NUR 111 - Final Exam - All Modules

Peripheral VAD

Not sterile, CLEAN procedure Med lock, or Saline lock- instead of IV fluids running, has a device with a port and an angiocath Very short-term (4 days/96 hours) SAS: saline, administer, saline Flush every shift and after medication administration with saline (according to hospital policy & procedure) MUST FLUSH AFTER EVERY SHIFT!

Acetaminophen dosing

Pediatric Dosage: 10-15 mg/kg/dose every 4-6 hours. Maximum per day: 60-75 mg/kg for children < 50 kg. Children > 50 kg take adult doses. Max 4 Gm/day currently; Newer recommendations may be decreasing to 2.6 Gm per day because of liver damage incidence.

Patricia Benner's proficient nurse

Perceives the situation as a whole, rather than in parts; decision making is easier with a focus on the most important attributes and the aspects of the problem.

Valsalva Maneuver

Performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon.

Undoing

Performing an action or using words designed to cancel some disapproved thoughts, impulses where the person relieves guilt by making reparation

Types of Vascular Access Devices (VAD)

Peripheral, PICC and central venous catheters

Value formation

Personal values develop from Individual observation and experience, social traditions and cultural, ethnic, religious norms. Professional values develop from socialization in into nursing profession by faculty and other nurses, clinical and life experiences, following established code of ethics.

Non-opiod analgesic for UTI problems

Phenazopyridine (Pyridium); promotes relief from symptoms of a UTI, such as pain, itching, burning, urgency & frequency

High-fiber diet

Plant material that cannot be broken down by human digestion. The high-fiber diet is a healthy way for the whole family to eat. It can help with constipation, diarrhea, diverticular disease, and may decrease the incidence of colon cancer, reduce blood cholesterol, and help manage diabetes.

Relate lack of effective communication to patient satisfaction/complaints

Poor communication skills may create the perception in the patient that the nurse may be less than competent. Poor communication coupled with a negative outcome can increase the chance of a malpractice claim. Clear communication of directions and explanations and provision of effect client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes.

Primary electrolytes found in ICF

Potassium, Magnesium & Phosphate (PO4 3-)

Corticosteroids

Prednisone, hydrocortisone, dexamethasone; natural hormone released by adrenal glands; suppresses severe cases of inflammation; short term side effects (monitor blood sugar, BP, mood, s&s of Cushing's syndrome if long term use); do not discontinue abruptly - must be tapered off

Semi-formal groups

Prestige, status often accrued from membership (i.e. country clubs)

Surgical debridement

Prevents, controls or removes infection and prepares wound bed for healing, skin grafting or flaps

Preventative healthcare - KNOW FOR TEST

Primary prevention is completely preventing a disorder from occurring. Secondary prevention is early recognition and treatment of a disorder. Tertiary prevention is effectively managing a previously diagnosed condition to prevent complications.

Advocacy

Protecting by expressing and defending the cause of another.

Acute pain

Protective, has an identifiable cause, has a short duration (usually 30 days to 6 months). It has limited tissue damage and emotional response. It usually resolves with or without treatment after the injury heals. Unrelieved acute pain can lead to chronic pain. Related to "Fight or Flight".

What does the Joint Commission do?

Protects the healthcare of the public

Right-sided heart failure

Pulmonary hypertension develops, the pressure on the right side of the heart must increase to push blood into the lungs; symptoms include fatigue, increase in peripheral venous pressure, ascites, enlarged liver & spleen, distended jugular veins, anorexia or complaints of GI distress, weight gain, dependent edema

Upper UTIs

Pyelonephritis (kidneys); signs & symptoms include high fever, chills, abdominal & flank pain, vomiting, dehydration (infants non-specific signs poor appetite, failure to thrive, lethargy & irritability)

Passive ROM exercises

ROM exercises performed by the nurse or therapist

Active ROM exercises

ROM exercises performed by the patient

Phases of proliferation

Rapid release in numbers - 1) Angiogenesis (development of new blood vessels), 2) Fibroblasts synthesize collagen fibers, 3) collagen fibers produce keratinocytes

Examples of bronchodilator medications

Rapid relief from short-acting beta agonists (Albuterol) & drying secretions from anticholinergics (ipratropium).

Infection definition

Reaction of host organism to invasion of microorganisms that results in disease

The role of the ADN nurse in EBP and nursing research

Recognizing problem Collecting data Correlating evidence Categorizing data Documentation

Renin-Angiotensin-Aldosterone System (RAAS)

Regulated ECF volume by influencing amount of Sodium and water excreted in urine; also regulates BP; increased levels increase the amount of Sodium & water retained by kidneys and restored to circulation and increased amounts of Potassium & Hydrogen ions excreted in urine; produced by the kidneys

Phosphate is regulated by...

Regulated by dietary intake, intestinal absorption and renal excretion

ADH

Regulates osmolality of body fluids by influencing amount of water excreted in urine; increased levels cause more water to be returned to the body; produced by the hypothalamus in the brain

Atrial Natriuretic Peptide (ANP)

Released by the cells of the atria when they are stretched by increased ECV; a weak hormone that inhibits ADH by increasing loss of Sodium & water in urine; as ANP increases, ADH decreases and water retention decreases

Celebrex is used for...

Relief of signs & symptoms of osteo & rheumatoid arthritis, & mgmt of acute pain including primary dysmenorrheal (painful menstruation)

Substitution

Replacing a highly valued, unacceptable or unavailable object with a less valuable, acceptable or available object

Nonmalficience

Requires that the nurse do no harm and instead safeguard the client

Withdrawal syndrome

Response when drug is stopped in person with dependence; nausea & vomiting, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions (autonomic nervous system effects) (Note that health care providers can initiate this as above with the administration of an antagonist.)

ANA Code of Ethics

Responsible decision making that is rational, systematic, and based on ethical principles and codes. Having ethical obligations to clients, agency, and primary care providers. The ANA Code of Ethics serve as a statement of ethical duties and obligations of the nurse. It gives the profession non-negotiable ethical standards.

Reticular Activating System (RAS)

Responsible for sleep

Non-pharmacologic pain management

Rest, elevate, heat and/or cold (must have an order)

Early signs of hypoxia

Restless, tachycardia, tachypnea, dyspnea, increased agitation, diaphoresis, retractions, altered LOC

alterations in urinary retention

Retention Urinary incontinence UTI

Formal groups

Rigidity of purpose, rules & authority comes from above, managers are symbol of authority, power (i.e. corporations)

yearning and seeking

SEPERATION ANXIETY tearing, sobbing, acute distress • 2w-3mo • Intense physical and psychological distress • Intense yearning for lost object/person

Physical assessment of elimination

SKIN- hydration, KIDNEYS- flank pain with infection or inflammation, URETHRAL MEATUS- discharge, BLADDER- distended bladder.

CDC (Infection Reports)

The National Outbreak Reporting System (NORS) is a web-based platform used by local, state, and territorial health departments in the United States to report all waterborne and foodborne disease outbreaks and enteric disease outbreaks transmitted by contact with environmental sources, infected persons or animals, or unknown modes of transmission to CDC

Cardiac output

The amount of blood that is pumped by the heart (altered cardiac function causes left-sided or right-sided heart failure).

O2 saturation

The amount of oxygen bound to hemoglobin (SaO2) in comparison with the amount of oxygen the hemoglobin can carry (SpO2). Pulse oximetry (SpO2) is a commonly used, noninvasive measure of arterial oxygen saturation. Particularly valuable in ICU and perioperative situations in which sedation or decreased LOC might mask hypoxia. Normal values should be >95.

Trendelenburg position

The body is laid supine, or flat on the back with the feet higher than the head by 15-30 degrees.

Transcendence

The capacity to reach out beyond one's self, to extend oneself beyond personal concerns and to take on broader life meaning & purpose - beyond the material world

Four nutrients that need supplementation for elderly

• Calcium: Age 50 and older: 1,200-1,500 mg. • Vitamin D-New 2010 IOM guidelines for intake Adults age 51-70: 600 IU /day, after age 70 > 800 IU/day (was 600) - they need more as they have less exposure to sunlight • Vitamin B12 (pernicious anemia) if low, will need replacement for life • B6

Nutritional requirements for elderly

• Calorie reduction (decreased need for energy) but need for nutrients, vitamins and minerals does not change • Females: 1800 to 1600 calories • Males: 2400 to 2000 calories • Diet should be high in complex carbs. and fiber with 30% fats (gives some protein and vitamins and minerals)

normal grief

• Characteristic pattern of multifaceted psychological and physiological responses one experiences after the loss of a significant other, object, belief, or relationship. • Intensity and duration of grief depends on numerous factors including significance of the loss and the person's personality • Inability to grieve is abnormal

grief effects on a school age child

• Children after age 8-9 understand permanence of death • Do not shield them from death • Include them in discussions regarding care, prognosis, etc.

Interventions for stage I pressure ulcers

• Cleansing of ulcer & surrounding area • Application of barrier cream • Application of protective dressing • Introduction of appropriate support surfaces and other measures to redistribute pressure • Frequent repositioning

Interventions for stage II pressure ulcers

• Cleansing of ulcer & surrounding area • Application of moisture-retaining protecting dressing • Assessment for necrosis and infection • Frequent repositioning • Comfort measures

Interventions for stage III & IV pressure ulcers

• Cleansing of ulcer & surrounding area • Debridement (surgically removing dead tissue) of wound bed and edges • Surgical removal of necrotic tissue • Application of medicated moisture-retaining dressing that maintains contact with skin • Assessment for and treatment of infection • Pain management

Immobility effects on the gastrointestinal system

1) Decreased peristalsis, 2) anorexia, 3) decreased fluid intake, 4) increased intestinal gas and 5) altered swallowing ability (can result in constipation, fecal impaction, ileus, flatulence, abdominal distension, nausea/vomiting, heartburn/indigestion, aspiration and malnutrition)

Immobility effects on the respiratory system

1) Decreased strength of respiratory muscles, 2) diminished lung expansion, 3) hypoventilation, 4) impaired gas exchange, 5) decreased cough reflex, 6) pulmonary secretion pooling and 7) blood redistribution and fluid shifts within the lung tissue (can result in atelectasis, hypoxemia, pneumonia, pulmonary edema, thrombus formation, pulmonary embolism)

Immobility effects on the cardiovascular system

1) Decreased systemic vascular resistance causing venous pooling in extremities and 2) decreased cardiac output (can result in orthostatic hypotension and thrombus formation)

Interventions for a patient with decreased appetite

1) Determine food likes/dislikes, 2) small, frequent feedings and 3) increase protein

Spiritual distress nursing diagnosis defining characteristics

1) Expresses concern with meaning of life/death and/or belief systems; 2) questions moral/ethical implications of therapeutic regimen; 3) describes nightmares/sleep disturbances; 4) verbalizes inner conflict about beliefs; 5) verbalizes concern about relationship with deity; 6) unable to participate in usual religious practices; 7) seeks spiritual assistance; 8) questions the meaning of suffering; 9) questions meaning of own existence; 10) displacement of anger toward religious representatives; 11) anger toward God;

Interventions for a patient with decreased peristalsis/constipation

1) Find out when was last BM, 2) provide adequate hydration (1,500 ml/day), 3) serve a diet rich in fruits, veggies & fiber and 4) get patient out of bed

The 5 stages of Tuckman's group development

1) Forming 2) Storming 3) Norming 4) Performing 5) Adjourning If you lose a member of a group, you regress to a lesser stage

Variables that increase vulnerability to illness or accident

1) Genetics, 2) gender, 3) physiological factors, 4) environmental factors, 5) lifestyle-risk behaviors and 6) age

Interventions for a patient with UTI

1) Good hygiene, 2) keep well hydrated and 3) monitor for signs & symptoms

Interventions for a patient with thrombus formation

1) Hydration, 2) leg, foot and ankle exercises, 3) changing positions, 4) getting out of bed, 5) sequential compression devices (SCDs), 6) elastic stockings, 7) anticoagulants and 8) avoid crossing legs or sitting too long and do not massage legs

The data analysis step of assessment

Interpreting findings requires making determinations about all of the data collected in the health assessment process. The nurse must determine the following: • Whether the findings fall within normal and expected ranges in relation to the client's age, gender and race • The significance of the findings in relation to the client's health status and immediate and long-range health-related needs Interpretation of findings is influenced by a number of factors including the ability to obtain, recall and apply knowledge, to communicate effectively and to use a holistic approach.

Factors that influence self-concept

Introversion or extroversion, emotional stability, risk taking behaviors, high or low sense mastery, health status, age, socioeconomic status.

Qualitative research

Investigates a question through narrative data that explores the subjective experiences of human beings

Severe anxiety

Involves feelings of dread and terror. The person cannot be redirected to a task; he or she focuses only on scattered details and has physiologic symptoms of tachycardia, diaphoresis, and chest pain

Ethic of care

Involves more than managing difficult care decisions or facing moral issues surrounding a client. Ethical care also requires managing common client care such as pain control for a surgical client, client teaching, assuring confidentiality, and assuring clients' right to self-determination

Soft diet

Involves only foods that are physically soft, with the goal of reducing or eliminating the need to chew the food. The goal is to transition patients from a liquid diet to a regular diet. Patients prescribed a soft diet are restricted to foods that can be mashed with a fork. This includes cooked fruits and vegetables, bananas, soft eggs and tender meats.

Immobility effects on the musculoskeletal system

1) Reduced muscle mass, 2) decreased muscle strength, 3) decreased endurance, 4) shortening or tightening of connective tissue, 5) impaired joint mobility and 6) impaired calcium metabolism (can result in fatigue, decreased stability & balance, muscle atrophy, joint contractures, foot drop, osteoporosis, falls and pathologic fractures)

D5W solution is used to...

1) Replace water loss & 2) treat hypernatremia

The Joint Commission

1) Requires healthcare organizations to provide pastoral care 2) Mandates that each patient admitted be assessed for spiritual beliefs & practices

Braden Scale risk factors

1) Sensory perception - the ability to respond meaningfully to pressure-related discomfort, 2) moisture - degree to which skin is exposed to moisture, 3) activity - degree of physical activity, 4) mobility - ability to change and control body position, 5) nutrition - usual food intake pattern and 6) friction & shear

Central lines

1) Short term to long term 2) Placed in the superior vena cava 3) PICC lines are placed in the SVC 4) Midlines exception

Veins to avoid using in patients

1) Site of A-V fistula (dialysis patient) - need to protect arm veins, 2) mastectomy patients - need to use opposite side of surgical site, 3) contractures or extremities that are paralyzed

Factors that affect spirituality

1) Spiritual distress 2) Acute, chronic or terminal illness 3) Near-death experience 4) Religion 5) Age

Treatment for extravasation

1) Stop the IV 2) Keep the IV in & pull back on plunger to take medication back out 3) MD will order topical and IV therapies to decrease necrosis of tissue 4) May need warm compress to vasodilate depending on the vesicant (blistering) 5) Call MD, incident report & document

5 functions of water in the body

1) Transport nutrients, waste products & other substances, 2) maintaining & regulating body temperature, 3) insulator & shock absorber, 4) lubrication of joints & membranes & 5) medium for metabolic reactions within cells

Interventions for a patient with atelectasis or hypostatic pneumonia

1) Turn, cough, deep breath q 1-2 hours, 2) chest physiotherapy percussion and drainage, 3) incentive spirometer 10x/hour

Most frequent nosocomial/HAI's

1) UTI's r/t catheters 2) Surgical wounds 3) Pneumonia - common in ICU r/t endotracheal intubation 4) Blood r/t central venous lines

Stages of inflammation

1) Vascular & cellular responses, 2) exudate production, 3) tissue repair

1st stage of inflammation - vascular & cellular responses

1) Vasoconstriction - release histamines, kinins & prostaglandins - hyperemia (large volume of blood) and 2) fluid, protein & leukocytes leak into interstitial spaces (edema & pain); phagocytosis and leukocytosis begins

Phases of inflammation

1) Vasodilation, 2) neutrophils destroy dying cells, 3) macrophages clean & produce growth factor

Peripheral lines

1) Very short term 2) Placed in peripheral veins 3) Catheter size 1 - 1.5 inches in length 4) SAS (saline, administer, saline) - flush every shift & after medication

Assessment for inflammation

1) vital signs to determine whether infection is present; patient may have increased temp, HR and RR (TTT), 2) immunosuppression (i.e. taking corticosteroids or receiving chemo) - classic manifestations may be masked, 3) patient may say "I just don't feel well" Diagnostic tests - ESR (erythrocyte sedimentation rate) will be elevated

Group dynamics

1. Commitment 2. Decision making ability, effective decisions are made when group listens to members ideas, members satisfied with their participation, problem solving is facilitated, group atmosphere is positive, time is well used, using expertise of members, members committed to decisions and responsible for implementation of decisions 3. Member behavior & their different roles, information givers/seekers, opinion givers, coordinator, initiator-contributor, energizer and evaluator 4. Cohesiveness - the attachment that members feel for each other & the group 5. Power - to encourage cooperation & collaboration in accomplishing a task

What is a medical diagnosis?

It is made by a licensed provider such as a physician, advanced practice nurse, or physician's assistant. Medical diagnoses refer to disease processes - specific pathophysiologic responses that are fairly uniform from one client to another.

Functional incontinence

loss of urine r/t functional deficits such as: altered mobility, cognitive impairment, environmental barriers, and caregivers not responding in time to assist• Who- frail elderly people, LTC residents, dementia patients • Characteristics: o Toilet access limited by problems with: > Sensory issues > Mobility issues > Cognitive issues > Manual dexterity > Environmental barriers

Ambiguous loss

lost person is physically present but not psychologically available

ambiguous loss

lost person is physically present but not psychologically available

oil retention enema

lubricates the rectum and the colon. The feces absorb the oil and become softer and easier to pass. o To enhance action of the oil, the pt. retains the enema for several hours if possible.

