset is centered over the femoral artery, slightly toward the inside of the leg. Launder stockings every 3 days

What is a electrocardiogram, how to prepare the patient: where is it placed? , what the patient can expect: is it painless or painful? they must lie? may need to? , post procedure routine for my patient, what can go wrong, how will I know something went wrong, what to do if something went wrong

Measures/print out a reading of electrical activity. -How to prepare the patient: gel/patches and wires attached are placed on chest and extremities flow of electricity is from the patient. -What to expect: painless must lie still while recording may need to shave hair for better patch conduction. -Post procedure: remove patches - may pull skin wipe off excess gel if any. -What can go wrong: poor contact between the skin and electrode, Patient movement, inaccurate placement. -How will I know: poor reading on recording strip. -What to do if it does: cleanse/shave/ reapply patches re-run graphing of rhythm.

Equipment for applying anti embolism stockings

Measuring tape an anti embolism stockings possible washcloth and towel

Measuring residual volume and injecting air into the feeding tube

Measuring the residual value of the aspirate and observing for unexpected changes in the volume. A dramatic increase in the residual volume may indicate that a small bowel tube has moved into the stomach If the tube is in the stomach, injecting 5 to 30 ml of air produces a gurgling sound audible by listening with a stethoscope over the stomach. This is the least reliable method for checking placement of an NE or NG tube.

Moderate dependence (no patient assist for lifting from floor)

Mechanical lift with full swing, or if transfer is manual, more than one helper might be needed.

Mechanical soft diet

Mechanical soft diet is the diet of choice for people with chewing difficulties resulting from missing teeth, your problem, or extensive fatigue. A soft diet includes all items on the full liquid diet plus soft vegetables and fruit; chopped, ground, or shredded meat, and breads, pastries, eggs, and cheese. Many food items can be added to this died by cooking them extensively or blending or grinding to alter their texture. This diet can supply a full range of nutrients but is quite low in fiber. As a result, constipation is a risk.

Risk FOR urge urinary Incontinence

Medication, Caffeine, alcohol Detrusor hyperreflexia from cystitis, urethritis, tumor, renal calculi, and central nervous system disorder Involuntary sphincter relaxation Ineffective toileting habits Small bladder capacity

Rest

Mild to no activity Relaxation; stress-free Leads to feeling refreshed

The physiological stages interventions include of dying

Mobility, oxygenation, safety, nutrition ,fluids, pain

Physiological needs of active dying include

Mobility, oxygenation, safety, nutrition, fluids, elimination, personal hygiene, comfort, and control of pain and symptoms

mobility, partial mobility, immobility, bedrest, and ADL

Mobility: the ability to engage in activity and unrestrained movement Partial mobility: some compromise in movement ex. Person in a cast Immobility: inability to move about freely or to change positions at will Bedrest: therapeutic restriction of mobility ADL: activity of daily living (feeding, bathing, grooming, dressing, toileting, walking, and transferring)

the spread of infection mode of transmission

Mode of Transmission Contact Direct - touching, kissing, sexual contact Indirect - contact with a fomite Droplet: cough, sneeze (moist) Airborne: via air conditioning, sweeping (dry)

nursing considerations of local anesthesia

Monitor client

managing diarrhea.

Monitor stools to quantify diarrhea Assess and monitor for fluid imbalance Monitor for alterations in Perineal skin integrity Proper dietary teaching -Clear liquid -Bananas, rice, applesauce, toast (BRAT) -Foods to avoid like highly spiced foods, high fat foods, greasy snacks, or large quantities of raw fruits and vegetables may cause diarrhea in some patients. Antidiarrheal medications -Not recommended for acute diarrhea -Teach clients about over-the-counter aids

spinal anesthesia nursing considerations

Monitor vital signs, encourage oral fluids

Clear diet

Moodily see through like tea, carbonated beverages, clear fruit juices, popsicles

Factors influence cardiovascular function developmental older adults they are more prone to?

More prone to orthostatic hypertension. cardiac efficiency gradually decline as the heart muscle loses contractile strength and heart valves become thicker and more rigid.

Assist with positioning for voiding

Most men stand to void and may have difficulty voiding in other positions. Whenever possible, assist the patient to the bathroom to use the toilet and allow him to assume his preferred position. Alternatively, provide a bedside commode or urinal for the patient to use. To place a urinal, position the patient in a semi Fowler's position with the legs slightly spread. place the urinal on the bed between the patient's legs, and insert his penis in the urinal. Women generally find an upright seated or squatting position to be the most comfortable position for voiding. If a female patient must remain in bed, provide a bed pan. Place her in a semi Fowler's position to urinate unless contraindicated. raise the side rails or provide an overhead trapeze so that the patient will have grip holds to maneuver herself onto and off the bed pan. If the patient is very weak, you may need an assistant to help you position her on the bed pan, and you may need to stay with her to help her maintain her position on the bed.

Facilitating toileting routines

Most patients void on awakening, after meals or drinking a large volume of fluid, before bedtime, or during the night for some. identify your patients pattern, and stick to it as much as possible. if you anticipate a change in the pattern for elimination, inform the patient. for example, if the patient is to receive a diuretic, explained that he would need to urinate more often.

Safety Hazards in the Community: motor vehicle injuries causes and preventions

Motor Vehicle Injuries -Causes: failure to use seatbelts; use of alcohol; pedestrian accidents; non-deployment of airbag -Prevention: >>avoid distractions in car (cell phone, text messages, loud music); >>use designated driver; >>use seat belts, >>proper age-dependent restraints for children

Abduction

Move body part away from midline of body

Adduction

Move body part toward midline of body

how to do Rotation?

Move, joint around its cental axis

what is Resistance training?

Movement against resistance increases muscular strength and endurance. Perhaps the most common type of resistance training is weight lifting. when a person is exercising for strength, the goal is to increase the amount of resistance with each exercise. when a person is exercising for endurance, the goal is to increase the number of repetitions with each exercise.

Why do we teach a client to move in bed

Moving in bed promotes blood circulation, stimulates respiratory function, and help mobilized gas in the intestines.

Safe Movement/Transfers

Moving/Positioning in bed Range-of-motion (ROM) Transfers >>Assisting OOB chair/WC >>Slideboard >>Mechanical Lift

Physiological stages of dying days to hours before death muscles and urine and vision and the final hours of life

Muscles throughout the body relax, causing the face to droop. as persistalsis slows, the patient may retain feces. urine output reduces in the urine often becomes more concentrated and foul smelling. Sphincters relax, and bowel and bladder incontinence can occur. Vision blurs, the eyes may be open or partially open, but un seeing. instead, the patient may see things that are not visible to others. in the final hours of life, many patients become restless and agitated. This response may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, or unresolved emotional or spiritual issues. near to the time of death, some people unexpectedly become more coherent and energized for time. others become less communicative, quiet, and withdrawn Fatigue is common.

Wheezing

Musical sound produced by air passing through partially obstructed small airways. It is often heard in patients with asthma and lung congestion.

changing a dressing must know?

Must know: - Type of dressing - Presence of underlying drains or tubing -Type of supplies needed - Check provider order -Solution ordered -Frequency -Ointments ordered

Stages of sleep

NREM REM

common types of charting

Narrative PIE SOAPIER Focus Electronic entry format

Patients have nausea, what are my nursing interventions?

Nausea can cause vomiting and loss of appetite, leading to impaired nutrition. Nursing interventions include assessing for the cause of the nausea, and providing comfort and prevention measures.

Review of body system gastrointestinal you want to know

Nausea, vomiting, weight gain or lost, ulcers, Crohn's disease, ulcerative colitis, devices

Ketones in urine

Negative

Nitrite and leukocyte

Negative

bilirubin

Negative

Metabolic/NutritionalAbnormal Findings

Negative nitrogen balance: nitrogen output exceeds intake (protein catabolism exceeds anabolism) Albumin(decreased): Serum albumin level is best predictor of prolonged protein depletion Hypercalcemia: increased serum calcium caused by reabsorption of calcium from bone Weight loss Problems with swallowing, anorexia, digestion

Hemoglobin

Negative on dipstick

Never change a Dsg without an order. If you have copus drainage you reinforce. Never change it unless the doc tells you too.

Never change a Dsg without an order. If you have copus drainage you reinforce. Never change it unless the doc tells you too.

Age and sleep, newborns young children experience? young adults? older adults?

Newborns and young children experience prolong sleep periods, young adults spend about 25 percent of their sleep in REM sleep, and older adults typically enter REM sleep quicker and spend more time in this active phase of sleep.

Spiritual distress what are the defining characteristics?

Nightmares or other sleep disturbances, concern over the meaning of life/death/suffering/existence, gallows humor, questions moral implications of therapeutic regimen, anger at God, desires but unable to participate in usual religious practices

noinvasive vs invasive

Noninvasive the body is not entered with any type of instrument. Invasive accessing the body's tissue, organ or cavity through some type of instrumentation procedure. example is lab work

Uncomplicated grief

Normal grief is the natural response to a loss. the bereaved person experiences the feelings, behaviors, and cognition that are expected in light of his culture, social status, and the relationship to the lost person or object. The emotions are intense but gradually diminish overtime can be to several months to several years. some emotions will always be present, but the intensity will change.

who does the Recognition of Practice Events?

North Carolina Board of Nursing Just Culture in Nursing Regulation

Acceptance stages of dying and grief

Not necessarily wanting death or the loss, but coming to terms with it and ceasing to fight it. the person may seem almost void of feelings. it is the final stage

Regional anesthesia is not practical for who and what is it

Not practical for someone who is highly anxious or if adequate pain control cannot achieved. It prevents pain in the area of the procedure by interrupting nerve impulses to and from the area.

Dietary Restrictions

Nothing by mouth after midnight NPOAM Optimal is at least 6 hours of NPO status prior to surgery DECREASES THE POSSIBILITY OF ASPIRATION Clarification should always be done concerning the patient's routine medications.

Preparation of client reporte practitioner

Notify practitioner of herbal supplements, allergies, previous adverse reactions, or suspected adverse reactions following administration of drugs . Notify practitioner of any client or family concerns you were not able to alleviate

During the testing report to practitioner

Notify the practitioner if the client has any concerns or questions that you were not able to resolve. Notify the practitioner of the client has family members present and where they are waiting during the procedure.

Post test care report to practitioner

Notify the practitioner of any signs of respiratory distress, bleeding, or changes in vital signs, adverse reactions to anesthetic, sedative, or dye, and other signs of complications. Notify the practitioner regarding client or family concerns or questions that you are not able to answer. Notify the practitioner when any results are obtained from the diagnostic test. notify the practitioner when the client is fully alert and recovered from an order to discharge.

Professional Guidelines for Ethical Decision-Making

Nursing Codes of Ethics International Council of Nurses American Nurses Association Standards of Care Canadian Nurses Association Patient Care Partnership

Nursing Process: Diagnosis

Nursing Diagnosis: "The diagnosis and treatment of human response to actual or potential health problems" (ANA, 1980) Includes strengths, problems, and factors contributing to the problems A health problem is any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness

assessment of patient who is at risk for infection include?

Nursing History Physical Assessment Presentation (complaints) Physical data Skin Lymph nodes WBC Cultures

Etiology (Causes) drives what

Nursing Interventions address the etiological factors of the human response (so if I fix the cause, the problem will be addressed and resolved)

etiology drives what

Nursing Interventions address the etiological factors of the human response (so if I fix the cause, the problem will be addressed and resolved)

Activity

OOB ASAP!! Usually within 24 hrs Psychological impact Needs encouragement! it is powerful both psychological and physiological

how do i administer nasal medication

Occlude one nare and administer drops to the other and to inhale deeply, repeat with other side Administer spray while patient breathes through mouth -prevents aspiration of drops into the lungs

Burnout

Occurs when nurses and other professionals cannot cope effectively with a physical and emotional demands of the workplace. Excessive demands by an employer serves as a catalyst for burnout. In some situations, the nurse receives no respect little support from the employer or coworkers. Filled with feelings of injustice for treatment receive, the nurse may respond with anger and frustration, feel overwhelmed and helpless, and suffer low self esteem and depression. Some nurses experience grief reactions, moral distress, and guilt feelings because the situation prevents them from performing as well as they believe they should. the nurse who burns out may develop a physical illness or a negative attitude or may use maladaptive coping techniques.

Masked grief is an example of complicated grief

Occurs when the person is grieving but expresses the grief through other types of behavior. For example, a man whose wife has died may begin drinking heavily, or a couple whose child has died may find themselves engaging in violent arguments with each other. this change in behavior is part of their grief response, but they don't recognize it as such.

Physiological stages of dying days to hours before death, what does dehydration mean?

Often a surge of energy brings mental clarity and a desire to eat and talk with family members. However, as death approach, patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume. the tissues of the tongue and soft palate sag, and the gag reflex declines, so secretions accumulate in the oropharynx and/ or bronchi. Often the mucous membrane becomes dry and tacky lips become cracked. Dehydration during the last hours of dying is thought to not cause distress, and perhaps to stimulate endorphin release.

Frequency & Time of evaluation

Ongoing Intermittent Terminal

Measuring urine from an indwelling catheter

Open the drainage spout and allow urine to drain into the measuring device, be careful to avoid touching the spout to the inside of the container. Pour the urine from the bed pan or urinal into a graduated measuring device. Place on a flat even surface and read the amount at eye level.

Classification of Wounds. what is open/ closed. acute, clean, contaminated, infected, superficial, partial thickness, full thickness, penetrating

Open/closed- >>open - exposed to air, break integrity. examples are abrasions, lacerations, puncture wounds, surgical incisions. >>closed- bruise or hematoma. skin intact Acute- new wound >>Clean= are uninfected wound with minimal inflammation. may be open or closed and do not involve gastro, respiratory, genitourinary tract. >> contaminated= include open traumatic wound or surgical incisions in which a major break in asepsis occurred. >>infected= when bacteria counts in the wound tissue are above 100,000 organisms per gram of tissue Superficial: involve the epidermal only. injury usually a result of friction or shear or burn partial :extend through the epidermis but not through the dermis or full-thickness: extened into the subcutaneous tissues and beyond Penetrating:is sometimes added to indicate that the wound involves internal organs. wound depth is a major determinant of healing. the deeper the wound the longer the healing.

Achondroplasia

Or dwarfism, occurs when the bone ossify prematurely.

to stimulate the patient's appetite if the patient is not in the room during meal time

Order a late food tray or warm the food

Nursing outcomes and interventions for ineffective peripheral tissue perfusion

Outcomes circulation status, fluid overload severity, sensory function cutaneous, tissue integrity skin and mucous membranes Intervention circulatory care ( arterial and venous insufficiency), fluid management, peripheral sensation management, skin surveillance.

disturb sleep patterns outcomes and interventions

Outcomes rest, sleep, personal well-being. Intervention coping enhancement, energy management, environmental management comfort, sleep relaxation therapy, sleep enhancement

Readiness for enhanced sleep outcomes and intervention

Outcomes rest, sleep, personal well-being. Intervention environmental management comfort, sleep enhancement

Sleep deprivation outcomes and interventions

Outcomes rest, sleep, symptom severity Interventions coping enhancement, energy management, environmental management comfort, simple relaxation therapy, and sleep enhancement

Factors affecting stress

Overall health, support system, perception of stressor, age, life experience, level of development

Subjective characteristics of impaired physical mobility

Pain or discomfort with movement, exertional dyspnea

End-of-life care includes

Palliative care and hospice care

Ability to obtain food and nutrition

Paralysis or hemiplegia can cause functional limitations that affect mobility and hence the ability to shop for food. Social factors also limits the ability to gather up or procure food. People with limited income may be forced to choose between buying food, medication, or household utilities. Homeless people and others in extreme poverty are often reduced to eating from trash cans and dumpsters or consuming non foods, such as paper, grass, and clay

Performing passive range of motion exercises

Passive range of motion is the movement of the joint through their full range of motion by another person. first explain the purpose of passive range of motion. you may also wish to teach family members and caregivers about the importance of range of motion exercise and enlist their help in exercising the patient when they visit. Observe the patient as you perform the range of motion. You may need to perform the exercises in several short segments if the patient tire easily or experiences discomfort. support the patient limb above and below the joint that is to be exercised. Move the joint in a slow, smooth, rhythmic manner. Avoid fast movements, they may cause muscle spasm. Never force a joint. Some patients may have limited range of motion. Move each joint to the point of resistance. This should not be painful. Perform passive range of motion at least twice daily. move each joint through the range of motion 3 to 5 times with each session. consider incorporating passive range of motion into care activities, for example, while bathing or turning the patient. Return a joint to a neutral position when exercise is complete Encourage active exercise whenever possible

Droplet precautions

Pathogen greater than 5 microns Influenza Parainfluenza Respiratory syncytial virus Pertussis Neisseria meningitis Group a strep -room with closed door or face mask for transport. -face mask or face shield before entering room -googles, gown, gloves if at risk of respiratory fluids.

in contact precautions, how are pathogen spread? what are the sources of infection? and what are the precautions to take?

Pathogen is spread by direct contact -Sources of infection: draining wounds, secretions, supplies -Precautions include >Possible private room >Clean gown and glove use >Disposal of contaminated items in room >Double-bag linen and mark

airborne precautions and the most dangerous. how is spread? how is it transmitted? what are the precautions to take? when transported a patient what must the patient have?

Pathogen is spread via air currents -Transmission via ventilation systems, shaking sheets, sweeping -Precautions include -Same as those for contact, with addition of special room, special mask, and mask for patient when transported

droplet precautions

Pathogen is spread via moist droplets Coughing, sneezing, touching contaminated objects Precautions include Same as those for contact Addition of mask and eye protection within 3 ft of client

Illness

Pathology affecting an organ or body system

how to Test stool for occult blood

Patient should avoid foods that may alter the accuracy of the test for 3 days before collecting stool specimen. Review the patients medications. take care that the sample is not contaminated by urine or menstrual blood. test two small stool samples from separate areas of the large sample. Follow the manufacturer's direction, place the correct number and size of drops of developer solution into the Windows of the opposite side on the hemoccult slide. record a positive result if the slide windows turn blue.

interventions to meet the psychological needs of the dying person? what is most helpful? what is a viable means of coping? what is a priority at this time? be aware of?

Patients experience many emotions at end of life, including anger, sadness, depression, fear, relief, loneliness, and grief. At this time, communication and support are most helpful. Discussing concerns and issues is a viable means of coping. ● Answer all questions honestly. ● Explain procedures that are being done. ● Realize that the patient may feel she is losing control. Help the person to acknowledge what she does have control over. Include the patient in care decisions as much as she is able to participate. ● Attend to social needs: Relationships are a priority at this time. Some patients may simply need to keep the bonds with family members and friends intact. For other patients, this may be a time to reestablish or mend relationships. ● Early in the dying process, finances may be a concern and may place an additional burden on the family. The patient may feel she is a burden to care for. As you assess these needs, it will be important to know the sources of support to assist the patient and family. ● Be aware of sexual needs and suggest ways a couple can be close and affectionate at this time. Some people may feel it is not right to have sexual feelings when the person they love is dying. Others may be afraid of harming the patient if they are sexually intimate. Provide realistic information about these issues. Expressions of sexuality may change as a person becomes closer to death. ● Some people seem to wait to die until after a significant date (birthday, anniversary, etc.) has passed. Others wait for family to gather; others wait until loved ones leave so they will not upset the family by dying while they are there.

Caring for the dying person meeting the psychological needs if there is advance directive or living will locate the document

Patients experienced many emotions at end of life, including anger, sadness, depression, fear, relief, loneliness, and grief. at this time, communication and support are most helpful. Discussing concerns and issues is a viable means of coping. - review the documents to be certain you understand the patients wishes. If you have not already done so, notify all relevant health professionals of the existence of these documents - answer all questions honestly. - explain all care and treatment even if the patient is unconscious because he may still be able to hear. - realize that the patient may feel he's losing control. help the person recognize what he does have control over. Include the patient in care decisions as much as he is able. - attend to social needs. Relationships are a priority at this time. Some patients may simply need to keep the bonds with family members and friends intact. For other patients, this may be a time to reestablish or mend relationships. Notify family members when the patient wishes to see them. Allow the patient and family to discuss death at their own pace. Offer to contact chaplain or other spiritual leader if the patient chooses. Pray with the patient if he request it and you are comfortable doing so. - encouraged patient to express feelings. - early in the design process, assess the sources of financial support. - beware sexual needs. - when the patient is very near death focused on relieving symptoms and emotional distress - if the person can communicate, ask about immediate concerns, for example are you in pain? are you comfortable? What can we do to help you go peacefully? who do you want in the room with you right now? if the patient ask whether he's dying, be honest - if the patient cannot communicate, ask the family what the patient would want. - when the patient is very near death, it may be helpful to say something like, your family will be fine rather than, it is ok for you to go now

Readiness for enhanced urinary elimination what are the defining characteristics

Patients expression willingness to enhance urinary eliminate need that can be strengthen 1. Patient express willingness 2. Urine color is straw color with no odor 3. Specific gravity within normal limit for age and output within normal limit

How does allergies increase surgical risk

Patients may be allergic to medications, tape, latex, and solutions using surgery. Reactions range from unpleasant to life-threatening.

Patients who are NPO, at risk for?, need?

Patients who can't have oral food and fluids need comfort measures. intravenous fluids for hydration may also include small amounts of glucose, but certainly not enough to meet bodily needs. Provide or assist patient with oral hygiene. It's allowed, provided by ice chips, hard candy, chewing gum, or sips of water for rinsing the mouth. tell family or visitors not to eat or drink around the patient, and try to schedule other activities for the patient at mealtimes. Remember, too, that remaining NPO for more than 3 days puts the patient at risk for malnutrition.

Factors affecting grief amount of support for the bereaved because people with?

People with more emotional and psychosocial support typically have less complicated grief.

Perceive constipation

Perceive constipation THE State IN Which An individual makes self diagnosis of constipation and ensures a daily bowel movements through abuse of laxatives, enemas, and suppositories

How to teach leg exercises ankle circles

Perform ankle circles, instruct the patient to: a. Start with one foot in the dorsiflex position. B. Slowly rotate the ankle clockwise. C. After three rotations, repeat the procedure in a counterclockwise direction. D. Repeat this exercise at least 3 times in each direction, then switch and exercise the other ankle.

how to teach ankle pumps?

Perform ankle pumps. A. Start with one foot, leg extended. B. Point the toe until her foot is plantar flex. C. Pull the toes back toward her head until the foot is dorsiflexed at the same time, press the back of the knee into the bed. D. Make sure she feels a pull, or a stretch, in the calf. E. Repeat the alternation between plantar and dorsiflexion several times. F. Repeat the cycle with the other foot.

how to teach leg exercise, what position do we want the client?

