FINAL 1

pulse rate is?

# of pulsations felt in 1 min.

Levels of Anxiety name each level and define each?

-Mild which is great for nursing students by increasing alertness and perceptual fields and motivates -Moderate shows inattention to detail, quivering voice, tremors, increased pulse and resp and muscles tense, butterflies, focus is on immediate concern -Severe all behavior geared to getting relief, can't learn, difficulty verbally communicating, heart racing, impaired learning, easily distracted, headache, tachycardia, hyperventilating, nausea, fearful look on face, increased motor activity, easily distracted -Panic loss of control an experience of dread and terror ^physical activity, distorted perception, loss of rational thought,difficulty communicating, agitation, trembling, poor motor control, sensory changes, sweating, hyperventilation, dyspnea, palpitations, chest pain and can lead to exhaustion and death

grading of edema and pitting edema

0(none), +1(trace, 2mm), +2(moderate, 4mm), +3(deep, 6mm), +4(very deep, 8mm). +1:mild pitting, +2:moderate pitting, +3:deep pitting, +4:very deep pitting

bereavement care define?

1 year after death of patient in hospice

normal breath rate

12-20 times a minute

Older adults RR

12-24

prehypertension range

120-139/80-89.

The patient has been taking 3 teaspoons of cough syrup. How many mL would this be?

15 mL

1 tablespoon (Tbsp.) = ?ml

15 ml

Completely dissolve crushed tabs and capsule contents in

15 to 30 ml of water

deriving patient goals/outcomes and nursing orders from nursing diagnoses

1st part of diagnosis-problem statement(identifies unhealthy response, indicates what should change) suggests patient goals/outcomes(expectations for change) 2nd part of diagnosis-etiology-identifies factors causing or contributing to the undesirable response and preventing desired change>suggests nursing interventions

bimanual palpation? ex?

2 hand, one hand applies pressure and other hand heels tissue/structure. Ex:palpating breast tissue

1 kg = ?lbs

2.2 lbs.

legs can go how far up from bed to possess sufficient power to begin walking

2.5cm(1inch)

snellen steps

20 ft from chart covering 1 eye at a time& with both eyes, wear corrective lenses if normal for them, use E chart/picture for client/child who cannot read

Young adult age range

20-40

Erikson's stages of psychosocial development- young adult: age? stage name? characteristics?

20-40. Intimacy vs. isolation Achieve independence Establish intimate relationships Choose a career

small intestine is how long? begins at? and joins?

21 feet long. begins at pyloric orifice and joins the large intestine at the ileocecal valve

pulmonic area location

2nd intercostal space, L sternal border

aortic area location

2nd intercostal space, R sternal border

How many lobes in right lung? What about left lung? how many bronchopulmonary segments/lobules in right? left?

3 2 10 8

Trough level drug at lowest concentration drawn? example ?

30 minutes before next dose, dosage schedule and half-life can modify trough level. Vancomycin

Venturi Mask volume rate? allows?

4-10L/min. Allows mask to deliver most precise O2 and high flow.

width of BP cuff requirement %?

40% of circumference

Middle adult ages

40-65

1 teaspoon (tsp) = ?ml

5 ml

Pain in relation to VS

5th vital sign

Simple Mask volume rate? FIO2 %? what volume is min?

6-10L/min 40-60% FIO2 5L/min. is minimum though

Partial Non-Rebreather volume rate? O2 %? mask must remain?

6-15L/min 70%-90% O2 Mask must remain 2/3rd full during inspiration

Oxygen Tent O2 volume rate? definition? what parts of body inside? over ? doesn't allow?

6-15L/min. Portable structure made of clear plastic attached to motor-driven unit that cools air. Head and thorax inside. Overtop of bed. Doesn't allow maintenance or precise O2 so usually only for pneumonia

The physician's order states to feed the infant 2 ounces every 4 hours. How many mL should the nurse prepare to feed the infant each time?

60 mL

One grain is equal to

60 milligrams, therefore a grain is a more powerful dose than a milligram

normal pulse rate is what for adults, infants, 12-14 years?

60-100 beats/min adult. 120-160/min infants. 12-14 80-90/min

1 grain (gr) = ?mg. gr1/4=?mg. griii=?mg

60mg. 15mg. 180mg.

Older Adult ages?

65 yrs +

Most adults need how much sleep

7-8hours each night

adults with no disease related fluid restrictions should drink

8-10 8oz glasses of fluid daily

PaO2 average range? Obtained via? definition?

80-100% Obtained via blood draw ABG. partial pressure of oxygen in the blood, as measured by blood analysis

how much cc liquid is absorbed daily by intestinal tract

800-1000cc

SpO2/SaO2 average range? what's usually abnormal? SpO2 definition? SaO2 definition?

95-100%, values as low as 86% may be acceptable with some illnesses but under or = 90% usually abnormal SpO2 is an indirect measurement of the oxygen content of blood (oximetry) where Sao2 is a direct measurement of the oxygen content of the blood (arterial blood gas sampling)

normal BP range? aka?

<120/<80. Aka normotensive

death can occur under which temps?

<34C/93.2F or >39C/102.2F

airborne transmission

<5mcm. Private room w/ negative air press., wear mask/respirator. Can be transported with a mask on patient

high BP range?aka? what should be done? can be cause of? most important risk factor for? interventions?

>140/>90-100 aka hypertension/silent killer. Return for 2 more additional readings. 3 or more readings elevated at 3 diff. Occasions over several weeks . Can be cause of heart disease. Most important risk factor for stroke. HTN treatment, weight, alcohol, physical activity, stress reduction,

Stage 2 hypertension range

>160>100

Danger signs of abnormal pigmented lesions

A, B, C, D, E. Asymmetry, border irregularities, color variation, diameter greater than 6mm, elevation or enlargement

Examples of Nursing Actions for Basic Needs and Safety and Security Levels: Air? water? food? elimination? sleep/rest? thermoregulation? pain? activity?

AIR - Provides O2, monitors O2 levels to be >92% CPR, positioning, maintains airway, includes cellular needs (heart, brain) WATER - monitors intake and output, maintains IV's, monitors lab results of Sodium (Na+), determines fluid overload or deficit FOOD - manages feeding, swallowing and appetite problems, monitors labs(protein and albumin and daily weight loss or gain. ELIMINATION - determine if a problem exists, monitors labs (BUN and creatinine) adjust fluids, food activity and habits to maintain function, use urinary catheters and medications as needed SLEEP/REST - determine obstacles (anxiety) and eliminate them, plan activity and rest as needed, use non-medication and medication aids appropriately Thermoregulation - monitor vital signs, signs of infection including lab results,, control environment, treat hyper or hypothermia. Pain - pain management, non med. therapies, medical management Activity - turn patients every 2 hours to prevent pressure sores (decubiti).

parasympathetic part of which system? functions under? regulates?

ANS, functions under normal conditions at rest. Regulates HR, stimulates secretions of gastric juices, stimulates insuling secretion

sympathetic part of which system? functions under? regulates?

ANS, functions under stress to bring fight or flight. ^HR and force, dilates blood vessels, stimulates release of glycogen stores

Paternalism definition? what kind of situation?

Acting for patient without their consent to secure good/prevent harm. Trouble nurse patient situation

Deontologic defintiion

Action right of wrong independent of consequences.

Inspiration: aka? What happens? Entire chest is?

Active Phase •Diaphragm contracts+descends •Thoracic cavity lengthens •Sternum is pushed forward intercostal muscles contract lifting ribs The entire chest is enlarged and intrapulmonic pressure decreases and air moves into the lungs.

Nursing Diagnoses : when respiratory function is a contributing factor to another problem

Activity intolerance Related to shortness of breath on exertion, dyspnea Acute confusion Related to impaired ventilation (excessive buildup of carbon dioxide) Fatigue Related to impaired oxygen transport system

Drug-to-Drug Interactions examples?

Acute or chronic alcohol ingestion or iodinated contrast media increase risk of lactic acidosis Furosemide may increase effects of metformin Drug-Natural Products Glucosamine may worsen blood glucose control Coenzyme Q-10 may produce increased hypoglycemic effects

Assessing dark skinned patients

Adequate lighting. look at palms/soles, conjunctiva, mouth, inner forearm where color change more easily seen.

Stat prescription

Administered once and immediately

Epidural implications administration of? steps?

Administration of opioid analgesia(morphise or fentanyl) catheter advanced through needle inserted in epidural space, infusion pumps are necessary to give meds

When to asses vital signs

Admission to facility, instutional policy, change in condition, loss of consciousness, before/after surgery/activity that increases risk, before meds affecting cardiovascular/respiratory function

pituitary hormones examples

Adrenocorticotropic(ACTH), thyroid stimulating hormone(TSH)

Drug Effects types?

Adverse Allergic Drug Tolerance Toxic Effects Idiosyncratic Effect Drug Interactions

Physiological Needs in Priority:

Air(most essential), Thermoregulation, Water, Food, Elimination, Rest/sleep, Physical activity, Sex

Sedative-hypnotics aka and types and what side effects

Aka Benzodiazepines. Flurazepam(Dalmane), Temazepam(Restoril) Can cause daytime drowsiness or hangover effect, can cause physical/psychological dependence, anorexia, diarrhea, palpitations Increases total sleep time

Trade name aka? definition? protected by? one med may have? what kind of letters?

Aka brand proprietary name. Selected by drug company that sells drug. Protected by trade mark. One med may have multiple trade names when made by other companies. Capital letters.

Skin barrier products aka? Functions?

Aka creams, ointment, films. Protect vulnerable skin for damage caused by excess water, urine, feces exposure. Good for incontenence.

Topical emollient agents aka? Function?

Aka moisturizers like lotion, cream, gel, ointments. Seals water into skin me given after bath or for incontenence

Approximated define

Aligned

Bronchoscope/Bronch definition

Allows for visualization of the trachea, larynx, and bronchi

Hair and scalp abnormalities that can be found

Alopecia, hirsutism, lice, dandruff

Disturbed sleep pattern(etiology) RN diagnosis

Altered sleep-wake patterns, anxiety r/t inability to fall asleep, activity intolerance r/t sleep deprivation, fatigue r/t insomnia

SVR/peripheral determines

Amount of constriction/dilation of arteries. raised SVR=raised BP vice versa

Drug or medication definition

Any substance that modifies body function when taken

Apical pulse location?

Apex of heart. 5th intercostal space, mid-clavicular line in between 5th and 6th rib

How to ride above moral distress 4 steps

Ask, affirm, assess, act

hypertension definition? types?

BP above normal for sustained period. Primary hypertension(no known cause.). Secondary hypertension(identifiable cause)

AACN

BSN+ degrees only. american association of colleges in nursing.

Supine position:description? Areas assessed? Cautions?

Back lying flat, legs extended, knees slightly flexed, with/without pillow under head. AA: head, neck, axillae, anterior thorax,lungs, breasts, heart, abdomen relaxation, extremities, peripheral pulses. C: tolerated poorly by clients with cardiovascular and respiratory problems

High Alert Medications definition? aka?

Bears a heightened risk causing significant patient harm when it is used in errors aka Black Box Warnings

Beneficence definition

Benefit the patient, and balance benefits against risk and harms

Health history components

Biographical(name, address, gender etc.)/demographical, chief complaints/reason for seeking health care, history of present health concern, medical history, family history, social/lifestyle history, source of history, health promotion behaviors.

Cardiopulmonary older adult changes?

Blood vessels become less elastic Venous return is less efficient extremity edema, cooling may occur peripheral pulses may not be palpable less able to ^ HR and CO with activity TED hose Pneumatic devices for the lower extremities Lower extremity edema may occur Body is less able to increase heart rate during activity Clearing of lungs is less efficient Respiratory rate may increase

Implementing component of nursing process description and purpose

Carrying out the plan of care to assist patients to achieve desired outcomes, promote wellness, prevent disease/illness, restore health, and facilitate coping with altered functioning

Mid adult changes

Changes in employment Career change Retirement Changes in relationships(disenchantment due to changes) Spouse Children Parents

Chemical drug name determined by

Chemical composition

Intra-op Nursing Role AKA

Circulating nurse

Intra op nursing role during surgery

Concerned with client safety Positioning to prevent skin and neuromuscular injuries Performing at "time-out" Sterile draping Skin prep Maintaining surgical asepsis Assisting the surgeon with instruments/sponge count Documentation Transfer to PACU

intra op nursing role during surgery?

Concerned with client safety Positioning to prevent skin and neuromuscular injuries Performing at "time-out" Sterile draping Skin prep Maintaining surgical asepsis Assisting the surgeon with instruments/sponge count Documentation Transfer to PACU

MS, MSO4, MgSO4 definition? mistaken as? write?

Confused for one another Can mean morphine sulfate or magnesium sulfate. Write "morphine sulfate" or "magnesium sulfate"

Cognitive development of young adult characteristics

Creative, objective, realistic Less self centered Learn from education and life experience

Intellectual Independence? Example?

Critical thinker does not allow the status quo or a persuasive individual to control their thinking. E.g., the teacher who makes a snap judgment that a student is "unreasonable" based on the comments of other teachers who say, "Oh that student just wants attention—he is always asking questions!

Sociocultural Dimension: cultural factors? social role functioning?

Cultural factors: social class -economic level race - ethnicity health and childbirth practices traditions, customs, norms, language Social role functioning: lifestyle family unit relationships birth order support system social network communication patterns self-concept and interpersonal relationships

Demerol 35mg IM every 4 hours prn for pain The medication is supplied as Demerol 50mg/ml How many milliliters will you give?

D × V = amount to give (ml) H First convert 0.5 Gm = 500 mg 35 mg × 1 ml = 0.7ml 50 mg

The basic formula for dosage calculations is:

D/H × V = amount to give. All must be in same unit system. D (desired dose): the dose ordered H (on-hand dose; supplied dose): dose on label of container V (vehicle): form and amount of supplied drug.

standards of care developed by and used as?

Developed by nursing profession, used as guidelines for peer review(evidence based practice 4 quality improvement)

Factors Affecting Drug Action

Developmental Weight Gender Cultural and Genetic Factors Psychological Factors Pathology Environment Timing

Body temp. Definition

Difference between amount of heat produced and amount lost.

Intuitive problem solving

Direct understanding of situation based on background of experience, knowledge, and skill that makes decision making possible. Welcoming intuition, validating intuitions, furthering nursing research

checklist to ensure informed consent

Disclosure, comprehension, competence, voluntariness. Description of procedure and alternatives, underlying disease process and its natural courses, names and qualification of person performing procedure, explanation of risks/benefits, right to refuse and ask questions, be in their language, explain expected outcome/recovery/rehab Can be given over telephone or via court order Witness: Physician, RN can sign as witness only, patient must have full consciousness and mentally competent and if not must be parent, spouse, next of kin or legal guardian that gives informed consen

Sleep nursing diagnosis

Disturbed sleep pattern/sleep deprivation(problem), disturbed sleep pattern(etiology) causing other issues

Hand washing steps

Don't allow clothes to touch sink, remove jewelry unless worn during, use warm water, hands/wrist lower than elbows, 1 tsp soap, wash at least 1 in. Above wrists/ contaminated area

Dry powder inhalers(dpi) administration

Don't shake inhale, hold breath 5-10 seconds

Ratio-Proportion Formula

Dose on hand/Quantity on hand =Dose desired /X (quantity desired). Cross multiply and solve for x. All must be in same unit system . Calculating for the quantity of supplied medication that is equal to the prescribed dosage

Middle adult physical changes

Drier skin Wrinkles Gray hair and men loose hair Decreased CO, muscle mass, strength, agility, hormones Loss of calcium from bones for women Increased fatigue Visual/hearing acuity diminishes Energy requirements decrease while eating same amount so can gain weight

Psychosocial Development older adults: erickson's theory? havighurst's theory?

Ericksons' theory: Ego integrity vs. despair and disgust Begin to reflect on life Accept physiologic decline without fear of death Havighurst's theory: adjust to decreased strength/health, retirement, reduced income, death of spouse. Est. affiliation with age group.Maintenance of social contacts and relationships. Adapt/adjust to new age-related roles. Establishing satisfactory physical living arrangments

Primary Healthcare define? universally? brings?

Essential healthcare based on acceptable methods and technology Universally accessible and affordable to individuals and families in the community Brings healthcare close to where people live and work

Therapeutic communication

Exchange of info via verbal and nonverbal so. Involves interpersonal communication between patient and nurse to help patient trust and relax

Explanation operationalizing critical thinking

Explain in writing or orally the assumptions and reasoning followed in reaching conclusions and to justify reasoning/conclusions using evidence

Perineal care do what? Position? Use what? Ensure what?

Explain procedure, supine position with knees flexed, gloves, ensure privacy

Prescriptions types?

Facility policies Types: Routine order/standard prescription Opiods and antibiotics must be reordered within a specified amount of time or automatically discontinued Single/one time prescription Stat PRN Nurse uses clinical judgment to determine client's need Standing

Breach of duty malpractice element definition

Failure to comply w/ Standard of care

Hematocrit range for females and also makes? define?

Female: 36-46% Male: 41-53% volume of RBC's

Intramuscular implications used for? common sites? needle size? gauge? length? angle? volume?

For irritating meds, solutions in oil, and aqueous suspensions. Most common sites include ventrogluteal, deltoid, and vastus lateralis. Use needle size 18 to 27 gauge usually 22 to 25 gauge, 1 to 1.5 inch long and inject at 90 degree angle and volume 1 to 3 ml

Intravenous implications for? vascular access devices can? gauges? preferred sites? ___effect?

For meds, fluid, blood products. Vascular access devices can be for short term(catheters) or long term(infusion ports). Use 16 gauge for trauma, 18 gauge for surgical, 22 and 24 gauge for children, elderly, medical, stable post op. Preferred sites are peripheral veins in arm or hand. In neonate so veins of head, lower legs, feet can be used. Immediate effect

GI+urinary assessment palpate what?

GI:all quadrants of abdomen in clockwise fashion using pads of fingertips to depress 1/2 inch. Urinary:bladder, urethra meatus/orifice, skin, urine, kidneys(advanced practitioner)

Respiration aka? occurs at the? involves?

Gas exchange, occurs at the terminal alveolar capillary system. Involves gas exchange between the atmospheric air in alveoli and blood in capillaries via diffusion,

Focussed assessment gathers? when done? purpose?

Gathers data about a specific problem that has already been identified. May be done during initial assessment. Purpose is to identify new problems not found.

Contraindications & Precautions for drugs

General Precautions Use only when necessary Benefit outweighs risk Precautions related to medical conditions Contraindications Serious or life threatening

Putting on PPE

Gown > mask> goggles>gloves>

Hyperthermia

Heat causing high body temp.

Hypothermia

Heat loss causing low body temp. Causing slower metabolic rate <36C/97F

Hyperpyrexia definition? temp.?

High fever, above 41C/105.8F

Diaphragm of stethoscope used for? pressure?

High pitched sounds(normal heart, breath, bowel sounds) with firm pressure

Pulse beats/min from newborn to old age

High to low

Respiration breaths/min from newborn to old age

High, low, high

models for organizing/clustering data holistic and medical types?

Holistic: 1.Human needs(Maslow) 2. functional health patterns(Gordon) 3. Human response patterns(Unitary Person)-- Medical: 1. body system model

Mechanism of action

How the medication produces the desired therapeutic effect

Chronic illnesses of older adults ?

Hypertension Diagnosed arthritis Heart disease Any cancer Diabetes Sinusitis

Hyperthermia differs from fever how?

Hypothalamic set point isn't changed with hyperthermia, just hot environment

Neurogenic fever definition? no response to?

Hypothalamus damage. No response to antipyretic meds

Prior to surgery intra op nurse?

ID client (2 identifiers) Meet/assess client just prior to surgery including VS Review pre-op data Verify consent signed (if there is a problem with consent NOTIFY MD) Verify NPO status Verify type of surgery Perform "time out" Answer any questions Provide reassurance & info to family Report any change of status to MD

gravity flow definition? set flow rate by? drop factor?

IV fluid flows via gravity. You set the flow rate for these infusions by counting the number of drops per minute in the drip chamber of the tubing. In this calculation, you will also need to consider the drop factor (drops/ml) of the tubing being used to administer the fluid. The drop factor of tubing may vary according to the type of solution to be administered, the rate to be infused, the clinical situation, and the company which manufactures the tubing. The drop factor for each tubing is noted on the container in which it is packaged.

Medications can be given intravenously by:

IV push, IV piggyback, continuous infusion(infusion pump, gravity flow)

Assessing memory times? asking? types of questions?

Immediate, longer term. asking questions that require answers demonstrating immediate recall and recall for past events. To assess immediate memory ask patient to repeat series of #'s forward or backward(start with 3 #'s, most adults repeat 5-8 #'s forward and 4-6 #'s backwards). To assess long term memory ask what they ate for breakfast, when their birthday or wedding anniversary

For trough levels blood is drawn when

Immediately before the next med dose regardless of route if admin

Allergic Effects- what organ system? occurs when? forms? what kind of symptoms? time frame? signs? symptoms become? what treatment?

Immune system response Occurs when the body interprets the administered drug as a foreign substance Forms antibodies against the drug Minor to serious symptoms Immediately or delayed Rash, urticarial, fever, diarrhea, nausea, vomiting Symptoms become more severe each time the drug is introduced into the body Epi - pen available

Respiration diagnosis

Impaired gas exchange

Offer Mr. Meyer 60 mL of fluid every 2 hours, correct/incorrect? if incorrect correct statement

Incorrect. Mr.Meyer will drink fluid every 2 hours

Signs and Symptoms of Impaired Oxygenation

Increased blood pressure Increased respirations Increased pulse rate Pallor Cyanosis Anxiety Restlessness Confusion Drowsiness Headache Chest pain Enlarged heart Clubbing of fingers and toes Anorexia Weakness of extremity muscles Muscle pain

perfusion diagnosis

Ineffective airway clearance

Nursing Diagnoses : when respiratory function is the problem

Ineffective airway clearance Related to thick secretions, fever, fatigue, dehydration, and poor nutrition, blocking airway passage in upper or lower airway Ineffective breathing pattern Related to anxiety, decreased energy or fatigue. Post op or the immobile patients. Impaired gas exchange Related to one pack/day smoking history and prolonged cold symptoms in lower airway, asbestos

Pulmonary Ventilation diagnosis

Ineffective breathing pattern

Minimum data set

Info that must be collected from every patient

Formats for nursing documentation

Initial nursing assessment Kardex/patient care summary Plan of nursing care Collaborative pathways Progress notes Flow sheets Discharge/transfer summary

Types of assessments

Initial(comprehensive), problem/focused, emergency, ongoing partial

Assessment of health problems for young adults

Injuries, substance abuse, suicide, nutritional problems, STIs, stressors

Damages element malpractice definition

Injury occurred to patient

Chest Tubes- inserted by? function? nurse function?

Inserted by the physician Drain fluid, blood, or air The Nurse: Assists with insertion and discontinuing. Monitors respiratory status. Assesses the dressing, ensures patency and integrity of the system (no kinks in tubing, tube is in place) Monitors and charts chest tube output.

Endotracheal Tubes inserted by? inserted through? function? can be?

Inserted usually by MD, but RN and RT are educated on tube placement. Inserted through nose or mouth into trachea to deliver O2 via ventilator, suction, or bypass upper airway obstructions. Can be uncomfortable but is choice for emergency

Integumentary physical assessment

Inspection(skin, nails, hair, scalp), palpation(skin, nails, scalp)

Musculoskeletal assessment

Inspection+palpation of muscles(size, symmetry, tone, tenderness), posture(spinal curves), joints(size, symmetry, redness), edema(pain, crepitus), gait and balance, coordination(finger to thumb test, shin to heel test), ROM(test each joint for passive or active+ROM), strength(equal and bilateral, resistance in shoulders, arms, legs, ankles).standing, sitting, or supine.

Techniques of physical assessments? for abdomen? why abdomen done that way?

Inspection, palpation, percussion, auscultation. Abdomen: inspection, auscultation, percussion, palpation(make bowel sounds so done last)

Respirators filter

Inspired air

IOM aka? Published? Why there are?

Institute of medics. Published future of nursing leading change, advancing health w/ Robert Wood Johnson Foundation.Why there are graduate degrees for nursing.

IV Piggyback definition? meds are? what meds used?

Intermittent/additive solution placed higher than primary solution container. medications are added to a small volume of fluid and run concurrently with other IV fluids over a short period of time. Antibiotics are frequently delivered by this method.

Plasma med level is in therapeutic range when? therapeutic levels are?

It's effective and not toxic. Therapeutic levels are well established for many meds and these levels can be used to monitor a clients response

Medication Reconciliation what requirement? definition?

JCAH requirement, Compare current medications from home with new prescriptions, Resolve discrepancies. Admission and transferring between units or facilities, and at discharge are principle cause of med error so this must be done.

urinary diagnostic testing

KUB(kidneys, ureters, bladder), cystoscopy, urinalysis for pH 7.35-7.45 book says 6 average 4.6-8, specific gravity 1.015-1.025, glucose, protein, WBC's + RBC's

Fidelity definition

Keep promises

Metric ladder

Kilo(10^3) hecto(10^2) deca(10) base deci(10^-1) centi(10^-2) milli(10^-3) micro(10^-6)

mental status assessment includes

LOC, level of awareness, behavior, appearance, memory, reasoning, language

A.S., A.D., A.U. definition? mistaken as? write?

Latin abbreviation for left, right, or both ears, Mistaken for each other (e.g., AS for OS, AD for OD, AU for OU, etc.), Write: "left ear," "right ear" or "both ears;"

O.S., O.D., O.U. definition? mistaken as? write?

Latin abbreviation for left, right, or both eyes, Mistaken for each other (e.g., AS for OS, AD for OD, AU for OU, etc.), write out "left eye," "right eye," or "both eyes

Q.D., Q.O.D. definition? mistaken as? write?

Latin abbreviation for once daily and every other day. Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I". Write "daily" and "every other day"

short half life definition?

Leave body quickly (4-8 hrs.) short dosing interval or minimum effective concentration(MEC) will drop between doses

long half life definition? meds are given at? meds take longer to?

Leaves body more slowly (24+ hrs.) greater risk for nee accumulation and toxicity. Meds are given at longer intervals without a loss of Therapeutic effects. Meds take longer to reach steady state.

Use tuberculin syringe for solution volume

Less than 0.5 ml

antibiotic resistant bacteria

MRSA(methicillin-skin), VISA(vancomycin intermediate staph. aureus- skin), VRSA(vancomycin resistant staph. aureus), VRE(vancomycin resistant enterococcus-intestines/urogenital tract)

Primary skin lesion examples. Those that arise from?

Macule, papule, patch, plaque, nodule, wheal, tumor, urticaria(hives), vesicle, cyst, bulla, pustules. Those that arise from normal skin.

Reasons why Leaving AMA ?

Male Medicaid coverage or lack of health insurance Lack of a primary care physician Admission through the emergency department Admission with a substance abuse-related diagnosis Previous AMA discharge

Health concerns for middle adult

Malignant neoplasms, heart disease,accidents Risk depends on combo of lifestyle and aging Chronic illness has a major effect

Nutritional status effect of med metabolism

Malnourished client may be deficient in factors that are necessary to make specific med metabolizing enzymes consequently causing med metabolism to be impaired

Frameworks for Healthcare Delivery

Managed care systems Case management Primary healthcare

legal standards definition & ex.

Mandatory, made by legislature like Nurse Practice Act

Partial agonist may act as? limited? example?

May act as agonist or antagonist. Limited affinity to receptor site. Example: nalbuphine(Nubain) acts as antagonist at mu receptors and an agonist at kappa receptors causing analgesia at low doses with minimal respiratory depression

Arterial blood gas/ABG Measures? via?

Measures the adequacy of oxygenation, ventilation, and perfusion, pH and pressure from gases via arterial puncture in radial, brachial, femoral arteries

Uncontrolled substances

Meds require monitoring but no risk of abuse and or addiction

fever interventions and outcomes

Meds, cool baths/packs, hypothermia blankets, fluids, monitor temp/BP/use/respiration, monitor seizures, IV, ice bag. Outcomes-vital signs, hydration, thermoregulation, risk control(hyperthermia)

Promoting client's Return to Health

Meet comfort and rest needs (pain medication, repositioning, etc.) Meet fluid and nutritional needs (assistance, consults) Meet elimination needs (early ambulation, fiber, laxatives if indicated, KEEP THE CLIENT MOVING!!!) Reduce risk for infection (wound care, hygiene, nutrition) Reduce respiratory infections/compromise (early ambulation, coughing/deep breathing with splinting) Reduce risk for blood clots (early ambulation, TED hose, repositioning, KEEP THE CLIENT MOVING!!!)

