Fundamentals Final

Mammography: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: xray exam of breasts P: help detect cyst,t tumors. DX or screening E: no lotions postions in breast area P: P:

Aortic Anuerysm: def, nursing actions

D:ballon like bulge in aorta that can dissect or rupture N: systolic bruit, strict control of sbp (100-120)

4 phases of illness

PHASE 1 self care remedies, take advil, go to bed early PHASE 2 assume sick role seek validation of symptoms: go to dr, call out of work PHASE 3 assume dependent role accept dx and tx plan PHASE 4 achieve recovery, resume ADL either d/t doing better or better mnging s/s

Skin - Verbalize 6 questions would you ask regarding a Skin, Hair and Nail Assessment

What is your normal skin care routine? Do you have any itching, bruises, lumps? Have you ever had a pressure injury before? Have you experienced hair loss before? Do you have allergies that affect your skin? Do you use sunscreen? Do you have any new or irregular skin growths? Have your nails changed at all?

nurses goal in chain of infection

break just one link

where can you take a bp

anywhere you have a pulse

why doesnt Cl- have its own hypo hyper category

bc it almost always travels w Na, so follow hyper-/hyponatremia to find cause/ss/tx

BSC

bedside commode

murmur what is it, emergency>

d/t valve not closing all the way, not an emergency unless emergent symptoms (SOB, etc)

*C

degrees Celsius

* F

degrees Fahrenheit

what muscle controls the bladder, what controls the release of urine, what volume can a normal bladder hold

detrusor muscle : 3 tix layer sphincter bt bladder and urethra 800mL

DM

diabetes mellitus

Sensory Processing Disorder: def

difficultly in the way that the brain receives sensory info OR the way the brain organizes and uses that info leads to challenges in interacting c eni different manifestations, can have >1

CXR

chest x-ray

COPD

chronic obstructive pulmonary disease

circulation vs perfusion

circulation: blood around the body perfusion: OXYGENATED blood around the body

daily

every day

spiromitry

exercise for lungs

deep breathing exercises what purpose, process, consideratoin

fully expands alveoli and mobilize the removal of secretions high fowlers for max lung expansion inhale slow, exhale twice as long splint chest if abdl incision 10xhr

what otcs/suppliments thin blood

garlic, vit E aka dont pair them with anticoagulants

CVC system plumbing (whats heart called, two types of circulation

heart = Myocardial pump -estnl to deliver O2 Coronary artery circulation -supplies O2 and nuts to myocardium Systemic circulation -supplies O2 and nuts to body tix

I&O

intake and output

NPO

nothing by mout

faith

refers to confident belief in something for which there is not proof or material evidence

R/O

rule out

S/P

status post

Sub cue

subcutaneously

5 special senses +2

visual auditory gustatory tactile olfactory kinesthetic -awareness of body position and movement -allows you to walk wo looking at your feet stereognosis -sense that perceives solidity of objects and their shape size, and texture

VS

vital signs

wt

weight

prn

when necessary

WA

while awake

do nurses have to administer medically futile care if the family insists

yes

do you put a pt on I&Os if they have a cath

yes

are vitamins and supplement and herbals medications?

yes!

q2h

every 2 hours

q4h

every 4 hours

hyperextension

exaggerated extention, usually double jointed, beyond 180*

lesion assessment

go over your derm terms!!!

what must be taken to do an intervention on an abnormal pulse

apical pulse for 60 sec

NSAIDs ixn c anesthesia

inhibit plt aggregation which prolongs bleeding

Frequency of pain assessment (5)

initial assesment new onset of pain pre intervention post intervention (within 1h if invasive method) routine intervals (qh, c VS)

Learning style def, VARK list

learning style -pts natural way of learning or acquiring info VARK Visual Auditory Reading Kinesthetic

post op circulatory interventions

leg exercises (ankle flex, push footboard, knee flex) early amb TED/SCD/IPC adequate hydration heparin/enoxaparin promote proper positioning

if a med lowers heart rate, when hold

less than 60bpm

Topical Medications: list 8 types

lotions, creams, ointments transdermal ophthalmic otic nasal inhaled vaginal rectal

Restraints: less restrictive

minimize any unecessary equiptment reorient pt distraction minimize stimulation ^supervision

Post-op complications: elimination

nausea vomiting paralytic ileus abdl distention -btw: normal to have faint BS 3day post abdl sx

N/V

nausea and vomiting

NEB

nebulizer

what types of procedures should you chose first

noninvasive

benefits of tympanic thermometer, method, concern

noninvasive most valic bc membrane shares b.supp w hypothalamus adult: ear up and back child: ear down and back (child down from adult) CONCERN: did you touch membrane? or wax

Pain: based on Mode of Transmission (1)

normally pain tranmissed obviously but can have REFFERED PAIN -pain in spot different than cause -male c MI: left arm hurting

rectal thermometer use? why/not? exception

not preferred except in infants invasive, some pass out from vasovagal response infants good: stims a bm

CDC hand washing recommendations, when (4)

plain or anitmoo soap 1. when hands visibly soiled 2. exposure to spore formers (c.diff, norovirus) 3. high risk clients 4. ^ likelihood to virulent pathogens

urometer

plastic attachment on a cath bag that can measure output up to the mL incriment

Evidence-Based Practice: def, components

problem solving approach to making clinical decisions using the best evidence available critical thinking + research clinical expertise (edu, experience, exposure) pts preferences, values (may override other evidence)

sensory reception

process of receiving data of external and internal environment via the sense

SOB

short of breath

ABD Assessment: urinary elimination normal x/day, normal volume, alarming volume

varies acrd to fluid intake ~5x/day WA = norm normal volume = 1000-2000ml/24 hours if <30ml/hr, NOTIFY PHYSICIAN

Cycle length, amt per night, hours per night, dev considerations

Cycle ~ 90mins Adults ~ 4-5 cycles/night Adults need ~7-9hrs sleep/night Children need much more Elderly get much less

Hormonal control of fluid and electrolyte balance: list

adrenal glands pituitary glands thyroid gland parathyroid gland

Perineal care

-pt most in need of peri-care are most at risk for inf -indwell caths, rectal genital perineal sx, vaginal delivery, childbirth -clean all pts from areas of least contam to most -performed c daily bath or after epi of incontinence -appropriate terminology -ok to model pts terminology, medical words always ok

PCA rules 3

-pt must be congnitively unimpaired and mng pushing -pt is ONLY person who make click the button -VS q4h on PCA

Is it within our scope of practice to decide if pain is occuring?

No!

respiratory rhythm (2) and depth categories (4)

RHYTHM regular irregular DEPTH shallow deep labored: think exercise breath unlabored

IV pylogram (IVP): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: XR contrast of urinary tract, kidneys, bladder, ureters P: assess s&f, dx stones, prostate probs E: may laxitive, no food 8hr P: assess renal and fluid status P: UOP

Colonoscopy: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: contrast visualixation of colon P: dx tumor cancer infectiomn, biopsy E: bowel prep, low residue diet, NPO 6hr P: d/c iron supps (sticky) P: encourage fluid intake, monitor rectal bleed

Renal Calculus: def, nursing actions

D: hard mineral deposits that form, painful, passed GU N: monitor pain, encorage amb, edu ^fluid intake, low animal fat, low na diet reduces future calculi

Arteriosclerosis: def, nursing actions

D: hardening of walls of arteries N: tch modifiable rf (lifestyle), admin cholV drugs

Cholecysitis: def, nursing actions

D: inflam of gallbladder N: antibx, NPO while acute, analgesic, pt teaching diet

Ultrasound: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: sound waves converted to images P: visualize, dx, eval blood flow, guide sx E: NPO, full bladder depd on site, smoking, gel P: ensure diet order, ensure proper psnting P: remove conductive gel, resume

4 nursing considerations for pts w diarrhea

1. answer call bells immediately -prevents falls due to urgency 2. remove cause of diarrhea whenever possible (ie Rx) -at least identify it 3. if impaction, get order for rectal exam -diarrhea can be s/s of constipation 4. give special care to tix around anus -acidic stool can >> perineal skin irritation

body position when taking bp

-best when pt sitting w back and arm supported -cuff at heart level (arm rest or pillow underneath) -feet flat or uncrossed -rest ~5min before reading (not running around) -position CUFF at level of heart

Statutory Law

-created by elected legistative bodies -Nursing Practice Act >varies from state to state >standards of care, legal scope of practice >licensure

Impact of immobility: Integumentary

-Impaired peripheral circulation

Immobility interventions: integument

-Turn q 2 for high risk patients, use natural alignment, pillows to support -Keep dry, wrinkle free linens -Progressive mobility (OOB as soon as possible)

feeding

-assess pts ability to feed self -allow them to do what they can -takes energy and muscle mvmt to ear -assess ability to safely chew and swallow **ASPRIATION RISK: fowlers, edge of bed, or in chair

Cardiac assessment: inspection (3)

-skin color: pallor, cyanosis inct heart fxnd -pedal edema: RT sided HF if bilateral -observe for visible pulsations: AAA

Hypoventilation def and causes

-ventilation inadequate to meet bodies O2 demand OR to elim sufficent CO2 -causes: atelectasis + COPD

ear care

-wash behind ears, check for PI c NC -wash external ear c washcloth covered finger -NOTHING goes in ear except hearing aids -clean hearing aids c soft cloth -assist c placement of hearing aids

Creatinine value range, what test measures, low and high value indications

0.7-1.4 Estimates GFR, follows progression of kidney disease LOW indicates: vMuscle mass, inadequate dietary prtein HIGH indicates: vKidfxn, muscle disease, CHF, dehydrn

2 tests for hypocalacemia

1. Chvostek's sign -tap facial nerve just anterior to ear causes tetany (invol twitch) on ipsilateral face or upper lip 2. Trousseau sign -inflate bp cuff abouve normal systolic (+)hypocalcemic respose = wrist, metatarsal, phalangeal, thumb flexion

what is a reasonable and achievable timeframe to expect pain to decrease

1 hour after medication administration

2 Theories of Ethics

1. Utilitarianism -greatest good -focuses on effect of action -rightness depd on consequence 2. Deonology -rights of indiviual -action right or wrong based on rule indepdt of consequences *med error, no harm. Right in 1, wrong in 2

research gap in nursing, one solution

10 year gap bt research and application to common practice sol: practicing nurses ask the question, research nurses research it

Sodium value range, what test measures, low and high value indicates what

135-145 Mmol/L Na+ level LOW indicates: hypovolemia HIGH indicates: dehydration

intradermal injection angle

15*

driving stat

37% drivers feel asleep at wheel this year

how often empty foley bag

AT LEAST every 8 hours

Needle Biopsy: def, nursing actions

D: obtain sample from organs tix bones N: pre/post outpatient but general aneths

abd

abdomen

Safety

call light in reach, bed low and locked, ID band, fall risk, no more than 3 side rails up, pathway clear

SBAR purpose

communication among hc team provides for pt safety and continuity of care

c/o

complains of

h/o

history of

what pulses should be used for routine vitals, how long take it

radial: if regular, 30sec x2 apical: 60sec

what are essential components of picking a EBP article

at least one nurse as an author within past 5 years

Med administration essential 6 step

triple check three checks six rights patient rights pre-administration assessment evaluation

Mobility enhancing exercises, what type of exercise, set s

quadriceps, gluteal, abdominal sets -isometric exercise: ^muscle tension s much movement quad: tighten muscle on front of thight/push knees toward mattress glut: contract buttocks abd: contract abdominal muscles *hold for 4 sec, then relax for 4 sec - push ups on matress, tricep dips on matress to promote upper body strength

Brief Confusion Assessment Method (bCAM) def, 4 steps

quick assesment tool to determine cognitive fxn/ACUTE MENTAL STATUS CHANGE 1. det if status changed in past 24hrs via family, chart 2. inattention: most important part -"can you name the months back from dec-july" -0-1 errors, no. 2+ or excessive time = yes 3. alt'd LOC? 4. eval for disorganized thinking -"can a stone float on water" -"is one pound heavier than two pounds" -" are there fish in the sea"

3 questions asked in process of critical thinking

What do I already know? (dont know?) How do I know it? What options are available to me?

universal pain scale, range, and populations that use it

Wong-Baker 0-10 children, pts in coma (grimace can show)

Self-care: lifespan consideration

Younger ppl -may be more indep -may have a harder time if suddenly become dependen Older adults -skin less elastic, thinner -hair thinner -dentures -may be hard of hearing *Dont injure c self care!!

high dose of prednisone causes what

^bg

wellness healthcare active or passive

active and purposeful CHOICE of living a healthy lifestyle want patients to make informed choices stress has a huge impact on wellness

ABG

arterial blood gas

ASHD

arteriosclerotic heart disease

ac

before meals

what sleep do you experience most in the begining of the night? end?

begining: more III IV cycles latter half: more REM (increase in length)

racism

belief that some races are inheirently superior to others and therefore have the right to dominate

Culturally competent nursing: what must we id in ourselves

beliefs, biases, prejudices (implicit bias test)

smaller the gauge number

bigger the needle, bigger the bevel

what should you use to fill out paper record, how are the lines used

black ball point pen: copies better NEVER skip a line draw line through remaining space ----------------- so no one can add to your entry

ABD Assessment: RLQ organs

cecum, appendix, portion of R kidney, right ovary and fallopian tube/right spermatic cord, section of ascending colon, R ureter

NEURO: Motor function which part of brain processes, list the 4 major tests

cerebellar function coordination balance equilibrium posture

gtt

drops

circle with crossed line below

female

GI

gastrointestinal

if a med requires aspriation per manufacuturer, and you see blood, then what

your in a vessel, not the muscle, so start over

VS post op time line

1st hour: q15min 2+3rd hour: q30min 4th hour +: q4h

minimum times OOB for a pt each day

3x/d

qid

4 times a day

Restraints: side rails

4 up is a physical restraint

Glucose value range, what test measures, low and high value indications

70-110 Evaluation of diabetes, hypoglycemia LOW indicates: malnut, endocrine disorder, liver damge HIGH indicates: DM, drug interaction, ^epinephrine

highest a IV pump can be programmed

999ml/hr

Circulating nurse main job 3

advocate for pt manages care ensures saftey

Pain: based on Duration (2)

ACUTE <6months beneficial: protects your body CHRONIC/PROLONGED/PERSISTANT >6months not beneficial malignants (all consuming) vs nonmalignant

ABCE for lesion warning signs

A. asymmetry B. border irregularity C. color: <2, no changing D. diameter: 6mm/pencil eraser e. evolving: any changing

Skin assessment ABCDE

A: asymmetrical B: border irregularity C: Color >2 or abnormal D: Diameter <6mm E: Evolution

Positron Emission Tomography (PET): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: meaure injected radioisotop and convert to imaged P: detetect CAD, eval myocaridum, distinguish infarction E: NPO, move slowly and ^fluid post P: ENSURE not pregnant P: slow get up (OHOTN), encourage fluids

how to check plaecmemt of an ng tube after its been confirmed with a CXR (like throughout the day

confirmed w tube length, gastric pH, visualization of contents, CXR

Computed Tomography: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: non invasive radiographic xray, cross sectional P: visualize, eval, detect structures, hemm, infarct E: NPO 8hr, may use contrast P: monitor if on sedatives for procedure P: encourage fluids

what should you do if your pt has spiritual items

advocate, see if they can leave them on if its not hurting, it might be helping may need HOH or leader to consult w before removing them

pc

after meals

Illeostomy: def, nursing actions

D: permanent ostomy, stoma RLQ, liquid drng N: ostomy care, skin integrity care and teaching, NPO and NG pre, NG decompression till peristasis returns, progress diet over 6weeks

Electromyogram (EMG): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: record electrical activty of muscle groups P: reveal nerve dysf, muscle disorders E: NO F/F rest, caffiene and smoke 2hr P: P:assess pain, monitor needle electrode sites

Cholecystectomy: def, nursing actions

D: removal of gallbladder N: incision, pain, diet edu

Amputation: def, nursing actions

D: removal of limb by trauma, illness, sx N: pain mgmt wound care, rehab, psych support

Gastrectomy: def, nursing actions

D: removal of part or all of stomach N: NPO, ng tube, pain, oral hygeine, BS, wt

Mastectomy: def, nursing actions

D: remove all breast tissue N: all pre/post, emotional support

external rotation

outward rotation

Paracentesis/Peritoneal fluid analysis: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: screening test of abdl fluid P: help dx liver, heart, kidney problems E: local anestethic P:empty bladder, labsx P:maintain pressure at insertion site, measure abdl girth

normal ranges for abg measurements

pH: 7.35-7.45 paO2: 85-95 paCO2: 35-45 HCO3-: 22-26

Osteomalacia: def, nursing actions

D: softening of bone d/t vVitD N: monitor/mng calcium, edu ^ca diet, braces

NEURO: mental and emotional status assessment

Alert and Oriented A&O x3 or 4 person place time and why you are here doc ex: "A&O x1: pt alert to name only"

Neuropathic Bladder: def, nursing actions

D: spastic of flaccid interference of nerve signaling N: bladder training, bhx mod, med, cath care, sx

how to secure cath

tape leg strap STAT LOCK

CO2 acid or base, HCO3- acid or base

CO2 acid HCO3- base

Rectocele: def, nursing actions

D: vaginal tix bulge into rectum, usually post birth N: mgmt bowel elim (soft easy), discouarge straining

Fx

fracture

Heparin therapuetic class, pt teach saftey, Lab values, anitdote

anticoagulant/antithrombolytic SAFTEY use electric razor, soft toothbrush LAB PTT or aPTT (1.5-2.0x normal) (60-100 seconds = therapeutic) ANTIDOTE Protamine sulfate

Health literacy def, consequence of poor literacy, factos

ability to read, understand, and act on health info poor lit- more likely to avoid screenings, need emergency attn factors: age, edu, language, culture, access to resources

asepsis

absence of pathogens

Restraints in hospital: 4 types just list

alternatives/less restrictive chemical physical side rails

pulse oximetry def, unit,

amount of usable O2 in blood % of RBCs that are fully saturated with O2

what does paO2 tell us

amt of O2 dissovled in blood plasma direct measurement contrary to indirect pulse ox not used in calcing ABG results tho

CBR

complete bedrest

CHF

congestive heart failure

Dsg

dressing

nonverbal communciation list

eye contact facial expression posture gait gesture personal apperance sounds silence

Topical Meds what ppe

gloves! contact w MM

parenteral meds technique and level of invasivness

invasive sterile procedure/aseptic technique -sterile = end of syringe, inside syringe, needle -can wear clean gloves

internal rotation

inward rotation

NAD

no apparent distress

NKA

no known allergies

NKDA

no known drug allergies

where do you hook at foley bag

on non moveable part of bed below level of bladder

where will you find contact precautions

on sheet by door of pts room

Common sensory alterations: neurological

periph neuropathy: d/t damage to periph nerve CVA/stroke: may have neuro/sensory changes d/t alt'd percptn or senstn

PVD

peripheral vascular disease

2*

secondary

tsp

teaspoon

Sensory Alterations: Assessment

thorough hx: injury fall burn exposures mental status physical assessment: cranial nerve assessment self-care abilities: ADLs impacted? health promotion: screening safety communication support other

Importance of REM sleep

thought to play a role in learning, memory, adaptation REM Rebound: dont get enough REM, your body will make up for it the next night

up ad lib

up as desired

Implimentation of oxygenation health promotion and illness prevention (9)

wt control diet exercise stress/anx reduction occupational safety smoke free (bx or envi) regular physcial exams UTD on flu, pneumonia vxs

critical thinking: best question to ask yourself

"what could go wrong" "what if" gray... let you see range of possibilities nursing is not "if, then"

Considerations when calling provider (4)

- Call for significant changes in physical assesment, lab findings, test results -id self by name status unit and pt name -state exact reason why youre calling -Have chart in front of you, be prepared ( current vs, lab results, meds, everything

Health Assessment: preparing for the PE (8)

- make sure theres adequate lighting -maintain a quiet, comfortable environment - provide privacy (need consent for visitors) -drape pt w sheet, visualize only one section of body at a time that youre working on (privacy, keep pts warm) -explain various assessments -keep hands and stethoscope warm -do NOT feel or listen over clothes (equipment to skin) -use standard precautions with fluids, wounds, everything really

Impact of immobility: respiratory system

-Decreased lung expansion: vO2 demand of body -Atelectasis: >> gas exhange -Retained secretions -Pulmonary embolus

nosocomial infections aka, def, stats, fun fact, how to reduce

-HAIs: hospital acquired infection -inf caused by a breach in control practices by HCPs -722,000 (1/25pts) / year in US acute hospitals -most high resistance -JUST WASH HANDS: vInf, vMortality, vMorbidity, vCost

Immobility interventions: neurological

-Meaningful stimuli -Promote natural/normal sleep patterns -Mobilize

Immobility interventions: respiratory

-coughing deep breathing -Incentive Spirometry -Increase fluid intake -Positioning -Promote activity

IVP

IV push

QSEN: Safety (4)

-minimize risk factors to self, pt, others -many interventions promote safety: bed alarm, barcode meds -nurses encouraged to share errors, near misses to learn -address safety issues as soon as identified

What can ROM detect for us (3)

-muscle strength >> grab my hand push pull >>atrophy: wasting away, sig red in size, PT need -muscle tone >>hypertonicity: rigidity >> stiff, fatigued >>hypotonicity:flaccidity: muscle loose, unmoveable -condition of the muscles >>rigidity: caused by non use, will >> contractures >>contractures: permanent shortening of tendons BAD!