Fecal specimens

measures microscopic amounts of blood in the feces. Useful for screening for colon cancer. o i.e. guaiac test o All positive tests should be followed up with sigmoidoscopy or colonoscopy

constipation

most common use for an enema

Avoiding errors in diagnostic statements

1. Verify & validate data 2. Build a good knowledge base & acquire clinical expertise 3. Have a working knowledge of what is normal 4. Consult resources 5. Base diagnoses on patterns - behavior over time, rather than an isolated incident 6. Improve critical thinking skills

pH scale

1.0 very acidic to 14.0 very alkaline/basic; normal pH level for blood is 7.35 to 7.45

Normal Mg levels

1.3 - 2.1 mEq/L

Erikson's Identity vs. role confusion

12 - 20 years; formation of strong sense of identity as an individual & as a member of society, identification of personal & occupational goals

Normal Sodium levels

136 - 145 mEq/L

Erikson's intimacy vs. isolation

18 - 25 years; development of healthy romantic relationships without compromising personal identity

Erikson's Autonomy vs. shame & doubt

18 months - 3 years; basic awareness of independence, autonomy & self-control

Erikson's generativity vs. stagnation

25 - 65 years; productivity & creativity, desire to care for and guide offspring

Normal serum osmolarity for adults

270 - 300 mOsm/L

Erikson's Initiative vs. guilt

3 - 5 years; emergence of basic sense of self-guidance & self-discipline

Normal Phosphate levels

3.0 - 4.5 mg/dL

Normal Potassium levels

3.5 - 5.0 mEq/L

Ibuprofen dosing

5-10 mg/kg/dose q6h

Erikson's industry vs. inferiority

6 - 12 years; confidence in ability to attain goals, initial formation of identity apart from nuclear family, successful peer group integration

Erikson's integrity vs. despair

65 years - death; sense of peace concerning life experiences, life choices framed within a meaningful context, development of wisdom

Normal bowel presentation

75% water 25% solid material soft but formed brown flatus

Normal Calcium levels

9.0 - 10.5 mg/dL

Normal Chloride levels

98 - 106 mg/dL

cause for concern

< 60 mL per 2 hours

Chronic constipation

need 2 or more symptoms to be considered... -sensation of incomplete emptying 25% of the time -use of manual maneuvers to help emptying in more than 25%of defication - < 3 bowel movements a week - straining 25%of the time -lumpy, hard stool

grief

normal response to loss

When to choose a central line over a peripheral line...

• Clinical instability of a patient and or complexity of infusion. (multiple infusions) • IV chemotherapy-3 months out • Continuous infusion therapy (parenteral nutrition, F&E, medications, blood products) • Invasive hemodynamic monitoring • Long term intermittent infusion of antibiotics • History of failed peripheral veins (use if ultrasound guidance has failed)

Prevention & treatment of IV infiltration

o Elevate extremity and apply compress o Avoid venipuncture over area of flexion o Anchor cannula and extension tubing securely o Assess IV site frequently o Monitor IV rate o DC IV o Restart o Document

Nutritional requirements for adults

• 34% Americans classified as obese in 2008 • Adult men require more calories than adult women • Calorie needs reduced with decrease in metabolic rate at around age 50 • Females of childbearing age o Eat foods with heme iron, vitamin C o Add folic acid supplements • Food choice similar to that of older adults

grief effects on a preschooler

• Able to understand something is wrong • Respond to them with short answers • Reinforce that the loss was not caused by their behavior • They are concrete thinkers so don't equate death with sleep when talking to them

types of loss:

• Actual: recognized by others • Anticipatory: loss is coming • Perceived: cannot be verified (ex: loss of innocence) Ambiguous: lost person is physically present but not psychologically there.

Factors influencing Bowel elinination

• Age (elderly- peristalsis slows down) • Diet and fluid intake (fiber) • Physical activity (promotes peristalsis) • Psychological factors (stress, IBS) • Personal habits (using own BR) • Position during defecation/pain • Pregnancy (baby presses on rectum and can cause hemorrhoids) • Surgery/anesthesia • Medications, laxatives, cathartics • Diagnostic tests (cleaning out GI tract)

definition of grief

• An emotional response to a loss, manifested in ways unique to an individual based on personal experiences, cultural expectations, and spiritual beliefs. • A "normal but bewildering cluster of ordinary human emotions arising in response to a significant loss, intensified and complicated by the relationship to the person or the object lost."

Medications that promote perfusion

• Anticoagulants: Enoxaparin (Lovenox), Heparin, Warfarin (Coumadin) • Fibrinolytic Therapy: Alteplase, Streptokinase If they are having an MI or stroke, they can use ATP or streptokinase; it is very expensive.

factors influencing grief

• Coping skills (hardiness and reliance) • Previous experiences with loss • Emotional stability/Physical health • Spiritual/Religious beliefs • Individual developmental stage • Other crises being experienced • Socioeconomic status • Presence/absence of support systems • Culture and Ethnicity

disenfranchised grief

• Deceased person not socially sanctioned and can't be openly acknowledged or publicly shared (death of ex-spouse, gay partner, etc.) • Cuts grieving person off from social support • marginal and unsupported

Low-residue diet

Designed to reduce the frequency and volume of fecal output while prolonging intestinal transit time. Indigestable carbohydrate intake is reduced by limiting ingestion of fruits and vegetables to limited amounts of well-cooked or canned vegetables and canned, cooked, or very ripe fruits, and by replacing whole-grain breads and cereals with refined products. Legumes, seeds and nuts are omitted.

Core measures

Developed by the JC; national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Compliance shows how often a hospital provides each recommended treatment for certain medical conditions.

Explain the role of the nurse to report practices that endanger the health or safety of patients.

It is the duty of the nurse to first make every effort to resolve the concern by following the internal reporting procedures of the agency that employs him or her. If the concern cannot be resolved, it is the duty of the nurse to go outside of the organization to protect the public interest when the organization fails to follow procedures regarding safety and client care. This is known as whistleblowing.

Pressure ulcer - stage IV

Full thickness skin loss with extensive tissue damage and necrosis; muscle, tendons and bone are exposed and directly palpable; slough or eschar may be present, undermining and tunneling are usually present

Pressure ulcer - unstageable

Full thickness tissue loss with depth completely obscured by slough or eschar in the wound bed, depth of the wound cannot be determined until slough or eschar is removed, once removed, it will be classified as stage III or stage IV

Types of urinary incontinence (FOURST)

Functional Overflow Urge Reflex Stress Transient

Pressure ulcers - inspection of bony prominences

Normal findings: Tissue s/b firm but not hard and have the same consistency as the surrounding area. Abnormal findings: Spongy or boggy tissue or skin is indicative of edema

Cataracts

Normal w/aging - blurry, hazy, cloudy or foggy vision, changes in color vision including a reduction in color saturation and brightness, increased glare and/or sensitivity to light (especially driving at night), and difficulty seeing in low light levels.

Glaucoma

Normal w/aging - peripheral vision loss, decreased visual acuity, trouble adapting to darkness, halo effect around lights and if not treated, can eventually lead to blindness.

Minimization

Not acknowledging the significance of one's behavior

Informal groups

Not bound by rules & regulations, ideal testing ground for leadership techniques

Risk factors for undernutrition in elderly

• Decreased salivation affects taste • Chewing affected by loss of teeth, dental cavities, ill-fitting dentures • Thirst dysregulation • Decreased number of taste buds

Arterial Peripheral Vascular Disease (PVD)

Intermittent claudication pain (pain in backs of legs when walking), no edema, no pulse or weak pulse, no drainage, round smooth sores, black eschar, sores on toes & feet

Hemorrhaging

Internal - 1) Distention or swelling at site, 2) increased drainage within surgical drain, 3) hypovolemic shock, 4) hematoma, 5) drop in BP. External - increased bloody drainage on dressing (observe closely within first 24 - 48 hours)

Transient incontinence

• Definition- Incontinence caused by medical conditions that may be treated or reversed • Characteristics: o Delirium/acute confusion o UTI o Medications o Excessive urination o Impaired mobility o Fecal impaction o Depression o Acute urinary retention

stress incontinence

• Definition- involuntary leakage of small volumes of urine associated with increased abdominal pressure and weakened external sphincter/pelvic support • Who- Women > 60 • Characteristics: o Loss of urine when coughing, laughing, bending, exercising

Identification ego mechanism

Attempting to manage anxiety by imitating the behavior of someone feared or respected

Hyperthermia

Elevated body temp r/t inability of the body to promote heat loss or reduce heat production

Bacterial phlebitis

Emergency placement of IV without cleaning

Nosocomial infection

(aka Healthcare acquired infection - HAIs) New infection that develops in a patient 48 - 72 hours following admission or treatment at a healthcare facility

Orthostatic hypotension

A drop in blood pressure of 15 mm Hg or more when an individual rises from a sitting to a standing position.

Accreditation

A peer review process that evaluates the quality of an organization

Mild anxiety

A positive state of heightened awareness and sharpened senses, allowing the person to learn new behaviors and solve problems. The person can take in all available stimuli (perceptual field)

Hope

A process of anticipation that involves the interaction of thinking, acting, feeling and relating

Confidentiality

A sacred trust. Nurses are important in ensuring that organizations create an environment to safeguard patients' rights and privacy.

Eustress

"Good" stress which is associated with accomplishment and victory

Piaget's formal operational stage

(11 years & beyond) - Adolescents' cognitive operations are organized in a way that permits them to think about thinking. Thought is now systematic & abstract.

Piaget's Pre-operational stage

(2 to 7 years) - young children use symbols (images & language) to explore their environment. Thought is egocentric, and children cannot adopt the perspectives of others yet.

Piaget's Concrete operational stage

(7 to 11 years) - older children acquire cognitive operations, or mental activities that are an important part of rational thought. Logical reasoning is possible but limited to concrete (observable) problems.

manifestations of grief

(A-MAGICS) • Depressed mood • Insomnia • Anxiety: tightness in chest, SOB • Poor appetite • Loss of interest • Guilt feelings • Dreams about the deceased • Poor concentration

functions of grief

(BIS) • To make the outer reality of the loss into an internally accepted reality • To sever the emotional attachment to the lost person or object • To make it possible for the bereaved person to become attached to other people or objects

kubler ross stages

(DABDA) • Denial • Anger • Bargaining • Depression • Acceptance

Stool softeners or surfactants

(Ducosate) Causes water & fat to be absorbed into the stool

Characteristics of quality documentation

(FACTO) Factual, Accurate, Complete, Timely (or Current) and Organized.

Affective domain of learning

(FEELING DOMAIN) Deals with expression of feelings and acceptance of attitudes, opinions or values. o Feelings o Emotions o Interests o Attitudes Examples: role play, discussion, one-on-one or group discussion.

types of grief

(NCAD) normal complicated anticipatory disenfranchised

bowlby's theory of grief

(NYDR) numbing yearning and seeking disorganization and despair reorganization

Extinguishing a fire

(PASS) P - Pull pin on extinguisher A - Aim low S - Squeeze the handle S - Sweep from side to side

Fire safety

(RACE) R - Rescue A - Alarm/alert C - Contain the fire E - Extinguish

The 6 aims of quality improvement in healthcare

(SEPTEE) S - Safe E - Effective P - Patient centered T - Timely E - Efficient E - Equitable for all

Psychomotor domain of learning

(SKILLS DOMAIN) Involves acquiring motor skills, such as fine motor skills, that require integration of mental and muscular activity. The simplest behavior in the hierarchy is perception, whereas the most complex is origination. Psychomotor learning includes: o Perception: Being aware of objects or qualities through the use of senses. o Set: a readiness to take a particular action. o Mechanism: the performance of an act under the guidance of an instructor. o Complex overt response: smoothly and accurately performing a motor skill. o Adaptation: the ability to change a motor response unexpectedly. o Origination: Using existing motor skills to perform a complex motor act. o MOTOR SKILLS Examples: demonstration, practice, return demonstration, independent projects and games.

Cognitive domain of learning

(THINKING DOMAIN) Includes all intellectual behaviors and requires thinking: Includes six intellectual abilities and thinking processes: In the hierarchy of cognitive behaviors the simplest is acquired knowledge, the most complex is evaluation. o Knowing: Learning new facts or information and being able to recall them. o Analyzing: Breaking down information into organized parts. o Comprehending: The ability to understand the learned material. o Synthesizing: The ability to apply knowledge and skills to produce a new whole. o Applying: Using abstract, newly learned ideas in. concrete situation. o Evaluating: A judgement on the worth of the information for a given purpose. Examples: one-on-one or group discussion, lecture, question and answer sessions, role play, discovery, independent project and field experience.

Anticholinergic drugs

(TOMS) Tolterodine, Oxybutynin, Mirabegron, Soifenacin

The defining characteristics of a nursing diagnosis

(What does it look like?) - refer to a cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client's signs and symptoms.

The diagnostic label (problem) of a nursing diagnosis

(What is the focus or subject of the problem?) - describes the patient's response to a health problem for which nursing care is given. It describes the patient's health status clearly and concisely in a few words. The diagnostic label identifies the topic that directs the formation of a patient goal and desired outcome; these are the standardized NANDA names for the nursing diagnosis

The etiology of a nursing diagnosis

(Where did it come from, what is it related to?) - identifies one or more probable causes of the health problem, thereby giving a direction to the required nursing care and enabling the nurse to individualize the patient's care. This may include a medical diagnosis but then the words "secondary to" must be used in the nursing diagnosis.

NSAIDs

(aspirin, ibuprofen, naproxen and ketorolac) useful for acute inflammation management such as orthopedic trauma or post-op pain (inhibits prostaglandins) and to treat mild to moderate pain. Can also be used with opioids to treat severe pain. They carry a "black box" warning from the FDA highlighting the risk of serious cardiovascular and GI side effects (bleeding). Will interfere with bone healing if treating for inflammation from broken bone. Upper GI bleeds and ulcers (especially elderly pt's); abdominal pain They have a ceiling effect, meaning once the client consumes a specific dosage, consuming more of the drug will not produce a greater analgesic effect but may increase toxic effects.

Overflow Incontinence

(associated with chronic retention of urine) • Definition- involuntary loss of urine caused by over-distended bladder r/t bladder outlet obstruction or poor bladder emptying because of weak/absent bladder contractions • Who- men with enlarged prostate, people with DM • Characteristics: o Distended bladder on palpation o High PVR o Frequency o Nocturia o Involuntary leakage of small volumes of urine

Piaget's Sensorimotor stage

(birth to 2 years) - infants use motor and sensory capabilities to explore the physical environment. Learning is largely trial & error.

diarrhea

*an increase in the number of stools and the passage of liquid, unformed feces o May be due to antibiotic use or enteral feeding -urge to defecate impossible to control.

Factors affecting body temperature

- Age (newborns & children avg 97.5F, older adults 98.6F) - Circadian rhythms - Exercise - Hormones - Stress - Environment

Causes of hypothermia

- Core body temperature below 95F - Excessive heat loss - Inadequate heat product to counteract heat loss - Impaired hypothalamic thermoregulation

Collaborative care for hyperthermia

- Decrease body temperature w/antipyretics (Ibuprofen & acetaminophen), assess for diaphoresis especially in babies - Antibiotics - Increase fluid intake, unless NPO

Local inflammation

- Edema - Erythema - Warmth - Pain/tenderness - Loss of function to affected by part

Signs & symptoms of hyperthermia

- Elevated body temperature - Warm or hot, flushed skin - Tachycardia - Tachypnea - Increased fluid requirements - Fatigue/malaise - Decreased appetite - Vomiting/diarrhea - Body aches

Systemic infection signs

- Fever - Fatigue/malaise - N&V - Enlarged, tender lymph nodes to affected area - Decreased LOC - Increased WBC - Microorganisms in culture - Change in vital signs (For older adults - absent fever r/t certain meds, hypothermia, alcoholics), confusion, agitation, incontinence

Causes of hyperthermia

- Fever - Illness - viral/bacterial infections, cancer, etc. - Heat exhaustion/stroke - Impaired hypothalamic thermoregulation

Signs & symptoms of hypothermia

- Lowered body temperature - Cool, pale skin - Cyanotic nail beds and decreased cap refill - Shivering & piloerection (goose bumps) - Initial hypertension & tachycardia followed by hypotension & bradycardia for more severe cases

A change or break in any of theses defenses may increase the risk of infection

- Natural immunity - Normal flora - Age - Hormonal factors - Phagocytosis - Protective barriers - Nutrition - Environment - Medical interventions

Factors that delay wound healing

- Nutritional deficiencies (vitamin C, protein, zinc) - Inadequate blood supply - Corticosteroid drugs - Infection - Smoking - Mechanical friction on wound - Advanced age - Obesity - Diabetes - Poor general health

Most at risk for MRSA

- Older adults - Immunosuppressed - Long antibiotic history - Invasive tubes or lines - ICU patients

Local infection signs

- Redness & swelling caused by inflammation - Drainage - Pain/tenderness - Altered function of affected area

Collaborative care for hypothermia

- Warm the body SLOWLY - Apply warm blanket for mild (hyperthermia blanket & warm IV fluids for severe) - Provide analgesics (pain killers) - Protect injured tissue (frost bite) - Assess vitals & urine output

Symptoms of constipation

-less bowel movement -frequent flatus -abdominal discomfort -low appetite -straining -hard, dry stool -distended abdomen -reduced bowel sounds

Hypotonic solutions

0.45% NS; do not use in patients w/head trauma or anyone w/increased cranial pressure; shifts fluids out of vessels into cells; to be used for volume replacement, severe NG losses or vomiting; can cause edema & worsen hypotension

Peripheral IV catheter lengths

1 or 1.5 inches in length

Criteria used when evaluating information on the Internet

1) Accuracy - if your page lists the author & institution that published the page & provides a way of contacting them 2) Authority - if your page lists the author credentials and it has a preferred domain (.edu, .gov, .org or .net) 3) Objectivity - accurate info is provided with limited advertising & the info presented is objective 4) Currency - timely, updated regularly, links are also up-to-date 5) Coverage - if you can view the info properly, not limited to fees, technology or software requirements

Collaborative care for Cellulitis

1) Assess 2) Skin care, warm/moist compress, elevate extremity 3) Treat with penicillins and cephalosporins

Healthy People 2020 - 4 overarching goals

1) Attain high quality, longer lives free of preventable disease, disability, injury and premature death, 2) achieve health equity, eliminate disparities, and improve the health of all groups, 3) create social and physical environments that promote good health for all and 4) promote quality of life, healthy development and healthy behaviors across all life stages

Labs for UTIs

1) Clean catch specimen for urinalysis (increased nitrates & leukocytes) in non-foley patients and 2) for foley patients, take specimen from tubing

Seven steps to positive approach

1) Come from the front 2) Go SLOWLY! 3) Get to the side 4) Get low - sit down 5) Offer your hand 6) Use the person's preferred name 7) Wait for a response before you start talking or doing!