Inhalant administered through?

Metered dose inhalers(MDI) or dry powder inhaler(DPI)

Havinghurst developmental task theory middle adult age range? accept? attain? assist? developing? adjusting? achieve?

Middle Adult (Age 40-65) Accept/adjust to physical changes Attain/maintain satisfactory occupational performance Assist children to become responsible adults relating to spouse as a person Developing adult leisure time activities Adjusting to aging parents Achieve social/civic responsibility

Virginia Henderson was? What did she do?

Modern day florence nightingale. Has her own theory 20th century leader of nursing.

nursing diagnosis, collaborative problem, medical diagnosis diagnostic statement

ND: why issue occurring, CP:issue related to, MD: diagnosis by physician

Causes of misreading of pulse oximetry

Nail polish/fake nails, cold hands, poor perfusion, hypotension, bright light

surgical complications

Nausea/vomiting Thirst Urinary retention Return of bowel function (24-72 hrs) Paralytic Ileus Change in mental status Coping issues r/t diagnosis, family/friends interruptions, change(s) in body image Infection

Esteem and Self-respect Needs 4th level define? example? interventions?

Need for others to think well of the client, need to feel good about themselves, to feel pride/accomplishment, believe others respect accomplishments -Respect and esteem for others and self -As the need is satisfied the individual experiences a sense of adequacy, self worth and self-fulfillment -intervention: Call patient by name, respect values/beliefs, encourage to set attainable goals

Intravenous barriers to absorption

No barriers. Immediate administered directly into blood. Complete all of it reaches blood.

Collaborative Healthcare Team name all the people

Nurse (RN) Advanced Practice Nurses Physician Physician's Assistant (PA) Physical Therapist restore function or prevents further disability Respiratory Therapist Occupational Therapist assists with physically challenged Speech Therapist Dietitian Pharmacist Social worker (SW) Unlicensed assistive personnel like RN assistant that help RNs

Malpractice duty element definition

Nurse has relationship w/ Client and follows standards of care.

type 2 ethics&the law?Ex.?

Nursing actions may be considered ethical but not legal. Ex: Nurse caring for terminally ill in pain. Nurse arranges at patient's insistence an overdose of nonprescribed drug for assisted suicide.

type 4 ethics&law?Ex.?

Nursing actions not legal or ethical. EX:Wrong meds given and doesn't inform doctor/make incident report

IV peak time might

Occur within 10 min

Ethical distress definition

Occurs when nurse knows the right thing to do but either personal/institutional factors make it difficult to follow correct course of action

intellectual humility

One should not claim more than one actually knows. knowing and accepting limits of your own knowledge, know when to seek help, sensitive to own biases and prejudices and ignorance, A person who is biased has an opinion for or against something without having an adequate basis for that opinion.

Doses are usually

One to two tablets or one single dose vial so questions multiple tablets or vials for single dose

Generic drug name definition? identifies? what kind of letters? benefits?

Only one, official nonproprietary name. Identifies active ingredients assigned by manufacturer that 1st develops drug, derived from chemical name. Lower case letters. Cheaper

IV advantages and disadvantages

Onset rapid, absorption immediate, control over precise amount of med, administration of large volumes, irritating meds can be given with free flowing IV. High cost, inconvenient,since immediately absorbed can be dangerous if wrong dose or med, increased risk for infection or embolism

Surface body temp measured where

Oral/sublingual, auxiliary, skin

Perfusion definition? Primary factor for effective perfusion? perfusion greater in? perfusion in body tissue depends on?

Oxygenated capillary blood passes through the tissues of the body. Amount of blood flowing in lungs is factor in amount of O2/gases are exchanged and depends on whether sitting, standing, lying,activity. Perfusion greater in dependent areas. Perfusion in body tissue depends on blood supply and CV funtion

Idiosyncratic Effect aka? result of? older patients may? responses?

Paradoxical effect Result of genetic enzyme deficiencies causing abnormal mechanism of drug breakdown Older patients may have erratic or unpredictable responses to medications Unusual or peculiar response Over response Under response Opposite of expected response

Pulse regulated by

Parasympathetic/sympathetic ANS through SA node

Expiration: aka? What happens? Entire chest is?

Passive Phase •Diaphragm relaxes and moves up •Sternum goes back to original position ribs down The entire chest is relaxed causing decreased volume in lungs and increase in intrapulomic pressure and air moves out of the lungs.

Peak and Trough Levels definitions?

Peak levels Consider route and absorption, highest plasma concentration of drug should be measured when absorption complete Trough levels Drug at lowest concentration Drawn immediately/30 min. before next dose regardless of route

Effects of Sensory deprivation & overload

Perceptual- Hallucinations Cognitive-Decreased attention span, impaired memory, confusion, disorientation Affective- Emotional Crying, apathy, annoyance with small matters, anxiety

Initial assessment performed when? purpose?

Performed after admission to hospital to establish a database for problem identification/care planning

Congruent communication

Person sends same message verbally and nonverbally

Meds are organized according to

Pharmacological action, therapeutic use, body system, chemical makeup, and safe use during pregnancy

Spiritual Dimension examples?

Philosophy of life: life values, beliefs about illness Concept of deity: religion, spiritual beliefs, perceptions of faith Sense of transcendence: hope or despair Self Actualization: creativity, aesthetic sense, beliefs about life and death.

Amount of Stress related data: physical symptoms? behavioral symptoms?

Physical Symptoms: Headaches or backaches Muscle tension Diarrhea or constipation Nausea Insomnia Chest pain, Palpitations Hives Loss of sex drive Frequent colds Behavioral Symptoms: Easting more or less Sleeping too much or too little Isolating yourself from others Procrastination Using alcohol, cigarettes or drugs Nervous habit (nail biting) Teeth grinding Overdoing activities -exercising, shopping Over reacting to unexpected problems Picking fights with others

Disturbed sleep pattern or sleep deprivation(problem) RN diagnosis

Physical discomfort, exercise just before sleep, physical illness, changes in bedtime rituals

Health Promotionand Disease Prevention for mid adults types?

Physical examination Cancer screenings Breast Cervical (pap every 3 years) Prostate (yearly) Testicular (self-monthly) Colorectal Skin (self-monthly) Oral (yearly) Bone density Vision(yearly) Immunizations

Serosanguineous define

Pink, pale red, watery; HEALING

Implementing a healthy sleep cycle

Preparing restful environment, promoting bedtime rituals, offering appropriate bedtime snacks/beverages, promoting relaxation, promoting comfort, respecting sleep-wake patterns, scheduling RN care to avoid unnecessary disturbances, using meds for sleep, teaching about rest and sleep

Safety examples: prevention? prevent? reduce? define the last two and give examples?

Prevention - injury (med., falls, bacteriological, elect., chemical, thermal) Prevent - skin breakdown Reduce fear - by teaching, inform of procedures in advance, encourage pt. Control in as many matters as possible. Belongingness and affection needs -involve support systems -decrease isolation -familiar objects and people in room Self-esteem -regard pt. with respect i.e. no first names and no "Honeys" -assist with coping when needed

Skin lesions abnormalities that can be found

Primary lesions, secondary lesions

Functions of skin

Protection, regulate temp, sensory organ for pain/temp/ touch, vitamin d production

Hospital Setting provide? vary? classified? employ?

Provide inpatient and outpatient care Vary in size and services Classified as profit or nonprofit, public or private Employ more nurses than any other facility

Community Based Nursing: provides? locations? examples of 3 locations?

Provides nursing care to a defined geographic area focusing on individual and family Where people live: Home Health Nurses Hospitals Where people work: Occupational health Where people worship: Congregational Nurses Parish Nurses Faith Based Nursing

Assessing The Respiratory System:The Physical Assessment: Other methods of assessing include

Pulmonary function studies/test- Usually performed by Respiratory Therapy (RT) to evaluate pulmonary status and detect abnormalities by getting vital capacity, fored expiratory/inspiratory, total lung capacity, residual volume Spirometer- Nurses>>>>Patients. Measures volume of air in L exhaled or inhaled to evaluate lung function and airway obstruction Peak expiratory flow rate- RT>>>>Patients. point of highest flow during forced expiration(airflow) that reflects changes in size of pulmonary airways via peak flow meter Pulse oximetry- Nurses and RT measures arterial oxyhemoglobin sat. SaO2 or SpO2 of arterial blood. Since only Hb must be aware of Hb level because person with low Hb might have normal SpO2

Morals definition?

Refers to personal/communal standards of right/ wrong. Principles and rules of right conduct. Commitment to values

Therapeutic

Refers to the science and art of healing

Intellectual Dimension define? examples?

Reflected in the ability to acquire, organize, recall and communicate information. Perception Cognitive abilities of memory Orientation Knowledge Judgment and insight Abstract thinking Thought content Educational background Past experiences with health care

Causation malpractice element definition? example?

Relationship between the breach of duty and injury. Failure to use safety that causes patient to fall resulting in fractured hip

Drug Tolerance Habit Forming/Potential Harmful Effects require? uncontrolled? controlled? categorized how? each level has?

Require stringent supervision Uncontrolled: do not pose risk of abuse and/or addiction Controlled: Potential for abuse and dependence Categorized in schedules Schedule 1 no medical use in US (Heroin) Schedule II through V approved Each level has a decreasing risk of abuse and dependence

Autonomy definition

Right to self determination

mid adult RN diagnosis types?

Risk for imbalanced nutrition (more than body requirements) Caregiver role strain Sedentary lifestyle Sexual dysfunction

Listening to patient nonverbally

S- site squarely facing patient O- observe open posture L- lean forward toward client E- establish eye contact R- relax

Time lapsed assessment function? usually?

Schedule to compare patients current status to baseline data obtained earlier. Usually residential patients or ones with long term care

25,000 units of heparin are added to 500ml of Normal Saline. The dosage of heparin ordered by the physician is 800 units/hour

Since the infusion pump is programmed in ml/hr., you will need to figure out at what rate to set the pump in order to deliver 800 units/hour. Total drug/Total volume = Hourly drug/Hourly volume 25000 units/500 ml = 800 units /X ml 25000X = 400000 X = 16 ml/hr.

Transdermal definition? steps?

Skin patch. Wash skin with soap and water and dry before applying new one. Place on hairless spot and rotate locations

Sleep assessment

Sleep history ( sleep wake patterns, effects on daily activities, sleep disturbances, sleep aids) Sleep diary /log ( provides data on sleep wakefulness patterns over a long period) Physical assssment( decreased energy levels, facial signs, behavioral characteristics, physical data)

Flat tone intensity? Location?

Soft. Bone, thigh

First pass effect definition? usually given via?

Some meds are inactivated on first pass through liver and must be given by nonenteral route because of this. These meds usually given via SL or IV routes

Outcome identification/planning component of nursing process description and purpose

Specification of outcomes to prevent/reduce/resolve problems identified in diagnoses and related interventions to develop individualized plan of care and strengths that can be tapped to facilitate achievement of desired outcome. Resolve problems/develop plan of action

Non-rapid eye movement stages stages? VS?

Stage 1-2 5-50% of sleep, light sleep. Stage 3-4 10% of sleep, deep sleep states(delta sleep) 75% of sleep. 4 stages. Stage1-2 light sleep. Stage 3-4 deep sleep aka delta sleep. VS decrease.

Good Samaritan law

State law giving civil immunity from negligence when giving care in an emergency

PRN prescription definition? nurse? aka? usually for?

Stipulates at what dosage what frequency and under what conditions a med may be administered. Nurse uses clinical judgement to determine clients need for med. aka as needed, requested, required. Usually for treatment of symptoms

Intellectual Perseverance

Strive for the truth or for better understanding in spite of repeated frustrations and difficulties because you feel it is worth the effort in the long run. Firm adherence to rational principles despite others. A sense of need to struggle with unsettled questions to achieve deeper understanding

SV aka? definition?

Stroke volume. Quantity of blood out of left ventricle with one contraction

Pharmacology definition? includes?

Study that deals with chemicals that affect body functioning. Includes drug nomenclature, types of preparations, classifications, mechanisms of drug action, drug blood level monitoring, drug legislation

Nursing ethics is subset of? definition?

Subset of bioethics(life science). Formal study of ethical issues that arise in practice of nursing.

Code of ethics serves what purpose

Succinct statement of ethical obligations and duties of every nurse, nonnegotiable ethical standard, expression of nursing understanding of its commitment to societ

Tracheostomy inserted by? RN ensures? put through? can be? consists of? can have? usually unable to ?

Surgically placed by MD. The RN ensures patency, suctions, and provides tracheostomy care (cleaning around site). Put through opening in trachea and can be temp. or permanent. Consists of outer and inner cannula, shaft, and obturator. Can have a cuff to seal opening around tube or fenestrated to allow talking. Usually unable to speak though

Throat/neck inspect what? patient position?

Symmetry and bulges/masses in mid line suprasternal notch of trachea/neck/throat(if unequal may mean tracheal displacement), ROM of of cervical spine, jugular vein distention at 45 degrees(may mean fluid overload or heart disease/problems), palpate lymph nodes and trachea(determines midline) and thyroid, assess strength+ contraction of sternocleidomastoid+trapezius muscles(via turning head side to side+shrugging shoulders with resistance), ascultate for carotid Bruits, assess swallowing(should feel larynx/trachea move up), assess range of motion by moving head. Patient sitting and neck slightly hyperextended.

Ethics definition? reasoning process of?

Systematic inquiry into principles of right and wrong conduct. Reasoning process of questioning and possibly changing ones morals

Scientific problem solving steps? in regards to nursing?

Systematic problem solving process 1. Problem identification 2.data collection 3.hypothesis 4. Plan of action 5. Hypothesis test 6.results interpretation 7.evaluation resulting in conclusion or revision. Used commonly with healthcare workers

Critical thinking definition

Systematic way to form and shape ones thinking. Thought that's disciplined, comprehensive, based on intellectual standards and as result well reasoned

Health assessment definition

Systemic collection of objective and subjective data

Medical assements vs. nursing assessments

Target data pointing to pathological conditions vs. patients responses to heal th problems.

Vital signs definition? can be?

Temp., pulse, respiration, BP, pain, pulse oximetry. Can be delegated to unlicensed staff.

What to check for skin palpations

Temp., texture, moisture, turgor.

Definitions of Holistic (= whole) definition? 6 dimensions are? holistic being is more than?

The human being is made up of 6 dimensions that influence behavior. The 6 dimensions are interdependent. The Holistic Being is more than the sum of the 6 parts.

Purulent define

Thick, yellow, green, tan, brown; INFECTED

infusion pump definition? delivers solution in?

This device controls the rate of administration to the programmed amount. Infusion pumps deliver solution in milliliters per hour. You will therefore, need to be able to calculate ml/hr. in order to program the pump correctly.

Continuous Medication Infusions definition? examples?

This type of therapy delivers a steady rate of medication to the patient thus providing a constant therapeutic effect. Heparin and Aminophylline are examples of medications which may be administered by this method. These medications should always be infused using an infusion pump.

Lungs location? Composed of? Normally?

Thoracic cavity. Composed of elastic tissue. Normally elastic fibers are partially stretched at all times and therefore are partially filling the thoracic cavity

Paul's 4 domains of critical thinking

Thought, abilities , affective dimensions, intellectual standards

Pulse definition? examples?

Throbbing peripheral/apical. arteries. Ex:Peripheral, central, apical

Tongue blades/depressors purpose

To depress tongue during assessment of mouthed pharynx

Transfer Within Hospital Setting to improve? the nurse on unit transferring patient? move patient's? transfer? example?

To improve continuity of care The nurse on the unit transferring patient gives verbal in person report to the nurse in the area transferred to Move patient's personal belongs to a new room Transfer patient chart (electronic) and medications or if all electronic provide client location Hand-Off Report

figure the units per hour. If you knew that the IV was running at 16ml/hr. and that your infusion contained 25,000 units/500ml

Total drug/Total volume =Hourly drug/Hourly volume 25000 units/500 ml = X units/16 500X = 400000 X = 800 units

sterile drape with no sterile gloves

Touch only outer 1 inch

Lower airway components? Function? aka?

Trachea, right and left stem bronchi, segmental bronchi, terminal bronchi. Provides conduction of air, mucociliary clearance, production of pulmonary surfactant that reduces surface tension to prevent collapse. aka tracheobronchial tree

Long-Term Care Facilities define? examples?

Transitional sub-acute care for people with chronic illness or disabilities Intermediate and long-term care Nursing homes Retirement centers Residential institutions for mentally or physically disabled "Aging in place" with living space that have services for health

Drugs cannot create new responses in the body. They can only:

Turn on and turn off Promote Block responses

Nasogastric and gastrostomy tubes nursing implications do what? what forms only? meds administered? to prevent clogging?

Use a syringe and allow med to flow by gravity or push it with plunger. Liquid forms only. Meds administered separately. To prevent clogging flush tubing before and after each med with 15-30 ml of water

SubQ and IM advantages and disadvantages

Use for poorly soluble meds, route appropriate for administering meds absorbed slowly for extended time. IM is more costly, inconvenient, pain with risk for local tissue damage and nerve damage, risk for infection at injection site

Communicating with a confused patient

Use frequent face-to-face contact to communicate social process Speak calmly, simply, and directly to patient Orient and reorient patient to environment Orient patient to time, place, and person Communicate that person is expected to perform self-care activities Offer explanations for care Reinforce reality if patient is delusional

Intradermal implications usually used for? volume? syringe? gauge? skin? angle?

Usually for tuberculin testing or checking for med and allergy sensitivities. Use 0.01-0.1ml in tuberculin syringe with fine gauge needle(26 to 27 gauge) in lightly pigmented thin skinned hairless sites at 10-15 degree angle

Hyperresonance tone intensity? Location?

Very loud. Lung with emphysema or excess flatus in intestines.

Palm can assess.

Vibration

Nasal speculum purpose? Blades inserted how deep and then? What speculum used?

View lower and middle turbinates, usually penlight used for illumination visualize lower and middle turbinates and internal nares of nose. Blades inserted 1 cm into each nostril and opened so they don't press on septum. shortest/widest speculum that will fit into nose used

HEENT older adult considerations

Visual acuity/ peripheral vision/ accommodation to darkness decreases. Conjunctiva yellow. Skin around eye darken/sunken. Hearing loss(usually high frequency sounds first), earlobe elongates, sense of smell and taste diminish(sweet/salty first), oral mucosa drier

Healthcare Agencies examples?

Voluntary agencies Parish nursing Congregational nursing Government agencies Veterans administration and military agencies Public health service Public health agencies

w/ high temp. assess/monitor what?

WBCs, sedimentation rates, electrolytes

activity intolerance nursing diagnoses related factors?

any condition that interferes with transport of oxygenated blood to tissue(congestive heart failure, arrhythmias, chronic obstructive pulmonary disease, diabetes mellitus), any condition that causes fatigue(depression, pain, sleep issues, prolonged bed rest, sedentary lifestyle)

decubitus(pressure) ulcers definition? caused by? resulting in? 1st sign is? if pressure continues after__ occurs than? compromised circulation___ to? __+___?

any lesion/wound caused by unrelieved pressure(immobilition, nutrition+hydration, moisture) resulting in damage of underlying tissue/necrosis. 1st sign is blanching(pale+white), if pressure continues after ischemia occurs than this happens. compromised circulation secondary to pressure or pressure combined with friction. friction+shear

nursing intervention definition? types?

any treatment, based on clinical judgement, and knowledge, that a nurse performs to enhance patient outcomes. Types: nurse-initiated, physician-initiated, physician-initiated, and collaborative interventions

Stressor is? example?

anything that is perceived as challenging, threatening, or demanding Can be internal or external. I.e. illness, hormonal changes fear cold temperature noises.

bruits assess where? what part of stethoscope? definition?

aorta, renal arteries, iliac, femoral arteries. use bell of stethoscope. Are swooshing sounds indicating partially blocked artery.

mitral area aka and location

apex. 5th intercostal space, L mid-clavicular line

geriatric cardiac variations

apical+distal pulses can be more difficult to palpate, dilated proximal arteries, varicosities more common, increased BP, widened pulse pressure. difficult to palpate apical pulse, difficult to palpate distal arteries, dilated proximal arteries, more prominent tortuous blood vessels, varicosities common, increased systolic and diastolic BP, widening pulse pressure

reciprocity def.

apply for and be endorsed as RN in another state

lesions are

areas of diseased or injured tissue. Ex:bruises, scratches, cuts, burns, bites, wounds. Types: Primary or secondary

techniques for assessing breasts in females 4 positions

arms at side or above head, hands on hips, leaning forward

nursing process is what? identifies? systematic method directing?

art+science of nursing. Identifies patients needs/strength to make care plan and evaluate effectiveness. Systematic method directing nurse and patient to assess, diagnose, identify expected outcomes, plan care, implement care, evaluate results.

Gliding joint define? movements? example?

articular surfaces flat. Flexion, extension, abduction, adduction occurs. Example: carpal bones of wrist and tarsal bones of feet

pupillary reaction guidelines

ask patient to look straight ahead, bring penlight from side of face and shine light on pupil, observe pupil reaction+size, repeat procedure and observe other eye

assessing abstract reasoning

ask to explain proverb(early bird catches the worm)

nursing interventions accomplishes?

assisting patient to meet outcomes, clearly/concisely describe nursing action, are dated when written/reviewed, signed by nurse, only w/ abbreviations accepted by institution, refer nurse to agency's procedure manual

cerebellum define? issue?

assists by making movements smooth and coordinated. Multiple sclerosis myelin sheaths deteriorate causing lack of coordination

psychological factors for drugs

associated with aging (decreased gastric motilility, muscle mass, acid production, and blood flow affect absorption- increase susceptibility to adverse to adverse effects. Liver function/enzymes declines with age involved with drug metabolism. Drugs excreted more slowly due changes in kidney function. Receptor sensitivity is altered and their sensitivity to certain drugs increases

Nail abnormalities that can be found

beau's lines(indentations from acute illness), infection, separation of nail plate from nailbed(onycholysis) from infection or trauma, increased brittleness or thickness &angulation(from anemia or Fe deficiency anemia), clubbing from long term lack of O2

preprandial vs. postprandial

before a meal or after/during meal

when to use alcohol hand rub

before/ after contact w/ patients, before gloves, before catheters, moving from contaminated body site to clean body, after contact w/ patients

pressure ulcer risk assessment

begins with this, Norton or Baden scale used

health promotion definition? levels?

behavior to increase well being and health. Levels: primary(preventing disease/injury, promoting health), secondary(screening/exams for detection, reverse/reduce disease), tertiary(after illness to reduce disability and rehab for functioning)

flexion

being bent

By viewing health and illness on a continuum it is possible to consider a person as

being neither completely healthy or completely ill, Instead, a person's state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death.

faith(confidence) in reason

believing it's best for all people to learn to use the best possible thinking skills. faith people should think for themselves and persuade each other by reason and become reasonable persons. when faculty encourage students to draw their own conclusions and give rationale

occult blood in stool

blood that is hidden in specimen or cannot be seen on gross exam can be detected with screening tests

cyanosis

bluish, greyish skin in response to inadequate oxygenation. Blue tinge in white, dullness with dark skin. Caused by cold environment, cardiac or respiratory disease

contusion

blunt instrument, overlying skin remains intact, with injury to underlying soft tissue, possible resultant bruising and/or hematoma

puncture

blunt or sharp instrument puncturing the skin, intentional(venipuncture) or accidental

appearance and behavior assessment

body build, posture, gait, height, weight, coordination, signs of illness(change in posture, skin color, respiration, short attention span), hygiene, grooming, cognitive processes(speech, orientation)

high pitched bowel sounds indicate

bowel obstruction

abdominal auscultation. bowel sounds? time? use what part of stethoscope? assess? start with? before reporting as absent ?

bowel sounds high pitched, gurgling, cascading sounds occurring every 5 to 20 or 34 seconds. Use diaphragm of stethoscope, assess all quadrants in clockwise manner starting with right lower quadrant. before reporting as absent listen for 2+ minutes in each quadrant

discharge, lumps, lesions, dimpling, asymmetry of breasts, palpable lymph nodes may indicate

breast cancer

auscultating breath sounds

breathe slowly and deeply through mouth. listen from side to side from top to bottom. listen for duration, pitch, intensity of sounds

ventilation definition?

breathing in/out. Component measured for respiration

orthopnea

breathing more easily in upright position

grading of reflexes - +3

brisker than average, possibly but not necessarily indicative of disease

ecchymoses definition

bruises that are larger extravasations of blood. collection of blood in subcutaneous tissues causing purplish discoloration

high fiber foods increase

bulk in fecal material. bulkier feces increase pressure on intestines causing stimulus for peristalsis. Examples:whole grains, bran, dried peas and beans fresh fruit & vegetables

use bleach for

c.diff

eschar

can hide pressure ulcers & are thick leathery scab or dry crust that is necrotic

assistants/lpn's delegation

cannot delegate. can be delegated to take vitals

nursing history does what? should be? identifies?

captures/records uniqueness of patient for individualization. Should be obtained ASAP and should be followed by nursing physical assessment.Identifies strengths/weaknesses, health risks, potential/existing health problems

test extraocular movements by assessing

cardinal fields of vision for coordination and alignment

skin vascularity, bleeding, bruising may relate to

cardiovascular, hematologic, liver dysfunction

10 rules to redesign/improve care

care based on healing relationships, custom based on needs/values, patient is source of control, shared knowledge, evidence-based decision making, safety, transparency, anticipitation of needs, decrease in waste, cooperation

central pulse locations

carotid, femoral, apical

inscription contains?

contains drug name, strength, dose

The individual's state of health is one of? it? his condition is? he may? the health-illness continuum illustrates?

continual change. It moves back and forth from health to illness and back to health again. His condition is rarely constant. He may wake up feeling great, develop a headache mid-morning, and feel fine again by noon. The health-illness continuum illustrates this process of change, in which the individual experiences various states of health and illness (ranging from extremely good health to death) that fluctuate throughout his life.

wheezes? types?

continuous sounds that originate in small air passages that are narrowed by secretions, swelling, or tumors. Inspiratory or expiratory and high pitched. Types:sibilant(squeaking, continuous, during inspiration+expiration, high pitch), sonorous(coarse, low pitched, continuous, during inspiration+expiration, coughing may clear sound)

biceps reflex guidelines

contraction of biceps seen and felt. Elbow bent and palm faces downward. Examiners thumb placed on biceps tendon at the bend in elbow and percussion hammer strikes examiners thumb

activity intolerance nursing diagnoses sample defining characteristics

decreased ability to perform self-care like turning in bed, changing position, ambulating, washing, dressing, eating etc. Altered response to activity like dyspnea(short breath with increase in rate), weak increase pulse with change in rhythm, BP that fails to increase with activity or decreases, weakness, pallor, confusion, vertigo

older adult abdominal variations

decreased bowel sounds, decreased abdominal tone, liver border palpated more easily

elderly decreased lean body mass, decreased total water for drugs

decreased distribution water-soluble drugs and higher plasma concentrations leading to increased possibility of drug toxicity

elderly decreased kidney function, renal mass, blood flow for drugs

decreased excretion of drugs, leading to possible increased serum levels/toxicity

elderly decreased liver function, decreased enzymes for metabolism and hepatic perfusion for drugs

decreased metabolism, higher drug plasma concentrations, leading to prolonged action and increased risk of toxicity

older adults abdominal variations

decreased motility, bowel sounds, skin tone and dry skin with pulsations and varied coloration

hypoventilation definition? causes?

decreased rate+depth. overdose of narcotics/anesthetics

flaccidity

decreased tone, hypotonicity resulting from disuse or neurologic impairment

as the gauge of the needle increases, the number of the gauge? example?

decreases. Example: 18 gauge is larger diameter than 30 gauge

Agonist- definition? example?

drug-drug interaction stimulates function of drug or cause a response ASA + warfarin

s2 sound? means? loudest where? compared to s1

dub. aortic and pulmonic valve closure, beginning of diastole/closure of aortic and pulmonic valves, loudest at base(aortic+pulmonic area). Higher pitched and shorter than s1

pain classified according to

duration(acute vs. chronic), location/source(cutaneous vs. somatic vs. visceral), its mode of transmission(referred), or etiology(neuropathic vs. phantom vs. psychogenic)

Drop in creatinine good indicator of

effective treatment

liability definition? elements?

elements must be established to prove malpractice/negligence occurred: duty, breach of duty, causation, damages

