ATI Fundamentals Comprehensive Review

*cardiovascular changes* due to immobility

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

Soft/low-residue diet

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

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

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

What is the purpose of medicated enemas?

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

What PPE is required for *contact* precautions?

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

nursing interventions to *reduce skin injury and maintain metabolism*

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

Where does gas exchange take place?

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

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

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

What are the therapeutic effects of *heat* applications?

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

How do you access skin turgor?

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

Clear liquid diet

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

What PPE is required for *droplet* precautions?

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

What PPE is required for *airborne* precautions?

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

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

- mass casualty -intra-facility -internal -external

cardiovascular assessment

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

mobility and immobility assessment focuses on:

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

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

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

What is role overload?

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

Vitamins

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

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

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

respiratory assessment [complete every 2 hours]

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

integumentary assessment [assess at least every 2 hours]

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

What is the purpose of an oil-retention enema

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

What position should the patient be in for an enema?

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

What is neuropathic pain?

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

What is nociceptive pain?

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

What are signs of stomal ischemia?

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

What are the modes of transmission for contact pathogens?

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

What are nursing interventions to *maintain intact skin*

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

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

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

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

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

How does consuming adequate fluids help prevent infection?

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

Fats

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

Carbohydrates

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

Dysphagia diet

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

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

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

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

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

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

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

What are the modes of transmission for airborne pathogens?

- sneezing; - coughing

What are the modes of transmission for droplet pathogens?

- sneezing; - coughing; - talking

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

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

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

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

Types of intentional torts

-Assault -Battery -False imprisonment

Right circumstance

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

Types of quasi-intentional torts

-Breach of confidentiality -Defamation of character

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

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

The 3 classes of fire extinguishers:

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

What are signs and symptoms of *dehydration*?

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

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

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

Registered Nurse (RN)

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

Federal laws impacting nursing practice include:

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

cardiac output (CO) is determined by

-HR -contractility -blood volume -venous return

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

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

Unlicensed Assistive Personnel (UAP)

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

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

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

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

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

Types of unintentional torts

-Negligence -Malpractice (professional negligence)

Refusal of treatment

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

cellulitis

-Pain; warmth; edema; induration; red streaking; fever, chills, and malaise. treatment, stop IV, elevate the extremity, warm compresses 3-4, culture if drainage is present

expected cognitive development: older adult (65+ yrs)

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

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

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

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

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

Nurse's roles in ethical decision making include:

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

tertiary prevention

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

transmission precautions (tier 2) include:

-airborne precautions -droplet precautions -contact precautions

medical asepsis

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

surgical asepsis

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

home safety risks for infants and toddlers include:

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

Right person

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

transfers and use of assistive devices

-assess client's ability to help with transfers (balance, muscle strength, endurance) -determine need for additional help or assistive devices (transfer belt, hydraulic lift, sliding board) -assist and monitor the client's proper use of mobility aids (canes, walkers, crutches) -include assistance or mobility aids needed for safe transfers and ambulation in the care plan

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

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

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

-avoid plastic bags -be sure crib mattress fits tightly -ensure crib slats no further apart than 6 cm (2.4 in) -keep pillows out of crib -remove drawstrings from jackets and other clothing

prone position

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

supine or dorsal recumbent position

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

sims' or semi-prone position

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

lateral or side-laying position

-client lies on side with most of weight on the dependent hip and shoulder; arms should be flexed in front of the body; pillow placed under head & neck, the upper arm, and under the leg & thigh to maintain body alignment -this is a good sleeping position but the client must be turned regularly to prevent development of pressure ulcers on dependent areas; 30 degree lateral position is recommended for clients at risk for pressure ulcers

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

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

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

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

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

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

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

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

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

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

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

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

expected psychosocial development : adolescent (12-20 yrs)

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

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

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

1. Assessment

LPN does data collection and lets the RN know pertinent information

Client Care Focus (Least Restrictive/Least Invasive)

Least restrictive interventions: close and constant supervision, assessing medications, bed and wheelchair alarms, mattress on floor next to client's bed Least invasive intervention: incontinent clients on bladder routine, incentive spirometers/inhalation treatments, oral or rectal administration of medications

2. Safety & Security

Living in safe environment Adequate income Shelter from environmental elements

3. Love & Belonging

Love Affection Relationships Involvement with community and spiritual groups help to meet this need.

Client Care Focus (Survival Potential)

Mass casualty situations when resources are scarce Client least likely to survive = lowest priority Client with severe injuries (but potential to survive with treatment) = highest priority

LPNs may delegate to

Other LPNs and AP

RNs may delegate to

Other RNs, LPNs, and AP

1. Physiological

Oxygentation Circulation Nutrition Elimination Fluid Balance Activity & Exercise Rest & Sleep

How to use a fire extinguisher

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

PIE

P-roblem I-ntervention E-valuation

to use a fire extinguisher:

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

Delegating

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

Ethical decision making

Process that requires striking a balance between science and morality

Least Restrictive

Protects clients civil and legal rights Unauthorized use of restraints can be: assault and batter, false imprisonment Use least restrictive methods of restraining first Physical restraints only when the client, staff, or others' safety is at risk

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

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

2. Analysis

RN only happens after nurse collects data second step of nursing process for RNs lays foundation for making decisions about client's plan of care takes priority over planning, implementation, and evaluation

dysrhythmia is

an irregular heart rhythm often noted as an irregular radial pulse

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

an organ or mass

Pharmacological pain relief

analgesics (NSAIDS & non-opioids, opioids, adjuvants)

tonsillar lymph node located

angle of mandible

What are the modes of transmission for vector borne pathogens?

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

MD, APRN office

annual PE and screening/ preventative education

UTI treatment

antibiotic- Siproflaxin; cranberry juice for prevention

hematologic effect

anticancer med, anticoagulants, thrombolytics.

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

arterial insufficiency

Autonomy

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

Accountability

ability to answer for one's own actions

tachycardia is

above expected range or faster than 100 bpm

supraclavicular nodes located

above the clavicles

psychomotor learning

acquiring skills that require the integration of mental / muscular activity

Types of pain

acute, chronic, cancer, by inferred pathology, idiopathic

transpersonal communication

addresses spiritual needs and provides interventions to meet those needs

atherosclerosis

affects intima of arteries; plaque froms and narrows lumen of arteries; pain when tissues don't get oxygen

developmental stage in hygiene

affects the patient's ability to preform hygiene care

capillary refill

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

factors affecting bowel elimination

age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics

Factors influencing pain

age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors

factors influenceing infection

age, stress, disease process, treatment/ condition that compromise the immune system

Beneficence

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

Fidelity

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

Fidelity

agreement to keep promises

fidelity

agreement to keep promises

expected findings for the Rinne test

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

report and document ___ incidents per facility policy

all

what does mobility mean?

allows ability to move freely about; musculoskeletal and nervous systems working together to make movement; decreases risk for injury

Nurse licensure compact

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

submandibular lymph node located

along base of mandible

anterior cervical lymph node located

along the sternocleidomastoid muscle

Pain tolerance

amount of pain a patient endures without its interference of ADLs

percussion of the thorax resulting in dullness is

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

percussion of the thorax resulting in hyperresonance is

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

hyperthermia is

an abnormally elevated body temp

hypothermia is

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

pulse deficit is

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

definition of nursing

an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems

hypertrophy

an enlargement of muscle due to strengthening

The foundation of ethics is based on:

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

extension

an extension of the angle

hyperextension

an extreme extension

Intuition

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

Safety & Risk Reduction

assigns priority to the factor or situation posing the greatest: safety risk to the client, greatest risk to the client's physical or psychological well-being multiple risks may require another priority setting framework to identify risk posing greatest threat

Paternalism

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

stage 1 PAD

asymptomatic; Bruit may be present; toes cool to touch; slow capillary bed refill

Nonmaleficence

avoidance of harm or injury

Nonmaleficence

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

non-maleficence

avoidance of harm/ hurt

home fire safety plan should include:

-emergency numbers near the phone -ensure number and placement of fire extinguishers and smoke alarms are adequate and that they are operable -set specific time to check batteries in alarms and operation of extinguishers -have family plan for evacuation and practice regularly -review "stop, drop, and roll" to extinguish fire of clothing or skin -review oxygen safety measures

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

-increase -elevated -decreased

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

prevention education for risk of poisoning in infants and toddlers:

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

prevention education for risk of suffocation in infants and toddlers:

-keep plastic bags out of reach -ensure crib mattress fits snugly and no more than 2 2/3 inches between crib slats -never leave alone in bathtub -remove crib toys, including mobiles, as soon as infant begins to push up -keep latex balloons out of reach -fence swimming pools and use locked gate -begin swimming lessons as soon as developmental status allows -keep toilet lids down and bathroom doors shut

pallor

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

internal emergencies include:

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

ulcer

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

erosion

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

infants have a ___ BP that gradually ___ with age

-low -increases

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

-lowest -peaking

feedback

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

expected psychosocial development (social changes): young adult (20-35 yrs)

-may leave home early and establish independent living situation -may establish close friendships (intimacy) -may transition from being single to being member of new family -may question their ability to parent -may experience increased anxiety and/or depression, esp. after the birth of a child

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

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

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

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

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

-serous (clear) -sanguineous (contains RBCs) -purulent (contains leukocytes and bacteria)

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

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

vesicle

-serous fluid-filled, <1cm -example: blister

By practicing nursing within the confines of the law, nurses are able to:

-shield oneself from liability -advocate for client's rights -provide care that is within the nurse's scope of practice -discern the responsibilities of nursing in relationship to the responsibilities of other members of the health care team -provide safe, competent care that is consistent with standards of care

Morals are:

the values and beliefs held by people that guide their behaviors and decision making

pressure ulcers

tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis

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

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

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

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

Nurse's role in the informed consent process is:

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

Increase Iron supplement's absorption rate

tomato juice, which contains vitamin C which enhance the absorption of Iron Vitamin C <-> Iron Supplement

Client Care Focus (Nursing Process)

tool to determine priority of nursing actions each step based on decisions from previous step most important: assessment (data collection) first evaluate client outcomes to determine effectiveness of care plan

heat loss- radiation is:

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

heat loss- conduction is:

transfer of heat from the body directly to another surface (when the body is immersed in cold water)

Fats

triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential

Erikson's 8 stages of development

trust vs mistrust autonomy vs shame and doubt initiative vs guilt industry vs inferiority identity vs identity confusion intimacy vs isolation generativity vs stagnation integrity vs despair

For an invasive procedure or surgery, the client is required to provide ____ consent.

written

Behavioral responses to pain

clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction

Implied consent

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

Preferred Provider Organizations (PPOs)

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

Patient Controlled Analgesia (PCA)

client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses

Autonomy

client's right to make own personal decisions, even when those decisions might not be in the client's own best interest

ICU

close monitoring; 1:2 staffing; equipped with most advanced technology; staff educated in critical care principles/ techniques

expected temporal temperatures are usually:

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

deep vein thrombosis

clots in the veins; usually in the extremities

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

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

Competence

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

the 3 domains of learning are:

cognitive, affective, and psychomotor

Assessment:

collecting vital signs, pain levels, other signs/ symptoms

autonomy

commitment to include clients in decisions

right direction/communication

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

safety guidelines in hygiene

communicate with team members; incorporate patient's priorities; move from cleanest to less clean areas; use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood; test tempo of water or solutions; use principles of body mechanics and safe patient handling; be sensitive to invasion of privacy

interpersonal communication

communication between two people

public communication

communication that occurs within large groups of people; community settings

small group communication

communication w/in a group of people

sterilization

complete elimination or destruction of all microorganisms including spores

health care delivery system

complex, dynamic, constantly changing; past 10-15 yrs managed care, primary care provider; services provided by a wide variety of licensed/ non-licensed staff

pulmonary emboli

complication of DVT

Managed Care Organizations (MCOs)

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

Water

comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids

adaptation

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

causes of obesity

corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone

ptosis

covering of the pupil by the upper eyelid

strabismus

crossed eyes

Experience

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

hypoventillation

decreased ability to remove CO2 from body; pH below 7.35; RR below 12; emphysema/ CVA; hypoxic

treatment for atherosclerosis

decreased cholesterol intake; smoking cessation; blood work; exercise

management of obesity

decreased food intake, increased physical activity

hypoxia

decreased tissue oxygenation; restlessness, anxiety, confusion, increased heart rate and RR

deontology

defines actions as right or wrong

Anesthetics

depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local

Continuing health care

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

ability to learn

developmental / physical ability

factors influencing communication process

developmental level, gender, values/ perception, personal space, territoriality, roles/ relationships, environment, congruence

personal preferences affecting hygiene

dictates personal hygiene practices for individual patients

expected psychosocial development (self-concept development): older adult (65+ yrs)

difficulties including: -seeing oneself as an aging person -finding ways to maintain a good quality of life -becoming more dependent on others for ADLs

Subjective data can be documented as:

direct quote, within quotation marks, or summarized and identified as the client's statement

heat loss- convection is:

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

heat loss- evaporation is:

dispersion of heat through water vapor (sweating and diaphoresis)

fluid overload

distended neck veins, increased BP, tachycardia, shortness of breath, crackles in the lungs, edema. Treatment: stop IV, raise the head of the bed, assess vital signs and oxygen saturation, adjust the rate as prescribed, administer diuretics if prescribed.

