Fundamentals of Nursing (all)

Radionuclide imaging

Radioactive chemicals

C

centigrade

define nocturnal enuresis

bed wetting

soft palate location

posterior part of mouth

postop

postoperative

LIST BARRIER PRECAUTIONS

Gloves Goggles Gown Face and eye shields Masks

auscultating pulmonic area

listen w/ diaphragm at left 2nd interspace near sternum

auscultating aortic area

listen w/ diaphragm at right 2nd interspace near sternum

Age-related changes affect wound healing

- thinning dermal layer of skin; decreased subcutaneous tissue

A nurse is caring for an adult pt who is NPO. The pt is refusing oral care. What is an appropriate response by the nurse?

- Oral care is still important even though you are not eating

rectal temp

"core" glass electronic NORMAL: 99.6 F/37.7 C

tendon reflex grading scale: 2+ or ++

"normal"

Define transfer

(1) discharging a client from one unit or agency and immediately admitting him or her to another (2) moving a client from place to place

breast self exam

(BSE) 1. perform one monthly right after menses or day 4-7 of cycle 2. include lifting arms to look for retraction

Celsius to Fahrenheit

(C x 1.8) + 32

Fahrenheit to Celsius conversion

(F-32)/1.8

nevus

(normal) mole birthmark circumscribed

How to obtain a sterile urine sample?

* this is when the catheter is already in place* - verify physician's orders - collect your supplies - wash hands / introduce yourself/ verify PT/ explain procedure - provide privacy - raise bed to a working position - check for urine in tubbing (bc you need to collect what is in the tube not what is in the bag) - if you need to promote more urine for your specimen, clamp the tubing for 15-30 min - wash hands/put on clean gloves - open specimen cup with lid upside down on flat surface / wipe with alcohol the port - insert needle to port at a 30-40 degree angle and aspirate 10mL of urine - transfer urine into the specimen cup careful not to touch needle to cup and close tightly - remove clamp from tubing - remove gloves and wash hands - label specimen cup - document procedrure

Snellen eye chart

***CN II - position pt 20ft in front of chart - pt covers eye w/ OPAQUE card - have pt read progressively smaller letters until they can't go further - record smallest line - do other eye

Rosenbaum pocket card

***CN II same as Snellen hold at 14in reading distance

general notes

***When taking the exam—there are questions about what should cause concern—think about the nurse action being incorrect. "What action should be discussed with the nurse?" means what nurse action was incorrect?

palpation of liver: alternate method

***method useful when pt is obese or examiner is sm compared to pt 1. stand by pt's chest 2. "hook" fingers just below costal margin and press firmly 3. ask pt to take deep breath 4. you may feel edge of liver press against your fingers

costovertebral tenderness

***often associated w/ RENAL DISEASE 1. warn pt what you're about to do 2. have pt sit up on exam table 3. use heel of closed fist to strike pt firmly over costovertebral angles 4. compare left and right sides

FABER test (hips/sacroiliac joints)

***stands for Flexion, ABduction, External Rotation of hip. Used to distinguish hip or sacroiliac joint pathology from spine probs 1. ask pt to lie supine on exam table 2. place the foot of the effected side on opposite knee (this flexes, abducts, and externally rotates hip) 3. px in groin indicates prob w/ knee, not spine 4. press down gently but firmly on flexed knee and opposite anterior superior iliac crest 5. px in sacroiliac area indicates prob w/ sacroiliac joints

obturator sign

***test for APPENDICITIS 1. raise pt's rt leg w/ knee flexed 2. rotate leg internally at hip 3. increased abd pain indicates positive obturator sign

rebound tenderness (Blumberg sign)

***test for peritoneal irritation. Warn pt what you're about to do. 1. press deeply on abd w/ hand 2. after moment, quickly release pressure 3. if it hurts more when you release, the pt has rebound tenderness

pap smear

***tests for CERVICAL CANCER 1. specimens taken from (in order) vaginal pool, cervical scrape, endeocervical specimen 2. post hysterectomy and cervix removal--scrape from end of vagina and cervical pool

What information do you put on a specimen label?

- PT name and ID - Time and date - What specimen was collected and how (example: Sterile urine specimen from port on catheter) - your sig/ initials

inspection

*always first* critical observation use all senses good lighting color, shape, symmetry, position odors from skin, breath, wound

kyphosis

- "hunchback" - over-curvature of thoracic vertabrae

What does the fluid level in the water seal chamber have to be at?

- 2cm at water seal - 20 cm in the suction chamber (or whatever pressure prescribed by physician

A nurse is about to transfer to a chair a pt who has a weak left leg. What action demonstrates correct transfer technique?

- Aligning the nurse's knees with the pt's knees just before the transfer

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

- Ask the patient in what order she/he typically performs their morning routine

Wat are the elements of Informed Consent?

- Capacity: Indicates the PT has the ability to make a rational decision if not then that they have a spouse, parent, or legal guardian - Comprehension: Shows that the PT understands the doctors explanation of risks, benefits, and alternatives available - Voluntariness: that the PT is acting on his/her own freewill without coercion or threat of elimination

Sources of carbohydrates

- Cereals and grains (rice, wheat, wheat germ, oats, barley, corn, corn meal) - fruits and veggies - seatners - milk

Nursing guidelines X-ray or any other imaging

- Check vitals - remove any metal, jewelry, ask if pt has any metal implanted - request a lead apron and collar to shield fetus and any vulnerable body parts - ask about allergies - know where all emergency equipment and drugs are in case of unexpected allergic reactions - know to schedule procedures that require iodine before those that use barium (that is to avoid interference with subsequent visual imaging - encourage/promote urinary excretion or drink large amounts of fluid after exams that used iodine to help flush it out - check pt bowel and stool elimination and characteristics for at least 2 days after administration of Barium contrast medium (because it can cause constipation or even bowel obstruction) - check vitals after

What does it mean if you do hear or feel air crackling while palpating skin around chest tube insertion?

- Possible air leak or internal displacement

Administering Oxygen safely (*think Fire safety!!)

- Post "Oxygen in Use" wherever O2 is stored or used - no burning candles during religuious rites (fire hazard) - check electrical devices all have 3 pronged plug - inspect elecrtical equipment for frayed wires - avoid using petroleum products, aerosol products, and anything containing acetone - Secure prtable oxygen cylinders to rigid stands

How to care for PT with a water seal chest tube

- Check your PTs medical record - Prep to do a physical assessment on pt and equipment - get your equipment - wash hands - introduce yourself/ verify pt/ explain procedure - Check to see if Hemostats are at bedside - Turn off suction regulator before assessing the pt (if it's being used) - assess lung sounds - inspect the dressing - palpate skin around chest tube insertion feeling and listening for air crackling - inspect all connections that they are taped and secure (reinforce where needed) - make sure all tubing is unkinked and hanging freely - check the fluid levels in water seal - add sterile distilled water to the 2cm mark and 20cm mark if needed - make sure water in the chamber is tidaling - check for continuous bubbling - regulate the wall suction so that it produces gentle bubbling - observe the nature and amt of drainage - keep drainage below chest level - position pt so to avoid compressing the tube - curl and secure tubing on bed - milk tubing if stationary clot is observed - encourage coughing and deep breathing every 2 hrs while pt is awake - have Pt move about in bed, ambulate (if they can) while holding the drainage system - exercise shoulder on the side of drainage tube - mark drainage level o the collection chamber at the end of your shift ** Normal evaluation findings** - PT shows no evidence of respiratory distress - Dressings dry and intact - No subcutaneous air detected around site of tube insertion - Equipment functioning correctly - Water at recommended levels ** - Document chart: assessment findings, any care provided, and amt of drainage during period of care

What are the nurse's responsibilities for examinations and tests/

- Clarify and explain - Prep the PT - Obtain equipment and supplies - arranging examination area - position and drape PT - assist examiner - care for specimens - record and report

A nurse is assisting a pt with personal hygiene care. What action by the nurse will reduce the risk of infection?

- Cleaning the least soiled areas prior to cleaning the most soiled areas

What things can interfere with the nutritional intake in an older adult?

- Diminished sence of smell and taste - psychosocial imparments - medical conditions - adverse medication effects - fuctional imparement

What foods should the PT avoid if taking Anticoagulants?

- Foods high in Vit K - cabbage, broccoli, brussels sprouts - kale - leafy greens

Modified standing position

- For prostate exam

You are preparing to use a tympanic thermometer. What steps has the highest priority in the accurate use of this piece of equipment?

- Gently pulling the pinna back and upward

A nurse in the emergency department is caring for a patient who has a knee injury. The patient will be discharged and will be using a pair of axillary crutches for the first time. How should the nurse instruct the patient for when they are going to sit?

- Hold your crutches on the unaffected side when preparing to sit in a char

How should specimens be sent to the lab?

- In it's appropriate container sealed and labeled with correct info - With proper lab request form - delivered to lab by nurse

Describe Purse Lip Breathing

- Inhale slowly through the nose while counting to 3 - purse your lips like you're going to whistle - contract your abdm muscles - exhale through pursed lips for a count of 6 or more

tracheal lung sounds

- Inspiratory and expiratory sounds are about equal - Very loud - Relatively high pitched - Over the trachea in the neck Equal in length during inspiration and expiration and separated by a brief pause

What are some nursing interventions for natural airway management?

- Liquifying Secretions (inhalation therapy) - Mobilizing Secretions (postural drainage/ percussion/ vibration) - Suctioning Secretions ( nasotracheal / nasopharyngeal/ oropharyngeal/ oral)

A nurse is caring for a pt who is on long term bedrest and requires frequent linen changes due to excessive diaphoresis. What is the priority rationale for frequent linen changes?

- Moisture from excessive diaphoresis can cause skin breakdown

What can interfere with an accurate Pulse Ox reading?

- Movement - Poor Circulation at sensor site - Barrier to light (like nail polish or acrylic nails) - Extraneous light (a lot of light) - Hemoglobin saturation with other substances (like carbon monoxide poisoning)

Signs of adequate breathing

- Normal respiratory rate (adult male 14-18 bpm/ Female 16-20) - clear even bilateral lung sounds - Normal pulse rate (60-100 per min) - Normal BP (120/80) - Normal level of consciousness ( Alert and Oriented) - Normal color of skin, nail beds, lips - Normal relaxed unlabored breathing pattern and effort

Who is at risk for disuse syndrome?

- Older adults - PT's who are bed bound for long periods of times

How is a contrast medium administered?

- Oral - intravenously (injected in the vein)

Nurse intervention for disuse syndrome

- Provide core activities like positioning and moving clients - Range of Motion exercises

A pt recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. What actions should the nurse take to prevent dry mucous membranes?

- Provide frequent mouth care

A nurse is caring for a pt who has a nasograstric tube connected to suction. What is the should indicate to the nurse that the tube has become occluded?

- Pt reports nausea

What equipment is necessary for Water-seal chest tube care?

- Roll of tape - Sterile distilled water

Teaching a PT how to use an incentive spirometer

- Sit upright unless you physically can't - Know where the goal of inhalation mark is - exhale normal - insert the mouthpiece and seal it with your lips around it - Inhale slowly and deeply until the goal mark has been reached then hold it for 3-6 seconds -remove the mouth piece and exhale normal - take a break an breath normal before you try again - Repeat the exercise 10-20 times an hour or however many times as directed by the physician

What supplies do you need for a throat culture?

- Sterile culture swan - glass slide - gloves - mask - paper tissues - emesis basin - tongue blade (depressor)

Common examination positions

- Supine - Prone - Dorsal recumbent - Lithotomy position - sims position - knee-chest position - modified standing

A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double barrel colostomy in the sigmoid colon. What instructions should the nurse include in her teachings?

- Tape a dry gauze pad over the distal stoma to collect drainage

When palpating AC space before drawing blood what are you looking for? or what are you feeling for?

- Veins = spongy - Arteries = pulsate - Tendons = firm

What important information are you paying attention to when checking the medical records of a PT who has a Water-Seal Chest Tube?

- Why do they need the chest tube? - Do they have more than one? - check the date of insertion - is the drainage going by gravity or suction?

A nurse is caring for a pt who has a newly inserted nasogastric tube. What method is appropriate for verifying initial placement?

- X-ray examination of chest and abdomen

Purse Lip Breathing

- a breathing exercise where the PT consciously prolongs the expiration phase of breathing - helps improve gas exchange - if done right it helps the PT eliminate more than the usual amt of carbon dioxide from lungs

What is a 24 hour urine collection?

- a collection of all urine produced in a full 24 hour period

a nurse preparing a sterile field knows that the filed has been contaminated when...

- a cotton ball dampened with sterile normal saline is placed on the field - the nurse turns to address the patient's questions concerning the procedure - The procedure is postponed for 30 min to accommodate the patient

Humidifier

- a device that produces small water droplets

Why is the attention to elimination part of pre-op important?

- a distended bladder increases risks for bladder trauma and difficulty performing the procedure - the catheter keeps the bladder empty during surgery - a clean bowel allows for improved visualization of the surgical site - prevents trauma to intestines - prevents accidental contamination of the abdominal cavity with feces

Flow meter

- a gauge used to regulate the amount of oxygen delivered to the pt and is attached to the oxygen source

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for what kind of pt?

- a pt with a bowel obstruction

You have assessed a 45 yr old pts vitals. What would be a sign that would require immediate attention

- a respiratory rate of 30/min

measuring head circumference

- birth to 36mo - non-stretchable measuring tape - broadest part of head - for greatest accuracy: 3x--take measurement at rt and lt side of head and at mid-forehead - tape pulled to compress hair - should be measured at each visit

essential pre surgical activities

- a spot for history and physical exam documentation - name of surgical procedure matches the name of procedure that is on the consent - surgical consent signed and witnessed - all labs and diagnostic test results returned and reported if abnormal - allergies identified - patient wearing an ID bracelet and allergy bracelet if needed - patients been NPO since midnight or the number of hours prescribed? - skin prep if needed - vials assessed and recorded - nail polish, glasses, contact lenses, and hairpins removed? - jewelry, wedding ring removed and secured - dentures left in or removed? - patient dressed in hospital gown and surgical cap? - patient voided, catheter/ enema given? - prescribed perioperative medication given?

Contrast medium

- a substance like a barium sulfate or iodine that adds density to a body organ or cavity * makes a hollow body area look more distinct when imaged*

incentive spirometry

- a technique for deep breathing using a calibrated device - it's used to encourage the pt to reach a goal directed volume of inspired air

Water seal chest drainage system

- a technique used for evacuating air or blood from the pleural cavity - helps restore negative intrapleural pressure and reinflate the lung

What are some developmental tasks the older adult might have to deal with and struggle with?

- adjusting to the physical limitations brought about from aging - finding satisfaction in retirement - secure acceptable living arrangement - develop meaningful social relationships - adjust to losses accompanying with aging - recognize meaning in one's life - accept and prepare for one's own death

Individual Nutritional needs are influenced by

- age - heigh/ weight - growth period - activity - health status

What Identifying data are you collecting for H&P?

- age, gender, marital status - general appearance - circumstances surrounding physician involvement - reliability of client as historian - others providing information about client's history

what psychosocial issue do older adults deal with?

- ageism - dependence - housing - economic concerns - loneliness - depression - fear for safety

Regular Diet

- allows unrestricted food selections

you are assessing a pt's vitals who has a temp of 102. What else would you expect to find?

- an elevated pulse rate

Oxygen Therapy

- an intervention for administering more oxygen than is present in the current atmosphere

chest inspection: A-P

- anterior-posterior diameter vs. transverse diameter - A-P should be less than transverse in adults: 1:2-5:7 - elevated A-P size=barrel chest, may be COPD; normal in children

What are some common patient response to admission to the hospital?

- anxiety - loneliness - decreased privacy - social isolation - fear - decisional conflict - situational low self esteem - powerlessness - ineffective self management

egophony

- ask pt to say "ee" continuously - auscultate several symmetrical areas over each lung - should hear muffled "ee" - if "ay" heard, referred to as E->A or egophony

To auscultate a pt's apical pulse properly, you position the bell or diaphragm of your stethoscope over the point of maximal impulse. Where is that located?

- at the 5th intercostal space at the left midclavicular line

What is needed for a patient to be admitted to the hospital or health care agency?

- authorization from a physician - collection of billing info - completion of agency's admission database - documentation of patients' medical history - development of an initial nurse care plan - initial medical orders for treatment

measuring wt

- balance beam or digital - spring type not acceptable - scales to be checked for accuracy annually - zero scale

What supplies are needed for Occult Blood testing?

- bed pan or toilet liner - tongue depressor - gloves - testing kit and reagent

what physiological changes occur in the respiratory system of an older adult

- calcification of costal cartilages cause rib cage to remain in expanded position (barrel chest) - wasting of respiratory muscles decrease respiratory efficiency - respiratory membranes thicken making movement of O2 from alveoli to blood slower

clear liquid diet

- can b e colored but must be transparent and do not have any kind of pulp or bits of food like water, broth, fruid juice, flavored gelatin, popsicles, clear soft drinks, tea, coffee (no creamer)

What can it mean if there is continuous bubbling is found in water chamber of Water seal chest tube?

- can mean air leak in tubing or connection * if using suction then bubbling in suction is normal and expected

signs and symptoms of impending death

- cardiac dysfunction - peripheral circulation changes - pulmonary funtion ipairment - central nervious system alterations - renal impairment - gastrointestinal disturbance - muscular skeletal changes

How to help a PT overcoming Simple anorexia

- cater to pt's food preferences - serve nutrient dense foods - offer smaller servings more often - make sure they're rested before meals - provide an opp for oral hygiene b4 meals - help pt to a sitting position - make the food look good - suggest spices and herbs for foods - serve food at the right temps - serve bland foods for pt's with a mouth irritation

Why do older adults often consume high carb diets?

- changes in tastes - changes in ablity to prepare / obtain foods - limited accessibiliy - finacial limitations

what physiological changes occur in the musculoskeletal system of an older adult

- changes in texture, calcification, and shape of bones - bone spurs develop around joints (lipping) - bones become porous and fracture easily -degenerative joint disease like Osteoarthritis is common

How would you perform the Occult Blood test?

- check orders for test - wash hands - introduce yourself / verify pt/ explain procedure - collect your supplies - give pt bedpan or have them void stool in commode or toilet lined with liner (this is to avoid urine or water mixing with the stool - using the tongue depressor collect a sample from the center of the stool and apply a thin smear on to the test area supplied in the screening kit - cover the entire test space and close the cover then flip over the kit and open the back - place 2 drops of the chemical reagent ono the test space and wait 60 seconds - inspect tested area for a blue color (that means there is blood present in the stool) - discard remaining stool in the toilet - remove and throw away used materials - wash hands - document findings - if test was positive for blood in stool notify physician

Nursing guidelines for administering Contrast medium

- check vitals B4 and after to set a base line (and helps detect any changes) - ask about allergies (seafood/ iodine/ or if ever had any adverse reactions like vasovagal during a diagnostic test prior - collect supplies for administering medium

Teachings for preventing and relieving stomach gas

- chew with their mouth closed - no straws - no gum or smoking - limit foods with large vol of air (yeast breads/sodas) - try not to stress eat - walk when uncomfortable - poss medications to relive gas accumulations (talk to the Doc)

What past health history is important to know during H&P?

- childhood disease summary - physical injuries - major surgeries/illness - previous hospital stay - drug history - alcohol and tobacco use - allergy history

What are you assessing when collecting data on Present illness on an H&P?

- chronologic description of onset, frequency, and duration of current signs and symptoms - outcomes of earlier attempts at self-treatment and medical treatment

What do you do if bubbling is found in the Water chamber of the Water seal chest tube?

- clamp hemostats at the chest and a few inches away to see if it stops - continue to clamp, releasing and re-applying going down toward the drainage system until bubbling stops - apply tape around tube above to where the last clamp was applied when bubbling stopped

A nurse is replacing the ostomy appliance for a patient whos newly created colostomy is functioning. After removing the pouch, what should the nurse do first?

- cleanse the stoma and peristomal skin

MDS (minimum data set) assessment includes

- cognitive patterns - communications nd hearing patterns - vision patterns - physical functioning and structural problems - continence patterns in the last 14 days - psychosocial well being - mood and behavior patterns - activity pursuit patterns - disease diagnosis - health conditions - oral and nutritional status - skin conditions - medication use - special treatments and procedures

health hx

- comprehensive hx, inc chief complaint, reason for visit, review of symptoms, fam/social hx, should be obtained ON FIRST ENCOUNTER BY RN, regardless of setting - across 3 generations - documentation must be completed for each visit/assessment

Non-pharmacologic interventions to promote sleep

- consistant sleep and wake times - ear buds, eye shades, adjusting room lighting - soft soothing music or sounds - night time rituals - avoid late night coffee - take diuretic early - exercise reguary during the day (not at night) - progressive relaxation exercises during night rituals -back or foot massages

You are washing your hands with a nonantimicrobial soap and water prior to repositioning a patient in bed. During the hand washing procedure, it is important to

- continue for at least 15 seconds

what losses might an older adult have to deal with?

- death of a spouse, friends, and family - kids no longer in the house - loss of their own independance

Symptoms of inadequate oxygen

- decreased energy - restlessness - rapid, shallow breathing - rapid heart rate - sitting up to breathe - Nasal flaring - uses of accessory muscles - hypertension - Sleepiness, confusion, stupor, coma

standard hand hygiene precautions mandate

- disinfecting hands immediately after removing hands

Teachings for weight gain

- eat a variaty of foods from My plate - eat small amts more often - eat with others - snack on high calorie/ nutrious foods - try fortifiing foods with powdered milk, gravies, or sauces to add calories - garnish foods with cheeses and meats - rest after eating

An older adult pt in a long term care facility is receiving intermittent enteral feedings in his room. His affect is flat and the nurse suspects that he's feeling isolated. what intervention is appropriate for this pt?

- encourage him to go to the dining room at meal times to talk with other pts

some ways to help a patient feeling common patient responses to admission to hospital

- encourage patient to use destressing methods that helped them before or teach them new ones - reduce external stimuli (lights, sounds in room) - establish trust - use their name (find out if they have a nickname or what they prefer to be called) - encourage visitors - close the door to help preserve their privacy - encourage them to have pictures in their room, especially if they're staying for a while

During a surgical handwashing, the hands are kept above the elbows to

- encourage water and soap to flow away from the clean hands

what physiological changes occur in skin hair and nails of an older adult?

- epidermis loses ability to retain fluids and makes the skin dry and less supple - lentigo senilis is common - skin is more thin and provides less support to fragile blood vessels making bruises more common and last longer - nails become yellow and thicker - more prone to pressure ulcer

Supine

- examinations of the head, neck, chest, abdomen, and extremities

Prone position

- examinations of the posterior head, back, buttocks, and extremities

As a nurse ambulates an unsteady patient, the patient becomes light headed and begins to fall. What is the appropriate intervention for the nurse to do at this time?

- extend one leg and allow the patient to slide down it.

What are signs of depression in older adults?

- fatigue - irritability - loss of interest in surrounding - decreased ability to concentrate - feelings of worthlessness

signs of depression in the older adult

- fatigue - irritability - loss of interest in surrounding - decreased ability to concentrate - feelings of worthlessness

cap refill

- finger or toenail - >2-3sec suggest peripheral vascular disease, arterial blockage, heart failure, or shock

some factors that influence nutritional needs

- food preferences - established patterns for meals - attitudes about nutrition - knowledge of nutrition - income level - number of ppl living in the same house - access to food markets - satisfaction or dissatisfaction with body image - religious beliefs - use food for comfort, celebration, or symbolic reward

Soft Diet

- foods soft in texture , low in residue, and readily digestible and has little to no spices or condiments, less fruit, veggies and meats than that of the light diet

A nurse observes an assistive personnel (AP) make a client's bed while the pt is out of the room. What action is appropriate for the AP for this task?

- for the AP to reuse the pt's blanket and spread

Full liquid diet

- fruit and veggie juices, creamed or blended soups, milk, ice cream, yogurts not fruit bits, puddings, milk shakes, gelatin, cooked cereal

What are some Gerontologic considerations for factors effecting sleep

- generally more comfortable with their own bed furnishings - prefer warmer room temps - insomnia and hypersomnia are frequent signs of depression - sundown and sunrise syndrome - relaxation teachings before bedtime - hypnotic medications not recommended for more than 2 weeks -difficulty falling asleep - institutional schedules may interfere with established patterns of sleep; modifications may be necessary - important to identify potential sources of sleep disorder - chronic conditions that interfere with sleep like: pain, difficulty breathing, frequent urination - suggest short naps or rest ca restore energy without interfering with night time sleep

How to do a dipstick test

- get your equipment - wash hands put on gloves - confirm pts info is correct on the specimen bottle - inspect color, clarity, odor - check dipstick exp date - remove test strip from container - inert dip stick into urine - remove strip and tap off access urine - read results - document findings

Coughing exercise after surgery can be painful for clients with abdomen or chest incisions what nursing interventions can be done for this?

- give pain medications 30 min prior to exercise - teach slinting method (gently pressing on the incision with both hands or hugging a pillow)

what adaptations might be needed in teaching older adults?

- go slowly to allow for info to sink in - include another person in the learning like who ever is going to be a caregiver after discharge - try to relate new information to past experiences

what nursing implications are advisable for the integumentary system changes in the older patient?

- good nutrition and hydration for hair nails and skin - less soap or bathing less to help combat dry skin - avoid too much sun - frequent position changes to avoid pressure ulcers in the patient who is bed bound especially - with nails it's a good idea to soak them for a few min before trimming to avoid cracking - regular massage to help promote better circulation

Internal respiration

- happens at the cellular level between hemoglobin and body cells *think: your tiny cells breathing*

How would you teach a Pt to collect their urine for 24 hours?

- have the PT urinate and empty bladder prior to collecting first urine specimen - after emptying bladder make sure they know to collect any urine produced into the specimen jug provided - time and date the first voided specimen into jug to mark the start of their 24 hour clock - 24 hours later have the pt void one last time into the specimen jug to conclude the collection

How would you prep your pt for an occult blood test?

- have them omit non steroidal anti inflammatory drugs like more than 1 adult aspirin, ibuprofen, naproxen, for 7 days before collecting stool, - avoid taking more than 250 mg of Vit C or consuming citrus fruits or juices for 3 days prior - eat high fiber diet whole grains, and cook veggies well - no red meat for 3 days prior - no raw turnips, radishes, broccoli, beets, carrots, cauliflower, cucumbers, or mushrooms for 2-3 days prior

What family history is important to collect for H&P?

- health problems in immediate family members (living and deceased ) - longevity and cause of death among deceased blood relatives (parents and grandparents)

what physiological changes occur in the cardiovascular system of an older adult

- heart pumps less efficiently because of damaged muscle fibers, loss elasticity to heath valve and cellular changes - blood vessels respond slower to changes in body positions causing patients to become dizzy if they get up too fast - Bp is common and without medications a typical bp would be 160/9 for your average 60yr old

When opening a sterile pack, what would compromise the sterility of the instruments and supplies inside the pack?

- holding the sterile pack below waist or table level

assessing visual acuity

- if eye pain, injury, visual loss check visual acuity before proceeding w/ exam or applying med - allow pt to use lens or glasses - assessing best corrected vision - Snellen eye chart or Rosenbaum pocket card

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a pt from the bed to a chair. What action would make the nurse intervene?

- if the AP leaves the bed in the lowest position during the procedure

How to address emotional and spiritual needs of the dying patient

- if the client indicates the want of someone associated with their refligion or church you can notify the approriate clergy - if the client is too ill to speak for themselves then it is your job to ask the family about spiritual needs

What can cause the blood culture to become contaminated?

- if you don't clean the area of puncture - if your needle is not sterile or if the tubes are not sterile (if your equipment is not sterile)

You are measuring a pt's temp orally. you place the covered probe where?

- in the posterior lingual pocket lateral to the midline

What are some common factors that invalidate examination or test results?

- incorrect diet preparation - failure to remain fasting - insufficient bowel cleansing - drug interactions - inadequate specimen volume - failure to deliver specimen in a timely manner - incorrect or missing test requisition

What factors affect airway patency?

- increased vol of mucus - thick mucus - fatigue or weakness - decreased level of consciousness - and ineffective cough - an impaired airway

measuring wt: clothing

- infants: wearing only dry diaper or light undergarments - children: remove outer clothing and shoes - adolescents and adults: minimal clothing

Transfer activities to a different agency

- inform patient and family of the need for transfer as soon as possible - if time allows, encourage patient and family to investigate various facilities - communicate with the facility/ agency where the patient will be transferred - make a photo copy of the medical record - provide a written clinical resume - place written information in a large manila envelope or send via fax (but make sure the agency is expecting the fax) - collect all of the patient's belongings - accompany EMTs to the patients room - help transfer patient to stretcher - give transfer personnel a copy of the medical record in a folder or envelope - complete original medical record by adding a summary of discharge - send completed chart within a folder to the medical records department - notify the business office, admitting office, and house keeping

Transfer activities within the same agency

- inform the patient and family of transfer - complete a transfer summary - speak with a nurse on the transfer unit to coordinate the transfer - transport the patient and their belongings, medication, nursing supplies and chart to the other unit

What should you do if tube and drainage system get separated in the water seal chest tube ?

- insert a sterile tube in to the sterile water until it can be reattached and secure - to help prevent air from entering the tube, cover it with a gloved hand or fabric if it's accidentally pulled out

A nurse is performing a nasogastric intubation. What action should he nurse take immediately after inserting the tube to the predetermined length?

- inspect the oropharynx with a penlight and a tongue blade

Hypoxemia

- insufficient oxygen within arterial blood

What are you looking for when inspecting the dressing of a PT with a chest tube?

- is it becoming loose? - is it saturated with drainage?

"knock knees"

- knees together when standing - normal to age 7 - abnormal if older

When providing peri care for a female patient who has an indwelling urinary catheter. What should the nurse cleanse last?

- the anus

Nursing guidelines when feeding a visually impaired PT

- lace a thick towel on chest and lap - if they can eat on their own try using dishes with a rim or a bowl - arrange as much as possible to have finger foods - describe the food and location on the tray - prep the food for them: open cartons, cut up the food, adding salt, buttering their bread - use the analogy of a clock when describing where their food is on the plate - if they need to be fed tell them what kind of food you are offering them with each mouthful - come up with a way for them to tell you when they are ready for more food - don't ever rush them

Stasis

- lack of movement

scoliosis

- lateral curvature of spine w/ unequal leg length - minimal w/ young children which resolves w/ change of position - more common as a concern in adolescents

While a nurse is administering a cleansing enema the pt reports abdominal cramping. What is the appropriate intervention?

- lower the enema liquid

How to operate a glucometer

- make sure meter is working properly - check dates on container of test strips - make sure the code number on test strips match the code n umber programed into the meter - turn on the glucometer and observe: the last reading, current test strip code and the insert strip msg - wash hands and put on gloves - select area to be lanced - apply lancet firmly to the side of the finger and press the release button - squeeze a little blood drop - touch the blood to test strip make sure area is completely covered - insert strip to glucometer - wait for meter to beet then wit for a series of beeps about 45 seconds after - read display on meter after the beeps - turn off the meter record readings

What teachings would you give to a PT/family who is not hospitalized regarding how to prepare for special tests or exams?

- make sure they have the number to call if test prep instructions are not understood or can't be followed - any dietary instructions: no eating or drinking 8 hrs before if fasting is required or if they cannot have any specific kind of food that would react with the exam - Check with doctor about taking or readjusting the scheduled time for taking any prescribed meds the day of testing - bathe or shower like normal the day of - dress casual/comfy and in layers so that they can easily take off or put something on to maintain comfort in the test area - make sure they know not to drive themselves the day of exam - always arrive 30 min prior to exam time - make sure they know to bring proper ID and all Ins or medicare verification info

Preoperative Teachings

- make sure they understand what to expect after procedure andwhat is expecte of the client and family because this can help enhance recovery

How is a prostate exam preformed?

- make sure you have all equipment for physician - if any local anesthesia is required, then carefully check the name and concentration of drug on the label - hold the medication as the physician withdraws it - assist the PT into a comfortable position for the exam: either a modified standing or a knee- chest position - provide emotional and physical support to PT as needed - the physician preforms the exam by inserting a finger into the rectum, palpating the prostate feeling for abnormalities

Common side effects of sleep medications

- many hypnotic drugs loose their effectiveness after 2 weeks - you can develop a drug tolerance which leads to misuse of the medications and can lead to increase in falls and injury disruption in the sleep cycles when discontinued abruptly - can have paradoxical effect on older adults

measuring height if under 2

- measure in recumbent position ***also if between 2-3 and can't stand unassisted - measuring board w/ stationary headboard: head held against board, knees held, so knees and hips are extended - or tape measure - measure to nearest 1/8 inch - modified technique: lay child on flat surface, mark feet and head - use growth charts to evaluate, educate and refer to

A nurse stands facing a patient to demonstrate active range of motion exercise. How should the demonstrate hyperextension of the hip?

- move the leg behind the body

signs of approaching death are a result of what?

- multiple organ failure

common oxygen delivery devices

- nasal cannula - simple mask - partial re-breather mask - non re-breather mask - venturi mask - Face vent - tracheostomy collar - nasal catheter

some special handling for irregular blood specimens

- neonatal blood collection: neve ruse lancet longer than 2.4 mm - ivy method - when you apply pressure cuff to the upper arm and inflate to 40mm Hg - bleeding time test - assesses the pt's function of platelets *always make sure you understand your orders especially if they're irregular

head vs. chest circumference

- newborn: head circumference will be about 2cm larger than chest - as child ages, chest circumference will become larger

Examples of Parasomnias

- nocturnal enuresis (bed wetting) - Sleep talking - Nightmares / terrors - restless leg syndrome

What supplies do you need to obtain a sterile sample of urine from a pt?

- non sterile gloves - sterile needle - alcohol wipes - clamp - 10mL syringe - sterile specimen cup - paper towel

"bow legs"

- normal to age 3 years

Nursing care during immediate preoperative period

- nursing assessment - provide pre-op teachings - performing methods of physical preperation - administering medications - assist with psychosocial preperation - complete the surgial checklist

in which order would you open a sterile pack?

- the flap furthest from your body - the side flaps - the clap closest to your body

What is debridement

- the removal of dead tissue, to promote healing.

What are the benefits of hospice/palliative care?

- nursing care and physicians 24/7 - hopsice aide and homake services - medications for symptom control or pain relief - medical supplies and equipment - physical therapy, occupational therapy, and speech-language pathology services - social work and counseling services for the client and caregivers - dietary counseling services - short term in patient care for pain and symptom management - grief and loss counseling for client and family - any other medicare - covered services needed to manage pain and other symptoms as recommended by the hospice team

You are assessing the vital signs of a newly admitted pt. To establish an accurate baseline of the pt's respiratory you would...

- observe the pt's chest movements while appearing to assess his pulse

What are some Gerontologic considerations for airway management?

- pathologic pulmonary changes in older adults - age related changes affecting respiratory system - pneumonia in older adults - respiratory secretions in older adults - dysphagia in older adults - cardiac dysrhythmias in older adults

percussion of ABD

- percuss in all 4 quadrants (clockwise) using proper technique: inspect, auscultate, percuss, palpate - categorize and tympanic or dull. Tympany normally present over most of abd in supine position. Unusual dullness may be d/t underlying mass or full bladder

When assisting with a pelvic examination / pap smear what steps should the nurse follow?

- place the client in lithotomy position - provide examiner with a vaginal speculum - hand the examiner a brush applicator - deposit the applicator in a chemical fixative solution - lubricate the examiner's gloved fingers

Teachings for Vegetarian Diets

- plan menus 1 day or 1 wk at at time - eat a wide variaty - eat a variet of diff plant protiens daily - include fortified read to eat cereals, soy, dried fruit, dried peas for iron - have a good source of Vit C with each meal - fortified ready to eat cereals and soy milk for Vit B12 D and zinc - choose a calcium fortified OJ, fortified soy, yogurt, milk, tofu, bok choy, broccoli, collards, kale, - Omega - 3 fatty acids = canola oil, ground flax seed walnuts and soy beans - breast feed if possible - consider cod liver oil - a good source for help finding meatless products and food prep classes contact Seventh Day Adventist church

How would you teach a patient or their family to perform Postural Drainage exercises?

