N2009 - Final Exam (COPIED)
what is bicarbonates major role in the body
"base" component or buffer in acid base balance
which route do you give meds by when using a feeding tube?
"per tube" or PT Example: Prostat 30 ml PT daily If PEG/J, we give feeding in J-port (jejunostomy) and medication into the G-port (gastrostomy)
which 2 tubes are used for long term nutritional support?
- PEG tube (gastrostomy) or PEG with J (jejunostomy)
who is at HIGH risk for sensory overload
-Acute/ chronic ill -ICU -Pediatric ICU -Disturbances in CNS Autism Asperger ADHD/ ADD Addicts Mental health patient Schizophrenia Bipolar PTSD
hypomagnesemia: causes
-NG suction (removing GI contents-lose electrolytes) -alcoholism -burns -insufficient dietary intake
how long can you leave a dobhoff in
1 week
what are the 3 stages of general adaptation syndrome
1- alarm 2- resistance (our body naturally resists) 3- exhaustion
What 2 factors does the evaluation of interventions examine?
1. The appropriateness of the intervention selected- based on the standard of care for a patient's health problem 2. The correct application of the intervention
what 3 questions should you ask yourself when coming up with your learning objectives
1. what is my main problem 2. what do i need to do 3. why is it important
avg. intake
2,000-3,000 ml/day
avg. output
2,000-3000 ml/day
how many grams of sodium per day should a patient get if they are on a mild restriction diet?
2-3 grams/ day
1 liter= ________lbs
2.2
what is the normal range for phosphorus?
2.4-4.4 mg/dl
documentation of an injection SAMPLE
2/15/15 11:00 Rocephin 250 mg injected IM in left vastus lateralis muscle using Z track technique. No complaints of discomfort. Injection tolerated without adverse effects. 3/5/15 18:00 Patient C/O intense pain in left lower back radiating around to lower abdomen and requested pain medication. Orders for Demerol 50 mg IM prn noted. Demerol 50mg IM PRN injected right ventrogluteal. Injection tolerated without adverse event.
aqueous solution require which gauge needle
20-25 gauge *21 & 23g needles are commonly used)
What is diarrhea defined as?
3 or more loose stools/day acute (short duration) or chronic (> 4 weeks)
what is the normal range for potassium
3.5-5.0 mEq/L
what is the onset of regular insulins
30 min.
how much money is spent on treating nosocomial infections in a year?
33 billion dollars **33% of nosocomial infections are preventable
what age is considered "adulthood"?
35-55 years
what are common sizes for syringes
3cc, 5cc, 10cc plastic syringes
End-of-Life palliative nursing care involves: 1. constant assessment for changes in physiologic functioning. 2. Administering large doses of analgesics to keep the patient sedated. 3. Providing as little physical care as possible to prevent disturbing the patient. 4. Encouraging the patient and family members to verbalize their feelings of sadness, loss, and forgiveness.
4
NREM (non rapid eye movement sleep) sleep consists of how many stages
4
how long can use a nasointestinal tube?
4 weeks
how long can you leave a levine in
4 weeks
what is the duration of regular insulin
4-5 hours
arterial end hydrostatic pressure:
40 mmhg
what is a desirable HDL level for men
40-50 mg/dl
how long as ayurveda yoga been around
4000 years
for EBP, use research that is from the past ____ years
5
what happens during stages 1 and 2 of NREM sleep
5% to 50% of sleep, light sleep • During these stages, the person can be aroused with relative ease -quickly startled, easily woken up
what is a normal WBC count?
5,000-10,000 ** if WBC count is too low, no fighters to fight infections
at what angle should the needle be at when administering an intradermal injection
5-15 degrees
how do you document the removal of a urinary catheter
5/21/14 1015: #16 Fr Foley removed without difficulty. 120cc clear amber urine emptied and bag discarded. No specimen obtained. Patient tolerated procedure without complaints. Instructed to notify MA when urge to void so output measurement can be obtained.
when administering a shot in the deltoid for children, how long should the needle be
5/8- 1 1/4 in.
when administering a shot in the vests lateralis, how long should the needle be
5/8- 1 inch
when administering a shot in the deltoid for adults, how long should the needle be
5/8-1 1/2
___________-_________ g of carbs daily to avoid ketosis
50-100 g
what is a desirable HDL level for women
50-60 mg/dl
what age is considered "late adulthood"?
55 years and older
_____% of adults total weight is water
60%
what does the "ABCD" acronym of the components of nutritional assessment stand for?
A = ANTHROPOMETRIC Measurement (height, weight, skin fold measure) B = BIOCHEMICAL Measurement (Lab Values) C = Clinical Examination- how do they look? skin turgor? pink? skin flaky? D = Dietary Analysis
when the body is aligned/ has good posture,
A body had no undue strain on joints, muscles, tendons or ligaments while balanced
what is an ampule
A glass flask containing a single dose of medication.
what is a nursing sensitive patient outcome
A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions
why should the nurse act as a role model?
A nurse's attitudes, biases and prejudices are readily transmitted to patients through actions, manner of speech and avoidance of certain discussions
what is a patient-centered goal?
A patient's highest possible level of wellness and independence in function, based on patient needs, abilities, and resources
what are the fat soluble vitamins?
A, D, E, K
A nurse is caring for older adults in the nursing home. Which of the following age related changes at affect the respiratory functioning of the patients living there? Select all that apply. A. Greater risk of aspiration due to slower gastric motility B. Less fibrous tissue in alveoli C. Less air exchange, more secretions in lungs D. Impaired mobility and inactivity, effects of meds E. Increased elastic recoil of lungs
A. Greater risk of aspiration due to slower gastric motility C. Less air exchange, more secretions in lungs D. Impaired mobility and inactivity, effects of meds Tissue becomes MORE fibrous as we age and elastic recoil of lungs is DECREASED
what what's affect drug action
AGE weight gender cultural and genetic factors pathology timing of administration
Which of the following can affect a pulse ox reading? Skin or room temp Position of the extremity in relation to the heart Skin pigmentation How securely the device is positioned Nail polish Hemoglobin/O2 sat
ALL OF THE ABOVE
when foreign substances are in the body and your body makes antibodies against it
ALLERGIC reaction
what is peristalsis regulated by
ANS
. You have finished with several nursing interventions. To evaluate interventions, you need to examine the: A. appropriateness of the interventions and the correct application of the implementation process. B. nursing diagnoses to ensure that they are not medical diagnoses. C. care planning process for errors in other health care team members' judgments. D. interventions of each nurse to enable the nurse manager to correctly evaluate performance
ANSWER: A
1. Your patient has met the goals set for improvement of ambulatory status. You would now: A. modify the care plan. B. discontinue the care plan. C. create a new nursing diagnosis that states goals have been met. D. reassess the patient's response to care and evaluate the implementation step of the nursing process.
ANSWER: B
The nurse provides minimal support in this type of exercise
Active-Assistive ROM Exercise
what are the different types of loss
Actual loss Perceived loss Physical vs. psychological loss Maturational loss Situational loss Anticipatory loss
What are some risk factors affecting the level of health of patients with inadequate oxygenation
Acute and chronic illnesses (renal or cardiac disorders) Anemia Physical changes (scoliosis) Obesity- shortness of breath, chronic bronchitis, lungs can't fully expand due to all of the subQ fat
when Humans react to threats of danger as if they were physiologic threats
Adaptive Response 1 - Mind-body Interaction
what is the procedure for continuous feedings
Administer with bag/bottle, tubing (administration set), and pump. Tube feeding comes in 8 oz cans or 1 liter bottle. If cans, shake first, empty into bag. Prime tubing. Replace bag, tubing, and 60 ml syringe at least every 24 hours. Wash and reuse if at home.
which layer of skin is an intradermal injection administered into
Administered into dermis just below epidermis.
what is informed consent needed for?
Admission Specialized Diagnostics Treatments Experimental Treatments
what are some risk factors to take into consideration when promoting health literacy?
Advanced age Low income Low educational level Poverty Inability to read Learning disabilities Lack of English proficiency Hearing or visual impairments
what are some considerations to remember when choosing an IM injection site
Age of patient Medication type: Viscosity Onset of action Medication volume: Appropriate for muscle mass?
what is sensory overload influenced by
Age, culture, personality, and lifestyle
what does Reviewing and revising the existing nursing care plan allow you to do
Allows you to validate a patient's nursing diagnoses, review the care plan, and determine whether the nursing interventions remain the most appropriate for the patient's needs
what are some values essential to the professional nurse
Altruism Autonomy Human Dignity Integrity Social Justice
Role of the Patient in Goal/Outcome Setting
Always partner with patients when setting their individualized goals. Mutual goal setting includes the patient and family (when appropriate) in prioritizing the goals of care and developing a plan of action. Act as a patient advocate.
Before collecting any specimen you should:
Always wash your hands Always wear gloves- right before you pick up specimen cup, put on gloves **always send specimen to the lab in biohazard bag
Question any order that is
Ambiguous Contraindicated (medication)
defines the standards of professional nursing practice
American Nurses Association (ANA)
Nurse-initiated interventions are A. determined by state Nurse Practice Acts. B. supervised by the entire health care team. C. made in concert with the plan of care initiated by the physician. D. developed after interventions for the recent medical diagnoses are evaluated.
Answer: A Rationale: individual nurse practice acts determine nurse initiated interventions
what are the unconscious states of arousal
Asleep Stupor Coma Vegetative state
A Catholic college student who does not attend Mass on Sundays may experience which one of the following types of spiritual distress? A. Spiritual pain B. Spiritual anxiety C. Spiritual anger D. Spiritual despair
B. spiritual anxiety Rationale: Spiritual anxiety may occur when a person challenges his or her beliefs and value system. Spiritual distress can be specified as spiritual pain, alienation, anxiety, guilt, anger, loss, or despair.
is LDL good or bad cholesterol
BAD L is for LOUSY
this lets you know you are underweight,normal or obese
BMI
what are some medications that decrease REM sleep?
Barbiturates, amphetamines, and antidepressants
how do you discontinue an NGT
Be sure you have an order to discontinue (DC). DC tube feeding does not mean DC NGT! Sit patient up; explain procedure. Towel under chin and emesis basin handy. Disconnect NGT from connection tubing to empty tubing, then turn off suction. Verify placement, if needed. Flush with 20 ml NS, then 10 ml air to clear NGT. Unpin tube and remove tape from nose. With towel in nondominent hand under nose, steadily, quickly remove NGT and grasp tip with toweled hand. Place in Biohazard receptacle. Document
what is the frequency for checking residual volume?
Before each use and at least Q 4 hours
¬ Competencies include:
Being systematic Using criterion-based evaluation Collaborating Using ongoing assessment data to revise care plan Communicating results
Nurses are positioned to contribute to the benefits and burdens of treatment and the realted harms. nurses spend more time with the patient than any other profession. They are at the forefront of patient care decisions
Benefits vs. harm in care of patients
what are some reasons for bladder surgery
Bladder cancer, spinal cord injuries, malfunction such as chronic infection of the bladder and birth defects such as spina bifida.
what do bloody or tarry stools refer to
Bloody or tarry stools refer to a stool sample that's either dark red or black in color. Bloody or tarry stools can indicate bleeding or other injuries in your gastrointestinal tract. You may also have dark, discolored bowel movements after eating dark-colored foods.
What are some alterations in bowel elimination that can occur?
Bowel Incontinence - inability to control bowel movements Constipation - dry, hard stool; difficult or incomplete passage. Elderly: more prone to constipation due to GI motility. Code Brown
what are some other words to describe stool?
Bowel Movement Stool Feces Each patient may have their own language when using a word to describe the act of elimination Remember: words like Stool can have more than one meaning
High pitch lung sounds mainly heard over the trachea
Bronchial
Normal lung sounds
Bronchovesicular, bronchial and vesicular
what is a GOOD example of a learning objective
By end of second teaching session, Mrs. Avery will state signs and symptoms of low blood sugar with 100% accuracy.
how can you identify a specific problem?
By isolating any defining characteristics not within healthy norms
The nurse is obtaining a history of the client's hearing loss. Which of the following is the most appropriate statement by the nurse during the assessment? A. "How long have you been deaf?" B. "You don't seem to be able to pay attention to me when I am speaking. " C. "How does your hearing loss compare to a year ago?" D. "Do you also have vision problems?"
C
for an intermittent catheter, which kind of technique is recommended?
CLEAN
NPH insulins ALWAYS what color in the vial
CLOUDY
SV x HR
CO
for the first 24 hours of injury, should you apply heat or cold
COLD
what machine helps with sleep apnea and what does it do
CPAP holds the airway open
what effects does immobility have on the body
Cardiovascular System Respiratory System Musculoskeletal System Atrophy: Decreased muscle size, tone and strength Decreased joint mobility and flexibility: Limited endurance Contractures
what are you responsible for as a student nurse
Careful preparation for clinical Notifying your instructor if you are unprepared to carry out duties Being familiar with facility policy Carrying personal liability insurance Responsible for your own acts Negligence in patient injury Clinical Site may be liable for you. You are considered an employee
what is the medical criteria for death?
Cessation of breathing No response to deep painful stimuli Lack of reflexes (gag, corneal reflex) & spontaneous movement
when does a nursing care plan change
Changes as the patient's problems and status change
how does stress affect family
Changes in family structure & roles Anger and feelings of helplessness & guilt Loss of control over normal routines Concern for financial stability
what are some characteristics of a great leader
Charismatic Dynamic Enthusiastic High energy Poised Confident Self-directed
what must you do before pronouncing someone dead
Check Respirations, HR, BP for one minute Recheck in 5 minutes Document time exact time death was pronounced!
what are some things you MUST report?
Child abuse Rape Suspected impairment by healthcare workers North Carolina mandatory reporting state (BIG trouble if found out) **Know your state laws and state practice act
what are some signs and symptoms of caregiver burden
Chronic fatigue Guilt Sleep problems Increased incidence of stress-related illness
collect sample for a routine urinalysis by having the patient void into:
Clean collection container 1st morning is best for U/A No stool or toilet paper in specimen Note if female is menstruating at time of collection- lets the lab know why blood is in the urine
how should you prepare injections from a vial
Clean stopper with alcohol wipe prior to each use. -Before withdrawing medication, inject same amt of air as the med you are withdrawing in the vial to equalize pressure
what are normal characteristic of stool?
Color- brown, diet can cause variations of this color Odor- varies, diet can effect Blood in stool creates a unique odor Consistency- soft, semisolid and formed
the nurses role when caring for the patient and family during the dying process is to
Communication Listen Be willing to discuss patient's fears and doubts openly Nonjudgmental
when do you reassess a patient?
Continuous process with each patient interaction
what does an interdisciplinary care plan include
Contributions from all disciplines involved in patient care -everyone is writing on the same form
Lung sounds that sound like velcro
Crackles
What are the adventitious lung sounds
Crackles, wheezes, rhonchi
what should nurses notes include?
Current nature of problem Intervention Patient's response or toleration When appropriate, future priorities of care Should demonstrate continuity of care Avoid incriminatory statements Time/Date action carried out Provider calls and when action was taken Noncompliance or patient and steps taken to help patient be compliant and if successful.
what are some physical factors affecting nutritional intake in older adults
Decreased number of taste buds Dental problems GERD Decreased gastric secretions Slowed peristalsis Food intolerances Health status Physical disability Medications
Nurse can be a______,_________, or___________ in a malpractice litigation
Defendant Fact Witness Expert Witness
what are the conscious states of arousal
Delirium Dementia Confusion Normal consciousness Somnolence Minimally conscious states Locked in syndrome
which layer of the skin are intramuscular injections administered into
Deliver medication through skin & SQ tissue into the muscle *.Greater blood supply to muscle.
what are the stages of grief
Denial Anger Bargaining Depression Acceptance
What can a nurse do if a patient can't breathe?
Depends on what is specifically going on
when obtaining a sexual history, what are you going to ask the patient?
Description- description of what is going on Onset- when did it start? Past- past history (did you try any OTC meds?) Goals- what do you wish to obtain?
what are the signs of impending death
Difficulty talking or swallowing Nausea, flatus, abdominal distention Incontinence Loss of movement & reflexes Weak, slow, irregular pulse Decrease BP Noisy, irregular, or Cheyne-Stokes respirations Restless/agitation Cooling, mottling, cyanosis in extremities & dependent area
how do you prepare medications fro a single vial
Doctors order: Demerol 50mg 50mg=1ml (Perform in class) Wipe top of vial with alcohol. Calculate dose and inject that amount of air into vial. Draw up correct dose! Recap one hand method.
how do you evaluate the effectiveness of heat/ cold therapy?
Does therapy promote comfort? Is there evidence of healing? Is there a decrease in muscle spasm or inflammation? Document assessment, interventions, and evaluation
when teaching a patient about self-care for vision, what are you going to tell them?
Don't rub eyes Avoid eyestrain Ultraviolet rays (sunbeds??) Protect from foreign bodies (protective eye wear) Caution with aerosol sprays Danger signals Persistent eye redness, pain or discomfort, visual disturbances, crossing eyes, growth on or near eyes, discharge, increased tearing, pupil irregularities
who came up with the Quality and Safety Education for nurses (QSEN) initiative?
Dr. Linda Cronenwett
disrupts nocturnal sleep = excessive daytime sleep
ESRD
Which types of people have decreased lung compliance
Emphysema, smokers, copd patients
when the kidneys have completely and permanently shut down
End-stage renal disease (ESRD)
clinical alarm safety guideline
Ensure that alarms on medical equipment are heard and responded to on time.
when mixing 2 medications in one syringe,
Ensure that the 2 drugs are compatible. Incompatible drugs may become cloudy or form a precipitate on syringe. Do NOT mix more than 2 drugs in one syringe. If 2 meds are in a single dose vial and a multi-dose vial, inject air into both and draw up the one from multi-dose vial first so no contamination will occur. When preparing medication from an ampule and a vial, draw up the one from vial first.
what are the 2 alternatives to oral nutrition
Enteral (gut) - tube feedings Parenteral - IV: total parenteral nutrition (TPN) aka hyperalimentation (HAL) *Enteral nutrition aka enteral feedings, gastric feedings or intestinal feedings
what medicines treat restless leg syndrome
Equip Mirapex
how would you "implement" a plan for pain related to lack of vaginal lubrication with sexual avoidance
Establish a trusting nurse-patient relationship: teach body awareness
this is a sedative that can treat insomnia
Eszopiclone(lunesta)
for reconstitution,what doe an example label look like
Example Label: Order: Rocephin 250mg IM X 1 dose. Label reads: Rocephin 500mg. Mix 1.8 mls of sterile water = 2 mls (total in vial). Dose to give: 1 ml injection Mix gently; Do NOT shake.
CONTINUOUS FEEDING EXAMPLE
Example: Begin Nepro feeding at 10 ml/hour and increase by 10 ml increments every 8 hours until reach 60 ml/hour
Factors that increase urinary output:
Excessive intake Diuretics Caffeine, watermelon Endocrine disorder that causes polyuria: diabetes insipidus (not enough ADH) diabetes mellitus (hyperglycemia)
Chest decompression (passive)
Expiration
what is the procedure for NGT insertion
Explain procedure and purpose of NGT. Establish a cueing signal for pausing the procedure if necessary. Prepare: Position the patient: raise HOB 45˚or higher. Place towel across chest, emesis basin handy Open supplies: NGT, lubricant, 60 ml catheter tip syringe Water in cup with straw or ice chips with spoon Stethoscope 1" tape: tear 2 pieces 2-3" long, partially slit to secure tube to nose. 1/4-1/2" to mark desired length on NGT for insertion. Alcohol wipe - may need to clean oil off bridge of nose Choose nostril - examine nostrils for size and deviated septum. Helpful: have patient occlude one nostril, breathe deeply to determine which one is most patent. Measure length of NGT for insertion - from tip of nose to earlobe, to xyphoid process. Mark with small piece of tape. Optional (depending on policy): local anesthesia with viscous or nebulized lidocaine. Lubricate 2-4 inches of tip with water soluble lubricant - KY jelly With head slightly extended, insert tube and advance, parallel to nasal floor til meet resistance - in nasopharynx. Gently push past this resistance Rotating tube slightly while advancing may decrease resistance. If unable to advance past this resistance, attempt other nostril. Once past resistance, advance less than an inch, then pause... before gagging and choking occurs Once past nasopharynx, gag reflex is stimulated - gagging, choking. Instruct/coach patient to flex head forward, offer sips of water or icechips and when they swallow, continue to pass the NGT to the pre-measured piece of tape. Pass initially during a swallow. If trachea is inadvertantly intubated, patient will experience respiratory distress - coughing, dyspnea, unable to talk. If this occurs, pull back til just below nasopharynx and reattempt with head maximally flexed. Tube may coil in mouth instead of going on down esophagus. If suspect, use light to inspect mouth. If this happens, pull tube back and reattempt with swallowing and rotating tube slightly. Once you've passed the tube into the stomach (premeasured tape mark), then need to.... Verify Placement! 5 ways 1. Observe for respiratory distress during and after tube placement - indicates tube is in trachea. May also note air with each exhalation air coming out of end of tube. Observe for respiratory distress 2. Once tube in stomach, use a 60 ml catheter tip syringe to aspirate 5-10 ml of gastric contents and inspect for color. Should be clear to pale yellow. Aspirate and inspect gastric contents 3. Assess pH of gastric aspirate. Normal gastric pH < 5.5 4. Quickly instill 30-40 bolus of air while listening with stethoscope over gastric area. Should hear gurgling - insufflation of air no longer considered reliable by itself but ok to use if pH paper is not available in conjunction with inspection of gastric contents...especially if it's agency policy! 5. Chest x-ray: gold standard although may not be routinely ordered due to cost. Follow agency policy Once you've verified placement, secure NGT by taping to nose. Very important: prevents migration of tube. Take care to avoid NGT pressing against edge of nare to prevent pressure sore. May measure length of tube from nose to end of tube as an additional way to assess for migration and verify placement in the future. Stabilize blue pigtail above level of stomach by pinning to gown or with a piece of tape. Insert anti-reflux valve into air vent (blue tip into pigtail)
what is a condom catheter aka texas catheter
Externally placed condom sheath that attaches to drainage tubing and bag. Choose appropriate size, clean penis, apply skin protectant, roll condom up onto penis to 1-2 inches of base
Preparing mixed insulin Physician order: Humalog R- 6U Humalog N-10U
FIRST: Select appropriate syringe. *Inject air into both vials in equal amounts to the amount you draw out! Always draw up regular insulin first! No air bubbles!
documentation Must be:
Factual Accurate Complete Timely
what are some types of stress encountered by a nursing school nurse
Fear of failure Anxiety about classroom/clinical Demands of program Balance work/study/family/friends Financial
Essentials Collection: collecting a midstream urine sample how should females and males collect their urine samples
Female: clean from front to back with cleansing wipe Male: clean end of penis with cleansing wipe in circular motion, moving from the middle to the outside Patient starts to urinate, and then collects urine in a sterile container midstream, removes container and finishes urinating in the toilet
Hat are abnormal lung sounds caused by
Fluid in the lungs and decreased oxygenation
how often should you flush a fecal management system?
Flush every shift
what can indwelling catheters also be called
Foley or Retention Catheters.
Frequency for checking residual? Before each ___________ and at least every ____ hours
Frequency for checking residual? Before each USE and at least every FOUR hours
when taking care of a confused patient, you should
Frequent face to face Speak calmly, simply and directly to the patient Orient and reorient - but not to point of making angry Orientation triggers- calendar, newspaper, TV, radio, watches Simple explinations Reminiscence and discussion
absorption of electrolytes and water
GI tract
what is calcium regulated by
GI tract, kidneys, phosphorus levels, parathyroid hormone (secretes PTH to increase calcium level in blood, pulls it from bones), calcitonin (takes calcium from blood and puts it back into the bone)
what can continued stress lead to?
GI ulcers, hypertension, cardiac issues, psoriasis can exacerbate during a stressful time
is HDL good or bad cholesterol?
GOOD
this is involved in the INHIBITION of sleep
Gamma-aminobutyric (GABA)
requires that disclosure or requests regarding health info be limited to the minimum necessary
HIPPA
you should not take st johns wort if you have
HTN or immunosuppressive therapy
what is the primary purpose of communication in documentation
Help healthcare providers from different disciplines (who interact with the patient at different times) communicate with each other!
what does a student care plan help you do
Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation
this test is mostly used for initial diabetes screenings- looks back 3-6 months, better than fasting blood sugar
Hgb A1C
Hyperperfusion can lead to
Hypertension
when should you check placement of an NGT
Immediately after NGT placement; CXR if ordered
Patient presents: Cyanosis Purses lip breathing Sitting hunched forward (Tripod)- uses accessory muscles Reports SOB, nausea Ankle edema x 1 week- peripheral edema Related factors are: Smokes 1 Pack per day Works with asbestos in auto factory Had cold x 7 days What is the big problem and what should you teach this patient?
Impaired gas exchange Teach pt. To quit smoking
When is the only time an artery carries unoxygenated blood
In the heart
how long is the urethra in a female
In women, it is 1 ½" to 2 ½" long
types of medication errors
Inappropriate prescribing of the drug Extra, omitted, or wrong doses Administration of drug to wrong patient Administration of drug by wrong route or rate Failure to give medication within prescribed time Incorrect preparation of a drug Improper technique when administering drug Giving a drug that has deteriorated
what are the components of a nursing health history?
Includes client's name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care
A nurse is teaching a patient with congested lungs how to keep secretions thin and more easily coughed up and expectorated. What would be one self care method to teach?
Increase oral intake of fluids to 2-3 quarts per day
How do you preform a physical assessment for oxygenation
Inspection LOC Demeanor- relaxed or restless/ anxious? Skin, mucous membranes, general circulation Chest appearance- structure/ shape (expanding normally or just on one side?) Palpate chest extremities (temp/color, masses, edema) and capillary refill Auscultation of lung and heart sounds
Chest expansion (active)
Inspiration
how do you collect a sputum specimen
Instruct patient to rinse mouth before coughing to remove oral contaminants Breathe deeply in and out 2-4 times , then give low, deep coughs to expectorate sputum. Collect sputum in appropriate collection container that has been labeled. Deliver sputum to lab within 30 minutes of collection.
What can happen if the hemoglobin level is critically high
Intravascular smudging CVA-stroke Other organ damage O2 saturation
what are some common stressors of the aged
Invasive or health - related tests or exams Surgical procedures Diagnosis of chronic illness- (if someone tells you you have alzheimers- devastating diagnoses) Declining physical and/or mental capabilities Retirement Loss of spouse and/or significant others Increased social isolation- (lose significant other, have to live alone) Chronic pain Alcohol abuse Loss of independence in living arrangements, driving, and ADLs (cannot drive anymore- life changes as they know it)
when sterile gloving:
It is essential to avoid touching nonsterile items once sterile gloves are applied; the hand maybe interlock to avoid accidental contamination. (Must keep Hands above waist level). Any break in the glove or touching the glove to a non-sterile surfaces requires immediate removal and application of new gloves.
evidence based practice from the national clearing house says what about hand washing TEST QUESTION******
It is strongly recommended that all health care providers that come in contact with patients wash their hands after gloves are removed
what are the major electrolytes in the ICF
K+ PO4- Mg++
-Risk of obesity with decreasing sleep compared to those with 7 to 9 hours sleep -23% - 6 hours -50% - 5 hours -73% - < 4 hours
KNOW
Every nurse should have malpractice insurance whether your institution carries it or not.
KNOW
when executing provider orders, what should you do?
Know who can write orders in your state Know your agency's policies Verbal and telephone orders should be limited Repeat back verbal and telephone orders for clarification VO = verbal order TO = telephone order ****Telephone and verbal orders should be limited to emergencies or when there are no alternatives (night shift without computerized order entry)
Web site pg 718; teaching tips pg 715 (box), holistic care box pg 717 LOOK AT
LOOK AT
what are some external factors affecting movement
Lack of time Insufficient financial resources Air Pollution Unsafe neighborhoods Lack of support and reinforcement
which medications affect hearing?
Lasix Gentamycin Vancomycin
the national student nurses association code of ethics includes which values
Leadership and Autonomy Quality Education Advocacy Professionalism Care Diversity
Ability of your lungs to expand/ contract
Lung compliance
how do you apply advocacy in the nursing process?
Make sure your loyalty to the employer or colleagues does not compromise the primary commitment to the patient Give priority to the good of the individual patient not society Evaluate the competing claims of the patient's autonomy Advocacy is linked to the belief that making choices about health is a fundamental human right that promotes the individual's dignity and well-being.
why might a patient be on a high iron diet
Manage anemias, malabsorption syndrome
You are teaching a patient how to safely use supplemental o2 in the home. What should you teach them
Measured in liters Room air= 21% FIO2 +1 liter= 24% (0.24) +2 liter= 28% (0.28) +3 liter= 32% (0.32) +4 liter= 36% (0.36) Can be humidified HIGHER CONCENTRATIONS USUALLY GO IN VENTURI MASK, THEN NONBREATHER Reference table- 38-5 p. 1428
what are some foods high in iron
Meats, egg yolks, shellfish, whole wheat products, leafy vegetables, nuts, dried fruits, legumes
how does exercise effect metabolic processes
Metabolism is increase. Body temperature regulation is increased
hypercalcemia: symptoms
N/V, constipation, bone pain, renal calculi (kidney stones), confusion
hypermagnesemia: symptoms
N/V, muscle weakness, lethargy, respiratory depression, decreased BP
NEED TO KNOW DIFFERENCE OF PATIENTS AT RISK FOR LOW RISK OF FALLS, MEIUM RISK OF FALLS AND HIGH RISK OF FALLS
NEED TO KNOW
snoring occurs ONLY in
NON-REM sleep
all of these are involved in the excitation of sleep
Norepinephrine Acetylcholine Dopamine Serotonin Histamine
what kind of standardized interventions are available in the form of clinical guidelines or protocols, preprinted (standing) orders, and Nursing Interventions Classification (NIC) interventions
Nurse- and health care provider-initiated standardized interventions
an example of justice
Nurses are moved to areas of greatest need when shortages occur on the floors. No floor is left without staff, and another floor that had five staff will give up two to go help the floor that had no staff.
What is hemoglobin
O2 carrying capacity
how many drugs can you mix in 1 syringe?
ONLY 2
3 things to know about reflection in action
Once you deliver an intervention, you continuously examine results by gathering subjective and objective data from the patient, family, and health care team members. At the same time you review knowledge regarding a patient's current condition, the treatment, and the resources available for recovery. By reflecting on previous experiences caring for similar patients, you are in a better position to know how to evaluate your patient.
where can subcutaneous injections be administered
Outer aspect of upper arm Abdomen Anterior thigh Upper back Upper ventral or dorso-gluteal area
family members might display which types of coping and defense mechanisms?
Overly protective Deny seriousness of the illness Blame health care providers
When you take oxygenated blood throughout all tissues in the body
Perfusion
what are the mechanisms of homeostasis
Physiologic homeostasis Autonomic nervous system Parasympathetic Sympathetic Endocrine system Pituitary Adrenals Thyroid **Reacting constantly to internal changes to maintain homeostasis and health
what is the role of nurse manager
Planning Organizing Directing Controlling Staffing Direct others Help others find their own gifts & talents
What is the best way to improve air flow?
Positioning
- defines skills and competencies
QSEN *both QSEN and ANA set standards that nurses are expected to preform regardless of role, patient population, or specialty
what are the steps for modifying a care plan
Reassessment Redefining diagnoses Goals and expected outcomes Interventions
Adequate perfusion=
Regular BP
Nurses are part of all of these and have tremendous opportunity to make a difference
Relationships between clinicians and patients Professional integrity of clinicians Cost effectiveness Culture and religious beliefs Abuse of power by clinicians
what are some reasons for catheterization
Relieve urinary retention. Obtain a sterile urine specimen. Empty the bladder before, during, or after surgery or diagnostic tests. Monitoring critically ill patients
why might a patient be on a restricted protein diet
Renal insufficiency, hepatic coma, cirrhosis
Blood flow to kidneys
Renal perfusion
what are the delegation rights?
Right Task Right Circumstances Right Person Right Direction / Communication Right Supervision Delegation of Nursing Tasks Coordination of Patient Care
when administering a rectal suppository, what position should your patient be in?
SIMS
what is an example of a physical response to stress
SOB and muscle tension
OTC for depression symptoms
ST john's wort
BP=
SV x HR x SVR
how do you select the appropriate insulin syringe?
Select the smallest syringe that will fit appropriate unit dose when possible!
What are relative, objective and appropriate evaluation indicators of self-management?
Self-efficacy, health behavior or attitude, health status, health service use, quality of life and psychological indicators
what is a potassium sparing diuretic
Spironolactone (Aldactone)
what are the 5 stages of the sleep cycle
Stage 1- interim between consciousness and sleep ( move to stage 2 after 5-15 min) stage 2- heart rate slows, brain does less complicated tasks (after another 15 minutes, move into non REM sleep, the delta stage) stage 3- body makes repairs stage 4- body temperature and BP decreases ( move into REM sleep approximately 90 minutes after first feeling sleepy) stage 5 (REM)- increase in eye movement, HR, breathing, BP and temperature
What effect can a critically low hemoglobin level have on the body
Strain on the cardiopulmonary system Angina MI Congestive heart failure (CHF) Cerebrovascular accident (CVA)-stroke
burnout is characterized by which types of behaviors
Supernurse Withdrawal with only minimal work done Drugs Alcohol Leaving profession
which diseases are transmitted by airborne transmission
TB SARS (adult respiratory infection, serious) chickenpox
which areas of the body are most commonly affected by muscle strain
The lower back and cervical spine
summary for advocacy-know
The patient is priority The nurse is the main advocate for the patient The nurse helps the patient maintain dignity and well-being. Often in nursing, ethical situations occur where the nurse and/or client needs guidance for resolution. Many facilities have ethics committees as an additional resource. Advocacy supports decision-making but it does not involve making the decision for the patient.
What often changes during an acute illness?
The patient's clinical condition
what is sputum?
The respiratory secretion expectorated by coughing or clearing the throat
The amount of air you move in and out in one breath
Tidal volume
what are the responsibilities of a nurse educator
To advise and supervise their students, collaborate with students to identify individual learning needs within the clinical setting, and facilitate the educational process
what is the purpose of a specimen (nun) hat
To assess and measure urine
What is the intent of evaluation?
To determine if the known problems have remained the same, improved, worsened or otherwise changed
what are the organs of the immune system?(all of the organs available to fight infection)
Tonsils Bronchial-associated lymphoid tissue Skin-associated lymphoid tissue Spleen Gut-associated lymphoid tissue Genital -associated lymphoid tissue Thymus gland Lymph nodes Bone marrow
things to know about feverfew
Tx : migraines S/E: mouth ulcers, N/V/D, nervousness, insomnia *warning * - can cause severe bleeding ! Do not take with : coumadin, aspirin, NSAIDS Not with pregnancy
what information is on the label of the vial for a powdered medication
Type of diluent Amount needed for total dose of medication Mix gently without shaking vial
has guidelines for geriatric nursing
University of Iowa (Heartford center)
what can you collect a specimen of
Urine Stool Sputum Wound
can you overdose on fat soluble vitamins?
