Nursing 111 Test One
Personal Knowing refers to?
- One of Carper's four types of knowing - Based on Personal experience - Developed through personal reflection own your own thoughts, emotions, and actions. - ex. Being aware of your own talents and limitations
Commitment refers to?
- One of Roach's Six C's - A merging between one's desires and obligations. - ex. Following through with agreements
Comportment refers to?
- One of Roach's Six C's - Appropriate demeanor, dress, and language that represent caring. - ex. Wearing a clean uniform and using clean language.
Conscience refers to?
- One of Roach's Six C's - Awareness of personal responsibility and ethics. (An informed sense of right and wrong)
Confidence refers to?
- One of Roach's Six C's - Comfort with the abilities of yourself and others. - ex. Walking with purpose, maintaining eye contact.
Competence refers to?
- One of Roach's Six C's - Having the knowledge, skills, and experience to respond to professional responsibilities and succeed. - ex. Changing a dressing using clean technique
Compassion refers to?
- One of Roach's Six C's - Participation in the experience of another (sharing joy, sorrow, pain, etc.)
What are the two forms of glaucoma?
- Open-angle - Angle-closure
Maslow's Safety needs refers to?
- Physical and psychological aspects, such as bodily safety, financial security, and personal health. - ex. Transferring clients or assault by a client may lead to musculoskeletal injury.
Maslow developed five levels of needs. These five needs are?
- Physiological - Safety - Belonging and Love - Self-esteem - Self actualization
What lifestyle changes can be implemented in order to help prevent sensory loss?
- Quite smoking - Minimize UV light exposure - Monitor Medication use (Narcotics, sedatives, antidepressants) - Manage stress - Prevent isolation (infants and older adults) - Avoid Injury
What risk factors are associated with the development of glaucoma?
- Race (Blacks, Hispanics, Asians) - Family Hx - Long-term steroid use - Hx of eye injury
The sensory process is comprised of which two components?
- Reception - Perception
Where are the four types of cataracts?
- Secondary (results from Sx, Medications, or other eye Tx) - Traumatic - Congenital
Visual acuity can be assessed using which two charts?
- The Snellen (distance *20ft) and the Rosenbaum (near 12in)
What does the Caring encounter: Competence refer to?
- The ability of a nurse to effectively demonstrate a set of attributes, such as: - Personal characteristics - Professional attitude - Values - Knowledge and skills
What causes Open-angle glaucoma?
- The cause is unknown, but it is believed to be genetic
Maslow's Belonging and Love needs refers to?
- The establishment of a support network to help with coping and stress. - ex. Having staff or family members to talk to. *New nurses are often bullied by experienced nurses leading to a lack of belonging and adding additional stress to the work place.
What is Open-angle glaucoma?
- The most common form - It refers to a chronic obstruction at the trabecular meshwork that blocks aqueous humor flow and gradually increases IOP *occurs in both eyes
Maslow's Self-Actualization refers to?
- The need to make time for one's self in order to provide a healthy distraction from pressures of work. - ex. Pursuing activities that bring joy and stimulate creativity
Demographic Data
-age: you're not going to access an infant the same as a person in their 80s -race: certain diseases effect certain races -sex: males can develop diseases that women do not -ethnicicty
Critical Thinking Attitudes
-independent thinking -intellectual curiosity -intellectual humility -intellectual empathy -intellectual courage -intellectual perseverance -fair mindedness
When inspecting head, look for:
1. Normocephalic (normal head size) 2. exophthalmos (protrusion of eyeballs, may result from HTN)
What are the types of nursing interventions?
1. Nurse-initiated (actions performed by a nurse w/o an order) 2. Physician-initiated (actions initiated by a dr in response to med dx, but carried out by a nurse) 3. Collaborative (tx initiated by other providers and carried out by a nurse)
Assessment Activities
1. Observing 2. Interviewing 3. Examining Techniques
Inductive reasoning
Bottom up reasoning
What is health promotion dx
Clients motivation to increase well being by a readiness to enhance specific health behavior example: Readiness for enhanced family processes Example: immunizations
Actual nursing diagnosis
Diagnosis---A problem statement of actual signs and symptoms, an existing response to condition Actual nursing diagnosis labels client responses/symptoms as: Physical Sociocultural Psychological Spiritual Educational
3 COMPONENTS OF ACTUAL NURSING DIAGNOSIS
Diagnostic Label Etiology Defining Charachterists
What are the 3 parts of the Nursing Diagnosis?
Diagnostic Label (ONLY USE ONE) R/T AEB
Larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds
Diaphragm of stethoscope
S2 represents
Diastole
Arteriosclerosis
Elastic and muscular tissues replaced with fibrous tissue lose much of their ability to constrict and dikate
Action potential
Electrical impulse that stimulates muscle contraction produces the waveforms on ecg strips
High humidity oxygen
Fill with sterile water and hook to oxygen flow meter/measured and written in percentages
Creativity
Finding unique solutions to unique problems when traditional interventions are not effective
Objective Data
Findings directly observed or indirectly observed through measurements (ex. body temperature)
What part of the examiner's hand is used to feel for fine discriminations: pulses, texture, size, consistency, shape, and crepitus
Fingerpads
HOW DO YOU START A CONCEPT MAP? STEP #3
Focus on the areas of priority: In the example we were given it's pain & GI The map focuses on real nursing care based on assessment data that you have collected. The map DOES NOT focus in potential problems at this stage in the process.
HOW DO YOU START A CONCEPT MAP? STEP #7
IDENTIFY GOALS / OUTCOMES ID a goal/outcome for each nursing diagnosis. They have to be: Realistic Understandable Measurable Believable Attainable Timed Your goal has to match your focus area, diagnosis and assessment data. This goal needs to be a collaborative agreement with the patient. EX: Patient Goal: Patient will verbalize rationale for and sit in chair for a period of 20 minutes 2 times on my shift.
Abdomen bowel sounds:
Hypoactive: 1 sounds per min Hyperactive: q 3-4 seconds True absence of sounds: listen 3-5 minutes
Alterations of Gas exchange
Hypoxemia Hypoxia Hypercapnia Hypocapnia Upper Respiratory Infection (URI) Influenza Lower Respiratory infection Abnormalities
NURSING PROCESS = PROBLEM SOLVING STEP 4
IMPLEMENTATION OF PLAN We are going to do things to help him get better. Such as: Assess his lung sounds at least ever 4 hours. Maintain supplemental O2. Encourage PO fluids.
The primary purpose of the health history is to
Identify risk factors to the client and his or her significant others
Clinical Decision Making STEP 1
Identify the situation/problem and then decide WHAT DECISION NEEDS TO BE MADE? EX: Patient is having trouble breathing
If the Board finds that a nurse has committed an act of unprofessional conduct related to patient care, it may Issue a letter of concern Issue an administrative penalty Issue a decree of censure Withdraw the application
Issue a decree of censure
What are the steps or phases of the health history interview?
Introductory phase, working phase, summary and closing phase
neonates
Irregular respirations and < 15 second apneas are expected in neonates.
Older adults may experience this variation in blood pressure
Isolated systolic hypertension 140/90
Aware of Self-Limits
Know what you're capable of. Know your limits of intellect and experience. Know you don't know it all and seek knowledge to improve skills and education. EX: If we do a skill on a patient, yet don't know how to do it... we can do more harm than good. EX: If we are dead tired, and asked to stay for another shift, KNOW OUR LIMITS... GO HOME.
Personal Knowing
Knowing that refers to the nurses ongoing self-exploration and self-actualization.
KSA
Knowledge, skills, and attitudes
KSA for quality improvement
Knowledge: Acknowledge that healthcare professionals affect client results Skills: Examine root causes of sentinel (unanticipated) events Attitudes: Recognize the value of contributions to care outcomes
KSA for safety
Knowledge: Detail common safety factors as well as unsafe practices Skills: show how successful protocol implementation can increase safety Attitudes: Recognize the benefits of standardization toward safety; recognize the limits of personal performance.
KSA for informatics
Knowledge: Detail the benefits of information technology skills Skills: Use information technology systems to provide safer care Attitudes: Recognize the need for continuous information technology education during a healthcare career
KSA for teamwork and collaboration
Knowledge: Detail the roles of team members Skills: Fulfill your role as a team member; ask for help in appropriate situations Attitudes: Respect the views and skills of all team members; recognize the client and family as essential team members
KSA for evidence-based practice
Knowledge: Display familiarity with scientific methods and processes Skills: Take part in quantitation and research activities; develop client care based on client values and beliefs, professional expertise and research evidence Attitudes: Recognize the pros and cons of scientific research in practice; recognize the necessity for research to be ethical and responsible
Venti-Mask
MOST PRESICE AMOUNT OF OXYGEN/face mask with different colors of adaption pieces according to liters/mixes oxygen and room air
MRI and CT scans
MRI and CT scans show more detailed images of soft tissues. CT with injected contrast medium can help identify and locate vascular obstructions and abnormalities such as a pulmonary embolus
5 CONCEPTS RELATED TO CLINICAL DECISION MAKING
Managing Care, Accountability, Collaboration, Communication, Oxygenation MNEMONIC: MACCO
Clubbing
Means not circulating well
Arterial blood pressure
Measure of pressure exerted by blood as it flows thru arteries
What pitch do bronchovesicular sounds have?
Moderate pitch
tachypnea manifestations
More than 20 respirations per minute with client at rest Shallow respirations
oxygen delivery systems
Nasal cannula 1-6 L/min 24%-44% Oxymizer 1-6 L/min 24%-88% Vapotherm 1-40 L/min 24%-100% Face mask 5-10 L/min 30%-50% Nonrebreather 10-15 /min Greater than 60% Venturi mask Set with jet adapter for flow rate and FiO
Artificial airway
"Inabation"
Preceptor
"Mentor" in a clinical setting.
What is glaucoma?
- A condition characterized by optic neuropathy with gradual loss of peripheral vision and increased IOP
What is vertigo and what are some common causes?
- A feeling of rotation or imbalance - May be caused by strokes, tumors, trauma, viruses, or idiopathic
What does the Caring encounter: Empowerment, refer to?
- A process in which the client identifies their own needs, rather than being instructed. - Allowing the client to make decisions or perform task to their fullest capability, with minimal assistance from the nurse.
What does the Caring encounter: Nursing Presence, refer to?
- A situation in which the nurse acts as a guide for the clients decisions by being present. - Helping the client to make decisions by being open, receptive, and available without judging or labeling.
What tools can be used to assess hearing?
- A tuning fork - An Otoscope
What risk factors are associated with the development of cataracts?
- Age - Genetics - Long-term Sun exposure - Smoking - Alcohol abuse - Trauma - Heat & radiation exposure
What risk factors are associated with AMD?
- Age - Smoking - Race (Whites) - CV health - Genetics
What is Angle-closure glaucoma?
- An acute narrowing or closing of the AC angle that occurs due to a corneal flattening, or bulging of the iris resulting in a rapid IOP increase. *Occurs unilaterally
What happens in glaucoma that causes vision loss?
- An disruption in the absorption or drainage of aqueous humor that leads to increased IOP that injures the optic nerve
Who is at risk for developing cataracts?
- Anyone over the age of 65 - Women more then men
Postoperative instruction for cataract surgery should include?
- Avoid reading, lifting, and bending - No strenuous activities - Don't sleep on operative side
Who has the greatest risk for developing Open-angle glaucoma?
- Blacks - Hispanics - Those with CV disease or DM
Opened angle glaucoma is most common in which race?
- Blacks and Hispanics
What manifestations are associated with AMD?
- Blurred VA - Colors appear less bright - More light is needed for vision - Loss of central vision
What are the six C's?
- Compassion - Competence - Confidence - Conscience - Commitment - Comportment
What manifestations are associated with cataracts?
- Decreased visual acuity - Glare (especially at night) - Impaired color discrimination - Cloudy pupil appearance
Clients with Angle-closure glaucoma should be careful to avoid?
- Dilation of the pupil which will cause bulging of the iris - Dilation can be influenced by Darkness, emotional upset, or medications
How should Bullying in the work place be recorded and who should you report it to?
- Document the incident, to include date, time, location, and witnesses - Report incidences to the nursing manager and human resources
What are the four way of knowing developed by Barbara Carper?
- Empirical - Aesthetic - Personal - Ethical
Postoperative cataract patients should be instructed to watch for what possible complications?
- Excessive pain - Decreased visual acuity - Headache - Nausea - Itching/redness - Discharge
What manifestations are associated with Angle-closure glaucoma?
- Eye and facial pain - General malaise - N/V - Seeing halos around lights - Abrupt decrease in VA
Maslow's Self-esteem Needs refers to?
- Feelings of confidence, independence, competence, respect, and achievement. - Self-esteem is built through experience.
How often should hearing screenings be done?
- For adults: every 10 yrs until 50 then every 3 yrs.
How often should vision screening be done?
- For children: at least once at 3-5 yrs - For adults: Annual or biannual (Annually for those w/ DM or HTN)
Maslow's five levels of needs can only be achieved in what order?
- From the lowest level (Physiological) to the highest (Self actualization) *Physical before psychological
The progression of cataracts generally progresses from the _________ to the ___________ of vision
- From the periphery to the center
What are some non modifiable risk factors r/t alterations in senses?
- Genetics - Prenatal infection - Prematurity - FAS - Illness/Disease (atherosclerosis/HTN, stroke, DM)
The nursing assessment should focus on?
- History of smoking, DM, use of Rx's - Impact that decreased VA has on ADL's
Watson's theory of human care focuses on?
- How genuine caring relationships have a positive impact on a client's health and can facilitate the healing process. - Caring is considered transpersonal; meaning that both the nurse and the client seek out meaning and connectedness. - Caring involves addressing the mind, body, and spirit.
What does the Caring encounter: Compassion, refer to?
- It is the willingness to become intimately involved in the client's experience through attentive listening, eye contact, and therapeutic touch. - Also, respecting the client's spiritual beliefs or lack of
What are the two internal stimuli?
- Kinesthetic (Awareness of position/movement) - Stereognosis (Awareness of objects through touch/feel) - Visceral (stimuli created by internal organs)
Refractive impairments are most common in which race?
- Native americans
Maslow's Physiological Needs refers to?
- Needs for survival, such as food, water, air, sleep, and shelter - ex. Longs shifts are associated with disrupted eating schedules and diminished sleep.
What are the four Caring Encounters?
- Nursing Presence - Empowerment - Compassion - Competence
Ethical Knowing refers to?
- One of Carper's four types of Knowing - Developed through an awareness and understanding of current ethical codes and values
Aesthetic knowing refers to?
- One of Carper's four types of knowing - Based on CREATIVITY - Relates to the specific personal style of the nurse (creativity)
Empirical knowing refers to?
- One of Carper's four types of knowing - Based on KNOWN FACTS and observations made. - Developed through ongoing education - ex. Knowing the right action to take, or appropriate supplies to use in a situation.
oxygenation assessment includes assessing?
nasal assessment respiratory reassessment. Inspection of the thoracic cavity inspection of the muscle of breathing. Inspection, and palpation of the thoracic wall for symmetry. Skin assessment in relation to the respiratory system
an early sign of compromise children
nasal flaring
antibiotics
natural substance produced by bacteria that kills other bacteria
30 - 60 BPM
newborns
Risk
no problem, but presence of risk factors -need nursing intervention to prevent
viruses
nonliving agents that infect bacteria, plants, animals intracellular parasite -must be in host cell to replicate and cause infection -many viruses infect specific host cells
12 to 24 BPM
normal respirations of older adults
Possible
not enough data to support -continue to monitor
over generalizations
not enough evidence to come to a conclusion
implementation
nurse applies knowledge, skills and principles of nursing care to move patient toward desired goal and optimal wellness
Independent Intervention
nurse do on basis of own skills and knowledge
implementation
nurse performs the actions identified in the interventions, include: pre-assessment, determining the need for assistance, implementing the nursing interventions, supervising any delegated care, documenting nursing actions
clinical judgment
nurse provides the best appropriate care to a client; combines critical thinking, decision making, and nursing experience
deductive reasoning
nurse works from top down by starting w a conclusion and analyzing it for valid significant cues
critical thinking
nurses ability to make meaningful observations, solve problems, decide on course of action
structure of viruses
contain a few dozens genes, either RNA or DNA -DNA contains information needed for replciation Most viruses are self limiting; require no pharmacotherapy
surfactant
control surface tension keeps the alveoli from collapsing and sticking to themselves it is only produced with adequate oxygenation
Implementation
coordinate and carry out nursing oders on care plan and medical order that r/t medical treatment
simple mask
covers the mouth and nose, and is fitted to the individual face. the mass provides an additional gas reservoir to that provided by the nasopharynx alone. Flow rates may be set from 5 to 10 L per minute. The FiO2 is from 30% to 50%
assessment interview of oxygenation topics
current respiratory problems.. History of respiratory disease. Lifestyle presence of cough. Description of sputum presence of chest pain. Presence of risk factors. Medication history
late sign of hypoxemia
cyanosis
abnormal assessment findings in skin
cyanosis, club, nails
clinical judgment
nurses determination and provision of appropriate care to the client: nurse provides the best appropriate care to a client; combines critical thinking, decision making, and nursing experience
intellect
ability to learn and understand knowledge, helps nurses differentiate facts from opinions, approach situations objectively, clarify concepts.
inductive reasoning
nurses work from the bottom up by putting significant cues together to reach a conclusion
diagnosis
analyze data identify health probs, risks, and strengths formulate diagnostic statements
responding (tanners model)
analyzing a situation and choosing the best course of action, intuitive "knowing" from past similar experiences, using past similar experiences to "make sense" of a present clinical situation, responsive actions by the nurse
abnormal assessments in the thoracic cavity
anterior posterior equals transverse thoracic diameter measurements barrel chest
Subjective Data
apparent to person affected and described or verified only by client
protozoan infections
are single celled organisms currently cause significant disease in africa, south america and asia thrive in areas of poor sanitation drugs used to treat bacterial and fungal infections are ineffective most common: malaria
non-rebreather mask
as a one-way valve between the attached reservoir in the face mask. Ensures appropriate levels of oxygen inhaled, with no carbon dioxide from exhaled gases.
additional assessment of respiratory system in pregnant women
assess for rhinitis(nasal stuffiness), nosebleeds these are due to increased estrogen. Assess for respiratory diseases assess for tactile fremitus due respiratory disease assess for low pitched resonance of moderate intensity due to high diaphragm assess the secular breath sounds with the longer inspiratory phase of 3 to 1
cognition nursing implications
assess medication and rule out acute brain trauma for considering other causes.
perfusion nursing implications
assess pulses, nail beds, color, body position for comfort, orientation. Administer 02 anticipate need for pharmacotherapy.. to improve cardiac output to correct deficit. monitor arterial blood gases
prevention factors in oxygenation
assess quality of indoor air. Exposure to secondhand smoke and other emissions from heat sources. Occupational exposure to chemical vapors use of cleaning agents, perfumes and air fresheners vaccination history
comfort nursing implications
assess related symptoms of increased pulse rate, respirations,blood pressure, restlessness, anxiety, diaphoresis;; client reports of discomfort. Anticipate need for additional assessments, medications for pain relief, diversional therapies.