- plan to do it 2-4 times a day - take prescribed inhalant meds before you start - have paper tissues and water proof container to collect coughed up sputum - position yourself to drain the appropriate lung areas - cough and expectorate secretions that drain into the upper airway - Remain in each position for 15-30 min but no longer than 45 min - Resume a comfortable position after expectorating the usual vol of sputum or if you become tired, light headed, or have a rapid pulse rate, or difficultly breathing or chest pains

Preoperative teachings examples

- pre-op meds: when they are given and what affect it will have on the client - post-op pain control: when to take and how much - explain and describe the post anesthesia recovery room or post surgical protocol - discuss frequency of assessing vital signs and the use of monitoring equipment - explain and demonstrate how to do Deep Breathing, Coughing, and Leg exercises

flatfoot

- pronation of foot in children - comes from turning medial side of foot - normal for 12-30mo - abnormal otherwise

What do you document after blood glucose test?

- pt's name and ID# - date and time - any pre assessment data - glucose measurement - treatment received if any was given

pupillary reactions: PERRLA

- pupils equal, round, reactive to light and accommodation - often used incorrectly - if accommodation not tested, use PERRL

While performing a complete bed bath for a pt, the nurse should...

- raise the temperature in the room

how to promote effective communication in an older adult?

- reminiscence therapy = stimulate the to talk about good times in the past helps boost self esteem - validation therapy = method used on the more confused and disoriented that act out in inappropriate ways due to perm and progressive loss of cognitive ability

how might you help a patient with loneliness ?

- suggest volunteer work - encourage hobbies - suggest community meal places or senior center - suggest getting a pet

A nurse is caring for an unconscious pt. What indicates an understanding of providing good oral hygiene for the pt?

- swabbing the pt's mouth with chlorhexidine

Some nursing guidelines for patients on sleep medications

- take only as directed by physician - if the pt notices that the medication is not helping or showing doing the opposite of it's intended use, they must notify the physician - try practicing relaxation techniques - night time rituals - consistent in sleep times and wake times to build a routine

external respiration

- takes place at the most distal point in airway: Between alveolar- capillary membranes *think: chest in and out*

-How do you document the procedure of specimen collection?

- time and date - what specimen was collected and how - any inspection of physical characteristics like color, clarity, consistency, smell, output info, input info, - how pt handled procedure - your signarue/initials (initial of first name. last name. SPN. mntc)

A nurse is obtaining health history from a young adult pt who has a colostomy. The patient reports frequent episodes of loose stools over the last month but no signs of infection or bowel obstruction. He reports that this concerns about leakage have limited his social activities. What should the nurse recommend for this patient?

- try consuming foods low in fiber

Client and family teachings for dealing with Insomnia

- try not to nap in the day time - use the bed and room for sleeping only - sleep rituals - go to bed and wake up at same time every day even on your days off - if you can't get to sleep (when you try 20-30 min or more) then do something else like reading a book, listen to soft music, watch tv - try bed time relaxation recordings that play soothing music, nature sounds or background sounds - exercise regularly during the day not at night - avoid nicotine, alcohol, and caffeine - use ear plugs, eye shades - avoid using nonprescription or prescription sleeping pills(unless directed by your doctor) - try drinking chamomile tea - always follow directions on ay medications - if you are taking diuretics make sure you take early in the day

While a nurse is teaching patient how to replace her ostomy pouching system, she reports that removing the skin barrier is sometimes painful. What advice should the nurse give?

- try pushing the skin away from the barrier while removing it

To help a client suffering from insomnia, which plan for nursing care would you suggest?

- try to duplicate the client's pattern of sleep riturals

Teachings for promoting weight loss

- try using MyPlate and follow food plans - count your portions - limit fats oils and sugars - no more junk food - smaller more frequent meals - sit at the table to eat and don't multi task - inrease fiber - increase exercise

List some common cultures

- urine - blood - stool - wound drainage - throat secretions, - throat

Nursing guidelines for ROM

- use good body mechanics - remove pillows and other positioning devices - position client to facilitate movement - follow a systematic repetitive pattern - perform similar movements with each extremity - Support the joint being exercised - move each joint until there is resistance not pain - watch for non verbal ques/signs for PT response - avoid exercising painful joint - stop if spasticity develops (sudden muscle contraction) - apply gentile pressure to the muscle or move the spastic limb more slowly -expect PT's HR and RR to increase - teach the family members how to do

measuring standing

- use portable stadiometer - only socks or bare feet - head, shoulder blades, butt, heels touching wall - knees straight - feet flat - pt looks straight ahead - flat surface of stadiometer until it touches head and compresses hair

sinus transillumination

- uses otoscope to look at passage of light through sinuses - not always definitive of disease process

toe walking

- usually stops by 3mo after start of walking

II - optic: test

- visual acuity: Snellen eye chart or Rosenbaum eye card at 14in reading distance - screen visual fields by confrontation

Sources for Oxygen

- wall outlet - portable tank - liquid oxygen unit - oxygen concentrator

How to collect a throat culture

- wash hands - check orders (if pt is on any antibiotics check with physician prior to test) - introduce yourself/ verify pt/ explain procedure - Delay collecting if the pt recently used an antiseptic gargle - get your supplies -wash hands - put on your PPE - have the PT open mouth wide and stick out their tongue and tilt head back a bit - depress the middle of the tongue with tongue blade with your non dominant hand - rub and twist the tip of the swab around the tonsil area and back of throat without touching the teeth or tongue - remove swab and throw away the tongue blade - spread secretions on the slide - carefully replace the swab back into the tube - crush the packet at the bottom of the tube - remove and discard gloves - wash hands - label culture tube - attend to the staining and examination of the glass slide - deliver the sealed culture to the lab - document

Which manual method is used more for a smear test?

- wedge method

When can you use the humidifier used typically?

- when oxygen is being administered at a rate over 4L / min - bc oxygen administration tends to dry the mucus membranes

What things can you do to help promote the patient's safety?

- when you're not in the room have 2 bed rails up if your patient is in danger of rolling over and falling - make sure the call light is always within reach and keep low lights around almost like night light so that if your pt has to get up in the middle of the night they can see better and not bump into things - always keep the bed in a low position when you leave

EFFECTS OF AGING Urinary system

-Blood flow to kidney decreases and therefore ability to form urine decreases -Bladder problems such as inability to void completely are caused by muscle wasting in the bladder wall

What is a k-pad and how is it applied?

-K-pad is usually called an aquathermia pad, is an electrical heating or cooling device, it resembles a mat but contains hollow channels through which heated or cooled distilled water circulates. -The k-pad is a applied by placing the client on the aquathermia pad or wrapping it around a body part, the nurse covers the pad to help prevent thermal skin damage.

What is a common nasointeststinal tube?

-Keofeed for gavage -maxter for intestinal decompression

What are the different types of nasogastric (NG) tubes? And what are they mainly used for?

-Levin: Lavage, Gavin, Decompression, Diagnostics -Salem Pump: Decompression -Sengstaken-Blakemore: Compression Drainage

What are risk factors for developing a pressure ulcer?

-Risk factors for Developing Pressure Ulcers -Inactivity, immobility, malnutrition, emaciation, diaphoresis, incontinence, vascular disease, localized edema, dehydration, and sedation.

What are some methods of debridement?

-Sharp debridement- is the removal of necrotic nonliving tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments. This method is preferred if the wound is infected because it helps the wound heal more quickly. -Enzymatic Debridement- involves the use of topically applied chemical substances that breaks down and liquefy wound debris. A dressing is used to keep the enzyme in contact with the wound and to help absorb the drainage. -Autolytic Debridement- or self-dissolution, is a painless, natural physiologic process that allows the body's enzymes to soften, liquefy, and release devitalized tissue. It is used when a wound is small and free of infection. The main disadvantage in autolysis is the prolonged time it take to achieve desired results. -Mechanical Debridement- involves the physical removal of debris from nonhealing wounds. Some of the techniques used are maggot therapy, hydrotherapy, and irrigation.

What are uses for heat and cold application?

-Uses for Heat: Provides warmth, promotes circulation, speeds healing, relieves muscle spasm, and reduces pain. -Uses for cold: Reduces fevers, prevents swelling, controls bleeding, relieves pain, and numbs sensation.

Nursing guidelines for obtaining a stool specimen and for doing a fecal occult test

-collect stool a toilet liner or bed pan -put on gloves& use applicator stick to collect the specimen -take a sample from the center area of the stool -apply a thin smear of stool onto the test area supplied with the screening kit -cover entire test space -place 2 drops of the chemical reagent onto the test space -wait 60 seconds -observe for a blue color

Nursing guidelines for continence training?

-compile a log of clients urinary patterns -set realistic, specific short term goal with client -discourage strict limitation of liquid intake -plan trial schedule for voiding -communicate the plan to nursing personal -assist client to toilet/commode

What are the different types of urinary intubation?

-external: more effective for male PT (AKA condom cath) -straight: urine drainage tube inserted but not left in, it is for sterile specimens or output(volume measured) -retention: (AKA indwelling) left in place for a period of time

assessing ear using otoscope: how to hold?

-hold upside -thumb and fingers so that ulnar aspect makes contact w/ pt

What complications can happen with an NG tube?

-if left in for long periods of time it can start to irritate and break down he nasopharyngeal -gastric tubes dilate the esophageal sphincter (cardiac valve) causing gastric reflux, especially when the tube is used for administration of liquid formula

When preparing to measure the vitals of a pt, what should you recognize as something that would affect the methods you will use?

-if the pt is over 60lbs over weight - The pt is reporting a stuffy nose - the pt is taking digoxin (Lanoxin) - if the pt has had a mastectomy 2 yrs ago

What are the potential complications of an ileostomy?

-nutritional problems like fluid and electrolyte imbalances, and b12 imbalances -this is b/c all that is usually absorbed in the colon but now w/this it doesn't get to reach the colon and the body cant absorb it

What are the different types of digestive (GI) intubation?

-orogastric: mouth to stomach -nasogastric: nose to stomach -nasointestinal: nose to intestine -ostomy: surgically created opening

A nurse is providing teaching to a pt who is receiving intermittent nasogastric feeding. What should the nurse instruct the pt to report immediately?

-persistent coughing

What is the conclusion of H&P?

-primary diagnosis (from chief complaint and physical exam) - secondary diagnosis, reflecting stable or preexisting conditions possibly affecting patients treatments

Prior to entering the surgical-scrub area, which personal protective equipment (PPE) items do the team members don?

-protective eyewear - hair cover -mask - shoe covers

How would you assess bowel elimination? What is important to ask first?

-usual patterns, frequency, and elimination and effort required to expel stool -

What is MyPlate?

An Internet-based educational tool used to teach healthy eating and exercise habits - replaced the food pyramid in 2011

When checking for nasogastric tube placement, the nurse should conduct which procedure?

Aspirate stomach content and check the ph

Spine - Lordosis:

Convexity of curve is anterior.

safest weight loss amount per week?

1-2lbs

Steps for performing venipuncture

1. Obtain the patient requisition. Complete information including age and sex. 2. Gather supplies: Vacutainer; safety needle (dual headed needle); needle holder/adapter; vacuum tubes; non-sterile gloves; tourniquet; gauze; band-aid; and alcohol prep pads.Check to see if any of the evacuated tubes require special handling such as being kept cold or in the dark. 3. Knock on the door andidentify yourself. 4. WASH HANDS. 5. Check the ID bracelet and ask the patient to state his/her name for identification. 6. Provide privacy for the patient. 7. Explain procedure to the patient. 8. Raise bed for proper body mechanics and lower theside rail on the side where you are working. Ensure patient is in a comfortable position. 9. Apply tourniquet 3-4 inches above the antecubital fossa. 10. Palpate the veins and select the site (by feel not by site) for venipuncture: Median Cubital, Cephalic, Basilic. 11. Remove the tourniquet. (Do not leave on longer than 1 minute.) 12. Cleanse site by using an alcohol wipe in a concentric motion beginning at the insertion site. Allow to air dry. 13. Don disposable gloves (if not done earlier). 14. Reapply tourniquet and, if the site must be re-palpated, wipe your gloved finger with alcohol before retouching the site. 15. Anchor the vein by placing the thumb of the non-dominant hand 1-2 inches below the site and usingthe finger of that hand to tightly hold the skin on the back of the arm. 16. Using the dominant hand, insert the needle with the bevel up at a 15-30 degree angle into the selected vein. Don't "thread" the needle. 17. Holding the tube adapter firmly, advance the evacuated tube (against free hand only) forward until the needle has punctured the rubber stopper. 18. If more than one evacuated tube of blood is required, carefully advanced the next tube into the adapter until the vacuum is broken by the needle. 19.Carefully remove the tubes when full. 20. Gently mix any tubes with additives as soon as they are removed. 21. Remove tourniquet when blood flow is well established or on last tube. Do not leave on longer than one minute. 22. Carefully remove the last tube without dislodging the needle. 23. After the last evacuated tube is removed, place sterile gauze (or clean gauze depending on your facility's policy) gently over the site. 24. Remove the needle. Activate the safety device .25. Apply pressure to the site with the sterile gauze. Do not bend the arm. 26. Carefully dispose of the needle in a sharps container. 27. Check to determine if the patient has stopped bleeding. If so, apply a bandage. If the patient is still bleeding, apply continuous pressure to the site until bleeding has stopped. 28. Properly dispose of all trash and contaminated materials in biohazard containers.Label the tubes with: patient's name; patient's ID number; date; time of collection; phlebotomist's identificationMark requisition with: date; time; initials 30. Remove gloves and wash hands. Document the procedure: time & date; # of attempts; needle size; site; tubes collected; patient's tolerance of the procedure; and signature and title.Make sure comfort and safety needs are addressed including: elevate the side rails (if used), return bed to lowest horizontal position, leave the patient in a position of comfort and safety with the call signal and needed personal items within reach.

blood culture order of draw

1 anaerobic 2 aerobic *the yellow and black tubes * typically drawn via syringe method

Safe weight loss

1 to 2 pounds per week

Steps for obtaining a blood culture.

1. Blood cultures -usually done 2 at a time from 2 different sites, 15 minutes apart are used to detect bacteria in the blood stream (blood is usually sterile)2. Bacteria in the blood will be transported to other areas of the body spreading infection3. Proper antibiotics are used to stop spread. Must know which bacteria are in blood to be able to prescribe effective antibiotics.Steps1. Checks physician's order2. Gathers supplies (needle, syringe, transfer device, tubes, tourniquet, alcohol pad, gauze/cotton ball, bandage)3. Wash hands and put on gloves4. Identify the client both verbally and by checking the ID band5. Explains procedure6. Hyperextend client's arm on a flat surface7. Apply tourniquet 3-4 inches above site8. Selects appropriate vein9. Cleanse site using Blood Culture Prep Kit (cleanses site in a circular manner for 1 minute with alcohol, let dry, cleanse site with iodine for 30 seconds, lets dry)10. Preps tops of blood culture vials with a new iodine swab, then wipes the tops of vial with new alcohol prep immediately before using11. Attaches needle to syringe, loosens plunger in syringe to break seal12. Anchors vein without touching venipuncturesite13. Removes cap from needle and positions needle with bevel up14. Inserts needle through skin into upper wall of vein at a 30-45 degree angle15. Observe blood return in needle hub16. Gently pulls on plunger to fill syringe with blood17. Loosens tourniquet when syringe contains the correct amount of blood18. Removes tourniquet -leaves tourniquet on no more than 1 minute19. Removes needle and engages safety device Rev. 6/201612120. Applies pressure with sterile gauze over the puncture site until bleeding stops21. Dispose of the needle in a sharp container without recapping22. Attaches transfer device to syringe23. Transfers blood into anaerobic vial first, then aerobic vial24. Inverts tubes 8 times25. Labels specimens and places in biohazard bag26. Removes gloves and washes hands27. Checks site for clotting and client comfort28. Specimens sent to lab

Five Routes of Transmission

1. Contact (direct and indirect) Direct: Physical transfer form one person to another requires close association between infected and susceptible host Indirect: use of infected surgical equipment 2. Droplet: transmission via airborne droplets within 3ft Ex. sneezing, coughing, talking 3. Airborne: When pathogens attach to evaporated water particles or dust that has been suspended in the air over 3ft Ex. (inhalation of spores) 4. Common vehicle: transmission by an inanimate reservoir Ex. food, water, air 5. Vector transmission: transmission of pathogen via insect or animal

Stool specimen collection

1. Do initial steps. 2. Prepare label for specimen with appropriate information and place it on specimen container, not the lid. 3. Put on gloves 4. When resident is ready to move bowels, ask him/her not to urinate at the same time. Ask the resident not to put toilet paper with the sample. 5. Provide resident with a bedpan, assisting if needed. 6. After the bowel movement, assist as needed with perineal care. 7. Remove gloves, wash hands and put on clean gloves. 8. Using two tongue blades, take about two tablespoons full of stool and put it in the container, Try to collect material from different areas from the stool. 9. Cover the container with lid. Label as directed per facility policy and procedure and place in the plastic bag supplied by the lab for transport. Dispose the remaining stool; clean and disinfect equipment as per facility policy. Notify nurse of collection. 10. Do final steps

diaphragmatic excursion

1. Find the level of the diaphragmatic dullness on both sides. 2. Ask the patient to inspire deeply. 3. The level of dullness (diaphragmatic excursion) should go down 3-5 cm symmetrically.

What are the possible positions for Postural Drainage exercises?

1. For lower lobes, superior segments of lungs - lay in a prone position with at least 2 pillows tucked under your lower abdm 2. For lower lobes, anterior basal segment of lungs - lay on your right side in a lateral Trendelenburg position with at least 2 pillows tucked under your lower abdm area 3. For upper lobes, anterior segment of lungs - lay in a dorsal recumbent position with at least 2 pillows tucked under your bottom 4. for lower lobes, lateral basal segment of lungs - lay on your left side in a lateral Trendelenburg position with at least 2 pillows tucked under your lower abdm

Fowlers Positions

1. Fowler's - the head of the bed to be elevated 45-60 degrees 2. High Fowler's - the head of the bed is elevated to 90 degrees 3. Low Fowler's - aka semi-Fowler's - the head of the bed is elevated only to 30 degrees * in Fowler's positions the buttocks bears the main weight of the body

How much sleep is required of infants

12-15 hours

How to document head-to-toe assessment?

1. Gathered equipment and placed at patient's bedside. 2.Washed hands (donned gloves only if the patient's condition warrants) 3. Identified patient and explained procedure. 4. Obtained vital signs (results written down or recorded). Blood pressure Temperature Pulse Respiration. 5.Used head-to-toe method and explained each technique to patient before it is performed. Head and NeckAssessed pupils -used pen lightAssessed oral membranesAssessed skin of face and earsChestAuscultated heart sounds (moves to all points A, T, P, M)Auscultated Apical pulseAuscultated lungs sounds -anterior and posterior moving side to side and top to bottomAbdomenAuscultated bowel sounds in all 4 quadrantsPalpated abdomen for tenderness, masses and/or distention Rev. 6/201678ExtremitiesAssessed capillary refill -fingernailsAssessed grip strengthAssessed arm strengthAssessed capillary refill -toenailsPalpated pedal pulsesAssessed lower extremity strengthPerformance Skills Checklist (continued)6.Positioned patient for comfort.7.Gathered and cleaned equipment as needed. 8. Washed hands (disposed of gloves if used). 9. Reported findings to charge nurse.10.Documented findings appropriately and timely.

chest percussion

1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest. 2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger. 3. Categorize what you hear as normal, dull, or hyperresonant. 4. Practice your technique until you can consistently produce a "normal" percussion note on your (presumably normal) partner before you work with patients.

precordial movement

1. Position the patient supine with the head of the table slightly elevated. 2. Always examine from the patient's right side. 3. Inspect for precordial movement. Tangential lighting will make movements more visible. 4. Palpate for precordial activity in general. You may feel "extras" such as thrills or exaggerated ventricular impulses. 5. Palpate for the point of maximal impulse (PMI or apical pulse). It is normally located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter. 6. Note the location, size, and quality of the impulse.

plantar response (Babinski)

1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. 2. Note movement of the toes, normally flexion (withdrawal). 3. Extension of the big toe with fanning of the other toes is abnormal in other than a young child. This is referred to as a positive Babinski 4. Positive Babinski is normal to age 24 months.

A nurse is planning on obtaining a urinary specimen from a patients closed urinary system. What steps and in what order do you do this procedure

1. Wipe the port with an alcohol swab 2. Insert a 10mL syringe and needle into the port 3. Withdraw 5mL of urine 4. Transfer the urine to a sterile specimen container 5. Transport the specimen to the laboratory

Phalen's test (median nerve)

1. ask pt to press backs of hands together w/ wrists fully flexed (backward praying) 2. have pt hold this position for 60sec and then comment on how hands feel 3. pain, tingling, or other abnormal sensations in thumb, index, middle fingers strongly suggest carpel tunnel syndrome

assessment of motor response: muscle tone

1. ask pt to relax 2. flex and extend pt's fingers, wrist, and elbow 3. flex and extend pt's ankle and knee 4. there is normally a sm, continuous resistance to passive movement 5. observe for decreased (flaccid) or increased (rigid/spastic) tone

tactile fremitus

1. ask pt to say "ninety-nine" several times in normal voice 2. palpate using ball of hand 3. you should feel the vibrations transmitted through airways of lung 4. increased tactile fremitus suggests consolidation underlying lung tissues

neurologic examination: mental status

1. assess LOC; facial expression and body language; speech; cognition and functioning 2. assess while doing health hx

Coordination and gait: Romberg

1. be prepared to catch pt if unstable 2. ask pt to stand w/ feet together and eyes closed for 5-10 sec w/o support 3. positive if pt becomes unstable (indicating vestibular or proprioceptive prob)

assessment of motor responses: involuntary movements

1. compare muscle symmetry left to right 2. proximal vs. distal 3. atrophy 4. pay particular attention to hands, shoulders, and thighs 5. gait

opthalmoscopic exam

1. darken room 2. adjust opthalmoscope: light no brighter than necessary, aperture to plain white circle, diopter dial to zero unless a better setting is determined 3. use LT hand and LT eye to examine pt's LT eye. Use RT hand and RT eye to examine pt's RT eye. Place free hand on pt's shoulder for better control 4. ask pt to stare at point on the wall or corner of rm 5. look through opthalmoscope, shine light into pt's eye from about 2ft away. You should see retina as "red reflex". Follow red color to move w/in a few inches of pt's eye 6. adjust diopter dial to bring retina into focus. Find blood vessel and follow it to optic disk. Use this as point of reference 7. inspect outward from the optic disk in at least 4 quadrants and record abnormalities 8. move nasally from disk to observe the macula 9. repeat other eye 10. normal color should be creamy yellow-orange to pink

What are four highest priority post surgical things for the nurse to maintain/ assess

1. ensure patient airway 2. maintain adequate circulation 3. shock 4. hypoxemia (look for any complications

XI - spinal accessory: test

1. from behind, look for atrophy or asymmetry of trapezius muscles 2. ask pt to shrug shoulders against resistance 3. ask pt to turn head against resistance, watch and palpate sternomastoid muscle on opposite side

A nurse is preparing to assist a pt with a tub bath. What sequence of steps should the nurse take?

1. gather all necessary supplies 2. Place a rubber mat on the tub floor 3. assist the pt into the bathroom 4. instruct the pt on using safety bars when getting in and out of the tub 5. instruct the pt to remain in the tub no longer than 20 min

testing eye accommodation

1. hold finger about 10cm from pt's nose 2. ask them to alternate looking into distance and at your finger 3. observe the pupillary response in each eye

high normal BP

130-139/ 85-89

how much does the average infant sleep?

14-15 hours of sleep a day

organ donation

1. if a dying or deceased peson has a document identifyig an intention to donate organs or has expressly refused organ donation nex of kin or pwesonw ith power of attorney for health care need not be involved 2. if no document of intent is available, consent for organ donation on behalf of the client can be sought 3. without a signed refusal, life support may not be withdrawn until the potential for organ donation is determined, even if doing so contradicts a person's advanced directives because life support that has the potential to save lives overrides the desire to withhold or withdraw life support involving next of kin or person with power of attorney is done as a courtesy

XII - hypoglossal: test

1. listen to articulation of pt's words 2. observe tongue as it lies in mouth 3. ask pt to protrude tongue 4. move tongue from side to side

X - vagus: test

1. listen to voice--hoarse or nasally? 2. ask pt to swallow 3. ask pt to say "ahh", watch movements of soft palate and pharynx 4. ask pt to turn head against resistance, watch and palpate sternomastiod muscle on opposite side

what nursing action do you need to demonstrate when your patient verbalizes suicidal thought?

1. notify the nursing supervisor and physician 2. remove any potentially articles that can be used to commit suicide: (guns, razors, knives, scissors, and medication both prescriptions and non 3. make sure there is always someone with the patient at all times

splenic dullness

1. percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanic 2. ask pt to take deep breath and percuss area again. Dullness in this area is sign of splenic enlargement

palpation of liver: standard method

1. place fingers just below right costal margin and press firmly. 2. ask pt to take deep breath 3. you may feel edge of liver press against fingers. Or it may slide under your as the pt exhales. Normal liver is NOT tender 4. usual location is about 1-2cm below rt costal margin

deep tendon reflexes

1. pt must relaxed and positioned properly before starting 2. reflex response depends of force of stimulus, use no more force than needed to produce definite response 3. reflexes can be reinforced by having pt perform isometric contraction of other muscles (clenched teeth) 4. exaggerated hyperactive reflexes in a pregnant woman may be related to pre-eclampsia 5. reflexes should be graded on 0-4 "plus" scale

VII - facial: test

1. sense of taste not usually tested unless specific concerns 2. observe for facial droop of assymetry: - ask pt to do following, note lag, weakness, or assymetry: - raise eyebrows - close both eyes to resistance - smile - frown - show teeth - puff out cheeks 3. test for corneal reflexes (CN V)

assessing visual fields

1. stand 2ft in front of pt and have them look into your eyes 2. hold your hands to the side half way between you and pt 3. wiggle fingers on one hand 4. ask pt to indicate which side they see your fingers move 5. repeat 2 or 3x to test both temporal fields 6. if an abnormality is suspected, test 4 quadrants of each eye while asking pt to cover the opposite eye w/ card

extraocular movement (EOM) assessment

1. stand or sit 3-6ft in front of pt 2. ask pt to follow finger w/ eyes w/o moving head 3. check gaze in 6 cardinal directions, cross or 'H' pattern 4. check convergence by moving your finger toward the bridge of pt's nose 5. pause during upward and lateral gaze to check for nystagmus 6. Test CN 3, 4, 6

testicular self-exam

1. start age 15 2. remember: TSE - timing: 1x/mo - shower: warm water - examine: should be no lumps ***men should perform BSE, but are less likely to have routine mammograms

Tinel's sign (median nerve)

1. use your middle finger or a reflex hammer or tap over the carpal tunnel 2. pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome

When suctioning the airway, suction should never be applied for longer than ___ seconds.

10 - 15 seconds

Bath Water temperatures

105 - 110*F

how many hours of sleep should children 5-6 yrs old get on average a night ?

11 hrs a night

How much sleep is required of toddlers

11-14 hours

how much sleep should a toddler get a day?

12 hours of sleep a night plus 1-2 naps during the day

Spine - Kyphosis

Convexity of curve is posterior.

mild HTN BP

140-159/ 90-99

how much sleep does a newborn baby need?

16-20 hours of sleep a day

moderate HTN BP

160-179/ 100-109

What is the national age for informed consent?

18, 16 if emancipated

severe HTN BP

180-209/ 110-119

Recommended Daily calories for a healthy female

1800-2400 cal / day

what is the recommended daily caloric intake

1800-3000

light palpation

1cm

light palpation

1cm ceep

tachycardia

>100 tachy is normal response to stress

crisis HTN BP

>210/ >120

Cholesterol DV

200 mg/dL

Recommended Daily calories for a healthy male

2400 - 3000 cal/ day

At what speed does the paper that records the ECG tracing more through the machine?

25mm/sec

pulse oximetry

A way for periodically or constantly monitoring the oxygen saturation of blood - its a simple noninvasive way * the sensor can attach to a finger, toe, ear lobe, or the bridge of a person's nose*

deep palpation

5-8cm

deep palpation

5-8cm or 2-3in

at what age is a person considered an older adult?

65

patients room temperature should be kept at

68 to 74 degrees

How much sleep is required of older adults?

7-8 hours

How much sleep is required of middle aged adults

7-9 hours

How much sleep is required of older adults?

7-9 hours

A nurse administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older adult pt who has hyperkalemia. The nurse should insert the tip of the rectal tube...

7.5cm to 10 cm (3-4in)

What is the average amount of sleep your average preschooler should get a night?

9 - 12 hours a night

how many hours of sleep a night should an 11yr old get?

9 hrs a night

What internal of time should the nurse allow to avoid interrupting a sleeping client's full cycle of NREM and REM sleep?

90 - 120 minutes

What is a good pulse ox reading?

95%- 100%

normal BP

<130/ <85

bradycardia

<60 athletes are often brady

WHAT TYPE OF TUBE IS USED WHEN OBTAINING A FDP

A 2 mL tube containing a special enzyme inhibitor plus thrombin

What is Healthy People 2020?

A NATIONAL agenda that communicates a vision for improving health and achieving health equity. AND A set of specific measurable objectives with targets to be achieved over the decade.

Nasal cannula

A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.

advanced directive (living will)

A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes.

define hypnogogic hallucination

A dream like auditory or visual expierences while dozing or falling asleep

Exudate

A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues.

Deep Breathing

A form of controlled ventilation that opens and fills the small air passages in the lungs - inhaling deeply using abdomen muscles - holding the breath for a few seconds - exhaling slowly * good for clients who recieved general anesthesia * clients who breathe shallow after surgery from pain * reduces post-op risk of respiratory complications

Malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.

throat culture

A laboratory diagnostic test to find a bacterial or fungal infection in the throat. Sampling is performed by throat swab, and the sample is put in a special cup (culture) that allows infections to grow. If an infection grows, the culture is positive. The type of infection is found using a microscope, chemical tests, or both. If no infection grows, the culture is negative.

scar

A mark on the skin that is left after a cut or other wound has healed.

Multiple Sleep Latency Test (MSLT)

A measure of daytime sleepiness the pt is hooked up to a polysmnography, they nap for 20 min abot 5 times in 2hour intervals - the test is looking for how fast or slow they fall asleep each time or how fast REM sleep starts

How do you assess pt neurological status?

A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.

The Referral Process

A referral is process of sending someone to another person or agency for special services Referrals generally are made to private practitioners or community agencies

General Safety

A safety inspection of an operation's facility, equipment, employee practices, and management practices is called a(n) ___________________ audit.

define cataplexy

A sudden loss of muscles tone triggered by an emotional change such as laughing or anger

What is a colostomy?

A surgically created opening of the colon out onto the abdomen wall.

laceration

A torn, jagged wound or an accidental cut wound.

When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready?

A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively.

Cholesterol

A type of fat made by the body from saturated fat; a minor part of fat in foods.

what vitamins are fat soluble?

A,D,E & K are stored in the body as reserves for future needs ADEK are fat soluble vitamins Too much fat soluble can accumulate and become toxic

Yellow specimen tubes

ACD or SPS (sodium polyanethol sulfonate) anticoagulants that prevent clotting by binding with calcium Tests: blood cultures

Fat Soluble Vitamins

ADEK

Fat-soluble vitamins

ADEK are stored in the body as reserves for future needs

What is external cath?

AKA condom cath which is device applied to the skin that collects urine, it surrounds the penis instead of being inserted into the bladder

What are retention caths?

AKA indwelling cath that is left in place for a period of time, foly cath

retention cath?

AKA indwelling cath, and is left in place for a period of time

What would you teach a patient about treating lice?

AKA pediculosis brown crawling insects that move over the scalp and skin and deposits yellowish white eggs on hair shafts including pubic area, skin bites cause itching and to treat it need to inspect skin carefully as adult live move quickly from light, look for eggs(nits) on hairs, 1/4 in to 1/2 in from the scalp or skin surface, DO NOT share clothing, combs, and brushes and it is spread by direct contact. Use a pediculicide in addition to lice comb

Steps in specimen collection

CHECK ORDER WASH HANDS ID PT IN 2 WAYS***(MOST IMPORTANT) EXPLAIN PROCEDURE

TYPES OF COLD APPLICATION

COLD COMPRESSES COLD SOAKS ICE BAG OR COLLAR HYPOTHERMIA BLANKET

Nursing guidelines for helping dying patients cope.

Accept the clients behavior no matter what it is, provide opportunities for the client to express feelings freely, try to understand the clients feelings, use statements w/ broad openings

___________ is an attitude of complacency that occurs after clients have dealt with their losses and completed unfinished business.

Acceptance

Potential nursing diagnoses for pressure ulcer?

Acute pain Impaired skin and tissue integrity Ineffective tissue perfusion Risk for infection

What is the key to wound healing?

Adequate blood flow to the injured tissue

Key to wound healing

Adequate blood flow to the injured tissue (cirulation)

Define: Drug tolerance

Adiminished effects from the drug at its usual dosage range

How is hypoxia treated?

Administering O₂ and correcting the cause.

WHAT TUBES MAY BE USED WHEN COLLECTING BLOOD CULTURES?

Aerobic and/or anaerobic culture media Black isolator Yellow

BIOLOGICAL CONDITIONS, WHICH MAY AFFECT THE RESULTS OF BLOOD TESTING

Age Sex Race Pregnancy

EFFECTS OF AGING Skeletal system

Aging causes changes in the texture, calcification, and shape of bones Bone spurs develop around joints Bones become porous and fracture easily Degenerative joint diseases such as osteoarthritis are common

WHEN WOULD A LPN/PHLEBOTOMIST WHERE A MASK?

Airborne Tuberculosis Measles (rubeola) Droplet Influenza Rubella Streptococcal pneumonia Meningococcal meningitis

What 6 things are monitored in the PACU?

Airway: breathing appropriately? Labored? Why? Mental Status: what is it? Is it appropriate? Surgical incision: bleeding? Look at it q15min. VS: Temp/Pulse/BP IV Fluids: solution type, amount in bag, rate Other Tubes/Drains: Foley, NG, trach, chest

EFFECTS OF AGING Special senses

All sense organs show a gradual decline in performance with age Eye lenses become hard and cannot accommodate for near vision; result is farsightedness in many people by age 45 (presbyopia, or "old eye") Loss of transparency of lens or cornea is common (cataract) Glaucoma (increase in pressure in eyeball) is often the cause of blindness in older adulthood Loss of hair cells in inner ear produces frequency deafness in many older people Decreased transmission of sound waves caused by loss of elasticity of eardrum and fixing of the bony ear ossicles is common in older adulthood Some degree of hearing impairment is universally present in the aged Only about 40% of the taste buds present at age 30 remain at age 75

What are proteins made up of?

Amino acids. Essential and non-essential amino acids.

describe a regular diet

Allows unrestricted food selections

Aquathermia Pad

Also called a K-pad Electrical heating or cooling device Resembles a mat, contains hollow chambers through which distilled water circulates Can be used on single body part or warm/cool entire body

Describe the nurse's initial assessment of the situation if artifact is present.

Always assess the patient first and then the leads

What should be the nurse's initial assessment be if the situation of artifacts is present during an ECG?

Always assess the patient first then the leads

Proper process for safeguarding patient's valuables

Always observe your agency policy first if a patient's family member cannot take home valuables then depending on your facility you could place valuables in a locker or agency's safe - always make note in the patient's chart - make a descriptive inventory and have yourself and the patient sign - make a copy of the inventory for the patient and attach the other copy to the patients chart and if there is ever any kind of change made to that inventory you need to make sure it is updated and that your patient and yourself sign it

How can aspirin affect bleeding time?

Drugs that prolong bleeding time- extends the bleeding time - blood thinners

- Culture

An incubation of microorganisms

Who is responsible for accompanying pt and providing report to PACU nurses? And what must they provide?

Anesthesiologist and circulating nurse Must provide a "Hand-Off Report" which allows for 2-way verbal communications, information must be clear & standardized (SBAR), and provides for clarification of information about patient.

Psychosocial Responses to Admission

Anxiety and fear Decisional conflict Situational low self-esteem Powerlessness Social isolation Risk for ineffective therapeutic regimen management

What are three (3) common causes of patient movement during ECG's?

Anxiety, cold, talking, restless

What can be cultured?

Any body fluid or substance suspected of containing infectious microorganisms

CLERICAL DISCREPANCY REQUIRING REDRAW OF SPECIMEN

Any discrepancy in labeling blood that will be used for a blood transfusion

WHERE ARE THE SPECIMEN LABELS APPLIED?

Apply labels at the bedside

WHEN IS PRESSURE APPLIED TO THE SITE?