Perform leg exercise: a. Lie supine In the bed. B. Slowly begin bending the knee, sliding the sole of the foot along the bed until the knee is in a flexed position. C. Reverse the motion, extending the knee until the leg is once again flat on the bed. D. Repeat several times. E. Repeat using the opposite leg.

perform percussion where, instruct the patient to and place and avoid

Perform percussion over the affected lung area while patient is in the desired draining position. Instructed patient to breathe deeply and slowly because relaxation help the patient tolerate the procedure. also place a towel over the patient's skin or cover with the patient's gown the area to be percussed because it protects the skin and promotes patient privacy and comfort Avoid clapping over bony prominences, female breast, or tender areas of the chest. percussing over these areas may cause discomfort and compromise tissue integrity. Cup your hands, keeping your fingers flex and your thumbs pressed against your index fingers because it promotes patient comfort during percussion percuss the lung area for 1 to 3 minutes by alternately striking your cup hands rhythmically against the patient. Perform vibration while the patient remains in the desired drainage position. Place the flat surface of one hand over the lung area that requires vibration. Place your other hand on top of that hand at a right angle. Because using the flat surface of the hands provides a larger surface area to transmit vibrations through the chest. placing one hand on top of the other provides better leverage for vibrating. and instruct the patient inhale slowly and deeply. instructed patient to make a ffff or sss sound as she exhale. Continue performing vibrations for three exhalation.

Active resistive range of motion, why is it done

Performed by client against manual or mechanical resistance. It is done to increase muscle power

isometric exercises

Performed by client, altenate contraction and relaxation of muscle without moving joint. maintains muscle strength when joint is immobilized.

Active assistive range of motion

Performed by the client with assistance of nurse, measure motion in the joints

Active range of motion

Performed by the client without assistance, maintains joint mobility and increases muscle strength

Passive range of motion and why is it done?

Performed by the nurse without assistance from client the reason is retention of joint range of motion to maintain circulation

Sleep Apnea

Periodic breathing cessation for at least 10 seconds during sleep

what is Chronic sorrow? what will the patient express?

Periodic, recurrent sadness feelings of varying intensity that interfere with high level well being, expresses one or more of the following feelings, anger, being misunderstood, confusion, depression, disappointment, emptiness, fear, frustration, guilt, helplessness, hopelessness, loneliness, low self esteem, being overwhelmed

Physiological stages of dying days hours before death what happens with the peripheral circulation,

Peripheral circulation decreases, and the person perspires and feels clammy. The blood pressure decreases, and the pulse may be hard to detect. The extremities become cool and mottled, and the underside of the body maybe much darker. Decrease circulation also results in reduce kidney function and decrease urinary output.

Anxiety and urine

Person who is anxious and tense cannot relax the abdominal and perineal muscles and the external urethral sphincter. It is then difficult to void. Also lack of time. Lack of privacy. Loss of dignity. Cultural influence.

Promoting exercise

Personalize the benefits of regular physical activity. In other words find out what motivates your patient. For instance, your patient might want to lose weight and improve his physical appearance. Yet another patient might be interested in improving the quality of sleep or overcoming. Periods Of low energy during the day Set personal goals for physical activity. Simple, realistic goals tend to be best. Be sure to define them so they are specific and measurable. Include a variety of activities to keep the patient from feeling bored. remind your patient to recognize and appreciate success. Suggest strategies to achieve the patient's goal . for instance, you might suggest a fitness program that is fun and entertaining. You can also inform your patient about ways to avoid joint injury or falls. provide encouragement. sometimes just the right approach is a positive, enthusiastic one. You might offer praise for taking steps toward health and fitness. Support from spouse, family members, friends, and coworkers can improve compliance and consistency. promote physical exercise as an enjoyable activity. Discuss barriers to regular activity and elicit ways to overcome those obstacles.

What Factors Disrupt Health?

Physical disease Injury Mental illness Loss Impending death Competing demands The unknown Imbalance Isolation

The Influence of Health Status on Self-Care Ability

Physical factors Pain Limited mobility Sensory deficits Cognitive impairments Psychosocial factors Emotional disturbances Mental health issues

what does Physical loss vs psychological loss

Physical loss include 1 injuries (e.g when a limb is amputated), 2 removal of an organ (e.g hysterectomy), and 3 loss of function (e.g loss of mobility). Psychological losses challenges our belief system. They are commonly seen in the areas of sexuality, control, fairness, meaning, and trust. some losses may be mix. For example, after removal of a prostate gland, a man may feel both the physical and psychological loss of sexuality.

Measuring urine output from a bed pan or urinal

Place the bed pan or urinal in the proper position and encourage your patients to begin voiding. Instruct the patient to press the call light button when finish or remain close by. Pour the urine from the bed pan or you're into a graduated measuring device. Place on a flat, even surface and read the amount at eye level.

Inserting nasogastric and nasoenteric tube

Place the patient in a sitting or high fowler position. Measure the length of the tube. NG tube are measured from the tip of the nose to ear lobe and from ear lobe to the xiphoid process. Nasoenteric add 8 to 10 cm to the ng measurement as directed. wrap 10 to 15 centimeters of the end of the tube tightly around your index finger, then release. Lubricate into with a water soluble lubricant. Ask the patient to hyperextend the neck and breathe through the mouth. Insert the tube gently through the mouth, advance the tube as the patient swallows. Instruct the patient to tilt the head forward, drink water, and swallow. Withdraw the tube immediately if respiratory distress occurs during or immediately after insertion. Confirm tube placement initially by xrays. Always reconfirm placement with a combination of bedside methods this before giving feedings or medicine. Secure the tube to the nose and onto the patient's gown.

To avoid injury when moving objects

Place your center of gravity closest to your base of support and stand with your head erect, buttocks pulled in, abdominal muscles tight, chest high, shoulders pulled back, and feet wide. Use a wide stance, with feet apart and one foot forward when standing for long periods of time. The broader the base of support, the lower the center of gravity, and the easier it is to maintain balance.

how do i administer optic medication? place pressure on what?

Placement: conjunctival sac Pressure to nasolacrimal duct to prevent systemic absorption Ointment placed from inner to outer canthus

Establishing a Bowel Training Program

Plan program with the client Increase fiber in diet gradually Increase fluid intake to 8 glasses water per day Establish a designated time for defecation Provide privacy for the client Treatment plan should be staged Treatment may include stool softener Modify the plan based on client results

Discharge PlanningAKA: Transition Planning

Planning for self-care and continuity of care after client leaves health-care setting Begins with initial assessment All clients need discharge planning Requires collaboration

Plantar flexion

Pointed toes away from the head

Dorsiflexion

Pointed toes toward the head

Safety Hazards in the Home what can be poisoning? how can be prevented? what is treatment?

Poisoning -Household chemicals, lead, medicines, cosmetics -Prevention: cabinet locks, store poison high, keep Poison Control telephone number available -Treat: depends on type of poison ingested; antidotes, charcoal, etc.

Critical aspects of obtaining a specimen by suction, what position? don what? lubricate with what? how long do you apply suction? and if you don't get enough suction what should you let the patient do?

Position in high or semifowlers position. Don protective eyewear. Attach the suction tubing to the male adapter of the inline sputum specimen container. Lubricate the suction catheter with sterile saline solution. Insert the tip of the suction catheter through the nasopharynx, endotracheal tube, or tracheostomy tube. Advance in to trachea. When the patient begins coughing, apply suction for 5 to 10 seconds to collect the specimen. if an adequate specimen is not obtained, allow the patient to rest for 1 or 2 minutes, and then repeat the procedure. administer oxygen at this time, if indicated. When an adequate specimen is collected, discontinue suction, and gently remove the suction catheter. label the specimen container.

Procedure steps what position do you want the client posterior section of the upper lobes

Position supine with pillow under the hips and knees flex. Have the patient rotates slightly away from the side that requires drainage

Documentation of preparation of client

Practitioner notification of allergies or suspected adverse reactions to contrast media. Presence, location, and characteristics of symptoms. Teaching and the clients response to teaching. Response to intervention

Reducing Anxiety and Fear

Pre-op teaching assessment of knowledge level Communication/ Therapeutic techniques verbalization of fears and hopes Rest "re-charging the batteries"

Lifestyle factors affecting oxygenation include

Pregnancy oxygen demand increases dramatically. - occupational hazards - nutrition - obesity causes :respiratory infections: excessive abdominal fat presses upward on the diaphragm, preventing full chest expansion, leading to hypoventilation and dyspnea on exertion. the risk for respiratory infection then increases because lower lungs lobes are poorly ventilated and secretions not remove effectively. causes: sleep apnea when the person lies down, chest expansion is limited even more. excess neck girth and fat deposits in the upper airway often lead to obstructive sleep apnea. A condition characterized by daytime sleepiness, loud snoring, and periods of apnea lasting 10 to 120 seconds Exercise increases metabolic demands. The body responds by increasing the heart rate and the rate and depth of breathing. Lack of exercise has the opposite effect Smoking tobacco smoking constricts bronchioles, increases fluid secretion into the airways, causes inflammation and swelling of the bronchial lining, and paralyzes cilia. These effects lead to reduce air flow increase production of secretions that are not easily removed from the airways - substance abuse overdose can cause death due to hypoventilation, apnea, respiratory failure.

Lifestyle factors that affect cardiovascular function include

Pregnancy, nutrition, obesity, exercise, tobacco, and substance abuse.

Factors influencing oxygenation developmental stage infant, premature infants are at high risk for? by 6 months of age they are at risk for?

Premature infants less than 35 weeks do not have a fully develop alveolar surfactant system. they are at high risk for respiratory distress syndrome. RDS is characterized by widespread atelectasis. Also has immature pulmonary circulation. Together with hypoventiliation, this leads to hypercabria and hypoxemia Infants born at term also at risk oxygenation problems - because the new borns lower airway structures are immature and small, an infectious agent can spread rapidly. - the infant airways are quite narrow in diameter and, therefore, easily obstructed by edema, mucus, or a foreign body such as meconium passed at birth - the central nervous system for preterm, and even some term, infants is immature, leading to periodic breathing pattern and apnea - immune system of infants in the first few months of life is immature. although at birth, infants enjoy the benefits of some maternal immunoglobulin circulating in their system, this protection is limited and not sufficient for fighting certain infections. - by 6 months of age, infants can grasp small objects and put them in their mouth. This new skill, combined with small airway diameter, puts them at risk for choking on small objects.

general guidelines for preparing a client for diagnostic testing

Preparing a client for diagnostic testing -Identification and assessment of client >>Establish baseline vital signs >>Identify known allergies Client teaching about the procedure -Test preparation >>Dietary >>Medication administration -Expectations during testing -Post testing care/follow-up

Ability to prepare food functional limitiation of nutrition

Preparing food takes time and energy. A person with severe dyspnea from chronic obstructive pulmonary disease for example may not have the stamina to prepare a nutritious meal. Instead she may be prepared foods that are high in sodium content. Fatigue is also caused by advance chronic disease, Severe anemia pregnancy, depression or excess work.

Hand rolls do what?

Prevent hand contractures.

Gastrointestinal Preps

Prevent injury Clear visualization of the area Reduce the number of bacteria in the operative site

Hip abduction pillows are good for?

Prevent internal hip rotation and hip adduction when the patient is in a supine position. there also use after a femoral fracture, hip fracture, or surgery

implementing medical asepsis

Preventing Infection: Implementing Medical Asepsis "A state of cleanliness that decreases the potential for the spread of infections" Promoted through Maintaining a clean environment Maintaining clean hands/Handwashing/Gloving Balanced hygiene Following Centers for Disease Control (CDC) guidelines

managing fecal impaction

Prevention is the best treatment Determine presence: digital examination Enemas (Procedure 28-3) Oil retention to soften Tap water or Fleet enemas  to remove and cleanse Manual/digital removal (Procedure 28-4) "disimpacting" Establish bowel program to prevent recurrence

Why do we put anti embolism stockings

Prevents venous distention and edema that occur when the patient is sitting or standing

what is somatoform Pain disorder?

Previously called somatoform pain disorder, this is emotional pain that manifest physically pain is the main focus of the persons life. the level of pain the person States is inconsistent with the physical condition that is, the physical cause it's either disproportionate to the pain or cannot be found at all. the pain does not change location.

Lines of Defense Against Infection primary

Primary Defenses Anatomical features, limit pathogen entry Intact skin Mucous membranes Tears Normal flora in GI tract Normal flora in urinary tract

vaginal supp administration

Privacy & dignity Insertion along the posterior wall of the vagina about 8cm (3inches) Lubricant if indicated

rectal supp administration

Privacy & dignity Insert past the internal sphincter Adult 1-3 inches Child: ½-1 inch Lubricate well with water based gel

Personal and sociocultural factors of bowel elimination

Privacy is important to most people, is sufficient time to have a bowel movement without feeling the need to hurry. clients working in a fast paced jobs may have difficulty even consciously recognizing the need to defecate, and some habitually ignore the need, promoting bowel dysfunction. parents and caregivers of infants and toddlers may postpone their own Toileting needs because of fear of leaving the children alone. some clients are acutely embarrassed by the thought that anyone might realize they are having a bowel movement and will wait until they are entirely alone before even entering the bathroom. stress has a major influence on motility of the GI tract. it may cause diarrhea or constipation and is the primary risk factor in development of irritable bowel syndrome.

pie charting? what does it not document? used in only what type?

Problem (Nursing diagnosis) Interventions Evaluation Used only in problem-oriented charting Establishes an ongoing plan of care Does not document the planning phase of the nursing process (AKA: goals and outcomes)

How Do Goals Relate to Nursing Diagnosis?

Problem statement describes the response/health status to be changed The goal states the opposite of the problem response The expected outcomes describe "correction" of the defining characteristics Wellness diagnoses goals demonstrate health maintenance or achievement of a higher level of health

common documentation system what is problem-oriented? and what are the 4 components?

Problem-oriented -Organized around client problems -Four components: database, problem list, plan of care, and progress notes -Allows greater collaboration -used for pie charting

transfer report include

Procedure performed. Type of anesthesia. medications administered in the surgical suite . duration of the procedure and anesthesia. Post operative vital signs. pulse oximetry values. Allergies. Lab values. estimated blood loss. Fluid intake and output, including urine, stool, gastric losses. Preoperative mobility status, skin integrity, and sensory perception abilities. surgical complications. Presence of tubes, drains, catheters. Existing IV line. Post operative prescriptions.

what are receptors? what are thermo? prop? mech

Process of receiving stimuli from nerve endings Occurs through receptors ex: thermoreceptors, proprioceptors, photoreceptors, mechanicoreceptors thermo:skin detect variation in temp prop: in the skin, muscle, tendons, ligaments and joint capsules coordinate input to enable us to sense the position of our body in space photo: located in retina detects visible light mech: in the skin and hair folliciles detect touch, pressure, vibration

Teaching

Process that involves a teacher and a learner Interactive Involves planning and implementing instructional activities Requires good communication skills Includes providing activities that allow clients to learn Goal of Teaching Activities To meet learner outcomes

hand off report

Process: Use a standardized format SBAR or PACE Keep it CUBAN >Confidential >Uninterrupted >Brief >Accurate >Named Nurse

Local anesthesia

Produces loss of pain at the desired site. Typically used for minor procedures

General anesthesia

Produces rapid unconsciousness and loss of sensation. Patient experience no anxiety that might affect cardiac and respiratory functioning. The anesthesia can be adjusted to accommodate the length of the procedure and the patient's age and physical condition

Fad diets

Promise quick and dramatic weight loss, which is usually achieve only temporarily because it results from loss of body fluid Limit the range of food from which the dieter can select only fruit and vegetables leading to an imbalance in nutrients Often recommend purchase of supplements and or special package meals; in many cases these are brand that endorse or actually produce. Fail to include practical strategies that help dieters permanently change eating and activity pattern.

Nursing Measures to Promote Activity and Exercise

Promote Exercise Plan and vary exercise routine Use buddy system and rewards. Integrate exercise into routine activities Attain target heart rate Positioning Patients Proper alignment of hospital bed Use of range of motion Incorporation of pillows, wedges, side rails, overhead trapeze, footboard, sandbags/trochanter rolls, splints

Cleansing enemas promote and for?

Promote removal of feces from the colon. they treat severe constipation or impaction. Clear the colon in preparation for visualization procedures such as colonoscopy. Emptying The colon when starting a bowel training program.

Fowler's position promotes? ideal for?

Promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. it is also an ideal position for some patients with cardiac dysfunction.

Principles of Body Mechanics

Proper alignment Wide base of support Avoid bending and twisting Squat to lift Keep objects close when lifting Raise beds Push vs. lift Get help

Principles of Body Mechanics

Proper alignment, Wide base of support, Avoid bending and twisting, Squat to lift, Keep objects close when lifting, Raise beds, Push vs. lift, Get help,

purpose of wound dressing

Protecting a wound from microorganisms Aiding hemostasis -pressure dsg prevents bleeding & eliminates dead space (cavity within a wound) Promoting healing by absorbing drainage and debriding a wound Supporting or splinting a wound

Potential Postoperative Complications:Collaborative Problems wound complications evisceration what is it, clinical signs, interventions

Protrusion of organs or tissues through the separated incision Clinical signs: visible protrusion of organ through incision. Interventions: cover with normal saline. Notify health care provider.

Meeting physiological needs of the dying patient provide what? IV fluids can cause? dehydration?

Provide artificial hydration( unless the patient has an advance directive requesting no artifical hydration) per ng or IV route. IV fluids can cause edema, nausea, and even pain in a patient who is actively dying. Dehydration is thought to not cause distress during the last hours and maybe even protective. Also take vital signs often unless contraindicated to observe for decreased level of consciousness and pallor

Perineal skin care

Provide dry clothing and bedding as soon as possible after incontinence occurs. Wash the perineum with soap and warm water after each episode and rinse and dry well. Use a skin moisturizer. use petroleum based ointment on dry skin. Antifungal creams may be prescribed for fungus growth

Promoting Regular Defecation

Provide privacy Correct position -Seated upright Timing -Often occurs after meals -Some clients may need assistance Encourage fluids & Proper diet Fresh fruits, vegetables, whole grains, fiber. minimum intake of 1500 ml. 25 to 30 grams of fiber. Exercise 3-5 times a week Range of motion for clients on bedrest to help with regular defecation -clients who can assist have them do thigh strengthening, abdominal tightening. teach when to see a PCP if the following symptoms last longer than three weeks. blood in the stool( unless they have hemorrhoids and this is not an unusual occurrence for them) severe stomach pain, change in bowel habits, unintended weigh t loss, constipation is not relieved after trying fiber, fluids, and exercise.

Meeting the needs physiologically of the dying if the patient is comatose or unconscious conscious provide what kind of care

Provide special care for the eyes so they do not become too dry. many agencies use a form of artificial tears for this purpose

Firm mattress

Provide support to the patient's body and makes it easier to turn the patient. To provide additional support, you can place a piece of plywood under a saggy mattress. a clean, dry bed also makes it easier to turn the patient and decreases the risk of skin maceration or pressure ulcer formation. bedding should provide coverage and warmth but not be tucked in so tightly as to restrict movement.

Post-op Exercises & Routines

Pulmonary Hygiene: TCDB Incentive Spirometry/IPPB Cardiovascular Conditioning Turn q2h while on CBR Leg exercises Ambulation Pain Control

Palpate to for cardio

Pulses, skin temperature, heart pulsations through the chest wall, and areas of tenderness

purpose of wound dressing

Purposes of dressings: Protecting a wound from microorganisms Aiding hemostasis -pressure dsg prevents bleeding & eliminates dead space (cavity within a wound) Promoting healing by absorbing drainage and debriding a wound Supporting or splinting a wound

Preoperative Medications

Purposes: relax/allay anxiety allows for smoother anesthesia induction* All parts of the pre-op checklist should be completed prior to the administration of pre-op meds

Collecting a clean catch urine specimen

Put clean procedure gloves. wash the perineum for the end of the penis first with soap and water, then with an antiseptic solution. for women, wash from front to back, for men, use a circular motion from urethra outward. ask the patient to begin voiding. After the stream begins, collect a 30 to 60 ml specimen. maintain sterility do not touch the inside of the container or the container lid. Avoid getting toilet paper, feces, pubic hair, or anything else in the urine sample. Pour the urine into a specimen container that is labeled with the patient's name, the date, and the time of collection. Place a lid on the container, label the container with the patient's name, the date and time of collection. Follow agency policy on additional packaging. transport the specimen to the lab as soon as possible. If there is a delay in getting the specimen to the lab, most facilities recommend refrigeration.

pureed

Put in a blender, scrambled eggs, mashed potatoes, think what baby food

woud drainage

Put in place to aid with drainage Caution with dressing changes - so as not to accidentally remove drain Types: Penrose - oldest and was most widely used Evacuator drainage (self-suction) exerts a constant low pressure Hemovac Jackson-Pratt: empty every 8 hrs or as needed

Measuring urine

Put on clean procedure gloves. record amount of urine on the input and output flow sheets.

Radiologic Studies "xray"

Radiologic Studies "xray" used to study internal organ structure Fluoroscopy is used to demonstrate the motion of organs when used with contrast medium

Situational stressors

Random, unpredictable (e.g., hurricane, accident)

Stress and cardiovascular

Release of catecholamines from the sympathetic nervous system. Results increased heart rate and contractility, vasoconstriction, and increase tendency of blood to clot. Suppression of immune and inflammatory response. Release of cortisol from the adrenal cortex, which results in altered glucose, fat, protein metabolism

coping strategies for assessing support systems

Recall that support systems such as family, friends, and coworkers can be important to the success of a person's coping strategies. Conversely, these individuals may be affected by the same stressors, or by the client's response to them. For these reasons, you should determine the supports available and their ability to assist the client—that is, do the significant others have the sensitivity and skills to be supportive? For example, you might ask: ● Tell me about your home. Describe your living environment. ● Who are the persons that provide the most support for you? In what ways do they support you? ● What support is available from family, friends, significant others, community agencies, and clergy that you may not have required until now? ● Do you have or do you seek spiritual support? ● How has your stress affected the family? (Ask about major life events that have occurred—e.g., birth, death, and divorce—job instability, a recent move, and so on.) ● What are your financial resources? What are your financial obligations? Do you feel you can adequately meet those obligations?

Facilitating therapeutic encourage and accept expressions of feelings

Receiving expressions of intense feelings (e.g., anger and guilt) may be painful for you. It may help to remember that it is therapeutic for people to express their feelings. - you don't need to change the persons feelings or make them better. As much as we would like to do this, it is not possible. - you do need to validate the person's feelings(e.g. , "it is normal to feel that way; it is OK").

What are signs of infection of wound

Red ness of the peri wound, purulent drainage, foul odor, edema

objective data for integumentary

Redness or impaired skin integrity over pressure points - sacrum, coccyx, heels, hips, posterior aspect of head (prolonged pressure to skin compresses capillaries and obstructing circulation causing tissue ischemia)

How Informatics Enhances the Nursing Profession

Reduces barriers to evidence-based practice Facilitates a literature search Provides on-line sources for and of nursing research Provides literature databases

Reflex urinary incontinence

Reflex urinary incontinence involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Defining Characteristics 1. no sensation of urge to void 2.complete emptying with lesion above pontine micturition 3. incomplete emptying with lesion above sacral micturition center 4.no sensation of bladder fullness 5. sensations associated with full bladder such as sweating, restlessness, and abdominal discomfort 6. unable to cognitively inhibit or initiate voiding 7. no sensation of voiding 8. predictable pattern of voiding 9. sensation of urgency without voluntary inhibition of bladder contraction Expected Outcome Patient verbalizes or demonstrates management techniques.

Helping families of dying patients help the family members explore past coping mechanisms to?