Nursing process
assessment diagnoses planning implementation evaluation
Syndrome
associated with collection of other dx that usually occur together
either-or fallacy
assuming a detailed question only has a couple of responses
abnormal findings of palpation of the thoracic wall for symmetry
asymmetry of movement occurs. Decreased expansion occurs. The trachea shifts from midline
collapse of lung tissue, affecting all or part of the lung
atelectasis
atelectasis
atelectasis (collapse of lung tissue) by removing pathologic fluid accumulation or pleural effusion
risk factor for obstructive apnea
obesity alters thoracic anatomy and effects accessory muscles
secondary infections
occur when too many host flora are killed by an antibiotic host flora normally prevent growth of pathogenic organisms
acquired resistance
occurs when pathogen develops gene that survives longer or grows faster -through maturation --antibiotics destroy sensitive bacteria --insensitive (mutated) bacteria remain --mutated bacteria multiply with less competition
long term goals
often used for clients who live at home and have chronic health problems: ex- client will progressively inc amount of time walking to 30 mins within 4 weeks
this catheter is more effective for removing thick mucous plugs
open text catheter
pathogens
organisms that can cause disease bacteria viruses fungi extracellular organisms multi cellular organisms must bypass the bodys defenses
Describe safety related to the individual care
orient clients assess ability to ambulate and transfer place tables near bed or chair for used items encourage use of railings, grab bars nonskid footwear remove obstacles keep rooms well lit assess clients vision Apply physical restraints when necessary be aware of clients medical regimen, side effects, and interactions.
evaluation (nursing process
outcomes are evaluated to determine if the clients goals have been met and for the effectiveness of the care plan; three situations nursing care should be evaluated: during or immediately after and intervention, at time specific intervals, at discharge
nonpharmacological therapy
oxygen administration, thoracic catheter use
helminth infections
parasitic worms that cause significant disease is certain regions of world
stage 2 pressure ulcer
partial thickness loss of dermis, intact or broken blisters, shiny or dry
indirect care
performed away from but on behalf of the client: ex- changing the sharps container when it is full
objective data
physical assessment, lab tests, other diagnostic sources
dependent interventions
physicians order that direct the nurses to provide meds, intravenous therapy, diagnosis tests, activity status, and diet
enterobius vermicularis
pinworm most common helminth infection in US
Interviewing
planned conversation with purpose
Evaluation
planned, ongoing, systematic activity in which clients and health care professional determine client's progress toward achieving of goals and outcomes and the effectivness of the care plan -conclusions determine whether to continue with interventions
risk diagnosis
presence of risk factors indicates a health problem can develop unless the nurse intervenes: ex- client who has surgery would be risk for infection
What is the Actual Dx?
present problem as to what is going on now. Example: Ineffective breathing patter, acute pain, anxiety
Actual
present problem based on s/s
pateint education
primary role for nurses directly relate to -deficient knowledge -noncompliance provide written material to pt elderly and pediatric pts are special challenges may need to co teach patients caregiver
planning
prioritize problems/diagnosis formulate goals/desired outcomes select nursing interventions write nursing interventions
planning
prioritizes diagnoses, formulated desired outcomes and selects nursing interventions that can assist pt to establish an optimum level of wellness
ranking activities
priority 1: must be done (ex-suctioning secretions form a trach tube to keep clients airway open), priority 2: should do, can happen once must do activities are done (ex- restocking dressing supplies in the room, priority 3: nice to do, only after 1 and 2 are done (ex-calling a family member for the clients to ask her to bring the clients hairbrush)
assessment
setting priorities for nursing begins w assessment: observe ques about pace and emotions, after receiving info from the previous nurse shift report, conducting ones own assessment by making a quick safety check of clients, become aware of clients who have an unstable status, risk of change in their condition, asking about any special safety concerns for the clients, making note of routine responsibilities and interventions that have time constraints, knowing how many nursing staff are available, asking about client preferences to take into considerations
outcomes
should be written and include -subject -actions required -circumstances -expected outcomes -specific time frame
catheter size in endotracheal suctioning
should not exceed one half internal diameter of the treaty ostomy or endotracheal tube.
inherited disease that impairs the transport of oxygen through the blood and can lead to organ failure
sickle cell disease
fungi
single celled or mutlicellular organisms more complex than bacteria molds, yeasts, mushrooms decompose dead organisms humans exposed by handling contaminated soil or inhaling spores
orthopneic
sitting up in bed at 90 degree angle sometimes resting forwRD SUPPORTED BY PILLOW ON OVERBED TABLE
bacteristatic
slow the growth of bacteria
Desired outcome
specific, observable crieteria to evaluate if goals were met
cocci
spherical shaped
spirilla
spiral shaped
clinical pathway
standardized evidence based multidisciplinary plan that outlines the expected care required for clients with common, predictable conditions. include interventions, time frames for completion, expectations of response, and expected outcomes each day
Conclusion
statement that goal or outcome was met or not
circular reasoning
supporting an opinion by restating it using different words
Assessment
systematic continuous collection, organization, validation and documentation of information (data) -initial -problem focused -emergency -time lapsed reassessment
assessment
systemic collection, organization, validation, and documentation of pt data health history and physical assessment baseline data gathered; will be compared to later information from observatons
abnormal findings in respiratory reassessment
tachypnea, bradypnea, apnea, Cheney Stokes respirations,shortness of breath, dyspnea, orthopnea
opportunistic
take advantage of suppressed immune system
cestodes
tapeworms
Describe safety related to the health care system
team effort by q person in the organization safety issues are similar to those in the home Promoting safety in health care safety
culture
tested for sensitivity to different antibiotics bacteria may take several days to identify viruses may take several weeks to identify broad spectrum antibiotics may be started before lab culture completed
residual volume
the amount of air remaining in the long after maximal exhalation
forced vital capacity
the amount of air that can be exhaled forcefully and rapidly after maximum air intake
planning (nursing process)
the clients assessment data and nursing diagnoses are used to formulate goals
expiratory reserve volume
the maximum amount that can be exhaled following a normal exhalation
inspiratory reserve volume
the maximum amount that can be inhaled over and above a normal inspiration
V - Q ratio
the movement of oxygen across the alveolar capillary membrane into a well perfusing capillary
closed airway suctioning system
the suction catheter attaches to the ventilator tubing and the client does not need to be disconnected from the ventilator. The nurse is not exposed to secretions. There is policy concerning changes of the system.will
vital capacity
the total amount of air that can be exhaled after a maximal inspiration. It is calculated by adding together the TV, IRV, and the ERV
guildlines
date and sign the plan, use category headings, use approved abbr and key words rather than complete sentences to communicate ideas unless facility policy dictates otherwise, be specific short and concise, refer to facility resources, customize the plan to include clients choices such as preferences about the times of care the methods used, ensure the plan incorporates preventives and health maintenance aspects as well as restorative ones, collaborative activities, plan for the clients discharge and health teaching needs
nasal cannula
ddelivers flow rates from 2 to 6 L per minute that administer 24% to 44% fraction of inspired oxygen
comfort relationships you oxygenation
decreased O2 the tissues manifests as pain
cognition
decreased O2 to the brain can cause changes in cognition.
hypoxemia.
decreased level oxygen
perfusion relationship oxygenation
decreased tissue perfusion decreases oxygen deficits to organs
Does rate of growth increase or decrease toddlers?
decreases
independent interventions for oxygenation
deep breathing exercises,, positioning, encouraging smoking cessation, monitoring activity tolerance, promoting secretions clearance, suctioning, assisting with activities of daily living
nursing diagnosis
deficient knowledge -pt not properly educated about med noncompliance -pt properly educated, but chooses not to take meds
wellness diagnosis
describes human response to wellness in an individual family, or community that has a readiness for enhancement: ex- client who makes yearly appt w a healthcare provider for physical assessment is exhibiting health seeking behaviors
Objective Data
detectable observer and can be measured or tested
health promotion diagnosis
determines a clients motivation and desire to inc well-being by a readiness to enhance specific health behaviors: ex- a client who would like to lose weight and seek nutrition counseling is exhibiting readiness for enhanced nutrition
Planning
develop goals and outcomes -develop nursing interventions to prevent, decrease or alleviate health problems -initial, ongoing, or discharge planning
abnormal findings in needles assessment
deviated septum,, foreign bodies,, asymmetry, purulent drainage, watery nasal drainage, pale turbinates
affects quality of circulation in perfusion
diabetes affects vascular health
Low blood pressure symptoms
dizziness, pale, clammy, and vomit
bandwagon
doing something because everyone else is doing it
narrow spectrum antibiotics
effective against only certain types of bacteria; ex: penicillins
cardiovascular disease
effects oxygenation
total volume(tidal volume)
the volume and held its help with normal white breathing
gram positive
thick walls that retain purple color after staining peptidoglycan
gram negative
thin walls lose purple stain
thoracentesis
thoracentesis is the insertion of a needle into the chest cavity in order to withdraw fluid from the pleural space. The fluid is examined for microorganisms, blood, and other substances. Thoracentesis also relieves pressure on the lung and
asthma
to constricted obstructive airways
What is caring?
to feel interest or concen
inspiratory capacity
total amount of air that can be inhaled phony normal quiet exhalation is calculated by adding the TV in the IRV
minute volume
total volume of air breathe in one minute
total lung capacity (TLC)
total volume of the lungs at their maximum inflation, for values are used to calculate the TLC total volume,, inspiratory reserve volume, expiratory reserve volume, residual volume
Delegation
transferring to a competent individual the authority to perform a selected nursing task in a selected situation
Wellness
transition between levels of wellness
trail and error
trying out a solution, seeing if it works, and if does not reflecting on why and making another different attempt
writing a nursing diagnosis: basic 1 part statement
used for wellness and syndrome diagnoses and uses the NANDA label only
mitts
used when scratching
short term goals
useful for clients needing a limited amount of nursing care: can be achieved in a few hours to a few days
column plan
uses columns to categorize data for each phase of nursing process. may include: nursing diagnoses, goals, nursing interventions, and evaluations
Observing
using own senses
venous stasis
usually feet and legs, slowing circulation
measures of perfusion
ventilation perfusion scan arterial blood gas. Pulse oximetry
this pulmonary function test decreases with age
vital capacity
functional residual capacity
volume of air left in the lungs after a normal exhalation. ERV in the RV are added to determine the FRC
subjective data
what patient describes
this type of catheter is less irritating to the airwaves
whistle tips catheter
nursing plan of care
written or electronic guild line that organized info about an individual clients family care
Do children have a slow and steady growth?
yes often appear thin and gangly Appetite increases in older school age child problems at school start around this time
cellular regulation relationship to oxygen
↓ O2 increases systemic work- load and shunts blood from periphery to vital organs.
Compassion
Often used interchangeably with "caring," "sympathy," and "empathy," this is a skill that can not be learned through academic study but can only be picked up through intimate involvement with the client.
What is spirituality?
One's search for life's meaning and purpose
Intellect
Our ability to learn and understand things.
Pronation
Palm of the hand turned down
Supination
Palm of the hand turned up
To qualify for licensure in Arizona, graduates of international nursing programs must show evidence of: Passing NCLEX, graduating from a comparable nursing program, and English language proficiency Licensure in another country, a valid visa screen document, and a social security number Passing NCLEX or an equivalent exam in their country and English language proficiency Passing NCLEX, licensure in another country, and proof of legal residence in the US
Passing NCLEX, graduating from a comparable nursing program, and English language proficiency
Requirements to become a CNA in Arizona include: A valid social security number Working 4 months at a longterm care facility Completing an approved program or the first semester in a nursing program Passing a manual skills and written examination
Passing a manual skills and written examination
Peak flow
Peak flow is a measure of the volume of air a client is able to exhale, also using a simple, handheld tool. It is often used by clients with asthma to monitor the effectiveness of medications
cognition
Perfusion of the brain requires approximately one fourth of the oxygen taken in by the respiratory system. Hypoxemia can have a profound impact on level of consciousness.
The abbreviation CNA may be used by: Persons currently certified by the Board as nursing assistants Persons authorized to perform nursing assistant activities CNA students during their clinical experience Nursing assistants employed in health care settings
Persons currently certified by the Board as nursing assistants
Chemical restraints
Pharmacologic agents administered for the purpose of controlling hyperactive behavior in agitated clients.
Diastole
Phase of ventricular relaxation
Depolarization
Phase when the heart contracts resulting from ion channel functions
What does the general survey assessment include?
Physical development and body build, gender and sexual development, apparent age vs reported age, skin condition and color, dress and hygiene, posture and gait, LOC, behavior, body movements and affect, facial expression, speech and vital signs
Collaborative Problem
Physiologic complications that nurses monitor to detect their onset or changes in status
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
Physiologic status
What are Maslow's five levels of needs?
Physiological, Safety, Belonging and Love, Self-Esteem, Self-Actualization
When assessing breath sounds what do you need to note?
Pitch, quality and amplitude
It would be a violation of the nurse practice act for an RN to delegate: Vital signs to a CNA Planning care to an LPN Changing a central line dressing to an LPN Application of commercial diaper cream to a CNA
Planning care to an LPN
Dyspnea risk factors
Pneumothorax Pulmonary embolus Lung mass Airway obstruction or constriction Deconditioning
Venous stasis
Pooling of blood within the veins
Hematocrit
Proportion of red blood cells to blood plasma
It would be a violation of the nurse practice act for an LPN to: Provide nursing services independent of a registered nurse (RN) or physician Plan and participate in a staff education meeting with a nursing supervisor Utilize the title "nurse" when employed in the school health office Delegate data gathering to a certified nursing assistant (CNA)
Provide nursing services independent of a registered nurse (RN) or physician
When dealing with a manipulative client it is important for the nurse to
Provide structure and set limits
Friction
Rubbing of skin against another surface produces friction, which may remove layers of tissue, example moving a pt up in bed by sliding pt across the bed linen
Sim's position
Side-lying position used during the rectal examination
Salient cue
Significant data that informs & influences conclusions about clients health
muscles of respiration
The scalene, sternocleidomastoid, and trapezius muscles are accessory muscles that play a major role in respiration, especially during periods of increased oxygen demand and with certain pathological conditions
CREATIVITY
Thinking outside the box. We might not always have the resources we need - and we need to think of other ways of doing things.
What are the three anthropometric measurements?
Triceps skinfold (TSF), Mid upper arm circumference (MUAC), Arm muscle circumference (AMC)
Intuition
Trust our guts! This is a REAL THING. This is why we change our answers (STOP DOING THIS!!!)
Intuition
Use of nursing knowledge experience & expertise for understanding without the conscious use of reasoning
Describe the objective components of pain assessment
Use of pain assessment tools
Wrist restraints
Used if pulling at tubes, or swinging at staff or others
Interpreting (tanners model)
Using logical reasoning to gain understanding about a situation and determine appropriate actions
client being discharged to home with supplemental oxygen, teaching includes
Using the devices properly Checking oxygen levels in tanks Using a portable device for trips outside of the house Maintaining the lines and keeping them clear of obstruction.
oxygen device used in neonatal intensive care units?