Verbal Rx only for

emergencies

standards of GI/urinary assessment

empty bladder needed, auscultation before palpation or percussion, locate findings according to ab quadrants

repositioning in bed if patient partially able and < 200 lbs

encourage to pt. to assist using aid with friction-reducing device and 2-3 caregivers

repositioning in bed if patient partially able and >200 lbs

encourage to pt. to assist using aid with friction-reducing device and 3 or more caregivers

elderly alterations in blood brain barrier for drugs

enhanced CNS penetration of fat soluble drugs, increased possibility for alterations in mental status, dizziness, gait, disturbances

hendrich fall model

evaluation for fall potential via 8 risk factors

HEENT assessment definition

head, eyes, ears, nose/mouth, throat/neck

scars are

healed wounds is dermis or subcutaneous layer

presbycusis

hearing loss occurring as an individual ages

paresis

impaired muscle strength or weakness

POC in post op phase begins

in preop phase

comfort scale

infants, children, adults unable to use NRS, Wong-baker, or FACES

basal ganglia define? issue?

integrate semivoluntary movements. Parkinson's disease causing progressive degeneration causing unnecessary skeletal movements

licensure

legal authority to practice

pediculosis

lice

tail of spence=

lymphatics part of breast near arm pit

3 decision options for how outcomes have been met

met, partially met, not met

grading of reflexes - 0

no response

endorphins definition? Produced at?

opioid neuromodulators. produced at neural synapses at various points along CNS pathway and are pain-blocking

rectal exam

optional/focused. Inspection of anus(color, integrity, hemorrhoids, lesions), palpate(lesions, nodules, massess, tenderness, sphincter tone firm and mucosal lining smooth), assess stool(color, consistency, shape, amount, odor, constituents)

po means

orally

Development definition

orderly pattern of changes in structure, thoughts, feelings, behaviors due to maturation, experience, learning

growth and development are? we all have?

orderly, sequential, continuous, complex. We all have same patterns and developmental levels but they are individualized so wide variation in biological and behavioral changes is normal

organism potential to make disease in a person depends on what factors?

organism #, virulence, competence, length of contact

psychomotor outcomes definition

patient's acheivement of new skills

litigation

process of bringing and trying a lawsuit

assimilation define

process of integrating new experiences into existing schemata

certification definition & ex?

process where person meets criteria est. by nongovernmental association. Certification (voluntary)

constipating foods

processed cheese, lean meet, eggs, pastas

CNS

processes stimuli to give response to efferent system

bacterial action in large intestine does what

produces vitamin K and some of B complex

nurse practice acts do what

protects public via patient bill of rights, create board/regulatory body, define important terms/activities SOP, establishes criteria for education/licensure, regulates.

pyuria

pus in urine

Peripheral pulse can be taken where?

radial, brachial, temporal, politeal, posterior tibial, dorsalis pedis

raised CO=?BP

raised BP

as HR raises CO?

raises

Immediately Before Administration check?

right patient, right time, right route

bill of rights for people with pain

right to have reports of pain accepted and acted on, right to have pain controlled no matter what, right to be treated with respect at all times

deep breathing position? technique?

semi-fowler exhale and inhale and hold breath 3-5 seconds 3 times ever 1-2 hours for first 24hours

ointment

semisolid prep containing a drug to be applied externally aka unction

Pre-filled Cartridges: definition? since it's different usually than what's ordered? some are designed so?

some medications are supplied in cartridges which must be placed in a holder for injection. Since the supplied dosage of pre-filled medication is often different from the amount ordered, care must be taken to expel the unneeded medication from the cartridge. Some cartridges are designed so that medication can be withdrawn from them, much like a vial.

grading of reflexes - +1

somewhat diminished, low normal

mechanical lateral assist devices

specialized stretchers that eliminate need to slide patient manually, some electric some are hand cranked

early morning care

toileting, refreshing for breakfast via washing face/hands/mouth. after breakfast. toileting, oral care, bathing, back massage, special skin care measures, hair care, cosmetics, dressing, positioning for comfort. Categories: self-care(patient can do it themselves), partial care(requires assistance), complete care(RN does everything)

lateral transfer to and from bed to stretcher >200 pounds patient partially able/not able

use friction-reducing device and 3 caregivers

repositioning in bed if patient cannot assist

use full body sling lift and 2+ caregivers

palpating precordium use? assess?

use palmar surface + 4 fingers. Assess aortic, pulmonic, tricuspid, mitral(apical impulse), Erb's point areas

Braden scale

used in hospital to assess+predict pressure ulcer risk. Braden scale score 13-18=low to moderate risk. Braden scale score 10-12=high risk.

healthcare associated MRSA treatment

vancomycin

pediatric cardiac variations

visible pulsations related to thin chest wall, sinus dysrhythmia, HR increases with inspiration+decreases with expiration. S3 present in 1/3 of all children, more rapid HR up to age 8. visible cardiac pulsation is chest wall thin, sinus dysrhythmia(rate increases with inspiration and decreases with expiration), presence of S2(1/3 of kids), more rapid heart rate

nurse observes how

visually, hearing, smell

common law? ex?

court-made law. Ex. Malpractice.

crackles definition? fine? coarse aka? when made?

crackling sounds as air moves through wet secretions(inspiration). Fine: when made by air passing through moisture in small air passages and alveoli. Coarse aka rhonchi: when made by air passing through moisture in bronchioles, bronchi, trachea.

restless leg syncdrom

creeping, crawling, tingling in legs, can't lie still. URGE- urge to move legs, rest-induced, gets better with activity, evening symptoms more severe

Secondary skin lesions examples? Those that arise from?

crust, scale, fissure, erosion, ulcer, excoriation, scar, atrophic scar, lichenification, keloid. Arise from changes in primary lesions

material on skin surface ex? type?

crust, scale. Type:secondary lesion

support measures for ROM exercises

cupping, cradling, supporting

incision definition

cutting or sharp instrument, wound edges in close approximation and aligned

Mixing 2 insulins in 1 syringe steps?

1) Frequently, you will be mixing two types of insulin (Regular and NPH) in one syringe. By mixing the insulins in one syringe, the patient avoids getting injections. 2) Some points to remember about mixing insulins: 3) Avoid contaminating one vial with the contents of the other.Regular Insulin is fast acting. 4) NPH Insulin has a delayed onset of action because a retardant has been added to the solution. 5) Always draw up Regular insulin first. (If NPH Insulin is drawn up first, traces of the retardant could enter the Regular Insulin vial and delay the onset of action.) 6) Add air to the NPH vial first, then add air to the Regular vial. 7) Draw up the Regular Insulin, then add the NPH. 8) Be very careful when withdrawing the NPH! You cannot inject medication back into the vial or correct the NPH dosage without altering the Regular dosage.

GIVING INSULIN INJECTIONS steps?

1) Insulin is ordered in units. 2) Always use an insulin syringe for administering insulin. 3) Insulin syringes are calibrated in units, therefore no calculation is necessary. 4) Fill the syringe to the desired unit marking. Example: you are to give 20 units of NPH insulin. You would draw up enough medication to reach the 20 unit marking on the insulin syringe. 5) Insulin syringes are to be used for insulin administration ONLY. 6) Do not shake insulin

Oral med may have a peak of

1-3 hr after admin

Nasal Cannula O2 volume rate? FIO2 %? FiO2 aka?

1-6L/min 24-44% FIO2 aka fraction inspired O2

3 Checks

1. Check the drug label with the MAR when removing/reaching for the container or unit-dose package 2. Check the drug label with the MAR again before dispensing, pouring, or preparing the medication 3. Check the drug label with the MAR once more when replacing the container and /or before administration of the medication to the patient

ICN Code of ethics 4 principle elements for ethical conduct

1. Nurses and people 2. Nurses and Practice 3. Nurses and profession 4. Nurses and coworkers

8 steps of malpractice litigation

1. claim determined to be appropriate via all elements of liability 2. All parties(nurses/physicians/agency) named as defendants and work towards settlement 3. Case presented to malpractice arbitration panel 4. defendants contest allegations 5.pretrial discovery occurs 6. trial takes place 7. Decision reached 8. may be appealed to appellate court if verdict not accepted

guidelines for writing nursing diagnosis 8 steps

1. phrase as patient problem 2. patient problem precedes the etiology(cause) and 2 are linked by related to 3.Defining characteristics are linked by as evidence by 4. write in legally advisable terms 5.Use nonjudgemental language 6.problem statement indicated what's unhealthy about patient or what patient wants to change 7.avoid using defining characteristics/medical diagnosis/something that can't be changed in problem statement 8. reread diagnosis to make sure problem statement suggests patient outcomes and etiology will direct the selection of nursing measures

AIMS of nursing

1.Promote health 2. Prevent illness 3.Restore health 4. Facilitate coping w/ disability+death

esophagus is how long? connects what?

10" long connects pharynx to stomach

how long to wash hands

10-15 seconds

Non-Rebreather Mask volume rate? O2 %? reservoir bag collapses?

10-15L/min 60-100%O2 Reservoir bag collapses only slightly during inspiration

1 gram (Gm) = ? mg

1000 mg

Stage 1 hypertension range

140-159/90-99

Rehabilitation Centers define? provide for patients requiring?

24 hour care for a limited period of time to Provide for patients requiring: Nursing care Specialized services Reasons for admission to Rehab Post Injury Post CVA Post Surgery

anuria

24 hour urine output <50mL aka kidney shutdown/failure

Most solutions considered sterile for how long?

24 hours after opened

Circadian rhythm

24 hr intervals, temp/BP

Diploma vs. associate degree RN's

24-36 mo. vs. 2 academic years. Biologic, physical science vs. basic, social science+general education. Same competencies

peristalsis after surgery doesn't return until

24-48hours

1 ounce (oz.) = ?ml

30 ml

Order: Heparin 3000 units subq twice daily Supply: Heparin 10,000 units in a 2 ml vial Give: ml Indicate this amount on the syringe:

3000_ X 2ml = 0.6 10000 2ml X units (H) X 3000 = 0.6 10000 units (D) 1

PaCO2 average range? Obtained via? definition?

35mm-45mm Obtained via blood draw ABG. Partial pressure of carbon dioxide in the arterial blood

Normal body temp. Range? average?

36 C/97 F - 37.5 C/ 99.5 F. Avg=37C/98.6F

erbs point location

3rd intercostal space, L sternal border

tricuspid area location

4th intercostal space, L sternal border

large intestine is how long? what does it do?

5 feet. absorbs water and electrolytes.

Rating muscle strength

5(normal full ROM against gravity and resistance), 4(full ROM against bur weak to applied resistance), 3(muscle moves actively against gravity), 2(moves with support against gravity), contraction(palpable and visible, 0(contraction undetectable)

droplet transmission

>5mcm. Requires PPE, private room w/ door open. Less Thant three feet it can travel. Can be transported around with mask

modified food pyramid for 70+ years how much water? bread/cereal/rice/pasta? fruit? vegetables? meat/poultry/fish/beans/eggs/nuts? milk/yogurt/cheese? fats/oils/sweets? calcium/vitamin B12/vitamin d?

>8 glasses water >6 servings bread, fortified cereal, rice, pasta >2 fruit servings >3 vegetable servings >2 meat, poultry, fish, beans, eggs, nuts >3 milk, yogurt, cheese Fats oils, sweets use sparingly Calcium, vitamin B-12, vitamin D supplements

Post-operative assessment (immediate) check what first? what second? what third? fourth? fifth? 6th?

A ---> Patent Airway PROTECT THE CLIENT'S AIRWAY!!! B ---> Effort of breathing, adventitious breath sounds C ---> Pulses, capillary refill, color of skin/ lips/ mucous membranes, O2 Sat Vital signs, temp (client may need warming), BP (compare to baseline) Fluid status; Urine Output & Fluid Intake during surgery, bowel prep before surgery, length of NPO Assess wounds, drains, tubes, skin status Focused assessment depending on surgery Pain management: early administration of opioids, NSAIDS, assessment of blocks, epidurals, spinals Positioning, Use of heat/ice/massage Patient Controlled Analgesia (PCA) Pain management consultation Assess use of prior pain meds, chronic pain

Hospice Centers define? services provided to?

A center where patients receive palliative care or supportive care at the end of life Services provided to patient, family, people important in the dying patient's life

Transferring a Patient to a Long-Term or Rehabilitation Center: a copy of? detailed? nurse often provides?

A copy of the chart is usually sent with the patient Detailed assessment and care plan is sent The nurse often provides verbal report to the new nurse via phone

Black Box warning definition? what's required? what can occur? example?

A method of flagging a serious warning so that prescribers do not miss seeing it Special and careful monitoring for onset of a problem is required Serious or life threating adverse reactions can occur E.g. Benicar olmesartan (antihypertensive)

US food and drug administration pregnancy risk categories

A, B, C, D, X. Classifies meds in terms of potential harm during pregnancy. A is safest and X most dangerous.

Mrs. Gatson will know how to bathe her newborn, correct the statement

After attending infant care class, Mrs. Gatson will correctly demonstrate the procedure for bathing her newborn

Patient will cope better. Correct

After teaching, 10/20, patient will describe 2 new coping strategies will to try and demonstrate decreased incidence of previously observed ineffective coping behaviors(chain smoking, withdrawal behavior, alcohol consumption.

Physical Dimension examples?

Age Developmental stage Race Gender Genetics Physiological functioning-independent in activities of daily living? Diseases Body type Appearance

Factors that contribute to falls

Age >65 History of falls Impaired vision or balance Altered gait or posture, impaired mobility Medication regimen Postural hypotension aka orthostatic hypotension Slowed reaction time Confusion or disorientation Unfamiliar environment

older adult Changes at the Cellular Level

Aging cells in the musculoskeletal and nervous systems begin to die off. Thickening of cells due to increased stiffness of collagen fibers reduces diffusion of nutrients and wastes. Elastin become fragmented and calcified and results in decreased elasticity Fat is redistributed from subcutaneous tissue to the trunk. Increased fat, decreased total body water.

You receive an order to administer 1000ml of fluid over 8 hours. The fluid is to run via an infusion pump. How many ml/hr. will you program into the machine in order to deliver 1000 ml in 8 hours?

Amount of solution/Hours to administer= ml/hr. 1000/8= 125 ml/hr.

Prototypes

An individual drug that represents groups of drugs

Pain interventions

Analgesics, non opioids(acetominophen, NSAIDS), opioids(can be used with adjuvants)

Diagnosing component of nursing process description and purpose

Analysis of data to identify strengths/problems that nursing can prevent/resolve to develop a prioritized list of nursing diagnoses. Statement describes clients actual/potential response to health problem. Focuses on client-centered problems. NANDA established. Allows nurses to individualize care. Clinical judgement about individual/group responses/experiences to actual/potential health problems/life processes. Provides basis for selection of nursing interventions to achieve outcomes for which nurse has accountability

Andropause definition? loss of?

Androgen levels diminish Loss of sexual potency

General skin care principles

Assess daily, clean when soiled using no rinse ph balanced no soap cleanser, avoid using soap and hot water+friction,minimize exposure to moisture, use skin barrier as necessary, use emollients

Physical examination for safety/mobility

Assess mobility status Assess ability to communicate Assess level of awareness or orientation Assess sensory perception Identify potential safety hazards Recognize manifestations of domestic violence or neglect

5 step model of ethical descion making (nursing process)

Assess situation/gather data>diagnose(identify) problem> plan > implement decision> evaluate decision>

Evaluation operationalizing critical thinking

Assess the credibility of sources to assess strength of evidence and assess for biases, stereotypes, close clichés

check and balance system definition?

Authorized Prescriber conveys medication plan (orders or prescriptions), Pharmacist prepares medication, Nurse administers medication

Homeostatic Regulators of the Body (Physical) examples?

Autonomic Nervous System:Parasympathetic, Sympathetic Endocrine System:Adrenals, Pituitary, Thyroid Cardiovascular Renal Respiratory Gastrointestinal

Nonmaleficence definition

Avoid causing harm

Implementation for drugs?

Avoid distractions Read labels carefully Measure doses accurately Double check high alert medications Follow 6 Rights Do not administer medications that were prepared for someone else. Clients become part of the safety net

Dorsal recumbent position: description? Areas assessed? Cautions?

Back lying position with knees flexed and hips externally rotated; small pillow under head; soles of feet on surface. AA: head, neck, axillae, anterior thorax, lungs, breasts, heart, extremities, peripheral pulses, vital signs, vagina. C: may be contraindicated for clients who have cardiopulmonary issues. Not for ab assessment since abs have increased tension

Lithotomy position: description? Areas assessed? Cautions ?

Back lying with feet supported in stirrups the hips in line with edge of table. aka dorsal recumbent position w/ butt at edge of table. AA: female genitals, rectum, female reproductive tract. C:uncomfortable and tiring for elderly, embarrassing

When administering liquids, suspensions, elixirs where should liquid level be

Base of meniscus at lowest fluid line

Eric Erikson based on? Stages of development based on? 4 major organizing concepts? Achievement of developmental goals affected by? Unsuccessful resolution at any stage may? how many stages? name each stage?

Based on Freud. Stages of development based on psychosocial. 4 major organizing concepts: stages of development Development goals/tasks psychosocial crises The process of coping Achievement of developmental goals affected by environment. Unsuccessful resolution at any stage may delay progress to next but mastery can still occur 8 stages: trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt, industry vs. inferiority, industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, ego vs. despair

Levels of critical thinking and definitions of each

Basic-learner trusts experts for right answers. Thinking concrete and rule based follow step by step Complex-detaches from authorities and examines alternatives more independently. More creative Commitment-makes choices without assistance from others and assumes accountability for decision

Institute for Safe Medication Administration (ISMP) be alert for? tall man letters? benefits? uppercase letters used within drug name to? Examples?

Be alert for drugs that sound-alike and look-alike Tall man letters reduce confusion between similar drugs Fewer errors, Similar drugs easier to distinguish Uppercase letters that are used within a drug name to highlight its primary dissimilarities with look-alike drug names Examples: NovoLOG and NovoLIN HumaLOG and HumuLIN oxyCODONE and OxyCONTIN clonazePAM and LORazePAM

Communicating with an unconscious patient

Be careful what is said in person's presence; hearing is the last sense that is lost Assume the person can hear you and talk in a normal tone of voice Speak to the person before touching Keep environmental noises at low level

How do we apply theory to nursing practice: be? be? anticipate? understand that? assess? families can? be prepared to?

Be knowledgeable about developmental stages Be flexible Anticipate regression during difficult times Understand that environment and culture have an impact on development Assess each person with understanding there is no exact beginning or end to a particular stage Families can have a positive or negative influence on development Be prepared to provide care to patients who fail to meet developmental goals

Legal responsibility of nursing students

Be prepared, ask for additional info supervision when needed, comply with policies, notify when noticing any changes in clients condition

General appearance characteristics

Body build/posture/gait/coordination, hygiene, signs of illness, LOC, position, skin color, respiration, s/s of pain/distress

less blood supply organs?

Bones Brain

Sanguineous define

Bright red; ACTIVE BLEEDING

Patient will list dangers of smoking and stop smoking. Correct

By next meeting, 3/11, patient will identify 3 dangers of smoking and describe a plan willing to try to stop smoking. By 6/20 patient will report he no longer smokes

risk factors for cancer

CAUTION. change in bowel or bladder habits, a sore that doesn't heal, unusual bleeding or discharge, thickening or lump in breast or elsewhere, indigestion or difficulty in swallowing, obvious change in wart or mole, nagging cough or hoarseness

medical history for surgery. examples of diseases and risk for each organ system?

CV- thrombocytopenia, hemophilia, recent MI, cardiac surgery, heart failure, dysrhythmias increase risk for hemorrhage and hypovolemic shock, hypotension, venous stasis, thrombophlebitis, and overhydration w/ IV respiratory- pneumonia, bronchitis, asthma, emphysema, chronic obstructive pulmonary disease increase risk for respiratory depression and postop pneumonia, atelectasis, alerations in acid-base balance kidney and liver disease change response to anestesia, affect fluid and electrolyte and acid-base balance and impair wound healing endocrine disease like DM increase risk for hypoglycemia or acidosis slow wound healing and increase risk for postop CV implications

Oropharyngeal or Nasopharyngeal tubes inserted by? oropharyngeal keeps/for? nasopharyngeal aka? allows? can be? from what part to what part?

Can be inserted by RN, RT, or MD. Oropharyngeal keeps tongue clear of airway until back of jaw and pt. on side and usually for post op patients until gaining consciousness. Nasopharyngeal aka trumpet allows suctioning and can be left in alert patients and from tragus of ear to nostril plus 1 inch

Pre operative phase can begin? assessment includes?

Can begin well prior to surgical date in pre admission testing or via phone Assessment includes: health history, family history, physical assessment, psychosocial assessment, establishing baseline data

Toxic Effects can occur from? definition? types?

Can occur from cumulative effect of drugs. Specific patterns or groups of symptoms related to drug therapy that carry risk for permanent damage to an organ or system and that may result in death. neurotoxicity, hepatotoxicity, nephrotoxicity, ototoxicity, cardiotoxicity, immunotoxicity

Subcutaneous and intramuscular barriers to absorption? rate of absorption determined by?

Capillary wall has large spaces so no significant barrier. Rate of absorption determined by: solubility of med in water(highly soluble are absorbed in 10-30min., poorly soluble are longer), blood perfusion at site of injection(sites with high blood perfusion will have rapid absorption, sites with low perfusion will have slow absorption)

Essential Nutrients examples? not? ex?

Carbohydrates,Fats,Proteins. not synthesized in body or made in sufficient amounts Ex: macronutrients since provide energy and build tissue or micronutrient

CO aka? definition? average? equation? goes up during?

Cardiac output. Amount of blood pumped a minute. Avg-3.5L/min to 8L/min in adult. CO=SVxHR. goes up during activity

Assessing language? what controls language? do what to assess?

Clear, slurred, unintelligible, aphasic(receptive, expressive). cerebra cortex controls language. Ask to name items in room, read sentence, follow commands

Serous define

Clear, watery plasma; HEALING

Why do preop teaching

Client education and emotional support have positive client outcomes physically and psychologically. Decreased pain/anxiety, fewer complications, earlier discharges, quicker return to normal, increased satisfaction

Components of Prescription Order characteristics? requires?

Client's Name and at least one other identifier (DOB), Date and time of Rx, Name of medication (generic or trade depending on policy), Dosage of medication, Route of administration, Time and frequency, Exact times or number of times per day, Signature of prescribing provider. Requires drug, dose, rate, route, frequency, and when appropriate duration to be explicit and specific to needs of patient in order to achieve desired outcome

Hygienic environment characteristics

Clutter free, ventilation, room temperature, lighting and noise, bed safety and comfort, making occupied/unoccupied bed

Assessing component of nursing process description and purpose

Collection, validation, communication of data to make judgement about health status and plan individualized care

What to check for scalp inspections

Color, dryness, scaliness, lumps, lesions, lice

What to check for hair inspections

Color, texture, distribution

What to check for skin inspection

Color, vascularity, lesions, odor, rash, wounds, scars, bites, bruises, scratches

Principle based approach to ethics

Combines elements of both utilitarian and Deontologic theories offering specific action guides for practice

Purposes of patient records

Communication, recording diagnostic/therapeutic orders, care planning, quality of care review, research, decision analysis, education, legal, reimbursement, historical documentation

Altruism definition

Concern for welfare and well being of others

knee reflex guidelines

Contraction of quadriceps causes knee to extend. Patient sitting, patellar tendon below patella struck with hammer

Plasma med levels can be regulated to? med dosing attempts to?

Control med responses. Med dosing attempts to maintain plasma levels between minimum effective concentration(MEC) and the toxic concentration

Preventing sensory alterations

Control patient discomfort whenever possible Offer care that provides rest and comfort Be aware of need for sensory aids and prostheses Use social activities to stimulate senses and mind Enlist aid of family members to participate in or encourage activities Encourage physical activity and exercise Provide stimulation for as many senses as possible

Why is it so important to manage post-op pain? controlled vs. uncontrolled pain?

Controlled pain Reduces recuperation time Provides for faster mobilization Assists in returning to full activities and work Increases client satisfaction Uncontrolled pain: Psychological and physiological consequences: impaired healing, impaired pulmonary effort and increased pulmonary complications, muscle/skin breakdown, immobility, anxiety, depression, decreased client satisfaction, weakness...

Managed Care Systems controls? limits? requires?

Controls cost of care while maintaining quality of care primary care provider aka case Manager aka "gatekeeper" plans and monitors the care Limits the choice of care providers Requires approval for specialty care

Case Management does what? role of nurse? controls? improves?

Coordinates care and promotes continuity through advocacy, communication, education to assess, plan, facilitate, advocate Role of nurse is coordinator of care Controls costs Improves access to healthcare

Examples: Psych. Mechanisms to adapt to stress: coping mechanisms examples? defense mechanism?

Coping Mechanism: crying, laughing, sleeping, cursing physical activity, exercise smoking, drinking lack of eye contact, withdrawal limiting Relationships with those of similar values and interest Defense Mechanism: compensation, regression, rationalization denial, suppression, displacement

Skin color abnormalities that can be found

Cyanosis, erythema, jaundice, pallor, ecchymosis, petechiae

Trailing zero (X.0 mg) definition? mistaken as? write?

Decimal point is missed. Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)

Menopause definition? depletion of? age range? after more likely to?

Decrease in ovarian function Depletion of estrogen/progesterone 40-55years after more likely to develop CV disease

Integumentary older adult changes?

Decreased skin elasticity Dryness, scaling Baldness (men), thinning hair (women) Skin pigmentation, loss of melanocytes Thickened nails More prone to dehydration Encourage fluids Observe for dizziness, lethargy High risk for skin damage Inspect/palpate Turn, handle with care Special protection devices in hospital Difficulty tolerating colder temperatures Extra clothing, linen, etc. Difficulty tolerating higher temperatures Educate regarding preventing heat stroke

Classification of surgery 2 degrees? define each degree?

Degree of urgency(emergency like trauma, urgent within 24-48hours not emergency like removal of malignant tumor, elective by choice like tonsilectomy or plastic surgery, optional) Degree of risk(major usually to preserve life/restore function/improve or maintain health and can be elective, urgent, or emergency and in hospital with higher risk. Minor usually elective to restore function or correct deformities in doc office or outpatient/same-day clinic and is brief, low risk.

Contributing factors to increase malpractice

Delegation, early discharge, nursing shortage/downsizing, technology Advances, increased autonomy/responsibility of nurses, better informed consumers, expanded legal definitions of liability.

Factors affecting sleep

Developmental considerations, motivation, culture, lifestyle and habits, physical activity/exercise, dietary habits, environmental factors, psychological stress, illness, meds

Pre operative teaching

Diagnostic tests, limitations on eating/drinking, list allergies/meds currently taking, instruct to stop meds per MD, notify surgeon of infection/cold before surgery,bowel preps, beta dine/chlorhexidine scrubs, leave valuables at home, no nail polish/makeup/jewelry, where and time to arrive, postop routine(drains/ambulation), incentive spirometer/deep breathing/coughing, pain management, visitor info, early mobility , sequential compression devices(SCD), thromboembolic deterrent (TED) hose, exercise

Surgery purpose

Diagnostic/exploratory Reconstructive/cosmetic to restore function to trauma or malfunctioning tissue Curative/ablative- remove diseased body part Palliative- to relieve/reduce intensity of illness Transplantation Preventative Constructive to restore function in congenital anomalies

Instillation in eye administration

Drop over conjunctival sac, close eye, apply pressure with finger and tissue on nasolacrimal duct for 30-60 seconds to prevent systemic absorption

Instillation definition?

Drops, ointments, sprays usually for eyes, ears, nose

Pain assessment

Duration, location, intensity, quality, time,

Proof of malpractice/liability elements

Duty, breach of duty, causation, damages

Source oriented records definition? Advantage? Disadvantage? Includes what else?

Each healthcare group keeps data on its own form Advantage:each discipline can find and chart pertinent data in their section Disadvantage:data fragmented and difficult to track issues chronologically Progress notes Narrative notes

older adult Health Maintenance and Promotion options?

Eat a diet low in fat & cholesterol, including fruits, vegetables & fiber. Use sugar, salt and sodium in moderation. Make regular exercise a part of life. Drink alcohol in moderation, if at all. Do not smoke. Get regular dental cleanings & checkups. Follow recommended guidelines for health-related screenings. Keep vaccinations (including seasonal flu and pneumonia) up to date.

