NURS 202 REVIEW QUESTIONS
What are some measures nurses can take to promote circulation?
VASCULAR: *avoid pillows under the knees or more than 15 degrees of knee flexion (lymph nodes are under the knee and you don't want to compress those) *encourage leg exercises *promote ambulation as soon as possible *encourage frequent position changes- sitting up in chair with legs elevated; not sitting up for long periods of time(4x per day typically)- check up on them every 30 min CARDIAC: *positioning the patient *monitor intake and output *fluid restriction if needed (last resort) MEDICATIONS PREVENTING VENOUS STASIS (blood pooling): *positioning *leg exercises *TED Hose *Foot pumps *SCDs- usually used for post-op for 24 hours; usually removed for 1 hour per day and removed if the patient can ambulate
What type of patient condition would restraints be used on and how often should the nurse check up on this patient? *MED SURG/BEHAVIORAL
Written order for restraints only valid for 4 hours (for chemical restraints) and 24 hours (for physical restraints). *Nurse must check on pt with restraints every 15 mins if violent (if not violent, then 2 hours) *Physical restraints include: -all side rails up -geriatric chairs with attached trays -appliances ties at wrist, ankle, or waist *Chemical restraints include: -drugs that control behavior and that are not part of a patients normal medical regiment
If the patient does not void in the next 6-8 hours after removal of a catheter, should you be worried?
Yes, you will want to bladder scan the patient, try to ambulate them if possible, help them void by running cold water from the sink, warm compress on the hands
What is the nursing process?
a systematic, person-centered, goal oriented method of caring that provides a framework for nursing practice. IT IS NURSING PRACTICE IN ACTION. Five steps: assessment, diagnosis, planning, implementation, evaluation
Which of the following patients are at most risk for tachypnea? (select all that apply) a. patient just admitted with four rib fractures b. woman who is 9 months pregnant c. adult who has consumed alcoholic beverages d. adolescent waking from sleep e. three-pack-a-day smoker with pneumonia
a, b, e
What are the various types of urine sampling techniques?
a. Input and output volumes measured b. UA *take care not to contaminate with feces *NOT sterile *pour urine into a specific container after pt urinates into clean receptacle using aseptic technique *do not leave in room temperature because chemistry might become altered c. specimen 'clean catch', urine culture, or midstreams (synonyms) *collected midstream after patient has voided a small amount of urine *helps to flush any organisms near meatus that would otherwise skew results d. 24 hour urine collection *collecting all the urine voided in a 24 hour period *remind pt not to discard urine *discard first void and then begin clock and collect all the urine for the next 24 hours *at end of 24 hour period, ask pt to void and add this to the previously collected urine *can keep urine together or separate e. sterile samples from catheter *always obtain from catheter itself using the special port since the drainage bag does not have "fresh" urine *be sure to observe sterile technique while collecting urine *CLAMP THE TUBE 15 PRIOR TO SAMPLING TO ENSURE "FRESH" URINE
what is tachypnea?
abnormally fast and shallow breathing rate (more than 20 breaths/min in adults)
what is bradypnea?
abnormally slow breathing rate (less than 12 breaths/min in adults)
what is apnea?
absence of breathing ex. sleep apnea is the condition in which an individual experiences pauses in their breathing patterns while they are asleep.
*What is the difference between active and passive exercises when individuals are bed rest?
active exercises are done by the patient, while the nurse performs passive exercises on the patient
Describe these movements/ positioning from midline of the body: adduction, abduction, flexion, extension, dorsal, frontal, medial, lateral, anterior, posterior, proximal, distal, pronation, supination
adduction: motion towards the midline of body (ADDING) abduction: motion AWAY from midline of body (like spreading your fingers) flexion: movement that decreases the angle between two body parts, BENDING *i.e. flexing the elbow, like telling someone to make a muscle extension: movement that increases the angle between two body parts, STRETCHING *i.e. extending the elbow dorsal: back medial: towards the midline of the body lateral: away from the midline of body anterior: front posterior: back superior: top (closer to the head) inferior: bottom (closer to the feet) proximal: closer to the main body, central distal: further from the main mass of the body, more peripheral
What are some factors/conditions affecting circulation?
age, heredity, gender/hormones, serum lipid levels (have a role in fatty plaque- lead to blockage of vessels), hypertension, smoking, obesity, DM (diabetes mellitus?) *also diet, heat, cold, stress, alcohol
What procedures would require sterility?