Interventions for a patient with changes in coping (such as depression, sadness or dejection)

1) Converse about current events and family members, 2) encourage visits from significant others to reduce the risk of social isolation and 3) provide routine and informal socialization

3rd stage of inflammation - tissue repair

1) Damaged cells replaced by healthy cells and 2) if inflammation is chronic, tissue defect full with granulation tissue (granulation tissue not as strong as collagen & may form scarring)

Interventions for a patient with orthostatic hypotension

1) Dangle first when getting out of bed to prevent dizziness and 2) doctor may ask for standing/lying BP

Thirst is controlled by...

1) Decrease in blood volume (baroreceptor-mediated thirst & angiotensin II & III mediated thirst) and 2) increase in plasma osmolality (osmoreceptor mediated thirst)

Immobility effects on the integumentary system

1) Decreased delivery of oxygen and nutrients to tissues, 2) tissue ischemia due to pressure between bed or chair and bony prominences, 3) inflammation over bony prominences and 4) friction and shearing of skin during movement (can result in skin breakdown, abrasions/excoriation, pressure ulcers and infection)

Hypotonic solution

A solution that is more dilute than blood or body fluids (lower osmolality) (i.e. 1/2 normal saline - 0.45% sodium chloride); causes water to enter the cells & swell

The Joint Commission's Hospital National Patient Safety Goals

1) Identify patients correctly - use 2 identifiers 2) Get important test results to the right person on time 3) Label all medications before a procedure 4) Take extra care w/patients on blood thinners 5) Records & pass along correct info about a patient's medications 6) Ensure that alarms on medical equipment are heard & responded to on time 7) Infection prevention - wash hands, prevent infection that are difficult to treat, prevent infection of blood from central lines, prevent infection after surgery, prevent UTIs from catheter use 8) Assess which patients are most likely to commit suicide 9) Prevent mistakes in surgery - correct surgery on the correct patient on the correct place on the patient's body, mark place on body where surgery will be done, pause before surgery to make sure a mistake is not being made

Risk factors associated with pressure ulcers

1) Immobility & inactivity, 2) inadequate nutrition, 3) fecal & urinary incontinence, 4) decreased mental status, 5) diminished sensation, 6) excessive body heat, 7) advanced age & 8) the presence of certain chronic conditions like diabetes

Interventions for a patient with osteoporosis

1) Increase calcium and vitamin D intake and 2) weight bearing exercises

Immobility effects on the metabolism

1) Increased catabolic (breakdown) activities and 2) calcium resorption or loss from bones (can result in weight loss, decreased muscle mass and osteoporosis)

Risk factors for developing UTIs

1) Indwelling catheter 2) Female anatomy 3) Poor perineal hygiene

The Patient's Bill of Rights

1) Information, 2) choice, 3) respect, 4) participation, 5) confidentiality, 6) appeals and 7) access

Assessments for pressure ulcers

1) Inspect pressure areas for discoloration which can result from impaired blood circulation to the area, 2) Inspect pressure areas for abrasions and excoriations, 3) Palpate the surface temperature of the skin over the pressure area and 4) Palpate the skin over the bony prominences

3 divisions of ECF

1) Intravascular fluid (liquid portion of the blood i.e. plasma); approx. 3 liters, 2) interstitial fluid (located between the cells & outside of blood vessels); approx. 11 liters, and 3) minor division of transcellular fluid (cerebrospinal, pleural, peritoneal synovial fluids secreted by epithelial cells)

Interventions for a patient with sensory alterations (such as altered sleep pattern)

1) Keep patient on regular schedule, 2) do not schedule nursing care between 10pm - 7am if possible and 3) maintaining a calendar or clock w/a large dial

Interventions for a patient with urinary stasis

1) Keep patient well hydrated (1,500 ml/day) to prevent calculi and infection, 2) monitor I/O, 3) have men stand to void, 4) get out of bed to go to the bathroom, 5) assess for distension, 6) bladder scan and 7) I/O catheter

Seizure precautions

1) Loosen restrictive clothing, especially around the neck 2) Stay w/patient 3) Protect head w/padding if a fall occurs & turn patient to the side 4) If seated, lower to floor in a side-lying position 5) Do not attempt to open patient's mouth

4 important functions of electrolytes

1) Maintaining fluid balance, 2) acid-base regulation, 3) facilitating enzyme reactions & 4) transmitting neuromuscular reactions

Spirituality includes...

1) Meaning (having purpose, making sense of life) 2) Value (having cherished beliefs and standards) 3) Transcendence (appreciating a dimension beyond the self) 4) Connecting (relating to others, nature, an Ultimate Other) 5) Becoming (involves reflection, allowing life to unfold, and knowing oneself)

Different pain scales

1) NPASS (Neonatal Pain Assessment & Sedation Scale) - infants less than 2 months old 2) FLACC (Face, Legs, Activity, Cry, Consolability) - non-verbal children over 2 months of age 3) Wong-Baker Faces Scale - patients older than 6 4) Numeric Rating Scale - patients who are awake, alert, able to verbalize or point to a number, understands number concept 5) OLDCARTS (onset, location, duration, characteristics, aggravating, relieving, treatment, severity)

Patricia Benner's 5 levels of proficiency for nurses

1) Novice 2) Advanced beginner 3) Competent 4) Proficient 5) Expert

Spirituality in the elderly population

1) Other members of the same religious faith are frequently used as a support group 2) Elderly highly value such religious coping strategies as prayer & worship services 3) Concern about having lived a purposeful life, maintaining loving relationships and preparing for a good death

Characteristics of a nursing goal

1) Patient centered 2) Singular goal/outcome 3) Observable 4) Measurable 5) Time-limited 6) Mutual factors - patient & nurse should agree on goals & time frame 7) Realistic

Interventions for a patient with increased workload

1) Patient should breathe out when having a BM, lifting or moving in bed, 2) patient should not hold his breath and 3) patient should avoid Valsalva Maneuver

Five stages of behavior change - ON TEST

1) Pre-contemplation - Not intending to change anytime soon, 2) Contemplation - Considering change, 3) Preparation - Making small changes for action plan, 4) Action - Actively engaged in plan, 5) Maintenance - Sustained change, possible relapses and 6) (Termination - Previous behavior no longer pleasurable)

PREVENTION is the key to stopping transmission of infection

1) Proper hand washing 2) Environmental controls 3) Sterile technique when needed 4) ID & mgmt of patients at risk

Interventions for a patient with changes in emotional responses (such as hostility, giddiness, fear or anxiety)

1) Provide meaningful stimuli, 2) do not schedule nursing care between 10pm - 7am if possible, 3) involve patient in own care and 4) allow family visits

Interventions for a patient with ischemia

1) Provide skin care, 2) prevent friction and 3) if incontinent, change patient q 2 hours

Interventions for a patient with joint contracture

1) ROM exercises 2-3x/day, 2) reposition q 2 hours and 3) proper body alignment

Healthy People 2020

A society in which people live long healthy lives developed by Dr. Howard Koh. A nationwide process of every 10 years, we identify what the goals of our health should be. The website identifies measurable, achievable goals.

Hypertonic solution

A solute that is more concentrated than blood or body fluids (higher osmolality) (i.e. 3% sodium chloride); causes water to leave the cells & shrink

High-calorie, high-protein diet

A balanced diet that is specially designed to help the patient increase his intake of calories.

Serum electrolytes

A blood test that analyzes electrolyte levels such as Sodium, Potassium, Chloride, Magnesium & Bicarbonate ions

Forgiveness

A change in feelings and attitudes about being wronged, and giving up such negative emotions as revenge

Actual nursing diagnosis

A client problem that is present at the time of the nursing assessment. This is based on a cluster of associated assessment data. Example...acute pain or anxiety.

Risk nursing diagnosis

A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. Example...risk for infection.

Identity

A combination of the ideal self (who we think we should be), the real self (the perceived true self) and the public self (how we wish to be perceived by others)

Atelectasis

A complete or partial collapse of lung (collapsed, airless alveoli).

Nursing care plan

A complete plan of care for ONE nursing diagnosis

Adverse Event Reporting

A computerized information database designed to support the U.S. Food and Drug Administration's (FDA) post-marketing safety surveillance program for all approved drug and therapeutic biologic products.

Hospital Compare

A consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. This information can help consumers make informed decisions about where to go for health care. Hospital Compare allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, heart failure, pneumonia, surgery and other conditions. In March 2008, data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, also known as the CAHPS Hospital Survey, was added to Hospital Compare. HCAHPS provides a standardized instrument and data collection methodology for measuring patient's perspectives on hospital care.

Isotonic solution

A fluid with the same concentration of nonpermeant particles of normal blood or body fluids (i.e. normal saline - 0.9% sodium chloride)

MRSA

A form of S. aureus that doesn't respond to methicillin or penicillin based therapies

Introjection

A form of identification that allows for the acceptance of others' norms and values into oneself

AP (anteroposterior) diameter

A measure of the shape and symmetry of the chest. Normally, the AP diameter is 1/3 to ½ of the transverse, or side-to-side, diameter. A barrel-shaped chest (anteroposterior diameter = transverse diameter) characterized aging and chronic lung disease.

Reaction formation

A mechanism that causes people to act exactly opposite to the way they feel

Stridor

A noise resulting from air moving through a narrowed trachea and larynx; it is associated with croup

Institute for Healthcare Improvement (IHI)

A nonprofit organization focused on motivating and building the will for change, partnering with patients and health care professionals to test new models of care, and ensuring the broadest adoption of best practices and effective innovations. Its goals are to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the per capita cost of health care.

What is a nursing diagnosis?

A nursing diagnosis is a statement of nursing judgment and refers to a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat. Nursing diagnoses describe the human response or a client's physical, sociocultural, psychological, and spiritual responses to an illness or a health condition. Nursing diagnoses come from NANDA. Only Registered Nurses can make a nursing diagnosis. Per Ms. Valentine, developing a nursing diagnosis is clustering/organizing assessment data based on the body system or concept to identify problems with the patient.

Ileus

A painful obstruction in the intestine

Diagnosis-Related Group (DRG)

A statistical system of classifying any inpatient stay into groups for the purposes of payment. The DRG classification system divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement. In other words, a method of payment for hospitals where specific procedures cost the same amount regardless of where the procedure is done.

Nursing research

A systematic and strict scientific process that test a hypothesis about health-related conditions and the processes of nursing care. It is a way to identify new knowledge, improve professional education and practice, and use resources effectively.

Complete Blood Count (CBC)

A test that measures the cells that make up your blood (RBCs, WBCs and platelets); increases in severe hydration & vice versa

Concept map

A visual representation of a nursing care plan which can include multiple nursing diagnoses & interventions

What is a concept map?

A visual representation of a nursing plan of care in a patterned diagram with data and ideas. Various shapes & colors are used to show relationships and connection in combination with lines or arrows. Concept maps are creative, conceptual images of concrete critical thinking. The visual image enhances clinical reasoning by "showing" how nursing diagnoses, goals, interventions, and evaluations relate to each other in a logical and patterned way. They can be a visual guide in analyzing relationships among clinical data, which helps in the prioritization of meeting client needs.

What is a nursing plan of care?

A written or electronic guideline that organizes information about an individual patient's care. One plan may include several nursing diagnoses. It is important to prioritize nursing diagnoses and to list only 3 - 5, to help the nurse focus on nursing care that provides the best patient outcomes. The RN initiates the plan when the patient is admitted to the facility. It is constantly updated throughout the patient's stay in response to changes in the patient's condition and evaluations of goal achievement. When the patient is discharged, the plan is included as part of the patient's permanent record of the care received.

Communication skills needed by a nurse during the working phase of a nurse-patient relationship

Empathetic listening and responding, respect, genuineness, concreteness (holding the patient accountable), reflecting, paraphrasing, clarifying and confronting.

The four components of the healthcare system

A. People B. Settings C. Regulatory agencies - monitor practitioners and facilities, provide information about industry changes, promote safety and ensure legal compliance and quality services. The Centers for Medicare and Medicaid (CMS) oversee most of the regulations related directly to the health care system. D. Health care financing

Dependent edema

Abnormal accumulation of fluid in certain areas of the body such as the feet (when hanging down) or the buttocks (when lying in bed) - gravity based

Second spacing of fluid

Abnormal accumulation of interstitial fluid (edema) which can eventually return to first spacing

Hypoxemia

Abnormal deficiency in the concentration of O2 in arterial blood.

Bulk forming laxatives

Absorb water, adding to the size of the fecal mass

Acculturation

Accepting the majority group's culture as one's own

2nd stage of inflammation - exudate production

Accumulation of fluid & dead tissue

Ascites

Accumulation of fluid in the peritoneal cavity causing abdominal swelling (due to disease)

Analgesics

Acetaminophen (Tylenol) for pain management

Interventions for mild-moderate anxiety

Acknowledge and validate patient's identification of anxiety and feelings, assist patient to identify the cause of anxiety, assist patient to increase awareness of usual response to anxiety, assist patient to problem solve, encourage safe & comfortable expression of feelings, lead patient through relaxation exercises

Patricia Benner's competent nurse

Actions are viewed in terms of long-term goals and feelings of mastery; the speed and flexibility of the proficient nurse are lacking.

Independent nursing intervention

Actions that nurses initiate - do not require a physician's order

Dependent nursing intervention

Actions that require an order from a physician

Communication skills needed to develop therapeutic relationships

Active listening, caring, developing trust, respect, showing a genuine interest, confidentiality, advocacy, unconditional positive regard, do not make promises, being truthful (even when it isn't what they want to hear), empathy (putting yourself in someone else's shoes), being aware of cultural differences that may affect meaning and understanding and finally, know your role & your limitations.

Incubation period of infection

Active replication of pathogen but no signs & symptoms yet

Battery

Actually following through on the threat & inflicting harm

Secondary healthcare - KNOW FOR TEST

Acute care facilities such as a general hospital setting where medical and surgical problems are managed.

Physical dependence

Adaptation manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist; can develop very quickly

How does access to healthcare affect healthcare delivery?

Affordable Care Act, free clinics, donations to hospitals

How do health disparities affect healthcare delivery?

African Americans, Hispanics, Native Americans and Asian Pacific Islanders (approximately 25% of the US population) experience shorter life expectancy and higher rates of diabetes, cancer, heart disease, stroke, substance abuse, infant mortality and low birth weight

Factors affecting urination:

Age Diet/fluid balance psycholgical factors pregnancy Disease conditions medications (laxatives/ Cathartics) socioeconomic factors personal habits

Innate characteristics of diversity

Age, gender, ethnicity, physical attributes and some illnesses (such as hemophilia)

Priority assessments for use of Celebrex

Allergy to sulfonamides (sulfa drugs), aspirin or NSAIDs, assess ROM, degree of swelling & pain in affected joints, monitor for s&s of Stevens-Johnson syndrome & toxic epidermal necrolysis

Communicating w/adolescents

Allow time to build rapport. Be honest and offer a choice only when one exists. Use active listening skills and be non-judgmental or non-reactive if the adolescent makes disturbing comments.

Licensure

Allows a nurse the legal privilege to practice nursing as defined in each state's NPA. Through this process, the BON ensures minimum standards of competency to provide safe nursing care to the public.

Pureed diet

Allows all foods as long as they are converted to a liquid form in a blender.

Hypoventilation

Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide (seen with respiratory depression for overuse of narcotics)

Ciprofloxacin classification

Anti-infective

Ibuprofen classification

Anti-pyretics, anti-rheumatics, non-opoid analgesics, NSAIDS

Celebrex classification

Anti-rheumatics, NSAID

Patient Self-Determination Act of 1991

An advanced directive is a legal document executed by an individual that expresses that individual's desires regarding medical treatment that may be used once the individual is no longer able to communication his or her preferences directly. This right is guaranteed through the Patient Self-Determination Act of 1991. It is the role of the nurse to reassure the patient and family that even if they make a decision and have an advanced directive, they will have the option to change their decision when competent. The nurse needs to assess whether the patient and family have an accurate understanding of life-sustaining measures. The nurse needs to incorporate teaching in this area and continue to be supportive of clients' decisions.

Case management

An approach that coordinates and links healthcare services to patients and their families while streamlining costs and maintaining quality. Case managers coordinate patient's acute care in the hospital & follows up with the patient after discharge home. Fueled by insurance. Includes nurses & social workers.

Ischemia

An inadequate blood supply to an organ or part of the body

Clubbing

An increase in the angel between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger; indicative of prolonged lack of oxygen

Urine specific gravity

An indicator of urine concentration; normal ranges are 1.005 to 1.030; when the concentration of solutes in the urine increases, the USG increases

Body image

An individual's mental picture of his physical self

Self-esteem

An individual's opinion of himself - the individual's judgments and opinions about the perceived characteristics of the self-concept; whether or not an individual likes the characteristics of himself.