Durable power of attorney for health care

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

anticholinergic effect

dry mouth, photophobia, urinary retention(urinating before taking the medicaation.)

xerosis

dry skin; becomes reddish; low humidity; frequent washing

ROM head: lateral flexion

ear to shoulder bilaterally

hematoma

ecchymosis at site. Treatment: do not apply alcohol, apply pressure after IV catheter removal, use warm compress and elevation after the bleeding stops

Effect of excess fluid therapy

edema, crackles in the lung sound, elevated blood pressure, jugular venous distention

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

elderly (geriatric)

labs for obesity

electrolyte/sodium/potassium, blood glucose, triglycerides, hemoglobin, serum albumin

disinfection

eliminates many or all microorganisms with exception of spores from inaminate objects

Primary health care

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

ethic of care

emphasizes the importance of understanding relationships, especially as they are revealed in narratives

Basal metabolic rate (BMR)

energy needed to maintain life

NSAIDS & non-opiates

has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction, possible liver failure

treatment for hyperventillation

have patient hold one nostril; try to reduce patient;s stress/panic; purse-lipped breathing

granulation tissue

healing tissue; looks beefy

Client Care Focus (ABCs)

health care providers use ABC framework frequently dictates order of care in emergency situations and with unstable clients helps recognize early signs of complications

primary care in community

health professionals, community members, govt

occupational health

health promotion, accident or illness prevention

Circulation

heart rate and blood pressure within expected reference range necessary for adequate cardiac, cerebral, and peripheral perfusion client might need: chemical and/or physical cardiac support, resuscitation, supplemental fluids (to re-establish intravascular fluid volume and blood pressure)

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

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

Airway

highest priority action must be open and clear client might need: temporary oral or artificial airway (tracheostomy or endotracheal tude), supplemental oxygen

BP classification is based on the

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

treatment for hypoventillation

if narcotic based, reduce/ discontinue; stroke- high fowlers/ oxygen; other meds to increase breathing

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

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

changes in pattern affecting sleep

illness (cardiac, resp, pain), RLS; food before bed; change in daily pattern

myopia

impaired far vision

presbyopia

impaired near vision or farsightedness

A determination of death must be made:

in accordance with accordance with accepted medical standards

preauricular lymph node located

in front of ear

incontinence

inability to control passage of feces or gas through rectum

cognitive learning

includes all intelectual behavior/ requires thinking

Secondary health care

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

High-fiber diet

includes: - whole grains such as barley and oats; - raw and dried fruits; - raw and gas-producing vegetables such as cabbage; - legumes such as lentils and black beans

What should you do before treating constipation with laxatives?

increase fiber and water consumption

uremic syndrome

increase in nitrogenous wastes in the blood

Obese

increased weight for height by 10% or more

impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in:

increases in the respiratory rate and alterations in rhythm to compensate

4 stages of infection

incubation period, prodromal stage, illness stage, convalescence

chain of infection

infectious agent/ pathogen > reservoir/ source for pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host

laryngitits

inflammation/ swelling of larynx; occurs as single problem or with resp infection; risk/irritant-smoking; dry coughing; voice changes; throat cultures to check for strep; comfort care

socioeconomic status affecting hygiene

influences type and extent of hygiene practice used

the use of info technology as a communication and information gathering tool that supports clinical decision making and scientifically based nursing practice

informatics.

Knowledge

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

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

information technology

Minerals

inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport

hospital and med centers

inpatient services, diagnostic and treatment services

stage 1 ulcer

intact skin; red/irritation; unblanchable

teaching

interactive process that promotes learning

evidence based practice

interventions nurses do that are based on evidence

futile care

interventions unlikely to produce benefit for the client

infection

invasion of a susceptible host by pathogens or microorganisms. resulting in disease

extrapyramidal symptoms

involuntary fine motor tremors, rigidity, uncontrollable retlessness, acute dystonia.

Restorative health care

involves intermediate follow-up care for restoring health. examples include home health care, rehab centers, and skilled nursing facilities

Tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

chenye-strokes

irregular breathing; altering rapid/apnea episodes; near death breathing pattern

ESRD

irreversible damage to kidney tissue

anuria

irreversible renal disease; need kidney transplant or dialysis; not producing urine; increased phosphorus in system

sleep deprivation causes

irritability, cognitive impairment, memory lapses/loss, severe yawning, s/s like ADHA, impaired immune system, risk of type 2 diabetes, increased heart rate variability, decreased reaction time and accuracy, tremors, aches, growth suppression, decreased temp, risk of obesity, hallucinations

rebound tenderness (Blumberg's sign) is an indication of

irritation or inflammation somewhere in the abdominal cavity

nystagmus

jerky or tremor-like eye movements

auscultatory sites for the heart: tricuspid

just left of the sternum at the fourth ICS

auscultatory sites for the heart: pulmonic

just left of the sternum at the second ICS

auscultatory sites for the heart: erb's point

just left of the sternum at the third ICS

auscultatory sites for the heart: aortic

just right of the sternum at the second ICS

nephrotoxicity

kidney damage

meds are excreted through:

kidney, liver, bowel, lungs, exocrine glands

auscultation of the lungs (expected sound): bronchovesicular

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

channel

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

How does good oral hygiene help prevent infection?

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

submental lymph node located

midline under the chin

Attitudes

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

Standards

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

What type of sedation is given for a colonoscopy?

moderate [aka conscious] sedation

dreams

occur in NREM and REM; REM in color; important for learning, memory, and adopting to stress

varient angina/ prinz metals

occurs at rest (sort of constant)

colonization

occurs when a microorganism invades the host but doesn't cause infection

intrapersonal communication

occurs within, self verbalization, self awareness, self talk, guided imagery

Language

precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to both the client and other health care team members. The nurse should consider the following: -"Did I use language appropriate for the client?" -"Did I communicate the message clearly to the provider?"

stable angina

predictable

Free Radical Theory

presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products

maxillary sinuses are palpated by

pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth

frontal sinuses are palpated by

pressing upward with the thumbs from just below the eyebrows on either side of the bridge of the nose

treatment for pulmonary emboli

prevention- anticoagulant therapy; thrombolytic therapy; surgery to remove thrombus

ABCs

priority of initial assessment

learning environment

privacy, room temperature, lighting, noise, furniture, ventilation

Ethical dilemmas are:

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

communication-

process by which people affect one another; exchange of info, ideas, feelings; basic component of human relationships; fundamental element of nurse-client relationship

heart sounds: S4

produced by a strong atrial contraction -can be normal finding in older and athletic adults and children -best heard with bell of steth

bruits are:

produced by an obstructed peripheral blood flow and are heard as a blowing or swishing sound with the bell of the steth

the nursing shortage

produces difficult working conditions and affects client outcomes

utilitarianism

proposes that the value of something is determined by its usefulness

Confidentiality

protection of privacy without diminishing access to high-quality care

Confidentiality

protection of privacy without diminishing access to quality care

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

provider's responsibility

Long-Term Care Insurance

provides for long-term care expenses not covered by Medicare

Medicare

public federally funded programs. clients over age 65 and/or with permanent disabilities.

to assess inner ear in children <2 years

pull auricle down and back

to assess the inner ear of adults and children >2 years

pull auricle up and back

during palpation, the fingertips detect:

pulsation, position, texture, size, and consistency

sleep

purpose unclear; physiological and psychological restoration; maintenance of biological function; regulated by reticular activating system > regulates sleep cycle in hypothalamus

learning

purposeful acquisition of new knowledge, attitudes, behavior, or skills

Reflection

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

assists nursing programs in preparing nurses to provide safe, high quality care in response to concerns about the safety and quality of client care in u.s

quality and safe education for nurses (QSEN)

care related and organizational processes that involve the development and implementation of a plan to improve healthcare services and better meet clients needs

quality improvement

the International Association for Healthcare Security & Safety (IAHSS) provides:

recommendations for the development of security plans

s/s of PAD

red, inflammed, shortness of breath, coughing, increased heart rate, sweating, anxious feeling

uriticaria

reddish, whitish, plaques edematous; usually show up on torso; usually caused by drugs, histamine, bed linen detergent

expected pulse oximetry ranges are

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

elements of communication

referent sender; message, receiver, channels, feedback, interpersonal

pulse rhythm can be

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

Traditional Insurance

reimburses for services on fee-for-service basis.

lap band reduction

removable, premanent life cange; can cause dehydration, electrolyte problem, backup into esophagus, blockage

reporting communicable diseases

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

normal percussion of the thorax should result in

resonance

Virchow's triad

stasis-immobility, bed ridden, car/plane/ train travel vessel wall injury, fracture, trauma hypercoagulability- altered coagulation (birth control, hormone therapy, smokers, dehydration)

definition of health

state of complete physical, mental, and social well being not merely the absence of disease or infirmity

treatment for MI

stent angioplasty or balloon; thrombolytic therapy- breaks clot apart; M-morphine, O-oxygen, N-nitrates, A-aspirin

constipation

stool gets lodged in the intestines; a symptom not a disease

tamaflu

stops flu virus multiplication; increases risk for self injury; take within 48 hr of onset

direct percussion involves:

striking the body to elicit sounds

what is a seizure?

sudden surge of electrical activity in the brain

school health

support educational success by enhancing health

Advocacy

support of clients' health, safety, and personal rights

Advocacy

support of the cause of the client regarding health, safety, and personal rights

pulse equality: peripheral pulse impulses should be

symmetrical in quality and quantity from right side to left

pulse pressure is the difference between

systolic and diastolic pressure readings

beneficence

taking positive actions to help others

___ is an interactive process driven by specific client goals

teaching

the delivery of client care and partnership with multi disciplinary members of the healthcare team to achieve continuity of care and positive client outcomes

teamwork and collaboration

during palpation, the dorsal surface of the hand detects:

temperature

Ishihara test

tests for color vision

respiratory depth is

the amount of chest wall expansion that occurs with each breath; altered depths are described as deep or shallow

systemic vascular resistance (SVR) is determined by

the amount of constriction or dilation of the arteries

expected findings for the whisper test

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

Exclusive Provider Organizations (EPOs)

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

right supervision/evaluation

the delegating nurse must: -provide supervision (direct or indirect) -provide clear instructions and understandable expectations of the task(s) to be performed -monitor performance -provide feedback -intervene if necessary (unsafe clinical practice) -evaluate the client and determine if client outcomes were met -evaluate client care tasks and identify needs for performance improvement activities and/or additional resources

LOC: lethargy

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

Creatine

0.6-1.3

INR

0.8-1.2

message

verbal and/or nonverbal information that is expressed by the sender and intended for the receiver

forms of communication

verbal, non-verbal

during palpation, the ulnar surface of the hand and the base of the fingers detect:

vibrations

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

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

What is surfactant?

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

What is a sick role?

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

Provider's orders

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

intrapersonal communication

"self-talk"

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

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

What is the purpose of a tap water enema?

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

Why does immobility cause pressure ulcers?

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

Romberg test

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

What is the difference between airborne and droplet precautions?

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

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

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

Latex allergy

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

Sterile Field

- To open a wrapped-sterile kit: Pull *the top flap* [the one furthest from your body] *away from your body* first; - Outer packaging and 1" border around edges are *NOT* sterile; - Any object below the waist, above the waist, or exposed to moisture should be considered contaminated; - Do *not* reach across or above a sterile field; - Do *not* turn your back on a sterile field; - Hold items to add to a sterile field at least 6" above the field

Donning Sterile Gloves

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

What *labs* indicate the *presence of infection*?

- WBC > 10,000 [aka leukocytosis]; - increase in specific type of WBCs [e.g., an increase in neutrophils aka left shift]; - ESR > 20 - note that an increased ESR = active inflammatory process or infection; - presence of micro-organisms upon culture of fluid or area

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

- adolescent boys: unilateral or bilateral [but asymetrical] gynecomastia; - older adult males: bilateral gynecomastia

discharge planning

- an interdisciplinary process started by nurse at time of admission -conducted with both client and client's family for optimal results

nursing interventions to *maintain urinary and bowel elimination*

- at least 2,000 mL of fluid/day unless restricted; - diet including fruits and veggies and high in fiber; - stool softener [consider laxatives only as a last resort]; - perineal care; - teach bladder and bowel training; - to relieve or manage bladder distention - insert a straight or indwelling catheter ; - promote urination by pouring warm water over perineal area

*musculoskeletal changes* due to immobility

- atrophy of muscles, decreased muscle endurance, strength, and mass; - impaired balance, decreased stability; - altered calcium metabolism = osteoporosis; - contractures; - foot drop; - altered joint mobility

What should you teach a client about their diet for the first few weeks after placement of an ileostomy?

- avoid high fiber foods *for first weeks after surgery* [ex. fresh veggies]; [gives small bowel time to adapt to the diversion] - can eat almost any food including high fiber foods *after ostomy heals* -- this will actually be encouraged to help ensure more solid stool to achieve success at irrigation]

What foods and beverages increase intestinal gas?

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

What happens during the *alarm reaction*?

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

What happens during the *exhaustion stage*?

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

What happens during the *resistance stage*?

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

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

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

How do you assess pitting edema?

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

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

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

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

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

What is the Modified Trendelenburg position?

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

How is the Romberg test performed?

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

Minerals

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

What are the common side effects of opioid analgesics?

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

Proteins

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

What are the therapeutic effects of *cold* applications?

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

*gastrointestinal changes* due to immobility

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

metabolic changes due to immobility

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

*respiratory changes* due to immobility

- decreased respiratory movement --- results in decreased O2 and CO2 exchange; - stasis of secretions and decreased and weakened respiratory muscles --- results in atelectasis and hypostatic pneumonia; - decreased cough response

What is a role conflict?

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

What are some general *crutch* instructions?

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

What is the Trendelenburg position?

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

What is the *Reverse* Trendelenburg position?

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

What should you do if you *feel resistance* or the *patient reports pain* when you are inserting the tube or the tip of the container?

- stop and try asking the patient to take a deep breath and then instilling a small amount of fluid; - this will relax the sphincter or soften the stool enough so that the tube or tip can be inserted and the enema can be administered

What are some physiological responses to *acute* pain?

- tachycardia; - hypertension; - anxiety; - diaphoresis; - muscle tension

What assessment findings would you expect for a client with prolonged diarrhea?

- tachycardia; - hypotension; - fever; - poor skin turgor; [all manifestations caused by dehydration]

What solutions are used for cleansing enemas?

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

What do the bronchioles depend on to remain open?

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

What is the purpose of a soap suds enema?

- to act as an irritant *to promote bowel peristalsis*; - use only pure castile soap in tap water or normal saline

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

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

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

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

What is included in *pulmonary hygiene*?

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

*genitourinary changes* due to immobility

- urinary stasis; - change in calcium metabolism w/hypercalcemia ---can result in renal calculi; - decreased fluid intake, poor perineal care, and indwelling urinary catheters = UTIs

What is the purpose of a normal saline enema?

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

heart sounds: S2

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

heart sounds: S1

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

What to do *AFTER* a client has a seizure

-*ASSESS* mental status, O2 sat, and vitals; -*EXPLAIN* what happened to client, provide comfort, and a quiet environment for client to recover; -*DOCUMENT* any precipitating behaviors and description of event [i.e., movements, injuries, duration, aura, postictal state], and report it to HCP

what is the difference between a partial seizure and a general seizure?