Sleep Hx (7)

-nature of problem -cause of problem -other rlt'd s/s -onset and freq of problem -how problem effects ADLS -severty and tx of problem -coping and how well tx is working (basically oldcart lmao)

Essential non-nursing theories: ABC model

-priority for pt life -airway, breathing, circulation -CAB when doing CPR

Historical nursing perspectives

1. 1860: Florence Nightingale -"founder of modern nursing" -her def: "nursing"=critical thinking, respect for pt rights -crimean war: created broad education for nurses -historical role >>1. responsible for standards used to control disease in hospitals thru hand washing >>2. est'd nursing as a respected profession for women >>3. est'd nursing as a distinct profession from medicine >>4. founded a nursing school 2. Civil War -Dorthea Dix: >>head of sanitary commission of Nursing Corps of US Army (which she founded) >>after war: founded/expanded >80 hospitals for mentally ill, revolutioner in not viewing mentally ill pts as untreatable -Clara Barton >> est. American Red Cross

Civil Law: Intentional Torts 5

1. Assualt -threat of harm 2. Battery -touching without consent 3. Defamation of Character -slander = oral -libel = printed 4. Invasion of privacy 5. False imprisionment -must be able to leave informed, but AMA -bx isolation = false imprisionment

Types of supplimental feeding (2) with subsections for delivery method

1. ENTERAL FEEDING -nasogastric -gastrostomy -jejunostomy 2.PARENTERAL NUTRITION -TPN (total parenteral nutrition) STRAIGHT into b.stream >>nuts thru central line (invasive, long term)

Last 6 Steps after any interaction

1. Ensure pt in safe position >>return personal items >>ensure pt has method of summoning help 2. Remove any unnecessary items from pts space 3. Answer any question from pt or family 4. ID any unmet needs and address them 5. Tell pt when you will return 6. Hand hygiene

Altered Cognitive Functioning: impaired communication 3 types and what consultations do all 3 need

1. Expressive Aphasia (Brocha's Aphasia) 2. Receptive Aphasia (Werneke's aphasia) 3. Dsyarthria: motor speech disorder speech therapist SWALLOW assessment for disphaGia

HEENT: Head assessment (4)

1. Head position -alignment -problems r/t muscle inj, skeletal inj/abnormality 2. Facial features for symmetry (same size, postn) -eyelids -eyebrows -nasolabial folds -mouth -pathology: facial droop >>aka facial ptosis, paralysis of facial nerve 7 >> common in CVA, Bells palsy 3. Shape and size of skull -normocephalic: normal sized head -hydrocephalic: excessive fluid in ventricals >>enlarged head. emergency shunt fluid into digestive system 4. tempomadibular joint (TMJ) -crepitus in TMJ: rice crispies crackling, air accum in joint >> ok if not painful, pain = problem

Change in Shift report/hand off reports should include7

1. ID-ing info: name room # dx attending physician 2. Current apprasial of health status 3. Current orders or any new orders 4. abn occurances during shift 5. any unfilled orders that need to be continued 6. pt/family questions/concerns/needs 7. reports on transfers/dcs

Civil Law: Unintentional torts

1. Negligence -practice below standard of care -doing or not doing something a reasonable nurse would have not done or done in a similar scenario -omission or commission 2. Malpractice -nurse acted outside scope of practice or standard of care -ie pt injured by nurse (attny doesnt have to prove intent to harm) >>just has to show you did harm to pt

2 artificial airways

1. OPA oropharyngeal airway measure to fit by corner of mouth to tip of ear indicated w swollen tongue 2. NPA nasopharyngeal airway keeps airway open aka nasal trumpet

2 nursing research methods

1. Quantitative Research Methods -#s, precise accurate measures -BASIC: "pure/lab" generate/refine theory, not usually directly useful in practice -APPLIED: "practical" directly influences or improves clinical practice 2. Qualitative Research Methods -discover or gain understanding of meaning, experiences, human behavior

Medication Administration: Six Rights

1. Right Drug -in your hand (LASA drugs) -AND ordered, does it make sense 2. Right Dose -in your hand AND ordered, does it make sense 3. Right Route -can only give in route as ordered -PO but pt cant swallow? talk w team 4. Right Time -frequency as ordered -military time -timing: laxitive before PT? probably not 5. Right Patient -verify with active communication EVEN if working with them for three weeks -ID a nonverbal pt: family, other HPC, pt photo in MAR 6. Right Documentation - do right after admin, NOT before -given/not given, by who, what time, location (Rt arm), any assessment, context if refused

Peripheral Vascular Assessment: carotid artery assessmemt (3)

1. Visualize carotid artery -avoid palpating both sides -avoid excessive manipulation of carotid sheath: syncop 2. Absent or diminished pulse way may indicate -occulsion -stenosis: most com = athlerosclerosis 3. Auscultate for Bruit -w bell, one at a time, pt hold breath (xbronchial sound) -normal = absent - bruit = NARROWING , still causing turbulent = bruit -if present palpate for THRILL (cat purr :)

ABD Assessment: bowel sounds (5)

1. active -high pitched gurgling 2. absent -may be 2* to bowel obstruction, sx, paralutic ileus (lack of peristalsis) or peritonitis ** IF YOU DONT HEAR, LISTEN LONGER AND IN EACH QUADRANT 3. hypoactive - infrequent bowel sounds - may be d/t sx, npo, inflam, fluid imbalance 4. hyperactive -increased BS -often accompanied by diarrhea -may be early sign of obstruction (tryna push it out) 5. borborygmi -stomach growling: w hunger, diarrhea, imflam, bleeding, anxiety -^intensity

5 names for apical pulse

1. apical 2. point of maximal impulse 3. mitral 4. bicuspid 5. apex

5 steps in implimenting EBP

1. ask the question 2. collect the evidence 3. critically appraise the evidence 4. integrate evidence c clinical expertise + pt prefs 5. eval practice decision or change

nursing considerations for catheter placement (3)

1. confirm the order 2. provide pt comfort: sign on door, 3. provide perineal care before procedure

DYSPHAGIA S/S (7) , interventions (4 w subcat of 7)

1. coughing/gagging while eating 2. choking 3. aspiration 4. drooling 5. pockets of food retained in mouth 6. gargily sounding voice 7. sensation of food getting stuck in throat 1. have suction set up, O2 avail 2. HOB @ 45* at all times 3. HOB @ 90* when eating +30min after 4. provide appropriate level of assistance or supervision @mealtime -dont leave pt w food tray unsupervised, know when it comes -head tilted slightly forward -encourage small bites -feed slowly in relaxed atmosphere -discourage talking while chewing -place food into unaffected side of mouth -allow time for pt to eat, may take a while

steps for abg interpretation

1. det if pH is acidotic or alkalotic 2. eval paCO2 3. eval HCO3- 4. if pH and paCO2 are inversley related, repiratory problem. if pH and HCO3- are directly related, metabolic problem ROME: resp opp, metab equal

mixing meds 4 basics

1. determine compatability of meds -assume everything is not compatable -meds will change color, consistancy, crystalize -check w pharmacist, drug guide, if compatable, can go in same syringe 2. do not contaminate one med c another 3. ensure final dose is accurate 4. maintain aseptic technique

process of micturation (4 steps)

1. detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra 2. muscles of perineum and external sphincter relax 3. muscles of abdl wall contract slightly 4. diaphragm lowers >> micturation

Nursing Process: Planning: establish priorities of nDx in 3 categories, what 2 frameworks can help you determine pt priorities

1. high -emergent >> ABCs greatest threat to pts wellbeing first 2. Medium -nonemergent 3. Low -non life threatening: can be taken care of at home, long term prob that wont be solved in this hospital stay frameworks: ABCS and maslows heirarchy: in hospital, we need to meet pts physical health and saftey ( 1 and 2)

5 pt teachings on colostomies

1. reason and rationale for an ostomy 2. demonstrate self-care, ostomy management 3. f/u care, support, resources in the community 4. verbalize related fears and concerns 5. demonstrate (+) body image

Other

Adtl focused assessment based on dx or complaint

which is more potentent hydromorphone or morphine

hydromorphone 10x more potent that morphine

Heat stroke temp range, def, etiology (4), signs/symps (6 and narrative),

41.1-44.9 C heat that will have an effect on neurological status ETIOLOGY (cause) -excessive environmental temperature -high humidity -medications: malignant hypertherm from anesthetics -excessive exercise SIGNS AND SYMPS narrative: dehydration caused by excessive sweating >> ^osmolarity in vasculature, body needs to ^volume to maintain cardiac output, steals fluids by not sweating and pulling fluid from cells, INCL CNS cells >> neuro changes -hot, dry skin: not sweating -giddiness > confusion > delirium > unconsciousness -excessive thirst -nausea -muscle cramps -^pulse, vBp: heart tryna maintain CO w less volume

spinal cord injury

>> paralysis below level of injury paraplegia: v motor/sens fxn of legs tetraplegia: formerly quadriplegia (arms and legs)

MSK Assessment - Demonstrate and define flexion, extension, inversion, and eversion

FLEXION movement decreasing the angle between two adjoining bones flex arm EXTENSION movement increasing the angle between two adjoining bones extend arm INVERSERION movement that turns a body part toward midline pointing toes inward EVERSION movement that turns a body part away from midline pointing toes outward

Abdomen

Gown from xyphoid process to symphasis pubis Skin assessment, inspect: wounds, PEG or G-tube, drains, scars, peristalsis, pulsations, contour. Ask where pain, auscultate then palpate 4 quadrants and abdominal aorta

HEENT - Verbalize 6 questions you would ask regarding a Head, Ears, Eyes, Nose and Throat Assessment

Have you ever had a head injury? Do you have itchy eyes? Do you have trouble hearing? Do you have any drainage from your nose? Are you able to breath easily from your nose? Do you have a history of thyroid disease?

Topical Medications: inhaled example (2) Administration

Inhaled Bronchodilator, corticosteriod MDI Administration -shake inhaler well -attach MDI and spacer, remove mouth piece covers -pt secure mouth piece w teeth, seal lips tightly, breath normally -NO SPACER: pt takes deep breath, exhales, holds inhaler in mouth, inhales slowly and deeply while depressing medication canister -instruct pt to exhale completely, then depress canister to release puff -inhale slowly and deeplu thru mouth -hold breath for 5-10 seconds, or as long as poss, then exhale slowly thru pursed lips -wait as indicated for next puff admin -inhaler and spacer may need to be rinsed, cleaned

Head to Toe Assessment order

Introduction orientation vital signs head neck arms chest abdomen GI/GU legs skin other equipment safety

Medical Dx vs. Nursing Dx

MEDICAL DX -ids disease, illness -done by provider who directs primary tx to disease -will remain same as long as disease is present NURSING DX -id pts RESPONSE to illness, clinical manifestation of disease -describe actual and potential problems tx'd by nurse within scope of practice -may change frequently as pts response change

pain assessment tool

OLDCART Onset Location Duration Characteristic Aggravating factors Relieving factors Treatment

Managing a fire: 2 acromyns

RACE = prioritized actions Rescue pts Alarm pull it Confine the fire Evacuate PASS = how to use extinguisher Pull pin Aim nozzle at base of fire Squeeze handle Sweep at base of fire

QSEN: informatics (2)

USE OF INFO, TECH TO COMM, MANAGE KNOWLEDGE, MITIGATE ERROR, AND SUPPORT DECISION MAKING -EMRs: vEfficiency but ^safety >> bedside charting >> UTD and real time

what do you need in order to think critically

a solid body of knowledge and options

First 5 teaching strategies

audiovisual: computer, online; can be time consuming disucssion/panel discussion: exchange ideas c nurse and other pts demonstration: opp for pt to perform skill discovery: let pt(s) solve problem together lecture: formal presentation; boring, overwhelming

bx

biopsy

normal osmotic concentration of blood and difference between dehydration and hypovolemia

blood osmotic concentration: 270-305 dehydration: hypertonic-loss of fluid bu retention of solutes hypovolemia: isotonic-loss of total fluid (fluid and solutes) (ie hemorrhage)

CVA

cerebrovascular accident

CO2

carbon dioxide

special considerations/implications with altered cognition

caregiver support -watch for strain, provide support, resources, edu be attune to elder abuse and neglect

CAUTI

cather associated urinary tract infection

corticosteriods ixn c anesthesia

cause adrenal glands to atrophy which reduces bodys ability to withstand stress before and after sx, may need increased doses to increase WBC and BG *prednisone

Nutrition and metabolism effect on sleep

certain foods ^sleep: carb meal, tryptophan certain vSleep: caffiene, nicotine ETOH induces sleep but fragments it too much or too little food >> discomfort, no sleep

delta

change

CTA

clear to auscultation

Communication: gait

confidence! fake it till you make it

7 common side effects of opioid

constipation (d.t vPeristalsis and intestinal secretions) n/v sedation dizzy pruritis: often prescribed c diphenhydramine ha dry mouth

CAD

coronary heat disease

dx

diagnosis

when do we conduct nursing health assessment, what are its components

during initial contact with healthcare Health assessment = health history + physical examination

dysphagia vs disphasia

dysphagia = difficulty swallowing (g for GI) dysphasia = difficulty speaking (s for Speaking)

lytes

electrolytes

ABD Assessment: hemorrhoids def

external or internal dilated blood vessels when they rupture they look like blood in stool or blood on toilet paper

PICO(t)

how to form an EBP research topic P: pt, poulation, problem of interest I: intervention of interest C: compairison of interest O: outcome of interest (t): timbound circomstances

when do you get a fuity breath odor

hyperglycermia DKA

what meds effect sleep

hypnotics: reduce sleep latency benzos: induce sleep, but vREM cycles barbs, amphet, antideprs: vREM sleep diuretics: nocturia streriods: euphoria > insomnia asthma, nasal decongestants: stimulants > insomnia

Neurological Focused Assessment

introduction 3 questons in regard to neuro status, history I. General Behavior and Appearance II Alertness 1. A&O x4 III. Glasgow Coma scale a. eye opening (max 4) b. verbal response (max 5) c. motor response (max 6) IV. Speech -dysphasia -aphasia IV. Deep Tendon Reflexes 1. brachial 2. knew V. Balance -Romberg test VI. Coordination 1. thumb to finger 2. walk tandemly 3. finger to nose VII. Cranial Nerve Assessments

oz

ounce

pt

patient

scope of practice

range of activities, services, and qualifications

Sensory Deprivation: def, s/s. causes, interventions

reduction in or absence of usual and accostumed stimuli s/s: anx, deprsh, boredom, unsettled feeling, hallucinations (RAS creating stimuli) c: alt'd sensory perception (spinal cord injury, sleep dep) C: deprived environment (immobilized, isolated) I: ^ normal/meaningful stimuli (clock whiteboard vistors) I: ^stim to encourage normal circadian rhythm I: supportive therapy (pet, art)

transcultural nursing

research on pts beliefs to better understand how to care for them in a culturally approriate way

ROS

review of systems

tab

tablet

S&S

swish and swallow

1st intervention for any abnormal vitals

take it again

doff

take off PPE

TPR

temperature, pulse, respiration

cognition

the systematic way a person thinks, reasons, uses language the mental process of knowing, including aspects of awareness, perception, reasoning, judgement all thinking process that allows knowledge to be gained manipulated and expressed that allows us to interact in meaningful ways

Communication: intonation

tone, mood coming thru voice, the way you say words indicate interest instead of boredom, patience instead of anger, acceptance verses hostility

Nursing Process: Planning: outcome statment criteria

use SMART S: specific, pt centered, contains behavioral verb "pt will _____" M: measureable A: attainable R: realistic (pt w 10/10 pain could get to 5/10, not 0/10, set the expectation T: timebound: shortterm (<7 days) longterm (>7 days) SMART statment: "pt will __verb___ by ____timeframe_____" "pt will verbalize pain of 5/10 after 3 days"

Restraints: chemical

use of med that impaires pts ability to ixn c envi -grey areas tx of a symptoms vs use to make your job easier dose dependent: relieve symptoms, DONT make it so high they cant ixn w envi

hydraulic lift how many ppl, uses

used w 2 caregivers: one on lift, other on pt used to lift OOB to chair, OOB for linen change, OOB to toilet, off floor after fall

critical reasoning

ways of thinking about pt issues det the prob, pvnt the prob, manage the prob

WBC

white blood cell

WNL

within normal limits

Peripheral Vascular Assessment: Allen test why, how

-used to check arterial sufficiency in hand -before ABG pull so you dont loose circ to hand if you ruin the radial artery -occlude both arteries, pt hand turn white, let go of each one at a time to see if the palm pinks up

straight catheter use, procedure technique, timeline

-used to obtain sterile urine specimin -used to check post void residual if no bladder scanner -removed after bladder empy: no balloon or colctn bag -sterile procedure

