Final exam study guide

CLEAN TEAM

Anesthesiologist Circulating RN -coordinates all activities in OR -client advocate who monitors sterile field -maintain environment -communicate with people outside OR respond to emergencies Biomedical Techs Radiology Techs team NEVER ENTERs STERILE FIELD--work around it

cardiac assessment

Anxiety level pain: location, duration, frequency, and radiation --at rest or activity? --pain typically lasts several minutes;may come/go MI Radiation-usually to left shoulder- down left arm up to left jaw fatigue -- 0-10 scale dyspnea peripheral circulation -Palpate peripheral pulses, assess skin color and temperature, and note the distribution of hair on the extremities

Horizontal/lateral workplace violence

Any physical assault, threatening behavior, or verbal abuse occurring in the work setting code 0--no tolerance

auscultating the heart: Aunt Polly Takes Meds

Aortic Pulmonic Tricuspid Mitral

occurrence report

-unusual occurrence or accident -Not a part of client's health record -Quality improvement

How to prevent norovirus

-wash hands frequently ◦ wearing gloves when working with food ◦ clean/disinfect surfaces and equipment ◦ no prep by ill ◦ wash fruits and vegetables thoroughly ◦ cook thoroughly ◦ wash clothes/table linens thoroughly

Edema Rating:

0 = No edema+1 = (minimal) to+4 = (deep depression lasting 2-3 minutes) "Pitting"

Strategies to enhance communication

1) Install and use blinking lights that alert an incoming call, doorbell ring, alarm Clock, and smoke detectors For patients with auditory deficits. 2) Encourage patients to wear a hearing aid if applicable. 3) American sign language. 4) Writing communication on paper or board.

NREM stages

1-3 NREM- • Non-Rapid Eye Movement • The Restful stages of sleep • Progresses 4 th REM- • Rapid Eye Movement • Brain is highly active • Needed for Mental and Cognitive Restoration • Dreaming

three checks

1. BEFORE you pour, mix, or draw up a medication, check its label against the entry on the MAR. Be sure that the name, route, dose, and time match the MAR entry. 2. AFTER you prepare the medication, and before returning the container to the medication cart or discarding anything, check the label against the MAR entry again 3. At the bedside check the label against the MAR entry again

What to do with S/S of hypoglycemia

1. CHECK & ASSESS S/S CHECK the BG right away! 2. TREAT by eating or drinking something high in sugar, such as: 15 Gm of a carbohydrate for example~ • 4 oz (1/2 cup) of regular fruit juice like orange, apple OR • 5-6 hard candies that can be chewed quickly (such as mints/Lifesavers) or 1 TBSP Sugar OR • 3 Glucose tablets or Gel: if unable to drink 3. WAIT, EVALUATE & DOCUMENT Wait15 minutes and then check the BG again!

What to do with S/S of hyperglycemia

1. CHECK & ASSESS S/S CHECK the BG right away! CHECK the urine for ketones 2. CHECK Dr. order for insulin 3. TREAT 4. WAIT, EVALUATE & DOCUMENT Wait 15 minutes and check BG again

Non-therapeutic Communication skills

Asking personal questions Giving personal opinions Changing the subject Automatic responses False Reassurance Sympathy Asking for Explanations Approval or Disapproval- Defensive Responses Passive or Aggressive Responses-

Antiplatelets

Aspirin Clopidogrel

Nurse Pre-Op responsibilities

Assess NPO status-usually NO meds are taken by pt pre-op--reduce risk of vomiting/aspiration Prepare skin: surgical scrub wipes Bowel Preparation (if ordered) Facilitate an empty bladder-have pt void Administer pre-op medications-on-call meds-pt void right before Apply anti-embolism stockings (TEDS) -May also use sequential compression devices (i.e. venodynes-elastic socks or compression devices that decrease risk of DVT SURGICAL CONSENT FORM health hx patient understanding of surgery and outcomes answer any questions--if pt has many questions--postpone surgery for patient-surgeon talk brief physical exam -focused per any RECENT health issues--ex. if had a recent cough- focus on respiratory assessment

Proliferation Phase- Granulation

1. New capillaries are forming from other capillaries 2. Connective tissue/collagen is growing: 'filling in & strengthens' 3. Granulation starts: Granulosis: "red/grainy/bleeds easily" look; a progression toward healing 4. More filling in (the scab protects all of this/ all happens underneath!) 5. Growth continues until all the cells meet and fill in

what to do if a med error occurs

1. assess vital signs and physical status 2. Report to provider 3. Notify the manager--follow policy

SENC competencies

1. goal-directed client-centered care 2. interpersonal collaboration 3. validate evidence-based research 4. provide safe quality care 5. embrace tech advances

VAD-choose the type of access on the basis of

1. patient's condition 2. type of fluid 3. length of treatment

Hepatic Portal Circulation

1. products of digestion are absorbed into capillaries within the villi of small intestine 2. digested food molecules travel through hepatic portal veins to liver 3. liver monitors blood contents 4. hepatic veins deliver blood to the circulatory system

PN solutions

10% to 70% concentration of dextrose in water w/amino acids provide 20 to 30 kcal per kg/day should be administered in a large, high-flow vein through a central venous access catheter, i.e., subclavian vein

normal respiration rate

12-20 tachy= > 24 brady = < 10

HHS recommendations for exercise

150 minutes per week of moderate exercise or 75 minutes of vigorous exercise

characteristics of Young adult

19-40 Healthiest stage of life Leaves home and explores options Begins to function as an independent person transition to independence and responsibility. Explore careers and intimate relationships.

Adapting to a bowel diversion

1st STEP: Adjusting to presence of ostomy - acceptance - self care - Diet changes d/t no longer controlling their sphincter... • Foods to avoid that may cause gas, that may control gas, high-fiber that may cause blockage, that cause loose stools, foods that alleviate diarrhea (BRAT) Life-long care of stoma and appliances

change position every

2 hrs

Cardiac arrest may occur when serum K levels fall below?

2.5

NIOSH limit for safe patient handling tasks

35lbs

Protein & carbs = ______ kcal/g

4

characteristics of middle adult

41 to 64 Andropause Menopause self-evaluation redefine role empty nest-- needs of children decrease needs of parents develop chronic health problems emerge most common cancer obesity diabetes hypertension cardiovascular disease.

Dash diet: based on 2000 calorie/day

6-8 servings/day of grain 4-5 servings/day of veggies 4-5 servings/day of fruit 2-3 servings/day low fat/nonfat dairy 2-3 servings/day fats/oils 6 or fewer servings of meat/poultry/fish 4-5 servings/week nuts/legumes/seeds

Glycosylated Hemoglobin (A1C)

6.4% and higher is a diagnosis for diabetes goal is less than 7% for someone with diabetes glucose attaches to hemoglobin on RBC...lifespan of RBC 120 days what the BG level has been in the past 120 days

Fat = _____ kcal/g

9

cardiac glycoside: digoxin

: Monitor AP for one full minute before administering Hold the dose if the pulse is less than 60 bpm toxicity sign Altered vision gold halo around objects levels should be 0.5-2 ng

fat soluble vitamins stored in liver

A D E K

malignant hyperthermia

A rare often fatal metabolic condition that occurs during use of muscle relaxers. metabolism increases in skeletal muscles--body temp rises rapidly often ask pt before sx about family hx with condition b/c it is hereditary

Dehiscence

A separation of layers, usually of a surgical incision

Sexual Health

A state of physical, emotional, mental & social well being r/t sexuality People who are sexually healthy have a POSITIVE and RESPECTFUL approach to sexuality and sexual relationships, that are pleasurable and safe, AND free of coercion, discrimination and violence. • People are sexual beings from birth to death. • Baby Boomers changing the way we view sexuality in the older adult. • Sexuality involves love, warmth, sharing and touching, not just the act of intercourse. • The physical need for touch and warmth DOES NOT DECLINE with aging. • Sexual preferences are as diverse as in younger adults! Changes in reproductive structures and function do not affect libido.

ADPIE

Assessment Diagnosis/analysis Planning Implementation Evaluating

bathing (ok to delegate)

Assist bath Bathe areas hard to reach Complete bath wash the patient's entire body without assistance from the patient partial bath Bathe only those areas absolutely necessary, including perineum Bag or packaged bath bag with supplies and cloths add warm water and give to patient

myelinated fibers with large-diameter transmit impulses at 6-32 m/stransmit fast impulses from acute, focused mechanical and thermal stimuli.

A-delta

differences between ACEN and the BORN

ACEN voluntary access quality & effectiveness cannot close program vs BORN mandatory can effect licensure/close a program visits every 8 years

benign prostatic hypertrophy (BPH)

AKA enlarged prostate common with men, incidents increases with age Enlargement of the glands surrounding the urethra leads to discomfort, difficulty in initiating a stream, feeling of bloating, increased incidents of cystitis.

Subjective/objective symptoms of Diarrhea

Abdominal pain & tenderness Loss of appetite Feeling rectal pressure Fatigue / headache/ indigestion objective symptoms Abdominal distension Blood in stool Decrease frequency of stools Decreased volume of stools Hard formed stools Hypo - or hyperactive BS

indirect visualization

Abdominal x-ray (AP - anterior/posterior) visualizes gallstones or fecal impaction Abdominal ultrasound

Perception

Ability to interpret sensory impulses Ability to give meaning to impulses •occurs when the person becomes aware of the stimulus and receives the information. It would not be possible to process all the stimuli that constantly bombard us. The brain discards about 99% of all sensory information as irrelevant and unimportant.

ADME

Absorption Distribution Metabolism Elimination

Intraoperative Phase: Outcomes

BE FREE FROM INJURY REMAIN PHYSIOLOGICALLY STABLE EXPERIENCE OPTIMAL SURGICAL OUTCOMES Maintains body temperature within the normal range Has clear lung sounds and patent airway Has urine output of at least 30mL/hr Will have no skin, tissue, or neuromuscular injury as a result of positioning Will not acquire healthcare-related infection

BG levels ac & pc

BG levels are lower ac and higher pc.

potassium-rich foods

Bananas Oranges Apricots Figs Dates Carrots Tomatoes Spinach Dairy products Meats

BALI

Be aware of your own cultural heritage Appreciate the client is unique. Learn about the client's cultural group. Incorporate the client's cultural values/behaviors into the care plan.

postoperative phase

Begins when the patient enters the postanesthesia care unit (PACU) ends when they have healed from the surgical procedure

Irregular respirations of variable depth (usually shallow), alternating with periods of apnea describes what type of breathing

Biot's breathing

Body Mechanics

Body Alignment "Posture" Balance Coordination Joint Mobility

Components of Self Concept

Body image Mental image of your physical self appearance size body structure/function Role performance The actions a person takes and the behaviors he demonstrates in fulfilling a role. Personal identity Your view of yourself as a unique human being different and separate from all. Self-esteem How well a person likes one's self difference between ideal self and actual self.

water soluble vitamins

C B complex

smaller unmyelinated fibers transmit slow pain impulses conduct pain from mechanical, thermal, and chemical stimuli. transmit dull diffused impulses @ slow rate

C fibers

changes in older adult cardiac system

CO and HR decreases heart rate doesn't increase in response to exercise as it did in youth

Cephalosporins

Capable of bactericidal action against gram positive or negative bacteria Classified in 'Generations' (1st to 4th) *Do not give if allergic to Penicillin ALL DO NOT WORK against MRSA

dietary changes for older adult

Carbs and Fiber- 45- 65%/130 grams/same as middle Fats- 20-35%--decreased Proteins- 10-35% Vit D and Vit b 12 is increased d/t malabsorption Minerals: Calcium 50+ and men 70+ --1200mg

The Joint Commission

Accredits hospitals and healthcare facilities Need to meet pt needs even if care must be denied in institution (if the hospital does not do procedure, one should be found for pt and ensure care is arranged)

Prevention interventions are used in

Actual nursing diagnoses--keep problem from becoming worse Potential nursing diagnoses--•remove/reduce risk to keep problem from developing. Collaborative problems--implement nsg orders/med Rx's to prevent development of complication Wellness diagnoses--assess wellness practices

Biggest Hurdle for the Older Adult is

Adjusting to Change

_______________ analgesics? reduce amount of opioid required Anticonvulsants, antidepressants, local anesthetics, topical agents, psychostimulants, muscle relaxants, neuroleptics, corticosteroids, and others Mild pain Neuropathic pain With opioids for moderate/severe pain

Adjuvant

dysrhythmias

All dysrhythmias can lead to decreased output decreased output can lead to hypoxia hypotension

Ace inhibitors

"PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. Blocks ACE in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) Orthostatic Hypotension adverse: nonproductive cough increase HR Output Contraction MONITOR SODIUM POTASSIUM

asking for Explanations--

"Why" questions can cause resentment, insecurity and mistrust. It's best to phrase a question to avoid using the word "why". use "You seem upset. What's on your mind?"