Apply pressure with gauze after the needle is withdrawn

define parasomnia

Are conditions associated with activities that cause arousal or partial arousal, usually during transitions in NREM sleep

WHAT SOURCE IS PRIMARY MEANS TO LABEL THE SPECIMEN?

Armband

Where do you get this info for venipuncture?

Armband primary source of information

WHAT DRUG MAY AFFECT A CLIENT'S CLOTTING TIME?

Aspirin

PERIPHERAL BLOOD SMEARS Why done?

Assess and diagnose abnormal RBC morphology Diagnose anemia Count the variety and proportion of WBCs Method Wedge

SAFETY ASSESSMENT of hot/cold application

Assess temperature of application Frequently monitor condition of skin Avoid contact between skin and heating/cooling device Used cautiously in children younger than 2, older adults, diabetics, and those comatose/neurologically impaired

WHY IS A BLEEDING TIME TEST ADMINISTERED. WHAT DOES A PROLONGED BLEEDING TIME INDICATE?

Assesses the function of platelets Indicates decreased or non-functioning platelets

What role would he LPN have?

Assist with cleaning and maintaining pressure; Observe the reaction of the client to the puncture, including comments, and nonverbal communication.

Admission involves:

Authorization from physician that person requires specialized care and treatment Collection of billing information by admitting department of health care agency Completion of agency's admission data base by nursing personnel Documentation of client's medical history and findings from physical examination Development of initial nursing care plan Initial medical orders for treatment Medical authorization The admitting department Preliminary data collected I.D. Bracelet Addressograph plate Initial nursing plan for care Medical admission responsibilities

LIST VACCINES, WHICH ARE AVAILABLE AND UNAVAILABLE.

Available OPV Hepatitis B Hepatitis A MMR Unavailable HIV/AIDS

what are the hours or sleep required on average for an adolescent, Adult, and older adult and what average REM should each get a night?

Ave 7-9 hours of sleep a night adolescent should get 25% REM adult should get 20 -25% REM older adult should get 13-15% REM

Lateral

Away from the midline of the body

Water-soluble vitamins

B + C Compelx Eliminated daily with body fluids so need daily replacement

Water Soluble Vitamins

B Complex and C

What are the water soluble vitamins?

B complex and C are eliminated with body fluids and so require daily replacement

a feeding that is the least desirable enteral feeding schedule because it distends the stomach rapidly, cause gastric discomfort

BOLUS

Describe steps for administrating a tube feeding.

BOLUS FEEDING Assessment 1. Check the medical order for the type of nourishment, volume, and schedule to follow.2. Check the date and identifying information on the container of tube-feeding formula.3. Wash your hands or perform an alcohol-based hand rub.4. Identify the client.5. Distinguish the tubing for gastric orintestinal feeding from tubing to instill intravenous solutions.6. Assess bowel sounds.7. Measure gastric residual if a 12 F or larger tube is in place.8. Measure capillary blood glucose or glucosein the urine.9. Assess how much the client understands the procedure.Planning1. Replace any unused formula every24 hours.2. Wait and recheck gastric residual in30 minutes if it exceeds 100 mL.3. Assemble the following equipment: Asepto syringe, formula, tap water.4. Warm refrigerated nourishment to room temperature in a basin of warm water.Implementation1. Perform hand hygiene.2. Place the client in a 30-to 90-degree sitting position.3. Re feed gastric residual by gravity flow.4. Pinch the tube just before all the residual has instilled.5. Add fresh formula to the syringe and adjust the height to allow a slow but gradual instillation.6. Continue filling the syringe before it becomes empty. Rev. 6/2016627. If a gastrostomy tube is being used, tilt the barrel of the syringe during the feeding.8. Flush the tubing with at least 30 to 60 mLof water after each feeding, or follow agency policy for suggested amounts.9. Plug or clamp the tube as the water leaves the syringe.10. Keep the head of the bed elevated for at least 30 to 60 minutes after a feeding.11. Wash and dry the feeding equipment.Return items to the bedside.12. Record the volume of formula and water administered on the bedside intake and output record.13. Provide oral hygiene at least twice daily.INTERMITTENT FEEDINGAssessment1. Follow the previous sequence for assessment.Planning1. In addition to those activities listed for bolus feeding, replace unused formula, feeding containers, and tubing every 24 hours.Implementation1. Fill the feeding container with room-temperature formula.2. Gradually open the clamp on the tubing.3. Connect the tubing to the nasogastric ornasoenteral tube.4. Open the clamp and regulate the drip rate according to the physician's order or agency policy.5. Check at 10-minute intervals.6. Flush the tubing with water after the formula has infused.7. Pinch the feeding tube just as the last volume of water is administered.8. Clamp or plug the feeding tube.9. Record the volume of formula and water instilled.10. Follow recommendations for post procedural care as described with bolus feeding.CONTINUOUS FEEDINGAssessment1. In addition to previously described assessments, check the gastric residual every 4 hours.Planning Rev. 6/2016631. In addition to previously described planning activities, obtain equipment for regulating continuous infusion (e.g., tube-feeding pump).2. Replace unused formula, feeding containers, and tubing every 24 hours.3. Attach a time tape to a feeding container.Implementation1. Flush the new feeding container with water.2. Fill the feeding container with no more than 4 hours' worth of refrigerated formula.Exception: Commercially prepared, sterilized containers of formula, or formula that is kept iced while infusing may hang for longer periods.3. Purge the tubing of air.4. Thread the tubing within the feeding pump according to the manufacturer's directions.5. Connect the tubing from the feeding pump to the client's feeding tube.6. Set the prescribed rate on the feeding pump.7. Open the clamp on the feeding tube and start the pump.8. Keep the client's head elevated at all times.9. Flush the tubing with 30 to 60 mL of water or more every 4 hours after checking and re feeding gastric residual and after administering medications.10. Record the instilled volume of formula and water.11. Follow recommendations for post procedural care as described with bolus feeding.Document1. Volume of gastric residual and actions taken if excessive2. Type and volume of formula3. Rate of infusion, if continuous4. Volume of water used for flushes5. Response of client; if symptomatic, describe actions taken and results

Chronic purging eventually weakens __________ __________.

BOWEL TONE

SCREENING OF BLOOD DONORS

BP Temperature Hgb Hct Weight Pulse Lesions General appearance

where do we get potassium

Banana's, potatoes, oranges

What are possible nursing diagnoses for a patient needing assistance with bathing and hygiene?

Bathing self care deficit, dressing self care deficit, activity intolerance, readiness for enhanced self care, self neglect, and risk for impoured skin integrity

When taking a pt's blood pressure, why is it important to notice pressure on the manometer when you hear the 4th Korotkoff sound or phase?

Bc you might not hear the 5th sound

What kind of pt would benefit from purse lip breathing exercise?

COPD PTs *kinds of COPD* - emphysema - chronic bronchitis - asthma - lung cancer - cystic fibrosis - sinusitis

When is the preoperative period?

Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite/operating room/procedure bed: time when you prepare the patient for surgery both physically and psychologically preoperative clearance is given informed consent is obtained preoperative teaching is done preop check list is done

Resolution of grief

Begins when the grieving person can complete the following tasks: have positive interactions, participate in support groups, establish goals and work to achieve them, discuss the meaning of the loss and its effect

examples of sedatives and hypnotics

Benzodiazepines nonbenzodiazepines antihistamines tricyclic antidepressants selective serotonin re up take inhibitors antidepressants antianxiety

DESCRIBE HOW THE NEEDLE IS INSERTED INTO THE SKIN

Bevel up at a 30-45 degree angle

WHAT FLUIDS DOES THE CDC CONSIDER INFECTIOUS FOR BLOOD BORNE PATHOGENS?

Blood Blood products Amniotic fluid Semen Tears are not considered infectious

LIST THE ORDER OF DRAW USING VACUUM TUBES

Blood cultures: black isolator, yellow, or culture media tubes Aerobic then anaerobic tube Red/Gold/Tiger Blue Green Grey Lavender (always Last)

BMI

Body mass index gives a numeric data to compare a person's size in relation to the norm

_________ become porous and fracture easily

Bones

Abdomen assessment

Bowel sounds: hyperactive, hypoactive, absent Abdominal girth measurement Genitalia

What foods or drinks interfere with sleep?

Caffeine: tea, coffee, most sodas

Green specimen tubes

Contains: Sodium Heparin ad lithium heparin, coagulants that prevents clotting by inactivating thrombin and thromboplastin Tests: Ammonia / HLA/ chromosome studies

EFFECTS OF AGING Respiratory system

Calcification of costal cartilages causes rib cage to remain in expanded position—barrel chest Wasting of respiratory muscles decreases respiratory efficiency Respiratory membrane thickens; movement of oxygen from alveoli to blood is slowed

extremities assessment

Capillary refill Muscle strength Fingernails and toenails Edema: measurement Skin sensation

Perioperative

Care that clients receive before, during and after surgery

What is the clouding of the lens called?

Cataract- if the lens becomes cloudy and significantly impairs vision and must be removed surgically.

nursing guidelines for helping a patient overcome simple anorexia

Cater to client's food preferences Serve nutrient-dense foods loaded with calories Offer small servings of food frequently Ensure the client rests before meals Provide an opportunity for oral hygiene before meals Help the client to a sitting position Arrange for the client to eat with others, because eating is a social activity Serve food attractively Suggest adding spices and herbs to food, to intensify flavors and aromas Serve foods at their appropriate temperature Serve cool, bland foods to client with a mouth irritation

What can cause a patient to faint (syncope)?

Caused by fatigue, a sudden decrease in blood vol., cardiac arrhythmia, hypoglycemia, hyperventilation, and psychological causes.

light blue specimen tubes

Contains: Sodium citrate an anticoagulant that prevents clotting by binding with calcium Tests: PT (prothrombin time) / PTT (partial thromboplastin time)

How can pressure ulcers be prevented?

Change client's position frequently Avoid using plastic-covered pillows Use the lateral position for side-lying Massage bony prominences Use pressure-relieving devices Provide a balanced diet and adequate fluid intake

what are other forms of communication

Change of shift reports Client assignments Team conferences Rounds Telephone calls

if interference from the electrical supply is a possible problem, what action should be taken?

Change power supply and check for connection problems

OR Time-Out

Check list before starting surgery to ensure the consent was signed, right PT, right surgery right site, etc

STEPS IN COLLECTION OF A SPECIMEN

Check order Wash hands and glove ID client 2 ways*** Most important step Explain procedure

what to check before bolus?

Check placement, check residual, high fowlers, a little water before and after to flush tubbing.

A nurse is assessing a patient's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. What action should the nurse do first?

Check the catheter for kinks

WHAT SHOULD THE NURSE DO IF THE CLIENT IS NOT IN THE ROOM AND HE/SHE NEEDS TO DRAW BLOOD?

Check with nurses Draw blood in new room Note why on requisition Inform nurse/charge nurse

Transduction

Chemical information in the cellular environment is converted to electrical impulses that move toward the spinal cord; release of chemical mediators Chemicals that are released by the damaged cells stimulate nociceptors Impulses transmitted by the fast pain pathway; person withdraws from the pain-provoking stimulus

Who qualifies for Home Health Care?

Chronically ill older adults in population in need of assistance; outcome of limitations imposed by Medicare and insurance companies on the number of hospital and nursing home days for which they reimburse care.

Nursing Responsibilities

Clarifying explanations Preparing clients Obtaining equipment and supplies Arranging the examination area Positioning and draping Assisting the examiner Providing physical and emotional support Attending to the client Caring for specimens Recording and reporting data

How do you prepare the skin for lead placement?

Clean and roughen with alcohol to remove oils

WHAT IS USUALLY PUT ON THE LABEL?

Client name Room number ID number Date Time Nurse's initials

Workplace Applications

Client names on charts no longer visible to public All clipboards must obscure private client data, including name Whiteboards cannot link client name with diagnosis, procedure, or treatment Computer screens not visible to public; flat screen monitors recommended Conversations regarding clients must occur in private places Fax machines and medical records must be limited to areas inaccessible to public Cover sheet on all faxes; emails warning that confidential information being transmitted Light boxes (for x-ray, scan results) must be located in private areas Documentation must be kept on all with access to client records

anus and rectum assessment

Client positioning; trauma; hemorrhoids

WHAT INFORMATION DOES A LAB SPECIMEN MANUAL PROVIDE THE NURSE?

Client prep Timing Labeling Pediatric Log - monitoring the amount drawn and number of time lab is collected on pediatric clients

Purpose of Surgical Consent

Client understands procedural risks and benefits Family member or guardian may sign consent form; Agency policies In emergency may operate without consent

Pain Assessment

Client's description of pain onset, quality, intensity, location, and duration Assessment for accompanying symptoms Should be treated as the fifth vital sign Assessment biases Client: Only reliable source for quantifying pain Nurses: Not consistent in responding to the client's description of pain intensity. Pain undertreated if the client's expressions are incongruent with the nurse's expectations Assessment Tools Numeric scale, word scale, and linear scale Wong-Baker FACES scale: Best for pediatric, culturally diverse, and mentally challenged clients

What does palliative care and hospice care provide?

Clients to live their final days in comfort, w/ dignity and ina caring environment

fall risks and prevention

Cognition, balance, gait, mobility, vision, peripheral neuropathy, awareness, medications. Toddlers, elderly most at risk. Bed to lowest point, only 2 guardrails left up, non-slip socks, remove throw rugs, remove clutter, orient to room, make sure patient knows how to use canes/walkers/crutches, call light within reach, prepare a fall assessment, clean, dry floors

Why is cold usually applied first to a painful injury

Cold usually applied first to a painful injury to eases pain by numbering the affected area; reduces swelling and inflammation; and reduces bleeding.

Gray specimen tubes

Contains: Sodium Fluoride, potassium oxalate sodium lithium, anticoagulants that prevents clotting by binding with calcium Tests: Glucose and insulin

DUTIES OF A LPN/PHLEBOTOMIST

Collect specimens Collect donor blood Therapeutic phlebotomies for Polycythemia Vera or Myasthenia Gravis Prepare specimens Interacting and communication Listener Empathizer

What is the major goal for care of the dying patient?

Comfort

What promotes sleep?

Comfort and Rest

Common Community Services that people are reffered to

Commission of Aging Hospice Visiting Nurses Association Meals on Wheels Homemaker Services Home Health aides Adult Protective Services Respite care Older Americans' Ombudsman

CBC (lavender tube)

Complete Blood Count

Depolarization causes the heart muscle to ___________

Contract

describe a clear liquid diet

Consists of items that may be colored but are generally transparent and do not include any pulp or bits of food. Examples, water, broth, flavored gelatin, popsicles, clear soft drinks, tea, and coffee.

Sterilization

Consists of physical and chemical techniques that destroy all microorganisms including spores

DESCRIBE MICRO-CAPILLARY TUBES

Contain about .5 mL of blood Different types of tubes contain the same anticoagulants as the larger tubes Lavender Red (amber)

LAVENDER/PURPLE STOPPER TUBES

Contain the anticoagulant - EDTA Prevents clotting by binding with Calcium Common tests CBC WBC Platelets

YELLOW STOPPER TUBES

Contain what anticoagulant - ACD or SPS Prevents clotting by binding with calcium Common tests Blood cultures

BLUE STOPPER TUBES

Contain what anticoagulant - Na Citrate Prevents clotting by binding with Calcium Common tests PTT PT

GRAY STOPPER TUBES

Contain what anticoagulant - Na Fluoride or Na Lithium and potassium oxalate Prevents clotting by binding with calcium Common tests Glucose level Insulin level

GREEN STOPPER TUBES

Contain what anticoagulant - Na Heparin or Lithium Heparin Prevents clotting by by inactivating thrombin and thromboplastin Common tests Ammonia HLA Chromosome studies

TIGER/GOLD STOPPER TUBES

Contain what anticoagulant - None, but contain a clot activator and serum separator Encourages clotting and the serum separator settles between the clot and the plasma Common tests Blood chemistries (BMP- basic metabolic profile)

describe a soft diet

Contains foods soft in texture, is usually low in residue and readily digestible, contains few or no spices or condiments, provides fewer fruits, vegetables, or meats than a light diet.

describe a full liquid diet

Contains fruit and vegetable juices, creamed or blended soups, milk, ice cream, yogurt, pudding, milkshakes, gelatin, junket, custards, and cooked cereal.

RED STOPPER TUBES

Contains what anticoagulant - None Allows clotting to occur Common tests Type and Screen/Crossmatch Drug levels Serum enzymes

Lavender blood specimen tubes

Contains: EDTA an anticoagulant that prevents clotting by binding with calcium Tests: CBC (complete blood count) / WBC (white blood cell differential) / platelets

Signs and symptoms of aspiration

Coughing, gagging, or choking during mealtimes and immediately afterward Rapid breathing, fatigue, or bubbly respirations during and immediately after meals Intermittent elevated temperatures Vomiting small amounts after meals and at night (spitting up) Needing to take multiple swallows to clear food from the mouth Drooling or having food fall out of the mouth Eating or drinking rapidly and stuffing food in the mouth Appearing fearful and reluctant to eat Unexplained weight loss or being underweight

Adventitious lung sounds AKA abnormal

Crackles Gurgles Wheezes Rubs

WHAT ORDER ARE VACUUM TUBES FILLED WHEN USING A SYRINGE?

Culture tubes - Black isolator, yellow or culture media Anaerobic then aerobic Blue Green Grey Lavender Red/Gold/Tiger

FACTORS AFFECTING TOLERABILITY to sitz bath

DURATION OF APPLICATION BODY PART RECEIVING APPLICATION DAMAGE TO SKIN PRIOR SKIN TEMPERATURE BODY SURFACE AREA REQUIRING APPLICATION AGE PHYSICAL CONDITION LOC

daily value

DV based on a 2,000 calorie diet

Neuropathic Pain

Damaged Pain pathways in peripheral nerves Pain processing centers in the brain Cause of nerve damage: Drugs or radiation used to treat cancerous tumor Acute Pain Discomfort that has a short duration Tissue trauma Physical and emotional distress

What factors promote sleep?

Darkness, Dim Light, consistent sleep schedule, secretion of melatonin, familiar environment, warmth and ventilation, sleep rituals, sedatives, depression, relaxation, satiation, comfort, quiet, etc

When assessing a sleeping client what observation would suggest that the client is in REM Sleep?

Darting movement beneath the eyelids

What action should the nurse take when removing a patients indwelling urinary catheter first?

Deflate the balloon completely before removal

EFFECTS OF AGING Cardiovascular system

Degenerative heart and blood vessel disease is among the most common and serious effects of aging Fat deposits in blood vessels (atherosclerosis) decrease blood flow to the heart and may cause complete blockage of the coronary arteries Hardening of arteries (arteriosclerosis) may result in rupture of blood vessels, especially in the brain (stroke) Hypertension or high blood pressure is common in older adulthood

The separation of wound edges

Dehiscence

True or False? Dreaming occurs in NREM of sleep

False

5 stages of death (Dr Kubler-Ross 1969)

Denial = speculataing diagnosis or flat out doesn't believe anger = shows missplaced anger/mad about everything barganing = a want to extend their lives as much as possible depression = sad all the time, crying, sleeping acceptance = reading for death

What are the 5 stages of death and dying according to Dr. Elizabeth Kubler-Ross?

Denial, Anger, Bargaining, Depression, Acceptance

Describe each stage and how a patient might behave.

Denial- A person refuses to believe certain info Anger- Emotional response to feeling victimized. No way to retaliate fate Bargaining- Delaying the inevitable involves a process of negotiation Depression- Indicates the realization that death will come sooner rather than later Acceptance- occurs after clients have dealt w/ their losses and completed unfinished business

How would you collect a culture?

Depending on the kind of culture. Use sterile technique - collect your supplies - wash hands and put on gloves - either swab, strain, smear, aspirate with syringe or pour into a cup the specimens collected from the pt

Each full beat of the heart represents transmission of an electrical impulse through the heart muscle. What is this process called?

Depolarization

Extent of Surgery, Radical:

Description: Extensive surgery beyond the area obviously involved; is directed at finding a root cause. Condition of Surgical Procedure: Radical prostatectomy, radical hysterectomy.

Extent of Surgery, Simple:

Description: Only the most overtly affected areas involved in the surgery. Condition of Surgical Procedure: Simple/partial mastectomy.

Degree of Risk of Surgery, Major:

Description: Procedure of greater risk; usually longer and more extensive than a minor procedure. Condition of Surgical Procedure: Mitral valve replacement, pancreas transplant, lymph node dissection.

Degree of Risk of Surgery, Minor:

Description: Procedure without significant risk; often done with local anesthesia. Condition of Surgical Procedure: Incision and drainage (I&D), implantation of a venous access device (VAD), muscle biopsy.

Extent of Surgery, Minimally Invasive Surgery (MIS):

Description: Surgery performed in a body cavity or body area through one or more endoscopes; can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast-growing and ever-changing type of surgery. Condition of Surgical Procedure: Arthroscopy, tubal ligation, hysterectomy, lung lobectomy, coronary artery bypass, cholecystectomy.

How do you assesses pt orientation?

Determine if the person is "awake, alert, and oriented, times three (to person, place, and time)." This is frequently abbreviated AAOx3 which also serves as a mnemonic. The assessment involves asking the patient to repeat his own full name, his present location, and today's date

nocturnal polysomnography

Diagnostic assesment, monitoring the client for an entire nights sleep to get physiologic data Records: brain waves, eye movements, muscle tone, limb movement, body posistion, nasal and oral air flow, chest and abdm effort, snoring sounds, O2 levels in blood

PHYSIOLOGICAL CONDITIONS THAT CAUSE A VARIATION IN THE BASAL STATE

Diet Exercise (moderate to strenuous) Stress Trauma Change in posture Time of day

HOW CAN THE NURSE TELL IF HE/SHE IS IN THE VEIN?

Direct draw - push on vacuum tube and blood appears into tube Syringe or butterfly - blood will return into the hub of the needle

The Discharge Process

Discharge is termination of care from a health care agency Discharge planning Special considerations related to discharge planning Obtaining written medical order Completing discharge instructions Notifying business office Helping client leave the agency Writing summary of client's condition at discharge Requesting room be cleaned

Chronic Pain

Discomfort that lasts longer than six months Longer pain periods: More far-reaching effects on the sufferer Negative reactions of others to chronic pain sufferer

cutaneous pain

Discomfort that originates at the skin level, is commonly experienced sensation resulting from some form of trauma.

How are needles disposed of?

Dispose of the needle in a sharp container

NURSING ACTIONS IF CLIENT HAS SEIZURE/SYNCOPE WHEN BLOOD IS BEING DRAWN

Don't let harm self Remove needle and tourniquet Remove harmful objects Protect the client's head Call for help Stay with client Notify physician

Visualize ear canal of a child

Down and back

What is the purpose of a wound drain?

Drains- are tubes that provide a means for removing blood and drainage from a wound.

What does preoperative teaching entail?

Education, expectations, safety issues, food/fluid restrictions, recovery period Example: where will family be during surgery, what will they have to do for you post-surgery, realistic amount of pain, what patient can do to recover (ambulation is VERY important)

What developmental stage is the older adult in Erikson's?

Ego vs Integrity

at what developmental stage is the older adult?

Egointegrity

What does the 12 Lead ECG record?

Electrical activity of the heart

What does the 12-Lead ECG record?

Electrical activity of the heart

dying with dignity

Ending one's life in a way that is true to one's preferences and controlling end-of-life care.

True or False? Hospice care is not provided in a client's home.

False

How do you prepare the patient prior to the procedure?

Ensure the patient is warm and relaxed, shave electrode site before cleaning if excessive hair is present, normal skin-wipe with soap and water, then dry, Oily skin-wipe with alcohol, then dry

admission

Entering health care agency for nursing care and medical &/or surgical treatment

Steps to performing an EKG - what each lead is reading

Equipment/Supplies: ECG machine; Skin prep supplies (according to hospital or clinic policy and procedure); Paper; and ElectrodesProcedure1.Checked physician's orders for procedure.2.Checked assessment data and client history for any contraindications for procedure.3.Identified client and explained procedure.4.Assessed client for need for additional skin preparation.5.Gathered equipment, supplies and appropriate client information and placed at client's side.6.Washed hands.7.Provided privacy, placed client in supine position and prepared skin for electrode placement. Headmay be up at a low angle.8.Placed electrodes correctly on client and attached lead wires correctly.9.Entered appropriate client data into ECG machine if applicable.10.Set machine and recorded ECG.Multi-channel or single channel ECG11.If single channel ECG machine, recorded appropriate client information/ data on recording.12.Removed electrodes and cleaned and dried skin. Disposed of electrodes in proper receptacle.13.Assisted client to comfortable position.14.Washed hands.15.Removed equipment and documented procedure.16.Placed copy in chart or sent to appropriate department for physician interpretation

Eructation

Eructation: belching/burping

Wound Separation with the protrusion of organs

Evisceration

Common vehicle: transmission by an inanimate reservoir

Ex. food, water, air

inspection

Examining particular body parts Looking for specific normal and abnormal characteristics Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques

How does daytime activity or exercise affect sleep?

Exercises increases fatigue and the need for sleep.

What is the physicians role in informed consent ?

Explaining the procedure. Ensure correct understanding and all risks involved. Describing alternate treatments. Reinforcing that the client has right of refusal.

pallor

Extreme or unnatural paleness caused by anemia, blood loss

T or F Trans fats are saturated fats that have been altered to be solid at room temperature

F

T or F body mass index (BMI) is calculated

F

An advantage of the nasointestinal tube that becomes obstructed easily.

False

Is diabetes mellitus a common disorder associated with dysuria?

False

True or False? It is advisable to start chronic insomnia treatment with hypnotic drugs instead of any nonpharmacologic interventions

False

True or False? The upper shelf of bedside stand should be used to store, bedpan, urinal, and toilet paper

False

True or False? There is a normal time period for completion of all the stages of dying.

False

Ture or False? A client who has died must be above 40 years of age for donation of his or her corneas to be possible.

False

Ture or False When preparing a PT who is scheduled for a sigmoidoscopy, you need to make sure that the Pt is not allergic to the anesthetic that will be used.

False an anesthetic is not administered for pts who will undergo a sigmoidoscopy

Is the following statement true or false? Radiography uses elements whose molecular structures are altered to produce radiation.

False. Radiography uses roentgen rays, or x-rays, to produce images of body structures.

Is the following statement true or false? Transfer involves discharging a client from one unit or agency and allowing him to go home.

False. Transfer involves discharging a client from one unit or agency and admitting him or her to another without going home in the interim.

Is the following statement true or false? Pain is always located in the organ of the body in which it is generated.

False. Referred pain is discomfort that is perceived in a general area of the body but not in the exact site where an organ is located.

Is the following statement true or false? The first step of admission is the collection of billing information by the admitting department of the health care agency.

False. The first step of admission is the authorization from a physician that the person requires specialized care and treatment.

T or F Ultrasonography uses x-rays to examine clients.

False. Ultrasonography uses a transducer that projects sound waves through the body's surface.

SYNCOPE DURING VENIPUNCTURE Why?

Fatigue Decreased blood volume Cardiac arrhythmia Hypoglycemia Hyperventilation Physiological causes

Start to finish postmortem care

First you assess : -check for breathing and pulse - find out if pysician and family have been notified - make sure a person of authority has pronounced death - notify nursing supervisor and switchboard - check medical records for the name of the mortuary where the body will go Second you Plan: - inform the mortuary personnel that the family chose them - find out when to expect the mortuary personnel member - contact any individual involved with organ procurement - collect your supplies; kit/ cleaning for wrapping and identify the body Next you Implement: - provide privacy -don ppe - position the body in supine with arms at side or folded across abdomen - remove all medical equipment (unless the body is going to the coroner) - remove hair pins or clips - close eyes - replace or keep dentures in - place a small rolled towel under their chin - clean away any secretions or drainage from skin (unless autopsy will be preformed) - place ne or more disposable pads between legs and under buttocks - attach an ID tag on ankle or wrist (if on wrist then make sure wrist is padded) - wrap the body in a paper shroud then cover with a sheet - tidy the bedside area, dispose of soiled equipment - remove ppe - leave the door closed after you leave or transfer body - make an inventory of valuables and send to the administrative office to place in safe - notify housekeeping Next is Evaluation: - make sure the body is clean and prepped for viewing or exam - make sure body has been transferred or is being transferred Finally Documentation: - the assessment that the pt was dead - time of death - right ppl were notified of death - the care you gave to the body - time the body was transferred

Flatus

Flatulence/fart/gas

what factors affect individual nutrition needs?

Food preferences acquired during childhood Established patterns for meals Attitudes about nutrition Knowledge of nutrition Income level Time available for food preparation Number of people in the household Access to food markets Use of food for comfort, celebration, or symbolic reward Satisfaction or dissatisfaction with body weight Religious beliefs

What foods or drinks help promote sleep?

Foods high in L-tryptophan: proteins, milk, dairy, fish, eggs, poultry, and some plant proteins (legumes)

Lithotomy position

For: - Internal pelvic examination (female) - Obstetric delivery - Cystoscopic (bladder) examination - Rectal examination

Sims position

For: - rectal examination - vaginal examination - rectal temp assessment - suppository insertion - enema administration

knee-chest position

For: - Rectal and lower intestinal examination - Prostate gland examination

dorsal recumbent position

For: - external genitalia inspection - Vaginal examination - Rectal examination - Urinary catheter insertion

4 methods of debridement

Four methods of debridement are sharp, enzymatic, autolytic, and mechanical.

An age related reduction in the number of laryngeal nerve endings contributes to diminished efficiency on the __________ reflux

GAG

Basic Activities During a Physical Assessment

Gather general data during first contact with client Physical appearance; gait; coordinated movement; use of ambulatory aids; mood and emotional tone Preliminary data Vital signs, weight, height, documentation Drape and position the client Ensure that client is covered with a drape (sheet of soft cloth or paper) Begin examination with the client standing or sitting Select a systematic approach for collecting data Head-to-toe approach: Advantages Body systems approach: Advantages; disadvantages Examining the client: Outline procedure for performing a physical assessment

What condition causes increased intraocular pressure?

Glaucoma- causes an increase in the pressure within the eyeball and, unless treated, often results in blindness.

HOW IS THE SKIN PREPPED BEFORE A BLOOD CULTURE IS DRAWN?

Green soap or alcohol for 2 minutes Air dry Clean with providone iodine Air dry

What tube has sodium heparin?

Green stopper tubes

HIPPA

HIPAA legislation protects the rights of U.S. citizens to retain their health insurance Requires health care agencies to safeguard written, spoken, and electronic health information Health care agencies must obtain authorization from client to release information to family or friends, attorneys, or for other uses Submits written notice to all clients identifying uses and disclosures of health information Obtains client's signature indicating knowledge of disclosure of information and right to learn who has seen his records Limits casual access to identity of client and health information Health agencies must ensure protection of electronic data

what disease has no preventative vaccine?

HIV

average HR/SBP 8yr

HR: 100 SBP: 100

average HR/SBP 2yr

HR: 110 SBP: 92

average HR/SBP 6yr

HR: 110 SBP: 95

average HR/SBP 1yr

HR: 115 SBP: 90

average HR/SBP 6mo

HR: 130 SBP: 90

average HR/SBP birth

HR: 140 SBP: 70

average HR/SBP 10yr

HR: 95 SBP: 105

What are sleep rituals?

Habitual activities performed before retiring

What is the most effective method for preventing wound infection?

Hand antisepsis and maintaining intact skin is the best method for reducing the transmission of microorganisms.

What is a multi-draw needle?

Has a retractable sheath over the part of the needle that extends into the evacuated tube

nursing interventions for feeding a visually impaired client and a client with dementia

Have staff member assist client/patient Be consistent with time and place for eating Reduce or eliminate environmental distractions to promote concentration on the task at hand Place the food tray close to the client, not the staff member, communicate visually and spatially that the client s to eat the food Remove wrappers, containers, and food covers to reduce confusion Pour milk from the carton into a glass so it is easily recognizable Encourage the clients participation by offering finger foods and utensils to stimulate memory

The Patient Self-Determination Act allow the patient to:

Have the right to have or to initiate advance directives, such as living will or durable power of attorney. Advance directives provide legal instructions to the health care providers about the patient's wishes and are to be followed. Surgery does not provide an exception to a patient's advance directives or living will.

Six General Areas for Data Collection

Head and neck Chest and spine Extremities Abdomen Anus and rectum

Home Health Care

Health care provided in home by an employee of home health agency Home care nursing services Help shorten time spent recovering in hospital Prevent admissions to extended care facilities Factors contributing to increased demand for home health care: Outcome of limitations imposed by Medicare and insurance companies on number of hospital and nursing home days for which they reimburse care Growing number of chronically ill older adults in need of assistance readmission's to acute care facilities

What is a healthy, over weight, and obese BMI?

Healthy : 19-24 Overweight: 25-29 Obese: 30 - 35

Heat Applications

Heat placed over painful area 24-48 hrs after injury Skin always protected with insulating layer (cloth or towel) Patient should never sleep with hot or cold pack in place

MOST COMMON COMPLICATION OF VENIPUNCTURE

Hematoma

WHAT VACCINATION DOES OSHA REQUIRE/RECOMMEND ALL HOSPITAL WORKERS TO RECEIVE?

Hepatitis B

WHAT VIRUSES ARE TRANSMITTED THROUGH THE BLOOD?

Hepatitis B HIV

What is H&P?

History and physical

Describe the nurse's role in providing terminal care.

Hydration, Nourishment, Elimination, Hygiene, Positioning, Breathlessness, Comfort

What doe the different Classes I -V of a Pap test represent?

I = Negative results with no abnormal cells II = Unusual result but not cancerous III = Results suggestive of cancer but not definitive IV = Strongly suggestive of cancer V = Definitely cancerous

abnormal or asymmertrical pupils: CN affected

II III

ptosis: CN affected

III

abnormal eye position: CN affected

III IV (4) VI (6)

LIST REQUIREMENTS SOME SPECIMENS NEED WHEN BEING TRANSPORTED TO THE LAB

Ice Body temperature STAT Shielded from light

EXAMPLES OF HEAT AND COLD THERAPY

Ice bag and collar Chemical packs Compresses Aquathermia pad

True or False? A flat electroencephalogram for at least 10 minutes is a reliable indicator of brain death.

True

What are you assessing during H&P?

Identifying data Chief Complaint Present illness Personal History Past Health History Family History Review of body system Conclusion

What are nursing interventions/actions when a patient verbalizes suicidal thoughts?

If an older adult confides suicidal thoughts, the nurse reports those intentions immediately to the nursing supervisor and primary care physician. Any potential articles that could be used to commit suicide are removed, such as guns, razors, knives, scissors, and medications (both prescription and nonprescription). The nurse has some stay with the client.

SYNCOPE DURING VENIPUNCTURE What should you do?

If sitting - remove needle if in arm, place head between knees and apply cold compress, use ammonia salts and stay with client

What is the proper procedure if AMA occurs?

If the client is determined to leave, the nurse ask him or her to sign a special form. This signed form may release the physician and agency from future responsibility for any complications, but it is not a guarantee.

Fecal _______________ occurs when a large, hardened mass of stool interferes with defecation.

Impaction

Why is packing often used in third intention healing wounds?

In the third-intention healing wounds, drainage devices or packing with absorbent gauze speed up healing for the reparative process. Packing absorbs the extensive drainage and tissue debris.

Family teaching for coping with a dying child.

Listen, provide, privacy, provide therapeutic intervention, provide info, use appropriate phases

What puts someone at risk for pressure ulcers?

Inactivity, immobility, malnutrition, emaciation Diaphoresis, incontinence, sedation Vascular disease, localized edema, dehydration

Hypoxia

Inadequate oxygen at the cellular level

What is the inflammatory response?

Inflammation - the physiologic process immediately after issue injury, last 2 to 5 days.

Steps Involved in Transfer

Informing client/family about transfer Completing transfer summary Speaking with nurse on transfer unit to coordinate transfer Transporting client and his/her belongings, medications, nursing supplies, and chart to other unit

How is general anesthesia administered?

Inhalation agents and or IV anesthetics

What is a contusion?

Injury to soft tissue underlying the skin form the force of contact with a hard object, sometimes called a bruise.

Types of admission

Inpatient and out patient

Define artifacts on the ECG tracing.

Interference

WHAT DOES THE NURSE DO WITH TUBES THAT CONTAIN A PRESERVATIVE OR CLOTTING AGENT AFTER THEY ARE FILLED WITH BLOOD?

Invert 8 times to mix

Nursing guidelines for postmortem care.