Reinforce a successful past coping mechanism

Stress management techniques include

Relaxation, exercise, relaxation techniques, -progressive relaxation: in a quiet meditation state or lying in bed, relaxing and contracting muscle groups is much less traumatic and damaging too fragile joints and muscles than active exercise therefore it may be used even by people who are not in good health. -passive relaxation: in which the person relaxes the muscle groups without first contracting them, it's even less traumatic and requires even less energy. Meditation Visualization or imagery Biofeedback use electronic instruments to measure neuromuscular and autonomic nervous system activity and provide information about those responses to the person. Acupunture Chiropractor adjustment involves manual realignment of the vertebrae. Reiki and therapeutic touch focus on energy modulation. Massage Reflexology is the application of pressure to specific points on the feet, hands, or ears, which are thought to correspond with certain organs of the body. The goal is to relieve blockage, promote the flow of energy, and reduce tension. Humor Listening to music Engage in art activities Dance and sports Journal writing

what is my otic medication after care?

Remain on side for 5-10 minutes Loose cotton may be placed to absorb extra medicine - do not occlude ear canal

Meeting physiological needs of the dying person monitoring the patient's energy level, perform, remove, and identify?

Remember that fatigue is a normal part of the dying process. Most dying patients sleep much of the time. - perform hygiene and other care, if the patient tires easily or lack the energy to care for herself - remove environmental stressors that interfere with sleep (e.g. , noise, too much light, a room that is too hot or too cold). Identified psychosocial stressors (e.g. , depression, anxiety, fear) that may keep the patient awake.

Increase levels of bun and creatinine mean

Renal failure, impaired renal perfusion, kidney infection or inflammation, kidney obstruction, dehydration, excessive protein intake, use of total parenteral nutrition

Complicated grieving nursing diagnosis

Repetitive use of ineffective coping behaviors reliving of past experiences with little or no reduction in intensity of grief, prolong interference with functioning, psychosomatic responses, expressions of grief (e.g. , anger, sadness, crying), idealization of lost objects or person, labile affect, developmental regression, denial of loss, expression of unresolved issues or guilt

Risk for imbalance nutrition more than body requirements

Reported use of solid food as a major food source before 5 months of age. concentrating food intake at end of day. reported or observed obesity in one or both parents. Reported or observed higher baseline week at beginning of each pregnancy. Rapid transition across growth percentiles in infants or children. pairing food with other activities. observe use a food as reward or comfort measure. Eating in response to internal cues other than hunger, such as anxiety. Eating in response to external cues such as time of day or social situation, dysfunctional eating patterns.

Surgery, anesthesia, and pathological conditions for urinary

Reproductive in urinary tract surgeries can affect urine solutes, normal urine characteristics, and the ability to pass urine normally. Surgery in the pubic area, vagina, or rectum is associated with a high incidence of trauma to the urinary organs, lower abdominal swelling, loss of pelvic muscle control, and increase pressure on the kidneys, uterus, or bladder. Anesthetic agents can decrease blood pressure and glomerular filtration, thus decreasing urine formation. Spinal anesthesia decreases the patient's awareness of the need to avoid, which may lead to bladder distention. Disorders of the unit system that affect unary lumination include the following infection or inflammation of the bladder, uters, or kidneys. renal calculi or tumors, which obstruct the normal flow of urine. older men, hypertrophy of the prostate gland do to benign or cancerous lesions, which interferes with the flow of urine from the bladder into the urethra.

Epidural anesthesia

Requires insertion of a thin catheter into the epidural space. mobility is limited for only a short time. epidural anesthesia can be used as a surgical anesthetic and to provide postoperative analgesia. epidural is safer than spinal

The Spread of Infection: Six Links Infectious agents reservoir

Reservoir Where pathogens live and multiply "Carriers" May be living Humans, animals, insects May be nonliving Food, floors, equipment, contaminated water Most pathogens prefer a warm, moist dark place to live and thrive

Kussmauls respiration

Respirations that are regular but abnormally deep and increased in rate. a compensatory mechanism for metabolic disorders that lower blood pH, as well as a form of hyperventilation caused by fear, anxiety, or panic.

what are my Immediate Post-op Hazards (PACU)

Respiratory Compromise -Hypoxemia( from anesthesia) -obstructed airway -Secretions Hemorrhage/Shock: drop in bp increase in HR. loc is not a great check because of anethesia still in their system

Side effects of general anesthesia

Respiratory depression, circulatory depression, delirium during induction and recovery, nausea and vomiting, aspiration during induction, myocardial depression

what do I want to Inspect or observe for respiratory

Respiratory pattern, signs of respiratory distress, chest structures and movement, skin and mucous membrane color, presence or absence of edema, sputum characteristics, an overall general appearance

what Local Adaptation Syndrome, response to? types? is short term or long term?

Response to stress involving specific body part, tissue, or organ -Short-term attempt to restore homeostasis -Localized Types -Reflex pain response -Inflammatory response

Safety Hazards: Patient Focus

Restraints Side rails

so when im about to apply a dressing i should do what?

Review provider orders for dressing change Assess size & location of wound, type of dsg and presence of any drains Review previous documentation Assess client's comfort, knowledge Assess Allergies

Five Rights of Delegation

Right: task circumstance person direction/communication supervision

Inversion

Rotate the ankle and sole of foot inward

Eversion

Rotate the ankle and sole of foot outward

Radial flexion

Rotate the hand inward at the wrist

Inflammatory response cellular response

Specialized white blood cells phagocytes migrate to the site of injury and engulf bacteria, other foreign material, and damaged cells and destroy them. sometimes they form a wall around invading pathogen. The accumulation of dead white blood cells, digested bacteria, and other cell debris in the presence of infection is called pus

Childhood stressors they occur primarily

School-age children may also experienced stressors at school or among peers, however, children's stressors occur primarily in the home - absence of parental figures - failure of parents to meet needs for safety, security, love, and belonging - failer of parent to meet basic physilogical need for oxygen, food, elimination, rest, and cleanliness

surgical attire include

Scrub Suit Mask Headgear Shoe/covers Cover gowns Gloves

Lines of Defense Against Infection secondary

Secondary Defenses Biochemical processes activated by chemicals released by pathogens Phagocytosis "seek and destroy" WBCs: phagocytes Complement cascade proteins that trigger the release of "caustic enzymes" that eat through the protective covering of pathogens Inflammation "vasodilation" brings in the good stuff Fever "creates a hostile environment"

Powerlessness defining characteristics?

See that the situation could be change but does not think it is within his power to change it, expresses helplessness, anger, frustration over inability to perform previous task, does not seek information or participate in care or decisions about care

Nurses self care for dying interventions

Self-knowledge of fears and beliefs, look for support, and allow own grief.

Self care for nurses

Self-knowledge of fears and beliefs. Look for support. Allow own grief

what is the effect of selyes resistance stage on the cardiovascular and respiratory hormone levels?

Selye's resistance stage has the following effects: ● Normalizes heart rate, blood pressure, cardiac output, respiratory function, and hormone levels ● Stimulates smooth muscle in the digestive tract and secretion of digestive juices, increasing peristalsis and improving digestion ● Stimulates insulin secretion, increasing glucose uptake by cells

Young adult stressors

Separation from family, starting college or job. Making the transition from youth to adult responsibilities. Preparing for careers, graduation from college, learning a trade. Establishing career goals and planning how to achieve success and career stability. Financial stressors around relationships and providing a home for sell for family. Parenting children. Conflict between responsibilities for work and family or other relationships.

Potential Postoperative Complications:Collaborative Problems wound complications dehiscence what is it, clinical signs, interventions

Separation of one or more layers of the wound due to poor nutritional status , obesity, or other strain on suture line, inadequate closure of the muscles or wound infection Clinical signs : a pop or tearing sensation, especially with sudden straining from coughing, vomiting, or changing position in bed. Usually an immediate increase in serosanguinous drainage occurs. Interventions : provide adequate nutrition. Use binders to support the incision. Have client avoid strain. Monitor for infection.

Risk factors for urinary tract infection

Sexually active woman, women who use spermicidal contraceptive gel, older women, pregnant women, men with an enlarged prostate, people with kidney stones, anyone who has an indwelling catheter. People have diabetes mellitus, immunocompromised patients, people who have a history of uti.

Managing constipation

Short-term constipation is usually caused by the person's lifestyle. clients most likely to experience constipation are those who have decreased activity or are on bed rest, are receiving opiates or other medications that slow peristalsis and has decreased fluid and fiber intake.

To limit discomfort when administering ear drop the nurse

Should warm it up

rectal supp after care

Side-lying for 5-10 min. Retain for 30 minutes

rectal supp assessment/position/ worries. should check for impaction?

Side-lying/Sims position gloves Contraindications: Rectal surgery, rectal bleed, cardiac patients Check for impaction need doctor order

Factors affecting grief

Significance of loss, support system, existing conflicts, circumstances, prior losses, developmental stage, spirituality, culture, timeliness

Factors affecting grief

Significance of loss, support systems, existing conflicts, circumstances, prior losses, developmental stage, spirituality, culture, timeliness

Reaction formation examples and examples and consequences of overuse

Similar to compensation, except the person develops the exact opposite trait. The person is aware of her feelings but acts in ways opposite to what she is really feeling. E.g it's okay that you forgot my birthday (when it really is not OK). Overuse can cause failure to resolve internal conflicts

Feeding the patient

Sit down while feeding the patient, do not rush. Position yourself so you can make eye contact. Be sure to provide adequate time for her to chew and swallow. If possible, ask her what food she would like next. Serve one food at a time, serve small amounts. Serve finger foods to promote independence. Cue older adults whenever possible with words or gestures. Have casual conversation with the patient while feeding her to make mealtime more pleasant and relax.

post op respiratory , cardio, gastrointestinal, genitourinary, surgical incision complications

Six types of potential postoperative complications may occur: Respiratory system ● Aspiration pneumonia ● Atelectasis and pneumonia Cardiovascular system ● Thrombophlebitis ● Embolus ● Hemorrhage ● Hypovolemia Gastrointestinal system ● Ileus Genitourinary system ● Urinary retention Surgical incision ● Dehiscence ● Evisceration ● Wound infection

what are my worries of skin medication

Skin irritation Don't apply dry powder to wet skin (paper mache` pts)

As a nurse I may be asked to place a

Small bore, nasogastric, nasal enteric, nasal jenunal. They are normally short term less than 6 weeks for NG or NE tube.

What equipment is needed for moving in bed

Small pillow or folded blanket. Pillows

Coordination

Smooth movement requires coordination between the nervous system and the musculoskeletal system. Voluntary movement is initiated in the cerebral cortex. However, the cerebellum coordinates movement. As you may recall, proprioception the awarness of posture, movement, and position sense is largely controlled by the cerebellum. the basal ganglia, located deep in the cerebrum, assist with coordination of movement.

Factors influencing oxygenation developmental preschool and school age children

So by this time they have developed mature lungs, heart, and circulatory systems that can adapt to moderate stress and change . healthy children typically have bouts of tonsillitis or URIs, which usually resolves without difficulty. Viral infections such as croup and pneumonia, are common, especially in preschoolers and younger school age children. Exercise-induced asthma is also a problem. Even few children as young as middle school age begin social habits such as tobacco use

Caring for the dying person meeting physiological needs encourage the patient to be as independent as possible because you want the patient to maintain a?

So she will maintain a sense of control

Provide anticipatory guidance for the family regarding the stages of loss and grief so that they will know?

So that they will know what to expect after their loved one dies

safety hazards take- home toxins what is the prevention?

Take-Home Toxins Pathogenic microorganisms** Asbestos, lead, mercury, arsenic Prevention Be aware of workplace preventive measures Remove work clothing Shower if appropriate Gloves

somatization what happens with this disorder? what happens with pain? the patient is unable to?

Somatization. In this disorder, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. The patient is unable to control the symptoms and behaviors, and complaints are vague or exaggerated.

somatoform pain disorder, how does it start?whats inconsistent? the pain does not?

Somatoform pain disorder. This is emotional pain that manifests physically. Pain is the patient's main focus of the person's life. The level of pain the person states is inconsistent with the physical condition—that is, no physical cause can be found for the pain. The pain does not change location.

Assess coping abilities and support system, what would be some coping assessment questions?

Some coping assessment questions include the following: - what do you do to help you reduce stress? - do you have family or friend you can talk with? - what would you say is your greatest support when going through difficult times? - tell me about a previous loss and what you did to cope with it. - are you using any community resources to help you get through this? Do you know what they are? the rationale is the way individuals have coped in the past will affect how they cope with dying or with their current loss. It may also be therapeutic for them to identify their resources and support.

Helping families of dying patients arrange for a formal multidisciplinary meeting with the family, when should it be done? discussion should cover?

Soon after the patient's admission, if possible. Discussions should cover personal, cultural, and religious tradition

Frequent minor complaints after the general anesthesia

Sore throat from intubation. nausea and vomiting from relaxation of gastrointestinal smooth muscle. Headache, uncontrollable shivering, and confusion.

Common Documentation Systems: source oriented? what are the disadvantages of source oriented?

Source-oriented -Disciplines chart in separate sections -Variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) -Disadvantages >>Data scattered; may lead to fragmentation >>Difficult to track treatments and outcomes

Factors affecting grief spiritual cultural beliefs and practices

Spirituality and religious beliefs can help or hinder the grieving process. One person might believe the deceased is in a place of contentment and happiness, where all suffering is over. Another may believe that the deceased will soon be reborn, possibly into the same extended family. another may believe that death is final and there is no longer any life after death. how do you think these beliefs might influence the grieving process? most cultures engage in rituals for example for funeral that help the beavered begin the grieving process by openly expressing their emotions and pain. Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings.

Squat to lift heavy objects from the floor because? avoid?

Squatting lowers your center of gravity. Push against the strong hip and thigh muscles to raise yourself to a standing position. avoid bending at the waist.

in order for the client to discharge from the PACU they must have?

Stable pulmonary status Stable vital signs** Oriented x 3 Adequate urinary output -minimum 30cc/hr N/V and pain controlled Extremity sensation return -spinal/epidural anesthesia

if someone has Limited dependence you use?

Stand/assist lift or friction-reducing device

types of wound closures and the nurse must note what

Staples - cause less trauma and provide extra strength Sutures - external & internal (internal dissolve on their own) Steri strips - sterile butterfly tape applied along both sides of a wound to keep the edges closed Nurse must note any edema, irritation and tightness of closures

what are my worries of MDI

Steroid inhaler: rinse mouth well to avoid thrush Bronchodilators before steroid inhalers

What does yogurt do to the Bowel

Stimulates peristalsis while at the same time promoting healing of intestinal infections

Pelvic floor muscle exercise

Strengthen perineal muscles and help to prevent and treat stress, urge, and mixed urinary incontinence. when doing kegels hold each contraction for 5 to 10 seconds and then rest for 5 to 10 seconds. recommended daily exercise routine is to perform 40 to 60 kegels divided into two to four sets of 15 exercises each time. do one set sitting, one standing ama and one lying down. Do not do all 40 to 60 exercises at one time spread them throughout the day

Environmental factors affecting oxygenation include

Stress because it stimulates the release catecholamines from the sympathetic nervous system. Results increased tendency of blood to clot as in pulmonary embolism - pulmonary allergens include dust, dust mites, cockroach particles, pollen, molds, newsprint, tobacco smoke, animal dander, sometimes. so includes hay fever and asthma - air quality air pollution triggers respiratory problems. even healthy people may experience headache, coughing, and other symptoms when exposed to air pollution. people with existing respiratory disease may become unable to function . pollutants are most harmful to infants, toddlers, older adults, and people with heart or lung disease. Altitude: oxygen pressure Falls proportionately, leading to decreased oxygen diffusion from alveoli into capillaries (impaired gas exchange). Low oxygen levels at high altitudes can cause hypoxemia and hypoxia. If a person is suddenly exposed to low oxygen levels, arterial chemoreceptors stimulate ventilation, making more oxygen available in the alveoli and at the tissue level. Over the long term, people who live at high altitudes undergo physiological changes that facilitate oxygenation. - ventilation, which brings more oxygen into the lungs. - production of red blood cells, which aids in the transport of oxygen to organs and tissues - lung volume and pulmonary vasculature, which results in increased surface area for alveolar capillary gas exchange. - vascularity of body tissues, which allows for improved oxygen delivery to the tissues. - production of hemoglobin, which readily binds with oxygen so that the tissue cells can use oxygen even when oxygen pressure is low in the environment.

Environmental factors include

Stress, allergic reactions, altitude, temperature, cardiovascular function.

what is flexibility training

Stretching before exercise helps warm up the muscles and prevent injury during exercise. stretching after exercise cool the muscles and limits post exercise stiffness. as we get older, joints and muscles become stiffer. A regular flexibility program helps maintain mobility as aging occurs.

Factors That Influence Adaptation Support system, strong support means?

Strong support = better adaptation

What is being evaluated?

Structure Process Outcomes

Facilitating therapeutic continue to communicate with dying patient even if they are in a coma. Encourage family members to do so as well. tell them patient? avoid discussing?

Talk to the patient. Tell him what is going on around him, what care you are providing, and when you or others enter or are about to leave the room. Research indicates that patients continue to hear even though they cannot respond, sometimes up to the moment of death. - avoid discussing dying person as though he were not present.

Explain what is evaluated in each of the following types of evaluation (i.e., the focus of each type of evaluation): structure, process, outcomes.

Structure evaluation focuses on the setting in which care is provided. It explores the effect of organizational characteristics on the quality of care. It requires standards and data about policies, procedures, fiscal resources, physical facilities and equipment, and the number and qualification of personnel. ● Process evaluation focuses on the manner in which care is given—the activities performed by nurses (and other personnel). It explores whether the care was relevant to patient needs, appropriate, complete, and timely. ● Outcomes evaluation focuses on demonstrable ("measurable") changes in the patient's health status that result from the care given.

What Are the Components of a Goal/Expected Outcome Statement?

Subject Action Performance criteria Target time Special conditions

soap charting?

Subjective data Objective data Assessment/analysis Plan Some Add IER Intervention Evaluation Revision

what are my worries of nasal medication

Taste of nasal medications can cause nausea Nosebleeds

Nutrition, hydration, and activity level? which substances increase activity level?

Substances that contain caffeine, such as coffee, tea, cola, and chocolate, act as diuretics and increase urine production. Consuming large amounts of alcohol impairs the release of a antidiuretic hormone, resulting in increased production of urine. In contrast, a diet high in salt causes water retention and decreases urine production. The kidney also spare water when a person is dehydrated, such as after heavy exercise or when fluid intake is inadequate. This closes the urine to be concentrated and low in Vol. During prolonged periods of physical activity, especially in hot weather, the body loses sodium and other electrolytes rapidly through sweat, for this reason, electrolyte replacement beverages may be more beneficial than plain water and helping to prevent dehydration for prolonged or vigorous intensity activity. For most adults, pale to clear urine indicates adequate hydration.

Foot deformities

Such as club foot, occur in about 4 percent of all newborns. Serial cast for surgery may be used to correct the defect and preserve function.

Pre-existing conditions that increase surgical risk neurological disorders

Such as paralysis or spinal cord injury, increase the risk for vasomotor instability and thus create the potential for wide swings in blood pressure. In addition, patients with seizure disorders are more likely to have a seizure in the perioperative period.

Paraxysmal nocturnal dyspnea

Sudden awakening due to shortness of breath that begins during sleep.

what are the 5 variables that determine the position of the patient in the or

Surgical site, access to the patient's airway, the need to monitor vital signs, comfort and safety. A position that is ideal for accessing the surgical site may not be used if any other factors are compromised. If the patient has pre existing injuries or discomfort, this information is also factored into the decision about how to position.. For example, a patient with chronic cervical spine pain maybe position using the neck roll.

the spread of infection susceptible host and includes four determining factors

Susceptible Host Person with inadequate defense Four determining factors -Virulence -Organism's ability to survive in the host's environment -Number of organisms -Host's defenses

what can objective data for cardiovascular?

Tachycardia (increased workload of the heart due to deconditioning) Peripheral edema (venous pooling due to loss of muscular contractions which aids venous return) Risk for deep vein thrombosis (Virchow's triad: stasis, activation of clotting and vessel injury) Orthostatic hypotension (loss of baroreceptor function involved in constriction and dilation of blood vessels. When changing positions unable to maintain an adequate blood pressure and cerebral perfusion

Preventive interventions of diarrhea

Teach hand hygiene. provide information about foods that cause diarrhea like highly spicy foods, high fat foods, greasy snacks, or large quantities of raw fruits and vegetables may cause diarrhea in some patients. tell patients to keep track of foods that trigger diarrhea and to eat them in moderation

Stress reductions interventions teach the importance? benefits of sleep include?

Teach importance of getting 7-8 hours of sleep per day Benefits of sleep >>increases mental performance .....improves learning .....help the storage of long term memory Restores energy

Helping families of dying patients when approaching death is apparent, ask family members directly do you want to be present while he is dying you tell them what? and when the expected death occurs you do what?

Tell them what to expect, if they do not know. when an expected death occurs, shift the focus of your care to the family and those who were caregivers.

Enuresis

Tends to be familial, is involuntary urination after about 5 to 6 years of age, when control is usually establish. Enuresis is primary if bladder training was never achieved and secondary if control was established and then lost. Enuresis has been associated with stress, uti, allergies, abnormal electroencephalographic patterns, sleep disorders, hearty laughing, and small bladder capacity, however the cause is not always apparent.

lines of defense against infection tertiary

Tertiary Defenses Humoral immunity B-cell production of antibodies in response to an antigen Cell-mediated immunity Direct destruction of infected cells by T cells

Evaluating Learning

Tests and written exercises Oral questions Interviews Questionnaires Checklists Direct observation of performance Client report Client records

Helping families of dying patients reassure families of patients who become withdrawn near the time of death? you want to tell the family what?

That this does not mean the patient is rejecting them, but only that his body is conserving energy and that he has come to terms with dying and letting go of his connections with life

what are the four characteristics of the local adapatation

The LAS has the following characteristics: ● It is a localized body response (involves only a specific body part, tissue, or organ). ● It is initiated by a stressor; it does not just occur on its own. ● It is short term. ● It is adaptive in nature; that is, it attempts to restore homeostasis.

In general, what is the difference between the alarm stage and the resistance stage of the GAS?

The GAS alarm and resistance stages differ as follows: ● In the alarm stage, the body is preparing to "fight" or "take flight." It is reacting physiologically to the stressor. The cerebral cortex sends messages to the hypothalamus and pituitary to increase various hormone levels. The hormones produce increases in heart rate, blood pressure, and respiratory function and shunt blood to the skeletal muscles. ● In the resistance stage, the body attempts to stabilize by using physiological and psychological coping mechanisms, and the body systems (e.g., heart, lungs, and immune response) return to normal.

Assessment Techniques

The Nursing Interview Physical Assessment Inspection Palpation Percussion Auscultation

Developmental and children for elimination

The ability to control defecation typically develops about two to three years of age. Toilet training requires neural and muscular control as well as conscious effort. The child must be aware of the urge to defecate, be able to maintain closure of the external anal Sphincter while getting to the toilet, and be able to remove clothing. when toddlers become engross in play, they sometimes ignore the need to move their bowels, soiling is common. As children mature, they gradually learn to gain more control over defecation. In fact, school age children and adolescents often delay defecation until they have come home or have completed an activity.

Factors influence cardiovascular function developmental stage adolescent

The average adolescent is developmentally at little risk for heart or circulatory disorders, although some athletes can be at risk for collapse and sudden cardiac dysrhythmias that is familial.