Religion

An organized system of beliefs and practices

Repression

An unconscious mechanism where threatening thoughts, feeling and desires are kept from becoming conscious

Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

Drug therapy for UTIs

Antibiotics such as Bactrim or Septra

Accessory muscles

Any of the muscles of the neck, back, and abdomen that may assist the diaphragm and the internal and external intercostal muscles in respiration, especially in some breathing disorders or during exercise. Often elevated effort of breathing contributes to increased anterior-posterior diameter of the chest (barrel chest) over time (Mosby's definition). E.g. scalene, trapezius, etc.

Fluid intake

Approx. 2300 mL/day from oral fluids (12-1500 mL), water in foods (1000 mL) and water as a by-product of food metabolism (200 mL)

Fluid output

Approx. 2300 mL/day from urine (14-1500 mL or 0.5 mL/kg/hr), insensible loss through skin & lungs (6-900 mL), sensible loss through the skin & loss through the intestines in feces (200 mL)

Fall prevention

Assess for individual risk factors such as previous fall, elimination needs (incontinent, high frequency), medication use for high risk meds (antihypertensives, diuretics, anticonvulsants, sedatives, laxatives, psychotropics, hypnotics or opioids), equipment use that could impair mobility such as catheter or IV tubing, is patient mobile, gait & balance - what assistance is needed, is the patient alert & oriented. Use of bed alarms, fall precaution sign outside the patient's door, non-skid socks, centralized video-monitoring which talks to a patient if they try to get out of bed.

Priority assessments for Vancomycin administration

Assess for infection, monitor IV site closely (very irritating to tissues and causes necrosis & pain), rotate infusion sites, assess for "red man syndrome", evaluate cranial nerve 8 function (hearing test), assess for superinfection (black, furry overgrowth on tongue, vaginal itching or discharge, loose or foul smelling stools), assess trough level concentrations (10mcg/mL - 20mcg/mL) to prevent toxicity

Priority assessments for Ciprofloxacin administration

Assess for infection, vital signs, appearance of wound, sputum, urine & stool, WBC, urinalysis, obtain specimens for culture & sensitivity

Potential consequences of sleep deprivation

Associated with significant cognitive and health problems. It hinders daily functioning and adversely affects health, contributing to difficulty with concentration and memory and contributes to diseases such as diabetes, cardiovascular disease, and depression. Sleep deprivation decreases the ability to perform tasks requiring speed and accuracy and is also linked to an increased risk for motor vehicle crashes. Sleep is also necessary for immune system repair functioning.

Deep vein thrombophlebitis

Associated with stasis of blood flow. Highest incidence of clot formation occurs in pts. who have undergone hip surgery, total knee replacement, open prostate surgery; can travel to the heart; be very attuned to pts who have undergone ortho surgery. Always want to compare side to side simultaneously—always, always, always! Feel pulses simultaneously as well.

How long to cleanse IV insertion site?

At least 30 seconds then must allow to dry

How does homeless/low income population affect healthcare delivery?

At risk populations who most often do not get healthcare but when they finally do get healthcare, they have comorbidities.

When is the best time to conduct a spiritual assessment?

At the end of the assessment process or following the psychosocial assessment because by that time the nurse will probably have formed a solid rapport with the patient & their support person

Stimulants (medications)

BISACODYL: stimulates peristalsis, alters F&E transport. SENNOCIDES: senna alters H2O, stimulates peristalsis

Anticholinergics

BLOCK ACETYLCHOLINE, CONTRACTION OF BLADDER TOMS TOLTERODINE OXYBUTYNIN MIRABEGRON SOLIFENACIN

Foods containing Chloride

Bacon, ham, processed foods, salt

Foods containing Potassium

Bananas, OJ, cantaloupe, apricots, peaches, veggies

living will

legal document that instructs family and physician about what life sustaining treatment a person does or does not want at some future time when they are unable to make a decision.

100,000 Lives campaign

Began in 2005 with a goal to eliminate HAI's such as ventilator associated pneumonia, central line related blood stream infections, surgical site infections and catheter associated UTI's. The campaign was updated in 2006 to be the 5 million lives campaign.

Pre-interactive phase of a nurse-patient relationship

Begins before the nurse's first contact w/the patient. The nurse's role is self-exploration and gathering data about the patient.

Pseudoaddiction

Behaviors that may occur when pain is undertreated; "Clock-watching", frequent visits to ED, hoarding, misusing, aggressive requests for more drugs (drug-seeking behaviors)

Accountability

Being answerable for the decisions made in the course of one's professional practice.

Faith

Belief in or commitment to something or someone

Polytheism

Belief in the existence of more than one God

Monotheism

Belief in the existence of one God

S4 (atrial gallop)

Best heard with bell at Apex. Low-frequency vibration caused by atrial filling and contraction against increased resistance in ventricle; precedes S1 of next cycle. (May be normal in infants, children, and athletes; pathologic in patients with heart disease) *** Can Indicate MI

S3 (ventricular gallop)

Best heard with bell at Apex. Low-intensity vibration of the ventricular wall usually associated with decreased compliance of the ventricles during filling; heard closely after S2. It is caused by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and HTN. (Common in children and young adults and during last trimester of pregnancy) *** Can Indicate CHF

Erikson's Trust vs. mistrust

Birth - 18 months; development of basic trust & sense of security

Projection

Blaming others

AntiCHOLINErgics action & use

Block the action of acetylCHOLINE, which sends the signals that triggers contractions of the bladder; they reduce bladder spasms & decrease urinary incontinence

Sanguineous exudate

Blood

Serosanguineous exudate

Blood stained fluid when serous exudate mixes with blood (red/pink in color)

Non-REM sleep

Body tissue restoration via · slowed biological functions (decreased HR, RR, BP etc.) · Release of human growth hormone for tissue repair & renewal Divided into four stages. 1.) very light sleep, feeling drowsy and relaxed. Eyes roll from side to side; respiratory and heart rates drop slightly. 2.) light sleep, body processes continue to slow; eyes are generally still. 3 & 4.) Deepest stage of sleep. Sleeper id difficult to arouse, not disturbed by stimuli, skeletal muscles are relaxed, and reflexes are diminished, snoring is most likely to occur in this stage, swallowing and saliva production are reduced. THIS STAGE is essential for restoring energy and releasing growth hormones. NOTE: number of sleep cycles depends on the total amount of time individual spends sleeping.

Serous exudate

Clear (straw colored) fluid which leaks out through cell membranes & blood vessels

Hand-off communication

Clear communication, accurate, complete & timely

Healing by primary intention

Clearly incised & re-approximated, healing occurs without complications, fine scar (i.e. surgical incision or paper cut)

Purulent exudate

Frank pus, yellow/green or brown/red color - indicates infection

osmotic medications

CEPHULAC: increase water content and softens stool. decreases pH of colon POLYETHYLIENE GLYCOL/ELECTROLYTE: osmotic agent that draws water into the lumen of the GI tract. POLYETHYLIENE GLYCOL: does not disturb electrolytes

Panic anxiety

Can involve loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. The person may bolt and run aimlessly, often exposing himself or herself to injury

Failure to validate data during the assessment phase

Can lead to an inaccurate or incomplete nursing assessment and could compromise client safety.

Primary healthcare - KNOW FOR TEST

Care delivered in physician's offices, hospital-based clinics that is often the point of entry and location of gatekeeping for all other care. It involves the provision of health maintenance services such as routine physicals, immunizations, treatment of common acute illnesses and support for psycho-social needs.

Watson's theory of human care

Caring is at the core of nursing, positivity impacts health & the healing process

Neuropathic pain

Caused by nerve malfunction or injury resulting in trauma, disease, chemicals, infections, and tumors. · Abnormal processing of sensory input · Can be acute or chronic · Opioids are NOT first line of treatment · Central & peripheral · Burning, shooting, pins and needles, electricity, numbness, hot, shooting, sensitivity, tingling · Pain with normal touch

Jugular venous distention

Caused by right sided heart failure

Behavioral manifestations of anxiety

Changes in problem solving, suppression, diminished or impaired self-control and fantasizing

The use of restraints

Check them every hour & release from restraints Q2H for bathroom & circulation

Patients at risk for developing confusion

Children & older adults are at a greater risk. Patients with hypoxia (inadequate oxygenation of the blood), inadequate perfusion (blood circulation to organs or capillary beds), patients on medication, patients with disease, elderly (especially men), patients with dementia, diabetes, undertreated pain, patients who are experiencing the onset of a new illness, patients with a severe chronic illness, patients who are hospitalized, individuals who are depressed or who have other mental illnesses, patients who abuse alcohol or drugs, ictal (post-seizure), injury, immobility, subdural hematoma, underhydrated/undernourished, patients with infection, electrolyte imbalance, emotional stress.

COPD

Chronic airflow limitation from diseases like emphysema or chronic bronchitis; signs & symptoms easily fatigued, frequent respiratory infections, use of accessory muscles to breathe, orthopneic, dysrhythmias, right-sided heart failure (cor pulmonale), thin in appearance, wheezing, pursed-lip breathing, chronic cough, barrel chested, dyspnea, increased respirations, prolonged expiratory time, bronchitis - increased sputum, digital clubbing, increased partial pressure of arterial carbon dioxide (PaCO2) leading to respiratory acidosis

Signs & symptoms of Cellulitis

Classic - erythema, warm, edema, tenderness/pain Other - fever, blisters, enlarged/tender lymph nodes

Vancomycin (Vancocin)

Classification: T - anti-infectives; used to treat potentially life-threatening infections such as MRSA Priority assessments: Assess for infection, monitor IV site closely (very irritating to tissues and causes necrosis & pain), rotate infusion sites, assess for "red man syndrome", evaluate cranial nerve 8 function (hearing test), assess for superinfection (black, furry overgrowth on tongue, vaginal itching or discharge, loose or foul smelling stools), assess trough level concentrations (10mcg/mL - 20mcg/mL) to prevent toxicity

Types of enemas

Cleansing Tap water Normal Saline hypertonic solutions soapsuds oil retention carminative medicated

The assessment phase of the nursing process

Collecting, organizing, validating and documenting a patient's assessment data. Note significant cues and how they may be clustered or patterned. The purpose is to establish a database about the patient's response to health concerns or illness and the ability to manage healthcare needs.

Combination agents (brochodilator/steroidal)

Combivent, Pulmicort (budesonide)

Elements of the communication process

Communication involves the sender, aka the source encoder. Encoding involves the selection of signs or symbols to transmit the message, such as which language to use or how to arrange the words. The message is the second component and is conveyed via a channel (i.e. talking face to face or writing a message). The third component is the receiver who must listen or observe. The receiver is also the decoder and must perceive what message the sender intended. The fourth component is the response or feedback which allows the sender to correct or reword a message

The nurse-patient relationship as a basis for communication

Communication with the patient should be all about them and their needs. Keep the focus on the patient, not ourselves, and try to redirect conversations back to the patient for their assessment. Focus 100% of your attention on the patient you're with at the moment. Provide client education (the more they know, the better they can make decisions). Most importantly is help the patient become better at helping themselves. Helpful, goal directed/oriented, unconditional positive regard, confidentiality, integrity, genuineness, empathy.

Purposes of documentation in healthcare

Communication, planning care, research, education, auditing healthcare agencies, reimbursement, legal documentation & health care analysis

Magnesium is regulated by...

Conserved & excreted by kidneys

Full liquid diet

Consists of liquids allowed on the clear liquid diet with the addition of milk and small amounts of fiber. The diet may be used for short term such as a transition step between the clear liquid and soft diet following gastrointestinal surgery or procedures. It may also be appropriate for those with certain swallowing and chewing problems.

Clear liquid diet

Consists of liquids which are transparent (you can see through them when held up to the light) and are liquid at body temperature. A clear liquid diet is easily digested and leaves no undigested residue in your intestinal tract. This type of diet is usually prescribed before certain medical procedures (such as a colonoscopy) or certain digestive problems (such as nausea, vomiting or diarrhea) or after certain types of surgery. It should be used only for a few days as it does not provide adequate calories and nutrients.

bowel elimination problems

Constipation Impaction Diarrhea Incontinence Flatulence Hemorrhoids

Side effects of morphine

Constipation, nausea & vomiting, sedation, pruritus (severe itching), hypotension and urinary retention. Of all the side effects associated with opioids, the most life-threatening is severe respiratory depression. Patients on opioids must be carefully monitored for respiratory depression. Normally, sedation precedes respiratory depression. If respiratory rate is less than 8-10 breaths/minute, wake the patient up. If less than 5 breaths/minute, shake the shit out of them!

Continuing Competence in NC

Continual learning; the ongoing application of knowledge and the decision-making, psychomotor, and interpersonal skills expected of the licensed nurse within a specific practice setting resulting in nursing care that contributes to the health and welfare of clients served.

Treatment for a potassium infiltration

Cool compress because you want to slow blood flow to the area so the skin will not slough

Mechanical phlebitis

Frequent movement of catheter or too large a catheter in the vein

Compensation ego mechanism

Covering up weaknesses by emphasizing a more desirable trait or by overachievement in a more comfortable area

Enculturation

Cultural transmission from adults to children

Leninger's theory of culture, care, diversity & universality

Culture plays a crucial role in nursing care

Lower UTIs

Cystitis (most common) & urethritis; signs & symptoms include increased frequency, dysuria, urgency, enuresis (urinary incontinence), strong smelling & cloudy urine, hematuria & pain

Chemical phlebitis

D10W, KCl, minibag replacement, Amiodarone and some antibiotics

Hypertonic solutions

D5.5W, D10W, D20W, D50W, 3% NS, 5% NS, D5NS, D5LR; do not give to patients with heart failure or renal failure; shifts fluids from cells back into circulation, vascular expansion; irritating to veins & may cause fluid overload

Stool softeners/laxatives

DOCUSATE SODIUM: Puts water in stool. DUCUSATE SODIUM/SENNOCIDES: incorporate electrolytes into stool. Stool softener/laxative.

Foods containing Mg

Dairy, dark green veggies, chocolate, nuts, peanut butter & seafood

Foods containing Calcium

Dairy, dark green veggies, sardines & salmon

Eschar

Dead, black tissue - as in stage IV pressure ulcers

Factors that increase ADH production

Decreased blood volume (either dehydration or blood loss), temperature, pain, stressors, some medications (drinking alcohol decreases ADH production leading to an increased frequency of urination)

State & local regulatory agencies

Dept. of Social Services, Dept. of Public Health

Factors that influence the communication process

Development, gender, values & perceptions, personal space, territoriality, roles and relationships, environment, congruence and attitudes. Development - age of the client. Gender - males vs. females communicate in very different ways. Territoriality - patients claiming items in the hospital room as their own. Roles and relationships - nursing student & instructor, client & primary care provider or parent & child. Environment - must be comfortable, temperature extremes or excessive noise can be barriers. Congruence - when the verbal & nonverbal aspects of the communication match.

How does uneven distribution of services affect healthcare delivery?

Different zip codes/areas/demographics - rural areas with few care providers vs. urban areas with multiple care providers

Dyspnea

Difficult or labored breathing; shortness of breath

Sublimation

Displacing energy associated with more primitive sexual or aggressive drives into socially acceptable activities

Spiritual distress nursing diagnosis definition

Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature

Elimination Diagnoses

Disturbed body image bowel incontinence constipation perceived constipation risk of constipation diarrhea nausea

Informed Consent

Doctors will give patients information about a particular treatment or test in order for the patient to decide whether or not they wish to undergo a treatment or test. This process of understanding the risks and benefits of treatment is known as informed consent. Informed consent is based on the moral and legal premise of patient autonomy: You as the patient have the right to make decisions about your own health and medical conditions. The patient must not be coerced and must give voluntary, informed consent for treatment and for most medical tests and procedures. The legal term for failing to obtain informed consent before performing a test or procedure on a patient is called battery (a form of assault). While the nurse is not technically, or even legally, responsible for providing the information necessary for informed consent there is an ethical responsibility to look out for the patient's best interest. The nurse's role is both as a witness that the physician has informed the patient of treatment and as the patient's advocate. Nursing students do not witness any types of consents. In cases of emergency, the law provides for consent so that life-saving procedures can be performed. However, the care cannot be something that the patient has previously refused.

Nonsurgical care of wounds

Dressings - do not heal wounds but enhance the body's ability to heal itself, use surgical asepsis when changing dressing, clean gloves to remove, do not use alcohol to clean wounds (irritating). Wound VAC - device that assist in wound closure by apply localized negative pressure to draw the edges of a wound together

Co-analgesic drugs

Drugs that are used primarily for another purpose but also have some analgesic properties; used to treat pain alone or in combination with other analgesic drugs -antidepressants, anticonvulsants, corticosteroids

Venous Peripheral Vascular Disease (PVD)

Dull-achy pain, lower leg edema, pulse present, drainage, sores with irregular borders, yellow slough or ruddy skin, sores on ankles

Normal assessment findings related to sensory-perception across the lifespan

During the developmental stage for infants and children, perception of sensation is critical to the intellectual, social and physical development. Infants recognize the face of mom/caregiver, young children respond to music by singing & dancing, older children interpret visual & auditory signals (i.e. traffic signal to cross the street). For older adults, normal physiological changes put them at higher risk for altered sensory function. Hearing starts to change around age 30. As we age, we experience loss of acuity (sharpness) for high-frequency tones, have difficulty understanding speech, and a decreased pitch discrimination. Low pitched sounds are the easiest to hear. For the eyes, there is a decreased accommodation to near/far which causes the need for glasses around the ages of 40 - 50. The cornea is flatter and thicker, causing astigmatism. Reduced visual fields, increased glare sensitivity, impaired night vision and decreased color discrimination.