-*PARTIAL* seizures are due to electrical surges in *one part of* the brain; -*GENERALIZED* seizures involve the *entire* brain

Sequence followed for a fire [RACE]

-*RESCUE* and evacuate clients close to fire. Able clients walk to safety; -Activate *ALARM*; report fire details and location; -*CONTAIN* fire: close doors and windows; turn off sources of O2 and electrical devices. Ventilate life support client w/bag-valve mask; -*EXTINGUISH* fire w/extinguisher

health promotion (immunizations): school-age (6-12 yrs)

--if not given between 4-5, then by 6 years: DTaP, IPV, MMR, varicella -yearly seasonal TIV or LAIV (nasal spray) -11-12 years: Tdap, meningococcal vaccine (MCV4), HPV2 in 3 doses for females and HPV4 may be given to males

expected physical development (fine and gross motor development): infant (birth-1 yr)

-1 month: (g) demonstrates head lag; (f) has a present grasp reflex -2 month: (g) lifts head off mattress; (f) holds hands in an open position -3 month: (g) raises head and shoulders off mattress: (f) no longer has grasp reflex, keeps hands loosely open -4 month: (g) rolls from back to side; (f) places objects in mouth -5 month: (g) rolls from front to back; (f) uses palmer grasp dominantly -6 month: (g) rolls from back to front; (f) holds bottle -7 month: (g) bears full weight on feet; (f) moves objects from hand to hand -8 month: (g) sits unsupported; (f) begins using pincer grasp -9 month: (g) pulls to standing position; (f) has crude pincer grasp -10 month: (g) changes from prone to sitting position; (f) grasps rattle by its handle -11 month: (g) walks while holding on to something; (f) can place objects into container -12 month: (g) sits down from standing position w/o assistance; (f) tries to build two-block tower w/o success

health promotion (immunizations): toddler (1-3 yrs)

-12-15 month: IPV (6-18 month), Hib, PCV, MMR, varicella -12-23 month: Hep A (given in 2 doses at lease 6 months apart) -15-18 month: DTaP -12-36 month: yearly seasonal TIV; at age 2, toddlers can receive the live, attenuated influenza vaccine (LAIV) by nasal spray

expected physical development (fine and gross motor skills): toddler (1-3 yrs)

-15 month: (g) walks w/o help, creeps up stairs; (f) uses cup well, builds two-block tower -18 month: (g) assumes standing position, jumps in place with both feet; (f) manages spoon without rotation, turns pages in book 2-3 at a time -2 year: (g) walks up and down stairs; (f) builds 6-7 block tower -2.5 year: (g) jumps with both feet, stands on 1 foot momentarily; (f) draws circles, has good hand-finger coordination

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

-4-6 years: DTaP, MMR, varicella, IPV -yearly: TIV or LAIV (nasally)

expected physical development (dentition): infant (birth-1 yr)

-6 to 8 teeth erupt in the infant's mouth by end of 1st yr -teething pain can be eased using cold teething rings, OTC teething gels, acetaminophen and/or ibuprofen; ibuprofen given only to children over 6 months -clean teeth using cool, wet washcloth -bottles should not be given when they are falling asleep; prolonged exposure to milk/juice can cause dental caries

Examples of tasks that can be delegated to AP

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

components of the General Adaptation Syndrome (GAS)

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

expected cognitive development: middle adult (35-65 yrs)

-Piaget: formal operations -reaction time/speed of performance slows slightly -memory is intact -crystallized intelligence remains (stored knowledge) -fluid intelligence (how one learned and process new info) declines slightly

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

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

botulism

-S/S: difficulty swallowing, progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing -treatment/prevention: airway management, antitoxin, elimination of toxin

smallpox

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

inhalational anthrax

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

Ebola

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

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

-S1 -S2

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

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -MCV: students entering college and living in dorm if not previously vaccinated -HPV2 or HPV4: 3 doses, recommended for females up to age 26 who were not vaccinated as a child; HPV4 may be given to males up to 26 -seasonal flu vaccine: 1 yearly

health promotion (immunizations): middle adult (35-65 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -pneumococcal polysaccharide vaccine (PPV): if not previously vaccinated, vaccinate once at 65 -seasonal flu vaccine: yearly; LAIV (nasal spray) only under 50 and not pregnant or immunocompromised -herpes zoster vaccine: 1 dose over age 60

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

-Td booster: every 10 years -varicella vaccine: 2 doses given to those w/o evidence of previous infection; 2nd dose 4-8 weeks after 1st for those who only had 1 previous dose -PPV: if not previously vaccinated, once at age 65 -seasonal flu vaccine: 1 dose annually -herpes zoster vaccine: 1 dose for all adults over 60

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

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

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

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

Health care regulatory agencies include:

-US Dept of Health and Human Srvcs -US FDA -State and local public health agencies -State licensing boards (to ensure providers & agencies comply with state regulations) -the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities) -Professional Standards Review Organizations (PSROs) -Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized clients)

Licensed Practical Nurse (LPN)

-Works under supervision of the RN -Collaborate with other team members -Possess technical knowledge and skills -Participate in the delivery of nursing care, using the nursing process as a framework

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

-a need to maintain and strengthen intimacy -provide assistance to aging parents, adult children, and grandchildren

expected psychosocial development (Erikson: industry vs inferiority): school-age (6-12 yrs)

-a sense of industry is achieved through advances in learning -motivated by tasks that increase self-worth -fears of ridicule by peer and teachers over school-related issues are common -some manifest nervous behaviors to deal with stress such as nail biting

CN VI

-abducens -assess extraocular movements

clubbing of the fingernail

-abnormal curvature of the nail with an angle >160* -can be result of chronic low SaO2, emphysema, chronic bronchitis

Mandatory reporting

-abuse: child or elder abuse, domestic violence -communicable diseases (according to CDC) such as hepatitis and TB

CN VIII

-acoustic -assess ears for hearing

primary prevention

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

the following must occur in order for seclusion or restraint to be used:

-all other less restrictive means have to be exhausted -the treatment must be prescribed by provider in writing based on a face-to-face assessment of the client (exception is in emergency situation where client is a danger to himself or others and providers order must be written asap) -rx must include reason, type, location, how long it may be used, and type of behavior that warranted the restraint -provider must rewrite the rx every 24hrs or as specified by the facility -PRN rx is not allowed

other responsibilities of health care providers when dealing with isolation/restraints include:

-always explain need to client and family -obtain signed consent from client or guardian, if required -review manuf. instructions for correct application -remove or replace restraints frequently to ensure good circulation and full ROM of restricted limb -pad bony prominences -use quick-release knot to tie restraints to bed frame -ensure restraint is loose enough for ROM and 2 fingers can fit between device and the client -regularly assess need for continued need -never leave client unattended w/o the restraint

guidelines for cleaning contaminated equipment

-always wear gloves -rinse 1st in cold water -wash the article in hot water with soap -use a brush or abrasive to clean corners or hard-to-reach areas -rinse well in warm or hot water -clean the equipment used in cleaning and the sink (still considered dirty unless a disinfectant is used) -remove gloves and perform hand hygiene

criteria to follow when identifying clients who can be safely discharged in an emergency situation

-ambulatory clients requiring minimal care should be discharged or relocated first -clients requiring assistance should be next and arrangements made for continuation of their care -clients who are unstable and/or require nursing care should not be discharged or relocated unless they are in imminent danger

radiological incidents

-amount of exposure is related to time exposed, distance from source, and amount of shielding -facility treating victims should activate interventions to prevent exposure to treatment areas -staff should wear water-resistant gowns, double glove, and fully cover bodies with caps/shoe covers/masks/goggles -staff should wear radiation or dosimetry badges to monitor amount of exposure -clients should be initially surveyed with radiation meter to determine amount of contamination -decontamination should occur prior to entering the hospital with soap, water, and disposable towels -after decontamination, client should be resurveyed and washed until free of all contamination

Nurses should be aware that security measures include:

-an identification system that identifies authorized personnel -electronic security systems in high-risk areas

health-care associated infections (HAIs)

-an infection acquired while the client is receiving care in a health-care setting -formally called nosocomial infections -can come from exogenous source or endogenous source -most common setting for HAIs is the ICU -best way to prevent HAIs is through frequent and effective hand hygiene -most common site of HAIs is the urinary tract -most common causative agents are Escherichia coli, Staphylococcus aureus, and enterococci -an iatrogenic infection results from a diagnostic or therapeutic procedure -HAIs are not always preventable and not always iatrogenic

components of the chain of infection include:

-an infectious agent (bacteria, virus, fungi, protozoa) -a reservoir where the infectious agent grows (wound drainage, food, oxygen tubing) -an exit portal of the infectious agent (skin, resp or GI tracts) -a means of transmission (droplet, person-to-person contact, touching contaminated items) -an entry portal to a susceptible host (same as exit) -a host that must be susceptible to the infectious agent

According to the UDDA, death is determined by one of two criteria:

-an irreversible cessation of circulatory and respiratory functions -irreversible cessation of all functions of the entire brain, including the brain stem

expected physical development (size): toddler (1-3 yrs)

-anterior fontanel closes by 18 months -weight: should be 4 times birth weight at 24 months -height: grows by 7.5 cm (3 in) per year

standard precautions (tier 1)

-applies to all body fluids (excluding sweat), non-intact skin, and mucous membranes -hand hygiene recommended after all contact and alcohol-based waterless product is preferred unless hands are visibly dirty; also required after removal of gown -clean gloves are worn when touching all body fluids, non-intact skin, mucous membranes, and contaminated equipment/articles -gloves removed and hand hygiene completed between each client -masks, eye protection, and shields required when splashing or spraying of body fluid may occur -gloves worn whenever touching anything that has potential to contaminate hands of the nurse -sturdy, moisture resistant bag used for soiled items; contaminated laundry to be bagged and handled to prevent leaking; equipment for client care properly cleaned and one time use items disposed of -safety devices on all equipment/supplies enabled after use and sharps disposed of properly -private room not needed unless client is unable to maintain appropriate hygienic practices

expected psychosocial development (body-image changes): toddler (1-3 yrs)

-appreciates the usefulness of various body parts -develop gender identity by age 3

upon admission (but prior to client arrival to room) take necessary equipment into the room including:

-appropriate documentation forms -equipment to obtain vital signs -pulse oximeter -hospital attire for client

Examples of questions to use to determine complexity of care:

-are complex tasks required as part of the client's care? -is the delegatee legally able to perform the task and do they have the skills necessary?

evaluation related to client education includes:

-ask client to explain info in his own words -observe the client demonstrating the learned activity -use written tools to measure accuracy of info -request client's self-evaluation of progress -observe verbal and nonverbal communication -determine client's ability to use info over time but re-evaluate learning during follow-ups -revise care plan as needed

heel-to-toe walk

-ask client to place heel of one foot in front of toes of the other foot as he walks in a straight line -expected finding: client is able to walk in a straight line without losing balance

LOC: alert

-client is responsive and able to fully respond by opening eyes and attending to a normal tone of voice and speech -answers questions spontaneously

assessment/data collection related to client education includes:

-assess/monitor the client's learning needs -assess the learning environment -assess/monitor the client's learning style (auditory, visual, kinesthetic) -identify areas of concern -assess/monitor available resources (financial, social, community) -identify the client's developmental stage -determine the client's physical and cognitive ability -identify special needs (visual impairment, decreased manual dexterity) -determine the client's motivation and readiness to learn

time requirements for handwashing

-at least 15 seconds to remove transient flora from the hands -up to 2 minutes when hands are more soiled

health promotion (injury prevention): middle adult (35-65 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

health promotion (injury prevention): young adult (20-35 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

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

-avoid exposing to lead paint -keep toxins/plants out f -use safety locks on cabinets (esp containing cleaners/chemicals) -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detectors in the home

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

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

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

-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing

health promotion (injury prevention-aspiration of foreign objects): infant (birth-1 yr)

-avoid small objects (such as grapes, coins and candy) that can become lodged in throat -provide age-appropriate toys -check clothing for safety hazards (loose buttons)

health promotion (injury prevention-aspiration of foreign objects): toddler (1-3 yrs)

-avoid small objects that can become lodged in throat -keep toys with small parts out of reach -provide age-appropriate toys -check clothes for choking hazards -keep balloons out of reach

Levels of critical thinking

-basic critical thinking -complex critical thinking -commitment

discharge education should:

-be clear and concise and also print ed for client to take home -identify safety concerns at home -review s/s of potential complications and when to contact provider -include provider phone number -provide names and numbers of community resources -instructions for continuing treatments -dietary restrictions and guidelines -amount and frequency of therapies -directions and information on medications

The client has the right to:

-be informed about the aspects of care in order to be active in the decision making process -accept, refuse, or request modification to the plan of care -receive care that is delivered by competent individuals who treat the client with respect

general measures to prevent falls includes:

-be sure client knows how to use call light, it is within reach, and encourage its use -respond to call lights in a timely manner -orient client to setting and assistive devices -place clients at risk for falls near nursing station -ensure bedside table and frequently used items are within client's reach -maintain bed in low position -for clients who are sedated, unconscious, or otherwise compromised, bed rails are kept up and bed kept in low position -avoid use of full side bedrails for clients who get out of bed or attempt to get out of bed without assistance -provide nonskid footwear -keep floor free of clutter with a clear path to the bathroom -keep assistive devices nearby after validation of safe use by client and family -educate client and family/caregivers on identified risks and plan of care -lock wheels on beds, wheelchairs, and carts -use chair or bed sensors for clients at risk for getting up unattended

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

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

Legal guidelines of documentation

-begin each entry with date & time -legible and in black, non-erasable ink -no white out or blackened out errors -info inadvertently omitted may be added as a "late entry" -signed with signature of person making entry and dated -should reflect assessments, interventions, and evaluations

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

-begins to understand the concepts of past, present, and future -by end of preschool years, child may comprehend days of the week

health promotion (immunizations): infant (birth-1 yr)

-birth: Hep B -2 month: DTaP, rotavirus vaccine (RV), inactive poliovirus (IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B -4 month: DTaP, RV, IPV, Hib, PVC -6 month: DTaP, IPV (6-18 months), PVC, Hep B (6-12 months), RotaTeq (alt to RV which required 3 doses completed by 32 weeks) -6-12 month: seasonal flu yearly, trivalent inactivated influenza vaccine (TIV) is available as IM injection

a murmur sounds like a

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

spider vein

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

cyanosis

-bluish: best noted in nail beds, lips, mouth, skin -indication of hypoxia or impaired venous return

health promotion (nutrition-feeding alternatives): infant (birth-1 yr)

-breastfeeding provides complete diet during 1st 6 months and is recommended -iron-fortified formula is an acceptable alternative; cow's milk is not recommended

expected psychosocial development (self-concept development): infant (birth-1 yr)

-by end of 1st year will be able to distinguish themselves as being separate from their parents

health promotion (nutrition): school-age (6-12 yrs)

-by end of school-age years is eating adult proportion of food and needs quality nutritious snacks advised parents to: not use food as reward; emphasize physical activity; ensure balanced diet according to USDA recommendations; teach children to make healthy food selections for meals/snacks; avoid frequent meals at fast food; avoid skipping meals -dental health should be encouraged, including: brushing and flossing daily; having regular check-ups and fluoride treatments

Upon admission, orient client and family to room/facility including:

-call light -bed operation -telephone/tv -overhead lighting -smoking policy -restroom locations -waiting areas -meal times -usual times for physician visits -dining/vending services -visiting policies

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

-can be introduced between 4-6 months -indicators for readiness include voluntary control of head and trunk, hunger less than 4 hrs after vigorous nursing or intake of 8 oz of formula, interest of the infant -iron-fortified rice offered 1st -new foods introduced 1 at a time over a 5-7 day period to assess for allergies or intolerance; veggies or fruits introduced between 6-8 months and after both have been introduced, then meats -milk, eggs, wheat, citrus fruits, peanuts, peanut butter, and honey delayed till after 1st year -chopped, cooked, and unseasoned table foods by 9 months -appropriate finger foods include: ripe bananas, toast strips, graham crackers, cheese cubes, noodles, peeled chunks of apples/pears/peaches -breast milk/formula decreased as solid food intake increases -parents encouraged to use iron-enriched foods after 6 months of age

What are some general *cane* instructions?