YES
does catheter removal require a doctors order
YES
how long can a person go without food
a week
which subcutaneous site allows for the fastest absorption
abdomen
the protection and support of another's rights
advocacy
traditional medical care
allopathy
when giving an intradermal injection, is the bevel always up or down
always up
what holds an indwelling catheter in place
an inflated balloon
Includes all activities to prevent or break the chain of infection
aseptic technique
which foods can affect the odor of urine?
asparagus and spinach
my way is the only way"
autocratic
this has statistically shown to increase patient care but many nurses will not do it
bedside reporting
hypocalcemia: treatment
calcium P.O. supplements or IV calcium
-sugars and starches -organic compounds composed of carbon, hydrogen, etc
carbs
for incontinent patients,
check every 2 hours to see if voided
The order of priorities changes as a patient's _________________ changes.
condition
vaginal medicines can either be
cream or a suppository
Determines the presence of abnormal cells that may indicate a malignant condition
cytology
The position in which the person sits on the edge of the bed with their feet dangling off the side of the bed. -give them a minute to get in position, gets blood flowing *make sure they have gripping socks on
dangling
what are some abnormal colors of urine
dark, concentrated "tea colored", hematuria (blood in urine - pink, red, rusty) in varying degrees: "pink lemonade", Hawaiian punch", "tomato juice". Urinary anesthetic Pyridium (phenazopyridine) causes orange/red urine Vitamin B complex - green, bright yellow
challenges you to be more observant when assessing skin color changes
darker skin
a patient is admitted to the hospital with shortness of breath. As the nurse assesses the patient, the nurse is using the process of:
data collection
on which day of the menstruation cycle are females most fertile?
day 14
not telling the patient the whole truth or lying to the patient to make them feel better
deception
does hypothyroidism decrease or increase NREM sleep
decrease
find ways to work together-activities and decisions are shared
democratic
when recording I&o..
document on worksheet in room, write down oral intake immediately. empty foley and drains at end of shift or earlier if necessary
A legal record that is permanent and retrievable for future purposes. Formal, written record of a patient's care and progress
documentation
Immunostimulant, tx - cold, flu, bladder infections Anti-inflammatory
echinacea
more likely with NREM sleep, depressed with REM sleep
epilepsy seizures
what sexual dysfunction occurs in men?
erectile dysfunction (impotence)- sometimes it is a physical problem, sometimes it is psychological. can be caused by medicines, such as blood pressure meds
just wanting to be a nurse does not give us some natural ability to always do the ethically right thing. It must be cultivated and comes with experience.
ethical agency
two or more clear moral principles apply but support mutually inconsistent courses of act
ethical dilemmas
cultural beliefs can differ by
ethnic customs, religion, dietary customs and interpersonal customs
Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.
false imprisonment
Glucose: Less than 100 mg/dl Hgb A1C Non-diabetic 2-5% Diabetic Control 2.5-6% High Average 6.1-7.5% Diabetic Uncontrolled > 8%
fasting blood sugar
what are some factors that decrease metabolic rate
fasting, sleep, decreased glucose levels
-insoluable in water and blood -saturated and unsaturated
fats
pure food and drug act of 1906
federal legal responsibilities
if its a PEG/J, which port do you give feedings in and which one do you give medications in?
feeding= J port meds= g port
Hypoalbuminemia causes
fluid shift into interstitial space, edema
this type of documentation makes clients needs/ problems the focus of care in the progress notes. includes clients condition, nursing diagnosis, S&S, or a significant client event or change in status.
focus charting
what is an intradermal injection used for
for allergy and TB testing
what is chlorides major role
gastric and pancreatic digestive enzymes
increase during REM sleep - Peptic ulcers wake at night with pain; GERD
gastric secretions
Body's general response to stress
general adaptation syndrome (GAS)
remember, you must be respectful and conform to the generation of the patient when you are taking care of them
generation gap
when communicating with the HEARING IMPAIRED, you must:
get attention face patient when talking sign language or paper and pencil check hearing aides
why might a 24 hour urine sample be done?
gives better indication of protein in the body than blood test
which subcutaneous sites have the slowest absorption
gluteal and thighs
establishes interventions for specific healthcare problems or conditions
guideline
-special bond with parents and grandparents -respect is given according to age and sex -perceive illness as a punishment from God -believe in folk healing
hispanic
anytime a HYPERvolemic state exists in the vascular system-----> _________ and __________
hypertension and tachycardia
greater concentration of solute (more concentrated) than normal blood plasma EX: 3% saline
hypertonic, hyperosmolar
what are 2 responses to infections
immune response- antibodies released inflammatory response- vascular (histamines released)
what is the nursing diagnoses for a patient with Poor oral hygiene, ill-fitting dentures, or oral surgery
impaired dentition
those with wounds are at risk for
impaired skin integrity and infection
what is the nursing diagnoses for a patient with Chronic neurological disorder such as MS, ALS. Muscle dysfunction such as stroke, dementia, or Parkinson's
impaired swallowing
how quickly can pressure sores occur
in as little as 1-2 hours
where is the primary support when using crutches
in hands **2-3 fingers width between the top of crutch/ axilla
does worry and anxiety slow or increase peristalsis
increase
what effect does exercise have on the cardiovascular system
increases heart rate, stroke volume, and contractile strength of myocardium to meet the demand of oxygen
which age groups have increased nutritional needs
infancy adolescence pregnancy lactation
a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations
inhibited grief
water in fluids, solid foods
input
Flushing a tubing or canal with solution
irrigation
a concept intended to promote fair and equitable treatment of individuals within populations.defined as the fairness of distribution of resources.
justice
selectively retain and excrete fluids & electrolytes. also have important role in acid base balance
kidneys
everybody does their own thing- non directed leadership, no control
laissez faire
what happens during the inflammatory phase of wound healing and how long does it last
lasts 4-6 days -WBC move into wound- leukocytes- invest debris and stay in wound until completely healed macrophages- also invest debris, cause formation of new blood vessels (release growth factors) - generalized body response s/s of inflammatory phase: pain, redness, heat, swelling
Acquisition of knowledge, behavior, or skill through experience, practice, study, or instruction that results in a change in behavior for the learner.
learning
Female, age 81, with dementia and weight loss. Her nurse reports that she has the characteristics of malnutrition. What results would support this interpretation?
low hemoglobin
a form of necessary loss and includes all normally expected life changes across the life span
maturational loss
what is an expected outcome
measurable change that must be achieved to reach a goal **Many times, several must be met to meet a single goal
what are sleep disorders associated with
medical or psychiatric disorders
this can affect sleeping
medication
what else can we usefeering tubes for other than enteral nutrition?
medication administration
what is the 1st time a woman has her period called?
menarche
if bicarbonate is low --->
metabolic acidosis
normal urine= 1.005-1.030 >1.030=
more concentrated
what can crutches cause if they aren't the correct length for the patient
nerve damage
what are magnesiums major roles in the body
neuromuscular function, cardiac conduction, metabolism of carbohydrates and proteins
what are some major roles of potassium
neuromuscular transmission, important role in cardiac conduction
sclera=
not sensitive
hypocalcemia: symptoms
numbness, tingling of fingers, feet and around mouth; muscle cramps---> tetany, seizures
leep is less sound • May sleep less • Insomnia, environmental factors or medical condition may interrupt sleep • Stage 4 sleep may be decreased or absent • REM sleep is shortened
older adults
this age group is able to relax easily
older adults
urine, feces, insensible water loss (sweat and exhalation)
output
when the drug works the best
peak
through the skin
percutaneous
stressors can be__ or________
positive or negative
increased number of chronically ill and older people Increasing role of government and industry in health care Rising cost of health care Changing patterns of health care delivery
process of change in management
Moving air in and out of the lungs
pulmonary ventilation
hyponatremia: symptoms
r/t swelling of cells, in brain, cerebral edema--> confusion, seizures
your skin pigmentation, body stature, facial features, and hair texture define you by your
race
what is REM sleep?
rapid eye movement sleep -this is the dreaming state, can recall dreams
the gathering of ADDITIONAL information to ensure the plan of care is still appropriate, NOT in the evaluation of care or response to an intervention
reassessing the patient
what is an example of a complete protein
red meat
what are some benefits of fish oil
reduces inflammation cancer prevention reduces alzheimers risk improved joint pain lifts depression gut health improved ADHD thickens hair glowing skin heart health
• Cannotliestill,irresistibleurgetomovelegs • Unpleasantcreeping,crawling,ortingling sensation in the legs • Usuallyincalf,butcanbeanywherefrom ankle to thigh • Usuallyoccureveningandnight • URGE
restless leg syndrome
hypermagnesemia: treatment
restrict Mg++ in diet
hypercalcemia: treatment
restrict dietary calcium, increase fluid intake to prevent renal calculi
hypernatremia: treatment
restrict sodium in diet and administer IV fluids (not saline), D5W- 5% dextrose
known to exist in plants, animals, and humans
rhythmic biological clock
for bolus feeding, when should you record I&O volumes on worksheet?
right after you administer
Healthy prostate Improves urine flow Anti-inflammatory S/E: mild nausea HTN, headache Watch for bloody urine False - PSA negative
saw palmetto
Enacted by a legislative body
statutory law
the application of mechanical laws to the human body specifically affect what
structure, function and position of the body
_____________should recognize the level of risk and seek help promptly
students
interactions can be __________ or ________
synergistic or antagonistic
what are some common STI's and why do we need to educate the public?
syphilis, trichinous, HIV, hepatitis, herpes etc. Louisiana is #1 for gonorrhea
what should you do if you get called out of the patients room but have medications?
take them with you! NEVER leave medication unattended
what should you teach the patient to do if they have trouble swallowing
teach to bend head forward to make food go down esophagus instead of trachea
a patient complains of pain and says he hasn't turned. the pain the patient is enduring is from a surgical site and the patient is lying with their arms by their side, their face looks unhappy, and they rate their pain at a 7/10. what would we as the nurse INFER?
that the pain is keeping him from repositioning himself
•fire, earth, metal, water, and wood correspond to organs and tissues and explain how the body works
the 5 elements of traditional chinese medicine
the RAS sends messages to
the hypothalamus and medulla
who issued a report in 2003 calling for health professional education programs to include evidence based care among 5 core competencies
the institute of medicine
if the outcomes are met what else is met?
the overall goals for the patient are also met
The ANA defines delegation as:
the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome Assignment: the downward or lateral transfer of the responsibility and accountability of one individual to another
what does intersex mean?
their sexual anatomy does not fit the typical definition as male and female
what does clinical judgement require a nurse to do?
to use or modify standard approaches, sometimes improvise new ones
for continent patients, let them use
toilet, bedpan, or urinal ** when using toilet-use specimen collection device under toilet seat when emptying bedpan-use calibrated measuring container
when you take a medicine for a long time, so you must increase the dose for it to have the desired effect (ex: sleeping pills and pain pills)
tolerance
what are some useful conversation skills?
tone of voice knowledgeable flexibility clear and concise truthful open mind
substance abuse is a _________ disorder
treatable
what are nursing interventions?
treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes
What should you look for when assessing evaluative measures?
trends
how does hyperthyroidism affect sleep
trouble falling asleep
what is insulin measured in?
units!
someone or something that is not in keeping with the standards expected in a specific position so acting outside of set expectations (Code of Ethics)
unprofessional behavior
grief that continues beyond what is considered a reasonable period of time; may affect the person's ability to function
unresolved grief
vegetable fats are what type of fats
unsaturated fats
for malnutrition, if you increase low serum albumin, calcium goes ________
up
forms of communication:
verbal (words, including spoken and written) nonverbal eye contact facial expressions (gestures, posture, gait) body language (nurses must develop own language skills to assist in reciprocal responses)
cornea=
very sensitive
what is the normal color of urine
yellow, amber
•the concept of two opposing, yet complementary, forces that shape the world and life
yin- yang theory
what are some key components of traditional chinese medicine
yin-yang theory Qi the eight principles the 5 elements
benzodiazepines
• Flurazepam -dalmane • Temazepam- restoril • Diazepam - valium
what percent of the chinese population uses complimentary and alternative therapies
60%
how much sleep do older adults need?
7-9 hours
what is the normal range for calcium
8.6-10.2 mg/dl *some calcium bound to albumin
how much sleep do teenagers need?
9-10 hours
_______% of carb intake is ingested
90
What is a normal pulse ox value
94-100% Below this is abnormal and requires a follow up
_______% of lipids in the diet are triglycerides
95%
what is the normal range of chloride
96-106 mEq/L
what is a desirable LDL level
<100 mg/dL
what is a desirable total cholesterol level
<200 mg/dL
how long does acute insomnia last
<4 weeks
what is the quantity of urinary output in people with anuria
<50 ml/24 hours
how long does chronic insomnia last
>5 to 6 weeks
The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in: A. Damage to the auditory nerve B. Alteration in perception C. Optic irritation D. Loss of taste
A
What does evaluating behavioral change typically rely on?
A patient's self-report, can be more difficult to identify
according to the Uniform Definition of Death Act, what is the formal definition of death
A person who has sustained either 1. irreversible cessation of all functions of circulatory & respiratory failure OR 2. irreversible cessation of all functions of the entire brain, including the brainstem, is dead
the institute of medicine (IOM) responded by publishing a series of reports:
"to err is human: building a safer health system (2000)" "health professions education: A bridge to quality" (2003) "keeping patients safe: transforming the work environment of nurses" (2004) "identifying and preventing medication errors" (2006)
what are some indications for catheter use
(CDC Guidelines) Acute urinary retention Need for accurate I&O measurements Perioperative use GU and GYN surgeries Prolonged duration of surgery Large volume infusions/diuretics during surgery Intraoperative monitoring of urinary output Incontinent patients with open perineal/sacral wounds Prolonged immobilization Improve comfort for end of life care Inappropriate Use of Indwelling Catheters As a substitute for nursing care of an incontinent patient. As a mean of collecting urine sample when patient can void voluntarily. For prolonged post op duration without appropriate indications.
The diagnostic process requires you to use __________ ____________
*!!!!!* critical thinking *Helps to be thorough, comprehensive, and accurate when identifying nursing diagnoses that apply to your patients.
to avoid data collection error:
*!!!!* assess the patient and if unsure of finding, ask faculty member
when administering the eye medication, have the patient look up, pull down the lower lid, provide kleenex, and wear gloves
**
avg intake and output should be within +/- 500 of each other
****
what is included in change-of-shift notes
**Done at beginning of shift -Brief assessment done on initial rounds -Current status of patient
what are the purposes of documentation
**Quality assurance -JCAHO, State Board of Nursing, state surveyors -Comparison to national standards -Admission assessment done and documented by RN -Includes biophysical, psychosocial, environmental, self-care, educational needs -Coordination of care with other disciplines -Ability of family/patient to manage care after discharge
how are you going to teach your patient about sensory
**Teaching is a significant nursing responsibility that helps prepare patients for sensory experiences. Explain procedures Discuss alterations in perception - give pt chance to express fears Reassure patient
what are some safe patient handling techniques for patients with dementia?
- "stand up" "sit down" -simple instructions -face the patient when speaking -call patient by name -use a calm/ reassuring voice
when collecting a sleep history during an assessment, what are some things to find out about
- Identify sleep-wake patterns - Identify effects of patterns on daily function - Use of sleep aids - presence of sleep disturbances and contributing factors - Nature of problem - RelatedS/S - When began, How often occurs - How effects daily living - Severity - Howpatientcoping
what is the anatomy of the esophagus and trachea
- esophagus is behind trachea so best accessed by flexing head forward
what does a stage 4 pressure ulcer look like
- full thickness tissue loss -exposed bone, tender or muscle (directly palpable) - slough or eschar -undermining and tunneling -there is often no pain involved in stage 4 pressure ulcers **ris kof osteomyelitis since bone is exposed
who is at risk for pressure ulcer development
- immobile patients -patients with inadequate nutrition and hydration- dehydrated skin damages easier -patients with excess moisture -patients with altered mental status (confused, unable to turn self) -age- elderly -patients who are over/underweight
what are some examples of wound complications?
- infection -hemorrhage -dehiscence -evisceration -fistula- weakening/ opening where an organ comes through
what are some factors affecting the risk for infection
- integrity of skin and mucous membranes -pH levels of GI and GU tract and skin -number of WBC's -age, sex, race, heredity -immunizations -fatigue/stress- increased fatigue and stress= decreased immune system -medications- steroids lower immune system, chemo -invasive or indwelling devices- breaks in skin, more pathogens enter circulation
what is the nurses role when dealing with skin integrity
- maintain skin integrity -identify risk factors -prevent complications -implement interventions essential to wound care (keep wound dry/ clean, make sure patient is hydrated) -get physical/ emotional support
what are some basic principles of skin integrity? (what is good skin integrity)
- unbroken, healthy skin and mucous membranes- 1st line of defense against microorganisms and infection -resistance to injury of the skin and mucous membranes -adequately nourished and hydrated body cells- if not hydrated, cells don't heal -adequate circulation
what is a "tertiary intention" wound
- wound left open for a couple of days (edemas/ infection) and then closed
which patients are at a high risk for falls?
-65 or older -Unsteady gait -Disoriented -Incontinent -Psychosis or dementia -History of Falls -Sedatives -Antipsychotic medications *Decreased mobility or difficulty walking. Need for assistance when getting out of bed or transferring to and from a chair. History of dizziness or seizures. Impaired vision, hearing. Need for assistive devices, such as a cane, walker, braces, wheelchair, crutches. Weakness or fatigue caused by a disease process. Confusion, disorientation, impaired judgment Medications such as diuretics, laxatives, analgesics (pain medications). Sedatives, diuretics, sleep aids
what should we teach patients about fire safety?
-85% of fires occur in the home -Most fatal home fires are while people are sleeping -Most fatalities are from smoke inhalation, not burns ***Do a patient risk assessment; do they smoke?, smoke in bed?, space heaters, burn candles, smoke detectors in home? 1/3 of fires occur in homes without smoke detectors,, what about fire safety in the hospital setting? Fire drills, are they a waste of time? a nurse needs to be prepared at all times to protect patients from injury
what is hand-off reporting?
-A critical time, when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions -Transferring essential information from one nurse to the next during transitions in care -Ask questions, clarify, and confirm important details about a patient's progress and continuing care needs
when taking care of a patient with reduced vision, you should
-Acknowledge your presence in the room -Identify yourself by name -Speak in normal tone (they aren't deaf) -Explain reason for touching -Keep call light in reach -Orient to sounds and room layout -Walk slightly ahead & allow person to hold onto your arm -Let them know when you leave the room
what are some examples of direct care?
-Activities of daily living (ADLs) Performed in the course of a day, including ambulation, eating, dressing, bathing, and grooming -Instrumental ADLs (IADLs) Skills such as shopping, preparing meals, house cleaning, writing checks, and taking medications. -Physical care techniques The safe and competent administration of nursing procedures -Lifesaving measures -Counseling -Teaching -Controlling for adverse reactions -Preventive measures
what are the 3 active verbs
-Affective Domain:discusses, shares -Psychomotor Domain:repeats, carries out, demonstrates, regulates (demonstration, discovery, printed materials) -Cognitive Domain: identifies, recalls, lists, describes, defines, discusses
which patients are at a low risk for falls
-Alert -Ambulates with a steady gait -Can perform self-care activities -No history of falls -Cognitively intact and cooperative **Patients are evaluated on admission and assigned a Risk Level with regard to falls.
what re some complications of tube feedings?
-Aspiration -Dumping Syndrome - most common with feeding directly into small intestine - diarrhea, distension, abdominal pain, cramping, dizziness, BP. -Excessive residual volume → nausea, vomiting and risk for aspiration - PEG or NG tube can be manually decompressed with 60 ml syringe or attached to suction to empty the stomach.
what do we assess when doing a nursing history?
-Assess for history of falls or accidents. -Note assistive devices. -Be alert to history of drug or alcohol abuse. -Obtain knowledge of family support systems.
what do we assess when completing a physical exam?
-Assess mobility status -Assess ability to communicate -Assess level of awareness or orientation (to time, person or place) -Assess sensory perception -Recognize manifestations of domestic violence or neglect
what are the steps for implementing the teaching-kerning process
-Assessment- looking. what is the problem?t -Diagnosis -Planning -Intervention-implement -Evaluation of Teaching -Evaluation of Learning for eval of teaching and learning "after I taught him this, he was able to show me this" **Compare Nursing Process to Teaching Process
what are the 4 types of terrorism
-Bioterrorism-deliberate spread of pathogenic organisms into a community of cause widespread illness, fear and panic. Ex anthrax, health care personnel must adhere to the standard precautions recommended by the CDC -Chemical terrorism-the deliberate release of a chemical compound that has the potential for harming peoples health, ex, pulmonary agents, bld agents, vesicants and nerve agents, incapacitation agents -Nuclear terrorism-involves the intentional introduction of radioactive materials into the environment for the purpose of causing injury and death -Cyberterrorism- use of high technology to disable or delete critical info or infrastructure data this threatens are national security (on the rise) ***Nurses will have multiple roles in the event of a disaster. Know your facilitys plan
what are some factors that increase risk for nutritional problems
-Body weight 20% > or < normal standards -Recent loss or gain in last 6 months (10%) -Inadequate food intake, food budget, or food preparation facilities -Chewing or swallowing difficulty -Excessive use of alcohol / drugs -Living alone -Use of fad diets -GI Surgery, including gastric bypass and lap-banding -Recent major surgery, illness, or injury -History of diabetes, cancer, liver disease, kidney disease, depression
Nursing Diagnosis: Application to Care Planning what will a nursing diagnosis ensure?
-By learning to make accurate nursing diagnoses, your care plan will help communicate the patient's health care problems to other professionals. -A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.
WBC reflects body's response to infection.
-Client's risk for infection increases as WBC decreases. -Immature neutrophils are called bands. -"Left shift", increased number of bands possible indication of infection. -Remember low WBC indicates neutropenia, could be worse than elevated KNOW
what are the "special super bugs"
-Clostridium dificile "C Dif" or "C dificile" -Main symptom is profuse, watery diarrhea -Patients are very ill and may die -Alcohol gels do not work against this organism !! -Diligent hand washing with chlorhexidene gluconate will kill it (RN, June, 2007). -MRSA -used to not be a problem -caused by overuse of antibiotics -caused by not finishing dose, not completely killing org= org becomes resistant -Carbapenem-Resistant Enterobacteriaceae (CRE)-in bloodstream=systemic infection *****patients who are hospitalized for long periods time are more likely to get CRE and other super bugs -VRE/VISA/VRSA (totally resistant) **Acinetobacter baumannii -"Iraquibacter" -Resistant to all commercially available antibiotics -Originates in soil of Iraq, Afghanistan -Acquired in ERs, ORs, ICUs of combat support hospitals -Hand hygiene, thoroughly clean all surfaces touched by patients
what are the 2 stages of assessment?
-Collection and verification of data -Analysis of data (Assessment involves collecting information from the patient and from secondary sources (e.g., family members), along with interpreting and validating the information to form a complete database.)
what are some less restrictive alternatives to restraints?
-Comfort measures-make sure they don't have any pain, don't need to go the rest room -Alter environment- turn the heat up -Exercise / ambulate / up in chair -Diversion-cards, bring to nurses station -Frequent observation -Family / sitter -Distractions (TV, music) -Cover exposed lines or tubes
what are 3 basic dimensions in end of life care that vary culturally
-Communication of "bad news" -Locus of decision making -Attitudes toward advance directives and EOL care
what is the purpose of patient care records
-Communication with other healthcare professionals (Record of diagnostic and therapeutic orders, Care planning) -Quality of care reviewing (make sure everything flows) -Legal and historical documentation (the chart is the LEGAL document, everything is important that you tell the patient) -Reimbursement (caregivers must follow a certain protocol to be reimbursed) -Research
what are assessment notes
-Complete head to toe assessment -Narrative, flow chart, charting by exception
what are some guidelines to use to prevent health-care associated infections?
-Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. -Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals. -Implement evidence-based practices to prevent central line-associated bloodstream infections. -Implement evidence-based practices for preventing surgical site infections. -Use proven guidelines to prevent UTIs caused by catheters
what are some other factors affecting sensory stimulation (besides developmental and older adult)?
-Culture How much sensory stimulation is normal? -Personality & Lifestyle -Stress & Illness -Medications ****Lasix - hearing Gentamycin - hearing Vancomycin - hearing Vision - Wellbutrin Taste- captopril, an ACE inhibitor diltiazem, a calcium channel blocker Enalapril, an ACE inhibitor Glipizide allopurinol Colchicine Smell- Flonase® (GlaxoSmithKline) fluticasone propionate Nasal Spray Imitrex® (GlaxoSmithKline) sumatriptan
what are some sources of diagnostic errors
-Data collection- you didn't ask the right questions, you misunderstood the patient, missing info -Interpretation and analysis of data -Clustering -Diagnostic statement
which types of deaths MUST be reported to the coroner
-Death by homicide, suicide, accident or other violent deaths -Sudden death not caused by readily recognizable disease -Death under suspicious circumstances -Death of person who will be cremated or otherwise disposed of that further examination can not be done -Death of inmates who are not hospitalized -Death related to employment (accident/disease) -Death related to contagious disease or other conditions that constitute a threat to public health -Additional reportable deaths which have been added by most states: -Death after recent transfer from another facility -Death where there is inadequate clinical information on admission or at the time of death -Death within 24 hours of admission -Unattended death -Death in emergency room -Death during or shortly after
what are the death rituals of hispanics
-Death is considered a family affair -Family members feel obligated to visit frequently -A family member must always be with the dying patient
what is sensory deprivation
-Decreased sensory input **Monotonous, unpatterned, or meaningless
what effect does cold therapy have on the body
-Decreases inflammation, swelling by reducing local release of pain chemicals. -Causes vasoconstriction which reduces edema. ¬-slows transmission of pain impulse in nociception. -Cold is nonpainful stimuli that closes the gate to pain - Gate Control Theory of Pain
hand hygiene non-compliance happens because
-Dispensers or sinks are placed in inappropriate locations -Lack of accountability -Failure to stress the importance of hand hygiene to staff -education regarding hand hygiene is insufficient -Hands are full with equipment or supplies -Belief that hand hygiene not needed when gloves are worn -inattentiveness distracts health care workers
what are some potential breaches in patient confidentiality? (HIPPA- everything about a patient is confidential!!)
-Displaying information on a public screen -Sending confidential e-mail messages via public networks -Sharing printers among units with differing functions -Discarding copies of patient information in trash cans -Holding conversations that can be overheard -Faxing confidential information to unauthorized persons -Sending confidential messages overheard on pagers
Planning care for patients in community-based settings involves what 2 things
-Educating the patient/family about care -Guiding them to assume more of the care over time
Laboratory Data Indicating Infection
-Elevated white blood cell count—normal is 5,000 to 10,000/mm3 -Increase in specific types of white blood cells -Elevated erythrocyte sedimentation rate -Presence of pathogen in urine, blood, sputum, or draining cultures
what are some benefits of electronic charting?
-Entry more accurate because entered immediately after intervention -Can review policies and procedures on line -Great for documenting things such as VS, Admission Assessment, I & O, Client Education, Care Plans
what are some secondary sources for gathering data?
-Family and significant others (obtain patient's agreement first) -Health care team- doctors, nurses, pharmacy -Medical records -Scientific literature
what are signs and symptoms of sensory overload?
-Feels little control -Confusion, agitation -Similar perceptual, cognitive, and emotional response as Sensory Deficit
what must you make sure of before an organ tissue procurement/ autopsy is done
-First make sure that patient's death has been pronounced per agency policy -Follow agency procedures regarding notification of various departments and personnel: -Is an autopsy to be performed? - Coroner need to be notified? -Is there a signed Donor card or decision to donate organs? -Follow any advance directives -Notify appropriate hospital personnel or local procurement organization for assistance with organ donation
what are admission notes
-First nurse's note of arrival of patient -Medical history and physical examination usually completed on a special form
which medications affect smell?
-Flonase® (GlaxoSmithKline) fluticasone propionate Nasal Spray -Imitrex® (GlaxoSmithKline) sumatriptan succinate
what are some developmental factors affecting sensory stimulation
-Growth and development needs -Sensory fxn declines with age or chronic illness **different types sensory stimulation needed for growth and development; newborn needs stimulus to develop neural pathways- soothing, holding, rocking, and changes in position, signing and being talked to, mobiles and bright objects
what are some things that are not considered restraints?
-Handcuffs -Voluntary mechanical support -A positioning or securing device used to temporarily immobilize during medical or surgical procedures **Any device used to immobilize a patient temporarily during a diagnostic procedure, or orthopedic supportive devices such as helmets or age appropriate protective equipment are not considered restraints. Maybe safety interventions, not restraints
what is the most effective way to prevent the spread of infectious diseases
-Handwashing with soap and water -Use of antiseptic hand rubs Surgical hand antisepsis (important for you and your family)
what are some teaching outcomes we aim to achieve
-High-level wellness and related self-care practices -Disease prevention or early detection- colon screening for colon cancer (colonoscopy) -Quick recovery from trauma or illness with minimal or no complications -Enhanced ability to adjust to developmental life changes and acute, chronic, and terminal illness -Family acceptance of lifestyle necessitated by illness or disability
what are the classifications of priorities?
-High—emergent -Intermediate—non-life-threatening -Low—Affect patient's future well being **Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing interventions
what are some factors that contribute to falls in those who are older than 65?
-History of falls -Impaired vision or balance -Altered gait or posture, impaired mobility -Medication regimen-sedatives, diuretics, sleeping pills -Postural hypotension- B/P drops when sitting or standing -Slowed reaction time; weakness, frailty -Confusion or disorientation -Unfamiliar environment- even cognitively intact elders may exhibit some confusion in a strange environment ***MORE FACTORS: greater the fall risk
Consider patients' cultural diversity when selecting a nursing diagnosis. Ask questions such as:
-How has this health problem affected you and your family? -What do you believe will help or fix the problem? -What worries you most about the problem? -Which cultural practices are important to you?
what are some examples of cold therapy
-Ice bag Fill ice bag with crushed ice 2/3 full, press out air, and mold to body part. -Ice gel pack kept in freezer -Chemically activated cold pack -Bag of frozen vegetables from freezer Place thin insulation barrier between ice bag and skin to prevent frostbite injury Apply for limited time intervals according to order i.e. 10 minutes on, 10 minutes off Polar ice machine - used with orthopedic surgery; circulates ice water to pad often placed within layers of dressing i.e. total knee replacement Do not place directly on skin Keep ice chest full of ice/water
what are some safety guidelines to help nurses prevent injury in the healthcare setting? (2016 national patient safety goals)
-Identify patient correctly -Improve staff communication -Use meds safely -Use alarms safely -Prevent infection -Identify patient safely risks -Prevent mistakes in surgery
what re some good ways to prevent complications
-Identify risks to the patient -Adapt interventions to the situation -Evaluate the relative benefit of a treatment vs. the risk -Initiate risk-prevention measures
when Formulating a Nursing Diagnosis Statement,
-Identify the correct diagnostic label with associated defining characteristics or risk factors and a related factor. -A related factor allows you to individualize a nursing diagnosis for a specific patient. -Most settings use a two-part format in labeling health promotion and problem-focused nursing diagnoses. -Some agencies prefer a three-part nursing diagnostic label: 1. problem 2. etiology 3. symptoms
when should you wash your hands with soap and water
-If your hands are visibly soiled -Before you eat -After using the restroom -Requires at least a 20 second scrub -If patient has C-Diff -Where risk for infection is high
what puts a person at risk for sensory overload
-Increased internal stimuli Pain Intrusive tubes/lines -Increased external stimuli Environment Lights, noise, smell, movement -Inability to disregard or selectively ignore some stimuli CNS disturbances, drugs
what are some patient problems when dealing with sexuality?
-Ineffective Sexuality Patterns -Sexual Dysfunction -Pain r/t sexual lack of vaginal lubrication (sexual avoidance) -At risk for sexual dysfunction (diagnosis of diabetes, hypertension,...) -Deficient Knowledge : STI's related to sexual myths Outcomes and Planning
who is at a high risk for sensory deprivation?
-Institutionalized patients -Confined to small living area -Bedrest -Isolation -Impaired ability to receive stimuli-impaired vision, hearing, taste, smell, touch, bandages, body casts, depression, affective disorders -Inability to process stimuli- spinal cord injury, brain damage, confusion, dementia, medications -nursing home patients -AIDS patients
why have firearm injuries become a major concern for healthcare professionals?
-Intentional injuries by firearms are a leading cause of mortality in children. -Having a gun in the home is a huge risk factor
Nursing Assessment for sensory stimulation
-Interview S/S disturbed sensory perceptions Sensory deprivation Sensory overload -At Risk Patients Physiologic Social and environmental Lifestyle ** Focused Assessment Guide** pg. 1641
Journals and Web Sites for complimentary and alternative therapy •
-Journal of Complementary and Alternative Medicine -IMCJ Integrative Medicine: A Clinician's Journal -National Center for Complementary and Alternative Medicines (NCCAM) nccam.nih.gov
When caring for an incontinent patient, make sure to:
-KEEP CLEAN AND DRY -Check patient every two hours. -Place a moisture barrier pad under patient and use absorbent products: pads, briefs/adult diaper Risk for Impaired Skin Integrity Impaired skin integrity related to incontinence can be the result of following conditions: Incontinence can cause IAD, or incontinence associated dermatitis, which is also known as perineal dermatitis and diaper rash. IAD does not necessarily affect only the aged but can have an impact all age groups - from babies to old people. If exposed to urine or feces for prolonged periods of time, the skin can become macerated or moisture-laden thus making it very fragile. Slight friction or pressure can result in skin shear. Even gentle rubbing by bed linens, diapers or cloth can cause the skin to break up. With longer exposure, the skin also comes into contact with bacteria present in these waste products. This can lead to the growth of bacterial infection. And moist and damp skin can also allow a fungal infection to develop with symptoms like fiery red skin, itching, and burning. The new international pressure ulcer treatment guidelines specify the following: "When selecting linens and incontinence pads to place on support surfaces with air-fluidized or low-air-loss features, efforts should be made not to impede airflow, as this will interfere with the thermal performance properties of the surface. Plastic-backed linens, pads, and dressings will block the airflow and may potentially trap heat and moisture against the patient's skin." Also, according to the Agency for Health Care Policy and Research (AHCPR): "When using support surfaces that increase airflow across the patient's skin (such as air-fluidized beds and low-air-loss beds), patients should not wear adult incontinence briefs, because these briefs obstruct airflow to the skin." Moisture in perineal area uncomfortable but also leads to skin breakdown.
when using critical thinking in planning nursing care, nurses need to:
-Know the scientific rationale for the intervention -Possess the necessary psychomotor and interpersonal skills -Be able to function within a setting to use health care resources effectively
what are some guidelines we need to follow in order to use medicine safely?
-Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. -Maintain and communicate accurate patient medication information **take special care of patients who are on blood thinners
what can we do for patients that are at a high risk for falls?