Non-pitting edema

Edema where pressure-induced indentation does not occur

Private funding of healthcare finance

Either employment based plans, self- employment based plans or direct purchase plans.

Adjourning stage of Tuckman's group development

Elderly - task ended, accomplishments recognized, reminisce about past, group breaks up

Vulnerable populations (to disease)

Elderly, children, homeless & immigrants

Communicating w/elderly patients

Ensure the client is using assistive devices like glasses or hearing aids and that they are in working order. Use communication aids such as communication boards, or pictures, when possible. Speak in short, simple sentences and focus on one subject at a time. Always face the client because coming up behind someone can be frightening. Include family & friends in conversation. Reminisce with the client to maintain memory connections, enhance self-identity & self-esteem. When verbal & non-verbal communication is incongruent, believe the non-verbal. Find out what is important and has meaning to the client and try to maintain these things as much as possible.

Safety issues associated with patient's environments

Environmental hazards could include clutter, noise or confusion. The transmission of pathogens could include c. Diff, MRSA or blood borne pathogens. Individual factors include age (young children for accidents, elderly for falling, but for children & elderly - adverse drug effects, incorrect dosage calculations, birth complications, surgical errors, diagnostic errors or risk of infection). Risks in the healthcare environment include being in an unfamiliar environment, HAI's or patients without significant others to help them answer questions or assist them after being discharged, a patient not speaking up or not being included as a full partner in their own care, and new medications. Physical hazards include MVA, poisons, falls, fire, disasters or pollution.

Calcium functions

Essential for proper function of cardiovascular, neuromuscular and endocrine systems, needed for blood clotting, bone & teeth formation, it is redistributed between the bones & ECF

Intellectualization

Evading the emotional response that normally would accompany an uncomfortable or painful incident by using rational explanations that remove from the incident any personal significance and feelings

How often do you check a pediatric patient for infiltration?

Every hour

Polydipsia

Excessive thirst. Associated with polyuria

Chloride is regulated by...

Excreted & reabsorbed along w/Sodium in the kidneys; Aldosterone increases Chloride reabsorption w/Sodium

Ethical dilemma

Exists when two or more rights, values, obligations, or responsibilities come in conflict. Conflict may arise between the nurse's personal values and those of another individual or the organization, between principles and the need to achieve a desired outcome, or between two or more individuals or groups to whom one has an obligation. Ethical dilemmas prominent in today's culture are genetic testing, abortion, stem cell research, organ transplants, euthanasia or assisted suicide, withdrawing or withholding life-sustaining treatment, or withdrawing or withholding food & fluids.

Pressure ulcer - stage III

Full thickness kin loss involving damage or necrosis of subcutaneous tissue; bone, tendons and muscle are not exposed, presents clinically as a deep crater with or without undermining and tunneling of adjacent tissue, slough may be present (note: depth of this stage varies by anatomical location; in areas without adipose tissue, the ulcer may be very shallow)

Questions to guide a spiritual assessment

FICA 1) Faith or beliefs - "what spiritual beliefs are most important to you?" 2) Implications or influence - "how is your faith affecting the way you cope now?" 3) Community - "Is there a group or like-minded believers with whom you regularly meet?" 4) Address - "how would you like your health care team to support your spirituality?"

Risk factors

Factors that cause a patient to be vulnerable to developing a health problem

Spirituality in the pediatric population

Faith is guided by parents and others

Spirituality in the adult population

Faith is internalized and serves as a directive for action

Psychological manifestations of anxiety

Fear, anxiety, anger, depression and a variety of other responses

Complications of hyperthermia

Febrile seizures - occur in children (3mo-5yr) as a result of rapid temp increase above 102F in association w/acute illness

Lab tests for elimination

Fecal specimens H&H blood analysis total bilirubin alkaline phosphatase and amylase CEA

Third spacing of fluid

Fluid accumulation in part of the body where it is not easily exchanged with ECF & can't return to first spacing

Institute of Medicine aka National Academies of Science, Engineering & Medicine

Focused on assessing and improving the Nation's quality of care; very concerned w/safety and best practices - in 1999 came out with a published article about crossing the quality chasm saying that healthcare systems are responsible for the safety of patients while the patients are in their care - not supposed to cause patients harm

The nurse as a protector & advocate

For example - Advocating for a patient who has a terminal illness where the family members disagree about the patient's care. The patient only wants to be provided with comfort measures while the family is trying to prolong the patient's life. The nurse needs to advocate for what the patient wants, which is comfort.

Priority assessment for Ibuprofen administration

For pain - assess pain prior to and 1-2 hours following admin; for fever - monitor temp & assess for signs of fever (diaphoresis, tachycardia & malaise)

Advanced consistency diet

For patients with dysphagia (difficulties swallowing), foods need to be moist and should be in "bite-size" pieces. Patients need to avoid foods that are very hard, sticky, or crunchy. Foods in this diet are easy to chew.

Communicating w/children

For young children, they need plenty of time to be able to verbalize their thoughts. Adults should ask simple questions, provide simple answers and use one-step directions due to the child's short attention span. Avoid sudden or rapid advances, threatening gestures or prolonged eye contact. Communicate through transitional objects such as a stuffed animal. Speak in a quiet, unhurried, confident tone. For school age children, talk to the child at eye level and try to include the child in the conversation if the parents or caretakers are present. Be honest and offer a choice only when one exists.

Non-dependent edema

Generalized edema - doesn't matter if it's in the lower part of the body or not

Cellulitis

Generalized infection (staph or strep) involving deep connective tissue; resulting from a bacterial infection of an open wound or unrelated to skin trauma; rapid onset; patients at risk include older adults, peripheral neuropathy, malnutrition, dehydration

Malpractice

Going outside the standard scope of practice as dictated by the profession.

Assessment of wound bed

Granulation - beefy red (good), sloughing (yellow/tan), necrosis (eschar) - black, also assess for 5 P's, measure wound, look for bleeding, foreign objects, associated injuries, contamination & assess sutures

Complications of wound healing

HIDE - Hemorrhage, Infection, Dehiscence, Evisceration

Phases of normal wound healing

HIPM - Hemostasis, Inflammation, Proliferation & Maturation/remodeling

Signs of thrombophlebitis

Hard, vein is like a cord, plus signs of phlebitis

Patricia Benner's expert nurse

Has an intuitive grasp of the situation and readily zeros in on the problem and solution without spending much time problem solving.

Beneficence

Have compassion, take positive actions to help others and follow through on the desire to do good

Excoriation

Having skin stripped off - does not constitute a pressure ulcer

Healing by secondary intention

Healing occurs in open wounds, wound edges are not approximated, healing occurs with formulation of granular tissue (the more granulation tissue, the bigger the scar)

The Wellness-Illness Continuum by John W. Travis, MD

Health & illness or disease can be viewed as the opposite ends of a health continuum. Beginning at a high level of health, an individual can move through good health, normal health, poor health, extremely poor health, and eventually to death. Individuals move back & forth within this continuum day by day. There is no distinct boundary across which individuals move from health to illness or from illness back to health. How individuals perceive themselves and how others see them in terms of health and illness also affect their placement on the continuum. The ranges within which individuals can be thought of as healthy or ill are considerable.

Nursing diagnoses relevant to patients with sensory/perceptual alterations

Hearing: • Impaired verbal communication • Risk of injury • Social isolation Vision • Cataracts o Risk of injury related to visual impairments o Risk of ineffective health maintenance o Decisional conflict - cataract removal • Eye injury o Impaired tissue integrity o Acute pain o Anxiety o Ineffective tissue perfusion - retinal

Hypothermia

Heat loss during prolonged exposure to cold overwhelms the body's ability to produce heat

Signs of Phlebitis

Heat, tenderness, redness, red streaking along vein

What sort of data does not require validation during assessment?

Height, weight, birth date and most lab studies that can be measured with an accurate scale can be accepted as factual. As a rule, the nurse validates data when discrepancies arise between data obtained in the nursing interview (subjective data) and the physical exam (objective data) or when the client's statements differ at different times in the assessment.

Religious care

Helping patients maintain faithfulness to their belief system and worship practices

Spiritual care

Helping people identify meaning & purpose in life, look beyond the present, and maintain personal relations as well as a relationship with a higher being or life force

Sodium functions

Helps nerves impulses & muscles contract, regulates ECF and maintains blood volume

Fine crackles

High-pitched, fine, short; interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing (rub pieces of hair together beside your ear to duplicate the sound)

Sleep deprivation

Hinders daily functioning and adversely affects health, contributing to diseases such as diabetes, cardiovascular disease and depression.

What to do after removing an IV?

Hold pressure for 2-3 minutes (for blood thinner patients, hold until bleeding stops) and check catheter for intactness

Short-term nursing goal

Hours to less than a week

Self-concept

How an individual perceives himself (personal traits, characteristics, values, beliefs & behavior).

Stages of infection

IPAC 1) Incubation period, 2) Prodromal stage, 3) Acute stage and 4) Convalescent stage

IV secondary/piggyback (IVPB)

IV bag (25-250 mL) with medication Short tubing that connects to the Y-port or cassette May need to use gravity depending on type of IV pump used Check compatibility of IV infusing Remember 3 checks o MD order and MAR o Amount of medication- mg and mL o Concentration diluted/undiluted and with how many mL and with what solution

IV therapy delegation to UAP?

IV insertion is NOT delegated to a UAP, RN ensures that the UAP knows how to bathe & position patients w/IVs, RN is responsible for assessment of IV site, UAPs CAN remove IVs

NSAIDs

Ibuprofen, naproxen sodium, aspirin, Celebrex; analgesic, anti-pyretic & anti-inflammatory properties; avoid in patients w/peptic ulcer and/or using anticoagulants; caution in elderly - potential reduction in liver & renal function

Signs of IV hematoma

Immediate swelling at site, ecchymosis (bruising), hard & painful lump at site

Patient related causes of phlebitis

Immunodeficiency, current infection, IV in the leg, age > 60, diabetes

Spiritual distress

Impaired ability to experience and integrate meaning & purpose in life through connectedness with self, others, art, music, literature, nature and/or a power greater than oneself

NC Board of Nursing

In addition to issuing, renewing and reinstating nursing licenses for Registered Nurses and Licensed Practical Nurses, Board responsibilities include: • Approving and monitoring the state's nursing education programs which lead to initial licensure throughout the state; • Interpreting the practice of nursing in North Carolina based on the Nursing Practice Act; • Investigating complaints against licensed nurses and taking appropriate actions when deemed necessary; • Administering the Nurse Licensure Compact; • Maintaining the Nurse Aide II Registry; • Regulating the practice of Nurse Practitioners and Nurse Midwives.

Gate Control Theory

In addition to the physical aspect of pain, there are emotional & cognitive components. It is theorized that pain impulses travel through an open "gate" and impulses are blocked if the gate is closed.

Hypoxia

Inadequate tissue oxygenation at the cellular level.

Late signs of hypoxia

Increased restlessness, somnolence, stupor, dyspnea, decreased respirations, bradycardia, cyanosis

Physiological manifestations of anxiety

Increases ventilatory rate and depth of respirations, dilation of bronchioles to facilitate increased oxygenation, increased heart rate & cardiac output to promote transport of oxygen & nutrients throughout the body, increased sweat production to offset increased body temperatures, inhibition of parasympathetic nervous system leads to a decrease in digestion, dry mouth, increased sodium and water retention which leads to decreased urine output and increased blood volume, pupils dilate to allow more light and enhanced visual perception, enhanced awareness and alertness, increased muscular tension, and increase in glucocorticoids and an increase in blood glucose.

Autonomy

Independence or freedom; the right to self-determination. Professional practice reflects autonomy when the nurse respects clients' rights to make decisions about their healthcare

Atheist

Individual who does not believe in any God

Agnostic

Individual who doubts the existence of God or a supreme being or who believes that that existence has not yet been proven

Restorative healthcare - KNOW FOR TEST

Individuals unable to completely care for themselves for may need additional short term recuperation assistance with this type of care either with support at home or at inpatient or outpatient rehab facilities.

Veracity

Individuals who always tell the truth reflect this principle. It is the principle behind giving complete information before obtaining a patient's informed consent for any procedure.

Forming stage of Tuckman's group development

Infant - task/purpose defined

Expected characteristics of cognitive development across the lifespan

Infants/toddlers develop a sense of "self" and "other" and come to understand object permanence. Require sensory stimulation. Learn by experiencing and manipulating the environment. Young children - egocentric thinking is demonstrated, they participate in imaginative play and begin to recognize that others don't see the world the same way they do. School age children are no longer fooled by appearances. They understand the basic properties of and relations among objects and events, and they are proficient at inferring motives. Logical reasoning is possible but is limited to concrete/observational problems. Adolescents through adults - logical thinking is no longer limited to the concrete or observable. This group engages in systematic, deductive reasoning and they ponder hypothetical issues. Older adults decline in the ability to perform information processing, divide attention between 2 tasks, maintain sustained attention or perform vigilance tasks, filter out irrelevant information, perform word finding, perform abstraction tasks, and maintain mental flexibility.

Convalescent stage

Infection is resolved

Intercellular Fluid (ICF)

Inside the cells (approx. 2/3 total body weight; 28 liters)

Mental status exam

It is used to gauge a patient's language abilities, orientation, memory, calculation ability, mood, perceptions and thought processes, to obtain a baseline cognitive functioning of the patient. It consists of personal information, appearance, behavior, speech, affect & mood, thought, perceptual disturbances and cognition (level of consciousness, orientation, memory, attention, abstract thinking, insight & judgement). Preparing the client & explaining what will be done, position & observe the client, assess language abilities, assess level of orientation, assess memory, assess computation ability, assess emotions and mood, assess perceptions & thinking abilities to make sure client is aware of reality and that statements are logical, coherent, relevant and complete, and finally assess client's decision making ability.

Rationalization

Justifying certain behaviors by faulty logic

Fidelity

Keep commitments, based on virtue of caring.

Interventions for a patient w/renal calculi

Keep patient well hydrated (1,500 ml/day)

Interventions for severe-panic anxiety

Label anxiety for patient & intervene immediately , do not explore feelings or cause of anxiety, reduce or place no demands on patient, support/accept safe & comfortable expression of feelings, assess need for anti-anxiety medication, time out, seclusion or restraint after other interventions have been tried

How do demographic changes affect healthcare delivery?

Lack of care in certain urban areas vs. plenty of care in Triangle region (for example).

Secondary groups

Larger and less personal, less sentimental. Once group goal has been achieved the group usually disbands. Members don't have to know each other. Communication is not always face to face. Member expectations administered through impersonal controls & external restraints (i.e. NUR 111 class)

Chronic illness

Lasts for an extended period, usually 6 months or longer and often for the duration of the person's life. They are usually slow onset and often have period of remission (when the symptoms disappear) and exacerbation (when the symptoms reappear).

Chronic pain

Lasts longer than 6 months and persists beyond expected periods of healing. It is constant or recurring with a mild-to-severe intensity with a gradual onset. It does NOT always have an identifiable cause. It is usually not life-threatening. Associated symptoms include fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, and anger. There is no objective evidence to confirm the existence of chronic pain. Most CP has a very strong neuropathic component because it represents an error in CNS processing of pain signals.

NC Nursing Practice Act

Law of nursing that tells what scope of practice a nurse is able to do, protects the public.

NC Practice Act

Law that governs the practice of nursing in the state of NC & guides the work of the Board of Nursing; it defines competency & protects the public

Topical pain management

Lidocaine, salicylates (Aspercreme)

Coarse crackles

Loud, bubbly sounds heard during inspiration; not cleared with coughing

Hypoxemia

Low blood oxygen concentration

Osmotic laxatives

Low dose polyethylene glycol and saline aren't absorbed in the intestine, they pull water into the fecal mass to create a watery stool

Medium crackles

Lower; moister sounds heard during middle of inspiration; not cleared with coughing

Atelectasis

Lung collapse

Sim's position

Lying on the left side, left hip and lower extremity straight, and right hip and knee bent. (often used for admin of enemas or other procedures)

Lateral position

Lying on the side

Lithotomy position

Lying supine with feet raised (in stirrups)

Dorsal recumbent position

Lying supine with knees bent

Evidence-based practice

Made up of clinical expertise, research evidence and patient values & circumstances. A problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician's expertise and patient preference and values in making decisions about the patient's care. It utilizes knowledge that is already known along w/studies completed by others to make a practical decision policy. It requires that the nurse base nursing practice on the best and most applicable evidence from clinical research studies. The nurse should also be alert to clinical issues that warrant investigation and develop a research problem about the issue.

Ways to maintain a safe environment for patients with sensory deficits

Maintain patient safety, reduce patient's anxiety, meet patient's basic needs, increase patient's participation in the environment, attempt to focus the patient's attention back to reality, reduce stimuli in the environment, do not convey belief of the misperceived stimuli - let the patient know you do not hear, see or feel what he/she does, but that you understand it is real to her, assist the patient to identify feelings, offer activities that will help the patient focus on reality instead of the false or distorted perception, or biological intervention with antipsychotic medication is almost always indicated to modify biochemical imbalance/changes.