Safety (Hierarchy of Needs)

#1 physiological--basic needs/food/water/warmth #2 safety #3 belongingness and love #4 esteem #5 self actualization

Doffing (OFF): (Before exiting the room)

* Gloves * Gown * Goggles * Mask/Face Shield

DONNING: (Before entering room)

* Gown * Mask * Goggles/Face shield * Gloves

diarrhea

- Caused by contaminated food, viral infection, diet change, or side effect of medication and is the abnormal increased frequent and fluidity of feces - Leads to fluid and electrolyte imbalances: top nursing priority is dehydration

Sources of ethical problems for nurses:

- Consumer awareness - Technical advances - Multicultural populations -Cost containment -Nature of the work and profession

Hyponatremia

- Serum Na+ less than 135mEq/L - Results from excess of water or loss of Na+ - Water shifts from ECF into cells symptoms abd cramps confusion pitting edema causes •Diuretics •GI fluid loss •Adrenal insufficiency •Excessive intake of hypotonic solutions, such as water or D5W IV fluids •Syndrome of inappropriate ADH interventions Diet IV therapy fluid restrictions

Hepatitis E virus

- inflammation of liver - transmitted through fecal and oral routs -waterborne disease - seen in people traveling to developing countries Symptoms Jaundice Anorexia enlarged liver abdominal pain nausea and vomiting fever occurs 2 to 8 weeks after exposure to the virus

HCO3

- normal range 22-26 mEq/L Function primary buffer in the body Levels rise and fall to maintain pH regulation Lost through diarrhea, diuretics, renal insufficiency Excess possible if person ingests quantities of acid neutralizers--aspirin--sodium bicarbonates source Present in acid neutralizers (e.g., sodium bicarbonate). Not consumed in the diet produced by the body to meet current needs

Dehiscence: postop

-A "pop" or tearing sensation (especially with sudden straining), immediate increase in serosanguineous drainage -Provide adequate nutrition, use binders to support the incision, have client avoid straining, monitor for infection

handoff report includes

-Client demographics and diagnoses -Relevant medical history -Significant assessment findings -Treatments (e.g., wound care, breathing treatments) -Upcoming diagnostics or procedures -Restrictions (e.g., diet, activity, isolation) -Plan of care for the client -Concerns -Use IPASS, SBAR, PACE - keep it CUBAN

health-illness continuum

-Conceptualizes a person's level of health -Views health as a constantly changing state with high-level wellness and death on opposite sides of a continuum -Illustrates the dynamic (ever-changing) state of health

sublingual nitrates

-Have patient sit or lie down. -While waiting for emergency care, take 1 tablet 5 minutes later, if unrelieved in 5 minutes, take another tablet repeat maximum of 3 times 5 mins apart

factors influencing flow rate w/gravity

-Height of solution container -Pt position/bending arm/hand -BP-more force is required to force fluid in vein w/ higher pressure -Gauge of IV/cath -Condition of cath/tubing

Important organizations

American Nurses Association- promotes the interest of the nursing profession and to update its standards. National League for Nursing-establish and maintain a universal standard of education. International Council of Nursing-aims to ensure quality nursing care for all. National Student Nurses Association-organization that represents nursing students in the US. Sigma Theta Tau International- honor society for nursing.

perception is affected by

-Location of the receptors and pathway activated. -Number of receptors activated. -Frequency of action potentials generated (which varies according to the intensity of the stimulus). -Changes in location, number, and frequency

purpose of the code of ethics

-PROFESSIONAL guidelines for ethical decision making -Inform the public about the minimum standards. -Demonstrate nsg commitment to the public it serves. -Outline major ethical considerations of nursing. -Provide general guidelines for professional behavior. -Guide the profession's self-regulating function

One part statement

-Problem only -Syndrome Diagnosis--a label that represents a collection of several nursing diagnoses. Ex. Disuse syndrome. Wellness Diagnosis--it does not describe a problem so no etiology is needed. Ex. Readiness for enhanced breastfeeding -Specific labels where "r/t" statement becomes redundant (Latex Allergic reaction r/t sensitivity to latex)

Promoting Regular Defecation

-Provide privacy -Correct position-seated upright -Timing-Often occurs after meals/Some clients may need assistance -Encourage fluids -Proper diet-Fresh fruits, vegetables, whole grains, fiber -Encourage exercise/3-5xs a week/ROM if on bed rest -Manage flatulence -Educate on when to seek medical advice--w/sudden change

ARBs

-SARTANS Block BP from increasing by blocking vasoconstriction and the release of aldosterone Orthostatic hypotension

Urinary Incontinence

-Stress - leakage of urine w/ cough, laugh, sneeze. -Urge/overactive bladder-leakage of urine w/ urge to urinate, unable to make it to BR. -Mixed -combination of urge/stress. -Functional - unable to access BR due to poor mobility or distance usually can be fixed by making access to toilet/commode easy -Overflow- leakage of urine w/ a distended bladder. -Reflex- the loss of urine when the person does not realize the bladder is full and has no urge to void. (CNS disease)

gustation- sense of taste.

-Taste buds atrophy and decrease in number, so there is less ability to perceive tastes, especially sweetness. -Dry mouth may alter the sense of taste . Etiology Xerostomia- (excessive dry mouth) low fluid intake, poor nutrition, inadequate oral hygiene, the common cold, infections, tobacco use, Vitamin B12 or zinc deficiency, head injury, and chemical exposures. Hazards: nutritional deficits, weight loss.

discharge summary

-Time of departure and method of transportation -Name and relationship of person(s) accompanying client at discharge -Condition of client at discharge -Teaching conducted and handouts/informational matter provided to client -Discharge instructions (including medications, treatments, or activity)/Follow-up appointments or referrals given

Evisceration: postop

-Visible protrusion of organs through incision -*Same as dehiscence

Respiratory mechanisms

-When pH is too acidic, the lungs remove CO2 through rapid, deep breathing. -reduces the amount of CO2 available to make carbonic acid in the body -if pH is too alkaline, the lungs try to conserve carbon dioxide through shallow respirations

transfer report includes

-Your contact information -Client demographics, diagnoses, reason for transfer -Family contact information -Summary of care -Current status, including medications, treatments, and tubes in the client; when the next medication is due -Presence of wounds or open areas of the skin -Special directives, code status, preferred intensity of care, or isolation required -Always ask if the receiver has any questions.

Preoperative Medications

-antibiotics -anticholinergics-reduce respiratory secretions -antidiabetics -antiemetics -benzodiazepines -beta-blockers -histamine receptor antagonists -opioids Many are held the day of surgery and not administered to the patient

anticoagulants

-arin antidote Vitamin K wear medical alert bracelet

Hearing

-cerumen is drier and more solid creating hearing loss. -scarring occurs from previous inflammation over the years. -presbycusis ( hearing loss of high-frequency tones) and decreased speech discrimination etiology -injury or disease in the structure of the ear, the nerves, or brain. Infections of the ear, build-up of cerumen, aging, hereditary, and loud noises. Hazards: injury due to inability to hear warnings ex may not hear fire alarm can lead to depression, social isolation.

Kinesthesia

-changes include a decrease in muscle fibers and diminished conduction speed of nerve fibers, resulting in slowed reaction time, decreased speed and power of muscle contractions, and impaired balance. These put older adults at increased risk for falling. Etiology mismatch between the position or the acceleration of the head and the visual field. Neuro disorders-- Parkinson's disease, tumor, medications; Stroke; problems with the inner ear. Hazards: a pressure injury, contracture, injury from falls

Antidepressants

Amitriptyline

Antibiotics

-cycline tetracyclines -mycin Aminoglycosides -floxacin Fluoroquinolones -vir antiviral Monitor bowel function d/t risk for diarrhea C diff Pseudomembranous colitis

Passive Thermal Care

-give blankets/socks

stress causes the release of catecholamines from the sympathetic Nervous system which results in

-increased BP -increased contractility -vasoconstriction -increased blood clots

Beta Blockers -OLOS

-olols pre admin HR BP Beta blockers reduce BP and HR decrease heart rate/contraction block vasoconstriction increase flow to kidneys reduce the workload of the heart/control dysrhythmias/hypertension

the Food Pathway

-passes through the mouth into the oral cavity and exposed to chemicals in the saliva. -tongue forces the food into a bolus, into the pharynx, then swallowing occurs. -bolus enters the esophagus and is propelled by peristalsis to the stomach. -Mechanical and chemical digestion occur in the stomach reducing the food to semi-fluid mass that is sent to sm intestine, where most absorption of nutrients occurs -remaining material passes into large intestine and is excreted as fecal matter

Calcium channel blockers: -pines

-pines block the flow of calcium into cells of the heart and blood vessels decrease BP and strength of contraction slow HR/dilate the arteries and arterioles slow HR. decrease demand for oxygen and nutrients vasodilation prevention/tx angina pectoris some arrhythmias hypertension Grapefruit increases TOXICITY REMEMBER Verapamil & Diltiazem--don't end in -pine

three part statement

-problem, etiology, signs and symptoms -...diagnosis r/t etiology as evidenced by -cannot be used for risk diagnoses Example: Constipation related to inadequate intake of fluids and fiber-rich foods, as evidenced by painful hard stools and bowel movements every three to four days.

Active Prewarming

-provide warming mattresses in certain conditions

Gradual increase in depth of respirations, followed by a gradual decrease in depth, than a period of apnea describes what type of breathing?

Cheyne-Stokes respirations

Narcolepsy

Chronic brain ineffective in regulating sleep/wake cycle Uncontrollable episodes of sleep during the day

Fluroquinolone

Cipro/Levaquin- may cause tendon rupture/tendonitis not effective for MRSA

circulation & perfusion

Circulation flow of blood throughout heart and vessels perfusion way blood flows to capillary membranes and provides O2 to organs and tissues

enemas

Cleansing enemas Treat severe constipation or impaction. Clear in preparation procedures/surgeries Empty colon for bowel-training program HYPOTONIC (saline, tap water, and soap) large volume 500-1000 mL volume distends and leads to evacuation of stool Soap Suds Enema acts by irritating intestinal mucosa and promoting peristalsis CAREFUL with clients who have weak intestinal walls HYPERTONIC... ex: sodium phosphate (FLEET enema) smaller volume 90-120 mL... attracts water into colon and leads to distension, peristalsis, and defecation because it leads to retention of fluid and sodium this is contraindicated on clients who have renal failure and congestive heart failure Retention enemas meant to be retained for a prolonged period usually small vol-90 to 120 mL (3 to 4 oz). Oil-retention enemas 90 to 120 mL of oil into the rectum to soften stool and lubricate the rectum may be used to pass hard stool or before digital removal of stool. Carminative enema mixed solution magnesium sulfate, glycerin, water 60 to 180 mL (2 to 6 oz) to help expel flatus and relieve bloating/distention used after abdominal or pelvic surgery when peristalsis is slow to return and the client experiences pressure from gas. Medicated enemas instill antibiotics to treat infections in the rectum or anus or to introduce anthelminthic agents for treatment of intestinal worms and parasites. Nutritive enemas administer fluid and nutrition through the rectum for dehydrated/frail pts most commonly used in hospice to provide hydration Harris flush (return-flow enema) help pt expel flatus and relieve abdominal distention. For adults, approximately 100 to 200 mL (3 to 7 oz) of tap water or saline is instilled into the rectum. Osmotic laxative Add water to bowel which distends bowel -examples polyethylene glycol (MiraLax) lactulose magnesium citrate magnesium hydroxide (MOM) - adverse effects bloating gas upset stomach dizziness increased sweating -considerations Lactulose is a disaccharide and should be used carefully with diabetics, also is contraindicated in patients with appendicitis, acute surgical abdomen, fecal impaction or intestinal obstruction

Safety assessment

Client environment • Risk for Falls = Morse Fall Scale • Get Up & Go Test • Timed Up & Go Test Home safety • Checklist & Safety Assessment Scale Risk for violence • Factors that increase aggression & anxiety

Components of Prescription

Client's full name Date and time Name of medication Dosage size, frequency, number of doses Route of administration Printed name and signature of prescriber, relevant credentials NPI DEA #(if controlled)

Clinical reasoning vs Judgement

Clinical Reasoning-reflective, concurrent, creative thinking about patient care. Clinical Judgement-interpretative thinking about patient's needs or concerns.