-cane goes on *stronger* side of body; -move *cane* first, then *affected* leg, then *unaffected* leg -maintain 2 points of support on ground at all times; -support body weight on both legs

expected cognitive development (Piaget: formal operations): adolescent (12-20 yrs)

-capable of thinking at an adult level -able to think abstractly and can deal with principles -able to evaluate the quality of own thinking -has longer attention span -highly imaginative and idealistic -makes decisions through logical operations -is future-oriented -capable of deductive reasoning -understands how the actions of an individual influences others

carbon monoxide poisoning

-carbon monoxide binds with hemoglobin and reduces oxygen supply to tissues -cannot be seen. smelled, or tasted -s/s include: nausea, vomiting, headache, weakness, and unconsciousness -death may occur with prolonged exposure -prevention by ensuring proper ventilation when using fuel-burning devices -gas-burning devices should be inspected annually -flues and chimneys should be unobstructed -carbon monoxide detectors should be installed and inspected regularly

locations to assess bruits include:

-carotid arteries: over carotid pulses -abdominal aorta: just below xiphoid process -renal arteries: MCL above umbilicus on the abdomen -iliac arteries: MCL below the umbilicus on abdomen -femoral arteries: over femoral pulses

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

-check temp of bath water -turn down thermostat on hot water heater -have working smoke detectors in the home -turn handles of pots/pans to back of stove -apply sunscreen when outdoors during daylight hours -cover electrical outlets

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

-check temp of bath water -turn thermostat down on water heater -have working smoke detectors in the home -turn pot handles to back of stove -cover electrical outlets -use sunscreen when outside

semi-fowler's position

-client lies supine with head of bed elevated approx 30 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used to prevent regurgitation of tube feedings and aspiration in clients with difficulty swallowing

fowler's position

-client lies supine with head of bed elevated approx 45 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used during procedures such as NG tube insertion and suctioning; also allows for better chest expansion & ventilation, as well as better dependent drainage, after abdominal surgeries

high-fowler's position

-client lies supine with head of bed elevated approx 90 degrees, and knees may or may not be elevated -position promotes lung expansion by lowering the diaphragm and used for clients experiencing severe dyspnea

LOC: obtundation

-client needs to be lightly shaken to respond, but may be confused and slow to respond

LOC: stupor

-client requires painful stimuli (pinching a tendon or rubbing sternum) to achieve a brief response -client may not be able to respond verbally

orthpneic position

-client sits in the bed or at bedside; pillow placed on over-bed table, which is placed over client's lap; client rests arms on the over-bed table -position allows for chest expansion and is especially beneficial to clients with COPD

Nurse's role in client rights includes:

-client understands their rights -protecting rights of clients under their care

Transfer reports should include

-client's demographic information -client's medical diagnosis and providers -and overview of the client's health status (physical and psychosocial), plan of care, and recent progress -any alterations that might become urgent or emergent situations -directives for assessments or client care essential w/in next few hours -most recent vital signs -meds prescribed and last doses administered (inc PRN) -allergies -diet & activity orders -presence of or need for special equipment or adaptive devices -advance directives and resuscitation status -family involvements in care & health care proxy, if applicable

indications for transfer and discharge

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

Advanced directives

-communicate client's end-of-life care wishes for them if they become unable to -PSDA requires all clients be asked if they have advanced directives upon admission -clients with out advanced directives must be provided with written information about their health care rights and how to formulate advanced directives -a health care rep should be available to help with the process

expected age-appropriate activities: school-age (6-12 yrs)

-competitive and cooperative play is predominant -activities for 6-9: simple board and number games, hopscotch, jump rope, collections, riding bike, building simple models, joining organized sports (skill building) -activities for 9-12: making crafts, building models, collections/hobbies, jigsaw puzzles, board and card games, organized competitive sports

normal spine curvatures: -cervical spine: ___ -thoracic spine: ___ -lumbar spine: ___

-concave -convex -concave

expected cognitive development (Piaget: sensorimotor transitions to preoperational): toddler (1-3 yrs)

-concept of object permanence is developed fully -have and demonstrate memories of events that relate to them -domestic mimicry is evident (playing house) -preoperational thought does not allow to understand other viewpoints, but does allow to symbolize objects and people in order to imitate activities seen previously

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

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

expected psychosocial development (moral development): preschooler (3-6 years)

-continues in the good-bad orientation of toddler years but begins to understand behaviors in terms of what is socially acceptable

seclusion and/or restraint must never be used for:

-convenience of the staff -punishment for the client -clients who are extremely physically or mentally unstable -clients who cannot tolerate the decreased stimulation of a seclusion room

expected psychosocial development (moral development): adolescent (12-20 yrs)

-conventional law and order: rules are not seen as absolutes; each situation needs to be looked at and maybe rules adjusted -not all adolescents attain this level during these years

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

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

components of hygiene/cough etiquette that applies to anyone entering a health care setting includes:

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

Factors to consider when selecting a delegated

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

implementation related to client education includes:

-create an environment conducive to learning (reduce distractions and interruptions, provide privacy) -use therapeutic communication to develop a trusting relationship that allows client to express concern -review previous knowledge and experiences -explain the therapeutic regimen or procedure -present steps building to more complex tasks -demonstrate psychomotor skills -allow time for return demonstration -provide positive reinforcement

-pain in the chest wall may ___ respiration depth -onset of acute pain may ___ respiration rate -anxiety ___ respiration rate and depth -smoking causes resting respiration rate to ___ -neuro injury to the brainstem ___ respiratory rate and depth

-decrease -increase -increases -increase -decreases

expected physical development: older adult (65+ yrs)

-decrease in skin turgor and subcutaneous fat, which leads to wrinkles and dry skin -loss of subcutaneous fat makes it more difficult to adjust to cold temps -thinning and graying of the hair, as well as more sparse distribution -thickening of finger and toe nails -decrease in chest wall movement, vital capacity, and cilia, which increases risk for respiratory infection -slower reaction time -decrease in touch, smell, and taste sensation -decrease in production of saliva -decline in visual acuity -decreased ability for eyes to adjust from dark to light, leading to night blindness -inability to hear high pitched sounds (presbycusis) -decrease in height due to intervertebral disk changes -decrease in muscle strength and tone -decrease in digestive enzymes -decrease in intestinal motility, which can lead to increased risk of constipation -increase in dental problems -decalcification of bones -degeneration of joints -decrease in bladder capacity -prostate hypertrophy in men -decline in estrogen/testosterone production -decline in tri-iodothyronine T3 production, yet overall function remains effective -decreased sensitivity of tissue cells to insulin -atrophy of breast tissue in women

petechia/purpura

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

expected cognitive development (language): school-age (6-12 yrs)

-defines many words and understands rules of grammar -understands that a word can have multiple meanings

coping

-describes how an individual deals with problems and issues -influencing factors include: number, duration, and intensity of stressors; individual past experiences; current support system; available resources (financial)

Objective data should be documented:

-descriptive and should include what the nurse sees, hears, feels, and smells -w/o derogatory words, judgments, or opinions -accurately

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

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

expected cognitive development (language): adolescent (12-20 yrs)

-develops jargon within the peer group -able to communicate one way with peer group and another way with parents/teachers -development of communication skills is essential

the second number of the recorded visual acuity is the ___ at which a ___-___ ___ can read the line

-distance -normal-sighted person

expected psychosocial development (social development): preschooler (3-6 years)

-do not generally exhibit stranger anxiety and have less separation anxiety; however, prolonged separation (hospitalization) can provoke anxiety but favorite toys and play can help ease fears -pretend play is healthy and allows children to determine the difference between reality and fantasy -sleep disturbances occur frequently and problems range from difficulty going to bed and night terrors -with sleep disturbances, advise parents to: assess if bedtime is too early/late or naps needed (needs about 12 hrs of sleep per day); keep consistent bedtime routine; use a night light; reassure child that is frightened, but avoid having child sleep with them

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

-do not leave infant unattended in bath tub

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

-do not leave unattended in bathtub -closely supervise while in pool/other body of water -teach how to swim

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

-do not leave unattended in bathtub -keep toilet lids closed -closely supervise at pool/other body of water -teach how to swim

microbes can move by gravity from a nonsterile item to a sterile item:

-do not reach across or above a sterile field -do not turn your back on a sterile field -hold items to be added to a sterile field at a min of 6 inches above the field

during a severe thunderstorm or tornado

-draw shades and close drapes to protect against shattering glass -lower beds to lowest position and move away from windows -place blankets over clients confined to bed -close all doors -move as many ambulatory clients as possible into the hallways (away from windows) -do not use elevators -monitor for severe weather warnings using tv, radio, or internet

crust

-dried blood, serum, or pus -example: scab

home safety risks for preschoolers and school-age children include:

-drowning -motor vehicle/injury -burns -poison

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

-early on, may not understand the reasoning behind many rules and try to find a way around them -instrumental exchange is in place ("I'll help you if you help me.") -child wants to make the best deal, and does not really consider elements of loyalty, gratitude, or justice when making decisions -in latter parts of school years, the child moves into a law-and-order orientation with more emphasis placed on justice being administered

categories of triage during mass casualty events

-emergent category (class I): highest priority given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized -urgent category (class II): 2nd highest priority is given to clients who have major injuries that are not yet life threatening and can usually wait 45-60 mins for treatment -nonurgent category (class III): the next highest priority is given to clients who have minor injuries that are not life threatening and do not need immediate attention -expectant category (class IV): the lowest priority is given to clients who are not expected to live and will be allowed to die naturally; comfort measures may be provided, but restorative care will not

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

-encourage attendance in driver's ed -emphasize need for adherence to seat belt use -discourage use of cell phones while driving -teach dangers of combining substance abuse with driving

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

-ensure child knows how to swim and knows rules of water safety -locked fences around home and neighborhood pools

seizure precautions include:

-ensure rescue equipment is at bedside -inspect client's environment for items that may cause injury in event of seizure -assist client at risk for seizure with ambulation and transferring -advise all caregivers and family not to put anything in client's mouth in event of seizure (with exception of status epilepticus) -advise caregivers and family not to restrain in event of seizure but to lower to bed/floor, protect head, move nearby furniture, provide privacy, put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement -after seizure, explain what happened to client and provide comfort and quiet -document the seizure along with precipitating factors along with description of event and report it to provider

expected physical development (size/growth): adolescent (12-20 yrs)

-final 20%-25% of height is achieved during puberty -acne may appear -girls may cease to grow about 2-2.5 years after onset of menarche; will grow 5-20 cm (2-8 in) and 7-25 kg (15.5-55 lbs) -in girls, sexual maturation occurs in order of: appearance of breast buds, growth of pubic hair, onset of menstruation -in males, sexual maturation occurs in order of: increased size of testes/scrotum, appearance of pubic hair, rapid growth of genitalia, growth of axillary hair, appearance of downy hair on upper lip, change in voice -changes in sleep habits

trendelenburg position

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

reverse trendelenburg

-entire bed is tilted with the foot of the bed lower than the head -position promotes gastric emptying and prevents esophageal reflux

lordosis

-exaggerated curvature of the lumbar spine -common during toddler years and pregnancy

kyphosis

-exaggerated curvature of the thoracic spine -common in older adults

factors leading to tachycardia include:

-exercise -fever -medications -changing position from lying down to sitting/standing -acute pain -hyperthyroidism -anemia/hypoxemia -stress, anxiety, fear -hypovolemia, shock, heart failure

CN VII

-facial -assess mouth for taste -assess the face for symmetrical movement

Professional negligence

-failure of person with professional training to act in a reasonable and prudent manner -issues that prompt malpractice suits include failure to: follow standards of care, use of equipment in responsible & knowledgeable manner, effectively & thoroughly communicate with the client, document care was provided

barriers to learning:

-fear, anxiety, depression -physical discomfort, pain, fatigue -environmental distractions -health and cultural beliefs -sensory and perceptual deficits -psychomotor deficits

expected psychosocial development (self-concept development): preschooler (3-6 years)

-feels good about self with regard to mastering skills, such as dressing and feeding, that allow independence -during stress, insecurity, or illness, may regress to previous immature behaviors or develop habits like nose picking, bed wetting, or thumb sucking

s/s of generalized or systemic infection

-fever -increased pulse and resp rate (in response to high fever) -malaise -anorexia, nausea, and/or vomiting -enlarged lymph nodes

responsibilities of the nurse when receiving the transferred client

-have any specialized equipment ready -inform roommate of client's arrival (if applicable) -inform other team members of arrival -meet with client and family to complete admissions/orientation process -assess how client tolerates the transfer -review transfer docs -implement appropriate nursing interventions in a timely manner

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

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

scale

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

shape/contour of abdomen can be described as: -flat: -convex: -concave: -distended:

-flat: lies in horizontal line from the chest to the symphysis pubis -convex: rounded -concave: has sunken appearance -distended: a large protrusion of the abdomen caused by fat, fluid, or flatus that can be differentiated as follows: *fat: client has rolls of fat along sides, and the skin does not look taught *fluid: flanks also protrude, when client turns onto side, the protrusion moves to the dependent side *flatus: protrusion is mainly midline, and the flanks are unchanged *hernias: protrusions through the abdominal muscle wall are visible

secondary prevention

-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health status -examples: communicable disease screening and case finding; early detection and treatment of diabetes; exercise programs for older adult clients who are frail

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

-follow age-related guidelines -DEXA screening for osteoporosis -eye exam for glaucoma every 2-3 years or annually depending on provider -mental health screening for depression

health promotion (health screenings): middle adult (35-65 yrs)

-follow age-related guidelines -dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis -eye exam for glaucoma and other disorders every 2-3 years or annually depending on provider -mental health screening for depression

all health care staff should:

-follow facility protocols for isolation and protection -wash hair frequently and keep it short or pulled back to prevent contamination of care area or client -not wear artificial nails while providing care and keep natural nails short and clean -remove jewelry from hands and wrists to facilitate hand disinfection

Nurses can avoid being liable for negligence by:

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

risk factor assessment should assess the following:

-genetics: a predisposition to various illnesses can be attributed to heredity (heart disease, cancer) -gender: some specific diseases are more common in one gender than the other (autoimmune disorders, suicide rates) -physiologic factors: various physiologic states place a client at greater risk for health problems (BMI, pregnancy) -environmental factors: presence of toxic substances and chemicals can affect health where clients work and live; water quality, pesticide exposure, and air pollution should be commonly assessed -lifestyle-risk behaviors: stress, substance abuse, diet deficiencies, lack of exercise, and sun exposure age- early disease detection and intervention is facilitates by following screening guidelines