Potassium functions

Maintains ICF osmolality, transmits nerve & other electrical impulses, regulates cardiac impulse transmission, regulates acid-base balance

Pressure ulcers - pressure area assessment

Normal findings: Pressure areas should have brisk cap refill or blanch response when gently palpated, skin over pressure areas s/b intact. Abnormal findings: Nonblanching redness, abrasions in areas where skin rubs on linens or bedding, excoriations in areas exposed to bodily secretions or excretions in the skin folds

Pressure ulcers - skin temperature assessment

Normal findings: Temp of pressure areas is the same as that of the surrounding skin. Abnormal findings: Increased temp indicates inflammation or trapping of blood in the pressure area, decreased temp indicates lack of blood flow

Common allegations against nurses

Malpractice suits as a result of negligence resulting from medication errors, communicating care concerns and key information about the client's condition, ignoring patient's complaints, ensuring physicians' orders are clear, understanding how to use equipment in practice and providing appropriate mentoring, assessment and care plans for patients. Strategies to prevent incidents of professional negligence include maintaining client safety (assess every patient for fall potential & document all nursing measure taken to protect the patient), properly identifying the patient, minimizing the risk of medication errors by applying the Six Rights of medication administration (right drug, right dose, right client, right route, right time, right documentation), using effective communication (attentive listening and accurate documentation and reporting )and carrying professional liability insurance.

Foods containing Phosphate

Meat, fish, poultry, legumes & dairy

Causes of phlebitis

Mechanical friction (too large a needle in vein) and chemicals (drugs too caustic for vein)

State funding of healthcare finance

Medicaid is available to certain lower income individuals & families, the elderly, and people w/disabilities. Children's Health Insurance Program (CHIP) is also available to provide health insurance to children under the age of 19 whose families earn more than the Medicaid limits but cannot afford to purchase private health care coverage; County Health Departments

Center for Medicare & Medicaid (CMS)

Medicare has contributed to a life expectancy that is five years higher than it was when the law went into effect in 1965.

Performing stage of Tuckman's group development

Middle adulthood - high productivity, flexibility, interdependence, loyalty to group (like a sports team)

Ibuprofen uses

Mild to moderate pain & fever

How do rising healthcare costs affect healthcare delivery?

Millions of Americans are uninsured because they are unable to afford the cost of health insurance resulting in individuals unable to negotiate better rates with providers and individuals who seek care less, and who seek care later in the disease process.

Common stressors that affect self-concept & self-esteem

Mobility (immobility have lower self-esteem), family (the ability to fulfill your roles & responsibilities), mood and affect, and ethics (your moral standards and who you are as a person affect how you treat people), and education.

How do advances in technology affect healthcare delivery?

More sophisticated technology, new discoveries which modify how and where can may be provided (for example, fewer hospitalizations for some surgeries because they can safely be performed at alternative sites such as surgical centers), shorter hospital stays due to advances in treatments, new job opportunities for individuals as a result of advances in technology requiring specialized personnel; safer health practices with technology in medication administration; electronic medical records allow easier access to patients health history for healthcare providers; less invasive surgeries due to robotics

Catheter Acquired Urinary Tract Infection (CAUTI)

Most common HAI caused by development of bacterial biofilms that are found on catheter's inner surface

Standard precautions

Most importantly hand hygiene and the use of PPE when necessary

Osmosis

Movement of fluid through a semi-permeable membrane from an area of low solute concentration to an area of high solute concentration

Wing-tipped needles

Must take special care as this is the cause of the majority of needle sticks to health care workers

Licensing boards

NCBON; state regulated; responsible for regulating the practice of nursing; also provide a lot of data about nursing (i.e. number of licensed nurses in the state)

Antidote for morphine

Narcan (naloxone - generic name)

Core measures

National standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Compliance with this type of reporting shows how often a hospital provides each recommended treatment for certain medical conditions. In other words, a type of healthcare that is evidence-based that says that everyone that comes to the hospital, specific measures are used on each person that come through with a certain diagnosis (i.e. Myocardial Infarction).

Addiction

Neurobiologic disease; genetic, psychosocial and environmental factors; 4 C's: impaired Control, Compulsive, Craving, Continued use despite harm

Constipation

No bowel movement after 5 days

Patricia Benner's novice nurse

No experience; relies on theory, guidelines and policies; lacks discretionary judgment and focuses energy on task performance.

Prodromal stage of infection

Non-specific symptoms

Pressure ulcer - stage I

Nonblanchable erythema of intact skin; affected areas may be painful and a different temperature and consistency than the surrounding skin

First spacing of fluid

Normal distribution of fluid in ECF & ICF

The function of laws in nursing

Nursing laws define the rights, responsibilities and scope of practice. Nursing laws are examples of statutory laws which are developed to maintain health, public order, safety and welfare of patients. Other statutory laws that affect the practice of nursing include statutes of limitation, protection and reporting laws, natural death acts and informed consent laws.

Best practice

Nursing practices that are based on the best evidence available from nursing research (YOU DO BETTER WHEN YOU KNOW BETTER) - may be referred to as the standard

Systemic inflammation

OATMEAL, tachy, tachy - Organ failure - All local plus... - Temperature >100.4 or <96.8 - Malaise - Enlarged lymph nodes - Anorexia, nausea/vomiting - Leukocytosis >12,000 - Tachycardia, tachypnea

Federal regulatory agencies

OSHA; DHHS

Assessment tools for assessing confusion

Obtaining a health history, a physical exam and a mental status exam. To differentiate between delirium (confusion) and dementia, a Confusion Assessment Method (CAM) may be used. This instrument screens for overall cognitive impairment and for traits associated with reversible confusion. History includes onset, duration and baseline mental status, review current medication use, any recent changes in vital signs and O2 saturation, any evidence of infections, labs & x-rays (tests for infection, electrolytes), results of the CAM, results of the mini mental status exam, signs of depression.

Healing by tertiary/delayed primary intention

Occurs when a primary wound becomes infected, is opened and allowed to granulate for a few days, then closed as if primary once infection is controlled, results in a larger, deeper scar

Diffusion

Passive movement of particles from an area of high solute concentration to an area of low solute concentration

Acute stage of infection

Pathogen proliferates & disseminates; symptoms are pronounced

Total patient care aka client focused care

One nurse assigned to comprehensive care (all tasks) of clients during an 8 or 12 hour shift (i.e. ICU)

Primary nursing

One primary RN assumes responsibility for a caseload of patients (24/7) even if the nurse does not deliver all the care personally (i.e. home health care)

Long-term nursing goal

One week to months...

Magnesium functions

Operates the Na/K pump, operates IC metabolism (ATP production & protein/DNA synthesis), relaxes muscle contractions, transmits nerve impulses, regulates cardiac functioning

Extracellular Fluid (ECF)

Outside the cells (approx 1/3 total body weight; 14 liters)

Types of opioids

Oxycodone, Hydrocodone, Codeine, Morphine, Dilaudid, Fentanyl

Medications to promote oxygenation & perfusion

Oxygen, Albuterol, bronchodilators, steroid inhalers

Components of a 3-part nursing diagnosis

P - Diagnostic label (Problem), E - Etiology (Related to - what's causing the problem?), S - Defining characteristics (Signs & Symptoms)

Components of a 2-part nursing diagnosis

P - Diagnostic label (what's the Problem) and E - Etiology - Related to (what's causing the problem); For example: Constipation related to prolonged laxative use, or severe anxiety related to threat to physiological integrity: possible cancer diagnosis. For NANDA labels that contain the word specify, the nurse must add words to indicate the problem more specifically but the format is still 2-part. For example: Noncompliance (specify) = Noncompliance (diabetic diet) related to denial of having disease.

The PICOT criteria of developing EBP

P - Population (patients) I - Intervention (for intervention studies only) C - Comparison group O - Outcome of interest T - Time

3 components of a nursing diagnosis

P - the diagnostic label from NANDA - the problem E - the etiology (where did it come from, what is it r/t?) S - the defining characteristics - the symptoms

nonopiod analgesic

PHENAZOPYRIDINE: relief of UTI (pain, itching, burning, urgency, frequency)

Bulk forming medications

POLYCARBOPHIL: Tx for constipation of diarrhea associated with diverticulitis or IBS PSYLLIUM: avoid straining, chronic watery diarrhea, chronic constipation

salines (medications)

POTENTIAL TO CAUSE EXCESS LOSS OF F&E MAGNESIUM SALTS: draws water in= peristalsis MAGNESIUM CITRATE: clean out bowels MAGNESIUM GLUCONATE/HYDROXIDE/OXIDE

Signs of catheter embolism (Medical emergency - call RRT!)

Pain along vein, decreased BP & LOC, cyanosis

Nociceptive pain

Pain resulting from external stimuli on an uninjured, fully functioning nervous system (i.e. sunburn or papercut). It is usually temporary. Somatic: · Results from stimuli in the skin, bone, muscle, connective tissue · Localized · Descriptors: Aching; throbbing, Sharp, stabbing, soreness Visceral: · Due to stretch, distention, or inflammation · Solid or hollow organs such as GI tract · Poorly localized; referred · Descriptors: Deep, crampy, pressure, dull, gnawing, squeezing, spasm

Signs & symptoms of extravasation

Pain, redness, burning, pallor, no blood return, edema, decreased IV flow or flush

Parasympathetic NS response to pain

Pallor, muscle tension, decreased HR & BP, rapid, irregular breathing

Calcium is regulated by...

Parathyroid hormone & calcitriol increase Calcium blood levels, calcitonin decreases Calcium blood levels

Dehiscence

Partial or total separation of wound layers

Pressure ulcer - stage II

Partial thickness skin loss involving the dermis, presents as a shallow open ulcer without slough, may also present an intact or open pus or blood filled blister or a shiny, dry ulcer without slough (note: skin tears, tape burns, incontinence-associated dermatitis, maceration, and excoriation are not included in this classification)

Foods containing Sodium

Salt, dairy, processed meats, snacks, pork, soy & canned soups

Nursing clinical research

Seeks answers to questions that will ultimately improve client care

Stimulant laxatives

Senna and bisacodyl (dulcolax) irritate the bowel to stimulate peristalsis

Pruritis

Severe itching (as a result of contact dermatitis, for example)

Acute illness

Severe symptoms for a relatively short duration. Symptoms often appear abruptly and subside quickly and depending on the cause, may or may not involve intervention by healthcare providers.

Central venous catheters

Short-term to long-term Up to 2 weeks

Orthopnea

Shortness of breath that occurs while lying flat but improves when sitting up.

Paroxysmal Nocturnal Dyspnea (PND)

Shortness of breath that wakes the patient up after laying down for a while (common with lung disease and heart failure).

Maturation/remodeling

Shrinking/strengthening of scar

Wheeze

Sibilant (hissing) wheeze; o Character: high-pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration; usually louder on expiration o Cause: high-velocity airflow through severely narrowed or obstructed airway o Site auscultated: heard over all lung fields

Primary group

Small & intimate. Personal, spontaneous, sentimental, cooperative and inclusive. Communicate primarily face to face. Support each other in times of stress.

Hematocrit

The ratio of the volume of RBCs to the volume of whole blood; approx. 42 - 52% for men & 38 - 48% for women

IV push/bolus (IVP)

Small volumes of fluid less than 10 mL Check compatibility of fluids infusing • 3 checks including: o MD order and MAR o Amount of medication- mg and mL o Concentration diluted/undiluted and with how many mL and with what solution Rate of administration mL/min Flush before and after medication administration (SAS) Choose injection port closest to patient Occlude tubing above injection port while injecting medication if IV fluids infusing (pinch release)

Primary electrolytes found in ECF

Sodium, Chloride & Bicarbonate (HCO3-)

Patricia Benner's advanced beginner nurse

Some task and situational experience, but the focus is the task and rules with little ability to take the complexity of the situation into consideration.

Rhonchi

Sonorous (deep & full) wheeze; o Character: loud, low-pitched, rumbling coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing. o Cause: muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence o Site auscultated: are primarily heard over trachea and bronchi; if loud enough, able to be heard over most lung fields

Various types of documentation reports

Source oriented reporting, problem oriented medical record (POMR) - using SOAP or SOAPIER (subjective, objective, assessment, plan, implement, evaluate, reassess) format, Problems, interventions, evaluation (PIE), focus charting, charting by exception (CBE) - what we use in EPIC, electronic documentation, flow charts

Tertiary healthcare - KNOW FOR TEST

Specialized care facilities such as regional trauma centers (ICU) care, burn care or other high level specialty care would take place.

Tolerance

State of adaptation in which exposure to a drug results in a decrease in one or more of the drug's effects over time

PICC VAD

Sterile procedure Long term 18-24 months

Examples of anti-inflammatory medications

Steroids, Leukotriene antagonists (Singulair), Mast cell stabilizers (Intal), Monoclonal antibodies (Xolair).

Phases of hemostasis

Stopping the blood flow - 1) Vasoconstriction, 2) platelet release, 3) clot formation

Distress

Stress that is associated with inadequacy, insecurity and loss

Assessing for perfusion status

Subjective: • Pain or discomfort (recognize that women and elderly may not exhibit classic pain symptoms with MI) • Dyspnea on Exertion (DOE) -difficulty breathing associated with activity, common with heart failure, but may also simply reflect anemia • Palpitations - caused by irregular heartbeat • Sudden weight gain - fluid retention...edema, polyuria, etc. • Syncope - brief loss of consciousness Objective/Diagnostic: • Hematocrit and Hemoglobin • Cardiac biomarkers • EKG

Indirect care intervention

Treatments performed away from the patient but on behalf of the patient (i.e. charting)

Semi-Fowler's position

Supine with head raised 15 - 30 degrees

Fowler's position

Supine with head raised 45 - 60 degrees

Debridement

Surgically removing dead tissue as in a stage III or stage IV pressure ulcer

Signs of air embolism (Medical emergency - call RRT!)

Tachycardia, SOB, decreased BP & LOC, cyanosis

Sympathetic NS response to pain

Tachypnea, tachycardia, peripheral vasoconstriction, increased blood glucose levels, diaphoresis, increased muscle tension, dilation of pupils, decreased GI mobility

Storming stage of Tuckman's group development

Teenager - important issues addressed - conflict surfaces

Reporting methods used in nursing

Telephone communication, incident of occurrence reports, hands-off communication, change of shift report and the SBAR (situation, background, assessment & recommendation) reporting.

Severe hypothermia

Temp < 82F, absence of respirations and pulse, dilated unresponsive pupils, coma

Moderate hypothermia

Temp = 82-90F, depressed mental status, no shivering, slow pulse, hypotension, coma, reduced respirations, hallucinations

Mild hypothermia

Temp = 90-95F, slurred speech, poor coordination, clumsiness

Direct care interventions

Treatments performed through interactions with the patient

The data organization step of assessment

The collected data must be documented at the time of collection or shortly thereafter. As part of the documentation process, the nurse uses a written or digital format that organizes the assessment data systematically. This is often referred to as a nursing health history, nursing assessment, or nursing database form. Most schools of nursing and healthcare agencies have their own structured assessment format. Data may be organized in formats based on Maslow's Hierarchy of Needs (physiological needs/survival needs, safety and security needs, love and belonging needs, self-esteem needs, self-actualization needs) or other developmental theories such as Freud's 5 stages of development, Erikson's 8 stages of development or Piaget's phases of cognitive development. Assessment data may also be organized by functional health patterns or by body systems.

Role performance

The demonstration of behaviors or actions associated with a given role

Care-giver role strain

The difficulties assuming and functioning in the caregiver role as well as associated alterations in the caregiver's emotional and physical health that can occur when care demands exceed resources. Stresses of being in the sandwich generation...strains can result in decline of health for caregiver, decline of health for care-receiver and dysfunctional or abusive relationships.

Coping

The dynamic process through which the individual applies cognitive and behavioral measures to handle internal and external demands that are perceived by the individual as exceeding his available resources

How does aging in the US population affect healthcare delivery?

The effects of aging, long-term illnesses, and lack of primary care with seniors aged 65 and up will increase the need for management of health care and support systems to assist individuals living in the community

Venous return

The flow of blood back to the heart.

Sodium is regulated by...

The kidneys & adrenal glands; Aldosterone tells kidneys how much Sodium to retain

Potassium is regulated by...

The kidneys; Aldosterone increases Potassium excretion

Braden Scale for predicting pressure ulcer risk

The lower the score, the more the patient is at risk for developing a pressure ulcer; scores can range from 6 (highest risk level) to 23 (lowest risk level)

Multi-culturalism

The many subcultures coexisting within a given society in which no one culture dominates. In a multi-cultural society, human differences are accepted and respected.

Serum osmolality

The measure of solute concentration in the blood (particles include sodium ions, glucose & urea/blood urea nitrogen or BUN); normal range is 280 - 300 mOsm/kg water

Introductory or orientation phase of a nurse-patient relationship

When the nurse & client first meet. The nurse seeks to find out why the client sought help. The tasks during this phase are to establish trust, understanding, acceptance, open communication and formulate a contract with the patient.

Pain

The most common reason people seek emergency care. It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is perceptual and emotional; a patient can only provide a subjective description of pain. It is a warning of injury, illness or disease. It is described in terms of location, duration, intensity, quality, and etiology.

Termination phase of a nurse-patient relationship

The most difficult, a summarizing process, discuss termination and allow time for patient adjustment to independence. Also a time to exchange feelings and memories and to mutually evaluate the patients progress and goal attainment.

Active transport

The movement of electrolytes across a cell membrane from an area of low concentration to an area of high concentration using ATP energy produced in the cells' mitochondria

Filtration

The movement of fluid & solutes in & out of capillaries and the interstitial compartment that is controlled by hydrostatic pressure and colloidal osmotic pressure (Starling's Law). At the arterial end of a normal capillary, capillary hydrostatic pressure is strongest, and fluid moves from the capillary into the interstitial area, bringing nutrients to cells. At the venous end of the capillary, capillary hydrostatic pressure is weaker, and the colloid osmotic pressure of the blood is stronger. Thus fluid moves into the capillary at the venous end, removing waste products from cellular metabolism.

What is a no-lift policy?

The no-lift policy calls for healthcare providers to avoid manual handling in virtually all patient care situations. With the development of assistive equipment and devices (mechanical lifts, standard assist devices, retractable seats and high-friction slide sheets), the risk of musculoskeletal injury to healthcare providers can be eliminated or significantly reduced.