-Locate these patients near nurses' station. -Answer call light as quickly as possible. -Assess them more frequently than usual. -Maintain a toileting schedule or routine. -Encourage family members to stay with this client. How to assess a patient more frequently? Ex. NA on even hours and RN on odd hr for assessing more frequently
how should you care for the body of a person after they have passed away
-Maintain proper body alignment -Raise HOB 30º -Close eyes - be careful applying tape -Replace dentures and close mouth -Remove any external objects causing pressure or injury to the skin (oxygen mask) -Check facility policy regarding removal of IVs, catheters, tubes, etc. -Clean body as needed -Place protective pad under buttocks -Change linen -Allow family time with body -After family has viewed body: -Label body (ID tag to big toe, wrist, morgue bag) -Be sure that arms and hands are loose at side or on abdomen -Place body in shroud or morgue bag -Label any personal belongings and place in separate bag -Make sure head stays elevated; transport to morgue/funeral home
what are the aims of teaching
-Maintaining and promoting health -Preventing illness- teach about preventing illness, decreases costs, decreases hospitalizations -Restoring health -Facilitating coping- teach how to do things like rearrange home to meet needs
what are the death rituals of arab americans
-Many do not openly anticipate death or grieve for a dying person -Prefer to die in hospital -Ritual of washing the body and all orifices after death -Designated head of the family -Usually do not donate organs Usually do not choose a DNR order
which patients are at a moderate risk for falls
-Needs some assistance or supervision performing certain daily activities -May have a chronic physical ailment-ex: arthritis, parkinson (allow these patients to ambulate only with assistance) -Alert and cooperative **Offer assistance frequently
what are effective cleansing agents for your hands
-Non-Antimicrobial agents -Antimicrobial agents (antibacterial) -Alcohol-based hand rubs **always wash hands after removing gloves, regardless on if you touched the patient or not
what is a nursing care plan
-Nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation
what are some interview techniques?
-Observation- eye contact, tone of voice, what do you see?, body language -Open-ended questions- give you the opportunity to learn more -Leading questions- limiting the patient to what they think you want to know. "you don't really want to stay after class, do you?" -Back channeling- "uh huh" "oh okay" "tell me more" -Direct closed-ended questions- yes/ no questions
why is observation of patient behavior important?
-Observations direct you to gather additional objective information to form accurate conclusions about the patient's condition. -An important aspect of observation includes a patient's level of function: the physical, developmental, psychological, and social aspects of everyday living. -Diagnostic and laboratory data -Results provide further explanation of alterations or problems identified during the health history and physical examination -Interpreting and validating assessment data -Ensures collection of complete database Leads to second step of nursing process -Data documentation -Use clear, concise appropriate terminology Becomes baseline for care -Concept mapping -Visual representation that allows you to graphically show the connections among a patient's many health problems- gives holistic view of what's going on with the patient
what are some defining characteristics of imbalanced nutrition (for less than body requirements)
-One who is not NPO reports or has inadequate food intake less than recommended daily allowance with or w/o weight loss -Actual or potential metabolic needs in excess of intake Minor (May Be Present)- Weight 10% to 20% below ideal Triceps skinfold, midarm circumference, and midarm muscle circumference less than 60% standard measurement Muscle weakness and tenderness Mental irritability or confusion Decreased serum albumin Sunken fontanelles in infants
when do you use surgical asepsis?
-Operating room, labor and delivery areas -Certain diagnostic testing areas -Patient bedside -For example, for procedures that involve insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine
what are the phases of an interview
-Orientation and setting an agenda- begin by introducing yourself -Working phase- during the day, during the 12 hour shift, gathering info, asking questions, etc. -Termination- at the end of your shift, as if there is anything you need to pass on to t he other nurse, tell them you are leaving
what are some defining characteristics of an imbalanced diet (more than body requirements)
-Overweight (10% over ideal)or Obese (20% or more over ideal) -Triceps skinfold > 15mm in men and >25 mm in women -Reported undesirable eating patterns -Intake in excess of metabolic requirements -Sedentary activity patterns
what are some Interventions to Prevent Transmission of Infection
-PPE (personal protective equipment such as gowns, gloves, masks, protective eye gear) -Standard Precautions (hand hygiene, PPE, sharps, environment and equipment, linen (Use with EVERY patient, regardless of the situation) ***Hand Hygiene Guidelines from CDC -Hand washing -Alcohol-based hand rub ****Indications for Hand Asepsis: -At the start of the working day -Between patient contacts -After removing gloves -When moving from a contaminated body site to a clean body site -Before eating -After using the rest room
what are some sources of data?
-Patient- BEST SOURCE, give them time to respond -Family and significant others-make sure you have permission to speak with the family -Health care team -Medical records -Other records and the scientific literature Nurse's experience
what is the focus of patient education?
-Preparation for receiving care -Preparation before discharge from health care facility -Documentation of patient education activity
NANDA-I (2014) nursing diagnoses include:
-Problem-focused- the patient's response to what is going on -Risk- what is going to happen to the patient if we don't do something -Health promotion- EX: healthy diets, doing things to prevent the problem, doing something to promote their wellbeing
what are the goals of EOL care
-Provide comfort and supportive care during the dying process -Improve the quality of the patient's remaining life -Help ensure a dignified death -Provide emotional support to the family REVIEW "CORE PRINCIPLES FOR END-OF-LIFE CARE" - P. 1365
how do you manage a patients symptoms of dying when you are a hospice nurse
-Provide warmth -Provide assistance with moving/positioning -Provide assistance with personal hygiene -Encourage patient to do as much as possible for self -Provide emotional support (spend time with the patient) -Recognize the grief pattern and support patient as he/she moves through it -Recognize symptoms of urgency and seek assistance as needed -Supporting the family/caregiver -Introduce yourself -Support family through grief process -Provide honest answers -Reinforce the patient's wishes for EOL care - DNR, Living Will, etc. -Ask family members how they want to participate in patient care -Encourage family/caregiver to take time alone to regroup and to take care of self (nutrition, etc.) -Encourage support group/counseling/social services (preparation for patient's death) -Cultural Diversity at the End of Life
what effect does sensory deprivation have on the RAS
-RAS not able to project normal level of activation to brain - causes Hallucinations
what must you document when you have put restraints on a patient?
-REASON for the restraint as well as LESS RESTRICTIVE MEASURES attempted must be documented. -Must have a DOCTORS ORDER to restrain any patient -Check with your agency's policy regarding using restraints -Inform the family
Who can pronounce death?
-RN with order from physician -MD -NP
what are some good tips for making decisions during implementation
-Review the set of all possible nursing interventions for a patient's problem -Review all possible consequences associated with each possible nursing action -Determine the probability of all possible consequences -Judge the value of the consequence to the patient
when identifying areas of assistance,
-Seek information about a procedure -Collect all necessary equipment -Ask another nurse provide assistance and guidance
how do we create a safe patient environment?
-Side rails up x 2 -Bed in low position- maybe even a mattress on the floor just in case -Bedside table and personal items within reach -Call light within reach -Night light -Wheel chairs and beds in LOCKED position **********Falls are the leading cause of death in people over age 65.*********** *Bed Check Alarm will alert staff to when patient is getting out of bed. *Keep floors clear of equipment and debris.
what re the 3 types of lumens for urinary catheters
-Single Lumen Intermittent -Double Lumen- foley Balloon inflation Urinary drainage -Triple Lumen Irrigation Balloon Urinary Drainage
what are some examples of cognitive behavioral therapy for insomnia (nonpharmocological treatment measures)
-Sleep hygiene measures -Stimulus control -Sleep restriction therapy -Biofeedback -Relaxation techniques
what are some assistive devices/ equipment that can help with safe patient transfer
-Sliding Board and Gait Belt- belt used to ambulate patient when they are weak and need help moving (PT)- stand on their weak side, hold belt back. Contraindications: abdominal/ thoracic surgery **must ALWAYS have doctors orders for a gait belt -Hoyer Lift
what are the death rituals of native americans
-Some avoid contact with the dying; others will want to be present 24 hours a day -Eating, playing games and making jokes in the hospital is appropriate for some tribes -May bring "healer" to attend the spiritual health of the dying -Some wrap the body for burial and do not allow mortuary to prepare the body; others may avoid all contact with body -Organ donation usually not accepts
what are the death rituals of chinese americans
-Some prefer to die in hospital; believe it brings bad luck to die at home -Others believe the spirit will be lost if death occurs in hospital -They do not discuss death even when it is imminent -Organ donation and autopsy are not accepted; believe body should be kept intact
the world health organization has a 3 step ladder for pain control. what were the 3 steps?
-Step 1: Nonopioid (c or s adjuvant drugs) Acetaminophen, Aspirin or another NSAID for mild-moderate pain -Step 2: Opioid for mild-moderate pain and nonopiod drugs (c or w adjuvant) Add codeine or hydrocodone to the NSAID (do not substitute) Drugs are administered in fixed-dose combinations with acetaminophen or Aspirin—this provides additive analgesia; dose-related toxicity might occur with the use of acetaminophen or NSAID -Step 3: Opioid for moderate-to-severe pain c or s nonopioid or adjuvant drugs This step is used when higher doses of opioids are necessary Pain control for persistent cancer-related pain is best accomplished with around-the-clock administration instead of PRN
how is sensory perceived?
-Stimulus -Receptor or sense organ- turn down music or you'll bust your eardrum -Nerve impulse -Brain- concussions, aneurisms, stroke, delirium
what are some physiologic hazards associated with restraints?
-Suffocation from entrapment -Impaired circulation -Altered skin intergrity (pressure ulcers) -Fractures -Altered nutrition and hydration -Incontinence -Aspiration and breathing difficulties -Changes in mental status **Restrained patients are 8 times more likely to die than those who aren't restrained. Patients tied to a chair or bed have been strangled while struggling to get free. Most patients feel demeaned by restraints and may respond with combativeness, anger, or depression. A 29-year-old woman having a severe asthma attack dies after refusing to go to a hospital emergency department for help. Two years earlier, she had been restrained against her wishes and intubated for a severe asthma attack. Afterward, she began having nightmares about the experience and told her family that she'd never go to a hospital again.
what are some things to know about suffocation and choking?
-Suffocation or asphyxiation -Occurs at any age but mostly in children -Suffocation by drowning, choking on a foreign object, or gas/smoke poisoning -Most risk of infants while sleeping
what is the nurses role with death of a patient
-Supporting family -Assessing spirituality -Assessing culture -Assessing coping -Donation of organs -Autopsy?
what are the duties of a hospice care nurse
-Symptom/ pain management- often include pain, nausea, fatigue, constipation or diarrhea -Advance care planning, spiritual care -Family support, including bereavement
how do you treat hypovolemia?
-TREAT THE CAUSE (i.e. N/V/D, endocrine disorder) -administer IV fluids; keep a daily weight log, measure I&O -oral care, offer moisturizer for lips
Nursing Interventions Classification (NIC) KNOW
-The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes. -The NIC model includes three levels—domains, classes, and interventions—for ease of use. -NIC interventions are linked with NANDA International nursing diagnoses.
CULTURAL CONSIDERATIONS- KNOW
-To conduct an accurate and complete assessment, you need to consider a patient's cultural background. -When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patient's uniqueness. -If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion **have an open mind, be respectful, don't make assumptions, don't assume stereotypes
what kinds of preliminary info can a urinalysis detect
-UTI -diabetes -vaginal infection -part of routine screening and diagnostic evaluation in patients and can detect an STD -1st morning is best for U/A
what are some reasons for using a restraint?
-Unable to follow instructions -Lack of awareness of potential harm to self -Disorientation -Confusion -Protection of invasive device: -ET Tube -Catheter -Major Dressing -Central Line -Drainage Tubes -preventing the patient from ambulating when its unsafe to do so,( ie, broken hip patient temporarily incapacitated may try to walk before medically appropriate) *another ex, dementia patient with urinary tract infection, keeps pulling his IV and urinary catheter out
what are the guidelines for documentation?
-Use the 24-hr Cycle Military Clock for Documenting Times -Legible -Black ink -Be brief and concise -No white out or erasures -Correction of mistakes -No blank spaces -Identify late entries: "(present time)Addendum: (time of event)Bedbath given." (make sure date and time are right) -Correct time and date -Use correct grammar and spelling -Chart what happened not opinions -NEVER chart ahead of time -Avoid use of words "appears", "good", "average", "normal" -Do not need to use complete sentences -No need to write the word patient -Chart facts - be objective -Use quantitative terminology -Signature after each entry - chart refusal of medication or treatment -Chart only what YOU have done or observed -Document patient complaints and how the issue was resolved- MUST FOLLOW UP
what are the death rituals of african americans
-Vary with respect for dying at home versus in hospital; may care for dying in home until death is imminent then bring patient to the hospital; some believe it is bad luck to die at home -No rituals associated with care of the body -Cremation is usually not done -Organ donation usually not done, except in the case of immediate family need
what are some factors affecting sensory stimulation for the older adult?
-Vision-cataracts, macular degeneration, glaucoma, diabetic retinopathy -Hearing-presbycusis, conductive hearing loss, sensorineural hearing loss, tinnitus, Meniere's disease -Taste/smell-decline in sensitivity to airborne chemical stimuli, decreased ability to detect foods that are sweet -Peripheral sensation- two-point discriminationand vibratory sense decrease with age, peripheral neuropathy - DM, phantom limb pain
what are some examples of dry heat
-Warm compress in plastic bag or wrapped in moisture barrier -Electric heating pad (prohibited in acute care setting). Apply heating pad on top of or on side of body, not under body -Hot water bottle -Aquathermia pad - Aqua-K pad; circulates warm water through pad. Recommended over electric heating pad. Assure pump reservoir stays filled to fill-line *use DRY HEAT for eye
what are some factors affecting patient learning
-age and developmental level -family support networks -financial resources -cultural influences -language deficits -health literacy level
what are some assessment parameters to be mindful of when dealing with the teaching/ learning process?
-anxiety and depression- won't absurd what your'e teaching -knowledge, attitudes and skills that are needed to be independent -readiness to learn - ability to learn -learning strengths
history of EBP
-arche cochrane, 1972 (cochrane library) -evidence based medicine guyatt et al, 1992 -shift from "intuition" to scientific, clinically relevant search -2003 sicily statement -2009 transdisciplinary model for EBP
what are some key points to effective communication
-be sincere and honest -avoid too much detail and stick tot he basics -ask for questions -be a cheerleader for the patient -use simple vocabulary -listen and do not interrupt -ensure the env. is conductive to learning and free of interruptions -be sensitive to the timing of teaching sessions
what happens during the maturation phase of wound healing and when does it begin
-begins about 3 weeks after injury -continues for months or years -collagen is remodeled -scar develops- scar tissue doesn't sweat or grow hair, may cause decreased mobility over a bony place
which medications affect taste
-captopril, an ACE inhibitor -diltiazem, a calcium channel blocker -Enalapril, an ACE inhibitor -Glipizide -allopurinol -Colchicine
how do you prepare a reconstituted medication from a vial?
-clean stopper with alcohol wipe prior to each use. -Before withdrawing diluent, inject same amount of air in vial as volume to be withdrawn to equalize pressure. -Withdraw diluent -Inject diluent into powder/mix gently -Withdraw correct amount of medication needed
what role does communication play in the nursing process?
-communicate with other health care professionals -gather patient information
what are the 4 purposes of an NGT (indications)
-decompression/suction, lavage - rinsing, gavage -tube feeding -Hydration -med administration
how does one give culturally competent nursing care?
-develop an awareness of your own beliefs -be knowledgeable -know that everyones beliefs differ -dont judge -be open and comfortable with encounters -be responsible for your own cultural competence (learn about the other culture before you take care of the patient)
what are some risk factors for poor nutritional status
-developmental factors -gender -state of health (need more food of nutritional composition when patients have wounds or infections) -alcohol abuse -meds -megadoses of nutrient supplements
what are 2 different ways to apply heat
-dry heat -moist heat
what are some symptoms of hypervolemia
-edema (peripheral and pulmonary) -vital signs( hypertension, tachycardia, dyspnea if pulmonary edema) -urinary output (depends on the renal function) -renal failure (oliguria, anuria specific gravity >1.030, with healthy kidneys, polyuria specific gravity <1.005) -distended neck veins (external jugular) -weight gain (for every liter retained- 2.2 lbs or 1 kg)
what is a "first intention" wound
-edges of wound are well approximated -surgical incision with stitched
Once you identify a patient's nursing diagnoses, what should you do?
-enter them either on the written plan of care or in the electronic health information record (EHR) of the agency. -Computer helps organize data into clusters -Enhances ability to select accurate diagnoses -When initiating an original care plan, place the highest-priority nursing diagnosis first.
-Data Interpretation -It is critical to select the correct diagnostic label for a patient's need. -When comparing patterns, judge whether the grouped signs and symptoms are_____________ and _________
-expected for a patient (e.g., consider current condition, history) and whether they are within the range of healthy responses.
blocks to communication
-failure to perceive the patient as a human being -not listening -inappropriate comments or questions -giving false assurance -gossip and rumors aggressive interpersonal behavior (don't use clichés - "don't worry" "everything is going to be fine")
what are some environmental hazards that we need to be aware of?
-falls -fires -poisoning -suffocation/ choking -firearm injuries
why is EBP important to families?
-families want a treatment that WORKS -EBPs have been put to the test (research proven treatments) -specify diagnoses, special populations (specific to disease) -effective treatment increases adherence -fewer "false starts" -promotes recovery
what will you observe when dealing with a systemic infection
-fever -increased pulse -increased respirations -lethargy -anorexia -tenderness -enlarged lymph nodes *may require lab data
what is the rule of thumb method for ideal body weight
-for adult females: 100 LB for height of 5 feet. + or - 5 feet for each inch over 5 feet for adult males: 106 lb for height of 5 feet. + or - 6 lbs for each additional inch over 5 feet
what does a sated 3 pressure ulcer look like
-full thickness tissue loss -subQ fat may be visible -NO bone, tendon or muscle visible - slough may be present but doesn't obscure depth of tissue loss -undermining and tunneling may be present
what are some agents that cause infection?
-fungus- causes athletes foot -bacteria (gram -/+) -virus- colds, flu -parasite- malaria
what is a concept map used for
-helps you critically think about a patient's diagnoses and how they relate to one another. -Helps organize and link data about a patient's multiple diagnoses in a logical way. -Graphically represents the connections among concepts that relate to a central subject.
what are some characteristics most religions share?
-higher power -scripture -ethical right/ wrong -ideas about what follows death -expectations
when diagnosing wound care, loo for the "actual problem", such as
-impaired tissue integrity -imaired skin integrity- -deficit knowledge about wound care -disturbed body image
why is patient identification important?
-improve Communication -Improve the effectiveness of communication among caregivers. -For verbal or telephone orders or for telephone reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.
what are some causes of hypovolemia
-inadequate intake -endocrine disorder I.e. diabetes mellitus or diabetes insidious -excessive diuretic therapy -excessive sweating -severe burns
what are the 2 types of catheters
-indwelling -intermittent
with EBP...
-information is collected -information is analyzed -patient preferences and values are considered -nursing clinical experiences are considered
what are some complications of total protein nutrition (TPN)
-insertion problems -infection and sepsis -metabolic alterations -fluid electrolyte and acid base imbalances -phlebitis -hyperlipidemia -liver and gallbladder disease
what does a stage 1 pressure ulcer look like
-intact skin -nonblanchable redness -localized area -usually over bony prominence
what re some wound classifications
-intentional or unintentional -open or closed wounds -acute and chronic wounds- diabetic pressure sores -partial thickness, full thickness (muscle/ bone exposed; hair follicles damages) or complex
what is a " secondary intention" wound
-large, open wound -edges not well approximated -takes longer to heal - more scar tissue
what happens during the proliferation phase of wound healing and howling does it last
-lasts several weeks -new tissue is built - granulation tissue- new tissue, highly vascular, breaks easily fibroblasts found in this phase: release growth factors that cause blood vessel formation, also release fibrin, stretches over clot) what are S/S of the proliferation phase: highly vascular, red and bleeds easily
what puts individuals at risk for poor skin integrity
-lifestyle variables- smoking, drug use, homosexuals, multiple sex partners, lots of piercings, working in sun all day -changes in health state -illness-paralyzed= not able to turn= pressure sores -diagnostic measures -therapeutic measures *diabetes causes the skin to not heal properly
what are the 5 categories of complimentary and alternative therapies
-mind-body medicine -energy medicine -manipulative and body based practices -whole/ alternative medical systems -biologically based practices
hyperkalemia: symptoms
-muscle weakness -K+ sparing diuretics, cardiac dysrhythmias (could be life threatening)
what needs to be documented for controlled substances?
-name and amount -date and time given -route -reason and response-must document of the med eased pain/accomplished what it was supposed to do or not
what factors affect contracting infection?
-number of organisms -virulence of organism -condition of immune system
when assessing in the nursing process for wound healing, look at
-nursing history -skin assessment -wound assessment 1-appearance of wound 2-draingae: serous- clear, sanguineus- bloody , serosanguineous- bloody and yellow, purulent- yellow 3- sutures or staples pressure ulcer assessment: 1. risk assessment-brazen scale 2. mobility 3. nutritional status 4. moisture, incontinence 5. existing pressure ulcer appearance *pain assessment
deterrents to EBP
-nursing shortage=overworked -avg. age of nurses is 47 -acuity level of patient -nurses skills in reading and interpreting research -organizational culture that doesn't support change (EBP has only been around of a couple of decades, was around when florence nightingale was alive, but no one noticed it)
what are some interview techniques
-open-ended (allow for a large range of responses) -closed (yes/ no questions) -validating ( "let me make sure i understand what you're saying") -clarifying -reflective (reflect back their words) -sequencing (get things in order) -directing (direct back to an important subject)
what re some psychological effects of wounds and pressure ulcers
-pain -anxiety and fear -activities of daily living -changes in body image
what does a stage 2 pressure ulcer look like
-partial thickness loss -shallow open ulcer -red pink wound bed -shiny or dry shallow ulcer -intact or ruptured blister
what are the components of a drug order?
-patients full name -date and time written -drug name(generic or trade) -dosage, volume, amount, strength -time and frequency of medication (waking hours only, around the clock dosing) -rule of administration (important b/c 1 drug can be administered 5 ways, need to know which way to give it) -signature of the prescriber
what are some important functions of the skin
-protection -temperature regulation -psychosocial -sensation -vitamin D production -immunological -absorption -elimination
what are some symptoms of peripheral edema
-puffiness around the eyes-(periorbital edema) -in hands/feet or the most dependent places of body (dependent edema) -in the liver (hepatomegaly) -spleen (splenomegaly)
what does a suspected deep tissue injury look like
-purple or maroon, localized area -intact skin -blood filled blister -S/S- painful, firm, mushy, boggy, warmer or cooler -more difficult to see on darier-skined patients
**types of evidence research**
-randomized controlled trial -controlled clinical trial -case control studies -cohort studies -meta synthesis (qualitative synthesis)
what will you observe when dealing with a localized infection
-redness -heat -edema (swelling) -pain -loss of function
hypervolemia may result from
-renal failure -heart failure (failing as a pump) -liver failure (hypoalbuminemia) -endocrine disorder ( too much ADH) -excessive fluid intake (p.o. or i.v.)
hypervolemia may result from
-renal failure -heart failure (failing as a pump) liver failure (hypoalbuminemia)
components of EBP
-research evidence -clinical expertise -patient preference -organizational
when handling and disposing of information you MUST
-safeguard any information that is printed from the record or extracted for report purposes -De-identify all patient data -Special considerations for faxing
what is the RAS responsible for?
-sensoristasis (optimal state of arousal) -adaptation (adapted to alarm tone, no longer hear it) -Receives fibers from the sensory pathways via long ascending spinal tracts -Controls sleeping, waking, and attention -A sophisticated filter -Creates blind spots to the junk -Acts like an executive assistant -Allows you to focus on what you value -Allows you to perceive a threat Supports you when you set goals
if the diagnosis = at risk for impaired skin integrity and the outcome= skin integrity not compromised, what are we going to implement?
-skin surveillance -incision site care -wound care -pressure management -pressure ulcer prevention
what are some examples of variables that affect fluid balance ( I&O)
-temp of env. -body temp. -sweating -respiratory rate - vomiting/emesis -diarrhea -impaired fluid regulation:renal, cardiac, endocrine systems
examples of EBP and its effect on nursing care
-the BRAT diet (bananas, rice, applesauce, and toast)-no longer in practice because EBP shows it is no longer the best -catheter associated w/ UTIs -turning patients every 2 hours- we now turn them based off of their individual need coke to clear a peg tube- now we just use saline
what are some types of assessments?
-the patient-centered interview during a nursing health history. **always look for patient cues -a physical examination. -the periodic assessments you make during rounding or administering care. -comprehensive assessment: moves from general to specific -problem oriented assessment: like what you would do in the ER, broken arm, x-rays, straight to the point
why is EBP important to students?
-to provide high quality care supported by evidence -to understand the concepts and process of nursing care -to learn strategies for implementing skills
how do you treat hypervolemia
-treat cause (renal/heart/ liver failure, endocrine disorder) -restrict fluids and sodium -place sign above bed to remind everyone (also communicate how much you have given) -monitor I and O- weigh daily -avoid dry, salty or sweet foods (increase thirst)
what is the nurses role in pressure ulcer prevention
-turn every 2 hours - float heels -encourage nutrition, hydration -education -reduce friction/ shearing -institution policies
what are some factors affecting skin integrity
-unbroken and healthy -resistance -age -subQ tissue- too much fat= obese people do not heal -illness - nutrition- adequate protein, carbs and fats -hydration-dehydrated cells die and cause necrosis -circulation
when would you NOT use the patient to gather your data?
-unconscious patients -confused patients/ dementia -mentally challenged -child
the condition of the restrained patient must be continually assessed, monitored, and re-evaluated: what are some things we need to evaluate?
-vital signs -circulation -hydration needs -elimination needs -level of distress and agitation -mental status -skin integrity -provide for range of motion -nutritional needs **assess every 4 hours for an adult
what states of health can affect skin integrity
-vomiting, dehydration, diarrhea -poor nutrition -medications -disease processes -overall body structure
for the administration of ear drops, you should:
-warm the solution to body temperature -have patient lay on unaffected side, or tilt head to unaffected side. straighten the ear canal by pulling back on the pinna
what 3 forms can reporting be done in
-written -oral -computer based **SBAR is an example of reporting and can be done any of these 3 ways
elderly people have decreased energy requirements but they still need protein. how much protein does an elderly person need? what about for healing?
0.8 g/kg/day 1.2-1.5 g/kg/day for healing (if they won't eat, push food or nutritional shakes)
The husband and daughter of a Hispanic woman dying from pancreatic cancer refuses to consider using hospice care. The nurse should: 1. Clarify their understanding of what hospice care services are. 2. Talk directly to the patient to see if she could change their minds. 3. Ask them how they will care for the patient without hospice. 4. Accept their decision since they are Hispanic and prefer to care for their own.
1
according to engel (1964), what are the 6 stages of grief
1 - shock & disbelief 2- developing awareness 3- restitution 4- resolving the loss 5- idealization 6- outcome
if administering a shot in the ventrogluteal area, how long should the needle be
1 1/2 in
how many nurses are impaired or in recovery from alcohol or drug addiction
1 in 10
how long should a patient wait between puffs when using an MDI?
1 minute
what are the 2 things you always need to check before giving an intermittent aka bolus feeding
1) placement of NGT 2) residual volume in stomach before giving a feeding.
An 80 year old female is receiving palliative care for heart failure. Primary purpose(s) of her receiving palliative care is (are) to (select all that apply) 1. improve her quality of life 2. Assess her coping ability with disease 3. Have time to teach patient and family about disease 4. Focus on reducing the severity of symptoms 5. Provide care that the family is unwilling or unable to give
1,4
according to cabler-ross, what are the 5 stages of grief
1- denial & isolation 2- anger 3- bargaining 4- depression 5- acceptance
what is the onset of NPH insulin
1-3 hours
What are some factors that affect bowel elimination
1. Activity - increased activity increases peristalsis. Effect of exercise? Effect of immobility? 2. Hydration - fluid intake softens stool 3. Diet - fiber provides bulk, enhances regularity 4. Daily patterns, habits - time of day, frequency, positioning, privacy
What are some examples of lifesaving measures?
1. Administering emergency meds 2. CPR 3. Intervening to protect confused/ violent patient 4. Obtaining counsel from crisis center for severely anxious patient
when a medication error has occurred, you should:
1. CHECK THE PATIENT (most important part) 2. notify nurse manager and doctor 3.complete incident report
What are some different types of enemas?
1. Cleansing enemas - large volume (500-1000 ml, hypotonic): tap water, saline, soap suds enema. Enemas till clear Small volume (50-200 ml, hypertonic) Fleets enema 2. Retention enemas - oil retention to soften stool 3. Medicated enemas - Kayexelate (hyperkalemia) Lowering of serum potassium with KAYEXALATE FDA - Caution is advised when KAYEXALATE is administered to patients who cannot tolerate even a small increase in sodium loads (i.e., severe congestive heart failure, severe hypertension, or marked edema). In such instances compensatory restriction of sodium intake from other sources may be indicated.
what are some factors affecting safety?
1. DEVELOPMENTAL CONSIDERATIONS-infants/toddlers have risk related to normal growth and development..... Oral activity, mobility curiosity. Drowning in toilet, mop bucket. Adolescents are more at risk for vehicle accidents and sports injuries, older adults at risk for falls 2. LIFESTYLE -occupation-office worker compared to construction worker. Nurse/other health care professionals, day care workers/teachers, -social behavior- such as smoking, alcohol, motor cycle, etc; -environment-for environment think of home, work and community environments. HOME; stairs, sanitary issues, mold, hazards(rugs), work environment, noise, electrical equipment, contact with blood/body fluids or infectious agents. COMMUNITY; environment; are or high crime, air pollution 3. MOBILITY-assistive devices 4. SENSORY PERCEPTION-vision, hearing 5. KNOWLEDGE- awareness of safety and security precautions 6. ABILITY TO COMMUNICATE- language barriers, ability to read 7. PHYSICAL HEALTH STATE-weakness, medications can increase risk for injury 8. PSYCHOSOCIAL HEALTH STATE-depression, mental illness can decrease good judgement
what are some health conditions that could cause sexual dysfunction?
1. Diabetes Mellitus-can cause ED among men, can cause loss of vaginal lubrication in women 2. Cardiovascular Disease: -Heart Attack -Hypertension- BP meds can cause sexual dysfunction -Disease of Joints/Mobility-painful 3. Spinal Cord Injuries 4. Surgery/Body Image 5. Mediations- narcotics, antidepressants, BP meds
How do you objectively evaluate the degree of success of achieving outcomes of care?
1. Examine the outcome criteria to identify the exact desired patient behavior or response 2. Evaluate a patient's actual behavior or response 3. Compare the established outcome criteria with the actual behavior or response 4. Judge the degree of agreement between outcome criteria and the actual behavior or response 5. If there is no agreement or only partial agreement between the outcome criteria and actual behavior or response, what is or are the barriers and why don't they agree? **The accuracy of any evaluation improves when you are familiar with the behavior, psychological status, and physiological status or have cared for more than one patient with a similar problem. Evaluate each expected outcome in it's place in the sequence of care
what are some High-Risk Errors in Documentation?
1. Falsifying client records- never write anything thats not truthful 2. Failure to record changes in client's condition- if you didn't write it, it didn't happen 3. Failure to document that physician was notified when client's condition changed- document EVERY time, follow up 4. Inadequate admission assessment- it is a baseline for someone else, NEEDS TO BE DETAILED 5. Failure to document completely 6. Failure to follow agency's standards or policies 7. Charting in advance- NEVER chart in advance
how do you apply the nursing process to environmental safety hazards
1. Identify people at risk 2. Recognize unsafe situations 3. Develop individualized plan of care 4. Come up with nsy interventions to protect the patient
what are some formats for Nursing Documentation
1. Initial nursing assessment- VERY important, MAIN ASSESSMENT 2. Kardex and patient care summary- has summary of the patient and assessment used to give report, NOTE ANY CHANGES WITH PATIENT HERE 3. Plan of nursing care- specific to diagnosis 4. Critical collaborative pathways 5. Progress notes- what the physician writes, any changes they're doing 6. Flow sheets- vital signs, input/output for shift, anything you're measuring recorded here 7. Discharge and transfer summary-call report to nurse accepting the patient if the patient is being transferred ANYWHERE 8. healthcare documentation 9. Long-term care documentation- ll aspects documented (USED IN NURSING HOMES)
when withdrawing insulins, 30 u NPH and 10 u regular insulin, how should you prepare the medications
1. Instill 30 units of air into the NPH vial and withdraw the needle. THE NEEDLE SHOULD NOT TOUCH THE INSULIN. 2. Inject 10 units of air into the regular insulin vial and withdraw 10 units of regular insulin. ALWAYS WITHDRAW REGULAR INSULIN FIRST 3. Withdraw NPH insulin
what are the 2 types of feedings
1. Intermittent, bolus feedings - usually just in NGT (not PEG, PEG/J). More closely resembles a pattern of feeding 2. Continuous feedings - all tubes; if PEG with J, give tube feeding in J. May be continuous or during the night only. EX FOR CONTINUOUS: 10 ml/hr---> 8hrs later: 20 ml----> 8 hrs. later: 30 ml **With all tube feedings, raise HOB 30-45˚ to reduce risk of aspiration
what are the 3 types of injections?
1. Intradermal In skin 2.subcutaneous In fat 3.Intramuscular In muscle
What are some pathological factors affecting bowel elimination?
1. Obstruction i.e. cancer tumor - causes change in caliber: narrower, thin or ribbon like. May see blood in stool: bright red - hematochezia; maroon - melena; black, tarry stools. 2. Diarrhea may result from diseases i.e. diverticulitis, ulcerative colitis, Crohn's disease 3. Change in color, consistency may result from gall bladder disease (clay colored, fatty stool), malabsorption syndrome (frothy stools) 4. Diagnostic studies - barium swallowed causes constipation 5. Surgery, anesthesia - can cause temporary stop of peristalsis in small intestine - "paralytic ileus", acts as obstruction Liquid stool (the stool is leaking around the impacted mass of feces and can be mistaken for diarrhea)
what are the phases of a helping relationship?
1. Orientation Phase 2. Working Phase 3. Termination Phase
what are some problems Involving Other Body Systems That May Effect Mobility
1. Oxygenation-immobile- SOB due to inactivity, fatigue, muscle strength 2. Breakdown of protein 3. Fatigue 4. Muscle Aches 5. Pain-in pain, not gonna be active 6. Mental Health 7. Depression-sleep a lot, inactive, may or may not eat a lot 8. Body process slow down 9. Lack of energy and enthusiasm **the way you were raised can affect how active you are
what kind of patients require a sexual history?
1. Patients seeking care for pregnancy, STD, infertility, or contraception 2. Patients experiencing sexual dysfunction 3. Patients whose illness will affect sexual functioning
what are some Critical Developmental Areas
1. Physical maturation and abilities- what age level are they in? 2. Psychosocial development 3. Cognitive capacity 4. Emotional maturity 5. Moral and spiritual development
how do you flush/ irrigate an NGT
1. Place towel under NGT connection and disconnect from connection tubing. Allow suction to empty tubing. 2. If not connected to suction, verify placement before flushing. 3. Use tap water or normal saline (NS) for flushing, according to agency policy. 4. Instill 20-30 ml of flush. Draw back to assess patency, repeat if necessary. Reconnect to suction, if ordered. Record as intake; or aspirate same volume back. DO NOT use air vent to flush. If air vent has gastric contents in it, flush with 20 ml NS then 20 ml air. Air vent should be empty.
what are some ways to promote urinary health
1. Prevent urinary retention or stasis greater risk of infection. More frequent emptying and complete emptying less risk of infection. Plenty of fluids (adequate hydration) leads to risk of infection If suspect urinary retention, have patient void and then assess for post void residual: bladder scan or do in-and-out catheter. >150 ml post-void residual indicates need for indwelling catheter 2. Strengthening muscle tone of pelvic floor/perineal muscles - Kegel exercises Reduce or eliminate incontinence Kegel exercises aka pelvic floor muscle training: contract pelvic floor muscles (same muscles used to stop urinating midstream and to control defecation) for 3, 5 seconds and work up to 10 seconds; relax for same period of time, repeat 10 times. Do several times/day. 3. Prevent Urinary Tract Infections (UTI)
what are the goals of palliative care
1. Provide relief from symptoms including pain 2. Regard dying as a normal process 3. Affirm life and neither hasten nor postpone death 4. Support holistic patient care and enhance quality of life 5. Offer support to patients to live as actively as possible until death 6. Offer support to family during patient's illness and in their own bereavement
what are some nursing interventions for sensory deprivation
1. Singing, reading 2. Visitors 3. Pet therapy 4. Visual stimulation-colorful uniform tops (nurses), fact to face human contact, clocks, calendar, pictures, flowers 5. Auditory stimulation-call patient by name, conversation, reading to patient, TV, radio, IPOD 6. Gustatory and olfactory-oral hygiene, properly fitting dentures, smelling food, flowers and talking about memories associated with them, foods from home stimulation 7. Tactile stimulation-backrub, foot rub, turn and repositioning, passive ROM, hair brushing, hugs, therapeutic touch 8. Cognitive input-orient pt to room/environment, encourage participation in self-care, discuss current events 9. Emotional input-encourage pt to share fears, concerns, perceptions, reassure pt that illusions and misperceptions do occur with sensory deprivation (explain what is going on)
what are some methods of documentation?