Change of shift report

-given at the conclusion of each shift by the nurse leaving to the nurse assuming responsibility for the client -can be given face-to-face, audiotaped, or presented during rounds -should include significant objective info, given in logical order, free of gossip and personal opinions, and relate recent changes in meds, treatments/procedures, or discharge plan

The client's responsibility for informed consent:

-giving informed consent -must give consent voluntarily (no coercion), be competent and of legal age (or authorized individual), and receive enough information to make a decision

CN IX

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

expected psychosocial development (body-image changes): young adult (20-35 yrs)

-greatly influenced by what young adults eat and how much exercise they get -pregnancy related body changes may also occur

isolation guidelines

-group of actions that include hand hygiene and use of barrier precautions, which are intended to reduce the transmission of infectious organisms -apply to everyone regardless of diagnosis, and must be implemented whenever contact with a potentially infectious material is anticipated -PPE is changed after contact with each client and between procedures with the same client if in contact with large amounts of blood and body fluids

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

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

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

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

Board of nursing

-has authority to adopt rules and regs for nursing practice in that state -has authority to both issue and revoke a nursing license -set standards for nursing programs -delineate scope of practice among RNs, LPNs, and APNs

When accepting an order from a provider over the phone or verbally, the nurse should:

-have a second RN/LPN listen to the phone order -repeat back the order given including med name, dosage, time and route -document reading back the order and presence of the second nurse on the telephone -question any order that may seem contraindicated due to a previous order or to the client's condition

the nurse should inform the client who smokes and his/her family about:

-hazards of smoking -available resources for smoking cessation -the effect of visiting or riding in a car with a smoker can have on a non-smoker

expected psychosocial development (self-concept development): adolescent (12-20 yrs)

-healthy self-concept developed by having healthy relationships with peers, family, and teachers -identifying a skill or talent helps maintain healthy self-concept -participation in sports, hobbies, or the community can have a positive outcome

safety prevention education/modifications for older adults includes:

-home hazard evaluation conducted by nurse, physical therapist, occupational therapist if deemed necessary -remove items that could cause client to trip, such as throw rugs and loose carpets -place electrical cords against wall and behind furniture -ensure steps and sidewalks in good repair -place grab bars near toilet and in tub/shower and installing a stool riser -non-skid mat in tub or shower -place shower chair in shower -ensure lighting is adequate inside and outside home

if evacuation of a unit is necessary due to fire:

-horizontal evacuation is done 1st -lateral evacuation is done if client safety cannot be maintained

when dealing with safety, all health care workers must be aware of:

-how to assess for and recognize clients at risk for safety issues -procedural safety guidelines -protocols for responding to dangerous situations -security plans -identification and documentation of the incidents and responses per health care agency policy

external emergencies include:

-hurricanes -floods -volcano eruptions -earthquakes -pandemic flu -industrial accidents -chemical plant explosions -major transportation accidents -building collapse -terrorist acts (including biological and chemical warfare)

CN XII

-hypoglossal -assess the tongue for movement and strength

behavior-change strategies nurses can use in health promotion/disease prevention

-identify client's readiness to receive and act upon health info -identify interventions acceptable to the client -help motivate the client to change by setting realistic timelines -reinforce steps the client makes toward change -encourage the client to maintain the change

planning related to client education includes:

-identify mutually agreed upon client outcomes -prioritize the learning objectives with the client's needs in mind -use methods that emphasize the client's learning style -select age-appropriate teaching methods/material -provide electronic educational resources as appropriate -demonstrate use of the internet as in regard to accessing info and support services and how to recognize reliable sources -organize learning activities to move from simple to more complex tasks, and known to unknown concepts -incorporate active participation in the learning process - schedule teaching sessions to coincide with the client's daily activities

pulmonary hygiene for immobile clients

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

Steps in ethical decision making

-identify whether or not the issue is indeed an ethical dilemma -state the ethical dilemma including all surrounding issues and individuals involved -list and analyze all possible options for resolving the dilemma and review implications of each option -select option that is in concert with the ethical principle applicable to this situation, the decision maker's values and beliefs, and the profession's values set forth for client care; justify why chosen over other options -apply this decision to the dilemma and evaluate the outcomes

transporting client in infection control/isolation

-if movement is unavoidable, take precautions to ensure that the environment is not contaminated -for example surgical mask placed on client with airborn or droplet infection and a draining wound is well covered

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

-if not given during 11-12, then years 12-20: Tdap, MCV4, HPV2 series (females), HPV4 (males), yearly seasonal flu TIV or LAIV (nasal)

Incident reports (unusual occurrences)

-important part of a facility's quality improvement plan -examples of incidence include med errors, falls, and needle sticks -facts documented without judgment or opinion -should not be referred to in client's medical record

risks of infection

-inadequate hand hygiene (client and caregivers) -compromised health or defenses against infection -use of poor medical/surgical asepsis by caregivers -clients who have poor personal hygiene, poor nutrition, and those who are stressed -clients who live in a very crowded environment -older adult clients -clients who used IV drugs and share needles -clients who engage in unprotected sex -clients who have recently been exposed to poor sanitation, mosquito-born/parasitic diseases, or diseases endemic to area visited but not in client's home country

health promotion (injury prevention): older adult (65+ yrs)

-install bath rails, grab bars, and hand rails on stairways -remove throw rugs -eliminate clutter from walkways/hallways -remove extension and phone cords from walkways/hallways -instruct on proper use of ambulation-assistive devices -ensure adequate lighting -remind clients to wear eyeglasses and hearing aids -avoid drugs, including alcohol; prevent substance abuse -avoid taking drugs and/or drinking while driving -wear seat belt when operating a vehicle -wear helmet when riding bike, skiing, snowboarding -install smoke and carbon monoxide detectors in home -secure firearms in safe location

When client arrives to room the nurse should:

-intro yourself, explain your role and role of other nursing staff, provide hospital attire, position comfortably, apply ID/allergy bracelets, provide written info and info on advanced directives, document advanced directives in medical record -assess/collect: baselines, reason for seeking care, health history, family history, psychosocial history, nutrition, review of systems, spiritual info, safety assessment, discharge info -inventory personal items brought by client

affective learning

-involves feelings, beliefs, and ideals -example: a client listens to the nurse explain life changes necessary to manage diabetes and then discusses feelings regarding the diagnosis

Criminal law:

-is a subsection of public law -relates to the relationship of an individual with the government -ex: a nurse falsifies a record to cover up a serious mistake may be found guilty of breaking a criminal law

Examples of questions to use to determine potential for harm:

-is there a chance something negative may happen to the client (risk for bleeding, risk for aspiration)? -is the client unstable?

Examples of questions to use to determine level of interaction with the client:

-is there a need to provide psychosocial support or education during the performance of the task?

A problem is an ethical dilemma if:

-it cannot be solved solely by a review of scientific data -it involves a conflict between two moral imperatives -the answer will have a profound effect on the situation/client

sterile fields and moisture

-keep all areas dry -discard any sterile packages that become wet

health promotion (injury prevention-substance abuse/poisoning): school-age (6-12 yrs)

-keep cleaners or chemicals in locked cabinet and out of reach -teach to say "no" to illegal drugs and alcohol

prevention education for risk of falls in infants and toddlers:

-keep crib and playpen rails up -never leave unattended on changing table or other high surface -restrain while in high chair, swing, stroller, etc -place in low bed when toddler starts to climb

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

-keep crib mattress in lowest position with rails all the way up -use restraints in infant seats -place infant seat on ground/floor if used outside of car and do not leave on elevated surfaces unattended -use safety gates across stairs

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

-keep sharp objects out of reach -keep firearms in locked box/cabinet -do not leave unattended with animals -teach stranger safety

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

-keep sharp objects out of reach -keep infant away from heavy objects that can be pulled down onto her -do not leave alone with animals -monitor for shaken baby syndrome

prevention education for risk of aspiration in infants and toddlers:

-keep small objects out of reach -check toys for loose parts -do not feed infant hard candy, peanuts, popcorn, or whole/sliced pieces of hot dog -do not place infant in supine position while feeding or prop the bottle -pacifiers should be constructed of one piece -provide information on prevention of lead poisoning

components of critical thinking

-knowledge -experience -competence -attitudes -standards

expected cognitive development (language development): toddler (1-3 yrs)

-language increases to about 400 words with toddlers speaking in 2-3 word phrases

before beginning any task or procedure that requires aseptic technique, health care team members must check for:

-latex allergies (client and team members) -if there is a known allergy, latex-free gloves, equipment, and supplies must be used

psychomotor learning

-learning how to complete a physical activity or motor skill -example: client practices preparing insulin injections

Client's rights

-legal guarantees that clients have with regard to their health care -situations where nurses have opportunity to protect client's rights include: informed consent, refusal of treatment, advanced directives, confidentiality, and information security

lab results indicating infection include:

-leukocytosis (WBCs > 10,000/uL -increases in the specific types of WBCs on differential (left shift = increase in neutrophils) -elevated erythrocyte sedimentation rate (ESR) -presence of micro-organisms on culture of the specific fluid/area

fissure

-linear crack -example: tinea pedis

all staff must be instructed in fire response procedures including:

-location of exits, fire extinguishers, and O2 shut-off valves -evacuation plan for the unit and facility

factors leading to bradycardia include:

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

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

-may personalize values and beliefs -reasoning may be based on ethical fairness principles, such as justice

expected psychosocial development (Erikson: initiative vs guilt): preschooler (3-6 years)

-may take on new experiences despite not having all physical abilities needed to be successful at everything -guilt may occur when unable to accomplish a task and believe they have misbehaved -guiding to attempt activities within their capabilities while setting limits is appropriate

transfer documentation should include:

-med diagnosis and care providers -client demographic info -overview of health status, plan of care, and recent progress -any alterations that may be of immediate concern -notification of any assessments/client care needed within the next few hrs -most recent vital signs and meds (inc PRNs) -allergies -diet and activity orders -presence of/need for special equipment or adaptive devices -advanced directives & emergency code status -family involvement and health care proxy (if applicable)

What is postural drainage?

-method for clearing the lungs by changing position; the Trendelenburg position is commonly used; -allows gravity to help drain mucous from lower and middle portions of lungs to the top of the lungs where it can be removed more easily

expected psychosocial development (Erikson-generativity vs stagnation): middle adult (35-65 yrs)

-middle adults strive for generativity -use life as an opportunity for creativity and productivity -have concerns for others -consider parenting an important task -contribute to well-being of the next generation -strive to do well in one's own environment -adjust to changes in physical appearance and abilities

promote healthy lifestyle behaviors by instructing clients to:

-minimize or reduce stress -get adequate sleep/rest - eat a nutritious diet to achieve and maintain a healthy weight -avoid saturated fats -participate in regular physical activity most days of the week -while outdoors, wear protective clothing, use sunscreen, and avoid sun exposure between 10am and 4pm -wear safety gear while participating in physical activity -avoid substances such as tobacco products, alcohol, and illegal drugs -practice safer sex -seek medical care when necessary, and visit provider for routine screenings

expected psychosocial development (body-image changes): preschooler (3-6 years)

-mistaken perceptions of reality coupled with misconceptions in thinking lead to active fantasies and fears -greatest fear is that of bodily harm, thus fear of the dark and animals -sex-role identification is occurring

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

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

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

-monitor for s/s of substance abuse in at-risk children -teach to say "no" to drugs and alcohol -present a no tolerance attitude

Examples of tasks that can be delegated to LPNs

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

food poisoning

-most cases caused by bacteria such as E. coli, Listeria monocytogenes, and Salmonella -healthy individuals usually recover in a few days -very young, very old, pregnant, or immunocompromised clients at highest risk for complications -clients who are especially at risk are instructed to follow a low-microbial diet -most cases due to unsanitary food practice -can be prevented by proper hand hygiene, cooking meats/fish to correct temp, handling raw and fresh foods separately to avoid cross-contamination, and proper refrigeration

home safety risks for young and middle age adults include:

-motor vehicle crashes -occupational injury -high alcohol consumption -suicide

home safety risks for adolescents include:

-motor vehicle/injury -burns

nursing responsibilities in regards to isolation/restraints:

-must be identified in the protocol -include how often the client should be: assessed; offered food/fluid; provided for means of hygiene/elimination; monitored for vital signs; offered ROM of extremities

seclusion and restraints

-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min

restraints should:

-never interfere with treatment -restrict movement as little as is necessary to ensure safety -fit properly -be easily changed to decrease the chance of injury and to provide for the greatest level of dignity

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

-nonpalpable -nontender -not visible

macule

-nonpalpable, skin color change, <1cm -example: freckle

expected age-appropriate activities: adolescent (12-20 yrs)

-nonviolent video games -nonviolent music -sports -caring for a pet -career-training programs -reading -social events (going to movies or school dances)

standards for emergency preparedness mandated by the Joint Commission require procedures be set for:

-notifying and assisting personnel -notifying external authorities of emergencies -managing space and supplies and providing security -isolating and decontaminating radioactive or chemical agents -evacuating and setting up alternative care site when the environment cannot support adequate client care and treatment -performing triage -managing clients during emergencies -interacting with families and news media -identifying backup resources for utilities and communication -orienting and educating personnel participating in emergency preparedness plan -providing crisis support for health care workers -providing performance monitoring and evaluations related to emergency preparedness -conducting 2 emergency preparedness drills each year

the first number of the recorded visual acuity indicates the ___ ___ ___ from the ___ the client is ___

-number of feet -chart -standing

RNs CANNOT delegate

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

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

-nutrient deficiencies tend to be: iron, calcium, and vits A & C -eating disorders commonly develop including: anorexia nervosa, bulimia nervosa, obesity -advise parents: ensure balanced diet according to USDA and teach children to make healthy food choices -encourage dental health including: brushing and flossing daily; having regular check-ups and fluoride treatments

health promotion (alterations in health): middle adult (35-65 yrs)

-obesity and type 2 diabetes mellitus -CV disease -cancer -substance abuse (alcoholism) -psychosocial stressors

health promotion (nutrition): middle adult (35-65 yrs)

-obtain adequate protein intake -increase consumption of whole grains -increase consumption of fresh fruits and veggies -limiting fat and cholesterol -increasing vit D and calcium supplementation (esp for women)

The provider's responsibility for informed consent:

-obtain informed consent -must give complete description of treatment/procedure, description of who will be involved in treatment, description of risks, options for other treatments, and the right to refuse -provide clarification if requested

cognitive learning

-obtaining new info, being able to apply the info, and being able to evaluate the info -example: client is taught s/s of hypoglycemia and then can verbalize when to notify provider

supervision:

-occurs after delegation -oversees a staff's performance of delegated activities -determines if: completion of task is on schedule; performance was satisfactory; abnormal/unexpected findings documented & reported; assistance is needed to complete assigned tasks in a timely manner; assignment should be re-evaluated & possibly changed

CN III

-oculomotor -assess corneal light reflex -assess pupillary reaction to light -assess extraocular movements

falls

-older adults at increased risk due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception -other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems, and cognitive dysfunction; also side effects of some medications -clients are at greater risk when >1 of the risk factors are present -fall prevention is a major nursing priority

CN I

-olfactory -assess nose for smell

responsibilities of the nurse when transferring/discharging the client:

-on day/time of transfer, confirm they are expecting and have a bed -communicate time client will be arriving -complete documentations -give verbal transfer report in person or over the phone -confirm mode of transportation to complete transfer/discharge -ensure client is dressed appropriately -account for all of client's valuables

CN II

-optic -assess visual acuity -assess visual fields -assess corneal light reflex -assess pupillary reaction to light

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

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

nodule/tumor

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

papule

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

wheal

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

in conjunctiva the ___ is pink and the ___ is transparent

-palpebral -bulbar

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

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

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

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

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

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

additional safety risks in home/community include:

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

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

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

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

-peer groups play an important part in social development -peer pressure begins to take effect -same-gender friendships begin to form; this is time period when clubs and best friends are popular -children prefer company of same-gender companions -most relationships come from school associations -at this age, may rival same-sex parent -conformity becomes evident

What is included in seizure precautions?