Vapotherm device delivers oxygen via a nasal cannula, but warms and filters oxygen and increases the positive end expiratory pressure of oxygen delivery via the cannula.
Ventilation/perfusion scan (V/Q scan)
Ventilation/perfusion scan (V/Q scan) provides information about the client's ventilation/ perfusion status. A radionuclide gas is inhaled and an image taken to determine if it has reached all parts of the lungs. CT with contrast is replacing this in the process of diagnosing pulmonary embolus
What happens during systole?
Ventricles contract
What happens during diastole?
Ventricles relax
What breath sound is long during inspiration and short during expiration?
Vesicular
Define fremitus
Vibrations of air in the bronchial tubes transmitted to the chest wall
Which nerve controls Hearing and balance?
- #8 Acoustic/Vestibulocochlear
Kidney stones
Caused by osteoporosis, extra calcium filtering through the kidneys
Planning
Developing a plan of nursing care and outcome criteria
Clotting
Process of coagulation where blood is converted from a liquid to a gel
Medical Diagnoses
Refer to specific pathophysiologic responses that refer to disease
virulence
ability of a microbe to produce disease when present in minute numbers
pathogenicity
ability of organism to cause infection
superinfections
secondary infections opportunistic infections
Empirical Knowing
"Science of knowing," Based in facts and observations relevant to nursing, as well as the analyses and theories that attempt to explain them.
Ethical Knowing
"The moral component," Knowing that encompases all voluntary actions that are deliberate and subject to the judgment of right and wrong.
Culture Care Diversity and Universality
"Transcultural nursing" calling for Preservation, accommodation, and/or repatterning of patient/client personal heritage/tradition.
Aesthetic Knowing
"the art of nursing," Subjective and relates to the specific personal style the nurse possesses when delivering care. Key elements include empathy, holistic thinking, compassion and sensitivity.
tanners clinical judgment model
"thinking like a nurse" Noticing, interpreting, responding, reflecting
tanners clinical judgment model
"thinking like a nurse" emphasizes the importance of elements the nurse uses in cognitive processing; different types of knowledge, length of nursing experience, values, morals regarding right and wrong, intuition, and knowing the client Noticing, interpreting, responding, reflecting
The Maslach ______ Inventory.
(Burnout) The most widely used tool for measuring burnout.
Yankaur Suctioning device
(oral pharyngeal suctioning) earlobe to corner of mouth, suction from the side
Nursing vs Medical Dx
*Nursing dx is a statement of nursing judgement *Medical dx is made by a licensed provider
Which neve controls smell?
- #1 Olfactory
Which nerve controls vision?
- #2 Optic
Benner and Wrubel's Theory of Caring focuses on?
- The phenomenon of care and caring practices to the experience of health and illness. - Caring is dependent on factors such as context, physical environment, the nurse's training and experience, and the client's capacities and perspectives.
Leininger's Theory of Culture Care Diversity and Universality focuses on?
- The pivotal role of culture in maintaining and encouraging health. - Client's culture is incorporated into nursing interventions to promote overall outcomes.
What is Sensory reception?
- The process of receiving stimuli
What four aspects of sensory must be present for someone to be aware of their surroundings?
- The stimulus - Reception - Impulse conduction - Perception
What types of alternative therapies are available for cataracts?
- There are no forms of alternative therapies or medications for cataracts - Antioxidants and lactose may help reduce opacities
Watson's developed the 10 Curative factors. What do these factors refer to
- They are caring philosophies that Watson believed needed to exist between a nurse and client in order to establish a caring relationship.
What diagnostic tools are sued to assess clients with glaucoma?
- Tonometry (pressure) - Funduscopy (Optic nerve) - Goniosopy (AC depth) - Visual field testing (Visual field narrowing)
Diagnosing
- Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status - Includes strengths, problems, and factors contributing to the problems
What is Benign paroxysmal positional vertigo (BPPV)?
- Vertigo caused by a disruption of the orientation of ear otoliths
What are the 5 stimuli?
- Visual - Auditory - Olfactory - Tactile (touch) - Gustatory (taste)
What vitamins and minerals can help prevent AMD?
- Vitamin C & E - Beta-carotene (vit-A) - Zinc - Copper - Antioxidants
Nursing Process
-Assessment -Diagnosis -Planning -Implementation -Evaluation
Primary Source
-Client (best source)
Problem Urgency
-High priority Life-threatening -Medium priority Not a direct threat to life, but may cause destructive physical or emotional changes -Low priority Requires minimal supportive nursing intervention
Goals
-Long-term goals: To be achieved over a longer period of time (week, month, or more) -Short-term goals: To be achieved within a few hours or days
Critical Thinking
-Purposeful -Outcome desired -Judgments -Scientific evidence -Clinical reasoning -Solve problems -Make decisions
Critical Thinking Skills
-objectively gathering information -recognizing need for more information -evaluating credibility/usefulness of information -recognizing gaps in your knowledge -listening carefully/reading thoughtfully -separating important from unimportant -grouping information in meaningful ways -making inferences about information -visualizing potential solutions -exploring potential actions for consequences
virus
-protein coat (capsid) -lipid bilayer (envelope_ -glycoprotein spikes
Medical Diagnosis
-refers to condition M.D. treats -disease process -medical dx remains the same
Nursing Judgement
-refers to condition nurses are licensed to treat -changes as client responses change -relate to nursing independent functions
Secondary Source
-support persons of significant others -front sheet demographics -medical records -therapy records -labs -health care professionals -literature -standards
Cognitive skills
...
Collaborative intervention
...
Defining characteristics
...
Dependent intervention
...
Diagnostic label
...
Etiology
...
Evaluation
...
Evaluation statement
...
Goal
...
Implementation
...
Independent intervention
...
Interpersonal skills
...
NANDA
...
Nursing diagnosis
...
Nursing process
...
Outcome
...
Planning
...
Qualifiers
...
Risk factors
...
SMART
...
Syndrome diagnosis
...
Technical skills
...
When assessing the peripheral arteries, palpate and note strength:
0-absent 1+ = diminished -weaker than expected 2+ = brisk, expected 3+ = increased 4+ = full volume, bounding
What are the three major taxonomies of nursing?
1. NANDA 2. Taxonomy II - multiracial system of naming nursing dx that are coded 3. Psychiatric nursing dx: psychiatric nursing.
What are the evaluating outcomes?
1. Cognitive: Asking pt to repeat info or apply new knowledge 2. Psychomotor: asking pt to demonstrate new skill 3. Affective: Observing pt behavior and conversation 4. Physiologic: using physical assessment skill to collect and compare data.
If edema is present, check for pitting:
1+ = trace, 2mm 2+ = mild, 4mm 3+ = moderate, 6mm 4+ = severe, 8mm
What is diagnosis ?
1. A CLINICAL JUDGEMENT about an individual or family or community responses to actual and potential health/life processes. 2. Guide as to what the nurse is going to do 3. Provides the basis for selection of nursing interventions to achiever outcomes for which the nurse is accountable.
What are the types of nursing dx?
1. Actual dx 2. Risk nursing dx 3. Wellness dx 4. Health promotion dx 5. Syndrome dx
Expected lung sounds:
1. Bronchial : loud high pitches hollow quality. Expiration longer than inspiration. over trachea 2. Bronchovesicular: Medium pitch, blowing sounds. hears over larger airways 3. Vesicular: soft, low pitch breezy. Inspiration 3 times long. heard over most of the peripheral areas of lungs.
What are HCAI?
1. Catheter-related bloodstream 2. Heathcare-associated pneumonia 3. Surgical site infections 4. Central line associated blood stream infections 5. C-diff
Categories of outcomes are?
1. Cognitive (describes increases in pt knowledge or intellectual behavior) 2. Psychomotor (describes patients achievement of new skills) 3. Affective (described changes in values, beliefs and attitudes
Evaluation Process
1. Collect date- draw conclusions 2. Compare data with outcomes 3. Write evaluation statement 4. Relate nursing activities to outcomes 5. Draw conclusions about problem status 6.Reassess client and nursing care plan 7. Continue, modify, or terminate care plan
Unexpected lung sounds:
1. Crackles or rales: Fine to coarse. bubbly (not cleared w/ coughing) 2. Wheezes: high pitched whistling. Musical 3. Rhonchi: course loud low pitches rubbing sounds resulting from fluid or mucous. (can clear w/ coughing) 4. Pleural friction rub: dry grating or rubbing sounds. Inflamed visceral and parietal pleura rub against each other 5. Absence of breath sounds: from collapsed or sx removed lungs
What are the components of a nursing dx?
1. Diagnostic label (name and meaning of problem, focus or subject of problem) 2. Definition (signs and systems) Etiology (where did it come from) 3. Defining characteristics (q dx, what does it look like)
Heart sounds
1. Dysrhythmias : heart fails to beat at regular intervals 2. Gallops: Extra heart sounds 3. Ventricular gallop: occurs after S2 (sounds like ken tuck y) 4. Atrial gallop: occurs before S1 (sounds like ten es see) 5. Murmurs: When blood volume in the heart increased or its flow is impeded or altered. 6. Systolic murmurs: Occur after S1 7. Diastolic murmurs: Occur after S2 8. Thrills: Palpable vibration 9. Bruits: Blowing or swishing that indicate obstructed peripheral blood flow
Abdomen:
1. Four quadrants, nine regions 2. Inspection, auscultation, palpitation, percussion
What to expect when assessing a child?
1. Frequently sort, classify collections 2. Hav open communication w/ adult family 3. A child w/ no hobby indicates one that is environmentally deprived.
What to expect when assessing an older adult?
1. Functional assessment 2. Comprehensive geriatric assessment
Assess Musculoskeletal system by assessing:
1. Gait 2. Alignment 3. Symmetry 4. Muscle tone 5. ROM 6. any involuntary movements 7. Indications of inflammation 8 Gross deformities
What to expect when assessing a middle aged adult?
1. Generally satisfied w/ accomplishments 2. End of childbearing
What is the nursing process?
1. Identify needs of client 2. Used throughout nursing career 3. ANA standards of practice
What to expect when assessing an adolescent?
1. Increased caloric intake 2. Eating disorders can appear 3. communicate better w/ peers and adults 4. Become more independant
Examining Techniques
1. Inspection- look 2. Ascultation- listen 3. Palpation- feel 4. Percussion- tapping
Inspection of mental status:
1. Language 2. Orientation
What are the factors that increase risk of human error?
1. Limited STM 2. In a hurry 3. Having to multi task 4. Constant interruptions 5. Increases stress/high stress environment 6. Fatigue 7. Other environmental factors
Types of lesions
1. Macule- non palpable. <1cm. freckle 2. Papule-palpable, circumscribed. <1cm. Elevated nevus 3. Nodule-palpable, deep, firm 1 -2 cm. wart 4. Vesicle- serious fluid filled <1cm. Blisters, herpes, varicella 5. Pustule- Puss filled, varies in size. acne 6. Tumor- solid mass, deep >1-2cm. epithelioma 7. Wheal- palpable, irregular borders, insect bite, 8. Atrophy- thinning of skin. shiny and translucent. Arterial insufficienctly
What are the types of Clinical safety problems?
1. Med errors 2. Wrong-site sx 3. Restraint related injuries and deaths 4. Falls 5 burns 6. Skin Break down 7. Misidentification of pts.
Assess sensory function by performing tests on all four extremities with clients eyes closed:
1. Pain sensation 2. Temperature by using 2 test tubes 3. Light touch 4. Vibration by using a tuning fork 5. Position 6. Discrimination
What are the 3 underlying principles for assessing an older adult?
1. Physical, psychological, and socioeconomic factors interact in complex ways to influence the health and functional status of the older person 2. Comprehensive eval 3. Functional abilities should be central focus
What do you do when a pt begins to fall while you assist to ambulate?
1. Place your feet wide apart w/ one foot in front 2. Rock your pelvis out on the side nearest the patient 3. Grasp the gait belt 4. Support the pt by pulling their weight backwards against your body 5. Gently slide the pt down your body to floor 6. Stay w/ pt and call for help
What are the processes of implementation ?
1. Pre assessment of the client 2. Determining the nurses need for assistance 3. Implementing the nursing interventions 4. Supervising any delegated care 5. Document nursing actions.
What are the types of prevention?
1. Primary: Teach to prevent. Immunizations 2. Secondary: screening, mammograms 3. Tertiary: Rehab
3 Part Statement
1. Problem 2. Etiology 3. Evidence
What is a three part nursing dx?
1. Problem RT etiology AEB defining characteristic 2. Diagnostic label rt/ contributing factors AEB signs and symptoms (subjective and objective data)
What is a two part nursing dx?
1. Problem r/t etiology (cause) 2. Diagnostic label rt possible contributing factors
Process of Implementation
1. Reassess 2. Need for assistance 3. Implement nursing interventions 4. Supervise delegated care 5. Document nursing actiavities
Medical Restraints
1. Requires 1-2 hour assessment and q2h removal 2. pts at risk for falls 3. Pts attempting to remove required equipment 4. Only use as required
Behavioral Restraints
1. Requires q 15 min assessment and q2h removal 2. Suicidial pts attempting self harm 3. Uncontrollable pts attempting to harm others 4. use until behavior subsides
5 Rights
1. Right task 2. Right circumstance 3. Right person 4. Right communication 5. Right supervison
Assess motor function for balance by using the following tests:
1. Romberg test 2. Heel to toe walk
Basic Needs
1. Safety and secutiry 2. Oxygenation 3. Circulation 4. Regulatory 5. Motor/sensory 6. Elimination/nutrition 7. Psychosocial
Types of knowledge nurses integrate
1. Scientific competence (scientific evidence) 2. Therapeutic use of self (how to care for pple from person experience) 3. Moral ethical awareness 4. Creative action
What does the Assessment include?
1. Subjective data 2. Health condition 3. Health practices 4. Values 5. Health hx 6. Lifestyle 7. Objective data
`What are the components of evaluation?
1. Was the outcome met? 2. Appraise the evidence of the achieved outcomes (AEB) 3. Continue, revise or resolve plan
Collect the following data in a general survey:
1. Written summary of overall health 2. Physical Appearance and mental status 3. Body structure 4. Mobility 5. Behavior 6. vital signs
Inspect joints for :
1. Tenderness 2. swelling 3. thickening 4. Crepitation 5. ROM
Special consideration for assessment of children:
1. They are not little adults 2. Head to toe approach my not work 3. Strong assessment skills 4. Conduct nutrition hx to establish rapport 5. Play should be incorporated into the assessment process 6. Anthropometric measure 7. clinical observations 8. call child by name 9. use words child understands 10. ask child to touch where it hurts 11. allow children to touch medical equipment
Problem Solving Approaches
1. Trial and Error 2. Intuition 3. Research
Functions of the Pulmonary System
1. Ventilation: Inspiration/exhalation 2. Transport 3. Perfusion
Caring behaviors in order:
1. appreciating the pt as a human being 2. showing respect for pt 3. being sensitive to the pt 4. Talking w/ the pat 5. treating pt info confidentially 6. Treating the pt as an individual 7. encouraging the pt to call w/ problems 8. Being honest w/ pt 9. Listening attentively to pt
nursing process
1. assessment: gathering info to determine what the problem is 2. nursing diagnosis: stating the specific problem to solve 3. planning: stating how to know when the problem resolved 4. implementation: giving solutions to resolve the problem 5. evaluation: evaluating if the problem has been resolved
What to expect when assessing young adults?
1. busy, productive healthy 2. intimate partnerships 3. childbearing choices 4. occupation chosen 5. values established
Caring encounters
1. caring is contextual 2. Knowing the client 3. Nursing presence 4. empowering the client 5. compassion 6. competence
Assess hair by checking for the following:
1. evenness of growth over scalp 2. Thickness or thinness 3. Texture and oiliness 4. Amount of hair
Inspecting the eyes includes:
1. external and internal anatomy of eye 2. visual pathways 3. visual fields 4. visual acuity 5. extrocular movements and reflexes
rules to follow when developing goals
1. from the nursing diagnosis what needs to be changed for or by the client 2. is there healthy response to correct a problem stated in the nursing diagnosis that the client can achieve as a goal 3. how will the client look or behave when the goal is achieved 4. what action must the client do and how well must the client do it , to demonstrate problem resolution or achievement of the goal
When should a geriatric assessment take place?
1. yearly 2. After a change in physical, social or psychological function 3. When hospitalized 4. When living situation has changed 5. a 2nd opinon.
steps to decision making
1. identify the situation or problem 2. list all possible alternatives and info about them 3. compare pros and cons of each alternative or solution and evaluate all of them 4. select best option 5. put the alternative into action 6. evaluate the success of using the alternative or solution as to whether the initial purpose was achieved
Assess memory
1. immediate 2. recent 3. long term
Assessing the skin, look for:
1. loss of color 2. Pallor (absence of underlying red tones) 3. cyanosis (bluish) 4. Jaundice (yellow, fist seen in eye sclera) 5. Erythema (redness) 6. Vitiligo (patches of hypopigmeneted skin) 7. Edema (excess ISF) 8. Lesions (alterations in skin appearance)
How do you validate the nursing dx?