1. Source-oriented records 2. Problem-oriented medical records 3. PIE charting 4. Focus charting 5. Charting by exception 6. Case management model 7. Computerized documentation 8. Electronic medical records (EMRs)- an electronic medical record is in ONE facility only, such as a doctors office or clinic, everything within that hospital stay (page 45 in smith and duell clinical nursing skills book)
what is included in the Factors Affecting Spirituality Spiritual Assessment Guide
1. Spiritual pain- unable to accept death of someone close 2. Spiritual alienation- separated from faith community 3. Spiritual anxiety 4. Spiritual guilt 5. Spiritual anger-inability to accept their illness 6. Spiritual loss-cannot find comfort in religion or anything 7. Spiritual despair- feels like no ones else cares-not even God
how do site based licensure requirements define the scope of practice
1. State passes a law known as the "nurse practice act" 2. Regulatory bodies create and implement rules and regulations to protect the publi
when preparing for implementation, what are 5 things you should check?
1. Time management 2.Equipment- make sure environment is arranged to prevent injury 3. Personnel 4. Environment- ensure adequate lighting, reduce distractions while teaching (turn off tv) 5. Patient- ensure the patient's privacy (ask family to leave politely, explain why)
NGT - Levine: single lumen; adults: 16F Risk for aspiration with tube feeding, med administration. Therefore, imperative that we:
1. Verify placement at time of insertion and before each use 2. Check residual volume before each use or at regular intervals. 3. Raise the head of bed (HOB) 30-45˚ when administering tube feeding, water flushes, and medication
what are some steps to the to reduce risk of aspiration
1. Verify placement when indicated 2. Check residual - in stomach for PEG with jejunostomy. 3. Keep HOB elevated 30-45˚ while feeding is in progress and for 1-2 hours after feeding. If need to lower HOB (i.e. bathing, transport), place feeding on hold.
Things to consider when implementing nursing care for a patient:
1. Who is the patient? 2. How does the patient's attitudes, values, and culture affect care? 3. What does illness mean to the patient and family? 4. Which clinical situation requires intervention? 5. How does the patient perceive the care you deliver? 6. How do you show care when intervening?
what are 4 types of nursing diagnoses?
1. actual diagnoses 2. risk diagnoses 3. wellness diagnoses 4. health promotion
what are some systemic factors affecting wound healing
1. age- small children= most prone to wounds on the skin 2. circulation and oxygenation- decreased circ= decreased cell nourishment, decreased healing 3. nutritional status 4. wound conditions 5. health status- smokers= decreased healing 6. immunosuppression- HIV, AIDS, or on immunosuppression drugs= decreased wound healing 7. medication use- corticosteroids= decreased healing
what are the 3 ways to check the patient
1. ask name 2. ask birthdate 3. look at bracelet
what are the 5 steps for the nursing process?
1. assess 2. diagnose 3. plan 4. implement-preform any actions identified in planning 5. evaluate- determine if expected goals/outcomes were achieved
what are the 6 steps for safe patient transfer?
1. assess for clutter 2. explain what you plan to do 3. administer analgesia prior to movement 4. lock wheels of bed, wheelchair, stretcher so they don't move while moving the patient 5. avoid friction of the skin when moving patients 6. know how to operate mechanical devices
how do pressure sores develop
1. blood vessels collapse 2. necrosis occurs 3. ulcer develops ** 2 mechanism contribute to ulcer development 1. external pressure 2. friction and shearing forces- caused by pulling them up in bed instead of picking them up and moving them
which of the major body systems does exercise effect
1. cardiovascular 2. respiratory 3. musculoskeletal 4. metabolic processes 5. gastrointestinal system 6. psychosocial outlook
drug names (4types)
1. chemical- tells exactly what the drug is made of 2.generic-what the drug is 3. official (U.S. pharmacopeia) 4. trade name- who makes it *generic and trade names are often used interchangeably
what is the color of urine affected by
1. concentration of urine 2. pH 3. metabolic activity 4. diet intake (beet) 5. drugs may change urine color
what are some local factors that affect wound healing
1. desiccation- dehydrated cells cause cell death 2. maceration- softening of the skin by moisture 3. necrosis 4. biofilm 5. pressure- disrupts blood supply 6. trauma 7. infection 8. edema- no oxygen in that area, decreases wound healing 9. excessive bleeding ** you WANT the wound to be moist, but not TOO moist
what are 6 factors to consider when selecting interventions
1. desired patient outcomes 2. characteristics of the nursing diagnoses 3. research-based knowledge for the intervention 4. feasibility of the interventions 5. acceptability to the patient 6. nurse's competency
the IOM called for the establishment of center for patient safety but also charged health professions: (2)
1. education to create a national focus to teach and enhance quality and safety 2. identify and learn from errors by establishing a vigorous error reporting system
*****VERY IMPORTANT**** Steps in EBPP (6)
1. form a clinical question 2.convert to searchable format 3.literature search 4.clinical appraisal 5.apply 6.re-evaluate the steps
how do you preform proper hand hygiene using soap and water
1. gather the necessary supplies. Stand in front of the sink. Do not allow your clothing to touch the sink during washing procedure. 2. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may remain in place. 3. Turn on water and adjust the force. Regulate the temperature until water is warm. 4. Wet hands and wrist area. Keep hands lower than elbows to allow water flow toward fingertips. 5. use about 1 tsp. of liquid soap from dispenser or bar soap and lather thoroughly. Cover all areas of hands with the soap product. Rinse soap bar and return to rack. 6. With firm rubbing and circular motions wash the palms and backs of hands, each finger, the areas between fingers, and knuckles, wrists, and forearms. Wash at least 1 inch above area of contamination if hands aren't visibly soiled, wash to 1 inch above the wrist. 7. continue this friction motion for at least 20 seconds 8. using fingernails of the opposite hand or a clean orangewood stick to clean under fingernails. 9. Rinse thoroughly with water flowing toward fingertips. 10. Pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately
what are the 4 phases of wound healing
1. hemostasis 2. inflammatory phase 3. proliferation phase 4. maturation phase
what are 3 types of interventions?
1. nurse-initiated intervention- independent- actions that a nurse initiates 2. health care provider initiated- dependent- require an order from a physician or other healthcare provider 3.collaborative-interdependent- require combined knowledge, skill, and expertise of multiple healthcare professionals- based on medical diagnosis
time devoted to nursing care has 3 components:
1. physical- the physical amount of time consumed and the completion of nursing activities 2. psychological- what nursing care patients experience and how they experience it 3. sociological- the sequencing of orders of events within the daily routines of the practice setting. Delayed and hurried responses convey this interest, timely interaction conveys care and concern
what are the 4 steps of hemostasis
1. primary activated platelets- form a plug 2. secondary-coagulation factors form thrombin (glue)- fibrin mesh holds plug in place 3. regulation-proteins stop thrombin generation 5. fibrinolysis- clot dissolves
5 preparatory activities for implementing a nursing care plan are:
1. reassessing a patient- assures you have selected appropriate interventions 2. reviewing and revising an organized nursing care plan 3. organizing resources and care delivery 4. anticipating and preventing complication 5. implementing nursing interventions
what are 3 important things to do before The Patient-Centered Interview
1. remember to be motivational (used for counciling) 2. remember to use effective communication- the first few minutes in the room sets the tone and how the patient feels about you 3. make sure to prepare for the interview
modification of an existing written nursing care plan includes these 4 steps:
1. revise data in assessment column to reflect the patient's current status 2. date any new data to inform the other members of the healthcare team of the time that the change occurred 3. revise the nursing diagnoses 4. delete nursing diagnoses that are no longer relevant and add and date any new ones
what are the 5 rights of medication administration
1. right patient/client 2. right drug 3. right dose 4. right route 5. right time *right reason *right documentation
before administering medicine through the buccal or sublingual route, you should:
1. rinse mouth out if necessary 2.clean mouth with swab and then administer med so food doesn't get in the way
what re some dangers of catheterization
1. sepsis- bacteria enter the urinary tract during catheter insertion/ after prolonged use 2. trauma- injury to urethra during injection, be gentle, do NOT use force! 3. CAUTI ( Catheter Associated UTI)
when identifying spiritual problems, what 3 things should you identify
1. spirituality (which faith does your patient identify with) 2. patient goals- what is your patients goal? 3. patient outcomes- we as nurses should support the following outcomes: -IDENTIFY spiritual beliefs that meet needs for meaning and purpose, love and relatedness, and forgiveness -DERIVE from these beliefs strength, hope, and comfort when facing the challenge of illness, injury or other life crisis -DEVELOP spiritual practices that nurture communion with inner self, with God/ higher power, and with he world -EXPRESS satisfaction with the compatibility of spiritual beliefs and everyday living
when doing a safety evaluation, which 3 categories should you focus on?
1. the person- look at nursing history and a physical exam 2. the environment 3. specific risk factors
what are the 2 types of tubes to administer enteral feedings
1. tubes passed through the nose or mouth to the stomach or small intestine a. stomach: nasogastric (NGT) or orogastric tube (OGT) - Levine tube b. small intestine (duodenum) - nasointestinal tube - Dobhoff tube (more flexible than levine tube) 2. tubes inserted through the abdominal wall into the GI tract with the assistance of an endoscope: PEG tube - percutaneous endoscopic gastrostomy May have an extra lumen threaded to the jejunum - jejunostomy "PEG with a J" ***Type of tube is based on patient's need for nutritional support - whether short term or long term
5 rights with 3 checks (name them)
1. when removing medications... 2.while preparing medications... 3. while opening unit dose package in patient's room or when replacing the multi-dose container in the drawer or shelf...
what is the normal range for Magnesium
1.5-2.5 mg/dL
Holistic Nursing: 3 Questions to Ask Self???
1.What do you know about the meaning of healing? 2.What do you do each day to facilitate healing in yourself? 3.How can you be an instrument of healing and a nurse healer?
when ealing with a care plan revision, what are the 2 choices you have
1.discontinue the care plan 2. modify the care plan
venous end hydrostatic pressure:
10 mmhg
what percent of the US population is diagnosed with insomnia
10%
what age is considered "preadolescence"?
10-13 years
how much sleep do growing children need
10-14 hours
how many milligrams of sodium per day should a patient get if they are on a moderate restriction diet?
1000-1500 mg/ day
what sizes do insulin syringes come in?
100U or 50U or 30U
for insulin needles, U100=
100U/1ml
how far apart should the legs of the crutches be apart
12 inches
How much blood flows through the arteries in one minute
1200 ml/min
what age is considered "adolescence"
13-19 years
what is the normal range for sodium?
135-135 mEq/L
what is the duration of NPH insulin
14-20 hours
example of documentation of NGT insertion
16F NGT inserted via right nare without difficulty. Placement verified and NGT secured to nose. Connected to low continuous suction. Gastric aspirate appears clear, pale yellow. K Davenport, RN
oil based solutions require what gauge needle
18-25 gauge *21 & 23g needles are commonly used)
KNOW BRADEN SCALE
19-23 = not at risk 15-28 = low risk 13-14 = moderate risk 10-12 = high risk < or = to 9 = very high risk
Renal perfusion is how much of the cardiac output
20-25%
what age is considered "young adulthood"?
20-35 years
the IOM said 90% of all patient-care decisions should be based on evidence by
2020
what is bicarbonates normal range in ABGs
22-26 mEq/L
what are some ways to monitor dietary intake
24 Hour Recall Food Frequency Questionnaire Food Diary / Calorie Count Diet History
Urine collected in a 24 hour period in a collection container
24 hour urine sample
how long are multi dose vials good for
24 hours
how long is a complete circadian rhythm cycle
24 hours
what equipment is needed for administering subcutaneous injections other than insulin?
25-30G needles; 3/8 to 5/8 long Usually less than 1 ml injected Choose needle length based on amount of SQ tissue at site.
how long is a regular menstruation cycle?
28 days **can last anywhere between 21-40 days but isn't common
how long can a person go without water
3-4 days
according to the ___________, Assisting in the suicide and participating in active euthanasia are in violation of the Code for Nurses, the ethical traditions and goals of the profession (of nursing), and its covenant with society. Nurses have an obligation to provide humane, comprehensive, and compassionate care that respects the rights of patients but upholds the standards of the profession in the presence of chronic, debilitating illness and at end-of-life.
ANA
formally reviewed on regular basis. Newest standards include: competencies for establishing professional and caring relationships, using evidence-based interventions and technologies, providing ethical/ holistic care across the lifespan to diverse groups, using community resources and systems ** standards emphasize using a timely plan following patient safety goals
ANA standards
how much of the nasointestinal tube do you insert
Add 8-10 inches to length with traditional way of measuring. Placement of SBFT: insert all but 4 inches of tube (Smith & Duell, 2017)
when caring for a dying patient it is important to know what they would and would not like done. some advanced are planning examples are:
Advanced directives: Physician order for life-sustaining treatment (POLST) Do not resuscitate DNR Allow natural death AND Comfort measures only: Terminal weaning Voluntary cessation of eating and drinking Active & passive euthanasia
does hand sanitizer kill C diff?
Alcohol does not kill c-Diff -soap and water considered more effective at removing C- Diff spores
for a malpractice litigation with the nurse as the defendant, what are the 3 outcomes?
All parties work towards a fair settlement Case goes to a malpractice arbitration panel or The case is brought to court
Tell whether the following statement is true or false. Among adults older than 65, fires are the leading cause of injury fatality. A. True B. False
Answer: B. False Among adults older than 65, falls are the leading cause of injury fatality.
Tell whether the following statement is true or false. Formal prayer should not be used with patients as it may alienate them. A. True B. False
Answer: B. False Formal prayer is appropriate if the patient desires it, but the religious background of the patient should be considered first
Tell whether the following statement is true or false. A side rail is considered a restraint even if the patient asks for it to be raised to assist in getting into and out of bed. • True • False
Answer: B. False Rationale: A side rail is not considered a restraint if the patient requests that it be raised to aid in getting in or out of bed. Some patients may request that side rails be used at night while they sleep so that they may feel more secure. The patient must be able to raise and lower the side rail him- or herself.
you are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5.
Answer: D Rationale: goals must be realistic and measureable
Which of the following is a priority emphasized in the RACE acronym guide to fire safety? A. Run to the nearest fire alarm. B. Act in a calm manner to prevent panic. C. Confine the fire by opening doors and windows. D. Evacuate patients and other people to a safe area.
Answer: D. Evacuate patients and other people to a safe area Rationale: The RACE acronym includes the following priorities: RACE R—Rescue anyone in immediate danger A—Activate the fire code and notify appropriate person C—Confine the fire by closing doors and windows E—Evacuate patients and other people to safe area
when collecting a nursing history for urinary elimination, what are some questions you should ask
Any difficulty or discomfort emptying your bladder? Do you feel a sense of urgency when you have to go? Do you experience incontinence, leaking? If so, how often? Is it sometimes hard to start your stream? Do you wake up during the night to empty your bladder? How many times? Do you ever see blood in your urine? Do you take any medication for or require special assistance with emptying your bladder?
what are specific risk factors to look for in your patient
Any risk factors specific for your patient? Falls, poisoning, suffocation and choking, firearms injuries, drowning, drugs/alcohol and burns
how do you effectively use alcohol based hand rub?
Apply about 1-3 ml of product in palm of your hand. -Rub hands together making sure to cover all surfaces of the hands fingers and area beneath the fingernails Rub until hands are dry (at least 15 seconds)
how do you test for fecal occult blood hemoccult
Apply clean gloves Collect small amount of stool in a container Use tongue blade to place stool on the hemoccult card This is collected x 3 bowel movements Place sign on bathroom door This can be done at home
how do you preform an open catheter irrigation
Aseptic Technique: Keep tip of syringe, end of catheter, end of catheter tubing, and irrigant sterile. Use 30-60 mls of sterile water. Allows drainage to flow by gravity. Assess characteristics of urine and record. Drainage solution amount should be equal to or greater than amount instilled. Repeat instilling solution and draining several times until drainage is clear of clots and sediment. If solution does not return, have patient turn on side facing nurse; if changing position does not help, reinsert syringe and gently aspirate solution
before very use, for an NGT you should
Aspirate 5-10 ml contents and visualize Check pH of aspirate Instill air and listen for swoosh
Intentional torts for which the nurse may be held liable include but are not limited to:
Assault and battery Defamation of Character Invasion of Privacy False imprisonment Fraud
What are the steps of the nursing process
Assess Diagnose Plan Intervention Evaluate
what do we assess when looking at environment
Assess the environment for potential safety issues. **Environmental safety hazards can result in falls, fires, poisoning and suffocation. Why is this important?. Because nurses need to identify people at risk and recognize unsafe situations. From this you identify problems or potential problems and come up with interventions to protect the patient. It the nursing process.
when assessing a patient for safe patient transfer, what are some things to consider
Assess the patient. Be familiar with the medical diagnosis, capabilities and any movement restrictions Assess patient's ability to help Does the patient understand the your instructions Are they cooperative with staff Have enough staff to help
APPLY THE NURSING PROCESS TO TREATING PRESSURE ULCERS
Assessing diagnosing outcome -identification and planning implementing
what steps are taken when applying the standards of practice in nursing
Assessment Diagnosis Outcomes Planning Implementation Coordination of Care Health Teaching and Health Promotion Consultation Prescriptive Authority and Treatment Evaluation
how should you feed a dysphagic client
Assist client to sit upright Towel, bib, napkin across chest Offer small portions of food Food first. Liquids last No straw Tuck chin slightly when swallowing
what are some types of stress encountered by professional nurses
Assume unprepared responsibility Work with unqualified personnel Work in unsupportive environment Care for dying patient Conflict with peer
how do you insert a nasointestinal tube? how do you verify placement?
Assure guide wire doesn't extend through tip before insertion. After insertion, lie on right side: enhances migration into duodenum. Verify placement with x-ray. Do not use SBFT until placement verified with xray. Remove guidewire once placement verified with xray.
When are evaluative measures preformed?
At the point of care when you make decisions about a patient's status or progress.
what are some internal factors affecting movement
Attitudes and Values Fatigue and Stress
the principle based approach to ethics includes
Autonomy Nonmaleficence Beneficence Justice
Cross-reactivity to latex has been shown with such foods as:
Avocado Banana Papaya Chestnuts Kiwi Potatoes Tomatoes Allergic to these foods may have latex allergy and vice versa
when teaching a patient about self care for hearing, what are you going to tell them?
Avoid excessive noise Do not put sharp objects in ears Don't clean ears excessively Treat infection early Symptoms of hearing loss- recognize and report
To prevent being gassy, you should:
Avoid gas producing foods: peas, beans, hummus, cauliflower, cabbage, Brussel sprouts, cucumbers, dried fruits, onions, peppers, melon
what are some important things to remember about documentation
Be objective Timely Legibility Accuracy Appropriate abbreviations No erasing or scribbling Black ink Follow institution policy on charting No sharing During assessment, only document what you heard, saw, or felt, only the hard facts to avoid bias. If you are documenting what a patient said, document verbatim and use quotes Always document refusals, the reason why, and your actions Time is everything! Document in REAL time when possible If written, write as clearly and legibly as possible Remember you are not writing a novel. Be to-the-point and brief Only use approved abbreviations Use strike-through documentation
what are effective responses to sexual harassment by a patient
Be self-aware Confront Set Limits Enforce Report
what are some factors that decrease urinary output
Bladder retention Increased sodium intake → water retention Dehydration - poor oral intake, endocrine disorder (SIADH - too much ADH), excessive output from other routes i.e. vomiting, diarrhea, sweating Heart failure, renal failure
If a patient presents with pursed lip breathing, what should you teach them
Breathe in for 3 seconds then out trough mouth for 7 seconds
When assisting a client with temporary visual loss to eat, the nurse should: A. Feed the client the entire meal B. Allow the client to experiment with foods C. Orient the client to the location of the foods on the plate D. Encourage family members to feed the client
C
Which of the following normal physiological changes in sensory function occurs with advancing age? A. Decreased sensitivity to glare B. Increased number of taste buds C. Difficulty discriminating vowel sounds D. Decreased sensitivity to pain
C
what does the "COPE" model acronym stand for
C- creativity O- optimism P- planning E- expert information
regular insulins are ALWAYS what color in the vial
CLEAR
In patients with heart disease, very important to avoid valsalva maneuver i.e. no straining with BM/constipation. Why?
Can cause a sudden increase in BP and drop in HR or even cardiac asystole/standstill (cardiac arrest).So with these patients, we administer stool softeners and/or laxatives as needed to prevent straining
what equipment will you need to insert a catheter
Catheter Kit that includes: Rubber catheter Sterile skin prep Lubricant 10cc sterile water syringe Tubing and Foley bag Fasteners
how do you remove a urinary catheter
Check physician/NP order in the chart. Perform hand hygiene. Gather equipment: 10cc syringe, alcohol wipes. Explain procedure to patient. Provide privacy. Position patient comfortable to expose catheter. Place protective pad under buttocks to protect bed. Apply non-sterile gloves (Clean technique). First, empty catheter bag & measure urine amount for output. Remove tape at leg using alcohol wipes. Be gentle. Attach 10cc syringe to balloon port and withdraw water (deflates balloon). Pull gently on catheter to remove. Try to pinch catheter to prevent spill. Clean perineum after catheter is removed. Instruct patient to void in a bedpan or urinal when able to void to measure output. Measure I&O. Dispose of catheter and bag system in bio-hazard bag. Clean area and provide comfort to patient. Document procedure.
You check your patients fingertip pulse ox and find that it is 90% on room air. What is your next action?
Check pt.'s position/ reposition/ recheck Use common sense! If pulse ox reads 50% don't wait and reposition, take action immediately!
what are some nursing interventions that will insure adequate nutrition for patients
Check trays Position client Prepare tray Assist with eating Assess intake and appetite Assess tolerance Provide more food...snacks Monitor food from visitors Administer medications a.c.; p.c.; during meals Education Notify MD or Registered Dietician of problems
computerized programs used within the health care setting to aid and support clinical decision making. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions to generate tailored recommendations for individual patients, which are presented to nurses as alerts, warnings, or other information for consideration.
Clinical decision support systems (CDSSs)
A systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations
Clinical practice guidelines and protocols
what re some examples of implementations skills
Cognitive skills Interpersonal skills Psychomotor skills
effective communication is essential for
Collaboration Accurate documentation Continuity of care (Workers from all aspects of healthcare work together to care for the patient. If we do not effectively communicate then the care we give the patient is not the best care possible. Communicating helps us to document effectively. Care is often based on what is documented by the nurse in the patient record, so if the nurse is not effectively documenting, the appropriate care may not be given by others involved in the care.)
how do you test for pinworms
Collect in the am Use clear tape Press against anal opening, remove and place on a slide.
what are some defense mechanisms
Compensation Denial Displacement Introjection Projection Rationalization Reaction formation Regression Repression Sublimation Undoing
what is the nurses role when it comes to informed consent
Confirm a signed consent is present Answer patient questions Have patient describe in own words what is about to happen Have patient sign AFTER provider has explained procedure Educate *******you are only witnessing the signature of the patient on the form, not the explanation of the procedure
what are effective responses to sexual harassment by a colleague?
Confront behavior Document data, time and behavior Consult supervisor File a grievance Seek legal advice
what should you teach the patient after administering the intradermal injection
DO NOT RUB OR SCRATCH SITE
according to harvard, what is death?
Death is the irreversible loss of brain function, accompanied by the more traditional signs
What are some age related changes that occur in the elderly pertaining to weaker defense systems due to poor oxygenation
Decline in cell mediated immunity of foreign antibodies Less forceful cough Fewer/ less functional cilia Drier mucous membranes More secretions remain in lungs Swallowing may be slower and reduced sensation in the pharynx can predispose to aspiration Increased meds=stiffer lungs
What are some structural age related changes that occur relating to oxygenation
Decrease in elastic recoil of lungs Decrease in chest wall compliance Stiffening of chest wall Calcification of coastal cartilages Changes in spinal configuration
what are factors affecting sexuality?
Developmental Considerations Culture Religion Ethics Lifestyle
What can diarrhea lead to?
Diarrhea may lead to fluid and electrolyte imbalance, especially in infants, children, older adults.
treatments preformed through direct care with patients EX: medication administration, insertion of IV infusion, counseling during a time of grief
Direct care nursing interventions
What should you do if a patient meets a goal successfully?
Discontinue that part of the care plan (unmet and partially met goals require you to continue intervention)
what are some ethical and professional boundaries when dealing with spirituality?
Discuss spiritual concerns in a respectful manner and AS DIRECTED BY PATIENTS Praying with patients Facilitating the Practice of Religion Familiarize patient with religious services within institution. Respect patient's need for privacy during prayer. Assist patient to obtain devotional objects and protect them from loss or damage. Arrange for patient to receive sacraments if desired. Attempt to meet dietary restrictions. Arrange for priest, minister, or rabbi to visit if patient wishes.
what are some medications that cause sleep deprivation
Diuretics, antiparkinson, antidepressants, antihypertensive, steroids ,decongestants, caffeine, and asthma meds
how do you calculate a waist to hip ratio
Divide the waist measurement by the hip measurement
what is a "powdered medication" and how do you administer it
Drugs supplied as a powder in a vial. A liquid (diluent) must be added to powder to inject
what are some different types of reactions to grief
Dysfunctional grief Unresolved grief Inhibited grief
what is abnormal urinary elimination
Dysuria: painful urination Dysuria is a symptom of pain, discomfort, or burning when urinating. Incontinence - loss of control, leaking Frequency and urgency Urinary retention - unable to empty bladder completely; post-void residual
what is the different between an EMR and an EHR
EMR- for that hospital stay in the one facility only EHR-SHARED record between different companies and different admission, shows ALL data, ALL admissions and pulls up ALL health history.
How does positioning affect how a patient breathes?
Eases respiration Allows free movement of the diaphragm and expansion of chest wall HIGH FOWLERS POSITION facilitates better air flow
which tests can be done to further confirm death
Electroencephalogram Cerebral blood flow study
Privacy, Confidentiality, and Security Mechanisms
Electronic documentation has legal risks. Most security mechanisms for computerized information systems use a combination of logical and physical restrictions to protect information. Physical security measures include placing computers or file servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access.
what are some ways to decrease discomfort when administering an injection
Firmly press insertion site for 10 sec prior to needle insertion Changing needles between drawing up med and actual injection Z-tract method Injecting into a relaxed muscle Use dart like motion Use smallest gauge needle possible
What are some questions to ask before preforming a physical assessment on a patient with inadequate oxygenation
First impression? Any emergency needs right now? Determine level of distress Address Most urgent needs first May need to order o2 immediately Complete health history (depends of level of distress) Decide if some/ all of this can wait until pt is more stable Vital signs
Procedure for Intermittent Feedings - After verifying placement and measuring residual:
Flush with 30 ml tap water using 60 ml catheter tip syringe. Water flush and feeding may be given by hand using plunger with 60 ml catheter tip syringe - given slowly (rate of slow drinking) OR by gravity, taking plunger out of barrel and allowing feeding to freely flow. When giving feeding by gravity, height of syringe determines rate of flow. Raise or lower to control rate. Raising increases rate; lowering decreases rate. Flush with 30-60 ml water after feeding. Clamp tube when appropriate to avoid allowing air to enter tube. Lopez valve/stopcock to control flow- " I would clamp so air doesn't get in the tubing"
What might gas be caused by?
Gas may be caused by new microbes (new places) or certain foods
how do you preform a closed catheter irrigation
Gather supplies (Irrigation kit). Perform hand hygiene. Apply clean gloves. Aseptic Technique: Keep 30-60 mls of irrigant sterile in sterile container. Closed Catheter Irrigation Place towel under catheter for protection. Clamp tubing distal to injection port. Wipe port with antiseptic swab. Connect syringe to port. Attempt to aspirate debris before injecting irrigant. May use needleless system. Inject slowly. Unclamp tubing and let flow to gravity. Repeat if necessary.
when evaluating your patients to assess if the nursing care plan worked in relation to mobility, you should evaluate what?
General ease of movement and gait Body Alignment Joint structure and function Muscle mass, tone and strength Endurance
how do you administer an insulin injection
Gently pinch an inch of skin or not. Inject 45-90 degree angle. Do NOT aspirate! Rotate sites with each injection. Do NOT recap needle!
PT presents to your ER... 32 year old black female, 24 weeks pregnant, diabetic, BP 200/100, HR 115, resp rate 36/labored, temp 102 F, lung sounds: crackles rhonchi, persistent coughing. What can you as the nurse do?
Get pt to calm down Positioning Suction
example of an intermittent aka bolus feeding order
Glucerna 240 ml every 6 hours PT
how should you facilitate the deliver of quality care?
Goals & priorities- ultimate goal/priority= patient care Evaluate -> how does this meets pt's needs? Work with others Time Line Evaluate -> success? Make tomorrow a better day
things to know about catheter size
Graded on French scale according to lumen size. Most are rubber (latex) Size 14-16 Fr with 5-10cc balloons. Infants- 5-8Fr Children- 8-12 Fr
what is the correct way to move a patient up in bed
Have patient help, if able, by bending knees and pushing up and lifting up their head Nurse: Flex knees and hips, spread feet shoulder width apart, one foot slightly in front of the other.
what are some factors that affect appetite
Headache or other pain Constipation Emotional upset Fatigue Changes in taste perception Depression served too hot / cold Food tasteless Eating between meals
things to know about terminal illness
Healthcare provider tells patient and family All healthcare team members have to know how much the patient and family know Cultural influences Stages of grief Right to consent & right to refuse treatment Poor investment of scarce resources I have the right to expect continuing medical and nursing attention even though "cure" goals must be changed to "comfort" goals. DNR or comfort care does not equal no care at al
if you extracted 150 ml of residual volume and didn't give it back you should ________________________
Hold the tube feeding for an hour, then restart at slower rate, gradually increasing til resume previous rate (this requires an order) metoclopramide (Reglan) given to gastric motility.
what are some important questions to ask when collecting a nursing history for bowel assessment
How often do you usually have a bowel movement? What is the usual time of day? When did you have your last BM? Has there been any recent change? Here is a good opportunity to give examples: any change in color? Bleeding: bright red - hematochezia; burgundy, black - melena, tarry stools. Any change in consistency? size, shape (caliber)? Do you have or have you ever had hemorrhoids? Do you take any medication for constipation? Do you require special assistance with having a bowel movement? i.e. ostomy Do you ever experience bowel incontinence
what might call for a restricted sodium diet
Hypertension, liver disease, heart failure (edema), renal insufficiency
Hypoperfusion can lead to
Hypotension
Poor oxygenation (hypoxia) can lead to what?
Hypoventilation and dyspnea
An inadequate amount of o2 available to cells
Hypoxia
do IM or SQ injections have a faster absorption and onset of action *Important for pain medications!
IM Most vaccines are given IM.
what data should you include in your documentation
Identification of patient Current Assessment Changes in status Pertinent monitoring, lab, or radiology data Irregular data/Abnormal findings in assessment Resolved issues Current patient standing on goal achievement and nursing plan Current/New/Changed orders Upcoming tests or procedures and instructions (NPO, bowel prep, etc.) / post procedure instructions Any unfilled orders that need to be in the continuum of care Patient/Family concerns and/or needs Reports on patients awaiting transfer or discharge
what steps are taken to complete a risk assessment?
Identifies safety risks inherent in its patient population. Identify patients at risk for suicide. Identify patient at risk for falls Identify patient at risk for domestic violence PREVENT MISTAKES IN SURGERY Conduct a preprocedure verification process. Mark the procedure site. A time-out is performed before the procedure. APPLICATION OF THE NURSING PROCESS Diagnosing Outcome identification and planning Implementing Nursing diagnosis ex: risk for fall related injury due to lack of awareness of environmental hazards and visual deficits ex: risk for fire related injury due to lack of awareness of environmental hazards Outcome / intervention ex: the patient will be able to identify unsafe situations in his environment and demonstrate measures to prevent falls ex: the patient will be able to demonstrate safety measures to prevent fires IMPLEMENTING Teaching Resources EVALUATING Final step of nursing process Evaluate the effectiveness of nursing intervention REMEMBER SAFETY SHOULD BE A PRIORITY IN OUR EVERY DAY, EVERY PATIENT CARE!! IT IS UP TO YOU TO KEEP YOUR PATIENTS SAFE!!
how would you administer on IM injection of demerol
Identify IM Site Inject at 90 degree angle. Do NOT aspirate! Gently massage site after injection. Use safety feature on needle. Do NOT recap!
when reporting by telephone or oral communication, make sure you:
Identify self to the patient and state your title Hi, I am Vonda Boone and I am your nurse today. Hi I am_____ , I am your ULM student nurse Identify your self to the provider or other discipline in the same manner If reporting to the provider, report concisely and accurately what you are calling about. Have the chart handy in case there are questions that need to be answered Give the provider current data (VS, and clinical issues "the reason you are calling") Record the date, time, and detail of your report or interaction If you are reporting to the patient/family, ensure that everyone in the room is on the HIPPA list
how do we evaluate expected outcomes of spirituality
Identify some spiritual belief that gives meaning and purpose to life. Move toward healthy acceptance of current situation. Develop mutually caring relationships. Reconcile interpersonal differences causing anguish. Verbalize satisfaction with relationship with God. Express peaceful acceptance of limitations and failings. Express ability to forgive others and live in present. Demonstrate interior state of joy, freedom from anxiety and guilt.
how do you assess for patency?
If connected to suction, must see GI fluids moving through it. Monitor movement of gastric contents through tube to assess for patency. May require prn intermittent irrigation/flushing. If NGT used for meds, hydration, feeding - then water flushes already being done.
why would you return contents after checking residual volume
If don't, may cause fluid/electrolyte imbalance AND residual may contain meds Taylor: consider not giving back high if residuals = >200-250 ml, >400 ml. Follow agency policy. *In practice, typically don't give it back if >150 ml.
if patient with NGT is vomiting, is the NGT patent? what should you do?
If patient with NGT to suction is vomiting, NGT is not patent and stomach is not being decompressed. What to do? Disconnect from suction and MANUALLY decompress. Empty connection tubing by briefly turning up suction and disconnecting from NGT Flush NGT to restore patency Increase suction Can connect G-port of PEG to suction if patent vomiting When auscultating bowel sounds, turn suction off. Don't forget to turn suction back on.