-rescue equipment at bedside: O2, oral airway, suction equipment, and padding for bed rails; -remove items from environment that may cause injury to patient if seizure occurs; -assist w/ambulation and transfers; -advise family not to restrain client or put anything in the mouth if a seizure occurs

expected psychosocial development (social development): adolescent (12-20 yrs)

-peer relationships develop -these relationships act as support system for the child -best friend relationships are more stable and long-lasting in comparison to previous years -parent-child relationships change to allow a greater source of independence

factors that enhance learning:

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

sterile procedure steps

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

Items to be transferred/discharged with the client include:

-personal belongings at the bedside -valuables from the safe -medications -assistive devices -medical records or transfer form

home safety risks for older adults include:

-physical, cognitive and sensory changes -changes in musculoskeletal and logical systems -impaired vision and/or hearing -nocturia and incontinence

health promotion (nutrition): toddler (1-3 yrs)

-picky eaters; repeated requests for favorite foods -consume 24-30 oz of milk/day; may switch from whole milk to 2% at age 2 -limit juice to 4-6 oz/day -food serving size is 1 tbsp for each yr of age -exposure to new food may take 8-15 times before acceptance -if there is a family history of an allergy to a certain food, gradually introduce while monitoring for reactions -finger foods may be preferred due to increasing autonomy -regular meal times and nutritious snacks best meet nutrient needs -avoid snacks/desserts high in sugar, fat, sodium -avoid foods that are potential choking hazards -always provide supervision during snack/mealtimes -cut small bite-size pieces to make them easier to swallow and prevent choking -do not allow drinking/eating during play or while lying down -suggest parents follow USDA nutrition guidelines

expected physical development (size): infant (birth-1 yr)

-posterior fontanel closes by 2-3 months -anterior fontanel closes by 12-18 months -weight: gains 150-210 g (5-7 oz) per month for 1st 6 months; birth weight should double by 4-6 months and triple by the end of the 1st year -height: grows about 2.5 cm (1 in) per month for 1st 6 months; then about 1.25 (0.5 in) per month til the end of 1st yr -head circumference: increases about 1.25 cm (0.5 in) per month for 1st 6 months; then about 0.5 cm (0.2 in)between 6-12 months)

complete documentation of isolation/restraint use includes a description of:

-precipitating events and behavior prior to seclusion/restraints -alternative actions taken to avoid seclusion/restraint -time restraints applied and removed (if discontinued) -type of restraint and location -client's behavior while restrained -type and frequency of care -client's response when restraint removed -meds administered

expected cognitive development (Piaget: still in preoperational phase>preconceptual though to intuitive thought): preschooler (3-6 years)

-preconceptual thought (2-4 year): make judgments based on visual apperances; misconceptions in thinking include artificialism (everything is made by humans), animism (inanimate objects are alive), and imminent justice (a universal code exists that determines law and order) -intuitive thought (4-7 year): can classify information and become aware of cause-and-effect relationships

Prior to delegating client care, the nurse should consider:

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

expected psychosocial development (self-concept development): toddler (1-3 yrs)

-progressively see themselves as separate from their parents and increase their exploration away from them

droplet precautions

-protect against droplets larger than 5 mcg (streptococcal phryngitis or pnemonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meningococcal pneumonia/sepsis, pneumonic plague) -require a private room or room with clients with the same infectious disease and masks for providers and visitors

Civil law:

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

contact precautions

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

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

-provide education

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

-provide education and resources for treatment

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

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

Nursing role in advanced directives

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

baseline data

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

purposes of client teaching include:

-providing clients with info and skills to maintain and promote health, and prevent illness (immunizations, lifestyle change, prenatal care) -providing clients with info about how to restore health (teaching how to admin insulin) -providing clients with info about how to adapt to permanent illness or injury (ostomy care, learning swallowing techniques, speech therapy)

ecchymosis

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

pustule

-puss-filled -example: acne

hematoma

-raised ecchymosis

steps of mobility assessment

-range of motion -moving from supine to sitting on side of bed -gait -exercise tolerance

cherry angioma

-red -1-3 cm -round -can be raised

spider angioma

-red center with radiating red legs -up to 2 cm -can be raised

s/s during 1st stage of the inflammatory response (local infection):

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

erythema

-redness: best noted in face, trauma and pressure sore areas -indication of inflammation

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

-reduce setting on water heater to no higher than 120 deg F -teach dangers of playing with matches, fireworks, fire arms, etc -teach school-aged children how to use microwave and other cooking instruments

State laws

-regulate the core of nursing practice -each state has enacted statutes defining parameters of practice and gives authority to regulate to the state board of nursing

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

-religious maturity -spiritual beliefs and religion may take on added importance -may become more secure in convictions -often have advanced moral development

safety prevention education for young and middle age adults includes:

-remind clients to drive defensively and not to drive after drinking -reinforce teaching about long term effects of high alcohol consumption -monitor for s/s of depression/suicide and refer as appropriate -encourage clients to be proactive about safety in workplace -ensure understanding of hazards of excessive sun exposure and the need to use sun block and protective clothing

screenings and exams for clients who are asymptomatic

-routine physical: (f) every 1-3 years beginning at 20/annually beginning at 40; 9m) every 5 years starting at 20/annually beginning at 40 -dental assessment: (f&m) every 6 months -blood pressure: (f&m) starting at 20, each routing health care visit, min of every 2 yrs -BMI: (f&m) starting at 20, each routing health care visit -blood cholesterol: (f&m) starting at 20, a min of every 5 yrs -blood glucose: (f&m) starting at 45, min of every 3 yrs -colorectal screening: (f&m) fecal occult blood test annually at 50 AND flexible sigmoidoscopy every 5 yrs or colonoscopy every 10 yrs or double contrast barium enema every 5 yrs -colonoscopy: (f&m) starting at 50, every 1-10 yrs depending on test used -pap test: (f) starting at 21 (or earlier if sexually active) every 1-2 yrs; after 30 every 1-3 yrs depending on provider/test used -clinical breast exam: (f) starting at 20, every 3 yrs; at 40, annually -mammogram: (f) starting at 40, annually -clinical testicular exam: (m) starting at 20, annually -prostate-specific antigen test & digital rectal exam: (m) starting at 50, as indicated by provider

internal emergency readiness includes:

-safety and hazardous materials protocols and infection control policies and practices

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

-scoliosis

health promotion (health screenings): school-age (6-12 yrs)

-scoliosis: screening for lateral curve before and during growth spurts; can be at school or provider's office

expected psychosocial development development (body-image changes): adolescent (12-20 yrs)

-seem particularly concerned with body images portrayed by the media -changes during puberty result in comparisons between the child and surrounding peer group -parents also give input as to hair styles, dress, and activity -may require help if depression or eating disorders result due to poor body image

expected cognitive development (Piaget: concrete operations): school-age (6-12 yrs)

-sees weight and volume as unchanging -understands simple analogies -understands time (days/seasons) -classifies more complex information -understands various emotions people experience -becomes self-motivated -is able to solve problems

equipment and sterile fields

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

discharge planning

-should begin when client is admitted (with the exception of LTC) -assess if the client will be able to return home and/or if they will need assistance at home -assess residence to see if adaptations or specific equipment will be necessary -make referral to social worker if needed -communicate client health status and needs to community service providers -if client chooses to leave before discharged, notify provider and have pt sign off

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

-should follow age-related guideline -routine health care visits should include: height, weight, and VS; stress screenings; education related to STDs, substance abuse, and contraception; encouragement of good nutrition and regular physical activity

expected physical development (gross and fine motor skills): preschooler (3-6 yrs)

-should show great improvements in fine motor skills such as copying figures on paper and dressing themselves -3 years: (g) rides tricycle, jumps off bottom step, stands on 1 foot for a few seconds -4 years: (g) skips and hops on 1 foot, throws ball overhead -5 years: (g) jumps rope, capable of walking backward with heel to toe, moves up and down stairs easily

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

-sit in approved forward-facing car seat in back set away from airbags -can usually sit in seat until 4 yo or 40 lbs -when outgrown, use booster seat in back seat -should be restrained in car seat or booster until adult belt fits correctly (laws vary from state to state)

stress may be:

-situational -developmental -caused by sociocultural -a contributor to illness vulnerability

the three essential components of hand washing include:

-soap -water -friction

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

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

expected age-appropriate activities: toddler (1-3 yrs)

-solitary play evolves into parallel play where toddler observes other children and then may engage in activities nearby -appropriate activities include: filling and emptying containers, playing with blocks, looking at books, toys that can be pushed and pulled, tossing a ball -temper tantrums result when frustrated with independence restrictions; providing consistent, age-appropriate expectations helps them work through frustrations -toilet training can begin when it is recognized that child has sensation of needing to urinate/defecate; parents should demonstrate patience and consistency; nighttime control may be last to develop -discipline should be consistent and with well defined boundaries established to develop appropriate social behavior

chemical incidents

-take measures to protect yourself and to avoid contact -assess and intervene to maintain the client's ABCs and admin first aid as needed -effectively remove the offending chemical/decontaminate -gather specific history of the injury, if possible -in the event of chemical warfare, have knowledge of which facilities are open to exposed clients and which are open to unexposed clients only -follow facility's emergency ops plans

CN XI

-spinal accessory -assess the shoulders for strength

What to do when a client *IS HAVING* a seizure

-stay with client - call for help; -lower client to floor or bed, protect head, remove nearby furniture, provide privacy, put client on side w/head flexed slightly forward if possible, and loosen clothing; -admin meds as prescribed; -note duration of seizure, sequence and type of movement

discharge instructions should include:

-step-by-step for procedures done at home -precautions to take when performing home procedures and with meds -s/s of complications that should be reported -names and numbers of providers and community services contacts -plans for follow-up care and therapies

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

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

health promotion (alterations in health): young adult (20-35 yrs)

-substance abuse -periodontal disease due to poor oral hygiene -unplanned pregnancies (a source of high stress) -STDs -infertility -work-related injuries or exposures

hazardous material incidents

-take measures to protect self and avoid contact -approach scene cautiously -try to identify the material and have knowledge of where MSDS manual is located -try to contain material to one area as much as possible until haz-mat team arrives -if individuals are contaminated, decontaminate as much as possible at the scene or as close to the scene as possible

biological incidents

-take measures to protect self and others -recognize s/s of infection/poisoning and appropriate treatments -incidents include: inhalational anthrax, botulism, smallpox, and ebola

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

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

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

-teach fire safety -use sunscreen when outside

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

-teach fire safety and potential burn hazards -have working smoke and carbon monoxide detectors in the home -use sunscreen when outdoors

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

-teach to swim -teach not to swim alone

prevention education for risk of burns in adolescents

-teach to use sunblock and protective clothing -teach dangers of sun bathing and tanning beds -educate on hazards of smoking

prevention education for risk of burns in infants and toddlers:

-test temp of formula and bath water -place pots on back burner and turn handle away from front of stove -supervise use of faucets

Entities with codes of ethics that may be used to guide nursing practice include:

-the American Nurses Association (ANA) -the International Council of Nurses (ICN) -the National Association for Practical Nurse Education and Services, Inc.

asepsis

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

bioterrorism

-the dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death -examples include anthrax, variola, Clostridium botulism, and Yersinia pestis

complex critical thinking

-the nurse begins to express autonomy by analyzing and examining data to determine the best alternative -results from increased nursing knowledge, experience, intuition, and more flexible attitudes

commitment

-the nurse expects to have to make more choices without help from others and fully assumes the responsibility for those choices -results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes

basic critical thinking

-the nurse trusts the experts and thinks concretely based on the "rules." -results from limited nursing knowledge and experience, as well as inadequate critical thinking experience

only sterile items may be in a sterile field

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

therapeutic communication is

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

Consent considered informed when the client has been provided and understands:

-the reason the treatment or procedure is needed -how the treatment or procedure will benefit the client -risk involved if treatment or procedure is chosen -other options to treat the problem (including no action)

adequate fluid intake/hydration prevents:

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

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

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

LOC: coma

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

individuals with compromised health or defenses against infection include:

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

CN V

-trigeminal -assess the face for strength and sensation

CN IV

-trochlear -assess extraocular movements

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

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

discharge documentation should include

-type of discharge -date/time of discharge, how the client was transported out and with who -where discharged to -summary of condition upon discharge -description of any unresolved difficulties and procedures for follow up -deposition of valuables and meds -copy of discharge instructions

passive smoking

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

heart sounds: S3

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

prevention education for risk of motor vehicle/injury in preschoolers and school-age children:

-use booster seats for children < 4'9" and <40 lbs -use seat belts properly after booster seats no longer necessary -use protective equipment when participating in sports or riding/passenger on a bike -supervise and teach safe use of equipment -teach to play in safe areas, rules of the road, and what to do if approached by a stranger -begin sex education for school-ages children

oxygen safety measures:

-use/store according to manufacture's recommendations -place a NO SMOKING sign near front door of home and on door of client's bedroom -inform client and family of smoking in presence of oxygen and that smokers should smoke outdoors -ensure electrical equipment is in good repair and well grounded -replace bedding that can generate static electricity (wool, nylon, synthetics) with cotton -keep flammable items (such as heating oil and nail polish remover) away from client when O2 in use -follow general safety measures for fire safety

