NURS 306 Exam #2

Which one of the following clients would the nurse assess first if concerned about a possible tissue integrity problem? A.Braden Score of 6 B.Braden Score of 23

A

_________ _____: when we move the muscle/joints for the client •Do ______ extend muscle any further than the point of resistance or when painful

passive ROM NOT

A nurse is caring for a H.K. who is experiencing nausea and vomiting. What is most important for the nurse to do? A. Encourage deep breathing. B. Use room-deodorizing sprays. C. Provide frequent oral hygiene. D. Maintain prescribed NPO status

d

A nurse is caring for a patient who had abdominal surgery. Which type of incisional drainage should the nurse expect 4 hours surgery? A.Serous wound drainage B.Purulent wound drainage C.Sanguineous wound drainage D.Serosanguineous wound drainage

d

A nurse is caring for a client who is obese and is scheduled for abdominal surgery in the morning. Which information is most important to include in a preoperative teaching plan for this client? A. How to cough and deep breathe effectively B. What to do to prevent a wound infection C. What to do to safely ambulate in the hall D. How to exit the bed independently

a

highest plasma concentration; measured when med absorption is complete (usually 1 hour, depends on route)

peak level

wound drains Passive: __________ drain -passively promote drainage -has _____________ Active: portable wound bulb suction device (______________) -suction by squeezing bottle

penrose paperclip jackson pratt

•How do we grade muscle strength?

0-5

•Mild pitting, slight indentation, no perceptible swelling

1+

3 checks of medication administration

1. PYXIS 2. Counter 3. Bedside

•Moderate pitting, indentation subsides rapidly

2+

Degree of edema: •__ mm = ___+ mild pitting •___ mm =___+ moderate pitting •___ mm = ___+ deep pitting •___ mm = ___+ very deep pitting

2, 1 4, 2 6, 3 8, 4

•What are two things that we need to take into consideration regarding personal hygiene?

1.Respect individual preferences 2.Provide only the care the patients cannot (or should not)

7 rights of medication administration

1.Right PATIENT 2.Right DRUG 3.Right DOSE 4.Right ROUTE 5.Right TIME 6.Right REASON 7.Right ASSESSMENT

when do you apply SPF?

15 minutes before out in sun and after getting wet or sweating

where is pulmonic valve located?

2nd intercostal space, left sternal border

Where is the aortic valve located?

2nd intercostal space, right sternal border

The heart extends from the ___ to the _____ intercostal space and from the ______ border of the sternum to the left ___________ line.

2nd, 5th right, midclavicular

•Deep pitting, indentation remains, leg looks swollen

3+

what kind of SPF?

30 or greater

Neck vessels Inspection •Position: Supine from a ___- to a ___-degree angle •Remove the _________ •The head in the same plane as the trunk. •Head turned slightly away from the examined side •Direct a strong light tangentially onto the neck

30, 45 pillow

oral medication Absorption rates •Oral typically ___-___ mins if does not have time-release mechanism •SQ ___-___ mins •IM __-___ mins •IV <___ mins (sometimes immediately)

30-60 15-30 5-15 5

where is erbs point located?

3rd intercostal space, left sternal border

•Very deep pitting, indentation lasts long time, leg very swollen

4+

Where is the tricuspid valve located?

4th intercostal space, left sternal border

What angle for intradermal injection?

5-15 degrees

Where is the mitral valve located?

5th intercostal space, midclavicular line

IM injections •Administer at ____-degree angle •Use ________ technique -Helps prevent backflow/leaking into tissues during admin; also reduces pain & discomfort -Pull skin _____ or to one ____ about 1" and hold in position with _________________ hand -Insert needle and inject med slowly -Withdraw needle steadily & ___________ displaced tissue to allow it to return to normal position -*Do NOT ___________ site* •Will need _____________ after injection (causes minor bleeding due to muscle rich in BV)

90 z-track down, side, nondominant replace massage bandaid

A nurse assessing client wounds would document which examples of wounds as healing normally without complications? SELECT ALL THAT APPLY A.The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. B.A wound with increased swelling and drainage C.A wound that feels hot upon palpation D.Increased Incisional pain after day 10

A

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? A.A client sitting in a chair who slides down B.A client who lifts himself up on his elbows C.A client who lies on wrinkled sheets D.A client who must remain on his back for long periods of time

A

Which interventions might a nurse be expected to perform when providing competent care for a client with a draining wound? A.Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. B.Change the dressing during meals. C.Avoid applying a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. D.Apply a wet to dry dressing

A

A nurse is caring for a postop patient who had abdominal surgery. The patient states, "That wound felt like it gave way." The nurse identifies that the patient had a dehiscence with slight evisceration. Identify the actions that the nurse should implement. Select all that apply. A.Instruct the patient to avoid coughing or bearing down B.Notify the HCP immediately C.Position the patient in a supine position D.Cover the incision with a sterile dressing E.Prepare the patient for surgery

A, B, D, E

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? SELECT ALL THAT APPLY. A.An older adult who is bed-ridden. B.A patient with a peripheral vascular disorder C.A patient who is obese D.A patient who eats a diet high in vitamins A and C E.A patient who is taking corticosteroid drugs F.A 10-year-old patient with a surgical incision G.An older adult with an orthopedic medical device

A, B, C, E, G

What does the nurse need to assess to monitor for manifestations of dehydration? SELECT ALL THAT APPLY A.Skin turgor B.Clubbing C.Weight D.WBC E.Crepitus F.Urine output G.Elevated serum sodium levels H.Serum osmolality

A, F, G, H, C

ABCDEF for moles/skin lesions

A: asymmetry B: border irregularity C: color variations D: diameter > 6mm E: elevation F: funny looking

•concentration of drug in the blood serum that produces the desired effects without causing toxicity

therapeutic level

As adults age, skin becomes _________, elasticity is ______, subcutaneous fat becomes thinner, blood supply is more sluggish, and the skin becomes less ____________. Therefore, shear, friction, and pressure can cause problems.

thinner, lost, hydrtaed

____________________ pills cannot be chewed or crushed

•Enteric-coated

•What are techniques for eye care?

•Eye care involves removing drainage and crusts from eyes or if client is sedated/unconscious, will provide eye drops to prevent drying •If client uses contacts or glasses, be sure to clean and provide for client

•What are techniques for perineal care?

•For females - wipe from FRONT to BACK •For males uncircumcised - pull foreskin back, clean skin underneath, and replace foreskin to natural position

musculoskeletal assessment overview

•History inquiry/subjective data gathering •Inspect •Palpate •ROM •Muscle testing

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? A. The client should use an electric razor. B. The client prefers shaving gel over shaving cream. C. The client likes to shave while in the shower. D. The client would like the spouse to assist with shaving.

a

•What are some techniques of performing a bed bath?

•When assisting in hygiene activities, nurse should use this time to inspect skin and skin integrity

H.K. is now experiencing decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, and apprehension. Which condition would the nurse suspect? A. Atelectasis B. Tuberculosis C. Hyperkalemia D. Thrombophlebitis

a

•What are techniques for ear care?

•warm washcloth, wiping outside of ear •Nothing should go inside a client's ear

The musculoskeletal assessment requires a patient to perform multiple exercises for identifying health status of this system. To test trapezius muscle strength, the nurse should ask the patient to: A.Shrug his shoulders against resistance B.Lift his knee against resistance C.Hyperextend his leg without resistance D.Touch his toes from the standing position

a

nasal medication •Pts typically want to do this themselves, so give instructions •Pt to ____ nose before instilling medicine •Pt should be sitting up ________, head _________ _________ •Tip of medicine should only just be slightly in nose •_______opposite nostril while distilling drop(s); instruct pt to gently _______ through the open nostril

blow straight, tilted back close inhale

parenteral medication •To draw up medication from a regular medicine vial, you need a _________needle

blunt

To draw up medication in a glass ampule, you need a _____ _______ needle

blunt filter

hips and lower extremities Inspect hips & knees •Unexpected findings: _________ of hips, deformity, or unequal _______ of leg; pain w/ movement, dislocation, frx; wide-based gait; presence of redness, swelling on the joints of knee Palpate •No pain, tenderness, warmth ROM •______ and _______of knees & hips •____ and _________ hips Muscle strength

asymmetry, length flexion, extension abduction, adduction

Ad lib=______ ______________ BR=________ _________ BRP=______________________ Up to chair

at pleasure bed rest bed rest with bathroom privileges

The nurse is performing a musculoskeletal assessment of an older adult patient whose mobility has been decreasing progressively in recent months. How should the nurse best assess the patient's range of motion in the affected leg? A.Observe the patient's unassisted ROM in the affected leg B.Perform passive ROM, asking the patient to report any pain C.Ask the patient to lift progressed weights with the affected leg D.Move both the patient's legs from a supine position to full flexion

a

What would the nurse do next if during the examination of the lower extremities, they are unable to palpate the popliteal pulse? a.Proceed with the examination. It is often impossible to palpate this pulse b.Document 0+ and notify the client to a vascular surgeon c.Schedule the client for a venogram d.Schedule the client for an arteriogram

a

Which of the following are atrophic skin changes that occur with peripheral arterial insufficiency? a.Thin, shiny skin with loss of hair b.Brown discoloration c.Thick, leathery skin d.Slow-healing blisters on the skin.

a

Which of the following medications would the nurse be concerned the client is taking prior to surgery? A.Anticoagulant B.Pain Medication C.Antibiotic D.Vitamins

a

Which of the following nursing actions will help prevent a DVT? A.Apply SCDs B.Teach TCDB C.Encourage IS every 1 hour x 10 D.Turn the client every 2 hours.

a

You are assessing capillary refill. The room is warm. Which finding would be considered normal? a.≤2 second b.>2 seconds c.2 to 3 seconds d.Time is not significant as long as color returns

a

What does a client's pulse with an amplitude of 3+ indicate? a.Irregular, with 3 premature beats b.Increased, strong pulse c.Normal d.Weak

b

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury ? A.Stage I B.Stage II C.Stage III D.Stage IV

B

A postoperative patient is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for a patient with a Penrose drain? A.Removing the excess external portion until the drainage stops B.Changing the soiled dressing carefully C.Maintaining the negative pressure D.Pinning the drain to the dressing

B

As the nurse assesses the patient, the following is noted. What would be the most accurate assessment of this? A.Boutonniere's deformity B.Ulnar deviation C.Bouchard's node D.Swan-Neck deformity Which musculoskeletal disorder is this most commonly associated with?

b rheumatoid arthritis

When the preoperative nurse is conducting her assessment which finding would be most worrisome? A: A history of smoking for 10 years B: A history of an allergy to shellfish C: Recent chest pain with upon exertion D: A history of ankle surgery

a bc increased risk of complications

Which teaching points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? A."Pressure injuries will not occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." B."Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time." C." A pressure injury may form in as little as 1 to 2 hours if the client has not moved or been repositioned to allow circulation to flow to dependent areas." D."Clients with casts, orthopedic devices, or support stockings are not at risk for the development of a pressure injury."