ANA Standards Professional Performance

Trusted because of their dedication to standards, guidelines, and principles. They work hard to elevate the nursing profession by defining the values and priorities for registered nurses across the nation. Through this work, ANA can provide direction to nurses across the nation, influence legislation, and implement a framework to objectively evaluate nursing excellence.

Most commonly occurring sentinel events

Unintended retention of a foreign object Falls Performing procedures on the wrong patient Loss of limb or functions

Legal responsibilities of nursing students

The nursing student is held to the same standard as a skilled experienced licensed nurse to ensure client safety, know the facility's policies and procedures, ensuring they are knowledgeable about the client's condition, never perform care for which you are unprepared and seek help before performing a procedure you are unsure about.

Culture

The patterns of behavior and thinking that people living in social groups learn, develop & share

Appraisal

The process by which individuals evaluate and cope with a stressful event

Assimilation

The process of adapting to and integrating characteristics of dominant culture

Chasing Zero

The story of Dennis Quaid's twins who were overdosed twice in one day with heparin because the heparin & heplock vials looked the same. As a result of his campaign, the color on the heparin vial was changed for better identification.

Hans Selye's General Adaptation Syndrome

The stress response as a 3-stage chain of events; alarm reaction, resistance and exhaustion. Alarm reaction is 2-stage - shock phase where the body prepares for the cascade of physiological reactions to the stressor and the sympathetic nervous system is suppressed and countershock phase where the sympathetic nervous system triggers the body's defenses as fight or flight. This phase is short-lived and lasts anywhere from 1 minute to 24 hours. Resistance is the second stage where the body attempts to move toward restoration of homeostasis while continuing to respond to the stressor. The third stage, exhaustion, if the body cannot maintain its adaptation to the stressor and the stressor overwhelms the individual's ability to cope or mount a continued defense, the result is depletion of energy and resources and an additional susceptibility to disease.

Justice

The upholding of what is just, especially fair treatment and due reward in accordance with honor, standards, or law

Collaborative nursing intervention

Therapies that require combined knowledge, skill & expertise of multiple health care disciplines

Nursing Home Compare

These are the official datasets used on the Medicare.gov Nursing Home Compare Website provided by the Centers for Medicare & Medicaid Services. These data allow you to compare the quality of care at every Medicare and Medicaid-certified nursing home in the country, including over 15,000 nationwide.

Hyperventilation

Ventilation in excess of that required to eliminate carbon dioxide (increase in respiratory rate & dyspnea - seen in patients with COPD or in patients with fever to meet increase in metabolic demands)

Norming stage of Tuckman's group development

Young adult - group norms are evident, leadership is shared, starting to be productive

Agency for Healthcare Research and Quality (AHRQ)

This agency's evidence-based tools and resources are used by organizations nationwide to improve the quality, safety, effectiveness, and efficiency of health care.

Acquired characteristics of diversity

Those that are developed throughout your life through your individual life experiences such as education, skills, manner of dress and personal style, religion, improvement of abilities, political views and some illnesses (such as lung COPD due to smoking)

Continuing healthcare - KNOW FOR TEST

Those who will need long term supportive care will be helped with this type of care such as at a skilled nursing facility or with hospice or respite care support.

Assault

Threatening to do something

Federal funding of healthcare finance

Through the Dept. of Health and Human Services, the Centers for Medicare & Medicaid Services. Medicare is funding health insurance for people aged 65 & older, younger people with disabilities and people with end-stage renal disease. It covers 16% of Americans. Supplemental Security Income (SSI) is funded by taxes & is designed to help aged, blind, and disabled people who have little or no income

Maceration

Tissues softened by prolonged wetting or soaking (as in urinary incontinence)

ANA Standards of Nursing Practice

To direct and maintain safe and clinically competent nursing practice. These standards are important to our profession because they promote and guide our clinical practice.

Values clarification

To plan effective care the nurse needs to identify what the patient values. If the patient's hearing is failing, they may value hearing.

Evisceration

Total separation of wound layers with protrusion of visceral organ through wound opening (walkers)

Displacement

Transferring emotional reactions from one object or person to another

Ciprofoxacin is used for...

Treatment of bacterial infections including UTIs, respiratory, skin infections, bone & joint infections and infectious diarrhea

HIPAA

United States legislation that provides data privacy and security provisions for safeguarding medical information. It is the role of the nurse to promote and advocate for patient's rights related to privacy and confidentiality. Nurses should request and record only information pertinent to the health status of clients to whom the nurse is assigned. Information obtained from the client should be disclosed only to individuals who are directly involved in providing that client's health care. Additionally, nurses are professionally obligated not only to avoid participating in discussions of clients outside communications directly related to providing care but also to curb others from participation.

common symptoms of urinary Alterations

Urgency Frequency Retention Dysuria Nocturia Urinary Hesitancy Neurogenic Bladder

Nocturia

Urination at night

diagnostic tests for urinary incontinence

Urodynamic testing stress test ultrasound cystoscopy

Certification

Used by the federal government to define the credentialing process by which a nongovernmental agency or association recognizes the professional competence of an individual who has met certain predetermined qualifications specified by the agency or association. The ANCC, a subsidiary of the ANA, provides credentialing programs to certify nurses in specialty practice areas.

Non-verbal communication

Uses other forms such as gestures, facial expression and touch known as body language which is less controlled than verbal behavior because it reinforces or contradicts what is said. Body language requires a systematic assessment of the overall physical appearance, posture, gait (how the patient walks/moves), facial expressions and gestures. Patients with autism have a hard time decoding non-verbal behavior. Patients w/communication problems rely on non-verbal communication such as sign language or reading lips for deaf/hoh, finger taps, eye blinks or object boards for expressive aphasia.

Quantitative research

Uses precise measurement to collect data and to analyze a description of the resulting findings

Verbal communication

Uses the spoken or written word and includes noticing things such as pace of speech, intonation (tone of voice), simplicity, clarity (saying precisely what is meant) and brevity (using the fewest words possible), timing & relevance, adaptability, credibility and humor.

Shared governance

Using a pool of knowledge - shared responsibilities & decision making

REM sleep

Usually recurs every 90 minutes and last 5-30 minutes. Most dreams take place during REM sleep. Brain is highly active. Levels of acetylcholine and dopamine increase. Ø Necessary for brain tissue restoration Ø Cognitive restoration - memory storage, learning & filtering info from the day's activities

The data validation step of assessment

Validation is the act of double-checking or verifying data to confirm that they are accurate and factual. Validating data helps the nurse 1) ensure that assessment information is complete, 2) ensure that objective and related subjective data agree, 3) obtain additional information that may have been overlooked, 4) differentiate between cues and inferences, and 5) avoid jumping to conclusions and focusing in the wrong direction to identify problems.

Murmur

Valvular dysfunction causes backflow or regurgitation of blood through the incompetent valve, makes "whooshing" sound; mitral murmurs best heard at the apex of the heart. Caused by increased blood flow through a normal valve, forward flow though a stenotic valve or into a dilated vessel of heart chamber, or backward flow through a valve that fails to close. It is an asymptomatic sign of heart disease. **Common in children.

Preferred treatment for MRSA

Vancomycin

Diversity

Variety, differences, unlikeness and dissimilarity (i.e. variety) among people.

Inflammation definition

Vascular and cellular response to injury, infection or irritation that protects against tissue injury and invading foreign proteins

Pediatric recommended PIV sites

Veins on hand, forearm and upper arm. For infants & toddlers - can use scalp or foot (if not able to walk or stand yet). Avoid hand if thumb sucker.

Tort

a civil wrongdoing (#1 by nurses is failure to properly assess patients, document & inform physicians of findings)

Left-sided heart failure

Vessels of the pulmonary system become congested or engorged with blood. Causes fluid to escape into the alveoli and interferes with gas exchange condition known as pulmonary edema; symptoms paroxysmal noctural dyspnea, elevated pulmonary capillary wedge pressure, pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea), restlessness, confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, cyanosis

Diagnostic labs for infection

WBC, cultures

Extravasation

When a vesicant (blister forming) IV medication escapes into the surrounding tissue by 1) cannula puncturing the wall of the vein or 2) fluid leaking from vein at insertion site

When to don gloves...

When cleaning the IV site, insertion and removal of the IV

Herd immunity

When infants or immune-compromised individuals who are unable to have immunizations are protected because the majority of the public is immunized and so the disease is not spreading - an entire community is able to protect those who cannot be immunized from the rest of the world's diseases.

Hypertonic fluid

When one solution has a greater concentration of solute than the other, the first solution exerts greater osmotic pressure (infusing this type of fluid would cause cells to shrink); this would include solutions greater than 300 mOsm/L

Hypotonic fluid

When one solution has a smaller concentration of solute than the other, the first solution exerts less osmotic pressure (infusing this type of fluid would cause cells to swell); this would include solutions less than 270 mOsm/L

Pitting edema

When pressure applied to the skin of the swollen area is released and an indentation is left behind

Remission

When symptoms of a disease disappear

Exacerbation

When symptoms of a disease reappear

Bruit

When the lumen of a blood vessel is narrowed, this disturbs blood flow causing a blowing or swishing sound. Easier to hear on very thin people; can be normal for some people.

Isotonic fluid

When two solutions have the same concentration of solute, therefore both solutions exert the same osmotic pressure; this would include solutions within 270 - 300 Mosm/L

The working phase of a nurse-patient relationship

Where most of the therapeutic work is carried out. The nurse & patient explore stressors and promote the development of insight in the patient by linking perceptions, thoughts, feelings and actions.

Fecal Impaction

a collection of hardened feces wedged in the rectum that a person cannot expel o Results from unrelieved constipation -NA 2 lowest person who can handle impaction. -associated with DRE - symptoms: # rectal pain # frequent/nonproductive desire to poop # general feeling of illness Oil retention enema -> cleansing enema -> daily enema -> suppositories -> stool softeners.

neurogenic bladder

a urinary problem caused by interference with the normal nerve pathways associated with urination

Phosphate functions

Works w/Ca to develop & maintain bones & teeth, needed for carb, fat & protein metabolism, essential for functioning of muscle, nerves & RBCs

Chloride functions

Works w/Sodium to regulate serum osmolality & blood volume, regulates acid-base balance; major component of gastric juice (HCl), acts as a buffer in O2 & CO2 exchange in RBCs

encopresis

abnormal elimination pattern. by child that should have achieved bowel continence. usually because child is busy, putting off defecation.

anuria

absence of urine (<100 mL/day)

flatulence

accumulation of gas in the intestines causing the walls to stretch

retention

an accumulation of urine due to the inability of the bladder to empty. Small amount of urine voided 2-3 times per hour.

durable Power of attorney

legal document assigning decision-making power to another person to make his or her health care decisions in the event they become incapable to make a decision.

soapsuds enema

can be added to tap water or saline to create effect of intestinal irritation to stimulate peristalsis o Use with caution in pregnant women and older adults because they can cause electrolyte imbalance or damage to intestinal mucosa

gentomycin/ tobramycin

can be toxic to kidneys

hospice care

care provided for the dying in institutions devoted to those who are terminally ill. >Priority is to manage the pt pain. >Pt in hospice for 6-12 months

Medications for elimination

cathartics/laxatives laxatives stool softeners mineral oils antidiarrheal agents

medicated enema

contain drugs Ex: neomycin solution, an antibiotic used to reduce bacteria in the colon before bowel surger

alpha-adrenergic blockers

decreases smooth muscle contraction of prostate gland TAMSULOSIN TERAZOSIN

hemorrhoids

dilated, engorged veins in the lining of the rectum

urinary diversion

diversion of urine to external source

Hypertonic Solution Enema

exerts osmotic pressure that pulls fluids out of interstitial spaces. o Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. o Contraindicated for patients that are dehydrated and young infants

"Just" culture

focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (eg, slips), at-risk behavior (eg, taking shortcuts), and reckless behavior (eg, ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event. For example, reckless behavior such as refusing to perform a "time-out" prior to surgery would merit punitive action, even if patients were not harmed. For human error (inadvertent action, slip, lapse or mistake) the consequences would be to console, encourage reporting, redesign & remediate. For at-risk behavior, consequences would be to coach, remove the incentives for at-risk behavior and create incentives for healthy behavior, increase situational awareness & remediate). For reckless behavior, punishment, disciplinary action & remediation.

polyuria

frequent urination (>2000 mL/day)

H&H

helps detect anemia from GI bleeding

Tap Water enema

hypotonic and exerts osmotic pressure lower than fluid in interstitial space

Fecal incontinence

inability to control passage of feces and gas to the anus o Can be caused by C. diff or food borne pathogens.

urinary incontinence

inability to control urination

abnormal

inability to grieve is __________.

diuresis

increased formation and secretion of urine

total bilirubin

increased in liver/gallbladder problems

alkaline phosphatase and amylase

increased in problems with the pancreas

constipation

infrequent stool and/or hard, dry, small stools that are difficult to elimination o A symptom, not a disease o 3 days without BM o Common in the older adult o Health hazard r/t straining (esp. people with heart problems, increased BP, or surgical wounds) o Causes: improper diet, reduced fluid intake, lack of exercise, certain meds

Moderate anxiety

involves a decreased perceptual field (focus on immediate task only); the person can learn new behavior or solve problems only with assistance. Another person can redirect the person to the task.

factors effecting normal grief

o Affection for loss o Intensity of relationship o Symbolic meaning of relationship o Circumstances surrounding loss

Prevention & treatment of IV hematomas

o Apply pressure and ice o When DC'ing a routine IV- apply pressure for at least 1 minute o DO NOT apply tourniquet to extremity immediately after unsuccessful venipuncture o Avoid piercing the posterior wall when starting an IV o DC IV immediately o Document

Prevention & treatment of thrombophlebitis

o Apply warm, moist compress o IV cannula gauge smaller than vein o Avoid small veins & irritating medications or solutions o Change IV site every 96 hours o Avoid venipuncture over area of flexion o Anchor cannula and extension tubing securely o DC IV site o Restart in opposite extremity

Prevention & treatment of phlebitis

o Apply warm, moist compress o IV cannula gauge smaller than vein o Avoid small vein for irritating medications or solutions o Change IV site every 96 hours o Avoid venipuncture over area of flexion o Anchor cannula and extension tubing securely o DC IV site o Restart in opposite extremity

Rales/crackles

o Cause: random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways o Site auscultated: are most common in dependent lobes; right and left lung bases

Nursing considerations for peripheral IV's

o Check MD order o MAR and complete 3 checks on ALL IV solutions o Keep IV fluid sterile (Remember: female first) o Protect cannula from contamination o Keep tubing free from air o Hang fluid correct height o Correct flow rate and amount to be infused o I&O o Assess IV site frequently for S/S of complications o Flush per agency protocol

0.9% normal saline solution is used to...

o Expand intravascular volume o Replace extracellular fluid losses o ONLY SOLUTION THAT CAN BE USED WITH BLOOD PRODUCTS o May cause intravascular overload (fluid overload = hypervolemia)

Common reasons for infusion therapy

o Maintain fluid balance or correct fluid balance o Maintain electrolyte or acid-base balance or correct electrolyte or acid-base imbalance o Administer medications o Replace blood or blood products o Nutritional formulas (Total Parenteral Nutrition- TPN)

Prevention & treatment of IV infection

o Maintain strict asepsis when caring for the IV site o Ensure IV solution is not hanging for more than 24 hours o Restart IV in opposite extremity o Place venipuncture device in sterile container for possible culture o Prepare for blood cultures o Possible antibiotics therapy o ID patients at risk o Assess IV site, patient, and lab results for s/s o Change tubing and IV site every 96 hours o Label IV site, bag, and tubing o DC IV/ Document

Prevention & treatment of catheter embolisms

o Remover catheter carefully not applying pressure until catheter is out o Inspect catheter when removed o Place tourniquet proximally of IV site o Notify healthcare provider o Prepare for x-ray and surgery o Document

Prevention & treatment of circulatory overload

o Slow infusion (i.e., 30 mL/hr to keep vein open) and call MD o Raise HOB to help breathe easier

Factors relating to elderly's experience of pain & rest

· Over 80% of older adults have at least one chronic condition associated with pain. · Have a greater likelihood for developing pathological conditions, which are accompanied by pain. · Potentially reduces mobility, ADLs, social activities, and activity tolerance. · Interpreting pain is complicated due to multiple diseases and vague systems. · With aging, muscle mass decreases, body fat increases, H2O decreases. This increases concentration of water-soluble drugs: volume of fat-soluble drugs increases · Poor nutrition resulting low albumin levels. (Protein Bound) · Lower renal and liver function, decreases metabolism and excretion of drugs.

Lactated Ringers solution is used to...

o Treat losses from burns and lower GI o Mild metabolic acidosis

Prevention & treatment of air embolisms

o Turn pt. on the left side in Trendelenburg position (so air will accumulate in R atrium & reabsorb) o Prime tubing with fluids before use o Monitor tubing for air bubbles o Secure all connections o Clamp tubing o Assess for s/s (sudden resp. distress) o Notify healthcare provider o Document

dysuria

pain in urination

reorganization

person begins to accept change, new role, or skills • 6mo-1yr; may continue for much longer time • Person gradually increases level of functioning • accepts change

disorganization and despair

person examines loss and expresses anger • 3-6mo • Manifestations of depression and social withdrawal • Retells loss story again and again • Express anger at anyone that seems responsible • Examines how and why

cholinergic

produce smooth muscle contractions BETHANECHOL

Cleansing Enema

promotes complete evacuation of feces from colon. Acts by stimulating peristalsis through the infusion of a large volume of solution or through local irritation of the mucosa of the colon. o Includes: tap water, NS, soapsuds solution, and low-volume hyperonic saline o Infants and children receive ONLY NS because they are at risk for fluid imbalance

numbing

protects person from full impact of loss (Shortest stage of mourning) • 1-2 weeks • Concurrent with shock; stunned, "feels unreal" • Drop to lower level of functioning

carminative enema

provides relief from gaseous distention. Improve ability to pass flatus.

suicide

risk for _______ if complicated grief lasts more than 6 months.