Involves cleaning and preparing the body to enhance its appearance during viewing at the funeral home, ensuring proper identification and releasing the body to mortuary personal

Describe the nursing care for a colostomy including when you would irrigate it.

Irrigating a Colostomy: A sufficient amount of solution is instilled; A comparable amount of solution is expelled; The stool is eliminated.Assessment1.Check the medical orders to verify the written order and type of solution to use. 2.Use two methods to identify the client.3.Determine how much the client understands about colostomy irrigation.Planning1.Obtain an irrigating bag and sleeve, lubricant, and a belt. A bedpan will be needed if the client is confined to the bed.2.Prepare the irrigating bag with solution in the same way as for an enema set.3.Un clamp the tubing and fill it with solution.Implementation1.Place the client in a sitting position in bed, in a chair in front or beside the toilet, or on the toilet itself.2.Place absorbent pads or towels on the client's lap.3.Hang the container approximately 12 in. above the stoma. 4.Wash your hands or perform an alcohol-based hand rub; don gloves. 5.Empty and remove the pouch from the face plate if the client is wearing one. 6.Secure the sleeve over the stoma and fasten it around the client with an elastic belt. 7.Place the lower end of the sleeve into the toilet, commode, or bedpan.8.Lubricate the cone at the end of the irrigating bag.9.Open the top of the irrigating sleeve. Rev. 6/20167110.Insert the cone into the stoma.11.Hold the cone in place and release the clamp on the tubing.12.Clamp the tubing and wait if cramping occurs.13.Release the clamp and continue once the discomfort disappears.14.Clamp the tubing and remove the cone when the irrigating solution has been instilled.15.Close the top of the irrigating sleeve. 16.Give the client reading materials or hygiene supplies.17.Remove the belt and sleeve when the draining has stopped. 18.Clean the stoma and pat it dry.19.If client is wearing an appliance, place a clean pouch over the stoma or cover the stoma temporarily with a gauze square.20.Repeat hand hygiene measures after removing gloves.Document1.Type of irrigation solution.2.Volume instilled.3.Outcome of

JCAHO

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishes criteria reflecting high standards for institutional health care Representatives of JCAHO periodically inspect health care agencies and determine evidence of quality care Based on inspection, agencies are accredited

Assessment Standards

Joint Commission standards related to pain management Aspects incorporated in the Joint Commission standards

what are some physiological changes in the urinary system of the older adult?

Kidneys: reduced blood flow, degeneration of tissue, decreased ability to filter decreased muscle in bladder and sphincter nocturia more common for men: enlarged prostate (BPH) reduces ability to void completely incontinence more common

Lipping:

before ea use, pour sm amt to wash away contaminates from mouth of the container

Removing poisonous substances from the stomach or intestines with gastric or intestinal tubes is know as performing _______________________

LAVAGE

Barriers to use of community-based services

Lack of finances or reluctance to spend for service payment Unwillingness to admit need; mistrust of service providers Lack of time, energy, or ability to find appropriate services

How can a nurse help maintain a safe environment?

Learn the fire and safety regulations of the facility; know the location of all exits; require staff to know the location of extinguishers and the used of one; know how to sound an internal fire alarm and when to call the local fire department; mention any safety problem, no matter how small, to your team leader.

A nurse is preparing an older adult for an enema. The nurse should assist the pt to which position?

Left lateral with the right leg flexed

Who confirms death?

Legally a physician, physician assistant, medical examiner, and in 20 states nurses

Palpation

Lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand Deep palpation Information: normal tissue and unusual masses; bilateral structures; skin temperature and moisture

Correcting Chart Errors

Line through the error, sign and date and also depending on your agencies policy

plasma

Liquid part of blood yellowish or straw color fluid

a.c.

before meals

Disuse Syndrome

Loss in the ability to perform ADL functions as a result of a sedentary lifestyle disability Approximately 14.2% of elders living in the community experience difficulty completing one or more ADLs because of health-related problems. Approximately 21.6% of elders report difficulties with instrumental ADLs (IADLs). The need for assistance in ADLs and IADLs increases with age.

What is the discharge METHOD?

M- Medications / teaching about any self administered medications E - Environment / explore how their home can be modified to ensure patient safety T- Treatment / teach how to do skills involved in self care, provide opportunities for returning for reteaching H- Health Teaching / identify information that is necessary for maintaining or improving health ex: signs and symptoms of complications O- Outpatient referral / explain what services are available that can help ease the transition to independent living D- Diet / arrange for a dietitian to provide verbal and written instructions for modifying or restringing some foods or suggesting alternative foods or ways of cooking

high CPK could indicate (Creatine Phosphokinase)

MI, ETOH, Skeletal muscle disease or just plain old over exercising

How would you teach a Male PT to perform a Clean Catch specimen?

Make sure they understand to - wash and dry hands - remove lid from specimen cup try not to touch the inside of cup or lid and place lid upside down on a flat surface - if not circumcised they need to retract the foreskin - cleanse in a circular direction around the tip of the penis towards its base using the pre moistened swab - repeat with another swab - initiate the first release of urine into the toilet (retracting foreskin if need) - after the first release then collect specimen into the cup (still retracting foreskin) - take care not to touch the inside of the cup with skin - once finished collecting urine into the specimen cup place cup on a nearby flat surface and finish peeing if need - wash and dry hands - cover specimen cup with lid

Respiratory Methods

Mask: Cannula: Rebreather:

a.c.

before meals (ante cibum)

Skin turgor

Measure of hydration, which tests how quickly the skin returns to its normal position after being pinched

Standard Procedures

Measures for reducing the risk of microorganism transmission from both recognized and unrecognized sources of infection.

standard procedure

Measures for reducing the risk of microorganism transmission from both recognized and unrecognized sources of infection.

WHICH VEIN IS THE "BEST CHOICE" FOR VENIPUNCTURE? WHY?

Median Cubital Skin less sensitive/less pain Stable Closest to surface of skin

Medical Records

Medical records are written collections of information about a person's health, the care provided by health practitioners, and the client's progress Also known as health records or client records

A dangerous condition of excessive anesthesia

Medullary Depression

_________________ is a hormone that induces drowsiness and sleep.

Melatonin

Head and neck assessment

Mental status assessment Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements Ears: cerumen; Weber test; Rinne test; audiometry Nose: abnormalities; smelling acuity Mouth and oral mucous membrane Unusual breath odors Assessment of taste Facial skin: alterations in skin Hair, scalp Neck

Intraspinal analgesia

Method of relieving pain by instilling an opioid or local anesthetic through a catheter into the subarachnoid or epidural space of the spinal cord.

Airborne precautions

Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei.

Dietary sources for Vitamin D

Milk egg yolks butter liver oysters in your skin from sunlight

TECHINCAL PROBLEMS

Missing vein Faulty vacuum tube Needle unscrews from hub

Methods of Charting

Narrative charting SOAP charting Focus charting PIE charting Charting by exception Computerized charting

Nursing guidelines for caring for a patient under general anesthesia, throughout duration and recovery

Monitor closely: - effective breathing - oxygenation - circulatory status (bp and pulse) - effective temerature regulation - adequate fluid balance

Nursing guidelines for caring for a client under local anesthesia

Monitor signs of: - allergic reactions to site and at all - changes in vitals - toxic reactions * also, protet the anestizied area if sensation is absent because the client is at risk for injury*

thrombus (clot)

Most likely to occur in leg veins of inactive people

Before Surgery:

Most patients will arrive approximately 90 mins before surgery Lorazepam is the only med that you want to wait to give at the very last minute possible Position patients body in a natural position At least 8 hours NPO before surgery Clear liquids may be given up 2 hours until surgery NPO before surgery ensures the stomach contains a limited amount of gastric secretions which decreases risk of aspiration

What is sputum?

Mucus coughed up from lower airways

What are physical signs of approaching death? S/s of impending death.

Multiple Organ failure. O2 begins to fall below levels required to sustain life. Cells, followed by tissues and organs begin to deteriorate

what nursing implications are advisable for the physiological musculoskeletal changes for the older adult?

Musculoskeletal: weight baring exercises like walking, dancing, jogging walking in place help for balance: exercises like tai chi help diet high in calcium help reduce effects from osteoarthritis have healthcare provider to review regular range of drugs and any over the counter medications to take into consideration for side effects that would increase risk of falling

What are the stages of sleep?

NREM (nonrapid eye movement) REM (rapid eye movement)

What happens during each phase of NREM sleep and during REM sleep?

NREM 1- onset of sleep last about 10 mins, drowsiness, light sleep, NREM 2- response to outside stimuli is somewhat suppressed. memory and info processed, NREM 3- difficult to wake person, dreaming, REM- happens about 90 mins after NREM deep sleep.

What are the main sleep stages?

NREM and REM

What are the stages of NREM

NREM1. onset of sleep, lasts 10 min you feel drowsiness and light sleep, you're aware of sounds and the hypnogogic jerk is typical NREM2. outside stimuli reduced, memory and info info being to be processed, lasts 10-25 min NREM3 deepest and most restorative sleep, dreaming not as vivid or memorable. Bp and breathing slows down. Snoring, sleepwalking, sleep talking, bed wetting are all more likely to happen during this stage lasts 20-40 min

S/S of narcolepsy and treatment/ nursing interventions.

Narcolepsy is followed by Sleep Paralysis, Cataplexy, Hypnogogic Hallucinations and Automatic Behavior. Te nurse can give stimulant drugs like Methylphenidate (Ritalin) or Amphetamine (Adderall)

Narrative charting

Narrative charting involves writing information about the client and client care in chronologic order. SOAP charting involves documenting client data under four essential components. Focus charting is a modified form of SOAP charting. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation

A pt with a gastric ileus postoperatively requires nutritional support for appox 2 weeks. What type of feeding tube is appropriate for this pt?

Nasointestinal tube

What entities make the guidelines for delegation?

National Council of State Boards of Nursing and the American Nurses Association

What is Healthy People 2020?

Natl effort to improve the health of Americans - gives us recommendations to enhance nutrition and weight status

Surgical Consent

Necessary Invasive procedures; Anesthesia Sign before preoperative medications Adult witness to signature

WHEN WOULD A SHORT DRAW OR NO BLOOD BE COLLECTED?

Needle bevel against the vessel wall Collapse of a vein Suction of the vacuum tube too great Pulling the syringe plunger back to quickly Needle comes out of the vein

CAUSES OF CLOTTING IN THE TUBE

No anticoagulant - red/gold/tiger tube Overheating Blood and anticoagulant not in proper ratio Anticoagulant not active or present Expired tube Insufficient mixing

Shaving

No blood disorder (hemophilia) shave the same way the hair is growing

Preoperative Care

Non-emergency surgery Perform history and physical examination Assess client's understanding Postoperative expectations Ability to participate in recovery Cultural needs privacy, and presence of family members Feelings related to disposal of body parts and blood transfusions Emergency surgical procedures

Who normally performs an arterial puncture?

Normally perform by Nurse or Respiratory Therapist

NANDA

North American Nursing Diagnosis Association, is the clearing house for proposals suggesting diagnoses that fall within the independent domain of nursing

nociceptive pain

Noxious stimuli transmitted from point of cellular injury through pathways to the cerebral cortex of the brain Subdivided into somatic and visceral Somatic pain Causes: Mechanical, chemical, thermal, or electrical injuries or disorders Affects bones, joints, muscles, skin, or other structures composed of connective tissue Types: Superficial somatic pain, also known as cutaneous pain; deeper somatic pain from trauma Visceral pain Diseased or injured heart, kidneys, and intestine Causes: Ischemia, organ compression, intestinal distention with gas or contraction Referred pain Discomfort perceived in a general area of the body

What are 4 simple pain intensity scales nurses use?

Numeric scale, word scale, and linear scale, Wong-Baker FACES scale: Best for pediatric, culturally diverse, and mentally challenged clients

How can the nurse facilitate the grieving process?

Nurse may empathetically share perceptions of what the client and family is experiencing

How does the nurse sustains hope for the dying patient?

Nurse must recognize the value of communicating a spirt of hopefulness

What are the basic nursing admission activities?

Nurses check the room to ensure it is clean and stocked with basic equipment for initial care. They later provide personal care items for clients who do not have them. They also place oxygen administration equipment, a stand for supporting intravenous fluids, and anything else required at the time of initial treatment.

When should the patient give informed consent?

before sedation or any surgery

What is the proper process for safeguarding patient valuables upon admission?

Nurses give certain items, such as prescription and nonprescription medications, valuable jewelry, and large sums of money, to family members to take home. If this is not possible, the nurse must carefully observe the agency's policies.

How can nurses help patients die with dignity?

Nurses provide emotional support to dying clients by acknowledging them as unique and worthwhile

Written Forms of Communication

Nursing care plan: list of client's problems, goals, and nursing orders for client care Nursing Kardex: quick reference for current information about client and client care Checklists: documentation with check mark or initials Flow sheets: documentation with sections for recording frequently repeated assessment data

Respiratory

O2 Stat Norms: 95-100 Preoxygenate: 2-3 minutes Risk for infection: CT purpose:

Type of outpatient admission

Observational = monitoring required possible need for inpatient admission determined within 24hours ex: head injury, unstable vitals, premature or early labor

What is the range for older adults?

Older adults are from age 65 to death; developmental period is subdivided into three categories: young-old (65-74), middle-old (75-84), and the old-old (85 and older).

Factors to Consider When Performing Examinations and Tests on Older Adults

Older adults may not be able to tolerate withholding of food or fluids for long periods Older adults are susceptible to dehydration Older adults become exhausted by preparations for gastrointestinal examinations requiring laxatives and enemas, which may also deplete electrolyte balance, leading to weakness or dizziness Older adults fatigue easily Older adults may need additional clothing, slippers, extra covers Cognitively compromised older adults should have a family member present during the procedure

who is at highest risk for malnutrition

Older adults* Homeless Children from economically deprived families Pregnant teenagers People with substance abuse problems Clients with eating disorders

Spine: Scoliosis

Scoliosis is a condition in which the spine curves to the left or right, creating a C- or S-shaped curve

Principles of Surgical Asepsis

Once equipment and areas are free of microorganisms, they remain in that state, if contamination is prevented Surgical asepsis - those measures that render supplies and equipment totally free of microorganisms Sterility preserved: touching one sterile item with another that is sterile Once a sterile item touches something that is not sterile, it is considered contaminated Any partially unwrapped sterile package is considered contaminated Question the sterility of an item considered unsterile Longer the time since sterilization, the more likely that the item is no longer sterile Commercially packaged sterile item is not considered sterile past its recommended expiration date Opened sterile item or area, left unattended, is considered contaminated Once a sterile item is opened or uncovered, it becomes contaminated The outer 1-inch margin of a sterile area is considered a zone of contamination Coughing, sneezing, or excessive talking over a sterile field causes contamination Reaching across an area that contains sterile equipment may cause contamination A wet sterile wrapper wicks microorganisms from its supporting surface, causing contamination Sterile items located or lowered below waist level are considered contaminated

Physical assessment

One method for gathering health data

Outpatient surgery (AKA: ambulatory surgery / Same Day surgery)

Operative procedures performed on clients who return home the same day as the procedure

Endoscopy

Optical scopes

Problem-Oriented Records

Organized according to client's health problems Four major components: data base, problem list, plan of care, progress notes Information compiled and arranged to emphasize goal-directed care; promote recording of pertinent information; facilitate communication among health care professionals

What complication may occur if the heel bone is damaged?

Osteomyelitis

O2

Oxygen

SpO2

Oxygen saturation measured by pulse oximeter

the FIFTH vital sign is

PAIN ASSESSMENT

What is a PEG tube and what is it used for? and what could cause it to leak?

PEG is percutaneous endoscopic gastrostomy tube(a trans-abdominal tube inserted under the endoscopic guidance -disconnection b/w the feeding delivery tube and the g-tube -clamped g-tube while tube feeding is infusing -mismatch b/w the size of the g-tube & stoma -increased abdominal pressure from formula accumulation, retching, sneezing and coughing -under inflation of the balloon b/w the skin -less than optimal stoma or stomal location

SITZ BATH

PROVIDES A SOAK OF THE PERIANAL AREA ​PURPOSE REDUCE SWELLING REDUCE INFLAMMATION PROMOTE HEALING WATER NO HOTTER THAN 110 DEGREES

EFFECTS OF HEAT APPLICATION

PROVIDES WARMTH PROMOTES CIRCULATION SPEEDS HEALING RELIEVES MUSCLE SPASM REDUCES PAIN

How is the artery located?

Palpate with middle and index fingers How long is pressure held at the puncture site? At least 15 minutes

What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called?

Palpation

______________ are conditions associated with activities that are abnormal types of partial arousal, usually during transitions in NREM periods of sleep.

Parasomnias

PTT (light blue tube)

Partial thrombin time

What information do you enter into the ECG machine immediately prior to recording the ECG?

Patient data

What is the most frequent cause of artifact?

Patient movement, crossed wires, interference in the electrical supply, unstable electrodes

To Obtain an Informed Consent:

Patient must be mentally competent. If patient just received medications that affect comprehensive neuro status, cannot sign consent. If the patient is a minor, a guardian, parent or court order will sign the permit; the state dictates that age.

Name 5 Expected Outcomes for Deficient Knowledge Nursing Diagnosis:

Patient will... Explain the purpose and expected results of the planned surgery. Ask questions when a term or procedure is not known Adhere to the NPO requirements State an understanding of preoperative preparations (e.g., skin preparation, bowel preparation). Demonstrate correct use of exercises and techniques to be used after surgery for the prevention of complications (e.g., splinting the incision, coughing/deep breathing, performing leg exercises, ambulating as early as permitted).

What tests can be done with blood smears?

Peripheral Blood smears: - abnormal red cell morphology and count - characteristic of certain diseases stats such as sickle cell anemia - variety and proportion of WBC

Transmission

Peripheral nerve fibers form synapses with neurons in the spinal cord Pain impulses move from spinal cord to brain; impulses ascend finally to the cerebral cortex

What are the uses of a pt record? and what must be on every page?

Permanent account Sharing information Quality assurance Accreditation Reimbursement Education and research Legal evidence name of pt, date/time, signature with title

Components of Medical Records

Person's health information Care provided by health practitioners The client's progress The plan for care Medication administration record Laboratory and diagnostic reports

True or False? Environmental Psychologists are specialists who study how the environment effects behavior and well- being of a client

True

COMMON COMPLICATIONS AND IF THE COMPLICATIONS INDICATES THE NEED TO SELECT ANOTHER SITE.

Petechiae - select different site Edema - select different site Obesity - okay to use Damaged or scarred veins - select different site Burned areas - select different site

What product can affect the permeability of gloves?

Petroleum-based hand lotion

Modulation

Phase during which the brain interacts with the spinal nerves to alter the pain Pain sensation reduced Release of pain-inhibiting neurochemicals

Perception

Phase of impulse transmission: brain experiences pain at a conscious level; brain structures in the pain pathway Pain perception: Conscious experience of discomfort Pain threshold: Point at which pain-transmitting neurochemicals reach the brain, causing conscious awareness Pain tolerance: Amount of pain a person endures once the threshold has been reached; influenced by gender, age, and culture

What is a circadian rhythm?

Phenomena that cycle on a 24 hour basis. Drowsiness and sleep correlate w/ the carcadian rhythm of the setting sun and night

_____________ is the technique for suppressing melatonin by stimulating light receptors in the client's eye.

Phototherapy

Preoperative Preparation

Physical Preparation Skin preparation Decrease bacteria; Maintain skin integrity Elimination Insert indwelling urinary catheter; Cleansing enema or laxative prn Food, fluids Restrictions before surgery 8-10 hrs Nutrients for healing process Care of valuables Denture removal Other prosthetic s

What does the initial nursing plan consist of?

Physical assessment skills, which taking vital signs

When are vital signs taken?

Physical exams, admitted, subacute care, b/a surgery, b/a tests, after fall/injury, care plan, complains of pain, dizzy, lightheaded, sob, rapid heart, feeling ill.

Who can ask for one and who can give consent?

Physician has to obtain permission and next of kin can give consent

WHERE CAN A LPN/ PHLEBOTOMIST WORK?

Physician's office Hospital Home health agency

7 mo milestone

begins crawling

Types of Inpatient admission

Planned emergency Direct

What do you ask the client to do during the recording of the ECG?

Please be very still and remain quiet during the recording of the ECG

PACU:

Post Anesthesia Care Unit

Describes entire span of surgery Three phases:

Preoperative intraoperative postoperative

Preoperative Teaching

Preoperative period Surgical procedure expectations pre-, post-operatively Clients are alert and free of pain Better participation in recovery Instruct at client's comprehension level Preoperative medications: Purpose & Effects Postoperative pain control Describe post-anesthesia recovery room (PACU) Discuss monitoring equipment Explain& demonstrate: Cough and deep breathing; Leg exercises Instruct re: IV fluids; Tubes

Nursing Admission Activities

Preparing client's room Welcoming client Orienting client Safeguarding valuables and clothing Helping client undress Compiling nursing data base

A nurse is teaching a patient how to apply an extended wear skin barrier. What teaching should the nurse provide to the patient for maximum adherence?

Press gently around the barrier for 1 to 2 minutes

What is a pressure ulcer

Pressure ulcer- also referred to as a decubitus ulcer, is a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue.

WHAT ARE SPLASHGUARDS? WHAT IS A COMMON BRAND NAME OF A SPLASHGUARD?

Prevent aerosolized mist when stopper is removed Hemoguard

Why is it important to keep a log of all blood draws from infants?

Prevent anemia

When should the patient give informed consent?

Prior to any preoperative medications or sedatives

S/S of sleep apnea and nursing interventions.

Snoring. Methods to help are sleeping in different position other than supine, loosing weight, avoid alcohol and sleeping meds. Severe cases a CPAP machine.

Inpatient surgery

Procedures perfomed on a client who is admitted to the hospital to remain over night and in need of nursing care for more than one day after surgery.

Anaerobic

Process that does not require oxygen

Aerobic

Process that requires oxygen

What effects do sedatives have on sleep?

Produce a relaxing and calming effect, promotes sleep

vitamin k

Produces prothrombin, avoid liver, eggs, green leafy vegetables, grape fruit juice. FAT soluble vitamin

What does prolonged bleeding time indicate?

Prolonged bleeding time indicates the platelet count is low or not functioning properly

Leg exercise post op

Promotes circulation and reduces the risk for forming thromus or emboli

LIST THE 3 NECESSITIES FOR ACCURATE SPECIMENS

Proper collection technique Proper evacuated tube Proper needle selection

Venturi mask Pros and Cons

Pros: Delivers f102 precisely though adjustable ports carbon dioxide build up is low Cons: condensation in tubig

Face tent Pros and cons

Pros: comfy, useful for pts with facial trauma or if claustraphobic Cons:interferes with eating, F102 can be inconsistent

T-piece Pros and cons

Pros: deliveres any desired F102 with high humidity Cons: can pull on tracheostomy tube, allows humidity to collect and moisten gauze dressing

Non- rebreather mask Pros and cons

Pros: delivers highest F102 possible with a mask, prevents breathing room air, exhaled air is not rebreathed, delivers F102, Cons: creates risk for oxygen toxicity, needs a min of 6L/min, risk of suffocation

Nasal cannula Pros and cons

Pros: easy to use, comfy, doesn't interfere with eating or talking Cons: dries the nasal mucosa, can irritate the skin around nose, cheek, and behind the nose, less effective for mouth breathers, not for hypoxic pt's

Simple Mask Pros and Cons

Pros: higher concentration than the cannula, better for mouth breathers, lets the pt to inhale a mx of 75% room air nd 25% oxygen Cons: need a humidifier, interferes wtih eating and talking, no for the clausrophobic pt, risk for re-breathing CO2 when less than 6L/min is used

Partial rebreather Pros and cons

Pros: increases the amt of oxygen with lower liter flows Cons: Needs a min of 6L/min, risk of suffocation, needs more monitoring to verify that reservoir bag remains inflated at all times

Tracheostomy Pros and Co

Pros: s humidifying and warming oxygen Cons: allows water vapor to collect in tubing that can drain into the airway

What foods or drinks promote sleep and what foods or drinks can interfere with sleep?

Protein and Diary products promote sleep. Caffeine is a stimulant.

PT (light blue tube)

Prothrombin time

Purpose of the PACU:

Provides ongoing evaluation & stabilization of patients. To anticipate, prevent, treat any complications of surgery.

Tube feeding complications

Pulmonary Aspiration Vomiting Diarrhea or Constipation Tube Occlusion or Displacement Electrolyte/Imbalance Dehydration

DESCRIBE PROPER DISPOSAL OF USED NEEDLES.

Puncture proof containers Never recap

How often should you look at the surgical incision in PACU?

Q 15min

QA

Quality Assurance

ECG Limb leads placement

RA (right arm) and LA (left arm) : place on the inside arm above wrist RL (right leg) and LL (left leg) : place o the inside of leg above ankle

Limb placement of electrodes:

RA and LA-Right arm and Left arm place on inside arm above wrist, RL and LL-Right leg and Left leg, place on inside of leg above ankle

EFFECTS OF COLD APPLICATION

REDUCES FEVER PREVENTS SWELLING CONTROLS BLEEDING RELIEVES PAIN NUMBS

passive ROM

Range of Motion in which the resident is unable to assist with movement

Lithotomy position

Reclining position with the feet in metal supports called stirrups

Dorsal recumbent position

Reclining position with the knees bent, hips rotated outward, and feet flat

What are the functions of sleep?

Reducing fatigue, stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaning the disease-fighting mechanisms of the immune system, promoting cellular growth and repair, improving the capacity for learning and memory stage

Who is responsible for medication reconciliation?

Registered nurse is responsible for the admission assessment.

Who is responsible for compiling the initial patient data?

Registered nurse, but he or she may delegate some aspect to the practical nurse, nursing student, or other ancillary staff.

What physical needs of the patient must the nurse make sure are met and how?

Relieving pain

hypnogogic hallucinations

dream-like auditory or visual experiences while dozing or falling asleep

List the post procedure steps the nurse should take in finishing the patient's care.

Remove the electrodes, provide safety and comfort for the patient.

WHEN IS THE NEEDLE REMOVED?

Remove the needle after the last tube is full

oral suctioning

Removing secretions from the mouth

Nasotracheal suctioning

Removing secretions from the upper portion of the lower airway through a nasally inserted catheter

Pt. teaching and nursing interventions for insomnia.

Resist napping during the day, use the bed and bedroom for just sleeping, perform sleep rituals, go to bed and get up at the same time everyday/night, if it takes longer than 30 mins to get out of bed get out of bed and do something else, try a bedtime relaxation tape that plays soothing music, sounds of nature, or a constant background noise, exercise regularly, avoid alcohol nicotine and caffeine, eat dairy and protein, modify the temp and regulation, use earplugs or eyeshades to reduce light and sound, avoid using nonprescription or prescription sleeping pills, calming tea, follow directions on all meds, take diuretics in the morning

ARTERIAL BLOOD PUNCTURES Who usually performs?

Respiratory therapist or RN How is the site cleansed? Betadine or alcohol Is a tourniquet used? No

what implications for nursing are advisable for the physiological respiratory changes for the older adult?

Respiratory: low impact exercise helps with strengthening the lungs exercises like walking, dancing, marching in place and breathing exercises discourage smoking look out for symptoms like fatigue fast pulse

How do you collect the Review of Body Systems during an H&P?

Results from physical examination

A pt who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which kind of enema?

Return flow

7 rights to medication prep and admin

Right Med Right Patient Right Route Right Time Right Dosage Right Documentation Right Reason

What are the 5 rights of delegation?

Right task, right circumstances, right person, right direction/communication, and right supervision/evaluation

EVENTS THAT MAY LEAD TO AN INCREASE IN THE LEVEL OF ENZYMES PRESENT IN CIRCULATION

Strenuous exercise Myocardial Infarction (MI) Polymyositis Polymyalgia rheumatica Systemic Lupus Erythematosus (SLE)

SAFETY MEASURES

SAFETY MEASURES FREQUENT SKIN ASSESSMENT ASSESSMENT OF EQUIPMENT CAUTIOUS USE IN PEOPLE AT RISK OF COMPLICATIONS DON'T PLACE HEAT OR COLD APPLICATION DIRECTLY ON SKIN INSTRUCT PT TO SIGNAL FOR ASSISTANCE IF NEEDED

USING AN ICE BAG

SKIN ASSESSMENT BEFORE DURING AND AFTER APPLICATION ASSESS FOR PATIENTS WITH INCREASED RISK OF TISSUE INJURY USE NO LONGER THAN 20 MIN AT A TIME

List safe and unsafe sites for collection of blood from an infant

Safe - Side of the heel Unsafe - any other area of the foot or toes or sole of the foot

During report, a nurse is informed that a pt has a nasogastric tube connected to continuous suction. The nurse should recognize that this pt must have which kind of tube?

Salem sump

Describe inpatient surgery:

Same day admission Stay in hospital 3-5 Patients already admitted in hospital go for surgeries as well

What is a lab specimen? Why is it collected?

Samples of tissue or body fluid collected to be tested in a laboratory

Planned inpatient admission

Scheduled in advanced for either elective or required major surgery

WHEN IS A GLUCOSE TOLERANCE TEST DONE? What is the purpose?

Screen for Diabetes Mellitus, hypoglycemia and determine blood glucose levels How long does the test usually take? Up to 5 hours What specimens are collected and in what containers? Blood in red, grey or tiger top tubes Urine

WHAT IS THE LIQUID PORTION OF THE BLOOD CALLED? WHAT COLOR IS IT?

Serum or plasma Clear or straw colored

percussion

Striking or tapping the body with fingertips to produce vibratory sounds Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change Pain: possible disease process or tissue injury

Guidelines/Rules for documentation

Should not be time-consuming to write and read Everyone involved in the care of a client should make entries in the same location in the chart The nurse should address specific content in charted progress notes Assessments should be documented on a separate form and give the client's problems a corresponding number for quick access Abnormal assessment findings, or care that deviates from the standard, should also be documented separately Client information should be documented electronically Information should always be legible Abbreviations and terms should be consistent with agency-approved lists The date of the documentation should be recorded The time of the documentation should be recorded

Which of the following positions may be used as an alternative to the lithotomy position during a rectal examination?

Sims'

Different types of binders

Single T-binder Double T-binder

What are you responsible for doing in the patient's physical pre-op prep?

Skin prep attention to elimination (pee or poo) food and fluid restriction care of valuables putting on surgical attire disposition of prostheses all physical pre-op orders must be well communicated and documented in orders

chest and spine assessment:

Skin turgor Assess chest shape and movement; chest expansion Spine: lordosis, kyphosis, scoliosis Breasts Heart sounds: S1, S2, S3, S4

What information is gathered when doing a sleep assessment?

Sleep Questionnaires, Sleep Diaries, Polysomnographic eval, Multiple latency sleep test

What is somnambulism and what are interventions for a person experiencing this?

Sleep Walking, and Stair Gates, Security locks on doors and windows

deep breathing

Slow, deep breaths whilst relaxed, reduces the postoperative risk for respiratory complications such as atelectasis, & pneumonia

What time interval do the small and large blocks on the ECG paper represent?

Small-.04 Large-.20

Which anticoagulant does not inhibit the clotting process by binding with calcium?

Sodium heparin (the green tube)

How does sodium heparin work compared to other anticoagulants?

Sodium heparin or lithium heparin inactivates thrombin and thromboplastin

Electrolytes are

Sodium, Potassium, Chloride

Environment for physical assessment

Special examination room or at bedside Easy access to a restroom; a door or curtain to ensure privacy Adequate warmth Lined receptacle for soiled articles Adequate lighting Padded, adjustable table or bed Sufficient room for movement around client Facilities for hand hygiene Clean counter or surface for placing examination equipment

Describe the satge 1-4 of pressure ulcers.

Stage I: intact but reddened skin Stage II: reddened skin accompanied by blistering or a skin tear Stage III: shallow skin crater that extends to the subcutaneous tissue Stage IV: deeply ulcerated, extending to muscle and bone; life threatening

WHICH INFECTION CONTROL PRECAUTION IS MOST IMPORTANT TO A LPN/PHLEBOTOMIST?

Standard Precautions Blood and body fluid exposure

Determining the Level of Care

Standard form developed by Health Care Financing Association MDS repeated every 3 months or whenever client's condition changes Problems identified on MDS are reflected in nursing care plan Cognitive patterns, communication/ hearing patterns, vision patterns Physical functioning and structural problems Continence patterns in last 14 days Psychosocial well-being Mood and behavior patterns, activity pursuit patterns, disease diagnoses Health conditions, oral/nutritional/dental status, skin condition Medication use Special treatments and procedures

What is an advantage of using staples to close a wound or incision?

Staples are advantageous because they do not compress the tissue if the wound swells.

Preoperative period

Starts when clients learn that surgery is necessary and ends when clients are transported to the operating room

_____________ are drugs that excite structures in the brain, causing wakefulness.

Stimulants

aireborne

When pathogens attach to evaporated water particles or dust that has been suspended in the air over 3ft Ex. (inhalation of spores)

- What info do you gather when assessing a PT's nutrition and diet?

Subjective Data: diet history Objective Data: physical assessment, lab data, anthropometric data, body measurements

nursing guidelines for preventing and relieving stomach gas

Suggest client chews with mouth closed, limiting the amount of swallowed air Advise against the use of a straw Advise against chewing gum and smoking cigarettes Limit or restrict foods that contains large volumes of air such as souffles, yeast breads, and carbonated beverages Recommended that when under stress, the client should avoid eating Propose walking if uncomfortable Consult the physician about use of medications that relieve gas accumulation

What position should the patient be in during recording of the ECG?

Supine

Who can give it? (informed consent)

Surgeon is responsible for obtaining the signed consent before sedation and/or surgery. The nurse's role is to clarify facts presented by the physician and dispel myths that the patient or family may have about surgery.

Describer outpatient/ambulatory surgery:

Surgery usually less than 2 hours Recovery is less than 24 hours Usually discharged 3-4 hours after surgery '23 hour admissions'- used for extended recovery and insurance will still cover costs Less likely to attain a nosocomial

urinary diversion

Surgical diversion of the drainage of urine such as a ureterostomy.

What is the primary indication of hematoma?

Swelling What interventions should the nurse do? Adjust the depth of the needle Remove the needle and apply pressure

T or F plant sources contain incomplete proteins

T

T or F Protein complementation helps a person to acquire all essential amino acids from non-animal sources

T

Uses for Cold Application

TRAUMA FIRST 48-72 HOURS SUPERFICIAL LACERATIONS/PUNCTURES INJECTION SITES DECREASED SWELLING AND PAIN ARTHRITIS PAIN JOINT TRAUMA FEVER

Medications to reduce fever are available in suppository form?

TRUE

increased peristaltic activity is termed the gastrocolic reflux

TRUE

Calorie

a way to express the energy value of food * the amt of heat that raises the temp of 1g of water by 1 celcius

What should you tell the client prior to starting to record the ECG?

That the procedure is painless and there will be no electrical shock

Define tolerance

The ability to survive and reproduce under a range of environmental circumstances

Which area of the hands require special attention before you begin a surgical hand scrub?

The area under each fingernail

What should be included on a written assignment sheet?

The assignment sheet includes the staff member's names, their break and meal times, room numbers of patients to whom they are assigned and any other general duties that staff members are expected to complete during their time on duty.

What is the recommended daily caloric intake?

The average adult needs 1800 - 3,000 per day! Women generally need less calories than men, proper range 1,800 to 2,400 calories Men generally require 2,400 t0 3,000 calories a day 1,200 calories to meet nutrient requirements assuming a balanced diet is met 50% carbs 30% fat 20% protein

What is the classic s/s of the inflammatory response?

The characteristic s/s or the inflammatory response are swelling, redness, warmth, pain, and decreased function.

Sims' position

The client lies on the left side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body

Knee-chest position

The client rests on the knees and chest and turns the head, which is supported on a small pillow, to one side

Modified standing position

The client stands with the upper half of the body leaning forward

What are the risks of obtaining this type of specimen from an infant's heel?

Too much pressure on the infant's heel may hurt the infant or may change test results

what is a calorie

The energy or heat equivalent of food is measured in calories. A calorie (cal) is the amount of heat that raises the temperature of 1 gram of water by 1 degree C

After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a facemask, and gloves, which of the following should the nurse remove first when removing PPE separately?

The gloves

Skin Prep

The goal is to decrease transient and resident bacteria without compromising skin integrity - clean - hair removal - have patient bathe or shower twice prior with (sometimes) 2% chlorhexidine gluconate

What is the key to wound healing and what factors can interfere with this?