Preoperative Screening Tests:

Complete Blood Count (CBC) Urinalysis if over 50-EKG

Advise pt. to contact healthcare professional if:

Complete inability to urinate Fever, vomiting, pain, chills Blood in the urine

Arousal

Composed of consciousness and alertness • Mediated by reticular activating system (RAS) located in the brainstem, controls consciousness and alertness neurons of the RAS make connections between the spinal cord, cerebellum, thalamus, and cerebral cortex, relaying visual, auditory, and other stimuli that help keep us awake, attentive, and observant. Without such stimuli, the CNS becomes lethargic, and the person may lose consciousness. Anesthesia, sedatives, opioids, and some other drugs depress the RAS, as does a darkened, quiet environment.

Surgical Consent Form

Confirm it is there Must be signed before the surgery Type of sx performed name and qualifications of surgeon risks/benefits of sx likelihood of achieving goals statement that pt has right to refuse/withdraw consent at anytime

Droplet precautions

Coughing sneezing touching contaminated objects Precautions • Same as those for contact • Add mask + eye protection • stay within 3 ft of client examples Influenza Mumps Haemophilus influenza B(Hib) Pertussis (whooping cough) Meningitis Pneumonia

cultural competent care

Cultural Awareness Cultural Sensitivity Culture Competence

Origins of pain

Cutaneous/superficial Visceral Deep somatic Radiating Referred Phantom Psychogenic

Maturation (Remodeling/Epitheliazation) Phase

Damaged tissue is replaced by scar tissue Continues even after wound has closed New cells look like old cells The scar is only 80% as strong as the original tissue! maybe 2 weeks-years

Elements of informatics

Data Information Knowledge Wisdom

Writing nursing orders

Date--change if revised Subject--written in terms of nurse behaviors Action verb-- tells nurse action --assist, assess, auscultate, bathe, change, demonstrate, explain, give, teach, and turn Times and limits--every hour between 0700 and 1900/9/15, day shift Signature--sign it

oliguria

Decreased urine output

Terminal evaluation

Describes health status/progress toward goals at discharge Most places have special discharge forms for terminal evaluation that also include instructions about medications, treatments, and follow-up care.

hypertension

Diagnosed when blood pressure is persistently higher than normal when taken on two or more occasions • Elevated: Systolic BP of 120 to 129 mm Hg and Diastolic BP of <80 mm Hg. • Hypertension, Stage 1: Systolic BP 130-139 mm Hg or Diastolic BP 80-89 mm Hg • Hypertension Stage 2: Systolic BP 140 mm Hg or greater or Diastolic BP 90 mm Hg or greater a major cause of illness and death in the United States increases the stress on the heart and blood vessels. untreated can lead to heart, renal, cerebral, or respiratory complications Severity is directly related to the degree of elevation Primary or essential--when there is no known cause 90% of all cases

Benzodiazepines

Diazepam/Lorazepam usually first line tx for insomnia daytime drowsiness/dizziness danger w/opioids/alcohol long term use can lead to dependency/withdrawal

State the Bristol CC Nursing Student Handbook policy on civility and incivility.

Disruptive behavior such as the following in unacceptable: engaging in side conversations during class, using a cell phone, using inappropriate language (cursing), threatening violence, engaging in physical or verbal abuse, or any other activity that would be considered inappropriate in the workplace. Civility and professional behavior also extend to the online environment and social media. Proper network etiquette, referred to as "netiquette," is also a required expectation. Proper netiquette includes respectful and thoughtful electronic communications. Creating a negative culture is also a violation of civility as it disrupts the teaching-learning environment. Gossip, rumors, slanderous and/or derogatory communication are not attributes of professionalism which is an essential nursing competency. It is expected that respectful lines of communication amongst students and faculty be used to resolve conflicts, to clarify, and to verify. Violations of civility may be referred to the Vice President of Student Services for appropriate disciplinary action or may result in dismissal from the course/program. The faculty reserve the right to dismiss students based upon violation of civility since any violation is considered evidence of failed professional competency.

Patient care partnership

Document published by the American hospital association and focuses on exceptions and responsibilities Be aware of treating patients ethically and protect rights

venus abnormalities s/s

Edema brown skin discoloration tissue dysfunction (e.g., stasis ulcers) PVI Narrowed vein deoxygenated blood can't get back to heart/lungs to get O2 blood pools NO O2 problem--arteries are fine Voluptuous pulses Edema Irregular shaped sores No sharp pain Yellow and brown ankles Promote return & clot/DVT elevate legs do not sit do not cross legs early and frequent ambulation -muscles contract and push blood return ROM exercises antiembolism stockings sequential compression devices

atrioventricular (AV) node

Electrical activity from SA node passes through __________ node into the left and right bundles of HIS and into Purkinje fibers to make the ventricles contract. if sa node defective AV picks up job at 40-60bpm

naturally occurring analgesic neurotransmitters that inhibit the transmission of pain impulses.

Endogenous opioids

Vision changes with aging

Everything decreases -the vitreous humor becomes thinner and floaters appear in the visual field . - the lens becomes less flexible less able to focus on near objects. - the ciliary body contracts and the lens thickens bringing loss of visual acuity, decreased ability to accommodate to distance and sudden changes in illumination, and decreased night vision. - Peripheral vision decreases

Strongest risk factor for obstructive sleep apnea (OSA)

Excessive body weight

#1 cause Nonfatal accidents

Falls

Korotkoff's Sounds - 5 Sounds

First sound • As you deflate the cuff, a sound that occurs during systole (systolic BP). It is a tapping sound that corresponds to a palpable pulse. • As you further deflate the cuff, a soft swishing sound caused by blood turbulence Fifth sound • Silence, corresponding with diastole (diastolic blood pressure)

body systems with greatest risk of infection post-op

GI GU Respiratory if they have an infection/dirty wound

conditions that might cause actual loss of potassium from the body

GI losses - nasogastric suctioning, vomiting, diarrhea Certain diuretic therapies (potassium-wasting: furosemide) Inadequate intake - ( body cannot e K, need PO intake)

bowel diversion nursing care

GOAL is to ASSUME SELF-CAREAssess SSS stoma stool output skin

The SURGEON is responsible for

Giving the patient the necessary information regarding surgery Determining the patient's competence to make an informed decision about the surgery

Diagnostics/Testing for Diabetes

Glucometer-70-130 Random test->200--w/symptoms FBS (Fasting BG)>126 Glucose Tolerance Test Urine Albumin

To be licensed as a RN

Graduated from a board-approved nursing program Are of Good Moral Character, as defined by state law No Open or Closed Criminal Case passed the NCLEX

healthcare acquired infections HAI vs Nosocomial

HAI an infection that is acquired in ANY healthcare setting Nosocomial specifically acquired in hospitals

what inflammatory substances are released during an allergic response?

HISTAMINE PROTEASE

sympathetic fibers increase

HR contraction

BG complications

HYPERGLYCEMIC Complications occur at the MACROVASCULAR (large blood vessels) and MICROVASCULAR (Capillary) level. • Cardiovascular Disease (CVD) • Nephropathy (kidney dysfunction) • Neuropathy (nerve dysfunction) • Retinopathy (visual dysfunction) • Gastroparesis (paralysis of stomach) • Ketoacidosis (diabetic coma) develops with insulin deficiency and uncontrolled hyperglycemia

Incentive Spirometry

High risk for atelectasis and pneumonia Facilitates deep breathing, increases lung volume, and promotes coughing to clear mucus from the respiratory tract Explain use during preop and postop

Focus charting

Highlights the client's concerns, problems, or strengths holistically in three columns •Column 1: Time and date •Column 2: Focus or problem •Column 3: Charting in a D A R format: Data: sub and obj data and all lab and diagnostics Action: interventions performed Response: response to your interventions. DAR stands for Data Action Response advantages -Compatible with use of nursing process. -Shortens time with flow sheets and checklists. -Focus is not limited to patient problems/nursing diagnoses. disadvantages -Incomplete database means patient problems will be missed. -Does not adhere to charting with focus on nursing diagnoses and expected outcomes .-lack of common problem-inconsistency in labeling

Routine hygiene care in the in-client facility

Hourly rounds comfort rounds or safety rounds. Seeing the patient every hour, on schedule, to offer help with self-care and safety needs Early morning care On awakening. Wash face and hands, mouth care A.M. care After breakfast. Bathing, toileting, hair, skin, bed making P.M. care Afternoon. Toileting, handwashing, oral care, readying for visitors H.S. care Prior to sleep. Relaxation activities, readying environment to facilitate sleep

insulin Mixtures

Humalin 70/30 (70% NPH -intermediate & 30% regular- short acting) Onset: 1-2 hrs Peak: None Duration: 24 hr

Insulin/Glucagon & cell types

INSULIN lowers blood glucose GLUCAGON raises blood glucose Alpha cells produce Glucagon TO RAISE glucose Beta cells produce insulin TO LOWER glucose

infiltration causes

IV catheter dislodges or the tip penetrates the vessel wall s/s Slowed or stopped flow Swelling, tenderness, pallor, hardness, and coolness at the site The patient may report a burning sensation in the area interventions Stop the infusion immediately. Restart the IV infusion in a different vein, higher in the extremity/another extremity. Elevate the affected arm on a pillow to promote absorption of excess fluid.

causes of insomnia/sleep deprivation

Illness Depression Side effects of medications (Ex: Steroids, Bronchodilators) Substance abuse Anxiety/Stress Menopause caffeine/smoking Watching TV in bed

Handoff: IPASS

Illness severity Patient summary, Action list Situation awareness and contingency plans Synthesis by receiver.

Most common sources of moisture

Incontinence Fever

Diuretics-cardiac lecture

Increase excretion of sodium and water from the kidney Treatment for hypertension often used to treat mild hypertension Monitor serum sodium levels and blood volume Thiazide or thiazide-like diuretics are considered the first-line medications to treat hypertension

Hypnotics medications

Increase the amount of sleep while decreasing the quality

trends in nursing

Increased use of CAM Telehealth nursing Mobile health vans Nurse Entrepreneurs

nursing process III independent/dependant

Independent RN prescribed/performed/delegates response to nursing diagnosis dependent interventions prescribed by a provider implemented by nurse usually for diagnostic tests, medications, treatments, IV therapy, diet, and activity assess need for Rx explain activities evaluate effectiveness of Rx Interdependent interventions implemented in collaboration with other health team members (e.g., physical therapists, nutritionists, and providers)

phlebitis

Inflammation of a vein as a result of repeated venipuncture on that vein s/s Redness, pain, and warmth at the site; local swelling; palpable cord along the vein; sluggish infusion rate; and elevated temperature Slowed or stopped infusion, localized warmth at the site, inability to restart flow of IV causes mechanical irritation, infusion of solutions that are irritating to the vessel, or sepsisDextrose solutions, potassium chloride, antibiotics, and vitamin C are associated with a higher risk of phlebitisTrauma to the vessel, compression of the line by client movement, or a low flow rate

BP regulation

Influenced by three factors 1. Cardiac function- An increase in cardiac output causes an increase in BP; a decrease in cardiac output causes a decrease in BP 2. Peripheral vascular resistance- arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls. • Viscosity (thickness) 3. Blood volume- normal volume of blood in the body is about 5 liters (5,000 mL). * increase in output causes increase in bp *decreases causes decrease in bp

Direct visualization

Insertion of various scopes to visualize interior cavity performed by gastroenterologists nurse assists in client prep

**you will use all four examination techniques to assess respiratory function**

Inspect Palpate Percuss Auscultate

IMPORTANT TO NOTE WITH VARIANCES in pulse

Is the rate regular or irregular? What is the quality of the pulse? • Bounding? • Thready?