1. making sure the data is sufficient 2. is the pattern identified and does the subjective and objective data match the pattern? 3. Is the ND based on scientific nursing knowledge
benners levels of competence
1. moving from no nursing experience to having concrete clinical experiences w new situations requiring critical thinking 2. progressing from following sequential steps to being able to customize and adapt actions using nursing experience and intuition 3. moving from trying to make sense of many cues to identifying significant cues and clustering them to form patterns 4. progressing from being a bystander to being an actively involved participant
When assessing the neck, check:
1. muscles 2. lymph nodes 3. Trachea (should be midline) 4. Thyroid gland 5. Carotid arteries (use bell) 6. Jugluar veins
Maintaining caring practice
1. nurses risk exhaustion, burnout, stress 2. caring for self 3. Self care connected to self awareness/ self esteem 4. American Holistic Nurses Associate code of ethics: nurse has responsibility to model health behaviors 5. A heath lifestyle 6. CDC: need a combo of moderate-intensity aerobic activity and muscle strength. for 2 hours 30 min over a period of 2 or more days a week
Types of knowledge in nursing
1. nursing integrates different types of knowledge 2. Empirical knowing (science of nursing0 3. Aesthetic knowing (art of nursing) 4. Personal knowing: the therapeutic use of self 5. ethical knowing (moral component) 6. developing ways of knowing
writing a nursing diagnosis: basic 3 part statement
1. problem 2. etiology 3. signs and symptoms(defining characteristics of problem, what does it look like); used for actual nursing diagnosis cause of signs and symptoms
Components of Nursing Diagnosis
1. problem and definition -problem or response for which nursing therapy is given 2. Etiology -ID cause of problem 3. Defining characteristics -s/s that indicate presence of this dx label
goals
1. providing direction for selecting nursing interventions 2. serving as criteria for evaluating clients progress 3. providing an opportunity go the nurse and client to determine when a goal has been achieved 4. helping motivate the clients and nurse by providing a sense of achievement
What are the types of restraints?
1. safety strap body restraint 2. Belt restraint 3. Mitt or hand restraints 4. Limb restraints
Steps of Planning (Care Plan)
1. set priorities 2. establish goals 3. establish outcomes 4. select nursing interventions 5. identify raionale
Things to do when assessing a preschooler:
1. talk about favorite activity to assess language ability, cognitive ability and development 2. Assess ability to concentrate, magical thinking, and reality imitation 3. Periodic health assessments
Variations
1. unknown etiology- don't know cause 2. complex factors- too many to state 3. specify- must describe more specifically 4. secondary to- disease process
What are some contact precautions:
1. use for pts infected by a micoorganism spread by direct or indirect contact. 2. pt in private room 3. Where PPE 4. Wash hands w/ antimicrobial or antiseptic agent 5. wear gown if in contact w/ agent Limit movement of pt out of the room
What are some droplet precautions:
1. use for pts w/ infection spread through droplets 2. use a private room (door can stay open) 3. we are PPE 4. place sx mask on pt when transferring
What are some airborne precautions:
1. use for pts who have infections spread through the air 2. Place pt in price room w/ negative air pressure and door closed 3. Use respiratory protection 4. Sx mask on pt when transferring
What do you assess when examining a toddler?
1..caloric intake 2. observe caregiver/toddler interactions. 3. Discuss eating expectation, with gain 4. Observe playroom activités.
2 Part Statement
1.Problem 2. Etiology
analysis in nursing process
1.compare data against standards to identify significant cues 2. clustering cues to generate tentative hypotheses 3. identifying gaps and inconsistencies
breathing exercises technique
1.place one hand on chest the other hand on the abdomen while taking a deep breath. Hand on abdomen should rise higher hand on chest, this ensures the diaphragm is pulling air into the base of each lung. 2. Exhale through mouth while depressing the abdomen. This ensures that care is being expelled
At what age can children have the option of being examined alone?
10
Puberty begins at the ages :
10-14 in females 12-16 in males
What is the normal respiratory rate for an adult?
12-20 per minute
What is the normal blood pressure of an adult?
120/80
A Health Promotion Diagnoses - - TYPES OF NURSING DIAGNOSES
2 parts. This is expressed in the readiness to enhance specific health behaviours. EX: Readiness for enhanced nutrition education AEB...
A Nursing Assistant certificate must be renewed every: 1 year 2 years 4 years 5 years
2 years
It is outside the scope of practice for an LPN to: 1Perform an electrocardiogram on a client 2Assess a client to formulate a plan of care 3Reinforce foot care teaching for a diabetic client 4Obtain a blood specimen from a client
2 (Assess a client to formulate a plan of care)
Where is the pulmonic area of the heart?
2nd ICS left
Where is the aortic area of the heart?
2nd ICS right
An example an additional act that may be performed by an LPN that requires additional education and training as prescribed by the Board and that is recognized as proper to be performed by a practical nurse would be (hint: see advisory opinions): 1Administration of conscious sedation 2Taking vital signs 3Administering IV medications 4Performing sclerotherapy
3 (Administering IV medications)
What is the normal temperature range of an adult?
96-99.9 F orally 36.5-37C
A nurse who changes his/her address shall notify the Board of the new address within: 10 days 15 days 30 days 45 days
30 days
What BMI is considered obese?
30-34.9
What waist circumference measurement is considered to put the client at risk for disease?
35 inches or greater for women and 40 inches or greater for men
Where is erb's point of the heart?
3rd ICS left
The definition of practical nursing includes: 1Assessing the health status of individuals 2Teaching nursing knowledge and skills 3Establishing goals to meet health care needs 4Maintaining safe nursing care that is rendered indirectly
4 (Maintaining safe nursing care that is rendered indirectly)
TANNERS CLINICAL JUDGEMENT MODEL
4 FEATURES OF HIS CLINICAL JUDGEMENT MODEL: (NIIR) Noticing (What did you notice?) Interpreting ( What does it mean?) Responding (What will you do?) Reflecting (Did it work?)
In Arizona a nursing license must be renewed every: 1 year 2 years 4 years 5 years
4 years
Middle age occurs between the ages of:
45-60
Where is the tricuspid area of the heart?
4th ICS left
Patricia Benner
5 levels of clinical competence. (Image on 2325)
Where is the mitral (apical) area of the heart?
5th-6th ICS midclavicular
Roach (caring, the human mode of being)
6 C's of caring caring is the human mode caring is core element of how humans operate
How long should you palpate/auscultate the apical pulse for?
60 seconds
What is the normal pulse rate for an adult?
60-100 beats per minute
tachypnea, for an infant
>60 BPM
What does the cover test detect?
Deviation in alignment or strength and slight deviations in eye movement
HOW DO YOU START A CONCEPT MAP? STEP #4
After you ID & group most important assessment data under each focus area (OBJ & SUB data) ID and GROUP clinical assessment data such as labs, diagnostics, medications that directly affect your areas of focus. MEDS: IV fluids, IV Reglan, IV Zofran, Cepacol spray LABS & DIAGNOSTICS: CT of abd, Scheduled K+ 3.4 NA 130 Hgb 10.1
tachypnea rrisk factors
Fever Metabolic derangements Panic attacks Pain Medication side effects
Factors affecting safety include...
Age and development lifestyle mobility and health status sensory cognitive awareness emotional state ability to communicate safety awareness environmental factors
The nurse licensure compact allows: Any nurse licensed and residing in another state to practice in Arizona A nurse licensed and residing in a compact state to practice in Arizona A nursing student from another state to complete clinical training in Arizona A nurse practitioner licensed and residing in a compact state to practice in Arizona
A nurse licensed and residing in a compact state to practice in Arizona
Presencing
A nursing concept involving the interpersonal arts of perception and communication and employing technique such as face-to-face discussions, silent immersions, and lingering
What is a spiritual assessment?
An assessment used to determine a client's spiritual needs
Define mental status
Client's level of cognitive and emotional functioning and stability reflected in their speech, appearance and thought patterns
Thrombosis
A blood clot develops within a blood vessel
What color fluorescence indicates the presence of fungus?
A blue-green color
Risk nursing diagnosis
A clinical judgement that a problem does not exist but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes
What is Critical Thinking
A combination of: Reasoned thinking Openness to alternatives Ability to reflect A desire to seek truth
What is concept mapping?
A concept Map is the nurse's own interpretation of the patients problems. It represents our own cognitive processes and more closely resembles our thinking pattern It promotes critical thinking. A concept Map demonstrates the flow of thought processes. This requires analyzing and synthesizing information. It also requires evaluation information.
Limb restraints
A device typically made of cloth that may be used when limb immobilization is needed for therapeutic purposes, for example, to prevent dislodgement of an intravenous infusion device.
Mitt restraints
A device used to protect confused clients from scratching or injuring their skin, or dislodging intravenous access devices. AKA hand restraints
Hand restraints
A device used to protect confused clients from scratching or injuring their skin, or dislodging intravenous access devices. Also called mitt restraints.
Electrcardiography
A diagnostic test of cardiac function
Pericardium
A double layer of fibroserous membrane covering the heart
An example of a nondisciplinary action the Board may take is: A decree of censure A civil penalty A conditional license A letter of concern
A letter of concern
If the Board believes that there is insufficient evidence to support a disciplinary action but sufficient evidence to notify a licensee or certificate holder of its concern, the Board may issue: A letter of admonition An administrative penalty A decree of censure A letter of concern
A letter of concern
What is a fissure?
A linear crack in the skin ex. chapped lips and athlete's foot
What else is concept mapping?
A method of planning care. This can be realistically completed during your patient care shift. This addresses the patient as a holistic being.
Self-Actualization Needs
At this level of the Needs hierarchy an individual can strive to develop her maximum potential and fully realize her abilities and qualities.
Pulmonary circulation
Consists of: rt side if heart, pulmonary artery,pulmonary capillaries, pulmonary vein,
Full Spectrum Nursing
A unique blend of thinking, doing, and caring for the purpose of affecting good outcomes from a patient situation
Atrophy
A wasting or decrease in size or physiologic activity of a part of the body because of disease or other influences (such as lack of physical evidence)
Pulse
A wave of blood created by contraction of the left ventricle of the heart
Moral Distress
A phenomenon in which one knows the right action to take, but is constrained from taking it.
Clinical decision making
A process nurses use in the clinical setting to evaluate & select the best actions to meet desired goals
Empowerment
A process whereby the client develops the autonomy to identify her own health needs in lieu of being instructed how to do so.
Quality and safety education for nurses
A program designed to identify and standardize the six core competencies of nursing: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Humanism
A progressive philosophy of life that, without theism and other supernatural beliefs, affirms our ability and responsibility to lead ethical lives of personal fulfillment that aspire to the greater good of humanity.
What is a pustule?
A pus-filled vesicle or bulla ex. acne or impetigo
Cicatrix is another name for?
A scar, a skin mark left after healing wound or lesion
Inquiry
A search for knowledge or facts when a nurse uses inquirt examines objective info to gain clarification & find solutions to problems
Under the definition of delegation, a nurse may delegate: Decision making and nursing judgment to other licensed nurses To any person whose job description includes the delegated activity All assessments except the initial assessment A selected task to a competent person
A selected task to a competent person
Wellness
A state of well-being involving sound nutrition, regular physical fitness, stable emotional health, self-responsibility, dynamic personal and professional growth, and preventive health care.
Wrong-site surgery (WSS)
A surgical operation that is performed at the wrong location on a client's body due to error.
Pneumothorax
Air trapped outside the lung in the pleural space placing pressure on the lung tissue and causing atelectasis or "collapsed lung"
Hypoxemia risk factors
Airway obstruction or constriction (as in asthma or allergic reaction) Altered oxygen transport Impaired circulation
Five phases of the nursing process:
ADPIE A= Assessment *collect, organize, and validate data D= Diagnosis *analyze data, Identify health problems, risk and strengths. Formulae diagnostic statements P= Planning *prioritize problems/diagnosis. Formulate goals/desired outcomes. Select and write nursing interventions. I= implementation *reassess, determine the need for nurses assistance, implement the nursing interventions, supervise delegated care, document nursing activities, administering meds. E=Evaluation *collect data related to outcomes, compare data w/ outcomes, relate nursing actions to client outcomes, draw conclusions about problem status, continue, modify or terminate the clients care plan.
BENNER'S LEVEL 2 OF CLINICAL COMPETENCE
ADVANCED BEGINNER * New Graduate. * Have limited experience. * Thinking like a nurse at this point.
Beta agonists
Beta agonists such as albuterol and levalbuterol act as bronchodilators. Tachycardia is a common side effect that may cause the client to feel anxious. This effect is less prominent with levalbuterol.
What are some indicators of good nutritional status?
Alert, energetic, good endurance, good posture, good attention span, psychological stability, weight within range for height, age and body type, no skeletal changes, eyes bright and clear, shiny hair, skin glowing, elastic, good turgor, smooth, healthy reflexes
comfort
Cells and tissues, inadequately supplied with oxygen for a sufficient time, will die. This condition is called ischemia. Ischemic events can cause significant pain.
CLABSI
Central line-associated bloodstream infections
NURSING PROCESS = PROBLEM SOLVING STEP 1
ASSESSMENT EX: Nurse admits a 4 yr old client. Suspicion of Asthma. He can't breathe well. Dad smokes, and he played with neighbors cat...
Intellect
Ability to learn & understand knowledge capacity for thinking & reasoning intelligently
Define adventitious sounds
Abnormal breath sounds heard during auscultation of the lung fields which may include crackles, wheezes or pleural friction rubs
Contracture
Abnormal, usually permanent condition of a joint characterized by flexion and fixation and caused by atrophy and shortening of muscle fibres
Define kyphosis
Abnormally increased forward curvature of the upper spine
Tachypnea
Abnormally rapid breathing. Greater than 20 breaths per minute in adults
bradypnea
Abnormally slow respirations. Less than 10 per m
Isoelectric line
Absence of electrical activity is represented by a straight line
Muscles of respiration Function
Accessory muscles play a major role, especially during periods of increased oxygen demand and with certain pathological conditions.
Reflection
Action of making sense of occurrences situations or desicions by carefully considering the totality of the experience
What is spiritual care?
Actions used to assist the client in meeting spiritual needs
Self-Care
Activities an individual performs independently to ensure personal well-being and good health.
TYPES OF NURSING DIAGNOSES
Actual, Risk, Health Promotion
This type of pain is usually associated with a recent injury
Acute pain
What are the three classifications of pain?
Acute pain, chronic nonmalignant pain and cancer pain
Holistic Nursing
All nursing practice that has healing the whole person as its goal. (may include but not limited to complementary and alternative medicine)
CRITICAL THINKING
All or part of the process of questioning, analysis, synthesis, intuition, application, and creativity.
Critical thinking
All or part of the process of the process of questioning analysis synthesis interpretation inference inductive & deductive reasoning intuition application & creativity
AHNA
American Holistic Nurses Association
Cardiac output
Amount of blood pumped by ventricles into pulmonary and systematic circulations in 1 min.
What is a cyst?
An encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis
What is an adverse event?
An illness or injury caused by medical management rather than the underlying disease. More than 50% are preventable
Polycythemia
An increase in red blood cells in an effort to increase the amount of hemoglobin available for oxygenation
Myocardial hypertrophy
An increase in the size of muscle cells of the myocardium
Lead
An insulated wire
Define estropia
An inward turn of the eye
Foramen ovale
An opening between the atria of the fetal heart
NOC (Nursing Outcomes Classification)
An outcome is defined as the status of the patient or family that follows and is directly influenced by nursing interventions.
Define exotropia
An outward turn of the eye
Diagnoses
Analysis of subjective and objective data to make a professional nursing judgement
cellular regulation
Anemias: Blood loss G6PD Aplastic
dyspnea manifestations
Anxiety Apparent distress Flared nostrils Posturing
Hypoxemia manifestations
Anxiety Visible retraction of ribs and chest wall Cyanosis Posturing
Restraints
Any devices or medications intended to protect the client from injuring self or others through partially or fully limiting the client's mobility.
The purpose of the comprehensive health assessment is to
Arrive at conclusions about the client's health
Where is S1 best heard?
At the apex of the heart
Where is S2 best heard?
At the base of the heart
Why is it important to only palpate one carotid artery at a time?
Bilateral palpation of the carotid arteries can result in reduced cerebral blood flow
What is the objective component of a nutritional assessment?
Anthropometric measurements are used to evaluate the client's physical growth, development and nutritional status as well as physical examination and hydration assessment
Anticholinergics
Anticholinergics such as ipratropium bromide block the response of the parasympathetic nervous system thereby relaxing the smooth muscle of the airways and reducing the production of secretions. Common side effects are dry mouth, headache, and bronchitis
Physical restraints
Any manual method, material, device, or equipment that is attached to the client's body with the intention of limiting or restricting free movement of the client's head, arms, legs, or body.
When to be concerned
Anything above 40% or 4 liters of oxygen
What are the 5 sites of auscultation for normal heart sounds?