2 Functions of normal sleep

1. restore physiological function -body tix restoration 2. restore psychological function -sort, discard neuropsychotic data for fxning memory -character reinforcemnt and adaptation (learn from our dreams, process things)

Purpose of enteral foods (3)

1. feeding -admin of nutritional formula via tube in digestive system 2. lavage -removal of stomach content -d/t accidental poisioning, OD -may INSTILL ns to "wash" stomach 3. Decompression -connected to low intermittent wall suction (LIWS) -txs: bowel obstruction, paralytic ileus -prevents:distension

4 must dos for assisting with ambulation

1. wash hands, id pt, verify order, explain plan, ensure you have adequate equiptment 2. use gait belt -hold or counterbalance pt if they sway 3. walk behind and to one side ( on their bad side) 4. if necc, have someone follow behind w a wheelchair

4 types of anesthesia

GENERAL -admin of drugs IV or inhaled -must be NPO prior d/t intubation -close monitoring req'd MODERATE SEDATION/ANALGESA (concious sedation) -used for short term, minimally invasive procedures -often @ bedside: chest tube, cardioversion REGIONAL -anesth agent injected near nerve or nerve pathway -ie nerve block epidural block spinal block TOPICAL AND LOCAL -used on mm, open skin, wounds, burns -can be used in conjunction c other anesthesias -local infiltrate: inject in to numb the area

NREM Stage II level, length, body conditions

NREM SII -slightly deeper level of sleep -lasts 10-20mins -bodily fxns continue to slow

where do adults spend the majority of sleep

NREM SII: up to 50%

What stages of sleep are considered deep sleep or slow wave sleep, what is slow wave sleep

NREM SIII, SIV see the delta waves on EEG

modifiable and non-modifiable risk factors

modifiable: -where we as nurses can take action, provide edu and support -ie diet, stress managment non-modifiable: -cant be changed -gender, ethnicity, age

Intraoperative nursing interventions

monitor vs safety psnt monitor for malignant hyperthermia monitor for asepsis aid in wound closure transport to pacu

how does the reticular activating system mediate sensory input

monitors and regulates incoming sensory stimuli, filters and blocks out unecessary stimuli, and regulates interpretation and rxn to simuli to achieve SENSORISTASIS: optimal arousal state, adequate alertness, not over or under

what norm is more important to compare a pts vitals to

more imp to compare to PT norm compare values against societal and pt norms, but cant interpret vitals in a vaccum

Range of Motion def, purpose, types

movement to fullest extent possible improves joint mobility, ^circ, vComplications, Active: pt dors themselves, ADLs by themself Passive: -nurse or assnt moves pts joints thru full range of motion to the fullest extent possible -move until theres resistance, but not pain

pronation

mvmt of front of body part downward

supination

mvmt of front of body part facing upward

flexion

mvmt that dec angle bt bones

extension

mvmt that inc angle bt bones

NG

nasogastric

Post-op interventions: elimination

obtain order for antiemetic bowel rest npo ngt: if vomiting too traumatic on surgical site promote amb and exercise maintain fluids admin fiber, stool softeners, suppositories as ordered encourage food pt likes

Post-op complications: psychological

often poor self concept in hospital vSleep, vAutonomy, vNormal hygiene

cranial nerve pneumonics

oh oh oh to touch and feel a girls v* sweet heaven some say marry money but my brother says big butts matter more

HEENT - Perform the six fields of gaze and visual fields.

ok!

critical thinking helps eval and anticipate change in a pt conditions before or while its happening

ok!

who's at a big r/f depression

older adults d/t isolation, role change, stimuli decrease

ICU psychosis

pt have sensory overload from being ill and in intensive care unit (beeps, activity, lights) >> alt'd though process -hallucinations, delusions, pull tubes, hard to reason with

= with slash

unequal

can meds go in enteral tubes? what meds are pref'd, which meds cant, what are some funky ways to do it

yes! liquid meds best enteric coated and time release NEVER allowed many tabs can be crushed and many capsules can be opened (ask pharmacist, check drug guide)

PE

pulmonary embolism

RBC

red blood cells

5 serious sef of opioids,

resp depression, arrest circulatory depression apnea HOTN shock

primary concern for those with cognitive impairment

safety

STI

sexually transmitted infection

clinical manifestation aka

signs and symptoms

Chest

skin assessment, heart sounds (APTM), lung sounds (B,BV, V ant/pst), chest wall abnormalities

Arms

skin assessment, radial and brachial pulses at same time, movement (symmetry and strength), hand grasps, cap refil, clubbing, IV site check (note which arm, follow tubing back to pump)

what do you clean a placed cath and perineum with

soap and water

Antibiotics interactions with anesthesia

some can potentiate anesthetic agents ie aminoglycosides ( the mycins) may increase respiratory depression into paralysis BUT some used just prior to surgery prophylactically

religion

subcategory of spirituality, faith oriented organized system of belief about a higher power including rituals, practices, and organizations

sup/supp

suppository

Sx

symptoms

inversion

turn foot in toward midline

ambu bag (4)

-used during CPR until pt placed on vent -used b/a suctioning -may provided temporary ventilation to ventilator pts while transporting -may be attached to O2 source

Hyperventilation def, causes

-ventilation in excess of that req'd to elim normal CO2 -causes: anx, infection, drug, hypoxia, fever, ASA od, DKA

NEURO: nervous system functions (5)

1. initiation/coordination of movement 2. reception/perception of sensory stimuli 3. organization of thought processes 4. control of speech 5. storage of memory

7 qualities of teaching-learning relationship

1. pt focused 2. start c somehting the patient is concerned with 3. discover what the learner knows 4. teach simple to complex 5. schedule time for review of topic 6. holistic: mind body spirit 7. interactive: willing pt x nurse

Resect: def, nursing actions

D: cut out tix or part of organ N: pre/post

Anastomose/Anastomosis: def, nursing actions

D: sx cxn bt two structures N: monitor body image, pain, nutrition

Gate Control Theory: whos the gate keepter

Gate keeper = dorsal horn provides ides for pain relief by remembering the >>sensory, emo, behx, and cognitive parts of pain address more dementions for more holistic and individualized approach to therapy -pts gotta believe in it for it to work

Peripheral site complications: Infiltration def, s.s, tx

IV fluids enter surrounding space and around veinipuncture site S/S edema pallor* coolness around site* pain difficulty flushing IV infusion dc, remove iv, raise extremity, apply warm compress

Similarities and differences between Depression and Dementia

Sim: -memory problems -sluggish speech, movment -apathy, decreased motivation Depression -rapid, know a&o, difficulty with concentration Dementia -slower progression, confused and disoriented, difficulty with short term memory

where is the brachial artery

always located medial to bicep tendon in antecubital fossa

Fluid balance, what effects it, how long for balance to adjust, output types

balance achieved w oral uptake of fluid matching kidney outpud perfect balance not met every day, over 2-3 days sensible output: can be seen and measured (urine) insensible output: cannot be measured (resp vapor)

Bar code administration definition

barcodes on individual dose packages scan package then ID band makes admin safer, NOT fool proof >>may not catch every errror

ABD Assessment: bowel habits regular, in hospital, natural laxatives (4)

baseline can vary widely: 1-2x/day to 2-3x/week will probably change in hospital prune juice, hot water, bran, fiber Try natural laxatives first

electrolytes why need em, ions, cations, who is where

basis foe chml rxns nec for metab cations: Na+, K+, Ca2+, H+, Mg2+ anions: Cl-, HCO3-, PO40- in cell: K+, PO4-, Mg2+ outside cell: Na+, Cl-. Ca2+, HCO3-

hemoptysis

bloody sputum

CA

cancer

respiratory assessment process

count resps for 30 if reg x2 if irreg (<12, >20) count for 60 sec **sneaky: do while still holding pulse or auscultating the apical so pt is unaware

arrow pointing down

decrease

direct and indirect measurement of bp

direct: -INVASIVE -catheter directly into artery via arterial line (aka ART line) -used only in critical care settings indirect: -NONINVASIVE -auscultation with diaphragm of steth and bp cuff or dinamap

ECG/EKG

electrocardiogram

L

liter

3 categories of food that effect bowel elimination , and the one biggest impact on constipation

**FLUID INTAKE = #1 impact, ^fluid:vConstipation 1. constipating foods -cheese, lean meat, eggs, pasta 2. foods w laxitive effect -fruits, veg, bran, fiber, choc, coffee, alcohol -last 3 = irritants >> ^peristalsis 3. gas effects *DONT help w contsipation >> more dicomfort -onions, cabbage, beans, califlower -usually veggies, tough to break down

when do we perform hand hygiene (9) and for how long

- 15 sec for each hand -enter/exit facility: 2MIN SCRUB -bt pts (even in same room) -b/a eating, toileting -b/a caring for any client -b/a gloving -after contact w any body fluid *even if gloves on -b/a touching a wound -b/a invasive procedure -after handling contaminated material

small intestine 3 parts, 3 functions

- duodenum, jejunum, ileum -fxns >>secrete enzymes aiding in prot and carb digestion >>receive liver and pancreatic enzymes for digestion >> food digestion and nutrient absorption into b.stream

Guidelines for nursing practice: Licensure name, who admin, exam goal, specialty, OH

- national counsel of licensure examination (NCLEX) -administered by State Board of Nursing -exam: standardized minimum knowledge base -specialty certs avail after time on specific unit -OH renew: 24hr course (1hr on OHRN law), every 2yr

QSEN: informatics (2)

- nurses need to access pt care and professional resources -EMRs: vEfficiency but ^safety >> bedside charting >> UTD and real time

Peripheral Vascular Assessment: jugular vein assessment how assess, 3 causes, influenced by what, whats normal

-Pt in semi-fowlers -visually inspect for distention -3 causes: RT sided HF, HTN, Hypervolemia -influenced by >>blood vol >>capacity of rt atrium to rcve and expell blood >>capacity of rt vent to move blood (AKA RtsdHF) NORMAL = (-) JVD >>normal to see during exercise

Cardiac assessment: palpation (2)

-cap refill: bilateral fingers and toes -assess for pulse deficit >>simultaneous apical and radial count (ususally use two nurses.. if a deficit, APICAL is always gonna be going faster)

Peripheral Vascular Assessment: hx question

-leg cramp, pain -numbness, tingling in extremitites: neuro or perfusion -cold sensation in hands or feet -pedal/ankle edema -cyanosis: feet ankles hands -sitting/laying w legs crossed -smoking: ^vc, platelet aggregation, vFxnl hbg -exercise -nutritional probs: atherosclerosis -medical risk factors >CAD >Atherosclerosis >HTN >phlebitis >DM >Vericose veins

NEURO: Coordination assessment

-performance of rapid, rhythmical alternating movements >> thumb to finger >> walk tandemly >> finger to nose

Nursing Process: Diagnosis: nursing diagnosis def (3), what to use to write

1. " a clinical judgement about individual, family, or communities responses to actual and potential health problems 2. nurse analyzing assessment data to determine dx 3. nursing dx are labels to pt-centered problems USE Gordon's fxnl health patterns to create dx -ONLY use current NANDA approved statements

3 post op respiratory complication

1. Atelectisis -diminished lung sounds 2. Pneumonia -crackles 3. PE -DEV IN FIRST 48HR POST OP -most freq in ortho sx -s/s: restless, check pulse ox

3 ways drugs are classified

1. Body System -how they act against a disease or disorder 2. chemical composition 3. clinical indications for therapeutic effect -therapeutic classifications: broader (antihypertensives) -Pharmacologic classifications: >> indications, precautions, MOA, contraindications and nursing implications are similar in this class >> IE beta blockers >>DIFF: dosage availability, onset, duration

NEURO: Deep Tendon Reflex assessment 2 types, how to do them

1. Brachial tendon -have pt stand hang arms to lap -two fingers on bicep tendon -tap own fingers w hammer, hand should clutch 2. patellar -pt sitting, feet dangle, eyes closed -dont get kicked in the face! -tap on soft divet under patellar, lower leg should kick

In event of med error 4 steps

1. DONT PANIC 2. ASSESS pt immedietly -collect data (what med, anticipated side effects) to determine what you need to assess 3. Notify prescriber -may need supportive tx, reversal agents, monitoring -report what they received, your assessment 4. Complete incident report -within 24h -communicate and collect error data to create change to prevent error in future

Sx based on purpose (6)

1. Diagnostic/explorative -try to confirm dx, look to see extent of disease, bx 2. Ablative -remove diseased body part -ie appendectomy 3. Palliative -ofter comfort to pt, relieve or reduce intensity of illness -not a cure -ie colosotmy 4. Reconstructive -restore fxn or improve self concept -ie skin graft, internal fixation of fracture, plastic 5. Transplant -replace organs that are diseased or malfunctioning 6. Constructive -restore fxn in congenital abnormality -ie cleft palate oral construction

safety concerns in older adults (3), our role

1. Loss in physical functioning 2. Loss in acuity of sensory-perception function 3. Loss in cognitive judgement Our role: advocate for, educate, protect vulnerable populations, id environmental hazards

Medication Order types 7

1. Routine -carried out until cancelled or expired -ie "metropolol" daily or "q6h for 3 days" 2. Standing -carried out if circumstances exist that require that med -ie: hypoglycemic order: if bg <60, then give xyz 3. PRN -only when pt requires it -will be given w a freqency -ie HTN, prn for pain q4h 4. Single -one time, now or later -ie anxiolytic before MRI tomorrow 5. STAT -single dose given immediately -usually if not given pt will be harmed -most facilities circumvent safety protocols for STAT orders, usually prescriber there or on the way 6. Telephone or Verbal Orders -less freq, mostly just goes into computer -saftey: #1 only accept this in an emergency #2 write it down and repeat it back to prescriber -you put order in chart, it gets flagged to be signed at a later time 7. Medication Reconciliation -helps protect pt from miscomm about regimines -reviewing and adjusting med lists -get med list when they come in, recosiliate w any new meds, when the change floors, upon discharge

Peripheral Vascular Assessment: carotid artery assesmemt (3)

1. Visualize carotid artery -avoid palpating both sides -avoid excessive manipulation of carotid sheath: syncop 2. Absent or diminished pulse way may indicate -occulsion -stenosis: most com = athlerosclerosis 3. Auscultate for Bruit -w bell, one at a time, pt hold breath (xbronchial sound) -normal = absent - bruit = NARROWING , still causing turbulent = bruit -if present palpate for THRILL (cat purr :)

Medication Administration: Three Checks

1. check med order 2. check patient allergies 3. check med expiration date

9 complications of tube feeding

1. diarrhea: most common, esp w continuous feedings 2. dry mouth 3. aspiration 4. displacement of tube 5. mucosal/skin irritation: r/t tube 6. lyte imbalance 7. ^blood gluc: especially when nut begins, nutdense 8. gastric distension 9. occulsion

Acute care implimentation: 5 considerations

1. dyspnea mngmt -any sob? pulse ox concerns 2. airway maintenance -mobilize secretions -suction -manage artificial airways 3. maintenance and promotion of lung expansion -psnting -incentive spirometer, productive cough, deep breathing -chest tubes 4. CPR -advanced airway considerations 5. Hydration

ostomy comfort measures (5)

1. encourage recommended diet and exercise 2. use meds only as needed 3. apply ointment or astringent 4. use suppositories that contain anesthetics 5. special ostomy sets designed by wound care nurses

medication administration: NG, G, PEG route 15 steps

1. gather 60ml warm water, 30flush before, 30 after 2. 7 steps and 6 med rights 3. crush and dilute meds in water if necc 4. perform any necessary assessment 5. elevate HOB to 30-45* 6. towel below tube, put on gloves 7. insert syringe into tube 8. follow insitutional policy about checking placement 9. close off tube 10. 30ml in, unclamp, flush tube with water 11. pour med, if discomfort, stop until better 12. flush 30ml water to clear any tube obstruction 13. clamp tube remove syrine 14. IF DECOMPRESSION wait 30 min b4 resuming 15. leave HOB elevated for 30-60min

developmental considerations that effect bowel elimination (infant, toddler, child/adol/adult, older adult)

1. infant -stool character/frequence depends on food choice (formula>>more formed, B.milk>>more freq, pastelike) 2. toddler -phys maturity is priority in bowel training -voluntary control begins ~22-36 months 3. child/adol/adult -variable freq: 1-2/day, 2-3/week -most imporant: det what the PTS normal is 4. older adult -constipation often a problem -vMobility: diarrhea, incontinence -change in muscle ton, diet, mobility, Rx

chain of infection (6)

1. infectious agent: bact, fungus, virus, prion 2. source: animal, human, inanimate object 3. portal of exit: sputum, emesis, stool, blood 4. mode of transmission: contact, vehicle, droplet, airborne, vectorborne 5. portal of entry: mms, nonintact skin, GI GU Resp tracts 6. susceptible hosts: immcomp, elderly, chronically ill, trauma, surgery (like, all hospital pts)

glove types (5)

1. latex: -check for allergies, -molds well to hands -better for precision -cheap 2. synthetic latex-free: -used most -harder to feel thru 3. vinyl -use if allergic to latex or powder -$$, but almost as good as latex 4. chemotherapy -chemo agents will absorb thru skin -use even when handling body fluids, give to anybody who cares for pt 5. rubber household: -use for cleaning instruments -ostomy bag explosion

Skin texture assessment (8)

1. smooth -normal 2. rough -usually in ppl in trades, dermatitis, eczema 3. thick -calloses 4. thin -elderly, caution w friction, tape removal (use adhesive remover) 5. tight -sometimes serus fluid will leak out of edema 6. indurated -hardened or raised 7. scarred -scar tix 70-80% weaker than normal skin 8. wrinkled

Bed Making

1x/daily or when soiled wear clean gloves encourage pt to get oob occupied bed change easier c two people place soiled linens in hamper, dont contam uni dont shake sheets do not place pillow under chin

Braden Scale categories, score range, concerning number, how to increase a category score, how often do you measure

6-23 low#:high risk, high #:low risk concerning # = 18/23 done every 24 hours 1. sensory perception -can they feel pressure related sensation 2. moisture -excessive moisture=risk factor (ESP incontinence) 3. Activity - getting OOB, walking 4. Mobility -can they turn and move IN bed 5. Nutrition -especially protein: most imp to skin health 6. Friction and Shear forces -rubbing vs pulling (and separating of layers)

what does "societal norm" mean with ie vitals

80% of healthy adults falling within a given range

ethnicity

A sense of identification with a collective cultural group, largely based on the group's common heritage *through birth OR through adoption of characteristics

pregnancy categories

A: no risk to fetus in the first trimester B: no adverse efs in animals, no human studies C: risk shown in animals, insufficient data in pregnant women, give only after risk to fetus considered D: definite fetal risk, give only if life-threatening condition exists X: absolute fetal abnormality, NEVER USE in pregnancy

what is insignificant and what is important about different temperature taking sites