Prolonged ELEVATED BG levels

Ketoacidosis

basic components of diet that need monitor/control w/ kidney disease

Kilocalories Protein Sodium Potassium Phosphorus ,vitamins D, calcium Fluids saturated fat & cholesterol iron, vitamins, and minerals

Treatment for abnormal bowel elimination should always start with:

Lifestyle changes - Diet - Fluid intake - Exercise before meds

External collection devices

Little pouch applied to anus to collect feces...a moisture-proof barrier is applied around anus and then the pouch is secured to the barrier NOT USED ON ACTIVE CLIENTS due to dislodging of the pouch and leading to skin breakdown

M.O.R.A.L.

M- massage the dilemma (Identify issues and consider all options, ensure all parties are heard) O - outline the options (All options to all parties are states no matter how unrealistic) R - Resolve the dilemma (Applying basic ethical principles - autonomy, justice etc) A - act by applying the chosen option (Put into action) L - look back and evaluate (Evaluate how the process went - debrief with all involved)

Metabolic disturbance alters bicarbonate

METABOLIC ACIDOSIS OR ALKALOSIS

Safety Measures intraop

Maintain the sterile field Provide supplies Monitor I&Os Handle specimens Perform instrument count--before and after surgery

external forces that result in pressure or friction against the body. involves stretching of body tissues (e.g., bleeding and swelling) and compression of tissues caused by the force of the trauma. surgical incisions, friction, skin shearing or pressure from a device such as a cast or brace are what type of stimuli?

Mechanical stimuli

Severe adverse reactions

Meets 1 or more of the following per FDA 1. life-threatening 2. require intervention to prevent permanent impairment or death. 3. lead to congenital anomaly, disability, hospitalization, or death Required to report!--to agency by policy and to FDA

Kussmaul's breathing is a sign of

Metabolic acidosis

most commonly heart valve abnormalities are seen in which valves?

Mitral aortic

Touch

Most potent form of communication. especially important for vulnerable clients

cognitive development older adult

NORMAL • Reaction time slows • Processing info slows • Learn new material slower • THERE IS NO LOSS OF INTELLIGENCE Dementia is NOT A NORMAL PART OF AGING ABNORMAL confusion--maybe polypharmacy

Intermediate-acting

NPH Onset: 1-2 hrs Peak: 4-12 hrs Duration: 18-24 hrs

Sleepwalking/talking

NREM appears awake no memory

Foods and medications to avoid before gFOBT

NSAIDs (7days prior) Vitamin C (change in chemicals in reagent for 3 days - can cause false negative) Red meats (3 days)

WBCs

Neutrophils 1st responders phagocytosis release Pyrogens-increase temp 55-70% increases in Bacterial infections/Inflammation Monocytes 2nd at site release Pyrogens-increase temp3-8% Reinforcement/phagocytosis lymphocytes 20-35% recognize, attack & destroy antigens increase in viral infections Eosinophils 1-3%Initiate allergic response phagocytosis active in later stages of inflammation Basophils 0.5-1%Phagocytosis release histamine to prompt inflammation

Cyanide toxicity may occur with

Nitroprusside

the most common type of pain visceral and somatic are types of this kind of pain

Nociceptive pain

Relieve mild to moderate pain Reduces inflammation/fever NSAIDS: largest group Acetaminophen Little anti-inflammatory effect Safest/fewer side effects Can cause liver toxicity

Nonopiod Analgesics

Top Pathogen causing disease

Norovirus

Nursing is regulated by

Nurse Practice Act--developed by MABORN ANA standards of practice

MABORN oversees

Nursing Licensure in MA Continued Licensure Nursing Education Standards for Nursing Education Practices

Three common conditions increase the risk of renal disease

Obesity Poorly controlled diabetes Hypertension

Health assessment During the procedure

Observe & Assess patient's ability to tolerate the procedure Identify actual and any potential problems that help to formulate Nursing Diagnosis

_______________Analgesics are Mu agonist Agonist-Antagonists Most effective for visceral pain Lowest dose/shortest time Not first line for chronic pain Can create other hazards Equianalgesia

Opioid

HDL

Optimal 60 mg/dL or higher dangerous under 40

Six Links "Chain of Infection"

Organisms Reservoir Where pathogens live and multiply Portal of exit: cough/ fluids Mode of transmission --Contact, Droplet, or Airborne Portal of entry Susceptible host

Classifications of pain

Origin Cause Duration Quality

Osmotic Diuretics

Osmotic diuretics Pull water into the renal tubule without sodium loss currently, there is only one osmotic diuretic available Manitol onset/peak/duration 30-60 minutes 1 hour 6-8 hours IV use only freely filtered at the renal glomerulus , poorly reabsorbed by the renal tubules, and resistant to metabolism Mannitol is sugar that's not well absorbed by the tubules ;it acts to pull large amounts of fluid into the urine due to the osmotic pull exerted by the large sugar molecule indications Acute attacks of glaucoma increased cranial pressure acute renal failure due to shock drug overdose or trauma contraindications renal disease , anuria pulmonary congestion intracranial bleeding Dehydration heart failure adverse effects sudden drop in fluid levels nausea, vomiting, hypo tension Lightheadedness, confusion, and headache patients need close monitoring for fluid and electrolyte imbalance

Self-Concept

Overall view of oneself The way individuals view themselves an evaluation of self

Cardiac ischemia

Oxygen requirements of the heart are unmet Prolonged ischemia leads to MI as necrosis takes over from lack of O2

Arterial blood gases (ABGs)

PO2 PCO2 HCO3

inflammation --Vascular response

Pain increase in temp edema-swelling Erythema-redness loss of function

arterial abnormalities s/s

Pallor, pain, weak or absent pulses, poor capillary refill, cool skin, and tissue dysfunction -Pain--unrelieved -Paresthesia -Pulses-diminished -Pallor -polar--cold limb -Paralisis PAD narrowed artery oxygenated blood can't get down to fingers/toes O2 problem Put Arterys DOWN ARTS: PAD Absent pulses Round red sores Toes and feet pale/maybe black Sharp pain in calf---intermittent claudication promote circulation (PAD) smoking cessation foot care comfortable fitting shoes regular exercise proper leg positioning graft bypass surgery/angioplasty Meds (NEVER direct HEAT--increases risk of burns r/t less sensitivity) --warmth ok--dilates area; avoid cold

Handoff: PACE

Patient/Problem Assessment/Actions Continuing/Changes Evaluation

Intermittent evaluation

Performed at specified times.

Elective Sx

Performed when surgery is recommended but is not time-dependent

sleep apnea

Periodic breathing cessation for at least 10 sec during sleep risk factors Overweight Large tonsils tongue nasal obstruction smoking Alcohol Family Hx

Ileostomy

Portion of ileum is connected to abdominal wall bypasses large intestine liquid continuous drainage

routine pre-op nursing interventions for all patients

Preoperative Coordination--preadmission diagnostics--anything abnormal findings--be sure to notify team of finding Surgical Preparation--care and documentation with pre-op checklist Teaching- assisting pt to understand and mentally prepare for sx and post-op recovery period -correct any unrealistic expectations

Regional Anesthesia

Prevents pain by interrupting nerve impulses to and from the area of the procedure pt alert--wide awake numb in the involved area epidural

Alzheimer's disease

Primary form of dementia Progressive Increasing age is the greatest risk factor Odds of developing double every 5 years after age 65

Levels of Prevention

Primary: prevention/promotion-- for healthy Secondary: illness--experiencing health issues Tertiary: end of life care/rehab focus is on recovery instead of tx or dx

Local Anesthesia

Produces loss of pain sensation at the desired site -Used for minor procedures Wound suture or skin growth removal -May be infiltrated the operative area with local anesthetics to provide postop pain relief--can be used with general anesthesia applied topically or injected -topical anesthetic is applied directly to the skin and mucous membranes

conscious sedation

Provides intravenous sedation and analgesia without producing unconsciousness

assessing pain: PQRSTU

Provoking/relieving Quality Region/radiation Severity Timing U...you

Sensory overload:

RAS is overloaded or excitedcaused by to many stimulus coming inThe complex sensory environment within the hospital can contribute to sensory overload. Monitor alarms; interruptions in rest and sleep by healthcare providers; medical therapies and procedures; patient care routines; and various odors, sounds, sights, and pain experiences can overwhelm the senses of patients in unfamiliar environments, such as the hospital.

Respiratory disturbance alters carbonic acid

RESPIRATORY ACIDOSIS OR ALKALOSIS

Delegation

RN skills assessment IV meds blood administration planning care physician orders teaching LPN skills vital signs some iv medication physical care Ancillary Personnel PT OT nutrition speech UAP feeding hygiene physical care ***cannot delegate any intervention that requires independent, specialized nursing knowledge, skill or judgment

type of pain that starts at the origin but extends to other locations. An example is chest pain that extends to the back or jaw.

Radiating

Sources of heat loss

Radiation Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air loss of heat through skin in a crowded cold room Convection: Transfer of heat through currents of air or water fan or AC cools or warm bath warms body temp Evaporation: Water is converted to vapor and lost from the skin or the mucous membranes perspiration & breathing Conduction: Transfer of heat from a warm to a cool surface by direct contact sitting on a cold table

general anesthesia

Rapid unconsciousness and loss of sensation suppresses CNS we are controlling body functions for them

wound healing

Regenerative epidermal wounds no scar -paper cut Primary intention tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring Clean surgical incision edges approximated Minimal scarring Secondary intention Wound edges not approximated Tissue loss left open because infected Heals from inner layer to surface fills in w/Granulation tissue slow to heal heals from the bottom up often pressure injuries Tertiary intention first heal by secondary intention later sutured after infection/edema Granulating tissue brought together Delayed closure of wound edges

Kussmaul's breathing

Regular but increased in rate and abnormally deep respirations

Emergency sx

Requires transport to an OR asap to preserve a patients life or function

metabolic acidosis causes

Retained acids in the blood (renal impairment, uncontrolled DM, or starvation. Decreased bicarbonate result from excessive GI loss Excessive intake of acids s/s • Headache • Confusion, drowsiness • Weakness • Peripheral vasodilatation • Nausea and vomiting • Kussmaul's breathing (rapid and deep) • Frequently associated with hyperkalemia correcting the underlying problem.

Repolarization

Return of the cell to resting state, caused by reentry of potassium into the cell while sodium exits the cell.