Aortic area, pulmonic area, erb's point, tricuspid area and mitral (apical) area
Point of maximal pulse (PMI)
Apical pulse is a central pulse
In 2009, the date for renewing a license was changed from July 1 of the year of expiration to: January 1of the year of expiration October 1 of the year of expiration The last day of the birthday month of the licensee April 1 of the year of expiration
April 1 of the year of expiration
Define stupor
Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
Arterial blood gas
Arterial blood gas (ABG) measures the pH, oxygen saturation (SaO2), which is oxygen bound to hemoglobin, free oxygen (PaO2), carbon dioxide (PaCO2) and bicarbonate (HCO3) in an arterial blood sample.
Compliance
Arteries ability to contract and expand
INQUIRY
Ask WHY! We need to ask questions. We need to be curious. We need to understand things, so we ask questions.
A nurse who administers anesthesia must do so: When there is an anesthesiologist available to handle emergencies At the direction and in the presence of a physician or surgeon In collaboration with a licensed physician or surgeon Only after being certified by the Board
At the direction and in the presence of a physician or surgeon
Evaluation
Assessing whether outcome criteria have been met and revising the plan of care if necessary
NURSE "ADDIE"
Assessment Diagnosis Develop a Plan Implement a Plan Evaluate a Plan
Phases of the nursing process
Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation
Name the five steps of the nursing process
Assessment, diagnosis, planning, implementation and evaluation
A nurse tells a patient that they are very attractive and the nurse would be interested in dating the patient. The nurse is: Violating the confidentiality of the patient Attempting to engage in a dual relationship Failing to safeguard a patient's welfare Intentionally causing emotional injury
Attempting to engage in a dual relationship
6 Attitudes of Critical Thinkers
Attitude is everything! Independence Fair Mindedness Aware of Self-Limits Integrity Perseverence Confidence I-F-A-I-P-C I-IF-CAP I will be smarter IF I put on my critical thinking CAP
What are the components of a complete health history?
Biographic data, reasons for seeking health care, history of present health concern, past health history, family health history, review of body systems (ROS) for current health problems, lifestyle and health practices profile, developmental level
HOW DO YOU START A CONCEPT MAP? STEP #1
Blank sheet of paper. In the middle write the reasons your patient needs health care * Gender, Age, Day of stay, medical/admitting dx, pertinent medical history.
Orthostatic hypotension
Blood pressure that falls when client sits or stands
What amplitude do each of the 3 breath sounds have?
B-loud, BV-moderate, V-soft
How to we develop a concept map?
Begin with our initial data collection (Info from their chart, why they are seeking care, pertinent health history) Patient report at change of shift (Nurse reporting off - SBAR reporting or bedside reporting) We go into the room with the nurse and there is a handoff at the bedside is how most hospitals are doing this nowadays. Conduct a patient assessment. *This allows you to further develop a basic skeleton diagram of the reason your patient needs care.
Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)
Bell of stethoscope
Hypotension
Below normal blood pressure reading
Thoracic wall
Babies and small children are more likely to exhibit intercostal retraction than adults. Barrel chest Asymmetry Intercostal retraction
Supine Position
Back-lying position used for examination of the abdomen (with one small pillow under the head and another under the knees); this position also allows easy access for palpation of peripheral pulses
Lithotomy Position
Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
HOW DO YOU START A CONCEPT MAP? STEP #5
Based on the info that we have gathered so far, we need to know: * What are your interventions? * Don't forget to include both nursing & collaborative interventions. EX: Position in semi-fowlers for comfort, offer ice chips (as ordered) and mouth swabs, inspect mouth, nose, lips for integrity q4, apply lip jelly as needed, assess and treat nausea, assess abd q4 hr and document bowel sounds, measure the NG output q4 hr, Reassure patient frequently, provide a calming environment, encourage ambulation, evaluate labs daily.
cellular regulation nursing implications
Be alert to signs/symptoms of fatigue, pal- lor, jaundice, tachycardia. Anticipate need for vitamin supplements, blood transfusions, dietary changes. Consider activity intolerance
independent interventions, therapies for pulmonary circulation
Breathing exercises promote ventilation and perfusion. They also help the client to gain control of his or her breathing pattern. This will help the client avoid alterations to oxygenation secondary to tachypnea as a response to pain or anxiety for example, or bradypnea (slow respirations; less than 10 breaths per minute in an adult) as a side effect of narcotic administration.
What breath sound is short during inspiration and long during expiration?
Bronchial
Which normal breath sound is heard when auscultating next to the trachea?
Bronchial sounds are heard when auscultating next to the trachea. Vesicular sounds are heard when listening to the lung fields. Stridor and rhonchi are adventitious breath sounds.
What are the three types of normal breath sounds?
Bronchial, bronchovesicular and vesicular
Respiratory Medications
Bronchodilators Anti-inflammatory agents Nasal Decongestants Antihistamines Cough suppressants/Expectorants Antibiotics/Antifungals
Bronchoscopy
Bronchoscopy allows visualization of the interior of the trachea and bronchi through a fiberoptic scope inserted through the mouth. Measures of perfusion: Miscellaneous studies:
What breath sound is the same during inspiration and expiration?
Bronchovesicular
Pulse-Ox
Device that measures the oxygen saturation of arterial blood in a subject by utilizing a sensor attached typically to a finger, toe, or ear
BENNER'S LEVEL 5 OF CLINICAL COMPETENCE
EXPERT * Many years of experience * Intuitive practitioner * Highly developed cognitive abilities.
respiratory acidosis nursing implications
Client c/o headache, irritability, ↓ LOC, flushed skin. Important in chest trauma, aspiration, pneumonia, OD. Be alert in clients with problems r/t airway clearance, limited ambulation, anxiety or signs/symptoms of ↓ O2
What is the subjective component of a nutritional assessment?
Client interview which may include a 24 hour dietary recall
Normal findings for level of consciousness
Client is alert, awake and orientated to time, place, date and purpose. Responds to questions and answers appropriately
Prone Position
Client lies on abdomen with head turned to the side; may be used to assess back and mobility of hip joint
Define obtunded
Client opens eyes to loud voice, responds slowly with confusion and seems unaware of environment
Define lethargy
Client opens eyes, answers questions and falls back asleep
Define coma
Client remains unresponsive to all stimuli, eyes stay closed
CRBI
Catheter-related bloodstream infections
The vertebra prominens is also called
C7
One way the Board ensures that nursing assistants who renew their certificates are competent and qualified is to require: A criminal background check on each CNA CNAs not employed to retake and pass the manual skills exam CNAs practice 160 hours in the past 2 years CNAs practice 960 hours in the past 5 years
CNAs practice 160 hours in the past 2 years
BENNER'S LEVEL 3 OF CLINICAL COMPETENCE
COMPETENT *Typically after 2-3 years experience. * We have intentional planning of care.
osteoporosis
Cause by calcium leaving the bones, need higher calcium and vitamin D diet
Theory of Human Care
Calls for a philosophy of moral commitment toward protecting dignity and preserving humanity while acknowledging the interconnectedness of individuals and employing the 10 clinical caritas.
This type of pain is usually due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemo, radiation or tumor growth and infiltration
Cancer pain
bradypnea risk factors
Cardiac failure Morbid obesity Narcotic or benzodiazepine or depressant overdose
Cardiac index
Cardiac output adjusted for the client's body size
MANAGING CARE
Care Coordination, Cost-effective Care, Delegation - We as nurses coordinate their care including client preferences, time constraints, resources and expertise of other disciplines. NURSING CARE IS ACHIEVED THROUGH THE COORDINATION OF MANY FACTORS.
Benner and Wrubel's Theory of Caring
Care is primary, sets up what counts as stressful, as well as what counts as coping and cannot be divorced from situation, physical environment, nurse training, nurse experience, or client perspective/capacity
Boykin and Schoenhofer's theory of caring focuses on the idea that?
Caring is an ongoing process that continually changes and evolves. Caring enables the nurse to nurture others.
Implementation
Carrying out the plan of care
COLLABORATION
Case Management & Interdisciplinary Teams - Many disciplines need to contribute to the care of our clients. TEAMWORK. Us + Doctors + other nurses + CNA's + Others.
Integrity
Challenge our own ideas and ways we perform our nursing care. Evaluate inconsistencies within our own practice. We need to pick the RIGHT thing over the POPULAR thing. Own up to our mistakes and using them to improve.
Integrity
Challenges own ideas and methods of doing nursing care, Evaluates inconsistencies within own nursing practice, Chooses the right thing to do over the popular thing to do.
Define the "COLDSPAA" accronym
Character, Onset, Location, Duration, Severity, Pattern, Associated factors, how it Affects the client
Diagnostic testing
Chest x-ray Computed tomography Ventilation-perfusion scans Positron Emission tomography Pulmonary Function Test
Chest x-ray
Chest x-ray shows a two-dimensional image of the chest cavity. It shows bony structures, fluids, or masses.
breathing pattern seen in individuals with congestive heart failure, increased ICP, and drug overdoses.
Cheyne- Stokes is characterized by deep, rapid breathing and slow,, shallow breathing with periods of apnea.
Discuss why children are at particular risk for preventable injury in healthcare.
Children are susceptible to injury due to pharmaceutical dosing and efficacy studies in children, affects throughout different stages of development, and dosages based on age, weight, and body surface area.
This type of pain is usually associated with a specific cause or injury and described as a constant pain that persists for more than six months
Chronic nonmalignant pain
The nurse in the emergency department is assessing an adult client with emphysema. What symptoms of emphysema would not be obvious from inspection and direct observation by the nurse? Barrel chest Shortness of breath Hyperresonance sounds from the lungs Pursed-lip breathing and clubbing of fingers
Clients with emphysema and COPD would have hyperresonance sounds during an assessment using percussion. These sounds would not be obvious on inspection or observation. A client with emphysema may be obviously short of breath, even at rest. A barrel chest is common in those with emphysema and would be obvious on inspection, even if the client has a shirt on. Pursed-lip breathing and clubbing of the fingers can be observed without palpation, auscultation, or percussion.
Nursing Diagnosis
Clinical judgement about individual, family or community responses to actual or potential health problems and life processes
The use of this type of question can keep a client interview from going off track
Closed-ended
CDI
Clostridium difficile- associated infections
1st heart sound (S1)
Closure of the AV valves produces the S1 sound
What is the S2 sounds?
Closure of the aortic and pulmonic valves (relaxation, diastole)
Nail beds
Clubbed nails occur in the setting of chronic hypoxia. Be aware of client history. Blue or gray color Clubbed nails with an angle greater than 180 degrees
reflecting (tanners model)
Cognitively reviewing a clinical situation, considering appropriateness of assessment data obtained in the situation, actions taken, and positive and negative outcomes for client, making mental response adjustments to be done in future similar situations, learning from actions (done or not done)
Atelectasis
Collapsed or airless ling
Assessment
Collecting data Using a systematic and ongoing process Categorizing data Recording data
Assessment
Collection of subjective and objective data
Name the four major steps of the assessment phase
Collection of subjective data, collection of objective data, validation of data and documentation data
Clinical judgement
Combones critical thinking abilities evaluative decision making & nursing experience to determine appropriate responses to a client's complex & often layered situation to achieve the best client outcomes
Theoretical basis of concept mapping
Comes from the fields of education Aka cognitive maps & mind maps
Clinical Decision Making STEP 3
Compare Pro's and Cons of each alternative or solution and evaluate them all. EX: O2 helps breathe easier... repositioning might not help... Do something and see if it DID/DID NOT work... Did it work on this patient??
Six Cs of Caring
Compassion, Competence, Confidence, Conscience, Commitment, Comportment
ACCOUNTABILITY
Competence - We have standards to meet in regard to our expectations. We are responsible for clinical decisions and judgements that we make. WE ARE ACCOUNTABLE FOR THE DECISIONS WE MAKE
CAM
Complementary and Alternative Medicine
To administer anesthetics, a nurse must: Be a certified registered nurse anesthetist Complete education specific to the agent administered Be supervised by an anesthesiologist Complete an accredited nurse anesthesia program
Complete an accredited nurse anesthesia program
A physician tells you that she would like to challenge the RN licensure exam (NCLEX) so she can work as an RN on the weekends. You would tell the physician that in order to do this she would need to: File a direct petition with the Board Take NCLEX review and refresher courses Inactivate her physician license Complete an approved nursing program
Complete an approved nursing program
Complete blood count (CBC)
Complete blood count (CBC) shows the quantity, type, and morphology of red and white blood cells and platelets in a blood sample. It is used in the diagnosis of anemia and infection.
HOW DO YOU START A CONCEPT MAP? STEP #2
Complete head to toe assessment and cluster your data using the "bubble" template or your choice of tool (we call it a concept map). * The clustered data represents the patient's specific reasons for seeking/needing health care * These can become your areas of focus for care. * You will select 2 priority focus areas of care.
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
Comprehensive
What are the three Professionalization of caring?
Connection Mutual recognition (counter balance fear) Involvement (advocate)
An activity that would meet the practice requirement of the Arizona State Board of Nursing would be: Raising children and attending to their needs Coordinating care and appointments for elderly parents Consulting on staffing plans with a health care facility Attending continuing education activities
Consulting on staffing plans with a health care facility
Five categories of Critical Thinking
Contextual awareness Inquiry Considering alternatives Examining assumptions Reflecting critically
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
Continuous
Cardiac cycle
Contraction and relaxation of the heart constitute one heart beat
Define crepitus
Crackling sensation like bones or hairs rubbing against eachother
What does Critical thinking have to do with Clinical Decision Making?
Critical thinking skills are used to make decisions.
Skin color in neonates
Cyanotic hands and feet are expected findings in neonates. Cyanosis, a blue, green, or gray coloring around the mouth or extremities.
Nursing Diagnoses
Describe the human response or a clients physical, sociocultural, psychological, and spiritual responses to an illness or a health condition. However, we ARE doing things for the doctor to treat the disease as well.
Wellness diagnosis
Describes human responses to levels of wellness in an individual family or community that have a readiness for enhancement
Health promotion diagnosis
Determination of the clients motivation and desire to increase well being and actualize human health potential as expressed by a readiness to enhance a specific health behaviors
If an applicant has an outstanding felony conviction during the 5 years before the application is received the Board shall: Deny the application based on the felony conviction Conduct an investigation into the circumstances of the felony Consider aggravating and mitigating circumstances Allow the applicant to withdraw the application
Deny the application based on the felony conviction
Nonrebreather
DELIVERS MOST OXYGEN/contains valve that does not allow any carbon dioxide into bag/10-15 liters or until bag inflates (100%)
Ischemic
Deprived of oxygen
NURSING PROCESS = PROBLEM SOLVING STEP 3
DEVELOP A PLAN Start with HOW DO WE KNOW WHEN THE PROBLEM IS RESOLVED?? Plan what we will do to help him breathe better.
NURSING PROCESS = PROBLEM SOLVING STEP 2
DIAGNOSIS (Nursing) State Specific prob: DIFFICULTY BREATHING
S2 can be described as this sound
DUB
writing an evaluation
Date and time evaluation was done, a conclusion statement about whether the goal was met, partially met, or not met, a supporting statement giving the results of how the client did or did not achieve the goal.
What is the taxonomy NANDA of nursing dx
Definition: system of identifying, naming and classifying phenomena-human responses Goal: to produce a workable classification system
It would be a violation of the nurse practice act for an RN to: Delegate assessment to an LPN Supervise the care of other RNs Delegate a sterile dressing change to an LPN Provide lab results to a client
Delegate assessment to an LPN
An RN license applicant was convicted of a Class 2 felony in 2007 and applies for licensure in 2009. The applicant will be: Given a civil penalty Placed on probation Denied a license Granted a conditional license
Denied a license
The Board may dismiss a complaint if it finds that the nurse: Did not commit a violation of the nurse practice act Did not intend to harm the patient Was unaware that the Board prohibited the activity Was not aware that a complaint had been filed
Did not commit a violation of the nurse practice act
Pulse pressure
Difference between the diastolic and systolic pressures
Dyspnea
Difficulty or pain with breathing
When converting pounds to kilograms what is the conversion factor?
Divide by 2.2
Victims of bullying should:
Document the incident, recording the date, time, location, and witnesses present for each episode, and report it to both the nursing manager and human resources.
COMMUNICATION
Documentation & Reporting - We use the clients plan of care to communicate priority of needs of the client. We use this to delegate too. We have to talk(communicate) with the clients too.
Independence
Does own thinking, objectively and honestly, Is open minded about different methods used to reach same goal, Looks for the facts; not easily swayed by opinions
Implementation Phase
Doing or Delegating Interventions are guided by regulatory organizations: The Joint Commission IMO State Board of Nursing, etc. Must include client values
Fair-mindedness
Don't be biased. EX: If someone is a frequent flier for pain meds, this time they might actually be in pain. EX: What if we were a nurse, and had to take care of the Boston Marathon Bomber?? We need to focus on taking care of this person regardless of why they are there.
Part of the examiner's hand used to feel for temperature
Dorsal surface of hand
HOW DO YOU START A CONCEPT MAP? STEP #8
EVALUATE!! Document patient responses throughout the day Evaluate your goals/outcomes and revise as necessary. -Did we meet our goal? - If not, how can I revise it? Changes or additions can be made to my map throughout the shift. Document patient responses to care in the chart.
NURSING PROCESS = PROBLEM SOLVING STEP 5
EVALUATION OF PLAN For past 12 hours his lung sounds have been free from wheezes and he's now clear. WE ARE NOT DONE BECAUSE WE NEED TO KEEP HIM CLEAR.