ALL sites norm falls bt 35.8-38.1 BUT be consistent in WHAT SITE you take temp on a pt!! or else your numbers will mislead you

Cardiovascular and Peripheral Vascular - Verbalize how to perform and Allen's Test and Pulse Deficit

ALLEN occlude both arteries (radial and ulnar) wait until palm pallor, then release one and see if pink up, rotate and repeate PULSE DEFICIT two care givers, one asses apical, one artery 60 seconds counting pulse Apical - Radial = deficit

Nursing Code of Ethics, year, who, what is it

ANA 1950 ethical obligations and duties of every nurse professional and non-negotiable ethical standard -may exceed legal requirements

7 Adverse effects of medications, def

ANY effect other than therapeutic effect 1. Side effects -can be minor - potentially dangerous -may cause pts to dc a drug 2. tolerance -require ^ and ^ of dosage to see same effect -often in long term opioid use 3. toxicity -accum of meds or byproducts d/t excretion or dosing problems -elders most at risk d/t vFxn of organs 4. idiosyncratic ef -unusual response to med: over ef or underef or opposite effect 5. Severe Adverse Effect -FDA label: response to med life threatening -would req intervention to prevent death, perm imparment 6. Allergic Rxn -unpredictable immunologic/histamine response after previous exposure to med 7. Anaphylactic Rxn -most severe allergiv rxn -pharyngeal edema, bronchoconstriction, resp/cardio collapse -tx: epinepherine AND CALL 911 -hospital tx: epinepherine + diephenhydramine or famotadine

Nonopiod analgesics: 4 categories, therapeutic actions, a few key pts

ASA -analgesic, anti-inflammatory, antipyretic, anticoagulant -take c food NSAID -analgesic, anti-inflammatory -take c food ACETAMINOPHEN -analgesic -works at brain, not at source -antidote: mucomyst CORTICOSTERIODS -analgesic, anti-inflammatory

Factors affecting cognitive function

Age: never normal to have impaired cognt Nut/metab: imbalance o2, nuts, wastes > imprd Sleep&rest: insuff > vCalculation, memory, prob sovling Self concept: internal voice telling you your capable Infctn: espc in elder, test for uri/utiI c impr, dehyd, vACh Degenerative process: dementia Head trauma: most in adolescents, elderly Pharm agents: polypharm, sefs, tox Envi: sensory overload, deficit Culture, values, beliefs: communication = part of cogntn

Professional nursing organizations: AACN who, goal, provides what

American Association of Colleges of Nursing -org for BSN and grad programs -goal: quality edu standards, influence nursing profession to improve HC, research, promote public support to edu -provides accreditation to edu programs

Professional nursing organizations: ANA who, who, mission, publication

American Nurses Association (ANA) - prof org for RNs in USA -made up of State Boards of Nursing -mission: involvement in public edu, clinical nursing standards, lobbying -publication: Nurses Code of Ethics >>values of a nurse, i.d boundary of duty, describes duty of nurse beyond pt encounters

9 drug classes that ^risks of sx

Antibx (some) Antidysrhythmias Anticoagulants Anticonvulsants Antihypertensives Corticosteroids Insulin Diuretics OTCs (some)

Numeric Sedation Scale (POSS)

Assess POSS q4h is opioid on board ^# = ^ sedation S: sleep, easy to arouse = no action needed 1: awake and alter = no action needed 2. octnly drowsy, easy to arouse = no action needed 3. freq drowsy, falls aslep during convo = ADJUST dose 4. somnolent c min/no response to sim = D/C opioid, consider NALOXONE

Nail assessment

Assess clients nails for I. Color II. Thickness III. Texture IV. Clubbing V. Capillary refill

flow of a normal sleep cycle

Awake > SI > SII > SIII > SIV > SIII > SII > REM > SII ...

whats a nurses role when it comes to pain

BELIEVE THEM not your job to determine if they are telling the truth Dr. Myers: 98-99% telling the truth

first thing you do for an alt'd mental status patient

BG and pulse ox

Non-pharmacological tx for dyssomnias

CBT -progressive muscle relaxation (toes up) -stimulus control: use bed for sex and sleep -biofeedback and relaxation therapy: breathing, etc -Sleep restriction > #1 therapy > get up at same time, only sleep when tired (no naps no sleeping in)

Respiratory - Identify lung sound on manikin and cause - Crackles

CRACKLES CAUSE -alveoli trying to expand c fluid in the (lower) lungs -left-sided heart failure, pneumonia

best teaching methods for each domain of learning

Cognitive Domains -discussions, handouts, reading, audiovisual Psychomotor Domain -physcial manipulation, demonstration Affective Domain -roles playing, values clarification

Upper GI Series: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: XR CONTRAST of esoph, stom, s.int P: det hernia, blockage, tumors E: barium consume, low residue diet, NPO/nic midnight plenty of fluids, light colored stools P: P: encourage fluids, enema if ordered

Amniocentesis: def, nursing actions

D: amniotic fluid from uterus removed and tested N: full bladder pre 20wks, empty post, monitor for leaking cramping, infection

Dialysis/hemodialysis: def, nursing actions

D: artifical kidney used to filter blood N: thrill and bruit check q8h, avoid extremity for bp or iv, monitor for hemorrahage

Ultrasound: venous doppler, extremeties studies: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: assess venous blood flow in U&LE P: dx venous disorders E: caf/nic restrict 2hr P: P: notify provider of emergent findings

Electroencephalogram (EEG): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: attached to scalp, record brain electrical activity P: det seizure disord, eval electrical activity r/t disease E: avoid caffiene 15m pre, NO SMOKE 8HR, P:wash pt hair, hold psych meds 24-48hr pre P: reomve electrodes, watch for seizure activity

Cholangiogram/Cholangiography: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: contrast xray to visualize bile duct post cholesystectomy P: assess patency and detect calculi E: NPO 6hr, remove metal P: fat-free dinner, dye admin P: asses kidney fxn

difference bt DTI and pressure injury

DEP on LOCATION over a boney prominence, then opens >> PI not over boney prominance >> DTI

Depression: 3 main characteristics, s/s

DEPRESSION: RAPID DECLINE, A&O, REVERSIBLE -sadness, anger, fatigue -losing interests in hobbies and pleasurable activts -social w/d and isolation -wt loss anorexia -sleep disturbances -loss of self worth -^use of alch drugs -fixation on death, suicidal thoughts attempts

Enteral Nutrition: tube feeding administration postion, 2 things to check before you start, asepsis technique style, formula consideration, tubing consideration

FOWLERS verify placement check GRV clean technique formula may be diluted if ordered tubing should be labeled w date and time and replaced regularly to prevent infection

Body Fluid compartments: intracellular fluid and extracellular fluid stats, types

INTRACELLULAR FLUID -ICF critical to cell size -70% of all body fluid is ICF -40% of adult body wt is ICF EXTRACELLULAR FLUID -30% of all body fluid is ECF -20% of adult body weight is ECF 1. intravasular fluid: plasma 2. interstitial fluid 3. transcellular fluid: csf, pleural, peritoneal, synovial, digestive secretions, sweat

where is bm involuntarily controled? voluntarily controlled? ef of diminished awareness of stim or ingoring it

INVOL -feces in area from sigmoid to rectum VOL -feces thru anal sphincter -ignore? may diminish signal reflex to brain when bm gets under vol control -loss of control >> incontinence, diar, constipation

IVPB

IV piggyback

jejunostomy aka, what is it, when is it preferred, what can still happen

J-Tube -tube inserted thru abdl wall into jejunum -by bypassing stomach, regurg and aspiration prevented -emesis MAY still occur, likely just bile, NOT tube feed

Safety goals in all healthcare organizations, who created them, why these, what are they (7)

Joint Commissions National Patient Safety Goals for Hospitals identified as high risk areas 1. improve accuracy of pt identification 2. improve effectivness of communication among caregivers 3. improve the safety of using medications 4. reduce the risk of HAIs 5. id pt safety risks 6. use alarms safely 7. prevent mistakes in surgery

MAR, eMAR def

Medication Administration Record -legal document where nurses document med administration as it occurs -every med every dose: route, freq, time, special instructions, who admin'd, where on body, how -especially important to avoid duplicate dosing Electronic Medication Administration Record -exact same, used electronically

Order of oxygen equiptment used on a patient

NC > simple face mask > venturi > non-rebreather > BIPAP/CPAP > ET tube/ventilation

Insulin: Intermediate-acting generic names, onset, peak, duration

NPH, isohpane 1-2 hr = ONSET 4-12 hr = PEAK 16 hr = DURATION

pt prep for sx 6 importants

NPO IV access bowel prep, empty bowel and bladder if indicated skin prep/hygeine pre-op meds: what needs to be held vs given removal of dentures, jewelry, hearing aids

Professional nursing organizations: NLN who, what do they do

National League of Nurses (NLN) -premiere org for nursing faculty and educators -recognizes CONS for excellence (kent 2x!)

Think your patient has a cognition change? expect these labs

O2 Sat: hypoxia >>imprd cog = one of 1st s/s. very senstv Glucose: 25% goes to brain, hypo = prob Na: hypo or hyper > vPressure or ^perfusion Ca: hyper >> lethargy Ammonium: hyper >> toxic to brain Urea: RF >> build up, impaired cog WBC/Hg/Hct: infct? hypoxia d/t anemia Drug toxicity

respiratory gas exchange

O2/CO2 exchange via diffusion will tell you about your pts cardiopulmonary status

Neuro - Identify CN 1- CN IV - names and how to assess

Olfactory -smell test: sense of smell Optic -Snellen eye chart: visual acuity Oculomotor -pupil moment: PERRLA Trochlear: -eyeball movement up and down: 6 fields of gaze

Parasomnias def, when, biggest concerns, and(7)

PARASOMNIAS -wakeful activities that happen during sleep (III, IV, sometimes REM) -biggest concern = saftey -Somnambulism: sleep walking -REM Bhx Disorder (RBD): acting out dreams -Sleep terrors: children in deepest sleep sit up screaming, cant be woken or consoled -Nightmares: vivid and disturbing dreams -Bruxism: teeth grinding -Enuresis -Sleep-Rlt'd ED: consumes food with no recolection

Stress: positive, negative

POSITIVE -eustress: motivational energy that brings happiness and hopefulness -may lead to constructive change, progress -ex: stress w throwing a party, getting married NEGATIVE -distress -may lead to chronic stress, illness, death -may lead to vSleep, vNutrition, neglect warning signs of illness, failure to seek tx

Stoma assessment: how often to assess, abnormal findings, healthy stoma apperance, special assessment consideration

POST OP -q2h for 24hr -q4h for 28-72hr -q4-8h routinely or prn HEALTHY -postop: some pain, bleeding, edema, lapse of fecal elim -highly vascular: beefy red or pink in appearance -smooth surface Consideration -no nerve endings that cause sensation of pain, so may be irritated w/o pt awareness -check for: dermatitis, rash, pimples of stoma or skin around it ABN: -blue purple dusky pale -extremely swollen, prolapsed -extensive edema -retraction

Respiratory - Identify lung sound on manikin and cause - Rhonchi

RHONCHI CAUSE -air moving over mucus in the large airway -smoking, chronic bronchitis

IM: syringe size, needle gauge, length, angle

SYRINGE 3-5mL NEEDLE 21-23 gauge = normal parameters 1"-1.5" = normal parameters (can be 18-25, 5/8"-1.5") *det length and gauge by wt, muscle mass, age, injection site, medication viscosity, residual effects of medication

SUBCUE: syringe types, needle gauge, length, angle

SYRINGE insulin syringe (orange cap) 1-3mL NEEDLE 25-31 Gauge 3/8" - 5/8" , sometimes up to 1" some insulin syringes may have 5/16" needles ANGLE 45* or 90* depending on pt size

what does pulse oximetry measure

SaO2 indirectly: diffusion and perfusion of O2

Major nursing theorists: Orem name, ct, def, nurses role, ex

Self-Care Deficit Theory -CT: pts self-care needs req nursing care when inj/ill -self care: learned, goal oriented activity directed toward maintaining life, health, dev, wellbeing -nurses role: i.d problem, make plan, intervention, eval how much youre needed -ex: feet pt who has 2 broken arms

vital signs

TRP, BP, Pulse ox, pain

Cardiac assessment: auscultation what side of steth, where do you auscultate for them, how long listen to each, what do you do if you cant hera

USE BELL cant hear? have pt lay SIMS to lean heart toward anterior listen for 3-4beats each valve 1. Aortic Valve -test at 2nd intercostal space to RT of xyphoid 2. Pulmonic Valve -test at 2nd inrtercostal space LT of xyphoid 3. Tricuspid Valve -RT AV valve -4th-5th intercostal LT of xyphoid 4. Mitral Valve -LT AV valve -4th-5th intercostal at MIDCLAVICULAR line

Topical Medications: Vaginal examples (3) and administration

Vaginal Antifungal, antibiotic, hormone replacement Administration -ask pt to void -put on gloves -dosal recumbant, draping, lighting -perineal care: clean front to back at vaginal orifice -remove gloves, put new gloves on -fill vaginal applicator w prescribed cream or get suppository ready -lubricate applicator or suppository as necessary -applicator: like a tampon -suppository: lube gloved finger on dominant hand, spread labia and insert rounded end along posterior walll of canal to the length of your finger -remain supine for 5-10 min -offer perineal pad to collect drainage

whats the rule about "risk for..." statment on NANDA dx sheet

any nanda statment can be made a "risk for..." statment but NO "risk for" statments can be made diagnoses >> theyre alluding to medical diagnoses, so we cant use them IE Risk for infection : "Infection" is NOT a nDx

spirituality

anything that pertains to a person's relationship with a nonmaterial life force or higher power

critical thinking def

application of ideas to an experience to arrive at a valid conclusion includes reasoning and judgment guided by ethics, laws, policies, procedures, nursing process, scientific method metathinking

Insulin: Rapid acting generic names, onset, peak, duration

aspart, glulisine, lispro 15-30 min = ONSET 30 min - 2.5 hour = PEAK 3-6 hour = DURATION

how to check gastric residual volume, why, acceptable level of residual, why

aspirate contents via the tube measure amt aspirated eval gi motility, if pt risk for aspiration, absorbtion efficiency return aspirated contents to stomach check MD order for acceptable amt prior to feeding IF >200mL, notify provider

nursing process: Acid base regulation assessment, interventions, eval

asses -resp rate and depth -cog fxn, loc changes, dizziness intervention -alt'd resp rate/depth: slow or speed breathing -admin O2 -admin HCO3- eval improved pH resp rate and depth normal and adequate

goal of perioperative nursing

assis ppl to achieve a level of wellness equal to or greater than which they had before

BRP

bathroom privileges

PO

by mouth

Communication: vocabulary

choose appropriate, let pt set tone no medical jargon unless w HCP pt ask and use pts preferred name

what causes 80% of errors in hospital

communication errors

CBC

complete blood count

Adventitious lung sounds (5) names, etiology listed

crackles ronchi wheezes pleural friction rub stridor fluid mucus narrowed or obstructed airway alveolar collapse or re-inflation inflammation of pleural lining

insulin ixn c anesthesia

decreased nutritional intake, but increased stress

Insulin: long-acting generic names, onset, peak, duration

detemir, glargine 3-4 hr = ONSET continious = PEAK 24 hr = DURATION

race

dividing ppl into groups/pops by various sets of PHYSICAL characteristics (skin pig, facial features, hair texture)

informed consent for sx who does, what is it

done by surgeon explains expected outcome, procedure, risks, complications legal document make sure its in appropriate language and literacy level

Post-op interventions: mobility and self care

early amb: watch tubes assist c care, but encourage self care get off iv meds asap so they can go home comfort and rest

5 values of the professional nurse

est'd by AACN in 1988 ALTRUISM -concern for the wellfare of others, advocate, take risks on behalf of others AUTONOMY -respect for the patients rights even if yo disagree HUMAN DIGNITY -treat as being of worth INTEGRITY -provide care based on Code of Ethics SOCIAL JUSTICE -fairness, nondiscrimination, equal acess

why do we do a PE and hx before surgery

establish a baseline establish pt risks

IV solutions: hypotonic solution example, tx what

half strength NS = 0.45%NS often used as maintenance fluids, provides Na+, Cl-, free water

ht

height

Skin moisture assessment (5)

i. hydration -normal = dry -too dry ^^risk for wound development >>>dehydration, smoking, stress, sun exposure -oily from washing too much ii. diaphoresis -^^^ in hormone imbalance (menopause), infection iii. flaking scaling crusting -more common in elderly: poor skin regen -overuse of soap: can be abrasive iv. excessive dryness -eczema: @joints, white plaque, skin regen too fast -dermatitis: inflam of skin, erythema, dry

arrow pointing up

increase

Peripheral site complication: Phlebitis def, s/s, tx

inflammation of vien s/s pain edema erythema* heat around site * redness traveling the path of vein dc infusion, remove IV, raise extremity, apply warm compress

Peripheral site compliations: basics, two types,

injury to vein infiltration, phlebitis perform IV assessment everytime your in room QH transparent bandage so you can visualize the insertion site

lt or L with a circle around it

left

ABD Assessment: LUQ organs

left lobe of liver, stomach, spleen, body of pancreas, L kindey, L adrenal gland, portions of transverse and descending colon

evaluation of pt teaching why, methods

lets nurse and pt know how well the learning objectives were met, where revisions are needed METHODS direct questions observations: did they just get 2 slices of cake on ADA return demonsration: watch them change dressing NURSES must evaluate themselves as teachers

Communication: eye contact

lets pt know you want to talk to them attending skill >> im paying attention to you

4 important things to ensure on your equipment before taking a bp

make sure needle on 0 or in box (calibration) quiet environment equipment to SKIN : remove any clothing use diaphragm

mcg

microgram

why cant you hear blood flow in radial artery with a stethoscope

not turbulent blood flow with a cuff >> turbulence >> sound

Temperature in Farenheit

oral 98.6 temporal 98.6 tympanic 99.5 axillary 97.7 rectal 99.5

Health Assessment: Head-to-Toe PE Framework def, use

organized assessment from head to toe used as quick assessment, brief examination every pt should get one

Nursing Process: Planning: aka, 2 steps

outcome identification 1. goals or outcomes are det'd and appropriate interventions chosen 2. nurse develops a plan of care that prescribes the strategies to obtain outcomes ("pt will.." statements)

aseptic technique

practices or procedures that minimizes or eliminates pathogens to help reduce the risk of infection