C

What medical conditions are we worried about when inquiring about medical history prior to surgery? Why?

CODP, OSA, asthma, CAD, and CHF d/t risk of complications

•What are other skin products may we consider using?

Chlorhexidine gluconate emollient

The nurse is assessing a 60-year-old client who has been on bedrest for 4 days. The nurse is concerned about PV complications. Which of the following priority focused assessments would the nurse want do perform? Select all that apply a.Cap Refill b.DP pulses c.PT pulses d.Bowel sounds e.Lung sounds f.LOC g.Temperature of lower extremities h.Symmetry of lower extremities

a b c g h

Which of the following will help allay fears in the preoperative phase? Select all that apply A.Explore the client's feelings B.Engage in active listening C.Tell the patient everything will be OK D.Do most of the talking so the client is distracted E.Realize many clients rely on spiritual resources to cope

a b e

Factors affecting wound healing can be remembered easily by the mnemonic DIDN'T HEAL

D= Diabetes I= Infection D= Drugs N= Nutritional problems T= Tissue necrosis H= Hypoxia E= Extensive tension A= Another wound L= Low temperatures

________________: Complete or partial separation of the suture line & underlying tissue fails to heal -Notify HCP, cover wound with ________ sterile dressings, probably giving pain med & fluids; prepare client to go back to OR ______________: Wound and all layers of tissue under the wound separate resulting in PROTRUSION of intraabdominal organs through the suture line -EMERGENCY -Placed sterile ___________-soaked dressing over organs -Client going back to OR ________

Dehiscence moist evisceration saline asap

•What is 'protective positioning'?

Involves aligning the body in a neutral position, supporting the body's natural curves, and eliminating pressure points, hyperextension, or lateral rotation.

•What type of soap do we recommend to be used on the skin?

MILD SOAP

When a patient complains of chest pain, which questions are pertinent to ask to gain additional data? Select all that apply. A."What were you doing when the pain first occurred?" B."What does the pain feel like?" C."Do you have episodes of shortness of breath?" D."Where in your chest does it hurt?" E."Has anyone in your family ever had a similar pain?"

a, b, c, d

post op care ØImmediate postop phase-> __________ (typically) then either surgical unit or ICU ØNursing responsibilities are to monitor client's _________,___________, ____________ ventilation, VS, & LOC

PACU airway, breathing, circulation

___________ medications are As needed; when pt requests or when nurse indicates it is required based on pt's condition •Treat symptoms (e.g., nausea, pain, BP)

PRN

what are the 7 P's?

Pain; Pallor; Pulses; Paresthesia; Paralysis; Pressure; Polar

The ____________________________________________________________ is a computerized pump with a syringe of pain medication connected to an IV line. The pump can either administer pain medications in a small constant flow as needed, or the client can self-administer the medication by the press of a button, based on their level of pain.

Patient Control Analgesia Pump (PCA)

____________ medications are given ASAP, usually just once, should be administered within ____ minutes if HCP placing the order

STAT 30

Which hygienic issues are of utmost importance for a patient using an indwelling urinary catheter?

Scrupulous, daily catheter care Inspection of the urinary meatus Notation of urine characteristics Notation of painful or burning urination (on nonparaplegic patients)

rectal medication •_________________- laxatives, fecal softeners; acetaminophen and antiemetics for systemic effects •Pt to lay _____ SIDE in ______ position •Use lubricant, inserting about __-__" using index finger •After insertion, pt should remain in position for ___ minutes; if laxative, some recommend 35-45 mins or until needing to defecate

Suppositories left, SIMS 3-4 5

A patient who has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bath experience less stressful for both the nurse and the patient? Select all that apply. A.Allow the patient to perform as much of the care as possible. B.Start by washing the patient's hair C.Try an alternative to traditional bathing, such as a bag bath D.Use soft restraints to prevent patient from injuring self or the nurse E.Come back at another time

a,c

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? A.Trochanter rolls B.Foot boards C.Foot splints Roller sheets

a

A nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion? A. Oliguria B. Cachexia C. Yellow sclera D. Suprapubic distention

a

skin color •Even and consistent with genetic background •____________: loss of melanin in patches • Freckles (ephelides) -Small, flat ________ of brown melanin pigment that occur on sun-exposed skin •Birthmarks, old scars

Vitiligo macules

A nurse is caring for a client who has mobility level 3 according to the MAT. Which of the following piece of equipment should the nurse use to transfer the client? A.Gait belt B.Mechanical left C.Sit-to-stand lift D.No need for any assistance

a

Which nursing interventions would be appropriate for a patient recovering from a surgical procedure? (Select all that apply.) A.Teach the patient to protect the incision by splinting when coughing and deep breathing. B.Encourage the patient to take frequent shallow breaths to improve lung expansion and volume. C.Place the patient in a semi-Fowler's position to perform deep-breathing exercises every 2 hours. D.Encourage the patient to lie still in bed with the incision facing upward to prevent putting pressure on the stitches. E.Teach the patient the appropriate leg exercises to increase venous blood return from the legs. F.Encourage the patient to use incentive spirometry 10 times each waking hour for the first 5 days after surgery.

a, c, e, f

A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is (are) appropriate actions? Select all that apply. A.Finding a female nurse to help the patient with hygiene care. B.Convincing the patient that he will work quickly and provide as much privacy as possible C.Skip hygiene care for that day except for the parts that the patient can complete independently D.Asking the patient if she prefers a family member to assist with hygiene care

a, d

What should the preoperative nurse teach this patient about the postoperative phase? Choose all that apply. A: Pain Control B: Skin preparation C: Removal of contacts D: Deep breathing and coughing

a, d

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? Select all that apply. A.Encourage the client to perform antiembolic exercises every 1-2 hours B.Restrict the client's fluid intake C.Reposition the client every 4 hours D.Instruct the client to cough and deep breathe every 1-2 hours Advise the client to use high-fiber diet if possible

a, d, e

Which of the following is a role of the skeletal system? Select all that apply. A. Protect vital organs B. Produce heat C. Pump RBCs around the body D. Responsible for movement E. Provide storage for minerals

a, d, e

develop as a result of injury and typically are a result of trauma.

acute wounds

•What are the different types of activity orders we may see on the provider orders?

ad lib: at leisure BR: bed rest BRP: bed rest with bathroom privileges up to chair

bring closer to baseline

adduction

best absorption for subcutaneous injection sites is the __________

abdomen

move away from baseline

abduction

auscultation of heart sounds: unexpected findings •Extra Heart Sounds -Third heart sound (S3) •S3 is associated with heart failure and is always _________ over the age of 35; can be normal in young children -Fourth heart sound (S4) •Murmurs -systolic murmur may occur with a healthy heart or with heart disease (sound heard between ___ and ____) -diastolic murmur always indicates heart disease (sounds heard between ____ and next _____) •Prosthetic Valve Sound -Sounds like __________ •Pericardial Friction Rub -Sounds like __________ rubbing against each other

abnormal s1, s2 s2, s1 clicking sandpaper

process by which a drug is transferred from its site of entry into the body to the bloodstream is ____________ •Route of administration!! -Oral medication take the ____________ to absorb into the body -Liquid oral medication is faster than tabs/caps because it does not need to ___________ -IM and SQ meds are absorbed more rapidly than PO, but not has fast as IV -IV medication absorbs ____________________ into the bloodstream - the ________________absorption route •Blood flow effects ________________ rates

absorption LONGEST dissolve immediately fastest absorption

what are we worried about when there is excessive bruising with varied stages of healing?

abuse

when client is able to move joint without assistance

active ROM

•What is active ROM? Passive?

active: pt is performing ROM without help passive: pt needs assistance from nurse in ROM

•What are ADLs? Functional vs instrumental

activities of daily living functional: dressing, walking, toileting, eating, bathing instrumental: driving, cooking, paying bills, grocery shopping, using phones, cleaning the house

_________________________________________ are basic essential skills that a person does independently every day and are usually related to personal care. Ø__________ Ø___________ Ø____________ Ø_____________ oneself ØProviding support to enable performance of ADLs is an important aspect for clients to achieve a high quality of life and independence!!!

activities of daily living (ADL) dressing toileting bathing feeding

an inadequate amount of physical or physiological energy to undergo or complete a necessary activity.

activity intolerance

the capacity to successfully complete a necessary activity without distress.