Balance

The body achieves balance when it is an alignment. for your body to be balanced, your line of gravity must pass through your center of gravity, and your center of gravity must be close to your base of support. The line of gravity is an imaginary vertical line drawn from the top of the head through the center of gravity. the center of gravity is the point around which mass is distributed. In the human body, the center of gravity is below the umbilicus at the top of the pelvis. The base of support is what holds the body up. The feet provide the base of support.

Developmental of bowels in adult, what decreases in aging?

The bowel pattern set in childhood normally continues into late adulthood if the client consumes adequate fiber and fluid and engages in regular physical activity. However, peristalsis, intestinal smooth muscle tone, perineal muscle tone, and Sphincter control normally decrease with aging. these physiological processes can contribute to bowel elimination problems among older adults especially if they decrease their activity and fiber intake

Nursing Care Plans

The comprehensive nursing care plan is the central source of information needed to Guide holistic, goal-oriented care Address each client's unique needs Importance: Ensures care is complete Provides continuity of care Promotes efficient use of nursing efforts Provides a guide for assessing and charting Meets requirements of accrediting agencies

Hemoptysis

The coughing of blood or bloody sputum. It may range from small streaks of blood to large amounts of Frank blood

Physiological stages of dying 1 to 3 months before death, what does the dying person do? what increase? what becomes difficult to do?

The dying person begins to withdraw from the world and people. sleep increases, it becomes difficult for the body to digest food, especially meats, and appetite and food intake decrease. liquids are preferred. Anorexia may be protective. The resulting ketosis can diminish pain increase the person's sense of well-being.

Physiological stages of dying moments before death

The dying person does not respond to touch or sound and cannot be awakened. Typically, there is a short series of long space breath before breathing ceases entirely and the heart stops beating.

Range of motion for the elbow

The elbow is a hinge joint. Flexion bend at the elbow to move the forearm from a straighten position up toward the shoulder. Extension straighten the arm by bringing the lower arm forward and down. Rotation for supination- with the arm at the side, elbow, bent , move the hand and forearm so that the palm is facing upward. Rotation for pronation with the arm at the side, elbow bent , Move the hand and forearm so that the palm is facing downward.

Ineffective airway clearance, what would be the symptoms?

The inability to maintain a clear Airways. The main mechanism for keeping airways open is a strong cough that move secretions into the throat to be expectorated or swallowed. Patient may have weak cough, adventitious breath, copious secretions, and signs of hypoxia Ineffective airway clearance: dyspnea, adventitious breath sounds, cough and excessive sputum ( what does the sputum look like), complaints of secretions and inability to cough

the final step of the nursing process

The final step of the nursing process Evaluate Client's progress toward goals Effectiveness of nursing care plan Quality of care in the health-care setting

inflammatory response

The fluid and white blood cells removed from the circulation to the site of injury are call exudate.

The following initial assessments are made in the PACU:

The following initial assessments are made in the PACU: ● Vital sign,including respiratory rate, respiratory competence, and breath sounds; cuff or arterial blood pressure; temperature and type of measurement used; pulse (apical and peripheral); and oxygen saturation ● Airway: patency, presence of artificial airway, mechanical ventilator settings ● Respiratory adequacy, including skin color and condition ● Peripheral circulation (postoperative tissue perfusion): for example, peripheral pulses and sensation at extremities ● Neurological status, including pupil response ● Mental status: level of consciousness, alertness, lucidity, orientation ● Patency of IV: location of sites and rates of solution(s) and/or blood products infusing ● Allergies and sensitivities ● Pain ● Motor abilities, including return of sensory and motor control in areas affected by local or regional anesthetics ● Skin integrity ● Temperature regulation ● Positioning ● Surgical incision site, including condition of suture line(s) if visible ● Condition of dressing(s) ● Type, patency, and amount of drainage from dressings, tubes, and catheters ● Nausea and vomiting ● Fluid and electrolyte balance ● Safety needs (e.g., siderails raised) ● Central venous pressure (CVP), arterial BP, pulmonary wedge pressure, and intracranial pressure (as indicated)

Identify the major interventions for preventing pressure ulcers.

The following major interventions prevent pressure ulcers: -Inspect skin daily -Manage moisture -Adequate nutrition -Frequent position changes -Use of therapeutic mattresses and cushions to minimize pressure -Adjunctive wound care therapies -Patient and family teaching

Range of motion exercise for the foot, what type of joint is it?

The foot is a gliding joint -Eversion turn the sole of the foot laterally -Inversion turn the sole of the foot medially

Range of motion for the knee

The knee is a hinge joint Flexion bend at the knee, Bringing the heel back towards the Buttocks Extension straighten the knee returning the leg to its original position

Factors affecting grief significance of the loss

The meaning the person has attached to the person or object loss will be different for each person. The more attachments to the relationship or object, the more difficulty is the grieving.

The circulating nurse

The most important role in the o.r. must be a registered nurse. it is a registered nurse who applies the nursing process to coordinate all activities in the or . she's a strong client advocate who continuously monitors the client and the sterile field. Maintains a safe, comfortable environment, communicates with appropriate personnel outside the operating room, manages care of the intraoperative client, and responds to emergencies. an important aspect is to attend to the patient during the induction of anesthesia.

To do range of motion exercises for the neck what do you do and it is what type of joint?

The neck is the pivot joint Flexion is where you move the head from upright midline position to the chin, resting the head on the chest. Extension you move the head from flex to upright midline position Hyperextension move the head from upright midline position to as far back as possible Lateral flexion tilt the head laterally from midline position toward the shoulder Rotation rotate the head in a circular motion from upright midline position to as far right or left as possible.

Characteristics of normal urine

The normal specific gravity range for urine is 1.002 to 1.028. As fluid in take increases, urinr becomes dilute and lighter in color to almost clear as it approaches specific gravity of 1.000.

Factors That Influence Adaptation Overall health status

The number of illnesses present and the chronicity of illnesses may affect the ability to adapt to new stressor/s

Why do we use elastic stockings

They reduce the risk of DVT and prevent phlebitis and also reduce the risk of pulmonary embolism

what happens in Crisis? what are the new ways of coping? do they recognize the problem?

The person experiences more anxiety and tries new ways of coping, such as withdrawal, rationalization, projection. The person recognizes the problem but denies that it is out of the control.

Hypochondriasis and what can trigger the physical sensations

The person is preoccupied with the idea that he is or will become seriously ill. The person is abnormally concerned with his health and interprets is real or imagined symptoms unrealistically, fearing that they will get worse or become incurable. The person is not faking it, anxiety about his health may trigger the physical sensations

Adaptive and when is it more likely

The person redefines the threat and perceived the crisis in a realistic way. She begins to think rationally and does some positive problem solving, regains some self esteem, and is able to be in socializing again. Adaptation is more likely if the person can use effective coping strategies and if situational supports are available

the problem suggest the goal and the etiology suggest the?

The problem suggests the goal The etiology suggests interventions

What range of motion do we do for the shoulder? what kind of joint is it?

The shoulder is a ball and socket joint Flexion raise the arm from a neutral position at the side to alongside the head Extension move the arm from flex to a neutral position at the side of the body. Hyperextension move the arm, keeping the elbow straight, from a neutral position at the side of the bed to behind the body. Abduction raise the arm laterally from a neutral position at the side of the body to position at the side of the head, palm facing forward. Adduction move the arm downward from a position beside the head to across the front of the body as far as possible. Circumduction circle the arm from the shoulder External rotation keeping arm held out to the side at shoulder level and bent to a right angle, Fingers pointing down, move the arm upward so that the fingers pointing upward and are above the shoulder. Internal rotation move the arm forward and down to return to the starting position, fingers pointing down.

Supine position is good for?

The spine is aligned and the arms and hands comfortably rest at the side

Nutrition imbalance less than body requirements

The state in which an individual experiences in intake of nutrients insufficient to meet metabolic needs. Defining characteristics pale conjunctival and mucous membranes. weakness of muscles required for swallowing or mastication. Sore, inflamed buccal cavity. Satiety immediately after ingesting food. reported or evidence of lack of food. reported inadequate food intake less then RDA. report it altered taste sensation. preceive inability to ingest food. misconception. loss of weight with adequate food intake. aversion to eating. abdominal cramping. Poor muscle tone. Abdominal pain with or without pathology. Lack of interest in food. Body weight 20% or more below ideal. capillary fragility. diarrhea or steatorrhea , excessive loss of here. Hyperactive bowel sounds. Lack of information, misinformation.

Range of motion for the thumb, what type of joint is the thumb.

The thumb is the saddle joint Flexion move the thumb across the palm of the hand toward the fifth finger. Extension move the thumb laterally away from the fingers Opposition. Touch the thumb to the top of each finger of the same hand

what is Loss?

The undesired change or removal of a valued object, person, or situation

what Range of motion excercise can you do for the wrist? what kind of joint is the wrist?

The wrist is a condyloid joint Flexion bend the fingers of the hand toward the inner aspect of the forearm Extension strengthen the wrists so that it is on the same plane as the forearm Hyperextension Bend The wrist as far back as possible toward the outer aspect of the forearm Abduction which is for radial flexion with the hand supinated, bend each wrist laterally toward the thumb side Adduction which is for ulnar flexion with the hand supinated, bend each wrist laterally toward the fifth finger side.

Positioning patients

They require a change of position at least every 2 hours to prevent skin breakdown, muscle discomfort, damage to superficial nerves and blood vessels, and contractures. Immobile people are more prone to pressure injury as a result reduce circulation, impaired oxygen exchange to the tissues, and edema.

What factors affect surgical risk age infants

The very young and very old are at greatest risk during surgical procedure. Infants have limited ability to regulate temperature and have immature immune, cardiovascular, liver and renal system. they are also at greater risk for infection. for infants, even minor blood loss may represent a substantial portion of the total blood volume. they are also at risk for volume overload.

Nasal flaring, what does it do?

The visible enlargement of the nostrils with inhalation. It helps reduce resistance to air flow in the nose and keep the nasal passages open to taking more air

signs of increased respiratory effort , what is Retractions?

The visible sinking in of intercoastal, super clavicular, and subcostal tissue caused by excessive negative pressure generated in the chest to try to increase the depth of inhalation.

Hospice care focuses on? for a patient to be eligible?its two key premises? treatment is? physical care is primarily? what can have high priority?

The way of care, dignity, quality of life, spiritual. Hospice care focuses on holistic care of patients who are dying or debilitated and not expected to improve. For a patient to be eligible a physician must certify that the patient is likely to die within 6 months . it is in this way the hospice differs most from palliative care. It is based on two key premises 1 the quality of life is as important as the length of life, & 2 those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families. thus, hospice providers consider helping family members an essential part of their role. Treatment is holistic, addressing the patient's emotional, spiritual, and physical needs. Physical care is primarily palliative, involving symptom management. for example, pain management is considered crucial because patients must be relatively free from pain to make the most of the time remaining to them . An interdisciplinary team plans care with the patient and family. Family members are encouraged to be an active part of the team as much as they are able. Nursing support is available 24 hours a day, and families are taught what to expect as a disease progresses . Psychosocial and spiritual care have high priority. As the patient nears death, hospice workers remain as long as necessary. After the patient dies, there is follow up bereavement care for the families.

Denial examples and examples and consequences of overuse

Transforming reality by refusing to acknowledge thoughts, feelings, desires, or impulses. This is unconscious the person is not consciously lying. Denial is usually the first defense learned. E.g a student refuses to acknowledge that he is barely passing anatomy, does not withdraw from the class, and is now failing a nursing course. An alcoholic States, I can quit anytime I want to. Overuse can lead to repression can dissociative disorders (e.g, dual personalities, selective amnesia).

Anesthesiologist or a nurse anesthetist

There job is to keep the patient alive. To continuously monitor and evaluate the patient's response to the anesthesia and surgical procedure

Minimize bending and twisting because

These movements increase the stress on the back. instead, face the object or person, bend at the hips or squat.

what is the purpose of Hand and wrist splint

They are custom made for the patient and the purpose is to hold the wrist and hand in natural position and prevent claw hand deformities

Helping families of dying patients encourage family members to ask questions because they may

They may hesitate to do so for various reasons such as they may not want to interrupt busy care providers

Helping families of dying patients encourage family members to help with care if they are able

This helps me there needs to be useful, promote family ties, and make the patient more comfortable. Instruct and supervise as appropriate. If family members are not physically or emotionally able to provide care. Accept it.

simulating the patients appetite offer frequent, small meals because it helps the patient by?

This helps prevent gastric distention and improve appetite by keeping the patient from being overwhelmed with a large amount of food

measuring the pH of the aspirate

This is currently the most reliable method for verifying to placement at the bedside. The lower the pH, the more likely the tube is in the stomach. The outcome of the pH testing is useful only if the fluid is acidic, indicating gastric placement. also ask for a stomach contents and inspect for color and curdling

Impaired gas exchange, the patient will show signs of?

This is the appropriate diagnosis if the patient is adequately ventilated but diffusion across the alveolar capillary membrane is impaired. Nanda specifies excess or deficit and oxygenation or carbon dioxide elimination at the alveolar capillary membrane. although ABG analyst is the most accurate way to detect impaired gas exchange, you will call on to assess adequacy of gas exchange without having this information available. patient will show signs of hypoxia which is confusion, nasal flaring, pallor, abnormal blood gases, diaphoresis, headache upon awakening impaired gas exchange felt all the way down to the toe nails , dyspneic, sense of impending doom, restless, confuse , move into lethargy, abnormal arterial blood gas , low oxygenation levels and high carbon dioxide levels , changes in o2 stat.

Preparation of client purpose

To increase the reliability of the test by providing client teaching on why the test is being performed, what the client can expect during the test, and the outcomes and side effects of the test

Use assistive devices at all times to limit?

To limit the risk of back and musculoskeletal injury.

Diabetic diet is done for?

To manage calories in carbohydrate intake for clients with diabetes mellitus

assess emotional and behavioral of stress

To assess emotional and behavioral responses, ask questions such as the following: ● Do you use tobacco products? If so, how often? ● How much alcohol do you drink every day? ● What do you eat? What is your typical eating pattern? ● How much fluid do you drink daily? ● How many hours do you sleep at night? Do you feel rested when you wake up? ● What prescribed medications, vitamins, over-the-counter medications, or herbs do you take? ● What regular physical activity or exercise do you engage in? ● How would you rate your personal energy level? ● How much time is spent at work versus at leisure and play? ● How do you relax? ● How do you most often express anger? ● Do you try to be perfect? How do you feel if you do not achieve that? ● Would you describe yourself as having the stress-filled lifestyle? ● How often do you find yourself feeling hopeless? Sad? Apathetic? ● Is your appetite normal for you?

Body positioning is done to?

To facilitate respirations the patient usually finds an upright posture the most comfortable. In the upright position, gravity pulls abdominal organs down and allows a diaphragm more room to contract. most patient with dyspnea cannot tolerate lying down. Orthopnea is the term used to describe difficulty breathing when lying down.

Renal diet is done to

To manage electrolytes and fluid for clients with renal insufficiency

Protein control diet is to manage

To manage liver and kidney disease

Stimulating the patients appetite restrict liquid intake with meals

To prevent gastric distention or feeling full before the patient consumes sufficient nutrients

Posttest care purpose

To restore the clients pre diagnostic level of functioning by providing care and teaching relative to what the client can expect after test and the outcomes or side effects of the test

What is external stressors

To the person, for example, death of a family member, hurricane, or even something as simple as excessive heat in room

What factors affect surgical risk age toddlers, preschoolers, teen, young adults

Toddlers understand simple explanation but may be anxious about separation from parents or caregivers. Many have fear of the dark. preschoolers fear damage to body parts. Fear of pain or of needles is common for children of any age. Teens might fear disfigurement resulting from scars. Young adults commonly have anxiety about the costs associated with hospitalization or surgery

Treatment interventions for diarrhea, whats not recommend for acute diarhhea? avoid?

Treatments include medications, diet modification, and attention to fluid balance and skin integrity opiates an opiate derivatives are the primary antidiarrheal drugs prescribed. They are not recommended for acute diarrhea. during the acute episode, the patient may need to modify his diet to control the diarrhea. You would need to promote skin integrity and fluid balance with interventions such as the following, provide assistance with hygiene to protect the skin. Teach the patient about or provide a clear liquid diet including electrolyte replacement fluids. Clear broth and gelatin are also good choices. encourage your patient to sip liquids or take ice chips or popsicles often to replace the losses. reduce the amount of fiber in your diet by cutting back servings of whole grain bread and fresh fruits and vegetables. limit foods contain caffeine, such as coffee, strong tea, and cola. avoid a sudden large intake of fluid or food when resuming a normal diet because this may trigger mass peristalsis.

Imbalance nutrition more than body requirements

Triceps skinfold greater than 15 mm in men, or 25 mm in women. wait 20 percent more than ideal for height and frame. Eating in response to external cues such as time of day or social situation. eating in response to an internal cues other than hunger. Reported or observed dysfunctional eating pattern. Sedentary activity level. concentrating food intake at end of day.

what is a stimulus?

Trigger that stimulates receptor Meaning depends on reception and processing (e.g., loud noise, bright light, sour fruit)

Birth to one year

Trust vs mistrust -success leads trust in self and others -mother feeding -consistency of the child primary care provider - if not achieve the child experience anxiety and insecurity

Pronation

Turn wrist so that the palm is down

types of nursing interventions

Types of Nursing Interventions: Observation/Assessment Prevention Teaching/Education Treatment

Describe the typical physical preparation of a client undergoing surgery. how long NPO should be maintain? what needs to be done with the surgical site? have the client void when? remove?

Typical physical preparation of a client undergoing surgery involves the following: ● Maintain NPO for 8 hours before surgery. ● Shower or scrub the surgical site with an antibacterial solution the evening before surgery and the morning of the surgery. ● Have the client void before receiving preoperative medications, including prophylactic antibiotics. ● Administer any prescribed preoperative medications. ● Review daily medications with the anesthesia team. ● Remove all artificial body parts, such as dentures, limbs, or contact lenses; wigs, eyeglasses, makeup, and jewelry must also be removed. ● Apply antiembolism stockings, if prescribed.

Ultrasonography

Ultrasonography Ultrasound (echogram) is a noninvasive study that uses high-frequency sound waves to visualize deep body structures and their movement

Echocardiography what is it? How to prepare the patient: what position are they in? is it painful or painless, they must lie how? , what to expect: how long does it take? how does the room need to be? may be uncomofortable to who? what is needed for good contact? , post procedure expectations, what can go wrong, how will you know, what to do if it does

Ultrasound to determine the position, size movement of cardiac valves and heart muscle wall, direction of blood flow. -How to prepare patient: painless, must lie still supine position. Gel is used to conduct the sound waves. -What to expect: takes 45 minutes, darkened room may be uncomfortable for women with large breast. Pressure needed for good contact. -Post procedure expectations: Remove all gel. -What can go wrong: needed pressure for accurate scanning. -How will I know: poor imaging. -What to do if it does : increase pressure to chest wall ( may be uncomfortable across breast and ribs

Types of Grief

Uncomplicated Complicated -Chronic -Masked -Delayed Disenfranchised Anticipatory

Repression examples and examples and consequences of overuse

Unconscious burying for forgetting a painful thoughts, feelings, memories, ideas, pushing them from a conscious to an unconscious level. It is a step deeper than denial. E.g having no memory of sexual abuse by sibling or father. And adolescent forgets to put out the trash because being boss makes him angry, but he feels guilty if he consciously chooses not to do it. Flashbacks, traumatic stress syndrome and amnesia

Restless Leg Syndrome, sometimes associated with?symptoms are? avoid? self care measures include?

Uncontrollable movement of legs while resting or before sleep onset. it tends to run in families. children and young adults experience this but is also common in elderly and sometimes associated with low levels of iron and use of some antidepressants. symptoms include unpleasant creeping, crawling, itching, or tingling sensations in the legs. symptoms are relieved only by moving the legs, which prevents the person from relaxing and falling asleep. avoid caffeine. self care measures include walking, massaging, stretching, heat or cold compresses, medication, vibration, and acupressure.

Factors affecting oxygenation developmental young, middle, and older adults.

Unhealthful practices of adolescents often continue into adulthood. Changes in the respiratory system that begin in middle age and increase in older adulthood may become significant when the person experiences stressors such as infection, surgery, anesthesia, and emotional problems. The number of cells and the efficiency the organs decline in a subtle and progressive way as a person ages. Keep in mind, though, that endurance training and regular exercise minimize the rate of these changes. In fact an older person who is physically conditioned by regular exercise may have better lung functioning than a young adult who is not well condition.

Maladaptive

Unhealthy style, temporary fix Possible other harmful effects Examples: substance abuse; overeating

The Ultimate Loss: Death

Uniform Determination of Death Act Ethical Issues: -Coma -Persistent vegetative state (PVS)

Review of body system genitourinary you want to know

Urgency, frequency, retention, urinary tract infection, need for Foley catheter or other devices

Signs and symptoms of urinary tract infection

Urine frequency, urgency, foul smelling urine, pyuria, dysruia, hematuria, bladder spasms, edema, chills, fever, back pain, nausea and vomiting.

Assist with hygiene

Urine is irritating to the skin. Therefore perineal cleansing is an integral part of toileting hygiene. many ill patients are unable to do this for themselves, so you would need to provide perineal care. If the patient can emulate to the bathroom, you really need to assist with her usual cleansing routine. You may assist a patient by pouring warm soapy water over the genitals while she is seated on the toilet, the bedside commode, or on the bed pan. Be sure to rinse with warm water because soap may be drying to the genital mucosa. also offer a moist washcloth or towelettes for washing hands after toileting.

Interventions for positioning

Use assistive devices for immobilization. Lock wheels of stretcher and operating room bed. use an adequate number of personnel to transfer patient. Support the head and during transfer. immobilize or support anybody part as appropriate. Maintain patient's proper body alignment. apply padding to bony prominences. Apply safety strap and arm restraint, as needed. Record position and devices used.

Removing an indwelling catheter

Use clean technique. wash hands before and after removing the catheter. Wear clean procedure gloves. Be sure to remove the tape securing the catheter to the patient. obtain a sterile specimen if needed. deflate the balloon completely by aspirating the fluid. if you cannot ask for it all the fluid, do not pull on the catheter. report to the charge nurse or the primary care provider before continuing. observe the first few voiding after the catheter is removed.

Critical aspects of obtaining A expectorated specimen? what position should the patient be in? caution the patient? instruct the patient to? if specimen transport is delayed what do you do? place the specimen where?

Use high or semi Fowler's position. caution the patient not to touch the inside of the sterile container or lid. Instructed patient to breathe deeply for three or four breaths, cough deeply, then expectorate in the container. Label the specimen container with the patient's name, test name, and collection date and time. Place the specimen in a plastic bag with a biohazard label. Send a specimen to the laboratory immediately. If specimen transport is delayed, consult the lab, refrigeration may be required.

Rationalization examples and examples and consequences of overuse

Use of logical sounding excuse to cover up or justify true ideas, actions, or feelings. An attempt to preserve self respect or approval or to conceal a motive for some action by giving a socially acceptable reason. Similar to intellectualization, but uses faulty logic. E.g it was God will that this happened to me. If I didn't have to work, I would be a better wife. This mechanism can lead to self deception.

Ethical Use of Electronic Records

Use of passwords Confidentiality & Data Security (Vol #2, p. 182) Audit trails "tracking" HIPAA regulations Consent Limiting disclosure

Calorie protein push diet used when?