Skin vascularity abnormalities that can be found

Ecchymosis, petechiae, purpura

Nursing interventions for growth and development for young adults?

Education or avoidance of injury/accidents/violence Wellness promotion Prenatal care STI prevention Immunization of flu yearly, hep. b series, tetanus every 10 years, meningococcal 1 dose self screenings Self breast, cervical cancer, testicular exams

Excretion definition? locations? monitor?

Elimination primarily through the kidneys but also in lungs(inhalants), as bile in GI tract, sweat, salivary, mammary glands too Monitor BUN and creatinine

Oral aka? Types of meds? Implications?

Enteral. Tablets, Capsules,liquids, suspensions, elixirs. Contraindications include vomiting, decreased GI motility, absence of gag reflex, difficulty swallowing, decreased level of consciousness, have client position seated at 90 degrees, administer irritating meds with small smount of food, avoid contraindicated foods/drinks like grapefruit, usually give on empty stomach, use liquid when possible

Theories of psychosocial development people

Eric Erikson and Robert Havighurst

Nonbenzodiazepines types, benefits

Eszopiclone(Lunesta) Zolpidem(Ambien) Less likely to cause adverse effects and abuse but can cause headache, drowsiness, lethargy Is short acting with quick onset to preserve deep sleep

Financial Aspects of Healthcare: federally funded programs? group plans? private?

Federally funded programs: Medicare—DRGs aka diagnosis related groups for payment plans and government pays a fixed amount. Pt. pays deductible and monthly premium. Part A pays inpatient costs, part B paid by monthly premium for outpatient and is voluntary Medicaid for those with low incomes, blind, elderly, disabled, and beneficiaries of aid to families with dependent children Group plans: Health maintenance organizations that make you go to specific providers Preferred provider organizations specific providers preferred but you can go to 3rd party and pay a percent to go there Private insurance members choose physicians but more expensive

Self care deficits address 4 activities to meet daily needs

Feeding, bathing/hygiene, dressing/grooming, toileting

Hemoglobin average range for males and also females?

Females: 12-16 g/dL Makes: 13.5-17.5 g/dL

FUO aka? definition? cause?

Fever of unknown origin. Fever of 38.3C/101F or higher for three weeks or longer. With no identified cause

General survey definition?

First component of physical assessment. Gets general appearance, behavior, VS, height/weight. Provides clues to overall health

Amoxicillin 0.5 Gm orally every six hours. The supplied medication is Amoxicillin 250 mg per tablet. How much medication would you give?

First convert 0.5 Gm to mg by moving the decimal point 3 places to the right. (0.5 Gm = 500mg) then 500mg x 1 = 2 tablets 250mg

Transmission based precautions for? Example?

For patients w/ Suspected infection that can be transmitted via airborne, droplet, contact. Ex. PPE

Usually takes how long to achieve a steady state of serum concentration? med intake=?

Four half lives. Med intake= med metabolism and excretion

Effects of unrelieved pain

Functional decline, immobility complications, skin breakdown, quality of life, depression, low self-confidence/esteem

Gordon associated with? includes?

Functional health patterns. Nutritional, metabolic, sleep/rest, coping, activity

Neurological assessment

General appearance/orientation/behavior, mental status(LOC, level of awareness, hygiene, thoughts, memory), cranial nerves, fine motor movement(touch nose with hand, pat knees, run heel down opposite shin) cognitive/motor/sensory functions(sharp+dull touch), reflexes. cerebral function, cranial nerve function, cerebellar function, motor+sensory function, reflexes

Type of anesthesia

General/systemic- Loss of consciousness/reflexes, inhalation or IV. CV, respiratory, GI, thermoregulation risks 3 phases: induction of med until incision, maintenance until completion, emergence as awakens. Injected Regional/nerve/spinal in subarachnoid/caudal in epidural of sacrum/epidural in intervertebral- no narcosis just analgesia+reflex loss. Less risks Local injected or topical Conscious/procedural sedation aka moderate sedation/analgesia that just raises pain threshold

Health history purpose? use?

Get subjective database providing info on health status and self-care obtained via interview, to ID actual/potential problems/risk factors/support systems/teaching referral needs. use effective communication.

When Patient Insists Leaving AMA: goal should? assessment of? follow-up?

Goal should be to provide best possible care under clearly suboptimal circumstances. Assessment of patient's decision-making capability is essential (CRUCIAL) Follow-up arrangements are of paramount importance

Taking off PPE

Gown untie>gloves>goggles > remove gown. Remove all at doorway/anteroom. Then remove respirator after leaving room.

Mary Elizabeth Mahoney graduated from? Did what?

Graduated from New England Hospital for Women/Children in 1879 as 1st American African American nurse

dorsum(back) and fingers of hand used for

Gross temperature

Drug classifications definition? example?

Groups with similar characteristics, knowledge related to class can be applied to individual drugs in the class. Effect on body system, chemical composition, or therapeutic action. Example: metFORMIN (antidiabetic), metoprolol(antianginal, antihypertensive)

Tuberculosis precaution?

HEPA/N95 respirators. Airborne precautions.

health illness continum is a? is used to? an x is?

HIC is a graduated scale with High level Wellness at one end and Death at the opposite end. HIC is used to measure a person's health status. It is a summary of factors. An X is placed on the HIC after data collection and analysis.

CO determined by

HR, contractility, blood volume, venous return

Types of Home Health Agencies: have? differ? name types?

Have uniform standards for licensing, certification, and accreditation from State and/or Federal regulations Differ in organization and administration Official or Public Voluntary or not for profit Private or Proprietary Institution based

Intellectual autonomy

Having control of on beliefs, values, interferences, to think for oneself. Commitment to analyzing beliefs on basis of reason and evidence

HIPAA def.

Health Insurance Portability and Accountability Act. Patients rights- see/copy health record, update record, get list of disclosures, request restriction on uses of disclosures, choose how to receive health info. federal.

Integument assessment

Health history(questions to ask), rashes, lesions, changes in color, itching, bruises, bleeding, allergies, sun exposure, sunburn history, moles, medications/chemo, radiation, chemical exposures, mobility, nutrition

The Concept of the Health-Illness Continuum: health is a? examples? influences? health is the? health is a relative?

Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (World Health Organization, 1974) Expanded definition, Beliefs and Values Influences:family, community, and society Health is the balance between the 6 interdependent parts of the Holistic Being Heath is a relative concept defined by each person

BP false low

Hearing loss, noise, too large cuff, stethoscope inserted wrong, release valve too fast, not placing diaphragm over artery, not pumping 20-30mmHg over baseline

The relationship of Homeostasis and the 6 interdependent parts: define homeostasis? any disturbance in 1 dimension affects?

Homeostasis is defined as various physiologic and psychological mechanisms responding to changes in the internal and external environment to maintain a balanced state. Any disturbance in 1 dimension affects the whole system. (interdependent parts)

Environmental Dimension examples?

Housing, housing codes, zoning regulations Sanitation, Waste disposal Climate Pollution of Air, Food, & Water, Work Place, recreation High Risk Jobs Available Resources: hospitals, fire, police Violent crime or drug use

Emotional Dimension define? examples?

How the mind interacts with the body and how the body responds Affect-observable feeling or emotional state Intensity of emotional response Subjective self reporting of feelings "sad" Emotional Symptoms: Moodiness Agitation Restlessness shorter temper Irritability, impatience Inability to relax Feeling tense Overwhelmed Loneliness/isolation Depression Unhappiness

Assessment of nursing process? purpose?

Identify priorities determined by purpose of assessment/patients condition, organize data for systemic collection, establish database, continuously update database, validate data, communicate data.make judgement of health status

Otoscope purpose? may have an__ that? use? head position?how to straighten ear of adult and <3yrs? inspect nostril with?

Iight to see eardrum/canal, tympanic membrane, and external auditory canal. May have an attached short wide nasal speculum to see nasal cavities. Speculum attached to body directs light in beam. Use the largest speculum that will extend into patient's ear canal. Head slightly tilted away from examiner. Straighten ear of adult via pulling pinna up and back, <3yrs straighten by pulling pinna down and back. Inspect nostril with short wide tip.

Illness is? types? Causes?

Illness is the response of the person to a disease - it is an abnormal process in which the person's level of functioning is changed when compared with a previous level. -Acute -Chronic:- permanent change, irreversible alteration in normal anatomy and physiology -Remission(when the disease is present, but the person does not experience symptoms) -Exacerbation( symptom of the disease reapear.) -Causes:Inherited genetic defects, Exposure to virus or chemicals during pregnancy, Biologic agents or toxins, Physical agents( temperature, chemicals and radiation Tissue response to injury or irritation),Physiologic and emotional reaction to stress, Excessive or insufficient production of body secretions (hormones, enzymes, etc.)

A nurse giving holistic care must consider the interrelated and interdependent dimensions of the whole person There are 6 dimensions that influence behavior and health: define each?

Intellectual (cognition, education, past experiences) Environmental Spiritual Sociocultural(economic level, lifestyle, family, culture) Emotional(stress+mind) Physical(genetics, age, developmental level, race, gender)

Case management model definition? Promotes? Works best for? What kind of charting? Why it's done? Advantage? Disadvantage?

Interdisciplinary documentation tool that identifies outcomes that patients are expected to do each day and list of interventions and sequence+timing Promotes collaborative pathways(aka critical pathways) and increases quality by focusing care on outcomes works best for typical patients with few individual needs Variance charting(when patient fails to meet outcome or planned intervention isn't implemented this is documented via unexpected event, cause of event, actions taken in response to event, and discharge planning) Advantages:efficient use of time due to interventions and outcomes written on plan, increased probabily patient will discharge in timely fashion, care is goal focused, promotes collaboration disadvantages: effective for patients with few complications, space to document+for individualization is limited. Separate narrative notes used for documenting care. Flow sheet, RN notes, critical path must all be reviewed to get idea of condition

Codes for ethics include

International council of nurses(ICN), an ANA code

How to Minimize Potential AMA?

Interventions to enhance social supports in marginalized populations may also be useful In some cases, a patient who plans to leave AMA may have a specific concern and may be persuaded to remain in hospital if the concern is addressed.

Techniques of general assessment

Interview, inspection, palpation

Types of distances

Intimate- closest Personal- close conversation with friends Social- strangers Public- public speaking

Steps to safe Drug Administration

Introduce & Wash Hands, 6 Rights 3 Checks, Explain Identify, Administer Stay with Patient, Document Assess Response

Communication

Involves at least 2 people. Speaker codes message into words and nonverbal actions then passes it to receiver that decodes and acts on message

Discharge Planning: involves? uses? provides? is focused on? example?

Involves the patient from the beginning Uses the strengths of the patient in planning Provides resources to meet the patient's limitations Is focused on improving the patient's long-term outcomes. Case Management Referrals

Mottling definiton

Irregular color in pale skin due to blood vessels with decreased perfusion

Prone position: description? Areas assessed? Cautions?

Lie on abdomen with head turned to side with or without head pillow. AA: posterior thorax, hip joint movement. C: elderly, cardiovascular+ respiratory issues

Mid adult cognitive changes: little? no? increased?

Little change from young adult No decrease in ability to learn Increased motivation to learn if knowledge is relevant

rich blood supply organs?

Liver Heart Kidney

Robert J Havighurst living and growing based on? Developmental tasks aka? occur at? Arise from?

Living and growing are based on learning/developmental Developmental tasks(learned behaviors) occur at certain periods in life and achievement leads to happiness&success in later tasks. Arise from maturation, personal motive, values that determine occupational and family choices and civic responsibility

Tympany tone intensity? Location?

Loud. Gastric bubble, puffed cheek(hollow)

mid adult Health Promotion types?

Low fat/cholesterol diet Include fruits, vegetables, fiber Keep sugar, salt, and other sources of sodium to a minimum Exercise regularly Alcohol in moderation No smoking Refer individuals with substance abuse problems to support group Refer individuals with depression to counselor, spiritual leader or support group

Bell of stethoscope used for? pressure?

Low pitched sounds(murmurs, bruits) with gentle pressure.

Blood pressure from newborn to old age

Low to high

Temp from newborn to old age

Low, higher, low

Evaluating component of nursing process description and purpose

Measuring extent patient achieved outcomes, identifying factors that positively/negatively influenced outcome revising if needed to continue/modify/terminate nursing care.

The process by which drugs alter cell physiology and affect the body.

Mechanism of action Interaction between medications and target cell, body systems, and organs to produce effects. The changes that occur to the drug while it is in the body

Drug dose and Serum Drug Levels? what is most important?

Medication responses levels Minimum effective concentration (MEC) Toxic Therapeutic range Effective and not toxic Efficacy of drugs most important, not necessarily potency

Dull tone intensity? Location?

Medium. Heart, liver(solid organ), intestinal obstruction like mass or tumor.

Routine standard prescription

Meds given on regular schedule

Rapid eye movement arousal ? VS?

More difficult to arouse. VS increase.

Anaphylactic Reaction seriousness? signs+symptoms? treated with?

Most Serious Life threatening Respiratory distress- check ABCs Severe bronchospasms Cardiovascular collapse #1 intervention airway Common meds: epinephrine(sympathetic neurotransmitter), bronchodilators, corticosteroids, antihistamines, vasopressors, oxygen therapy, IV

6 cranial nerve motor or sensory? aka? controls?

Motor. Abducens. Lateral movement of eyes

Absorption definition? rate of med absorption determines? amount of med absorbed determines? route of administration affects? more lipid soluble drugs can be? pH-acidic drugs can? blood flow affects? local conditions affect? the more extensive absorbing surface the? patient with burns would have? drug dosage affects?

Movement of a drug from the site of administration(GI tract, muscle, skin, SQ, parenteral) into the blood stream rate of med absorption determines how soon med takes effect Amount of medication absorbed determines its intensity The route of administration affects the rate and amount of absorption(orally-longest time, injected-more rapidly, IV-fastest) More lipid soluble drugs can be absorbed easily pH-acidic drugs can absorb easier in stomach Blood flow affects absorption local conditions affect absorption- the more extensive absorbing surface the greater absorption, patient with burns would have poor absorption via IM drug dosage affects absorption- loading/large dose given or maintenance dose

Pulmonary ventilation definition? Aka?

Movement of air into/inspiration and out/expiration of the lungs/Inspiration and Expiration. aka breathing

Effects of immobility on the body

Muscle atrophy(decreased size) Contractures Orthostatic hypotension Venus stasis/thrombus Decreased Lung Expansion Urinary Tract Infection Constipation Pressure ulcers

Self-actualizationHighest level must? reach? means? examples? interventions?

Must reach maturity to have a sense of self-actualization. reach full potential Means relatively satisfied with most aspects of life, highly independent, humble, decisive, problem centered versus self centered, self confident, desires privacy, accept self and others, focuses on problems outside oneself, ability to be objective, feeling of happiness, respect for all, discriminate between good and evil, creativity for solving problems and pursuing interests -Inner directed, loving, accepts the world as it is. They embrace reality and facts rather than denying truth. -They are spontaneous. -They are interested in solving problems. -They are accepting of themselves and others and lack prejudice. -RN focuses on strengths and possibilities and aimed to provide sense of direction and hope and providing teaching that's aimed to maximizing potentials

nursing diagnosis, collaborative problem, medical diagnosis sample data cluster

ND: age, height, weight, what patient states, CP: age, when it occurred, what happened, what is happening, MD: signs/symptoms

nursing diagnosis, collaborative problem, medical diagnosis select nursing responses

ND: teach, CP: monitor offer things to help, MD: report signs/symptoms to physician

Safety Needs: needs to be? safety threats? needs to feel? includes?

Need to be safe Safety Threats: bacteriological, chemical, thermal, mechanical, electrical, falls Need to feel safe Includes physical safety, freedom from fear, security, order, structure, law order, limits. Also emotional safety to be free from fear, anxiety, apprehension by allowing religion, independent decision making, explaining procedure.

Blood pressure controlled by

Neural/humoral. ANS short term. Within circulatory system-chemo/baroreceptors. Outside circulatory system-pain, cold, ischemia, mood. Humoral/hormones. Kidney-renin-angiotensin-aldosterone. Posterior pituitary-ADH, vasopressin, increase in PVR

Stages of sleep

Non-rapid eye movement(NREM has 4 stages) and rapid eye movement(REM). Wakefulness>NREM(stage 1-4)> NREM stage 3,2> REM>NREM stage 2

Afebrile definition? example?

Normal body temp. 36C/97F-37.5C/99.5F

Upper airway components? Function?

Nose, pharynx, larynx, epiglottis. Air warmed, filtered, humidified

type 3 ethics&law?Ex.?

Nursing actions may be considered legal but not ethical. EX: Nurse gives large dose of pain drug to AIDS client as prescribed by doctor even though she fears it may compromise respiration

NOC aka? developed by? definition? includes?

Nursing outcomes classification. Developed by Iowa, language used to describe the patient outcomes that are responsive to nursing intervention. Includes outcomes w/ definitions, indicators, measurement scales, supporting references.

Issues that can affect health later in life for young adults

Obesity can lead to CV disease, diabetes STIs can lead to infertility and death Poor nutrition: inadequate calcium intake(osteoporosis)

Physical assessment purpose

Objective database, obtained by observation and physical assessment, completes clients health picture. head to toe sequence

Data types

Objective(observable/measurable), subjective(perceived/nonmeasureable)

Vital Signs and Laboratory Values to Monitor for when taking diuretics

Obtain baseline BP and P Potassium deficiency ACE inhibitors or ARBs + diuretics may not experience hypokalemia Monitor kidney function Creatinine > 1.8 mg/dl Notify healthcare provider Hypovolemia Furosemide- hearing loss Be aware of cumulative effect if taking diuretics and antihypertensive medications

Charting by exception definition? Better? Disadvantage? Advantage?

Only significant findings are documented in narrative notes Standardized assessment Better tracking of patient responses Disadvantages:Limited usefulness when trying to prove high quality safe care to negligence claim, preventive+ wellness functions not documented, requires predictable patient outcomes which are more difficult to predict for some, more difficult to computerize Advantage: abnormal status seen immediately, flow sheet shows trends, guidelines provide info regarding normal assessments, documentation time decreased

Chief complaint

Onset/duration, onset sudden/general, how often it occurs, location, character of complaint, activity client was involved/symptom occurred, aggravating factors, alleviating factors, other symptoms from chief complaint, improvement/change/worsening

Problem oriented records definition? Includes? All healthcare groups? Advantages? Ex?

Organized around pt. problem. Includes database, problem list, care plans, progress notes(SOAP), discharge notes All healthcare groups record on same form Advantages:teams work together in identifying master list of problems, and contributes collaboratively to plan of care Ex. SOAP, SOAPE, SOAPIE, SOAPIER s-subjective data, o-objective data, a-assessment, i-intervention, e-evaluation, r-response

4 characteristics of sounds assessed?

Pitch(high or low), loudness(soft, loud), quality(gurgling, swishing), duration(short, medium, long).

Patient interview definition? phases? initiates? use what?

Planned communication. Phases:prep phase, intro, working, termination. Initiates nurse/client relationship. Method of data collection. Use open ended questions

Examples of Medical Diagnoses that Alter Respiratory Functions? State whether acute or chronic for each?

Pneumonia- Acute Chronic obstructive pulmonary disease/COPD- Chronic Asthma- Acute and chronic Congestive heart failure- Acute and chronic Pulmonary emboli- Acute

ANA standard V of professional performance

Practice guided by code for nurses, maintain confidentiality, patient advocate, nonjudgmental, maintain autonomy/dignity/rights, seeks avail. Resources to formulate ethical decisions

The Home Visit phases? define each?

Pre-entry Phase that includes referral, scheduling visit, gathering supplies, preparing Entry Phase: including assessments, diagnoses, outcomes, establishing rapport Identifying needs and safety Determining Interventions including controlling infection and teaching Documentation

Standard precautions are? applies to? examples?

Precautions used for all hospital individuals. Applies to all body fluid except sweat w/out blood, and also skin/mucous membranes. Ex. Respiratory hygiene, same injections, masks.

Therapeutic effect definition? can have?

Preferred and expected effect for which the med is administered to specific client. Can have more than 1

Perioperative period includes?

Preoperative: time patient/surgeon decide on surgery Intraoperative: from the OR until transferred to postoperative recovery area Postoperative: recovery area until fully recovered

Home Healthcare Locations

Private homes Apartments Homeless shelters Boarding homes Dormitories Nursing homes Group homes Older adult housing

Contact transmission requires?

Private room, PPE, limit patient movement out of room. Used for patients w/ multi drug resistant organisms

PIE definition? POC? Assessment is? Advantage? Disadvantage?

Problem, intervention, evaluation at each shift POC incorporated in progress notes in which problems identified by number in order identified Pt. assessment is performed and documented on flow sheets(fill-in-the-blank) at the beginning of each shift Advantage:promotes continuity of care and saves time and consistent with RN process Disadvantage:RN needs to read all the nursing notes to determine problems and POC

Thoracentesis definition? done to?

Procedure for aspirating pleural fluid or air via puncturing chest with needle. this procedure is done either to collect fluid for a specimen or to remove built up fluid that may be causing breathing difficulty

Pharmacodynamics definition

Process by which drugs alter cell physiology or effect on the body by the drug

respiratory Interventions

Promote Best respiratory functioning: Teaching (lifestyle, environment, smoking cessation, nutrition) Decreasing anxiety (How do people tend to breathe when they are feeling anxious) Maintaining good nutrition Comfort: Effective positioning & support for positioning (high fowler's, use of pillows, prone position for pulmonary disease). Adequate fluid intake (to assist with thinning secretions 2-3Qts.). Humidified air Promote Proper breathing: Deep breathing (instruct the patient to take slow deep breaths through nose than out mouth- for hypoventilation) Using incentive spirometry for inspiration Pursed lip breathing ( for dyspnea and panic and COPD helps to slow and deepen each breath, exhale through lips inhale through nose) ab/diaphragmatic breathing for COPD which reduces RR, increases tidal volume, reduces residual capacity by one hand on stomach and other on mid chest and breathing in nose and out mouth Promoting&Controlling coughing: Voluntary coughing (helps to clear secretions, thus creating a patent airway). Involuntary coughing Meds(expectorant that liquifies or suppressant or lozenges that controls cough via anesthestic) Ensure a patent airway Performing chest physiotherapy: Percussion, vibrating, and postural drainage (to loosen secretions and to promote optimal drainage from the lungs). Suction the airway (secretions): Suctioning the airway is done using sterile technique. Provide pre-oxygenation prior to suctioning (suctioning irritates the mucosa and removes oxygen from the airway possibly causing hypoxemia) Suction either from the mouth or the nose Clear obstructed airways (foreign-body objects) Abdominal Thrusts Ensure administration of respiratory medications (as prescribed): Bronchodilators (Nebulizers, metered-dose inhalers, and dry powder inhaler) ex. Albuterol, Theophylline aka Aminophylline Corticosteroids (reduce inflammation in lung tissue, patients must be weaned off of these medications can be administered via nebulizer or inhalers)ex. prednisone. Cough medications (Expectorants, Cough suppressants, and Lozenges) ex. Guaifensin Provide oxygen therapy (as prescribed): wall outlet or portable cylinder with flow meter and valve and regulator with a gauge to indicate L/min and another that indicates amount/pressure in tank Educate patients about the danger of smoking when oxygen is in use. Confirm that all electrical monitoring is grounded. Oxygen is a gas that supports combustion (fire) Be sure to provide humidification for O2 therapy 5L/min or greater.

Advocacy definition

Protection and support of another's rights

Fever aka? definition? causes? temp.?

Pyrexia, febrile, hyperpyrexia, hyperthermia. Increase above normal temp causing loss of appetite, headache, hot skin, thirst, muscle aches, fatigue, ^respiratory/pulse rates. >37C/98.6F.

areas of abdomen from upper right to left, middle right to left, lower right to left

R hypochondriac, epigastric, L hypochondriac. R lumbar, umbilical, L lumbar. R inguinal or iliac, Suprapubic, L inguinal or iliac

6 Rights of Medication Administration +In the hospital setting applies to

RX and OTC medications

ROM aka? tests?

Range of motion. Tests each joint for passive or active.

Characteristics of pulse that are indicators of effective heart

Rate, quality/amplitude, rhythm, volume ejected

Controlled substance law states?

Record meds given, report incorrect counts, 2nd person witnesses and signs discarded meds, physician must be registered with DEA, nurse responsible for laws

PACU: Post anesthesia care unit Aka?

Recovery room

Six rights of safe med administration

Right client, right med, right dose, right time, right route, right documentation and sometimes right reason

After Medication Administered do what

Right drug, right dose, and right rate, Right documentation(Immediately, Pertinent information, Client's response, Reassess)

Refusal of meds steps?

Right to refuse Determine reason Discuss risk of refusal Notify health care provider Document

Utilitarian definition

Rightness or wrongness of an action depends on consequence of action

Nursing diagnosis for growth and development for young adults: risk for? ineffective? altered? health behavior? knowledge?

Risk for injury Ineffective coping, individual Altered nutrition less than/grater than body requirements Health-behavior, risk prone Knowledge deficit

Benefits of nursing process

Science based/holistic care, work collaboratively with other nurses, continuity of patient care, making difference, grow professionally

Intraoperative team people?

Scrub nurse of sterile team to maintain asepsis and handles instruments Circulating nurse identifies and assesses patient on admission, during operation to monitor, maintain safety and counts instruments RN first assistant(RNFA) provides exposure of operating area, hemostasis, and wound closure advanced practice nurse that coordinates care with everyone Surgeon Physician's assistant Scrub tech Surgical Residents Anesthesiologist/Nurse Anesthetist

Types of meds for sleep

Sedative-hypnotics(benzodiazepines) and nonbenzodiazepines

Havinghurst developmental task theory young adult 20-40 characteristics?

Selecting a mate Starting a family/marriage Managing a home Starting occupation taking on civic responsibility Finding congenial social group

Bed exercise: position? how to do exercise?

Semi-fowler, bend knee and raise foot to elevate for a couple seconds, extend leg, lower leg to bed. Do this 5 times with one leg then repeat with other leg. Point tow and pull toes forward and make circles with ankles right to left

8 cranial nerve motor or sensory? aka? controls? test?

Sensory. Vestibulocochlear. acoustic. Hearing, vertigo(balance), weber, Rinne, whisper tests

Meds with low TI should have

Serum med levels monitored closely so monitor peak levels based on route of admin

Metered dose inhaler (MDI) administration

Shake inhaler, inhale , hold breath for 10 seconds. Spacer can be used to keep med in device longer to increase amount of med

What to check for nail inspections

Shape, angle, texture, color

Side effects definition? Adverse reaction definition? report severe ones to?

Side Effects Unpleasant effect of a med that can be managed Adverse Reaction Effect severe enough that it can be hazardous to the pt.'s health. Report severe ones to MedWatch

Sims' position: description? Areas assessed? Cautions?

Side lying with lower most arm behind body, upper arm flexed at shoulder&elbow, both knees flexed, uppermost leg flexed at hip and knee. AA: rectum, vagina. C: difficult for elderly, or those with joint issues.

Verbal or Telephone Prescriptions steps?

Signed within set amount of time by provider Second nurse Ensure Rx is complete and correct by "reading back" Enter in the client's health record Electronic entries by provider by some facilities

Caring for hearing impaired patients

Teach measures to prevent hearing problems Orient person to your presence before speaking Decrease background noises before speaking Check patient's hearing aids Position self so light is on your face Talk directly to the person while facing him Use pantomime or sign language as appropriate Do not chew gum, cover your mouth, or turn away Write any ideas you cannot convey in another manner

Caring for visually impaired patient

Teach patient self-care behaviors to maintain vision and prevent blindness Acknowledge your presence in patient's room Speak in normal tone of voice Explain reason for touching person before doing so Keep call light within reach Orient person to sounds in environment Orient person to room arrangement and furnishings Assist with ambulation by walking slightly ahead of person Stay in person's field of vision if he or she has partial vision Provide diversion using other senses Indicate conversation has ended when leaving room

Tuning fork purpose? tests that can be done with tuning fork? definition? how is it activated? held where?

Test hearing acuity, and vibratory sense. weber test-(top of head. activate and place on mid forehead at hairline. normal is equal lateralization, abnormal is one sided). Rinne test(2n's and 2 steps-activate tuning fork and place behind ear on occipital bone process. ask to tell you when he can't hear anymore. move tuning fork to in front of ear and pt. should be able to hear it in the air. Normal AC>BC.). 2 pronged metal. Activated to vibrate by holding base and gently tapping prongs against palm of hand. Held at base to avoid diminishing vibration

Percussion reflex hammer purpose? triangular rubber head to? handle held how? pointed end for?