What is a wheal?
Elevated mass with transient borders size and color may vary. ex hives or insect bites
The Arizona State Board of Nursing is composed of: Nine members: 5 RNs, 2 LPNs and 2 public members Nine members: 4 RNs, 1 RN educator; 2 LPNs, 1 LPN educator and 1 public member Eleven members: 5 RNs, 2 LPNs, 1 NP or CNS, 1 CRNA and 2 public members Eleven members: 5 RNs, 2LPNs, 2 public members; 1 CNA or CNA instructor and 1 NP or CNS
Eleven members: 5 RNs, 2LPNs, 2 public members; 1 CNA or CNA instructor and 1 NP or CNS
3 Categories of The Maslach Burnout Inventory
Emotional exhaustion, Personal accomplishment, Depersonalization.
Barbara Carper's Four types of knowledge
Empirical, aesthetic, personal, ethical
Caring as the Human Mode of Being
Employs the six Cs (compassion, competence, confidence, conscience, commitment and comportment)
Stage 1 pressure ulcer
Erythema skin over bony prominences that remain for 15-20 mins and does not blanch
Which of the following is included in the definition of registered nursing (RN): Activities are performed under the direction and supervision of a physician Establishing a nursing diagnosis Managing the physical and psychosocial health status of clients Using research skills
Establishing a nursing diagnosis
What is the purpose of conducting a health history interview?
Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information and to gather information on the client's developmental, psychological, physiologic, sociocultural and spiritual statuses
Clinical Decision Making STEP 5
Evaluate the success of using the solution or alternative solution as to whether it fixed the problem.
Ectopic beats
Extra beats
Oxygen face masks
Face masks and trach collars are measured in percentages. Disadvantages of face masks: can't eat/drink, can get pressure ulcers
It is an act of unprofessional conduct for a nurse to: Fail to provide for the comfort of a patient's family Refuse to follow a physicians order Be absent for a scheduled shift without prior notice Fail to document the care the patient received
Fail to document the care the patient received
It would be unprofessional conduct for a nurse to: Fail to report another nurse with evidence of impairment while on duty Fail to arrive for a scheduled shift at a health care facility Practice nursing with a diagnosis of bipolar disorder Fail to honor an agreement to work for a hospital after accepting a scholarship
Fail to report another nurse with evidence of impairment while on duty
Why must subjective and objective data be verified?
Failure to validate data may result in premature closure of the assessment or collection of inaccurate data
Unprofessional conduct would include: Falsely claiming CPR certification on an employment application Failure to pay court ordered child support Posting nude pictures of oneself on an adultonly website Refusing a client assignment in a health care facility
Falsely claiming CPR certification on an employment application
Afterload
Force the ventricles must overcome to eject their blood volume
Explain the purpose of National Patient Safety Goals.
Formulated goals to assist accredited organizations with specific topics about client safety.
National patient safety goals (NPSGs)
Formulated goals to assist accredited organizations with specific topics about client safety.
The result of a nursing assessment is the
Formulation of nursing diagnoses
How often to infants get assessed?
Frequently in the first year. Look for eye contact b/w parent and infant and observe for negative patterns.
Where is the left upper lobe located?
From 3cm above the medial 1/3 of the clavicle to the 6th rib at the MCL to the 5th rib at the MAL to T3-T1
Where is the right middle lobe located?
From the 4th rib at the right sternal border to the 5th rib at the midaxillary line to the 6th rib at the midclavicular line
Where is the left lower lobe located?
From the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL
Unstageable
Full thickness tissue loss but are impossible to accurately stage due to the wound bed being completely obscured by eschar or excessive slough
stage 4 pressure ulcer
Full thickness, only involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone
What are the three variations in communication that must be considered as you interview clients?
Gerontologic, cultural and emotional
NOTICING (TANNER CLINICAL JUDGEMENT MODEL)
Having a sense of what is happening. You see, smell, hear, notice things. EX: WHAT DID I NOTICE? I walking into the patients room... or home... Pt is 4 days postop following abdominal surgery... On IV abx... Reports gas....
Electrocardiogram (ECG)
Graphic record of heart's activity
Heart murmur
Harsh blowing sounds caused by disruption of blood flow into heart, between chambers, or into systems
Fair-mindedness
Has neutral judgments without bias, Considers opposing views to understand all aspects before making decisions, Is open to new ideas and ways of doing things.
Perseverance
Has stick-with-it motivation to find the best solution for quality client outcomes, Is patient with processes.
noticing (tanners model)
Having a sense about what is happening in the client situation, may include recognition of or absence of expected significant cues from the client's response to illness or medical condition, includes influences of the nurse's own health beliefs about client situations and expectations of the work culture for client care
Trendelenburg
Head low and body and legs elevated on an incline
Semi fowlers
Head of bed raised approximately 30 degrees
Fowlers
Head of the bed raised 45 to 60 degrees
HAP
Healthcare associated pneumonia
Healthcare-associated infections (HAI)
Healthcare-associated infections (HAIs) (2704) Infections associated with the delivery of healthcare services in a facility such as a hospital or nursing home. AKA nosocomial infections.
Bradycardia
Heart rate less than 60 bpm
Cardiac reserve
Hearts ability to respond to an increase in strenuous activity and adjust
cellular regulation
Hemoglobin is a protein that makes up most of each red blood cell. Its function is to carry oxygen to the other cells in the body. When hemoglobin is decreased for any reason such as blood loss, or from inherited or nutritional anemia, less oxygen is carried to the cells. Impaired cardiac function may also result in systemically decreased perfusion.
What pitch do bronchial sounds have?
High pitched
What are the four sections of the nursing assessment framework?
History of present health concern, past health history, family history and lifestyle and health practices
What sort of approach do we take when making a care map?
Holistic approach.
Oxygen flow meter
Hooks to nasal cannula/found in all hospitals/measured in liters
This fissure seperates the RUL from the RML
Horizontal fissure
Prone
Horizontal position when lying face down
Roach's Theory of Caring focuses on?
Humans being caring entities and that all nurses share the same caring traits. These traits are known as the six C's
The Nurse Practice act authorizes the board to adopt rules for nurse practitioners to practice: In collaboration with one or more licensed physicians As fully autonomous licensed professionals Within a scope of practice similar to a physician Within a framework of delegated medical acts
In collaboration with one or more licensed physicians
Where are vesicular sounds heard?
In the peripheral lung fields
acid-base balance
In the presence of tachypnea, excessive CO2 is expelled from the body, which triggers a series of metabolic events that raise the cellular pH in the body. This is called respiratory alkalosis. In the presence of decreased ventilation, CO2 accumulates, leading to decreased cellular pH and respiratory acidosis.
A nurse practicing nursing on a compact license from another state must abide by the nurse practice act In the state where the patient is located In the nurse's home state In the state that is most applicable to the patient situation In either the home state or the state where nursing is practiced
In the state where the patient is located
Where are bronchial sounds heard?
In the trachea and thorax
If a nurse from a compact state changes their primary state of residence to Arizona they should: Inform the Board if they will be practicing on the compact license issued by the original state Obtain an additional compact license in Arizona within 60 days Inactivate their home state license and obtain an AZ compact license within 30 days Continue to practice on the compact license from the other state until expiration
Inactivate their home state license and obtain an AZ compact license within 30 days
An ongoing or partial assessment of a client
Includes a brief reassessment of the client's normal body system
The definition of unprofessional conduct: Is limited to acts committed in this state Is limited to acts performed on duty as a licensee or certificate holder Includes any conduct that may be harmful to the public Includes all misdemeanor offenses
Includes any conduct that may be harmful to the public
Nursing diagnosis
Ineffective Breathing Pattern Impaired Gas Exchange Ineffective Airway Clearance Risk for Aspiration
Phlebitis
Inflammation of a vein
Inhaled corticosteroids
Inhaled corticosteroids such as butesonide and mometasone furoate reduce airway inflammation. These are often formulated in combination with beta agonists when used to control moderate to severe persistent asthma.
Contractility
Inherent capability of cardiac muscle fibers to shorten
What are the four basic types of assessments?
Initial comprehensive assessment, ongoing or partial assessment, focused or problem oriented assessment and emergency assessment
An example an additional act that may be performed by an RN that requires additional education and training as prescribed by the Board and that is recognized as proper to be performed by an RN (excluding advanced practice nurses) would be (hint: see advisory opinions): Insertion of an intraarterial catheter Amniotomy Certification of Death Epidural Anesthesia
Insertion of an intraarterial catheter
Name the four basic techniques used for physical assessment
Inspection, palpation, percussion, auscultation
6 CRITICAL THINKING SKILLS
Intellect, Creativity, Inquiry, Reflection, Intuition, Reasoning
What is Assessment?
It is a systematic continuous data collection carried on through all phases of the nursing process. Focused on clients response to health problem.
KSA for patient centered care
Knowledge: Exhibit comprehension of pain and suffering as well as physiological modes of pain and comfort Skills: Evaluate levels of client pain and suffering as well as client emotional and physical comfort; assess client and family's expectations of pain relief Attitudes: Acknowledge the nurse's position as a source of pain relief and treatment; acknowledge that client expectations can affect outcomes
Aware of self-limits
Knows limits of intellect and experience, Seeks new knowledge or skills in current evidence, Expresses a willingness to self-reflect on own beliefs and ideas.
Confidence
Knows that he knows what he knows. Trusts the skills and abilities of intellect, creativity, inquiry, reasoning, reflection, and intuition
S1 can be described as this sound
LUB
Nasal cannulas
MOST COMFORTABLE/anything above 3 liters you must have humidity
Clinical Decision Making STEP 2
List all possible alternatives & information about them. EX: Reposition them: This opens airway. OR Put some O2 on them (You CAN do this without an order). OR check to see if Neb is ordered...
Defining Characteristics (AEB) (PART #3)
Look at both SUBJECTIVE & OBJECTIVE We will already know these from our Assessment. EVIDENCE: What the pt says or what we observe (HR, BP, etc) EX: Report of fatigue/weakness, abnormal HR, BP response to activity, ECG, SOB, etc... We don't have to stay within what is listed on page 219 in our Nursing Diagnoses book. These are examples. We can word things somewhat how we want. Include as much as you can!!
REFLECTION
Look back for improvement ideas. How could we have done things differently, or better. Did this work? Did it not work?
Identify 3 age related changes that occur within the lungs
Loss of elasticity, fewer functional capillaries and loss of lung resiliency
What pitch do vesicular sounds have?
Low pitched
Pulmonary circulation
Low pressure system
What factors influence dietary habits?
Lower socioeconomic status, long working hours and fast food consumption, poor food choices, chronic dieting, chronic diseases, dental issues, limited access to sufficient food, eating disorders, illness or trauma
Hypoxemia
Lower than normal amounts of oxygen in the blood
Lithotomy
Lying supine with hips and knees flexed and thighs abducted and rotated externally
Abduction
Movement of an extremity away from the midline of the body
Adduction
Movement of an extremity toward the axis of the body
Flexion
Movement of certain joints that decrease the angle between two adjoining bones
When converting inches to centimeters what is the conversion factor?
Multiply by 2.54
A swishing sound caused by turbulent blood flow throught the heart valves or great vessels
Murmur
Muscles of respiration
Muscles of the thoracic cage (internal and external costal), diaphragm, accessory muscles (trapezius, scalene, sternocleidomastoid), abdomen (rectus), and chest (pectorals).
NANDA (North American Nursing Diagnosis Assosciation)
NANDA International is a professional organization of nurses whose goal is to standardize nursing terminology by developing, researching, disseminating and refining the nomenclature, criteria and taxonomy of nursing diagnosis
HOW DO YOU START A CONCEPT MAP? STEP #6
NEXT IS A NURSING DIAGNOSIS Analyze each area of focus What are the possible nursing diagnoses Develop your diagnosis EX: Imbalanced nutrition - Less than body requirements R/T inability to ingest food x 4 days AEB NPO status, absent bowel sounds and NG to LIS.
BENNER'S LEVEL 1 OF CLINICAL COMPETENCE
NOVICE: *Beginner without experince.
If applying for initial registered nurse practitioner (RNP) certification after July 1, 2004 the applicant must possess: A doctor of nursing practice (DNP) degree Proof of completion of an advanced practice educational course National certification as a nurse practitioner Proof of a supervisory relationship with a physician
National certification as a nurse practitioner
What preparation is required for conducting a physical assessment?
Necessary equipment and how to use it, preparing the setting, onself and the client for examination and how to perform the four basic assessment techniques
Belonging and Love Needs
Needs at this level are fulfilled by relationships with family, friends, and colleagues and are particularly important to nurses, who depend on solid support networks to help them talk through and cope with pressures of work.
Safety Needs
Needs at this level have both physical and psychological aspects, which include the body, financial security, and personal health.
Self-Esteem Needs
Needs at this level include feelings of confidence, independence, competence, respect and achievement.
Physiological Needs
Needs at this level include the necessities of food, water, air, sleep and shelter.
Respiratory rate in breaths/min counted over 60 seconds various populations
Neonates: 30-60 Infants: 20-40 Children: 16-20 Teens: 12-20 Adults: 10-20 Older adults: 12-24
Coronary circulation
Network of vessels that supply the heart muscle
Normal Respirations
Newborns 30 to 50 Preschool and school age 20 to 30 Adults 12 to 20
Are the lymph nodes normally palpable?
No
NANDA
North American Nursing Diagnoses Association This is a group of people that determine our nursing diagnoses.
Graduates of approved nursing programs, who are not yet licensed, may use the title (hint: see advisory opinions): Graduate Nurse Nurse Trainee Nurse Extern Nursing student
Nurse Extern
A person can practice nursing in Arizona without an Arizona or multistate compact license when the person is a: Nurse with a license in good standing in any other US state or territory Nurse licensed in another state and employed by the federal government Nurse licensed in another state and still in orientation at a health care facility New graduate of a Boardapproved nursing program before taking the licensure exam (NCLEX)
Nurse licensed in another state and employed by the federal government
The Board ensures that nurses who renew their licenses are competent and qualified by requiring: A criminal background check and continuing education Inactive nurses to retake and pass the NCLEX exam Nurses to meet a practice requirement or take a refresher course Nurses who do not work at the bedside to take a refresher course
Nurses to meet a practice requirement or take a refresher course
The Arizona State Board of Nursing has authority over: Nursing students and certified nursing assistant students Nursing education programs leading to initial licensure or certification All college undergraduate and graduate nursing programs Continuing education nursing programs
Nursing education programs leading to initial licensure or certification
NIC (Nursing Interventions Classification)
Nursing interventions are "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes." These interventions may include direct or indirect care and may be initiated by a nurse, a physician, or another care provider. NIC is an additional opportunity for clarifying and organizing what nurses do
nutritional therapy
Nutrition can be inadequate for clients experiencing altered oxygenation. Use of accessory muscles for breathing leads to increased calorie expenditure while fatigue may lead to anorexia or insufficient endurance for finishing meals. Anemia is often a consequence of iron and B vitamin deficiency. A clinical nutritionist may review the client's status and make recommendations for smaller, more frequent meals, supplements, and foods containing iron and B vitamins. The nurse should assist the client in accomplishing his or her nutrition plan.
This fissure seperates the RML from the RLL as well as the LUL from the LLL
Oblique fissure
Where are bronchovesicular sounds heard?
Over the major bronchi: between the scapulae, around the upper sternum in the first and second ICS
PERRLA
P : pupils clear E: equal in size (3-7mm) R: Round RL: (reactive to light) A: Accommodation
What is P.A.S.S.?
P= pull the pin A- AIM S= Squeeze S= sweep
BENNER'S LEVEL 4 OF CLINICAL COMPETENCE
PROFICIENT * Can see whole picture * Formulates own rules for actions by analyzing significant cues.
comfort -concepts
Pain from ischemic events including: Cerebral Cardiac • Pediatric congenital issues such as heart defects • Adult infarcts, congestive failure, valvular issues, cardiomyopathy Shock states Pulmonary
Describe the subjective components of the pain assessment
Pain is whatever the client says it is, directly quote description of pain use COLDSPA mneumonic
Sitting Position
Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities
Standing Position
Position used to examine male genitalia and to assess gait, posture, and balance
positioning
Positioning is useful in improving oxygenation. Upright positions allow greater thoracic expansion as they reduce the effects of gravity on the anteroposterior chest. Clients in Fowler's or high-Fowler's position are also at reduced risk of aspiration.
creativity
Possess knowledge about the problem, can assess the problem, use knowledge of underlying facts and principles that apply to the problem, take risks to come up with creative solutions
Referral Problem
Problem that requires the attention or assistance of other health care professionals
It is a class 6 felony to: Advertise being a nurse when selling a healthrelated product Use the RN or LPN title when conducting personal business Practice registered or practical nursing without a license Defaults on a student loan while holding an RN or LPN license
Practice registered or practical nursing without a license
The Board may issue an administrative penalty to a nurse who: Practices nursing with an expired nursing license Commits a onetime act of unprofessional conduct Fails to disclose complete information on an application Submits payment to the Board with insufficient funds in the account
Practices nursing with an expired nursing license
It is within the scope of practice for a clinical nurse specialist (CNS) in Arizona to: Prescribe overthecounter drugs Establish a medical diagnosis Prescribe durable medical equipment Perform radiography
Prescribe durable medical equipment
It would be a violation of the nurse practice act for a registered nurse practitioner (RNP) to: Prescribe narcotics to a chronic pain client Prescribe in a different specialty than the RNP's certification Delegate the administration of parenteral drugs to a medical assistant Dispense controlled substances
Prescribe in a different specialty than the RNP's certification
Diatolic blood pressure
Pressure when the ventricles are at rest
Pulmonary vascular resistance
Pressure within the pulmonary blood vessels that must be overcome in order for blood to flow through the vessel
Interventions
Prevent Infection Promote smoking cessation Maximize Ventilation**** Prevent Aspiration Nutrition
The Board will open a complaint on a licensee only if the person making the complaint: Was an eyewitness to the events reported Discloses their identity and relationship to the licensee Is unrelated to the nurse and the complaint is not made in retaliation Provides information that the nurse violated the nurse practice act
Provides information that the nurse violated the nurse practice act
Knee chest
Pt kneels, weight of body supported by knees and chest, with abdomen raised, head turned to one side and ares flexed
Pulmonary functions tests
Pulmonary functions tests (PFTs) are performed using a device called a spirometer, which measures and records inspiratory, expiratory, total, and reserve lung volumes.