Diabetes management:

SELF CARE education support of the diabetes team

health promotion older adults

Safe use of Medications Don't drive when drinking Install smoke detectors Use seat belts Safely store firearms

bony prominences

Scapula sacrum ischium greater trochanter coccyx heels

Urgent sx

Scheduled within 24-48 hours to alleviate symptoms, repair a body part, or restore function (cancer, internal injuries, fracture)

Recovery from Surgery

Second phase of postoperative care Patient is discharged from the PACU and admitted to the surgical nursing unit Only after they are recovered from anesthesia and must be in STABLE condition--mentality and VS back at baseline Goal is to facilitate healing and prevent postoperative complications

6 elements of communication process

Sender-initiates content delivery Encoding-the words/expressions/gestures chosen message-the information received channel-the route the message is delivered-face to face/written/touch/pamphlet Receiver-decodes/interrupts message Feedback -response by receiver

Braden scale 6 Major Risks measured

Sensory perception Activity Moisture Nutrition Shear Friction

never events

Serious preventable errors that should never occur foreign object left inside after surgery 1. clearly identifiable/measurable 2. serious 3. usually prevented air embolism wrong blood severe pressure injuries urinary infections associated with catheters

exudate

Serous clear watery plasma like blister fluid Sanguineous bloody fluid Sero-sanguineous mixture of clear and blood-tinged drainage (ex. surgical incision) Purulent pus--end product of phagocytosis

Sleep disturbances because of:

Side effects of medications Underlying illness/discomfort/pain/menopause/OSA Depression Declining melatonin Wake frequently to go to bathroom

cardiac cycle

Simultaneous contraction of the two atria, followed by simultaneous contraction of the ventricles regulated by electrical activity of myocardium

S =P = I = C = E = S =s

Sleep disorder Problems with eating or feeding Incontinence Confusion Evidence of falls Skin breakdown

Parasomnias (common sleep disorders)

Sleepwalking/talking Bruxism Night terrors REM disturbances Enuresis

low self-concept behaviors

Slumped posture Unkempt appearance Lack of eye contact Overly critical Frequent crying Negative self-evaluation

Major electrolytes

Sodium Potassium Calcium Magnesium Chloride Bicarbonate Phosphate

SMART goals

Specific Measurable Attainable Realistic Timely

REM (rapid eye movements)

Spontanious awakenings dreaming mental/emotional restoration loss impairs memory/learning

condition that causes fat in stool

Steatorrhea

Subjective & Objective data

Subjective something the patient says--my throat hurts Objective Data we observe/collect--usually can be measured--vitals

SOAP notes

Subjective data: what the client/family tells you about signs/symptoms Objective data: factual findings-vitals quality of breath sounds Assessment: conclusions drawn from S & O data/nursing diagnosis Plan: goals and strategies to relieve pt problems

ORAL HYPOGLYCEMIC-- for Type 2 diabetes

Sulfonylurea agents: -glipizide -glyburide Biguanide agents: -metformin Drug interaction with Betablockers and alcohol (additional hypoglycemic effects)

STERILE TEAM

Surgeon Surgical Assistant--RN 1st assisstant--extra edu. helps with procedure Scrub person ONLY PERSONEL who enter STERILE FIELD set up sterile field/instruments sterile draping assist surgeons needs

Clinical practice guidelines

Systematically developed statements to assist providers and patients in making decisions about appropriate healthcare for a particular disease or procedure. They are typically developed by clinicians, patients, and advocacy groups and are published by specialty organizations, universities, and government agencies.

rust colored sputum is associated with

TB pneumococcal pneumonia possibly the presence of blood

Oxygenation Diagnostic testing

TB testing Pulse oximetry Capnography Spirometry Arterial blood gases Peak flow monitoring

STARR criterion

Technical and scientific knowledge evaluated by a community of peers have a service orientation and a code of ethics

Food elimination

The absorption of water from the large intestine reduces water content of the material left inside the large intestine, and the waste product (feces) has a solid consistency. Mucus, the only secretion in the large intestine, provides lubrication for a smooth passage of feces

Pain Management

The primary goal of postoperative pain management is to minimize the dose of medications while still providing adequate pain management Pain control should be individualized An interprofessional team approach should be used Benefits of adequate pain management Analgesics given by more than one route Administer round-the-clock NSAIDS Sufficient pain control for the older adult Monitor for side effects from analgesics

5 rights of teaching

Time Context Goal Content Method

patient rights

To be free of Mental, Physical, Sexual, & Verbal Abuse, Neglect, and Exploitation

Nociceptors become activated by the perception of mechanical, thermal, and chemical stimuli

Transduction

Peripheral nerves carry the pain message to the dorsal horn of the spinal cord

Transmission

tetracyclines

Treatment of various infections caused by unusual organisms (ex: Mycoplasma, Chlamydia, Lyme disease, Acne) OK for Use in Penicillin allergic patients Cause Yellow/brown/permanent discoloration to teeth cause Photosensitivity

post-op care on surgical unit

Upon arrival: perform assessment and get report from PACU nurse Assessment: Identical to the assessment in the PACU: Every 15 minutes for the first hour Every 30 minutes for the next 2 hours Every hour for the next 4 hours Then every 4 hours may have minor fluctuations--follow policy

Urostomy

Ureters are brought to abdominal surface, stoma is created collection bag outside of body

bowel training program

Used in clients with chronic constipation, impaction, bowel incontinence Plan program with the client Increase fiber in diet gradually Increase fluid intake to 8 glasses/day CAREFUL w/Heart Failure Establish a designated time for defecation Provide privacy for the client--uninterrupted times plan should be staged may include stool softener Modify based on client results

menstrual cramps, GI infections, and organ cancers are associated with what type of pain? originates from internal organs

Visceral

American Nurses Association (ANA)

Write code of ethics Create standards of care

Erikson Psychosocial development

Young Adult Intimacy vs Isolation develop long-lasting relationships middle adult Generativity vs or Stagnation establishing and guiding the next generation older adult integrity vs despair life has meaning-death is inevitable start facing own death integrity-retrospective appraisal despair-fail like a failure-didn't meet goals/make a change

Nonbenzodiazepines

Zolpidem tartate (Ambien) eliminated quickly no daytime drowsiness

visual analog scale

a pain rating scale using a straight line; the left end of the line represents no pain, the right end represents the worst pain, and patients mark the place on the line that best represents the severity of their pain

tort

a wrongful act or an infringement of a right (other than under contract) leading to civil legal liability.

drug absorption: pH/ionization

acidic meds, ie aspirin, are absorbed in the stomach basic meds ie sodium bicarbonate, absorbed in alkaline small intestine.

Hyperkalemia

acidosis

Justice

act fairly and provide equal treatment to all patients

anabolism

act of building up forming triglycerides

Sensory deficits

actual defect in neuro system not caused by the environment may stem from impaired reception, impaired perception, or both. Impaired vision and hearing are the two sensory deficits that you are most likely to encounter in nursing practice.

why should ANTI-Diarrheal medications be avoided with ACUTE diarrhea?

acute episodes are related to a virus or side effect of a medication or food....its the natural way of the body to get rid of the pathogens or food or med

culturally competent teaching: self knowledge

admit unfamiliarity w/culture--express willingness to learn find sources that help learn respect, accept, and validate the clients culture, beliefs and values find ways to incorporate into plan of care client teaching materials in own language

General Adaptation Syndrome (three-stage reaction to stress)

alarm fight or fight- HR increases O2 increase blood flow increases more alert blood sugar increased pupils dilate resistance functions return to normal exhaustion cannot adapt any longer and experience illness

for patient to sign informed consent they must be

alert rational mentally competent not sedated when signing--no sedating meds

hypokalemia

alkalosis

Describe the various healing modalities

alternative medical systems Western: focus on illness but that is slowly changing cardiology; Neurology Eastern: used for centuries pre-date Western Medicine Chinese medicine illness is due to an imbalance of yin and yang acupuncture homeopathy Mind boy interventions prayer imagery humor meditation yoga hypnosis music therapy biofeedback biology-based therapies dietary herbal aromatherapy nonherbal dietary supplements (hormonal; minerals) manipulative/body-based chiropractic massage osmotherapy energy therapies therapeutic touch reiki tai chi magnet therapy

Nonpharmacological Pain Relief

alternative to drugs used alone or in addition to pharmacological methods always assess for openness to different therapies/effectiveness cutaneous stimulation oral sucrose immobilization & traction cognitive-behavioral interventions

subcutaneous injection

angle 45-90 gauge 25-27 given into the subcutaneous tissue Absorption is slower than IM d/t tissue not having as rich a blood supply as muscle. abdomen and arms offer fastest absorption thigh and upper buttocks slowest absorption. more evenly from the abdomen than from the thighs and buttocks because it is less affected by activity

cardiac valves

aortic valve between the left ventricle and the aorta tricuspid valve between the right atrium and the right ventricle pulmonic valve between the right ventricle and pulmonary artery mitral valve between the left atrium and the left ventricle

A diet high in saturated fat predisposes a person to the development of

atherosclerosis coronary artery disease hypertension

Goals of nutrition therapy

attain and maintain optimal nutritional status prevent net protein catabolism--minimize protein intake minimize uremic toxicity maintain adequate hydration status maintain normal serum potassium levels modify diet to meet other related concerns such as diabetes, constipation or heart disease.

Foul smelling sputum usually indicates

bacterial infection

BRAT diet

bananas, rice, applesauce, toast

preop phase

begins when pt decides to have sx ends when pt enters OR

Intraoperative phase

begins when pt enters the OR suite ends when admitted to PACU consists of sterile team & Clean team

Characteristics of Culture

beliefs provide identity and a sense of belonging consist of common beliefs and practices universal and dynamic exists at many levels inhabits our unconscious diverse

anti spasmotics

blocking parasympathetic activity -> leads to relaxation of the detrusor and other urinary muscles Oxybutinin administered orally, also has patch, gel rapidly absorbed metabolized in the liver excreted in the urine onset : 30-60 minutes Peak : 3-6 hours Duration: 6 - 8 hours

the most irregular breathing patterns result from __________ _________or the effects of __________

brain injury drugs

changes in older adult nervous system

brain volume decreases blood flow to the brain decreases thirst sensation is less operative

catabolic

breaking down nutes to extract energy

Veins & Venules

bring deoxygenated blood back to heart/lungs thin, muscular, inelastic, collapse easily contract/collapse in response to SNS if blood is vol. is low (hypotension)--contract which increases BP if blood Vol. high (hypertension) --they relax to make room for volume which decreases BP

Precursors to violence

bullying incivility

TIME OUT

called before the start of a procedure/surgery with ALL personnel. Make sure that everyone is on the same page in regards to: 1. The right patient 2. The right procedure 3. The right site anytime new surgeon comes into procedure

skin dries and wrinkles because

cannot synthesize Vit D as well

apnea

cessation of breathing--is a MEDICAL emergency

affective

changing feelings beliefs, attitudes, and values Tools: role modeling mentoring counseling group work interactive applications examples makes eye contact when nurse explains something asks questions about what to expect during procedure parent expresses commitment to staying w/child after a nurse explains impact of hospitalization a client who has overcome drug addiction chooses to present his story w/high school students

drug Metabolism

chemical conversion of the drug into a more water-soluble compound or metabolites that are then able to be excreted from the body. factors affecting liver function health/disease first-pass effect

Food Management

clean separate cook chill

black sputum is caused by

coal dust smoke soot

3 Domains of Learning

cognitive psychomotor affective

white or clear sputum

colds bronchitis viral infections

respiratory acidosis causes

conditions or medications that IMPAIR GAS EXCHANGE at the alveolar-capillary membrane, depressed respiratory rate and depth, or injury to the respiratory center in the brain

sign of dehydration for elderly

confusion

Fistula

connecting 2 body cavities or a cavity & skin

Traditional Thinking

considered a biological attribute identified by external physical traits such as skin tone based on "five races" concept of human population distribution across continents

depolarization

contraction

AV node

creates delay between atria and ventricles allowing the ventricles to fill

Root Cause Analysis

deep investigation into a sentinel event to determine why the event occurred, and exploring the circumstances that led to it to determine where improvements can be made

NREM (non REM)

deep sleep muscles relax temp lowers HR/RR/BP decrease cortisol lowest divided into 4 stages

fractures, sprains, arthritis, and bone cancer can cause what kind of pain described as achy and tender

deep somatic pain

Quasi-intentional torts

defamation of character slander libel

Nurse Practice Act

define the practice of nursing standards specifically require nurses to formulate a plan of care •may be written or unwritten designed to: Protect patients/society. Define the scope Identify the minimum level of care

Flow of blood through heart

deoxygenated blood from body through superior and inferior vena cava to right atrium through tricuspid valve to right ventricle up through pulmonary valve and out left and right pulmonary arteries to alveoli in capilaries of lungs where gas exchange occurs and makes it oxygenated oxygenated blood comes back in from lungs through left and right pulmonary veins to left atrium through mitral valve into left ventricle through aortic valve in aorta and then out of aorta to body to fuel tissues and organs