The key to wound healing is Adequate blood flow to the injured tissue. and nutrition and controlled blood sugars, tissue integrity, age, fragile or thin.

How is level of care determined and evaluated?

The level of care is determined at or prior to admission. Each client is assessed using a standard form developed by the Health Care Financing Association called a "Minimum Date Set (MDS) for Nursing Home Resident Assessment and Care Screening". MDS is repeated every three months or whenever a client's condition changes. The MDS requires an assessment of the following: i. Cognitive patterns ii. Communication and hearing patterns iii. Vision patterns iv. Physical functioning and structural problems v. Continence patterns in the last 14 days vi. Psychosocial well-being vii. Mood and behavior patterns viii. Activity pursuit patterns ix. Disease diagnoses x. Health conditions xi. Oral and nutritional status xii. Oral and dental status xiii. Skin condition xiv. Medication use xv. Special treatments and procedures

What is the role of a mortician?

The person who prepares the body for burial or cremation is responsible for filing the death certificate w/ the proper authorities

How does the nurse address emotional and spiritual needs of the dying patient?

The nurse must be flexible and to interrupt physical care if and when the client indicates a need for companionship, support, and communication. The nurse notifies appropriate clergy if required by the nurse. nurse may pray with client if asked and if the client is to ill the nurse must ask family about spiritual care.

to visualize the ear canal and tympanic membrane:

The otoscope is used to visualize the ear canal and tympanic membrane.

informed consent

The physician is responsible for providing it - you can answer some questions the client might have -it is a permision a client gives ater an explanation of risks, benefits, and alternatives regarding the surgical procedure - you must witness the signature of the client

Nutrition

The process by which your body takes in and uses food

What are the purposes of the inflammatory response?

The purpose of the inflammatory response is (1) limit the local damage, (2) remove injured cells and debris, and (3) prepare the wound for healing.

Aspects of Documentation

The type of information recorded The people responsible for charting The frequency for making entries on the record The type of response given for the information recorded

Residual urine that remains in the bladder after voiding can support the growth of the microorganisms, leading to infection

True

dipstick urine

The visual examination of urine using a special chemically treated stick

How is polycythemia vera treated?

Therapeutic phlebotomies i. Drawing some blood out of your veins in a procedure called phlebotomy is usually the first treatment option for people with polycythemia vera. This reduces the number of blood cells and decreases your blood volume, making it easier for your blood to function. How often you need phlebotomy depends on the severity of your condition.

What are complete proteins?

They contain adequate amounts and proportions of all of the essential amino acids

What should you tell the client prior to starting to record the ECG?

This will be painless and there will not be an electrical shock

Purpose of physical assessment

To evaluate the client's current physical condition To detect early signs of health problems To establish baseline for future comparisons To evaluate client's responses to medical and nursing interventions

What is the purpose of an autopsy?

To examine organs and tissues of the human body after death

Patient/Family teaching for promoting weight loss and weight gain

To gain weight, add butter, add protein, add cheese to potato To lose weight,

How can the nurse promote family coping?

To help families feel that they can express their feelings w/ nurses who are compassionate listeners

What are the DV's

Total Fat: less than 65g Sat Fat: less than 20g Cholesterol: less than 30mg Sodium: less than 2400mg Total Carbs: 300mg Dietary Fiber: 25g

Patient/Family teaching for vegetarians

Total fat: less than 65 grams Saturated fat: less than 20 grams Cholesterol: less than 300 mg Sodium: less than 2,400 mg Total carbohydrates: 300 g Dietary fiber: 25 g

Normal Lung sounds

Tracheal sounds Bronchial sounds Bronchovesicular sounds Vesicular sounds

How does the nurse assess the nutritional status of an older adult?

Tracking body weight is a good assessment tool for evaluating the nutritional status of older adults.

The Transfer Process

Transfer: discharging client from one unit or agency; admitting him/her to another without going home in interim Transfers used when there is need to: Facilitate more specialized care in life-threatening situation Reduce health care costs Provide less intensive nursing care

A sign of urinary retention is a progressively distending bladder

True

Gastric sump tubes, which are double-lumen tubes, are used almost exclusively to remove fluid and gas from the stomach ?

True

Intestinally placed tubes may lead to dumping syndrome.

True

Nurses can insert nasogastric tubes into clients?

True

Is the following statement true or false? Home care nursing services help shorten the time spent recovering in the hospital.

True. Home care nursing services help shorten the time spent recovering in the hospital.

Is the following statement true or false? Macrophages are types of white blood cells.

True. Macrophages are types of white blood cells.

Is the following statement true or false? Paracentesis is the procedure for withdrawing fluid from the abdominal cavity.

True. Paracentesis is the procedure for withdrawing fluid from the abdominal cavity.

Is the following statement true or false? Steri-Strips can be used to close superficial lacerations instead of sutures or staples.

True. Steri-Strips are also used to close superficial lacerations instead of sutures or staples.

Is the following statement true or false? The proper time to get a client's signature on a surgical consent is prior to administration of preoperative medications.

True. The proper time to get a client's signature on a surgical consent is prior to administration of preoperative medications. After the medication has been administered, the client is considered "under the influence" and not legally competent to sign legal papers.

Is the following statement true or false? There are three phases to the perioperative process.

True. There are three phases to the perioperative process: Preoperative, Intraoperative, and Postoperative phases.

Is the following statement true or false? Pain is exactly as the client describes it.

True. Margo McCaffery, a nursing expert on pain, states, "Pain is whatever the person says it is, and exists whenever the person says it does" (McCaffery & Beebe, 1989).

Is the following statement true or false? Skilled nursing facility provides 24-hour nursing care under the direction of a registered nurse.

True. Skilled nursing facility provides 24-hour nursing care under the direction of a registered nurse.

REFUSAL TO HAVE BLOOD COLLECTED

Try to persuade Point out why needed Don't force Note on form and document Notify physician

What equipment is taken to the bedside?

Tubes, alcohol, gauze, and lancet Is a tourniquet used? No

True or False? Hydration involves the maintenance of an adequate fluid volume in the body.

Ture

How is wound drainage documented?

Type of dressing Antimicrobial agent used for cleansing Assessment data

CAUTION on sitz bath

USE OF THE SITZ BATH MAY CAUSE HYPOTENSION SECONDARY TO LARGE AMOUNT OF BLOOD MOVING TO THE PELVIC AREA

Emergency inpatient admission

Unplanned, stabilizing in the ER then transferred to a nursing care unit ex: unrelieved chest pain or trauma

Visualize ear canal of an Adult

Up and back adult

Auscultation

Used for assessing the heart, lungs, and abdomen Soft sounds, loud sounds Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise

Intraoperative:

begins when the patient is transferred to the OR bed until transfer to the post anesthesia care unit (PACU) the time the patient is in the OR

How should a leader handle conflict among team members?

Using the problem-solving approach outlined (outlined in ch.2), the leader should identify the problem and consider possible solutions. Often advisable to discuss the problem and proposed action with a supervisor or other nurse manager whom you respect and who can maintain confidentiality of information. Discussing the problem and getting feedback from someone whose judgment you trust often helps you clarity the problem and evaluate your proposed solution before you act. Once you have chosen a course of action, follow it through to the end. Don't change you mind (unless you are obviously wrong), and don't be influenced by the opinions of others. Keep disciplinary sessions private and professional. Shouting or threatening will no accomplish a solution. Have your facts straight, listen to what the individual or team members have to say, clearly state what action will resolve the problem, and specifically identify what you expect in the future.

articulation of words: CN affected

V VII (7) X XII (12)

What are the six unipolar precordial, chest leads?

V1 - V6

Steps to performing an EKG- where to place leads

V1-4th intercostal space at right margin of sternum V2-4th intercostals space at left margin of sternum V3-Midway between position V2 and position V4 V4-5thintercostals space at junction of the left midclavicular line V5-At horizontal level of position V4 at left anterior axillary line V6-At horizontal level of position V4 at left midaxillary line

Explain the chest electrode placement.

V1-4thintercostal space at right margin of sternumV2-4thintercostals space at left margin of sternumV3-Midway between position V2 and position V4V4-5thintercostals space at junction of the left midclavicular lineV5-At horizontal level of position V4 at left anterior axillary lineV6-At horizontal level of position V4 at left midaxillary line

Name the six (6) unipolar precordial, chest leads.

V1-V6

ECG Placement V1 - V6

V1= 4th intercostal space at "Right" margin of sternum V2= 4th intersostal space at "Left" margin of sternum V3= midway between position V2 and position V4 V4= 5th intercostal space at junction of the "Left" midclavicular line V5= at horizonal level of position V4 at left "Anterior axillary" line V6= at horizonal level of position V4 at left "Mid axillary" line

HIGH RISK PATIENTS for hot/cold application

VERY YOUNG OR VERY OLD PATIENTS WITH IMPAIRED SKIN INTEGRITY PATIENTS WITH EDEMA (NOT FROM INJURY) PATIENTS WITH PERIPHERAL VASCULAR DISEASE

facial droop or asymmetry: CN affected

VII (7)

frontal sinus location

below eyebrows

Nursing assessment immediate pre-op period

Varies depending on the urgency of the surgery because you may not have enough time to give a detailed assessmet - detailed history and physical exam - client understanding of procedure - client understanding of post operative expectation - assess the clients cultural needs and how it might pertain to this particular surgery - personal privacy - presence of family members during pre and post surgery times - question the client regarding feelings about disposal of body parts or blood transfusions - review pre operative instructions to ensure the client has followedthem

The electrodes record from _________ angles on the body.

Various

WHEN PALPATING THE ANTECUBITAL SPACE PRIOR TO A VENIPUNCTURE THE NURSE IS ASSESSING THE TISSUE FOR WHAT?

Veins - spongy Arteries - pulsate Tendons - firm

CAUSES OF HEMOLYSIS

Vigorously shaking tube Needle gauge too small Drawing back too hard on plunger Expelling blood too quickly Exposure to alcohol

Nurse must always assess proper functioning of heating/cooling device Assess temperature of heat/cold application:

Warm and neutral - 93-98F Tepid - 80-93F Cool - 65-80F

A nurse is preparing to administer the first of two large volume cleansing enemas prescribed for a pt in preparation for a diagnostic procedure. What is one of the first appropriate steps for this procedure?

Warm the enema solution prior to insertion

Describe steps for administering a saline (fleets) and a soap suds enema.

Wash the hands thoroughly with soap and warm water for a minimum of 15 seconds before beginning the procedure. Gather the needed materials (enema bag or bulb, lubricant, gloves, enema solution, ramp clamp, and a towel). Warm the solution before placing it into an enema bag or bulb to a temperature between 99 and 106 degrees. Place a towel under the patient to collect any leakage during the procedure. Lay the patient in a position to receive the enema. The ideal positions for enema administration are the right side position, left side position, knee chest position, and on the back. It is advised that the patient remain in one of these positions to receive the enema for one-third of the time. Lubricate the tip of the enema applicator before inserting it into the rectum of the patient. Ensure that the entire length of the enema tip is lubricated and that the opening of the tip remains free from clogs so that the solution flows freely when the time comes to administer the enema. Insert the lubricated enema tip into the patient's rectum and release the enema tubing clamp. Monitor the patient for cramping as the enema solutions flows comfortably into the patient's rectum. Signs of cramping may include abdominal muscle tension. If signs of cramping are notices while monitoring the patient, stop the flow and ask the patient to take several deep breaths. Continue the process once the patient becomes comfortable again. Gently massage the patient's abdominal area. Massage down the left portion of the patient's abdomen then massage from left to right across the lower belly button. Continue to massage up the right portion of the abdomen then massage from right to left under the patient's rib cage. Remove the tip of the enema from the patient's rectum once the device is empty. Ask the patient to remain in the current position until he or she has a strong urge for a bowel movement. The patient may need assistance with walking to the restroom so the nurse should provide this help if needed. Many patients may have the ability to walk to the restroom on their own while the solution is still in the colon. Ask the patient to massage the abdomen while the enema is being expelled from the body. Tell the patient to massage the area under the belly button from right to left, starting on the right side and from left to right under the patient's rib cage. The massaging process helps to loosen fecal matter. Dispose of the gloves used to administer the enema. Wash hands with soap and water after the process is complete.

maxillary sinus location

below zygomatic arch

auscultating tricuspid area

listen w/ diaphragm at right 3rd, 4th, 5th interspaces near sternum

What is objective data?

What you observe and can measure

ADVENTITIOUS an Abnormal lung sound 1?

Wheezing Wheezing is an adventitious lung sound; it is not normal. Tracheal sound, bronchial sound, and vesicular sound are normal lung sounds.

When would a Water seal chest drainage system be used?

When a lung collapes due to excess fluid or blood entering the pleura space (the space between the parital pleura and visceral pleura)

straining urine for stone

When monitoring a PT with kidney stones the pt will have to urinate in a bed pan or "white Hat" or small urinal for men. you collect the pee and strain it looking for any stones to send to the lab

WHEN IS THE TOURNIQUEST LOOSENED?

When there is a good blood flow and the final tube in almost full

WBC

White Blood Cell

WHAT FACTS DOES THE LPN NEED TO KNOW PRIOR TO OBTAINING A BLOOD SPECIMEN?

Why obtaining - to ensure accuracy What type of test - to select right tube

What technique is recommended when obtaining a specimen from an infant?

Wipe away the first drop of blood Apply pressure to stop bleeding No Band-Aids

EFFECTS OF AGING Integumentary system (skin)

With age, skin "sags" and becomes thin, dry, wrinkled Pigmentation problems are common Frequently thinning or loss of hair occurs

While waiting for a sterile procedure to begin, how do you position your hands and arms?

With your hands clasped together in front of your body above waist level

What is the nurses role in informed consent ?

Witness signature and client signed voluntarily. Competent to provide consent. Received necessary information and has any further questions.

Which pain intensity scale is most appropriate for children?

Wong-Baker FACES scale

Commonly irrigated structures include

Wounds, eyes, ears, vagina

Late Entry

Write "late entry" chart as usual, sign and date

hoarse voice: CN affected

X

Radiography

X-ray

Fecal impactions result from retained barium from and intestinal ________________.

X_RAY

What do you do if you see a break in sterile technique during surgery?

You have to say something

How do you know if your needle is in the vein?

You will not see a blood return if using the vacuum system ii. Place your thumb on the bottom of the collection tube and your index and middle fingers on the wings of the adapter iii. At the same time, stabilize the adapter and needle with your other hand (usually non-dominate) iv. Squeeze your thumb and forefingers toward each other a. The rubber stopper will slide onto the needle v. Vacuum pressure is now accessed vi. Blood from the vein will be drawn into the collection tube if you are within the lumen of the vein

assessment

___________ is the systematic collection of facts or data

What is an open drain?

____________ drain- are flat, flexible tubes that provide a pathway for drainage toward the dressing. Draining occurs passively by gravity and capillary action (the movement of a liquid at the point of contact with a solid, which in this case is the drain). ex: pin rose drain

What is a closed drain?

____________ drain- are tubes that terminate in a receptacle. Some examples of the closed drainage systems are the Hemovac and the Jackson-Pratt drain. Closed drains are more efficient than open drains because they pull fluid by creating a vacuum or negative pressure. This is done by opening the vent on the receptacle, compressing the drainage collection chamber, then capping the vent. ex:

focus

________________ assessment is information that provides more detail about specific problems and expands the original database

A patient who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. What kind of pouch should the nurse recommend that will meet the patients requests?

a Kock's pouch

Partial bath

a bath given on days when a complete bath or shower is not done; includes washing the face, hands, underarms, and perineum

How would you decide whether to give your patient a bed bath, tub bath, or shower?

a bed bath is offered to clients who can not take a tub or cannot take a shower

tan

a browning of the skin resulting from exposure to the rays of the sun also by ethnic variation, pregnancy and addisons disease

anesthetic

a chemical agent clients receive prior to a surgical procedure to induce loss of consciousness, amnesia, and analgesia

What are the layers in a specimen tube after it is centrifuged?

a clear solution of blood plasma in the upper phase (which can be separated into its own fractions, see Blood plasma fractionation), the buffy coat, which is a thin layer of leukocytes (white blood cells) mixed with platelets in the middle, and. erythrocytes (red blood cells) at the bottom of the centrifuge tube.

Biofeedback

a client learns to control or alter a physiologic phenomenon (eg, pain, blood pressure, headache, heart rate and rhythm, seizures) as an adjunct to traditional pain management.

macule

a color change, flat, circumscribed of less than 1 cm, ex freckles

granulation tissue

a combination of new blood vessels, fibroblasts, and epithelial cells. beefy red base

What is a bag bath?

a commercially packaged kit with 8-10 premoistented, disposable cloths in a plastic bag or container

Protien

a component of every living cell *made up of amino acids

terminal illness

a condition from which recovery is beyond a reasonable expectation

define brain death

a condition in which there is an irreversible loss of function of the whole brain, including the brainstem

malnutrition

a condition resulting from a lack of proper nutrition in the diet

Brain death

a conditionin hwich there is an irreversible loss of function of the whole brain including the brain stem

Diet History

a detailed record of dietary intake obtainable from 24-hour recalls, food frequency questionnaires, food diaries, and similar sources

Oxygen Analyzer

a device that measures the percentage of delivered oxygen * can measure the oxygen percentage in the air and from the device used to deliver oxygen to the PT

drug tolerance

a diminished effect from the drug at its usual dosage range

You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear?

a face shield

sleep inertia

a feeling of incomplete awakening or grogginess as though still in a sleep state may persist for 15 min or as long as 4 hours this is when your sleep stages are interrupted

Pre-op check list

a form that identifies the status of essential pre-surgical activities

What is the order of draw (order of tubes) when using a syringe?

a. Black isolator or yellow stopper (blood culture) b. Blood culture i. Anaerobic ii. Aerobic c. Blue stopper- contains Na citrate d. Green- contains Na heparin e. Gray- Na fluoride/ Na fluoride and lithium f. Lavender stopper- contains EDTA g. Gold stopper- contains SST clot and gel activator h. Tiger- serum separator i. Red stopper- no additives

ausculatation

listening to sounds within the body

What is a pre-op checklist and what are some things typically included on it?

a form that identifies the status of essential presurgical activities & is completed before surgery. the nurse verifies the following: H & P name of procedure on consent form matches scheduled in OR surgical consent form has been signed and witnessed all lab and diagnostic test results have been returned & reported if abnormal allergies have been identified pt wearing an identification bracelet & allergy bracelet if any make sure pt was NPO since midnight or hours prescribed skin prep vitals assessed & recorded nail polish, glasses, contact lens, and hairpins have been removed jewelry (all) removed dentures removed pt wering only a hospital gown & hair cover pt has urinated location of IV site, type of solution & rate of infusion are identified prescribed preop meds have been given

define death rattle

a gurgling sound heard in a dying persons throat

Fluoroscopy

a kind of x-ray that displays the image in real time observes the media being swallowed or injected

What is rectal tube?

a long slender tube inserted into the rectum to relieve flatulence and contain stool (rectal catheter) and retain for about 20 minutes in a pt with decrease peristalsis, use a preassesment and check abdominal gurth (make sure it goes down), check the WBC, distention and firmness, vasovagal response -- have to tape or hold in place

anorexia

a loss of appetite

vomitting

a loss of stomach contents through the mouth

proliferation

a period during which new cells fill and seal a wound, occurs from 2 days to 3 weeks after the inflammatory phase. It is characterized by the appearance of granulation tissue that forms in the bed of an open wound.

Remodeling

a period during which the wound undergoes changes and maturation, following the proliferative phase and may last 6 months to 2 years

define living will

a person advance, written directive identifying medical interventions to use or not to use in cases of terminal condtions, irreversible comas, vegetative states

define advance directive

a person appointed to make medical decisions if your not able to do so for yourself

define morgue

a place were dead bodies are kept to be claimed or identifed

What is urinary diversion?

a procedure where one or both ureters are surgically implanted elsewhere; life threatening conditions

Resolution

a process by which damaged cells recover and reestablish their normal function

How is a prostate exam performed

a prostate exam is with the patient in the MODIFIED STANDING position where the client stands with the upper half of the body leaning forward

What kind of pt would require a therapeutic phlebotomy?

a pt with polycythemia vera or myasthenia gravis

Ecchymosis

a purplish patch on the skin caused by leaking blood vessels, caused by trauma to soft tissue

multiple draw needle

a retractable sheath over the part of the needle that extends into the evacuated tube

plume

a rising column of smoke, dust, or water from the laser

Dietary guidelines for Americans

a set of recommendations about smart eating 30% grains (whole) 30% veggies 20% fruits 20% protiens (milk and milk products added to that)

What are the Dietary Guidelines for Americans?

a set of recommendations for healthful eating and active living Total fat: less than 65 grams Saturated fat: less than 20 grams Cholesterol: less than 300 mg Sodium: less than 2,400 mg Total carbohydrates: 300 g Dietary fiber: 25 g

renal impairment

a sign of impending death low caridac output causes urine volume to deminish and toxic waste product to accumulate

Gastrointestinal distrubance

a sign of impending death peristalsis slows down tht causes gas and intestinal content to accumulate can stimulate vomitting and nausea

musculoskeletal changes

a sign of impending death reflexes become hypoactive, losing urinary and rectal sphincter muscle control. jaw and facial muscles relax, tongue falls to the back of the throat and respiration becomes noisy (death rattle)

Sleep apnea

a sleep disorder where the person stops breathing or slows breathing for 10 seconds or more at a time more than 5 times an hour

dementia

a slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes

What is an ileostomy?

a surgical operation in which a piece of the ileum is diverted to an artificial opening in the abdominal wall.

what is central nervous system alterations?

a symptom of impending death with hypoxia the brain is less sensitive to accumulating levels of carbon dioxide so: the patient experiences periods of apnea, their pain preception may be deminished, the senses may become impaired, hearing seems to last longest but they eventually become insensitive to all by extreme pressure

Hypnosis

a therapeutic technique in which a person enters a trance-like state resulting in an alteration in perception & memory

respite care

a type of care provided for caregivers of homebound ill, disabled, or elderly patients helps give relif for the care giver to be able to run errands outside the house

Nursing guidelines for obtaining a sterile urine specimen

a urine specimen can be collected under sterile conditions using a catheter, but usually done when clients are catheterized for other reasons such as to control incontinence in an unconscious client -already catheterized nurse clamps the drainage tube for 30 min and then aspirates a sample through the lumen of a latex catheter or from a self-sealing port that has been cleaned with an alcohol pad

L

liter

sensory responses: discrimination: 2 pt discrimination

a) Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion. b) Use an opened paper clip to touch the patient's finger pads in two places simultaneously. c) Alternate irregularly with one point touch. d) Ask the patient to identify "one" or "two." e) Find the minimal distance at which the patient can discriminate

Dietary sources for Vitamin K

liver eggs leafy greens syntesiszed in the GI tract by bacteria

What constitutes elder abuse?

a. Abuse may be Physical, Psychological, Social, and Material i. Physical- in the form of beatings ii. Psychological- in the form of threats iii. Social- in the form of abandonment or unreasonable confinement iv. Material- in the form of theft or mismanagement of money

What is included in managing day-to-day patient care?

a. Assessing staff capabilities b. Diagnosing patient needs for nursing care c. Planning and delegating patient care d. Implementing assignments e. Evaluating performance

CN VII

facial mixed motor: facial expressions, close eye and mouth sensory: front 2/3 tongue parasympathetic: saliva and tear secretion

steps for irrigating a wound.

a. Assessment i. Check the medical order for a directive to irrigate the wound ii. Determine how much the client understands about the procedure b. Planning i. Plan to irrigate the wound at the same time that the dressing requires changing ii. Gather the equipment required, which is likely to include a container of solution, a basin, a bulb or Asepto syringe, gloves, absorbent material including a towel to dry the skin iii. Bring supplies for changing the dressing iv. Consider additional items for standard precautions such as goggles or face shield and cover apron or gown. c. Implementation i. Wash your hands or use an alcohol-based hand rub ii. Pull the privacy curtain iii. Drape the client to expose the area of the wound iv. Follow directions in Skill 28-1 for removing the dressing v. Wash your hand or repeat the alcohol-based hand rub vi. Position the client to facilitate filling the wound cavity with solution vii. Pad the bed with absorbent material and place an emesis basin adjacent to and below the wound viii. Open and prepare supplies following the principles of surgical asepsis ix. Put on gloves and other standard precautions apparel. x. Fill the syringe with solution and instill it into the wound without touching the wound directly xi. Hold the emesis basin close to the client's body to catch the solution as it drains from the wound xii. Repeat the process until the draining solution seems clear. xiii. Tilt the client toward the basin xiv. Dry the skin xv. Dispose of the drained solution, soiled equipment, and linens xvi. Remove gloves, wash hands, and prepare to change the dressing

steps for setting up sterile a field and adding to a sterile field.

a. Assessment i. Inspect the work area to determine the cleanliness and orderliness of the surface on which you will work ii. Obtain the prepared package that contains items needed for performing the clinical procedure iii. Check that the package is sealed and that its use date has not expired iv. Determine whether additional sterile items are needed but not contained in the sterile package. b. Planning i. Explain what is about to take place to the client ii. Plan to perform the procedure that requires a sterile field when the client is comfortable and there are no potential interruptions iii. Remove objects from the area where the field will be created. c. Implementation i. Perform hand washing or hand antisepsis with an alcohol-based rub ii. Place the wrapped package on a surface at or above waist level. iii. Position the package so that the outermost triangular edge of the wrapper can moved away from front of the body. iv. Unfold each side the wrapper by touching the area that will be indirect contact with the table or stand, or touch no more than the outer 1 inch of the edge of the wrapper v. Unfold the final corner of the wrapper by pulling it toward the body vi. Add additional wrapped sterile items by unwrapping them, securing the edges of the wrapper in one hand, and placing them on the sterile field vii. Add additional paper-wrapped sterile items by separating the sealed flaps and dropping the contents onto the sterile field viii. Add a sterile solution to a sterile container, if it is needed, by: Opening the cap on the solution without touching the inner surface with anything that is unsterile ix. Holding the labeled portion of the solution in the palm of the dominant hand x. Pouring and discarding a small amount into a waste container xi. Pouring the amount desired from a height of 4 to 6 inches into the container on the sterile field without splashing the surface of the field.

Review the Nursing Care Plan for acute pain.

a. Assessment- i. Determine the source of the client's pain: when it began; its intensity, location, characteristics; and related factors such as what make s the pain better or worse ii. Ask how the client' pain interferes with life such as diminishing the person's ability to meet his or her own needs for hygiene, eating, sleeping, activity, social interactions, emotional stability, concentration, and so on. iii. Identify at what level the client can tolerate pain. iv. Measure the client's vital signs. v. Note pain-related behaviors such as grimacing, crying, moaning, and assuming a guarded position. vi. Perform a physical assessment, taking care to gently support and assist the client to turn as various structures are examined. Use light palpation in areas that are tender. Show concern when assessment techniques increase the client's pain. Post-pone nonpriority assessments until the client's pain is reduced. b. Interventions- i. Assess the client's pain and its characteristics at least every 2 hours while awake and 30 minutes after implementing a pain management technique. ii. Modify or eliminate factors that contribute to pain such as a full bladder, uncomfortable position, pain-aggravating activity, excessively warm or cool environment, noise, and social isolation. iii. Determine the client's choice for pain relief techniques form among those available iv. Administer prescribed analgesics or alternative pain management techniques promptly v. Advocate on the clients' behalf for doses of prescribed analgesics of the addition of adjuvant drug therapy if pain is not satisfactorily relived. vi. Administer a prescribed analgesic before a procedure or activity that is likely to result in pain or intensify pain that already exists. vii. Plan for periods of rest between activities.

steps for changing a gauze dressing.

a. Assessment- i. Inspect the current dressing for drainage, integrity, and type of dressing supplies used ii. Check the medical orders for a directive to change the dressing iii. Determine if the client has allergies to tape or antimicrobial wound agents iv. Assess the client's level of pain and its characteristics b. Planning- i. Explain the need and technique for changing the dressing ii. Consult the client on a preferred time for the dressing change if there is no immediate need for it iii. Give pain medication, if needed, 15-30 minutes before the dressing change iv. Gather the necessary supplies, which are likely to include a paper bag for the soiled dressing, clean and sterile gloves, individually packaged gauze dressings, tape, and, in some cases, an antimicrobial agent such as povidone-iodine swabs for wound cleansing. c. Implementation- i. Wash your hands or use an alcohol-based rue ii. Pull the privacy curtain iii. Position the client to allow to the dressing iv. Drape the client to expose the area of the wound v. Loosen the tape securing the dressing; pull the tape toward the wound vi. Put on at least one glove and lift the dressing from the wound vii. Moisten the gauze with sterile normal saline if it adheres to the wound viii. Discard the soiled dressing in a paper bag or other receptacle along with the gloves ix. Wash your hands again or repeat the alcohol-based hand rub x. Tear several long strips of tape and fold the ends over, forming tabs xi. Open sterile supplies using the inside wrapper of on of the gauze dressing as a sterile field, if needed. xii. Put on sterile gloves. xiii. Inspect the wound xiv. Cleanse the wound with the antimicrobial agent xv. Use a technique that prevents transferring microorganisms back to a cleaned area. xvi. Use a single swab or a small gauze square for each stroke xvii. Allow the antimicrobial agent to dry. xviii. Cover the wound with the gauze dressing xix. Secure the dressing with tape in the direction of the incision or across a joint. Place a strip of tape at each end of the dressing and in the middle if needed. xx. Remove and discard gloves xxi. Rewash hands or repeat the alcohol-based hand rub.

Describe an authoritarian leader versus a democratic leader.

a. Authoritarian or autocratic leader- is one who is primarily concerned that tasks are accomplished. The authoritarian leader usually dictates what the work is and how it is be done. b. Democratic leader- encourage staff participation and often consults and collaborates with staff. The democratic leader encourages participation in decision making.

what is needed for a patient to be admitted to the hospital or health care agency?

a. Authorization from a physician that the person requires specialized care and treatment b. Collection of billing information by the admitting department of the health care agency c. Completion of the agency's admission database by nursing personnel d. Documentation of the client's medical history and findings from physical examination e. Development of an initial nursing care plan f. Initial medical orders for treatment

What do you do if you see a hematoma forming?

a. Best intervention is to remove the tourniquet and needle and apply firm pressure to the site. b. By adjusting the depth of the needle, it may be possible to stop the hematoma from enlarging.

lateral

further from midline of body

What is a butterfly needle and when would you use one?

a. Butterfly needles (usually 21-G ¾" x 12) i. Used to administer fluids/meds but may be used to collect blood from patients with difficult veins to access ii. Place butterfly then use a syringe or evacuated tube to withdraw blood from vein

What would you do if you have an order for a blood draw and the patient is not in their room?

a. Check with assigned nurse to locate the patient i. Draw blood from the patient in the new location (note room change on requisition form and on the tube of blood) b. Make a note "why" on the requisition form if unable to collect the specimen i. Inform the nurse or charge nurse

How do you obtain a microcapillary specimen?

a. Collect blood in appropriate microcapillary tubes (volume of each is usually < 1 ml) i. Keep capillary tube parallel to puncture site to avoid air bubbles, when full to line, seal with critoseal ii. Allow blood to flow into microtainers using capillary action, tap container as needed to move blood into microtainer, when full to line, seal and gently rotate to mix with additives

Identify Common community services that are used as referrals?

a. Commission of aging- assists older adults with transportation to medical appointments, outpatient therapy, and community meal sites b. Hospice- supports the family and terminally ill clients who choose to stay at home c. Visiting Nurses' Association- Offers intermittent nursing care to home bound clients d. Meals on Wheels- Provides one or two hot meals per day delivered at home or at a community meal site e. Homemaker Services- Sends adults to the home to assist in shopping, meal preparation, and light housekeeping f. Adult protective services- Investigates and pursues accountability of individuals who are physically, socially, emotionally, or financially victimizing vulnerable adults g. Respite care- Provides short-term, temporary relief to full-time caregivers of home bound clients h. Older Americans' Ombudsman- Investigates and resolves complaints made by or on behalf of nursing home residents; at least one full-time ombudsman is mandated for each state

What are the common patient responses to admission and the nursing interventions that address these responses?

a. Common reactions include anxiety, loneliness, decreased privacy, and loss of identity. b. Anxiety interventions- i. Encourage the client to use methods that have successfully relieved anxiety in the past ii. reduce external stimuli such as bright lights, noise, sudden movement, and unnecessary activity iii. maintain a calm manner when interacting with the client iv. take a position at least an arm's length away from the client v. avoid touching the client without first asking permission vi. Establish trust by being available to the client and keeping promises vii. Advise the client to seek out the nurse or another supportive person when feeling heightened anxiety viii. Stay with the client during periods of severe anxiety ix. Follow a consistent schedule for routine activities x. Encourage the client to identify what he or she perceiver to be a threat to emotional equilibrium xi. Use a soft voice, short sentences, and clear messages when exchanging information xii. Provide specific, succinct directions for task the client should complete or assist the client who becomes agitated xiii. Instruct and help the client with moderate or severe anxiety to perform one or more or the following until anxiety is within a tolerable level: 1. Count slowly backward from 100 2. Breathe slowly and deeply in through the nose and out through the mouth 3. Offer a warm bath or back rub xiv. Help the client to progressively relax groups of muscles form the toes to the head xv. Suggest that the client repeat positive statements such as, "I am relaxed," "I am in control", "I am safe" xvi. Encourage the client to visualize a pleasant, relaxing place xvii. Have the client listen to a relaxation tape or soothing music xviii. Advise the client to reduce dietary intake of substances that contain caffeine such as colas and coffee. c. Loneliness- Act as temporary surrogates and should make frequent contact with the client. d. Decreased Privacy- The nurse closes room doors unless safety issues require observation. Always shield clients form the view of others when giving personal care. The nurse knocks and asks permission to enter. e. Loss of Identity- Nurses learn and use the client's first name and surname. First names only at the client's request. Encourage clients to display pictures or other small personal objects that reaffirm their unique life and personality.

How would the nurse promote effective communication and create a sense of self-dignity in the older patient?

a. Create a sense of self-dignity in the older patient by promoting hygiene and Symptoms are fatigue, irritability, loss of interest in surroundings, decreased ability to concentrate, or feelings of worthlessness. b. grooming. The clients feel better about themselves when their hair is neatly arranged, their skin is clean and healthy, and they are dressed attractively. c. Effective communication- involves stimulating the older adult to talk about past experiences and events. Referred to as reminiscence therapy and is a good technique for reinforcing self-esteem. Older adults have the need to talk about past events, achievements, and losses. Asking them to recall their personal history encourages communication between the older adult, health care personnel, and the family. d. Validation therapy is a method used to communicate with the elderly who are confused, disoriented, and act out in inappropriate ways because of permanent and progressive loss of cognitive ability.

What are the psychosocial issues of the older adult?

a. Depression and the potential for suicide in older adults b. Nurse assesses for signs of increased alcohol consumption, decreased interest in friends and social activities, complaints of fatigue, anger, and feelings of hopelessness.

What does the discharge process consist of?

a. Discharge process consist of establishes the anticipated knowledge, skills, and community resources that the client will need to maintain a safe level of self-care. b. Method is a one discharge planning technique. i. M- Medications ii. E- Environment iii. T- Treatments iv. H- Health teaching v. O- Outpatient referral vi. D- Diet

What does a peripheral blood smear monitor?

a. Done to asses and aid diagnosis i. Abnormal red cell morphology and count ii. Characteristic of certain disease states such as sickle cell anemia iii. Varity and proportion of WBC

What is the purpose of a wound dressing?

a. Dressing - the cover over a wound b. Purposes are the following: i. Keeping the wound clean ii. Absorbing drainage iii. Controlling bleeding iv. Protecting the wound from further injury v. Holding medication in place vi. Maintaining a moist environment.

amt

amount

Which dressing is ideal for covering fresh wounds that are likely to bleed? a. Gauze b. Transparent c. Hydrocolloid d. Tape

a. Gauze

What technical errors can happen when drawing blood?

a. Hematoma, short draw, or less common complications such as Petechiae, edema, or obesity.