activity tolerance

subcutaneous injections •Administered into __________tissue •Administered at a __ to ____degree angle -____ is usually for smaller, thinner patients & when using a longer needle •Pinch the skin fold for thinner patients & longer needles to gather tissue away from underlying muscle. Once needle is inserted, release the skin and stabilize the needle to avoid injecting into compressed tissue. •Do not need to ________ site* •Rotate sites if pt is receiving frequent injections

adipose 45-90 45 massage

unwanted and nontherapeutic effects of the medication; can range from mild to severe

adverse drug reaction

•If you are using a multi-dose vial, when you puncture the rubber top, you must inject ____ into vial in order to get medication out properly •When needing to inject air, pull plunger to the _____ amount (mL) that you will be needing to draw up -So, if you are drawing up 2 mL of the medicine, you need to put ______ of air in the syringe and then inject the 2 mL into the vial -You will feel the pressure, so keep a good hold of the plunger while inverting and drawing up medicine

air same 2 mL

post op assessments Respiratory system ØMaintain ________ and __________ ØMay have artificial airway, suppl. O2 ØOnce conscious, encourage ___, cough, deep breathing, early ambulation CV system ØAssessing _________ (bleeding!!), F&E status ØInitiating SCDs, anti embolism stockings, _____________ Neurologic System Ø_______ & Mental status - goal to return to baseline Pain Management - _____________ approach ØOpioid-based pain meds usually used immediately postop ØNonopioid meds will be used as well ØNonpharmacological interventions encouraged as well Integumentary system ØSterile dressing may be applied to the site -> should be left in placed for __-__ hours (at the discretion of surgeon) -Assess frequently for signs of infection or bleeding ØDrain tube may be placed; monitor Positioning ØDone frequently (every _____) to prevent muscle weakening, blood clots, lung infections Ø___________** for abd or chest incisions -Hold a pillow over incisions when coughing GI System Ø_______ sounds Ø_______ and __________ ØEarly ambulation ØStool softeners Renal System ØClosely monitor _____ __________ ØStrict I&Os

airway, breathing IS circulation ambulation LOC multimodal 24-48 hour splinting bowel nausea and vomiting urine output

health promotion for skin Bathing & hygiene practices •Skin care products - use __________-free and ___________-free products to reduce skin irritation •Abrasions - need to be clean & dry, not covered so that it can be exposed ______ to promote healing •Excessive skin dryness - ___________-free lotions to moisturize skin, cotton clothing, mild soaps •Acne - cleaning skin & hair with warm water & soap daily to remove oil from skin Skin protection from sun exposure •Exposure to ____ radiation from sun •Apply sunscreen (SPF ___ or greater) ____ mins before sun exposure; reapply after _____________or sweating •Wide-brimmed hat, sun-protective clothes w/ long sleeves •Discourage indoor ________ _____ Self-assessment of moles & suspicious lesions •Increases knowledge about their skin's characteristics •Use _______ to help w/ hard-to-see areas •Notify HCP asap with new lesions found and when lesion starts to ______, has drainage, or feels different that it previously did (swollen, hard, lumpy, itchy, or tender to touch)

alcohol, perfume air alcohol UV 30, 15 swimming tanning bed mirror bleeding

Integumentary System Effects OF IMMOBILITY Ø____________ skin integrity d/t prolonged pressure compressing against skin ØMost susceptible to effects of pressure are ______ ___________(e.g., back of head, shoulder blades, elbows, __________*, ischium, and heels ØSkin that is exposed to ___________ are at even greater risk for skin breakdown Ø_________ _____________ = localized damage or necrosis of the skin and/or underlying tissue -Range from intact skin with nonblanchable redness -> deep wounds w/ exposed bone & necrotic dissue Nursing Interventions ØBiggest thing: Reposition AT LEAST every ___ hours!! ØUse pillows & cushions to support joints/bony prominences ØUse pressure redistribution devices & mattresses to decrease pressure to susceptible areas Ø___________ dry skin (to prevent cracking/skin breakdown/infection) -But also, do not want skin to be moist from incontinence, wound drainage or perspiration -> leads to skin breakdown ØEnsure intake of calories, _________, & micronutrients to promote wound healing

altered bony prominences sacrum moisture pressure injury 2 moisturize protein

spine and body alignment Inspect •__________ - observe gait & posture •Spine - noting ________, alignment •Expect: symmetrical & smooth, coordinate movement •Expected variation: w/ aging, vertebral discs flatten resulting in loss of ________ •Unexpected: __________ deviation of spine, asymmetry, exaggerated curvatures ROM •Bend forward & touch toes (_________) •Bend sideways, right & left (_________flexion) •Bend backwards (______________) •Twist shoulders (____________)

ambulate curvature height lateral flexion lateral hyperextension rotation

glass container that stores liquid medication

ampule

an acute allergic reaction to an antigen that may result in life-threatening shock, producing vasodilation, bronchospasm, and laryngeal edema

anaphylaxis

common cause of pallor

anemia

auscultation fo heart sounds (APETM) •2nd ICS right sternal border: __________ valve area •2nd ICS left sternal border: ___________ valve area 3rd ICS left sternal border: ________ point (best place to hear ___) •4th ICS left sternal border: _____________ valve area •Fifth ICS at around left midclavicular line: ________ valve area; also where you listen for ________ _________

aortic pulmonic erb's S2 tricuspid mitral apical pulse

Five areas for listening to the heart

aortic, pulmonic, erb's point, tricuspid, mitral

S1 is loudest at

apex

An ulcer at the tips of the toes, with a yellow and pale wound bed

arterial

Cramping deep muscle pain occurs with activity and relieved with rest

arterial

Delayed capillary refill (greater than 3 seconds)

arterial

Pain improves with the extremity in a dependent position

arterial

Shiny skin

arterial

scheduled hygiene care •Early morning care -Shortly after patient _________ -Goal is to prepare for the day and/or breakfast -May include toileting, washing hands, face •Morning care (AM care) -Typically after __________ -Goal is to feel refreshed in a comfortable/safe environment -May include ______/______, oral care, hair/skin routines, dressing, changing linen •Afternoon care (PM care) -Typically after _________, when patients receive ___________ (tidy up) •Hour of sleep care (HS care) -Before patient ___________ for the evening (oral care, toileting, etc.) •As needed care (PRN Care) -Consider _________ pt needs (ex: pt is diaphoretic will need more linen and gown changes)

awakens breakfast shower/bath lunch, visitors retires individual

A 42-year-old male patient complains of shoulder pain when the nurse moves his arm behind the back. Which question should the nurse ask? A."Are you able to feed yourself without difficulty?" B."Do you have difficulty when you are putting on a shirt?" C."Are you able to sleep through the night without waking?" D."Do you ever have trouble lowering yourself to the toilet?"

b

A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety? A. Assist the client in taking a stand-up shower B. Obtain a shower chair so the client can take a sit-down shower C. Give the client a bed bath D. Give the client a towel or bag bath

b

A nurse is using the Mobility Assessment Tool (MAT) for a client to determine the mobility level and assistance need. The client is not able to sit on the edge of the bed for one minute. What is the client's mobility level and assistance need? A.Level 2 mobility, requires moderate assistance B.Level 1 mobility, requires maximum assistance C.Level 4 mobility, requires no assistance D.Level 3 mobility, requires minimal assistance

b

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate? A.Place your head lower than your heart if you begin to feel dizzy. B.Move slowly and sit on the edge of the bed for a few minutes before transferring to the chair. C.Place feet firmly on the floor when rising to maintain balance. D.Drink a glass of water before attempting to stand to promote circulation.

b

Assessing a client's skin turgor is done to assess which clinical finding? A.Edema B.Dehydration C.Vitiligo D.Scleroderma

b

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? A.In front of the client's head B.Supporting the client's back C.In front of the client's abdomen d. Under the client's feet

b

Which of the following is an effect of immobility on the body? Select all that apply. A. Increased rate & depth of respirations B. Decreased bladder muscle tone C. Increased sense powerlessness D. Decreased joint motility E. Increased peristalsis F. Altered sleep-wake pattern

b, c, d, f

Which of the following are proper body mechanics? Select all that apply. A.Using back muscles to lift heavy objects B.Pushing (rather than pulling) the patient towards their new bed during a bed-to-bed transfer C.Holding heavy objects close to my body when lifting D.Ensuring the bed height is in the lowest position when positioning a patient up in bed E.Bending knees and widening base of support by keeping feet shoulder-width apart when lifting F.Avoid twisting movements

b, c, e, f

S2 is loudest at the

base

S2 is loudest at the ____ of the heart S1 is loudest at the _____ of the heart

base apex

steps to prepare parenteral medications 1.Gather supplies; hand hygiene, don gloves 2.Attach _______ needle to _________ without touching each ends to anything else 3.Take cap off ______ 4.Clean vial top for ____ seconds with ___________ wipe 5.Uncap blunt needle and puncture the rubber part of the vial using _____ ______ 6.Once punctured, use both hands to _____ vial; keep the bevel submerged in the medicine 7.Pull the syringe plunger and fill medicine to the appropriate mark 8. Once you have the appropriate amount, ______ the vial and syringe 9. Pull out the syringe and needle, replacing the needle cap with the blunt cover using _____ ______ 10. Place selected _____ for IM or SC injection on the syringe of prepared medication 11. ________ the prepared medication •Includes name of drug & dose 12. Dispose of blunt needle in _______ container

blunt, syringe vial 30, alcohol one hand invert revert one hand needle label sharps

inhalation medication •Aerosolized, delivered in small particles, and ____________ in by the patient •Hand atomizer or nebulizers

breathed

osteoporosis •Decrease in skeletal bone mass -> low bone mineral density (________ bones) •↑ risk for __________ in hip, spine and wrist (usually ____ sign) •Associated with smaller height, younger age at menopause •Causes: decline in _________; low ca2+ & vit D intake; lack of ___________; cigarette/etoh use; ______ lifestyle ___________ is key* •_________________ exercises (walking, jogging, climbing stairs, tennis, dancing, etc.) •Ca2+ & Vit D intake •Quit ___________ •Limit/eliminate etoh Bone density exam -> ______ •Screening for bone __________ •Can detect risk for osteoporosis before frx

brittle fractures, first estrogen, exercise, inactive prevention weight-bearing smoking DXA density

common cause of ecchymosis

bruising, abuse

A client has been admitted to the medical-surgical unit for exacerbation of congestive heart failure. The nurse notes bilateral +2 pitting edema and dry scaling skin. As the nurse assesses the dorsalis pedis pulse, the nurse is unable to detect it and notes that both feet are warm. What is the best action for the nurse to take? a.Call the physician immediately. b.Assess skin turgor over the clavicle. c.Use a Doppler and assess capillary refill. d.Use a Doppler and assess for renal artery stenosis.