Use when there is a need to heal wounds, maintain or increase weight, or promote growth. If the person cannot consume enough kcal by adding fats and proteins to his regular diet, high calorie high protein supplements maybe use.

Ineffective breathing pattern, what are some of the signs the patient will have?

Used to describe inadequate ventilation, such as hypoventilation, hyperventilation, tachypnea, or bradypnea. Patient may have abnormal respiratory rate, depth, or pattern, dyspnea, orthopnea, and other signs of difficulty breathing. ineffective breathing pattern patient complain of feeling breathless , dyspnea, patient in change in depth of their breathing, use of accessory muscles, nasal flaring, grunting when their breathing

Regression examples and examples and consequences of overuse

Using behavior appropriate in an earlier stage of development to overcome feeling of insecurity in the present situation E.g cooks and eats a comfort food (hot fudge sundae). A 60 year old divorced dresses and act like a teenager Can interfere with perception of reality

Foul smelling sputum

Usually indicates bacterial infection such as pneumonia, lung abscess.

When is the patient position

Usually position after anesthesia has begun. Use strap, wedges, pillow, and surgical table attachments to maintain the position during the surgery. To prevent shearing, lift do not slide the patient in position. In many cases the surgical team assist with positioning.

White or clear sputum. usually present when? often requiring what type of care?

Usually present in viral infections such as cold or viral bronchitis, often requiring only supportive care

Providing postpartum care legal responsibilities

Usually the physician must pronounce death however in some areas a coroner or nurse may also perform this task. - the person who pronounces death must sign the death certificate. in some agencies the nurses responsible to see that it is sign. - if the patient is donating organs, review and make necessary arrangements - if an autopsy is to be performed, as a rule the physician is responsible for a obtaining signed permission from next of kin

Factors in Moral Decision-Making values:

Values -Belief about the worth of something -Highly prized ideals, customs, conduct, goals -Freely chosen -Learned through observation and experience -Vary from person to person

Calcium, iron, and zinc vegetarianism

Vegan, fruitarians, and other who limit animal food may need to supplement the diet with this. Especially for pregnant and lactating and children Iron from plant food is not absorb as well as from animal source. It is easier to absorb when eaten with food containing vitamin c Calcium, vegan especially may find it difficult to obtain enough dietary calcium. Important to include fortified soy milk and calcium rich food vegetables ( bok choy, broccoli, collards, Chinese cabbage, kale, mustard green, okra, and fortified tomato juice). Calcium fortified cereal are also available.

disturbed sleep pattern. the patient will verabilize

Verbal complaints of not feeling well rested. dissatisfaction with sleep. Change in normal sleep pattern. Decreased ability to function. Reports being awakened. Reports no difficulty falling asleep.

Hopelessness, what are my defining charactersitics?

Verbal cues (e.g, " I can't or why go on") , sighing, closing eyes, shrugging, decrease appetite, lack of emotion, increase or decrease sleep, little or no involvement in care, passivity , lack of initiative, seeing no solution or way out

Verbal/Telephone Physician Orders

Verbal orders Spoken to you; often during a client emergency Should be made for critical change in patient condition Telephone orders Received by phone and transcribed onto chart order sheet Have an increased risk for errors "Read-backs"

Removing a nasogastric tube

Verfied the primary providers prescription for removal of a nasogastric tube. Assisted patient to sitting or high Fowler's position. Clear the tube of secretions by injecting 10 ml of air through the main lumen. ask the patient to hold his breath, and gently, but quickly, withdraw the tube. Discard the equipment. Provide or assist with care of nose and mouth.

Procedure steps of collecting an expectorated specimen, verify? put on what type of gloves? collect how much?

Verify the medical prescription for the type of sputum analysis. put on gloves. Collect 5 to 10 ml of sputum.

The Spread of Infection portal of exit

Via Bodily fluids Coughing, sneezing, diarrhea Seeping wounds Tubes, IV lines

arteriogram (femoral approach) what is it? How to prepare the patient: check for allergy to? NPO when? mark site? void when?, what to expect: warm flusing with? what positon? requires? , post procedure expectations: pressure to? assess? can't do what for 8 hours , what can go wrong, how will you know, what to do if it does

WHAT IS IT: contrast dye injected into femoral artery in groin to x ray blood flow, ex: cardiac catheterization HOW TO PREPARE THE PATIENT : check for allergy to dye ( shellfish) NPO 2-8 hrs before procedure mark site of periph. pulses prior to study, void before procedure because dye acts like diuretic WHAT TO EXPECT: warm flushing with dye injection supine, requires femoral artery puncture POST PROCEDURE EXPECTATIONS: pressure to femoral artery site frequent assessment of distal pulses on extremity used for insertion complete bed rest / no bending at hips for 8hrs WHAT CAN GO WRONG: hemorrhage, loss of peripheral circulation, allergic reaction to dye HOW WILL YOU KNOW? Change in vital signs which means -- shock state, increase size of leg( bleeding inside), loss of distal pulses/numbness/tingling respiratory distress WHAT TO DO IF IT DOES: notify physician of v/s and decrease pulses force fluids if able or iv fluids to enhance dye excretion

lumbar puncture what is it? How to prepare the patient: i need to do what time of assessment? what do they need to do before?, what to expect: what must they do and what position they are in? how long does it take? , post procedure expectations: what do I need to do to the site? position in what position after? encourage? when do I recline?, what can go wrong, how will you know, what to do if it does

WHAT IS IT? insertion of needle into subarachnoid space to measure pressure and obtain csf for studies HOW TO PREPARE THE PATIENT: baseline neuro assessment--> lower extremities strength, sensation, movement no prep required empty bladder & bowel WHAT TO EXPECT: must lie still: movement = injury lateral decubitus position (fetal) numbed then needle inserted takes 20 minutes POST PROCEDURE EXPECTATIONS/ROUTINES: pressure/dressing to site positioned prone encouraged fluid intake recline 1- several hours after initial prone WHAT CAN GO WRONG? csf leak- profound headache damage to spinal cord post puncture spinal headache HOW WILL YOU KNOW: headache numbness/ tingling lower extremities WHAT TO DO IF IT DOES... report to provider analgesics for headache

(MRI) what is it? How to prepare the patient: no exposure to? must remove? may feel what so give? , what to expect: contraindicated in who? and how must the patient be? they can hear what type of sound? , post procedure expectations: if contrast dye is used what do you do?, what can go wrong, how will you know, what to do if it does

WHAT IS IT? the use of magnetic field & radio frequency signals to image the body anatomy HOW TO PREPARE THE PATIENT: no exposure to radiation must remove all metal objects my feel claustrophobic in closed MRI - antianxiety medications WHAT TO EXPECT: contraindicated in extremely obese > 300# & those with implanted metal ( pacemaker, piercings, scrapnel etc) must stay still loud thumping during scan POST PROCEDURE EXPECTATIONS/ROUTINES: no special instructions if contrast dye used- force fluids to excretion WHAT CAN GO WRONG? panic by patient metal objects in scanner-- injury failure to remove nicotine patch-- burns HOW WILL YOU KNOW:panicked behavior/inability to lie still, c/o pain WHAT TO DO IF IT DOES... stop procedure reassure patient assess for injury / burns- notify provider

bronchoscopy what is it? How to prepare the patient: what has to be done before the procedure? , what to expect: what is not impaired? what position and how long is it? , post procedure expectations: NPO for how long, maybe what? what is expected?, what can go wrong, how will you know, what to do if it does

WHAT IS IT? visualation of breathing structures (bronchials, larnyx, trachea) by scope. HOW TO PREPARE THE PATIENT: NPO 4-8hrs before procedure, good oral hygiene to decrease introduction of microorganisms into lungs, sedation will be provided WHAT TO EXPECT: breathing is not impaired, nasal oropharynx is anesthetized and trachea to prevent cough, sitting or supine, 30-45 minutes POST PROCEDURE EXPECTATIONS /ROUTINES: NPO= 2 hrs until gag reflex returns throat maybe sore= warm saline gargles small amount of blood streaking in sputum is expected WHAT CAN GO WRONG? hemorrage laryngospasm HOW WILL YOU KNOW? v/s , large amount of bleeding impaired respirations, stridor, respiratory distress WHAT TO DO IF IT DOES... notify provider support breathing

cystoscopy what is it? How to prepare the patient: force? and maintain? if general anesthesia? what does the sedatitive do?, what to expect: what position the client in? they must lie? and how long is the procedure?, post procedure expectations: assess? what is expected? encourage:, what can go wrong, how will you know, what to do if it does

WHAT IS IT? visualization of urethera, bladder and erters( prostate in males) HOW TO PREPARE THE PATIENT: force fluids -maintain good uop if general anesthesia + NPOAM sedative will be administered: decrease anxiety + spasm of bladder sphincter WHAT TO EXPECT: lithotomy position must lie very still to trauma will have desire to void as scope passes 25 minutes. POST PROCEDURE EXPECTATIONS/ROUTINES: assess voiding pattern pink tinged urine is expected encouraged good fluid intake abdominal/ back disconfort/ burning in urination WHAT CAN GO WRONG? perforation urinary retention (from urethral edema) HOW WILL YOU KNOW: bright red blood in urine, v/s inability to void, distended bladder. WHAT TO DO IF IT DOES... notify provider urinary catheterization.

intravenous pyelogram what is it? How to prepare the patient: they cant do it if they are allergic to? they may have what the night before? what can there dietary restriction be? what to expect: what position do you want the client and IV inserted? , post procedure expectations: you need good? monitor? what is expected? , what can go wrong, how will you know, what to do if it does

WHAT IS IT? x-ray contrast study of the kidneys, bladder and ureters serial xrays show movement of dye through glomeruli--> renal tubules HOW TO PREPARE THE PATIENT: allergy to dye/ shellfish may have laxative/ cathartic night before dietary restriction per facility: NPO or CL WHAT TO EXPECT: supine, xray done clear visualization of renal system IV inserted (dye: flushing) every 5 minutes & a image after the client voids one post void POST PROCEDURE EXPECTATIONS/ROUTINES: good hydration to facilitate dye excretion monitor output pink tinge urine expected WHAT CAN GO WRONG? renal failure dye allergy HOW WILL YOU KNOW: Decrease uop,increase bun, increase creatinine respiratory distress WHAT TO DO IF IT DOES... notify provider/ monitor renal status respiratory support

barium swallow what is it? How to prepare the patient: they need be what before the procedure? i need to asses? and tell them?, what to expect: is given how? what position? how long does it take? , post procedure expectations: what color may the stools be? what is given to facilate evacuation of barium?, what can go wrong, how will you know, what to do if it does

WHAT IS IT? xray study using contrast to examine the esophagus HOW TO PREPARE THE PATIENT: npo 8hr a procedure assess swallowing ability no discomfort associated with procedure WHAT TO EXPECT: barium sulfate in milkshake is taken expect to be positioned many ways to visualize esophagus on fluroscopy 15-20 min POST PROCEDURE EXPECTATIONS/ROUTINES: stools may be white in color cathartic given to facilitate evacuation of barium WHAT CAN GO WRONG? barium induced fecal impaction HOW WILL YOU KNOW: 0 BM abdominal distention abdominal discomfort WHAT TO DO IF IT DOES... cathartics enema

colonoscopy what is it? How to prepare the patient: what type of diet? what color liquids are not allowed? whats given? , what to expect: what is required? what position is the client? takes how long? , post procedure expectations: force, what can go wrong, how will you know, what to do if it does

WHAT IS IT? scope inserted into rectum to view colon from anus to cecum HOW TO PREPARE THE PATIENT: bowel preperation: clear liquids x 2 days ( no red / purple colored liquids) + strong cathartic go- lightly : tday prep WHAT TO EXPECT: IV required, sedation/ twilight sleep lateral decubitus position takes 30-60 min. may require air insufflation to distend' POST PREPERATION EXPECTATIONS/ROUTINES: effects on sedation gas pains/ flatulence force fluids: combat dehydration from prep WHAT CAN GO WRONG: bowel perforation persistent bleeding form biopsy sites oversedation HOW WILL YOU KNOW? abdominal pain, bleeding, distention Decrease BP , increase-PULSE which means -SHOCK, decrease LOC, decrese RR WHAT TO DO IF IT DOES.... notify provider v/s, bleeding, pain safety until sedation clears

endoscopy what is it? How to prepare the patient: what needs to be done before the procedure, what to expect: takes how long? client wont be able to? what is not affected? what position they are in? , post procedure expectations: fluids are held for how long? they may have? , what can go wrong, how will you know, what to do if it does

WHAT IT IS? direct visualization of upper GI tract using a lighted scope HOW TO PREPARE THE PATIENT: oral hygiene fasting 8-10hrs before procedure mildly uncomfortable throat numbed & gag reflex usually sedated WHAT TO EXPECT? takes 20-30 min wont be able to talk, tube doesnt go into lung so breathing isnt affected left lateral decubitus position POST PROCEDURE EXPECTATIONS/ROUTINES may have hoarsness/soar throat from tube inserted through mouth * fluids held until gag reflex returns (usually 2-4hrs) WHAT CAN GO WRONG: perforation of esophagus, stomach or bleeding from biopsy site aspiration HOW WILL YOU KNOW? vital signs, LOC, coughing/ choking WHAT TO DO IF IT DOES: notify provider-coagulation intervention maybe needed clear airway

Factors affecting grief circumstances of the loss

Was this a sudden, unexpected death, or has the person been suffering from a chronic illness? specifically, was there an opportunity to prepare for it? was the death a suicide or homicide? was the death in any sense avoidable? was the person in pain? if the circumstances of the loss leave the beavered feeling guilty or responsible, his healing process may be impeded. this can result from losses other than death as well (e.g., loss of valued property by theft or disaster, loss of a relationship, loss of a job, rejection from college).

hand washing guidelines

Wash for at least 15 seconds in nonsurgical setting; 2-6 minutes in surgical setting Remove jewelry and clean beneath fingernails Use a bactericidal solution or use water if hands are visibly soiled Use warm water, not hot Apply soap to wet hands Use friction Rinse soap Towel or hand dry

Helping families of dying patients remind family members and significant others to take care of themselves and what are some interventions that can be done?

Watching a loved one die is a very difficult experience. A sensitive, caring nurse can make it a little easier. - many times they need permission to go out to eat or go to home and rest. - if the patient is near death and family and friends do not want to leave the patient side, make them as comfortable as possible - provide comfortable chairs, coffee, and snacks, and be alert for other needs they may have

Meeting physiological needs of the dying person if the patient is unable to take fluids

Wet the lips and mouth frequently with cool water or with a prepared products to prevent dryness and cracking of lips and mucous membranes of the nose, mouth, & eyes. There is some evidence that glycerin swab dry the mucous membrane and should not be used

what are nursing interventions?

What Are Nursing Interventions? Purpose: to facilitate achievement of client outcomes AKA: nursing actions, measures, strategies, activities based on clinical judgment and nursing knowledge

What factors affect surgical risk?

What factors affect surgical risk? Answer: Seven factors affect surgical risk: ● Age ● Type of wound (potential for infection) ● Preexisting conditions ● Mental status ● Medications ● Personal habits ● Allergies

what does the Footboard do?

When a person is supine, the toes tend to point downward toward the bed which is foot drop and the feet are in plantar flexion. A person who is unable to move independently will experience a shortening of the gastrocnemius muscle and may have difficulty walking again if prolonged plantar flexion occurs. So the foot board prevent foot drop and outward hip rotation, but it does not relieve heel pressure. For it to be effective the heels must be touching it.

infection

When microorganisms capable of producing disease invade the body (and are successful!)

what is it Palliative care? general issues for mst end of life care include?

When patients reach a stage in their illness in which cure is no longer possible, or when they refuse further treatment, they may be eligible to receive comfort care meaning that no further efforts will be made to stop disease process or prevent the patient from dying, although certain symptoms like nausea for example will be treated. Many patients receive palliative care from their general practice provider, and even in acute care hospitals, especially if staff are comfortable and skilled with pain management and end of life care. palliative care is actually aggressively planned, holistic comfort care. General issues for most end-of-life care patients include the following: supporting families and caregivers. Ensuring contunity of care. Ensuring respect for persons. Ensuring informed decision making. Attending to emotional and spiritual concerns. Supporting function and survival duration. Managing symptoms (e.g. pain, dyspnea, or depression) The patient does not necessarily have to be actively dying to receive palliative care. it is also provided over a long period Of time for those who have slowly progressive diseases. It should result increase patient satisfaction, improve symptom control, and cost savings for hospitals.

Adjustable beds

When providing care always adjust a bed to waist height and in its lowest position before helping a patient get out of bed or if the patient is at risk for falling. Airfluidized and oscillating beds for pressure ulcer Circular and Stryker frame are used in the care of patients with severe mobility restrictions.

why do nurses need teaching skills

Why do nurses need teaching skills? Teaching clients is part of independent nursing practice ANA standard related to promoting health demands skill in teaching clients Clients/families need information for decision making Shorter hospital stays increase need for teaching about home-care needs Teaching facilitates compliance and shortens hospital stays and medical complications Teaching empowers clients and families

interventions when the patient is very near death, the focus should be on? if the person can communicate ask?

When the patient is very near death, focus on relieving symptoms (e.g., pain, nausea) and emotional distress. ● If the person can communicate, ask about immediate concerns ● "Are you in pain?" ● "Are you comfortable?" ● "What are you afraid of now?" ● "What can we do to help you go peacefully?" ● "Who do you want in the room with you right now?" ● If the patient asks whether he is dying, be honest. ● If the patient cannot communicate, ask the family, who may know what the patient would want. Some students may choose the following intervention, but it is probably not the preferred response unless it is given in addition to the above intervention: ● When the patient is very near death, it may be helpful to say something like "Your family will be fine" rather than "It is okay for you to go now."

Validating Data

When to validate Subjective/objective data do not agree or make sense Client's statements differ at different times in the interview Data are far outside normal range Factors are present that interfere with accurate measurement

Raise the height of the bed and over the bed table to waist level

When you are working with a patient

handwashing

When you arrive in the unit When you leave the unit Before and after restroom use Before and after client contact Before and after contact with client belongings Before gloving After glove removal Before and after touching your face Before and after eating After touching a contaminated article When you see visible dirt on your hands lather and scrub for 20 secs and rinse for 10

When possible, keep your elbows bent

When you carry an object.

Use both hands and arms

When you lift, move, or carry heavy objects.

Keep objects close to your body

When you lift, move, or carry them. The Closer an object is to the center of gravity,, the greater the stability and the less strain on the back

Push, slide, pull heavy objects rather than?

Whenever possible rather than lifting

Documentation during the testing

Who perform the procedure. Reason for the procedure. Type of anesthesia, dye, or other medications administered. type of specimen obtained and where it was delivered. vital signs and other assessment data, such as client tolerance to the procedure or pain and discomfort level. Any symptoms of complications. Who transported the client to another area

In the following predicted outcomes, identify the subject, action verb, performance criterion, target time, and special conditions (if any). State which components are assumed, if any.

Will walk to the doorway with the help of one person by 12/13/10. Answer: ● Subject: client (assumed) ● Action verb: will walk ● Performance criterion: to the doorway ● Target time: by 12/13/10 ● Special conditions: with the help of one person

Physiological stages of dying include

Withdrawal, systems deterioration, cheyne Stokes breathing, mottling, organ failure, death.

Components of Quality and Safety what are the three aspects essential to their implementation

Within each component of quality and safety, three aspects are essential to their implementation: Knowledge Skills Attitudes

how do you cleanse a wound

Wound is less contaminated than the surrounding skin Never cleanse across an incision twice with the same gauze Drain - is highly contaminated - move from the incision area to the drain site

wounds: clean wounds, clean-contaminated wounds, contaminated, infected?

Wounds are categorized based on four levels of contamination: ● Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (these systems frequently harbor bacteria). There is very little risk of infection for these wounds. ● Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection. ● Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds. ● Infected wounds are wounds with evidence of infection, such as purulent drainage or necrotic tissue. Wounds are considered infected when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue or in which there is the presence of beta-hemolytic streptococci in any number.

Maintain a good grip on the patient or object

You are moving before attempting to move it.

stress affecting cognitive function how to assess

You can assess the client's cognitive functioning as you assess other functional areas. ● Notice whether the person has difficulty focusing and responding to your questions. ● When you ask the client to describe and rate the intensity of her stressors, you can begin to assess whether she perceives the stressors realistically or in an exaggerated way. ● Asking the client about her coping strategies will give you an idea of her problem-solving abilities. ● Difficulty concentrating ● Poor judgment ● Decrease in accuracy (e.g., in counting money) ● Forgetfulness ● Decreased problem-solving ability ● Decreased attention to detail ● Difficulty learning ● Narrowing of focus ● Preoccupation, daydreaming

Cognitive restructuring

You have clients to recognize their negative focus and to restruct their thinking and more positive realistic ways

Helping families of dying patients as physical signs of death become apparent, keep the family informed

You may say something like, " her blood pressure is becoming difficult to hear. that is one of the sign that she is closer to death." help the family to understand what the patient is experiencing, as this may be very different from what they are saying.

Procedure steps of collecting a suction specimen you should wear what kind of gloves?

You wear sterile gloves for this procedure

safety hazards in home firearms injuries and prevention

Youth suicides; domestic violence Prevention: firearms safety education for parents and children, proper locked storage, keep ammunition separate

C-reactive protein (CRP)

a blood test to measure inflammatory change or bacterial infection.

White blood cell count with differential

a breakdown of the number and types of WBC; normal WBC count is 5,000-10,000/mm3

disturbed sensory perception

a change in the amount or patterning of incoming stimuli accompanied by diminished, exaggerated, distorted, or impaired response to such stimuli. use this diagnosis when there is excessive or insufficient environmental stimuli or when the patient has altered sensory reception, transmission, and/ or integration; biochemical or electrolyte imbalances; or psychological stress.

contustion type of wound

a closed wound caused by blunt trauma. may be referred to as a bruise or ecchymotic area

Common Post-op Discomforts constipation , clinical signs and interventions

a decrease in the frequency of bowel movements, results in the passage of hard stools. usually related to opioids, immobility, inadequate fluids intake, or low fiber diet. clinical signs: abdominal discomfort, bloating, hypoactive or absent bowel sounds. interventions: encourage and assist the patient to move in bed, ambulate, and increase fluid an fiber intake after bowel sounds return.

stage 3 pressure ulcer

a deep crater charcterized by full thickness skin loss with damge or necrosis of subcutaneous tissues may extend down to but not through underlyign fascia undermining of tissue may be present

what does the norton scale include

a low score indicates a high risk Physical Condition Mental Condition Activity Mobility Incontinent

multiprong canes

a multiprong cane usually has three or four prongs, and all types have a straight handle. these canes provide a wide base of support and are useful for patients with balance problems

Identification examples and consequences of overuse

a person takes on ideas, personality, or characteristics of another person, especially someone that the person fears or respects. E.g children play cowboy , police, fireman, or mommy Assume mannerisms, wears clothing, and arrange arranges hair and physical appearance to match those of the other person

blood cultures

a sample of blood placed on culture media and evaluated for growth of pathogens. normally, should show no growth

abrasion type of wound

a scrape of the superficial layers, usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces

Depression of cycle loss and grief, what will you see in the client?

a withdrawn sadness, not to be confused with clinical depression. This is a response to the current loss as well as to any accumulated and or future losses 4 stage

tunnel is what type of wound

a wound with entrance and exit site

what is reckless behavior?

conscious disregard of substantial and unjustifiable risk must be reported to the board

wounds assessment incision

a. assess site: edematous, inflamed, excoriated. b. assess draingage: serous, serosanguineous, purulent. c. note the type of sutures. d. note if edges are well approximated e. risk of infection 3-5 d post op f. debride wound, if needed, to reduce inflammation g. change dressing frequently to prevent skin breakdown around site and minimize bacterial growth.