A difference between radial and apical pulses
Pulse deficit
Peripheral pulse
Pulse located away from the heart
Pulse oximetry
Pulse oximetry measures oxygen saturation through a bedside spectrometer applied to the client's finger, toe, or ear. The normal value is >95%
Define tachycardia
Pulse rate of greater than 100 beats per minute
Define bradycardia
Pulse rate of less than 60 beats per minute
Arrhythmia
Pulse with an irregular rhythm
Dysrhythmia
Pulse with an irregular rhythm
When testing accomodation of pupils what is the normal result?
Pupils constrict and eyes converge
When testing pupillary reaction to light what is the normal result?
Pupils should constrict in both eyes
Nursing interventions
Purpose: to achieve client outcomes Also called nursing actions, measures, strategies, activities Based on clinical judgment and nursing knowledge Reflect direct and indirect care
What is R.A.C.E.
R= remove anyone from the immediate area A= alert others and pull the manual fire alarm C=contain or confine E=Extinguish or evacuate
nursing diagnosis (nursing process)
RN are responsible for making nursing diagnoses, diagnoses may be made only after thorough assessment and documentation and analysis of data collected; it may describe health states, deviations from health, presence of risk factors and areas of enhanced personal growth
Pulse deficit
Radial pulse falls behind the apical rate
What should the nurse be assessing when observing respiration?
Rate, rhythm and depth
When assessing the pulse what should the nurse note?
Rate, rhythm, amplituded and contour
Which independent nursing intervention is most appropriate for a client experiencing tachypnea? A.Repositioning the head of the bed to less than 30 degrees B.Instructing the client to complete breathing exercises C.Suctioning the upper airway D.Administering oxygen
Rationale A client who is experiencing tachypnea will benefit from the nurse implementing breathing exercises, as they promote ventilation and perfusion. These exercises will also help the client gain control of the breathing pattern. Administering oxygen can only be done with a prescribed order and should be based on pulse oximetry readings. The nurse would reposition the head of the bed to greater than 30 degrees to help with dyspnea. Suctioning the airway is done for secretion clearance.
incorrect, 15.1.3post2 A nurse is participating in a free community health clinic. Which clients will the nurse identify as being at risk for compromised oxygenation? (Select all that apply.) A 56-year-old male who has been working at a textile factory This is the correct answer. A 64-year-old female with osteoporosis and limited mobility This is the correct answer. A 28-year-old male who smokes with a 10-pack/year history A 70-year-old female who eats a well-balanced diet and exercises daily A 46-year-old female with a history of anxiety attacks
Rationale Clients with occupations that cause them to inhale chemicals and dust are at increased risk for developing lung disease. Individuals who live a sedentary lifestyle have diminished alveolar expansion, placing them at risk for altered respiratory function. Additionally, musculoskeletal impairment such as kyphosis (which may result from osteoporosis) diminishes lung capacity. Clients who smoke are at risk for pulmonary and cardiac disease. High levels of anxiety can cause bronchospasms and the onset of bronchial asthma. Some clients hyperventilate in response to stress. The client's arterial oxygen levels rise, and the arterial carbon dioxide levels decline. Intake of a diet high in fat predisposes clients to cardiovascular disease.
The nurse is assessing an 8-year-old client during a well-child visit at a clinic. Which anatomical differences does the nurse expect to finding during the assessment process? (Select all that apply.) Smaller nasopharynx This is the correct answer. Atrophy of the tonsils Small mouth with large tongue Larynx and glottis lower in the neck Soft tracheal cartilage This is the correct answer. Review
Rationale Normal findings for the pediatric client from infancy until the age of 12 include a smaller nasopharynx, a small mouth with a large tongue, and soft tracheal cartilage. The nurse would expect to find enlarged tonsils; atrophy does not occur until after 12 years of age. The nurse would expect the larynx and the glottis to be higher in the neck, not lower.
An adult client returns from the postanesthesia care unit (PACU) following a laparoscopic appendectomy. The nurse checks the postoperative notes and determines which factor is most important with regard to the client's immediate oxygenation status? Amount of drainage on the surgical dressings in the last 1 hr Amount of narcotics the client received over the last 4 hr Amount of urine output over the past 4 hr Amount of intravenous fluid infused over the last 2 hr
Rationale The amount of narcotics the client received over the last 4 hr is of most immediate consideration. Narcotics depress the central nervous system, decreasing respiratory function and rate and thus placing clients at risk for alterations in respirations. While the other options are important areas to assess, they do not directly influence the client's respiratory status.
The nurse is interviewing and educating a client about anatomy and knows that the ribs and muscles surround the thorax, or the chest. What explanation by the nurse would describe the primary purpose of the ribs in the chest? A. To protect the lungs from external injury This is the correct answer. B. To aid in exhalation C. To push the lungs during deflation D. To aid in inspiration
Rationale The main job of the ribs is protecting the more fragile lungs and heart from injury during daily activity. Each set of ribs assists with respiration, but the primary purpose of ribs is to protect the lungs from puncture, bruising, and injury
The nurse is caring for a client who is receiving oxygen. Which intervention is appropriate by the nurse? Increasing the flow if the client requests Suctioning upper airways each shift Ensuring the client is comfortable with the manner of administration Assessing the client for anxiety
Rationale The nurse ensures that the client is comfortable with the manner in which the oxygen is being administered. There are several choices and the client should be consulted in terms of which method is most comfortable. The nurse should not increase the flow of oxygen at the client's request, as the flow is prescribed by the healthcare provider. Clients who are prescribed oxygen are at risk for depression not anxiety. Suctioning the upper airway should only be done as required, if at all.
The nurse is caring for a client with a thoracic catheter, also known as a chest tube. Which interventions are appropriate for this client? (Select all that apply.) Ensuring oxygen is available Monitoring for air leaks Reporting hyperresonance with percussion Assessing for pain Prescribing prn pain medications
Rationale When caring for a client with a thoracic catheter, the nurse would ensure that oxygen is available, monitor tubing for air leaks, and assess for pain. The nurse would not report hyperresonance with percussion, but would report tymphany or a hollow sound. It is outside the scope of nursing practice to prescribe pain medications.
The nurse is caring for a client with a pneumothorax. Based on the client's history, which is the most likely cause for this alteration in oxygenation? Asthma Obesity Trauma Pneumonia
Rationale While a pneumothorax may occur spontaneously, most occur as the result of trauma. Obesity can cause apnea. Asthma and pneumonia can cause orthopnea.
Confidence
Realize that we DO know a lot. Stand up straight - look them in the eye. Trust that what we've learned is enough!!
What methods are used to verify data?
Recheck objective data through reassessment, clarify with client by asking additional questions and compare your objective findings with subjective findings for discrepencies
A nurse can clarify a client's statements by
Rephrasing the client's statements
Ejection fraction
Represents the percent of the diastolic volume that is ejected from the heart during systole
RESPONDING (TANNER CLINICAL JUDGEMENT MODEL)
Respond to what you know/what you think you know. WHAT WILL I DO?? BASED ON ANSWERS TO THIS: Give Gas drops Monitor IV fluids Ambulate more - this gets things moving... Auscultate bowel sound every 8 hrs - Do they have them? If so - is gas med needed? THESE ARE DETERMINED WITHIN A FEW SECONDS... WEIGH ALTERNATIVES... MAKE A DECISION.
Belt restraints
Restraint used to ensure the safety of clients who are transported by wheelchair or gurney, or to protect patients confined to a bed or chair. Also called safety strap body restraint.
Safety strap body restraints
Restraints used to ensure the safety of clients who are transported by wheelchair or gurney, or to protect clients confined to a bed or a chair. AKA belt restraint.
The nurse who is convicted of a felony is subject to: A decree of censure Payment of a civil penalty Probation to ensure rehabilitation Revocation of the license
Revocation of the license
This lung lobe is located from the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL
Right lower lobe
Which lung lobe is located from 3cm above the medial 1/3 of the clavicle to the 4th rib at the right sternal border to the 5th rib at the midaxillary line to T3-T1
Right upper lobe
What is a SMART goal?
S - ACTION M- MEASURABLE A- ATTAINABLE R -RELEVANT T - TIME LIMITED
secretion clearance
Secretion clearance can be accomplished by promoting coughing and deep breathing or through mechanical suctioning of the upper airway. The need for mechanical suction is a nursing decision based on assessment findings such as obvious distress, persistent rhonchi, cyanosis, or oxygen saturation <95%.
Clinical Decision Making STEP 4
Select the best option or alternative to try. DO SOMETHING.
Subjective Data
Sensations or symptoms that can be verified only by the client (ex. pain)
Korotkoff sounds
Series of sounds heard when taking a blood pressure
What is religion?
Shared practices and rituals used to express one's faith
What is an ulcer?
Skin-loss extending past epidermis, necrotic tissue ex. pressure ulcer
anatomic differences in children and older adults
Smaller nasopharynx, easily occluded during infection. Tonsils and adenoids are enlarged and grow rapidly. These atrophy after age 12. Smaller nostrils are easily blocked. Smaller mouth and relatively large tongue increase risk of obstruction. Long, floppy epiglottis easily blocks the pharynx if swollen. Larynx and glottis are higher in neck, increasing risk of aspiration. The tracheal cartilage is softer and may easily collapse when neck is flexed. Fewer functional muscles in the airway and decreased ability to compensate for constriction or edema. Decreased soft tissue integrity and loosely anchored mucous membranes increase the risk of edema and obstruction. Narrow airways are more susceptible to inflammation and blockage through aspiration of small objects.
smoking cessation
Smoking cessation is an extremely important step toward improving respiratory and overall health. Nurses should quantify and document the client's use of tobacco as well as marijuana and other inhaled substances. Assess the client's interest in quitting. Encourage smoking cessation or reduction. Give positive feedback on efforts at cessation. Express confidence in the client's ability to quit. Provide strategies and resources for community support. Nicotine replacement may be requested from the provider. Remind the client that the more often they attempt smoking cessation, the more likely they are to succeed.
psychosocial aspects of supplemental oxygen
Some clients may feel they have lost their quality of life. The nurse can assist the client in understanding that supplemental oxygen will help the client maintain quality of life, and that the client can still participate in any number of activities. The nurse should be alert to any possible signs of depression in a client whose oxygen impairment is sufficient to warrant supplemental oxygen. Frustration, rising medical costs, and other issues can contribute to depression in a client with respiratory impairment.
Sputum culture
Sputum culture identifies microorganisms present in a sample of expectorated material.
Ejection fraction
Stroke volume divided by the end-diastolic volume
Components of a goal statement
Subject Action Performance criteria Target time Special conditions
dorsal recumbent
Supine position with patient lying on back, head, and shoulders, with extremities moderately flexed, legs may be extended
SSI
Surgical site infections
ASSESSMENT (Nurse Addie)
Systematic & continuous collection of data about a client
What is evaluation?
Systematic and ongoing process of examining whether expect outcomes have been achieved and whether nursing car has been effective.
S1 represents
Systole
If another nurse arrives for duty with alcohol on her breath, the nurse's first action should be to: Observe the nurse for other signs of impairment while she is working Call the Arizona State Board of Nursing for advice Notify the nurse's supervisor when she comes on duty Take measures to remove the nurse from patient care activities
Take measures to remove the nurse from patient care activities
Ray (theory of bureaucratic caring)
Take spiritual care into consideration focuses on caring in organizations influenced by organizational structure
What is included in the vital signs assessment?
Temperature, pulse, respiration, blood pressure and pain
When palpating lymph nodes what should the nurse be assessing?
Tenderness, mobility, size and shape
What does the positions test consist of?
Testing the six cardinal positions of gaze to assess for extraocular muscle weakness or dysfunction of the cranial nerve
What is the Romberg test?
Tests the client's equilibrium, client stands with feet together and arms at sides eyes open and then closed. Client should be able to maintain the position for 20 secs with minimal or no swaying
Describe why safety protocols were implemented after the 1999 Institute of Medicine (IOM) report "To Err is Human: Building a Safer Health System".
The (IOM) report did not single out individuals that made mistakes, but rather the system and work environment conditions. Every health care worker needs to be conscious of details while working with patients.
What does the AEB support?
The AEB portion of this is intended to support the DIAGNOSTIC LABEL!
What test is used to test near visual acuity?
The Jaeger reading card results are expressed as 14/14 representing the distance in inches from the chart and the last line the client was able to read
Atrial gallup
The S4 sound caused by atrial contraction and ejection of blood into ventricles in late diastole
What is used to test distant visual acuity?
The Snellen chart or E chart results are expressed as 20/20 representing the distance from the chart and the last line the client was able to read
Competence
The ability of a nurse to effectively demonstrate a set of attributes, such as personal characteristics, professional attitude, values, knowledge, and skills, and to fulfill his/her professional responsibility through their practice.
Define edema
The abnormal accumulation of fluid in interstitial spaces of tissues
What is implementation?
The action phase of the nursing process, in which the nurse provides services to achieve outcomes.
Preload
The amount of cardiac muscle fiber tension, or stretch, that exists at the end of diastole, just before contraction of ventricles
Explain the importance of a contextual approach to nursing health assessment
The client's culture, family, community and spirituality all affect their overall health
What test is used to test peripheral vision?
The confrontation test
Evaluation phase
The final step of the nursing process Evaluate Client's progress toward goals Effectiveness of nursing care plan Quality of care in the healthcare setting Goals are met, partially met, or not met.
The mediastinum contains
The mediastinum contains the heart, trachea, esophagus, a portion of the right and left main bronchi and the great vessels.
Makes up upper respiratory system?
The nose, mouth, and pharyngeal cavity make up the upper respiratory system, the inlet for air into the body.
What does concept mapping represent?
The nurses ideas about patient care.
Reasoning
The reason we do things. We can't do things "just because" - there has to be a logical reason behind it.
What are normal findings of a corneal light reflex test?
The reflection of light on the corneas should be in the exact same spot on each eye which indicates parallel alignment
When performing tactile fremitus on a client, where is the strongest vibration felt
The strongest vibration should be felt over the trachea. It will diminish over the bronchi and become almost nonexistent over the alveoli of the lungs
What are normal results of the cover test?
The uncovered eye should remain fixed straight ahead, the covered eye should remain fixed and straight ahead after being uncovered
Clinical reasonment
The use of careful reasoning in the clinical setting to improve client care
NURSING PROCESS = PROBLEM SOLVING
There are 5 STEPS (MNEMONIC: NURSE "ADDIE" This is ongoing... it's a circle.
Nursing Diagnoses *vs* Medical Diagnosis
There is a HUGE difference.
DIAGNOSTIC STATEMENTS
These are legal documents. In AEB portion, quote your patient if you can! This upholds much better than medical terms. BE SPECIFIC. Cover our butts!!
Diagnostic Label (PART #1)
This is our NANDA list. The Diagnosis/Diagnoses EX: Activity Intolerance (specific Level) Pg 45 in Nursing Diagnosis Book
Etiology (R/T) (PART #2)
This is the R/T (Related to) EX: Activity Intolerance R/T: Bedrest/Sedentary Lifestyle/Immobility... etc... Our assessment will help us find out WHY the problem is a problem to begin with. Maybe they have a respiratory infection so their body has an imbalance between o2 supply and demand... Maybe they have a sedentary lifestyle...
WHAT IS CLINICAL DECISION MAKING?
This is the process we use in the clinical setting to evaluate and pick the best actions to meet the desired goals.
An Actual Diagnoses - - TYPES OF NURSING DIAGNOSES
Three parts
Vest restraint
To keep pt from climbing out of bed or wheel chair
What are two reasons for a healthy nurse lifestyle?
To maintain a strong immune system is important when working with the ill and nurses are role models.
What is the purpose of the physical assessment?
To obtain objective data
What is the purpose of the general survey assessment?