c

A nurse is assisting an older adult with an unsteady gait to a tub bath. Which action is recommended in this procedure? A. Add bath oil to the water to prevent dry skin B. Allow the patient to lock the door to guarantee privacy C. Assist the patient in and out of the tub to prevent falling D. Keep the water temperature very warm because older adults chill easily

c

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A.Decreased subcutaneous fat B.Muscle atrophy C.Pressure injury D.Fecal impaction

c

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? A. Stand with as much weight distributed on the cane as possible B. Hold the cane in the same hand of the leg with the most severe deficit C. Support weight on stronger leg and cane and advance weaker foot forward D. Do not use the cane to rise from a sitting position

c

On auscultation of the heart, the nurse recognizes which expected finding? A.A low-pitched blowing sound is heard over the abdominal aorta. B.A high-pitched vibration is heard over the base of the heart. C.The S1 heart sound is louder at the apex of the heart. D.The S3 heart sound.

c

A new graduate nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions indicate the need for further education? A.Assist the client as needed to ensure proper hygiene is performed B.Instruct the client to lightly dab the skinfold dry to manage moisture C.Use pH-balanced liquid soap to cleanse the skinfolds and rash area D.Apply moisturizer to the skinfolds & rash area

d

Outcome statement: Client will assist fully in bath during AM care. Which evaluation statement is not appropriately written? A. Goal partially met. The client was able to participate during most of the bath, but got very tired when washing lower body. Will continue to encourage client to participate. B. Goal met. The client was able to fully participate in bath this AM and will encourage client to continue participating. C. Goal met. I was able to wash the patient at 1100 and the client tolerated it well. D. Goal not met. The client felt too weak after physical therapy to participate fully during bath. Will consider performing bath at an appropriate time to allow for patient to participate more.

c

The intraoperative nurse arrives to the holding area to complete her assessment. Which of the following would need further evaluation? A. Hemoglobin (HgB) 15.2 g/dL B. Patient states "I am ready to get this over with!" C. Consent form not signed D. Patient's verbalization of surgical site matches consent form

c

While testing the patient's muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient's muscle strength as level A.1 B.2 C.3 D.4

c

A nurse is instructing a student nurse how to perform passive ROM on their patient. Which of the following are correct techniques of passive ROM? Select all that apply. A.The student nurse will instruct and mirror the ROM movement before asking the patient to perform ROM B.Instruct patient to flex arm while the student nurse moves the patient's shoulder in a circular motion C.Support the patient's elbow with one hand and shoulder in another while gently rotating the patient's shoulder D.While patient's muscles are relaxed, the student nurse will move the patient's joint to assess ROM

c, d

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? A. Make a recommendation for the patient to see an oral surgeon B. Report the condition to the pcp C. Gently scrape the oral cavity with a tongue depressor D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa

d

3 main muscle types -___________: only located in the heart and functions involuntarily. -____________: located in the blood vessels and the visceral organs and functions involuntarily. -____________: attached to the skeleton (bones) by tendons and functions voluntarily.

cardiac smooth skeletal

A nurse is ambulating a client with a gait belt. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? A.The nurse should place his or her feet close together with one foot in front of the other. B.The nurse should rock his or her pelvis out of the opposite side of the client. C.The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D.The nurse should gently slide the client down his or her body to the floor.

d

Bluish mottled color that signifies decreased perfusion

cyanosis

CV assessment •Neck -__________pulse - observe and palpate -Observe jugular venous pulse -Inspect for ________. •Precordium -Inspection and palpation -Describe location of ___________pulse -Note any _________ (lift) or thrill •Auscultation -Identify anatomic areas noting _____ and __________ -Listen in systole and diastole for murmurs -Repeat with _________ -Listen at apex and base

carotid JVD apical heave rate, rhythm bell

_________ is a firm, yet flexible connective tissue found in many areas such as the ears, nose, larynx, ribs, intervertebral discs, knees, and ankles.

cartilage

an infection of the superficial layers of skin

celluitis

common cause of cyanosis

chronic hypoxia

develop over time from acute wounds that do not progress in healing.

chronic wounds

the skin holds information about the body ____________, ____________ status, and signs of _____________ diseases

circulation, nutritional, systemic

circular motion

circumduction

body movements -Reaching, bending, and twisting motions can increase the risk of muscle strain and injury -Ensure client or object that you are handling is ________ to your body as possible -Keep abd muscles __________ & lower back in normal position -Maintain head _________ with shoulders raised ____ -Bow the hips slightly and ________ -Pivot or _____________ rather than twisting -Bend at the knees and use ________muscles when lifting; do not bend over with ______

close contracted upright, up squat side-step leg, back

how would you assess pallor with dark skin tones?

color of lips, mucous membranes, nail beds

wound assessment •Usually completed during dressing changes; typically would not take off a dressing to assess it •Note changes in _________, _________, and ________of exudate •Wound exudate may be: -__________: thin, watery -_____________: thin, watery with blood -__________: bloody -__________: green/yellow •Measure wound -Circumference or _______ & __________ w/ paper rule -__________ & ___________ - measured with cotton tip applicator under wound until resistance if felt & mark the spot on the applicator

color, amount, odor serous serosanguinous sanguineous purulent length, width depth, tunneling

what are some instrumental ADLs?

companionship, transportation, grocery shopping, preparing meals

nursing responsibilities for intraoperative ØVerify the preop checklist is __________ Ø_________ ____________ is signed ØSurgical preparations for scheduled procedure have been performed ØAdministering prescribed meds ØEnsuring blood products are available ØObtaining IV access ØRemoving dentures, _________, prosthetics

complete informed consent piercings

4 properties of muscles (CEEE) -C: _______________: the ability to shorten (contract) and then relax. -E: __________________: muscle fibers can receive and respond to nerve or hormone stimulation. A resting muscle is negatively charged. When stimulated (excited), it becomes positively charged and active. -E: _______________: the ability to stretch (extend), which occurs simultaneously as other muscles contract. -E: _____________: the ability to bounce back or recoil to its original state after being contracted or extended.

contractility excitability extensibility elasticity

what is an unexpected finding of MSK assessment? •_______________ -______ deformity, limiting ROM; -Results in disuse, atrophy and shortening of muscles

contractures joint

Wound Culture Collection •Collected w/ sterile _______ applicator •First ______ wound with 0.9% sodium chloride solution (NS) (to remove skin flora or crusted exudate that may contaminate the specimen) •Then use applicator to obtain a drainage sample from wound - be careful NOT to touch the swab to ______________ tissue •Place applicator in vial solution to keep swab ________

cotton clean surrounding moist

nail assessment Expected •Nails should be __________ or flat •Edges should be smooth & rounded •Nail is ____________ •Capillary refill __ 2 seconds Expected variations •Nails of older adults grow slower, become thicker, more diff. to trim Unexpected findings •Color changes (brown, blue, or white tinged) •____________ •Jagged nails •Structure variations •cap refill __ 2 seconds

curved translucent < clubbing >

A student has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the student do? A. Provide total physical hygiene, including perineal care B. Provide total physical hygiene, excluding hair care. C. Provide supplies and orient the client to the bathroom D. Provide supplies and assist with hard-to- reach areas

d

How would the nurse assess to screen for deep vein thrombosis (DVT)? a.Measure the circumference of the ankle b.Check the temperature with the palm of the hand. c.Compress the dorsalis pedis pulse, looking for blood return. d.Measure the widest point of the calf with a tape measure.

d

The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? A.Erb's point B.Mitral area C.Aortic area D.Pulmonic area

d

The nurse is preparing to position an immobile patient. Before doing so, the nurse must understand: A. Manual lifting is the easier method and should be tired first B. Following body mechanic principles alone will prevent back injury C. Body mechanics can be ignored when patient handling equipment is used D. Body mechanics alone are not sufficient to prevent injuries

d

What is the best technique for checking for skin temperature? A.The palmar surface of the hands B.The ventral surface of the hands C.The fingertips D.The dorsal surface of the hands

d

Which should the nurse do to best assess for a sign of postoperative ileus in a client after abdominal surgery? A. Identify the time of the first bowel movement. B. Monitor the tolerance of a clear liquid diet. C. Palpate for abdominal distention. D. Auscultate for bowel sounds.

d

You assess a client who has 4+ edema of the right leg. What is the best way to document this finding? a.Mild pitting, no perceptible swelling of the leg b.Moderate pitting, indentation subsides rapidly c.Deep pitting, leg looks swollen d.Very deep pitting, indentation lasts a long time

d

You note a lesion during a skin assessment. Which is the best way to document this finding? A.Raised, irregular lesion the size of a quarter, located on dorsum of left hand B.Open lesion with no drainage or odor, approximately 1/4 inch in diameter C.Pedunculated lesion below left scapula with consistent red color and no drainage or odor D.Dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, with no drainage

d

The nurse is caring for a client who has a pressure injury on his back. What nursing interventions would the nurse perform? SELECT ALL THAT APPLY. A.The nurse places pressure reducing boots to keep body weight off the patient's heels. B.The nurse uses a ring cushion to protect reddened areas from additional pressure. C.The nurse increases the amount of time the head of the bed is elevated. D.The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair. E.The nurse turns the patient at least every two hours.

d, e

ear medication •Usually admin in __________ __________ __________ •Pt should lay on unaffected side, allowing affected ear to be up •Pull pinna ____ and ______for adults (__________ back for child >3 and _____ and ______for infant and child <3) •Squeeze one drop at a time •Release pinna and have pt maintain side-lying to prevent medicine from escaping; you can gently press on _____ to help move medicine from canal into TM

external auditory canal up, back, straight, down ,back tragus

what are the Safety Considerations for the Surgical Client?