Common sensory alterations: hearing (2)

presbycusis: age rlt'd hearing loss cerumen accumulation

what 2 categories of bed positions are there

procedural positions therapeutic positions

Good Samaritan Law

protect HCPs practicing within scope and standards of care provide legal immunity after providing appropriate assistance during an emergency NOT legally required to help in OHIO

P

pulse

learning definition, 4 processes we do to learn

purposful aquisition of new material the process by wich a person aquires or incresaes knowlwedge or changes behavior in a measurable way as a result of experience study, instruction, reflection, practice

Insulin: Short-acting generic names, onset, peak, duration

regular 30-60 min = ONSET 1-5 hour = PEAK 6-10 hour = DURATION

R

respirations

rt or R with a circle around it

right

What levels of hygiene care can a pt be

self care assisted care total care

Post-op intervantions: wound care: skin an incisions

splinting c movment hydration and nutrition adbl binder prevent infection (standard precautions, prophylactic antibx)

Communication: facial expression

stay NEUTRAL***** during odor, questions, if pt says something inappropriate, stay neutral

systolic and diastolic pressure defs

systolic: the amount of pressure put on your arteries by the force the heart exerts during L ventricular contraction diastolic: the amount of pressure put on your arteries by the force the heart exerts at rest

tbsp

tablespoon

Common sensory alterations: other uncommons

taste: can be d/t meds sefs, smoking, lose c age smell

T

temperature

bid

two times a day

good wound documentation includes (8)

type size loc edges drainage odor infection treatment

UGI

upper gastrointestinal

URI

upper respiratory infection

UTI

urinary tract infection

UA

urine analysis

stairs with cane or crutches

use cane, ONE crutch up with the good, down with the bad Up: good leg, crutch + weaker leg Down: crutch, weaker leg, strong leg

minimizing discomfort during injectable (8)

use smallest suitable needle position client comfortably select proper size use distraction as appropriate stabilize the skin hold syringe steady insert needle quickly, dart-like, and smoothly inject med slowly

ABD Assessment: what divides the abdomen

vertical: xyphoid process and symphysis pubic horizontal: umbilicus

c^

with

QSEN: Quality Improvement def, how

** MONITORS OUTCOME OF CARE -done by quality departments and nurses at point of care

9 types of therapeutic diets, 3 types of preparation orders, whats they deal between these

** can be on more than one, or on a preparation order WITH a therapeutic diet :) 1. NPO: NOTHING, MAYBE sips w oral meds if ordered 2. Clear liquids: liq you can see thru AND liq @ roomtemp (includes jello) 3. Full liquids: anything liquid at room temp 4. GI soft/slow residue: gentle to digest: BRAT (banana, rice, applesauce, toast) 5. High fiber: whole grain, fruits, veggies 6. Low sodium: <2g/day 7. Low cholesterol: "low animal fat diet"> lean meats 8. Diabetic (ADA): no added sugar, vCarb to acheive bp,bg,chol,wt goals 9. Regular: anything, no restrictions 1. pureed: pt unable to chew, baby food consistancy 2. mechanical soft: easy to chew 3. enteral feeding: formula, can be in-place of or supplemental to oral diet

Preadministration Assessment (9)

**BEFORE any/every administration 1. Include direct (pt convo) and indirect (chart, pe) data 2. medication hx 3. allergies: what are their s/s of rxn 4. current med list: any poss ixn 5. diet hx or diet order: poss ixn, ac/pc 6. neurological probs: can swallow? alt'd sense of reality and dont want to take/pocket meds 7. current condition: plan of care for day, no lax b4 PT 8. lab values: many meds impact lab work 9. PE: assess bp before antihypertensive, find out last BM before laxative

Impact of immobility: Cardiovascular system

-Increased cardiac workload: low venus return, ^HR -Orthostatic hypotension: sluggish baroreceptors -Thrombus formation and embolism

Impact of immobility: Musculoskeletal system

-Muscle atrophy, weakness, impaired endurance -Contractures and joint pain (long term complctn) -Disuse osteoporosis= s wt- bearing activity, bone bv faster than rebuild

Nursing interventions for alt'd resp fxn

-O2 therapy -aerosol therapy -cough and deep breath -incentive spirometry -chest tube and trach care -BIPAP and CPAP

nose care

-O2, anticoag >> dry mm, epistaxis -particular attn req for NG or ET tube placed >>look for skin bV >>clean accum secretions from around the tube >> replace tape 1x/day to prevent nasal mucosal irrtn

Immobility interventions: GU

-OOB for elimination -Increase fluids -Progressive mobility (as tol, dangle, nonslipsocks, assitive devices, proper assistance)

Immobility interventions: cardiovascular

-Orthostatic VS -Gradual position changes -DVT prevention

Potential breaching in confidentiality

-SIGN OFF COMPUTER: other logging in as you -display info on public screen -sending confidential emails from you gmail accnt -discarding pt info into trash can -holding convos that can be overheard -faxing confidential info -sending confidential info over pagers that can be overheard

most common HAIs (4)

-SSIs: surgical site inf -respiratory infections (pneumonias) -UTIs: #s down recently due to aseptic tech for foleys -vascular access-related bacteremia

Health Assessment: PE Inspection def, what youre looking for, notable

-close careful visualization of person and each body system beginning when you 1st enter room -look at: general appearance-lookin good, lookin bad, color, breathing -symmetry: side to side comparison, equal movements -look and observe BEFORE touching

Medication Administration: Post-administration Evaluation (3)

-completed based on onset and duration of action (minutes up to weeks) -define therapeutic effects: is it doing what its supposed to be doing -define adverse effects

Sleep definition

-cyclical physiological process that alternates with longer periods of wakefulness -rest + altd level of conciousness + inactivity -necessary for a healthy, restored body and wellbeing

Hypoxia def, causes, signs

-inadequate tix oxygenation at cellular level -causes: low Hb, vInspired O2, inability to exact O2, vDiffusion of O2, poor tix perfusion, impaired ventilation -signs: presentation will differ depending on if acute or insidious ACUTE S/S: apprehensive, anx vLOC vLung sounds ^pulse rate, bp ^rate, depth of breath dypnea, use of accessory muscles to breath cardiac dysrhythmias INSIDIOUS S/S: pallor fatigue vAbility to concentrate dizziness bx changes cyanosis clubbing adventitious lung sounds

where to inflate bp cuff to, how to take estimated systolic pressure

-inflate cuff +30mmHg past pts typical systolic pressure -if pt or chart knows, use that -2 step method, if not 1. put fingers over radial pulse 2. inflate cuff until pulse disappears (est'd), +30mmHg

Major nursing theorists: Nightingale notables, ct

-initial model of nursing -CT: environment of the pt -cleanliness, fresh air, ventilation, temperature, light, nut - used data to link ^^ to health outcomes >>STILL used today

Major nursing theorists: Nightingale notables, ct

-initial model of nursing -CT: environment of the pt -cleanliness, fresh air, ventilation, temperature, light, nut - used data to link ^^ to health outcomes RESEARCH >>STILL used today

Local factors effecting wound healing (4)

-moisture: if its dry wet it, if its wet dry it >>dessecation: cells dehydrate, die, form crust >>maceration: bv from prolonged moisture -trauma: repeated inj to area (fingertip) -edema: interfere w b.flow -infection: stress on body, takes energy away -bleeding: cant heal if bleeding. clots must clear too -necrosis: must be removed to heal -biofilm: occurs in wounds, sugar and protein film protecting bact. tough to manage

tracheostomy

-opening into trachea where O2 can be delivered -used when UPPER airway blocked d/t illness (throat/mouth ca) , trauma

urine tests: Urinalysis what testing

-test pH, protein, glucose, ketones, blood, wbc -pH range 4.5-8.0

strength of pulse scale

0/absent: requires doppler for assessment +1: thready: weaker, hard to find, can be normal for pt if symmetrical +2: normal +3/4: bounding, see pulse through skin, can be normal for pt if symmetrical

Types of wound healing (3)

1. 1* intention -clean incision: edges approximated -early suture -hairline scar -granulation tix not visable -vRisk of infection 2. 2* intention (aka contraction and epithelialization) -edges not well approxd: gapping irregular wound >>ie pressure injury, burn -granulation -epithelium grows over scar -slow, more scaring, relatively ^risk of inf for being open so long 3. 3* intention (delayed closure) -wound deep, purposely unsutured and left open -granulation -closure w wide scar, deep scar

effect of medications on stool 5 categories and their effects

1. ASA, Anticoaggulants -pink, red, black stool r/t gi bleeds 2. iron -black, contipating -pts perscribed iron or on high iron diet -often prescribed a stool softener bc iron is constipating -need occult blood test or other test to det gi bleed 3. antacids (high doses) -white or speckling in stool 4. opiods -constipation

Health Assessment: Functional health patterns (first 6) (usually a def and then some questions youd ask in an assessment)

1. Activity and Exercise -gait and balance -decreased motility, assistive devices -self care -exercise amt? SOB in short distances? 2. Circulation -ability to transport O2 and nuts necessary to meet cellular needs -Bp? good tix perfusion? 3. Coping/Stress/Ego Integrity -ability to manage life experiences -coping strategies? perception of stress? support system? 4. Elimination -adequacy of bowl and bladder function -normal bowel/bladder patterns? constipation, diarrhea? incontinence? 5. Nutrition/Fluid -ability to utilize nuts and liquids to meet physiological needs -dietary habits? signif wt chg? dysphagia? n/v? med problems that are altering diet? 6. Perception and Cognition -clients ability to think -alert and oriented (a&o) x3/4: person, place, time, reason why youre here -^^ start v broad if appropriate (what year is it)

Principles of Body Mechanics (4)

1. Assess the situation before acting -is the area safe? -what might happen next? 2. Work at the appropriate height -work at waist or hip height -use a wide base of support and soften knees -face direction of movement -bend knees, work close to object to be moved -use big and long muscles: arms and legs, NOT back -be conscious of core strength to stabilize and support your back -contract glut and ab muscles when lengthening spine 3. Use leverage, rolling, pivoting and gravity instead of lifting -whenever possible -use motility devices to reduce friction, make easier - easier to push objects instead of pull 4. Move on a level surface -ensure wheels are locked before movement initiated

5 diagnostic tests for urine assessment

1. BUS -bladder ultrasounds, amt in bladder, assess post void residual 2. KUB -kidneys ureter bladder XRay 3. IVP -Intravenous Pylogram: KUB with contrast 4. Cystoscopy -visualize lining of bladder -camera up thru urethra, eval bladder 5. Urodynamic studies -series of tests to see how everything is working, up to 12 different studies can be chosen from

6 Principles of Ethics

1. Beneficience -doing good or promoting good for others -careful eval of harm/bene for each indvidual 2. Nonmaleficence -"do no harm" 3. Autonomy -respect for persons right to make own decisions 4. Justice -fairness 5. Veracity -being honest 6. Fedelity -keep promises -never abandon pts entrusted in your care

BIPAP and CPAP

1. Bilevel Positive Airway Pressure -mechanical ventilator to assist inspiration -pushes air into lungs during inspiratory effort - (+) pressure helpts prevent atelectasis -bilevel: more air pushed in than comes out in expiration 2. CPAP -O2 under constant pressure -used @ night w periodic hypoxemia, sleep apnea

6 diagnostic studies related to CVC status

1. Bloodwork -CBC (Hbg/Hct >> anemic?) -Cardiac enzymes >> creatinine kinase (CK), troponin: ^^could indct MI, chest trauma -Serum electrolytes: BMR (Na, K, Cr) -Cholesterol: compare to last screening 2. Stress Test -EKG + physical activity: look for rate, SOB, abn rhythm -NPO light breakfast (NO caffine) -chml induced stress test if cant get on tredmill 3. Cardiac Catheterization -guidewire up femoral artery to SupVenaCava, eject dye thru coronary arteries to detect blockages -implications: usually NPO, after: remain flat for 1+hr, monitor femoral puncture site, sandbag, HOB^ later to vPressure on femoral site 4. TEE -Transesophogeal Echocardiogram -scope thru esoph shine light on heart for imaging -NImpl: concious sedation, NPO that AM, sore throat 5. 12 Lead EKG -leads on chest, one on each extremity -12 views of heart, can narrow down issues 6. Halter Monitor -leads + ADLs, results recorded -pt notes pains, palpitations, check if rhythm disturbance

Respiratory assessment: Palpation 2 tests

1. Chest excursion -measurement of proper ventilation - hands at end of exhalation, placed under scapulae with thumbs touching -ask pt to breath w maximal inhalation, thums should spread -NORM: equal spread, ABN: one hand doesnt move COULD INDCT lung not filling w air 2. Vocal/tactile fremitus -vibrations felt on hands on scapulae, between scapulae, below scapulae -"99" should feel vibration -lack of vibration: accum of mucus, lung collapse, lesion

Factors that ef integumentary system (7)

1. Circulation -v: abn color, text, moisture, thick, temp, injury 2. Nutrition -vit/minerals, protein needed for wound healing 3. Condition of epidermis -excessive drying:broken skinm 4. Allergy -rxn often first seen in skin (rashes, hives, swelling) -mediated by histamine release 5. Infection -comm: strepto/staphylo opportunistic, fungus, warts 6. Abnormal Growth Rate -psoriosis, excema: non malignant chronic excess skin prod 7. Systemic diseaes -PVD, edema (itchiness caused by tox buildup) -peripheral neuropathy >> injury, lack of sensation

3 Learning domains

1. Cognitive Domain -store comprehend and recall new knowledge -intellectual thinking and understanding -defines, decribes, identifies, relates, recognize 2. Psychomotor Domain -learning a physical skill involving integration of mental and muscular activity (motor skill) -demonstrates, assembles, creates, constructs -measured in speed, precision, or technique in exicution 3. Affective Domain -includes changes is attitudes, thoughts, values, feelings -shares, answers, actively participates -demonstrates interest in topic, discusses feelings

2 pieces of O2 equipment that hang on the wall

1. Flowmeter -attaches to wall-unit O2 outlet -adjust how much O2 being delievered -ALWAYS know and check that its set correctly 2. Humidifier -sterile water that provides moisture to the O2 -air goes straight to lungs, so its STERILE -prevents drying, cracking, bleeding w nasal mucosa >>>happens w NC

alterations in fluid balance: two types of problems w subcats

1. Fluid Volume Problems -hypovolemia >>fv deficit >>loss of fluid and solutes from ECF, draws fluid out of ICF -dehydration >> loss of total body water >> ^Serum Na+ -hypervolemia >>Fv excess >>retain water and sodium in ecf >> intravascular excess = hypervolemis >> interstitial excess = edema 2. Fluid Distribution problems -Third Spacing >>fluid moves into transcellular spaces or interstitial spaces >>>>Causes hypobvolemia bc fluid is unavail for use

Wound healing 4 stages

1. Hemostasis (0-48hr) -vasoconstriction: stop bleeding >>platelets activated, then v.dialation -exudate production: plasma leak into injury area due to ^capillary permiability (exudate = plasma) -clot formation: plug bleeding at site 2. Inflammatory (4-6days) -vasodilation: bring in the troops -phagocytosis : WBCs injest foreigns, relase Gfactors -localized inflammatory response >>normal: pain, warmth, red, swelling -generalized inflammatory response (sometimes) >>fever, malaise, ^WBC 3. Proliferative (3-24 days) -new tix built to fill wound space -fibroblasts and growth factor create collagen and b.vessels -granulation tix formation: thin beefy red layer of epitheial cells that are highly vascularized 4. Maturation (up to 2 yrs) -collagen matures: continues to be deposited -scar tix creatd: avascular, no hair, no sweat, ~70-80% strength of normtix after full heal SO a pressure injury more likely to occur in same spot than new spot

6 formats of nursing documentation

1. Initial Nursing Assessment -baseline for later comparison: all hx, ht2 2. Care Plan -problems, goals, interventions 3. Patient Care Summary -overview of valuable data: achieving goals? 4. Progress notes -info EACH caregiver of progress pt is making -ex: narrative notes, SOAP : free text 5. Flow Sheets and Graphic Records -Flow Sheet: quickly document care -Graphic Record: graphs specific variables 6. MAR -must include all meds -includes ONLY nurse giving drug, reason drug was ordered, its effectivness 7. Discharge and Transfer Summary -summarizes reason for tx, findings, procedures, tx -pts condition on d/c should be recorded (even if its death) 8. Home Healthcare/Longterm documentation -sent to 3rd party payers for insurance verification -est need for continuing home healthcare as well as reimbursments for necessary services

6 indirect GI visualization studies whats done, what are they looking for

1. KUB -abd xray of kidneys ureter bladder -look for air, blockages, narrowing 2. UGI/small bowel series -pt consumes barium contrast, coats tract, Xray -look for strictures, narrowing, fistulas, delayed emptyin 3. Barium edema/ lower bowel series - instead of drinking, barium instilled thru enema 4. Abd Ultrasound -eval for gallbladder disease, abd in general 5. MRI -sliced cross sectional view, much clearer than xray -look for fluid collection, abn structures 6. abd CT scan -sliced cross sectional view, much clearer than xray -look for fluid collection, abn structures

5 General Med Administration Principles

1. Keep med in OG packaging until immd prior to admin -only person who prepped the med should admin it >>if in syringe, HECK NO, in og packaging, check chart -this is the 3rd check, also you need that barcode 2. Do NOT leave meds unattended -med security -verification of administration: watch pt take med 3. Unused meds disposed of following special rules 4. Hold meds based on your assesment, collab w prescriber -SHOULD hold if assesment indicates its unsafe to give 5. Controlled substances -reg'd by federal law >who can prescribe, specific record keeping, procedures for dispensing and wasting

Essential non-nursing theories (3)

1. Maslow's Heirarchy of needs 2. Lewin's Change theory 3. ABC model

NEURO: 5 intellectual functions to assess

1. Memory -recent/short term: have them remember 3 word for 15m -remote/long term: ask fam what they should know, then ask them (NOT y/n questions) 2. Knowledge: "why were you admitted" 3. Abstract thinking: interprets colloquialisms ("dont put the cart b4 horse") 4. Association: mneumonics, analogies (bird:nest::beaver:what?) 5. Judgement -logical decision making -"what would you do if the car in front of you stopped"

Inhaled medication devices

1. Metered Dose Inhaler (MDI) -spacer (aerochamber) allows particles to be suspended longer so pt can deep inhale into lungs with a few breaths (5-6) instead of just one 2. Handheld Nebulizer (HHN) -med + O2/air becomes vapor to inhale

Health Assessment: PE Head-to-Toe Assessment lifespan considerations (4 cat)

1. Neonates, infants -keep covered -involve parents, communicate, build therapeutic rlxn w parents 2. Toddler, preschoolers -involve parents -explain in simple terms -use role playing (bp: "give your arm a big hug") 3. School-age, adolescents -proper draping -honest answers to questions 4. Adults, older adults -prepare client for all procedures -provide privacy -older clients can be chilled easily -provide warmth: warm blankets, espc after bathing -make accommodations for limited flexibility, prepare to go slow and not rush pt, if necessary