Test reflexes aka percussion hammer. Triangular rubber head to test deep tendon reflexes. Handle held between thumb and index finger for brisk firm tap with downward and backward wrist action of broad end of head on body. Pointed end for smaller areas

Trial and error problem solving definition? in regards to nursing?

Testing number of solutions until one is found that works for the problem. Not efficient for nursing and dangerous.

palmar(front) and finger pads of hand used for

Texture, shape, fluid, size, consistency, pulsation

Pharmacokinetics definition? 4 phases?

The effect of the body on the drug & how meds travel through body 4 Phases: Absorption Distribution Metabolism Excretion

Distribution definition? depends on?

Transportation of medications by the circulatory system to sites of action. Depends on blood flow to tissues, drug's ability to leave blood stream, drug's ability to enter the cells, if drug binds with plasma proteins(causing unequal distribution and possibly not reaching site of action), blood-brain barrier

Off-Label Uses for management of neuropathic pain

Tricyclic antidepressants such as amitriptyline Anticonvulsants such as phenytoin Mexiletine (Mexitil) an anti-arrhythmic Gabapentin (Neurontin) an anti-seizure drug

Core Temp. Measured where

Tympanic, rectal usually or esophagus, pulmonary artery, bladder

Z track definition? usually for? once med is drawn?

Type of IM injection that prevents med from leaking back into Subcutaneous tissue. Usually for meds that cause visible and/or permanent skin stains like iron preparations. Once med is drawn a new needle is put on.

do not use abbreviations

U, IU, Q.D., Q.O.D., trailing zero(x.0), MS, MSO4, MgSO4, µg, H.S., T.I.W., S.C. or S.Q., D/C, c.c., A.S., A.D., A.U., O.S., O.D., O.U.

False high BP

Uncalibrated cuff, BP after exercise, too small cuff, release valve too slowly, re inflate bladder during auscultation

Sublingual def. buccal def. have med?

Under tongue. Between cheek and gum. Have med remain in place until absorbed and don't eat or drink while in place

interpretation operationalizing critical thinking

Understand, comprehend, decipher, explain meaning of written materials, verbal and nonverbal communication, empirical data, and graphics using inductive/deductive reasoning

Deltoid site can only accommodate

Up to 1 ml of fluid

Pre operative screenings

Urinalysis(U/A), CBC, basic metabolic panel(BMP), prothrombin time(PT), partial thromboplastin time(PTT), international normalized ration(INR), chest X ray, electrocardiogram (EKG, ECG), human chorionic gonadotropin (hCG), electrolyte levels, urinalysis

Focus charting uses? Definition? Advantage. Disadvantage?

Uses a focus column of problem or need to incorporate aspects of the patient and their care. DAR- data, action, response for narrative Advantage: holistic emphasis on patient, ease of charting because DAR not required for each focus Disadvantage: categories aren't helpful when documenting care, difficult documenting in DAR categories

home healthcare reimbursement source

Varies with type of agency Medicare Medicaid Private insurance Private Pay

Parenteral implications which site for 1 yr and younger? do what for sites? don't use sites with?

Vastus lateralis recommended site for infants 1 yr and younger. Rotate sites. Don't use sites with edema inflammation or with moles, birthmarks, scars

Drug-to Food Interaction examples

Warfarin - Vitamin K (antidote for warfarin) Avocados/dark leafy vegetables counteract warfarin Grapefruit juice Zoloft Allegra Procardia

Nail and foot care

Wash and dry one at a time. Don't trim nails

urinary older adult changes?

Waste products may be filtered and excreted more slowly Voiding becomes frequent May experience incontinence or incomplete bladder emptying Men may experience hypertrophy of the prostate gland blood flow to kidneys decreases Bladder capacity decreases by 50% Hypertrophy of prostate causing urinary retention

The 6 general categories of nutrients are:

Water Proteins Carbohydrates Fats Vitamins Minerals

Identifying skin lesions- wear? document?

Wear gloves to inspect/palpate. document size(mm/cm), shape, depth, location, presence of drainage or fluid filled, odor, itching, if lesion new or has changed(primary or secondary)

Alfora-LeFevre suggests RN's ask what 4 questions when setting priorities?

What problems need immediate attention? Which problems are your responsibility? Which problems can be dealt with by using standard plans? Which problems aren't covered by protocols/standard plans but must be addressed?

Emergency assessment

When physiological/psychological crisis present nurse identifies the life threatening problem

Similar metabolic pathways effect of med metabolism

When two meds are metabolized by same pathway they can interfere with metabolism of one or both of meds so rate of metabolism can be decreased for one or both of meds leading to med accumulation

asthma define

When your airways react, they get narrower and your lungs get less air.

Meds with high therapeutic index(TI) have a

Wide safety margin so no none Ed for routine serum med level monitoring

Topical so apply how

With glove tongue blade or cotton tipped applicator

Standing prescription definition? if practice is specialized?

Written for specific circumstances and/or for specific units. Carried out as specified until cancelled by another order. If practice is specialized a specific set of written orders for all patients

Older adulthood can be categorized into four groups: name the name and age range

Young-old: 60-74 years Middle-old: 75-84 years Old-old: 85 and older Elite old: 100 years +

urinary effects of exercise+immobility

^ blood flow to kidneys, efficiency in fluid+acid-base balance, efficiency of excreting body waste ^urinary stasis, risk for renal calculi(Stones), lower bladder tone, risk for UTI

CV system effects of exercise + immobility

^ efficiency of heart, lower resting HR+BP, ^blood flow and O2. ^cardiac workload, ^risk for orthostatic hypotension, ^risk for venous thrombosis, ^ HR+CO+SV

GI effects of exercise+immobility

^appetite+intestinal tone disturbance in appetite, altered protein metabolism+digestion+utilization of nutrients

respiratory effects of exercise+immobility

^depth of respiration, ^respiratory rate, ^gas exchange, ^CO2 excretion lower depth+rate of respiration, pooling of secretions, impaired gas exchange, risk of pneumonia, risk of atelectasis(incomplete expansion or collapse)

metabolic system effects of exercise+immobility

^metabolic efficiency and body temp. regulation ^risk for electrolyte imbalance and altered exchange of nutrients+gases

if criminal law broken it can be

a felony or misdemeanor

Ageism is

a form of prejudice

3 ml syringe definition? calibrated?

a popular syringe for many types of medication administration. This syringe is calibrated in tenths (0.1ml).

Insulin syringe definition? calibrated?

a slender syringe designed to be used with insulin administration only. This syringe is calibrated in units; insulin dosages are ordered in units. No other type of syringe should be used for insulin administration.

Tuberculin (TB) syringe volume? calibrated?

a slender, 1ml syringe used when the amount of solution to be give is less than 1 ml. This syringe is calibrated in tenths (0.1 ml) and hundredths (0.01ml).

example of documenting normal findings of assessment of GI tract

abdomen is smooth, flat, lighter in color than extremities, with smooth, symmetric contour and no visible peristalsis. Umbilicus is midline and rectus abdominis muscle becomes prominent when head raised. bowel sounds present in all quadrants with no vascular sounds. No tenderness, masses, aortic pulsations to light or deep abdominal palpation. Umbilical ring feels round with no irregularities or bulges

statutory law def?ex?

abides by federal and state constitutions. Nurse practice act is example.

Dx considerations for drugs?

ability to swallow, allergies, heart liver or kidney disorders

fistula

abnormal passage from an internal organ to the outside of body or from one internal organ to another

open wound types

abrasion, incision, laceration, puncture, avulsion

abnormal bowel sounds- absent bowel sounds after 5 minutes in each quadrant mean

absence of bowel motility peritonitis or paralytic ileus(inhibited peristalsis), and/or immobility

paralysis

absence of strength secondary to nervous impairment

psuedoaddiction

abuse like behaviors driven by relieving pain

elderly increased adipose tissue for drugs

accumulation of fat soluble drugs, delay in elimination from and accumulation of drug leading to prolonged action and increased possibility of toxicity

Antipyretic drugs examples?

acetaminophen or aspirin(Not for children under 2) (for both not given to children/teens w. Chickenpox/influenza

implementing guidelines

act in partnership w/ patient/family, before implementing actions reassess, approach competently, approach caringly, modify interventions, check interventions are consistent w/ standards/legal, always question intervention selected is best, develop repertoire of skilled interventions

transduction

activation or pain receptors

Decreased toxicity when

active forms are converted to inactive forms

wellness define

active state of being health by living lifestyle that promotes good physical, mental, emotional health

shock define? most common due to surgery? interventions?

acute circulatory failure due to loss of fluid or aleration in circulation. Most common due to surgery: hypovolemic due to decreased blood volume. Interventions: improve/maintain tissue perfusion. Notify doc, ABC, flat position with legs elevated, O2, VS, hemocrit, blood gas

0-10 scale

adults and children >9 years

Behavior types of general survey

affect, attitude, mood

Illness affects

affects every dimension or interdependent part of the Holistic Being, Each interdependent part affects the way the client responds to illness

evaluative statement definition? includes?

after data have been collected/interpreted to determine outcome acheivement, this is made to document judgement. Includes a decision about how well the outcome was met, and patient data/behaviors supporting decision

factors contributing to BP variations

age(^), circadian rhythm, gender(men=^), food intake(^), exercise, weight(^), emotional state, body position, race, meds, eating, body position, emotions, blood volume

factors affecting respiratory rate

age(decreases), gender, exercise, acid-base balance(acidosis=^), brain lesions, increased altitudes(^), respiratory diseases(^), anemia(^), anxiety(^), meds, pain, emotions

systemic wound healing factor types

age, circulation, oxygenation, nutrition, health status, medication

factors affecting skin integrity

age, immobility, poor nutrition, mechanical forces(pressure, shear, friction), bony prominences, poor circulation, altered sensation, incontinence, edema, radiation, hypothermia, hyperthermia, AIDS

factors interfering w/ accurate measurement of pulse

age/gender, exercise/conditioning, stress, fever, meds, volume status, pain, position changes

measles/mumps/rubella precautions

airborne

TB precautions

airborne- n95, - pressure room, door closed

chicken pox precatuions

airborne-N95, gloves, gown for open sores. Contact

critical thinking indicators aka? By? Define?

aka CTIs by LeFevre. Evidence based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking

Metabolism aka? definition? occurs primarily in? factors that affect rate?

aka biotransformation. Change medications into a more or less potent or more soluble form Occurs primarily in the liver also in GI tract, lungs, kidney, skin Factors that effect rate: aging, presence of liver disease, or other factors impairing liver function decreasing liver metabolization

IV Push aka? are? what meds ?

aka bolus medications are injected once with a syringe into IV tubing/line or intermittent device slowly. Pain medications may be given via this route.

complex regional pain syndrome aka? Occurs in?

aka causalgia. occurs in partially injured peripheral nerve

collaborative pathways aka? Used in? Definition?

aka critical pathways or care maps. used in case management model and charting by exception. Specifies plan of care linked to expected outcomes along timeline

fowler's position aka? HOB? support for? prevents?

aka simi sitting. HOB 45-60 degrees. support for back, forearms, hands, feet with foot board for dorsal flexion. Prevents neck flexion contracture, wrist contracture, external rotation of hips, foot drop

musculoskeletal pain aka? definition?

aka somatic pain, pain of muscles, joints, connective tissues, bones

asphyxiation def.

aka suffocation greater in children

mini-infusion pump aka? define?

aka syringe pump for intermittent infusion & is battery operated and allows med mixed in syringe to be connected to primary line and delivered by mechanical pressure applied to syringe plunger

bronchial sounds aka? heard over? characteristics?

aka tubular. heard over trachea are high pitched, harsh, blowing, hollow with expiration being longer than inspiration

tests for peripheral vision aka? used to?

aka visual fields are used to assess retinal function and optic nerve function

GI tract aka? length? includes

alimentary tract. 27ft. Esophagus, stomach, small intestine, large intestine, rectum, anal canal

asepsis definition? categories?

all activities to prevent infection/break chain of infection. 2 categories: medical, surgical

old age begins at 65 most older adults live in nursing homes most older adults are sick older adults don't care how they look bladder problems are problem of aging

all are false

when patient believes they are injured b/c of negligence & pursues legal action the outcomes that can occur are:

all parties work toward settlement, case presented to malpractice arbitration panel, case brought to trial court

Advance directives allow patient to? forms?

allow patent to give instructions for treatment, cessation, rescusitation, end of life if they are unable to communicate postop. Forms:Living will, durable power of attorney

xanax generic name? common? effects?

alprazolam. common preop med for sedation. benzodiazepine effect:antianxiety

Small body size, reduced weight, reduced water, decreases in cardiac output and organ perfusion do what? expected responses based on? need to know the? drug doses for children calculated by?

alter distribution. Expected responses based on healthy adults (18-65 150 lbs (68 kg). Need to know the usual dose before admin. Drug doses for children calculated by wt or body surface area (BSA)

most common causes of postop complications

alterations in CV and respiratory function including atelectasis, pneumonia, thrombophlebitis, emboli and activities to reduce risk are deep breathing, coughing, incentive spirometry, leg exercises, turning in bed

common etiologies for disturbed sensory perception

altered environmental stimuli(excessive/insufficient), altered sensory reception/transmission/integration, chemical alterations(endogenous[electrolytes], exogenous[drugs]), psychological stress

before palpating the bladder

always ask the patient when they voided last then observe the lower ab wall noting swelling and palpate for tenderness

Leaving AMA aka? patient is? choice carries? patient must? patient is informed? patient's signature? form becomes? unit nurse contacts?

ama aka against medical advice Patient is legally free to leave Choice carries a risk for increased illness or complications Patient must sign a release form Patient is informed of risks prior to signing form Patient's signature must be witnessed Form becomes part of medical record Unit nurse contacts: MD Supervisor Risk Management

gait belts for

ambulating patients with leg strength, can cooperate, and require minimal assistance

abnormal thorax

anteriorposter diameter greater than transverse diameter aka barrel chest indicated chronic lung disease, abnormal breathing patterns(respiratory disease such as chronic obstructive pulmonary disease or asthma), unequal chest expansion(chest trauma or pneumonia)

nursing intervention for temp.

antibiotics per order, fluids/rest, antipyretics, precautions w/ ASA, cooling blanket/tepid bath, oral hygiene, dry clothing/linens

surgical risk increased by drugs in what categories

anticoagulant, diuretics(electrolytes), tranquilizers(hypotension), steroids(CV collapse), antibiotics(respiratory paralysis), oral antidiabetics(change xrays and renal failure)

Endocarditis definition?

antimicrobial prophylaxis prior to invasive dental or procedures/surgery

The most common response to stress is

anxiety

precordium definition? portion of body?

aortic area, pulmonic area, erbs point, tricuspid area, mitral area. portion of body over heart and lower thorax encompassing aortic, pulmonic, tricuspid, apical areas, Erb's points

palpation at apex position? may not?

apical impulse, 4th or 5th intercostal space at midclavicular line. May not be palpable in obese or with thick chest. Mitral area

unconscious states

asleep(can be aroused), stupor(aroused via extreme stimuli), coma(cannot be aroused), vegetative state(cannot be aroused but has sleep cycles and nonpurposeful movement)

intentional tort examples

assault/battery, defamation of character, invasion of privacy, false imprisonment, fraud

tachycardia interventions

assess/monitor for other signs/symptoms, assess/monitor meds, prevent injury, notify primary care provider

bradycardia interventions

assess/monitor signs/symptoms, hypotension/chest pain/diaphoresis/dyspnea/altered mental status, prevent injury, notify primary care provider

weber test -don't know

assesses bone conduction of sound. top center of head. activate via holding it at base and strike it against palm and place on mid forehead at hairline/on top of midhead. normal is equal lateralization/both ears hear equally, abnormal is hearing sound better in affected ear(conductive), sound heard better in ear without problem(sensorineural or nerve disorder)

activities of assessment

assessment(collecting data, identifying cues/making inferences, validating, organizing/clustering data, identifying patterns/testing 1st impressions, reporting/recording data)>interpreting data(analysis&synthesis)>diagnosis (creating list of problems/diagnoses, ruling out problems/diagnoses, clarifying what's causing/contributing to them, determining risk factors that must be managed, identifying resources/strengths/areas for health promotion)

when moving patient height of bed should be

at staff elbows

examples of physical illnesses associated with stress

autoimmune disorders:Graves' disease aka hyperthyroidism, rheumatoid arthritis, ulcerative colitis, psoriasis, myasthenia gravis CV disorders: hypertension, coronary artery disease respiratory disorders: asthma GI disorders: esophageal reflux, constipation, diarrhea, ulcerative colitis

nurse-initiated interventions definition? no what? derived from?

autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes. no physician order required. derived from diagnosis/cause of problem

grading of reflexes - +2

average, normal

assessing LOC

awake+alert, lethargic(can be aroused by saying name, gentle shaking), stuporous(unconscious most of time must be shaken or yelled at to awake), comatose(cannot be aroused may have some reflexes unless in coma)

dorsiflexion

backward bending of hand or foot

assessing motor and sensory function

balance, gait, coordination, discrimination of pain+light touch+vibrations

bcma

bar code enabled medication administration

nephron is

basic structural and functional unit of the kidneys. nephrons remove the end of products of metabolism such as urea, creatine, and uric acid from the blood plasma and from urine

valsalva maneuver? caution?

bearing down results in a decreased blood flow to the atria and ventricles thus temporarily lowering cardiac output. upon release there is rebound overfill. Contraindicated in patients with cardiovascular problems

hypotension definition? range? causes?

below normal BP. <90 systolic. normal in athletes. Causes: vasodilation, loss of blood, heart failure, dehydration, pallor, tachycardia, LOC, diaphoresis

bladder is usually positioned where

below symphysis pubis and can't be palpated or percussed when empty

general adaptation syndrome(GAS) define? stages?

biochemical model of stress that describes body's general response to physical or emotional stress. Stages: alarm reaction(fight or flight), stage of resistance(adapting to stressor), stage of exhaustion

Superinfection symptoms & signs

black, furry overgrowth on tongue, vaginal itching or discharge, foul-smelling stools

prolonged periods of immobility decrease

bladder and sphincter tone which can result in poor urinary control and urinary stasis

autonomic bladder

bladder no longer controlled by brain, void by reflex only

urinary acute pain related to

bladder spasms, dysuria, urinary retention, cancer of bladder, diagnostic procedure

people with indwelling catheters lose

bladder tone because bladder muscle isn't being stretched by bladder filling with urine

embolus define? s&s? interventions?

blood clot or foreign substance that moves and lodges in vessel. Pulmonary embolus is in lungs. S/S:dyspnea, chest pain, cough, cyanosis, rapid respirations, tachycardia, anxiety. Interventions: notify doc, maintain bed rest, semi-fowler's, assess VS, O2, meds, avoid Valsalva's maneuver during bowel movements,

common peripheral vascular diagnostic tests

blood flow tests(angiogram, doppler flow, cardiac catheterization, RBC count), tests to visualize structures of circulatory system, CXR, echocardiogram, test to identify abnormal cells+infections(Complete blood count aka CBC)

peripheral vascular auscultate where? palpate? check for?

carotid arteries, palpate gently. check for bruits(swooshing sound, heard over major arteries)

exogenous

causative organism is acquired from other people

right lower quadrant contains

cecum, appendix, right ovary and fallopian tube, right ureter and lower kidney pole, right spermatic cord

balance define? increases when?

center of gravity is close to its base of support(center of pelvis). Increases when feet spread and flexed hips and knees causing lower center of gravity

ambulatory care define? example?

centers and clinics to provide technical service like administering meds and teaching ex. urgent care for ilnesses and minor trauma

gate control theory

certain small nerve fibers conduct excitatory pain toward brain but larger nerve fibers inhibit transmission of pain from spinal cord to brain via gate in spinal cord

transfer chairs

chairs that can convert into stretchers for people who have no weight bearing capacity

affective outcomes definition

changes in patient values, beliefs, attitudes

laws pertinent to nursing can be either

civil or criminal

tort definition? most often? can be either?

civil wrong by 1 against person or property of another for $$. Most often civil action encountered by nurses. can be either intentional or unintentional.

care of catheter

clean perineal area with soap/cleanser, clean from meatus outward

medical asepsis definition? examples?

clean technique, involves procedures & practices that reduce number and transfer of pathogens. Ex. gloves or hand hygiene

what to expect during hospital stay

clean/safe, involvement in care, protection of privacy, preparation when leaving hospital, help w/ bill/filing claims

omit or delay doses as indicated by

client's condition, document and report

outcome ID and planning definition? establishes? what is useful for establishing priorities?

client-centered goals/expected outcomes establishes Priorities are set relating to unmet needs. Maslow's basic human needs theory useful for setting priorities.

nursing diagnosis vs. collaborative problem vs. medical diagnosis definitions

clinical judgement about clients responses to health problems/life processes&provides basis for selection of nursing interventions to achieve outcomes for which nurse is accountable, certain physiologic complications that nurses monitor to detect onset of changes in status, traumatic/disease condition or syndrome validated by medical diagnostic studies

Nephrotoxicity signs

cloudy or pink urine may be sign of nephrotoxicity

acute vs. chronic confusion

cluster of transient changes&disturbances in attention, cognition and LOC. Irreversible progressive deterioration of intellect and personality via decreased ability to interpret stimuli and memory

types of outcomes-

cognitive(involves increase in patient knowledge), psychomotor(describe patient's achievement of new skills), affective(pertains to changes in patient values/beliefs/attitudes), physiologic(physical changes)

inspection of thorax

color even with face, shape,+contour(downward equal slope at ribs, transverse diameter greater than anteriorposterior diameter), breathing patterns, muscles

abdominal inspection

color, contour, symmetry, ubilicus, pulsations, peristalsis

assess urine

color, odor, clarity, sediment

peripheral vascular assessment inspection

color, temperature warm, integrity is intact+undamaged, moisture, hair quantity+distribution, edema, nails

weakening of pelvic floor muscles is

common cause of urinary incontinence

sundowning syndrome define

common with dementia older adult becomes confused, restless, agitated after dark

kardex care plan

communicates plan of care for patient. recorded on folded card

community health nursing vs. community based nursing

community health nursing- focuses on population in community community based- centered on individual and family healthcare needs

CPOE define

computer prescriber order entry system

cmar definition? MARs are? define?

computerized medication administration record. MAR's are a legal document. Record administration of drug name, dosage, route, site, time, and initial as soon as possible after given

spine curves

concave curves at thoracic and sacrococcygeal spine

problems with bone formation or muscle development

congential(achondroplasia causing dwarfism, osteogenesis imperfecta causing brittle bones), rickets(bone deformity due to low vitamin D), paget's disease(excess bone destruction), osteoporosis(bone destruction)

ankylosis

consolidation and immobilization of joint causing it to be permanently fixed can be caused by immobility

VRE precautions

contact protections-gown, mask, gloves, good handwashing, if splashing than mask

c.difficile precautions

contact- gloves, gown, handwashing

MRSA precautions

contact-gown, gloves

triceps reflex guidelines

contraction seen as elbow extends. Patient's elbow is sharply bent the forearm placed across the chest wall with the palm turned toward body. Triceps tendon struck with hammer above elbow

if civil law broken it can be

contracts or torts(torts can be intentional/unintentional)

convalescent period

convalescent period

Afferent nervous system does what

conveys info from receptors in periphery to CNS

efferent nervous system

conveys response from CNS to skeletal muscles via somatic nervous system

nursing interventions should include

date, verb, subject, descriptive phrase(when,where, how long/much, how)

factors contributing to tachycardia

decrease BP to meet needs for CO, elevated temp, conditions resulting in poor oxygenation, exercise, acute pain, emotions, medications, changing from lying to sitting/standing, hyperthyroidism, anemia/hypoxemia, stress, hypovolemia(shock/heart failure leads to decreased CO w/ ^HR)

neutropenic precautions

decrease in WBCs. No sick people around, no plants/fresh vegetables

bradypnea definition? causes? rate?

decrease in respiratory rate. Ex- ^intracranial pressure, depression of respiratory center, drugs. <12 breaths/min

absent, weak, thready peripheral pulse=

decreased CO

s4 -don't know

dee-lub-dub. fourth heart sound. Normal in older adults but abnormal in kids+adults

kussmaul definition? causes?

deep breathing/hyperventilation/acetone fruity breath. usually due to acidiosis(diabetic ketoacidosis(DKA), ASA, OD)

fissure define? ex?

deep linear crack extends into dermis Ex:athlete's foot

for GI+urinary assessment light palpation always precedes

deep palpation(done by advanced clinician)

ischemia

deficiency of blood in particular area

osteoarthritis

degenerative joint disease, noninflammatory disorder of movable joints causing pain w/ motion

desiccation

dehydration

possible revisions to plan of care include

delete/modify diagnosis, make outcome more realistic, adjust time criteria, change nursing interventions

conscious states

delirium(confusion), dementia(memory), confusion(reduced awareness), somnolence(drowsiness), locked-in syndrome(quadriplegic)

physician-initiated interventions aka? involves?

dependent nursing actions, involve carrying out physician prescribed orders

moderate palpation is conducted by? depth?

depressing skin 1-2cm

sterilization

destroys all microbes including spores

disinfection

destroys all pathogens except spores

Half-Life helps?

determine frequency of drugs.

safe handling of those with dementia

determine is receptive aphasia present, phrase instructions positively(stand up, not don't sit)

pulse oximeter determines? where to use? measured in? ranges?

determines Hb/oxygenation(SpO2/SaO2) of blood. Finger/nose/toe/ear. If low Hb SpO2 could appear to be normal but not meet body requirements. Measured in %. Normal range 95-100%. <91% requires RN intervention, <86% indicated emergency, <80% life threatening.

numeric sedation scale

determines patients at risk for respiratory depression

people who habitually urinate infrequently

develop more UTI's and kidney disorders than those who urinate every 3-4 hrs. due to stagnation of urine in bladder which serves as good medium for bacterial growth

Voluntary standards def. & examples

developed by nursing profession itself, not mandatory. Ex. Professional nursing organizations like ANA

factors affecting normal bowel elimination

developmental stage, daily pattern, fluid or food intake, level of activity, lifestyle, emotional state, meds, surgery and diagnostic tests

valium generic name? common? effects?

diazepam. common preop med effects: antianxiety, anticonvulsant, sedative, relaxant

pulse deficit

difference between apical and radial pulse

pulse pressure

difference between systolic and diastolic

Gender factors for drugs

differences in distribution of body fat and fluids in men and women. Most research on drugs and their actions and effects has been conducted on men.

dyspnea

difficult/labored breathing

elderly decreased production of oral secretions; dry mouth for drugs

difficulty swallowing oral meds

mydriasis

dilated pups due to glaucoma, meds

abnormal bowel sounds- decreased bowel sounds mean

diminished bowel motility caused by abdominal surgery or late bowel obstruction

NCLEX-RN programs

diploma, associate, baccalaureate

Expected outcome must be what 3 things?

directly related to nursing Dx on NANDA list, outcomes realistic/measurable, identify times for attainment of outcome

purpura defintion

discoloration of skin or mucous membranes due to hemorrhage from small blood vessels

infection

disease state resulting from pathogens

negative nitrogen balance define? examples?

diseases that cause breakdown of protein(catabolism) causes this resulting in muscle wasting and decreased physical energy for movement. Examples:anorexia, cancer.

nonpharmacologic relief measures

distraction, humor, listening to music, imagery, relaxation, cutaneous stimulation(TENS, accupressure), acupuncture, hypnosis, biofeedback(machine monitors, therapeutic touch

Standing orders definition

document containing orders for conduct of routine therapies, monitoring guides, and/or diagnostic procedure for specific condition. empowers RN to initiate actions that ordinarily require order/supervision of physician.

flow sheets

documentation tools to record routine aspects of nursing care. fill-in-the-blank

cascade iatrogenesis define

downward spiral and decline w/ dementia

treatment for community acquired MRSA

drainage of abscesses, antimicrobial therapy, tetracycline

crust define? ex?

dried residue of serum, pus, blood ex:impetigo

ptosis definition

drooping of upper lids caused by damage to oculomotor nerve, myasthenia gravis, congenital

gtt means

drop

orthostatic hypotension definition? causes? range?

drop in systolic/diastolic BP after standing. Peripheral vasodilation, meds, fluid depletion, SBP decreases >20mmHg and/or diastolic decreases more than 10 mmHg. 20-10% increase in HR.