Use a wide base of support

feet spread apart

AKA

above knee amputation

knowledge deficit and defining characteristics

absence of deficiency of cognitive information related to specific topic 1. verbalization of problem 2 .inappropriate or exaggerated behaviors ( hysterical, hostile, agitated, or apathetic 3.lack of exposure 4.lack of interest in learning 5.lack of recall 6.unfamiliarity with information resources

ADL

activities of daily living

critical aspects removing and applying drying dressing

administer pain 30 before procedure place in comfortable position that provides easy access to the wound wear clean gloves, remove the soiled dressing and discard in biohazard receptacle change gloves and clean the wound saline moistened gauze assess the wound for location, appearance, odor, and drainage apply a dry dressing you use sterile gloves secure with tape

critical aspects of wet to damp dressing so what do you want to do?

administer pain 30 before procedure place in comfortable position that provides easy access to the wound wear clean gloves, remove the soiled dressing and discard in biohazard receptacle change gloves and clean the wound saline moistened gauze assess the wound for location, appearance, odor, and drainage don sterile gloves and apply a single layer of moist, fine mesh gauze to the wound. be sure to place gauze in all depressions of wound apply a secondary moist layer over the first layer. repeat this process until wound is filled with moistened sterile gauze cover the moisture gauze with an absorbent, surgical pad secure the dressing with tape of montgomery straps

the proliferative phase--granulation

also called the regeneration phase occurs from days 5 to 21. cells develop to fill the wound defect and resurface the skin. fibroblasts ( connective tissue cells) migrate to the wound where they form collagen, a protein substance that adds strength to the healing wound. new blood and lymph vessels sprout from the existing capillaries at the edge of the wound. the result is the formation of granulation tissue, a beefy red tissue that bleeds readily and is easily damaged. as the clot or scab is dissolved, epithelial cells begin to grow into the wound from surrounding healthy tissue and seal over the wound epitheliaztion.

assessment for intramuscular injections

always palpate the landmarks and the muscle mass to ensure correct placement of the needle

alternatives to restraints are?

ambularms and bed alarms are used as an alternative for restraints with clients who out of bed and are in danger of falling

Amb

ambulation, ambulatory

p, - p

after

pc

after meals

Potential Postoperative Complications:Collaborative Problems respiratory aspiration pneumonia what is it, clinical signs, interventions

airway inflammation caused by inhaling gastric secretions because of absent gag reflex secondary to anesthesia. Clinical signs: cough, fever, elevated white blood cell, decreased or absent breath sounds, decreased oxygen saturation, tachypnea, dyspnea, blood tinged sputum. Interventions: preoperative: institute NPO for at least 8 hours prior to surgery. Postoperative: Continue NPO until intestinal motility return, carefully monitor sedated patient and place in side - lying position.

Amt

amount

assault?

an assault occurs when a nurse intentionally places a patient in immediate fear of personal violence or offensive contact. an assault must include words expressing an intention to cause harm and some type of action. For example, a nurse has committed an assault if she says to the patient "i will slap you" and raises her hand as if to slap the patient. the combination of the words and action causes the patient to believe the threat will be carried out

chemoreceptors

for taste are located in our taste buds

what is a puncture?

an open wound caused by an sharp object. often there is collapse of tissue around the entry point, making this wound prone to infection

Helping families of dying patients acknowledged the family feelings and? many times family members begin the grieving process when?

and the loss they are experiencing. Many times family members begin the grieving process before the loved one dies

acupuncture

application of extremely fine needles to specific sites in the body to relieve pain . it is believe to stimulate the endogenous analgesia system . well documented to provide relief from dental pain and has been used extensively after surgery and chemotherapy to treat nausea

What factors affect surgical risk age older adults

are at increase risk because they have less physiological reserve and often have comorbid conditions. Many of the physiological changes of aging predisposed older adults to increase risk. Increased time for wound healing.

insulin syringes

are calibrated in units and are used to administer insulin only. they are calibrated in 100 units per millimeter. they are made in 0.3, 0.5, 0r 1 ml sizes with very small needle gauge (26 to 30)

nurse practice act

are established by state boards of nursing to govern the practice of nursing

what are never ever events?

are health care acquired complications that medicare will no longer reimburse institutions -foreign object left in patient after surgery ex. sponge -air embolism -administering the wrong type of blood -severe pressure ulcers -falls and trauma -infections associated with urinary cathether -infections associated with intravenous cathether -symptoms resulting from poorly controlled blood sugar levels -surgical infections following certain elective procedures (e.g certain orthopedic surgeries, bariatric, surgery for obsesity) -dvt or pulmonary embolism following total knee and total hip replacement.

superficial or cutaneous wounds are? examples?

arises in the skin or the subcutaneous tissues. example like touching a hot object or paper cut

international council of nurse

as a guide for action based on social values and needs. standard for nurses worldwide. it stress respect for human rights, including cultural rights, the right to life and choice, the right to dignity, and right to be treated with respect. its to guide nurses in every day choice and it supports their refusal to participate in activities that conflict with caring and healing.

ad lib

as desired, if the patient desires

prn

as needed

ASAP

as soon as possible

patients response of wound assessment

ask about pain, discomfort, itching related to wound care or wound

assessment for renal

asses the bladder for distention. monitor urine output it should be at least 30 ml. if the client does not have a foley catheter, the client is expected to void within 6 to 8 hours postoperatively depending on the type of anesthesia administered, ensure that the amount is at least 200 ml.

Respiratory assessment data post op and interventions

assessment: check breath sounds, monitor vitals, monitor airway patency, monitor for secretions, observe chest movement, monitor 02, note the rate, depth and quality of respirations, monitor for signs of respiratory distress. Interventions: TCDB O2 therapy Teach incentive spirometer/ IPPB (need physician order, patients non compliment with incentive spirometer) get out of bed as soon as possible splint wound offer pain medication

noc

at night

hemostasis

at the time of the injury, tissue and capillaries are destroyed, causing blood and plasma to leak into the wound. area vessels constrict to limit blood loss. platelets are activated and aggregate ( clump together) to slow bleeding. at the same time, the clotting mechanism is activated to form a blood clot.

Assessment techniques and abnormal findings for cardiovascular

auscultation show orthostatic hypertension. As well as auscultation and palpation will show increased heart rate, third heart sound, weak peripheral pulses, and peripheral edema.

you should avoid which site for administering IM injections . which is the site of choice

avoid dorsogluteal because you may hit the sciatic nerve and superior gluteal artery use ventrogluteal site located on the lateral hip

uti

back

applying bandages

bandage the body part in its natural position work from distal to proximal position choose a bandage of the proper width clean the wound if present apply primary dressing apply the bandage as needed to secure primary dressing

BRP

bathroom privileges

BR

bed rest

BSC

bedside commode

Immunoglobulin (IgG, IgM) levels

blood test to evaluate humoral immunity status

disease titers

blood tests for specific disease immunity (e.g., to rubella)

what panels are used to evaluate specific disease exposure

blood tests to evaluate exposure to specific disease (e.g. HIV, hepatitis

BM

bowel movement

invasion of privacy

breach of confidentiality

why is breast feeding good for infants? infants should not receive?

breast feeding enhances maturation of the infant immune system and provides passive immunity against a number of infections. reduce exposure to foreign dietary antigens and a reduced risk of subsequent allergies and less risk of developing DM. infants under 1 should not receive regular cow milk because it can cause gastrointestinal bleeding and too much strain on kidney and iron deficiency anemia. honey and corn syrup are potential sources for botulism toxin

PO

by mouth

massage

by providing cutaneous stimulation and relaxing muscles, massage helps to reduce pain. effeleurage the use of slow guiding strokes is used for patient during labor and as back rubs for post op. massage may improve sleep

prothrombin time (clotting time) and wound

critical values > 20 seconds (uncoagulated) or 3 times normal control ( anticoagulated) altered coagulation may result from anticoagulant medications, a concurrent illness, trauma, or reaction to transfusion.

c/o

complaint of

cal

calories

Common Post-op Discomforts sore throat

can be due to tubing

cath

catheter

CBC

complete blood count

what is visceral pain? most often experience where? what are examples?

caused by deep stimulation of deep internal pain receptors. most often experience in abdominal cavity, cranium, thorax. examples are menstrual cramps, labor pains, gastrointestinal infections, bowel disorders, and organ cancers

chronic wounds arterial ulcer are caused by? which leads to? and how does it appear?

caused by inadequate ciruclation of oxygenated blood to the tissue, which leads to tissue ischemia and damage ulcer appears punched out small and round with smooth borders. the wound base is pale with no necrtoic tissues. tend to occur in the distal part of the leg especially the ankles,, toes, side of the foot and shin. the surrounding skin apperrs shiny, thin, dry and cool to touch. often hair loss in surrounding area. delayed capillary refill

chronic wound venous stasis ulcer caused by? located usually around? the wounds are usually? and pain occurs?

caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function resulting in venous pooling, edema, impaired micocirculation of the skin located usally around the inner ankle, or lower parts of the calf. surround skin is reddened or brown and edematous. wounds are usally shallow with irregular wound margins. the wound bed appears ruddy or beefy red and grannular.. pain occurs with leg dependence and dressing changes

chronic wounds pressure ulcer caused by?

caused by pressure resulting in tissue ischemia and injury. tend to be located over bony prominences

CVA

cerebrovascular accident (stroke)

what is my assessment for sub q injection? heparin

check aPTT and for signs of bleeding( bleeding for gum, IV sites, and so on)

assessment for gastrointestinal

check bowel sounds in 4 quadrants 5 min each. abdominal distention, monitor for passage of flatus and return of bowel sounds. administer frequent oral care, at least every 2 hours. maintain the npo status until the gag reflex and peristalsis return. when oral fluids are permitted, start with ice chips and water. ensure that the client advances to clear liquids and then to a regular diet, as prescribed, and as the client can tolerate.

what is my assessment for sub q injection? for insulin

check capillary blood sugar level and determine when the patient will be having the next meal; check for signs of hypoglycemia or hyperglycemia

gerd

chest

applying binders

choose a binder of the correct type and size for intended purpose make sure the binder is positioned properly to provide support but not comprise circulation or impair breathing pad any pressures areas or skin abrasions abdominal binder: remove every 2 hrs and assess underlying skin and dressings. fasten from the bottom up triangular strap binder: position patients arm across the chest with elbow flexed slightly place one end of the triangle over the shoulder of the uninjured arm, allow the triangle to fall open so that the elbow of the injured arm is at the apex of the triangle t-binders: they come in 2 basic types those for females have a perineal strap those for males have a split in the perineal strap

how does diminished sensation or cognition affect skin. which patients?

clients with peripheral vascular disease, spinal cord injury, diabetes, CVA, trauma, or fractures have diminished tactile sense. more prone to skin breakdown if they get a cut they may not notice they have and it becomes untreated. also because they don't have sensation they are unable to feel pressure in an affected area . as a result may not shift position to relieve pressure over bony prominces or be aware shoes or clothing are restricting clients with impaired cognition (dementia, alzhemiers, altered level of conscious) are at a higher risk to have skin breakdown because they are not aware to reposition.

fear

cognitive response

crutches are used for

commonly used for rehabilitation of an injured lower extremity. purpose is to limit weight bearing on the legs and cause the user to rely on the strength of arms and shoulders for support

A full liquid diet

contains all the liquids included in the clear liquid diet plus any food items that are liquid at room temperature for example soups, milk, milkshakes, pudding, custard, juices, some hot cereals, and yogurt. it is difficult to obtain a balanced diet on a full liquid plan, so it should be used for short time only. If it is needed for a longer time, it should be planned by professional dietitian. High calories, high protein supplements are often added.

CCU

critical care unit or coronary care unit

wounds assessment dressing, who changes the first dressing?

document amount and character of drainage. health care provide changes first post op dressing. aseptic technique. note presences of drains.

fowler and semi fowler

if client becomes sob raise head of the bed fowler the head is elevated at 60 semi fowler: position head 30-45

what is friction?

damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions

ascorbic acid vitamin c and skin

deficiency can delay wound healing. zinc and copper deficiencies may impair healing

toddlers diet are sometimes deficient in?

deficient in fat and meat. they need whole milk to provide for adequate fat for the still growing brain. deficiencies in iron, calcium, and vitamins A and C are also common during this period. toddlers assert their autonomy and manipulate their parents into not eating.

dressing/grooming self-care deficit definition and defining characteristics

defining characteristics: -impaired ability to put on or remove necessary items of clothing , fasten clothing, or obtain or replace articles of clothing -inability to put clothing on upper body or lower body , choose clothing, use assistive devices, use zippers, put on socks, and shoes, maintain appearance at a satisfactory level.

bathing/hygiene self care deficit defining characteristics

defining characteristics: -inability to wash body or body parts -obtain or get to water source -regulate temperature or flow of bath water -get bath supplies -dry body -get in and out of the tub or shower

wound assessment location

describe location of wound in anatomical terms. an ex. incision from cardiac surgery as midsternal incision from cardiac surgery as midsternal incision extending from the manubrium so the xiphoid process

critical aspects of PCA, you should determine? review? verify pca when?

determine the patient baseline vital signs, cognitive staus, physical mobility, and pain level review the physician order for PCA including the initial bolus ( loading dose) the basal rate, the demand dose , the lockout interval between each dose and the 1hour to 4 hour lockout dose limit determine if patient has any allergy to the medication verify PCA with two nurses before initiating PCA, discounting it, change of shift, and when wasting the remainder of the medication insert the medication cartidge/syringe into the pump prime the connecting tubing and lock the pump set the pump for the loading dose (if prescribe), basal rate, demand dose, lockout interval, and the 1 hour or 4 hour lockout interval connect the tubing to the patient iv line start infusing meds place the button within the pt reach change tubing per facility protocol

adolescent and nutrition?

development of reproductive system. boys experience increase in muscle tissue and bone length and density. at menstruation girls experience fat deposition. . the needs of adolescent approach those of infants. they need protein calcium, iron, and b and d vitamins.

sensory overload

develops when either environmental or internal stimuli or a comb of both exceed at a higher level than the patient sensory system can effectively process. ppl in the hospital experience this to combo of physical discomfort, aniexty, and separation from loved ones and the experience of being in an unfamiliar environment caffeine and otc weight loss pills, meds may contribute to overload patients at risk are those those in an environment with excessive stimuli or more stimuli than is usual for that person. for example a patient who lives alone might experience sensory overload

DM

diabetes mellitus

DX or Dx

diagnosis

life style choices includeNutrient Intake -Dietary Patterns -Cooking methods -Use of food to cope -Alcohol/Caffeine

dietary patterns: whole foods, such as fresh fruits and vegetables, whole grains, and legumes promote health, whereas foods high in simple sugars, saturated, trans fat, and sodium lead to increase risk for health problems. cooking methods: one half of the water soluble vitamin content is lost in the cooking water of boiled veggies. keeping foods hot longer than 2 hours results in further loss. birth control: lowers the serum levels of vitamin c and b using food to cope: results in poor nutrition smoking: use vitamin c faster alcohol contributes to obesity. decreases the rate of fat metabolism. people who use alcohol heavily need multivitamin especially vitamin b and folic acid. excessive alcohol replace food in the person diet, depressing appetite, decrease absorption of nutrients by its toxic effects on the intestinal mucosa, impairs storage of nutrients. caffeine: associated with bone loss. it enhances mood, mental, and physical performance. it aids the ability to burn fat for fuel instead of carbs and lower risk of parkinson disease, type 2 diabetes stroke, and dementia

D&C

dilation and curretage

MDI assessment/prep/position?

do Respiratory assessment Sitting upright Shake canister well Teaching of proper timing of inhalation with puff (spacer if available)

documenting wound care nemonic wound picture

documenting wound care; Example d-6day post op abdominal surgical incision assessed. Incision well approximated, staples intact with no inflammation, tenderness, and no exudate Wound or ulcer location Odor? (in room or just when wound is uncovered?) Ulcer category, stage (for pressure ulcer), or classification (for diabetic ulcer) and depth (partial thickness or full-thickness Necrotic tissue Dimension and Drainage- dimension of wound (shape, length, width, depth); drainage color, consistency, and amount (scant, moderate, large) Pain? (where it occurs, what relieves it, patients description, patients rating on scale of 0-10) Induration? (surrounding tissues hard or soft) Color of wound bed (red-yellow-black or combination) Tunneling? (record length and direction, using clock references to describe Redness or other discoloration in surrounding skin Edges of skin loose or tightly adhered? Flat or rolled under?

dsg or drsg

dressing

what are the six rights of medication adminstration

drug, dose, time, route, patient, documentation

Common Post-op Discomforts muscle aches

due to anesthesia or how they put you in the or

Impaired urinary elimination

dysfunction in urine elimination. due to dysuria, frequency, hesitancy, incontinence, nocturia, retention, urgency

q

every

qh

every hour

qam

every morning

EEG

electroencephalogram

ED/ER

emergency department, emergency room

anxiety is what type of response

emotional responses

EBL

estimated blood loss

lordosis

exaggeration of anterior convex curve of lumbar spine

Common Post-op Discomforts abdominal distention, due to? clinical signs? interventions?

excess gas within the intestine, may be due to slow return of peristalsis or from handling of the intestine during surgery. clinical signs: abdominal discomfort, bloating, hypoactive or absent bowel sounds. interventions: encourage and assist to move in bed and ambulate. maintain npo until return of bowel sounds; avoid drinking with a straw. provide fluids at room temperature.

how does moisture affect skin integrity?

exposure to moisture (maceration) softening of the skin and increases the likehood of skin break down. incontinence and fever most common source of moisture. bowel incontinence is trouble some because feces contain digestive enzymes that can lead to excoriation (denuding) of superficial skin layers, placing patients at risk for MASD, dermatitis, pressure ulcer, and infection

swing to swing through

fast gait but requires more strength and balance; advance both crutches followed by both legs ( or one leg is held up) use when partial weight bearing is allowed on both legs; requires coordination

three point gait

faster gait, safe advance weaker leg and both crutches simultaneously; than advance good leg use when weight bearing is allowed on one leg

two point gait used for? and has less support than? how do you use it? and when used?

faster, safe right crutch and left foot advance together left crutch and right foot advance together used when weight bearing is allowed for both legs; less support than four point gait

FBS

fasting blood sugar

What is the difference between fear and anxiety

fear is a cognitive response, where is anxiety is an emotional response. Fear is related to a present event, where is anxiety is related to a future or anticipated event. the source of fear is easy to identify, where is the source of anxiety may not be identifiable. fear can result from either a physical or psychological event, anxiety results from psychological conflict rather than physical threat.

Caregiver role strain

fear that loved one may need to be institutionalized, alterations in caregivers health, ability to give care, or complete caregiving task, apprehension about the future

infants and nutrition: vitamins and minerals

fetal iron stores are depleted at 4 to 6 months, so intake of iron becomes important. the infant needs calcium for bone growth and development of teeth, calcium and vitamin c for iron absorption, and vitamin D for calcium regulation.

removing medication from an amuple

filer needle invert ampule quickly and insert the needle of the syringe into the center without touching the sides ( will result in contamination) don't hit the bevel of the needle on the bottoms-it dulls it be sure the end of the needle remains in the fluid as you withdraw the medication or you will withdrawal nothing but air

How to teach a patient to deep breathe and cough, we want the patient in what position first? how long should they hold their breath

first step assist the patient to a fowlers or semi Fowler's position, with the shoulders relaxed. Assist the patient who will have a chest or abdominal incision to practice splinting the site with a folded blanket or pillow. 3. Teach the patient diaphragmatic/deep breathing. Tell patient to:a. Place her hands anteriorly, along the lower end of the rib cage. The tips of the third fingers should be midline. B. Slowly deep breath in through the nose. Tell the patient that she should feel her chest expanding as the diaphragm moves down. C. hold her breath 2 to 5 second. Because it's stimulate surfactant production and helps prevent alveolar collapse. D. slowly and completely exhale the breath through her mouth. 4. teach the patient to cough in conjunction with diaphragmatic Breathing. Instruct her to: a. Complete 2 or 3 cycles of diaphragmatic breathing. B. On the next breath in, have the patient lean forward and cough rapidly, through an open mouth, using the muscles of the abdomen, thigh and buttocks. cough several times on that breath.

whats is sims and used for what? and shouldn't use if?

flexion of the hip and knees in a side lying position use to examine the rectal area. use for female pelvic exam if patient is unable to assume the lithotomy position. do not use if the client has total hip replacement.

pregnant/ lactating and nutrition

folic acid is critical in the first trimester of pregnancy to prevent neural tube defects. 0.6 to 0.8 mg is recommended during pregnancy. adequate protein and calcium are important for growing muscle, brain, and bone tissue. iron is essential to maintain maternal and fetal blood supplies and stores during pregnancy.

Providing post mortem care, care of the body: what should be respected? what should be done to the body?if the family ask about coldness what do you say? what do you document?

follow agency policies, - respect culture and spiritual preferences. - wash the body if there has been any incontinence or drainage place abd pads between the buttocks to absorb rectal drainage. In some cultures the body is not wash so contact the family. - dress the body in a clean gown, comb the hair, and straighten the bed linen. - place the body supine In a natural position. Place dentures in the mouth before rigor mortis occurs. Close the eyes and mouth before rigor mortis occurs. Close the eyes by gently pressing on the lids with your fingertips. If do not stay close, place a moist compress and try again - be sure that the dressings are clean, and unless an autopsy is to be done, remove all tubes and drains. - if the family asked about the coldness and color of the body, explain to them about algor mortis and liver mortis - after the family has spent time with the body, arranged to have it sent to the morgue, weather either an autopsy will be performed. - make sure their identification tags, and hazards labels - follow institutional policy if the patient has died of a communicable disease - handle the body with dignity - documentation varies among health care facilities but you will document the time that you noted absence of heartbeat and respiration, any auxiliary equipment still present, the disposition of the patient's possessions, and a date and time the body is transported to the morgue or funeral home.

contact precautions include

follow all standard precautions

Ft

foot

Fat restricted diet are for who?

for clients with elevated cholesterol or triglyceride levels, may also be ordered for general weight loss

Fx

fracture

Stimulating the patients appetite suggest smokers refrain

from smoking one hour before meal

GI

gastrointestinal

GU

genitourinary

when providing perineal care what are the key points to perieneal care

gloves male-supine, retract foreskin, circular cleaning for glans, firm strokes for shaft female- dorsal recumbent/sims, front to back, cleanse labial folds from outside, last cleansing urinary meatus

when your do the planning phase of the nursing process what would be done in terms of infection?

goal no infection expected outcome patient will have labs values of 5,000-10,000

relaxation good for? and how is it done?

good for chronic pain, SMR person sits comfortably and tenses a group of muscles for 15 seconds and then relaxes the muscle while breathing out . after a brief rest this sequence is repeated using another set of muscles. patients often start at the facial muscles and work downward to feet

ESR

great hallmark in inflammation process

toddlers and preschoolers nutrition?

grow more slowly in comparison to infants need 900 to 1800 kcal and 1250 ml of fluid a day. by age 3 all of their deciduous teeth.

worries of hair care

hair dryers have potential to burn soap in eyes irritation from hair products

what is acute pain?

has a short duration and is generally rapid in onset. it varies in intensity and may last up to 6months. most frequently associated with injury or surgery it may absorb a patient physical and emotional energy for a short time

tuberculin syringe have what capacity and are calibrated in?

have a 1 ml capacity and are calibrated in 0.0l ml increments they come with a small gauge (25-28) short needle. use tuberculin syringes to administer small precise dose of medication

hob or HOB

head of bed

HA

headache

Epidural considerations

headache not experienced, monitor vital signs

heat and cold in cardiovascular what do they cause

heat generally causes vasodilation, which increases cardiac output and oxygenation. however, he also increases metabolism. as a result, people are naturally more sedentary in hot weather. Cold slow cell metabolism, reducing oxygen demand. It also causes vasoconstriction, and slows the heart rate. Induced hypothermia is used in some surgical procedures. Prolonged exposure to cold causes frostbite, loss of hypothalamic temperature regulation, & death.