Electrical conduction that initiates myocardium contraction

depolarization of SA node to AV node and left atrium down to bundle of HIS which branches off to Left and Right Bundle branches to Purkinje fibers

Jean Watson

developed transpersonal caring-- humans are valued, respected, cared for, and understood and nurses deserve the same. mutual and reciprocal--each person is changed by the caring act--which is why it is transpersonal said caring is the essence of nursing developed 10 carative factors

Nephrosclerosis causes

diabetes hypertension

Potassium sparing diuretics (PSD)

distal tubule and collecting duct Used for patients at high risk of hypokalemia (example patients receiving digitalis or patients with cardiac dysrhythmias ) causes a loss of sodium while promoting the retention of potassium amiloride spironolactone triamterene onset/peak/duration 24-48 hours 48-72 hours 72 hours Hyperkalemia -which can then cause lethargy confusion ataxia muscle cramps cardiac dysrhythmias

Nonmaleficence

do no harm nurses take: Nightingale pledge

Stool softener example

docusate sodium

Implementation

doing delegating recording overlaps all parts of nsg process The final step of implementation is -documentation

Six rights of Medication Administration

drug dose time route patient documentation

first pass effect

drugs given orally are carried to the liver after absorption, where they are inactivated before entering circulation oral drugs are given in higher doses than other routes because of this effect

Diuretics

drugs that increase the amount of urine produced by the kidneys. --Increases the volume of urine produced --increases sodium excretion . prevent cell lining of the renal tubules from reabsorbing an excessive proportion of sodium in the filtrate Why use a diuretic -increase sodium excretion, and therefore water excretion -relieve edema associated w/heart failure, pulmonary edema, liver failure and cirrhosis, and various other renal diseases -primary agent used to treat high BP

-satins

drugs used to lower cholesterol toxicity Digoxin grapefruit warfarin

drug Excretion

elimination of the drug factors affecting organ function exocrine glands

surgical consent form Nurse responsibilities

ensuring that the form is signed and witnessed make sure pt has no questions -if yes notify and delay if necessary -document any and all conversations and notifications of surgery -must be given in language and vocab they understand w/out medical jargon

-afil

erectile dysfunction drugs

why do athletes have a slower HR?

exercise strengthens muscles-- stronger heart = increased efficiency = lower HR

pressure injury

extrinsic risk factors Friction--happens when the head of the bed is more than 30 degrees-- Pressure--high fowlers--on bottom Shearing--downward force Exposure to moisture ONLY WOUNDS CAUSED BY PRESSURE ARE STAGED STAGING NEVER REVERSES

trendelenburg position

facilitate drainage from lungs lying on back with body tilted so that the head is lower than the feet

Diabetes Type 1

failure of the pancreas to produce insulin d/t damage of beta cells Autoimmune destruction of Beta cells Genetics or viral infection Age of onset: younger than 20, but any Abrupt onset, thirst, weight loss Insulin dependent Non-obese/ Thin Insulin & Nutrition control mandatory

Fidelity

faithfulness; loyalty

P wave

firing of the SA node and conduction of the impulse through the atria. leads to atrial contraction atrial depolarization

inflammatory phase (Cleansing)

first phase -A vascular reaction that delivers fluid, blood products and nutrients to the area that is injured by WBCs removing dead tissue and repairing cells and tissue 2 parts- Hemostasis--stopping bleeding Inflammation--local reaction to injury

Centering

focus on this patient only

Use of restraints

follow agency policy try alternative methods bed alarms patient sitter use least invasive method verbal chemical seclusion physical SHOULD ONLY BE USED AS A LAST RESORT AND USED ONLY WHEN ALL OTHER REASONABLE ALTERNATIVES FAIL. obtain consent form obtain medical order(must rewrite order every 24h) ensure circulation is not impaired release and assess every 2 hrs

The Radura symbol

food treated with radiation

Campylobacter

from raw chicken Most common organism causing diarrhea in the world

Type 1 alveolar cells

gas exchange

Pain is perceived by the interplay between two different kinds of fibers—those that produce pain and those that inhibit pain--describes what theory?

gate-control theory

IM injections

gauge 22-25 angle-90 pinch skin-inject syringe absorbed faster than SC because of the rich blood sites deltoid rectus femoris (not recommended) vastus lateralis ventrogluteal

Bruxism

grinding teeth clenching jaw can loosen teeth

psychomotor

hands-on skill that requires thinking and doing tools: demonstration return demonstration stimulation journaling self reflection examples identifies own need to read directions before starting project brings personal equipment to teaching session follows along w/instructor during demonstration diapers newborn after observing demonstration independently changes complex dressing--wound heals w/out infection creates new approach for giving his daily injections

Arteriosclerosis

hardening of the in large and middle-sized arteries. Atherosclerosis it is the process of how plaques (LDL) build up in the tunica intima and cause calcification of the artery walls--Arteriosclerosis most often in larger/middle arteries Arteriolosclerosis hardening of the smaller arterioles --r/t BP issues- -loss of compliance ex. protein build-up in arteriole walls

purposes of bathing

health promotion, social interaction, and pleasure or relaxation removes/prevents odor by removing perspiration and bacteria improves circulation stimulates depth of respirations and provides sensory input can strengthen nurse patient relationship

HIPPA (Health Insurance Portability and Accountability Act)

healthcare agencies and their employees must take steps to ensure the confidentiality of patient information and medical records. Established to: Protect health insurance benefits for workers who lose or change their jobs. Protect coverage to persons with preexisting medical conditions. Establish standards to protect the privacy of personal health information.

Leading cause of death older adult

heart disease Most common/costly Heart disease diabetes stroke cancer

Staphylococcus Aureus

heat does not destroy toxin to prevent must keep good hygiene/ keep food below 40 or above 140

Complications of wound healing

hemorrhage infection dehiscence evisceration

peak level

highest level in blood absorption at same rate of excretion

Hyperventilation vs hypoventilation

hyper: Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea) hypo: The rate and depth of respiration are decreased and C O2 is retained-hypercapnea

Extreme sensitivity to pain

hyperalgesia

respiratory alkalosis causes

hyperventilation-from anxiety fever sepsis thyrotoxicosis lesion in the respiratory center in the brain excessive ventilation with a mechanical ventilator s/s Confusion difficulty focusing Headache Tingling Palpitations Tremors relax and breathe slowly

Context for interpreting experiences, health, & illness based on shared

ideology values beliefs norms customs & practices

impaired: communication techniques

impaired speech • Hand gestures • Family assistance • Be positive and patient impaired cognition • Always communicate. • Address the patient. • Don't rush. • Eliminate distractions. • Use short sentences. • Ask yes/no questions.

lifestyle: exercise

improves circulation & oxygenation Increases metabolic demands. increasing the HR increases respiratory rate and depth

Baroreceptors

in the brain center regulates BP sensitive to changes in pressure

Proprioceptors

in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable us to sense the position of our body in space (proprioception).

Diabetes Type 2

inadequate insulin secretion A decline in insulin production with a decline in the effectiveness of the insulin • Gradual/Progressive • Pancreas makes less insulin over time• Insulin resistance • Heredity• Obesity = Hyperglycemia-Hypertension-Dyslipidemia • Age: 50 but decreasing • May require insulin • Nutrition management mandatory • Delayed or prevented by wt. loss & activity

Acculturation

incorporation of attributes of broader society by diverse groups

greatest risk for Alzheimer's is

increasing age

The goal of interventions for the oldest old adults

independence for as long as possible by maximizing function and preventing disability or loss of function arrange for appropriate care, and teach clients and caregivers how and when to call for professional help.

Nephrotic syndrome

inflammation of the kidneys , also known as nephritis acute or chronic--can be from infection-ie strep or auto immune disease ie lupus usually reversible

beta blockers can cause

insomnia nightmares

Pre assessment medications

insulin digoxin antihypertensive chemotherapy drugs

Rapid-acting insulin

insulin aspart insulin lispro insulin glulisine Onset: 15 min Peak: ~1 hr Duration: 3-5 hrs Administer approx. 10-15 min. before meal

Long-acting insulin

insulin glargine insulin determir Onset: 1-4 hrs Peak: none Duration: 24 hrs

Direct care interventions

interaction with the client such as physical care, emotional support, and patient teaching.

chronic pain resistant to relief or often needs multiple methods of relief describes what type of pain?

intractable

Sensory deprivation

is a state of RAS depression caused by a lack of meaningful stimuli. environmental stimuli are deficient, the remaining stimuli, such as distant noises, minor pain, and cold extremities, can become overly noticeable or distorted, filling in the "sensory gap" and causing the patient a level of distress that is out of proportion to the intensity of the stimulus. example--person in soleitary confinement senses depressed because of lack of stimuli a small tapping noise can cause over excitement pt feels level of distress

Primary organ of drug excretion

kidneys

medications used to treat fever

know action & onset..ie stop production of prostaglandins and onset is 5 mins PO Acetaminophen-- PO=0.5-1hr rect=0.5-1hr IV=w/in 30min Ibuprofen--also anti-inflammatory PO=0.5-2.5hr IV=w/in 2 hrs Acetylcylic acid (aspirin)--also blood thinner PO=5-30min Chemical effect: all stop fever by inhibiting synthesis of Prostaglandin production

Renal Mechanisms

last line of defense regulate the concentration of plasma bicarbonate serum pH is too acidic, the kidneys conserve additional bicarbonate to neutralize the acid If the serum pH is too alkaline, the kidneys excrete additional bicarbonate to lower the amount of base and thereby decrease the pH The kidneys also buffer pH by forming acids and ammonium (a base)

Assessing risk

less than 2 hrs or as long as 5 days for pressure wound development lighter skin --Initially, skin is pale & cool darker skin --may look like cyanosis Turn patient→ vasodilation & blood returns to area Outcome: Area turns bright red OR if redness does not appear = tissue damage has occurred.

Primary organ for drug metabolism

liver

Accessory Organs

liver-production of bile gallbladder-stores bile pancreas-secretes enzymes

Osteoporosis

loss of bone density spontaneous fractures fall risk treatment is prevention-- after 50-- calcium and vitamin d weight-bearing exercise helps balanced diet avoid alcohol/drugs

Assimilation

loss of original cultural

cardiac factors older adults

lower exercise tolerance need more rest after exercise efficiency gradually declines -loss of contractile strength -valves thicker/ridgid -peripheral vessels less elastic--more resistant More prone to ORTHOSTATIC hypotension

The Patient Self-Determination Act (PSDA)

mandates client's right to make decisions regarding own healthcare, based on the information provided to him by provider regarding the medical or surgical treatment options available, the benefits, risks, and alternatives

BiPAP (Bilateral positive airway pressure)

mask delivers air Airflow changes with breathing in and breathing out

CCAP (Continuous Positive Airway Pressure)

mask delivers room air at high pressure pressure keeps airway open prevents Airway collapsing users have to exhale against the pressure which might make it difficult for some patients

Spirometry

measure of air that moves into and out of the lungs

Capnography

measures CO2 in inhaled and exhaled air

capnography

measures CO2 in inhaled and exhaled air

local infection

microbial contamination of the cannula or IV site

process that changes the perception of pain by either facilitating or inhibiting pain signals through the endogenous analgesia system and the gate-control mechanism. suggests that the perception of pain does not occur only by direct stimulation of nociceptors

modulation

drug Absorption

movement of the drug after administration into the bloodstream Factors of Absorption Route Solubility pH/ionization Blood flow

the _________________ agonist is the most effective in relieving pain because they treat all types of pain.

mu

Approval or Disapproval-

must not impose own attitudes, values, beliefs, and moral standards-- often contain terms such as should, ought, good, bad, right or wrong.

substances absorbed by small intestine

nutrients

Why are vitals measured?

obtain a Baseline detect deviations monitor health/condition provide data to establish nursing diagnoses implement planned treatments evaluate outcomes after interventions need to be accurately implemented interpreted and documented

FACT documentation

only documents abnormalities Flowsheets individualize specific services Assessment with baseline data Concise progress notes Timely entries

Ibuprofen

onset 30-60 minutes peak 1-2 hours duration 4-6 hrs normal dose 200-400 mg every 4-6 hours DO NOT EXCEED 1200 mg/day Do not give w/ active GI bleeding ulcers

Aspirin:

onset 5-30 min peak 1-3 hours duration 3-6 hrs normal dose 325-1000 every 4-6 hours do not exceed 4000mg/day prolongs bleeding 3-7 days

The Incivility Continuum

onset of stress impact abusive conduct despair, suicide physical violence, injury, death

LDL

optimal < 100 high 160-189 very high 190+

total cholesterol

optimal <200 mg/dL Borderline 200-239 mg/dL high 240+ mg/dL

The client's condition or well-being is improved. is what type of evaluation?-

outcome

where is the best place to test skin turgor?

over the clavicle

Alkalosis

pH above 7.45

Acidosis

pH below 7.35

sinoatrial (SA) node

pacemaker of the heart 60-100 bpm right atrium initiates an impulse that triggers each heartbeat. The impulse travels rapidly down the atrial conduction system so that both atria contract as a unit.

numeric rating scale

patient chooses level of pain for each site 0-10; most adults, but not old

involves the recognition and interpretation of pain in the frontal cortex.

perception

Ongoing evaluation

perform while implementing, immediately after an intervention, at each contact.