influenza precautions

droplet

meningitis precautions

droplet

pertussis precautions

droplet

Pathology presence of disease can affect what for meds? primary organ from drug breakdown? what excretes most drugs?

drug action. Liver primary organ for drug breakdown, so pathologic conditions that involve the liver may slow metabolism alter dosage to reach therapeutic level. The kidneys excrete most drugs. Pathologic conditions that involve kidneys would change excretion and alter drug dosage. Also influence presence of adverse effects such as toxicities.

drug-enzyme interaction

drug combines with other molecules in body to achieve effect

drug-receptor interaction

drug interacts with cellular structures/receptor sits to alter cell function

intermittent intravenous infusion definition?

drug mixed with small amount of IV solution(50-100mL) and administered over short period at prescribed interval usually via infusion pump

Environment sensory deprivation and overload may affect? have may have longer benefit from pain med?

drug responses. Quiet environment and guided imagery may have longer benefit from pain medication.

analgesic definition? Classes?

drug that relieves pain. 3 classes:nonopioids(acetominophen+NSAIDs), opioids, adjuvants(anticonvulsants, antidepressants, multipurpose drugs that aid opioids)

Antagonist- definition? example?

drug-drug interaction blocks or produces the opposite effect of an action H2 Blocker (PUD or GERD)

Health care quality improvement act does what?

encourages identification and discipline for those who engage in unprofessional conduct and restrict ability of incompetent practitioners to move from state to state via National Practitioner Data Bank and immunity from civil damages for peer review

lymphadenopathy

enlarged lymph nodes may indicate infection, autoimmune disorders, metastasis of cancer

most common routes of administration are

enteral(gi tract), parenteral(injection)

oral route types of meds? how they are given? meds must absorb via? absorption varies?

enteric coated(EC) and extended released(ER): enteral(tube), sublingual(under tongue), buccal(cheek). Meds must absorb via stomach or epithelial cells of GI tract. Absorption varies greatly due to stability & solubility of med, GI pH & emptying time, presence of food in GI tract, other meds, forms of med(EC, liquid)

high risk factors for sensory deprivation

environment with decreased or monotonous stimuli, impaired/interfered with ability to receive stimuli, inability to process stimuli(brain/spinal cord injuries, drugs)

adrenal hormones examples and what they do

epinephrine(fight or flight), norepinephrine(depresses), mineralocorticosteroids(aldosterone fluid and electrolytes), glucocorticoids(raise glucose), androgens

loss of skin surface define? size? ex?

erosion, ulcer, fissure. Type: secondary lesion

gi diagnostic testing

esophagogastroduodenoscopy, sigmoidoscopy, upper gi and small bowel series, barium enema, abdominal ultrasound, MRI(magnetic resonance imaging), C-t scan(computerized axial tomography)

outcome identification+planning steps of nursing process RN works w/ patient/family to

establish priorities, identify/write expected outcomes, select evidence based RN interventions, communicate plan of RN care

assessing sensory perception

evaluate response to pain, light touch, normal shapes, vibration

q means

every

when and how to sign documentation

every entry sign first initial last name and title

lordosis

exaggerated lumbar curve during pregnancy or obesity

agent host environment model define? agent is? environment includes? when out of balance?

examines causes of disease. agent is environmental factor or stressor that's present or absent for illness to occur. Environment includes all factors external to host that make illness more or less likely. when out of balance illness occurs

elderly alterations in normal homeostatic responses, altered peripheral venous tone for drugs

excerbated response to cardio drugs, more pronounced hypotensive effects from meds

hirsutism

excess amounts of hair on face and body

hemorrhage define? S&S? intervention?

excess internal or external bleeding and can lead to hypovolemic shock. S&S: restlessness, anxiety, hypotension, coolness, weak/thready/rapid pulse, rapid deep respirations, decreased urine output, thirst. Intervention: pressure dressing then notify doc

diaphoresis

excess perspiration

hypersomnia

excess sleep during day

polyuria

excessive output of urine(diuresis)

diffusion

exchange of O2 and CO2 between alveoli and blood

perfusion

exchange of O2 and CO2 between circulation blood+tiss.

health history for cardiovascular+peripheral vascular

exercise amount+type, usual foods eaten, changes in color or temperature of extremities, history of pain in legs when sleeping or pain worsened by walking, history of blood clots or sores on legs that don't heal, orthopnea, proximal nocturnal dyspnea. history of chest pain, palpitations, dizziness, ankle+feet swelling, number of pillows used, daily meds, heart defect, rheumatic fever, chest+heart surgery, personal and family history of hypertension+myocardial infarction+coronary artery disease+high cholesterol+diabetes, drugs, exercise, foods eaten, pain in legs, blood clots, sores that don't heal

Surgical mask filter

expired air

ear inspect what?

external ear(color, shape, size,lesions), internal ear(should be smooth and pink), tympanic membrane(intact, translucent, shiny, gray), assess gross hearing(ticking watch, rubbing fingers, whisper testd 1-2ft away out of line of vision with opposite ear covere), romberg test

nose inspect what? head must be?

external nose, turbinates, internal nares+septum w/ penlight+nasal speculum or otoscope with short wide tip. Children push tip of nose up with thumb. note color of membranes(moister and darker than oral), is septum straight/intact, note drainage, or polyps(allergies) assess patency by occluding one nostril and inhaling/exhaling. Head must be tilted back

murmurs definition? characteristics?

extra heart sounds caused by disruption of blood flow through heart. Characteristics: adequacy of valve function, rate of blood flow, size of valve opening. 1-6 grading aka faint to exceptionally loud

older adult oral meds technique

extra time, crushed or liquid, massage laryngeal prominence to initiate swallowing

snellen definition? tests for? consists of? largest characters where? smallest where? scores on ? distances on?

eye chart for visual acuity. test for distant vision. Consists of characters arranged in 11 lines. Largest characters(20/200) at top to smallest at bottom(20/10). Scores on left hand column and distances on right hand column. numerator is 20 representing distance from which person with normal vision(20/20) can read letters. denominator represents smallest line read accurately by patient. 20 over smallest line read by patient with no more than 2 inacurate readings. the larger the denominator the poorer the vision

miosis

eye constriction due to drugs

Wong-Baker

faces pain scale for adults and children >3years

intellectual traits

faith(confidence), intellectual courage, intellectual empathy, intellectual integrity, intellectual humility, intellectual independence, intellectual perserverence, intellectural fair-mindedness-sense of justice

leading cause of injury fatality of >65 age

falls

7 f's of abdominal distention

fat(obesity), flatus(air or gas), fetus(pregnancy), feces, fluid(ascites), fibroid(tumor), fatal growth(malignancy)

Ligaments

fibrous connective tissue that binds joints and connect bones and cartilage

pustule define? size? ex?

filled with pus ex:acne, impetigo

vesicle define? size? ex?

filled with serous fluid <0.5cm. ex:herpes simplex

bulla define? size? ex?

filled with serous fluid >0.5cm ex:2nd degree burn

precordial thrills

fine palpable rushing vibrations over right or left second intercostal space. Abnormal.

suspension

finely divided undissolved particles in liquid should be shaken before use

light palpation apply pressure with? depth?

fingers together and depressing skin and underlying structures <1cm

mass consistency types

firm, edematous, spongy, cystic

What to check for nail palpations

firmness, tenderness

when pulling a patient up in bed bed should be

flat or in trendelenburg position with side rail down

nevus define? ex?

flat to slightly elevated, round, evenly pigmented ex:common mole

contours of abdomen

flat, rounded (convex), scaphoid(concave), protuberant, pendulous, obese

if patient can assist when repositioning up in bed ask him to

flex knees and push on count of 3

plantar flexion

flexion of foot aka footdrop

To write diagnostic statement for collaborative problem

focus on potential complications of problem. Use PC: and list complications that might occur and link PC and collaborative problem by using "related to".

palliative care define?

focused on relief of physical, mental, spiritual distress to prevent and releieve suffering by early assessment and treatment

foot drop define?

foot unable to maintain itself in perpendicular position, heel toe gait is impossible and patient experiences extreme difficulty in walking. Plantar flexion no dorsiflexion

c.c. definition? mistaken as? write?

for cubic centimeter, Mistaken for U (units) when poorly written., Write "ml" for milliliters

D/C definition? mistaken as? write?

for discharge, Interpreted as discontinue whatever medications follow (typically discharge meds). , Write "discharge"

H.S. definition? mistaken as? write?

for half-strength or Latin abbreviation for bedtime, Mistaken for either half-strength or hour of sleep (at bedtime) q.H.S. mistaken for every hour. All can result in a dosing error. Write out "half-strength" or "at bedtime"

volume-control administration set define?

for intermittent IV infusion. Med diluted w/ small amount of solution and administered through IV

IU definition? mistaken as? write?

for international unit. Mistaken as IV (intravenous) or 10 (ten). Write "international unit".

µg definition? mistaken as? write?

for microgram, Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose, Write "mcg"

powered stand assist and repositioning lifts used for? define?

for patients who can bear weight on at least one leg. sling is placed around patient's back and under arms, feet rests on footrest and places hands on handle and device mechanically assists patient to stand and once standing device can be wheeled to chair etc

S.C. or S.Q. definition? mistaken as? write?

for subcutaneous, Mistaken as SL for sublingual, or "5 every", Write "Sub-Q", "subQ", or "subcutaneously"

T.I.W. definition? mistaken as? write?

for three times a week, Mistaken for three times a day or twice weekly resulting in an overdose, Write "3 times weekly" or "three times weekly"

U definition? mistaken as? write?

for unit. Mistaken as zero, four or cc. Write as unit

blood pressure definition? controlled via? when not to take BP?

force of blood against arterial walls. controlled via peripheral vascular resistance, CO. Avoid arm w/ axillary node dissection/mastectomy. Uncross legs

penetrating

foreign object entering the skin or mucous membrane and lodging in underlying tissue, fragments possibly scattering throughout tissues

graphic sheet

form used to record variables like VS and other patient characteristics

Dr. Mildred Montag did what?

founder of ADN. Dr. Montag's doctoral dissertation. research project to alleviate a critical shortage of nurses by decreasing the length of education to 2 years.

Because a grain is a powerful unit, dosages of strong medications are often written as

fractions

abrasion

friction; rubbing or scraping epidermal layers of skin, top layer of skin abraded

lower GI bleeding from? may produce?

from hemorrhoids or polyp may produce bright red blood in stool

reticular activating system

from hypothalamus to medulla to mediate arousal(sensoristasis), selects impulses to reach cortex to be perceived

sensorineural hearing loss

from inner ear damage

palpating sinuses

frontal(above inner eyebrow) and maxillary(upper cheek) sinuses in frontal and maxillary bones palpated for pain and edema

foods with laxative effect

fruits and vegetables, bran, chocolate, spicy foods, alcohol, coffee

pressure ulcer stage 4

full thickness tissue loss with exposed bone, tendon, muscle

pressure ulcer stage 3

full thickness tissue loss; subcutaneous fat may be visible but bone, tendon, or muscle; may have slough

turgor definition? best place to assess?

fullness or elasticity of skin. best place to assess is on sternum or under clavicle

during any patient transferring task if caregiver required to lift >35lbs of patient's weight then patient considered to be

fully dependent and assistive devices should be used for the transfer

inspection for cardiovascular+peripheral vascular

general appearance of skin color, temp., moisture, precordium, neck veins, hair quantity+distrobution, edema, nails, neck veins CVP, auscultation(PV:carotid, abdominal aorta), pulses, capillary refill

Erikson's stages of psychosocial development psychosocial stage 7 name? age range? guide?accept?adjust? adjust to? reevaluate?

generativity vs. stagnation middle adults Guide the net generation, get involved Accept middle age changes Adjust middle age changes Adjust to needs to age parents Reevaluate goals and accomplishments

muscular dystrophies define? example?

genetic disorders of degeneration and weakness of skeletal muscles. Example: myasthenia gravis preventing muscle fibers from contracting

Subcutaneous (Subq): given where? usually given with? how much fluid? gauge? length? locations?

given into the fatty, subcutaneous layer of skin; usually given with a shorter needle (ex: 1/2 inch). Small amounts of fluid (ex: 1 ml or less) are injected via this route. Gauge: 23, 25, 26. Length(inches):3/8 ½ 5/8. Locations: upper arm, abs, anterior thigh, upper back, upper ventral or dorsogluteal area

Intramuscular (IM): given where? needle length? liquid? gauge? length? used with what meds? degree angle?

given into the muscle; this is a deeper injection and requires a longer needle, usually at least 1 inch long. As much as 3 ml can be injected into one site. Gauge: 18 20 21, 22. Length(inches): 1, 1 ½, 2. For antibiotics, hormones, vaccines. 72 or 90 degrees

Intradermal (ID): given where? often used for? needle types? gauge?length? absorption rate? degree angle?

given just under the skin in dermis; often used for skin tests such as the Mantoux TB tests and allergy tests and local anesthesia. Short needles are used for these injections and tiny amount of fluid are injected. Gauge: 25, 26. Length(inches): 3/8 ½ 5/8. Longest absorption of all parenteral routes.5-15 degrees

Vial: definition? may contain? can be supplied as? med removed by?

glass bottle with self sealing rubber top; may contain a single dose or multiple doses. Medication in vials may be supplied as a liquid or as a powder which will need to be mixed (reconstituted) with the appropriate fluid. Medication is removed from the vial by puncturing the rubber top with a needle or plastic tip attached to a syringe and withdrawing the medication into the syringe.

Ampule: definition? to remove med?

glass bottle/flask with pointed top and breakable neck containing one dose of liquid medication. To remove medication, the ampule is broken at the neck and a needle attached to a syringe is used to withdraw medication into the syringe.

personal protective equipment

gloves, gowns, masks, eyewear

dehydrate patients elasticity does what

goes down

Phenobarbital, gr i PO is ordered. Available in 30 mg tablets how many tablets should be administered?

gr i=60mg. 30mg/1tablet=60mg/xtablets. 60=30x, x=2 tablets

most frequent unit of measurement for apothecary is

grain which is a unit of weight measurement.

gm means

gram

old adult breast variations

granular, pendulous breasts in women

crepitation

grating/crackling sound heard or felt on movement

goal of care definition? time frame? expected outcome specifies?

guideposts to selection of interventions and criteria in evaluation of intervention. Short/long term. Expected outcome specify step-by-step objective that leads to goal and resolution of the etiology of the diagnosis

Abnormal liver findings

hard and firm(cancer of liver), nodularity(tumor, metastatic cancer, cirrhosis), pain(vascular engorgement as in congestive heart failure, hepatitis, abscess). Border >1-3cm below costal margin considered enlarged from hepatitis, tumors, cirrhosis, vascular engorgement

stridor

harsh high pitched sound heard on inspiration when there's a narrowing of upper airway(larynx, trachea). Infants or young with croup often have this

when discarding narcotic

have a witness, both of you sign documentation

auscultation process of CV+PV

have patient breath normal, use diaphragm and bell of stethoscope, caused by closure of valves, systemic method=ape to man. CV+PV locations:aortic area(2nd intercostal space, R sternal border), pulmonic area(2nd intercostal space, L sternal border), erb's point(3rd intercostal space, L sternal border), tricuspid area(4th or 5th intercostal space L sternal border), mitral area or apex(5th intercostal space, L midclavicular)

peripheral vision guidelines

have patient sit or stand 2 ft away facing you at eye level, ask patient to cover one eye and to look at your nose, cover your own eye opposite to patient's closed eye, hold one arm outstretched to one side equidistant from you and the patient then move your fingers into visual fields from various peripheral points, ask patient to tell you when fingers are first seen(should be seen at same time you see finger), repeat procedure for other eye

inspecting balance and fait? abnormal findings?

have patient walk across room on toes on heels and heel to toe. Abnormal findings indicate disorders of motor, sensory, vestibular, cerebellar systems

People with chronic illness or disability may be viewed as having

having the potential to attain a high level of wellness if they are successful in meeting their health potential within the limits of their chronic illness or disability

Assessing breast history

health history, family history, history mammograms, past breast history. pain in one or both, history of lumps, swelling, redness, change in size, dimpling, discharge, ovarian+breast cancer of oneself or family, breast disease, biopsy, surgery, menstrual+pregnancy history, hormones, contraceptives, radiation exposure, chemical exposure, dietary intake, drugs, breast self-exam, most recent breast exam and mammogram

bronchovesicular sounds heard over? aka? sounds?

heard over mainstem bronchus aka first and second interspaces anteriorly and scapula posteriorly and are moderate, medium pitched, medium intensity blowing sounds with inspiration equal to expiration

When SV decreases when blood volume decrease due to hemorrhage?

heat rate increases trying to maintain CO.

Blood levels of a drug are often measured to

help evaluate whether a drug's dose is at level to achieve desired effect and below the level at which adverse effects occur.

complications of healing

hemorrhage, dehiscence, evisceration, infection, fistula

wound healing stages

hemostasis(maybe included with inflammation, exudate), inflammation(WBCs), proliferation(granulation aka connective tissue), maturation(scar)

high alert drugs?

heparin and insulin

lumbar curve may be flattened with

herniated disk

patient bill of rights

high quality care, clean/safe environment, respect, dignity, info, pain management, participation/involvement in their own care, privacy, help with bill/insurance claims. established by nurse practice act

Priorities classified as

high, intermediate, low

elderly decreased # of protein binding sites for drugs

higher drug plasma concentration leading to increased possibility of drug toxicity

systolic pressure

highest pressure. when heart contracts

congenital or acquired postural abnormalities

hip dysplasia, clubfoot, scoliosis(lateral spine), kyphosis(thoracic spine)

convergence guidelines

hold finger about 6-8" from bridge of nose, move finger toward the patient's nose to assess convergence. Eyes should normally converge

accommodation guidelines

hold forefinger, a pencil, other straight object 10-15cm(4-6") from bridge of nose, ask patient to look first at object then at distant object, then back to object being held. Pupil normally constricts when looking at near object and dilates when looking at distant object

H.S. care

hour of sleep. Toileting, washing face/hands, oral care, massage

morbidity define

how frequently diseas occurs

nursing care

human response to disease, treat whole patient, interventions based on concepts

forceful or bounding peripheral pulse=

hypertension and circulatory fluid overload

keloid

hypertrophied scar

etiology/cause part of nursing diagnosis definition? purpose?

identifies factors that are maintaining the unhealthy state/response contributing or causative factors. Purpose- suggests appropriate nursing measures/intervention

after writing outcomes nurse does what?

identifies various nursing interventions to help patient achieve outcomes

problem part of nursing diagnosis definition? purpose?

identifies what's unhealthy/health state about the patient indicating the need for change. Purpose-suggests patient outcomes(expectations for change)

diagnosing is to identify what?

identify how an individual/group/community responds to actual/potential health+life processes, identify factors that contribute to or cause health problems(etiologies), identify resources/strengths they can draw on to prevent/resolve problems

defining characteristics part of nursing diagnosis definition? written in terms of? purpose?

identify the subjective/objective data that signal existence of problem, cues that reflect the existence of problem. Written in terms of patient problem/alteration in health state/patient strength for which RN provides primary therapy. Purpose-suggest evaluative criteria. Not medical diagnoses or statements of patient need.

5 elements of evaluation

identifying evaluative criteria/standards, collecting data to determine whether criteria/standards/outcomes are met, interpretting/summarizing findings, documenting judgement, terminating/continuing/modifying plan

how exercise affects sleep

if <2 hours before sleep can hinder sleep. If before then can help sleep

cradle used for? define?

if top bedding must be kept off lower extremeties this is use. framing that supports linen.

risk factors from pressure ulcer development

immobility, poor nutrition+hydration, prolonged moisture on skin, increased age+decreased mental status

fibrous joints movement? aka? define? example?

immovable aka synarthrosis. Fibrous connective tissue between bones. Examples: sutures between skull bones

old adult head and neck variations

impaired near vision(presbyopia), decreased color vision and peripheral vision, decreased adaptation to light and dark, white ring around cornea(arcus senilis), entropion and ectropion, hearing loss(presbycusis), impaired conductive hearing, elongated ear lobes, prominent ear landmarks, decreased neck range of motion, nodular thyroid gland, smaller more easily palpated lymph glands

integument effects of exercise+immobility

improved tone, color, turgor due to improved circulation ^risk for skin breakdown and formation of pressure ulcers

turning in bed improves? how to turn?

improves venous return, respiratory function, intestinal peristalsis, skin raise knee reach across to grasp side rail on side toward turning every 2 hours when awak

According to standards of care RN will?

in complete, accurate, timely manner, report+document assessments/observations, give care, monitor client's response to care

narrative notes definition? Includes? Advantage? Disadvantage?

in source-oriented records, progress notes written by RN and address routine care, normal findings, patient problems identified in plan of care. Includes description of status of problem, related interventions, patient responses, needed revisions in plan of care. Advantages: allows RN to describe in their own terms Disadvantages: time-consuming and difficult to read through weeks or notes to find problem, treatment, response

Increased toxicity when

inactive forms are converted to active forms

atelectasis define? s&s? intervention?

incomplete expansion or collapse of alveoli with retained mucus. S/S: decreased lung sounds over affected area, dyspnea, cyanosis, crackles, restlessness, apprehension. Intervention: semi-fowler/fowler, O2, meds

partial rebreather incorporates? for?

incorporating non-rebreathing valves and reservoir bags for exhaled air to inhale 1/3 expired air from bag plus 100% O2

cognitive outcomes definition

increase in patient knowledge

older adult thorax+lung variations

increased anteriorposterior chest diameter, increase in dorsal spinal curve(kyphosis), decreased thoracic expansion, use of accessory muscles to exhale

abnormal bowel sounds- increased bowel sounds mean

increased bowel motility caused by gastroenteritis, diarrhea or early bowel obstruction

hypertrophy

increased muscle mass

tachypnea definition? causes? rate?

increased respiratory rate. Causes- increased metabolic rate from fever, acid-base, altitudes, disease, anemia, anxiety, pain >20/24 breaths/min

kyphosis

increased thoracic spinal curve usually in old

spasticity

increased tone that interferes with movement caused via neurologic impairment

infection phases

incubation period>prodromal stage>full stage of illness>convalescent period

nurse initiated interventions aka? involves?

independent nursing actions. Involve carrying out nurse prescribed interventions resulting from assessment of patient needs written on plan of case

active exercise define? define active assistive?

independently moves joints through full ROM(isotonic exercise). Active-assistive, nurse provides minimal support.

unlicensed assistive personnel definition

individuals trained to function in assistive role to licensed RN

types of catheters

indwelling, intermittent, condom, suprapubic

tendons

inelastic fibrous and flattened connective tissue that attach muscle to bone

to address HAIs following measures are successful:

infection control committees, written infection prevention practices, using practices to keep patients in better physical condition

iatrogenic

infection when resulting from a treatment or diagnostic treatment

infection occurs as result of what components

infectious agent, reservoir, portal of exit, means of transmission, portals of entry, susceptible host

pneumonia define? s&s? interventions?

inflammation of alveoli due to aspiration, infection, depressed coughing,increased sections, dehydration, immobilization. S/S: fever, chills, cough, crackles, wheezes, dyspnea, chest pain. Interventions: semi fowler/fowler position, O2, meds, oral hygiene

stomatitis

inflammation of oral mucosa

glossitis definition? Caused by?

inflammation of tongue, can be due to vitamin b12, folic acid, iron deficiency

thrombophlebitis define? s&s? interventions?

inflammation of vein associated with thrombus from venous stasis. S&S: pain, cramping, redness, swelling, elevated temp. Interventions: prevent clot from breaking loose via meds, maintaining bed rest, applying heat, stockings, compression devices

phlebitis define? in lower extremities?

inflammation of vein. In lower extremities is indicated by pain, redness, swelling

Ethnicity influences? Examples? Avoid ? Ask? aka?

influences response to certain medications due to genetic differences Ex ACE inhibitors less effective in African Americans. Alternately, certain thiazide diuretics appear to be better for controlling hypertension. Avoid making geralizations and assumptions. Ask the right questions when interacting with patients of varying backgrounds., aka ethnopharmacology

decision analysis

info from record to provide data to identify needs and the means and strategies most likely to address needs. Also reveals underused and overused services, costs.

signature defintion?

information to be written on label like directions to patient

propioreceptor or kinesthetic sense

informs brain of location of limb or body part as result of joint movement stimulating nerves in muscles, tendons, fascia

pulmonary route definition

inhalation

what to chart

initial assessment when admitted/transferred/at beginning of each shift, all treatments including time+outcome+reactions, diagnostic tests including time+type+ unusual stuff+ reaction +outcome, the time patient leaves unit, time patient returns to unit, symptoms, changes, complaints, character+ amount of drainage/ vomit/ stool/urine/bleeding, pain, action taken to relieve pain, dressings, wounds, ambulation, diet, body care, room #, age, height, weight, allergies, meds, dentures, contacts, valuables, meds given+time +amount+ site+method, IC's, unusual occurences, emotions, discharge notes, doctor's visits, other members of healthcare visits

3 basic stages planning outcome ID

initial planning, ongoing problem-oriented planning, discharge planning

venous ulcers

injury and poor venous return resulting from underlying conditions like incompetent valves or obstruction

diabetic ulcers

injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure

arterial ulcers

injury and underlying ischemia, resulting from underlying conditions such as atherosclerosis or thrombosis

neuropathic pain

injury or abnormal functioning or nerves or CNS

aphasia define? types?

injury to cortex causing language disorder. May be expressive:individual understands written+spoken words but cannot write+speak to communicate, or receptive: individual cannot understand written or spoken words

parts of syringe and needle that must be kept sterile

inside of barrel, part of plunger, tip of barrel, needle

inspecting a stoma. inspect with? stoma should appear? stool characteristics depend on? small bowel stool is? lower colon stool is?

inspect with ileostomy or colostomy to describe stoma. stoma should appear red and moist(maybe edematous 6-8 weeks after surgery). Stool characteristics depend on location of ostomy. Small bowel stool is thick liquid consistency. Lower colon stool more solid.

breast physical assessment

inspection and palpation. sitting or supine

wound assessment involves

inspection(sight+smell), palpation for appearance, drainage, odor, pain

wound classification

intentional or unintentional, partial thickness(all or a portion of dermis) or full thickness(entire dermis and swear glands and hair follicles are severed), open(skin broken) or closed(skin not broken),or complex(dermis and subcutaneous fat are damaged or destroyed)

Any disturbance in the 6 dimensions affect the whole system they are

interdependent

incubation period

interval between invasion and appearance of symptoms

cardiovascular+peripheral vascular physical assessment technique

interview, inspection, auscultation, palpation, percussion, subjective+objective, PE+PHI+interview history. CV=inspection, palpation, auscultation. Stethoscope and sphygmomanometer needed. Patient sitting or supine with head raised 30 degrees. PV=inspection, palpation for BP perfusion and peripheral pulses. Patient sitting or supine

payen behavioral pain

intubated critically ill patients using bodily indicators of pain

entropion

inward turning of lower lid and lashes

dysrhythmia

irregular pattern of heartbeats

wheal define? size? ex?

irregular, superficial area of localized skin edema ex:hives, mosquito bite

sensory function assessment. is patient? do what?

is patient reliable? ask patient to close eyes testing for sharp(pain), dull, and warm/cold light touch vibration sense

when patient has had surgery, is transferred to another service, or health agency

it is general practice that all orders are discontinued and new orders are written at new setting

when bladder is distended

it rises above the symphysis pubis and may reach to just below the umbilicus. Distention=inflation

maslow heirarchy based on theory that something is basic need if

its absence results in illness, its presence prevents illness or signals health, meeting it restores health, its preferred over other satisfactions when unmet, one feels something is missing when need unmet, one feels satisfaction when need met

internal standards of care definition

job description, institutional policies/procedures

hyperventilation causes?

kaussmaul's, fear, diabetic ketoacidosis, overdose of aspirin

Verbs to be avoided when writing outcomes

know, understand, learn, become aware

feces formed in

large intestine and held until defication

loading dose

larger than normal dose, given when patient in acute distress and max therapeutic effect is desired as quickly as possible

scoliosis

lateral curvature of spine with increased covexity on the side that is curved. Screening: is head level and centered over the trunk? is the shoulders the same height? are the hips at same level? when bent forward with arms dropping towards feet is rib cage level on both sides?

abduction

lateral movement away from midline of body

adduction

lateral movement toward midline of body

Isabel Hampton Robb: leader in? Organized what? Initiated? 1st?

leader in nursing&nursing education; organized nursing school at Johns Hopkins Hospital; initiated policies that included limiting # of hours in a day's work +wrote textbook to help student learning; the first president of Nurses Associated Alumnae of the US+Canada(which became American Nurses Association)

macule define? size? ex?