How should you administer a larger volume cleansing enema?
If using disposable bag and tubing for larger volume enema: Insert lubricated tip 3-4 inches. If resistance met, permit a small amount of solution to lubricate or soften, then continue. Do not force entry. After inserting tip, lower bag to level of buttocks before opening clamp. Raising will increase rate of flow. Don't raise more than 12-18 inches above buttocks. Introduce solution slowly, over 5-10 minutes, holding tubing in place. Use Castille soap for Soapsuds enema (usually comes in kit)
What will happen to a COPD patient if you increase their o2 levels?
In humans, CO2 causes us to want to breathe, but COPD patients are used to increased CO2 levels, therefore, if you increase their O2 levels they will not breathe at all
how long is the urethra in a male
In men, it is 5 ½" to 6 ¼" long. - more prone to trauma
What is an approach to ensure appropriate application of an intervention
Increasing or decreasing the frequency of interventions
what are the stages of infection
Incubation period— the time you were exposed (organisms growing and multiplying) Prodromal stage— person is most infectious, vague and nonspecific signs of disease Full stage of illness—presence of specific signs and symptoms of disease Convalescent period—recovery from the infection
treatments preformed away from a patient but on behalf of patient/ group, based off of documentation. EX: managing the patient's environment, documentation, interdisciplinary collaboration *nursing actions that manage the patient care environment and interdisciplinary collaborative actions that support the effectiveness of direct care interventions
Indirect care interventions
Patient presents: "I feel as though I'm not getting enough air" Thick yellow secretions Pale skin, circumpolar cyanosis RR= 40 bpm, shallow Coarse king sounds bilaterally Can't sit still in chair/ bed Ineffective cough Related factors are: Fatigue Sedentary at home Decreased fluid intake Poor nutrition 20 year hx of copd Recent development of pneumonia What is the big problem?
Ineffective airway clearance
Patient presents: Tachypneic (RR rate of 40) "Tingling in my fingers" "Can't catch my breath" "Feel like I'm suffocating when I lay down in bed" Related factors: Anxious about results of cardiac catheterization and possible cardiac surgery What is the big problem?
Ineffective breathing pattern
What patients are at the most risk for a specific type of injury or specific hazard ( based on age)?
Infant-Choking toddler- drowning or poisoning school age- falls, bike accidents teenage-Drugs/alcohol/car accidents elderly- Fires, Falls **children also have a high risk of falling, climbing equipment, playgrounds are usually responsible for pediatric falls.
Which age group has the highest respiratory rate?
Infants
what re some problems affecting joint mobility
Inflammation Degeneration Osteoarthritis- Degenerative joint disease: non inflammatory, progressive disorder of movable joints characterized by the deterioration of articular cartilage and pain with motion. Affects weight-bearing joints Trauma Fractures Sprains Strains Dislocations
Nurse is beginning to conduct a health history for a patient with respiratory problems. He notes that the patient is having respiratory distress. What should the nurse do next?
Initiate interventions to help relieve the symptoms THINK PRIORITY
what are the 2 methods of administering parenteral medications
Injections into body tissues Injections into circulatory system (IV)
where can you give an intradermal injection
Inner surface of forearm. Upper back below scapula.
How should you administer a fleets enema?
Insert pre-lubricated tip, pointing toward umbilicus. Compress bottle slowly, over 1-2 minutes. Taylor, p. 1366
what are the 3 types of exercise
Isotonic Isometric Isokinetic
CASE STUDY Miyoko is a nursing student assigned to Mr. Mashoud, a 48-year-old Arab admitted to the hospital with kidney stones. Upon Mr. Mashoud's admission to the emergency department (ED) this morning, he was experiencing excruciating pain. The treatment plan for Mr. Mashoud includes keeping him in the hospital until he passes the stones and adjusting his pain medication as needed. Miyoko evaluates Mr. Mashoud's response to the medication therapy to update his care plan. Miyoko assesses Mr. Mashoud's pain before NSAID administration and then approximately one hour after administration. Miyoko knows that evaluation is an ____________ process that occurs whenever contact with a patient occurs. ANSWER: ongoing Miyoko determines the patient outcomes for Mr. Mashoud based on his reaction to the medication regimen. ¬ Which of the following is an end result that translates into observable patient behaviors that are measurable and desirable? A. Unexpected outcome B. Expected outcome C. Sensitive outcome D. Accomplished outcome ANSWER: B Miyoko follows which steps to objectively evaluate the degree of success in achieving outcomes of care for Mr. Mashoud? (Select all that apply.) A. Identify the exact desired patient behavior. B. Evaluate the patient's actual behavior. C. Compare the outcome criteria with the actual behavior. D. Assess the desired behavior and anticipated outcome. E. Judge the degree of agreement between the outcome criteria and the actual behavior. ANSWER: A, B, C, E
KNOW
CASE STUDY υ Miranda is a nursing student who is assigned to Mr. Bagley. Mr. Bagley is a 52-year-old Asian who was admitted to the medical-surgical unit for management of tuberculosis. Mr. Bagley travels internationally because of his executive position with a global company and most likely contracted tuberculosis during his travels. υ Mr. Bagley's current symptoms are shortness of breath, night sweats, muscle pain, fatigue, and a productive cough. Miranda reviews Mr. Bagley's plan of care to determine which interventions are to be implemented first. υ Miranda searches the hospital's database for additional information on tuberculosis. υ True or False: A clinical practice guideline is a collection of institutional policies that assist nurses, physicians, and other health care providers in making decisions about appropriate health care for specific clinical situations, such as the management of tuberculosis. Answer: False Rationale: a clinical practice guideline protocol is a systematically developed set of standards that assist nurses, physicians , and other healthcare providers in making decisions about appropriate healthcare for specific clinical situations υ Mr. Bagley's plan of care calls for oxygen therapy to improve his respiratory status. υ A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a __________ _____________. Answer: standing order υ Mr. Bagley is placed on Isolation Precautions. υ Isolation Precautions as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety Answer: B Rationale: indirect care interventions are treatments preformed away from the patient but on behalf of the patient/ group of patients. Implementing precautions is an example of indirect care by managing the patient's environment
KNOW
In the fast-moving world of health care, it is vital that nurses are able to practice to the full extent of their education and abilities, in order to deliver the most efficient, quality care to patients. State law in North Carolina (only state to have elections for members) mandates elections to elect board members NCBON. Know the rules and regulations in the state in which you want to practice.
KNOW
Most institutions have ethics committees to help in resolution of issues that come up. TJC mandates accredited agencies have a mechanism for addressing ethical problems. As nurses, you should be aware of your institutions process
KNOW
Nursing diagnosis: Constipation, Risk for constipation Treatment: stool softeners, laxatives, enemas, manual removal Table p.1362 - Classifications of laxatives. Know actions, nursing implications. Before giving a routine stool softener or laxative, always ask "When did you have your last BM?" Hold if having diarrhea. Constipation can lead to fecal impaction - severe form of constipation → abdominal pain, distension. Suspect if patient hasn't had a BM in an extended period of time (1-2 weeks) and is oozing diarrhea. Treatment: enemas and manual/digital removal.
KNOW
Passive and active exercise improve joint mobility and increase exercise to thee affective part Active exercise increases muscle mass, tone and strength, as well as improving cardiac output. Exercise should be as active as the patient's physical conditions permits
KNOW
SELF - Evaluation--See Box 22-2 -HOW, WHAT, WHEN, WHY?
KNOW
TERMS TO KNOW CONGESTED VS NON CONGESTED PRODUCTIVE VS NON PRODUCTIVE COUGH VOLUNTARY VS INVOLUNTARY COUGH
KNOW
potassium is regulated by the kidneys, transcellular shift (ICF <---> ECF), and aldosterone (directly effects sodium, indirectly effects potassium) -GI secretions are high in K+, so lost in vomitus (if someone vomits a lot- will have sodium deficit), K+ wasting diuretics= low potassium levels
KNOW
¬ You are responsible for knowing when one type of implementation skill is preferred over another and for having the necessary knowledge and skill to perform each. KNOW
KNOW
how do we measure achievement of the competency?
KSAs
How does kidney failure cause cardiac issues and hypoxia
Kidneys not working—>fluid overload—> poor O2-> cardiac probs—>hypoxia
when taking care of a patient with reduced hearing, you should:
Let person know you are there Face to face Decrease background noise Hearing aids on? Batteries good? Don't chew gum, cover mouth, or turn away Demonstrate or pantomime (be careful) Good ol' pencil and paper
What are some risk factors pertaining to oxygenation
Level of health Developmental considerations Medication considerations Lifestyle considerations Environmental considerations- do they work around chemicals Physiological health considerations
who approves and signs standing orders?
License prescribing healthcare providers in charge of care at time of implementation
What does the NOC( nursing outcomes classification) do?
Links outcomes to NANDA-I nursing diagnoses
tend to cause reversal of day-night sleep
Liver failure and encephalitis
what are some problems/ complications that can occur when administering an injection
Local site reactions: redness, tenderness. Apply cool compress. Do NOT massage. Patient pulls away before fully injected. Replace needle and inject remaining medication. Nurse hits the bone on an IM injection. Withdraw and discard needle. Apply a new needle and choose alternate site. Document and notify MD
what are some psychosocial factors affecting nutrition intake in older adults
Loneliness or loss Mental awareness Social isolation Income level Ability to shop/cook
gives a preset dose each "push".
MDI
how long can an external condom catheter stay on?
MUST be removed daily
What are some independent nursing interventions for oxygenation?
Maintain a patent airway Auscultate breath sounds Initiate/ maintain supplemental O2 as prescribed Appropriate pain Rx prn Ambulate as appropriate Monitor resp and Ox status Appropriate Rx to promote airway patency and gas exchange (resp treatments as ordered) Teach pursed lip/ slower breathing Initiate program of muscle strength/ endurance Positioning as appropriate Pt. Teaching (ex: turn, cough, deep breathe. Respiratory secretions settle to bottom of lungs like water settles to the bottom in a wet sponge
what are the four primary principles of manual patient handling that should be used in conjunction with SPH techniques when handing and moving patients?:
Maintain a wide, stable base with your feet Put the bed at the correct height (waist level when providing care, hip level when moving a patient Try to keep the work directly in front of you to avoid rotating the spine Keep the patient as close to your body as possible to minimize reaching
how do you care with patient with a suprapubic catheter
Maintain closed system. Do NOT open to irrigate or get specimen. Assess skin around catheter. (color, integrity, drainage, bleeding, sutures) Requires sterile dressing change. Check patency of catheter: Hourly for first 24 hrs. Output should be in excess of 30ml/hr. Every 8 hrs on day 2 & daily thereafter. Check for signs of UTI: color, clarity, odor, pain
what are some important principles of catheter insertion
Maintain sterile technique! Obtain assistance if needed. Lubricate the catheter tip to prevent injury/friction. Check tubing to make sure it is NOT kinked. Keep bag below level of bladder to drain. Keep drainage bag off floor. Check all connections to secure closed system
what are the 2 categories of aseptic technique
Medical asepsis—clean technique Surgical asepsis—sterile technique
how should you collect the stool sample?
Medical aseptic technique is imperative. Wear disposable gloves. Wash hands before and after glove use. Do not contaminate outside of container with stool. Obtain stool and package, label, and transport according to agency policy.
CNS stimulants
Methylphenidate-Ritalin Modafinil - Provigil
what are the 4 levels of anxiety
Mild Moderate- when a person focuses on certain concern- voice shakes, trouble speaking Severe-focuses on specific details, can't focus on task/ function Panic- no control, doesn't matter what you do or say, hypoventilation, tachycardia, SOB, can die from this
what are some good assessment tools when assessing sensory stimulation
Mini Mental Exam- checks orientation, registration, recall and language Snellen eye chart (pg. 633)- the big "E" chart PERRLA (pg.644) Glasgow Coma Scale (pg. 667)- if they are a 3, they are basically a manican, if they are a 1- no verbal response, not opening eyes Romberg Test (pg.680)- positive test is bad= loss of balance
what are the world health organization's (WHO) 5 moments for hand hygiene
Moment 1- Before touching a patient Moment 2- Before a clean or aseptic procedure Moment 3 - After a body fluid exposure risk Moment 4- After touching a patient Moment 5- After touching a patient's surroundings
why is a nasointestinal tube inserted with a guide wire
More flexible than NGT so inserted with guidewire
What are some age related changes that occur due to decreased oxygenation pertaining to altered respiratory control
More gradual response to changes in blood O2 or CO2 levels Longer response time affects the bodies ability to bounce back from stress SEE FOCUS ON THE OLDER ADULT P. 1406
what age group is most at risk for being poisoned and why?
Most at risk are children -Due to unsafe storage -Lack of caregiver attention -Spending time in other environments other than home -Grandparents meds **make sure to teach safe storage of medications to all patients
which patients are most at risk for nosocomial infections
Most likely to occur in patients with tubes or lines: -Catheters -Feeding tubes -Tracheostomies
what is the normal expression of grief
Mourning Bereaved
what is a BAD example of a learning objective
Mrs. Avery will understand about diabetes before discharge
what must be included in the documentation for catheterization
Must include type and size of catheter inserted. Include amount of water used to inflate balloon. How patient tolerated the procedure. Record amount of urine returned and any specimen obtained. Document characteristics of urine. Record urine amount on I&O record. Documentation Example 9/12/16 1015: Dr. Smith notified of palpable bladder, patient reports discomfort in suprapubic area, and inability to void. Orders for foley cath received. #16 Fr foley catheter inserted without difficulty. 10cc sterile water injected into balloon port. 700 ml clear, yellow urine returned. Patient states, "I feel relief now!" Bladder no longer palpable. Patient tolerated procedure without adverse event. B Smith, RN Return Documentation 9/13/16 0800: 16 F foley catheter inserted with 500 cc of clear amber urine obtained. 10 ml of sterile water instilled into balloon. Tubing secured to inner thigh and bag hung to gravity drainage. Patient tolerated well. ---------S.Ogg, RN
which tube would you use for short term nutritional support
NG tube
when are NG tube feedings contraindicated?
NG tube feedings are contraindicated if risk for aspiration i.e. GERD or unable to raise the HOB ***Nasointestinal tube (Dobhoff) feeding reduces risk of aspiration but risk of dumping syndrome **DOBHOFF only goes into the duodenum
public resource for evidence based clinical practice guidelines
NGC (national guidelines clearing house)
example of documentation for flushing an NGT
NGT flushed with NS and is patent
offer a level of standardization to enhance communication of nursing care across settings and compare outcomes. -incorporated In many healthcare information systems -By using NIC, you learn the common interventions recommended for the various NANDA international nursing diagnoses.
NIC interventions
Is oxygen in a simple mask typically humidified?
NO
can long acting insulins be mixed with other insulins?
NO
do you ever press on inflammatory edema?
NO
for a routine urinalysis, is a sterile urine specimen required?
NO
for nurse-initiated interventions, is a doctor's order needed?
NO
is it ok to leave toilet paper in the stool sample
NO
is stress the same for everyone?
NO IT IS HIGHLY INDIVIDUALIZED
is the urethra sterile?
NO, because it is an external opening
Are herbs regulated by the FDA?
NO, but drugs are
does having a goal for the patient to lose 5 pounds in one week use the SMART acronym?
NO, the goal is not realistic
if the patient is a minor, do you need permission to talk to the family?
NO, the parent MUST be included in the conversation
Starts at I and moves to IV , then pattern reversed If awakened during this time, start back at stage I
NREM sleep
major electrolytes in the ECF
Na+ Cl- Ca++ HCO3-
Documentation needs to conform to standards of the___________ and______ to maintain institutional accreditation and minimize liability
National Committee for Quality Assurance (NCQA) and TJC
what are some factors that affect the way a person adapts to stress
Nature of stress- painful, physical, mental Intensity Timing Number and duration of stressors Person's age Developmental level Past experiences Support systems Coping mechanisms
what re the 3 spiritual needs
Need for meaning and purpose Need for love and relatedness Need for forgiveness
what equipment do you need to administer an intradermal injection
Needle: ¼ to ½ inch; 25-27 G needle 1cc syringe: Measures tenths Dose usually less than 0.5ml
things to know about achieving patient goals
Nurses implement care to meet patient goals. At times, multiple interventions may be needed. Priorities help nurses to anticipate and sequence nursing interventions. Patient adherence means that patients and families invest time in carrying out required treatments.
The use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research -also recognized as a specialty area of nursing practice
Nursing informatics
any treatment based on clinical judgement/ knowledge that a nurse preforms to enhance the outcomes; evidence based
Nursing interventions
Differentiates nursing practice from that of other health care disciplines by offering a language that nurses use to describe a set of actions in delivering nursing care
Nursing interventions classification interventions
Example to illustrate the relationship b/t psychological stress and physiologic stress
Nursing student stays up all night to take a final exam that must have a passing score to move to the next course. Next morning- Can't eat breakfast High heart rate Feelings of apprehension Diarrhea
what is objective data?
Observations or measurements of a patient's health status
what are some important ways to implement spiritual care?
Offering supportive presence Facilitating patient's practice of religion Nurturing spirituality Praying with a patient Praying for a patient Counseling the patient spiritually Contacting a spiritual counselor Resolving conflicts between treatment and spiritual activities
What should you always base your clinical judgements on?
On the basis of what is occurring with a specific patient and not merely on what happens to patients in general. Evaluations are patient specific
when should you use sterile gloves?
Operating Room Labor and Delivery Certain Diagnostic Procedures: Procedures at the bedside, such as: 1. Inserting Urinary Catheter 2.Sterile Dressing Changes STERILE GLOVES vs UTILITY GLOVES WHEN TO USE UTILITY GLOVES Changing Bed Linen Empting Catheter Bags & Urinals Taking out Catheters Collecting certain Specimens Removing Peripheral IV's While performing daily mouth care and empting out basins, giving bed bath
for hydration needs-
Order for PT water intake is usually written with tube feeding order i.e. 240 ml water every 4 hrs
This type of supplemental oxygen machine is used in nursing homes, homes, psychiatric units, and anywhere that constant o2 flow is needed and not available by a wall
Oxygen concentrator
***a TOOL for evidence based research****
P- PATIENT OR PROBLEM(disease or condition) OR POPULATION OF INTEREST I-INTERVENTION (therapy, procedure, drug, exposure, test, strategy) C-COMPARISON (compared to alternate intervention or control) O- OUTCOME (the consequence, effect or improvement of interest and the measurement thereof)
Do we need to check placement? residual? when 5. giving medication in a PEG? placement __________ residual _________
P: NO R: YES
Do we need to check placement? residual? when 6. giving a continuous feeding in a PEG? placement __________ residual _________
P: NO R: YES
Do we need to check placement? residual? when... 1. giving a bolus feeding in a PEG tube? placement __________ residual _________
P: NO R: YES
Do we need to check placement? residual? WHEN 3. starting a continuous tube feeding in a newly placed NGT? placement __________ residual _________
P: YES R: YES
Do we need to check placement? residual? when 2. administering medication in an NGT? placement __________ residual _________
P: YES R: YES
Do we need to check placement? residual? when 4. beginning an intermittent feeding in an NGT? placement __________ residual _________
P: YES R: YES
which tube would you use for long term nutritional support
PEG tube
hypophosphatemia: treatment
PO4 supplements
this pain is more likely during REM sleep
Pain associated with coronary artery disease and myocardial infarction
describe normal bowel elimination
Painless, formed, soft, normal caliber for age (adult about 1"), color: usually brown but can be affected by what is ingested i.e. beets (red), iron (black)
what is normal urinary elimination?
Painless, may be discomfort with distension Moderate frequency: q3-4 hours Amount matches intake and other output Continent, urinary continence - ability to stop and start stream; control
what are the characteristics of normal urine
Pale yellow, straw colored or amber Aromatic odor Clear or translucent Specific gravity of 1.015-1.025 Turbidity PH 4.6-8
the patient is unable to move independently, and the nurse moves each joint through its ROM during this exercise.
Passive ROM Exercise
Three models of healthcare decision making:
Paternalistic Patient Sovereignty Shared Decision Making (preferred)
what is a realistic goal for an immobile patient whose outcomes are directed towards preventing complications related to inactivity?
Patient will be free from signs of skin breakdown or patient will change from a lying to standing position safely Patient will have normal bowel elimination AEB a soft BM every other day
What are some outcomes for the problems we have identified? (Impaired gas exchange, ineffective breathing pattern, ineffective airway clearance)
Patient will experience improved gas exchange, pulmonary tissue perfusion, ventilation, cardiopulmonary status, cellular tissue perfusion
what is a realistic goal for a patient with no immobility problems whose outcomes should be aimed toward promoting physical fitness?
Patient will identify target heart range or describe an exercise program that they are willing to follow
what are some nursing considerations pertaining to stress and adaptation
Patient's major concern Specific illness Sociocultural background Available resources
what is subjective data?
Patient's verbal descriptions of their health problems
What are the 6 QSEN competencies ( plus the one ULM added?)
Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics *professionalism
name the QSEN competency: recognize the patient/family or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient preferences, values, and needs.
Patient/ family centered care
which QSEN competency does this KSA go with: acknowledge and respect cultural diversity, ethnic and social backgrounds as sources of patient/family values. communication skills: ability to interview patients and families effectively and then communicate unique needs to other members of the health care team. shared decision making. don't be judgmental. acknowledge patients rights (be your patients advocate)
Patient/ family centered care
Who needs home oxygen?
Patients with COPD (Reminder: read p. 1426 under oxygen flow rate) Patients with chronic lung disease have special considerations related to oxygen flow rate and CO2 levels ALWAYS MONITOR YOUR PATIENT FOR RESPIRATORY RATE AND O2 LEVELS
what is a vial?
Plastic or glass bottle with self-sealing stopper *Can be single or multi-dose vials. Check/mark date on multi-dose vials.
what are some ways to develop leadership skills
Preceptor / Mentor Nursing and other Professional Organizations Find others to model and learn from Stay current on literature Research / Evidence-Based Practice Continuing Education Stay Smart : Stay Sharp! A Dull Nurse is Dangerous!
how do you collect a wound culture
Press and rotate the swab into the wound several times, avoid touching the swab on the skin area or wound edges Package, label, date and initial it and transport according to agency policy. **make sure you clean it first
Why is the Z-track technique used for IM injections
Prevents backflow of medication into tissues (prevents irritation)
what are the 3 preventative measures
Primary prevention aimed at health promotion includes: health education programs, immunizations, and physical and nutritional physical fitness activities Secondary prevention aimed at health promotion includes: screening techniques and treating early stages of disease (people who are experiencing health problems or illnesses and are at risk of developing complications or worsening conditions) Tertiary prevention aimed at health promotion includes: minimizing the effects of long term illness or disability including rehab
what are some problems with the "harvard criteria" of death
Problems with the "Harvard Criteria" Hypothermia Drug or metabolic intoxication Circulatory shock Child < 5 years old
The three professional liability issues of particular concern for nurses are:
Professional practice conduct Adherence to the Principles for Delegation established by the ANA and legally binding within each state's Nurse Practice Act Accurate and timely documentation.
how do you preform the Z track technique
Pull skin to side approximately 1 to 1.5" prior to injecting needle into skin. Inject medication slowly (10 sec/ml). Withdraw needle and release the skin. Apply gentle pressure. Do NOT massage.
For oxygenation to take place, which 3 things must be working
Pulmonary ventilation Respiration (transport) Perfusion
Measures o2 sat of hemoglobin in blood
Pulse oximetry
This is a noninvasive method of evaluating the oxygen saturation of the hemoglobin in arterial blood as well as the pulse rate and it is based on density of blood/ oxygen content
Pulse oximetry
why can intestinal feedings cause and increased risk of dumping syndrome
Pyloric sphincter regulates rate of flow from stomach to intestine. Intestinal feedings - the pyloric sphincter is bypassed (symptoms of dumping syndrome) If given too fast, hypertonic tube feeding may cause cramping, abdominal distension, and even lightheadedness (from fluid shift BP) **be sure to elevate the HOB at least 30-45 degrees to prevent dumping syndrome
established standard competencies and knowledge skills and attitudes (KSA's) for the preparation of future nurses.
QSEN institute
a vital energy or life force that circulates in the body through a system of pathways called meridians
Qi
• System of posture • Exercise—gentle and dynamic • Breathing techniques • Visualization
Qi gong
what does QSEN stand for
Quality and safety in education for nurses
Name the QSEN Competency: use patient care data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Quality improvement
which QSEN competency does this KSA go with? learn about outcomes of care. participate in root analysis of an incident or sentinel event. identify gaps between local and best practice, describe the process of change
Quality improvement
both control sleeping and waking
RAS and hypothalamus
believed to be essential to mental and emotional equilibrium and play a role in learning, memory and adaptation
REM sleep
more difficult to arouse -20% - 25% of person's nightly sleep time -Dreams
REM sleep
You are________ for responding within the scope of your power and responsibility.
RESPONISIBLE
the complete extent of movement of which a joint is normally capable.
ROM (range of motion)
The new ANA Scope and Standards of Practice Call nurses to action - to RAISE the bar by: (define RAISE acronym)
Reading Nursing: Scope and Standards of Practice, Third Edition Assessing the document and contemplating what it means to you and your practice Integrating Scope and Standards of Practice into practice by developing culturally congruent care in every situation and setting Sharing the word and encouraging other nurses to integrate Scope and Standards into practice Excelling in using knowledge and conducting and applying research to achieve the highest quality, evidence-based care.
If everything else in the vital signs check is normal but the pulse ox value is low, what should you do?
Recheck it, may not be reading normally
how do you document an injection
Record in MAR Include patient name, drug, dose, date, time, site of administration. Include any adverse effects: redness, swelling, pain. All PRN injections should be documented in MAR and the nurses notes with description of patient's condition that warranted the medication administration AND his/her response.
What does a complete blood count measure
Red blood cells (RBC) Hemoglobin (hgb) Hematocrit (hct) White blood cell count (WBC) Platelets (PLT)
what does a nursing care plan help with
Reduces the risk for incomplete, incorrect, or inaccurate care
what are values
Reflect what we believe Related to ethical conduct Directs ethical conduct Stand alone guide to one's behavior If I place high value on patient safety, I am likely to go out of my way to ensure the patient remains safe.
What does nursing care help patient do?
Resolve actual health problems, prevent potential problems, maintain a healthy state
Exchanging gases in the alveoli
Respiration (transport)
How can we promote regular bowel habits?
Respond quickly when patient calls for assistance to have BM Positioning, privacy Teach about adequate hydration, fiber in diet, activity/exercise Respond quickly after a BM - to assist with hygiene
the code of academic and clinical conduct includes which values
Responsibility to Society Uphold trust that society places in the student Advocate for the rights of patients Maintains confidentiality Safety of clients Timely care Compassionate care Professional care
how do you insert a catheter in a male
Retract foreskin if not circumcised. Cleanse meatus outward in circular motion using 3 cotton balls. Inject lubricant into meatus. (Some places use Lidocaine gel for lubricant) Hold penis perpendicular to body for insertion. Insert catheter to bifurcation ports.
what is the procedure for putting someone on a bedpan/ fracture pan?
Roll patient to their side, slip bedpan under buttocks, turn back and raise head of bed to 30˚ Regular pan- Buttocks rest on rounded shelf Fracture pan- Buttocks rest on shallow rim Place call light and toilet paper within reach; raise siderails x 2. Tip: dust bedpan with powder prior to placement; makes it easier to place and remove.
what are some different ways to collect a urine specimen?
Routine urinalysis Clean-catch or midstream specimens- used for urine cultures Sterile specimens from indwelling catheter 24-hour urine specimen
what does the joint commissions acronym "SPEAK UP" stand for
S- speak up, ask questions P- pay attention to the care E- educate yourself (about illness) A- ask trusted family member/ friends to advocate K- Know what your meds are and why your'e taking them U- use facilities that you can check out carefully P- participate in healthcare decisions
when writing goals and expected outcomes, you should use the SMART acronym. what does it stand for?
S-Specific M-Measurable A-Attainable R-Realistic T-Timed
what are some side effects of st johns wort
S/E: dry mouth, dizziness, fatigue, sensitivity to light
Rules and regulations governing nursing practice are reviewed and revised on a regular basis. To stay current, nurses must read updates from their boards of nursing and seek continuing education in the legal aspects of nursing practice. Inform patients of procedures before initiating care. If there is any doubt about a patient's comprehension of a procedure, asking the patient to explain what is to be done will alert the nurse to any areas of ambiguity that need clarification and ensure patient understanding. Nurses must be careful when discussing information about patients and colleagues.
SAFE PRACTICE ALERT!
What is the "circle of life" and what should you teach patients to stop it
SOB—> anxiety —> SOB—> Respiratory treatments—> increased HR—> anxiety —-> increased RR—-> anxiety and then it is a continuous loop Teach the patient: the respiratory treatment will increase HR, if they know it'll happen, it will decrease their anxiety and fears, breaking the circle
what are some signs and symptoms of sensory deprivation
Sensory deprivation - perceptual, cognitive, and emotional disturbances Perceptual - daydreams, hallucinations, unusual body sensations Cognition- attention span, memory, problem solving, task performance, confusion Emotion- apathy, anxiety, fear, anger, panic, depression Physical - drowsiness, excessive yawning Escape behaviors- eating, exercising, sleeping
Why is the texas cath called a texas cath
Service men from the Korean War were sent to a VA hospital in Texas if they were injured. Many required the internal catheter that were popular at the time, many got urinary track infections. Nurses came up with the idea of cutting the nipple of a condom and inserting a hose, an idea that should of been patented but was not. After the war a nurse got a patent and started a company called Clinical Products with the Texas Catheter as the main product. The company later sold to Cheeseboro Ponds
what are some signs and symptoms of narcolepsy
Sleep attacks, cataplexy, hypnagogic hallucinations, sleep-onset REM periods, sleep paralysis
a patient is on a restricted sodium diet, they should avoid high sodium foods. what kinds of foods should they avoid
Smoked meats Can vegetables Butter, margarine, cheese Shellfish Can soups Snacks Microwave meals
Preprinted, established guidelines used to care for patients who have similar health problems
Standardized care plans or clinical care guidelines (CPGs)
things to know about "standard nursing interventions"
Standardized interventions most often set a level of clinical excellence for practice
Used as evidence of the standard of care that registered nurses (RNs) provide their patients
Standards of practice
Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problem *directs the conduct of patient care in a specific clinical setting. *give nurses legal protection to intervene appropriately in the best interest of patients with rapidly changing needs.
Standing orders
how do you collect a 24 hour urine sample
Start collection of urine on an empty bladder Mark you start and stop time Must be kept on ice until turned into lab May be done at home or in hospital
When administering an enema, when should you stop and what should you instruct the patient to do after it is administered?
Stop procedure if patient develops dizziness, nausea, diaphoresis: possibly a vagal response. Once solution given, clamp tube and remove. Encourage patient to hold solution as long as possible, then assist to bedpan, BSC, or toilet when urge to defecate is strong.
during the assessment phase of the teaching/ learning process. the acronym "TEACH" is used. what does it stand for
T- Tune into the patient E- edit patient information A- act on every teaching moment C- clarify often H- honor the patient as a partner in the education process
hinders to effective communication:
T.V. (may be too loud to hear) pain/discomfort (can't absorb info while in pain) noise non participation past experiences feelings sociocultural level (education, culture)
do not take echinacea if you have:
TB, AIDS, PREGNANT , ON IMMUNOSUPPRESSANTS
Unless contraindicated, active, active-assisted or passive ROM exercise should be encouraged and part of a patient's plan of care (T/F)
TRUE
When finding a problem or diagnosis, which steps should you take to solve it?
Take a huge problem Consider what is going on Boil it down to the basics- the pieces Determine the specifics of the problem(s) Name it THEN you can fix it
what is the temperature range and duration of use for moist heat
Temperature: 105-109˚ for 15-20 minutes Change compresses frequently or cover with an Aqua K pad to keep warm (if ordered)
What is standard of care?
The minimum level of care expected to ensure high quality of care to patients
Which is better, a 100% O2 sat with a hemoglobin of 12 or a 100% O2 sat with a hemoglobin of 6?
The more O2 carrying capacity the better! With a HgB of 6- 100% looks well oxygenated but isn't bc there's not enough HgB to carry O2 to cells
how would you "evaluate" a plan for pain related to lack of vaginal lubrication with sexual avoidance
The nurse evaluates the effectiveness of sexual counseling
why is it important to promote sexual health
The patient will establish open patterns of communication with significant other or teach body awareness
what are some outcomes to expect during the identification and planning stage of the nursing process for sleep
The patient will: - Maintain a sleep-wake pattern that provides sufficient energy for day's tasks - Identify stress-relieving rituals that enable the patient to fall asleep more easily - Verbalize feeling less fatigued and more in control of life activities
What is missing in documentation???
The patient's response to the pain medication that is documented! Can be spoken or observed. Pain is relieved. Pain is improving. Pain is worse.
what are the responsibilities of a student nurse
To behave responsibly and respectfully toward all, be accountable for their actions, develop professionally, and strive to learn all that is necessary to care for patients and their families
What is the purpose of NOC?
To identify, label, validate and classify nurse sensitive patient outcomes to field test and validate the classification and to define and test measurement procedures for the outcomes and indicators using clinical data; for each outcome, there are specific, recommended evaluative measures called evaluation indicators- such as the patient's physical condition, behaviors, or perceptions that are measured of outcome achievement
What is the aim of self-management?
To minimize the impact of chronic disease or sudden acute illness on physical health status and functioning and to enable people to cope with the physiological effects of an illness
What action should the healthcare provider take if the hemoglobin level is below 8 g/dl
To order blood transfusion
what are some of the functions of a nephrostomy
To remove or dissolve renal calculi To obtain direct access to the upper urinary tract for various endourologic procedures To diagnose ureteral obstruction, filling defects, and anomalies via antegrade radiography To deliver chemotherapeutic agents to the renal collecting system To provide prophylaxis after resection for local chemotherapy in patients with tumors of the renal pelvis
what is an example of contractures?
Tonus: state of slight contraction of skeletal muscle-the usual state of muscle contraction Contractures: permanent contraction of a muscle
what is sensory overload and what can cause it
Too much sensory stimuli (Brain unable to respond meaningfully or ignore the stimuli) Autism PTSD Generalized Anxiety **Person feels out of control and may exhibit all the manifestations observed in sensory deprivation
what do you need to include when documenting irrigation of a catheter
Type & amount of solution used. Open or closed irrigation. Rate of solution administration. Description of output- color, presence of clots or debris. Discomfort/pain. Amount of output.
what does URGE (pertaining to restless leg syndrome) stand for
U- urge to move legs R-rest induced G- gets better with activity E- evening symptoms are more severe
what are some complications of immobility?
Unable to perform activities of daily living (ADL) Bathing self-care deficit r/t cast on right arm Dressing self-care deficit r/t effects of stroke Or Activity Intolerance r/t prolonged bed rest At risk for constipation r/t immobility At risk for skin breakdown r/t immobility
Bowel assessment, collecting history:
Uncomfortable topic for us and the patient. We must overcome our discomfort, part of developing our professionalism. Our professionalism and questions help the patient overcome their reluctance and jog the patient's memory.
what are some variables Leading to Back Injury in Healthcare Workers
Uncoordinated lifts Manual lifting and transferring of patients without assistive devices Lifting when fatigued or after recent back injury recovery Repetitive movements such as lifting, transferring, and repositioning patients Standing for long periods of time Transferring patients Transferring/repositioning uncooperative or confused patients
this act gives the legal definition of grief
Uniform Definition of Death Act (1981)
how would you document a Patient's Rude Behavior?