Post-op nursing assesment 6 systems

1. Neuro -routine A&O, pupillary response, muscle strength 2. Resp -routine c VS -monitor patency, rate, depth, 3. Cardiac -routine c VS 4. Dsg -monitor for drainage, hemorrhage, hematoma -dsg post op = 1* dsg, most surgeons want to change -if drainage, just reinforce it. if more, call 5. pain mgmt -intensive pharm and non intervention, antiemetic 6. renal -I&O (>30ml/hr) -use bladder scanner to check rtn

3 Phases of Nurse-Client relationship

1. Orientation phase -est. trust/rapport -macro: 1st ixn at hospital, micro: start of every ixn -bring up termination in every orientation 2.Working phase -develop and implement solutions to concerns -evaluate interventions -the "everything else" 3. Termination -closure of relationship -macro: last ixn at hosp, micro: end of each ixn -usually discussed and det'd at orientation bc ppl usually in a rush to get out

Skin color assessment (4) where you look, why, what about in dark skinned clients

1. Pallor (lack of color) -face: low o2 -mucus membranes: low o2 2. Cyanosis -hypoxemia:hypoxia:blueing -LATE sign of hypoxia, should know by pulseox before! -lips: circumoral -nailbeds/fingers/toes: peripheral -core cyanosis: very severe, intvnt before this 3. Jaundice -yellowing, accum of bilirubin r/t liver disease -can be relatively normal in certain ethnicities -sclera: yellowing of the eye white 4. Erythema -redness on bony prominences -SI pressure injury: non-blanching, intact -capillary occlusion:hypoxia:necrosis -sacrum: sitting, heels:weight of foot, greater trochanter:hip prominence *Dark skinned pts: look for pallor in mm, erythema by palpating for heat

3 abnormal respiratory conditions

1. Pneumothorax -air or gas in pleural cavity -r/t puncture thru pleura, chest wall -AEB: SOB, DOE, absent lung sounds/fremitus -causes collapsed lung -needs reinflation via chest tube 2. Atelectasis -collapse or incomplete lung expansion -r/t mucus, hypoventilation (d/t immobility), compression by tumors of enlarge lymph nodes -tx: get them OOB and incentive spirometry 3. Subcutaneous Emphysema -leak of air from lung tix into Subcue tix -r/t post-op thoracic sx, blunt chest trauma, chest tub leaking -AEB: rice krispie feeling upon palation

Health Assessment: Health History: Sources for gathering information (2)

1. Primary source -direct info from the patient -can be meds, cc, pmh 2. Secondary source -info from ANY OTHERS: family member, close friends, EMT, PCP, medical records

oxygenation diagnostic studies (9)

1. Pulmonary Function Test -pt breath into machiene, record tidal vol, any restrctive issues 2. ABG 3. Oximetry 4. CXR -PA and Lateral: post/ant/lat (pt must be able to stand) -Portable: brought to bedside if pt cant stand 5. Bronchoscopy -NPO, concious sedation, after, NPO till gag returns -scope thru nares, visualize down to lungs, bxs taken 6. Lung Scan (V/Q Scan) -ventilation perfusion scan: eval circ of air and blood IN the lungs 7. Thoracentesis -take fluid off lungs, pt dangle lean on table, needle into pleural space to aspirate **MONITOR the puncture site 8. Throat Cultures -swab off back of throat 9. Sputum Specimens -r/o bactl infection

Medication Administration: Patients Rights (7)

1. Right to Information - tell them what your administering, why (especially if a new drug), what side effects may occur 2. Right to Refuse -pt can refuse anything -our job: be sure they understand what theyre refusing (informed refusal), find out why theyre refusing, document, tell prescriber 3. Right to Careful Assessment -ensuring correct administration 4. Right to Informed Consent -tell them what youre administering 5. Right to Safe Administration -cognitive processes (saftey) and technique 6. Right to Supportive Therapy -mom stuff: antiemetic, but also wash their mouth, wipe their face 7. Right to have NO Unnecessary Medication -tx pts for symptoms they are experiencing, NOT for our connivence (considered chemical restraint)

4 elements of communication

1. Sender (encoding) -person who initiates the convo, usually the nurse -encode in manner receiver can understand -AVOID medical jargon except w medical professionals 2. Communication channel -verbal and nonverbal (70%) 3. Receiver (decoder) -gotta be able to decode: hard of hearing, too complex a message -blind pt: describe nonverbal to them 4. Feedback -receiver becomes sender

Skin assessment Braden Scale categories

1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear

Guidelines for nursing practice (3)

1. Standards of Nursing Practice 2. Nursing Practice ACT 3. Licensure

4 types of drug ixns

1. Synergy/Synergism -therapeutic effect ^ w presence of second med -ie Multimodal pain mngmt: opioid + local anesthetic + NSAID + muscle relaxant 2. Antagonist/Antagonism -one med impacts eftvness of anthoer in a (-) way -vTherapeutic ef (ie vit k and warfarin 3. Incompatability -chml incompatability w liquid meds, two meds make new substance -most concern: injectables -sol: give them 2 inj, or flush iv between 4. Teratogenic -med ef developing fetus -see pregnancy categories

3 methods of problem solving

1. Trial and Error -use judiciously: when nurse has adq knowledge and experience and the risk is minimal to the pt 2. Scientific Problem Solving -lab situation, not clinically applicable 3. Intuitive Problem Solving -used frequently in nursing: nursing intuition "somethings wrong" -"expert decision" -validate intuitions when possible, if you cant, elevate the pts care to prvnt a (-) outcome

Peripheral Vascular Assessment: peripheral venous assessment (3)

1. Varicose veins -superfical dilated veins -typically in legs -common in long standers and sitters 2. Peripheral edema -dependent, pitting non pitting 3. Phlebitis -inflam of veins >> redness, swelling, warmth, pain -many turn into clots (thrombus = clot from phlebitis) -if in calves >> DVT

factors effecting bowel function (9)

1. age: ^infants, vElderly 2. lifestyle: more active >> ^peristaltic activity 3. diet: ^fiber fruits veg ^ body rid of wastes 4. exercise: more active >> ^peristaltic acitivity 5. meds/anesthesia -meds can cause diarrhea, constipation -anesth: bowel asleep for a while, pass gas or have bm = gut waking up, starting to move to normal, can slowly take off NPO 6. pain: hemorrhoids, may need stool softener 7. tix integrity: poop = acidic > incont or diar >vTixInteg 8. hydration: vFluid slows passage of food > hardening 9. habits: hospital may affect normal habits

Supportive devices (6)

1. bed pillows/foam wedges -maintain psnt, support extremities 2. footboards/boots/high top sneakers -prevent footdrop/plantarflexion common in long term immobility >>shortening on tendons>>diff ambulating in future -keeps foot in dorsiflexion to prevent foot drop 3. cradle -keeps blankets/sheets off legs if friction causes trauma or pressure 4. trochanter rolls -rolled up blankets @trochanter to prevent external rotation of femurs 5. hand rolls -washcloth/foam held in palm to prevent excessive contraction of fingers 6. abduction pillow -hip replacement risk of dislocation from internal rotation of femur -triangle pillow bt knees to prevent dislocation

withdrawing medication from a vial 9 steps

1. disinfect stopper on vial 2. pull back plunger on syringe equal to desired amt of fluid 3. remove cap from needle, place on table 4. pierce stopper c needle using 90* angle 5. keep tip of needle in air at top of vial 6. inject air into vial, keep thumb on plunger 7. invert vial and syringe, keep thumb on plunger 8. retract needle so it remains in fluid 9. aspirate plunger to withdrawal desired amt of fluid

Meds and their ef on urination

1. diuretics -prevents reabsorption of water and some elctrolytes in renal tubules >> ^vol urine 2. Cholinergic meds -stim detrusor contraction >> urination 3. Analgesics, tranquilizers -supress CNS -diminish effectiveness of neural reflex

2 complications when straining for bm

1. hemorrhoids 2. vagus nerve stim >> bradycard >> fainting

I&O ice chips, popsicle

1. ice chips: 1/2 solid volume (ie 1Tbsp of ice chips = 7.5 mL on intake) 2. popsicle: 2oz, but check box

6 outcome ID and planning steps for pt edu

1. id SMART goal for learning 2. decide which domain of learning involved 3. prioritize 4., select content and appropriate teaching strategies 5. relate content to pt learning style 6. formulate verbal or written contract c pt >> share goal, a game plan

steps to det if body is compensating for an abg problem

1. if pH abnormal, but both paCO2 and HCL3- abnormal = partially compensated 2. if pH abnormal, and only one of variables abnormal = uncompensated 3. if pH normal, use 7.4 to det if its over or under, then det primary problem =totally comensated

ABD Assessment: abdominal assessment pt setup (8)

1. pt supine 2. head resting on small/no pillow 3.arms straight @ sides 4. knees flexed to relax abd muscles (dorsal recumb) 5. abd exposed, drape other areas 6. room lit well and warm 7. have pt empty baldder 8. inspect AUSCULTATE, PERCUSS, PALPATE

ket points on positioning (4)

1. pts who req asstnc when postn need to be reposntd at least q2h around the clock 2. promote independence and CHOICE when repontg -let them choose or assist if able 3. include ROM activities w psnt changes -if pt can bend knees, grab rail, push up 4. consider use of supportive devices or specialty mattresses -if pt has ^risk of complications

7 Skin nDx

1. risk for impaired skin integrity 2. impaired skin integrity 3. impaired tissue integrity 4. bowel incontinence (braden assesment) 5. ineffective individual coping 6. disturbed body image (5&6: impact of scars 7. self mutalation

HEENT: Nose assessment (8)

1. shape -palpate externally for tenderness, swelling 2. size -watch for edema 3. skin -breakdown or excoration (top layer scratched away) >>of nares: blow nose too hard, NGtube=abrasive 4. color 5. patency -occlusion of nares, open or ease of flow -test: occlude one, nostril have them breath, note congestion or unequalness 6. mucosa -color -lesions: nasal polyps (wart-looking, benign) -discharge -swelling -evidence of bleeding (bleeding nose= EPISTASIS) 7. deformity -deviated septum: offcenter septum r/t break 8. sinus -inflammation: externally palpate from and maxially facial areas for tenderness (pain=sinus inf) >>front = above eyebrown >>maxillary = below eyes under cheekbones

Assistive devices (4)

1. side rails -used for leverage 2. draw sheet / bed pad -used to help repsnt pt -draw sheet: under shoulders and to thighs -bed pad: @small of back 3. mechanical bed -raise, lower bed 4. trapeze -triangle bar suspended so pt can use upper body to move self in bed -make sure you teach them and theyre using it!

Principals of nutrition (4)

1. study of how food noursihes the body 2. physiology, pyschology, SES 3. nurteints=special biochml substances used by body to operate 4. water= MORE VITAL than food >>provides necc medium for all chml rxns >>NOT stored in the body

3 processes and systems in place that reduce errors

1. tallMAN letters -for Look Alike Sound Alike (LASA) meds -ie: ePHEDrine, EPINEPHrine 2. high alert meds -meds likely to cause harm if an error occurs -ie insulins, heparin 3. Dual Verification -two people confirm the Med Rights

PT EDU: assessment before teaching(5)

1. what needs to be taught, how 2. physical condition: pain, sob, noise 3. leaning ability: whos the pt, cultural and language barriers, learning style 4. motivation: leads to better compliace 5. compliance: increased c fam support, home nurse

3 methods to adress health literacy

1. written material at 5th grade level 2. "ASK ME 3" -three questions pts should ask provider to promote communication and improve understanding - What is my main problem -What do I need to do -Why is it important for me to do this 3. TEACH BACK METHOD -allows pt to repeat key concepts from teaching to confirm understanding

Organs/systems that manage fluid and electrolyte balance: kidneys, heart and vascular, lungs, gi tract roles

1.Kidneys -filter 180L of plasma, excrete 1.5L / day -manage plasma volume and osmolarity -regulate lyte levels by retaining or excreting 2. Heart and vascular -circ fluid, get perfusion and glomerular pressure to kidneys for filtration -stretch receptors respond to changes in volume, stimulate fluid rnt if hypovolemic 3. lungs -water vapor excreted/lost perday ~300ml -can increase w hyperventilation 4. nervous system -osmorecpetors sense change in ECF concentration -stim pituitary to release or inhibit ADH -cellular dehydration activates hypothalamus (thirst center) 5. GI tract -absorbs water and nutrients

BUN value range, what test measures, low and high value indications

10-20 mg/dL Liver fxn, indirect assessment of kidney fxn LOW indicates: malnutrition, overhydration, liver disease HIGH indicates: chrnc renal failure, CHF, shock, MI

Platelet value range, what test measures, low and high value indications

150,000-450,000 mm3 Total platelet component of whole blood LOW indicates: chemotherapy, anemia, leukemia HIGH indicates: polycythemia, post splenectomy

where to place bp cuff

2" above artery

how fast to inflate/deflate cuff, how long to wait bt bp assessments

2-3mmHg/sec (SLOW) 2 min

Circadian rhythm: def, what does it control

24hr day/night cycle influence the pattern of major bio and bhx fxns controls body temp, hormones, bp, mood >>>temp lowest at 0200, bp low in morning too

Potassium value range, what test measures, low and high value indicates what

3.5-5.0 Mmol/L K+ level LOW indicates: hypovolemia HIGH indicates: dehydration

WBC value range, what test measures, low and high value indications

4,500-11,000 mm3 Total WBC component of whole blood LOW indicates: toxic/radiation exposure, b.marrow fail HIGH indicates: inf disease, leukemia, severe stress

sleep disorder stats

40mil americans have chronic long term sleep disorders sleep deprvtn/disor = >100Bil/yr d/t lost productivity, expenses, sick leave, damagess

normal adult cardiac output

5L/min

HEENT: Eye assessment last 6

6. Lacrimal gland -normal = inability to palpate -loc'd above eyebrow 7. Tear ducts -normal = inability to palpate -can have clogged, might need sx 8. Conjunctiva -mm of eyelid -normal = pink, pale = anemia, hypoxia -conjunctivitis = pink eye, discharge 9. Sclera -white of eye -jaundice seen here 1st or only in dark skinned patients 10. Cornea -abnormal = cloudy/opaque 11. pupils PERRLA=pupils equal, round, react to light, accommodate PERRL= pupils equal, round, react to light (if they react to light, KNOW they accomodate, but only doc "perrl") -size: normal = 3-7mm (penlight pupil gauge) -shape: normal = round -equality: normal = equal size and shape bt two -accomidation: can see at different distances >> test: pt stare into light, then at far away wall >> close object: constrict, converge >> distant onject: dilate, diverge -rxn to light: dim lights, remove glasses, opthalmascope or penlight into eye 4x, normal = rapid constriction to light

Post-op interventions: comfort

analgesics, PCA backrub imagry distaction

SUBCUE administration sites, 5 ways to prevent tissue damage

ABDOMEN -at least 1-2" away from umbilicus -rotate sites (RUQ, LUQ, LLQ, then RLQ) OUTER ASPECTS OF ARMS OUTER THIGH UPPER BUTTOCKS SCAPULAR AREA 1. rotate sites 2. do not aspirate 3. do not massage 4. aboid sites c bruising pitting lumps trauma 5. use smallest syringe and needle for the job

Legal: Credentialing: accreditation, licensure, certification

ACCREDATION -ANA approves edu programs -Commission on Collegiate Nursing Edu evals programs LICENSURE -NCLEX: ensures minimum competency CERTIFICATION -demonstrate advanced proficiency in nursing specialty

MSK Assessment - Demonstrate and define Adduction, Abduction, supination, and pronation

ADDUCTION movement extremity toward the midline swipe arm toward midline of body ABDUCTION movement of extremity away from midline swipe arm to midline of body SUPINATION movement of a body part so the front faces upward turn palms up PRONATION movement of front of body part downwards turn palms down

Rule of Thumb Method for ideal body weight, bmr how to calculate and factors that effect it, bmi, obesity stats

ADULT FEMALE Ideal body weight -100 lb for 5 ft, +5lb for every adtl inch BMR 10 x healthy body weight (10cal/lb) ADULT MALE 106 lb for 5 ft, +6lb for every adtl inch BMR 11 x healthy body weight (11 cals/lb) BMR ^: fever, growth (CA, preg, child), emotional stress, extreme envi temp, elevated certain hormones (epi, TH) v:aging, prolonged fasting, prolonged sleep BMI another way to det ideal body weight -doesnt accnt for body composition wt/m2 <18.5 = underweight >25 overweight, obese, extreme obesity Central/apple shaped obestiy : ^risk DM, CVdis, HTN female waist circumferance: >35" Male waist circ >40"

EHR adv disdv

ADV -data legible -quick access and multi-access at same time -easily retrievable -confidentiality: protected by UN and PW -minimizes repetition and redundancy -WOW: increase accuracy and speed or charting -meets JC standards c built in safegaurds -increases speed and completeness of reimbursment DISADV -expensive to purchase and update -problems c downtime -increase charting time if not enough terminals -may not be user friendly -may be difficult to find info

AV Shunt/ fistula meaning, why, assessment, concerns

Arteriovenous shunt/fistula put artery and vein together for dialysis pts ASSESSMENT LISTEN FOR BRUIT, FEEL FOR THRILL. SHOULD HEAR IT AND FEEL IT cant use that side for bp, iv may have limb alert band

GI/GU

Ask last void if they dont have a cath, last BM if they dont have an ostomy, continent bowel/bladder, difficulty urine or bowel elimination, foley catheter (follow tubing to bag, note urine amount)

3 ways to class surgeries

Based on Urgency Based on Risk Based on Purpose

Nonpharmacologic pain management name, 3 unique examples

CAM: complimentary and alternative modalities Collateral stimulation -stim contralateral limb of phantom pain to overwhelm the spinal cord location Biofeedback -pt trained to lower HR and BP TENS -electrical stimulation to overwhelm sensory neurons to lessen the pain

Skin - Clubbing assessment. What does is identify? Braden Scale - what does it measure? - Range

CLUBBING ASSESMENT push two middle fingernails together, should see a window, if you dont, clubbing > identifies chronic hypoxia BRADEN SCALE Measures pts risk for developing a pressure injury score range is from 6-23, invention @18 -Sensory perception, moisture, nutrition, mobility, activity, friction/shear

Pain: based on Source (3)

CUTANEOUS superficial, usually acute papercut, abrasion, burn SOMATIC diffused, scattered, hurt all over flu, sprained ankle, bone cancer VISCERAL body organ pain d/t stretch, spasm cholangitis

Calcium normal value, role, hyper name, causes (4), s/s (8), tx (4)

Calcium Ca2+ 8.6-10.2 mg/dL important in blood coagulation, transmission of nerve impulses, muscle contraction and relaxation Hypercalcemia Cause: immobilization, hyperparathiroidism, cancer, diuretics S/S muscle weakness, lethargy, constipation, n/v, decreased memory, kidney stones, MI Tx monitor ekg, encourage amb, encourage oral fluid intake