How to do cough and deep breathing? what is the best position? includes

high Fowler is the best position it is an independent nursing activity each cycle of cough and deep breath includes at least 3 deep breath and a deep cough at least 10 cycles every 1 to 2 hours

h/o

history of

Digital removal stool

if fecal impaction does not respond to use of stool softeners and enemas, you will need to digitally remove feces from the rectum. Digital removal is accomplished by breaking up the hardened mass into pieces and manually extracting the pieces. You may administer an oil retention enema at least 30 minutes before Digital removal to soften the stool and decrease the patient discomfort during the procedure you must have a prescription from the primary care provider because you may stimulate the vagus nerve which slows down the heart rate.

tips for initial wound care

if its dirty clean it if it slough, dont fluff if it open, cover it if its dry, moisten it, if if is wet absorb it

what is the response of human error?

if not a pattern of behavior may be addressed by consoling nurse

Procedure steps of pulse oximetry: what do you do if the patient is allergic? if the peripheral circulation is compromised? how often should it be rotated if continuous monitoring is indicated?

if the patient is allergic to adhesive, use a Clip on probe sensor. Use a nasal sensor if the patient's peripheral circulation is compromised. If continuous monitoring is indicated for adhesive probe sensor rotate the site every 4 hours. for clip on probe sensor rotate the site every 2 hours because probe sensors and prolonged pressure may irritate the skin, rotating the side prevent skin breakdown.

stat

immediately

how is impaired mobility a factor affecting skin. what are my examples?

immobility cause an increase in pressure and may lead to skin breakdown. impaired immobility is caused by condition that require complete bed rest or serious limit activity like paralysis, extreme fatigue, high risk pregnancy, sedation, altered levels of consciousness, casts, traction, and altered sensory perception

Effects of immobility on the gastrointestinal system

immobility slow peristalsis, which leads to constipation, gas, and difficulty evacuating stool from the rectum . in extreme circumstances, a paralytic ileus may occur. when peristalsis slows, appetite diminishes and food also is digested slowly. The net effect is usually decreased calorie intake an inability to meet the protein demands of the body. body muscle is broken down as a fuel source, causing further wasting.

ana standards of care

in addition to the code of ethics the ana sets standards for all aspects of clinical practice. focuses on ethical practices. speaks to nurse responsibilities to patients and direct nurses to manage ethical dilemmas and to report practices that are illegal, incompetent, or impaired.

mechanoreceptors

in the skin and hair follicles detect touch, pressure, and vibration

thermoreceptors

in the skin detect variations in temperature

proprioceptors

in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable us to sense the position of our body in space

what is kyphosis

increased convexity in curvature of the thoracic spine

kyphosis

increased convexity in curvature of thoracic spine

infants and nutrition: fluid

infants higher metabolic rate and greater water loss through skin . they need more fluids than adults. they require 1.5 to 2 ounces of breast milk and formula per pound of body weight per day. breast milk is ideal because it has enzymes, digest fats, protein, and carbohydrates. portable drinking water should be boiled for one minute before mixing with formula.

pneumonia what is it, clinical signs and interventions

inflammation of the alveoli due to infection with bacteria or viruses, toxins , or irritants. caused by hypoventilation secondary to anesthesia and opioid analgesic, and by poor cough effort as a result of aging or weakness. clinical signs: productive cough with blood-tinged or purulent sputum, fever, elevated WBC, decreased or absent breath sounds, decreased Sao2, chest pain, tachypnea, dyspnea. interventions: monitor for clinical signs. encourage and assist with deep breathing, coughing, moving in bed, ambulation, use of incentive spirometry.

what are the three stages of healing

inflammatory, proliferative, and maturation

examples of droplet precautions

influenza

which shots are given in the deltoid

influenze and pneumonia

I&O

intake and output

incision

intentional wound cause by sharp instrument

penetrating is what type of wound

is a open wound in which the agent causing the wound lodges in body tissues

IVP

intravenous push

what is Urge urinary incontinence? what are my defining characteristics?

involuntary passage of urine occurring soon after a strong sense of urgency to void . Defining Characteristics Sudden, "unannounced" need to void Frequent urinary accidents associated with "not getting there in time" Inability to delay voiding 1.urinary urgency 2.bladder contracture or spasm 3. frequency (voiding more often than every 2 hours) 4.voiding in large amount (more than 550 ml) 5. voiding in small amounts less than 100 ml 6. nocturia more than two times a night 7. inability reach toilet in time Expected Outcome Patient is continent of urine or verbalizes management. like a uti

self neglect

involves culturally framed behaviors in which the patient's performance of one or more self care activities fails to maintain a culturally accepted standard of health and well -being

stage 2 and you shouldn't use this stage to describe what? and mistake for what?

involves partial thickness loss of dermis. are open but shallow and with a red pink wound bed. no slough. may be intact or open/ruptured serum filled blister; or shiny or dry shallow ulcer without slough or bruising do not use this stage to desribe skin tears, tape burns, pernieal dermatitis, maceration or excoriation do no mistake mositure associated skin damage or fungal infections for stage 2 ulcer - do not involve brusing or sloughing

TENS

is a battery powered device about the size of a pager that is worn externally. TENS unit consist of electrode pads, connecting wire, and the stimulator. pads are directly applied to the painful area once activated the unit stimulates A-delta sensory fibers. it can be worn intermittely or for long periods of time depending on the patient pain.

adult failure to thrive

is a complex disorder seen in many institutionalized older adults. it is characterized by weight loss, decreased activity and interaction, and increasing frailty.

Developmental dysplasia of the hip

is a congenital abnormality of the development of the femur, acetabulum, or both that shows as hip dislocation

Malignant hyperthermia, what is the first sign and late sign of it? its cause from what type of anesthesia?

is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium (Dantrium) is a skeletal muscle relaxant that is used to treat this complication.

what is sensory deprivation? what increases risk for sensory deprivation?

is a state of RAS depression caused by a lack of meaningful stimuli what increases sensory risk for deprivation -impaired sensory reception -inability to transmit of process stimuli -restricted mobility -sensory deficits -a nonstimulating, monotonous environment -being from a different culture and unable to interpret received cues

toileting self care deficit definition and defining characteristics?

is a state which the individual experiences an impaired ability to perform or complete toileting activities independently defining characteristics; -inability to get to toilet or commode, sit on rise from toilet or commode, manipulate clothing for toileting, carry out proper toileting hygiene, flush toilet or commode, or get to the bathroom

impaired skin integrity is appropriate for which clients?

is appropriate for patients who have experienced damage to the dermis or epidermis for example patients who have superficial wounds or stage 1 and stage 2 ulcers

risk for impaired skin integrity

is appropriate for patients who have one or more risk factors for skin breakdown (immobility, incontinence, extreme of age, impaired circulation, impaired sensation, undernutrtion, emaciation) nanda recommends you use a risk assessment tool to identify patients

impaired tissue integrity is appropriate for which clients

is appropriate for patients with wounds who extend into the subcutaneous tissue, muscle, bone. use this diagnosis for patients with deep wounds, or stage 3 and 4 ulcers

the response of at risk behavior?

is coaching

Disenfranchised grief

is experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies. Disenfranchised grief may be experienced by a man whose wife has had a miscarriage, a mistress whose lover dies, or a bereaved partner in a homosexual relationship not recognized by the families. in each of these instances, the beavered person lacks the communal support that is helpful in grieving.

an example of Open feeding system? and it should not hang more than?

is exposed to the environment. One example is to open cans of formula and use a syringe to inject the formula into the tube. you should flush and clean the system after each delivery. Most agencies require that open system feeding not hang for more than 4 hours.

risk for impaired tissue integrity

is for clients with impaired skin integrity who are risk for delayed healing . example mr harmon has a stage 1 ulcer but is at risk for further progression if the ulcer because of his age, nutrtionatal state, and presensce of another wound

Assess a cough? we want to know what?

is it dry, productive, or hacking? When does the cough occur and how long has the patient been coughing? What makes it worse? What seems to help it? What has been used to treat the cough, and what were the effects?

the response of reckless behavior?

is punishment

what is beneficence? example

is the duty to do or promote good. you can think of this principle as being on a continuum with nonmaleficence. at one end of the continuum is the duty to do no harm; beneficence, at the other end is the duty to bring about positive good. the following illustrates duties in the priority order. >do no harm( don't pus the man into the river.) >prevent harm (if the man is getting danergrously close to the river edge, warn him that he is about to fall in the river.) >remove harm when its being inflicted( if you see a struggle and someone is trying to push the man into the river, interfere and try to stop it if you can do so without undue harm to yourself.) >bring about postive good. ( if the man has fallen in the river, jump in and try to save him, or toss him a life line and call 9-1-1 if you can't swim.) others may identitfy benefits and harms differently. a benefit to one may be a burden to another

what is slander and example?

is the spoken or verbal form of defamation of characters. a person is not guilty of defamation of character if is is true.

what is nonmaleficence? example

is the two fold duty to do no harm and to prevent harm. it refers to both actual harm and risk of harm. it requires you to think critically about patient care and research situations. when using nomaleficence to guide treatment regimens, ask the question. "does this treat cause more harm or good to the patient. risk of harm is not always clear. suppose you are about to get a patient out of bed for the first time after surgey. the benefit is clearly is that this will prevent post of complications such as pnemonia and thrombophlebitis, but the risk of terms of excessive pain or unintentional damage to the operative site, may be less clear. weighing risks and benefits is a value laden exercise. who is to say what amount of pain is excessive---- you or the patient? to the honor the principle you would need to be sure to premedicate the patient and carefully assess his status as you are helping him to ambulate.

what is libel and example?

is the written or published form of defamation

what is evisceration? what intervention should you do?

is total separation of the layers of a wound which internal viscera protrude through the incision. rare and surgical emergency intervention immediately cover the wound with sterile towels or dressing soaked in a sterile saline solution to prevent organs from drying out and become contaminated with environmental bacteria. pt stay in bed with knees bent to minimize strain on the incision/ notify surgeons an prep for surgical procedure

xerosis is a threat to who

itchy, dry, red, scaly, cracked, fissured skin is a problem for up to 85% older adults can be a threat to integrity of skin

angina

jaw

Joint mobility

joint movement allows us to sit, stand, bend, walk, and perform other activities. Range of motion is the maximum movement possible at a joint. Active range of motion is defined as the movement of the joint through the entire range of motion by the individual. Full range of motion is part of being physically fit, for that reason, stretching exercises are included in comprehensive exercise program. passive range of motion involves moving joints through their range of motions when the patient is unable to do so for himself.

so how can having fever affect skin integrity

leads to sweating which causes maceration increases metabolic rate thereby raising the tissue demand for oxygen and increase demand of oxygen is difficult to meet if there are any circulatory impairments or tissue compression secondary to pressure

stage 1

localized area skin intact with non blanchable redness usually over a bony prominence. may be warm or cooler as compared to adjacent tissue. discoloration will remain > 30 after pressure is relieved . may be difficult to detect in a dark skin person

abscess type of wound

localized collection of pus due to an invasion from a pyogenic bacterium or other pathogens. must be opened a drained to heal

chronic pain longer than ? interferes with? may lead to?

longer than 6 months and often interferes with daily activities it can be related to a progressive disorder, or it can occur when there is no current tissue injury as in neuropathic pain. may experience periods of exacberation and remission. chronic pain is viewed insignificant may lead to withdrawal, depression, anger, frustration, and dependence.

how does calorie intake affect skin? and what can low calorie intact lead to?

low intake the body then uses protein for energy which makes them unavailable for building and maintance . long low calorie intake leads to loss of subcutaneous tissue and muscle atrophy. as a result padding between the skin and bones decreases predisposing the skin to pressure ulcers

how does cholesterol affect skin

low levels predispose patient to skin break down and inhibit wound healing. patients like low fat tube feedings. together the fats aid in providing fuel for wound healing and maintain a waterproof barrier in the stratum corneum

pancritis

lower back pain

supine what is it used for?

lying flat on the back with arms and legs fully extended used to assess the abdomen breast,extremeties, and pulses

prone and is difficult for what clients

lying on the stomach use to examine the muscoskeltal system, especially hip extension; may able to used to examine the back and buttocks. may be difficult to assume with clients with respiratory problems

Boots prevent what?

made of spongy rubber with heel cutout and ankle cushioning prevent foot drop, skin breakdown, and external hip rotation.

Identify five signs of sensory deprivation.

manifestations of sensory deprivation: ● Irritability ● Confusion ● Reduced attention span ● Decreased problem-solving ability ● Drowsiness ● Depression ● Preoccupation with somatic complaints (e.g., heart palpitations) ● Delusions (misinterpretations of external stimuli) ● Hallucinations (seeing, hearing, feeling, tasting, or smelling something that is not there) Note: Some clinical manifestations of sensory deprivation overlap with those of sensory overload.

Promote venous return why is it done, what are our interventions for it?

measures that promote venous return increase the flow of blood back to the vena cava and the right side of the heart - elevate the patient's leg above the level of the heart. gravity promotes venous return from the feet and legs. - flexion of the hips, legs, and knees constricts the veins and slows venous blood flow. If one is available, have the patient sit in a recliner that elevates the legs rather then sitting upright in a chair with legs elevated on a stool. teach patients to avoid sitting with legs crossed this interferes with blood flow. encourage and support early and frequent ambulation. Contraction of the muscles in the legs move blood upward against gravity. - encourage or provide range of motion exercises, which increase venous blood flow through rhythmic massaging of the vein by the active muscle. - apply compression devices. anti embolism stockings Ted hose elastic stocking that compress superficial leg veins and promote venous return. - sequential compression devices also called pneumatic compression devices, are cuffs that surround the legs and alternately inflate and deflate to promote venous return to the heart. Anti embolism stockings and scd are frequently used in perioperative patient to promote venous return and prevent clot formation.

Complete dependence immobile Mobile, no assistance

mechanical lift with full sling

what is the assistive device for a patient with complete dependence (immobile, no assistance)

mechanical lift with full sling

what is the assistive device for a patient with extensive dependence (holds on to device but with minimal strength)

mechanical lift with full sling or stand/assist

moderate dependence (no patient assist for lifting from floor)

mechanical lift with full sling or stand/assist lift, or if transfer is manual more than one helper might be needed

Extensive dependence hold on to the device but with minimal strength

mechanical lift with full swing or stand/ assist lift

Autopsy:

medical examination of the body to determine the cause of death

MN

midnight

os

mouth, opening

embolus what is it, clinical signs and interventions

movement of a thrombus or foreign body from its original location. movement in the arterial system results in symptoms in the area affected (e.g CVA, MI, or loss of circulation into the area .venous system often result in a pulmonary embolism interventions: monitor for clinical signs. prevent thrombophlebitis, if it does occur position and immobilize the limbs do not massage the calves

Outcomes and interventions for an ineffective breathing pattern

outcome respiratory status ventilation vital signs Interventions airway management and vital signs monitoring

a patient with diabetic ulcer what is done

must have all pressure taken off that area because every step traumamtizes the healing tissues. apprioate dressing in addition patient will need to wear special shoes

NG

nasogastric

N/V/D

nausea, vomiting, diarrhea

school age and nutrition

need about 2400 kcal and 1750 ml of fluid per day. an adequate supply of vitamins and minerals is critical because the body is still growing and preparing for the demands of adolescence. encouragement of breakfast to provide nutrients, energy to fuel problem solving skills, memory, and sports and play ground activities. poor eating habits may lead to obesity. 32% overweight, 16% obese, 11% extremely obese.

infants and nutrition: calories and need protein for, carbs for?

need adequate protein for tissue building and enough carbohydrates to furnish energy and spare the protein. for maximum brain growth the baby needs optimal nutrition.

Glucose in urine

negative

wound cultures it is used for what?

negative , no growth of pathogens wounds cultures may be prescribed to determine the types of bacteria present in the wound. cultures may be obtained by swab. aspiration, or tissue biopsy. a positive culture may not indicate an infection as chronic wounds are colonized with bacteria

neuropathic pain is what type of pain? what conditions are included? it is described as what?

neuropathic pain is a complex of often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli . conditions include diabetes, stroke, tumor, alcoholism, amputation, viral infection. some meds like chemotherapetic agents can trigger nerve injuries . described as burning , numbness, itching, and pins and needles prickling skin

Checking feeding tube placement

ng and ne feeding tubes are place without direct visualization. As a result there is a risk for placing the tube into the respiratory tract. Therefore you must check the location of the feeding tube before each enteral feeding or once per shift for continuous feeding. To verify placement could be disastrous because it may result in fusion of formula into the lungs. radiographic verification is the most reliable method for confirming to placement, and must be performed before the first feeding is a administered.

NAS

no added salt

NKA or NKDA

no known allergies or no known drug allergies

Outcomes and interventions for impaired gas exchange

outcomes Respiratory status gas exchange and vital signs Interventions airway management, oxygen therapy, a respiratory monitoring

Patients with impaired swallowing

no straws, tuck chin to chest because it helps with the closing of the epiglottis. Patience with our strokes we want to make sure we are putting food on the stronger side. Small bites. in addition you must also take aspiration precautions. Monitor level of consciousness, call free flex, gag reflex, and swallowing abilities. position the patient upright 90 degrees or as far as possible. keep head of bed elevated for 30 to 45 minutes after feeding. feed in small amounts. Avoid liquids or use of a thickening agent. Cut food into small pieces.

factors affecting pain nociceptive

nociceptive pain is the most common type of pain experienced. it occurs when pain receptors which are called nociceptors responed to stimuli that are potentially damaging, for example as an result of noxious thermal, chemical, or mechanical types of injury. may result of trauma, surgery or inflammation most commonly describe as aching

worries/challenges of bathing a client

non-compliance/combative/dementia (calm, unhurried, routine timing, stop if needed and complete later) incontinence during care

Protein in urine

none

iron level

normally 60-90 grams/100 mg. lower in chronic infection.

Minimization examples and examples and consequences of overuse

not acknowledging or accepting the significance of one's own behavior, making it less important E.g it doesn't matter how much I drink. I never drive when I'm drinking Person engages in unhealthy or antisocial behavior, there is no motivation to change behavior

NPO

nothing by mouth

what is human error?

nurse inadvertently, unintentionally did something other than intended or other than what should have been done; a slip, a lapse, or an honest mistake. Human errors are not reportable events.

advocacy

nurses have special knowledge that the patient does not. another is to defend patient autonomous decisions. nurses have a special relationship with patients. your role as an advocate is to inform, support, and communicate. and last advance directives.

what is at risk behavior?

nurses makes a behavioral choice that increases risk where risk may not be recognized or is mistakenly believed to be justified; nurse does not appreciate risk; unintentional risk taking. they may be reported events

bathing the obese patient what is obesity and morbidly obese

obesity more than 20% to 40% above ideal weight morbidly is 100% ideal weight -through skin assessment is essential -

OT

occupational therapy

what is referred pain?

occurs in an area that is distant from the original site example a heart attack pain may be experience down the left arm, through the back, or into the jaw

Anaerobic exercise occurs when? the muscles must obtain energy from?

occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity. therefore, the muscles must obtain energy from metabolic pathways that do do not use oxygen. rapid, intense exercise, such as lifting heavy objects or sprinting, are examples of anaerobic exercise.

what is shear?

occurs when the epidermal layer slides over the dermis causing damage to the vascular bed. it is most commonly concerns when the HOB is elevated and the patient slides downward, causing shear to the sacral area. when shearing occurs the amount of pressure needed to occlude circulation is cut in half

battery?

offensive or harmful physical contact is made with the patient without his consent. or there is unauthorized touching of a persons body by another person

-- ss

one-half

mixing medication from the vial first and then from the ampule

open both containers withdrawal the medication from the vial first and then from the ampule

Helping families of dying patients encourage the family to visit the hospital chapel or to speak with a chaplain

or with their own spiritual advisor

ortho

orthopedics

Osteoarthritis

osteoarthritis involves a loss of articular cartilage in the joint, with pain and stiffness as the primary symptoms. patients may also have decreased range of motion crepitus, a creaking or grating sound, with joint motion. symptoms are aggravated by weight bearing and joint use and are relieved by resting the affected joint . osteo arthritis is more common in women, older adults, and people who are overweight.

OOB

out of bed

Nursing outcomes and interventions for decreased cardiac output

outcome blood loss severity, cardiac pump effectiveness, circulation status, tissue perfusion cardiac, tissue perfusion abdominal, cerebral, pulmonary, peripheral, and vital signs Intervention bleeding reduction, cardiac care, cerebral perfusion promotion, circulatory care:arterial or venous insufficiency. Hemodynamic regulation, hemorrhage control, intravenous therapy, shock management

pca

patient controlled analgesia

patient care partnerships

patients admitted to hospitals of to extended care facilities, they are are entitled to specific rights in terms of their treatment: the right to make their own decisions, to be active partners in partners in the treatment process, and to be treated with dignity and respect.