Why would a specimen be rejected by the lab?

a. Hemolysis b. Clots c. Short draw d. Clerical discrepancies e. Too much blood f. Wrong collection tube g. Improper transport

What are infectious and non-infectious bodily substances?

a. Infectious bodily substances- i. Blood and blood products ii. Semen iii. Vaginal secretions iv. Cerebrospinal fluid v. Synovial fluid vi. Pleural fluid vii. Peritoneal fluid viii. Amniotic fluid ix. All moist body substances whether or not they contain visible blood 1. Feces 2. Urine 3. Sputum 4. Wound drainage b. Non-bodily substances- (unless blood is present) i. Sweat and tears

What are the various types of admissions?

a. Inpatient b. Outpatient

What do you assess when selecting a vein?

a. Knotting or inflammation of vein

How do you assess staff capabilities?

a. Know the functions all team members are legally permitted to perform, their educational preparation, how long they have been working in their positions, and what technical and interpersonal skill they have. The functions your staff is permitted to perform are defined by the nurse practice laws of your state and are also outlined in job descriptions developed by employers.

What tests is each common type of tube used for?

a. Lavender- contain anticoagulant EDTA that prevents blood from clotting by binding calcium. i. Used to collect hematology specimens b. Blue stopper tubes- contain sodium citrate that prevents coagulation by binding Ca) must have exact vol. of blood for accuracy c. Green stopper tubes- contain anticoagulant sodium heparin or lithium heparin, inactivates thrombin and thromboplastin d. Gray stopper tubes- contains Na fluoride/ or Na fluoride and lithium that is combined w/ K oxalate which inhibits clotting by binding calcium. e. Yellow stopper- contain ACD (acid-citrate-dextrose), may also contain SPS (sodium anethole sulfonate) that binds with Ca. f. Red stopper- contains no additives g. Tiger stopper- no anticoagulant h. Black and dark blue stopper- contain variety of additives; find out what additive present before using i. Black isolator tubes are used for blood cultures i. Light green- contain PST gel and lithium heparin j. Gold- contains SST clot and gel activator

What is the order of draw (order of tubes) when using a vacuum tube system (vacutainer)?

a. May vary depending on institution's policy i. Black isolator or yellow (used for blood cultures- contains SPS Na polyanetholesulfonate) ii. Blood cultures 1. Aerobic 2. Anaerobic iii. Red- no additives iv. Gold stopper - contains SST clot and gel activator v. Blue- contains Na citrate - PT (prothrombin time), PTT vi. Green- contains Na heparin or Na lithium vii. Gray- contains Na fluoride or Na fluoride and lithium- glucose viii. Lavender- contains EDTA- use for CBC- always Drawn last

Describe different types of power?

a. Power- is the ability to control, influence, or hold authority over an individual or group. b. Reward power- which a person attains through the ability to grant favors or rewards. c. Coercive or punishment power- is the ability to threaten or punish someone who fails to meet expectations. d. Legitimate power- through a designated position, which also may be referred to as authority. e. Expert power- results from knowledge, expertise, or experience in a particular area. f. Referent power- concerns the power a person has because of his or her association with others who are powerful. Also may be called charismatic power, referring to personal characteristics such as charisma. g. Informational power- which exists when a person has information that others need to accomplish certain goals. h. Connection power- involves the use of networking or involving more than one person to work collaboratively toward a common goal.

Nursing guidelines for managing pain.

a. Never doubt the client's description of pain or need for relief. b. Follow the written medical orders of administering pain medications c. Administer pain-relieving drugs as soon as the need becomes evident. d. Consult the physician if the current drug therapy is not controlling the client's pain e. Collaborate with the physician to develop several pain-management options involving combinations of drugs, alternative routs of administration, and different dosing schedules. f. Support the formation of an interdisciplinary pain management team who can be consulted on hard to manage pain problems. g. Administer pain medication before an activity that produces or intensifies pain. h. When the client's pain is continuous, administer analgesic drugs on a scheduled basis rather than irregularly. i. Monitor for drug side effects such as respiratory depression, decreased levels of consciousness, nausea, vomiting, and constipation. j. Consult the professional literature or expert s on the equi-analgesic dose. k. Change the client's position, elevate a swollen limb to reduce swelling, loosen a tight dressing, and assist the client with bowel or bladder elimination. l. Implement independent and prescribed nondrug interventions, such as client teaching, imagery, meditation, distraction, and TENS, as additional techniques for pain management. m. Allow rest periods between activities.

What would you do if a patient refuses to have their blood drawn?

a. Note on requisition form- return to lab b. Document in nurses' notes/ notify the nurse c. Notify physician

Describe what is occurring during each unit of the ECG:

a. P Wave-atria contracting b. QRS Complex-ventricles contracting c. T Wave-time until repolarization d. flat line-not contracting

How might a nurse help a patient combat loneliness?

a. Pets serve as family substitutes, provide comfort, and decrease feelings of loneliness. b. Hobbies or other special interest and social contacts help older adults cope c. Become involved in community volunteer work or take advantage of activities and meeting places specifically for older adults. d. Community meal sites and senior centers try to meet the older adult's needs for companionship by providing opportunities for socialization.

What is a referral and what does it promote?

a. Referral- is the process of sending someone to another person or agency for special services b. Promotes continuity of care and avoid any loss of progress that has been made.

What physiological changes occur in the following of older adults? What are the implications for nursing care related to these changes?

a. Respiratory- i. costal cartilages that connect the ribs to the sternum become hardened or calcified. ii. Make it difficult for the rib care to expand and contract as it normally does during inspiration and expiration; the ribs gradually become fixed to the sternum, and chest movements become difficult; when this occurs, the rib cage remains in a more expanded position, respiratory efficiency decreases, and a condition called "barrel chest" results. b. Urinary- i. Number of nephron units in the kidney decreases by almost 50% between the ages of 30 and 75. Less blood flows through the kidney as an individual age, there is a reduction in overall function and excretory capacity of the ability to produce urine. Bladder significant age-related problems often occur because of diminished muscle tone. ii. Muscle atrophy (wasting) in the bladder wall results in decreased capacity and inability to empty or void completely. c. Musculoskeletal- i. Bones undergo changes in texture, degree of calcification, and shape. Older bones develop indistinct and shaggy-appearing margins with spurs which this type of degrative change restricts movement because of the piling up of bone tissue around the joints. ii. Changes in calcification may result in reduction of bone size and in bones that are porous and subject to fracture. The lower cervical and thoracic vertebrae are the sites of frequent fractures. The result is curvature of the spine and the shortened stature so typical of late adulthood. Degenerative joint diseases such as osteoarthritis are also common in elderly adults. d. Integumentary- i. With advancing age the skin becomes dry, thin, and inelastic. ii. Pigmentation changes and the thinning or loss of hair are also common problems associated with the aging process. e. Gastrointestinal/elimination systems- i. Constipation is more likely in those who are immobile, who fail to drink sufficient fluids, or whose diet lacks sufficient bulk. ii. Help the client maintain adequate fiber and fluid intake and having a regular time for evacuation helps restore regularity.

S/s of wound infection.

a. Signs of wound infection include pus, spreading redness, increased pain or swelling, and fever b. A break in the skin (a wound) shows signs of infection c. Includes infected cuts, scrapes, sutured wounds, puncture wounds and animal bites d. Most dirty wounds become infected 24 to 72 hours later e. Pus. Pus or cloudy fluid is draining from the wound. f. Pimple. A pimple or yellow crust has formed on the wound. g. Soft Scab. The scab has increased in size. h. Red Area. Increasing redness occurs around the wound. i. Red Streak. A red streak is spreading from the wound toward the heart. j. More Pain. The wound has become very tender. k. More Swelling. Pain or swelling is increasing 48 hours after the wound occurred. l. Swollen Node. The lymph node draining that area of skin may become large and tender. m. Fever. A fever occurs. n. The wound hasn't healed within 10 days after the injury.

Nursing guidelines for sitz bath

a. Sitz bath- a soak of the perianal area. b. Obtain disposable equipment unless specially installed tube is available. c. Inspect and clean the bathroom area or the tub room. d. Fill the container with warm water, no hotter than 110 F. e. Hang the bag above the toilet seat. f. Help the client pat the skin dry after soaking for 20-30 minutes.

What can cause hemolysis of a blood specimen?

a. Technical i. Vigorously shaking the tube of blood ii. Using too small a needle iii. Drawing too hard on the syringe plunger iv. Expelling blood too quickly through syringe into the collection tubes v. Allowing the specimen to overheat vi. Introduction of alcohol (used for cleaning the site) into the vacuum tube b. Physiological i. Transfusion reaction ii. Autoimmune hemolytic anemia iii. Paroxysmal nocturnal hemoglobinuria iv. Disseminated intravascular coagulation

examples of stimulant drugs

amphetamines amphetamine-like caffeine nicotine

define EEG

an examination of the energy emitted by the brain

What are the developmental tasks of older adults?

a. The developmental state is ego integrity versus despair. i. Ego integrity is the felling of personal satisfaction that life has been happy and fulfilling ii. Despair, on the other hand, results when a person views life as disappointing and unfulfilling and anguishes over what might have been. b. The developmental tasks of the older adults are the following: i. Adjustment to the physical limitations brought about by aging ii. Find satisfaction in retirement iii. Secure acceptable living arrangements iv. Develop meaningful social relationships v. Adjust to losses accompanying aging vi. Recognize meaning in one's life vii. Accept and prepare for one's own death

Describe objective versus subjective signs/symptoms of pain?

a. There are no objective s/s of pain and no perfect way for determining whether pain exists and how severe it is. The different pain intensity assessment tools are used to quantify a client's pain. b. Subjective s/s- observe for behavioral signs that are common nonverbal indicators of pain, such as moaning, crying, grimacing, guarded position, increased vital signs, reduced social interactions, irritability, difficulty concentrating, and changes in eating and sleeping. ANS responses such as tachycardia, hypertension, dilated pupils, perspiration, pallor, rapid and shallow breathing, urinary retention, reduced bowel motility, and elevated blood glucose levels may be apparent.

What are some kinds of special handling that different specimens might need?

a. Transmission based- i. Airborne- door closed, handwashing, mask 1. Pulmonary tuberculosis 2. Measles (rubeola) ii. Droplet- door open or closed, mask 1. Influenza 2. Rubella 3. Streptococcal pneumonia 4. Meningococcal meningitis iii. Contact- gloves, gown, leave equipment in room 1. G.I. respiratory, skin, or wound infections that are drug resistant 2. Gas gangrene 3. Acute diarrhea 4. Acute viral conjunctivitis 5. Draining abscess

What is the most common complication for phlebotomy?

a. Uncooperative clients i. If client too old or young to understand what is going on and will probably resist or struggle, do not attempt to perform the venipuncture alone. ii. Take precautions to ensure the safety client and yourself 1. May hold a child on your lap with arm outstretched and held with one of your hands, while the other arm encircles the child's chest and restrains the other hand. iii. Reassure the client iv. Clients may refuse the procedure 1. Try to persuade the client to allow you to collect the blood sample. a. Point out why test is needed by the physician i. To properly manage the client's illness ii. Never attempt to force, either physically or with threat v. If client continues to refuse the blood collection 1. Note on requisition form - return to lab 2. Document in nurses' notes/ notify the nurse 3. Notify physician b. Medical/ physiological complications i. Syncope (fainting) 1. Caused from a. Fatigue a. A sudden decrease in blood volume 2. Cardiac arrhythmia 3. Hypoglycemia 4. Hyperventilation 5. Psychological causes - Site of blood or needles a. Most often cause when syncope occurs during venipuncture ii. Prevention 1. Observe client before phlebotomy a. Acting nervous or hyperventilation? b. Engage in conversation to keep client's mind off the procedure i. After venipuncture, ask the client how he or she feels ii. Never perform venipuncture with a client standing c. If your client faints i. If sitting in a chair before venipuncture is done, put the client's head between his or her knees 1. Cold compress on back of neck may help 2. Ammonium salts are strong and should be used with care 3. Stay with client 4. Once recovered have client lie down for the venipuncture a. Clients who are lying down very seldom feel faint b. If client feels faint after the venipuncture has been started i. 1. Remove the tourniquet ii. Carefully remove the needle iii. Apply pressure to the site iv. Support the client v. Call for help

What do you need to know before obtaining a specimen?

a. Why obtaining specimen i. Ensure accurate tests ii. Results used to diagnose the patient's illness b. What type of test i. Obtain appropriate collection tube test may require- depending on type of sample needed 1. WBC 2. RBC 3. Plasma a. Plasma made of water, nutrients, gases, waste materials, and electrolytes, clotting factors, antibodies and hormones.

sensory responses: discrimination: GRAPHESTHESIA

a. With the blunt end of a pen or pencil, draw a large number in the patient's palm. b. Ask the patient to identify the number

V trigeminal: test temporal masseter muscle strength

a. ask pt to both open mouth and clench teeth b. palpate temporal masseter muscles as they do this

V trigeminal: test corneal reflex (normally not checked unless specific concerns)

a. ask pt to look up and away b. from the other side, touch the cornea lightly w/ fine wisp of cotton c. look for normal blink reaction of BOTH eyes d. repeat on the other side 3. use of contact lens may decrease this response

V trigeminal: test 3 divisions for pain sensation

a. explain what you intend to do b. use suitable sharp object to test the forehead, cheeks, and jaw on both sides c. substitute blunt object occasionally and ask pt to report "sharp" or "dull" d. if you find abnormality then: test 3 divisions for temp sensation w/ turning fork heated or cooled by water e. test 3 divisions for sensation to light touch using a wisp of cotton

VIII - acoustic: initial test

a. face pt, hold out arms w/ fingers near each ear b. rub fingers together on one side while moving fingers noiselessly on other c. ask pt to tell you when and on which ear they hear rubbing d. increase intensity as needed and note any asymmetry e. test hearing w/ normal voice and whispers ***if abnormal, proceed w/ Weber and Rinne tests

VIII - acoustic: test for lateralization WEBER test

a. not used as often as in past b. use 512 Hz or 1024 Hz tuning fork c. start fork vibrating by tapping on opposite hand d. place the base of the tuning fork firmly on top of the patient's head e. ask pt where the sound appears to be coming from (normally in the midline) f. normal is to hear equally in bone ears. If louder in one ear, it is abnormal. Abnormal indicates conductive hearing loss in that ear or sensory hearing loss in opposite ear

VIII - acoustic: compare air and bone conduction (Rinne)

a. screening tool - not used as often as in past b. use a 512 Hz or 1024 Hz tuning fork c. start fork vibrating by tapping it on opposite hand d. place the base of the tuning fork against the mastoid bone behind the ear e. when pt no longer hears the sound, hold the end of the fork near the patient's ear (air conduction is normally greater than bone conduction) f. normal (positive result) = hearing sound still once moved behind mastoid bone. Abnormal = not hearing the sound, usually indicates conductive hearing loss

sensory responses: discrimination: stereognosis

a. use as alternative to graphesthesia b. place familiar object in pt's hand (paper clip, coin, etc) c. ask pt to tell you what it is

Standard documentation: use of abbreviations, military time, etc.

abbreviations need to be agency approved and Traditional time Two 12-hour revolutions; identified with hour and minute, followed by a.m. or p.m. Military time Based on 24-hour clock; uses different four-digit number for each hour and minute of the day First two digits indicate hour within 24-hour period Last two digits indicate minutes

abd

abdomen

CN VI

abducens motor: lateral eye movement

What is artifact?

abnormal appearance due to external distortion

hirsutism

abnormal facial hair growth, esp on woman

What is anuria?

absence of urine, or up to a 100 mL volume in 24 hours

tendon reflex grading scale: 0

absent

What is flatulence?

accumulation of intestinal gas

CN VIII

acoustic sensory: hearing and equilibrium

A patient has a healthcare associated infection (HAI). This terminology means that the patient

acquired the infection while hospitalized

What is medication reconciliation?

act of obtaining and verifying medications a client is currently taking

Universal Precautions

actions taken to prevent the spread of disease by treating all blood and other body fluids as if they contained pathogens

isotonic exercise

activity that combines muscle contraction with repeated movement

LDL cholesterol

bad. Low Density Lipoprotein. low protein, high fat

neurologic examination: general notes--CEREBELLUM

gait coordination balance etc.

Describe general anesthesia. Nursing guidelines for caring for a patient under general anesthesia (what needs to be monitored?).

acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. throughout the duration of the and recovery the client is closely monitored for effective breathing and oxygenation; effective circulatory status, including BP, P WNL and effective T regulation and adequate fluid balance. ADM via inhaled gas!

general anesthesia

acts on the central nervous system to produce loss of sensation, reflexes, and consciousness

Types of exercise

aerobic, anaerobic, isometric, isotonic, isokinetic

When should pre-op medications be administered?

after client signs the consent form and has asked all their questions and after the client has been dressed and prepped

p.c.

after meals

p.c.

after meals (post cibum)

Ice collars applied for?

after tonsil removal

When should the nurse administer the pre-op medications?

after using 2 methods of identifiers to identify the patient and when they are ordered

AMA

against medical advice

What is AMA?

against medical advice

AMA

against medical advice form when the patient leaves before the physician authorizes discharge - if your patient wants to leave then you have to offer and AMA for them to sign and if they refuse to sign then you need to make sure to note their records

Health History:

age use of drugs or alcohol current med history use of complimentary or alternative practices medical history hearing aids, glasses, contacts, loose teeth, crowns, caps, dentures prior surgery NPO status retained hardware or metal autologous transfusion allergies general health fam history type of surgeries knowledge about perioperative period adequacy of patients support system communication assessment assess patients readiness to learn religion herbal products

Diminished mobility requires

aggressive skin care to prevent pressure ulcers

atelectasis

airless collapsed lung areas

What are the 4 highest priority post-op complications in the immediate post-op period?

airway conclusion shock hypoxemia/adynamic ileus hemorrhage

postoperative top 4 complications

airway occlusion shock hemmorrhage hypoxemia/adynamic ileus

pathologic grief

aka: dysfunctionl grief when a person can't accept someone's death

Non-rebreather mask

allows higher levels of oxygen to be added to the air taken in by the patient

Trapeze Bar

allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises

What are common side-effects for opioid analgesics?

almost all NSAIDs cause gastrointestinal irritation and bleeding, so they should be given with food

define pathologic grief

also called dysfunctional grief, a person cannot accept someones death

What is a pressure ulcer?

also referred to as a decubitus ulcer, is a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue

What are the steps for shaving a patient?

always ask about patients preferences first use a safety razor or electric razor, prepare basin with warm water, soap and a face cloth, and towel. wash the skin with warm soapy water, lather the skin with soap/shaving cream, begin at the upper areas of the face and work down, pull skin taut below area to be shaved, pull razor in the direction of hair growth, use short strokes, rinse the razor after each stroke, rinse face, apply direct pressure to areas that bleed, then last apply aftershave lotion, cologne or cream to the area

What are proteins made of?

amino acids which are composed of chemical compounds: nitrogen, carbon, hydrogen, and oxygen

A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the pt that his entire large intestine and rectum will be removed. The nurse should explain the kind of ostomy he will have is...

an ileostomy

-gram

an image

What is MyPlate?

an improved simplified tool for promoting a healthful daily intake of food

pain

an unpleasant sensation usually associated with disease or discomfort or injury

Early discharge planning

and appropriate community resources may return older adults to own homes

What are opioids?

and opiate analgesics are controlled substances such as narcotic drugs, synthetic narcotics ex: morphine sulfate codeine sulfate meperidine (demerol) fentanyl (durgesic, sublimaze)

vitamin B 12 is a lack of what?

anemia is a condition in which your body doesn't have enough healthy red blood cells because of a lack of vitamin B-12. This vitamin is needed to make red blood cells. These cells carry oxygen to all parts of your bod

Dietary sources for Vitamin A

animal fats fish livear dark green leavy veggies deep orange fruits ad veggies

hard palate location

anterior part of mouth

___________________ data are measurements pertaining to body size and composition

anthropometric

What are the most common reasons of patient movement during an ECG?

anxiety cold talking restless

What are some physiological indicators of pain?

anxiety depression despair even suicide

general assessment: appearance

appears to be reported age sexual development appropriate A&O facial features symmetrical no signs of acute distress

A nurse who is preparing to insert a straight urinary catheter for a male patient should

apply light traction to the penis

approx

approximately

What are the Daily Value (DV's) based on

are calculated in percentages based on standards set for Total Fat, Saturated Fat, Cholesterol, Sodium, Carbs, and Fiber in a 2000 - cal diet

Transparent dressings

are clear acrylic film wound coverings (such as OpSite r Tegaderm). One of their chief advantages is that they allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and to not require tape because they consist of a single sheet of adhesive material. Commonly are used to cover peripheral and central intravenous insertion sites.

Pets

are integral social support system

gauze

are made of woven cloth fibers. Their highly absorbent nature makes them ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. Gauze dressing usually are secured with tape.

what are carbohydrates?

are nutrients that contain molecules of carbon, hydrogen, and oxygen an are generally found in plant food sources

Hydrocolloid dressings

are self-adhesive, opaque, air- and water-occlusive wound coverings (such as DuoDerm and Tegasorb).

What is an informal evaluation and when is it typically done?

are those that occur almost daily. Evaluation of staff member; do patients have any comments on their nursing care; are procedures being done properly; are assignments being completed on time; are break and meal times being followed; discussing poor performance with a staff member (private place).

What is a formal evaluation and when is it typically done?

are written and include an assessment of an employee's overall performance over a period of time, usually a year. Assessment employee's overall performance, basis for an increase in salary

abrasion

area that has been rubbed away by friction

Disposition of prosthesis

artificial limbs are removed unless otherwise ordered partial or full dentures sometimes are removed

ad lib

as desired

PRN, ad lib

as needed, as desired

What is recommended when providing grooming for a patients hair?

as often as needed to keep it clean, wide combs, avoid hair pins, oil and apply conditioner and a hairstyle the patient prefers

Depression, poor appetite, cognitive impairments, and physical/economic are

barriers that interfere with adequate nutrition; may impair wound healing

BRP

bathroom privileges

Nursing management for end-of-life care (see med/surg ch. 10).

assessing needs, controlling pain, facilitating breathing administering food, and fluids, reg temps, maintaining skin and tissue integrity, assisting w/ self-care and activity, promoting sleep, facilitating elimination, addressing fear, social isolation, hopelessness and powerlessness, facilitating grieving, addressing spiritual distress, promoting family coping

The first step of the nursing process is

assessment

weber test

assessment technique for determining equality or disparity of bone-conducted sound

When does the discharge care planning begin?

at admission or shortly there after

A nurse is preparing to administer an oil retention to a pt who has constipation. The nurse explains to the pt that they should try to retain the instilled solution for

at least 30 min but as long as they can

measuring chest circumference

at nipple line

An _________ is an examination of the organs and tissues of a human body after death

autopsy

Patient teaching and nursing guidelines for patient undergoing radiography (x-ray)

avoid if pregnant high exposure can cause cell damage or lead to cancerous cells NO METAL worn

least accurate temp

axillary

What are the benefits of bath and proper hygiene?

baths eliminate odor, reducing potential for infection, stimulating circulation, providing a refreshed and relaxed feeling and helps with improve self image. Hygiene is beneficial for maintaining personal cleanliness an healthy integumentary structures

promoting coping

be a compationate listener for both client and family (no judgment) encourage family memebrs to talk sit with family express concern for their well being

charting BMs

be specific as possible, odor, color, formation and so on

What can LPNs delegate and to who?

b. LP/VN delegate to and who- does the patient need care that can be provided only by an LP/VN or can a nursing assistant meet a particular patient's care needs. Important to excise extreme caution when delegating tasks to unlicensed assistive personnel (UAPs) and other whose position is not well defined by practice.

Most common site in adults for blood draws?

b. Median cubital vein

A nurse is preparing to insert an indwelling catheter for a female patient. When beginning the insertion procedure, the nurse should instruct the patient to

bear down

bpm

beats per minute

Why do they discourage shaving during patient physical skin prep?

because it causes microabrasion

Moist wounds heal more quickly because

because new cells grow more rapidly in a wet environment

General Anesthesia

cause of loss of sensation, consciousness, and reflex when a client is undergoing major surgery or one that requires complete muscle relaxation

what is pulmonary function impairment?

because of the hearts failure to pump it causes fluid to collect in pulmonary circulation and breath sounds become moist (death rattle) and oxygen doesn't diffuse well and the paitient ends up not being able to exhale carbon enough

A seat like container that is used to collect urine or stool is called _____________?

bed pan

Implications for nursing care for lipping?

b. What developmental stage is the older adult in (Erikson's)? What are the developmental This type of degenerative

4 mo milestone

babbles few words

What are the benefits and risks of tube feeding?

benefits: instill nutritional formulas into the stomach, uses the bodies natural reservoir for food reduces potential for enteritis risks: dumping syndrome, increase potential for gastric reflux, and diarrhea

taking respirations

best done after taking pulse don't announce you're taking it keep holding wrist while counting resp labored? count for 15sec, mult by 4 NORMAL: 14-20 rapid = tachypnea

normal HR

between 60 and 100

body measurements: head circumference for which age?

birth - 36 mo

rooting reflex

birth to about 3-4mo

palmar grasp reflex

birth, stronger at 1-2mo, gone by 3-4mo

ecchymosis

bleeding under skin caused by bruising black, blue, purple

What is hematuria?

blood in the urine

BP

blood pressure

cyanosis

bluish discoloration of the skin caused by a lack of insufficient oxygen

Splinting

bone immobilization by application of an orthopedic device to the injured body part

BM

bowel movement

wound

break in skin

What are positive signs of death?

breathing and circulation have ceased

what are positive signs of death?

breathing and circulation have stopped

Regurgitation

bringing stomach contents to the throat and mouth without the effect of vomiting

regurgitation

bringing stomach contents to the throat and mouth without the effort of vomiting (infants)

where do we get these vitamins (water and fat soluble)

by eating a variety of foods, various commercially packaged foods such as margarine, milk, and flour have been vitamin enriched and fortified to promote health

p.o.

by mouth

How do you sign your documentation

by name and title

via

by way of

per

by, through

What effects do stimulants have on sleep?

cause wakefulness

What would make you avoid an area?

c. I.V. sites, trauma, or other complication such as dialysis or mastectomy

Define: deeper somatic pain

caused by trauma (ex. fracture) produces localized sensations that are sharp, throbbing & intense

Patient/Family teaching for special exams or test?

call if test preparation instructions are not clearly understood or cannot be followed refrain from eating or drinking anything for at least 8 hours before a test or exam that requires a fasting state follow all dietary specifications for eating or omitting certain foods exactly as directed check with the physician about taking or readjusting the time schedule for taking prescribed medications on the day of the test or exam dress casually and in layers so that the items of clothing can be removed or added to maintain comfort in the test environment ask a friend or family member to provide transportation to and from the sire if there is a potential for drowsiness, lingering pain, or weakness after the procedure arrive at least 30 min before test is scheduled identify oneself at the information or appointment desk upon arrival bring information to verify insurance or medicare coverage

What should you do if you see a break in sterile technique during surgery?

call them out/say something

a _____________ is the amount of heat that raises the temperature of 1 gram of water 1* centigrade

calorie

What can cause poor hygiene in older adults indicate?

can be indicators of conditions such as visual impairment, functional limitations, dementia, depression, abuse or neglect

What are the dangers of undertreating pain?

can lead to pneumonia due to shallow breathing suppressed coughing, and reduced movement

Elements of Informed Consent

capacity; comprehension; voluntariness

what levels are associated with increased cardiac arrest from cholesterol?

cardiac arrest risk can be estimated by dividing the total serum cholesterol level, which should be less than 200 mg/dL, by HDL level. A result greater than 5 suggests that a client has a potential for coronary artery disease.

what implications for nursing care are advisable for the physiological cardiovascular changes for the older adult?

cardiovascular: moderate exercise, walking, jogging, discourage smoking weight loss and heart healthy diet look out for symptoms of pending trouble like shortness of breath, fatigue, edema in lower extremeties heart attack symptoms can be different in the older adult look out for indigestion, sweating, difficulty breathing, appearance ( they can look pale or flush) since blood vessels respond more slowly to changes in body positions if your pt becomes dizzy when getting up from a sitting position advise them to sit up more slowly to allow the blood flow to move where it needs to before standing up

Postoperative nurse purpose

care for the patient after they have surgery, monitors their condition, and does vitals while in their care

What is perioperative care?

care that clients receive before, during, and after surgery

X - vagus: parasympathetic

carotid reflex slows HR

CAUTI

catheter associated urinary tract infection

Tracheostomy suctioning

catheter half the size of the lumen 100% O2 before suctioning lubricate end of catheter in sterile water or 0.9% NaCl adjust suctioning to 120 mm Hg and no more than 150 mm Hg

The act of applying or inserting a hollow tube inside the bladder is called _________________?

catheterization

Local Anesthesia

cause of loss of sensation without loss of consciousness. local anesthetic block transmission along nerves, thus achieving loss of autonomic function and muscle paralysis in a specific area of body

Regeneration

cell duplication

If interference from the electrical supply is a possible problem during your ECG what action should be taken?

change the power supply and check for connection problems

Sleep apnea interventions

chanings sleeping positions losing weight avoid smoking anddrinking or sleep medications CPAP mask surgery on tonsils, uvula, pharynx, tongue, or the epiglottis

irregularly irregular pulse

chaotic no real pattern difficult to measure accurately

Degenerative changes

characterize older adulthood (also called senescence)

define narcolepsy

characterized by the sudden onset of daytime sleep

Computerized

charting is used to document client information electronically

cardiovascular assessment: clubbing

check for clubbing of fingers - normal = 160 degrees - curved = 160 degrees or less - early clubbing = 180 degrees

cardiovascular assessment: cyanosis

check for cyanosis of feet or hands

cardiovascular assessment: edema

check for edema in feet and lower legs

What is the first thing you have to do before you draw blood from your pt?

check the doctor's orders

What is the most important step in performing venipuncture?

check the order and then ck pt

What do you do if your pt is not in the room you need to draw blood?

check with the other nurses look for them you can always draw blood in another room but you have to note why on the requisition you must tell the charge nurse

Vitamins

chem substances necessary in minute amts for normal growth, mainaint health and body function

what are vitamins

chemical substances necessary in minute amounts for normal growth, the maintenance of health and the functioning of the body

Occult blood test

chemical test for the presence of blood in the feces that is not visible to the eye

neuropeptides

chemicals that stimulate nociceptors

Ostomy care

chk for skin irritation if red around area when stoma is out its bad where you put the actual bag you cut 1/16 to 1/18 bigger than stoma if stoma looks purple or brown report normal is red beefy to empty the pouch from 1/3-1/2

Describe how to clean dentures or a bridge.

clean with a toothbrush cleaner, denture cleaner, or toothpaste and cold or tepid water, plastic bowl with a lid or basin and remember that they can easily be broken if dropped.

How do you prepare the skin for lead placement?

clean with alcohol to remove oils

What are the nurse's responsibilities in the patient's physical preparation including skin prep, elimination, and food and fluids?

cleansing the skin hair removal possibly inset a cath enemas or lax encourages pt to maintain good nutrition & hydration before restricted time to promote nutirients

What is the major goal for care of the dying patient?

client comfort is the number one goal ultimate goal is assisting the client to die with dignaty and comfort

another use of medical records

client safety and continuity of care

GABA

gamma-aminobutyric acid

How is a patent airway maintained during surgery?

closely for effective breathing & oxygenation

medial

closer to midline of body

A nurse inserting a nasogastric tube asks the pt to flex her head toward her chest after the tub passes through the nasopharynx. this action facilitates proper insertion of the tube by..

closing off the glottis

What is a 24 hour urine collection?

collecting each void within a 24 hour time frame, should be kept in refrigerator or with perservative

Throat culture

collecting infectious specimens or microorganisms from the throat and examining their characteristics with a microscop

examination of skin: inspect

color uniformity of color moisture hair pattern rashes lesions pallor edema

What promotes comfort and rest?

colorful walls room décor reduced noise increased natural sunlight comfortable climate familiar sleep environment melatonin consistent sleep schedule darkness/dim light sleep rituals sedatives/hypnotic drugs relaxation quiet effortless breathing proteins containing L-tryptophan

how is moderate pain treated?

combined medications of opioids and non-opioids

Protien complementation

combining plant sources of protiens so that amino acids missing from one sources is compensated by those found in the other

Dietary protiens

come from aimals and plat food sources

Opiates

comes from plants

c/o

complaints of

What are common sign and symptoms of constipation?

complaints of abdominal fullness/bloating abdominal distention pain on defecation

What can cause evisceration?

complications are most likely within 7 to 10 days after surgery, may be caused by insufficient dietary intake of protein and sources of vitamin C; premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; weak tissue or muscular support secondary to obesity; distention of the abdomen from accumulated intestinal gas; or compromised tissue integrity from previous surgical procedures in the same area.

what are the functions of iron

component of hemoglobin, assistance in cellular oxidation

What is the function and dietary source of iron

components of hemoglobin, assistance in intercellular oxidation found : liver, clams, oysters, egg yolks, soy beans, tofu, read meat, swiss chard, spinach

CT

computed tomography scan - uses contrast medium - form of roentgenography that shows planes of tissue

What is fecal impaction?

condition in which it is impossible to pass feces voluntarily

What is constipation?

condition in which stool becomes dry, compact, and difficult and painful to pass

malnutrition

condition lacking proper nutrients in diet

Subjective data

consists of information that only the client feels and can describe

What are common factors that affect bowel elimination?

constipation, fecal impaction, flatulence, diarrhea, and fecal incontinence

Hydrocolloids

contain granules of gelatin or pectin in the matrix of the dressing. the granules in hydrocolloids become gelatinous when in contact with exudate in a wound, keeping the wound moist. For proper use, these dressings must be sized generously, allowing at least a 1-inch margin of healthy skin around the wound.

a ________________ ostomy is also referred to as a Kock pouch!

continent

CQI

continuous quality improvement

Describe functional incontinence?

control over urination lost because of inaccessibility of a toilet or a compromised ability to use one

A nurse preparing to flush and change the dressing on a patient's central venous catheter should understand that the primary purpose for preforming this intervention using surgical asepsis is to ...

control the introduction of micro organisms at the catheter site

III oculomotor: motor

controls extraocular movements (EOM) opening eyelids

CCU

coronary care unit

A person legally designated to investigate deaths that may not be the result of natural causes is called a ________________.

coroner

forced coughing

coughing that is purposely produced, for pts with diminished or moist lung sounds or who raise thick sputum

taking pulse

count for 15 sec, mult by 4 if pulse irregular, always count for a min

fissure

crack in skin especially in or near mucous membranes

ADVENTITIOUS an Abnormal lung sound 2?

crackles, AKA Rales, are intermittent, high pitched, popping and heard in distant areas of the lungs, primarily during inspiration

The goal of surgical asepsis is to

create and maintain a micro - organism- free environment

Describe the 5 types of pain

cutaneous, visceral, neuropathic, acute, and chronic

Continuous instillation of liquid nourishment for 8-12 hours is know as ____________ feeding.

cyclic

Question Which type of debridement breaks down and liquefies wound debris? a. Autolytic b. Sharp c. Mechanical d. Enzymatic

d. Enzymatic

Arterial Blood puncture

done by an RN cleaned with alcohol or betadine no tourniquet used artery located by palpation 15 min pressure time on site of puncture after needle has been taken out

What is the appropriate action for the nurse to take with a client's valuables? a. Hand them over to the supervisor b. Ask the client to keep them with himself or herself c. Hand them over to the admitting department d. Place them in the hospital's safe temporarily

d. Place them in the hospital's safe temporarily The nurse should place the client's valuables in hospital's safe temporarily. Losing a client's personal items can have serious legal implications for both the nurse and health care agency; therefore nurse should not hand them over to supervisor, ask client to keep them himself, or hand them over to admitting department.