To provide the nurse with an overall impression of the client's whole being.
Deductive reasoning
Top down reasoning
Breathing/chest expansion
Tracheal deviation Asymmetry Apparent distress Trachea remains midline Symmetric expansion with inspiration
Leininger theory of culture care diversity and universality
Transcultural nursing Culturally congruent care provided a. by PRESERVING clients familiar ways of life b. by making ACCOMMODATIONS in care that are satisfying to clients c. STRUCTURING nursing care to help client move toward wellness.
Pneumothorax risk factors
Trauma May be spontaneous
A Risk Diagnosis - - TYPES OF NURSING DIAGNOSES
Two parts
Part of the examiner's hand used to feel for vibration, thrills, or fremitus
Ulnar surface or palm of hand
What is a sentinel event?
Unexpected occurrence involving death or serious physical injury or the risk of.
Pneumothorax clinical manifestations
Unilateral (one sided) chest pain Client reports shortness of breath
What are three types of pain assessment tools?
Visual analog scale (VAS), numeric pain intensity scale (NRS) and simple descriptive pain intensity scale (VDS)
REFLECTING (TANNER CLINICAL JUDGEMENT MODEL)
WHAT WAS THE EFFECT OF WHAT I DID? This is determined with follow-up assessments. We gave the gas drops and it helped. We ambulated them and it helped. We auscultated for bowel sounds every couple of hours - and it improved. Did it work? Make sure we do our assessments before we call a Dr.
Perseverance
We need to stick it out. Keep going. NURSING SCHOOL!!!
OXYGENATION
We use clinical decision making following assessments of airway patency to identify (a) additional assessment data essential to determine care needs and (b) priority interventions necessary to promote effective respiration and gas exchange. We need a knowledge of oxygenation, client health history, and the protocols of where we work when we make decisions about the care of our clients who have issues with oxygenation. We NEED oxygenation to make clinical decisions. :-)
Independence
We work on our own a lot. Not always someone over our shoulder managing what we do.
How is BMI calculated?
Weight in kg/height in meters squared
INTERPRETING (TANNER CLINICAL JUDGEMENT MODEL)
What does that mean? Is it normal? Is it abnormal? EX: They are having gas pains - but they had surgery... trapped gas in a sluggish colon? Maybe possible complication? WE ARE NOT HERE TO DIAGNOSE... OUR SCOPE ALLOWS US TO TREAT THE PATIENT RESPONSE
DIAGNOSES (Nurse aDdie)
What's the actual or potential problem?
Desaturated blood
When oxygenated & deoxygenated blood mix
shearing force
When the tissue layers of skin slide on each other, causing subcutaneous blood vessels to kink or stretch and stops blood flow to the area
What are some indicators of poor nutritional status?
Withdrawn, apathetic, easily fatigued, stooped posture, inattentive, irritable, overweight or underweight, flaccid muscles, wasted appearance, diminished reflexes, skin dull, pasty, scaly, dry, bruised, eyes dull, hair brittle, skeletal malformations
During what phase of the interview between a nurse and client do you collaborate to identify problems and goals
Working phase
Which of the following activities would be outside the scope of practice for an RN: Writing orders for laboratory tests Administering blood products Evaluating the effects of medication Initiating a drug regimen based on protocols
Writing orders for laboratory tests
COPD medication treatment
Xanthines are often prescribed for clients with COPD. While the other medications may be useful, xanthines are commonly prescribed to those with COPD.
Xanthines
Xanthines such as theophylline dilate the distal airways and promote increased heart rate and blood flow. These may be used in chronic obstructive pulmonary disease (COPD) but require careful monitoring of their narrow therapeutic range. For this reason, they are being replaced in practice by long acting beta agonists when possible.
used to suction the oral cavity
Yankauer device
Critical Thinking
a combination of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to seek truth
embolus
a foreign substance, blood clot, fat, air, or amniotic fluid travels through the bloodstream and becomes lodged in a blood vessel. Can cause death if travels to vital organ.
concepts related to oxygenation
acid-base balance cellular regulation. Comfort cognition
reflection
action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience: what worked or did not work, what could have be done differently to achieve better outcomes, what was done well, what necessary resources were available, and so on
Interdependent/Collaborative Intervention
actions carried out with other health team members
Nursing Interventions
actions nurse perform to achieve specific outcomes
nursing interventions (nursing process)
actions, tasks, and documentation taken to help a client achieve identified goals
nursing diagnosis
activity intolerance pain risk for falls urinary incontinence constipation
implementation
administer meds continue assessment of pt monitor drug effects carry out interventions in planning phase provide patient teaching
documentation
administration of medication therapeutic and adverse effects pt statements objective assessment data
12 to 20 BPM
adolescents
10 to 20 BPM
adults
anti infective drugs
affect target organism's structure, metabolism, or life cycle
developing a diagnoses
after data is grouped and clustered, the nurses and client together identify problems that support actual, risk, and possible diagnoses: at this time the nurse determines if the clients problem is nursing, medical, or collaborative problem
Define decerebrate posture
aka Abnormal extensor posture, client with lesions of the diencephalon, midbrain or pons extends arms and legs arches neck and rotates hands and arms internally when stimulated
Define decorticate posture
aka Abnormal flexor posture, client with lesions of the corticospinal tract draws hands up to chest when stimulated
What is a nevus?
aka a mole, is a flat or raised tan/brownish marking up to 6mm wide
triage
allow nurses and other healthcare staff to set priorities based on severity and urgency of a clients condition: emergent (ex- blood pressure 88/56 and pulse 108), urgent- serious health condition in which delay of treatment and care would not result in life threatening situation (ex- patient has productive cough for the past 4 days), nonurgent- ex: client w splinter in foot and needs removed
broad spectrum antibiotics
an antibiotic that is able to affect a wide variety of organisms
anaerobic
bacteria that survives without oxygen
aerobic
bacteria that uses oxygen
goals
based on nursing diagnosis focused on what patient will achieve or do prioritized discussed with pt or caregiver can be short or long term
these three drug classes can cause decreased depth in rate of breathing
benzodiazepines, barbiturates, opioids
pharmacological therapy
beta agonists inhaled corticosteroids anticholinergics Xanthines
seen in individuals with central nervous system disorders
biot respirations present as shallow breathing with periods of apnea
Goals
broad statement about status and desired outcomes
direct care
changing a dressing or teaching about a medication
causes of changes in PFTsin older adults
calcification of the costal cartilage and weakening of the intercostal muscles which reduce movement of the chest wall. Vertebral osteoporosis, which decreases spinal flexibility increases the degree of kyphosis,, further increasing the anterior posterior diameter of the chest diaphragmatic flattening and loss of elasticity
What can measuring head growth in an infant do?
can help indicate hydrocephalus. Early intervention can prevent or diminish neurological effects
standardized plan
care specifies the nursing care for groups of clients with common needs
antibiotic selection
careful selection of correct antibiotic essential use of culture and sensitivity testing ideally done first, but may not be practical or needed
Benner and Wrubel
caring is primary provide conditions to help client grow quality service to pt/families care is dependent on factors
Dependent Intervention
carried out under M.D. orders and supervision
Tuberculosis
caused by mycobacterium tuberculosis -cell was resistant to anti-infectives body's immune response attempts to isolate pathogen by walling it off tuberculosis may remain dormant in walled-off areas called tubercles decreased immune system can giver tuberculosis opportunity to become active
antiviral therapy
challenges -viruses mutate rapidly, and drug becomes ineffective -difficult for drug to find virus without injuring normal cells -each antiviral drug specific to one particular virus
evaluation
checkpoint compares pt current status with desired outcome -if goal not met, focus may shift to next highest priority health need -if not met, plan may require revisions overall goal is safe, effective medication admin therapeutic outcome should be best possible; take steps to ensure success
NANDA (North American Nursing Diagnosis Association)
classify or categorize nursing diagnosis terminology -provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
actual diagnosis
client problem thatt is present at the time of nursing assessment and is based on a cluster of associated data. ex- client in pain after surgery diagnosis would be pain
Supporting data
client responses that support conclusion
Nursing Diagnosis
clinical judgement about client's responses to actual and potential health problems or life processes
What is risk dx?
clinical judgment that a problem does not exist, but risk factors indicate the problem can occur Example: Falls
What is the S1 sounds?
closure of the mitral and tricuspid valves (contraction, systole)
sign of chronic hypoxemia
club nails
syndrome diagnosis
cluster of nursing diagnoses that occur together and may improve client outcomes if addressed at the same time: ex- client who has an autoimmune disorder may have nursing diagnoses for impaired coping, risk for infection, and activity intolerance
Wha is syndrome dx?
cluster of nursing dx that occur together Example: risk for disuse syndrome, may be r/t long term bed ridden clients.
assessment
collect data organize data validate data document data
evaluation
collect data related to outcomes compare data with outcomes relate nursing actions to pt goals/outcomes draw conclusion about problem status continue, modify or terminate the patients care plan
defining characteristics
component explains what the problem looks like, refers to the cluster of signs and symptoms and that indicate a particular diagnostic label: for nurses its signs and symptoms
implementation
reassess the pt determine the nurses need for assistance implement the nursing interventions supervise delegated care document nursing activities
sims
enema procedure, administering suppository lying on side with knee and thigh drawn upward toward chest
prioritizing care factors
ethics, safety, available resources, time management, multiple pts, point preference, change in pt condition, the unexpected, nurses self care, delegation
etiology
explains where the problem came from or what is related to, component gives direction to the required nursing care and helps the nurse individualize care
trematodes
flukes
medication assessment
focus on reaction to medication -desired response -adverse effects -patient capability of assuming responsibility for self administration
diagnostic label
focus or subject of the problem, it describes the clients response to a health problem as the focus of nursing care
FiO2
fraction of inspired oxygen
Two factors that can cause skin break down
friction, and shearing force
stage 3 pressure ulcer
full thickness loss damage to the epidermis, dermis, and subcutaneous tissue, not including the muscle or bone
mycoses
fungal infections superficial -affect scalp, skin, nails, mucous membranes -treated with topical agents -deeper infections may require oral antifungal therapy systemic -affect internal organs (lungs, brain, digestive organs) -less common -can be fatal in immunosuppressed patients -treated with oral or parenteral agents
Watsons theory of human care
genuine caring relationships have a + impact on a clients health caring involved addressing the mind body and spirit 10 clinical caritas processes
clients strengths
helps client develop a healthier self-concept and self image
Genetic considerations and nonmodifiable risk factors associated with alterations in oxygenation are linked to what?
hemoglobin and hematocrit. Various research studies have examined the genetic link to hemoglobin and hematocrit. These studies indicate that there is a significant inherited pattern of variation in hemoglobin concentration; however, the hematocrit shows a lower genetic effect. Differences among hemoglobin concentration and hematocrit between the genders add to this evidence of the genetic control of these variables. Therefore, hemoglobin and hematocrit variations influence the ability to oxygenate. Women typically have lower concentrations of hemoglobin and hematocrit when compared with men.
imminent death
highest urgency: time to action to prevent threat of life takes priority over everything: ex- client stops breathing
What is wellness dx:
human responses to levels of wellness that have readiness for enhancement. Example: Readiness for enhanced spiritual well being and readiness for enhanced family coping
The typical drive to breathe occurs due to
hypercarbia, an increased level of carbon dioxide in the blood.
techniques used to minimize complications of suctioning
hyperinflation - giving the client breasts that are one - 1.5 times the title volume set on the ventilator circuit work via a manual resuscitation bag 3 to 5 breths are delivered before and after each passage of the suction catheter Hyperoxygenation- done with a manual resuscitation bag or through the ventilator bby increasing the oxygen flow to hundred percent before in between suctioning.
complications of suctioning
hypoxemia, trauma to the airway, nosocomial infection, cardiac dysrhythmia,, which is related to the hypoxemia.
how to treat orthopnea
identify injury underlying cause. Elevate the head, neck, and chest while sleeping
Problem Solving
identifying a problem, suggest reasonable solutions, use critical thinking skills to pick best solution, and hold other solutions in reserve
when to administer 02
if it falls below 90
urgency factor
illustrate how much time can safely lapse before doing intervention without compromising client outcomes
collaborative interventions
improving nutrition, pharmacological therapy
incentive spirometry
incentive spirometry measures the volume of a client's exhalation using a simple, handheld tool. It is often used to monitory pulmonary function and encourage deep breathing for clients who are in a period of immobility or decreased activity such as postoperatively or on strict bed rest.
collaborative interventions
include both independent and dependent, actions taken in collaborationg w other healthcare team members, such as PT, social workers, dietitians, and physicians; reflect overlapping responsibilities of healthcare personnel
writing a nursing diagnosis: basic two part statement
includes: 1. the problem 2. the etiology (what is causing the problem)
respiratory acidosis
increased CO2 levels. The to vasodilation, which leads to increased intracranial pressure and pulse rate
20 to 40 BPM
infants
obligatory nose breathers
infants
independent interventions
initiated by the nurse within the scope of practice, include: physical care, ongoing assessment, emotion support, comfort, teaching, counseling, managing the environment and making referrals; carried out by nurse or delegated
primary intervention
monitoring drug effects -monitor for identified therapeutic effect reassessing pt -physical condition -vitals -body weight -lab values -serum drug levels taking pt statements monitoring side or adverse effects
List the techniques used when performing a physical assessment of the lungs and thorax in the order that they are performed
inspection palpation percussion auscultation
non acute factor
interventions w low urgency, delay in providing these interventions would not negatively impact client outcomes
What is the planning phase?
it is deliberate and systematic during which the nurse refers to the assessment data and nursing dx for direction in coming up w/ client goals. Need to realistic and measurable.
contactures
joint becomes fixed
type of breathing seen in metabolic acidosis
kassamaul very deep and rapid breaths trying to rid the body of CO2
bactericidal
kill bacteria
Boykin and Schoenhofer's nursing as caring theory
know individuals and nurture them theory of human care (watson) not a goal, ongoing process self-awareness
What are the aspects of caring?
knowing (understanding the others needs) alternating rhythms (moving back and forth b/w immediate and long term) Patience (enables others to grow in their own way) Honesty (awareness to ones own feelings) Trust (allowing others to grow in their own way) Hope (belief in the possibility of others growth) Courage (sense of going into the unknown)
Orthostatic Vital Signs
lie down for 20-30 minutes, assess heart rate and blood pressure, sit on side of bed for 5 minutes, stand up for 2-3 minutes, assess heart rate and blood pressure. (observe patient, make sure they don't pass out) *IF MORE THAN 10 ML DECREASE IN SYSTOLIC BP AND HR INCREASE OF 10-20 IT IS CONSIDERED ORTHOSTATIC
cause-and-effect fallacy
linking something that happens to something that occurs before it happens
dorsal (supine)
lying horizontally on the back
Venturi mask
masks that are set acidic oxygen flow rate in specific jet adapter device.low rates of 24% to 40%. He set within three mask.
diagnosis
may focus on patients response to actual or potential health and life processes
acute
medium priority: low potential for the cleints condition to become life threatening if these interventions are not accomplished within short amount of time. ex: nurse can schedule a PCT to turn and preposition client every 2 hours
critical
medium to high urgency: ugent need for nurse to repond quickly to high priority physical or psychological problems within a short period of time because there is potential for clients condition to become life threatening. ex: cleints develops shortness of breathe and air hunger from smoke inhalation
What do parents and caregivers relay regarding the infant?
milestones, abilities,
Decision Making
process for choosing best actions to meet desired goal -use thinking skills -make judgement -seek/examine alternatives -implement -evaluate outcome
clinical decision making
process nurses use in the clinical setting to evaluate and select the best actions to meet desired goal
prioritizing care
process that helps nurses mange time and establish order for completing responsibilities and care interventions for single client or for a group of clients
plan of care
provide individualized client centered care to meet the unique needs of each client, provide for continuity of care thru communication with nursing staff and other healthcare providers involved w the care of the client, inform the nurse about which specific observation of action need to be documented in the nurses progress notes about the client care, provide medical insurance companies documented proof for reimbursement amount to pay in relation to services rendered to the client, provide the nurse a guide when assigning nursing staff to care for each client
outcome
provide specific, measurable criteria evaluate degree to which goal is met focus on what pt will achieve or do are discussed with pt or caregiver
aim of interventions
pt returned to optimal level of wellness safe and effective admin of meds
Clinical Reasoning
reflective, concurrent creative thinking about patients and patient care -logical thinking that links thought together to create meaning
clinical reasoning
requires clinical thinking and the ability to reflect on previous situation and decisions and evaluate their effectiveness
this pulmonary function test increases with age
residual capacity
widespread use of antibioitcs
resistance not cause by, but is worsened by, over-prescription of antibiotics -results in loss of antibiotic effectiveness -long time use increases resistant strains -healthcare associated infections often resistant -prophylactic use
orthopneic
respiratory distress, pt sitting up in bed at 90 degree angle, or leaning on bedside table while sitting up in bed
abnormal findings in muscles of breathing?
retraction of the intercostals. Sternocleidomastoid muscles of the neck contract. Posturing occurs
bacilli
rod shaped
nematodes
roundworms
goals
safe and effective admin therapeutic outcomes treatment of side effects