Calcium normal value, role, hypo name, causes (5), s/s (7), tx (4)

Calcium Ca2+ 8.6-10.2 mg/dL important in blood coagulation, transmission of nerve impulses, muscle contraction and relaxation Hypocalcemia Cause hypoparathyroidism, malabsorption, VidDdef, acute pancreatitis, alkalotic states S/S increased excitability of muscles and nerves, Troussau and Chvostek signs, paresthesia of fingers and toes, mental changes, seizures, laryngeal spasm, cramps in extremity muscles TX Seizure precautions, monitor airway, monitor for ecg changes, replace calcium (po, vit d, IV)

Bicarbonate aka, value range, what test measures, low and high value indicates what

Carbon dioxide 22-26 Mmol/L Blood pH, indicates alkalosis/acidosis LOW indicates: hyperventilation HIGH indicates: hypoventilation

Virtues of nursing

Competence Compassionate Trustworthy Conscientious Humility Intelligence Practical Wisdom Courage Integrity

Factors that effect the pain experience 6

Culture/ethnicity Family/gender/age Religious beliefs Environment: fall alone or infront of crush Anxiety: synergistic c pain Past pain experience

Rectovaginal Fistula: def, nursing actions

D: abnormal cxn bt rectum and vagina N: post op cath mgmt, wound hygeine, pt wellbeing

EGD (esophagogastroduodenoscopy): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: visual esoph, stom, upper duo c endo and biopsy P: dx, eval, biospy E: NPO 6hr, mouth gaurd, sedative on baord P: suction, P: assess for aspiration, test gag reflex

Percutaneous Transhepatic Cholingiography: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: visualize biliary system c contrast P: asses for obstruction, jaundice E: NPO 6h P: lax/enema maybe P: VS E&O, puncture site assess

Nursing Process: Evalutation: def, 4 steps to evaluate

DEF: review pt goals and det if expected outcome criteria were met/achieved 1. collect data to id pts response to interventions 2. measure goal/outcome achievement: >>>assess facilitators to goal achievement >>>assess barriers to goal achievement 3. document degree of goal achievement 4. terminate, continue, or revise/modify plan of care >>term if goal met, all others if goal not met

Medication dose response terms: Duration and Trough

DURATION -amt of time the concentration in the body is great enough to produce a therapeutic response -will det dose frequencies TROUGH the lowest level of concentration in blood reached before next scheduled dose -pt w kidney probs may have trough level drawn before next dose like a GRV

Dysarthria aka, d/t what, s/s

DYSARTHRIA/MOTOR SPEECH DISORDER -r/t stroke, brain injury -speech is slurred, garbled, slow, soft

Insomnia defs, dx criteria, s/s

DYSSOMNIA -chronic difficulty falling or staying asleep -disorder of poor sleep quality or quantity -most common sleep disorder -pts often underestimate how much sleep theyre getting -1 month prev ~4-48% pop, >1month = chronic 10-15% -s/s: diff concentrating, lethargic, irritablitiy

Circadian rhythm sleep disorders (2)

DYSSOMNIA -time zone changes (jetlag) -shift work disorders: nights, changing shifts

Charting by exception

Documentation method nurse documents only deviations form pre-established norms -document will have once what is acceptable, then deviations -avoids lengthy and repetitive notes -used often in extended care facility where there may bve no change for months

Abdominal - Define enuresis, hematuria, polyuria, pyuria, nocturia, stress incontinence

Enuresis: bed wetting Hematuria: blood in the urine: UTI bladder ca, stone Polyuria: excessive urination >2500-3000ml/day aka diuresis Pyuria: pus in the urine: poss UTI, odor Nocturia: getting up ~3-7x/night to urinate Stress incontinence: caused by pelvic floor weakness, laugh sneex pregnant >> urine

Factors affecting sensory function

Envi: RAS dets how sense intrptd (shot at church v club) Prev expr: hypervigalance Age: >75 most ppl have sens deficit, norm (50% hearing) Culture: dif acceptable, touch, volume of talking Personality: huggers vs non huggers Stress/illness: dm/htn = vision changes, cva, internal stim Meds: ototoxic drugs, opioids vawareness

Factors effecting self care 7

Environment -lack of access to facilities, resources Motivation -must believe self care is valuble -may need to borrow your motivation Cognitive Abilities -may not recg need for self care -may not be able to perform it safely Energy -takes lotta energy -illness, sx >> weakness, may need help Pain -EVAL before hygeine -may be unwilling to care for self -balance pain and sedation for self care Neuromuscular Fxn Sensory Deficit

3 sx safety concern: things in the room

Equiptment saftey Electrical safety: grounding pad Chemical safety: burns, allergies, staff exposure

never event

Errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a facility

Hemoglobin value range, what test measures, low and high value indications

F: 12-16 g/dL M: 13-18 g/dL Component of RBC that carries O2 LOW indicates: anemia, blood loss, vit deficiencies HIGH indicates: polycythemia, ^altitude, dehydrn

Hematocrit value range, what test measures, low and high value indications

F: 35-47% M: 42-52% vol of RBCs : vol of whole blood LOW indicates: blood loss, cancers, anemia HIGH indicates: high altitude, polycythemia, dehydrn

Stage III pressure injury characteristics, intervention

FULL-thickness SKIN LOSS with damage or necrosis of SUBCUTANEOUS tix, present as a DEEP crater (doesnt have to be big, just deep) Interventions -frequent extensive dsg -meticulous skin care -pressure relieving surfaces (specialty mattress) -nutrition interventions -likely require wound care expert -surgical intervention

Stage IV pressure injury characteristics, intervention

FULL-thickness skin loss with extensive necrosis or damage to MUSCLE BONE OR TENDONS *Risk of inf ^^^^^, take months, years to heal Interventions -frequent extensive dsg -meticulous skin care -pressure relieving surfaces (specialty mattress) -nutrition interventions -likely require wound care expert -surgical intervention

Verify order Introduce self Hand hygiene ID pt Explain Gather equipment Provide privacy

First 7 steps of all nursing skills

Health Assessment: Body Systems PE Framework aka, def, 6 body systems

Focused assessment focus on specific body systems 1. skin hair nails 2. head ears eyes nose throat 3. musculoskeletal 4. neurological 5. respiratory 6. abdominal

gastrostomy, aka, what is it, how is it put in, use, problems that can happen w it (1 normal, 2 abn)

G-tube or PEG tube -inserted sxl directly thru abdl wall into stomach -PEG TUBE inserted endoscopically -for LONG TERM USE: less invasive, can be permanent -normal for leakage of gastric juice or formula at insertion site -can come out it ballon cath pops -at higher risk for aspiration: pts usually already at risk for aspiration, but tube can even ^risk

Neuro - GCS Scale (3 categories: eye, verbal, motor, and range - 3-15). How to assess LOC. Test/Assess coordination

GCS Eye opening - x/4 -spontaneous, to speech, to pain, none Verbal response- x/5 -oriented to none Motor response- x/6 -obeys commands to none RANGE: 3-15 GCS is how we measure level of consciousness COORDINATION -series of rapid, rhythmic, alternating moments -finger to thumb, extended arm-touch nose, walking tandem, toe tapping

Neuro - Identify CN IX-XII - names and how to assess

Glossopharyngeal -gag/swallow, taste on back of tongue -we dont test, close eyes salt/sug on tongue Vagus -swallow, vc move, sensation of pharynx -swallow, say ah Spinal accessory -head and neck: move head and neck, shrug Hypoglossal -tongue movemnt: stick out and around

7 factors influencing communication

Gender Culture/language roles/rlxnships alt'd sensory perception: vision, hearing mental and emo states values environment

Major nursing theorists: King name, ct, nurses role

General System Framework -CT: "Goal attainment" interactions, communications bt 3 systems (individual/personal, group/interpersonal, society) -nurses r: help pt navigate the 3 to achieve goal of continuous adjustment to stressors

HEENT: head assessment (5)

HEAD 1. size 2. shape 3. position 4. symmetry 5. TMJ for crepitus

Nursing Process: Assessment: components, when does it start, data types, how organize info

HH + PE -starts as soon as you walk in room -subjective data: source = pt. what patient tells you, direct quotes in chart -objective data: observations (PE), lab results, diagnostic tests, previous medical records, vs, xrays: things that can be measured, seen, read, felt -organizing information >>cluster data: put on CCM in appropriate categories >>review data >>validate findings: missing anything? compare sub+obj >>id pt problems, needs >>PRIORITIZE pts: ABCs >>formulate Ndx: how youre gonna procede

symptoms of hypotension, hypertension

HYPO dizziness, blurred vision, cool clamy skin, ^HR, vUrine output, usually ascd w willness HYPER blurred vision, SEVERE H/A, n/v, nose bleed usually asymptomatic

Rebreather Mask flow type, O2%, how different from non-rebreather, contraindication

High Flow 70% O2 mask w bag attached to bottom DIFF bc 2 way valve allows pt to rebreath exhaled air CONTRAINDICATED with COPD pts

Venturi Mask flow type, rate, O2 %, why that flow level

High Flow 3-8L/min 24-50% O2 pt receiving constant O2 regardless of their rate or depth of respiration

6 chemical messengers that stimulate nociceptors and what they do

Histamine: excites nerves Lactic acid: excites nerves >heat+pressure cause vBlood Bradykinin Prostaglandins: ^sensitivity to pain Substance P: ^sensitivity to pain Seratonin: vSensitivity to pain

HSN focused assessment

Introduction 3 questions about HSN status/history Assess clients skin for I. Color II. Moisture III. Temperature IV. Texture V. Turgor VI. Vascularity/Petechiae/discolorations to the extremities VII. Edema (pitting, non-pitting) VIII. Lesions/rashes/abrasions IX. Body piercings/tattoos Teach client the ABCDE Assess clients bony prominences Define the Braden Scale and score range Assess clients hair for: I. Color II. Distribution III. Quantity IV. Thickness V. Texture VI. Sheen VII. Hirsutism VIII. Alopecia IX. Assess scalp Assess clients nails for I. Color II. Thickness III. Texture IV. Clubbing V. Capillary refill Assess clients mucus membranes in dark skinned clients I. Color II. Moisture

types of asepsis (2)

KNOW WHICH U NEED FOR UR PROCEDURE 1. MEDICAL ASEPSIS -aka clean technique -reduce # and transmission of moos -procedures: hand hygiene, proper gloving 2. SURGICAL ASEPSIS -aka sterile technique -render and keep surfaces FREE of moos -i.e inserting indwelling urinary catheter

components of critical thinking

Knowledge Experience Competence: reliably carry out solution Attitudes: confidence, independence, fairness, integ Standards: laws, professional scope

MSK Assessment - Lordosis, Scoliosis and Kyphosis - abnormal curvature -which part of spine

LORDOSIS -exaggerated curvature of the lumbar spine -aka sway back -congenital, poor posture, hip problems -most often seen in children -tx: PT SCOLIOSIS -Lateral "S" curve of spine" -screen yearly age 11-14 c growth spurts -one shoulder or hip higher than other -tx: braces, >40% curvature >> sx -can lead to back pain, respiratory problems, mobility problems, self esteem issues KYPHOSIS -exaggerated curvature of the thoracic spine -can be caused by osteoporosis >> shortening of vertebral columns -most common seen in elderly -hump back appearance -watch for steroid use

2 types of nasogastric tubes, characteristics, usages, placement specifics

Levin/Salem Sump -clear, larger, firm plastic tube -shorter term usage -placed blindly Corpak -smaller diameter, softer plastic, used ONLY FOR FEEDING, cannot aspirate or will collapse -ONLY FEEDING, long term use -placed by APRN or physician, confirm ONLY w CXR

Topical Medications: Lotions, Creams, Ointments examples (5), administration

Lotions, Creams, Ointments Emollients, steroid, antihistamines, hormone replacement, nitroglycerine Administration -put on gloves -apply to affected area

Nasal Cannula flow type, rate, O2 %, benefits, disadvantages

Low Flow 1-6L/min 24-44% O2 MOST COMMON effective, easy to apply, most comfortable can be used w mouth breathers allows eat, drink, talk, perform ADLs WATCH for skin Bv behind ears

Simple Face Mask flow type, rate, O2 %, benefits, disadvantages

Low Flow 6-10 L/min 40-60% O2 provides most constant effective delievery of O2 interferes w talking, eating, (may be ordered NC while doing these) may cause claustrophobic rxn CONTRAINDICATED FOR COPD PTS

Peri-care: male, female, urinary tube

MALE clean from urinary meatus downward toward trunk clean all folds and crevaces around and behind scrotum retract, clean, DRY, and replace foreskin FEMALE -clean front to back: pubic bone to sacrum -avoid harsh soaps TUBE clean privates normally, clean tube c cloth @ body entrance down ~6"

resistant moos ex, stats, best practice

MRSA -S.aureus normal on skin, mm, Resp GI tracts -1/3 US colonized carriers -1960 MRSA discovered, tx w vancomyocin -CDC: "mrsa v in hospital settings!" VISA/VRSA: vanco intermediate/resistant s.aureus VRE: vanco resistant enterobacteria BEST PRACTICE: hand hygiene, glove properly

Magnesium normal value, role, hyper name, causes (2), s/s (4), tx (3)

Magnesium Mg2+ 1.3-2.3 mEq/L important for metab of carbs, proteins, neuromuscular fxn Hypermagnesemia (rare) Cause - ESRD, admin of IV mg S/S -HOTN, flushing, drowsiness, decreased reflexes TX admin calcium gluconate, diuretics, dialysis

barrel chest

Measurement of bony prominences, not soft tix normal anterioposterior diameter (3or2:1) barrel chest (1:1) rib cage expand bc lungs expanding to compensate for chronic bronchitis

Opioid analgesics names (7)

Morphine Codeine Hydromorphone: 7-10x ^^ Oxycodone Meperidine Fentanyl Methadone

dev considerations with spirituality

N/I -trust becomes faith T/P -dev consciousness, sense of existence S/A -value group belonging, sensitive to good and bad -abstract thinking YA -separate from peer think, make personal boundries and commitments A/MA -spiritual growth -BROAD world view OA -SMALLER world view if loved ones limited, stay in house

Lifespan considerations c pain

NEONATE/INFANT under tx of pain >cry for all needs, fear to dose TODDLER/PRESCHOOLER hard time ID-ing pain >hard to tx SCHOOL AGE/ADOLSCENTS can rationalize pain give incentive/context to improve compliance ADULT/OLDER ADULT MSK pain: stiff joints, aches

Pain: based on Etiology (3)

NOCICEPTIVE PAIN -noxious stimuli > nociceptors -transmission of pain from visceral to somatic sites NEUROPATHIC PAIN -abn fxn of peripheral nervous system or CNS -burning, electric, tingling, stabbing pains -Allodynia: pain after non-painful stimuli -pain syndroms: fibromyalgia, peripheral neuropathy PSYCHOGENIC PAIN -no physical cause -emotional pain that manifests somatically

Stage I pressure injury characteristics, interventions

NON BLANCHABLE erythema of INTACT skin -will feel different than reg tix: warm, squishier Intervention -check all at risk spots -reposition -re-eval -keep skin clean -moisture barrier cream (if area ef'd by incontinence). -protective foam dressing to prevent further breakdown

HEENT: Nose assessment (8)

NOSE 1. size 2. shape 3. position 4. symmetry 5. patency 6. discharge 7. excoriations 8. sinuses for tenderness

Stages of sleep list

NREM SI NREM SII NREM SIII NREM SIV REM

Major nursing theorists: list 8

Nightingale Peplau's Henderson's Rodger's Orem's King's Newman Roy

Medication dose response terms: Onset Therapeutic Range, and Half-life

ONSET -time it takes for med yo produce a response THERAPEUTIC RANGE -bt MEC and toxic level, rand of sage effectivness -may need blood test to determine HALF-LIFE -amount of time for excretion to vtotal concentration of med by 1/2

Assessment of Pain: OLDCART+

Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment + wong baker rating adaptation and effect on ADLs physiologic indicators, behavioral responses (gaurding, vocalizing, signs of SNS/PNS activation)

PQRST wave, abn P, abn QRS, abn T meaing

P - atrial contraction abn QRS - ventricular contraction abn T- ventricular relaxation abn

5 invasive pain management strategies and 3 indications for use

PCA, IV, nerve block, epidural, intrathecal post-op pain chronic non-malignant pain severe cancer pain

Peripheral Vascular Assessment: Peripheral pulse assessment PPP stand for, what are the 4 your assessing, how to assess, what do you document

Palpable Peripheral Pulses 4 = both radial, both dorsalis pedis OR post tib -eval at same time to assess for SYMETRY 0 +1 +2 +3/4

What system has control during NREM sleep what are those effects on VS

Parasympathetic dominating VV HR, BP, RPM

PCA programing, numbers

Perscribed bolus and doses set up, settings changed, edu, adovcacy done by RN PCEA not able to modified by nurse, can only hang an extra bag Hydromorphone IVPCA 0.5mg/ml 0/0.2/6/10 #1: bolus #2: demand dose #3: time (q6min) #4: times/hr multiply 2x4 this pt can get up to 2.0mg/hr

Phosphorous normal value, role, hyper name, causes (3), s/s (2), tx (1)

Phosphorus PO4- 2.4-4.7 promotes energy storage, A-B balance, RBC and muscle fxn Hyperphosphatemia Cause -ESRD, chemotherapy, hyperthyroidism S/S -retany, long term can lead to calcification of tix TX -phosphate binders given c meals

Phosphorous normal value, role, hypo name, causes (6), s/s (5), tx (2)

Phosphorus PO4- 2.4-4.7 promotes energy storage, A-B balance, RBC and muscle fxn Hypophorphatemia Cause glucose admin, refeeding after starvation, PTN, alcohol withdrawl, DKA, respiratory alkalosis S/S resp failure, seizure, decreased tix oxygenation, joint stiffness, increase risk for infection Tx replace carefully and slowly, indirectly r/t ca so can cause hypocalcemia

Receptive Aphasia aka, def

RECEPTIVE APHASIA/WERNEKE'S APHASIA -difficulty comprehending written or verbal words -impaired auditory comprehension and feedback -CAN talk

Potassium normal value, role, hyper name, causes (4), s/s (3), tx (4)

Potassium K+ 3.5-5.0 mEq/L cell enzyme activity, electrical impulses in nerves, heart, muscle, gi, lung tissue Hyperkalemia Cause: -ESRD, acidosis, tissue trauma (burns), diuretics S/S -muscle weakness, cardiac arrhythmias, parasthesia of face tounge feet hands TX -either will prevent K uptake or move it back to cells -Kayexalate (binds to K in GI and excretes it -severe: tx w Ca insulin and glucose -can tx w diuretics and dialysis

HEENT - Define Ptosis, Strabismus, Exophthalmos, Myopia, Hyperopia, Presbyopia

Ptosis: drooping of the eyelid Strabismus: crossed eyes Exophthalmos: bulging of the eyes Myopia: nearsightedness Hyperopia: farsightedness Presbyopia: impaired near vision ascd c age