What is DAR charting?

data, action, response

How should specimens be sent to the lab? What must be included and when should they be sent?

date/time pertinent pre-examination assessments & preparations type of test performed who performed the test or exam where test or exam was performed response of client during exam & afterward type of specimen obtained, if any appearance in size or volume of specimen where specimen was transported to

what can effect the circadian rhythm?

day light and darkness

Senescence culminates in __________

death

what economic concerns do older adults experience

deceased income due to poorly financially planned retirements compulsory retirement or serious or chronic illnesses are major factors that contribute

pitting edema: 3+

deep indentation remains for short time leg looks swollen

Every organ system of the body undergoes ________________ ________________

degenerative changes

What are the basic components of a pain assessment?

description of the onset, quality, intensity, location, and duration of the pain

hemolysis

destruction of red blood cells

glucometer

device for measuring blood glucose levels from a drop of blood obtained by a fingerstick

newborn-toddler: anterior fontanel

diamond shaped closes 9mo-2yr

What can reduce the incidence of constipation?

dietary habits, lack of adequate fiber

Where do we get protein from in our diet?

dietary proteins are obtained from animal and plant food sources, which include milk, meat, fish, poultry, eggs, soy, legumes(peas, beans, and peanuts), nuts and components of grain

pulse pressure

difference between systolic and diastolic bp reading

Insomnia

difficulty falling asleep, waking up often at night or waking up early

Transfer

discharging a patient from one unity or agency and admitting to another without going home in the interim

visceral pain

discomfort arising from internal organs, is associated with disease or injury

Define somatic pain

discomfort generated from deeper connective tissue

acute pain

discomfort of short duration, lasts a few seconds to less than 6 months

Define referred pain

discomfort perceived in an area of the body away from the site of origin

chronic pain

discomfort that lasts longer than 6 months, almost totally opposite from those of acute pain

dc

discontinue

Narcolepsy

disorder characterized by the sudden onset of daytime sleep in a short NREM period before the first REM phase and pathologic manifestation of REM

DNR

do not resuscitate

KNOW EVERYTHING ON YOUR ECG WORKSHEET.

do you????

How would you document specimen collection ?

document the volume, odor, clarity, and color time/date signature/title

Sterile solutions:

don't contaminate inside lid

What is sordes?

dried crusts containing mucus, microorganisms and epithelial cells shed from mucous are common on the lips, and teeth of an unconscious patient

Define: adjuvant drugs

drugs that assist in accomplishing the desired effect of a primary drug

stimulant drugs

drugs that stimulate or excite the central nervous system

To decontaminate your hands with an alcohol based gel, you run them together until the gel has evaporated and your hands are dry. The primary reason you do this is that

drying provides the full antiseptic effect

aural temp

ear electronic NORMAL: 99.6 F/37.7 C

define sunset syndrome

early morning confusion

sunrise syndrome

early morning confusion

sleep ritual examples

eating a light snack watching tv reading performing hygiene

ECG

electrocardiogram

What is the function and dietary source of potassium

electrolyte balance, neromuscular activity, enzyme reaction found: bananas, oranges, and potatoes

EMR

electronic medical record

What formula is most appropriate to administer to a pt who has a dysfunctional gastrointestinal tract?

elemental

Radionuclide imaging

elements whose molecular structures are altered to produce radiation

nodule

elevated solid mass, deeper and firmer than papule (enlarged lymph note)

wheal

elevated, irregular, no free fluid (hives)

papule

elevated, palpable solid (wart)

pristule

elevated, raised border and filled with pus (boil)

vesicle

elevated, round, filled with serum (blister)

ED

emergency department

how to facilitate grieving

empathetically share preception of what the client and family may be feeling be there to listen with no judgment and avoid critisim. the family and client must be able to feel comfortable to speak freely

hyperresonant chest percussion indicates

emphysema pneumothorax

A nurse is teaching patient with a new ileostomy about incorporating preventative strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to...

empty the pouch when it is no more than half full

cyst

encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin (tissue growth)

How is patent airway maintained during surgery?

endotracheal tube

_______________ or belching, is discharge of gas from the stomach through the mouth

eructation

Hyperthermia

especially high core temperature

regular pulse

evenly spaced beats

q

every

Due to decreased blood supply to skin, older adults may need position changes

every 60-90 min., instead of every 20

Significant Findings

ex no bowel sounds

-scope

examination instrument

autopsy

examintion of the organs and body tissue post death to dertermine the cause of death

Hypercarbia

excessive level of carbon dioxide in the blood

Isokinetic exercise

exercise involving muscle contractions with resistance varying at a constant rate stationary bike

ECF

extended care facility

ECF

extended care facility, a health care agency that provides long-term care, is designed for people who do not meet the criteria for hospitalization

VI - abducens: test

extraocular movements (lateral)

V trigeminal: sensory

face scalp mouth nose

Define syncope

fainting

syncope

fainting

food and fluid restriction

fasting is used to reduce potential aspiration of stomach contents while the patient is anesthetized but is not as common these days More common : with a healthy patient to consume clear liquid at least 2 hours prior to elective surgery - light breakfast 6 hrs before surgical procedure - heavier meal before the light breakfast

possible nursing diagnosis from sleep assessment

fatigue impaired bed mobility disturbed sleep pattern seep deprivation readiness for enhanced sleep relocation stress syndrome risk for injury impaired gas exchange

what can cause a person to faint during blood drawn?

fatigue sudden decrease in blood volume cardiac arrhythmia hypoglycemia hyperventilation psychological causes

hypersomnia

feeling sleepy despite getting normal sleep think of Sleepy from Snow White

Pyrexia

fever

Nursing care during the immediate preoperative period. What should the nurse do and when?

few hours before surgery that needs to be done before but cant be done to early, conducting a nursing assessment, providing preoperative teaching, performing methods of physical preparations, administering medications, assisting with psychosocial preparation, and completing the surgical check list.

housing issues for the older adult

finding safe and affordable living can be difficult retirement communities combine smaller residences with conveniences a lot of the time the older adult must part with treasured objects to accommodate a smaller living space familiar objects serve as reminders of past accomplishments and relationships can be very useful and comforting

How can electronic data be protected?

firewalls & passwords help prevent breaches in confidentiality by protecting unauthorized access to confidential info, periodically backed up on systems, protected from destruction should there be a fire or other type of disaster

Dietary sources for B complex vitamins

fish pork lean meat and poultry glandualr organs milk whole fortified enriched breads and cereals and grains peas beans peanuts dried yeast liver bananas dairy products

What should you see when you get into the vein?

flash of blood

macule

flat, round, colored, non-palpable area (freckles)

A nurse is caring for a hospitalized pt who is performing active range of motion exercise. What movement should indicate to the nurse the pt has full rang of motion of the shoulder

flexing the shoulder by raising the arm from the side position to a 180 degree angle

When suctioning the airway how long should you preoxygenate?

for 1 - 2 minutes until SpO2 is at 95 - 100%

what are the functions calcium

formation of teeth and bones, neuromuscular activity, blood coagulation, and cell wall permeability

QID, q.i.d

four times a day

q.i.d., qid

four times a day

What is diarrhea?

frequent and urgency to pass watery stools

Use special care when moving older adults; avoid

friction of skin

X - vagus: sensory

general sensation from carotid body, carotid sinus, pharynx, viscera

cachexia

general wasting away of body tissue, consistent with severe malnourishment

cahexia

general wasting away of the body tissue

What do you do if your patient has an abnormal stool?

get a sample and get tested get doc lab results to see what else to do further, more testing or antibiotics

axillary temp

glass electronic NORMAL: 97.6 F/36.3 C

oral temp

glass paper electronic NORMAL: 98.6 F/37 C

CN IX

glossopharyngeal mixed motor: pharynx (phonation and swallowing) sensory: posterior 1/3 of tongue

What is glycosuria?

glucose in the urine

HDL cholesterol

good. High Density Lipoprotein. high protein, low fat

When donning sterile gloves using the open- gloving method, it is important to remember to

grasp only the inside of the clove with your ungloved hand

6 mo milestone

grasps things may hold bottle

What is the level of cholesterol associated with cardiac risk?

greater than or equal to 240 mg/dL

define bruxism

grinding of the teeth

bruxism

grinding teeth

ADVENTITIOUS an Abnormal lung sound 3?

gurgles, AKA Rhochi, are low pitched, continuous bubbling, and heard in larger airways, More prominent during expiration (wet snoring)

Sleep rituals

habitual activities performed before going to bed

anatomical position

hands at sides, palms forward

how to assess thyroid gland

have person swallow water, gland will move upward w/ swallow

When assessing a pt's respiration, it's recommended that the pt

have the head of the bed elevated to 45 - 60 degrees

How do you collect sputum?

have the pt cough up into a specimen cup

Bronchial lung sounds

heard over trachea; expiratory sound predominates; is higher pitched and louder; if heard in other locations it indicates consolidation -- a space that usually contains air now has fluid shorter on inspiration and expiration w/pause b/w them

Rinne test

hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction

VIII - acoustic: sensory

hearing and equilibrium

myocardial infarction (MI)

heart attack

apply cold first and then

heat

What are the benefits of pre-op medications?

help ease anxiety promote sleep decrease the amount of anesthesia used destroy enteric microorganisms promote skeletal muscle relaxation decrease respiratory secretions, dry mucous membranes prevent vagal nerve stimulation

Preoperative nurse purpose

help plan, carry out, and asses treatment for patients undergoing surgery

What is the most common complication with blood draw?

hematoma

crackles

high pitched discontinuous similar to rubbing hair between fingers aka Rales

wheezes

high pitched musical in quality

diaphragm of stethoscope

high pitched resp sounds

Ultrasonography

high-frequency sound waves (ultrasound) are directed at soft tissue and reflected as "echoes" to produce an image on a monitor of an internal body structure; also called ultrasound, sonography, and echo

normal change in hearing in older adults

high-tone hearing loss

Cloth items:

hold with one hand and unwrap corners. Then hold all four corners to avoid "flopping" and "drop onto the field

The term ___________ is used to indicate a facility for providing care for terminally ill clients.

hospice

Surgical attire for patient

hospital gown and surgical cap is typical thigh high or knee high TED hose legs wrapped in elastic roller bandages (prevents venous stasis) hair ornaments are removed makeup and nail polish removed if the patient has acrylic nails then, at least one is removed

where do we get iron

liver, clams, oysters, egg yolks, soybeans, tofu, red meat, swiss chard, spinach Caffeine decreases iron absorption

What should the nurse explain and demonstrate?

how to perform deep breathing, forced coughing and leg exercises

what are the physical needs of a patient receiving terminal care and how are they met?

hydration - maintain adequate fluid vol nurishment - tube feeding parental nutrition elimination - catheterization, enemas, or sopositories, and skin care hygiene - clean, well groomed and free of unplesant odors positioning - promote comfort and circulation comfort - keep client free from pain

tendon reflex grading scale: 4+ or ++++

hyperactive w/ clonus indicative of disease

tendon reflex grading scale: 3+ or +++

hyperactive w/o clonus may indicate disease, but also may be normal

tendon reflex grading scale: 1+ or +

hypoactive

CN XII

hypoglossal motor: movement of tongue

What are the basic nursing admission basic room supplies?

i. A wash basin ii. A soap dish iii. An emesis basin iv. A water carafe v. A bedpan and a urinal

What are the components of an H&P?

i. Age, gender, marital status ii. General appearance iii. Circumstances surrounding physician involvement iv. Reliability of client as historian v. Others providing information about the client's history Chief Complaint Reason for seeking care (from client's perspective) Present Illness Chronologic description of onset, frequency, and duration of current signs and symptoms Outcomes of earlier attempts at self-treatment and medical treatment Personal History e. Past Health History i. Childhood disease summary ii. Physical injuries iii. Major illnesses and surgeries iv. Previous hospitalizations (medical or psychiatric) v. Drug history vi. Alcohol and tobacco use vii. Allergy history f. Family History i. Health problems in immediate family members (living and deceased) ii. Longevity and cause of death among deceased blood relatives (especially parents and grandparents) g. Review of Body systems i. Results of physical examination h. Conclusions i. Primary diagnosis (from chief complaint and physical examination) ii. Secondary diagnoses reflecting stable or preexisting conditions possibly affecting client's treatment.

How can a pressure ulcer be prevented?

i. Change the bedridden client's position frequently. Remind a client who is sitting in a chair to stand and move hourly or at least to shift his or her weight every 15 minutes while sitting. ii. Lift rather than drag the client during repositioning iii. Avoid using plastic-covered pillows when positioning clients iv. Use positioning devices such as pillows to keep two parts of the body from direct contact with each other. v. Use the lateral oblique position vi. Massage bony prominences only if the skin blanches with pressure relief. vii. Keep the skin clean and dry especially when clients cannot control their bladder or bowel function. viii. Use a moisturizing skin cleanser rather than soap, if possible. ix. Rinse and dry the skin well x. Use pressure-relieving devices such as special beds or mattresses xi. Pad body areas such as the heels, ankles, and elbows, which are vulnerable to frication and pressure. xii. Use seat cushions such as a commercial gel-filled pad when clients sit for extended periods. xiii. Keep the head of the bed elevated no more than 30 degrees. xiv. Provide a balanced diet and adequate fluid intake.

What are qualities of a good follower?

i. Competent in performing his or her job responsibilities ii. Has experience iii. Positive attitude towards the role of the leader iv. Will help the leader achieve nursing team goals v. Will assist the leader by offering suggestions, giving information, willingly complying with assignments, asking for constructive criticism, and following policies and guidelines of the employer.

what factors can interfere with wound healing?

i. Compromised circulation ii. Infection iii. Purulent, bloody, or fluid accumulation that prevent skin and tissue approximation. iv. Excessive tension or pulling on wound edges contributes to wound disruption and delays healing. v. May be secondary to poor nutrition, impaired inflammatory, or immune responses related to drugs like corticosteroids, and obesity.

What are the qualities of an effective leader?

i. Emotionally mature- even-tempered, tolerant, and patient and maintains a businesslike atmosphere everywhere, especially in patient care areas. ii. Open-mined iii. Fair iv. Consistent v. Assertive vi. Responsible vii. Courageous viii. Ability to teach ix. Problem-solving abilities- effective leader defines the problem, gathers the facts, analyzes the information, proposes several solutions and the consequences of each, makes a decision, and evaluates the effectiveness of the that decision. x. Critical thinkers xi. Sensitive xii. Objective xiii. Flexible

What are the levels of management and what level do LPNs most often work in?

i. First level of management is the team leader, charge nurse, or manager of a patient care unit ii. Second level is supervisor, clinical specialist, or assistant director of nursing iii. The third level of management is chief nurse executive, vice president for nursing, or director of nursing b. LPN's are most often first-level managers responsible for a specific patient unit.

What can cause a patient to faint (syncope)? What do you do if it happens?

i. If sitting in a chair before venipuncture is done, put the client's head between his or her knees 1. Cold compress on back of neck may help 2. Ammonium salts are strong and should be used with care 3. Stay with client 4. Once recovered have client lie down for the venipuncture a. Clients who are lying down very seldom feel faint b. If client feels faint after the venipuncture has been started i. Remove the tourniquet ii. Carefully remove the needle iii. Apply pressure to the site iv. Support the client v. Call for help

common types of open wounds?

i. Incision - a clean separation of skin and tissue with smooth, even edges ii. Laceration - a separation of skin and tissue in which the edges are torn and irregular iii. Abrasion - a wound in which the surface layers of skin are scraped away iv. Avulsion - stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed. v. Ulceration - a shallow crater in which the skin or the mucous membrane is missing vi. An opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object.

activities that are involved in transfer?

i. Informs the client and family about the transfer ii. Completes a transfer summary briefly describing the client's current condition and reason for transfer iii. Speaks with a nurse on the transfer unit to coordinate the transfer iv. Transport the client and his or her belongings, medications, nursing supplies, and chart to the other unit.

How should a nurse prioritize care? What things are most important to do first?

i. Items critical to maintaining life ii. Critical symptom management iii. Items need to progress in health restoration iv. Items needed to move toward self-care. Essential assessment, airway management, breathing support, circulation needs, and neurologic stability

What are qualities of an effective manager?

i. Outstanding clinical skills ii. Outstanding communication skills iii. Organized iv. Punctual v. Knows and follows the rules vi. Adheres to schedules vii. Solves problems quickly viii. Anticipates staff needs for equipment and supplies ix. Prevents situations from becoming problems x. Works well with others xi. Finds ways to streamline work xii. Gets broken equipment fixed promptly xiii. Delegates work assignments according to skills and ability

What are some of the goals of a nursing team leader?

i. Providing a safe environment for staff and patients ii. Providing excellent nursing care iii. Working as a team iv. Minimizing nursing and medical errors v. Establishing pleasant working relationships among nurses, patients, families, physicians, and other members of the health care team. vi. Sharing knowledge and experience vii. Communicating accurately and effectively viii. Motivating each team member to achieve his or her maximum potential ix. Promoting an interest in incorporating new nursing skills in nursing practice x. Developing a creative problem-solving environment

Pt./family teaching for applying an ice bag or ice collar.

i. Test the ice bag or leaks ii. Fill it one-half to two-thirds full of crushed ice or small cubes so it can be molded easily to the injured area. iii. Eliminate as much air from the bag as possible iv. Pour water over the ice to provide slight melting, This tends to smooth the sharp edges from frozen ice crystals. v. Cover the ice bag with a layer of cloth before placing it on the body. vi. Leave the ice bag in place no more than 20-30 minutes. Allow the skin and tissue to recover for at least 30-minutes before reapplying. vii. If the skin becomes mottled or numb, remove the ice bag-it is too cold.

What are the Medicare criteria for coverage of Home Health services

i. The services must be ordered by a primary care provider ii. The person must be home bound. Home bound status is met if leaving home requires a considerable and taxing effort, such as needing personal assistance or the help of a WC, or specialized van. Allowable activities include attendance at an adult day care center or religious service. iii. The person needs skilled nursing care or rehabilitative services iv. The person requires intermittent, but not full-time, care. v. The care must be provided by, or under arrangements with, a Medicare-certified provider.

What factors affect wound healing?

i. Type of wound injury ii. Expanse or depth of wound iii. Quality of circulation iv. Amount of wound debris v. Presence of infection vi. Status of the client's health

What are barrier precautions?

i. Wear gloves in all venipuncture or capillary punctures ii. Wear goggles (when splashing may occur) iii. Wear gown (when splashing may occur) iv. Shields v. Mask- droplet or airborne

GOOD FOR SMALL INJURIES

ice bag

Initial nursing plan for care

identifies priority problems and includes the clients projected needs for teaching and discharge planning

when you apply heat what o you look for?

if it is to hot

how do you know if you have to invert your blood specimens and how many times do you invert them?

if the tube you're using to collect has an additive at the bottom of the tube you know you have to invert after collection Rule of thumb with how many is light blue 3 to 4 times all others 8 to 10

What should be reported immediately when assessing the nature and amount of drainage in the collection chamber of the Water seal chest tube?

if there is more than 100mL/hr drainage is observed or bright red drainage is found

what do you do if your pt faints?

if they're sitting in a chair put their head between their knees use ammonium salts stay with them once recovered have them lie down for a

Intestinal ostomies?

ileostomy is a surgical created opening to the ileum colostomy is a surgically created opening to a portion of the colon (material enter & exit through the stoma)

STAT

immediately

stat

immediately

define terminal care

immediately before a clients death, nurses meet his or her basic physical needs

What is incontinence?

inability to control urination

urinary incontinence

inability to control urination

Define: placebo

inactive substance or treatment measure that charades as one that is legitimate

Post-op shock or shock

inadequate bloodflow

What is dysuria?

painful or difficult voiding

What are some things that interrupt sleep patterns?

inconsistent sleep schedules suppression of melatonin strange sleep environment climate in room (too hot or too cold? disturbance of sleep ritual stimulant drugs depression anxiety worry activity hunger or thirst low protein diet metabolism of alcohol pain, nausea, full bladder noise difficulty breathing

What is the inability to control either urinary or bowel elimination?

incontinence

What can affect lab test results and make them inaccurate?

incorrect diet preparation failure to remain fasting insufficient bowel cleansing drug interactions inadequate specimen volume failure to deliver specimen in a timely manner incorrect/missing test requisition

Conditions that interfere with circulation

increase the older adult's susceptibility to delayed wound healing/wound infections

What is gastrocolic reflux?

increased peristaltic activity

hospice

indicates both a facility for providing the care of the terminally ill clinets and theconcept of the care itself

capacity of (informed consent)

indicates that the client has the ability to make a rational decision; if not a spouse, parent, or legal guardian must do so

voluntariness (informed consent)

indicates that the client is acting on his/her own free will without coercion or the threat of intimidation

comprehension of (informed consent)

indicates that the client understands the physicians explanation of the risks, benefits, and alternatives that are available

hypnotics

induce sleep

What patients are most often under assessed or undertreated for pain?

infants children younger than 7 yrs of age culturally diverse clients clients who are mentally challenged clients with dementia clients who are hearing/speech impaired clients who are psychologically disturbed

Contact precautions would be mandated for a hospitalized adult patient diagnosed with

infectious diarrhea

assessing the deep cervical chain of lymph nodes

inform pt that it'll cause discomfort because it lies below the sternomastoid and is palpated by getting underneath muscle

Malignant hyperthermia

inherited disorder tht occurs when the body temperature, muscular metabolism and heart production increase rapidly, progressively, and uncontrolleably in response to stress and some anesthetic agents

I+O

input and output

When taking a pt's temp rectally it's important to

insert the probe about an inch and a half into the pt's anus

Attention to Elimination

insertion of indwelling urinary catheter have patient urinate immediately before receiving pre-op medications administer enemas or laxative

order of assessment technique--ABDOMEN

inspect auscultate percuss palpate

order of assessment technique

inspect palpation percussion auscultation

stridor

inspiratory wheeze associated w/ upper airway obstruction indicative of CROUP

Care of valuables

instruct patient to leave valuables at home prior or you can have the patient entrust valuables to a family member if you have to do it then, itemize each valuable and place inside an envelope and have the patient rev and sign a receipt and note the area stored and the items stored in the report

-meter

instrument for obtaining measurements

I & O

intake and output

local anesthesia and Nursing guidelines for caring for a patient under local anesthesia.

interferes with the conduction of sensory and motor nerve impulses to a specific area of the body. and local is a type of regional anesthesia and spinal anesthesia is the other regional anesthesia. The Major disadvantages of regional anesthesia is the decreased risk for respiratory, cardiac, and GI complications. We monitor for signs of allergic reactions, changes in vitals, and toxic reactions.

ICF

intermediate care facility

What does leadership mean?

is the process that help a group of people achieve those goals.

Evaluation

is the way by which nurses determine whether a client has reached a goal

ICF

intermediate care facility, this type of agency provides health-related care and services to people who, because of their mental or physical condition, require institutional care but not 24-hour nursing care. Clients who require intermediate care may need supervision because they tend to wander or are confused. They need assistance with oral medications, bathing, dressing, toileting, and mobility.

IM

intramuscular

IV

intravenous

nystagmus

involuntary eye movement which differs in each eye

Meditation

involves concentrating on a word or idea that promotes tranquility and is similar to imagery except the subject matter tends to be more spiritual

define palliative care

involves providing relief from distressing symptoms, easily pain and enhancing quality of life

palliative care

involves providing relief from distrssing symptoms, easying pain and enhancing quality of life

IV trochlear: motor

inward and downward movement of eye

IV trochlear: test

inward and downward movement of eye

arrythmia

irregular heart beat

Charting by exception

is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from the standard

Concept Mapping

is a method of organizing information in a graphic or pictorial form

First-intention healing (healing by primary intention)

is a reparative process in which the wound edges are directly next to each other. Because the space between the wound is so narrow, only a small amount of scar tissue forms.

start low and go slow

is a rule of thumb when administering analgesics

What is polycythemia vera?

is a slow-growing blood cancer in which your bone marrow makes too many red blood cells. These excess cells thicken your blood, slowing its flow. They also cause complications, such as blood clots, which can lead to a heart attack or stroke.

What is the purpose of an enema? What is the normal result?

is a solution into the rectum to cleanse lower bowel, soften feces, expel flatus, soothe irritated mucous membranes -

relaxation

is a technique for releasing muscle tension and quieting the mind, which helps reduce pain, relieve anxiety, and promote a sense of well being

urostomy ?

is a urinary diverson that discharges urine from an opening on the abdomen

What are the purposes of catheterization?

is an act of applying/inserting a hollow tube, to relieve bladder contents

Stage I pressure ulcer

is characterized by intact but reddened skin. The hallmark of cellular damage is skin that remains red and fails to resume its normal color when pressure is relieved.

a nurse is likely to receive an order for urinary catheterization of a newly admitted pt who

is in the ICU for a gastrointestinal bleed

What is an open wound?

is one in which the surface of the skin or mucous membrane is no longer intact.

in regards to signs and symptoms of impending death what is cardiac dysfunction?

is one of the first signs that the patient's condition is worsening - the heart rate first increases in attempt to deliver oxygen to cells then cardiac output decreases becausse a hast heart rate impairs the hearts ability to fill with blood and this deminishes the hearts own oxygen supply which causes the bp to fall

PIE charting

is organized according to the problem, intervention and evaluation

What is a culture?

is performed by collecting body fluid or substances suspected of containing microorganisms in a nutritive substance & examining their characteristics w/a microscope

What does a healthy ostomy look like?

is pink and moist and the skin around the outside of the area and the skin around the stoma should appear normal in appearance

Nasogastric tube feedings is an appropriate choice for a pt who....

is postoperative following laryngectomy

Joint Commission

is responsible for accreditation of health agencies

What effects do hypnotics have on sleep?

is sleep producing, induce sleep

Define management.

is the coordination of all activities associated with delivering nursing care.

Define vasoconstriction

is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles.

PENS therapy

is thereapy administered 3 times a week for 30 min for 4 or more weeks, Percutaneous electrical nerve stimulation, which is a pain management technique involving a combination of acupuncture needles and TENS

morgue

is used for the storage of human corpes awaiting identification or removal for autopsy or disposal by burial cremation or other method

Kardex

is what nurses us to quickly obtain quick access to current information about a client

check list

is what nurses uses to document the types of care that are regularly repeated briefly and efficiently

how is giving a patient the chance to express their feelings freely helping them cope with dying?

it demonstrates an attention to meeting individual needs

how does accepting a patient's behavior no matter what it is helping them cope with dying?

it demonstrates respect for individuality

what does using statements with broad openings like "It must be hard" and "Do you want to talk about it?" helping the client cope with their condition?

it encourages communication and allows the patient to choose the topic

What is a major advantage of a TENS unit?

it is a nonopioid, noninvasive method without harmful side effects

on a PCA pump what is lockout?

it is where the pt can not administer another dose for a specified amount of time

What effect does alcohol have on sleep?

it promotes sleep BUT as it s metabolized, chemicals that were blocked by the effects of the alcohol surge from neurons d cause early awakening

What is an advantage of using alcohol- based gel?

its use takes less time than washing with soap and water

J-tube

jejunostomy tube, trans abdominal tube that leads to the jejunum of the small intestine

How would you help prevent or treat dry skin?

keeping your pt hydrated and applying lotion regularly

Kg

kilogram

how do nurses help a patient die with dignity

know what their wishes are include the patient or family member in making decisions regarding help care being their someone to talk to candidly listen with nojudgement

Describe REM sleep

known as Paradoxical sleep phases 4-6 times a night at ave 20 min each time eventually lengthening in time towards morning happens after NREM stages, 90 min after the onset of sleep. dreams are more intense and you can remember them more in this stage

prostate screening: PSA

lab test recommendations vary--every 1-2 yrs

What is polyuria?

larger than normal urinary volume

assessing ear using otoscope: size of speculum

largest that will fit comfortably

Postoperative:

lasts from admission to recovery room to complete recovery from surgery and last follow-up physician visit Monitor urine output (30-45 mL per hour) Less than 30mL of urine output can be a sign of a hemorrhage

VI - abducens: motor

lateral eye movement

Foods high in Vitamin K

leafy greens

Dietary sources for Vitamin E

leafy greens wheat germ oil brown rice

L & Lt

left

How can sordes be treated?

lemon and glycerin swabs

Outpatient admission

length of stay generally less than 24 hours with possible return for continued care or treatment ex: minor surgery/ cancer treatment/ physical therapy

Inpatient admission

length of stay generally more than 24 hours

palpation

light and deep touch back of hand (dorsal aspect) to assess temp fingers to assess texture, moisture, area of tenderness deep=5-8cm or 2-3in light=1cm

To prevent common complication of continuous enteral tube feedings, a nurse should

limit the time the formula hangs to 4hr

additional cardiovascular auscultation

listen w/ bell at left 4th and 5th interspace near sternum

auscultating mitral area

listen w/ diaphragm at apex (PMI = point of maximum intensity)

vesicular lung sounds

located in periphery of ALL lung fields soft and rustling, quality is longer on inspiration and expiration w/NO pause

anorexia

loss of appetite

alopecia

loss of hair

Describe stress incontinence?

loss of small amounts of urine when intrabdominal pressure rises

vomiting

loss of stomach contents through the mouth

Describe total incontinence?

loss of urine without any identifiable pattern or warning

Signs and symptoms of shock

low blood pressure systolic 90-100 (beginning stage) Systolic under 80 (your pt is full on in shock and needs immediate care) *fast pulse, low bp, cold and clamy skin

bell of stethoscope

low pitched sounds such as heart murmur

prolonged bleeding time

low platelets

A nurse who is administering a return flow enema to a pt should instill 100mL of enema fluid and then

lower the container to allow the solution to flow back out

recumbent

lying down

Prone

lying face down

hard palate: composition and color

made of bone pale or whitish

What causes artifact?

magnets, metal, electric blankets, and high voltage areas can interfere with an accurate interpretation of the test.. movement

S/S of shock and how it's treated?

main symptom of shock is low blood pressure. Other symptoms include rapid, shallow breathing; cold, clammy skin; pale, rapid pulse; dizziness, fainting, or weakness.... Septic shock is treated with antibiotics and fluids. put feet up in air head down

general assessment: behavior

maintains eye contact appropriate expressions comfortable cooperative speech clear clothing appropriate to climate looks clean and fit appears clean and well-groomed

what are the functions of potassium

maintenance of electrolyte balance, neuromuscular activity and enzyme reactions

what are the functions of sodium

maintenance of water & electrolyte balance

How would you teach a female PT to perform a Clean Catch specimen?

make sure they understand to : - wash hands with soap and water - remove the lid of specimen cup careful not to touch the insides of cup or lid and to place lid upside down on a flat surface - sit on the toilet with legs spread - separate labia with fingers - using moist swabs to clean each side of the urinary meatus wiping from front to back - then to use the last swab to wipe down the center of the separated tissue - still separating labia with fingers start to urinate - after releasing the first small amount of urine into the toilet then catch the remaining urine into the specimen cup - try not to touch the mouth of the cup with your skin - once finished urinating into the cup place it on a plat surface, release your fingers and finish peeing if need to - wash and dry hands - cover and close specimen with lid

What is the second thing you have to do before you draw blood from your pt?

make sure you have the correct pt! verify NAME DOB and ID BAND

What is the function and dietary source of calcium

makes teeth and our bones, blood coagulation, cell wall permeability, neuromuscualr activities found: milk and milk products

Preparing Patient's room

making sure it is clean and stocked with basic equipment for initial care -

Opoids

man made

Whose responsibility is it to maintain a safe environment for staff and patients?

manager is responsible for seeing that unsafe situations and environments are corrected.

Circulating nurse on preoperative team

manages all necessary care inside the surgery room, assisting the team in maintaining and creating a comfortable, save environment for the patient and observing the team from a wide perspective

Older adults

may minimize symptoms

Define: terminal illness

means a condition from which recovery is beyond a reasonable expectation

implementation

means carrying out the plan of care

define insomnia

means difficulty in falling asleep awakening frequently during the night or awakening early

When you're assessing the water in the chamber of a water seal chest tube what does tidaling mean?

means that the water in the chamber is rising up and down like breathing

What is delegation?

means to assign some or all of the responsibility you have for the care of patients on you unit to someone else.

call light

means to communicate to staff a need for assistance. The call light should be available to the resident at all times

pediatric leg length measurement

measure from anterior superior iliac spine, cross to the medial side of knee and measure to the medial malleolus, further testing can be done by x-ray

measurement of ABD growth

measure the distance around the abd at a specific point, usually at belly button

Anthropometric data

measuremets pertaining to body size and composition - height - weight - BMI - Mid arm circumfrence - tricep skin fold thickness - abdm circumfrence

Oxygen

measures aprox 21% in earth's atmosphere

what does ekg do?

measures the electrical activity of the heart

Measurement of capillary blood glucose

measuring the amount of glucose in capillary blood

conductive hearing loss is due to

mechanical dysfunction of inner or middle ear

who does an autopsy?

medical examiner or a coroner have the authority to do autopy on deaths that amy not have been caused naturally

MAR

medication administration record

neurologic examination: general notes--CEREBRAL

mental status

A unintentional sleep lasting for 20 to 30 seconds is termed as ____________.

microsleep

pitting edema: 1+

mild slight indentation not noticeable

Examples of complete proteins

milk meat fish poultry eggs

where so we get calcium

milk, and milk products

Electrolytes

minerals that help maintain the body's fluid balance

Sputum

mixture of saliva and mucus coughed up from the respiratory tract

pitting edema: 2+

moderate indentation subsides rapidly

external cath?

more effetive for a male PT, AKA as condom cath

A _________ is a person who prepares the body for burial or cremation and is also responsible for filing the death certificate with the right authorities

mortician

Coughing exercise after surgery

most appropriate for clients who have diminished or moist lung sounds or who raise thick sputum - helps loosen mucous

grading motor strength: 3/5

movement against gravity, but no against added resistance

grading motor strength: 4/5

movement against resistance, but less than normal

grading motor strength: 2/5

movement at joint, but not against gravity

XII - hypoglossal: motor

movement of tongue

Embolis

moving blood clot

"Fluoroscopy" is used to record ________

moving body parts

V trigeminal: motor

muscles of mastication

VII - facial: motor

muscles used for facial expressions close eye and mouth

clonus

muscular spasm involving repeated, often rhythmic, contractions

How to determine the level of care needed for ECF, SNF, or ICF?

must determine prior to admission using a standard form MDS (minimum Data Set)

What are you looking for when doing a medication reconciliation?

name of med dosage frequency of administration route

The added length of _________________ tubes permits them to be placed in the small bowel.

nasiontestinal

Describe the steps for NG tube insertion and removal, and what is the purpose of each step?

nasogastric tube: are smaller in diameter than the orogastric tube but are larger and shorter than a nasointestnal tube levin tube: is commonly used, single lumen gastric tube with multiple uses. 1 of which is decompression Gastric sump (double lumen tubes) are used almost exclusively to remove fluid and gas from the stomach.

autolytic debridement

natural physiologic process

What is an endogenous opioid?

naturally produced morphine-like chemicals

Describe urge incontinence?

need to void perceived frequently, with short lived ability to sustain control of the flow

nociceptors

nerve receptors that transmit pain impulses

How to correct a charting error

never scribble over entries or use correction fluid to obliterate what has been written only draw a single line through erroneous information so that it remains readable, add date, initial and document correct information... Record facts only

red specimen tubes

no anticoagulants allows clotting to happen Tests: type and screen/ crossmatch, drug levels, serum enzymes

What is a short draw and what can cause this to happen?

no blood collected i. The blood flow may slow or stop after a short time 1. The needle bevel may be against the vessel wall, preventing the flow of blood ii. Collapse of vein 1. Suction of the vacuum may be too great iii. The needle may come out of the vein

NKA

no known allergies

grading motor strength: 0/5

no muscle movement

define DNR,

no to ressesitate

What are nonopioids?

non narcotic drugs ex: ASA, tylenol, NSAIDs such as motrin, advil, aleve

NREM

non rapid eye movement

what amino acids are protein components manufactured within the body

non-essential

how is mild pain treated?

non-opioids

minerals

noncaloric substances in food that are essential to all cells * they help regulate the body's chemical processes

what are minerals

noncaloric substances in food that are essential to all cells, and helps regulate many of the boys chemical process such as blood clotting and the conduction of nerve impulses

What safety measures can be used in the bath to prevent falls?

nonskid strips on the floor of tubs and showers, grab bars, shower or tub seat, long handled bath sponges or hand held shower attachments

How do you auscultate bowel sounds?

normal bowel sounds are clicks or gurgles 5-34 times a minute hyperactive: if frequent hypOactive: occur after long intervals of silence absent: if NO sound is heard for 2-5 minutes

NSS

normal saline solution

grading motor strength: 5/5

normal strength

Moro (startle reflex)

normal to about 4 months

What are characteristics of normal vs abnormal stool?

normal: brown, aromatic, soft, formed, round, full, undigested fiber abnormal: black, tan colored, yellow, foul, soft, bulky, hard, dry, watery, paste like, unformed, flat, pencil shaped, stone like, worms, blood, pur and mucus

ice collars

normally used for after removal after tonsils

What must you access before insertion of NG tube? What are the risks/complications with insertion?

nose/throat discomfort, dilates the esophageal sphincter, AKA (cardiac valve) and can damage nasal and pharyngeal mucosa from pressure or function

What can contaminate the specimen?

not cleaning the site, not washing hands,

palpation of the spleen

not normally palpable on most individuals

I - olfactory: test

not routinely tested unless indicated

NPO

nothing by mouth

what information should a nurse gather when doing a nutritional/dietary assessment of a patient

number of meals per day fluid intake food preference, amounts food preparation, purchasing practices, access history of indigestion, heartburn, gas allergies taste chewing and swallowing appetite elimination patterns medication use activity levels religious, cultural food preferences & restrictions nutritional screening tools

Which pain intensity scaled used most often?

numeric scale, when assessing adults

When is the immediate post-op period?

nursing care after surgery

what are fats?

nutrients that contain molecules composed of glycerol and fatty acids called glycerides and are part of the family of compounds known collectively as lipids

Fats

nutrients that contain molecules composed of gycerol and fatty acids call glycerides

the process by which the body contains nutrients from food is known as _________

nutrition

pallor

pale

III oculomotor: test

observe for ptosis (drooping eyelid) test for extraocular movements test pupillary reactions to light

the best way to determine the depth of a pt's respiration is to

observe the degree of chest wall movement during inspiration and expiration

objective data (O)

observed by the nurse

OB

obstetrics

The most reliable method for verifying initial placement of a small bore feeding tube is by

obtaining an abdominal x ray

Medication reconciliation

obtaining and verifying medications that the patient is currently taking

What personal history should you collect for an H&P?

occupation highest level of education religious affiliation residence country of origin primary language military service foreign travel

airborne transmission

occurs through contact with contaminated respiratory droplets spread by a cough or sneeze

CN III

oculomotor mixed nerve motor: EOM, opening eyelids parasympathetic: pupil restriction, iris shape

assessment of hernia

often need to assess standing up

Who qualifies for home healthcare

older adults 65yrs old or over with one or more disability - hearing, vision, cognition, ambulation, self care, or independent living

Signs of inflammation may be more subtle in ?

older adults?