anything invasive such as urinary catheter insertion, wound debridement, dressing change of PICC/CENTRAL line/port
what is Kussmaul's breathing?
associated with metabolic acidosis; hyperventilation
The nursing assistive personnel NAP reports to you that the blood pressure of the patient in Question 13 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information. (select all that apply) a. notify the health care provider immediately b. ask the patient if she has taken her blood pressure medications recently c. obtain blood pressure measurements on lower extremities d. verify that the correct cuff size was used during the measurements e. review the patients record for her baseline vital signs f. compare the right and left radial pulses for strength
b, e
What is the standard anatomical position?
body in a standing position with arms at sides and palms facing forward
What are some problems that are associated with bed rest patients?
can form decubitus ulcers within 2 hours
What is venous stasis?
cessation or impairment of venous flow, such as venous insufficiency
Whats the difference between colonized and infected?
colonized= people who carry bacteria without evidence of infection infected= bacteria can be transmitted even if the patient is not infected *if infection develops, it is usually from bacteria that colonizes patients
What is observation of cues as it pertains to the nursing process?
conscious and deliberate use of the five senses to gain significant information that is helpful in making decisions *make inferences after identifying cues
What is observation as it pertains to the nursing process?
conscious and deliberate use of the five senses to gather data
A nurse comes into a patients room and notices that the patient is feeling overheated. She puts a fan in the room to cool down the patient. What example of the mechanisms of heat loss is this describing?
convection
what is dyspnea?
difficulty breathing or labored breathing; short of breath
what is orthopnea?
difficulty breathing when individual is lying down *common for individuals to use pillows to prop themselves up while sleeping *caused by COPD as alveoli cannot expand well while lying down
what is Cheyne-Stokes respirations?
end of life breathing pattern; alternate between deep, fast breathing, and periods of apnea; regular
What is released from the body to alter metabolism?
epinephrine and norepinephrine
How often do you check a patients vital signs after a procedure?
every 15 min for the first hour
Define hand washing, antiseptic hand washing, alcohol based hand washing, and surgical hand hygiene/antisepsis.
hand washing- *washing hands w/plain soap and water antiseptic hand washing- *washing hands with water and soap or other detergents containing an antiseptic agent alcohol based hand washing- *rubbing hands with an alcohol-containing preparation surgical hand hygiene/antisepsis- *hand washing or using an alcohol-based hand rub before surgery by surgical personnel
what is the difference between hyperventilation and tachypnea?
hyperventilation is fast and deep; tachypnea is fast and shallow
what is hyperventilation?
increased rate and depth in breathing ex. anxiety
What is the difference between inductive and deductive reasoning?
inductive- bottom up logic; begin with some data and then determine what general conclusions can logically be derived from those data deductive- top down logic; begin with some statements (called premises) that are assumed to be true, you then determine what else would have to be true if the premises are true
What is inference as it pertains to the nursing process?
judgement reached about a cue
What is a primary source of heat loss?
metabolism
How do you convert Celsius to Fahrenheit?
multiply by 9/5 and add 32
What are the different age and risk factors associated with them?
neonates/older adults more susceptible to infections -older adults more at risk for: *pulmonary infections *UTIs *skin infections Fetus: x-rays, smoke, drugs, alcohol, and some pesticides Newborns/Infants: falling, suffocation, choking, burns, poisoning, electric shocks, crib and motor vehicle accidents Toddlers: physical trauma from falling, cuts, or banging into objects, burns, poisoning, drowning, electric shocks, motor vehicle crashes School-age: injury from traffic/playground, choking, suffocation, obstruction of airway or ear canal, poisoning, drowning, fire/burns Adolescents: motor vehicle/bike crashes, recreational injury, substance abuse, firearms Adults: falling, burns, motor vehicle crashes
what is eupnea?
normal, good, unlabored breathing (quiet breathing)
What is thrombophelbitis?
occurs when a blood clot blocks one or more of your veins, typically in your legs *can be superficial or deep within a muscle causing DVT *can be caused by trauma or surgery *treated with blood thinning medication
Whats the difference between open ended questions and closed ended questions?
open-ended questions: *allows patient to respond with a wide amount of responses *express what they understand to be true, yet specific enough to prevent digressing from the issue at hand close-ended questions: *provides pt with limited choice of possible responses *used to gather specific questions from patients *allows nurse to focus on a particular area
What are the normal temps for healthy adults?