Indirect care interventions

performed away from the client may include advocacy, managing environment, collaborating w/team, making referrals.

pain __________ is referred to as episodic, intermittent, or constant

periodicity

patient readiness depends on

physical condition and emotions

Maslow's Hierarchy

physiological safety social esteem self-actualization

Major electrolytes in the ICF

potassium (K+) magnesium (Mg2+) phosphate (HPO4 2-)

Preload/Afterload

pre volume of blood in ventricles at end of diastole after The force/resistance against which the heart pumps.

Buffers

prevent wide swings in pH consists of a weak acid and a weak base first-line against Acid-Base Imbalances

ASPIRIN regimen

prevents heart disease blocks production of prostaglandins reduces risk of heart attack/stroke 50+ w/risk of heart disease-recommended 81mg/day

Socialization

process of learning behavior & norms to become a group member

Type 2 alveolar cells

produce surfactant

liver primary function

production of bile-breaks down dietary fats

food Absorption

products of digestion move from the GI tract into the blood and lymphatic system. Most digestion takes place in the small intestine. **inner surface of intestine has mucosal folds, villi and microvilli to increase surface area for maximal absorption

Evaluate

progress towards outcomes/goals effectiveness of care plans quality of nsg care final step of nsg process

Kidney failure: Chronic (CKD)

progressively destroys nephrons occurs overtime usually irreversible elevated serum levels of BUN/creatinine/uric acid

Good Samaritan Law

protects when helping victims in emergency situations

glomerulonephritis s/s

proteinuria-protein in urine severe edema low blood protein levels anemia hyperlipidemia

Nursing Roles

provider of care manager of care member within nursing discipline

Admission Assessment

provides baseline data helps predict needs/services presents illness/reason for admission, VS, allergy info, current meds, ADL status, physical assess data, and discharge planning info

Americans with Disabilities Act (ADA)

provides protection against discrimination of individuals with disabilities. A person has a disability if he or she has a physical or mental impairment that substantially limits one or more major life activities. employers must provide reasonable accommodations within the work setting to allow employees with disabilities to perform their jobs.

Evidence of Recovery from Anesthesia

pt able to maintain patent airway pt is conscious and easily reoriented VS stable and within normal limits-might be lower than pre-op d/t anxiety before sx I&O--at least 30 mL per hour & in fluid balance dressing and drainage dry and intact OR normal for procedure

Pink frothy sputum is associated with

pulmonary edema

heart failure

pump inefficient Blood is oxygenated BUT not well circulated to the organs and tissues Impaired circulation leads to systemic and pulmonary edema pt feels tired/ lacks endurance from lack of O2

Pain ______________ is described as dull sharp aching throbbing stabbing burning ripping searing tingling

quality

guaiac fecal occult blood test (gFOBT)

reagent detects presence of peroxidase, an enzyme present in hemoglobin

Archetypes

recurrent characteristics based on facts

Autonomy

refers to a person's right to choose and ability to act on that choice

Short-acting insulin

regular insulin Onset: 30-60 min. Peak: 2-5 hrs Duration 5-7 hrs *Regular is the only insulin that can be given IV

ablative sx

removal of diseased body part

HITECH

required to notify clients of breaches without unreasonable delay and by no longer than 60 days. civil penalties for breaches caused by willful neglect up to $250,000, with a maximum penalty of $1.5 million Posting client information online can trigger HITECH violations.

Cognitive Development Theory: Piaget

requires three core competencies; adaptation assimilation accommodation. Cognitive development occurs from birth through adolescence in a sequence of four stages: sensorimotor, preoperational thought, concrete operations, formal operations. A child must complete each stage before moving to the next. The rate at which a child moves through the four stages is determined by the inherited intellect and the influence of the environment.

Continent Urinary Reservoir

reservoir surgically created emptied through straight cath

positive chvostek test

respiratory alkalosis

chemoreceptors

respond to changes in pH O2 CO2 main function is ventilation

Respiratory effort/dyspnea (SOB)

retractions, grunting, pursed-lip breathing **If pt has SOB-- circulation and oxygenation should be done FIRST before anything else

interventions to prevent falls in healthcare

review meds call light within reach orient patient to surroundings/bathroom disoriented patients near nurses' station keep things within patients reach night light floors dry/free of clutter teach fall prevention strategies have stickers in chart if fall risk use bed/chair alarms

cardiac monitoring identifies baseline

rhythm rate

OSA (obstructive sleep apnea)

s/s Complete/partial obstruction of airway during sleep Loud snoring Hypoxia Disrupted sleep Frequent awakenings Daytime sleepiness, groggy Memory problems Fatigue Depression Dry mouth Headaches aids CCAP BIPAP

Respiratory Mechanisms: lungs

second line of defense to restore normal pH. control carbonic acid supply via carbon dioxide retention or removal to maintain the 20:1 ratio of base to acid. • When the serum pH is too acidic (pH is low), the lungs remove carbon dioxide through rapid, deep breathing. This reduces the amount of carbon dioxide available to make carbonic acid. • When the serum pH is too alkaline (pH is high), the lungs try to conserve carbon dioxide through shallow respirations.

effects of immobility on respiratory system

secretions and pooling of blood in airways, and blocking the airways, which can lead to pneumonia, decreased respirations and a collapsed lung

Extravasation

seepage of a vesicant substance into the tissues causes IV catheter dislodges/tip penetrates the vessel wall s/s Slowed or stopped flow Pain, burning, and swelling at IV site, blanching, and coolness of the surrounding skin Blistering is a late sign If extravasation resulted from vasoconstricting medication may see necrosis (death) of dermis interventions Treatment depends on the severity of the infiltration.Stop the IV infusion immediately.Administer an antidote, if one is available. (Antidotes alter the pH, alter DNA binding, neutralize the drug, or dilute the extravasated drug.)Apply cold compresses, and elevate the extremity.

Explain how personal hygiene relates to health and well-being.

self-image socialization

International council of nurses (ICN)

serves as the standard for nurses worldwide. The Code stresses respect for human rights, including cultural rights, the right to life and choice, the right to dignity, and right to be treated with respect.

Yellow or green sputum

sign of infection

do not combine Nitrates with

sildanefil tatalifil varderfil

orthopneic position

sitting up and leaning over a bed table SOB (shortness of breath) COPD (chronic obstructive pulmonary disease)

gut failure

situation in which the small intestine fails to absorb nutrients properly

intradermal injection

skin taught bevel up bleb will form angle 5-15 gauge 26-28 given into the dermis commonly used for allergy or tuberculosis (TB) testing nurses use non-dominant arm for TB screening dominant arm, chest, or upper back for all other tests

Parasympathetic fibers

slow HR have NO effect on Contractility

HEENT: Cranial Nerves Function

smell vision hearing motor sensory

learning theories

social behavioral cognitive humanism

Major electrolytes in the ECF

sodium (Na+) chloride (Cl-) bicarbonate (HCO3 -)

pain that originates from skin, muscles, bones, or connective tissue.

somatic

Purkinje fibers

specialized muscle fibers that conduct the cardiac impulses from the AV bundle into the ventricular walls if SA & AV node not firing --picks up job--sends impulses but only at 20-40bpm--not enough to sustain life

what term describes reduced tidal volume (air exchanged with each breath) and increased inspiratory and expiratory pressures. process unrelieved pain can cause in respiratory system can lead to pneumonia, atelectasis, respiratory acidosis and underventilation (retained carbon dioxide, also called hypercarbia)

splinting

Slander

spoken defamation

Contact precautions

spread by direct contact draining wounds secretions supplies Precautions Possible private room (or cohort double) • Disposal of contaminated items in room • Double-bag linen and mark • gown + gloves examples multidrug-resistant organisms C diff MRSA MDRO vancomycin (VRE) Lice norovirus skin infections

angina

stable angina predictable consistent pain occurs on exertion relieved by rest/nitroglycerin unstable angina ischemic chest pain that worsens not relieved by nitroglycerin Prinzmental angina uncommon pattern occurs at rest due to arterial spasm responds to vasodilators

pressure injury stages

stage 1 pressure injury intact skin stage 2 pressure injury Open shallow maybe serous fluid NO SLOTHING stage 3 pressure injury Full thickness tissue loss maybe subcutaneous NO BONE TENDONS MUSCLE Stage 4 pressure injury Full-thickness tissue necrosis to bone, muscle, tendons

cognitive

storage and recall of information Tools: lectures readings panel discussions case studies examples reports names and doses of the 3 meds he is taking explains expected effect of Rx med makes schedule for dressing changes for her wound describes normal inflammation vs signs of infection of a wound recognizes need for behavioral changes to decrease reoccurrence of infection

choice vein for PN feedings

subclavian vein use large vein

Hot and Dry cold and clammy

sugar high give them candy

wound classification

superficial wound only epidermis partial thickness wound epidermis dermis full thickness subcutaneous and beyond penetrating wound enters internal organs tunneling wound open passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound.

pulse pressure

systolic minus diastolic pressure 120/50=70--heart is taking a long time to fill 110/100=10 heart is filling rapidly

Five Rights of Delegation

task circumstance person direction/communication supervision/evaluation

isometric exercise

tensing and relaxing muscle without moving pressing arm against the wall--flexing-yoga-stretching does NOT improve respiratory function activity that combines muscle contraction with repeated movement--Enhance circulatory & respiratory function. Add Muscle mass, Strength & Tone ree weights-swimming

C&S (culture and sensitivity)

test that determines the causative organism of an infection and identifies how the organism responds to various antibiotics

two part statement

the problem and the etiology can be used for actual, risk, and possible diagnoses. example: anxiety (NANDA diagnosis) r/t fear of unknown

discharge planning

the process of anticipating and planning for client needs after discharge begins at initial planning!

data that will be collected when measuring respirations

the rate--· count/12-20 Depth--deep/shallow/normal rhythm--regular/irregular effort--the amount of work it takes to breathe breath sounds chest/abdomen movement

Reception

thermoreceptors proprioceptors photoreceptors Process of receiving stimuli from nerve endings in the skin and inside the body. receptor converts stimulus to impulse transmits impulse along neurons to the CNS most receptors adapt to stimuli; Adaptation explains why, over time, you become unaware of an unpleasant smell or the persistent hum of an air conditioner.

assault

threat or attempt to injure

usually remains fairly constant for an individual over time, but repeated experience with pain can reduce a patient's ______________?

threshold

Thrombophlebitis

thrombosis and inflammation clot which caused inflammation causes Use of veins in the legs for infusion, use of a hypertonic or highly acidic solution; can be a result of untreated phlebitis s/s Sluggish flow rate edema tender/cord-like veins warmth erythema at site