fall risk aspiration impaired cognition

GI System Effects of Immobility ØBR tend to have _____________ appetite ->muscle activity slows, absorption of protein decrease -> malnutrition Ø______________ d/t decreased urge to defecate & slower peristalsis -> prolonged transit time -> increases absorption of water from the feces ->drier, harder stool ØFecal ____________ (blockage) Ø______________________ - supine positioning places more pressure on the LE sphincter -.causes backflow of gastric fluids -> damaging the lining of the esophagus Nursing Interventions ØEarly & often ____________, when able & as client can handle ØEncourage fluid to soften stools ØEncourage high-__________ foods ØConsult dietitian for malnourished clients; will need extra guidance ØElevate HOB after meals to reduce _________

decreased constipation impaction gastroesophageal reflux ambulation fiber GERD

bariatric challenges •Clients who are referred to as "bariatric" are of increased weight or body mass index (BMI) •Increased BMI causes distinctive physiological changes that affect skin integrity, such as extremely ____ _____ _____ •Overheating is not uncommon -> excessive sweating and persistent moisture buildup in skin folds -> friction may cause rash or skin breakdown (_________-___________ _______ _____________) •Manage this with ____-balanced liquid soap and dabbing skin dry; use barrier _______ to protect skin in perineal area from irritants (i.e., urine, stool)

deep skin folds moisture associated skin damage cream

skin mobility and turgor Expected findings •Skin should rise easily when pinched & rapidly return to flat position when released Expected variation •____________ skin turgor (normal part of aging) Unexpected findings •___________: skin remains elevated after release •___________: fluid accumulation in interstitial space -Press finger firmly against skin for __-__ seconds -Normally skin will stay smooth, retract normally -Abnormal "_______" edema - skin leaves dent

delayed tenting edema 3-5 pitting

where to inject subcutaneous?

deltoids, abdominal area, upper thigh, love handles

ROM for MSK assessment •_____________ how the maneuvers should be performed •Movement should be _____________, ________, full _______ without hesitation to any movement •Expected findings: -Move without discomfort, hesitancy, obstruction, or crepitation -Symmetrical joint/joint movement •Unexpected findings: -_________ROM, deformity, _______________, or pain,

demonstrate coordinated, smooth, ROM limited, asymmetry

a red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates.

dermatitis

•What are things we need to consider before moving a patient?

determine amount of assistance required (more people, equipment -- MAT level), client body weight & height, level of cooperation, health-related conditions/equipment

Occurs after a drug has been injected or absorbed into the bloodstream •The drug molecules are transported throughout the body to where they take action

distribution

draw toes upward toward the body

dorsiflexion

What do you need to know when administering medication? •The medication -___,______, Frequency, -______ Effects -Nursing indications - What to ______ the patient about this medication •Is it ____________ to give to this patient? -Look at labs, VS, assessment, whole picture •When was the _____ ________ they received this medication? (especially for PRN meds) •Patient's ___________* - do they want/know this medication?

dose, route side teach appropriate last time consent

Known as a bruise, also result from bleeding

ecchymosis

peripheral vascular assessment •Inspect symmetry, size, color, presence of lesions, varicosities (verbalized) Inspect/palpate pretibial __________ •Palpate skin for _______________ and moisture (bilateral) • Palpate pulses (carotid, radial, brachial, posterior tibial, and dorsalis pedis) • ________ ___________-upper and lower extremities

edema temperature capillary refill

muscle testing MSK •Expected findings: -Maintain the position of the joint against resistance -_______exertion/strength on both sides -> grade ___ •Unexpected findings: -Muscle grade ___ or < -Discomfort -_________ muscle testing

equal 3 3 unequal

health promotion for MSK •_____________: Focus on reducing stress & eliminating injuries r/t overuse of muscles, repetitive movements, and poor posture & lifting techniques -*maintaining body alignment w/ movement & when lifting •Injury prevention -Basic safety precautions •Exercise -Improves muscle _________, reduces bone ____, and promotes joint _______ -Wear supportive shoes when exercising •__________ and Vitamin ___ intake -Essential mineral needed to build & maintain bone mass -Calcium rich foods??? -Vitamin D foods + sunlight

ergonomics strength, loss, ROM calcium, D

Intense redness of the skin due to excess blood in the dilated superficial capillaries

erythema

turn outward

eversion

•How frequently do we change a patient's position in bed?

every 2 hours

•The process of removing a drug or its metabolites from the body is _______________ •Primary organ = ______________ •Very important to know if person has impaired ____________*** •Lungs excrete inhaled medications

excretion kidneys kidneys

•Parts of medication order - all must be _______________ stated to avoid med errors 1.Patient ______, ______, MR# 2_____ AND _______ of order is written 3.__________ of Drug to be administered 4._______of drug 5.________ 6.____________ of drug to be administered 7.____________ of prescribing provider •Ambiguous orders are NOT acceptable and you must seek clarification

explicitly name, DOB date, time name dose route frequency signature

straighten the limb

extension

shoulders and upper extremities Inspect •Compare side to side Palpate •Muscles should feel ____ & full •Muscles relaxed, _____________ •Expected variation -Muscle slightly less dominate in non-dominate arm •Unexpected -___________, heat, __________ w/ palpation -Atrophy -Dislocation ROM •Arms, Elbows - flexion, extension •Arms - hyperextension •Arms - internal, external rotation •Arms - abduction, adduction •Elbow - supination & pronation Muscle strength

firm symmetrical swelling, tenderness

a loss in the curvature to the spine referred to as straight back.

flat back

bend; reduces the angle between the bones

flexion

break or disruption of the integrity of the bone

fracture

perineal care •Perineum is area between tail bone & pubic arch -Females - between anus & vulva -Males - scrotum & anus •For females - wipe from ______ to _______ •For males uncircumcised - pull foreskin ______, clean skin ___________, and replace foreskin to ________ position •DAILY urinary catheter care -First clean __________ area, then clean ___________, then the _________

front, back back, underneath, natural perineal, urethra, catheter

Assistive Devices for Ambulation Ø_____ _________ ØCane -Top of cane should be level with inside of the wrist, elbow bent at ___-___degree angle - Cane on _______ side -Supporting weight on the stronger leg and the cane, the patient moves _________ foot forward parallel with the cane. Supporting weight on the weaker leg and the cane, the patient brings the stronger leg forward to finish the step. ØWalker -Top of walker level with wrist, elbows should be bent at ____-degree -angle -Patient lift the walker (without wheels) ahead of themselves and step into it - usually patient will place one leg into the walker, keeping walker still. Then step forward with the remaining leg into the walker, keeping walker still. Repeat by moving walker forward ØWheelchair -When putting pt into wheelchair, foot rests are ____& brakes on ____________!!! Consider angling wheelchair to bed -Once pt is in wheelchair, place pt's feet on foot rests; don't let pt's feet dangle or force them to hold them up ØCrutches -Must be able to use ________ body strength -Crutch pads rest __-__ inches below axilla -Hand grips level with hips -Elbows at 15- to 30-degree bend when holding grips -Body weight supported by _________ on the grip, NOT the ______ -> leads to _______ damage

gait belt 15-30 strong weaker 15 up locked upper 1-2 hands axilla nerve

Needles - need to select appropriate: •________ (diameter of the needle) -Range from ___g-___g •The smaller the number, the __________ the gauge •Needle length -Range from ____ inches to ____ inches

gauge 18-30 bigger 1/2-1 1/2

The use of drugs or inhalants to depress the central nervous system. ex: unconscious

general anesthesia

name assigned by the manufacture that first develops the drug; usually identifies the drug's active ingredient; universally accepted •EX: Ibuprofen

generic name

amount of time it takes for 50% of serum concentration of drug to eliminated from the body

half-life

balance -Center of gravity is the central point of weight for an object or the body -Imaginary ____________ line just below the umbilicus -Shifts as the person changes positions ØEx: when a person bends their legs or leans over, the center of gravity lowers the balance and keep the body from falling over -Creating a wide base by spreading the feet __________ width apart and _________ the knees improves stability and __________

horizontal shoulder flexing balance

***occasionally a nurse may decide to forego ____________ because patient's need for undisturbed rest may be a higher priority***

hygiene

An abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual patient.

idiosyncratic effect

skin integrity •Can become compromised when skin becomes irritated and inflamed, or when skin barrier is open form a cut or tear •Changes in skin integrity increase risk of _________, loss of arm or leg, and death •Washing skin regularly keeps it healthy by removing ____, dead skin cells, and bacteria that might cause skin breakdown •______ ________ is recommended (as fewer chemicals that might irritate the skin) •Clean skin around hips, genitals, buttocks, and perineum with ____ balanced cleansers to decrease skin irritation & dryness

infection mild soap pH

common cause of erythema

inflammation, bed rest

A client's full understanding and choice to have a treatment or procedure, including the risks involved, benefits, and other alternatives available, as well as the benefits and risks in-lieu of having the treatment or procedure. The client must be aware of what the treatment or procedure is, who will perform the treatment or procedure, the purpose, and expected outcome

informed consent

osteoarthritis •OA is characterized by hard, __________, _______________nodules, 2 to 3 mm or more •_____________ joint involvement (commonly affecting hands, knees, hips, and lumbar) •Joint stiffness, pain with ____________ •These osteophytes (bony overgrowths) of the distal interphalangeal joints are called __________ _________ •Those of the proximal interphalangeal joints are called ____________nodes and are less common

noninflammatory, nontender asymmetric movement Heberden nodes Bouchard

stages of pressure injury ØStage 1. _________ skin, _____________ redness/no maroon or purplish discoloration. ØStage 2. ____________________ skin loss: a pink/red wound bed that is moist and viable; may include a ruptured or intact serum-filled blister. ØStage 3. ____________________ skin loss: ___________ and granulation tissue can be seen in the ulcer. ØStage 4. __________________ loss of skin and tissue: fascia, muscle, ligaments, cartilage, or ________ are exposed. Øunstagebale pressure injury: _____________ full-thickness skin and tissue loss (wound covered in__________ or ___________) ØDeep tissue pressure injury: typically happens in ______________ confused w stage 1

intact, nonblanchable partial-thickness full-thickness, adipose full-thickness, bone obscured, slough, eschar non-bony prominences

skin assessment •_______________with other assessments or could be conducted as a stand-alone focused clinical visit (i.e., concerned about a skin condition) •Inspect for ___________, texture, ___________, & integrity •Palpate for texture, moisture, __________, mobility, & ____________ •Health promotion about skin & nail care, prevention of skin __________

integrated color, moisture temperature, turgor cancer

The time period from which clients are moved onto the bed in the OR to transfer to the recovery or post anesthesia care unit.