oral: 37.0 *C or 98.6* F rectal: 37.5*C or 99.5*F axillary: 36.5*C or 97.7*F tympanic: 37. 5*C or 99.5*F forehead: 34.4*C or 94.0* F
Who are at the greatest risk for complications due to bedrest/immbolization?
paralyzed/long term patients, malnourished, suppressed immune system
In considering obtaining a blood glucose and using an Accurate-check, how and where do you get a blood sample?
prick side of fingerpad of infrequently used finger (usually ring finger) *wipe first drop of blood away with cotton ball and bald second drop of blood on the Accu-check test strip *avg. range is 70-110 *usually check before breakfast and one hour of sleep
What are SCDs?
sequential compression device that is a sleeve attached to a pump that goes around a patients leg and creates pressure around the calf in sequence. *it improves venous return, prevents development of DVT, and peripheral edema in immobile patients
What are SCDs and what is the purpose of them?
sequential compression devices that promote circulation and prevent thrombus/embolism and DVT
How do you convert Fahrenheit to Celsius?
subtract 32 and multiply by 5/9
What are the signs of dyspnea?
tachycardia, tachypnea, anxiety (facial expressions), restlessness or confusion; use of accessory muscles, retractions and nasal flaring (in adults); change in level of response/consciousness, increased blood pressure
What are the key vital signs?
temperature, respiratory rate, pulse oximetry, blood pressure, heart rate, pain *if pain is "4 or more" then you have to do something about it and check up on it in an hour
What is validation as it pertains to the nursing process?
the act or confirming or verifying to keep data free from error, bias, and misinterpretation *suspicions are not objective, must validate with patient (i.e. suspicion of hearing loss)
what is Biots respirations?
varying depth and rate of breathing, followed by periods of apnea; irregular *associated with brain trauma (i.e. brain stem, medulla); erratic respirations
What are some patient conditions that require specific nursing actions related to vital signs?
you must take blood pressure in the "good" arm in patients who had their lymph nodes removed in one arm (as seen in patients who had a mastectomy) to prevent fluid build up and edema.
What are the different types of urinary catheter sizes?
#14 is average w/ 5-10 ml balloon #14-16 is used for urine collection (and for long term use in adults) #22-30 used to drain clots and stones #5-8 for infants/young children #8-12 for older children *larger than #18 should be temporary used due to potential urethral damage *bigger the number= bigger the catheter diameter (French system) *the size must be chosen in relation to purpose (e.g. draining blood clots vs. antibiotic admin vs. urine collection) *catheter balloon sizes vary from 3ml to 30 ml
What are the various types of documentation?
*SOAP Note- subjective objective assessment plan *SOAPIER- SOAP + Implementation Evaluation and Revision *PIO- Problem, intervention, outcome *DAR- Data, Action, Response *PIE- Problem, Intervention, Evaluation *CBE- Charting by Exception; this is shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes DOWNSIDE: does not prove useful when a negligence claim is made against a nurse because of the lack of detail beyond the significant findings or "exceptions" that have been documented *Focus Charting- to bring the focus of care back to the patient and the patients concerns
What can nurses do to promote oxygenation?
*changing positions frequently, *ambulating (best way) *exercising, *promoting comfort (giving pain meds), *deep breathing and coughing (turn, cough, deep *breathe, splinting for abdominal surgery patients), *medications (bronchodilators and expectortants), *incentive spirometers *pulmonary percussion *postural drainage-usually for chronic conditions such as CF *oxygen therapy
What are the types of urinary catheters?
*intermittent urinary catheter- straight catheter used to drain the bladder for short periods (5-10 minutes); patients can use this at home (not sterile, CLEAN technique) *indwelling urinary catheter- catheter that remains in place for continuous urethral drainage; synonym for "Foley catheter"; STERILE PROCEDURE *suprapubic catheter- catheter inserted into the bladder through a small abdominal incision above the pubic area; can be used for long term continuous drainage (some patients find this more comfortable because you can have sex with this kind of catheter)
Identify appropriate outcomes for nursing diagnostic statement.
*look at the first clause of nursing dx and restate it in a statement that describes improvement, control, or absence of problem *risk for infection r/t surgical procedure *the pt will demonstrate no signs or sx of infection
What are some oxygen delivery systems?