What is lipping?

older bones develop indistinct and shaggy-appearing margins with spurs.

CN I

olfactory sensory: smell

Sources of good fats in our diets

olives canola oil avocado peanuts and other nuts fish (fish oils) poultry

When is medication reconciliation done?

on admission readmission before transition in care

Bronchovesicular lung sounds

on either side of central chest/back, Medium range sounds are equal in length during inspiration and expiration and have NO pause

sundown syndrome

onset of disorientation as the sun sets

ulcer

open, crater like area

OR

operating room

Describe inpatient versus outpatient surgery.

operative procedures from which clients recover and return home on the same day

Outpatient surgery:

operative procedures performed on clients who return home the same day, performed on patients of optimal health and who's recovery is expected to be uneventful

Inpatient surgery:

operative procedures performed on persons admitted to a hospital and expected to remain for a period of time

CN II

optic sensory: vision

temperature

oral axillary rectal aural (the ear) ***use back of hand (dorsal aspect) to assess skin temp

important information for cutting toe nails

order required be aware if diabetic

Degenerative joint diseases such as ___________ are common

osteoarthritis

OOB

out of bed

general survey

overall review or first impression of person's well being

Define: analgesic medications

pain relieving drugs

Define intractable pain

pain unresponsive to methods of pain management

neuropathic pain

pain with atypical characteristics is also called functional pain, type of pain that is experienced days, weeks, or even months after the source of the pain has been treated and resolved

acupuncture

pain-management technique in which long, thin needles are inserted into the skin

skin conditions indicative of heat stroke, shock, or other cardiac comp

pale cool moist skin

charting on lymph nodes

palpable nodes? soft or hard tender or non-tender mobile or fixed

IX - glossopharyngeal: parasympathetic

parotid gland carotid reflex

sensory-neural loss is due to

pathological problem of inner ear, CNS, or cerebral cortex

pt

patient

What is a PCA pump?

patient controlled analgesic - an intervention that allows pts to self administer opioid pain medication through use of an infusion device

What's the most frequent cause of artifact on ECG?

patient movement crossed wires interference in the electrical supply unstable electrodes

When is cutting a patients toenails contraindicated? and what do you need to cut their toes?

patients who have diabetes, impaired circulation or thick nails are at risk for complications secondary to trauma, a podiatrist

Chemical sterilization

peracetic acid, ethylene oxide gas

What is perineal care?

pericare, techniques used to cleanse the perineum, especially important after a vaginal delivery or gynecologic or rectal surgery so that the impaired skin remains as clean as possible

What is informed consent?

permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.(paper document with pt signature)

What is informed consent?

permission that a person gives after having the risks, benefits, and alternatives explained

Tympanic

pertaining to the eardrum

IX - glossopharyngeal: motor

pharynx (phonation and swallowing)

X - vagus: motor

pharynx and larynx (swallowing and talking)

circadian rhythm

phenomena that cycles on a 24hour basis

Pelvic examination

physical inspection of the vagina and cervix with palpation of the uterus and ovaries

PT

physical therapy

What are common factors that affect urinary elimination?

physiologic, emotional and social factors

vitiligo

pigment lost from areas of the skin

nasal turbinates should appear

pink and moist

flushed

pink of the skin, caused by fever, hypertension

Stoma appearance should normally look

pink or red and moist/red and beefy

To prevent aspiration during the administration of an enteral tube feeding, a nurse should

place the pt in a Fowler's positoin

nurse is preparing to administer cleansing enema to a pt who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which intervention is appropriate for this pt?

place the pt in a dorsal recubent position o the bedpan

flat or dull chest percussion indicates

pleural effusion lobar pneumonia

ADVENTITIOUS an Abnormal lung sound 4?

pleural friction rubs, grating, leathery sounds caused by 2 dry pleural surfaces moving over each other

what causes multiple organ failure?

poor quality of cellular oxygen

Name some Chest physiotherapy

postural drainage = drainage with the use of gravity percussion = rhythmic striking of the chest wall vibration =shake underlying tissue and loosen retrained secretions

lb

pound

What is a Discharge Care plan and when does it begin?

predetermining a clients post discharge needs and coordinating the use of appropriate community resources to provide a continuum of care Discharge care plan- is a process that improves client outcomes. Soon as possible

preop

preoperative

Phases of perioperative period

preoperative, intraoperative, postoperative

Basic nursing admission activities

preparing the patients room welcoming the patient orientation for the patient safeguarding patients valuables and clothes helping patient undress compiling nursing data base

How can you help your patient cope with anxiety and fear before surgery?

preparing the pt emotionally and spiritually is important as well. assess pts way of coping, careful listening and explaining

Splinting

pressing on the incision with both hands or pressing on a pilow ove the incision or wrapping a bath blanketaround before coughing exercises

Stage III pressure ulcer

pressure ulcer has a shallow skin crater that extends to the subcutaneous tissue. It may be accompanied by serous drainage, undermining, slough, or purulent drainage caused by a wound infection.

Stage II pressure ulcer

pressure ulcer is red and accompanied by blistering or a skin tear without slough. Impairment of the skin may lead to colonization and infection of the wound.

Stage IV pressure ulcer

pressure ulcers are life-threatening. The tissue is deeply ulcerated, exposing muscle and bone. Slough and necrotic tissue may be evident. The dead or infected tissue may produce a foul odor. If an infection is present, it easily spreads throughout the body, causing sepsis.

common vehicle transmission

primarily transmission by contaminated items such as food, water, medications, devices, and equipment

Paracentesis

procedure for withdrawing fluid from the abdominal cavity

Lumbar puncture

procedure for withdrawing spinal fluid

urinary diversion

procedure in which one or both ureters are surgically implanted elsewhere

Laboratory test

procedure that involves examining body fluids or specimens and comparing the components of a collected specimen with normal findings

Diagnostic examination

procedure that involves physical inspection of body structures and evidence of their functions

Radiography

procedures that use roentgen rays, or x-rays, to produce images of body structures

Nutrition

process by which the body uses food

Referral

process of sending someone to another person or agency for special services

Discharge Care plan

process that improves patient outcomes 1. predetermining post discharge needs in a timely manner 2. coordinating the use of appropriate community resources to provide a continuum of care

Sedatives

produce a calming and relaxing effect and promote rest

benefits of sleep

promotes emotional well being enhances various physiologic processes reduces fatigue stabilizes mood improves blood flow to the brain increases protein synthesis improves immune system promotes cellular growth and repair improves capacity for learning and memory storage

Good posture stance

proper body mechanics

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must

protect your eyes

complete proteins

protiens that contain adequate amts and proportions of all the essential amino acids

inspection of newborn ABD: normal contour

protuberant and soft

Define biofeedback

technique in which the client learns to control or alter a physiologic phenomenon

Pain management

techniques for preventing, reducing, or relieving pain

source oriented records

provide a documentation approach that is sometimes criticized for being fragmented or disjointed Organized according to source of documented information Contain separate forms for physicians, nurses, dietitians, physical therapists to make written entries about their specific activities in relation to client's care This record provides fragmented documentation

What can be done to help prevent post-op complications?

provide food & oral fluids promoting venous circulation perventing thrombus formation performing wound management

local anesthesia

provides local loss of sensation client remains awake

post operative assessments

pt airway maintain adequate circulation prevent/assist with the management of shock maintain proper positions and function of drains, tubes & intravenous infusions detect evidence of any complications

Paper wrapped items:

pull back paper and flaps, drop without touching

assessing ear using otoscope: how to hold child ear

pull ear down and back

assessing ear using otoscope: how to hold adult ear

pull ear upwards and backwards to straighten canal

Once blood is drawn what do you do with your needle?

pull the needle cover and throw in the sharps bin

P

pulse

III oculomotor: parasympathetic

pupil constriction iris shape

What is pyuria?

pus in the urine

who can confirm death of a patient?

pysician pysician's assistant medical examiner coroner

QC

quality control

q.s.

quantity sufficient

How would you document a direct quote from a pt and when would you do this?

quote the clients verbal comments, and avoid phrases like seems to be and appears to be

Physical sterilization

radiation, boiling water, free-flowing steam, dry heat, steam under pressure

X-Ray

radiology

active ROM

range of motion in which the resident assist with the movement

REM

rapid eye movement

tachycardia

rapid heart rate

malignant hypertension

rare, life-threatening type of hypertension evidenced by optic-nerve (eye) edema and extremely high systolic and diastolic blood pressure

prostate screening: digital exam

recommended annually hemoccult any specimen

Electrical graphic recordings

recording electrical impulses from structures such as the heart, brain, and skeletal muscles

EEG (electroencephalogram)

recordselectrical impulses generated by the brain

most accurate temp

rectal

RBC

red blood cell

Sources of bad fats

red meat margarine full fat dairy palm oils coconut oils vegetable oil butter

erythema

redness of the skin caused by superficial burns, inflammation, CO2 poisoning

Diminished immune response

reduced T-lymphocyte cells predisposes older adults to wound infections

Chronic sleep deprivation effects

reduced physical stamina altered comfort (head ache and nausea) impaired coordination (fine motor skills) loss of muscles mass and weight more susceptible to infection less tolerance to pain impaired judgement unstable mood suspiciousness

What are the effects of chronic sleep deprivation?

reduced physical stamina, altered comfort such as headaches and nausea, impaired coordination, loss of muscle mass and weight, increased susceptibility to infection, slower wound healing, decreased pain tolerance, poor concentration, impaired judgment, unstable moods, suspiciousness

Cold does what?

reduces localized swelling and promotes vasoconstriction decreasing circulation of pain-producing chemicals

Vasovagal

reflex that happens when circulating blood is diverted to the legs rather than the head ad results in dizziness and fainting

Wound healing delayed in older adults?

regeneration of healthy skin takes twice as long for 80-year-old vs 30-year-old

examination of skin: palpate

temp turgor lesions edema texture

TRP

temperature, pulse, respiration

regularly irregular pulse

regular pattern overall w/ "skipped" beats

How does exercise effect sleep?

regular sleep increases fatigue and the need for sleep at night but exercise at night has a stimulating effect

Biopsy

removal and study of tissue to make a good diagnossis

Nasopharyngeal suctioning

removing secretions from the throat through a nasally inserted catheter

oropharyngeal suctioning

removing secretions from the throat through an orally inserted catheter

How to treat shock

replace fluids administer oxygen give emergency drugs and place in trendelenburg position

What are the common sign and symptoms of fecal impaction and how is it treated

reporting of frequent desire to defecate but an inability to do so and to treat the nurse would insert a gloved lubricated finger into the rectum

what does a living will represent?

represents the patient's wishes on continued liefe sustaining health care ro the termination of care depending the the physical condition of the patient

R

respiration

Inhalation therapy

respiratory treatments that provide a mixture of oxygen, humidification, and aerosolized medication

What are nursing nursing interventions for a patient with diarrhea?

rest bowels, avoid solid foods and only clear liquids for 12-24 hours

diagnosis

results from analyzing the collected data and determining whether they suggest normal or abnormal finding

Good standing position

results when abdominal and gluteal muscles are contracted

A _________________ enema uses solution held within the large intestine for a specified period, usually at least 30 min

retention

What is peristalsis?

rhythmic contraction of gastrointestinal smooth muscle

R & Rt

right

How do you assess gastric residual?

rule of thumb: the gastric residual should be no more than 100 mL or no more than 20% of the previous hours tube feeding volume

somnambulism interventions

saftey stargates security locks on doors and windows

subjective data (S)

said by the client

VII - facial: parasympathetic

saliva and tear secretion

Dietary sources for C complex vitamins

saltwater fish oysters citrus fruits tomatoes berries cabbage green veggies potoatoes

What is a lab specimen and what are they collected?

samples of tissue or body fluids collected and to be sent to the lab for testing

what are bad sources of fats in our diets

saturated fats are lipids that contain as much hydrogen as their molecular structure can hold and are generally solid. Saturated fats are the predominate type of fat in red meats, full fat dairy products, and palm and coconut oils

What are drugs that induce or promote sleepiness?

sedatives and hypnotics

Death rattle

terminal respiratory secreations or terminal secreations. oftern produced by someone who is near death as a result of saliva and bronchial secreations accumulating in the throat and upper chest

Fowler's

semi-sitting body position in which a person's head and shoulders are elevated 45 to 60 degrees

When auscultating a pt's apical pulse you listen until you hear the s1 ands2 heart sounds clearly an regularly. S1 is produced when the

semilunar valves close

VII - facial: sensory

sense of taste in front 2/3 of tongue

Isolation

separation from others; to not spread the infection

abnormal findings of ear assessment: dull, nontransparent gray

serous otitis media w/ effusion

goal

setting and evaluating a _________ helps the nursing team know whether the nursing care has been appropriate for managing the clients nursing diagnosis and collaborative problems

what causes hemolysis

shaking the tube too hard needle gauge is too small drawing back too hard on the plunger expelling blood too quickly exposure to alcohol

normal color of eardrum

shiny translucent pearly gray

common complications associated with drawing blood

short draw hematoma fainting uncooperative pt

location of pain: back-SHOULDER PAIN

side - muscle spasm front - bursitis or rotator cuff, glenohumeral joint

location of pain: back-HIP PAIN

side - sciatica front - bursitis, hip joint

how do you compare lung sounds?

side to side

5 mo milestone

sits up w/ support

8 mo milestone

sits w/o support stranger anxiety

proximal

situated next to nearest point of attachment or origin

SNF

skilled nursing facility

SNF

skilled nursing facility, provides 24-hour nursing care under the direction of a RN.

peristomal skin

skin surrounding an ostomy

What is the itegumentary system?

skin, mucus membranes, hair, and nails

What other disorders can Narcolepsy be confused with?

sleep paralysis cataplexy hyponogogic hallucinations automatic behavior hypersomnolence

what kind of sleep assessments are there?

sleep questionnaires, sleep diaries, polysomnographic evaluation, and multiple latency sleep test

somnambulism

sleep walking

Why are sleep rituals important?

sleeping patterns

bradycardia

slow heart rate

what things can interfere with nutritional intake in older adults

slower metabolic rate requires fewer calories thirst sensations diminish disease and illness medications

Enteral nutrition is nourishment provided via the stomach or ____________ _____________.

small intestine

papule

small, raised, solid pimple or swelling, often forming part of a rash

I - olfactory: sensory

smell

2 mo milestone

smiles recognizes parents

sleep apnea s/s

snoring waking at night feeling tired after sleeping stopping from breathing or slowed breathing

rhonchi

snoring or gurgling quality extra sound that's not a crackle or wheeze prob rhonchi low pitched

SS

soap suds

assessment of motor response: muscle strength

test by having pt move against resistance always compare one side to the other grade strength on scale from 0-5

What is the purpose of deep breathing, coughing, and leg exercises?

to help reduce post-op risk of respiratory complications help loosen mucous help reduce risk for circulatory complications

-metry

to measure

soft palate: composition and color

softer, more mobile pink

how is a 24 hr urine stored?

some need to be stored on ice, others need preservative

percussion

sounds produced by striking area bell--low pitched sounds such as heart murmur diaphragm--high pitched resp sounds

Examples of incomplete proteins

soy legumes (peas,beans, peanuts) nuts components of grains

What would you document for a pt discharge?

specific information provided when teaching a client and the evidence that indicates the client has understood the instructions, follow up dates with doctors, meds that they should be taking and how to take care of a wound if they have or whatever else they need to know

CN XI

spinal accessory motor: trapezius and sternomastoid muscles

Voiding reflex

spontaneous relaxation of the urinary sphincter in response to physical stimulation

assessing abdomen: general considerations

start in RLQ over ileocecal valve watch face for signs of discomfort during examination

anesthesia

state of depressed central nervous system activity with depression of consciousness, loss of response to stimulation, and muscle relaxation

isometric exercise

stationary exercises that are generally performed against a resistive force using an elastic band or exercise ball or holding weights steady

drugs that induce wakefuless

stimulants

What do you do if you get a hematoma?

stop and pull the needle out and apply pressure

Gerontology

study of the aging process

SOAP charting

subjective, objective, assessment, plan a style more likely used in a problem oriented record

SOAPIER

subjective, objective, assessment, plan, intervention, evaluation, revision

Cataplexy

sudden loss of muscle control

Narcolepsy

sudden onset of daytime sleep short NREM before the 1st REM phase and pathologic manifestions of REM

Clinical resume

summary of previous care includes 1. reason for hospitalization 2. significant findings 3. treatment rendered 4. current condition of patient 5. instructions (if any) to patient or family members ** always make sure that the patient has been notified and has given consent for release of their personal health information**

What factors can interfere with/alter sleep patterns?

sun light, bright lights, inconsistent sleep schedule, suppression of melatonin, strange sleep environment, cold, hot, stuffy room, protein deficient diets, metabolism of alcohol, difficultly breathing, pain, full bladder, hunger, thirst, etc

erythema

superficial reddening, usually in patches

PENS is considered

superior to TENS in providing pain relief because the needles are located closer to nerve endings

A __________________ is inserted into a body cavity such as the rectum?

suppository

abnormal findings of ear assessment: erythema

suppurative otitis media, purulent drainage

-plasty

surgical correction or repair

-otomy

surgical incision

-ectomy

surgical removal

What is a posterior rhizotomy

surgical sectioning of a nerve root close to the spinal cord

-ostomy

surgically create an opening

What is an ostomy?

surgically created opening

-orrhaphy

suturing or repair

what physiological changes occur in the GI system of the older adult?

swallowing and peristalsis slows and causes - constipation - acid reflux - indigestion - diverticulitis taste changes over time due to - diminished senses of taste and smell more prone to - lactose intolerance - stomach inflammation - side effects to medications normally taken in the past liver no longer metabolizes drugs as rapidly as before kidney ability to eliminate medications decreases

What body fluids are non infectious?

sweat and tears

inspection of child ABD: normal contour

symmetric and slightly rounded

where so we get sodium

table salt, processed meat

caudal

tail or hind part

define micro capillary specimen

taking blood from babies

Precussion

tapping surface of body to determine density

IX - glossopharyngeal: sensory

taste on posterior 1/3 of tongue gag reflex

What is the gate-control theory?

that the sensory information travels over slow small fibers as well as fast large fibers. Slow fibers, through which pain stimuli travel, open gates within the spinal cord, allowing its transmission toward the brain. Fast fibers that are responsible for transmitting other types of sensory information can close the gates through which pain stimuli travel. The gating mechanism helps to explain why competing sensory stimuli, such as heat, cold, massage, acupressure, and so on, can decrease the perception of pain or its intensity

What is important to remember when providing hygiene to n elderly patient?

that their skin is fragile, pat do not rub, their skin tears easily

S2

the "dub" sound when ventricular pressure falls (after emptying) below the pressure in the aorta and pulmonary artery allowing the aortic and pulmonic valves to close - (DIASTOLE)

S1

the "lub" sounds & is louder at the apex or mitral area when using the diaphragm of a stethoscope

Calorie

the amount of heat it takes to raise 1 gram, 1 degree Celsius

pain tolerance

the amount of pain a patient can endure without its interfering with normal function

What is the perineum?

the area around the genitals and rectum, requires special or frequent cleansing in addition to bathing

postmortem care

the care of the body after death, preping the body for viewing by cleaning and removing all medical equipment, iv catheters, urine catheters however if the body is to be examined for autopsy then you must keep all medical equipment in place secured and taped to reduce risk of leaking or risk of injury to the person who will preform the autopsy

What can be cultured?

the cells are isolated from the tissue and proliferated under the appropriate conditions until they occupy all of the available substrate

lipping

the development of a bony overgrowth in osteoarthritis

sleep paralysis

the experience of waking up unable to move

nausea

the feeling you get before you throw up

When is immediate post-op care?

the first 24 hours after surgery

Semi-Fowler's Position

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

What is fecal incontinence and how can it be managed?

the inability to control the elimination of stool, can be managed by several things a few examples are eat regularly and nutritiously and monitor the patter *more in FN book pg 735 bottom right pg*

A nurse donning sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the non contaminated glove because

the inner edge of the cuff will like against the skin and this will not be sterile

distraction

the intentional diversion of attention to switch the person's focus from an unpleasant sensory experience to one that is neutral or more pleasant

Who has legal responsibility when delegating?

the licensed nurse is legally responsible for the delegated tasks according to applicable state laws, staff capabilities, and patient needs.

Who is responsible for getting the medication reconciliation information?

the nurse The RN is responsible for admission of patient however they can delegate most of the duties to the LPN

True

the nurse obtains information beginning during the admission interview and physical exam

define sundown syndrome

the onset of disorientation as the sun sets

What is urinary elimination?

the passage of excess fluid and metabolic wastes through the urinary tract by means of the urinary sphincter and urethra

If a 12-lead EKG shows a flat line in more than 1 lead please assess?

the patient for cardiac arrest. Always assess the patient first and if there is no apparent distress the likely cause is the connection or equipment

Sim's

the patient lies on his or her left side and chest, the right knee and thigh drawn up, the left arm along the back

define sleep paralysis

the person cannot move for a few minutes just before falling asleep

What is intubation?

the placement of a tube into a body structure, digestive, orogastric, nasogastric and nasointestinal intubation

TED hose purpose

to breakup blood clots

what is the purpose of an autopsy?

to determing the cause of death

What does the patient experience on a TENS unit?

the pt perceives the electrical stimulus, generated by a battery powered stimulator, as a pleasant tapping, tingling, vibrating, or buzzing sensation

The difference between a pt's systolic and diastolic blood pressure is called

the pulse pressure

who notifies the family of death or impending death of a loved one?

the pysician is in charge of contacting the family and releasing that information

What is the chief complaint?

the reason for seeking care

biopsy

the removal of living tissue from the body for diagnostic examination

Dehiscence

the separation of wound edges

what does peripheral circulation changes mean?

the skin tuns pale, mottled, nail beds and lips turn blue and they are always cold this is all due to poor blood circulation due to the failing heart

Carbohydrates

the starches and sugars present in foods nutrients that contain molecules of carbon, hydrogen, and oxygen

suffering

the state of undergoing pain, distress, or hardship.

Gerontology

the study of aging

ileostomy

the surgical creation of an artificial excretory opening between the ileum, at the end of the small intestine, and the outside of the abdominal wall

What would you teach your patient about treating fungal nail infections?

the thick, yellowed, rough appearing toenails or fingernails that can be spread one nail to another, to treat seek professional nail care from a podiatrist and follow directions for topical antifungal medications

Nursing guidelines for operating a glucometer

the user must follow the manufacturers instructions for accurate use the blood glucose level usually is measured 30 min before eating and before bedtime to determine what are likely to be the lowest levels of glucose. this allows time for the client to increase or decrease food consumption or, if insulin-dependent, to administer additional prescribed insulin, referred to as coverage measuring blood glucose involves risk for contact with blood, because blood may contain infectious viruses, nurses always wear gloves when performing this test

define Vasodilation

the widening of blood vessels, opposite of vasoconstriction.

Third-intention healing

the wound edges are intentionally left widely separated and are later brought together with some type of closure material. This reparative process results in a broad, deep scar.

Second-intention healing

the wound edges are widely separated, leading to a more time-consuming and complex reparative process. Because the margins of the wound are not in direct contact, the granulation tissue needs additional time to extend across the expanse of the wound.

What is a closed wound?

there is no opening in the skin or mucous membrane. Occur more often from blunt trauma or pressure. ex: hematoma

What are artifacts on the ECG tracing?

they are interferences like if the patient moves

What is the purpose for anti-embolism stockings?

they are knee high or thigh high elastic stockings sometimes called TED-HOSE, thromboemnolic disorder, they compress superficial veins and capillaries, redirecting more blood to larger and deeper veins, where it flows more effectively toward the heart

Where do we get carbohydrates in our diet

they are the bodys primary source for quick energy, carbohydrates may contain fiber

What are common side-effects for non-opioid analgesics?

they cause sedation, nausea, constipation

What is the purpose for sleep assessments?

they provide information for you to be able to identify one or more of nursing diagnosis

Surgical asepsis

those measures that render supplies and equipment totally free of microorganisms

Nosocomial infections are

those which occur in the course of being treated in a hospital

TID, t.i.d.

three times a day

What is the preoperative period?

time that starts when the client is informed that surgery is necessary and ends when he or she is transported to the operating room

What information should be documented in the patient's chart regarding the procedure?

time the procedure was completed, a copy of the recording, the patient's reaction to the procedure

intraoperative period

time when a client undergoes surgery

Food and Fluid Restrictions:

to prevent aspiration and pneumonia most patients are NPO after midnight

Leg exercises

to promote circulation and reduce the risk for forming a thrombus(stationary blood clot) in the veins.

-centesis

to puncture

-graphy

to record

-scopy

to see

A nurse is performing a physical assessment on a pt and instructs the pt to stand with his feet together and arms at his sides. What is the purpose of positioning the pt in this manner?

to test balance

Snellen chart

tool for assessing FAR vision

Jaeger chart

tool for assessing NEAR vision.

TQI

total quality improvement

24 hour urine specimen

total urine excreted over 24 hours, collected for analysis

how do you assess the nutritional status of an older adult?

tracking body weight

What is a TENS unit?

transcutaneous electrical nerve stimulation, a medically prescribed pain management technique that delivers bursts of electricity to the skin and underlying nerves, is an intervention implemented by nurses.

Describe the four phases of that occur when someone experiences pain.

transduction, transmission, perception, and modulation

What order do the four phases occur when someone experiences pain?

transduction, transmission, perception, and modulation

Vector transmission

transmission of pathogen via insect or animal Ex. mosquitoes, fleas, ticks, rats

What is cholesterol?

transported through the blood in molecules of lipoproteins ( a combo of fats and proteins)

XI - spinal accessory: motor

trapezius and sternomastiod muscles

How should you care for a patients hearing aid or glasses?

treat them as if they were my own and handle with care, keep well maintained and safely stored when not in use and care for the devices at the same time you care for your patient

newborn-toddler: posterior fontanel

triangle shaped closes 1-2mo

CN V

trigeminal mixed nerve motor: muscle of mastication sensory: face, scalp, mouth, nose

CN IV

trochlear motor: inward and downward movement of eye

True or False? Client's on phototherapy should use he lights for two to six hours to simulate the amount of daily sunlight an individual might encounter during the sunnier months

true

How would you avoid disrupting the sleep of a hospitalized pt?

try to avoid going into their room at night between 90-120 min blocks of sleep - be quiet - don't turn on all the lights - do what you need to do quickly and quietly

Rectal Tube

tube inserted into the rectum to aid in the expulsion of flatus (gas)

invert

turning vile up blood over an back up 8-10 times, unless its a blue tube then it is 4 times

b.i.d., bid

twice a day

what are complementary proteins?

two or more dietary proteins whose amino acid assortments complement each other in such a way that the essential amino acids missing from one are supplied by the other

Total Cholesterol:

under 200 mg/dL

Direct inpatient admission

unplanned , bypass the ER ex: for acute condition like prolonged vomiting or diarrhea

what are good sources of fats in our diet

unsaturated fats are missing some hydrogen, they are healthier form of fats and are liquid at room temp or congeal slightly when refrigerated

What are healthy fats to suggest to patients?

unsaturated fats: fish, poultry, nuts, and most plant oils, such as corn, safflower, olive, peanut, and soybean

Preoperative Care Assessment:

urgency of the surgery (emergency, urgent, required, elective and optional) Risk for complications Review preoperative instructions

UA

urinalysis

Urostomy

urinary diversion that discharges urine from an opening on the abdomen

Patient teaching and nursing guidelines for obtaining a 24 hour urine collection

urinate just before starting the test and then discards that urine, from then all urine voided becomes part of the collected specimen, exactly 24 hours later ask client to void one last time to complete the test collection

UA

urine analysis

What is straight cath?

urine drainage tube inserted but not left in place

straight cath?

urine drainage tube inserted but not left in, it is for sterile specimens or output (volume measured)

What is oliguria?

urine output less than 400mL in 24 hours

postural drainage

use of body positioning to assist in removal of secretions from specific lobes of the lung, bronchi, or lung cavities

application of heat and cold

used therapeutically to treat conditions such as infection or trauma

define hospice care

used to indicate both a facility for providing the care of terminally ill clients and the concept of such care itself

FSBS (Finger Stick Blood Sugar)

used to test glucose level in blood

military time

uses different four-digit numbers for each hour and minute of the day

The most important factor in measuring blood pressure accurately is

using a cuff of the appropriate size for the pt

Enzymztic debridement

using chemical substances

sharp debridement

using sterile scissors, forceps, etc.

light palpation

using the fingertips,the back of the hand, or palm of the hand.best used when feeling the surface of the skin,pulsation from peripheral arteries, and vibrations in the chest .

Imagery

using the mind to visualize an

Sleep diary

usually for a 2 week period the PT records: time of sleep, time of wake, daily wake activities (the first 15min after waking), a 24hour food/drink log, and notes on any medications such as what medications, the dose, and time of day to take it

nausea

usually precedes vomiting and is produced when gastrointestinal sensations, sensory data, nd drug effects stimulate a portion of the medulla that contains the vomiting center BRAT Diet, bland foods

CN X

vagus mixed motor: pharynx and larynx (swallowing and talking) sensory: general sensation from carotid body, carotid sinus, pharynx, viscera parasympathetic: carotid reflex, slows HR

What is generally included in pre-op teaching?

varies depending upon type of surgery and length of hospital stay, what to expect before during and after meds for after and when given and effects postoperative pain control explanation & description of the postanesthesia recovery room or postsurgical protocol discussion of the frequency of assessing vital signs and the use of the monitoring equipment

people who rely exclusively on plant sources for protein are called ____________

vegans

What must the nurse do before administering any medications?

verify patient (2 forms ID, name birthdate) ask about any allergies obtain vitals have patient void ensure consent has been signed

pitting edema: 4+

very deep indentation remains for long time grossly swollen and misshapen

-oscopy

viewing

grading motor strength: 1/5

visible muscle movement, but no movement at joint

II - optic: sensory

vision

What do the physical characteristics of urine include?

volume, clarity, color and odor

What are the normal and abnormal characteristics of urine, including volume, color, and clarity?

volume: Normal is 500-3000 mL/day, 1200 daily average Abnormal is <400 mL/day color: Normal is light yellow Abnormal is dark amber, brown, blue, reddish brown, orange, green clarity: Normal is transparent Abnormal is cloudy odor: Normal is faintly aromatic Abnormal is foul, strong and pungent smell

projectile vomiting

vomiting that occurs with great force

Projectile vomiting

vomiting with great force

musculoskeletal system: general considerations

w/ musculoskeletal system always BEGIN W/ INSPECTION, PALPATION, & ROM, regardless of region you're examining (except for ABD)

12 mo milestone

walks alone

Basic room supplies

wash basin a soap dish an emesis basin a water carafe a bed pan and a urinal * all other personal care items are later provided for along with medical equipment if they are needed

Patient/Family teachings for males/females for obtaining a clean catch/mid stream urine specimen

wash your hands remove the lid from the specimen container rest the lid upside down on its outer surface, taking are not to touch the inside areas sit on the toilet & spread your legs separate our labia with your fingers cleanse each side of the urinary meatus with a separate swab, wiping from front to back toward the vagina use the final clean, moistened swab to wipe directly down the center of the separated tissue begin to urinate after releasing a small amount of urine into the toilet, catch a sample of urine in the specimen container take care not to touch the mouth of the specimen container nearby on a flat surface release your fingers and continue voiding normally wash your hands cover the specimen container with the lid MALES: retract your foreskin, if you are uncircumcised, or cleanse in a circular direction around the tip of the penis toward its base using a pre-moistened swab repeat with another swab continue retracting the foreskin while initiating the first release of urine and until you have collected the midstream specimen

After assisting a newly admitted patient in removing his shoes and outerwear, you notice what appears to be soil or grime on your hands. You

wash your hands with soap and water

What is a partial bath?

washing only those body areas that are subject to greatest soiling or that are source of body odor, generally, the face, hands and axillae, and perineal area and is done at bedside

H20

water

What is the function and dietary source of sodium?

water and electrolyte balance Found: table salt and processed meat

Wt

weight

WC

wheelchair

Allow additional time

when admitting, discharging, or transferring older adults

dependence issues for the older adult

when an older adult need for help in their regular day to day lives. some live in nursing homes or extended care facilities some dey they need assisted living and insist on remaining at home even when it jeopardizes their safety

When would you need to notify the doctor?

when anything is abnormal than the planned outcome, vitals decreased/increased, pain increase, no urination for a long period of time

Ageism

when people characterize older adults as sick, feeble, rigid, disagreeable, opinionated or demented persons who live in the past

short draw

when the blood flow is show or stops after a short time - can happen if the needle comes out of the vein - the needle bevel is against the vessel wall preventing blood flow - collapse of vein

terminal care

when you give basic physical needs for hydration nourishment elimination hygiene and comfort

When would you use a butterfly needle?

when your pt has small difficult veins

When is pain assessed?

whenever he/she considers it appropriate & routinely in the following circumstances: pt admitted nurse takes vitals once per shift when pain is problem-focused or a risk when pt is at rest and when involved in a nursing activity after each potentially painful procedure/treatment before implementing a pain management intervention, such as administering an analgesic

slough

which is dead tissue on the wound surface that is moist, stringy, yellow, tan, gray, or green.

necrotic tissue

which is dry, brown or black devitalized tissue. non-living tissue

What are some nursing interventions for dry skin?

whirlpool, lotion skin remedies, or a medicated bath

How is oxygen measured?

with an Oxygen Analyzer

Pain from trauma best treated initially?

with cold application

How is incontinence managed?

with continence training, and Q2 hour toileting or a different type of bladder program

WNL

within normal limits

Evisceration

wound separation with protrusion of organs

Evisceration

wound separation with the protrusion of organs.

Applying heat or cold can be used in the treatment of?

wounds, soft tissue and muscle strain/sprains and for pain management

How do you document a late entry

write late entry at the beginning of nurses note, "late entry"

Transfer summary

written review of the clients current status

general assessment: body structure/mobility

wt/ht w/in normal range (BMI) body parts equal bilat stands erect sits comfortably gait coordinated walk is smooth and well-balanced full mobility of joints

To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the pt's nose to the ear lobe an then from the earlobe to the...

xiphoid process plus 20 to 30 cm more

jaundice

yellowing of the skin, caused by liver/kidney disease, destruction red blood cells

What are you demonstrating when you try to understand the client's feelings when helping them cope?

you 're reinforcing the client's uniqueness

What complication can happen if the heel bone is damaged during a neonatal collection?

you can cause osteomyelitis

What do you do if your pt refuses to allow you to draw their blood?

you can't force them you can try to talk to them but if they are a "no" then note their chart and make sure you tell the physician

What affect does aspirin have on bleeding time?

your pt will bleed a lot! you'll have to hold pressure on site of puncture for 10 to sometimes 20 min

How do you auscultate the lungs?

zig-zag movement, have pt. take a full breath while you are listening - start C7 to T10