Upon entering the patient's room, he stared at me with what appeared to be an angry expression. When asked how he was feeling this morning, he responded in a very loud voice, "Get out of my room and don't come back. You're always interfering with visitor time."
why are suprapubic catheters sometimes used
Urethral trauma (damage that has been caused to the urethra - the tube where urine comes out) People who require long-term catheterisation and are sexually active After some gynaecological operations e.g. surgery for prolapsed uterus or bladder, or surgery for stress incontinence Long-term catheterisation for incontinence. Although this is not recommended, sometimes medical staff feel it appropriate to avoid skin problems or other medical complications. Some wheelchair users or people who can't self-catheterise find this method simpler to manage
nursing interventions for stressed patients include:
Use a calm, reassuring voice Explain all the procedures, including sensations they will likely feel Stay with the patient to promote safety, reduce fear Listen attentively Instruct patient to use relaxation techniques Assess for verbal and non-verbal signs of anxiety Stress Relievers
Tips To Remember For Injections!
Use a darting motion Use Smallest needle gauge for site selected and appropriate needle length! Inject into Relaxed Muscles! Avoid areas that are hard to palpation or tender to the patient! Inject medication slowly (10 sec per ml)! Apply gentle pressure after injection! Rotate site when giving repeated injections! Allow patient to express their fears. Take time to answer questions!
what is the correct way to turn a patient in bed
Use a friction reducing sheet and move the patient to the edge of the bed, opposite of the side which he or she will be turned. If patient is able, have them grasp the side rail on the side they are turning
As you implement interventions, what should you do
Use critical thinking to confirm whether the interventions are correct and still appropriate for that patient
how should you break the ampule neck and draw up the medication
Use gauze to break the ampule neck and draw up medication using a filtered needle or straw.
which sites can you use the Z track Technique for when administering IM injections
Use in larger muscles: Ventrogluteal or Vastus lateralis. Recommended for all IM injections. Reduces pain and discomfort. Recommended for elderly patients with reduced muscle mass.
when administering PT (per tube) meds you should-
Use liquid meds when possible. Otherwise, crush meds to fine powder. Never crush sustained release (i.e. SR, ER, LA) meds. Certain capsules may be opened and emptied into med cup - not sustained release spansules. (would cause them to get whole dose at once) Dissolve med in small amount water. If NGT or PEG without J, stop tube feeding to administer meds. If PEG with J, may administer meds in G port while simultaneously administering tube feeding in J port. Verify placement as appropriate; check residual volume. Flush with at least 15 ml water before and after each medication. Exception: if on fluid restriction, eliminate water flushes except at beginning and end of med administration. Never add meds directly to tube feeding formula. If tube is connected to suction and PT meds are ordered, turn off suction to give meds and leave suction off for 1-2 hours after med administration. *verify placement for NGT only!
how do you insert a catheter in a female
Use only non-dominant hand to separate labia. Use 3 strokes downward to cleanse: One on either side of meatus (within the labia) Once down middle (Tip: WINK of Meatus) Insert using gentle motion. Never force catheter! Always protect privacy!
things to know about recapping needles/ safety
Use safety guard if present. Do NOT re-cap needle otherwise. Goal: prevent needle-sticks! Dispose of entire syringe & needle into Sharps container marked "Biohazard".
which kinds of patients are intermittent catheters used on
Used by patients with spinal cord injury or neurologic conditions.
what are coordinated body movements
Using major muscle groups, rather than weaker ones, and taking advantage of the body's natural levers (arm) and fulcrums (joints)
give one utilitarian belief and one deontologic belief in the instance of abortion
Utilitarian - one nurse may believe that abortion is ethically justified in situation that result in the best consequences for the woman Deontologic - another nurse may believe that abortion is wrong based on a rule that an innocent life should never be taken.
what is produced when straining to have BM, coughing, vomiting.
Valsalva maneuver (VM) "bearing down" *can cause a brief drop in blood pressure: bearing down increases intrathoracic and abdominal pressure which exerts pressure on vena cava and reduces venous return to heart in BP. When stop VM, surge in venous return and blood pressure, dangerous with hypertension. Avoid straining with hypertension. Valsalva maneuver also causes vagal stimulation which can decrease or stop heart rate (HR) especially in patients with heart disease. Implications for nursing? In patients with heart disease
THINGS TO KNOW ABOUT RENAL FAILURE
Varying degrees - nephron begins to fail to regulate fluid, electrolytes, wastes. Usually causes decrease in output, but may increase. Acute vs chronic dialysis. Nephrotoxic meds can damage the kidney/nephron i.e. long-term use of NSAIDS, some antibiotics
what are the IM injection sites
Ventrogluteal Vastus Lateralis Deltoid Dorso-gluteal (No longer recommended)
Full flow from flow meter Adjustable to allow more/ less room air to dilute pure o2 USED FOR HIGHER CONCENTRATIONS OF O2 24-50% Not usually humidified
Venturi mask
Most people with pulmonary/ vascular problems are
Very anxious
Low pitch, soft- peripheral lung sounds
Vesicular
what are the parts of the Sensory
Visual Auditory Olfactory Gustatory Tactile Sterognosis- the ability to touch something and know what your'e feeling
what is a concept map
Visual representation of all of a patient's nursing diagnoses that allows you to diagram interventions for each -Group and categorize nursing concepts to give you a holistic view of your patient's health care needs and help you make better clinical decisions in planning care -Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information
what is the antidote for coumadin
Vitamin K
what vitamin helps clot blood
Vitamin K
what re the patient guidelines for stool collection
Void first so that urine is not in stool sample. Defecate into the collection container rather than toilet bowl. Do not place toilet tissue in the bedpan or specimen container. Notify nurse when specimen is available
what are some examples of moist heat
Warm soaks - warm compress: fabric or gauze soaked in hot water; squeeze excess water out. **increases blood flow to site= vasodilation
How should you care for someone with a catheter
Wash hands before and after providing care to the patient. Clean around the meatus daily and after each bowel movement. Cleanse catheter gently from meatus outward during bath. Use mild soap and water to cleanse. Do NOT use: powders, butadiene or lotion Do NOT open the drainage system. Encourage generous fluid intake unless contraindicated. Note and record volume and characteristics of urine
additional tips for feedings
Wear utility gloves any time administering feeding, flushes, or meds. Use tap water (or per agency policy) for flushes unless critically ill or severely immunocompromised. Then use sterile water for flushes. Assure patient has bowel sounds when receiving tube feeding. Place towel under connection to reduce spill on bedding. Cost-effective: if partial can or bottle used, label remainder with patient's name and date; refrigerate. Be sure to include all feedings, meds, and water flushes on I&0 record as PT intake.
How do you calculate BMI?
Weight (pounds) X 703 = BMI _____________________________ Height (inches)squared
which medication affects vision
Wellbutrin
What do we do with the residual? Give it back unless __________________designated by agency/physician i.e. ______ml
What do we do with the residual? Give it back unless AMOUNT designated by agency/physician i.e. ____150__ml
Lung sounds that sound like whistling during inspiration and expiration
Wheezes
When is coughing bad
When it doesn't clear airway
When is coughing good
When it is productive and clears airway
When does reflection-in- action typically occur?
When there is a trigger event. The trigger usually involves a breakdown or perceived breakdown in practice. Involves a nurse's ability to recognize how a patient is responding, then adjusting interventions as a result
You should teach a patient to cough at which times of the day to help clear airway?
When they 1st wake up, before eating and before bed
Complete systems of practice Set of beliefs about origin of disease, ways to promote health, and types of treatment • homeopathy • naturopathy • ayuverda
Whole/Alternative Medical Systems
emergency preparedness- things to know (words in bold are on sheet)
Why do we need emergency preparedness? What is a disaster? tragic event of great magnitude that requires the response of people outside the involved community. Nurses are FIRST RESPONDERS, and need to be aware of their role when emergency or disaster occurs Since 9/11 and subsequent anthrax attacks, attention has been focused on national security and strategies for sustaining emergency preparedness levels DISASTERS can be NATURAL (flooding, hurricane) or MAN MADE (terriorist attack) NDMS (NATIONAL DISASTER MEDICAL SYSTEM) has responsibility for the coordination of health care practitioners who supplement local disaster responses in large scale disasters. -HOMELAND SECURITY, VETERANS AFFAIRS, DEFENSE DEPT. all supply funds, equipment, training and medical personel. but nurses have a critical role in caring for victims of a disaster -CDC is committed to responding rapidly to mass trauma events as well as chemical, biological, radiologic and nuclear agents STRATEGIC NATIONAL STOCKPILE OF DRUGS needed for outbreaks of man-made disease such as anthrax are available across the country. These are large quantities of medicine and medical supplies ready to be moved out in the event of a public health emergency
Why give it back? To prevent _____________ & __________________ imbalance; aspirate may contain _______
Why give it back? To prevent FLUID & ELECTROLYTE imbalance; aspirate may contain MEDS
How do you preform a Manual Removal of Fecal Impaction
With gloved and lubricated finger (KY jelly), assess rectum for impaction: Obtain order from physician. Have patient lie on side. May have order to administer cleansing or oil retention enema first. With gloved and lubricated finger, work slowly and gently to break up and remove impaction; minimize discomfort. Vagal stimulation during fecal impaction can also cause bradycardia.
if you are mixing medications from 2 vials( a multi dose and a single dose vial) which one are you going to withdraw from first?
Withdraw from multi-dose first
is you are mixing medications from 1 ampule and 1 vial, which one are you going to withdraw from first?
Withdraw from vial first
according to the ____________, palliative care is an approach that improves the quality of life of patients and their families who face problems associated with life-threatening illness.
World Health Organization (WHO)
Is the bladder sterile?
YES
can an intermittent catheter be inserted by a caregiver at home?
YES
can herbs interact with medications? do they have side effects?
YES
do you need a doctors order for insertion and removal of a catheter?
YES
does closed catheter irrigation require a doctors order?
YES
does open catheter irrigation require a doctors order
YES
does stress affect the whole person?
YES
for suprapubic catheter care, do you need a physicians order?
YES
is narcolepsy rare?
YES
Is an ABG test invasive?
YES - requires a blood draw
Does CBC require a blood draw
Yes
what does a culture and sensitivity test check for with a sputum specimen
a bacterial infection **collect in a sterile container
what is a goal?
a broad statement that describes the desired change in a patient's condition, perceptions, or behavior; an aim, intent or end
what is a suprapubic catheter
a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the tummy, a few inches below the navel (tummy button).
what is consultation?
a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies. **Planning involves consultation with members of the health care team.
what is an act-o-vial
a special vial designed to mix the solvent with powder. used in emergency situations
if the urine has a foul odor, the patient may have
a urinary tract infection
what makes an object more stable
a wider base of support and a lower center of gravity
what are some risk factors for urinary tract infections
a. Female - short urethra & in close proximity to anus. Wiping back to front will contaminate urethra. Female: always wipe FRONT TO BACK. b. Indwelling Foley catheter - tubing is direct route for microbes to migrate up into the bladder. Clean around meatus before inserting. Insert using sterile technique. Do Foley catheter care daily during bath and prn Using washcloth and gentle soapy water, clean around meatus and 6 inches of Foley tubing. Avoid raising drainage bag above level of bladder. Causes reflux of urine from tubing into bladder which may introduce infection into bladder. c. Sexually active women Instruct patient to void immediately after sexual activity. May prescribe prn antibiotic/urinary antiseptic to take after sex i.e. Macrodantin (nitrofurantoin) d. Diabetes - hyperglycemia glycosuria. Promotes growth of bacteria. Blood sugar control diminishes risk. e. Elderly - due to retention. Identify and prevent with Foley catheter. Some patients with recurrent UTIs require daily prophylactic antibiotic or urinary antiseptic.
Constipation May be caused by:
a. effects of meds - anticholinergics, opioids, sedatives, Iron b. decreased fluid intake - hardens stool. Ideal fluid intake: 2,000-3,000 ml/day but may be contraindicated. c. inactivity - slows peristalsis. d. inadequate fiber in diet - consume more whole grains, fresh fruits, vegetables, dried peas and beans. e. Chronic anxiety and worry f. Diseases i.e. irritable bowel syndrome g. Hospitalization - combination of all of the above
what is an advantage of intradermal injections
able to see local site reaction to medication. Administer bevel up to visualize wheal in skin.
what is the goal when giving drugs
achieve a blood level within a therapeutic range
phosphorus: major role
acid base buffer, bone and teeth formation, energy storage (ATP; carbohydrate, fat, protein metabolism)
patients with renal failure have______
acidosis
helps use muscle groups that keep many joints in effective range of motion
activities of daily living (ADL)
occurs when a person can no longer feel, hear, see, or know a person or object
actual loss
•Qi flows vertically through body through 12 meridians •Places thin needles at particular acupoints to change flow of energy and restore the balance of yin and yang •Reduces pain, promotes adherence to substance abuse programs, minimizes nausea and vomiting
acupuncture
a sudden loss of kidney function caused by an illness, an injury, or a toxin that stresses the kidneys (kidney function may recover)
acute renal failure (ARF)
Change that takes place as a result of the response to a stressor Ongoing process to maintain homeostasis Necessary for normal growth & development Ability to tolerate change Ability to respond to physical & emotional stressors
adaptation
MOST COMMON HUMAN RESPONSE TO STRESS Vague uneasy feeling of discomfort or dread Unknown source Alert signal that warns of impending danger Enables individual to take measures to deal with threat
adaptive response 2- anxiety
technique for injections- subcutaneous
administer at 45-90 degree angle This depends on size of patient and length of needle *Usually NOT necessary to apply pressure on SQ injections. Gently pat with gauze if bleeding. May apply SLIGHT pressure if needed
technique for injections intradermal
administer at 5-15 degree angle. Aspiration is no longer recommended prior to injection. Likelihood of injecting vascular is very minimal. **Do NOT apply pressure or massage area after intradermal injections! Will disperse medicine. May gently pat with gauze if bleeding
Technique for Injections Intramuscular-
administer perpendicular to skin (90 degrees) *Apply SLIGHT PRESSURE after removing needle on IM injections DO NOT MASSAGE!
hypokalemia: treatment
administer potassium supplements (p.o. or IV)
enacted by agencies with power to make administrative rules and regulations (state boards of nursing)
administrative law
what are some types of nursing documentation
admission notes change-of-shift notes assessment notes electronic charting
Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
admission nursing history form
what re some common record keeping forms
admission nursing history form, flow sheets, graphic records, patient care summer, standardized care plans or clinical care guidelines (CPG's), and discharge summary forms
a mineralocorticoid secreted by adrenal cortex. increases sodium retention in kidneys, water follows
adrenal glands, aldosterone
harmful or unintended effect of medication, diagnostic tests, or therapeutic intervention
adverse reaction
not planned or intended but expected. ex: Benadryl causes sleepiness but you took it for itching
adverse/ side effect
self determination, whistle blowing, being politically active, and being trustworthy are all included in a nurses job as an
advocate
changing attitudes, values, and feelings -At the end of the first teaching session, the client will freely discuss his feelings about his diagnosis of diabetes. -The client will share, at the end of the third group meeting, 2 ways that his lifestyle will have to change to adapt to having heart failure
affective domain of learning
-strong ties to the church -connections to all family -have family loyalty -clergy are highly respected -older ones adhere to folk healing
african
the avg. systolic blood pressure of _____________ is 5mmhg higher than european americans
african americans
may be expanded roles and responsibilities for nurse anesthetists, nurse practitioners
agency legal responsibilities
What is the goal of palliative care?
aggressive management of symptoms
what do transmission based precautions include
airborne, droplet or transmission precautions
what problems may be encountered when giving a loading dose?
allergic reactions to the medication could occur
Resource allocation refers to the allocation of resources to a service, department or project. Rationing suggests that the resources to be allocated are scarce, and thus, there will not be enough to provide everything that is required. This could be supplies or this could be staff. Short-staffing - Robbing Peter to pay Paul. Nurses pulled to other departments leaving department short where pulled from. Very controversial subject right now. Also could be time and how it is prioritized.
allocation of resources
a concern for the welfare and well-being of others, reflected by the nurses concern for the wefare of patients, other nurses, and other health care providers
altruism
people with this disease have trouble sleeping at night
alzheimer's disease
what is a nephrostomy
an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects. Its job is to temporarily drain the urine that is blocked. This allows the kidney to function properly and protects it from further damage. It also helps clear any infection.
what are some medications that cause urinary retention
analgesics, sedatives
how do medial procedures affect the RAS?
anesthetics- affect consciousness by turning off the RAS **melatonin affects the RAS
when communicating with the VISUALLY IMPAIRED, you must:
announce yourself explain before touching safety tell them when you're going orient them to their room/surroundings
if food intake is decreased, the patient is at risk for
anorexia
what are some causes of hypersomnia
another sleep disorder,drug/alcohol abuse, head trauma, injury to central nervous system, medications, depression, obesity, other medical conditions, genetics
IM medications are formulated to have longer duration of effect. Ex.
antibiotics
condition in which a person displays loss and grief behaviors for a loss that has yet to take place
anticipatory loss
what is an example of an internal stressor
anxiety
live close to each other elderly are highly respected limited contact w healthcare isolation is accepted
appalachian
how does exercise effect the GI system
appetite is increased and digestion and elimination are improved
for administering a vaginal cream or suppository, you should use an
applicator *** for a suppository, lubricate with K-Y jelly
when does menopause occur?
around 45-55 years of age
bicarbonate is primarily measured in
arterial blood
what lab should you run to test bicarbonate?
arterial blood gases (ABGs)
when administering a rectal suppository, how far should you insert it?
as far as you can for an adult, 3-4 inches
for PT medications and water flushes, record volumes on I&O worksheet when?
as you administer ** if pump delivered, obtain at the end of shift, clear pump, record
what are some examples of 3rd spacing?
ascites, pleural effusion, pericardial effusion, joint effusion, tympanic effusion
what are the 4 types of yoga
ashtanga lyengar bikram kripaulaor gentle yoga
: focuses on synchronizing breath with a fast-paced series of postures
ashtanga yoga
-extended family is common -lineage is very respected -sharing among family is expected -ying/yang -herbal remedies -believe they should die with their body intact -may refuse surgery -food has an increased salt content
asian
threat or an attempt to make bodily contact with another person without the person's consent
assault
communication that demonstrates respect for all parties, hallmark of professional nursing relationships, "I feel", confident open body posture, eye contact
assertive communication
how do you apply the nursing process for making ethical decisions
assess-Clarify that the situation is ethical in nature Identify- a plan for short-term and long-term using personal and professional moral positions and values to decide course of action plan Implement- your decision Evaluate - what have you learned that will make it better in the future? How can reasoning and decision making be improved in the future? Does the institutional culture need to change
what is the nurses role in assisting male patients with elimination
assist to sit, stand (if able) at bedside to use urinal. If unable, assist with placement of urinal while lying down. Place all the way up to base of penis.
what is the nurses role in assisting female patients with elimination
assist with bedpan or bedside commode (BSC) Position and privacy are important; hygiene afterwards
when can consultation occur?
at any step in the nursing process, most often during planning and implementation.
for continuous feeding, when should you record I&O volumes on worksheet?
at the end of your shift, pump will keep count
what are the different leadership styles
autocratic democratic laissez-faire transactional quantum
self-determination
autonomy
the right to self-determination, professional practice reflects this when the nurse respects patients rights to make decsions about their health care, based on rational thought or reason
autonomy
what is the quantity of normal urinary output
average 2,500 ml/24 hours
if a patient is allergic to latex, what else might they be allergic to?
avocados, bananas, nuts
When should you take Antidiarrheal meds, what do they treat, and what else should you do after taking them?
avoid if acute diarrhea because we want the causative agent to 'exit the system'. Usually treat chronic diarrhea (chronic illness or tube feedings) See Table p.1364 for Antidiarrheal Medications Most common: diphenoxylate and atropine (Lomotil), loperamide (Imodium). Give these meds + replace fluids and electrolytes Teach about laxative abuse If antibiotic induced, replace intestinal microbes with fermented foods that contain probiotics - yogurt, Kefir, Kombucha
•Originated in Vedic civilization of India •Balance among people, environment, and larger cosmos integral to health •Central is patient's basic constitution—dosha •Vata (changeable), pitta (intense), kapha (relaxed) Uses nutrition, exercise, herbs, breathing, meditation, massage, aromatherapy, and purification
ayurveda
what does an unstageable pressure ulcer look like
base of ulcer is covered by slough or eschar 1. slough- can be yellow, tan, grey, green or brown 2. eschar- can be tan, brown, or black **eschar is necrotic tissue that has to be removed before the wound can be staged
assault that is carried out and includes willful, angry and violent or negleigent touching of another person's body, clothes or anything attached to or held by the other person.
battery
why may a suprapubic catheter be chosen over a regular catheter
because it is more comfortable and less likely to give you an infection than indwelling urethral catheters.
why is a student care plan more elaborate than a care plan used in a hospital or community agency?
because its purpose is to teach the process of planning care
when administering vaginal meds, it is important to always wear gloves. what time is the best to administer vaginal meds?
bed time
when is your body in stage 2 in the sleep process?
before and after REM sleep
how should you consult
begin with your understanding of the patients clinical problem -direct the consultation to the right professional -provide the consultant with relevant information about the problem area: summary, methods used to date and outcomes -DON"T influence consultants -be available to discuss consultants findings -INCORPORATE the suggestions
where should the medication be I'm the ampule before breaking it
below the ampule neck
the quality or state of doing or producing good
beneficence
enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties. • Methylphenidate-Ritalin • Modafinil - Provigil
benzodiazepines
all electrolytes except _________ are measured in venous blood-chemistry profile aka metabolic profile
bicarbonate
measured in arterial blood
bicarbonate
what are some sources of bicarbonate
bicarbonate/carbonic acid buffer system (constantly creates bicarb if needed), oral ingestion of sodium bicarbonate(baking soda), OTC meds, aka seltzer, HCO3- supplements
is done in a 105-degree studio with 26 set postures
bikram yoga
aids in improving workplaces and ensuring nurses' ability to provide safe, quality patient care as nonnegotiable
bill of rights
Use of botanicals (herbs), animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, prebiotics and probiotics, whole diets, and functional foods. •Botanical agents= herbs & nutritional supplements are chemical compounds •Available OTC •Dietary supplements - includes herbs and nutritional supplements - are considered foods and manufacturers need to follow FDA labeling requirements •Herbs are NOT regulated for quality or potency
biologically based practices
what are some examples of holistic care?
birth control, family planning, infertile looking to conceive, STI's
-can cause Menopausal symptoms Do not take with chasteberry or evening primrose = seizures Hx seizures, alcoholism,liver disease? = no check BP daily, no alcohol. Don't take with hypertension meds = hypotension. S/E headache, dizziness, cramping , weight gain
black cohosh
What color will stool be if there is blood in it
black, tarry **with the exception of hemotochezia- fresh red blood in the stool
17-23 mg/dL
blood urea nitrogen (BUN)
standard precautions apply to
blood, body fluids, secretions, excretions, non-intact skin, mucous membranes
how is homeostasis controlled in the internal environment
body functions mental health
calcium: major role
bone and teeth formation, neuromuscular transmission, blood coagulation
what is a "PEG with a J"
both a gastrostomy and jejunostomy
OU (oculus uterque)
both eyes
vagal stimulation during fecal impaction can cause what
bradycardia
thirst center, also produces ADH stored in the pituitary gland
brain-hypothalamus
what are areas to avoid when administering a subcutaneous injection
bruised, scarred, inflamed or swollen due to problems with absorption. Avoid area 2 in. around umbilicus
grinding teeth during sleep
bruxism
between the cheek and gum
buccal
Becoming overwhelmed and develop symptoms of stress comparative to the exhaustion stage of anxiety
burnout
How is a PEG tube inserted?
by a physician: inserted into the stomach with a scope that has a light on it, hole pictured in stomach, attached by a balloon on inside and a flange on outside
how would you assess the nature of someone's pain
by asking the patient to describe the pain **also ask if its worse in morning/evening and what provokes it
exerts the opposite effect as PTH: (deposits calcium in the bone preventing resorption) and thereby lowering serum Ca levels
calcitonin
what can zolpidem (ambien) do to elderly people
can make elderly person crazy, may not remember taking before bed
what are the 6 classes of nutrients?
carbs proteins lipids vitamins minerals water
The human capacity to extend care to others, to nurture relationships and to develop the communication, psychological skills and responsibility needed to sustain these networks of care. (Approach to bioethics that directs attention to the specific situations of individual patients viewed within the context of their life narrative- book's definition but teacher prefers the first)
care-based approach
Stress experienced by caregiver usually after caring for family member for extended period of time
caregiver burden
this type of documentation is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options of services required to meet the clients health and human services needs
case management model
Insufficient nutrient intake results in the breakdown of muscle and lean body mass for energy
catabolism
belief: worship of the one God revealed to the world by Jesus Christ. love of neighbor is central tenet. Other beliefs include sin, redemption, salvation, and a final accounting with God. Care of the sick is encouraged. God the author and healer of life is also the healer. human life is a gift from God, many take antiabortion stance, many accept medical science practices: importance of private devotions and Mass attendance on sunday, seven sacraments (importance of baptism, eucharist, penance and anointing the sick), dietary habits (fish on fridays during lint), sexual ethical norms, only natural means of birth control; abortion, euthanasia and sterilization are forbidden
catholic
causes wound to heal much more slowly
cellulitis
this type of documentation focuses only on significant findings or findings from the norm. less time documenting, uses flow sheets, protocols and standards of practice, nursing diagnosis, care plans, SOAP progress notes, and a nursing database
charting by exception
hyperkalemia: nursing
check serum K+ before administering routine K+ supplements
what must you do before you begin to administer medicine
check the dr orders with your MAR before you begin
involves the use of a drug to restrict a patients movement or behavior
chemical restraints **Many healthcare facilities prohibit the use of medications for chemical restraints
During which type of illness (acute or chronic) do slow, subtle changes to the body occur?
chronic
a long and usually slow process where the kidneys lose their ability to function
chronic kidney disease (CKD)
What is an Indication for use of a fecal management system
chronic watery diarrhea.
feeling drowsy a a certain time of day everyday is a part of your ________
circadian rhythm
Liquids that are thin, without pulp, and able to see through
clear liquids
what are some types of therapeutic diets
clear liquids full liquids soft foods
what is the normal clarity of urine
clear, yellow
include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. A monitoring system includes devices that automatically monitor and record biometric measurements (e.g., vital signs, oxygen saturation, cardiac index, and stroke volume) in acute care, critical care, and specialty areas. The devices electronically send measurements directly to the nursing documentation system. Order-entry systems allow nurses to order supplies and services from another department. Computerized provider order entry (CPOE) systems allow health care providers to directly enter orders for patient care into hospital information system. In advanced systems, CPOE has built-in reminders and alerts that help a health care provider select the most appropriate medication or diagnostic test. The direct entry of orders eliminates issues related to illegible handwriting and transcription errors. Potentially speeds the implementation of ordered diagnostic tests and treatments, which improves staff productivity and saves money because the unit secretary no longer transcribes a written order onto a nursing order form.
clinical information systems (CIS)
to disperse the eye medication, have the patient:
close eyes and move eye around evenly, blot gently-DO NOT RUB
what is the abnormal clarity of urine
cloudy
ANA Nurses are expected adhere to moral norms of the profession and to embrace them. See page 98, Column 2 Show book
code of ethics
storing and recalling of new knowledge in the brain The client will list 3 side effects of Lanoxin by the end of the teaching session. The client will score 80% or greater on a 10 question multiple choice test about a vegetarian diet after the presentation.
cognitive domain of learning
what do you examine the patients sputum for
color, volume and odor
2 studies in 2000 reported statistics of deaths in the US hospitals due to medical errors: colorado, utah: new york:
colorado, utah: 44,000 deaths/ year new york: 98,000
damage to the RAS could result in
coma, sleep disorders such as narcolepsy, chronic fatigue, attention deficit disorder
based on decisions that have been set in previous rulings and become precedent for cases that follow.
common law
rapport builders (ways to build a trusting relationship w co-workers etc)
communication and listening skills
Know what your boundaries are . Do not work outside your scope of practice. This varies from state to state. Always follow policy where you work. If you do not agree with policy or think it is outdated, then talk to your administration and join a team to improve or have input into policy updates. Don't stand on the sidelines and gripe about it. Evaluate assignments... if you are pulled to another floor and asked to do vitals or other normal nursing functions, then do them. If you are asked to perform certain functions you have not been trained to do or checked off or certified to do, then it is your responsibility to speak up. Routine skills of nursing are expected from nurses. Some skills are out of your scope and some take special training. Keep skills up to date with the latest EBP. (ie...coke in feeding tube to unstop (old practice) Respect your patients and treat them with dignity
competent practice
Most Important and Best Legal Safeguard
competent practice
a patient has multiple health problems and medical diagnoses. the best way to preform a nursing diagnoses/ intervention is by developing a :
concept map
HIPAA and all that jazz... a patient may tell you something in confidence about his personal life that has nothing to do with his medical condition. Should you go tell your co-workers?
confidentiality
occur at all levels in the medical field- disagreements or difference of opinion causes friction
conflicts
how do you decompress an NGT with suction
connect NGT to connection tubing and to suction. NGT → connection tubing → suction cannister → suction NEVER connect NGT/connection tubing directly to suction. Must connect to suction canister.
the integrity of the urethra is needed to maintain
continence
what is the recommended suction for a salem sump with 2 lumens/ air vent
continuous low negative pressure (suction) is best because air vent prevents injury to mucosa. Recommended: continuous low (30-40 mmHg suction) OR intermittent high (120 mm Hg suction). Never connect suction to air vent. Low intermittent wall suction (LIWS) is no longer recommended for Salem Sump NGT
if violated can be detrimental to your career. Refusing to accept resonable assignments, coming to work late repeatedly or habitually can hinder you completing your work in a timely manner
contracts
when these are kept as stock on a unit: cabinets are double locked ONE nurse carries the keys inventory is counted and signed by 2 nurses beginning and end of shift (witness disposal-know your facility's policy)
controlled substances
Task oriented reactions with higher level of anxiety Attack behavior Problem solving Aggression/ Anger Withdrawal Compromise
coping mechanism II
Behaviors used to decrease stress & anxiety Learned Family Past experiences Sociocultural influences & expectations
coping mechanisms
Curved tip catheter designed for easy insertion **insert tip up, towards patients nose
coude catheter
a direct care method that helps patients use problem solving processes to recognize and manage stress to recognize and facilitate interpersonal relationships. Many counseling techniques foster cognitive, behavioral, developmental, experiential and emotional growth in patients
counseling
****** one ignores differences and proceeds as though they do not exist
cultural blindness
differences in culture, ethnicity, and race. the existence of a variety of cultural or ethnic groups within a society
cultural diversity
***** belief that everyone should conform to your beliefs
cultural imposition
physiologic variations reactions to pain mental health gender roles communication personal space food and nutrition family support socioeconomics health disparities
cultural influences on healthcare
Values are learned through observation and experience. Therefore, they are influenced greatly by what
cultural, ethnic, and religious groups and by family and peer groups. So you can see some of the same things expected of nurses is expected of student nurses.
The manner in which sexuality is perceived by society in turn influences the individual
culture
a shared system of beliefs, values, and behavioral expectations that provides structure for daily living (can be both formal and informal)
culture
******* people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel better
culture conflict
-one is placed in a culture -may cause physiological disturbances due to differences among cultures (some cultures perceive gestures different ways)
culture shock
leads to toxic dose-medicine isn't metabolized like it needs to be and it can cause toxicity or liver/kidney damage
cumulative
what does taking vitamin D in middle age people supposedly do?
cuts the risks of dementia and falls later in life
what are some indications for use for cold therapy
decrease inflammation of new injury, decrease muscle spasm - may alternate with heat for comfort after first 24 hours following injury
what are some indications for heat therapy
decrease inflammation, localize infection, comfort
for the active adult, isotonic exercise _________ HR and ________ BP
decreases both
Intetional tort in which one party makes derogatory remarks about another that diminish the other party's reputation.
defamation of character
Better get yourself an attorney
defendant
hypernatremia: symptoms
dehydration. fluid shifts from cells and cells shrink- symptoms primarily neurological: restlessness, disorientation, hallucinations
Lateral aspect of upper arm. Located just below lower edge of acromion process and midline with the axilla. (Taylor p. 782) Recommended site for adult vaccines and may be used for children 1-18 in age.
deltoid
Not recommended for infants because muscle is not developed enough for medication absorption to be affective. Injections here should be limited to 1 ml amounts. Measure 2-3 finger widths below the acromion process. Avoid radial nerve and artery by administering in midline with axilla.
deltoid injections
An action is right or wrong based on a rule, independent of it's consequences
deontologic
what should you do after inserting an NGT
depends on purpose of tube: decompression/suction, lavage, gavage (feeding, fluids) or med administration
what effect does exercise have on the respiratory system
depth of respirations respiration rates and gas exchange increase
hair follicles and nerves are found in what layer of the skin
dermis
what are the 7 drug effects
desired adverse/ side effect idiosyncratic ALLERGIC interactions tolerance cumulative
what you want the drug to do
desired effect
when preparing for physician-initiated or collaborative interventions, what should be done before implementing the therapy?
determine whether the therapy is appropriate for the patient or not
what factors influence communication?
developmental level gender sociocultural roles and responsibilities space and territoriality physical,mental and emotional state values environment
if the urine smells sweet, the patient may have
diabetes
what is numeric supposably good for
diabetes fat burner potent natural detoxifier natural remedy for inflammation
EXAMPLE OF DIAGNOSIS/ OUTCOME identification for WOUND CARE
diagnosis (problem) -at risk for impaired skin integrity outcome (goal) -skin integrity not compromised diagnosis: impaired skin integrity outcome: tissue integrity
which type of patient should you NEVER give salt substitutes to?
dialysis patient, throws off potassium levels
dumping syndrome is also known as
diarrhea
Means of transmission
direct contact, indirect contact, droplet transmission, touch
if You stick yourself with a needle before injection, you should:
discard needle and syringe appropriately, prepare new syringe with medication and administer to the patient, follow institution policy regarding accidental needle stick injuries.
stock supply- (comes in bulk, typically without a patients name on it) individual patient supply unit dose system computer controlled systems
distribution systems
Discussed further in Chapter 16 Legal safeguard for the nurse If it isn't documented, it isn't done!! TJC do not use abbreviations Signatures
documentation Some states require you to sign entire name when ending documentation Vonda Boone, RN Some first initial and last name.