*nasal cannula- 1-6 L/min; if over 4 L/min you would add a humidifier (22-42% O2) *simple face mask/face tent- 6-12 L/min (40-60% O2) *non-rebreather- 12-15 L/min (max 80-100%) *Ammu-bag- breathing for the pt, before ventilation or during CPR -ADD HUMIDIFIER IF LONG TERM TREATMENT, ABOVE 2 L/MIN, OR PER PATIENT REQUEST
What are some reasons for urinary catheterization?
*obstruction is present *patient cannot physically empty bladder *the bladder residual must be measured *an accurate output of urine must be noted (done with patients who've had trauma, major fluid loss, cardiovascular disease, kidney disease) *post operative drainage is necessary *direct administration of antibiotics *diversion of urine is necessary for healing *chronic retention condition where body retains liquids in body****
What are some safe body mechanics when moving a patient or moving objects?
-LIFT WITH YOUR LEGS -DO NOT LIFT WITH YOUR BACK -DO NOT LET PATIENT TUG ON YOU OR PULL ON YOUR NECK; have them push up with whatever they are seated on -if patient is falling, do your best to protect their head, straighten out one of your legs and let them slide to the floor -keep whatever you're lifting close to your body and use a wide base
What is the proper identification of patients when giving medication or treatments?
-double check bracelet and order -use the 2 patient identifiers (NAME, DOB) -6 rights of medication administration *right PATIENT *right DOSE *right DRUG *right ROUTE *right TIME *right DOCUMENTATION
How can you prevent complications related to individuals on bedrest?
-frequent repositioning -skin maintained dry/clean -proper nutrition -ambulation, if possible
How can organisms spread?
-indirect contact (contact with inanimate objects) -direct contact (mucous membrane, or indigestion) -vectors (mosquitos) -airborne (talking, coughing, sneezing- person more than 3 ft away) -droplet (similar to airborne, but larger particles- person CAN BE up to 3 ft away)
Why do you monitor blood glucose levels?
-make sure levels are not too high or low -remember "cold and clammy? need some candy?" indicates hypoglycemia... *need to raise sugar with 15 g of carbohydrates AKA 4 ounces of orange juice or 3 lifesaver candies -remember "warm and dry? sugar is high!" indicates hyperglycemia... *pt needs insulin, but this is not as emergent as hypoglycemia *check blood sugar every 15 min after an intervention like giving orange juice or insulin
Identify appropriate outcomes for nursing diagnostic statement.
-make sure outcome statements are SMART: specific, measurable, attainable, realistic, time-framed -components of outcome statement: *SUBJECT- who will be achieving outcomes *VERB- what actions will be done to achieve the outcomes *CONDITIONS- under what circumstances *PERFORMANCE CRITERIA/QUALIFIER- how well or to what extent will actions be performed *TARGET TIME- when will goal be reached (i.e. patient will report a 5 or below on the pain scale within 8 hours of treatment)
What patients/patient conditions are predisposed to infection?
-patients include: neonates, older adults, immunosuppressed, recent sx -conditions: *integrity of the skin/mucous membranes (which protect the body from microbes) *pH levels in GI tract which ward off microbial invasion *incontinence *age, sex, race, hereditary factors which influence susceptibility *immunizations *decreased WBCs *level of fatigue and nutritional/general health *stress level *indwelling devices *patients already on antibiotics
When do you take rectal temp vs. oral temp, and radial vs. carotid pulse, etc.?
-rectal temp is core temp, but should not be taken in newborns, children with diarrhea, rectal surgery/disease, heart surgery/disease, low WBC (leukemia), spinal cord injuries, low platelet count -apical pulse needed for children under 2, preferred for children under 10, or if peripheral (radial) pulse is irregular or weak -circulation to the legs and feet assessed at femoral, popliteal, posterior tibial, or dorsalis pedis sites -take carotid pulses for emergency assessments (patients in shock or cardiac arrest)
What are some general patient hygiene practices that should be taught?
-teaching how to prevent a UTI -hand hygiene -oral hygiene -refrigeration of foods -preparing foods at high enough temps to kill bacteria (i.e. prep of fresh meat) -clean utensils and equipment in hot soapy water to kill bacteria -washing fruits and veggies before consumption -use of pasteurized fruit juices and milk -use of individualized personal care products (towels, toothbrushes and washcloths)
A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (select all that apply) 1. cuff too small 2. arm positioned above heart level 3. slow inflation of the cuff by the machine 4. patient did not remove his love sleeved shirt 5. insufficient time between measurements
1,5
When do you assess vital signs?