intraoperative phase

turn inward

inversion

•removes surface materials & decreases bacterial levels in wound; usually use NS

irrigation

Increase in bilirubin in the blood causing a yellow color in the skin

jaundice

Head and Neck Inspect •Open & close mouth to assess mvmt of ___ •Observe neck & vertebrae alignment •Expected variations: ___________ Palpation •_______ - ask client to open & close jaw •Stand behind client to palpate vertebrae in neck (flex neck forward, placing chin to chest), look for alignment •Expected: neck _______ (full, firm) •Expected variation: _________ in jaw (but not painful) ROM •Jaw - lateral & protrusion •Neck - flexion, extension, hyperextension •Neck - lateral flexion •Head - rotation Muscle strength •Repeat ROM, but now apply ___________ with your hand

jaw kyphosis TMJ supple clicking resistance

effects of decreased mobility Joints -Immobility leads to changes in tissue tension, elasticity, and shape, leading to ____ _____________ & decreased ______ -Joint ________________ - abnormal fixations of the joints that occur as a result of changes to muscles & connective tissue -______ _______ - type of joint contracture that results in a partial or total inability to pull the toes up toward the head (foot is left arched with toes point in a downward or dropped position)

joint stiffness, ROM contractures foot drop

CV and PV assessment Neck Vessels: Inspection •Inspect ____ _______ & ________ ______ -From JV you can assess CVP and judge heart's efficiency as a pump •Inspect for JVD -JVD = jugular vein distention -Position patient supine anywhere from 30-45-degree angle -Remove the _____ to avoid flexing the neck -Turn the person's head slightly away from the examined side and -Direct a strong ________ tangentially onto the neck to highlight pulsations and shadows -Should be able to see carotid artery pulsing & no jugular vein distention

jugular vein and carotid arteries bounding pillow light

Provider's role in Informed Consent 1. Giving the client __________ about the procedure, 2. Educating the client on the __________ for the procedure, _____ will be present during the procedure, the risks, and the potential benefits of the treatment and the procedure

knowledge reason, who

upper back is abnormally rounded with a forward tilt in the pelvis.

kyphosis

acute wounds Traumatic •_________ - caused by blunt or sharp objects •____ ______ - typically caused by mechanical forces such as removing tape from skin Surgical Wounds •Often closed with _________, _________ or surgical skin adhesive -Staples, sutures usually removed ___-___ days postop •Should be intact, ____-____________ edges •Color: 1-4 days = ____; 5-14 days = ____ _______; day 15-1y = ____ _____ •____________ - should decrease each day & resolve by postop day 5 -_____________________ -> serous exudate •Scar tissue - white, silver; pale pink to darker than skin tone (all mean healing well) MASD (moisture-associated skin damage) •Form of ____________ that develops when skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates •Excessive sweating, increased skin temp, abnormal skin pH, deep skin folds predispose MASD -occurs in _________ fold and _______ area where moisture builds up

lacerations skin tears staples, sutures 10-14 well-approximated red, bright pink, pale pink exudate serosanguineous dermatitis abdominal, groin

nurses are the _________ line of defense for the patients. We MUST be able to stop medication ____________! Do not ever think you are to just administer a medication without understanding ______ and determining if it is appropriate for YOUR patient.

last errors WHY

•There are also different forms of medication within the vials -Most vials contain the _______ form of the medicine -Others contain medication powder •This requires you to ______________ the medication, usually with normal saline, sterile water, or bacteriostatic water •The vial will include instructions on how to reconstitute

liquid reconstitute

common cause of jaundice

liver dysfunction

Prevents conduction of pain impulses by affecting both the motor and sensory nerves at the surgical site. ex: lidocaine in one area

local anesthesia

documenting pressure injuries •___________, stage, size •Description of tissue •________ of wound bed •Condition of _______________ tissue •Appearance of wound ______ •Presence of undermining and _____________ •Any foul ______ present •Presence & characteristic of wound ____________, if present •Any ______ associated with wound

location color surrounding edges tunneling odor drainage pain

lower back significantly curves inward with the pelvis tilting anteriorly.

lordosis

medication administered by a route that does not involve the GI tract. usually refers to an injection and is administered by a needle such as IV or IM

parenteral medication

eye medication •Administered on the _______ ___________ ____ and not directly on eyeball -Pull down bottom eyelids with your gloved fingers, instruct pt to look ___, instill one drop at a time -Instruct pt to close eyes gently and apply slight pressure to inner ____________ to prevent drops flowing to _________ _________ •Eye ointment - apply ½" (usually) to lower conjunctival sac, instruct pt to keep eyes __________ and move eye to spread ointment under the lids and eyeball; encourage pt not to_______ eye

lower conjunctival sac up canthus tear duct closed rub

irritation of epidermis caused by moisture

maceration

venous ulcer •Usually located at the _________ __________ or lateral aspect of ankle •____________ or flat wound border •Ulcer wound is ______ in color •Ankle or leg _________ •Discoloration of ankle -Usually _______-________ pigmentation •Dull ache or heaviness in ankle; ulcer often ________ •Pedal pulses __________ •______ skin temperature usually •__________ veins present usually

medial malleolus irregular pink edema brown-bronze painful present warm varicose

comparing the current list of medications a patients has, with the new medication ordered (i.e., antibiotics, BP meds from illness in hospital) to prevent duplicates, interactions, or omissions

medication reconciliation

•The change of an active drug from its original form to an inactivated or new form is _____________ of the drug •__________ is the primary site -Aging, liver disease, other meds affecting the liver can influence medication metabolism •Other sites include Kidneys, GI tract, Lungs

metabolism liver

____________: Another way to say motion or movement. -Our bodies are designed for motion and require the muscles, skeleton, and nerves to function in unison. -A nursing goal is to assist in ____________, ___________, and __________as much _________ and function as possible. -The ability to walk from place to place independently is __________

mobility preserving, maintaining, restoring mobility ambulation

Permits the client to remain relaxed and calm so they can follow commands without pain or anxiety. ex: temp knockout to put bones in place

moderate or conscious sedation

wound dressings •Basic wound principles: for healing to occur, need to have a __________(not wet) wound bed •Clean vs Sterile dressings -First 24-48 hours postop-> ______ -After -> ______ •Dry vs Wet dressings -Depends on _______ __________ & provider preference •Open -Gauze moistened with NS (AKA ____ to ____ dressing) -Rarely used anymore •Semi-open -3 layers - ______________+_____________+________________

moist sterile clean wound type wet to dry gauze infused w/ ointment + absorbent pad + adhesive layer

how would you assess erythema with dark skin tones?

more purplish, and warm, darker skin tone

nursing interventions for mobility -If client on BR - encourage __________ of extremities often, sitting client with legs ____________ from bed -Encourage ______________ -Teach and promote _________ __________ activities (walking) -Safety!!! Protect clients from falls and injuries -Use splints to support & strength joints if joint contractures present

movement, dangling ambulation weight-bearing

where would you assess cyanosis in dark skin clients?

mucous membranes, nail beds

intramuscular injections •Administered into _________ •Faster absorption and onset than _______ •Gauge will depend on type of med you are giving; thinner/aqueous solutions _____g; thicker/oil-based solutions _____g

muscle SC 20-25 18-25

functions of a muscle M: ______________ C: _____________ and P: _____ ___ G:_____________ M: _____________

muscles contract and pull to generate movement

documenting med admin •What do you document? -Drug _____, ______, _______, _________ given -Sometimes will include the SITE med given -Your _________ -May need __________ on highly regulated meds -______________ to medication!!!! •Must document if pt __________ medication -Best practice to document _____________ -When you informed the provider & any plan/orders given •Document when _____ hold medication -Document HCP conversation/new orders, etc.

name, dose, route, time initials co-sign Reaction refuses conversation Hold

the nurse must know: •Drug _______ •Drug _______________ •___________ effects •How to ____________ the drugs •Typical ___________ of medication safe to administer •What to ____________ the patient about the drug •How to properly ___________ the medication

names classification adverse prepare amount educate administer

proper positioning ØInvolves aligning the body in a _________ position, supporting the body's natural _________, and eliminating pressure _________, hyperextension, or lateral ___________. ØGoals for client positioning and alignment consist of the two Ps, ____________ and ____________

neutral curves points rotation promotion prevention

Moles (__________) •A clump of melanocytes, tan-to-brown color, flat, or raised •Acquired nevi have symmetry, small size (___mm or less), smooth borders, and single uniform pigmentation •Warning signs for malignancy: ABCDEF •A____________ •B__________ ____________ •C________ _________________ •D_____________ greater than _________ •E____________ •F__________ ________________

nevus 6 asymmetry border irregularity color variation diameter, 6 mm elevation funny looking

Skin redness is usually referred to as blanchable or non-blanchable erythema. _________________ erythema is redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin.

non-blanchable

feet •Performed daily, cleaned with soap & water if using traditional bath •Do _____ soak feet •Important to completely ______ feet afterwards •Apply lotion to feet, especially on heels, but avoid placing between the _____ •Trim toenails if needed - trim __________ across, filing the edges •Special care taken for client's with diabetes and other conditions that may impair peripheral circulation

not dry toes straight

Describe how to make an occupied bed vs unoccupied bed: OCCUPIED BED •Safety first!!! -Put side rails up on the side you are ____ standing on; pt will usually hold onto this for help -Adjust bed height to ___________ height -HOB ______________ unless contraindicated •You'll take off ____ of the dirty sheets, rolling ____________ pt, making the bed with clean fitted sheet on the side you're standing on •You'll then roll the patient gently over the pile of sheets, taking off the _________ and then finish making the bed with the rest of the clean sheets.