lesion < 1cm Ex: petechiae, freckle

patch define? size? ex?

lesion>1cm Ex:vitiligo

when to wear gloves for integument assessment

lesions of skin or scalp, lice

negatives of restraints to prevent from harm

less able to perform activities of daily living, lower cognitive abilities, difficulty walking causing need for more staff, skin breakdown, contractures, incontinence, depression, delirium, anxiety, aspiration, respiratory difficulty

enkephalins

less potent than endorphins and reduce pain by inhibiting substance P

LPN

licensed practical nurse. practical+vocational nursing program. NCLEX-PN

miscellanious lesions ex?

lichenification, atrophy, excoriation, scar, keloid, comedo, telangiectasia, nevus

eyes inspection?

lids, lashes, cornea, sclera, lacrimal apparatus, conjunctiva, PERRLA(pupil equal, round, react to light, accommodate from far to near 6in. w/ pupil constriction and convergence), assess EOM/6 cardinal fields of vision(cover eye on one side)external&internal structures, visual acuity, extraocular movements, peripheral vision. external eye structures assessed:eyes, eyebrows, eyelids, eyelashes, lacrimal glands, pupils, iris for position and alignment. internal eye structures assessed with? what's assessed?with ophthalmoscope. Fundus, retina, optic nerve disc, macula, fovea centralis, retinal vessels inspects

CAPITALS indicate

life threatening

trapeze bar for

lifting, moving, turning, exercise

palpation abdominal assessment palpation type? do what?

light(1/2 inch deep), have patient flex knees to relax abs, avoid tender areas, watch body language not abdomen when palpating, bladder should be palpable with 500ml urine under symphysis pubis, may feel stool in descending colon,, rebound tenderness(more pain felt on release than with pressure may indicate inflammation via appendicitis or diverticulitis), liver+spleen may be palpable in young kids, deep palpation for liver borders usually reserved for advanced practitioners

Ophthalmoscope purpose? parts? labels? zero lens used when?

lighted instrument used to visualize interior eye. 2 parts: body with light source and detachable head with lenses to magnify internal eye that has dial to turn on illumination. Each lens labeled with positive(black used for far-sighted/hyperopic) or negative(red used for near sighted/myopic) number with units of strength called diopters. Zero lens used when examiner or patient has refractive(visual) errors

chronic pain define? Can be?

limited intermitted persistent and last beyond healing. Periods of remission and exacerbation(symptoms reappear). Can be malignant(cancer or progressive) or nonmalignant(nonprogressive or healed)

mouth and pharynx includes

lips, tongue, teeth, gums, hard+soft palate, salivary gland, tonsillar pillars, tonsils

which ab organs are not normally palpable

liver, spleen

local adaptation syndrome(LAS) define

localized response of body to stress involving only specific body part instead of whole body

SOAP notes advantages and disadvantages

location of problem at front of chart, problem focused, easy retrieval of info, healthcare workers from different disciplines chart on same progress notes, consisten with RN process disadvantages: problem focus may reduce patient to problems to be solved, maintaining up to date problem list takes constant review

temp. varies due to

location taken(core vs. surface), circadian rhythms, age, gender, stress, environment, exercise, food/smoking, dehydration, illness/injury, ovulation(^)

ativan generic name? common? effects?

lorazepam. common preop med. effects: adjuvant for anesthesia, antianxiety, sedative

ulcer define? ex?

loss of epidermis and dermis that may bleed and scar Ex:stasis ulcer

erosion define? ex?

loss of superficial epidermis, moist, nonbleeding Ex: chicken pox, moist area after rupture of vesicle

Resonance tone intensity? Location?

loud, normal lung

maintenance dose

lower dose that becomes the usual or daily dose

contents from esophagus enter stomach through

lower esophageal sphincter and mix with digestive enzymes and hydrochloric acid

diastolic

lowest pressure. when heart relaxes between beats

s3 -don't know

lub-dub-dee. 3rd heart sound, best heard with bell at mitral area, patient lying on left side. Normal in kids and young adults only

s1 sound? means? loudest where? can also be heard where?

lub. mitral and tricuspid closure, beginning of systole/ventricular contraction, loudest at apex, can be heard at tricuspid area

circumscribed flat nonpalpable change in skin color ex? type?

macule, patch. Type: primary lesion

nursing guidelines of urinary catheterization

maintain sterile field, make sure catheter is patent

male vs. female urethra

male urethra for excretory+reproduction 5.5-6.25 " long and has 3 parts:prostatic, membranous, cavernous portions. Female urethra 1.5-2.25" long, no portion is external to body like male

Top Leading Causes of Death: Ages 40-65

malignant neoplasms

nodule define? size? ex?

mass 0.5-2cm; firmer than papule. Ex:nevus(wart)

papule define? size? ex?

mass <0.5cm ex:mole

tumor define? size? ex?

mass >2cm Ex:lipoma

plaque define? size? ex?

mass>0.5cm ex:coalesced papules

manual removal of fecal impaction may cause?

may cause great discomfort to patient as well as irritation of rectal mucosa. physician order required.digital removal of feces can stimulate the vagus nerve

parenteral route definition? characteristics? types?

means outside intestines or alimentary canal via injections. tissue perfusion, water solubility, variable time of onset: subcutaneous, intramuscular, intradermal(corium under epidermis), intravenous

Rx means?

means take thou and per inscription

additional assessment techniques after GI history and physical

measure urine output, collect urine specimens, determine presence of abnormal constituents in urine, assist with diagnostic procedures

diagnostics for CV+PV

measures blood flow: angiogram, doppler flow studies, cardiac catheterization. RBC count(H&H). visualize circulatory system:chest xray, echocardiogram. tests to identify abnormal cells or infections: CBC

incentive spirometer measures?

measures how much you can inhale

define perfusion scan

measures the blood supply through the lungs

liniment

med mixed with alcohol, oil, soap, rubbed on skin

PVD or cardiac disease may delay

medication distribution

Pre-filled Syringes: definition?

medication for injection may also come packaged in a pre-filled syringe. Again, since the supplied medication is often different from the ordered dose, care must be taken to expel the unneeded medication before injecting into the patient.

Continuous infusion definition? example?

medications are added to IV fluids/solution and administered as a continuous infusion slowly. Potassium, as an electrolyte replacement, is frequently given via this route.

increase in nodularity and tenderness of breasts may indicate

menstrual period or fibrocystic disaese

neurologic physical exam is conducted to verify

mental status, LOC, cranial nerve function, muscle strength+coordination, reflexes

Nurse needs to administer 50mcg fentanyl. Pharmacy supplies amoule of fentanyl 0.1mg/2mL. How much should be administered?

mg needs to be converted to mcg. mL=(2mL/0.1mg)x(1mg/1000mcg)x50mcg =1mL

colonization definition

microbe invades host not causing infection

Florence Nightingale- time? Did what? Nationality? Established? Identified? Established? Recognized? Institutioned? Stressed what? Maintained?

mid18th cent.-19th cent. founder of nursing that is separate from meds in crimean war. British. Est. training school for nurses&wrote books about healthcare&nursing to make is respected, improve quality. Identified personal needs of patient/meeting the needs. Est. standards for hospital management, a respect for women, nursing education. Recognized 2 components of nursing(health+illness), nutrition is important to health. Institutioned occupational+recreational therapy for sick. Stressed need for continuing education 4 nurses. Maintained accurate records for nursing research.

mini-mental status examination

mini-mental status examination

nursing diagnosis, collaborative problem, medical diagnosis focus

monitoring responses to health problems, monitoring pathophysiologic responses of body, correcting/preventing pathology of specific organs/body systems

w/ respiratory infection how far should you stay away

more than 3 feet

Italics indicate

most frequent

prodromal stage

most infectious stage. early signs/symptoms.

4 cranial nerve motor or sensory? aka? controls? test?

motor+propioreceptor. Troclear. Downward inward eye movement. Visual acuity/fields

7 cranial nerve motor or sensory? aka? controls?

motor+sensory. Facial. Face muscles+function(smile, frown, whistle, raise eyebrows, wrinkle forehead, close eyes against resistance), sense of taste on anterior 2/3 of tongue.

9 cranial nerve motor or sensory? aka? controls? test?

motor+sensory. Glossopharyngeal. Glossopharyngeal+pharyngeal movement+swallowing, sense of taste on posterior 1/3 of tongue. Check soft palate via ah and yawn, uvula movement, taste, gag reflex, swallow, speech

11 cranial nerve motor or sensory? aka? controls? test?

motor+sensory. Spinal accessory. Movement of shoulder muscles. Spinal accessory.check sternocleidomastoid muscles for strength, resistance (shoulder shrug and turn head against resistance)

5 cranial nerve motor or sensory? aka? controls?

motor+sensory. Trigeminal. Jaw movement, sensation of face+neck, jaw strength, pain, bite(clench), bilateral face sensation

10 cranial nerve motor or sensory? aka? controls? test?

motor+sensory. Vagus nerve. Swallowing and speaking. Check soft palate by swallowing, uvula movement, taste, gag reflex, swallow, speech

12 cranial nerve motor or sensory? aka? controls? test?

motor. Hypoglossal. movement+strength of tongue, push tongue against cheek and protrude tongue

3 cranial nerve motor or sensory? aka? controls? test?

motor. Oculomotor. Pupil constriction, raise eyelids. Visual acuity/fields, PERRLA,

isometric exercise

muscle contraction without shortening

nocturnal myoclonus

muscle contractions during sleep that can wake patient causing insomnia

isokinetic exercise

muscle contractions with resistance

isotonic exercise

muscle shortening and active movement independently

fact witness

must base testimony on only 1st hand knowledge

official name

name by which drug is identified in official publications often the generic name

record for for each narcotic administered

name of patient, amount of narcotic used, hour given, name of physician who prescribed, name of nurse who administered

identifying patient correctly steps

name, dob, identification #, medical record # comparing with CMAR or MAR. at least 2 patient identifiers should be used. Room # and physical location cannot be used.

promoting postop rest and comfort

nausea and vomitting: small amounds of fluid/food at one time, avoid straws, avoid strong smelling food thirst: offer sips of H2O or ice chips when NPO hiccups: take swallows of H2O while holding breath(non NPO), breathe in paper bag, eat teaspoon of granulated sugar surgical pain

cheyne-stokes definition? causes?

near death alternating periods of deep/rapid breathing followed by apnea. OD, heart failure, increased intracranial pressure, renal failure

mouth inspection needs what? inspect what? head is? mouth is? remove what to see what?

need tongue blade, 4x4 gauze sponge(to hold tongue), gloves and penlight- lips, mucous membrane, under tongue, hard+soft palate, pharynx, uvula should rise, teeth, gums, gag reflex(coughing swallowing via tongue blade on back of tongue). Head tilted back+mouth open wide. Remove dentures to see gums

Needle size includes the length of

needle and the gauge aka diameter of the opening in the needle. #18-30

malpractice definition

negligence by professional

unintentional tort examples

negligence, violation of professional standard resulting in injury of patient

diabetic neuropathy

nerve damage in legs/feet

uncoordination or spontaneous movements may suggest

neurologic problems

allodynia

nonpainful stimulus felt as painful in spite of normal appearing tissues.

sleep hygiene define? Includes?

nonpharmacologic recommendations that help get better sleep. Includes: restricting caffeine, nicotine, alcohol; avoiding stimulating activities after 5; avoiding naps; eating light meal before bed; sleeping in cool dark room; eliminating clock; taking warm bath before bed; staying quiet

muscle tone

normal condition of muscle at rest.

eupnea definition? rate?

normal respiration. 12-20 breaths/min

healthcare associate infections(HAIs) aka? categories?

nosocomial infection. can be either exogenous or endogenous

adventitious breath sounds

not normally heard in lungs but may be auscultated

progress notes definition? Examples?

notes written to inform caregivers of progress of achieving expected outcomes. In source-oriented records and problem-oriented records. Examples: narrative notes, SOAP notes, PIE notes, focus charting, charting by exception, case management model

mortality define

number of deaths

types of interventions

nurse-initiated, physician-initiated, collaborative interventions

type 1 ethics& the law? Ex.?

nursing actions are both ethical&legal. Ex: Right drug given

NIC aka? definition?

nursing intervention classification- 1st validated list of nursing interventions applicable to all settings that can be used

Divergent Thinking for cognitive skills in critical thinking

o Ability to analyze a diversity of opinions and judgments. o When nurses obtain histories from patients, they separate out all irrelevant data, analyze pertinent data, and explore possibilities in order to draw accurate conclusions o Inference is a conclusion or deduction drawn about data o Analyzing means to closely study or evaluate data.

Reasoning for cognitive skills in critical thinking

o Uses general principles of logic o Must be able to discriminate between observation and inference, between facts (truth) and conjecture (guess or belief), and draw conclusions for themselves -Inductive—involves generalization o If one patient with advanced COPD experiences fatigue with activity you conclude that all patients with COPD experience fatigue -Deductive—involves applying on an individual basis from a larger group o All postop patients are at increased risk for pain. You assume your surgical patient is at risk for pain

comprehensive nursing interventions specify

observations, interventions(when/how), teaching/counseling/advocacy

motor function & coordination assessment

observe gait, alignment, bed activity, balance(romberg's test via standing up with closed eyes), coordination(finger to nose, heel down shin). have client rapidly touch each finger with thumb, put hand on thigh and tap the foot on floor or against your hand. Then repeat on opposite limb. If not able to perform it can indicate disease of upper motor neurons or cerebellum

when believed a factor is affecting endurance

obtain VS at rest, perform activity, observe response during+after activity, take VS after, reassess VS after rest for 3 min.

endemic

occurs in one region/population

endogenous

occurs when causative organism comes from microbe harbored on person

reassessment of skin for long term care setting

on admission, reassess every 48 hours for 1st week, weekly for the first month, followed by monthly to quarterly assessments; more if condition changes

reassessment of skin for home healthcare

on admission, reassess every visit

reassessment of skin for acute care setting

on admission, then every 48 hours if condition changes. If intensive care and stable, daily. If unstable, every shift

canes are held

on patient's stronger side

defendant

one being accused of crime/tort

shear

one layer of tissue slides over another separating skin from underlying tissue

gas producing foods

onions, cabbage, beans, cauliflower

OPQRST system

onset, palliating and provoking factors, quality, region&site of symptom, severity, timing of onset and duration of system

assessing the internal eye guidelines

ophthalmoscope at large white light and lens wheel at 0. Darken room with patient sitting/no glasses. Patient looks straight ahead with both eyes open. Use right hand+eye to examine right eye and vice versa. Shine light on pupil to observe round red/orange glow(red reflex). Move scope toward eye. Rotate lens wheel until internal eye structures sharp+clear. Follow blood vessels toward midline to locate optic disc. Patient looks up, down, side to side. Locate macula by toward patient's temple for a small structure near disc

ANA

organization for RN's. American nurses association. Developed standards of practice to guide performance. american nurses association. writes codes for nurses.

NLN

organization for all. National league of nurses

Environmental preparation

organization, privacy. quiet, gown, drape given, instruments gathered, warm room, adequate lighting, have patient empty bladder

somatic pain

originated in tendons, ligaments, bones, vessels, nerves. diffuse or scattered.

OASIS define? Group of data elements that? Used with?

outcome and assessment information set. Group of data elements that: represent items of assessment for adult home care patient, forms the basis for measuring outcomes for purposes of outcome-based quality improvement. Used with medicare. comprehensive assessment documentation in home healthcare including demographics, history, living arrangement, supportive assistance, senses, skin, respiratory, elimination, neurologic, behavior, activities of daily living(ADLs), meds, equipment

how regular RN process is different from perioperative

outcomes identified first due to being preventative in nature then patient assessed for relevance of outcome, diagnoses, then interventions

ectropion

outward turning of lower lid and lashes

condyloid joint define? movements? example?

oval head of one bone fits into shallow cavity of another. Flexion, extension, abduction, adduction can occur. Example: wrist

maceration

overhydration

nociceptive definition? feeling?

pain caused by tissue injury in joints, bones, muscles, organs. nervous system functioning normally. aching/throbbing.

postherpetic neuralgia

pain follows acute CNS infection like shingles

phantom pain

pain from amputated leg where no nerves present

transmission

pain from site of injury/inflammation conducted via pathways to spinal cord and then to higher centers

neuropathic pain definition? feeling?

pain initiated/caused by primary lesion or dysfunction in nervous system. burning/tingling/numb/itching

visceral pain

pain of internal organs, subtype of nociceptive pain

psychogenic pain

pain originated from physical cause and cannot be identified

breakthrough pain

pain that increases above the level of pain addressed by ongoing analgesics. includes incident pain and end of dose failure

dysuria

painful or difficult urination

pallor

paleness resulting from decrease in amount of circulating blood or hemoglobin causing inadequate oxygenation from anemia, shock. Pallor in dark-skinned people seen as ashen gray or yellow tinge

abnormal mouth findings

pallor, cyanosis, redness, swelling(swollen red bleeding gums=nutritional deficit or inflammation, or poor oral hygiene), lesions, white tongue(poor hygiene, irritation, smoking), fissured tongue(dehydration), bright red tongue(Fe,Niacin, or vitamin B12 deficit), black hairy tongue(antibiotic use)

breast palpation

palpate 4 quadrants(upper outer+inner, lower outer+inner)

when conducting palpation any area of tenderness is

palpated last

genitourinary assessment

palpation, urine assessment, intake+output

palpable elevated solid massess ex? type?

papule, plaque, nodule, tumor, wheal. Type: primary lesion

paraplegia vs. quadriplegia

paralysis of legs, paralysis of arms and legs

hemiplegia

paralysis of one half of body

paxil generic name? effects?

paroxetine hydrochloride. effects: antianxiety, antidepressant

dehiscence

partial or total separation of wound layers as result of excessive stress on wounds that aren't healed. Premature opening of incision

pressure ulcer stage 2

partial thickness skin loss; shallow ulcer with red or pink wound bed

deep tendon reflex assessment

patellar reflex(knee, brachical, radial,achilles) via 0-5 rating. Babinski(foot/upper motor neurons), normal: toes flex downward, abnormal:toes extend up and fan outward) aka plantar reflex. determines functional ability of specific spinal segment levels. Use reflex hammer. Reflex grading 0-4. Grade 2=normal

elbow extension and flexion guidelines

patient 1st extends the elbow against resistance by the examiner, then he flexes the elbow against resistance

hip flexion guidelines

patient attempts to raise his thigh against examiner's resistance

ankle plantar flexion and dorsiflexion guidelines

patient first pushed the balls of the feet against resistance of the examiner's hands, then the patient attempts to pull against examiner's resistance

shoulder flexion guidelines

patient flexes shoulder muscle against resistance of examiner's hand

buerger's test

patient in supine position and raise one are or leg about 1 foot above level of their heart, ask patient to move leg or arm up and down for 1 minute then sit up and dangle arm or leg downward, observe time it takes for original color of skin to return and for veins to fill(color take 10 seconds, veins fill in 15 seconds)

wrist extension guidelines

patient makes first and resists examiner's attempts to pull down wrist

If a health institution wants to release patient's health info for purposes other than treatment, payment, or routine healthcare operations?

patient must be asked to sign an authorization

guidelines for outcome writing

patient outcome must have subject(client), verb(action), conditions of which the outcome is to be achieved, performance criteria(observable/measurable expected behavior), target time, involve patient+family in development, identify culturally appropriate outcomes, supportive of total treatment plan, brief/specific, positive, derived from 1 diagnosis

allen's test

patient rests hand on examining table with palm up to make a fist, use thumbs to occlude radial and ulnar arteries and ask the patient to open hand(palm will be pale) release your thumb pressure and observe return of color to pal(3-5 seconds normally)

extraocular movements guidelines

patient sits or stands about 2 ft away facing you at eye level, ask patient to hold the head still and follow movement of forefinger or penlight with eyes, keeping finger or light about 1 foot from client's face move it slowly through cardinal positions: up and down, left and right, diagonally up and down to left, diagonally up and down to the right

grip guidelines

patient squeezes the examiner's index and middle fingers

passive exercise?

patient unable to move independently and nurse moves joint through ROM

knee flexion and extension guidelines

patient's knee bent and foot on the examining table, the patient attempts to keep foot down while the examiner attempts to straighten the patient's leg to test flexion. To test extension examiner supports the patient's knee and the patient attempts to straighten his leg against resistance at the ankle

superscription contains?

patient's name, address, age, date

administering analgesics via other methods

patient-controlled analgesia(PCA or PCA by proxy meaning someone else controls but shoudln't be done, MOD aka med on demand), epidural, local anesthesia

powered full body lifts sued for? define?

patients who cannot bear weight . sling under body and sling attached to lift

stand-assist and repositioning aids

patients who need minimal assistance to stand. give them support to grasp and lift themselves

Parasomnias examples

patterns of waking behavior that appear during sleep. Somnambulism(sleepwalking), sleep talking, night terrors, bruxism(grinding teeth), enuresis (urinating during sleep)

apnea

periods where there is no breathing

nociceptors

peripheral nerve fibers that transmit pain

contractures define? cause of contractures?

permanent contraction of muscle. if prolonged bed rest this can happen.

pressure ulcer staging stage 1

persistent redness; intact, non-blanchable

side rails danger? not considered?

person with small stature can become wedged causing asphyxation. not considered restraint if patient requests it be raised to aid in getting up etc.and patient must be able to raise/lower rails themselves

Self actualization definition? what must be met before achieved?

person's motivation to reach their full potential. A person's basic needs must be met before self-actualization can be acheived

plaintiff

person/government bringing suit against another

phr

personal health record containing health history to provide access to up-to-date info to assist in self-care and communication with providers

postoperative phases

phase 1(giving care from anesthesia to less acute interventions) phase 2(preparing for self/family/extended care envrionment) phase 3(ongoing care for extended observation/intervention after transfer/discharge)

defining characteristics of sensory deprivation and overload

physical behaviors(drowsiness), escape behaviors(eating), changes in perception(unusual sensation), changes in cognitive behavior(decreased attention span), changes in affective behavior(excess behavior)

restraints define? examples? used as? must be? never?

physical devices used to limit movement to protect patient and/or staff and must be discontinued as early as possible. Examples: side rails, geriatric chairs, attached trays, appliances tied at wrist, ankle, waist, drugs to control behavior and are not normally given(chemical restraint). Used as last resort. Must be prescribed and never PRN

health promotion/prevention for urinary/GI tract

physical exam, nutritional status, color&rectal cancer screening(yearly FOBT or FIT, plus flexible sigmoidoscopy every 5 years, colonoscopy every 10 yrs), GU urinalysis yearly or every other year(to detect diabetes, renal issues, infections), pap smear yearly, testicular exam monthly, PSA prostate specific antigen

dimensions of developmental level

physical, intellectual, emotional, sociocultural, spiritual, environmental

psychosomatic disorders

physiologic alterations caused by psychological influences

collaborative problem definition? manage via? primary? prescription of? when nurse?

physiologic complications that RNs monitor to detect onset or changes in status. Manage via physician prescribed and RN interventions to minimize complications of event. Primary responsibility of Rns. Prescription of treatment comes from nursing, medicine, other disciplines. When nurse writes patient outcomes that require delegated medical orders for goal acheivement.

responses to pain

physiologic, behavioral, affective(psychological)

effects of stress on basic human needs

physiologic- change in appetite, activity, sleep, elimination, increase in pulse, respirations, BP safety/security- feels threatened and nervous, uses ineffective coping, is inattentive love/belonging- withdrawn+isolated, blames others, aggressive, dependent self-esteem- workaholic, attention seeking self actualization- refuses to accept reality, centers on own problems, demonstrates lack of control

Maslow hierarchy of needs is what? name steps from bottom of pyramid to top?

physiological, safety, belonging, esteem, self actualization Physiological Needs in Priority: Air(most essential), Thermoregulation, Water, Food, Elimination, Rest/sleep, Physical activity, Sex (follows the life cycle. A baby's needs are almost entirely physiological. As the baby grows, it needs safety, then love. Toddlers are eager for social interaction, attention and affection. Teenagers are anxious about social needs, young adults are concerned with esteem and only more mature people transcend the first four levels to spend much time self-actualizing. Holistic: human/physiologic/basic needs. Physiologic/survival(food, fluids, O2 etc.), safety and security need, love/belonging, self-esteem needs, self-actualization needs. A basic human need is one that is essential to the emotional and physiological health and survival of humans. Basic human needs are essential and common to all people Basic human needs arranged in priority order based on how critical to survival each need is. The needs on the basic physiological level must be met before proceeding to the next level.)

protective supine/dorsal recumbent position define? prevents?

pillows under upper shoulders, neck, head, arms, lumbar(if needed), lower legs. sandbags or trochanter roll along side and hips and upper thighs, footboard. Prevents flexion of hips, neck contracture, rotation of shoulders, extension of elbows, flexion of lumbar, rotation of femurs, hyperextension of knees, foot drop

Diploma/ADN's vs. BSN

plans/gives direct care to patients+works w/ other members of healthcare team vs. plans/gives care + directs other members of healthcare team+leadership

'needleless' systems definition? reduce?

plastic tip replaces the needle and can be used for withdrawing medication from the containers. Needleless systems reduce the risk of accidental needle sticks and the risk of exposure to pathogens.

comedo define? ex?

plugged opening of sebaceous gland, hallmark of acne Ex:blackhead

infant+child neurologic variations

positive babinski reflex, grasp reflex, motor control develops in head+neck+trunk+extremities sequence

elderly decreased lipid content in skin for drugs

possible decrease in absorption of transdermal meds

pacu definition

post anesthetic care unit. average stay is 1 hour. they assess respiratory, CV, etc every 10-15 minutes. patient discharged when physical status and LOC stable

RN bill of rights

practice that fulfills obligations, in environment allowing to act in accordance, supports/facilitates ethical practice, freely/openly advocate for themselves/patients, fair compensation, safe environment, negotiate conditions of employment

a barium enema and routine radiography should

precede an upper GI series because retained barium from upper GI could take several days to pass through GI tract and cloud anatomic detail on barium studies

Developmental factors for drugs

pregnancy many drugs contraindicated because of possible adverse effects on fetus. These drugs are called teratogenic (alcohol, cocaine, phenytoin (Dilantin), isotretinoin (Accutane-severe acne). Some drugs cross into breast milk, breastfed infants are at risk from adverse effects from drugs in mother's circulation. Elderly everything decreases changing absorption, metabolism, excretion, susceptibility

first room patient enters when transferred to surgical area

preop holding area where RN identifies, assesses, verify info on preop checklist, preop care

extended release definition? aka?

prep of med that allow for slow and continuous release over a predetermined period. aka CR or CRT(controlled release), SR(sustained or slow release), SA(sustained action), LA(long acting), TR(timed release)

a successful interview requires

prep, including reviewing all available info about the patient, preparing the interview environment, and timing to avoid interruptions

rebound tenderness steps

press down firmly at 90 degree angle to abdomen in area away from point of pain, press down firmly and release fingers quickly, more pain at release indicated positive finding

peripheral vascular assessment edema signs?

pressure areas, skin discoloration, shiny skin, lesions, phlebitis-inflammation of a vein

local wound healing factor types

pressure, desiccation, maceration, trauma, edema, infection, necrosis

wound repair types

primary intention(skin tight, intentional wounds), secondary intention(large open wounds from unintentional), tertiary aka delayed primary(left open for several days for drainage)

Outcomes are derived from

problem statement of RN diagnosis to resolve the problem.

elevated INR indicates

problem with ability of patient to clot

conductive hearing loss

problem with transmission of sound waves through outer and middle ear

nurses nurse people not what? meaning?

problems meaning every outcome should support overall treatment plan making sense in terms of long term goal

genitourinary skin assessment

problems with urinary functioning may result in disturbance in hydration and excretion of body waste so assess skin around urethra, problems with incontinence may result in severe excoriation

modulation

process by which sensation of pain is inhibited or modified via neuromodulators(endogenous opioid compounds)

elderly decreased CNS efficiency for drugs

prolonged effect of drugs on CNS exacerbated response to analgesics and sedatives

community/public nursing interventions does what?

promotes/preserves health of populations. emphasize health promotion/maintenance/disease prevention and includes strategies to address climate

pronation define? aka?

prone position aka lying on abs or palm facing downward

Body Mechanics

proper movements and prevention + correction of posture, coordination, endurance. Erect posture Use arm and leg muscles Use your internal girdle Work closely to object you're moving Slide, roll, push, pull object rather than lift Use broad base of support Use weight of body for pushing/pulling Avoid twisting