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

-used approved car seat in back seat away from airbags -should be rear facing till reaches 9.1 kg (20 lbs) and is 1 yr old; then can use forward facing seat in back seat-usually until 4 yo old 40 lbs -children who meet weight but not age requirement of 1 yr should remain rear facing and a 5 point harness or T-shield should be a part of convertible harness

airborne precautions

-used to protect against droplet infections smaller than 5mcg (measles, varicella, pulmonary or laryngeal TB) -require a private room, masks/respiratory devices for caregivers and visitors (N95 or HEPA respirator for known/suspected TB), and negative pressure airflow exchange room of at least 6 exchanges per hr

Telephone report

-useful when contacting provider or other members of the interdisciplinary team -important to have all data prepared before calling; use professional demeanor; use exact, relevant, and accurate info; document name of person called, time, content of message, and instructions or information received

CN X

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

expected axillary and tympanic temperatures are usually:

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

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

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

5 rights of delegation help decide:

-what task should be delegated (right task) -under what circumstances (right circumstance) -to whom (right person) -what info should be communicated (right direction/communication) -how to supervise/evaluate (right supervision /evaluation)

bomb threat

-when a phone call is received: >lengthen conversation as much as possible >listen for distinctive background noise >be alert for distinguishing voice characteristics >ask where the bomb will explode and at what time >note if the caller indicates knowledge of the facility by his description of the location -if what appears to be a bomb is found, don't touch, clear the area, isolate it, and obtain professional assistance -notify authorities and key personnel -cooperate with police and others -keep elevators available for authorities -remain calm and alert and try not to alarm clients

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

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

Examples of questions to use to determine predictability of care:

-will the completion of the task have a predictable outcome? -is it a routine treatment? -is it a new treatment?

steps to donning sterile gloves:

-with cuff side pointing toward the body, use non-dominate had to pick up dominate glove -while picking up edge of the cuff, pull the dominate glove onto the hand -with sterile dominate hand gloved, place fingers of dominate hand inside cuff of left hand, lifting it off the wrapper and put non-dominate hand into it -when both hands are gloved, adjust fingers as needed -during this time, only sterile gloved hand can touch the other sterile gloved hand

The nurse's responsibility for informed consent:

-witness informed consent -must ensure provider provided necessary information, ensure the client understood and is competent to give consent, have the client sign informed consent document, notify provider if more information or clarification needed/requested by client, and document client questions and that the provider was notified (also if interpreter was used)

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

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

jaundice

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

adherence

...

cardiovascular effect

...

expected rectal temperatures are usually:

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

What are the steps for changing a stoma pouch?

1) remove old pouch; 2) inspect stoma; 3) use mild soap and water to cleanse the skin, then dry it gently and completely; 4) apply paste if necessary; 5) measure and draw where to cut the skin barrier, allowing only the stoma to appear through the opening; 6) cut the opening in the skin barrier; 7) if necessary, apply barrier paste to creases; 8) apply skin barrier and pouch; 9) fold bottom of pouch and place closure clamp on the pouch

Pharmacist

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

always count the apical pulse rate for

1 min

What are the 3 types of nociceptive pain?

1) *somatic* - bones, joints, muscles, skin, or connective tissues; 2) *visceral* - internal organs such as the stomach or intestines; can cause referred pain; 3) *cutaneous* - skin or subcutaneous tissue

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

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

5 elements necessary to prove negligence

1) duty to provide care as defined by a standard 2) breach of duty by failure to meet standard 3) foreseeability of harm 4) breach of duty has potential to cause harm (combines 2&3) 5) harm occurs

What is the proper order for removing PPE?

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

What are the stages of infection?

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

4. Implementation

4th step RN 3rd step LPN interventions for health

To clean a surgical instrument prior to sterilization

1) rinse under *cold* water [because hot water coagulates proteins which makes them adhere]; 2) wash with *soap and water*; 3) remove organic materials w/a brush; 4) rinse under *warm water*; 5) dry instrument

steps to assessing orthostatic BP changes

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

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

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

Nursing Process

1. Assessment First 2. Analysis 3. Planning 4. Implementation 5. Evaluation

Maslow's Hierarchy of Needs

1. Physiological 2. Safety & Security 3. Love & Belonging 4. Self-Esteem 5. Self-Actualization

how to process an ethical dilemma

1. ask if this is an ethical dilemma 2. gather all relevant info 3. clarify values 4. verbalize problem 5. identify possible courses of action 6. negotiate a plan 7. evaluate plan

Mg

1.5-2.5

How long should the patient retain the cleansing enema solution?

5 to 10 min

Morbid Obesity

100% over weight for height

Normal range for BP

100/60-140-90

stage 4 of sleep

12-15%; very deep sleep; rhythmic breathing

Normal range for respirations

12-20

for an infant the expected pulse rate range is

120-160 bpm

prehypertension range

120/80 - 139/89

Na

135-145

stage I hypertension

140/90 - 159/99

the line on the Snellen chart for which ___ or ___ letters are missed is recorded as the visual acuity

2 or fewer

hepatotoxicity

2 or more med that are hepatotoxic are combined, the risk of r liver damage is increased

client must stand ___ ___ from the Snellen chart

20 feet

stage 5 of sleep

20-25%; REM; brainwaves speed up and dreaming occurs; increased heart rate; rapid and shallow breathing

expected school-age respiratory rate

20-30 rpm

Hco3

22-26

What is the recommended fiber intake for a normal diet?

25-30 g/day

PTT

25-35 seconds

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

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

hemodialysis

3 days out of week, 3-4 hr long process; blood circulated through the machine and nitrogenous waste, fluid, electrolytes removed; BP before and after treatment; weight before and after; can be used for drug overdose

a diagnosis of hypertension is made is made if readings are elevated on at least

3 separate occasions over several weeks

How far should you insert the rectal tube?

3 to 4 inches

K

3.5-5.0

expected newborn respiratory rate

30-60 rpm

PaCo2

35-45

an older client's average body temperature is

36* C (96.8* F)

expected oral temperature ranges:

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

newborns' temperature should be maintained between

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

fever is not usually harmful unless it exceeds

39* C (102.2* F)

3. Planning

3rd step RN 2nd step LPN establish outcomes and plan of care

5. Evaluation

5th step RN 4th step LPN in process or completed

BUN

6-20

blood pressure (BP) is determined by

CO x SVR

with menopause, intermittent body temperature may increase by up to

4* C (7.2* F)

stage 1 of sleep

4-5%; light sleep; muscle activity slows

stage 3 of sleep

4-6%; deep sleep

stage 2 of sleep

45-55%; breathing and heart rate slow

Normal range for pulse

60-100

expected range for an adult client's pulse is

60-100 bpm at rest

pH

7.35-7.45

Glucose

70-120

Ca

8.5-10.5

PaO2

80-100

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

80-90 bpm

hypoxemia is an SaO2 below

90%

Chloride

95-108

Normal range for temperature

96.8-100.4

normal BP range

<120/80

stage II hypertension

>160/100

hyperventillation (kussmaul)

>40 RR; over-breathing, decreased CO2 leads to alkaline; panic attack, stress/anxiety, fever/infection, intense exercise

Normal range for pulse ox.

>95%

SaO2

>95%

3 Classes of fire extinguishers

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

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain

A. Role conflict ____________________ A. CORRECT: The client is experiencing role conflict because his career is extremely physical, and he can no longer perform his job duties. However, the client is the primary wage earner in the family. B. INCORRECT: Although the client may feel overloaded and overwhelmed, role overload occurs when the client is trying to juggle too many roles. C. INCORRECT: The client is not experiencing role ambiguity because his job duties and his physical limitations are quite clear. D. INCORRECT: The client is not experiencing role strain. That occurs when one feels inadequate for assuming a role.

Clergy

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

Client Care Focus (Additional Frameworks)

Acute asthma vs chronic emphysema Urgent leaking sensation from abdominal wound vs nonurgent pain medication request Unstable potassium level vs stable potassium level

Acute vs Chronic

Acute needs may pose more of a threat Chronic needs usually develop over period of time Attend to alteration in acute phase before they evolve into chronic alteration

Category X:

Adverse effects have been demonstrated on animal and human fetuses based on studies and data from investigational or marketing experience. The use of the medication is contraindicated during pregnancy because the risks outweigh the potential benefits. Estradiol (Estrace), an estrogen replacement, is a Category X medication.

category C

Adverse effects have been demonstrated on animal fetuses, but there are no adequate and well-controlled studies in pregnant women. Or there have not been any studies done in animals or pregnant women. The use of these medications during pregnancy may be warranted based on the potential benefits. Glipizide (Glucotrol), an antidiabetic, is a Category C medication.

Category D

Adverse effects have been demonstrated on human fetuses based on data from investigational or marketing experience, but use of the medication during pregnancy may be warranted based on the potential benefits. Sorafenib (Nexavar), an antineoplastic, is a Category D medication.

Client Care Focus (Safety & Risk Reduction)

Assess for external factors: complete risk assessment, integrate interventions, assistive devices Assess for internal factors: ABC combined with safety and risk reduction

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

B. Autonomy In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy.

5. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B. The nurse *moistens* a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is *delayed* 1 hr because the provider receives an emergency call. D. The nurse *turns* to speak to someone who enters through the door behind the nurse.

4. A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.

labs for kidney/ renal disease

BUN, creatinine, GRF, Rennin, EPO

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. *A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client.*

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

C. Justice Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources.

2. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

Social Worker

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

Survival Potential

Chance client has for survival during mass casualty event Appropriate use of resources to save greatest number of lives Different from civilian triage system in emergency departmets

Emergent

Class I - Life threatening injuries Immediate treatment = chance for survival Highest priority

Urgent

Class II - serious and extensive injuries Do not pose immediate threat to life Potential for survival even with delayed treatment

Nonurgent

Class III - less serious and less extensive injuries Do not pose a threat to life No threat to life even with delayed treatment

Expectant

Class IV - injuries are not compatible with life Potential for survival does not exist, even with treatment Scarce resources reserved for Classes I, II, III

Sources of Safety Issues

Client Nurse Provider Medical equipment and environment Home environment Community

DAR (focus charting)

D-ata A-ction R-esponse

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

D. Beneficence Beneficence is taking positive actions to help others. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

D. Nonmaleficence Nonmaleficence is the avoidance of harm or injury. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

3. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. The flap farthest from the body Unless the nurse pulls *the top flap [the one furthest from her body]* away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.

UTI causes

E. coli, young and old women at risk; uncircumcised men (smegma); frequent sexual intercourse/ unprotected/ multiple partners; poor hygiene; HAI; med/surg related

infiltration

Edema, pain, coolness at site, May or may not have a blood return. treatment: elevate the extremity, active range of motion, warm or cold compress

Supervising

Process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team

swine flu

H1N1; person to person transmission; touching infected surfaces; nose/throat culture; vaccine

avian flu

H5N1; bird to human trough droppings, saliva, blood; stayed in Asia

Client Care Focus (Maslow's)

Higher levels may compete with lower levels (depends on client situation) Maslow's Hierarchy provides a framework Consider all client factors before determining order

the correct order for performing abdominal assessment techniques is:

Inspect, Auscultate, Percuss, Palpate

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

Inspect, Palpate, Percuss, Auscultate

Right task

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

Physical Therapist

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

Occupational therapist

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

Provider

Job: assess, diagnose, and treat cllient for disease and/or injury; includes MDs, DOs, APNs, and PAs Refer to when: ex- client experiences change in vital signs

Registered dietitian

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

Speech therapist

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

Respiratory therapist

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

Lab tech

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

Rad Tech

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

5. Self-Actualization

Personal growth Fulfilling own potential Maslow's belief: very few individuals reach this level

Least Restrictive/Least Invasive

Priority goes to interventions that are least restrictive and least invasive to a client Make sure it won't put the client at risk for harm or injury

Additional Priority Setting Frameworks

Priority goes to: Acute over chronic alterations in health Urgent over nonurgent needs Unstable over stable clients

Least Invasive

Reduce number of organisms introduced into body to reduce hospital acquired infections Reduce client infections to reduce need for antibiotics

Critical thinking incorporates: R___, L___, and I___.

Reflection Language Intuition

SOAPIE

S-ubjective O-bjective A-ssessment (inc nursing diagnosis) P-lan I-ntervention E-valuation

six QSEN competencies

Safety, Patient centered care, evidence based practice, informatics, quality improvement, teamwork and collaboration.

Client Care Focus (Summary)

Select framework most applicable to the client situation Also consider: use of a second framework to help support first framework Maslow's Hierarchy ABCs

4. Self-Esteem

Self respect Personal worth Social recognition

treatment for PAD

Statins- help metabolize cholesterol; Crestor, Lipitor- muscle pain, leg pain, cramping, diarrhea

When is a problem an ethical dilemma?

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

category B

There is no evidence of risk to animal fetus based on studies but there are no adequate and well-controlled studies in pregnant women. Or there is evidence of risk to animal fetus, but controlled studies in pregnant women show no evidence of risk to the fetus. Esomeprazole magnesium (Nexium), an antiulcer, is a Category B medication.

category A

There is no evidence of risk to fetus during pregnancy based on adequate and well‑controlled studies. Ferrous sulfate (Feosol), an iron supplement, is a Category A medication.

What infections require *contact* precautions?

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

What *SKIN* infections require *contact* precautions?

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

What infections require *droplet* precautions?

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

What infections require *airborne* precautions?