1. Upon admission to any healthcare agency 2. Based on agency institutional policy and procedures 3. Anytime there is a change in patient condition 4. Before and after surgical or invasive diagnostic procedures 5. Before and after activity that may increase risk 6. Before administering meds that affect cardiovascular or respiratory functioning
What are the the National Patient Safety Goals 2018?
1. identify patients correctly 2. improve staff communication 3. use meds safely 4. use alarms safely 5. prevent infection 6. identify patient safety risks 7. prevent mistakes in surgery
What are the sources of heat loss?
1. skin (#1 source) 2. evaporation of sweat 3. warming and humidifying inspired air 4. eliminating urine/feces
What is a real fever (degrees)?
100.4 and above (PYREXIA)
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (select all that apply) 1. right arm BP: 118/72 2. radial pulse rate: 72 and irregular 3. temporal temperature: 37.4 *C (99.3 *F) 4. respiratory rate: 28 5. oxygen saturation: 99%
2,4,5
The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is finding a blood pressure of 65/46 and alarming. Place your care activities in priority order. 1. press the start button of the electronic blood pressure machine to obtain a new reading 2. obtain a manual blood pressure with stethoscope 3. check the patients pulse distal to the blood pressure cuff 4. assess the patients mental status 5. remind the patient not to bend her arm with the blood pressure cuff
4,1,3,2,5
A 55 year old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right anticubital fossa, and pneumatic compression stocking are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patients blood pressure and temperature? a. right antecubital and tympanic membrane b. right popliteal and rectal c. left antecubital and oral d. left popliteal and temporal artery
A
The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? a. 84 year old man recently admitted with pneumonia, RR 28, SPO2 89% b. 54 year old woman admitted after surgery for fractured arm, BP 160/86 mm HG, HR 72 c. 63 year old man with venous ulcers from diabetes, temperature 37.3 *C (99.1 *F), HR 84 d. 77 year old woman with left mastectomy 2 days ago, RR 22, BP 148/62
A
Define the steps of the Nursing Process in the correct order.
ADPIE Assessment- *subjective and objective data is obtained by the observation, examination and interviewing patient *data is verified and organized in order to make inferences and identify patient needs *data is confirmed and communicated with appropriate members of the health care team Diagnosis- *data is analyzed and related to factors are identified and then an appropriate nursing diagnosis is developed Planning- *short term and long term goals are identified with specific deadlines and outcomes *SMART goals: specific, measurable, attainable, realistic, time oriented ex. the patient will ambulate in the hallway by lunch time *nursing diagnosis is prioritized where ABCs takes highest priority Guidelines for setting priorities: 1. immediate life threatening issues 2. safety issues 3. patient identified issues 4. nurse identified priorities; hierarchy of needs based on holistic care, time and resources *PLAN OF CARE IS THEN DEVELOPED* Implementation- *the nurse selects strategies based on the knowledge that certain nursing actions produce desired effects *nursing interventions must be safe, within the legal scope of practice, and compatible with nursing orders Evaluation- *the way that nurses determine whether a patient has reached a goal *it is the analysis of the patients response *helps determine the effectiveness of nursing care
What population is at the greatest risk for hypertension? *hypertension= abnormally high bp*
African Americans
What part of the nursing process is this describing? -collection, validation, and communication of patient data (identifying patient needs)
Assessment
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7 *C (101.6 *F) (0400), 36.6. *C (97.9 *F) (0800), 36.9 *C (98.4 *F) (1200), 37.6 *C (99.6 *F) (1600), and 38.3 *C (100.9 *F) (2000). How would you describe this pattern of temperature measurements? a. usual range of circadian rhythm measurements b. sustained fever patterns c. intermittent fever patterns d. resolving fever patterns
C
A patient presents in the clinic with dizziness and fatigues. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? a. Request that the nursing assistant repeat the pulse check. b. Call for a stat electrocardiogram (ECG) c. Assess the patients apical pulse and evidence of a pulse deficit d. Prepare to administer cardiac-stimulation medications
C
As you are obtaining the oxygen saturation on a 19 year old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish on her nails and she asks you why her nail polish had to be removed. What is the best response? a. Nail polish attracts microorganisms and contaminates the finger sensor b. Nail polish increases oxygen saturation c. Nail polish interferes with sensor function d. Nail polish creates excessive heat in sensor probe