not working lowered half, underneath dirty

CV and PV assessment Neck Vessels: Palpation •Palpate carotid arteries -Gently palpate each artery medial to sternomastoid in neck -Palpate only _______ carotid artery at a time to avoid compromising blood to brain -Feel contour and amplitude of pulse -Findings should be same bilaterally -Unexpected finding = full, ___________ pulse ->indicative of fluid ___________; diminished or weak pulse-> narrowing or ___________ -"swooshing" sound or turbulent BF ->_________

one bounding overload, blockage bruit

NO MED CAN BE GIVEN WITHOUT AN ________ •Usually orders are typed, but can be written or verbalized •NOTE: NURSING STUDENTS ALONE ARE NOT ALLOWED TO ACCEPT __________ ORDERS FROM HCP (need RN with you)

order verbal

effects of decreased mobility in CV ___________ ____________ -A decrease in systolic BP of 20 mmHg or more OR -A decrease in diastolic BP of 10 mmHg or more within 3 mins of changing to a sitting or standing position -Encourage client to change positions _________ ______: Increased risk of forming d/t increased blood viscosity & atrophy of muscles that normally pump the blood -Antiembolism stockings/socks to decrease venous pooling -Sequential Compression Device (SCDs) to promote venous return -Leg exercises in bed to promote contraction of the LE muscles & venous return -___________ client frequently, when able -Encourage ________ intake -May be prescribed anticoagulants

orthostatic hypotension slowly DVT ambulate fluid

Absence of red-pink tones from the oxygenated hemoglobin in blood

pallor

•If someone has a sluggish capillary refill, what other signs and symptoms might you expect? What can cause these signs and symptoms?

pallor, decreased sensations

how would you assess jaundice with dark skin tones?

palms and soles

________ ___________Defined as maintaining a minimal level of personal cleanliness and grooming •Promote physical & psychological well-being •Include bathing and care of skin and specific body areas, including oral cavity, eyes, ears, nose, hair, nails, feet, and perineal & vaginal areas •Vary widely among people!! •As nurses we must: 1.Respect ____________ ________________ 2.Provide only the care the patients __________

personal hygiene individual preferences cannot

______________ is What the drug does to the body •Therapeutic effect •Side effects •Adverse drug reactions •Allergic effect (& anaphylaxis) •Drug Tolerance •Toxic effect •Drug interactions (other medication, food, drink, dietary supp. or other substances)

pharmacodyanmics

Effect the body has on a drug once the drug enters the body is __________________ 1. ____________ 2. ___________ 3. _____________ 4. ______________

pharmacokinetics ABSORPTION •DISTRIBUTION •METABOLISM •EXCRETION

Inspection for MSK assessment •Ask if there are any painful areas •Ask if client is feelings of "_____ and __________" or burning sensation (indicative of _______ involvement) •Inspect joints, muscles, and bone structure for: -_________ -__________ -Alignment -ROM -Presence of deformities or ___________ •Observe client's _______ for balance and symmetry with movement

pins, needle, neuro size symmetry inflammation gait

Why are we worried about a history of smoking and alcohol use in preop?

places increased risk of complications

point toes downward away from the body

plantar flexion

Final phase immediately after surgery. This period can be brief, lasting only a few hours, or include rehabilitation and recuperation.

postoperative phase

___________ ____________ for clients can be extensive. The goal preop is to prepare and inform them of what to expect _____ and ______ surgery.

preop teaching before, after

_________ ____________ should include the need for splinting surgical incisions to decrease pain and prevent __________ (the opening of a surgical wound either internally or externally).

preop teaching dehiscence

Initial phase of care before surgery where both physical and psychological preparations are made for clients based on their individual needs; starts when client decides to have surgery

preoperative phase

localized damage to the skin and/or the soft underlying tissue, which can be caused by prolonged contact with a form surface that interferes with circulation to the area

pressure injuries

ØA mobility assessment should be performed ________ to initially mobilizing client & repeated every 24 hours ØStandardized mobility assessment tool (MAT) - objectively determine a client's mobility level -4 levels 1=_________ assistance: cannot bear weight or maintain __________ position 2=______________ assistance: can maintain seated position, lacks lower ext. strength 3=______________ assistance: can rise from seated position & stand steady; use _____ ______and ambulation devices as needed 4=______ assistance

prior maximum, seated moderate minimal, gait belt no

Ambulation!!! ØImproves muscle & joint strength ØPrevents complications of immobility ØDecreases client's LOS in hospital ØPromotes well-being & independence ØAssess mobility ________ to ambulating ØIf orthostatic hypotension is present, will instruct client to change positions slowly, waiting a few mins with each position change & dangle feet Ø_____-______ socks! Ø___________room - nothing blocking client's path to walk

prior non-skid declutter

•What are compression socks? SCDs?

promote venous return

turning to face backwards

pronation

_________:Lying flat on abdomen with head turned to one side ØAllows for full extension of hip & knee joints to prevent contractures ØPromotes __________ of secretions _________ or dorsal recumbent: Lying flat on back, possibly with knees bent ØEnables visualization of client for examination __________ position: Semi-seated or reclined position w/ HOB at ____-degree angle ØSemi-Fowler's = HOB at ___-___ degrees ØHigh-Fowler's = HOB elevated ___-___ degrees Trendelenburg: Lying flat on back with FOOT of bed _________ the head of bed ØPromotes _________return ØPromotes drainage of lower lobes of the lungs Reverse Trendelenburg: Foot of bed ________ than HOB

prone drainage supine fowler's, 45 15-30 45-90 above venous below

nursing considerations for MSK •Assess for pulses, sensation, cap refill in surrounding extremities •For musculoskeletal injury: Think PRICE -__________ -_______ -____ or intermittent cold therapy -________ -___________

protect rest ice compression elevate

why do you need SPF?

protect skin

cardiovascular assessment •Inspect chest wall movement and precordium for __________, heaves or lifts • Inspect for __________ and bounding __________ pulse • Auscultate rate and rhythm for APETM (using bell and diaphragm) • __________ pulse auscultated for 1 minute • Describe sounds heard (S1 and S2 and/or S3 and S4, murmur)

pulsations JVD, carotid apical

green/yellow wound drainage

purulent

med supply systems •Where you will go to dispense medication •Many hospitals use "______" •Locked rooms on units •Must have badge & code to access •Find patient's name/ID, select medication •*where you will complete the _____ _______ ______*

pyxis first medication check

Women signs of MI

really fatigue, upper or lower back pain, right sided arm pain for MI

Causes a temporary loss of feeling in an area of the body. ex: epidural in spine

regional anesthesia

Once bones have matured, they undergo the process of ______________where old bone is constantly being replaced with new bone.

remodeling

promoting skin integrity and healing •Prevention •_________________ & early mobilization •Hygiene •Hydration •Plenty of fluid intake to assist in eliminating waste from body •Nutrition -___________, omega-3 & 6 FA, vitamins ___ and ____, & zinc -High __________, high __________, fortified foods & supplements should be offered

repositioning protein, a,c calorie, protein

side-to-side

rotation

___________ or ____________ medications are ordered for a specific time or frequency; i.e.. daily, twice a day, etc

routine or standing

•bloody wound drainage

sanguineous drainage

how would you assess jaundice in lighter skin tones?

sclera, hard palate

C- or S-shaping of the spine.

scoliosis

The ______ nurse may also function as the ___________ nurse is responsible for ensuring utensils used during surgery are sterile and ready for use. Handing the equipment or tools to the surgeon is also a task of the scrub nurse.

scrub, instrument

thin, watery wound drainage mixed with blood

seroanguineous

thin, watery wound drainage

serous

hands Inspect •Note _____ of bones, joints, muscles •Should be _____________ •Unexpected finding: presence of ___________ or nodules on joints; ___________ deviation; any limitation to movement or asymmetry Palpate •Each joint, noting any swelling, _________, tenderness, ___________ •Joints should be ___________, symmetrical, no swelling/lumps/nodules ROM •Wrist - flexion, extension, hyperextension •Fingers - flexion, extension, abd, add •Thumb - flexion, extension, abd, opposition •Muscles strength

shape symmetrical swelling, ulnar masses, temperature smooth

topical medication •Skin, mm, eyes, ears, nose, rectum, vagina, and lungs - acts directly at site •Topical med should NOT be _________ •Meds to skin - usually _____________ -Clean skin before admin, helps _______________ -Must wear gloves when admin ointments, otherwise could be absorbing ______________ •___________________ patches - contains medicine intended to be released throughout the day -Common for hormone, narcotic, nitro, nicotine -Must remove ______ patch before replacing with _____ patch** easy to miss - make it a habit

shared ointments absorption medicine transdermal OLD, NEW

an unwanted physical or mental effect caused by a drug

side effect

Nurse's Role in Informed Consent 1. Verify the client or client's legal representative has _________the consent in their presence, is legal _____, and ____________ 2. Responsible for confirming the client has adequate ____________ to make a decision

signed, age, competent information

at-risk vulnerable skin

skin frailty

•When assisting in hygiene activities, nurse should use this time to inspect skin and ____ ____________

skin integrity

loss of top skin layer caused by mechanical forces. the severity of a skin tear is defined by the depth of the skin layer loss

skin tears

skin texture and moisture Skin should be _________ & uniformly _____ Expected variations •Amount of oil on skin -___________: dry skin - ___________: oily skin •Acne •Wrinkles •Scars; stretch marks; keloid Unexpected findings •___________ skin (___________disease) •Roughness, dryness, flakiness (thyroid disease or dehydration) •Diaphoresis

smooth, dry xerosis seborrhea velvety, thyroid

JCO developed; NPSG ______ _______ ØEnsures that the correct surgical procedure is performed on the correct _____ & correct ____ ØInvolves client & surgical team ØIncludes standardized forms ØMarking surgical site by surgeon ____-___ ØPerformed at regular intervals, usually by circulating nurse ØTeam must agree that the identity of ______, surgical _____, and _________ are correct

speak up pt, site time-out pt, site, procedure

injury to ligaments & tendons that support a join resulting from a twisting motion or hyperextension of the joint

sprain

ankles and feet Inspect •While ___________ & sitting/laying Palpate •________ of ankle, heel & foot should feel smooth & firm ROM •________ __________: toes pointed down •________________: toes pointed up •Eversion, inversion •Extension, flexion, hyperextension Muscle strength