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

Private plans

Traditional insurance reimburses for services on a fee for service basis. Private plans include: MCOs, PPOs, EPOs, and Long term care insurance

Risk Reduction

Types of Risk: external- risks in client's environment; internal- lab values and VS outside their normal Use Maslow's Hierachy or ABC to determine greatest risk Risk posing immediate threat usually becomes highest priority

Unstable vs Stable

Unstable clients have needs that pose threat to client's survival Life-threatening needs often involve ABCs Client at risk for becoming unstable are higher priority than clients who are stable

Urgent vs Nonurgent

Urgent needs pose more threat to client Needs become urgent when related to an intervention needed within a specified time When caring for a group of clients, attend to the client with the most urgent need first

3-Point Gait

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

consent

a signed form required for all routine treatment, hazardous procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language clients

postural (orthostatic) hypotension is a BP that falls when

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

Problem-orientated medical records consist of:

a database, problem list, care plan, and progress notes; examples include SOAPIE, PIE, and DAR

atrophy

a decrease in muscle size due to disuse

flexion

a decrease of the angle

allocating scares resources

a key issue in discussions about access to care

What is flexion?

a movement that *decreases* the angle

What is extension?

a movement that *increases* the angle

pulse oximetry is

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

thrills are:

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

body image affecting hygiene

a person's subjective concept of his/her body appearance

catheter embolus

a piece of catheter breaks off & travels in the vein until it lodges.Treatment: place the tourniquet high on the extremity to limit venous flow, prepare for removal under x- ray, save the catheter after removal to determine the cause.

external emergency readiness includes:

a plan for participation in community-wide emergencies and disasters

equipment should only be used by the nurse after:

a safety inspection and instruction

Narrative documentation records information as

a sequence of events

professional nursing code of ethics

a set of guiding principles that all members of a profession accept; helps professional groups settle questions about practice or behavior; includes responsibility, accountability, and confidentiality

Diabetic diet

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

occipital lymph node located

base of skull

absence of breath sounds should:

be noted

justice

being fair

bradycardia is

below expected range or slower than 60 bpm

What is plantar flexion?

bending the foot and toes downward

left sided failure

blood backing up into lungs; shortness of breath; impaired gas exchange; hypertrophied left ventricle wall; coughing up blood; orthopnea; exertional dyspnea; cyanosis of extremities; paroxymal nocturnal dyspnea

hematocrit

blood blood viscosity

hematuria

blood in urine; not a good sign

older children and adolescents have varying BP based on

body size (larger children have a higher BP)

stage 2 ulcer

broken skin; partial thickness; blister epidermis and dermis; can ooze

exophthalmos

bulging eyes

phlebitis, thrombophlebitis

burning, pain, increased skin temp, erythema, red line up the arm. Treatment:elevate the extremity, apply warm compresses 3-4 times, restart on the another site.

urinary incontinence

can be temporary; affects everyone especially elderly

functional incontinence

can't make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule

roles of nurse

caregiver, advocate, educator, communicator, manager, autonomy and accountability

peripheral artery disease

caused by atherosclerosis; usually lower extremities; deprives lower extremities of oxygen; cramps and muscle pain with activity

quality of life

central to discussions about futile care, cancer therapy, physician assisted suicide, DNR

brown pigmentation of skin

changes with venous insufficiency

pruritis

chemical, allergic, physical agent; drugs, food, sweat-act on nerve fibers, releases histamine and affects itch receptors; insect bites, scabies, medication (opioid) , systemic effect

myocardial ischemia

chest pain, aching, associated with activity, pain leaves when patient rests

ROM head: hyperextention

chin up

lab work for atherosclerosis

cholesterol; LDL/HDL, homocystine; C-Reactive protein

loose stool

chunks of stool

need for nurse to teach client

clarify info given by doc or other health care providers; has to be complete, accurate, and relevant; should be based on patient's needs and learning ability

stage 2 PAD

claudication; muscle pain/ cramping

Mechanical soft diet

clear and full liquids + diced or ground foods

Pureed diet

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

Full liquid diet

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

What is the bowel prep for a colonoscopy?

clear liquids only and a bowel cleanser

slough

dead tissue; yellowish, brownish; makes wound unstageable; has to be debritied

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

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

purpose of teaching

gaining new knowledge, change attitudes, adopt new behaviors, preform new skills,

arteriosclerosis

hardening of arteries

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

damaged tissue is replaced by scar tissue

prevention education for risk of motor vehicle/injury in adolescents

ensure teen has completed driver's ed -set rules on # of people in car, seat belt use, and to call for ride home if driver is impaired -reinforce teaching on proper use of protective equipment used in sports -be alert to signs of depression -teach about hazards and safety precautions of firearms -teach to check water depth before diving

stage 3 ulcer

epidermis, dermis, and subQ tissue; oozing, signs of infection; full thickness loss

Breathing

essential for oxygen exchange: respiratory rate with expected reference range, adequate ventilatory effort client might need: artificial ventilation, negative pressure gradient in pleural cavity, chest tube might re-establish negative pressure

Proteins

essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance

Vitamins

essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight

social patterns affecting hygiene

ethnic, social, and family influences on hygiene patterns

The use of current knowledge from research and other credible sources as which to base clinical judgement and client care

evidence based practice.

scoliosis

exaggerated lateral curvature

Malpractice (professional negligence)

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

Breach of confidentiality

example: a nurse releases the medical diagnosis of a client to a member of the press

Defamation of character

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

Negligence

example: a nurse who fails to implement safety measures for a client who has been identified as at risk for falls

False imprisonment

example: a person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility)

Battery

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

Assault

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

polyuria

excessive urine; sign of diabetes or hormone issue

affective learning

expression of feelings and acceptance of attitude, opinion, values

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

factors that influence nutrition include: -GI alterations -difficulty getting to and from supermarket to shop for food -low income -impaired mobility -depression or dementia -social isolation (preparing meals for 1 and eating alone) -meds that alter taste or appetite -prescribed diets that are unappealing -incontinence that may cause a person to limit fluid intake -constipation -metabolic rates decline so caloric intake should decline and be pf good nutritional value -nutritional recommendations include: increasing intake of vit D, B6 and calcium; increasing fluid intake to minimize dehydration and prevent constipation; take low-dose multivitamin along with mineral supplementation; follow provider;s recommendation for sodium intake

Evaluation:

goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient

Justice

fair treatment in matters related to physical and psychosocial care and use of resources

Justice

fairness in care delivery and use of resources

narcolepsy

falling asleep at inappropriate times

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

fibrocystic breast disease: tender cysts often more prominent during menstration

auscultation of the lungs (abnormal or adventitious sound): crackles or rales

fine to coarse popping heard as air passes through fluid or re-expands collapsed small airways

What is dorsiflexion?

flexing the foot and toes upward

decorticate rigidity

flexion and internal rotation of upper extremity joints and legs

psych facilities

focus on clients with emotional / behavioral problems

nursing centers

focus on health promotion/ health education, disease prevention, chronic disease management, support for self-care and caregivers

Preventive health care

focuses on educating and equipping clients to reduce and control risk factors of disease. Examples include immunizations, stress management programs, and seat belt use

feminine ethics

focuses on the inequality between people

Implementing:

following through with plan that was developed for the patient

When should seizure precautions be implemented?

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

Medicaid

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

fist percussion is used to assess:

for tenderness over the kidneys, liver, and gallbladder

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

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

UTI s/s

frequency/ urgency; burning pain when voiding; hematuria; fever; chills; nausea; vomiting; pyelonenephritis; malaise

Latrogenic HAI

from a procedure in a hospital

Exogenous HAI

from microorganisms outside the individual ( Salmonella)

What is role strain?

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

stage 4 ulcer

full thickness loss; can see organs/ bones; very painful

Resident rights

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

timing/relevance

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

sleep apnea

lack of airflow through mouth/nose >10sec during sleep; airway collapses, blocking airflow to lungs

bariatrics-

lap band reduction; gastric bypass

toxicity

lead to liver damage

___ is an intentional gain of new information and represents a change in behavior

learning

auscultatory sites for the heart: apical/mitral

left midclavicular line at the fifth ICS

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

legal

Living will

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

standards of care

legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care

source of laws

legal guidelines that come from statutory, regulatory, and common law

Informed consent

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

Pain threshold

level of stimulus needed to produce the perception of pain

causes of atherosclerosis

lifestyle; HTN; smoking; diabetes; genetic

diarrhea

liquid stool; associated with disorders affecting digestion, absorption, and secretion in GI tract

auscultation of the lungs (expected sound): bronchial

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

right sided failure

lower extremity edema; dependent edema; HTN; daily weights; increased peripheral venous pressure; distended jugular veins; cyanosis of extremities; asites, GI distress

Carbohydrates

main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey

gastric bypass

malabsorption surgery; can cause dehydration and electrolyte problems; overeating can cause dumping syndrome-food deposits into small intestines too quickly

new philosophy of health care

manage health; wellness and prevention

old philosophy of health care

manage illness; disease management

JCAHO's ethical standards

mandate that health care institutions provide multidisciplinary ethics committees or similar structures to write guidelines and policies, provides education, counselling, and support for staff on ethical issues

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

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

physical condition in hygiene

may lack physical energy / dexterity to preform self-care

Hospital's ethics committee

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

insomnia

more than 45 min to fall asleep/ trouble staying asleep

___ influences how much and how quickly a person learns

motivation

health beliefs and motivation

motivation is the key factor in hygiene

ROM head: flexion

movement chin to chest

abduction

movement of extremity away from midline

adduction

movement of extremity toward midline

dorsiflexion

movement toward the dorsum (or top of wrist or foot)

plantar flexion

movement toward the plantar surface (or bottom of the foot)

decerebrate rigidity

neck and elbow extension, with wrists and fingers flexed

stage 4 PAD

necrosis/ gangrene; loss of oxygen to toes > toes fall off/ need to be removed

eschar

necrotic/black; surgically removed

parasomnias

night terrors, sleep walking/talking/eating/driving, bed wetting

Low sodium diet

no added salt or 1 to 2 g of sodium

Low cholesterol diet

no more than 300 mg/day of dietary cholesterol

hypotension is classified with a reading below

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

kidney/ renal disease

not enough RBCs; anemia; metabolizes calcium and Vitamin D; ADL intolerance; risk for hyper/hypotension, anemia, soft bones, and fractures; caused by diabetes; patient has to out out at least 30mls per hour

Planning:

nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks)

Diagnosis:

nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis

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

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

reflex incontinence

on urge to go; it just comes out

interpersonal communication

one on one interaction; most frequently used; exchange of idea, problem solving, decision making

Naloxone (Narcan)

opiate antagonist, reverses opioid induced resiratory depression

tympany from percussion is expected to be found:

over a gastric bubble

flat percussion sounds are expected to be found:

over muscles

dull percussion sounds are expected to be found:

over the liver

resonance from percussion is expected to be found:

over the lungs

postauricular lymph node located

over the mastoid

urinalysis

pH; protein; glucose; ketones; blood; specific gravity; WBCs; bacteria

myocardial infarction

pain (sudden onset, substernal, crushing/ tightness/severe; affects back, neck, jaw, arm, shoulder), dyspnea, syncope with low BP, shortness of breath, nausea, vomiting, sweating, increased heart rate, DENIAL

dysuris

pain or burning on urination

Opioids

pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status

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

pasty and brown

oliguria

patient has some form of renal failure; not producing as much urine as regular patient; strict I&Os

cultural variables in hygiene

people from diverse cultures practice different hygiene rituals

When is the incubation stage?

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

When is the prodromal stage?

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

When is the convalescence stage?

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

When is the illness stage?

period when symptoms specific to the infection occur

motivation to learn

person's desire/ willingness to learn

Values

personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior

transpersonal communication

persons spiritual domain; higher power; prayer, meditation, guided reflexion

indirect percussion involves:

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

Beneficence

positive actions to help others

posterior cervical lymph node located

posterior to the sternocleidomastoid muscle

stage 3 PAD

rest pain

impaction

result of unrelieved constipation; leaky drainage

factors that affect med absorption

route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication

clinics

screening to comprehensive care

block and parish nursing

services based on need vs availability of reimbursement; religous involvement

do not ___ linens because do can spread micro-organisms in the air

shake

Telephone orders (TO) or verbal orders (VO)

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

peritoneal dialysis

shunt placed in peritoneum; diasolate poured in peritoneum, about 1hr later diasolate, nitrogenous waste, fluid, electrolytes removed

SOLER

sit close, observe, lean forward, eye contact, relax

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

slow the flow of solution by lowering the container

small group communication

small number of people meet; committees; group meetings

cardiac panel

sodium, LDL/HDL, potassium, ABG, CKMB, triponin, C-Reactive, protein

auscultation of the lungs (expected sound): vesicular

soft, low-pitched, inspiration three times longer than expiration heard over most of the peripheral areas of the lungs

expected findings for the Weber test

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

unstable angina

spontaneous pain

Ethical principles

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

Ethical theory examines:

the different principles, ideas, systems, and philosophies used to make judgments about what is right/wrong and good/bad

environment

the emotional and physical climate in which the communication takes place

diffusion is

the exchange of O2 and CO2 between the alveoli and the RBCs; measure with pulse oximetry

ventilation is

the exchange of O2 and CO2 in the lungs; measure with respiratory rate, rhythm, and depth

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

the floor is considered "grossly" contaminated

perfusion is

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

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

the height of the bag above the rectum

referent

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

communicable disease

the infectious process transmitted from one person to another

hand hygiene

the most important technique used in preventing and controlling transmission of infection

respiratory rate is

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

pulse rate is

the number of times per min the pulse is felt or heard

respiratory rhythm is

the observation of breathing intervals; a regular rhythm with an occasional sigh is expected in adults

Medication absorption

the passage of medication molecules into the blood from the site of administration

receiver

the person to whom the message is aimed at and received by

sender

the person who initiates the message

pacing

the rate of speech can communicate a meaning to the receiver

clarity/bervity

the shortest, simplest communication is usually most effective

Pharmacokinetics

the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions

intonation

the tone of voice can communicate a variety of feelings

interpersonal variables

variables that influence communication between the sender and the receiver

pronation

ventral surface is facing down

eversion

turning body part away from midline

inversion

turning body part toward midline

expected physical development: middle adult (35-65 yrs)

typically experience decreases in: -skin turgor and moisture -subcutaneous fat -melanin in hair (graying) -hair -visual acuity -auditory acuity -sense of taste -skeletal muscle mass -height -calcium/bone density -blood vessel elasticity -respiratory vital capacity -large intestine muscle tone -gastric secretions -estrogen/testosterone -glucose tolerance

What is role ambiguity?

uncertainty about what is expected when assuming a role

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

upon admission & at regular intervals

treating CHF

upright position, high semi fowlers; nitrates- vasodilate coronary arteries and myocardium (dizzy feeling, hypotension); Lasix- diuretic/ urine output; oxygen- when pulse ox. under 95%; ACE inhibitors- Vasotech, Nosinopro (check BP before admin, low potassium or under 60 bpm hold); Digoxin- slows heart rate; apical pulse before admin; nausea and vomiting; toxic if stays in blood for too long; cardiac glycocide- increases contraction, slows heart rate, increases CO and oxygen in blood; decrease fluids to 1500ml; decrease salt to 2000-3000mg; test dig level, ABGs, potassium

causes of urinary incontinence

urethral obstruction, surgical trauma, alterations in sensory/ motor innervation, medication side effects, anxiety

nephrostomy

urinary diversion; bypasses the ureters, bladder, urethra; used in patient with kidney stones, cancer, ureter problem, any GU problem

stress incontinence

usually in women who didn't do kegels during labor

supination

ventral surface is facing up

Flow charts are used to record and show trends in:

vital signs, blood glucose levels, pain level, and other frequently performed assessments

nocturia

voiding at night; early sign of hypertension; pressure on bladder during pregnancy

gastrointestianl effect

vomiting

Measurements for obesity

waist size, BMI, ideal weight for height

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

watery and yellow-brown

denotative/connotative meaning

when communicating, participants must share meanings

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

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

medication interactions

when one med modifies the action of another

Endogenous HAI

when patient's normal flora becomes altered (C.diff)

asymptomatic infection

when the infection does not cause any signs or symptoms, making the diagnosis difficult

symptomatic infection

when the infection has signs and symptoms like fever, cough, etc

Responsibility

willingness to respect obligations and follow through on promises

public communication

with an audience; speaking at conferences; leading class

steregnosis

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

graphesthesia

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

vocabulary

words used to communicate either a spoken or written message

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

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