Previously common site for injections. Inadvertent administration of medication into SQ tissue and sciatic nerve injury NOT RECOMMENDED TODAY! However, you may see older nurses commonly use this site.
dorsogluteal
for administering ear drops for a baby, child under 3, pull the ear
down and back
doing these things late at night can make you stay up
drinking alcohol, caffeine and smoking
eye applications come in the form of
drops or ointment
nasal instillations can be either
drops or spray
determine if drug is in the therapeutic range (ex: lanoxin 0.8-2 ng/dl) -peaks and troughs half life
drug levels
how long the drug will last
duration *nurses need o know the onset,peak, and duration of medications
Every nurse who witnesses unsafe care has a________ to patients to report it!
duty
abnormal or distorted grief that may be either unresolved or inhibited
dysfunctional grief
which sexual dysfunctions occur in females?
dyspareunia- pain during sexual intercourse caused by: emotional problems, lack of secretions vaginismus- the vaginal opening is so tight that penetration cannot happen- kind of rare, can be treated with anti anxiety meds to help the muscle relax vulvodynia-chronic inflammation in the internal/ external genitalia, painful, raw, no cause for it
-Difficulty in swallowing
dysphagia
what are some symptoms of PULMONARY edema?
dyspnea, tachypnea, adventitious lung sounds (crackles, rhonchi)
Insomnia,hypersomnia,narcolepsy, sleep apnea, restless leg syndrome (RLS), sleep deprivation
dyssomnias
use the clean catch method of urine collection for patients with:
dysuria frequency and urgency fever of an unknown origin
what happens during stage 3 and 4 of NREM sleep
each representing about 10% to total sleep, these are deep- sleep states termed delta sleep or slow wave sleep
eason for checking residual? To reduce risk of __________________and assess __________________ ____________________
eason for checking residual? To reduce risk of ASPIRATION and assess GASTRIC MOTILITY
what are some things that can make periods irregular?
eating disorders (anorexia), pregnancy, PCOS (polycystic ovary syndrome), uterine fibroids (benign tumors in the uterus)
what are some physical, sociocultural, and psychosocial factors that influence food choices
economics, culture, religion, tradition, education, politics, social status, food ideology
the increase in hydrostatic pressure and the decrease in osmotic pressure of hypervolemic (diluted) state in the vessels----> fluid shift out of vascular space into the interstitial space=
edema
what is the hallmark of hypervolemia
edema (cane either inflammatory or non-inflammatory (pitting or non-pitting))
caregiver=
effective communicator
accumulation of space in an atomic space
effusion
an abnormal accumulation of fluid
effusion
this age group are at risk for malnutrition
elderly
what is the most popular way to communicate today?
electronic communication (HIPPA) social media email text messages secure communication (a secure portal for info) *** don't post to social media-dint even like or comment
what are some changes in the diet that have been shown to reduce restless leg syndrome
eliminating caffeine, tobacco, and alcohol
which type of patient would require a shorter needle
emaciated patients
what are some examples of nurse initiated interventions
encouraging fluid/P.O. intake, I&O, vital signs, daily weights, assessments, repositioning
Refers to the final phase of a patient's illness when death is imminent. The period of time during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age even if death is not clearly imminent.
end of life
Is the term used for issues related to death and dying, as well as service provided to address these issues. EOL care focuses on physical and psychosocial needs for the patient and family
end of life care
with a scope
endoscopic
• Use of energy fields, such as magnetic fields or biofields
energy medicine
how does exercise effect ones psychosocial outlook
energy, vitality and general well-being increased
what are some causes of urinary retention?
enlarged prostate, decreased bladder contractility
before mixing medications in one syringe, you should always check what
ensure compatibility of the medications first
bedwetting during sleep
enuresis
- occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action
ethical distress
identification with a collective cultural group based on common heritage -largely develops through day-to-day life with family and friends within the community
ethnicity
when one believes that their culture and beliefs are superior to others
ethnocentrism
how often should you change out the feeding bag and administration set ( syringe and tubing) for continuous feedings
every 24 hours
name the QSEN competency: integrate the best evidence with clinical expertise and patient/ family preferences and values for delivery of optimal health care.
evidence-based practice
which QSEN competency goes with this KSA: recognize research findings and clinical practice guidelines and apply to clinical experience. question rationale for routine approaches to care that may result in less than optimal outcomes. facilitate new evidence into standards of practice.
evidence-based practice
a problem solving approach to making clinical based decisions, using the best evidence available
evidence-based practice (EBP)
you can gain water in your system by
excessive drinking, endocrine disorder (both lower serum sodium)
hypermagnesemia: causes
excessive magnesium supplements or laxatives/ antacids that contain Mg++, renal failure
what is the quantity of urinary output in people with polyuria
excessive output
Active exertion of muscles involving the contraction and relaxation of muscle groups
exercise
nurse: need a solid background with specialty area or strong clinical experience.
expert witness
How should you prepare the patient before administering an enema?
explain if never had an enema Position: left side lying or knee chest, drape patient Wear gloves, lubricate tip of tubing Equipment: Fleets enema or disposable enema kit Place a blue pad or towel under patient Have BSC or bedpan available Enema should be warm 105˚-110˚
Soft, pliable sheath made of silicone with self-adhesive externally applied to the penis.
external condom catheter
which kind of catheter requires vigilant skin care
external condom catheters
which fluid compartment is outside the cells (vascular, interstitial)
extracellular (ECF)
water outside the cell
extracellular fluid
nurse called to be a witness who has knowledge of actual case
fact witness
immature renal, hepatic, GI systems, lack certain enzymes for drug metabolism more body water/less body mass
factors affecting drug action ; infants and children
slowed absorption, metabolism, excretion -polypharmacy ( takes lots of drugs (makes metabolism different)) -incorrect taking of meds (may accidentally take spouses med/wrong med)
factors affecting drug action; elderly
used to define a religious preference ** it's like the wind, you cannot see it but you know it's there
faith EX: I am of Christian faith
drape with a hole in it to give you a larger sterile area for males
fenestrated drape
how long does the alarm stage of general adaptation syndrome last?
few minutes to hours
what happens to the body in the first stage (ALARM) of general adaptation syndrome?
fight or flight kicks in- burst of adrenaline, increased blood pressure, increased heart rate, blowing off less oxygen
hydrostatic pressure pushes fluid from greater pressure to an area with less pressure and this movement of fluid is called____
filtration
-described the work of nursing as putting patients in the best condition for nature to act upon them, emphasizing touch and kindness along with the healing properties of the physical environment, including fresh air, sunlight, warmth, quiet, and cleanliness. - viewed people as multidimensional beings inseparable from their environment. Takes in all aspects of the pt , not just the disease All aspects of the patient are connected - a change in one part will be reflected in other parts
florence nightingale
Nursing theory based on holism =
florence nightingale
who are some examples of great leaders
florence nightingale billy graham mother teresa
Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
flow sheets and graphic records
What are some causes of diarrhea?
food intolerance i.e. lactose, gluten. when tube feeding started (dumping syndrome) side effect of antibiotics - killing off 'healthy' bacteria which allows overgrowth of others i.e. clostridium difficile (c. diff), leading to diarrhea Acute anxiety Meds - magnesium, MOM for constipation
why does an indwelling catheter remain in place?
for continuous drainage
how long should you leave a catheter in?
for the shortest time possible
willful and purposeful misrepresentation that could cause or has caused loss or harm to a person or property. Misrepresentation of a product. Calling oneself a nurse when you have no nursing license. Misrepresenting the outcome of a procedure could be considered fraud.
fraud
what are some sources of potassium
fresh fruits (especially oranges, bananas and cantaloupe) and dried fruits, vegetables (especially beets, tomatoes, lima beans, and potatoes) died peas and beans
Milkshakes, all juices, blenderized foods, custards -anything liquid at room temp
full liquids
after administering the ear drops you should:
gently press on the triages a few times and loosely insert a cotton ball in the ear. instruct the patient to stay in the same position for at least 5 minutes
-stimulates appetite Lack of sleep produces this hormone
ghrelin
this hormone increases with lack of sleep - it also makes you hungry
ghrelin
__________________ develops within 6 nights of sleep deprivation -cortisol levels also increase
glucose intolerance
what are some things that can prevent rest
going to the gym, going to walmart, cleaning etc.
The alignment of body parts that permits optimal musculoskeletal balance and operation **Promotes healthy physiologic functioning
good posture or body alignment
Designed to protect healthcare workers when they give aid in emergency situations. These laws vary from state to state but all states have them. Nurses are covered in some states but not in others. Certain acts are covered in some states but not in others. In some states it is mandatory for healthcare personnel to help in emergencies and in some states it is optional to help or not. The GSL will cover the nurse unless there is gross negligence found.
good samaritan law The GSL will cover the nurse unless there is gross negligence found.
our program includes
graduate competencies, course competencies and unit competencies
Is an emotion in relation to loss; it can be viewed as a behavioral response to death and dying
grief
what are some factors that increase Basal metabolic rate
growth, infection (UTI's), fever, emotional tension, extreme environment, temperatures, elevated levels of certain hormones
how long should you clean your hands for hand sanitizer vs. soap and water
hand sanitizer= 15 seconds soap and water= 20 seconds
the transfer of patient specific info by one healthcare professional to another with the purpose of providing a patient with safe, continuous care
hand-off communication
to give effective care to a dying patient, the nurse must FIRST:
have accepted his/her own feelings about death & understand the stages of grieving and dying
what are some questions to ask yourself before delegating?
have i communicated clearly to the UAP? (unlicensed assistive personnel) -is there adequate RN supervision available -would a prudent nurse delegate this task? -does my state have rules and regulations that support this delegation? -does my state/ facility allow delegation -have I assessed the patient and evaluated current needs? -have I assessed the UAP's abilities?
to administer nasal instillations, you should:
have the patient blow the nose first, if necessary. for spray: insert in nostril, teach patient to inhale while spraying for drops:tilt head back to instill
what are the pressure areas where pressure sores can occur
head, back of upper/ lower arm, hand, wrist, elbow, shoulder blades, spine- anywhere that the bone hits the chair
is the "application of computer and information science in all basic and biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use, and communication of health-related data."
health informatics
what is a Stronger predictor of health status than age, ethnic background, socioeconomic status
health literacy
responsible for perfusion
heart, blood vessels
Example of implementing care to meet patient goals:
help patients adhere to the treatment plan
what type of relationship is a nurse-patient relationship?
helping relationship
-Adults: 12 -18 g/dl -Elderly: 10 - 17 g/dl -Hematocrit Adults: 40- 50% ( a little lower in elderly)
hemoglobin
what are common medications that are administered subcutaneously
heparin and insulin. *Requires rotation of sites if giving repeated injections. Ex: Insulin
are sodium levels high or low in the blood
high
men with a waist to hip ratio of >1.0 and women with a waist to hip ratio of >0.85 are at a ___________________ risk of MI
high
if my calcium level is low, my phosphorus level will be_________
high (inverse relationship) (decreased phosphorus levels puts you at risk for hypercalcemia)
connection and interactions between parts of the whole
holism
• Theory and philosophy that focuses on connections and interactions between parts of the whole. • All living organisms, including humans, are continuously connecting and interacting with their environment. • Parts of the organism, whether they are systems, subsystems, or cells, are also continuously interacting and changing. • This continual interaction and change means that the body is not the sum of its parts (as in reductionism), but that it is a unified, dynamic whole.
holism
• theory and philosophy that focuses on connections and interactions between parts of the whole.
holism
Priority setting begins at a __________ level when you identify and prioritize a patient's main diagnoses or problems.
holistic
Mind+ body+ spirit+ emotions+ environment =
holistic nursing
Balance of internal and external environment
homeostasis
state of equilibrium or balance (normalcy) of various functions and chemical compositions in the body
homeostasis
what are nursings core values?
honesty, respect for human dignity, responsibly, accountability, caring and compassion
BULLYING in the workplace
horizontal violence covert bullying
sexuality is defined by
hormones, genitalia
Care provided for people with limited life expectancy, often in the home Focus on the needs of the dying
hospice
Not a place, but a concept of care that provides compassion, concern and support for the dying; providing support and care for persons in the last phases of incurable disease so that they might live as fully and as comfortably as possible.
hospice care
respect for the inherent worth and uniqueness of individuals and populations, in professional practice this is reflected when the nurse values and respects all patients and colleagues
human dignity
what are some kinds of NPH insulin
humulin N and novalin N
what are some kinds of regular insulin
humulin R and Novalin R
essentially blood pressure,the force or pressure within a fluid compartment
hydrostatic pressure
for calcium, >106 is
hypercalcemia
hypophosphatemia: causes
hypercalcemia, excessive PTH
for chloride >106 is
hyperchloremia
for potassium, >5.0 is
hyperkalemia
for magnesium, >2.5 is
hypermagnesemia
for sodium, above 145 is
hypernatremia
for phosphorus, >4.4 is
hyperphosphatemia
condition characterized by excessive sleep, particularly during the day
hypersomnia
• Excessivesleep,particularlyintheday • Mayfallasleepforintervalsduringwork, while eating or during conversations • Naps do not relieve symptoms • Oftendisoriented,irritated,restlessandhave slower speech and thinking processes
hypersomnia
excess of fluid
hypervolemia
excess of water (fluid retention)in interstitial and/or vascular space (ECF)
hypervolemia
for calcium, <96 is
hypocalcemia
for chloride, <96 is
hypochloremia
for potassium, <3.5 is
hypokalemia
for magnesium, <1.5 is
hypomagnesemia
caused by a loss of Na or a gain of water
hyponatremia
for sodium, <135 is
hyponatremia
for phosphorus, <2.4 is
hypophosphatemia
anytime a HYPOvolemic state exists in the vascular system -----> _____________ and ___________
hypotension and tachycardia
has control centers for sleeping and waking
hypothalamus
injury to this may cause a person to sleep for abnormally long periods
hypothalamus
less concentration (more dilute) than blood plasma (normally, the ECF and ICF are isotonic to each other)
hypotonic, hyposmolar
deficiency of water, in interstitial and or vascular space (ECF)
hypovolemia
deficit of fluid (dehydration)
hypovolemia
what are the 3 ways we identify the patient?
identify patients, name, date of birth, check bracelet and ask them to identify themselves when providing care treatment and services
when you get a reaction that is totally opposite of what was supposed to happen- unexpected -typically unique to the patient
idiosyncratic
what are some developmental considerations to think about when dealing with skin integrity
if they are younger than 2 years: skin= thinner and weaker than adults - as child grows, skin becomes increasingly resistant to injury and infection -structure of the skin changes as a person ages -older adults: -maturation of epidermal cells= prolonged -leads to thin, easily damaged skin -circulation and collagen formation is impaired - leads to decreased elasticity and increased risk for damage from pressure
the correct use of body mechanics is a part of _________ _____________ and ____________ _______________
illness prevention and health promotion
what are some benefits of coconut oil (or supposed to be benefits)
improves or reverses alzheimer disease improves type 1 and 2 diabetes improves/ heals many skin diseases provides peak performance energy kills candidas fungus helps w hypothyroidism increases metabolism raises body temp conditions and moisturizes hair kills lice penetrates roots improves dandruff kills many types of bacteria AND viruses promotes weight loss preserves muscle mass promotes ketosis
why would loading doses be given?
in order to increase the volume of the drug in your system
in what direction should you insert a vaginal suppository?
in the direction of the vaginal vault- towards lower back ** make sure to insert the full length of the vagina
black or tarry stools with a foul smell are a sign of a problem where
in the upper digestive tract The term melena is used to describe this finding. *Eating black licorice, blueberries, blood sausage, or taking iron pills, activated charcoal, or bismuth medicines like Pepto-Bismol, can also cause black stools
hypocalcemia: causes
inadequate dietary intake, vitamin D deficiency, hypoparathyroidism or parathyroidectomy (removal of parathyroid)- insufficient PTH, renal failure
hypokalemia: causes
inadequate dietary intake; may be lost through vomiting, GI suction, diarrhea, potassium wasting diuretics
hypernatremia:causes
inadequate water intake, N/V/D, endocrine disorders, diuretic therapy, severe burns, excessive Na+ intake, dehydration
Why is EBP needed?
increase disease rates limited funding (cut costs of hospitals) scientific basis for intervention demand **technology and meds have grown so quickly that it is hard to keep up with
hyponatremia: treatment
increase sodium intake, p.o. and or IV
-standard of care in the ICU -heart disease, kidney disease, endocrine disorders, edema, patients with IV fluids, drains, foley, GI suction, vomiting, diarrhea, NPO, patients with fluid restrictions, newly prescribed diuretics
indications for I&O
a pathogen such as a bacteria, parasite, virus or fungus
infectious agent
name the QSEN competency: use information and technology to communicate, manage knowledge, mitigate error, and support decision making
informatics
which QSEN competency does this KSA go with? continuous learning of information technology skills. recognize and utilize online resources. navigate the electronic health record. protect confidentiality of protected health information
informatics
Nurse's job to provide________ONLY do not give advice, but be supportive of patient and family decision
information
refers to the management and processing of information, generally with the assistance of computers
information technology (IT)
18 years of age Varies from state to state Written - signed by patient or responsible party Not needed in emergency if serious threat to life and patient unable to consent Promotes patient well-being Promotes self-determination (eduate/well-informed patient)
informed consent
what is a situation that you would use moist heat in
insect bite, skin abcess
where is the NG tube inserted
inserted through the nose/nostril into stomach
Difficultyfallingasleep,intermittentsleep,early awaking from sleep • Mostcommon • >60 yrs. , women esp. after menopause, history of depression • During stress, changes in environment, time zones, medications
insomnia
difficulty in falling asleep, intermittent sleep, or early awakening from sleep
insomnia
what is intake and output?
intake- what goes into your body output-what comes out
combination of allopathic and complementary and alternative modalities
integrative care
is acting in accordance with an appropriate code of ethics and accepted standards of practice, this is reflected in professional practice when the nurse is honest and provides care based on ethical framework that is accepted within the profession
integrity
A person committing an _________________ is considered to have knowledge of the permitted legal limits of his or her words or acts.
intentional tort
Assault Defamation Invasion of Privacy
intentional torts
what is the recommended suction for a levine with only 1 lumen
intermittent low suction (30-40 mmHg) to prevent injury to stomach mucosa
your circadian rhythm (sleep wake cycle) is influenced by both _________ and ________ factors
internal and external
provides meaning behind what is spoken, able to manipulate what is said to say what the nurse actually means
interpreter
what is considered the intimate zone? friend zone? social zone? audience zone?
intimate- 45 cm friend zone- 1.2 meters social zone- 3.6 meters audience zone- >3.6 meters
in which layer of the skin are subcutaneous medications administered in
into adipose tissue just below the dermis of the skin. *Slower, sustained rate of absorption. Less blood supply to tissue
which fluid compartment is inside the cells?
intracellular (ICF)
water in the cell
intracellular fluid
When fluid deficit in interstitial and vascular spaces, fluid shifts from__________ which continues dehydration (showsup most when brain cells shrink)
intracellular space
what are the 3 fluid compartments?
intracellular, extracellular and transcellular
which type of injection has the longest absorption time of ALL parenteral
intradermal injection
What is the purpose of an enema
introduction of a solution into the large intestine usually to remove feces Lubricate, soften, increases peristalsis, irritate mucosa
insertion of a tube into a canal
intubation
In the U.S., a citizen has the right to privacy. This can be brought as a civil suit as well as having hefty (individual not institutional) fines The Health Insurance Portability and Accountability Act can fine you up to $250,000 and 10 years in prison.
invasion of privacy
this mineral helps with anemia
iron
hypophosphatemia: symptoms
irritability, fatigue, paresthesias, confusion---> seizures, coma
what are some signs and symptoms of sleep apnea
irritable during day, fall asleep during monotonous activities, difficulty concentrating, slower reaction time
what is a urostomy and what does it do
is an opening in the belly (abdominal wall) that's made during surgery. It re-directs urine away from a bladder that's diseased or not working as it should. The bladder is either bypassed or removed. There are several different types of surgeries, but the most common are ileal conduit and colonic conduit.
belief: allah, one god, who is only one, all seeing, all hearing, all speaking, all knowing, all willing, all powerful. must be able to practice the 5 pillars of Islam. may have fantastic view of health Practices:obligatory prayers, holy days, fasting (ramadan) and almsgiving. koranic law and customs that influence birth, diet (eating pork and drinking alcohol are forbidden), care of women, death and prayer rituals. some muslim women are not allowed to make independent decisions, husbands may need to be present when consent is sought
islam
involves muscle contractions with resistance. Examples: rehab exercise for knee and elbow injuries, lifting weights
isokinetic exercise
muscle contraction without shortening (no movement, minimal shortening of muscles Contracting the quadriceps and gluteal muscles while sitting, increases muscle tone
isometric exercise
same concentration (osmolarity or tonicity) as normal blood plasma.
isotonic EX: isotonic saline is "normal saline"naka NS or 0.9%NS, same tonicity as blood
during which type of exercise does the patient independently moves joints through their full ROM? ***Only active exercise increases muscle mass, tone, and strength. Improves cardiac and respiratory functioning.
isotonic AKA active exercise
involves muscle shortening and active movement. Examples: ADLS, Independent ROM exercises, walking, jogging ... -what we do everyday
isotonic exercise
why is it important to ALWAYS ask you patient if they are allergic to latex?
it can send them into anaphylactic shock ** if they are, don't allow certain things like bandaids with latex, balloons, or rubber bands in the room
if you become impaired when you're a nurse, what should you do?
it is best to self-report to the board. You can be remediated. Never deny you have a problem if you are reported. Own up to your issues and the board will work with you to find a solution. Try to deny it or hide it when the board has proof will only make it harder on you. They will work with you to help you through this issue but only if you are upfront and honest with them. It is not worth losing your license over.
belief: oppose the "false teachings" of other sects; opposition often extends to modern science, including medicine Practices: blood transfusions violated gods laws and, therefore, are not allowed. courts have NOT supported the right of Jehovahs witness parents to refuse lifesaving treatment for their children, therefore its NOT allowed, court can intervene . alcohol and tobacco are discouraged
jatovas witness
belief:formation closely bound with a vine and revelation and with commitment to obedience to gods will. the hebrew bible is the authority, guide, and inspiration of the many forms of religion of the jews Practices: for observant jews: special needs in areas of diet (pork and shellfish forbidden, meat and dairy not combined, meat must be slaughtered and salted to remove all traces of blood) birth rituals, male and female contact, and death. treatment and procedures should not be scheduled on the sabbath. celebrate hannikah
judaism (jewish)
what is chloride regulated by?
kidneys
what is sodium regulated by
kidneys, ADH (retains water, may cause hyponatremia- Na+ follows H20), aldosterone (sodium retention, direct effect on sodium)
what is magnesium regulated by?
kidneys, parathyroid hormone ( increased PTH--> hypercalcemia, hypermagnesemia)
what is phosphorus regulated by?
kidneys, parathyroid hormone ( if PTH is the problem, going to have heypermagnesimia and hypercalcemia too), calcium levels (inverse relationship w phosphorus), vitamin D
when communicating with UNCONSCIOUS PATIENTS, you must:
know hearing is the last sense lost normal tone explain speak before touching environment
focuses on relaxation and coming into balance
kripaula yoga
-Condition of starvation caused by decreased protein intake -Occurs in young children after weaning
kwashiorkor
Statement that describes the intended results of learning
learning objectives
OS (oculus sinister)
left eye
Nurses enter into ___________ with employer and patient. ***Read your job description and know what is expected!
legal contracts
this hormone is lowered by loss of sleep this hormone also tells us to STOP eating
leptin
-suppresses appetite Sleep-Weight Connection with this hormone
leptin Research participants; slept 4 hrs./night; showed an 18% increase in appetite along with marked increases in Ghrelin, marked decreases in Leptin.
lack of sleep can affect which hormones
leptin and ghrelin
how long does a short term goal last for a patient
less than a week
what is the quantity of urinary output in people with oliguria
less than normal output - <400 ml/24 hours
written defamation
libel
- a physical care technique to use when a patient's physiological/ psychological state is threatened
lifesaving measure
what position should you put your patient in when administering vaginal meds?
lithotomy position (provide your patient with draping)
a greater amount of the drug on the first dose to have a higher circulating volume quicker
loading dose
Localized response of body to stress Short term
local adaptation syndrome (LAS)
The diagnostic reasoning process involves using the assessment data gathered about a patient to do what
logically explain a clinical judgment or a nursing diagnosis.
what are some signs and symptoms of sleep deprivation
loss of concentration ,inattention, and impaired information processing, serious safety risks
what is physiologic response II (General adaptation syndrome) seen with?
loss of relationships, severe injuries, and isolation
are potassium levels high or low in the blood?
low
if sodium is high, potassium will be____
low
What does neutropenia cause?
low WBC count **going to treat as immunocompromised
men with a waist to hip ratio of <0.9 and women with a waist to hip ratio of <0.8 are at a ___________________ risk of MI
lower
eye applications: the eye medication is given where
lower conjunctival sac (apply 1/2 inch), NEVER directly over the cornea
what is coffee supposedly good for
lowering the risk of developing alzheimers disease and other memory related illnesses
focuses on proper alignment and holding poses for a relatively longer time
lyengar yoga
hypomagnesemia: treatment
magnesium P.O. supplements or IV magnesium
which 2 electrolytes would you look at if the heart goes into an abnormal rhythm?
magnesium and potassium
what does clinical judgement include?
making appropriate conclusions about interventions to address a patient's response to health conditions or a life process
what are some common sexual orientations?
male, female, asexual, transsexual
BMR is about 1 cal/KG of body weight higher for ________
males
__________ have a higher basal metabolic rate due to larger muscle mass
males
are coude catheters used mostly in males or females
males
Any disorder of nutrition caused by imbalanced, insufficient, or excessive diet or impaired absorption or metabolism of nutrients
malnutrition
when albumin and total protein are both low
malnutrition
Many states have_________________which means your healthcare institution must report positive drug screens or issues relating to impairment to the state board. Not reporting will get them in big trouble later down the road when it is discovered in an investigation. Some states do not have these laws and impaired nurses travel from job to job risking harm to patients. It is imparitive that you report impairment of your own or of someone you work with.
mandatory reporting laws
Work on the structures and systems of the body, including bones and joints, soft tissues, and circulatory and lymphatic systems. therapeutic massages are included in this practice
manipulative and body based practices
Condition of starvation that results from deficient caloric intake
marasmus
how do you measure output on a Nasogastric tube? (NGT)
mark canister at end of shift and measure from previous shifts mark, record the difference
if bicarbonate is high--->
metabolic alkalosis
what are some contraindications for using an NG tube
midface trauma, recent nasal surgery, recent esophageal or stomach surgery, esophageal varices or stricture
what are some sources of calcium
milk and milk products, green leafy vegetables, dried peas and beans, small fish with bones (aka sardines)
-organic elements found in all body fluids and tissues -iron -zinc
minerals
document I&O in
ml
men with a waist to hip ratio of 0.9-1.0 and women with a waist to hip ratio of <0.8-0.85 are at a ___________________ risk of MI
moderately high
personal or communal standards of right and wrong
morals
normal urine= 1.005-1.030 less than 1.005=
more dilute
how many impaired nurses began the slippery slope of drug/alcohol addiction when in nursing school?
more than 1/2
when applying an eye application, clean it by:
moving from the inner canthus to the outer canthus to prevent cross contamination ** do not use the same washcloth for both eyes
which diseases are transmitted through contact (infective colonized)
multi-drug resistant organisms RSV can be transmitted by: diarrhea wound drainage
the united states is...
multicultural, multiethnic and multiracial
hypokalemia: symptoms
muscle weakness, leg cramps, fatigue, cardiac dysrhythmias (could be life threatening)
hypomagnesemia: symptoms
muscle weakness, tremors, tetany, seizures, cardiac dysrhythmias (may be life threatening), disorientation
-the man in the family is the boss -marriage is for sex and parenthood -cremation is not allowed -like to be buried immediately after death -modest dress
muslim
a condition characterized by an uncontrollable desire to sleep
narcolepsy
with this, you experience no stage 1 sleep
narcolepsy
• Uncontrollable desire to sleep • Fall asleep quickly • Difficult to wake up • Sleep fewer hours than others • Sleep restlessly • Neurological disorder
narcolepsy
which tubes are used for short term nutritional support
nasogastric (NGT) and nasointestinal (Dobhoff)
-have medicine men -speak in low tone for sign of respect -indirect eye contact accepted and preferred -grandparents=leaders -peace pipe -family is expected to be a part of their care
native american
12% of _____________have 25 vertebrae instead of 24, leads to increased number of back problems
native americans
what kind of irrigation is preferred
natural irrigation by the patient with increased fluid intake
air moves through the med to create a mist that is inhaled; given with mouthpiece or mask over 15-20 minutes (more like 10 minutes) ** tell them to take slow, deep breaths (to pull it past the dead space)
nebulization
inhaled medications come in which 2 forms?
nebulizer medication or metered dose inhaler (MDI)
what kind of injuries can log rolling cause if not done correctly?
neck, back and spinal injuries. **don't twist the patients head, spine, shoulders, or knees when log rolling. All one motion- get plenty of help
this is determined by the medication being administered
needle gauge
racism, ageism and sexism are all examples of
negative stereotyping
restricted sodium diet AKA
no added salt diet (NAS)
how long should you use echinacea
no longer than 8 days
do we need to verify placement before using a PEG with a J (PEG/J)?
no, because it is surgically placed and well secured
would you every administer a continuous feeding in a peg tube?
no, increased risk for dumping syndrome
marked muscle contraction that results in the jerking of one or both legs during sleep
nocturnal myoclonus
wishy-washy
nonassertive communication
what is the normal odor of urine
none or slight. Infection or concentrated: strong, ammonia smell. Asparagus causes unique odor - normal
what is the benefit of a condom catheter
noninvasive so less risk of infection
The ethical principle of doing no harm
nonmaleficence
beliefs, communication style, values, handling emotions, notions of time, handling physical space, notions of modesty, competition vs, cooperation are all ______ aspects of culture
nonvisible
a BMI of 18.5 to 24.9 is considered_________
normal
where is a nasointestinal tube- small bore feeding tube (SBFT) placed?
nose to small intestine **Assure your agency allows RN to insert (Nurse Practice Act, your state)
what are healthcare-associated infections called
nosocomial infections-Something originating or taking place in a hospital. ****mostly caused by E. Coli, strep, pseudomonas, and staph Iatrogenic -caused by treatment or invasive procedure EX: getting UTI after having a catheter put in- latrogenic and nosocomial infection
defines legal scope of practice for safe, effective care for nurse as advocate
nurse practice act
what is the largest segment of the nations health force?
nursing
Better access to information. Enhanced quality of documentation through prompts. Reduced errors of omission. Reduced hospital costs. Increased nurse job satisfaction. Compliance with requirements of accrediting agencies (e.g., TJC). Development of a common clinical database. Enhanced ability to track records.
nursing clinical information systems
Systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing
nursing ethics
which type of patient would require a longer needle
obese patients
how does body structure affect skin integrity?
obese- excess moisture= skin breakdown emaciated- dehydration- dehydrated skin. also at risk like obese, must be healthy to have healthy skin
a BMI of 30 to 39.9 is considered___________
obesity
if food intake is increased, the patient is at risk for
obesity
what is the nursing diagnoses for a patient with excessive intake related to metabolic requirements, decreased activity patterns, or decreased metabolic needs
obesity or overweight
what can cause insomnia
obesity, depression, diabetes, HTN, MI, alcohol, and caffeine abuse
Nurses have the________ to be competent and willing to secure the health and well-being or good to the patient.
obligation
what are some examples of urinary problems/ diagnoses
obstruction Functional Urinary Incontinence r/t unable to get to the bathroom in time Stress Urinary Incontinence r/t weak pelvic muscles (leaks with coughing, sneezing, jumping) Urinary Retention r/t enlarged prostate Where primary problem results from urinary malfunction Anxiety r/t incontinence Risk for infection r/t indwelling catheter Acute pain r/t bladder spasm Disturbed sleep pattern r/t nocturia
what can urinary retention result from
obstruction of the urethra nerve problems medications weakened bladder muscles
when would an ostomy be used permanently
occurs with cancer or some type of intestinal disease
urinary output diminished, <400 ml in 24 hrs. exception is a patient who has polyuria (seen in people with healthy kidneys- diabetes insipidus & mellitus) as a CAUSE of hypovolemia ** urinary output WILL be concentrated
oliguria (symptom of hypovolemia)
osmotic pressure attributed to colloids i.e. albumin ( a protein) that exerts "pull pressure" in the vascular space
oncotic pressure AKA colloid osmotic pressure (in capillaries)
according the the institute of medicine (1997), what is considered a good death?
one that allows a person to die on one's own terms, relatively free of pain, and with dignity, free from avoidable distress and suffering for patients, families, and caregivers, in general accord with families wishes, and reasonably consistent with clinical, cultural, and ethical standards.
when the drug starts working
onset
what should you drink with high iron foods to increase iron intake
orange juice
if a patient can tell you why they are in the hospital, they are oriented X
oriented X 4
concentration of a solute (i.e. electrolytes, glucose in a fluid (solvent)
osmolality, osmolarity, tonicity
water moves from more dilute area of greater concentration to less dilute
osmosis
a hole in the stomach
ostomy
surgically created opening from inside of an organ to the outside.
ostomy
what is JCAHO
our hospital governing body. They base their safety goals on prior actual incident reports. They are adjusted as goals are reached and as other problems develop.
what is Oh Mittelschmerz?
ovarian pain- one sided or middle pain
where do pressure ulcers occur
over bony prominences, any skin that covers bony prominences
where should you NOT apply heat on the body
over non-inflammatory edema, open wound, acutely inflamed area, scrotum, abdomen of pregnant woman. Do not use heat on bleeding area.
a BMI of 25 to 29.9 is considered ___________
overweight
arterial blood gases (ABGs) MEASURE SEVERAL THINGS, 2 of which are:
pH and oxygenation
Any form of care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure.
palliative care
Care of the whole person - body, mind, spirit, heart & soul Dying is natural and personal - the most appropriate type of care across the spectrum of ideas and illness
palliative care
sleepwalking
parasomnia
include sleep walking
parasomnias
• Somnambulism,sleeptalking,night terrors, bruxism, enuresis, sleep- related eating disorder
parasomnias
regulates calcium, phosphorus hypocalcemia stimulates greater secretion of PTH--> bone reabsorption in increased blood/calcium levels (reabsorption-pulling calcium from bone)
parathyroid glands- PTH
means "outside of intestines or alimentary canal".
parenteral
acting in what is determined to be someone's best interest
paternalism
clinicians make decisions and do it
paternalistic
what are critical pathways?
patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially.
which action is an example of cognitive learning?
patient discovers how to portion food to maintain within a prescribed calorie range
Legal duty of the nurse Standards of education come from nurse practice acts and national professional standards Failure to assess educational needs and educate patient is negligence Be familiar with agency policy Determine your responsibility to education in practice setting Failure to document education can be seen as negligent.
patient education
what is ALWAYS your first concern for everything?
patient safety
Patients and/or their surrogates tell the clinician what to do and he/she does it
patient sovereignty
goals and expected outcomes MUST be
patient-centered
what are the primary causes of musculoskeletal disorders among nurses
patient-handling tasks **Mechanical lifts and other such devices reduce the effect of cumulative trauma and injuries
which people are more vulnerable to stress as adults
people who were neglected and abused as children
loss of youth, of financial independence, and of a valued environment experienced by a person, but intangible to others
perceived loss
coping mechanisms+ sources of support=
perception of stress= adaptation
prepares med checks accuracy contacts prescriber if outside the therapeutic range dispenses information (legally liable to tell what meds do- must give a handout with the med info on it)
pharmacist
Hyperphosphatemia: treatment
phosphate binders, assess PO4 levels before giving PO4 supplements
how is homeostasis controlled in the external environment (food, water, shelter, friends, family)
physical psychosocial
stress can be perceived on multiple levels. what are they?
physical emotional intellectual social spiritual (sometimes it can include all of these, sometimes just one)
what is the difference between physical and psychological loss
physical loss includes injuries, removal of an organ, & loss of function psychological losses challenge our belief system. they are commonly seen in areas of sexuality, control, fairness, meaning, & trust.