standing bones plantar flexion dorsiflexion

linen changes OCCUPIED BED •Safety first!!! •Put side rails up on the side you are not _______on; pt will usually hold onto this for help •Adjust bed height to working height •HOB _________ unless contraindicated •You'll take off half of the ______ sheets, rolling _________ pt, making the bed with ____ fitted sheet on the side you're standing on •You'll then roll the patient gently over the pile of sheets, taking off the _____ and then finish making the bed with the rest of the _____ sheets

standing lowered dirty, underneath, clean dirty, clean

injury to muscle or tendon, usually result of overuse or excessive stress

strain

muscle testing for MSK •Testing the __________ of the muscle group associated with that particular joint •*Perform ROM and apply opposing __________ •Should be able to maintain position against resistance bilaterally •Muscle grading scale: -Grade 5: _____ ROM against gravity, ____ resistance -Grade 4: ____ ROM against gravity, ______ resistance -Grade 3: _____ ROM with gravity -Grade 2: Full ROM with gravity _________ (_________) -Grade 1: __________ contraction -Grade 0: ______ contraction

strength force full, full full, some full eliminated (passive) slight no

•Insulin is usually given _______________ •Insulin requires an insulin syringe -_________ cap -Measures ___________ -Not used for any other med •Insulin pens

subcutaneously orange units

•Heparin & Lovenox are usually admin _________________ •Comes ____________ •Contains air bubble - do NOT _______ -Intended to help push all medication to the subcutaneous level and from the syringe so none of the medication seeps into subdermal area, which tends to burn

subcutaneously in abdomen prefilled expel

Risk factors for Melanoma: •____________, indoor _______ _________, family h/o melanoma, presence of atypical or numerous _______ •Increased risk for persons that _____ easily or have natural red or blond hair •Advancing age increases risk d/t accumulation of DNA damage over time •95% of skin melanomas are attributable to _____ radiation exposure •Using _______ _____ has a 23% increased risk of developing melanoma

sunlight, tanning beds, moles burn UV tanning bed

turning to face forward

supination

Respiratory System Effects of immobility ØReduces the amount of air exchanged & increases risk of infection Ø___________ positioning impairs ability of the ribcage to freely expand, shifts abd organs toward diaphragm (decreases the depth of breaths & effectiveness of cough) Ø_______________ (partial or complete collapse of lung); decreases number of alveoli available for gas exchange Ø____________ - usually as a result of shallow breathing, thickened mucus, & decreased ability to cough Nursing interventions ØMonitor _________ levels, RR, lung sounds -Supplemental O2 when needed Ø__________ HOB ØUse of incentive spirometer ØDeep breathing & cough exercises ØTurn & reposition client every___ hours

supine atelectasis pneumonia SpO2 elevate 2

attire for OR

surgical cap, gown, mask, gloves, shoe covers

________ _____________ - accumulated debris (also called _________) and dead tissue are removed with a scalpel or scissors. Debridement decreases the number of bacteria in the wound and stimulates the rebuilding of the wound bed by contraction and epithelialization.

surgical debridement, biofilm

the back extends backward while the lower back abnormally curves inward and the pelvis tilts forward, positioning the head in front of the pelvis; results from loss of muscle tone in the abdomen and lower back, which allows the spine to sag.

sway back

rheumatoid arthritis •__________ and bilateral joint involvement •Heat, redness, swelling, painful & limited motion of affected joints •Worse in ____, better with __________ vs rest •___________ and _____________deformity •________deviation or drift

symmetric AM, movement Swan-Neck & Boutonniere ulnar

CV and PV assessment Anterior Chest: Inspection •Chest ___________ on inhale & exhale •Pulsations: you may or may not see ______ _________, pulsation created as left ventricle rotates against chest wall during systole -When visible, it occupies the fourth or fifth intercostal space, at or inside midclavicular line -Easier to see in children and in those with thinner chest walls •Unexpected findings: Lift or _________ at the sternal border (visual prominent, forceful thrusting)

symmetry apical impulse heave

MSK assessment •Assess for __________ on both sides of body •___________ joints when assessing -Take extra care when swollen, red, painful •Use __________ movement when manipulating joints & always ________ joint to a neutral position of comfort for the client -Avoid rapid, ___________ movements

symmetry support gentle, return jerky

PV and extremities assessment: Inspection •Inspect upper & lower extremities -Note overall skin tone & _________ of size of limbs -Inspect hair & skin texture -Inspect hair distribution or presence of _________ -Inspect _____________ to determine color & shape of nail bed -Expected = __________ size, intact skin, even coloring & hair distribution; nail curvature is slightly curved of 160 degrees -Unexpected = __________, presence of _________, pallor or darker tone skin; lack of hair, thin, shiny skin; presence of ulcers; dilated or twisted veins (___________ veins); pale or blue-tinged skin; swelling or ________of nails

symmetry ulcers fingernails symmetrical asymmetrical edema varicose clubbing

PV and extremities assessment: Palpation •Skin for ____________, texture, turgor, _____________ •_____ _________ •___________ •Peripheral __________ -Note rate, rhythm, strength •Strength grading: 0 = _________ +1 = _____, thread, diminished +2 = ________, ________ (EXPECTED) +3 = Increased, ___________ +4 = ___________, full volume

temperature, moisture cap refill edema pulses absent weak normal, brisk strong bounding

arterial ulcer •Usually located at the end of _______ •regular, _____ wound border •Ulcer wound is ______ or black eschar •Foot is ______ in temperature •Hair ______ noted on legs, feet, toes •________ _____________ or rest pain often reported in foot; ulcer may/may not be painful •Nails thickened; brittle •Skin color - DEPENDENT ______, ELEVATION _______ •Skin texture - thin, _______, taut skin •__3 seconds cap refill •Pedal pulses ________

toes even pale cold intermittent claudication rubor, pallor shiny > absent

•selected by the pharmaceutical company that sells the med; protected by trademark •EX: Advil, Motrin, NeoProfen

trade (brand) name

point when the drug is at its lowest concentration, which indicates elimination; drawn 30-mins before next dose is scheduled to be admin

trough level

gout •Common chronic arthritis characterized by excess_____ ____in the blood and deposits of urate crystals in the joint space (usually in the ___ toe & ears) •Episodes are characterized by redness, swelling, heat, and extreme pain such as a continuous throbbing •Increased prevalence is caused by increases in obesity, metabolic syndrome, and diuretic use

uric acid big

Type of skin lesions •______________(result from blood leaking from BV to dermis) -______________: small tiny bleeding under skin -________________: bigger version of petechiae -Ecchymosis: bruising under skin •___________ (result of specific triggering agent which cases a change to previously intact skin) •_____________(evolved from their original state as a primary lesion; passage of time changes their characteristics)

vascular petechiae purpura primary secondary

Aching tired feeling in the calf after prolonged standing

venous

Brown discoloration to the skin of the lower legs

venous

Pain that improves with the elevation of the extremity

venous

IM injection sites •__________gluteal, _________ ___________, and __________ -Deltoid recommended when admin vaccines to ________ •IM injections to deltoid should be limited to __mL; anything >1mL should be admin somewhere else -_______________ recommended for general IM injection in adults

ventrogluteal, vastas lateralis, deltoid adults 1 ventrogluteal

RN's role in medication administration -___________ order (is it appropriate for this patient?) -______________patient about medication -_____________ medication

verifies educates administers

ØThe nurse's role is to ________ and __________ that the client or representative has signed the consent in their presence, is of legal _____, and is ____________ ØAlso responsible for giving the client knowledge about the procedure ØClient must give consent ____________without coercion & given the opportunity to ask questions

verify, witness age, competent voluntarily

body alignment -Positioning of the various parts of the body while performing activities -Good body alignment is determined based on an imaginary line that passes _______ through the body and divides it into two equal halves -When handling clients or lifting objects, keep back __________, chin _______, and tighten__________ muscles throughout task

vertically straight level abdominal

vaginal medication •Usually in the form of creams, foams and tablets •Ask pt to _____ prior to admin •Perform _____________ •Maintain privacy during admin

void pericare

PV and extremities assessment Expected findings •Skin temp _________, consistent bilaterally •Skin smooth, dry, intact, no _________ •Cap refill <___secs •Pulses ____________, regular, equal bilat, and ___+ amplitude Unexpected findings •Excessively ___ or _____ skin temp •Rough or scaly skin texture •Lack of body hair •_________ of skin when testing skin turgor •Cap refill >___ secs •Skin is ______, diaphoretic •Pulses _______, weak, bounding, or asymmetrical •Any _________ present in lower extremities or ankles •Assess for ______ _____(indention left after pressing down on skin for __-___ seconds)

warm edema 2 palpable, 2 hot, cold tenting 2 pale absent edema pitting edema, 3-5

•Ear care is very simple - ___ ____________, wiping __________ of ear •Nothing should go ___________ a client's ear •If client uses hearing aids, be sure to clean & return to client

warm washcloth, outside inside

what do you palpate for in the MSK. assessment?

warmness, tenderness, muscle tone, and crepitus

3 key principles of body mechanics

ØBody alignment ØBalance ØBody movement

•What are proper body mechanics?

ØEnsure client or object that you are handling is CLOSE to your body as possible ØKeep abd muscles contracted & lower back in normal position ØMaintain head upright with shoulders raised up ØBow the hips slightly and squat ØPivot or side-step rather than twisting ØBend at the knees and use leg muscles when lifting; do not bend over with back

•What is mobility assessment? Which items can be included?

ØNormal mobility status ØAbility to sit, stand, walk ØUse or need for assistance ØDegree of mobility & immobility ØCondition of skin

nursing responsibilities during preop

ØPreop assessment ØClient teaching ØEnsuring informed consent has been obtained

Subcutaneous Route •Appropriate Needle Length: ______________________ •Appropriate Needle Gauge: _____________

•3/8", ½", 5/8", 1" •25g-30g

Intramuscular Route •Appropriate Needle Length:___________ •Appropriate Needle Gauge: ___________

•5/8"-1.5" •18g-25g

•Skin lesions (broad term) Make note of:

•Color •Height •Shape •Size •Location •Presence of drainage