Normal Saline Enema

safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel o Doesn't create danger of excess fluid absorpti

oliguria

scanty urine (100-400 mL/24h)

nephrostomy tubes

small tubes tunneled through the skin into the renal pelvis

palliative care

supportive medical and nursing care that keeps the patient comfortable but does not cure the disease. person is at end of life. Focus is on the entire course of the illness. Best quality of care.

CEA

tests for cancer and inflammation

enema

the introduction of fluid into the rectum and lower colon

UTI

the presence of microorganisms in the urinary tract, causing pain, burning fever, chills, n/v, frequent urge sensation.

urinary hesitancy

trouble voiding

Tricyclic antidepressant

used for stress and urge incontinence IMIPRAMINE

advanced directives

written document prepared by a competent individual specifying what, if any, extraordinary actions the person would want when no longer capable of making decisions about their personal health care

Loss of REM sleep leads to...

· Altered mood, motor performance, memory & equilibrium with prolonged sleep deprivation. · Altered immune function occurs with moderate to severe lack of sleep. · Accidents, lost productivity

Factors relating to different culture's experience of pain & rest

· Clients from stoic cultures rarely vocalize pain through groans or crying and may avoid showing a reaction to pain. They may tolerate a high level of pain without asking for relief. · Client's with expressive cultures routinely moan and scream when faced with pain. They expect others to care for them and relieve the pain. · Culture may affect how a client describes pain. · Culture can affect the methods of treatment the client is willing to undergo. Some believe that pain is punishment or builds character may refuse treatment. · Some cultures prefer to treat pain with herbal supplements and alternative medications.

Factors relating to adult's experience of pain & rest

· Conditions associated with chronic pain are more prevalent in women than men. · 80-90% of fibromyalgia cases are women. · Women are more likely to develop diseases that cause pain, such as osteoarthritis. · Women have a lower pain threshold, and lower pain tolerance than men. · Men are more likely to experience pain from cluster headaches, coronary heart disease and gout.

Factors relating to children's experience of pain & rest

· Infants are very sensitive to drugs, response to drugs are often intense and prolonged. Absorption is faster than expected. Dosages excreted from the kidneys need to be reduced. · Children as young as 3 can give a description and location of pain. · Toddlers and preschoolers are unable to explain the pain. · Consideration with children and pain: · Children normally have a higher pulse and respiration and a lower BP. · A normal sympathetic response to pain is not always present in children, changes in vital signs may not be a good indicator in children.

urge incontinence

• Definition- involuntary loss of urine associated with strong, sudden urgency r/t overactive bladder caused by: bladder inflammation, neurological problems, bladder outlet obstruction • Who- all ages, older adults with physical and cognitive decline • Characteristics: o Sudden urgency o Frequent urination o Difficulty holding urine once urge felt o Leaks on the way to bathroom o Strong leaks when one hears water, drinks fluids

reflex incontinence

• Definition- involuntary loss of urine occurring at somewhat predictable intervals when pt. reaches specific bladder volume r/t spinal cord damage between C1 to S2 • Who- older adults, patients with spinal cord dysfunction • Characteristics: o Diminished awareness of bladder filling, the urge to void and leakage of urine o May not completely empty bladder o Caution: At risk for developing autonomic dysreflexia (life-threatening; causes severe elevation in BP/HR with diaphoresis)

Furosemide (Lasix)

• Diuretic • IV push, undiluted, over 2 minutes • Nursing implications: monitor BP, daily weights, edema, lung sounds, skin turgor, and mucous membranes

Infiltrations

• Edema, pain, coolness at site, paleness • Size selection and correct gauge and needle length have biggest impact • Assessment and securing the catheter are key!

Preventing sensory deprivation

• Encourage the patient to use eyeglasses and hearing aids if normally used • Address the patient by name and touch the patient if that is not culturally offensive. • Communicate frequently with the patient and maintain meaningful interactions. • Provide a telephone, radio, TV, clock, calendar • Provide pictures, murals etc. • Have family and friends bring flowers/plants • Pet therapy • Increase tactile stimulation i.e. massages, hair care, etc. • Group activities • Puzzles, games to stimulate mental function • Encourage environmental changes i.e. walks, outings, sit near nurses station • Encourage patient to sing, whistle, hum (self-stimulation)

Features of an effective group

• Goal accomplishment • Maintaining cohesion • Develop & modify structure to improve effectiveness

anticipatory grief

• Grieving loss of terminally ill before it occurs

grief effects on a midlife adult

• Have major life transitions such as aging parents, families, and marital status • Usually do not seek immediate replacement for the lost loved one

grief effects on a young adult

• Have many developmental losses secondary to evolving futures which death can interfere with • Usually do not seek immediate replacement for the lost loved one

The major methods of nutritional screening & assessment

• Height • Weight • Weight change • Waist-To-Height ratio • Primary diagnosis • Comorbidities • Screening tools

Potassium Chloride

• High alert • Continuous infusion, diluted slowly using an infusion pump • DO NOT administer concentrations of greater than or equal to 1.5 mEq/mL undiluted • Rate: infuse slowly at a rate up to 10 mEq/hr in adults or 0.5 mEq/kg/hr in children • Check hospital policy and procedure for max infusion rates

Gauge sizes 16 & 14 for peripheral catheters

• High-risk surgical procedures and trauma • LARGE volumes and rapid flow • Requires large vein • Mechanical irritation and phlebitis likely Size 16 is used to draw blood

Assessing the oxygenation status of a patient

• History of Present Illness • Past Health History • Medications • Surgery or Other Treatments • Functional Health Patterns

grief effects on an elderly adult

• House, income, spouse, friends, child • May have built up spiritual reserves that help with coping loss and death or have personal outcomes with major loss

ISBARR reporting

• I - Introduction & stating your role in the patient's care • S - Situation describes what is happening at the present time which is prompting you to contact doctor • B - Background includes relevant background info • A - Assessment to provide as much information & content about the patient as possible. • R - Recommendation • R - Repeat the order given by the doctor.

Signs of circulatory overload

• Increased BP • Distended jugular veins • Rapid breathing (SOB) • Dyspnea • Moist cough and cracks • Can happen quickly in frail, elderly, and young children

What are some developmental changes associated w/immobility?

• Infants, children may have genetic disorders or congenital malformations • Children, adolescents, young adults are prone to trauma from sports, abuse or accidents • Older adults present inflammatory and "wear-and-tear" problems • Pregnant women may have decreased ROM and increased back pain

Roles of group members

• Information givers/seekers • Opinion givers • Coordinators • Initiator - contributor • Energizer • Evaluator Can also be maladaptive roles such as monopolize, recognition seeker, playboy/girl, help seeker, aggressor, groupthink, scapegoat, or blocker.

Gauge size 22 for peripheral catheters

• Infusion rates slightly slower • Adults, especially those with small or fragile veins • NOT appropriate when rapid flow rates are required such as trauma/surgery

D5W IV Fluid

• Isotonic- dextrose enters cells rapidly, leaving free water • Remaining free water (hypotonic) dilutes ECF and then enters cells by osmosis • Provides free water necessary for renal excretion of solutes (good for dehydrated patients and kidney function)

0.9% normal saline solution

• Isotonic- expands ECV (vascular and interstitial) • DOESN'T enter cells

Lactated Ringers solution

• Isotonic- expands ECV (vascular and interstitial) • DOESN'T enter cells • Similar in composition to normal plasma, except doesn't contain Mg2+

Signs of IV infection

• Local- redness, swelling, drainage at site • Systemic- fever, chills, N/V, tachycardia, increase in WBCs

Nursing interventions for the confused patient

• Maintain safety at all times • Minimize stimuli to decrease anxiety • Arrange the physical environment so that it is clear • Make sure to have clocks and calendars to maximize orientation to time • Keep glasses & hearing aids within reach • Ensure adequate pain management • Keep familiar items in client's environment • Keep room will lit during waking hours • Encourage family to visit if appropriate • Provide clear, concise explanations • Eliminate unnecessary noise • Reinforce reality • Schedule activities consistently • Assign same caregivers if possible • Provide adequate sleep

Preventing sensory overload

• Minimize unnecessary light, noise and distraction. Provide dark glasses and earplugs as needed. • Control pain • Introduce yourself by name, and call the patient by their name • Provide orienting clues i.e. clocks, calendars • Provide a private room • Limit visitors • Plan care to allow for uninterrupted periods of rest or sleep • Follow a schedule so patient knows what to expect • Provide new information gradually • Explain tests/procedures ahead of time • Reduce noxious odors • Correct misinterpretations as needed • Assist the patient with stress reducing techniques

Tasks that an RN can delegate to an LPN

• Monitoring findings (as input to the RN's ongoing assessment) • Reinforcing client teaching from a standard care plan • Performing tracheostomy care • Suctioning • Checking nasogastric tube patency • Administering enteral feedings • Inserting a urinary catheter • Administering medication (excluding IV medications in some states)

Factors that facilitate learning

• Motivation of the learner • Readiness of the learner • Active involvement of the learner • Relevance of the content of the learner • Feedback that is meaningful to the learner • Nonjudgmental support: • Simple to complex: material organized from simple to complex. • Address early any area that is causing anxiety • Repetition • Timing: people retain information and skills when there is a short time between learning and using. • Good environment (well lit, good ventilation, private, quiet, etc)

Morphine

• Opioid • High alert • IV push, diluted with at least 5 mL sterile water or 0.9% NS for injection • Administer 2.5-15 mg over 5 minutes • Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse

Nursing interventions for patients in respiratory distress

• Positioning o Reduces pulmonary stasis, maintains ventilation and oxygenation • Incentive Spirometry & TCDB o Encourages voluntary deep breathing o Pursed lip breathing/Abdominal breathing • Chest tubes o A catheter placed through the thorax to remove air and fluids from the pleural space or to prevent air from reentering or to reestablish intrapleural and intrapulmonic pressures • Oxygenation therapy - to prevent or relieve hypoxia

Physical conditions that influence groups

• Privacy • Comfort of room and seating • Ability of everyone to have eye contact • Environmental noise level • Temperature • Lighting

Team Nursing

• RN leads team of other RNs, LPNs, and assistive personnel • LPNs provide direct patient care under supervision of RN, physician or other licensed practitioner • Team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. • There is hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. • NA's assume delegated aspects of basic client care

Nutritional requirements for adolescents

• Rapid physical, emotional, social growth • Increased need for protein, calcium, iron, overall caloric intake o Calcium especially important o Adolescent bone density leads to adult bone health • Growth spurts • Struggles about food intake, food choices Social pressure on females to be thin - Eating disorders Pressure on males to gain muscle mass: • Puts pressure on bones • Overweight, obesity • Associated with depression, hypertension, type 2 diabetes, poor self-esteem

Nutritional requirements for infants & children

• Rapid physical, functional changes from growth, development • In first year, body weight triples • Breastfeed exclusively first 6 months • Continue to breastfeed as foods introduced in first year • Ready-to-feed formulas available

Behaviors associated with a confused patient

• Reduced awareness - limited or absent span of attention, highly distracted, difficulty keeping track of what is said, little activity or response to the environment • Impaired thinking skills - impaired memory (especially recent memory), disorganized thought, disorientation to place, time, date and/or person, rambling, incoherent or illogical speech, poor word finding ability, difficulty reading, writing or understanding speech, hallucinations and/or illusions • Changes in behavior - agitation, irritability, restlessness or combative behavior, altered sleep patterns, mood swings and extreme emotions, fear, anxiety and/or depression, withdrawal • Sundowning—confusion that intensifies in the evening or at bedtime

Signs of respiratory failure/inadequate oxygenation

• Restlessness, confusion headache • Tachypnea; decreased sats • Tachycardia • Diaphoresis • Late signs = bradycardia, depressed respirations, decreased or absent breath sounds, cyanosis

Dietary guidelines - REDUCE the following

• Saturated & Trans fats (animal in origin) to less than 10% of calories/day. • Refined grains: (ex: rice, flour and sugars that have been bleached and processed such that many nutrients have been removed.) • Sugar: new limit for sugar to 200 calories/day and limit added sugar and sweeteners so that < 10% calories are from added sugars. • Sodium: Slight increase from 2,200 mg to 2,300 mg, even for those at risk for heart disease. Limit added salt.

Functions of groups

• Socialization • Support • Task completion • Camaraderie • Information • Normative function - Boy Scouts, Church groups • Empowerment - support group or education group, AA or NA • Governance - Political

Culturally competent care

• The ability to apply knowledge, skills to provide high quality care to clients of diverse backgrounds. The American Association of Colleges of Nursing has 5 competencies for providing culturally competent care: 1. Apply knowledge of social and cultural factors that affect nursing 2. Use relevant data sources and best evidence 3. Promote achievement of safe, quality outcomes 4. Advocate for social justice 5. Participate in continuous development • One model of cultural competence is called LEARN: 1. L - listen to the patient's perception of the problem 2. E - explain your perception of the problem and of the treatments ordered by the physician 3. A - acknowledge and discuss the differences and similarities between these 2 perceptions 4. R - review the ordered treatments while remembering the patient's cultural parameters 5. N - negotiate treatment

Vulnerable populations who need an advocate

• Those who are poor or homeless • Those with a disability or mental illness • Children • Elderly

complicated grief

• UNABLE TO PROCESS GRIEF • Exaggerated, delayed, masked, or chronic • Grief BEYOND 6 mo- 1 yr • Unsuccessful use of intellectual and emotional responses to work through grief • Person becomes stuck, isolated, unable to work through grief

grief effects on a toddler

• Unable to distinguish fact from fantasy • For them it is separation from parents or disruption in routine • React with fear and sadness • RN must make sure needs are met

Communication within the healthcare team

• Understanding of anxiety and how it affects communication • Understanding of the process that occurs within groups • Always safety geared & mindful of patient confidentiality • Standard reporting like ISBARR decreases miscommunications

grief effects on an adolescent

• Understands death at adult level, but difficulty accepting it as reality • Think death can be defied and participate in risk-taking behaviors

Gauge size 20 for peripheral catheters

• Used for all infusions including blood and blood products • Suitable for minor surgical procedures • Most commonly used size

Gauge sizes 22 & 24 for peripheral catheters

• Used for neonates (24), toddlers (22), and elderly (22) • Extremely small-diameter veins • Suitable for most infusions, but flow rates slower

Gauge size 18 for peripheral catheters

• Used for trauma and surgery (Operating room) • Rapid flow rates • Requires large vein to allow room for blood to flow in the vein around catheter • Irritation to vein wall and phlebitis result when catheter is too large for chosen vein

Dietary guidelines - INCREASE the following

• Whole grains, legumes, nuts, seeds & soy products • Vegetables/fruits (still 5 servings/day) (high cost involved) • Low-fat/fat free dairy • Eat variety of proteins, seafood, lean meats, poultry, eggs • Drink more water • Eat Potassium rich foods

Barriers to evidence-based practice

• Work schedule or demands • Lack of access to technology • Limited knowledge and skills in evaluating evidence • Lack of experience or confidence in promoting EBP • Lack of support from supervisors • Attitudes from staff • Resistance to change

Culture of safety

• acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations • a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment • encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems • organizational commitment of resources to address safety concerns Safety culture has been defined and can be measured, and poor perceived safety culture has been linked to increased error rates. However, achieving sustained improvements in safety culture can be difficult. Specific measures, such as teamwork training, executive walk rounds, and establishing unit-based safety teams, have been associated with improvements in safety culture measurements and have been linked to lower error rates in some studies. Other methods, such as rapid response teams and structured communication methods such as SBAR, are being widely implemented to help address cultural issues such as rigid hierarchies and communication problems, but their effect on overall safety culture and error rates remains unproven.

communication barriers of dying

• fear of own mortality • lack of experience with dying • fear of expressing emotions • insensitivity to the situation • feel guilty can't cure patient • fear of not knowing answers • disagree with pt decisions • experience of personal grief

Common conditions that could cause alteration in fluid & electrolyte balance...

• gastroenteritis • burns • kidney disorders • oral fluid restriction for surgery • anorexia or bulimia • dehydration • athletics • hot weather

indicators of approaching death

• increase sleeplessness • coolness and color, especially extremities, nose, fingers • bladder/bowel incontinence • decrease urine output • restlessness • decrease food/fluid intake (inability to swallow)• congestion/ pulmonary secretions (death rattle) • altered breathing•decreased muscle tone • weakness/fatigue

comfort measures for a dying patient

• massage and touch • heat therapy • mouth and oral care • breathing techniques • pain relief

Mechanisms that regulate sleep

● Biological Rhythms: Daily cycles ● Circadian rhythms - begin to develop at about 6 weeks, by 3-6 months the baby has a regular sleep cycle.

Adverse effects of unrelieved pain

● Changes in vital signs are not reliable over time as body adapts to pain ● Repeated pain experiences may LOWER the pain threshold and contribute to pain syndromes later in life - especially if pain not well managed ● Anxiety, restlessness, fear, powerlessness, poor concentration, fatigue, immobility, decreased immune response... (Any of these also associated with lack of rest?) ● Can significantly alter the individual's quality of life (as well as impacting family & others) In children, physiological consequences of unrelieved pain may include decreased growth and development, decreased immune function, lack of appetite, hypertension, and increased sensitivity to future pain. In adults, unrelieved pain can dramatically reduce the patient's quality of life, decreasing their ability to perform activities of daily living and increasing their dependence on others. It can cause mood, sleep and appetite disturbances; decreased mobility; falls, slow rehabilitation; and altered cognitive functioning. Decreased mobility can lead to DVT, pulmonary embolism, bone fractures and reduced participation in social activities.