Any manual method or physical or mechanical device that restricts freedom of movement or normal access to one's body. A physical restraint is also material or equipment, attached or adjacent to the patient's body that he/she cannot easily remove.
physical restraint (A patient in a New Jersey hospital is restrained in a vest and wrist restraints against the wishes of the family and without a doctor's order, which is required by law. Facing a lawsuit, the hospital settles for $25,000 to avoid a lengthy court battle.) **Ex; applying a wrist, ankle or waist restraint, using an enclosure be, side rails up to prevent patient from getting out of bed. Typically, if the patient can easily remove the device, it doesn't qualify as a physical restraint.
genetic disorders, diseases, fever, poison, drugs, bacteria, heat, and trauma are all examples of which type of stressor
physiologic stressors
what are the 2 types of stressors
physiologic stressors psychosocial stressors
quantified by depth of pitting trace 1+ 2+ 3+ or 4+
pitting edema
this is a questionnaire to determine if you are getting enough sleep
pittsburgh sleep quality index
if a patient is having menstrual cycle irregularities, what should you check? EX: only 3 periods a year
pituitary gland
ovaries "talk" to the
pituitary gland
leads to water retention in kidneys
pituitary gland- ADH
Nurses can and should have a political voice on behalf of those least well served in the healthcare system (ANA is a good organization on political views)
politically active
what are some symptoms of hypovolemia
poor skin turgor (no recoil if dehydrated but can be normal for aging person), dry oral mucous membranes, oliguria, weight loss, elevated labs due to hemoconcentration -vital signs:hypotension,tachycardia, weak thready pulse
the point of escape for the organism from the reservoir EXAMPLES: cuts in the skin, respiratory tract, reproductive tract
portal of exit from reservoir
the point at which organisms enter a new host EXAMPLES: respiratory tract, digestive tract
portals of entry
salt substitutes are high in_________
potassium
what is the chief intracellular ion
potassium
what are the major electrolytes?
potassium (K+) sodium (Na+) chloride (Cl-) magnesium (Mg++) calcium (Ca++) phosphorus (PO4-) bicarbonate (HCO3-)
Patient-centered care requires you to know a patient's _________, ____________, and _________ ____________
preferences, values, and expressed needs
KNOW THESE TERMS
pressure, desiccation, maceration, trauma, edema, infection, necrosis, excoriation
in the nursing process, if the patient is immobile, the outcomes should be directed toward what?
preventing complications related to inactivity EX: constipation, bed sores, pneumonia
Combines elements of both utilitarian and deontologic theories Specific action guides for practice
principle-based approach to ethics
Ethical care is a part of
priority setting
in this type of documentation, the chart is based on a problem list- all problems, present or potential, that are identified with a particular client. everyone adds progress notes on the same sheet
problem oriented medical records
additional ULM competency: competent and skillful behaviors alignment with professional standards. behaving in a manner defined and expected by chosen profession.
professionalism
in the nursing process, if the patient is not having any mobility problems, outcomes should be aimed toward what?
promoting physical fitness
representing the patient in making decisions or having the patient delegate decisions by to another caregiver
promoting self determination
-required to build muscle -labeled as complete (high quality) or incomplete (low quality)
protein
includes baptist, methodist, lutheran and church of christ belief: worship of the one God revealed to the world by Jesus Christ. love of neighbor is central tenet. Other beliefs include sin, redemption, salvation, and a final accounting with God. Care of the sick is encouraged. God the author and healer of life is also the healer. many accept medical science Practices:vary according to denomination; may include prayer, faith healing, "laying on of hands", and anointing, Sacraments: baptism, communion, confirmation Christian- don't believe in medical intervention
protestant
how does sleep-wake transition affect the RAS
provides an inhibitory influence (from external stimuli)- by reducing afferent (sensory neurons) activity during sleep **neurons in the RAS have a higher firing rate during wakefulness
Maslow's hierarchy of needs is included in which type of homeostasis
psychological
to maintain the mental wellbeing of humans, you must maintain________________
psychological homeostasis
learning a physical skill -The client will demonstrate how to correctly withdraw 6 units of insulin from a multidose vial, at the end of the second training session. -The client will perform 2 of the exercises that are suggested for relief of low back pain after reading the pamphlet.
psychomotor domain of learning
floods and car wrecks are examples of which type of stressor
psychosocial stressors
Physiologic alterations d/t psych influences Effect of life changes on person More changes correlated with increased illness (+ & - changes) Life change = event in persons life that requires energy for adaptation. When energy expended to adapt- resistance to illness lowered
psychosomatic disorders
what happens to your body during REM sleep
pulse, respiratory rate, blood pressure, metabolic rate and body temperature increase, increase in gastric secretions • General skeletal muscle tone and deep tendon reflexes are depressed
how does a wound vac work?
puts out negative pressure to help heal the wound, draws out debris- makes wound heal faster
dynamic, ever-present, unfolding
quantum
what are some examples of Local Adaptation syndrome
reflex pain response or inflammatory response to injury or infection
what are the 2 types of bedpans
regular and fracture pan
sodium: major roles
regulates extracellular fluid volume, neuromuscular transmission
what kind of therapy uses the bracelets that "enhance balance"
reiki therapy, softball and baseball players wore them
what are some health benefits for garlic
relieves ear aches, controls diabetes, treats colds, controls asthma, treats intestinal probs, reduces hypertension, prevents acne, treats wounds, prevents cancer, lowers cholesterol levels, protects eyes from infection
what are some cultural influences for sexuality?
religion-In many religions the concept of virginity can be synonymous with purity and sex synonymous with sin-some families don't teach about birth control ethics-A healthy sexuality depends on freedom from guilt and anxiety lifestyle- Lifestyle variables may influence sexual expression
REMEMBER when applying a transdermal patch, you must date and initial it -use firm pressure and warmth of your hand to assure adherence -when disposing of old patch, fold in half and dispose according to policy if applicable (ex: opioids)
remember
when taking care of an unconscious patient, you should
remember Hearing is last to go Talk to person Speak before touching Reduce environmental noises
hypervolemia may result from
renal failure
hyperphosphatemia: causes
renal failure and other causes of hypocalcemia, excessive oral PO4 supplements
hyperkalemia:causes
renal failure, medications (excessive potassium supplements, potassium sparing diuretics EX: spirolactone) - acidosis -tissue trauma (injury where cell has been broken----> potassium in body---> hyperkalemia
if the edema is the same on both sides, the patient has
renal or heart problems
where growth and multiplication of microorganisms occur. - in the natural habitat of the organism EXAMPLES: fingernails, humans, bodies of water, soil, milk, inanimate objects
reservoir
Acutely ill patients often have delayed emptying time in their stomach - gastroparesis, delayed gastric motility. So they may be more prone to retain contents in stomach =
residual volume
what are some examples of different types of formulas for certain diseases/ issues
respiratory disease (Pulmocare) renal disease (Nepro) diabetes (Glucerna) ICU/trauma (TraumaCal)
Individualized Structured by: Culture Family Genetic inheritance Life experiences
responses to stress all of these determine how you handle stress and your stress level
the body is in a decreased state of activity with the consequent feeling of being refreshed, many factors affect a person's ability to rest
rest
OD (ocular dexter)
right eye
diagnosis is applied to vulnerable populations
risk diagnosis
which diagnosis is this an example of: "I'm at risk for falls because I'm taking narcotics"
risk diagnosis
what is the nursing diagnoses for a patient with CVA, neuromuscular disease, decreased LOC, or NG intubation
risk for aspiration
-transcription -administration -recording -monitoring and recording effects of meds-patient assessment(record SEs) -can the patient safely administer? education (teach the patient about the med and the SEs) -communicate with he prescriber -question any unusual order -ACTS AS PATIENT ADVOCATE (calls doc to get patient pain order if she's in pain)
role of the nurse
before drawing up NPH insulin you should always
roll the vial first
which diseases are transmitted by droplet transmission **produced by coughing or sneezing, travel 3 feet or less
rubella mumps diphtheria RSV
What do normal heart sounds sound like
s1, s2 lub dub
name the QSEN competency: minimize risk of harm to patients and providers through both system effectiveness and individual performance
safety
which QSEN competency does this KSA go with? effective use of technology. fall prevention. proper body mechanics for patient and nurse. infection prevention. medication administration. correct surgical site. establish a blame-free culture with our fear of punishment. enhance openness, accountability.
safety
what are the 2 types of NGT's
salem Sump (2 lumens) and Levine (single lumen) Salem Sump: second lumen is air vent → end of tube; equalizes air pressure in the stomach with atmospheric pressure and prevents gastric mucosal damage during suction Salem Sump NGT for suction and intake Levine NGT for feeding Different sizes, measured by 'French' 14-18 Fr for adult. Average length: 42-50 inches *** CAN'T USE LEVINE FOR SUCTION- NO AIR VENT
what are some sources of sodium
salt (naCl), sodium preservatives in processed food (i.e. lunch meats, bacon, processed cheeses) snacks (i.e. chips, pretzels,canned soups and vegetables, condiments and sauces, frozen entrees, fast foods)
what are some sources of chloride?
same as sodium since salt is NaCl- **chloride is the "sister" to sodium *if hyponatremic, often hypochloremic as well
animal fats are what type of fats
saturated fats
what are some sources of phosphorus
seafood, dairy, dried beans, peas, nuts
refers to the confinement of a person alone in a room where the person is physically prevented from leaving.
seclusion *Ex psychiatric issues. Used for patients who are behaving violently. May be used with a physical restraint also
edema is also known as
second spacing
theses are more likely to occur during NREM sleep
seizures
-Adult: 3.5-5.5 g/dl -Elderly: 2.8-3.5 moderate depletion < 2.8 severe depletion Prealbumin -Can more readily measure short-term changes in protein status -Half-life of 48 hours. -Reduced by surgery, trauma, burns, infection
serum albumin
what 2 things are you going to look at if your patient has edema
serum albumin and total protein
A data cluster is a ________________________________________________
set of cues- the signs or symptoms gathered during assessment *!!!!!* Data clusters are compared with standards to reach a conclusion about a patient's response to a health problem. *!!!!!* Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion
hyperkalemia: treatment
several options i.e. Kay Exolate p.o. or PR (per rectal)
when someone has more control over another
sexual harassment
The preferred gender of the partner of an individual
sexual orientation
the degree to which a person exhibits and experiences maleness and femaleness physically, emotionally and mentally
sexuality
•It is the most widely practiced medical system. •Illness is thought to originate in the spirit world. •The shaman or medicine man/woman accesses the spirit world to obtain information on the proper treatment. •Treatment may consist of retrieving lost soul energy, restoring the individual to right relationship with the spirit world, and treating symptoms. •Healing techniques involve native plants and herbs, animals, rituals, ceremonies, and purification techniques
shamanism
respects and uses the preferences of the patient and the expertise and judgment of the clinician
shared decision making
regular insulin is AKA
short acting insulin
Boost energy, stamina, reduces stress, raises HDL Levels, improves blood sugar and diabetic symptoms, improved Sexual performance S/E: jitters, headaches, HTN, vaginal bleeding, pruritus Increased bleeding, manic behavior, increase digoxin levels not with - Coumadin, ASA, NSAIDS nardil (MAO), ALCOHOL, antidepressants -no HTN, PREG., asthma, emphysema
siberian ginseng
what are some other communication skills
silence touch humor
what is an antiflatulent medication?
simethicone
when communicating with someone with a PHYSICAL BARRIER, you must:
simple means of communication PATIENCE safety
a profiled cartridge (EX: tubex) provide how many doses of medication
single doses (Cartridge is inserted into a reusable holder. )
what are some useful listening skills
sit alert but relaxed natural eye contact pay attention think before speaking don't pretend themes
experienced as a result of an unpredictable event
situational loss
what areas should you avoid with transdermal medications?
skin breakdown and hairy areas
spoken defamation
slander
a state of rest accompanied by altered consciousness and relative inactivity; a complex rhythmic state involving a progression of repeated cycles, each representing different phases of body and brain activity.
sleep
-periods of no breathing between snoring intervals
sleep apnea
• Absenceofbreathing(apnea)ordiminishedbreathingefforts (hypopnea) during sleep between snoring intervals • Breathing may cease 10 to 20 seconds - as long as 2 minutes • O2 sat drops, pulse becomes irregular, BP increases • Middle age men, obese and thick necks
sleep apnea
decrease in the amount ,consistency, and quality of sleep
sleep deprivation
• Decreaseintheamount,consistency,or quality of sleep • Results of decreased REM or NREM sleep • Effectsincreasinglyapparent>30hours continual wakefulness
sleep deprivation
Zaleplon (Sonata) and zolpidem (ambient) are what types of medications
sleeping pills
the bladder allows for
slow filling and storage under low pressure
does sympathetic stimulation increase or slow peristalsis
slows
the larger the number, the ____________ the needle
smaller
Choose the __________syringe for the appropriate amount of solution if possible for accuracy.
smallest
when selecting needle gauge,Select the ____________ needle appropriate for the site! *If medication comes in prefilled syringe, determine if that is the correct needle size for the patient.
smallest
upholding moral, legal, and humanistic principles, this value is refected in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality health care
social justice
what is the chief extracellular ion
sodium
-Indicated when clients have difficulty with chewing food -Low in fiber, no grains, no raw fruits or vegetables
soft diet
hypercalcemia:causes
some cancers, hyperparathyroidism (excessive PTH), excessive calcium supplements
in this type of documentation, info is organized and presented in separate sections according to its source (narrative charting is found in this charting system)
source-oriented records
when someone who has a relationship with a higher power -unified force, presence of a higher power, God, can be experienced with a group of people
spirituality **religion, faith and spirituality are often used interchangeably
which stage do you always go back to if woken up during NREM sleep
stage 1
what are some physiologic/ physical factors affecting food habits
stage of development, state of health, medications
ANA established standards of performance as well as standards of care in 1991
standards of practice
Physiological response to food deprivation
starvation
increased BUN levels are associated with___________ or ________________
starvation or excessive protein intake
defines scope of nursing practice-changes from state to state
state federal responsibilities
assumption that all persons from a culture, ethnic group, or race act alike. can be positive or negative
stereotyping
for suprapubic catheter care, use which kind of technique
sterile
which technique should you use to preform urinary catheterization
sterile
Obtained by collecting a urine specimen from an Foley catheter or catheterizing the patient's bladder
sterile urine samples
for administering ear drops for a child 3 years or older, pull the ear
straight back
A condition in which the human system responds to changes in it's normal balanced state. Change in environment that is perceived as a challenge, threat or danger
stress
Anything perceived as a challenge, threatening , or demanding Can be internal or external Body's Response to Stress -(physical, behavioral, cognitive, emotional)
stressor
which side of the body does a cane go on? (strong or weak)
strong
-found in cultures -members of a larger culture but have certain ethnic, occupational, or physical characteristics not common to the culture
subculture
for the nursing process for physical assessment, data should be both________ &__________
subjective and objective
what are the 2 types of data?
subjective and objective
under the tongue
sublingual
what is an example of a negative stressor
substance abuse because of the physical response to stress
Nurses who make slander/ libel remarks against patients or coworkers run the risk of being _____
sued
which type of catheter is preferred for long term use
suprapubic
Surgically inserted into the bladder through a small incision above the pubis. **goes directly into the bladder
suprapubic catheterr
a person likely to get an infection or disease, usually because body defenses are weak
susceptible host
what are the stages of pressure ulcers
suspected deep tissue injury stage 1-red/ inflamed stage 2- blister, open sore-red irritated stage 3- crater-like, extends to layer of fat beneath skin stage 4- extends down to muscle/ bone unstageable
what are the steps of problem solving
suspend judgement----> analyze---> explore solutions
A set of planned activities performed to influence knowledge, behavior, or skill; an interactive process
teaching
a direct care method that focuses on intellectual growth or the acquisition of psychomotor skills.
teaching
name the QSEN competency: function effectively with nursing and inter professional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care
teamwork and collaboration
which QSEN competency does this KSA go with? act with integrity, consistency and respect for differing views. recognize contributions of team members, value their perspectives, expertise, and unique contributions. adapt own communication style to the needs of the team and situation, work together and accomplish patient care goals
teamwork and collaboration
most calcium is found where in the body?
teeth and bones, very little in blood
what can your circadian rhythm influence?
temp the way your hormones secrete metabolism mood
hyperphosphatemia: symptoms
tetany, anorexia, nausea, muscle weakness, tachycardia
you should not take st johns wort with which types of medicines
tetracyclines, digoxin, birth control Antidepressants, anticonvulsants , coumadin
•cold/heat, interior/exterior, excess/deficiency, and yin/yang (the chief principles) analyze symptoms and categorize conditions
the 8 principles of chinese transitional medicine
what happens if the body is deprived of REM sleep?
the body tries to make up for it
during the nursing process, when organizing your approach to nursing care to care for patients, you'll need to incorporate the nursing process and what?
the interview process
Defines "who," "what," "where," "when," "why," and "how" of nursing practice Who: Registered Nurses (RN) and Advanced Practice Registered Nurses (APRN) comprise the "who" constituency and have been educated, titled, and maintain active licensure to practice nursing. What: Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations. Where: Wherever there is a patient in need of care. When: Whenever there is a need for nursing knowledge, compassion, and expertise. Why: The profession exists to achieve the most positive patient outcomes in keeping with nursing's social contract and obligation to society.
the nursing scope and standards of practice
what is your primary source for gathering data?
the patient
a patient is suffering from shortness of breath, what is the correct goal statement?
the patient will breathe unlabored at 14-18 breaths per minute by the end of the shift
in humans, what is the center of gravity while standing
the pelvis
who is responsible for obtaining the consent?
the person preforming the procedure
When implementing an intervention, It's important to know:
the purpose of an intervention, the steps in performing the intervention correctly, the current medical condition of the patient, and his or her expected response, Apply intellectual standards (the guidelines for a rational follow up and responsible action)
when administering a rectal suppository, which end should you insert first?
the rounded end (make sure you always wear gloves and lubricate the suppository)
also known as frameworks, are systems of thought that attempt to explain how we ought to live and why
theories
what do older generations tend to do with stress?
they bottle it up
What are Cheyne-Stokes respirations?
they involve periods of apnea alternating with periods of hyperventilation
when fluid shifts into the transcellular compartment, it is called
third spacing
what are the most missed areas when cleaning our hands
thumbs, fingertips, in-between fingers **some healthcare providers clean their hands less of half of the times they should
produces calcitonin
thyroid gland
what are the signs and symptoms of insomnia
tired,lethargic,irritableduringday, difficulty concentrating
why is a suprapubic catheter used
to Divert urine from urethra during injury, stricture, or swelling.
why might heat or cold be applied to a specific part of the body
to alleviate pain
what is an indwelling catheter used for
to decompress a distended bladder
what is the main purpose of critical pathways
to deliver timely care at each phase of the care process for a specific type of patient.
What is the purpose of a Fecal management system
to drain watery diarrhea and to protect the skin
when instructing a patient on how to use an MDI, what are you going to tell them?
to exhale completely, place the mouthpiece in mouth, then when beginning with inhalation, push canister and take a slow deep breath to get med to ends of airways. (a spacer (between medication and mouth) may be used)
what is the purpose of documentation in nursing
to facilitate communication, to promote good nursing care and to meet professional legal standards
what is the goal of ROM?
to keep the patient in the best possible physical state when bed rest is necessary.
why do you keep the catheter below the bladder?
to keep the urine from going back into the bladder and causing an increased risk of infection
GOAL of QSEN:
to prepare nurses so they can continuously improve the quality and safety of the healthcare systems in which they work
what is the goal of the QSEN competencies
to prepare nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare system in which they work
what is the purpose of irrigation
to restore or maintain patency of the catheter. Must have a doctor's order! Irrigation rinses out the bladder and can instill medication into the bladder.
after administering the rectal suppository, what are you going to teach the patient?
to stay in the same position for at least 5 minutes so you have no urger to expel
medicated creams, lotions, powders (ex: topical powder for fungal infection) **** apply to clean,dry skin
topical route
Intentional acts of wrongdoing Unintentional acts of wrongdoing can also be a crime meaning it can be prosecuted under both criminal and civil law.
torts
• Characteristics of Yin and Yang • Yin: Cool, moist, dark • Yang: Hot, dry, light • Preponderance (Excess) of Yin/Preponderance (Excess) of Yang Weakness (Deficiency) of Yin/Weakness (Deficiency) of Yang
traditional chinese medicine (TCM)
what is the name of fat when manufacturers partially hydrate liquid oils
trans fat
"I pay, you do"- pay and reward-only work for the reward
transactional
cerebrospinal, intraocular, pleural, pericardial
transcellular compartment
which fluid compartment includes the cerebrospinal, intraocular (in eye, space w fluid but no cells), pleural (visceral pleura and parietal pleura),pericardial (tough fibrous membrane protecting the heart), and peritoneal (around tissues and organs)
transcellular compartment
ointment and patches (nitroglycerin ointment/patch, fentanyl patch, estrogen patch) *** note the ordered frequency (daily or less frequently) -be sure to remove old patch or cream before applying to prevent double dosing
transdermal medication
- intellectually stimulating ex: having the gift of speaking
transformational
what are the 2 types of flora found on the hand
transient- easily washed away by hand washing resident- harder to wash away **to prevent transient from becoming resident, wash with soap and warm water when hands are visibly soiled, touch body fluids, or patient has C. DIFF.
restates in targeted language
translator
what are used in addition to standard precautions for patients with suspected infection
transmission based precautions
what is the difference between transsexual and transgender?
transsexual-crossdresser (transvestite) (male and dresses like female) transgender- changes their genitalia
what is the procedure for taking someone off of a bedpan/ fracture pan
turn patient off pan, being careful not to tip pan. Place pan on floor prior to emptying and while assisting with hygiene. Note color, clarity, and quantity of urine and any abnormal odor or sediment. If keeping I&O, don't drop toilet paper in bedpan or BSC.
to administer local application of heat or cold, what must the doctors order include
type of therapy, duration of each treatment, frequency of treatments For example: warm compresses to left forearm 15 minutes, four times a day
standing orders prn orders-usually for pain medicine administration (strictly nurses responsibility) single dose or one time orders-dint see often STAT orders- Must be given then **** all medication orders must be rewritten after surgery
types of medication orders
what is urinary retention?
unable to empty bladder completely. increases risk of infection.
a BMI < 18.5 is considered_________
underweight
Negligence Liability
unintentional torts
ICU nurses, OB nurses
unit responsibility
for administering ear drops for an adult, pull the ear
up and back
when administering a rectal suppository, which direction would you push it?
up towards the umbilicus (do it quickly)
To insert a catheter through urethra into bladder to drain urine.
urinary catheterization
what are coude catheters used for
urinary tract obstructions -also used if urinary strictures
to measure output from surgical/wound drains, or chest tubes...
use a measuring cup with appropriate volume. if more than 1 drain, number and specify in documentation
when communicating with someone who SPEAKS A DIFFERENT LANGUAGE THAN YOU, you must:
use an interpreter simple sentences hand gestures/demonstrate nonverbal communication
To become competent in informatics you need to be able to :
use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively.
when communicating with someone that is COGNITIVELY IMPAIRED, you must:
use eye contact environment K.I.S.S. avoid open ended questions PATIENCE
what if all you have is a gastrostomy tube?
use it for both feedings and meds
When are standard precautions used?
used in care of all hospitalized patients
how do you check residual volume
using a 60 ml syringe, aspirate all stomach contents, measure, and then depending on volume, return contents.
at what age does menstruation usually start?
usually around 12 years old
why would an ostomy be used for temporary purposed?
usually to let bowel heal after surgery, inflammation, or injury
The rightness or wrongness of an action depends on the consequences (end justifies the means)
utilitarian
Nature's Valium Promotes: sleep and relaxation S/E : restlessness, headache, giddiness, nausea Not with alcohol, barbiturates, other sleep aides
valerian
Nurse must give all the facts...Patient has the right to refuse.
valid consent/refusal
this system ranks values in order of importance and leads to a personal code of conduct
value system
Quadriceps femoris on anterolateral aspect of thigh. Avoid rectus femoris muscle anteriorly. Located by dividing thigh into thirds, horizontally & vertically. Use outer middle third section. **this IM injection site has no large vessels or nerves and is not covering a joint
vastus lateralis
which IM injection site is desirable for infants & children. Minimal Pain
vastus lateralis
what is an example of an incomplete protein
vegetables
Includes gluteus medius and gluteus minimus muscles. LARGE MUSCLE MASS FREE OF MAJOR NERVES AND BLOOD VESSELS
ventrogluteal site
when observing a patient's behavior, its important to observe what
verbal AND nonverbal behaviors -adds depth to objective database
dress, food, language music, literature, games, rituals visual art, and festivals are all _______ aspects of culture
visible
which vitamin affects visual acuity?
vitamin A
______________ enhances absorption of plant-based iron
vitamin C
you must have __________ to absorb calcium from the GI tract
vitamin D
What is nocturia?
voiding at night; in young person, not present but increases with pregnancy, aging
sodium loss can happen by
vomiting, diarrhea, sweating or the use of diuretics
-the Obesity measure most strongly associated with MI -3 x stronger predictor of heart attack than BMI -More concerned with visceral fat and its association with low level inflammation.
waist to hip ratio
what are some characteristics of a nurse-patient relationship(helping relationship)- also promotes effective communication
warmth and friendliness openness and respect empathy honesty, authenticity, trust caring competence
what is more vital for life, water or food
water
when using database for info, what is a good one to use?
webMD
what do many people use apple cider vinegar for
weight loss
if a patient is anorexic/ underweight do not put them on___________- it suppresses the appetite
wellbutrin
when assessing the patient, make sure you know______________
what religion your patient is
what is holistic care?
when Healthcare providers educate patients with issues related to sexual functioning
when does false menopause occur?
when a woman has had a hysterectomy before menopause
when is the ability to recognize incorrect therapies particularly important?
when administering medications or implementing procedures
when is an object "balanced"
when its center of gravity is close to its base of support
provide patient with calibrated drinking cup and count anything liquid at room temp (jello, ice-cream,popsicles, icechips-melted volume 1/2 frozen volume, broths, soups, milk in cereals (don't count thick soups)
when measuring intake
what is menopause?
when periods stop happening
when should you consult
when the exact problem remains unclear
when does teaching/ planning for discharge start?
when the patient arrives
when does Oh Mittelschmerz happen?
when you are ovulating
what are some examples of loading doses
when you take 2 pills the first day and only 1 every day after that
when collecting a nursing health history, what will you learn during the patient interview?
which components of history to explore **based on what they say, you'll explore more
Reporting any unsafe practice observed
whistle blowing Many states have whistle-blowing laws that protect nurses who report unsafe inappropriate care
-nuclear families -take lots of OTC drugs -diet a lot -like to self diagnose -like to exercise
white
what are some sources of magnesium?
whole grains (especially bran), nuts, potatoes, dried peas and beans
what is a pressure ulcer?
wound with localized area of tissue necrosis -can be acute or chronic -etiology- pressure from longs periods of time -AKA decubitus ulcer, bed sore or pressure sore -hospital/ institution pressure ulcers (HAPU's) are not typically reimbursable by payers
what are some restraints used for adults and children
wrist restraint- main kind, mummy restraints (babies), elbow restraints- used on children and adults to keep from pulling out IV site
what should you do if a patient refuses to sign a consent
you should document the refusal and the patient should be informed of the consequences
which hand do you glove first when sterile gloving?
your dominant hand
this mineral helps with wound healing
zinc
what are some examples of indirect care?
¬ Communicating nursing interventions Written or oral ¬ Delegating, supervising, and evaluating the work of other staff members
when Comparing Achieved Effect with Goals and Outcomes, what should you do
¬ Compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. ¬ Evaluate whether the results of care match the expected outcomes and goals set for a patient.
Evaluative Measures
¬ Evaluative measures are assessment skills and techniques ¬ Evaluating behavior ¬ Self-management Nursing Outcomes Classification (NOC)
Collaborate and evaluate effectiveness of interventions
¬ Family ¬ Health care team ** always document the results
Recognize Errors or Unmet Outcomes
¬ Must have an open mind, actively pursue truth, be patient and confident, and engage in self-reflection ¬ Systematic use of evaluation ¬ Self-reflection and correction of errors
what effect does heat have on the body
¬ Promotes healing by accelerating inflammation → healing → ultimately reducing inflammation. Heat vasodilates capillaries, improving tissue perfusion which: a. improves delivery of oxygen and nutrients b. improves removal of waste products c. increases delivery of leukocytes (white blood cells) which fight infection ¬ Relieves pain reduces muscle tension; may alternate heat with cold warmth and cold are non-pain stimuli (A-fibers) that close the gate to C-fibers (pain stimuli) - Gate Control Theory of Pain EX: achy from skiing, hot tub stops the ache
things to know about Interpreting and Summarizing Findings
¬ When you evaluate the effect of interventions, you interpret or learn to recognize relevant evidence about a patient's condition ¬ Early detection is first line of defense ¬ Compare actual and expected findings ¬ Steps to objectively evaluate the degree of success in achieving outcomes of care
what are some Types of CAT Systems and Therapies
• Ayurveda • Yoga • Traditional Chinese Medicine • Acupuncture • Qi Gong • Shamanism • Homeopathy • Naturopathy • Chiropractic Medicine
which interventions should you implement when trying to enhance a patients sleep
• Bundlingnursingcare • Medication • Natural/herbalremedies • Eliminatenaps • Meditation • Guided imagery • Decrease caffeine • Decrease fluids before bed • Exercise ( not too close to bedtime) • Only use bed for sleep/sex • Avoid heavy foods (greasy, high fat) - take longer to digest • Deep breathing • Yoga • Biofeedback • Aromatherapy • Comfortablebed • Good body alignment • Quiet and dark room • Whitenoise • Earplugs • Eyemask • Coolertemperatureinroom • Bedtimeritual • Reading • Listeningtoradio* • prayer • Talk with family/friend • Journalingaboutworries • WatchTV* • Backrub • Warmbath/shower • Controlpain • Keep same sleep-wake pattern
What makes a Great Leader?
• Comfortable w/ self-critical thinker, responsible decisions Positive self-image • Role model for others • Visionary • Sees & brings forth the best of others • Support & cooperation
what are some key findings of a sleep assessment
• Confirm adequate rest OR existence of problem - Energy level - Facial characteristics- eyes sag w/ decreased sleep - Behavioral characteristics-slow? sluggish? - Physical data suggestive of potential sleep problems - obesity, enlarged neck, deviated nasal septum
what are some factors that affect sleep
• Developmental considerations • Motivation • Culture • Lifestyleandhabits • Physical activity and exercise • Dietary habits • Environmental factors- go to friends house, used to sleeping on soft bed- may not sleep as well • Psychological stress • Illness • Medications
Anxiety R/T inability to fall asleep, inability to control behavior while asleep, and sleep apnea • Activity intolerance R/ T sleep deprivation • Fatigue R/T prolonged excessive role demands •Ineffective coping R/T insomnia :insufficient quantity or quality o fsleep
• Disturbed sleep pattern as etiology - disturbed sleep pattern is the cause of another problem:
- Physical discomfort or pain - Emotional discomfort or pain caused by anxiety or stress - Changes in bedtime rituals or sleep environment
• Disturbed sleep pattern as problem if problem time-limited • Sleep deprivation if problem prolonged
what are some chiropractic medicine approaches
• First do no harm • Physician as teacher • Treat the whole person • Prevention • Healing power of nature • Treat the cause
what are the principles underlying naturapathy
• First do no harm • Physician as teacher • Treat the whole person • Prevention • Healing power of nature • Treat the cause
(mind body medicine) what are some good techniques to enhance the minds ability to affect bodily function and systems
• Relaxation • Meditation • Guided Imagery • Prayer • Humor therapy • Aromatherapy
what re some sleep characteristics to identify
• Restlessness • Sleep postures • Sleep activities • Snoring • Leg jerking
what are some good interventions to implement to ensure good sleep hygiene
• Restrict intake of caffeine, nicotine, and alcohol, especially later in day • Avoiding activities after 5pm that are stimulating • Avoiding naps • Eating light meal before bed • Sleeping in cool, dark room • Eliminating use of bedroom clock • Warm bath before bed • Keep sleep environment quite as possible
work together to control cyclic nature of sleep
• Reticular activating system (RAS) & bulbar synchronizing region
what are some examples of therapeutic massages
• Rolfing • shiatsu • Feldenkrais • Alexander • myofascial release • ashiatsu
why should you choose complimentary and alternative therapy?
• Stress management • Chronic disease • Improve health • Side effects of traditional medication • Holistic health philosophy • Stop smoking • Weight loss • Pain
what are some examples of energy medicine
• Therapeutic Touch • Healing Touch • Sound Healing /Music Therapy
what are the theories of homeopathy
•"Like cures like": the notion that a disease can be cured by a substance that produces similar symptoms in healthy people •"Law of minimum dose": the notion that the lower the dose of the medication, the greater its effectiveness; many homeopathic remedies are so diluted that no molecules of the original substance remain
what are the 4 scientific premises of therapeutic touch
•A human being is an open energy system. •Anatomically, a human being is bilaterally symmetrical. •Illness is an imbalance in an individual's energy field. •Human beings have a natural ability to transform and transcend their conditions of living.
what are the national center for complimentary and alternative medicines (NCCAM'S) 10 guiding principles for CAT (complimentary and alternative therapy)
•A wholeness orientation in health care delivery •Evidence of safety and efficacy •The healing capacity of the person •Respect for individuality •The right to choose treatment •An emphasis on health promotion and self-care •Partnerships as essential to integrated health care •Education as a fundamental health care service •Dissemination of comprehensive and timely information •Integral public involvement
when providing any type of patient care, it is important to:
•Ask if patient uses any alternative medicines •Respect for patient's beliefs •Education for the patient
what are some good teaching tips for biologically based practices for your patients
•Get information from reliable sources •Buy name-brand products from reputable companies •Look for "standardized" on label •By single products - not combos •Take proper dose & watch for side effects •Takes time to work •Know your product
some beliefs about allopathic medicine are:
•Illness occurs in either the mind or body, which are separate entities. •Health is the absence of disease. •The main causes of illness are pathogens. •Curing seeks to destroy the invading organism or repair the affected part. •Emphasis is on disease and high technology (drugs, surgery, and radiation are key tools). Dominant for about 100 years
what is complimentary/ alternative medicine and what are some beliefs that go along with it?
•Mind, body, and spirit are integrated and contribute to health and illness. •Health is balance of body systems: mental, social, and spiritual, as well as physical. •Illness is a manifestation of imbalance or disharmony. •Symptoms are a sign or reflection of a deeper instability within the person; restoring physical and mental harmony will alleviate the symptoms. •Emphasis is on health, healing is done by the patient, care is individualized.
why do nurses need to know about complimentary and alternative therapy?
•Patients, families, physicians, and institutions increasingly expect practicing nurses to be knowledgeable about CAT. •Many patients use these types of therapies as outpatients and want to continue their use as inpatients. •Many nurses are expanding their clinical practice by incorporating CAT. •Nurses play an important role in educating the public to use these therapies safely and effectively. •Many institutions now provide complementary therapies to inpatients as part of total patient care.
what are the 5 categories of complimentary and alternative therapies
•Whole/Alternative Medical Systems •Energy therapies •Manipulative and body-based therapies •Mind-body therapies •Biologically based approaches