Beneficence

to do good-promote good

goal of evidence-based practice

to identify the most effective and cost-efficient treatments for a particular disease, condition, or problem

lipid panel

total cholesterol less than 200 LDL- less than 100 HDL-at least 60 --less than 40 dangerous triglycerides less than 150 used to assess risk factors of ischemic heart disease

Evisceration

total separation of the layers & internal viscera or organs protrude

Battery

touching of another person without consent

Healing modalities

traditional modalities antibiotics surgery holistic modalities complementary used with traditional medical care alternative used instead of traditional medical care integrative modalities encompasses all treatment modalities

drug Distribution

transportation of the drug to the tissues and organs Factors affecting Local Blood flow Membrane permeability Protein-binding capacity

Aminoglycosides

treats serious infections when Penicillin is contraindicated PEAK AND TROUGH levels ordered!!! 2 examples gentomycin streptomycin

anxiety is a priority intervention b/c

triggers the stress response release of aldosterone- --promotes fluid retention --increases BP HR and contraction force increase, vessels constrict blood clots more readily All of these make a cardiac or vascular condition more serious.

idiosyncratic reaction

unexpected, abnormal, or peculiar responses to medications. may take the form of extreme sensitivity to medication, lack of response, or a paradoxical (opposite of expected) response, such as agitation in response to a sedative Benadryl--sometimes makes some kids hyper instead of sleepy

Ileal conduit

ureters are attached to the ileum and a stoma is created on the abdomen uses piece of ileum as reservoir

sanitizer vs soap

use sanitizer Use when hands are not visibly soiled soap When hands are visibly soiled when suspect bodily fluids After known or suspected exposure to Clostridium difficile (C-diff.) or Anthrax • After known or suspected exposure to patients with infectious diarrhea Ex: Norovirus • Before eating • After using a restroom • Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed) • After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings • After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient • If hands will be moving from a contaminated body site to a clean body site during patient care • Before and after glove removal • After using a restroom • Before and after eating

an allergic response causes what cardiovascular events

vasodilation- -increased blood flow -increased capillary permeability -more fluid leakage

QRS complex

ventricular depolarization leads to ventricular contraction

T wave

ventricular repolarization leads to relaxation ventricles relax and fill

Airborne precautions

via ventilation systems shaking sheets sweeping Precautions Same as those for contact PLUS- negative pressure room N95 mask--with HEPA filters mask for patient when transported Examples TB (Tuberculosis) Chicken Pox (Varicella) Measles (Rubeola)

Metabolic Alkalosis causes

vomiting or gastric suction use of potassium-wasting diuretics hypokalemia excess bicarbonate intake hyperaldosteronism s/s Dizziness Tingling of extremities Hypertonic muscles Decreased respiratory rate and depth correcting the underlying problem.

main substance absorbed by large intestine

water

Hepatitis A virus

water contaminated by raw sewage & shellfish harvested from fecally contaminated water. infected workers can contaminate food and spread Symptoms abrupt onset fever malaise anorexia nausea abdominal discomfort Jaundice

Lung sounds

wheezes High-pitched continuous musical sounds, usually heard on expiration caused by narrowing of airways Rhonchi Low-pitched continuous sounds secretions in the large airways. Coughing helps clear sounds. Crackles Discontinuous sounds usually on inspiration; high-pitched popping sounds/low-pitched bubbling sounds fine or course Stridor A piercing, high-pitched sound heard primarily during inspiration Stertor/rales Labored breathing that produces a snoring sound

decisional conflict

when pt. is uncertain about which course of action to take. Pt. may verbalize distress and uncertainty may delay decision making may show physical signs of distress (e.g., increased heart rate) may question moral rules, values, and personal beliefs

When to use gloves-

when touching a patient/belongings when contact with blood or other body fluid is anticipated when touching mucous membranes or non-intact skin when touching contaminated surfaces or objects.

Libel

written defamation of a person's character, reputation, business, or property rights.

focus for young middle and older adult

young education and prevention Middle identifying risk factors and promoting a healthy lifestyle older Tie past experiences to what you are teaching. Provide a quiet setting and decrease background noise. Close windows & doors if noise interferes with teaching prevention/safety

Piaget: formal operations -young, middle, and older adult

young-Creativity, critical thinking, and memory improves build friendships/social interactions Middle-Memory is intact and ability to retain knowledge is intact BUT how to process the new information declines slightly Older-Speed of the cognitive function declines BUT the ability to process does not

Factors affecting response

‒Intensity of stimulus ‒Contrasting stimuli ‒Adaptation to stimuli ‒Previous experience In order to respond to all of these systems--RAS system must be working

Examples of 15 Grams of Carbohydrates

• 1 small fresh fruit • 2 small cookies • 1 cup milk (8oz) • 1 slice bread • ½ c. OJ • ½ c. regular ice cream • 4-6 snack crackers • ¾ cup dry cereal • 3 cups raw veggies • 1 TBSP. sugar • ½ cup pretzels/chips

Enhance Therapeutic Communication

• Address the patient. • Listen actively. • Establish trust. • Be assertive. • Restate, clarify, and validate message. • Interpret body language and share observations. • Explore issues. • Use silence. • Summarize the conversation. • Use process recordings

Collaborative Professional Communication

• Assertive style • Uses standard communication tools

Types of Physical Assessment

• Comprehensive * includes a health hx & head-to-toe assessment • Focused * To obtain data on an identified actual, potential problem, body part (Ex: Fx toe) • System specific * limited to 1 body system (Ex: Lungs) • On-going * as needed: continuing to monitor

Bicarbonate

• ICF and ECF; • Regulated by kidneys • Produced to act as primary buffer in the body

Healthcare System Cultures

• Impact perceptions, understanding of health & healthcare interventions • biomedical - scientific investigation, technology, conquering disease • alternative - not part of mainstream care • holistic - harmony & balance of body in nature • indigenous - folk / traditional practices • magico-religious - supernatural forces

Erikson: Psychosocial Development

• Must negotiate eight stages as they progress through the lifespan. • A person can regress during times of stress to earlier stages/or be forced to face tasks of later stages. • Failure to successfully move through a stage leads to maladjustment

Hyperglycemia S/S

• Polyuria= freq. & excessive urination • Polydipsia= increased thirst • Polyphagia= excessive eating • 'Fruity' breath • Ketones= fat in the blood

organizations

• The Joint Commission National Patient Safety Goal 2 • Goal to improve patient safety by improving communication among caregivers. • Right to receive effective, understandable information • Right to have a language interpreter, if necessary. • The Health and Medicine Division (HMD; formerly the Institute of Medicine [IOM]) • Values patient-centered care by communicating in a way that respects patients' differences, values, preferences, and expressed needs. • Focuses on providing patient education so that patients can make informed decisions, become involved in their care, and health maintenance and healing. • National League for Nursing • promotes excellence in nursing practice with core values for caring, integrity, diversity, and excellence. • Open, clear, and respectful communication is the foundation for nurses' providing quality care that contributes to patient's well-being

Nursing Knowledge

• Theoretical Knowledge: 'knowing why'-consists of information, facts, principles, and evidence-based theories. It includes research findings in rationally constructed explanations of a phenomena. • Practical knowledge- 'knowing what to do and how to do it'- It consists of processes, for example, the decision process and the nursing process, and procedures. Example, how to give an injection. • Self knowledge- Self understanding, being aware of your own beliefs, values, cultural and religious biases. • Ethical knowledge- Knowledge of obligation, or right and wrong. This involves the use of moral principles and the processes for making moral decisions.

Sodium (Na)

• chief electrolyte in extracellular fluid (ECF) • major cation • Regulates fluid volume • Kidney reabsorbs • nerve impulse & muscle fiber transmission (Na/K pump) • Regulated by kidneys/ hormones normal 135-145

For people with visual impairment

•Introducing themselves when entering the room. •Calling the elderly woman by her name so that she can be certain that you are addressing her. •When entering a room of a client who is visually impaired, they would describe the room, room layout, and activities that are occurring. •Explain unfamiliar sounds, such as the paging system and monitor and pump alarms. •If the client has limited vision, be sure to position yourself in the client's field of vision. •Speaking to the visually impaired person before physical contact with her so that she is prepared for touch. •Avoiding speaking loudly unless the client also has a hearing impairment. •Letting the client know when the nurse is leaving the room. •Using the words see and look as you would with a sighted person. •Avoiding expressions such as "over there" or "right here." Guiding the client to the location or placing her hand on the object.

impaired sensation to the feet and lower legs

•Use a bath thermometer to monitor water temperature and prevent burns. •Change position often to relieve pressure on bony prominences. •Teach the patient to use properly fitting shoes and socks. •Report signs of circulatory impairment (declining motor function, cool, gray-blue coloration). •Inspect for wounds, abrasions, redness. •Use a bed cradle; keep bed linens loose. Inspect for open areas, cuts, abrasions, erythema.

Inadequate sleep causes

↓ Mental performance/ Impaired cognition Fatigue Daytime sleepiness Nausea Irritability & Moodiness Inability to concentrate Poor judgment Can result in stress-related illnesses Affects immune system & healing Injuries (car accidents)

hypotonic examples

▪ 0.45% normal saline ▪ 0.33% normal saline ▪ 0.2% normal saline

Hormonal Regulation

▪ Antidiuretic hormone (ADH)-hold on to water- ▪ Renin-angiotensin system ▪ Aldosterone ▪ Thyroid hormone ▪ Brain natriuretic factor, BNP

Potassium (K)

▪ Chief electrolyte of ICF ▪ Major electrolyte in all cellular fluids ▪ muscle contraction, nerve & electrical impulse ▪ conduction regulates enzyme activity, regulates IC H20 ▪ regulated by kidneys/ hormones ▪ Maintains osmolality of intracellular fluid ▪ Kidneys eliminate ▪ Assists with acid-base balance Normal levels 3.5-5.0

hypertonic examples

▪ D5 0.9% NaCL ▪ D5 0.45% NaCl ▪ D5 lactated ringers ▪ 10% dextrose in water ▪ D20W

Fluid Intake

▪ Primarily through drinking fluids 2,700 mL/day women; 3,500 mL/day men ▪ 20% from food/metabolism of food ▪ `Fluid intake regulated by thirst

Hypertonic Fluids

▪ Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartments. ▪ Used to stabilize BP, increase urine output, and reduce edema.

Hypernatremia

▪ Serum Na+ more than 145mEq/L ▪ Results from Na+ gained in excess ▪ Water shifts from cells to ECF causes •Excessive sodium intake •Water deprivation •Increased water loss through profuse sweating, heat stroke, or diabetes insipidus •Administration of hypertonic tube feeding s/s thirst dry mucous membranes & lips oliguria increased temp & pulse flushed skin confusion interventions IV therapy/diet

HyperKalemia

▪ Serum level >5 mEq/L ▪ Results from excessive intake, trauma, crush injuries, burns, renal failure s/s muscle weakness cardiac dysrhythmias Peaked T-waves on EKG causes •Renal failure •Potassium-sparing diuretics •Hypoaldosteronism •High potassium intake coupled with renal insufficiency •Acidosis •Major trauma •Hemolyzed serum sample produces pseudohyperkalemia tx diet/meds IV therapy possible dialysis

Hypokalemia

▪ Serum level less than 3.5mEq/L ▪ Results from decreased intake, loss via GI/Renal & potassium-depleting diuretics ▪ Life threatening-all body systems affected s/s muscle weakness & leg cramps decreased GI motility cardiac arrhythmias causes • Diuretics • GI fluid loss through vomiting, gastric suction, or diarrhea • Steroid administration • Hyperaldosteronism • Anorexia or bulimia tx diet/supplements/IV therapy *ensure kidney function is good before IV

Fluid Output

▪ Urine: 1,500 mL/day ▪ Skin: Perspiration (insensible/sensible) ▪ Lungs: Exhalation (insensible) ▪ Feces: 100 to 200 mL/day