Sojourner truth did what?time?

provided nursing care to soldiers during civil war+worked for women's movement. 1787-1883

Maslow was a? wrote?

psychologist. wrote his theories in the book, Motivation and Personality

exceptions where authorization isn't required prior to releasing patient health info(PHI)

public health activities(disease outbreaks, statistics), law enforcement and judicial proceedings, deceased individuals(coroners, organ donations)

bradycardia rate?

pulse rate <60 beats/min

PERRLA definition?

pupil equal, round, react to light, accommodate from far to near 6in. w/ pupil constriction and convergence

right upper quadrant contains

pylorous, duodenum, liver, right kidney, adrenal gland, hepatic flexure of colon, head of pancreas

risk for constipation

r/t abdominal surgery, bedrest, and opioid pain management

body image disturbance

r/t alteration in elimination through colostomy

urinary incontinence

r/t effects of the disease process. any involuntary loss of urine

anxiety

r/t fear of urinary incontinence

tachycardia definition? does what? rate?

rapid rate. decreases cardiac filling time in turn decreasing SV and CO . pulse rate is >100-180 beats/min

routes of administration- rate of absorption depends on? which is longest and most common? which is fastest?

rate of absorption depends on route, oral longest & most common, IV is fastest

palpations of peripheral vascular checks for

rate, symmetry, amplitude=o:absent, +1:weak, +2:normal, +3:increased, +4:bounding, non-pitting or pitting edema, capillary refill

too narrow cuff

reading will be higher

Ways in which nurses can practice in another state

reciprocity, nurse licensure compact(certain states allow you to practice w/out applying)

analyzing info process? conclusions?

recognize patterns, identify strengths/problems of client, reaching conclusions: possible problem on NANDA list, nursing diagnosis, clinical problem other than nursing diagnosis

verbal orders steps

record order in patient's record, read back the order to verify, note the date and time, record verbal orders name of physician or NP followed with your name and title. After emergency physician or NP must review order, sign the order with name title and pager number, and note date and time

R or PR means

rectally

erythema

redness of skin, more often in face and neck. caused by: sunburn, inflammation, fever, trauma, allergic reaction, alcohol, infection

cardinal signs of acute infection

redness, heat, swelling, pain, loss of function

lateral assist devices

reduce friction during side to side transfers

for actual RN diagnoses interventions seek to

reduce/eliminate contributing factors of diagnosis, promote wellness, monitor/evaluate status, reduce/eliminate risk factors, prevent problem

neck veins reflect? position?

reflect central venous pressure in right atrium. position is important:supine, remove pillows to avoid neck flexing, HOB elevated 45 degrees, jugulars begin to empty, at 90 degrees flat

growth and development follow?

regular and predictable trends starting from head/brain and in order all the way to toes(aka cephalocaudal), promimodistal development(gross motor movements to fine motor movements), and both sides of body developing equally

common reasons for urinary catheterization

relieve urinary retention, obtain sterile urine specimen, measuring the post void residual, obtaining urine specimen when specimen can't be secured satisfactorily by other means, emptying bladder before during or after surgery and before certain diagnostic exams, monitoring of critically ill

telephone and fax orders

repeat back to physician, transcribe order and if judged to be inappropriate have another nurse listen to order. Note date time, full name and title of physician or NP, your name and title

why use nursing process for care plans/concept maps?

requirement set by ANA, basis for NCLEX, based on principles/rules promoting critical thinking

apical-radial pulse requires? definition?

requires 2 nurses. one listens to apex, other radial

Home Healthcare requires? what components? referral source for home healthcare?

requires order from MD and primary caregivers approved treatment plan Patients Family Caregivers Referral source for home healthcare: Hospital Family Physician, RN, social worker, therapist, discharge planner

genitourinary intake and output requires? measurement per day average and measure reportable?

requires patient and family cooperation, 1200-1500ml/day average, <30ml/hour reportable

RAI definition? Helps? Consists of?

resident assessment instrument for long term care(Medicare, medicaid, hospice, those in facility >14days). Helps gather info on strengths, needs, and plan of care, and goal achievements, and revisions to care. Consists of minimum data set, triggers, resident assessment protocols, utilization guidelines

refractory pain

resistant to ordinary treatment

stress definition

response to changes in environment perceived as challenge, danger, threat in normal balanced state

RICE

rest, ice, compression, elevation due to injury

trauma to spinal cord results in?

results in complete bilateral loss of voluntary movement below level of trauma

peripheral vascular disease

results in decreased blood flow and oxygenation of tissue. skin of lower extremities is usually pale and cool, shiny with brown discolorations and hairless with thick toenails

what controls the cyclic nature of sleep

reticular activating system and bulbar syncronizing region and hypothalamus

how consciousness occurs after surgery

reversed: unconsciousness, response to touch and sounds, drowsiness, awake but not oriented, awake and oriented

clonus

rhythmic oscillations between flexion and extension

Preparation to Administer Medications

right drug, right reason, right dose and preparation

Pivot joint define? movements? example?

ringlike structure that turns on a pivot. Rotation. Example: radius and ulna

lifts or heaves

rise along border of sternum with each heartbeat. Abnormal

interventions to prevent falls

risk assessment, keep bed low, eliminate all physical hazards

cerebral motor cortex

role of controlling precise discrete movments. stroke or head trauma can damage this

abdominal assessment patient prep

room warm and patient's upper chest+legs draped, abdomen exposed just above the xiphoid process down to symphysis pubis, patient supine with arms down side, knees slightly bent, small pillow to relax abs, keep hands+stethoscope warm to help patient relax

mass shape types

round, ovoid, tubular, regular

ball-and-socket joint define? movements? example?

rounded head of one bone in cup cavity of other. Flexion, extension, abduction, adduction, rotation can occur. Example: shoulder and hip joints

Oral advantages and disadvantages

safe, inexpensive, easy and convenient. Highly variable absorption, inactivation can occur by GI tract of first pass effect, client must be conscious, contraindications include nausea and vomiting.

four domains for perioperative RN care

safety, physiologic responses, patient/family behavioral responses, health system(elements that must be present to support safe, effective, high-quality care)

general survey equipment

scales, sphygmomanometer, stethoscope to observe general appearance, hygiene, posture, gait, thought process, speech patterns, evaluate height and weight, take vital signs

oliguria

scanty amount of urine voided in given time, <400mL in 24 hrs

gerontology define

science and behavioral study of aging and its' consequences

excoriation

scratch of epidermis

montgomery's tubercles

sebaceous glands on areolae of breasts are normal

incidental disclosure of PHI definition

secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as byproduct of an otherwise permitted use or disclosure of PHI

Common preop meds: each group and drugs in each group and what they do?

sedatives-diazepam/Valium, benzodiazepines (Alprazolam aka Xanax, Lorazepam aka Ativan, Midazolam aka Versed) anticholinergics like atropine and glycopyrrolate/Robinul to decrease pulmonary/oral secretions narcotics-Opioids and meperidine/Demerol Neuroleptanalgesics like fentanyl/Innovar for calmess/sleep antacids(Famotidine aka Pepcid, Ranitidine aka Zantac, Omeprazole aka Prilosec), antiemetics(Ondansetron aka Zofran, Metoclopramide aka Reglan, Promethazine aka Phenergan),

HIPAA rights for patient

see copy of health record, update health record, get list of disclosure for purposes of treatment+payment+healthcare operations, request restriction of certain uses or disclosures, choose how to receive health info

nursing diagnoses provide the basis for? using both?

selecting nursing interventions that will achieve valued patient outcomes for the which the nurse is responsible using both nursing model and a body systems approach to organize assessment

effective coughing position? how to effectively cough?

semi-fowler, pillow to splint incision, inhale/exhale 3 times, take deep breath and hold for 3 seconds, hack out for three short breaths, take breath cough deeply once or twice, take another deep breath every 2 hours while awake

labyrinthine sense define? stimulated by?

sense of position and movement provided by inner ear that are stimulated by body movement and transmit impulses to cerebellum

Palpation purpose?

sense of touch to assess temp., turgor, texture, moisture, vibrations, shape

factors contributing to severe sensory alteration include

sensory overload, sensory deprivation, sleep deprivation, cultural care deprivation

2 cranial nerve motor or sensory? aka? controls?

sensory. Optic. Visual acuity/fields

1 cranial nerve motor or sensory? aka? controls?

sensory.Olfactory. Smell test each.

hazards of catheterization

sepsis and trauma

shower and baths

shower is preferred. Give stool/commode chair with no pan if needed. 110F-115F. Dont lock door

left lower quadrant contains

sigmoid colon, left ovary and fallopian tube, left ureter and lower kidney pole, left spermatic cord

examples of incidental disclosure of PHI

sign in sheets, possibility of confidential conversation with patient is overheard, placing patient charts outside exam rooms, use of white boards, x-ray light boards, calling out names in waiting room, leaving appointment reminder voicemail

techniques for assessing breasts in males

sitting or lying

what position for head and neck assessment

sitting position

sbar

situation, background, assessment, recommendation

breast assessment inspection check what?

size+symmetry, shape(convex/round, conical/narrow/pointed, pendulous), symmetrical venous pattern and consistency of skin color, absence of lesions/edema/erythema, round shape of areola, darker pigmented areola+nipple, direction of nipple, texture, lesions

plan of care to reduce pressure ulcers

skin care, pressure reduction, incontinence care, nutritional interventions, rehab to improve mobility, repositioning schedule every 2 hours(minimums to turn or shift that's individualized or heel relief), positioning, pressure reduction devices(beds, wheelchairs or chairs)

susceptibility of host depends on

skin/mucous membranes, pH levels, WBC #, age/sex/race/heredity, immunizations, level of fatigue, stress, use of invasive devices, nutrition, high blood sugar

Dyssomnias examples

sleep disorders characterized by insomnia or excess sleepiness. Insomnia, hypersonic, narcolepsy, sleep apnea, restless leg syndrome, sleep deprivation

SPICES for elderly define

sleep disorders, problems with eating/feeding, incontinence, confusion, evidence of falls, skin breakdown

factors contributing to bradycardia

sleep, men, thin people, hypothermia, aging, meds, physical fitness, changing position, chronic pain, hypothyroidism

somnambulism

sleepwalking

muscle tone define? assess by?

slight tension remaining at rest. Assess by flexing and extending and noting degree of resistance

cartilaginous joints movement? aka? define? example?

slightly moveable aka amphiarthrosis. No joint cavity, cartilage between bones. Example:pubic symphysis, joints between vertebrae

sinus bradycardia

slow SA node.

lozenge definition? aka?

small oval round or oblong prep containing a drug in a flavored or sweetened base which dissolves in mouth and releases med aka troche

petechiae definition? length? assess what?

small purpuric lesions up to 2mm across. small hemorrhagic spots caused by capillary bleeding. if present assess location, color, size

telangiectasia

small, dilated, red, bluish surface vessels may be part of a basal cell carcinoma or skin injury from radiation

mass surface types

smooth, nodular, granular

c. diff hand hygiene

soap + water

vesicular breath sounds? aka? during inspiration?

soft low pitched heard best over base of lungs aka lung periphery during inspiration longer than expiration

inversion

sole of foot inward

eversion

sole of foot outward

korotkoff sounds

sounds listed for when assessing BP via stethoscope. 1st sound is systolic pressure. 2nd thud softer than first=1st diastole. Last sound heard before nothing else heard=2nd diastolic.

nursing interventions communicate?

specific nursing care to be implemented for patient

Toxic effect definition? can occur from?

specific risks/groups of symptoms and manifestations of toxicity that carry risk for permanent damage or death. Can occur from cumulative effect(body can't metabolize+excrete a dose before another one is taken)

full stage of illness

specific signs/symptoms

clues to mood and mental health are provided by

speech, facial expressions, ability to relax, eye contact, behavior

some abnormal findings of assessment of gi tract

spleen enlargement and tenderness may mean infection or trauma. liver enlargement or tenderness may indicate cirrhosis or hepatitis. Palpable tender gallbladder may indicate cholecystitis. Fluid in abdomen may indicate ascites.

hinge joint define? movements? example?

spool-like surface of one bone fits into concave surface of another. Flexion and extension occurs. Example: elbow, knee, ankle joints

trigeminal neuralgia

stabs of pain in trigeminal V cranial nerve

Post op nursing care: stages? define each stage?

stages:Immediate postoperative care: think ABC's! every 10-15 minutes for 1 hour in PACU ongoing care Emphasis on continuous assessment and prevention of complications -Respiratory status -Cardiovascular status -CNS status -Fluid status -Pain management -Wound management -General condition -ASEPSIS!!!

romberg test definition? positive romberg means?

stand with feet together and eyes closed. positive romberg is seen with vestibular or propioreceptor disorders

hep c precautions

standard- gloves

HIV precautions

standard-gloves, goggles for splashing

pneumonia precautions

standard-gloves, handwashing, mask if secretions. Droplet.

glasgow coma scale define? parameters evaluated?

standardized assessment tool that assesses LOC. Parameters evaluated: eye opening, motor response, verbal response. Higher scores indicate more normal level of functioning. Score of 7 or less defines coma. Can go up to 15

why nurse needs to know nurse practice act

state laws are all different. different SOP per state

health define

state of complete physical, mental, social well being

Health definition? Includes? What kind of data?

state of optimal functioning/well-being. includes physical, social, mental components. Subjective.

tonus define? complete bed rest can?

state of slight contraction, usual state of skeletal muscles. Complete bed rest can cause losing tonus

external standards of care definition?

state practice act, professional organizations(ANA/NLN), specialty organizations(ONS/CCRN), Federal (OSHA, HIPAA)

OPQRST additional info

statement of general health, course since onset, effects on activity, associated signs and symptoms, what does patient think is going on, is anyone else having similar symptoms

Nursing Home Reform Act states?

states nursing home resident has right to be free from physical or chemical restraints for purpose of convenience/discipline

surgical asepsis definition? examples?

sterile technique, includes practices used to render/keep objects/areas free from microbes. Ex. inserting catheter, dressing changes, injections

barrier technique includes?

sterilization, decontamination, disposing of waste

adaptation

stimulus must be variable or irregular to evoke response

elderly decreased GI motility, increased gastric pH for drugs

stomach irritation, nausea, vomiting, ulceration

left upper quadrant contains

stomach, spleen, left kidney, adrenal gland, splenic flexure of colon, body of pancreas

extension

straight line

pulse strength/amplitude strength should be? grade? scale #'s?

strength of impulse should be same beat to beat. Graded on scale 0-4. 0=absent, 1+=diminished, 2+=brisk/expected, 3+increased, 4+full volume/bounding

halitosis

strong mouth odor or persistent bad taste in mouth, first sign of periodontal disease

NSNA

students in nursing. national student nurses' association.

aspiration procedures? ex?

studies which a needle or instrument inserted into organ or cavity. Fluid or tissue is aspirated, prepared, labeled, sent to lab for exam. Ex: liver biopsy, lumbar puncture, paracentesis, thoracentesis

to be measurable outcomes must have

subject, verb, conditions, performance criteria, target time

Lung + airway+thorax assessment

subjective+ objective. inspection, palpation, percussion, auscultation

neurotranmitters definition? ones that cause pain?

substances that excite or inhibit nerve cells. Cause pain: histamine, lactic acid, bradykinin, prostaglandins, substance P, serotonin

Person harmed by tort can? for?

sue for compensation for past and future noneconomic(pain) and economic(medical bills) damages

supination

supine position aka lying on back or palm facing upward

breast circular guidelines

supine, start at tail of spence and move in smaller circles, use pads of 1st three finders to gently compress breast tissue against chest wall

trochanter rolls

support hips and legs so femurs don't rotate outward

Saddle joint define? movement? example?

surfaces are convex on one side and concave on another. Side to side and back and forth. Example: trapezium and metacarpal of thumb

urinary diversion

surgical creation of alternate route for excretion of urine

postural tonus definition? depends on?

sustained contraction of skeletal muscles that keep body in upright position against force of gravity and depends on labyrinthine sense, propioreceptor/kinesthetic sense, visual/optic reflex, extensor/stretch reflex

edema causes what to skin? results from?

swelling, taut, shiny skin. results from: overhydration, heart failure, kidney failure, trauma, peripheral vascular disease

colitis define

swelling/inflammation of large intestine

bilateral body parts are normally

symmetric meaning same size, shape,, characteristics

head and face inspect for?

symmetry/drooping, position/alignment, lesions, redness, edema, drainage, inspect/palpate scalp/hair, facial expression

diarthroses aka? define? example?

synovial joints are freely moving cavity with synovial fluid. Example: ball-and-socket joint, condyloid joint, gliding joint, hinge joint, pivot joint, saddle joint

non-invasive procedures usually

take precedence over invasive procedures

avulsion

tearing a structure from normal anatomic position, possible damage to blood vessels, nerves, and other structures

laceration

tearing of skin and tissue with blunt or irregular instrument, tissue not aligned often with loose flaps of skin and tissue

name each vital sign

temp, pulse, RR, BP, pain

hearing test without a tuning fork

test each ear with sound of watch/fingers rubbing together. whisper 1-2 behind patient and ask what was said

if client has abdominal pain that you suspect is due to inflammation?

test for rebound tenderness

most of restraint use is in

the ICU to prevent disruption of therapies and elderly with dementia

Half life is? monitoring these levels ensures?

the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body. Monitoring these levels ensures that therapeutic ranges are obtained without reaching toxic levels.

Nutritional state may affect? many drugs bind with? lowered protein levels mean? leading to?

the body's reaction to certain drugs. Many drugs bind with proteins in plasma. Lowered protein levels means less drug bound to plasma proteins leading to higher concentration of free drug in the body leading to increased risk for adverse effects

applying standards to plan nursing care

the law, national practice standards(ANA), speciality professional organizations, joint commission, agency for health care research and quality(AHRQ), employer

Three systems of measurement can be used for medication administration:

the metric system, apothecary system, and the household system

The therapeutic range of a medication occurs between? definition?

the minimum effective concentration and the toxic concentration. Concentration of drug in the blood serum that produces the desired effect without causing blood serum that makes the desired effect without causing toxicity.

Religious restricts and beliefs or cultural practices may affect what in relation to drugs? healthcare providers need? Examples?

the patient's acceptance of, response to, and compliance with certain drug therapies. Healthcare providers need an understanding of patient's cultural values, beliefs, and practices to provide culturally acceptable care. Ex from book Christian Scientist place their faith in spiritual healing and do not take medications, no childhood vaccinations. Herbal treatments may interfere with or counteract the action of prescribed medication.

ANA scope and standards of nursing practice is?

the protection, promotion, optimization of health and abilities, prevention of illness/injury, alleviation of suffering through the diagnosis/treatment of human response, and advocacy in care of individuals

Psychological patient's expectations may affect? study showed?

the reponse to medication. Study showed placebo worked as well as active drug.

Nutrition is

the study of how well food nourishes the body

peripheral vascular assessment nails

thick nails indicate poor nutrition, clubbing may indicate chronic low o2 saturation

lichenification define? ex?

thickened and roughened epidermis, with increased visibility of skin furrows Ex:atrophic dermatitis

scale define? ex?

thin flake of exfoliated derms Ex: dandruff, dry skin

atrophy signs? cause?

thinning of skin, loss of skin furrows, shiny appearance. peripheral vascular disease

5 ml syringe: used when? calibrated?

this syringe is usually used when fluid amounts greater than 2 1/2 ml are to be given. This syringe is calibrated in two-tenths (0.2ml).

general adaptation syndrome steps

threat> ^HR, BP, peripheral vasoconstriction, metabolism, water retention, and glucose, dilated pupils bronchi, mental alertness>fight or flight> stage of resistance via neuroendocrine activity returning to normal, LAS, coping and defense>recovery and if no recovery>stage of exhaustion>vasodilation, lowered BP, ^ pulse and respirations, panic resulting in either rest+recovery or death

hyperthyroidism define? can do what? what does it cause?

thyroid gland produces too much of the hormone thyroxine. Hyperthyroidism can accelerate your body's metabolism significantly, causing sudden weight loss, a rapid or irregular heartbeat, sweating, and nervousness or irritability.

thyroid hormones examples

thyroid hormones and calcitonin

individuals with impaired awareness first lose

time orientation, followed by place orientation, then person orientation

assessing level of awareness

time(what's today's date? what day of week? what season? what was last holiday), place(where are you, what is name of city, what state), person(name? age? who came to visit this morning?)

regular bowel habits can be promoted in well and ill patients by attention to

timing, positioning, privacy, nutrition, exercise

Nurse practice act of GA

title 43 ch. 26 article 1

standards allow nurses

to carry out professional roles, serving as protection for the nurse, patient, instituition

more significant function of kidneys is

to help maintain composition and volume of body fluids. every 30 minutes body's total blood volume passes through for waste removal. filters and excretes blood constituents that aren't needed while retaining those that are

babinski

toes bend or curl, lateral aspect of sole of foot is stroked from heel to ball of foot

pain process stages

transduction, transmission, perception, modulation of pain

delegation definition

transfer of responsibility while retaining accountability for outcome

indirect care nursing interventions definition? includes? actions do what?

treatment performed away from the patient but on behalf of patient/group. include nursing actions aimed at management of the patient care environment and interdisciplinary collaboration. Actions support effectiveness of direct care interventions

direct care nursing intervention definition? includes?

treatment performed through interaction w/ patients. includes physiological and psychological nursing actions and includes laying of hands actions and those that are more supportive and counseling in nature

special surgery positions

trendelenburg position(head angles down to raising BP and lowers venous return) and lithotomy position(pooling of blood in legs and lower BP)

when to do ROM exercises

twice a day, each exercise 2-5 times

dynorphin

type of endorphin has the most potent analgesic effect

The choice of what needle to use depends on

type of injection being given, the viscosity of the fluid, body size, and type of medication

dietary habbits that affect sleep

typtophan from protein makes one tired, but studies have shown protein can actually aid alertness and now suggest carbs

cheilosis

ulceration of lips and caused by vitamin b deficiencies

infant/child abdominal variations

umbilical cord dries and falls off within first few weeks. pot belly <5years. Visible peristaltic waves. Easily palpated liver and spleen

Belongingness and Affection/love Needs of Maslow (3rd level) define?examples? interventions?

understanding and acceptance of others in giving and receiving love and feeling of belonging Affectionate relationships -Identification with groups (family, church, work, gangs) Companionship -The need for love includes both giving and receiving mutually -If not met patients feel alone, alienated, estranged, distant. -Interventions: include friends/family, est. RN-patient relationship, refer to support groups

sentinel event

unexpected occurrence involving death/serious physical or psychological injury or risk thereof

young adult top leading cause of deaths

unintentional injury

when to write progress note

upon admission+transfer to another unit+discharge, when procedure is performed, receiving patient pre/post-procedure, upon communicating with physicians regarding critical patient info, for any change in patient status

black stool indicates

upper GI bleeding such as from peptic ulcer, due to reaction between hemoglobin and gastric acid. possibly due to meds or foods

midline of quadrants contains

urinary bladder, urethra

sexual dysfunction related to

urinary incontinence, urinary diversion

enuresis

urinating during sleep

process of emptying bladder is called

urination, micturition, voiding

urinary retention occurs when

urine is made normally but not excreted from bladder. causes:meds, enlarged prostate, vaginal prolapse

lateral transfer to and from bed to stretcher <200 pounds patient partially able/not able

use friction reducing device

rinne test -don't know

used to compare bone and air conduction of sound(usually greater than bone-conducted sound). If hearing loss conductive sound of bone conduction will be same or greater than air conduction. 2n's and 2 steps-activate tuning fork and place behind ear on occipital bone process/against mastoid process tell when sound can no longer be heard, then place still vibrating fork to external/front ear and ask if they can hear sound in air(normally they will). Normal=air conduction(AC)>Bone conduction(BC)

stertorous breathing

used to refer to noisy strenuous respirations

define ventilation scan

used to see how well air and blood flow moves through lungs

percussing abdomen useful in? percuss? sounds?

useful in assessing full bladder or changes in ab contents. Percuss in all 4 quadrants in clockwise manner. Tympany(dominant percussive tone)+resonant sounds heard over abdomen since hollow while dullness over liver and full bladder

visible pulsations for neck and precordium

usually absent except apical impulse

topical route locations? usually for?

vaginal, rectal, inunction(into skin), instillation(mucous membrane), irrigation(mucous membrane), skin application(transdermal patch). Usually for direct action at site but some can have systemic effects

incidence report aka? definition?

variance or occurrence. Documents occurrence of anything out of ordinary that results in or has potential to harm patient/employee/visitor

biot's definition? causes?

varying in depth+ rate of breathing, followed by periods of apnea. irregular, meningitis, severe brain damage

respiration includes? regulated by? responsible for? rate=?

ventilation, diffusion, and perfusion. Regulated by ANS/voluntary control. Responsible for evaluating effectiveness of ventilar process of O2/CO2 exchange. Rate= full inspirations/expirations in 1 min.

adults IM site

ventrogluteal or deltoid

palpation types of breast assessment

vertical strip, circular, wedge of breast or nipple

grading of reflexes - +4

very brisk, hyperactive, often indicative of disease, often associated with clonus

circumscribed superficial skin elevations formed by free fluid in a cavity within skin layers ex? type?

vesicle, bulla, pustule. Type: primary lesion

meds for injection package

vial, ampule, pre-filled cartridge, pre-filled syringe

fremitus

vibrations

name senses

vison, auditory, olfactory, gustatory(taste), tactile, stereognosis(solidity,shape, texture,size), kinesthesia(awareness of positioning of body), visceral(inner organs), proprioception(subconscious sense of movement and position of body limbs)

consciousness is the degree of

wakefulness or ability to be aroused, patient may be conscious but not oriented

cleaning equipment

waterproof gloves, rinse w/ cold water, wash with warn water w/ soap, brush, rinse, dry, prepare for sterilization/disinfection, clean brush/gloves/sink

accreditation

way an EDU program is evaluated and recognized as having met certain standards. (state board NCLEX-mandatory. NLN(NLNAC)/ANCC-voluntary).

credentialing definition and examples?

ways a professional competence is assured. Accreditation(state board NCLEX-mandatory. NLN/ANCC-voluntary).Licensure(state).Certification (voluntary).

hemiparesis

weakness of one half of body

expert witness

what happened based on patient's record to offer opinion

health belief model define?

what people perceive to be true about themselves in relation to health based on perceived susceptibility, seriousness of disease, and benefits of action

Peak highest plasma concentration measured when

when absorption is complete, may be affected by absorption and route

extensor or stretch reflexes

when extensor muscles are stretched beyond point stimulation causes reflex contraction aiding to reestablish erect posture

referred pain define? Example?

when it originated in one part of body but perceived in distant area from point of origin. Ex: heart attack felt in neck, shoulder, arms

intractable

when pain resistant to therapy and persists despite interventions

discharge summary

when patient discharged or transferred to another unit. Summarizes reason for treatment, significant findings, procedures performed and treatment, patient condition, any pertinent instructions given to patient/family

logrolling use for? how many nurses?

when patient has spinal injury or is recovering from neck, back, or spinal surgery. 2-3 nurses.

when to use standard precautions

when to use standard precatuions

vitiligo

whitish patchy areas caused by depigmentation

stertorous respirations, stridor, wheezes can be heard

without amplication, crackles and pleural friction rubs heard only by stethoscope

wedge breast guidelines

work in clockwise direction and palpate from periphery toward areola, use pads of 1st three fingers to gently compress breast tissue against the chest wall

evisceration

wound completely separates with protrusion of viscera through incision. Disemboweled, opening of incision allowing organs to come out

older skin variations

wrinkles, dryness, scaling, decreased turgor, raised dark areas(senile keratosis), flat brown age spots(senile lentigines), small round red spots(cherry angioma), fine brittle gray or white hair, hair loss, coarse facial hair in women, decreased body hair in men and women, thick &yellow toenails

NANDA nursing diagnosis statement

written as 2 part listing problem and its cause(etiology) or 3 part that includes also the problem's defining characteristics

protocols definition

written plan specifying procedures to be followed during care of client w/ a select clinical condition/situation.

protocols definition? includes?

written plans that detail nursing activities to be executed in specific situations. Includes RN responsibilities when patient is admitted or discharges and standing orders

jaundice

yellow color resulting from liver and gallbladder disease causing increased bilirubin, anemia, excess hemolysis. For darker colored people can be observed on sclera, oral mucous membranes, palms, soles

oucher scale

young children who can point to face to indicate pain