C
The nurse observes a nursing student taking blood pressure on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patients BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an inaccurate technique? a. 96/40 mm Hg b. 110/66 mm Hg c. 130/90 mm Hg d. 156/82 mm Hg
C
Which patient is at highest risk for tachycardia? a. a healthy basketball player during warmup exercises b. a patient admitted with hypothermia c. a patient with a fever of 39.4 *C (103*F) d. a 90 year old male take beta blockers
C
A 52 year old woman Is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs in admission are: HR 112, BP 138/82, RR 22, Tympanic temperature 36.8 * C (98.2*F) and oxygenation saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? a. temperature: 37*C b. radial pulse: 112 c. respiratory rate: 24 d. oxygen saturation: 96% e. blood pressure: 134/78
D
A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right side facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistant personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? a. Direct the NAP to hold the thermometer in place with her glove b. Direct the NAP to switch the thermometer prove to the left sublingual packet c. Direct the NAP to obtain a right tympanic temperature d. Direct the NAP to use a temporal artery thermometer form the right to left
D
What part of the nursing process is this describing? -analysis of patient data to identify patient strengths and health problems that independent nursing interventions can prevent or resolve
Diagnosis
What part of the nursing process is this describing? -measuring the extent to which the patient has achieved the outcomes specified in the plan of care; identifying factors that positively or negatively influenced outcome achievement; revising the plan of care if necessary
Evaluating
Know what each liter increase of O2 will yield what percentage of O2.
Example: Room air is 21% O2. Your patient receives 2 L/min... for every liter added, 3-4% is administered. SO 21% room air plus 2 L/min (time 4% each L) is 28% O2. 1 L/min= 24% 2 L/min=28% 3 L/min=32% 4 L/min= 36%
What part of the nursing process is this describing? -carrying out the plan of care
Implementation
What part of the nursing process is this describing? -specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnosis and (2) related nursing interventions
Outcome Identification and Planning
Describe what these patient positions mean: Prone, Sims, Supine, Orthopneic, Trendelenburg, Fowlers, Dorsal Recumbent
Prone: on belly Supine: on back Sims: patient lies on either side with lower arm on below the body and upper arm flexed at the shoulder and elbow; both knees flexed *usually used when inserting an enema or anything of/related to the RECTUM Orthopenic: sitting up with several pillows for support Trendelenburg: lowering of upper torso with feet raised Fowlers: Sitting up at or above 45 degrees High Fowlers: sitting up at 90 degrees Semi/Low Fowlers: sitting up at 30 degrees Dorsal Recumbent: on back with knees bent, soles of feet on bed; SHOULD NOT BE USED FOR ABDOMINAL ASSESSMENTS *pelvic exams, perineal care, foley insertions
What is the blood flow through the heart?
RIGHT side of heart: *blood enters the heart through the two largest veins- inferior and superior vena cava- emptying oxygen poor blood from the body into the right atrium of the heart into the semilunar valve *as the atrium contracts, blood flows from the right atrium into the right ventricle through the open tricuspid valve. *When the ventricle is full, the tricuspid valve shuts. This prevents blood from flowing backward into the atrium while the ventricle contracts. *As the ventricle contracts, blood leaves the heart through the pulmonic into the pulmonary artery and the lungs where it is oxygenated LEFT side of heart: *the pulmonary vein empties oxygen-rich blood from the lungs into the left atrium of the heart *as the atrium contracts, blood flows from the left atrium to the left ventricle through the open mitral valve. *when the ventricle is full, the mitral valve shuts. *as the ventricle contracts, blood leaves the heart through the aortic valve, into the aorta and to the body in other words.... vena cava, right atrium, tricuspid valve, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, mitral valve, left ventricle, aorta, body
Describe radiation, convection, evaporation, and conduction.
Radiation- *transfer of heat from surface of one object to surface of another w/o direct contact between the two *body to environment heat loss Convection- *transfer of heat away by air movement (dispersing) *like an oven dispersing heat throughout the whole thing Evaporation- *liquid changed to gas (perspiration or sweating) *liquid to vapor Conduction- *when warm skin touches a colder object, heat is lost *transer of heat to another object via DIRECT CONTACT