Anti embolism stockings should not use in and what position should I place the client

peripheral arterial disease, such as weak or absent pulses, discoloration or cyanosis, or gangrene. place the patient supine for at least 15 minutes. This prevents trapping v of pooled venous blood.

pt

physical therapy

PPBS

postprandial blood sugar

to do drainage of wound assessment what should you do?

presence of drainiage or exudate-describe the color, consistency, amount or odor. assess the quantity of wound drainiage. by weighing dressings before they are applied again when they have been removed. the change in weight reflects the amount of drainiage that have absorbed

what is the result for throat cultures, wound cultures?

presence of microorganisms is normal, but there should be no growth of infectious microorganisms

Meeting the physiological needs for the dying patients, provide, continue, document, record?

provide medications for other symptoms such as nausea and breathlessness. Continue to speak to the patient as if he can hear. Do not talk about the patient to others in his presence. document changes in vital signs and level of consciousness. Record intake and output, noting changes. Document the times of cardiac arrest and cessation of respirations.

when doing perieneal care what are critical aspects of perieneal care

privacy and comfort warm water 105-110

Physiological effects of immobility

prolong immobility, whether in the hospital or at home, leads to isolation and mood changes. Showed signs of depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self care activities. Patients who are in bed for long periods of time can suffer all these problems, as well as disorientation, apathy, and altered body concept. other notable psychological effects of inability include a diminished ability to concentrate, recall sequential events, problem solve, and perform self care.

worries/challenges or ear care/hearing aids

proper fitting? ear trauma hearing aid gets wet=dry well, remove and discard battery, leave open over night, replace battery in the morning>>>never put new battery into damp casing

how does protein affect skin

protein is necessary to maintain the skin, repair minor defects, and preserve intravascular volume. if protein decline and fluid leaks from the vascular compartment of dependent areas, and edema develops. edema decreases skin elasticity and interferes with the diffusion of oxygen to the cells cause the skin to be prone to breakdown

Continuous feedings

provide a constant flow of formula and an even distribution of nutrition throughout the day. For example, and infusion of 50 ml per hour for 24 hours of 1 kcal formula provides 1200 kcal per day. Continuous infusion are usually administered through small bore ng, NJ, peg, or Pej tubes, or g button, to patient in debilitating state who require intensive nutritional support. Meetings may be interrupted for periodic instillation of medication or flushing with water.

for rapid diarrhea

put a drainage bag in rectal

when doing hearing and ear care what are key ponts of hearing aid /ear care

red dot=right ear blue dot=left ear =do not use alcohol/water on hearing aid =clean and frequently replace batters =to remove: turn off and rotate ear mold slightly, do not pull on volume control or battery door =to insert: gently motion, turn on after placed in ear

false imprisonment

restraining a client against her/his will

gall bladder referred

right back pain

cholecycystitis

right scapula

liver pain referred

right shoulder

Ulnar flexion

rotate the hand outwards at the wrist

R/O

rule out

what is dehiscence and what is the nursing intervention. what are the common causes

rupture (separation) of one or more layers of a wound. is most likely to occur in the inflammatory phase of healing before large amounts of collagen have been deposited in the wound to strengthen it . most common causes are poor nutritional status, inadquate closure of muscles and most likely in obese patient. normally associated in abdominal wounds report feeling a pop or tear especially with sudden straining from coughing. immediate increase in serosanguineous drainage. interventions include maintaining HOB elevated at 20 degree and the knees flexed. to prevent a binder may be applied and activity modified. physician should be notified

assessing for untreated wound

same as a treated wound but in addition i want to know bleeding . if bleeding after i applied pressure or spurting continues after 5 minutes call the physician severity last tentnus shot' give shot if was ten years or longer. dirt in the wound and tentanus was given more than 5 years whether by a bite pain numbness or loss of movement presence of chronic or medical condititon

SCD

sequential compression device

what are the lab values for serum protein, serum albumin, serum prealbiumium

serum protein 6.0-8.0 serum albumin 3.4 -4.8 serum pre albimuium 12-42 low serum levels indicate limited nutritional stores that delay wound healing or place the patient at high risk for pressure ulcers serum protein may be monitored as an indicator of the ability to heal a wound or prevent a pressure ulcer. serum protein and albiumum levels are closely related. however both fluctuate slowly. a more accurate measures of a patients immediate protein stores is reflected in pre albumin level

what are the lab values for serum protein, serum albumin, serum prealbiumium and skin

serum protein 6.0-8.0 serum albumin 3.4 -4.8 serum pre albimuium 12-42 low serum levels indicate limited nutritional stores that delay wound healing or place the patient at high risk for pressure ulcers serum protein may be monitored as an indicator of the ability to heal a wound or prevent a pressure ulcer. serum protein and albiumum levels are closely related. however both fluctuate slowly. a more accurate measures of a patients immediate protein stores is reflected in pre albumin level

preparing medication from an ampule how to clear medication from the top of an ampule

shake method the swing method

pre procedure assessment perieneal care

skin assessment presence of catheter, drainage, lesions, surgery, assist with elimination prior to care

worries of perieneal care

skin care for incontinence

laceration

skin or mucous membranes are opened resulting in a wound with jagged margins

how is hydration important for skin

skin turgor depends on hydration

worries/challenges of restraints? most important thing

skin/circulation complications restraints monitoring (if patient needs to be restrained temporarily so that a procedure can be done, this is not considered a restraint)

pre procedure assessment of ear care/hearing aid

skin/ear assessment assessment of hearing aid working properly

how does impaired skin circulation affect skin

so impaired circulation restricts activity, produces pain, and leads to muscle atrophy and development of thin tissue that is prone to ischemia and necrosis. impaired venous circulation results in engorged tissues with high levels of metabolic waste products that are prone to edema, ulceration, and breakdown. both forms of delayment delay wound healing . circulatory impairment is one of the main causes of chronic wounds

SSE

soapsuds enema

Avoiding the stressor coping strategies

sometimes it is healthful to avoid a stressor. For example, you may find that being with a certain person is stressful for you, even though you have tried many times to change the dynamics of the relationship. in that case, it may be best to minimize or end relationship with the person. In other situations, avoidance maybe maladaptive

when assessing older adults for falls you can do the get up and go?

stand up without using your arms for support walk several paces, turn, and return to chair sit back in chair without using your arms for support

when moving a patient with limited dependence?

stand/assist lift or friction reducing device

droplet precautions follow what?

standard and contact precautions

radiating pain and examples are

starts at the origin but for some reason extendes to other locations. example pain of severe sore threat may extend to the ears and head . or heart burn may radiate outward from the sternum to involve the upper entire thorax

airborne infections include?

tb, varciella (chicken pox) SARS, measeles( rubella)

also risk for infection can be serve as educational purposes

teaching about hand hygiene and immunizations

TO

telephone order

TPR

temp, pulse, respirations

Factors affecting grief timeliness of the death

the death of a child or a young person its almost universally more difficult to accept then the death of an elder person. In addition to the loss of the person, there is A sense of unfairness because of the loss of potential of what the child might have become or achieved. You may hear someone ask, "why was her life cut short? " or state, "he had so much going for him, but God didn't give him a chance."

Reticular activating system

the duration of sleep

what is Bladder training? what does it involve?

the goal of bladder training is to enable the patient to hold increasingly greater volume of urine in the bladder and to increase the interval between voiding. this involves patient teaching, schedule voiding, and self monitoring using a voiding Diaries. teach the mechanisms of urination. Teach distraction and relaxation strategies to help inhibit urge to void for example instruct the patient to perform serial subtraction or become involved in an activity that requires concentration like a crossword puzzle when she feels the urge to void. Alternatively the patient my perform several rapid pelvic floor muscle contractions to quiet the sensations from the bladder. other techniques include deep breathing and guided imagery.

what is included in the inflammatory---cleansing stage of healing

the inflammatory (cleansing) phase last from 1 to 5 days and consists of two major process: hemostasis and inflammation.

inflammation

the inflammatory reaction is characterized by edema, erythema, pain, temperature elevation, migration of WBC into the wound tissue. within 24 hours, macrophages begin engulfing bacteria (phagocytosis) and clearing debris. In conjunction with plasma proteins and fibrin, they form a scab at the surface of the wound, which seals the wound and helps prevent microbial invasion.

the maturation phase--epithelization

the maturation phase ( or remodeling) is the final phase of the healing process. it beings in the second or third week and continues even after the wound has closed. over the next 3 months to 6 months, the initial collagens fibers that were laid in the wound bed during the proliferative phase are broken down and remodeled into an organized structure, increasing the tensile strength of the wound. a wound that has healed by primary intention leaves little scarring. even so, a scar is only 80% as strong as the original tissue.

key points to intramuscular injection

the ventrogluteal is site is preferred. the deltoid sites is acceptable for smaller doses and adult vaccines. -clean the skin with alcohol from inner to outer allow to dry - with side of your non dominant hand, displace the skin away from the injection site -hold the syringe like a dart. and briskly insert at a 90 degree angle to the skin surface. insert fully -stabilize the syringe with the thumb and forefinger of your non dominant hand. keep displacing the skin with your other three fingers -aspirate before injecting - inject medication -withdraw needle -gently blot the site

walkers are best for

these walkers are best for patients whose mobility problems are related to fatigue or SOB rather than gait instability

preschoolers and nutrition

they are similar in growth and nutritional needs to toddlers. eating patterns improve. begin forming response to specific foods like green veggies and drinking less milk. often refuse casseroles and foods with sauces. and eat only 1 food for several days. because of they are active they require nutritious between meal snacks. lifelong food habits are developed at this stage. between ages 2 to 5 fat should provide only about 30 percent of child intake.

older adults and nutrition continue

they need complex carbs to maintain bowel function. primarily green leaf veggies and brightly colored fruits to help prevent constipation and dehydration. they need supplements of vitamin d, calcium, and b12. low concentrations of b12 have been linked to cognitive decline

single ended cane with a half circle handle

this is ideal for the patient who needs minimal support and is able to negotiate stairs

single ended cane with a straight handle

this is ideal for the patient with hand weakness who has good balance

tid

three times a day

During the test purpose

to increase cooperation and participation by ally the client's anxiety and to provide the maximum level of safety and comfort during a procedure

if patient can assists with limited mobility you should use what?

transfer belt or gait belt

Supination

turn wrist so that the palm is up

bid

twice a day

area of referred of appendicitis

umbilicus

state board of nursing are responsible for?

under the states's nursing practice act are responsible for licensing, credentialing, and disciplinary procedures involving nurses and nursing. they do not manage day to day oversight.

urine cultures

urine is normally sterile with no microorganism growth

how to open an ampule

use an alcohol pad (unopened) around the neck of the ampule avoid getting too close to the tip briskly snap neck away from ampule set opened ampule upright dispose of top in a sharps container

how do I administer an subcutaneous injection. used for what?

use for heparin, insulin, anticoagulants -most common injection sites, outer aspect of upper arm, abdomen, and anterior aspects of the thighs -pinch the skin to inject. inject at a 90 angle. do not aspirate for injecting insulin or heparin - do not massage the site

sitting

used to assess vital sign, head and neck, chest, cardiovascular, system, and breast. if your client is weak, he may need assistance to maintain this position

agglutinins, warm or cold

used to diagnose atypical infections by detecting antigens in the blood

guided imagery as a nonpharmacological pain relief. you should use?

uses auditory and imaginary process to affect emotions and help calm and relax. acute and chronic pain, physical and psychological, may respond to guided imagery however it is more effective for chronic pain. audio media can help patients to create images of temporary escape that will elicit a sense of well being

aPTT coagulation studies: partial thromboplastin time, activated

varies with respect to equipment and reagents used. critical values >70 seconds or < 53 prolonged coagulation times may result in excessive blood loss or ongoing bleeding in the wound bed. shortned coagulation times increase the risk for blood clot formation problems, such as DVT, pulmonary embolus, or stroke

older adults and nutrition

vary slightly from middle adult. lean body mass, physical activity, and BMR decrease , so the older adults tend to need fewer kcal but need the same of higher levels of nutrients. taste and smell diminishes. diminished vision or hearing limit mobility and interaction making it more difficult to purchase and prepare food. other physical problems include gastroesphogeal reflux, decreased gastric secretions, decreased intestinal peristalsis, and glucose intolerance.

intramuscular sites

ventrogluteal, vastus laterialis, deltoid

VO

verbal order

Vs

vital signs

wt

weight

what are the defining characteristics of Bowel incontinence?

what are the defining characteristics of Bowel incontinence? Change in normal bowel habits characterized by involuntary passage of stool Defining characteristics 1. Constant dribbling of soft stools 2. Fecal odor 3 . inability to delay defecation 4. Self report of inability to feel rectal fullness 5 . urgency 6 fecal staining of clothing or bedding 7 . recognize rectal fullness but reports inability to expel formed stool 8. Inattention to urge to defecate 9. Inability to recognize urge to defecate 10. Red perianal skin Out come will have no more than one soft formed stool per day by

w/c

wheel chair

urinary retention defining characteristics? and outcome

when an individual experience incomplete emptying of bladder 1. bladder distention 2. small, frequent voiding of absence of urine output 3. sensation of bladder fullness 4.dribbling 5. residual urine 6. dysuria 7. overflow incontinence expected outcome patient will void under voluntary control and empty bladder at least every 4 hours

distraction can be what? can be used for what? but most effective for?

when this happens patient only has peripheral awareness of pain. it can be visual, tactile, intellectual, or auditory. it can be used for severe pain. it is most effective for mild to moderate pain and for brief periods of time . some patients experience an increase in pain and may become fatigued and irritable when they are no longer distracted.

WBC

white blood count

- C

with

Physiological steps of dying include

withdrawal, systems deterioration, cheyne Stokes breathing, mottling, organ failure, death

WNL

within normal limits

- s

without

adults and nutrition:

young adults continue to require adequate amounts of protein, vitamins, and minerals, but not at same levels as adolescent. for woman calcium, vitamin D, folic acid and iron are critical for bone and reproductive health . bmr of middle adults decrease, potentially causing weight gain.

What is "Just Culture" in Health Care?

• A just culture also recognizes many errors represent predictable interactions between human operators and the systems in which they work. Recognizes that competent professionals make mistakes. • Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, "routine rule violations"). • A just culture has zero tolerance for reckless behavior.

interventions to promote sleep, encourage? allow? but limit? explain? listen? schedule? use nursing judgment when? alter? unless the patient is critically ill do? create?support? offer? advise? teach

• Encourage use of relaxation exercise. • Allow visitors when needed for emotional security and relaxation, but limit visitors if the patient requires rest/sleep. • Explain procedures to decrease anxiety and promote healthy coping. • Listen attentively to decrease anxiety and convey compassion and caring. • Schedule nursing care to avoid interruption of sleep (e.g., don't awaken a patient to administer a sleeping pill, provide for rest periods). • Use nursing judgment to decide when a procedure must be done and when it is more important for your patient to sleep. • Alter routines; for example, allow the patient to sleep as long as he can in the morning and bring his breakfast later. • Unless the patient is critically ill, do not awaken him for morning vital signs when he is sleeping. • Create a restful environment; for example, be sure the bed linens are tight on the bottom and loose on top to allow movement; keep linens clean and free of irritants; use extra pillows, a blanket from home, or any other item that may help the patient rest; keep the patient in good body alignment; keep the room dark and quiet, unless the patient prefers a light; as much as possible, control the temperature of the room and provide good ventilation. • Promote comfort (e.g., be sure to offer pain medications at their scheduled times and before time to sleep; offer fluids, cool cloths, massage, or backrub). • Support bedtime rituals and routines (e.g., reading, watching TV, or praying; having warm milk, a favorite doll, blanket, or bedtime story; brushing teeth or hair). • Offer appropriate bedtime snacks/beverages (e.g., juice, crackers). • Teach the client to avoid alcohol and caffeine (e.g., tea, coffee, chocolate, colas.) • Advise the client to drink plenty of fluids during the day, but restrict large amounts of fluid close to bedtime. • Advise the person to not smoke after the evening meal. • Promote relaxation (e.g., guided imagery, progressive muscle relaxation, music therapy).

LAS responses

● Blood clotting ● Pupil constriction in response to light ● Reflex pain ● Inflammatory response

when does burnout occur? the nurses feel? suffer from? they may develop?

● Burnout occurs when nurses and other professionals cannot cope effectively with the physical and emotional demands in the workplace. The nurse feels overwhelmed and helpless and suffers low self-esteem and depression. The nurse who burns out may develop a physical illness or a negative attitude or may use maladaptive coping techniques, such as smoking, substance abuse, or distancing from patients—"going through the motions" but not really interacting with patients in a meaningful way. Many nurses in such situations give up and leave nursing.

assess physiological changes and disease caused by ongoing stress . assess client history of somatoform disorders?

● Check the client's records for a history of somatoform disorders. Ask the client: ● What physical illnesses do you have? How long have you had them? ● What, if any, physical changes have you noticed? ● Do you have other physical conditions—for example, hypertension, cardiac disease, diabetes, arthritis, joint pains, and cancer?

compression stockings are used for who?

● Compression stockings are used with venous stasis ulcers on the lower extremities. They apply continuous pressure to the veins, which facilitates venous return and allows the ulcers to heal.

interventions for helping grieving families

● Encourage family members to help care for the patient, if they are able. This helps meet their need to be useful, as well as promoting family ties and making the patient more comfortable. If they are not physically or emotionally able to provide care, accept that. For family members who are able to help with care, provide instruction and supervision. ● Encourage family members to ask questions, listen actively to client and family concerns, and help them problem solve when needed. ● Follow up with other healthcare team members promptly when the family has questions that are outside your scope of practice. ● Encourage the family to visit the hospital chapel and talk with a chaplain or to speak with their own spiritual adviser. ● Provide anticipatory guidance to the family regarding the stages of loss and grief, so that they will know what to expect after their loved one dies. ● Acknowledge feeling of the family and the loss they are experiencing. (Many times family members begin the grieving process before the loved one dies.) ● Help the family members to explore past coping mechanisms and reinforce successful past coping mechanisms. ● Remind family members and significant others to take care of themselves. Many times they need "permission" to go eat or to go home and rest. If the patient is near death and family and friends do not want to leave the patient's side, make them as comfortable as possible. Provide comfortable chairs, coffee, and snacks (according to organizational policy), and be alert for other needs they may have. Watching a loved one die is a very difficult experience. A sensitive, caring nurse can make it a little easier. ● Teach the family what to expect with regard to medications, treatments, and signs of approaching death. If family members know what is normal, they will be less likely to panic or fear the inevitable. As physical signs of death become apparent, keep the family informed. You may say something like, "Her blood pressure is becoming difficult to hear. That is one of the signs that she is closer to death." ● Reassure families of patients who become withdrawn near the time of death that this does not mean the patient is rejecting them, but only that his body is conserving energy and that he has come to terms with dying. ● When approaching death is apparent, ask family members directly, "Do you want to be present while he is dying?" Tell them what to expect, if they do not know. ● At the moment of death, do not interrupt or intrude upon the family. Wait quietly and observe. Give them as much time as they need. When they move away from the body or have said last goodbyes, then it is time to assess and report the lack of vital signs. Be accepting of their behavior at this time, no matter how strange it may seem to you. A family might want to take a picture, or the spouse may lie down beside the deceased person.

initial, ongoing, discharge planning

● Initial planning is done for the purpose of identifying patient problems and creating the care plan. ● Ongoing planning allows you to revise and individualize the patient's care plan as new data are obtained. ● Discharge planning is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency. Knowledge Check 5-2

health promotion to prevent or relieve stress

● Nutrition. Nutrition is important for maintaining physical homeostasis and resisting stress. For example, adequate nutrition is essential to maintain the integrity of the immune system, and proteins are needed for tissue building and healing. In addition, obesity and malnutrition are stressors that may lead to illness. but to summarize, you should advise clients to: ● Maintain a normal body weight ● Limit the intake of fat (especially animal fat) to no more than 30% of daily calories ● Limit the intake of sugar and salt ● Eat more fish and poultry and less red meat ● Eat smaller, more frequent meals to aid digestion ● Consume 25 grams of fiber (fruits, vegetables, and whole grains) daily to promote bowel elimination ● Consume no more than two alcoholic beverages per day ● Exercise. Regular exercise promotes physical homeostasis by improving muscle tone and controlling weight. It also improves the functioning of the heart and lungs and reduces the risk of cardiovascular disease. Exercise improves emotional homeostasis by promoting relaxation and reducing tension. During exercise, endogenous opioids are released, creating a feeling of well-being. ● To achieve health benefits, the client needs to exercise for at least 30 minutes at least 5 days a week. ● Advise clients who are obese, chronically ill, or who have always been sedentary to consult a primary care provider before beginning a new exercise program. ● Suggest that the client identify a variety of physical activities that he or she enjoys (e.g., swimming, bicycling, walking, sports), and, if possible, schedule regular sessions with one or more exercise "buddies." These strategies help the client adhere to the exercise routine. ● Sleep and rest. Sleep and rest restore energy levels, allow the body to repair itself, and promote mental relaxation. Most people need 7 or 8 hours of sleep a day, but the amount of sleep varies among individuals. Stress, pain, and illness may interfere with the ability to sleep, so some clients may need help identifying and implementing techniques for relaxing and going to or staying asleep. Refer to Chapter 33 in Volume 1 for more information on sleep. ● Leisure activities. As compared to exercise, which not everyone enjoys, leisure activities are any activities that provide joy and satisfaction. They may involve physical activity (after all, many people do enjoy exercising), or they may be sedentary activities, such as reading, painting, and even watching television. Leisure activities are a form of rest and, as such, are restorative. ● Time management. People who manage their time efficiently and organize their life routines feel more in control and therefore less stressed. If clients feel overwhelmed, you can help them to prioritize tasks and make "to do" lists. It is also important they learn to delegate responsibilities and set boundaries on the use of time. A working couple with three children may need to assign each child mealtime tasks, such as setting the table, drying the dishes, and so forth. Or they may need to limit the amount of time they spend cooking, reserving elaborate meals for weekends. They might also consider limiting the number of extracurricular activities and/or sports each child is involved in. Time management also includes saying no. Out of a need to be liked or a strong sense of responsibility to others, people sometimes try to make everyone happy by agreeing to all requests for assistance: from spouse, children, parents, friends, church, school, and the community. You can prompt clients to identify how much they can realistically accomplish—what is essential to do, and what would be "nice" to do. Help clients to work out a balance between their responsibilities to self and their responsibilities to others. ● Avoiding maladaptive behaviors. Some people use maladaptive behaviors as a response to stress. For others, the behaviors themselves become stressors. Advise clients to help avoid the following unhealthy behaviors: ● Drinking more than two alcoholic beverages per day ● Consuming excess caffeine (e.g., coffee, tea, and colas) ● Eating large quantities of nutrient-poor food, such as sweets ● Smoking or chewing tobacco ● Using illegal street drugs ● Abusing over-the-counter medications ● Avoiding social interaction

What environmental and lifestyle factors that influence ventilation and circulation can be avoided or minimized?

● Poor nutrition ● Obesity ● Sedentary lifestyle ● Smoking ● Substance abuse To a lesser extent, exposure to poor air quality, altitude, temperature extremes, and stress can be minimized.

assessing adapting to stress, what type of questions would you ask?

● What coping strategies have you used previously? What was successful, and what was not successful? ● Tell me about previous experiences you have had with stressful situations in your life. ● What do you usually do to handle stressful situations? (If the client needs prompting, you can ask, "Do you cry, get angry, avoid people, talk to family or friends, do physical exercise, pray? Some people laugh or joke, others meditate, others try to control everything, and others just work hard and look for a solution. What is your usual response?") ● How well do these methods usually work for you? ● What have you been doing to cope with the present situation? ● How well is that working? ● During the interview, you should also observe for the use of psychological defense mechanisms. If the patient has not exhibited any defense mechanisms, you could ask about the common ones. For example, "Do you ever cope with a situation by denying that it exists or just trying to put it out of your mind?"

assessing and identifying stressors? what kind of questions would be ask?

● You might begin gathering this data by having the client complete a stress inventory, such as the Holmes-Rahe scale. ● You might ask the client: ● What is causing the most stress in your life? ● On a scale of 1 to 10 (1 is "not much" and 10 is "extreme"), rate the stress you are experiencing in each of these areas: work or school, finances, community responsibilities, your health, health of a family member, family relationships, family responsibilities, and relationships with friends. ● How long have you been dealing with the stressful situation(s)? ● Can you track the accumulation of stress in your life? ● How long have you been under this stress?

assessing developmental and stress. what type of questions would you ask?

● You should note the client's developmental stage and determine whether he is functioning as expected for his stage. You might ask questions such as: ● What challenges do you face as a result of your life and your age? ● Have you had recent life changes? ● Do you anticipate any life changes?