QSEN name, stat, top priortiy, emph, goal, 6

QSEN: Quality and Safety Education for Nurses -medical errors >> >100,000 US death/YR -top priority: pt saftey -emphasis: id all contributing factors, id all roots of errors -goal: prepare nurses to gain knowledge, skills, attitudes, needed to continuously improve quality and safety of care - 6 competencies all nurses must develop 1. Pt centered care 2. Teamwork and collaboration 3. Evidence-based practice 4. Quality improvement 5. Safety 6. Informatics

last 6 defense mechanisms

RATIONALIZATION -try to give logical, socially acceptable explanation for questionable behavior, try to justify behavior REACTION FORMATION -dev concious attitudes or behavior opposite of what theyd like to do REGRESSION -return to earlier method of bx, immature but more gratifying state of development of thoughts, feel ,bxs REPRESSION -voluntarily excludes anx-prod event from concious awareness SUBLIMATION -substitue socially acceptable goal for normal channel of expression blocked -ie aggressive person >> wrestler UNDOING -uses act or communication to negate previous act or communication -ie buy flowers after fight

REM occurances, body responses

REM -vivid, colorful, emotional, implausible dreams -stage increases in length at each sleep cycle -vMuscle tone: only eyes and face have tone -deep tendon reflexes depressed -^brain blood flow and O2 consumption -fluctuation of ^ in BP, HR, RPM -very difficult to awaken

7 blocks to communication

RESCUE FEELINGS/CODEPENDENCY -nurse feels they are the only one who can care for pt -esntl for care, have exceptional abilities for pt -expectation too high for pt FALSE REASSURANCE -ultimetly has a (-) effect GIVING ADVICE -never answer "if you were me" -talk about options, facts, not opinions SHARING PERSONAL OPINIONS -trap for nurse, eitherend up making all their decisions or being the one to blame CHANGING THE SUBJECT -listen to what pt saying, dont avoid or ignore BEING MORALISTIC -imposing views on pt ASKING FOR EXPLANATIONS/WHY -puts pt on defense, may shut down -instead " tell me more "

Abdominal - Identify at least one organ in the RUQ, LUQ, RLQ and LLQ

RUQ -Liver LUQ -Spleen RLQ -Appendix LLQ -Sigmoid colon

Topical Medications: Rectal examples (4), administration

Rectal Laxative, anti-emetic, analgesic, anti-pyretic Administration -put on gloves -pt in sims, upper knee toward chest -drape to expose buttocks -apply lubricant to suppository and index of dom hand -separate buttocks w opposite hand -instruct pt to breath slowly and deeply -insert round end first along rectal wall ~3-4" -use toilet tix to clean any stool or lubricant from around anus -encourage pt to stay in sims for 5 min

NEURO: Balance assessment name, steps, saftey note

Romberg test * if they sway a bunch, have them open their eyes! 1. position pt: feet together, arms at sides, eyes closed 2. stand close to pt at their side 3. evaluate amount of swaying for ~20-30sec 4. have pt stand on one foot eyes closed ~5sec 5. walk tandemly

Hand-off communication

SBAR SITUATION -D:current info, interventions, labs, vs, in last 15 min -N:everything during hospitalization BACKGROUND -D: relevant pt hx for this situation -N: everything before hospitalization ASSESSMENT -D: assessment of situation, what do i think is going on, nursing dx, deduction -N: how they are doing RECOMMENDATION -D: recommend next step, i think its PE, CXR? -N: continue plan, terminate plan, revise plan

if it lowers bp, when hold

SBP <90mmHG

what stages get about 5-50% of sleep

SI, II (light sleep)

Pain process: Perception

STEP 3 when pain gets to thalamus, youre perceiving it individual interpretation threshold: lowest intensity to cause recognition of pain All depends on individual, experience, and WHERE and how many nociceptors are there (face vs bottom of foot)

Sodium normal value, role, hyper name, causes (4), s/s (7), tx (3)

Sodium Na+ 135-145 mEq/L important in water volume Hypernatremia Cause: -poor oral water intake, increased fluid losses (sweat, burns), increased salt intake, enteral feeding w/o water S/S: -thirst, dry mm, hallucinations*, lethargy*, seizures*, coma* TX: -gradual rehydration, measure I&O, Na-restricted diet

Sodium normal value, role, hypo name, causes (3), s/s (10), tx (4)

Sodium Na+ 135-145 mEq/L important in water volume Hyponatremia Cause: -diuretics, GI losses, excessive water intake S/S: -n/v, muscle cramps, hypotension, edema, weakness, confusion, lethargy*, twitching*, seizures*, coma* Tx: I&O, encourage Na-rich foods, seizure precautions, IV preplacement

List Methods of documentation: 5

Source Oriented Notes Problem Oriented Medical Records (SOAP) Charting by Exception Computer Documentation/EHR MAR

how do you start and end an entry

Start c capital letter end c period STD sign date and time ( with KSU, SN) >>Signature, not written name

Adjuvant Analgesics (6)

TCAs Antihistamines Caffeine Muscle Relaxants Anticonvulsants Antiemetic

hyperthermia temp, cause, treament

TEMP: 40*C cause: bacteria, viruses tx: antipyretics (common: acetominophen, asprin) hypothermia blanket: cool slowly, careful not to shiver

Vitals societal norms, range

TEMPERATURE Societal norm: 35.8 C - 38.1 C Hypothermia: 35 C Healthy fever: 38.1 C -38.49 C Interviene at: 38.5 C Dangerous fever: 39 C Severe/life threatening: 40 C Heat Stroke: 41.1-44.9 C PULSE Societal norm: 60-100 bmp Bradycardia: <60 bpm Tachycardia: >100bpm RESPIRATION Societal norm/eupnea: 12-16 rpm Interviene at: 20 rpm Bradypnea: <12 rpm ("bray-dip-nea") Tachypnea: >20 rpm ("tah-kip-nea") PULSE OXIMETERY Societal norm: 94-100% SaO2 Intervention: 91% BLOOD PRESSURE Societal norm: <120/<80 mmHg Societal norm pulse pressure: 30-50 mmHG Hypotension: <90/60 mmHg PreHTN: 120-139 OR 80-89 mmHg HTN: 140-159 OR 90-99 mmHg PAIN 0: no pain 10: worst pain of your life 0-10 (Wongbaker scale) Unit: /10

HEENT: Throat assessment (8, 2 complex)

THROAT 1. mouth: size shape position symmetry color 2. tonsils 3. uvula 4. soft palate 5. neck size shape position symmetru 6. lymph nodes 7. trachea alignment 8. thyroid gland

pt teaching for surgery done when, what are 4 key teaching points, and why do we do them

Teach during Pre-op, what to expect post-op reduces complications increase compliance vAnx/fear teach: turning, deep breathing (incentive spriometry), early AMB, leg exercises

Topical Medications: Transdermal examples (7), administration

Transdermal Smoking cessation, BC, HRT, nitroglycerin, fentanyl, lidocaine, scopolamine Admin -put on gloves -assess where patch going to be: new spot, clean, dry, intact, free of hair -remove any old patches of same med, fold, discard acrding to facility policy, wash skin at that spot -remove covering on patch w/o touching med -apply to pt skin, press w palm for 10 sec -can apply transparent dsg to confirm adhesion -initial and date on tape placed next to patch -document location *DO NOT RUB NEW PATCH WHEN PLACED *DO NOT CUT PATCH *DO NOT WRITE DIRECTLY ON PATCH

pulse sites additional to radial/apical (7) legal note, why take them

USED to see if we have proper circulation in the body, not for routine pulse checks posterior tibial: inside of ankle behind ankle bone dorsalis pedis: top of foot bt big and 2nd toe ** if distal pulses present, indicates prox pulses are present: upheld in court ADTL: temporal, brachial, femoral, popliteal, carotid (only one at time, feeds 80% of blood to brain)

Slough, eschar characteristics, effect on staging

Unstageable is base of wound covered by slough or eschar, need debridement before staging 1. Slough -yellow, grey, tan, green, brown -necrotic tix in wound bed, often adheres, needs to be removed for staging and healing 2. Eschar -dark brown, black -crust-like necrotic tix -needs to be removed for staging and healing

Respiratory - Identify lung sound on manikin and cause - Wheeze

WHEEZE CAUSE -severe constriction in the lower airways -d/t mucus: asthma, chronic bronchitis

Nursing Process: Diagnosis: writing a dx (describe the 3 parts) 3 types of Ndx

WRITING a DX 1. Diagnosis (problem) stated using NANDA approved statements 2. r/t (related to) is the etiology (cause of the problem) specific to the patient, but CANT be a medical diagnosis 3. AEB (as evidenced by) is evidence to support the actual problem TYPES 1. Actual Nursing Diagnosis (3-part statement) -diagnosis (NANDA statment) -r/t: cause (pathophysiology, tx, situational) -AEB: data, defining characteristics 2. Risk Nursing Diagnosis (2-part statement) -diagnosis: "risk for ...any nanda statment" -r/t: risk factors and why theyre suspected 3. Wellness/Health Promotion Diagnosis -diagnosis: "potential for ... nanda statment" -for the community

urine tests: 24 hour collection

accuratly measures kidney excretion over 24hr keep on ice in jug pt voids, timer starts, at end of 24, void 1 last time before timer stops no stool no tp contam, hat in toilet, dump in jug

what remains constant with different manufacturers of the same drug, whats different

active ingredient must meet standards of uniformity and purity by the FDA difference: marking, dyes, fillers, coatings **pts may be allergic to inactive ingredients (fillers) so may be intolerant to some brands, but not all

Home care / dc post op

activity restrictions incisional care dietary instructions when to call phys: fever, anorexic, 5 cardnial inf signs post op med instructions arrange homecare c case manager if necessary

Risk factors for surgery (5)

age nutrition obesity electrolyte and fluid imbalance pregnancy

factors effecting pain (12)

age: young ^, older you get, less reporting of pain fatigue: vTol to pain genetic predisposition neurological fxn: paralyzed, no pain, sensneurons disfx attention: hence distraction tx previous experince: chronic pain not ef other vitals family or social support spiritual factors anxiety: ^ pain coping style cultural meaning of pain ethnicity

factors effecting respirations (9)

age: young small lungs faster rate activity, exercise: ^ pain: ^ anxiety: ^ altitude: ^ (less O2) meds: ^ or v depending brainstem disorder: usually v rate and depth smoking: ^ rate bc diffusion worse increased body temperature: ^ bc metab ^, need more O2 to meet metabolic demands

acid base imbalances

all can be uncompensated, compensated, or partially compensated respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis

sleep hygiene

all efforts to encourage sleep -routines, temp of room, noise preference

Big things on the hx to get before sx

allergies PMH previous sx med hx smoking, drinking, illicit drug use family support status job concerns religious and cultural concerns

AMB

ambulatory

crutches requirement, positioning, gait (3)

axillary crutches req sig upper body and arm strength wt should be supptd on hands arms, not axillae gait: 2pt: walk crutch and contralateral foot together 3pt: crutches, then good leg swings to or through 4pt: R crutch, L leg, L crutch, R leg

Religious freedome protection in HC

believer has right to individual interpretation of scripture and can make decisions even if they may result in their death children? its the parents choice

best way to measure oral liquid medications, alternative

best: oral syringes can use medicine cup: if you do, measure at eye level and measure at MINISCUS (bottom of the warped line)

7 Conditions that ^risks of sx

bleeding disorders DM heart disease URI/Chronic respiratory disease liver disease fever kidney disease

hemodynamics of bp (5) and what does that mean??

bp measurement reflects the ixns bt these vv 1. cardiac output -amt of blood pumped out of aorta and against arterial walls (^co:^bp) 2. peripheral vascular resistance -det'd by diameter of blood vessels -more resistance : ^bp -atherosclerosis: fatty plaque buildup, ^resistance 3. blood volume: -vBvol:vBp (via dehyd, hemorrhage) 4. blood viscosity: -ef ease of b.flow -heart must contract more to push viscous blood 5. arterial elasticity -^age:vElasticity:^bp -arteriosclerosis

ethnicities share what (5)

bx patterns language food preference religious practices political interests

Diuretic ixn c anesthesia

can cause electrolyte imbalances can cause resp depression ixn c aneth

hyperthermia cause, treament

cause: bacteria, viruses tx: antipyretics (common: acetominophen, asprin) hypothermia blanket: cool slowly, careful not to shiver

NEURO: language assessment where is language processed in brain, what two things are we assessing, 6 qualities, dysphasia, aphasia 2 types, how to communicate when theres aphasia

cerebral cortex - ability to understand spoken or written word -ability to express thought >> writing, word, gestures, voice inflection, tone, manner of speech Disphasia: difficulty talking Aphasia: inability to talk 1. Sensory aphasia (receptive) -inability to UNDERSTAND written or verbal speech 2. Motor aphasia (expressive) -inability to PRODUCE written or verbal speech aprptly **MOST PEOPLE ARE BOTH **COMM W PICTURE CARDS

Elements of documentation 4

content timing format confidentiality

hypotalamus role in sleep

control centers located here for sleeping and waking

interventions for respiratory maintenance post op

cough and deep breath q2h hydration: 2000mL/24hr incentive spirometer qh w/a check for resp dep d/t opioids (hold if rr <12, O2 92%) EARLY AMB q2h turns admin O2 as ordered

C&S

culture and sensitivity

electronic bp machine name and notable

dinamap can read in odd #

Communication: Clarity and Brevity

dont beat around bush use honesty, be accurate, have knowledge use as simple of language as possible let pt decide how they feel

how to correct an error on a health record

draw a SINGLE line thru above error, write "Mistaken entry, PR" or "Error, PR" NO white out erasers covering up of materials

Communication: personal apperance

dress odor grooming

insulin administration always req what

dual verification "ow much of what is in this syringe" "4 units of NPH"

4 ways to categorize pain

duration, source, mode of transmission, etiology

dyspnea, apnea, hyperventilation, hypoventilation

dyspnea: difficulty breathing apnea: not breathing (sleep ap >5x/hr for >10sec) hyperventilation: over ventilate in volume hypoventilation: under ventilate in volume

whats the #1 bacteria found in UTI

e.coli

Communication: Timing and relevance

education session during 8/10 pain? no edu sesh when putting on SCDs, yes!

Interventions for fluid and electrolyte imbalance: prevention

education: s/s of dehyd, indv risk factors monitor I&O, daily wts, labs

=

equal to

somnolent, stupor, coma, normal state of arousal

extreme drowsiness, but will respond normally to stimuli unconscious, can be aroused by extreme and/or repeated stimuli unconscious, cannot be aroused and doesnt respond to stimuli normal = alert, aware, responsive to stimuli

FUO

fever of unknown origin

ergonomics big def, brief def

fitting the task to the worker, NOT the worker to the task practice of designing equipment and work tasks to conform to the capability of the worker and providing a means for adjusting the work environment and practice to protect and prevent the worker from injury

plantar flexion

flexion of toes and foot downward

dorsiflexion

flexion of toes upward

Health Assessment: Functional Health Patterns PE Framework 2 defs, approach style, how is it organized

focus on effects of health or illness on pts quality of life holistic approach aka def: evaluated the effects of the mind, body, and evi in rlxn to bodies/pts ability to perform tasks of daily living (assess pt as a whole, not just physical -organizes data collection by functional health patterns

GU

genitourinary

Progression of mobility: goal, method, adaptive strategies

goal: fxnl mobility >>longer theyre immoble, more complications encourage free mobility as allowed and able adaptive strategies to safely progress mobility -take rest periods -modify activity: walk to br! but sit in chair to do makeup -use of tools **getting up makes people and their pain feel better

Communication: gestures

good gestures: nodding bad: tapping foot, anything annoying

sequence for putting on PPE

gown, mask, goggles/faceshield, gloves

g/gm

gram

Shaving

groom beard and mustache shave in direction of hair growth to prev irrtn pt on blood thinners, use an electric razor

HOB

head of bed

H/A

headache

Sensory Alterations: implimenting (4)

health promotion screening safety promoting stimulation and communication

Nursing role in wellness, prevention types

health promotion/illness prevention -primary: prevention -secondary: early detection or diagnosis, screening -tertiary: when disease exists, goal is to mitigate disability, minimize dysfunction/complications

skin integrity implimentations

health promotion: spf 15+, q2h, ABCDEs, nutrition prevention of PI: postn, skin care, pressure vSurfaces pt teaching: handwashing, inf symptoms ABCDEs protect/manage wounds monitor lab values provide nutritional support teach pt appropriate wound care

cane positioning, size, gait

held on strong side OR if using for stability, either side should be 4" to side of foot, handle should be @ crease of wrist gait: cane, weak leg, strong leg *can move cane and weak leg at same time if its not painful

HPI

history of present illness

TPN aka, where infused, when do we use it, what kind of solution, complications (3), nursing responsibilities 4)

hyperalimentation infused into central line used when enteral or gi nut impossible for 7-10days >> pts difficulty absorbing nuts >> pts w persistant n/v >> pt w need for complete bowel rest complications -infection: line into supVenaCava... holy shiz, AND fluid =perfect medium for all life (MOOS) -fluid overload: espc HF, RF, DM pts - metabolic imbalances: can be nutdense at first, ^andVbg nursing responsiblities -I&O: urinary output often ^^ -daily wts -assess and mng central line -monitor lab values >> glucose, urine ketones&specific gravity, BUN, liver fxn, electrolytes >>>>>>can be tough on liver and kidneys

HTN

hypertension

what is our primary internal clock

hypothalamus

Urine assessment (6)

i&o volume color (clear to amber) clarity (pus, blood clots odor urine testing/specimen collection

Hair assessment (9)

i. color ii. distribution: should be symmetrical iii. quantity: thinning alopecia iv. thickness: v. texture: smooth, pliant (brittle/not brittle) vi. sheen: normal = shine vii. hisutism: male patterned facial hair on female viii. alopecia ix. scalp

Nail assessment (5)

i. color: i,ii,iii can indicate fungal infection ii. texture iii. thickness iv. clubbing >>sign of chronic hypoxia v. capillary refill >>blanch nail bed >> normal refil in <3 >> >3 incts: PVD, arterial blockage, heart failure, shock

nuses role in asepsis

id, prevent, control, and teach pts about infection

Chemical name

identifies drugs atomic and molecular structure ie Asprin = acetylsalicylic acid

socumentation of pt learning

if you didnt document it it didnt happen! -doc: assessment, plan, implementation, evaluation, and any deficits in the learning -MUST show concrete evidence that learning occured -helps other HCP eval the pt, the tx, etc

what is an addition administration essential for injectable meds

immediately engage safety mechanisms on all needles and dispose of used equipment in sharps container

STAT

immediatley

paralytic ileus def, s/s

inability of intestine to conduct peristalsis >>obstruction most often occurs post op (also can be inflam response s/s: pain, severe abdl bloat, ABSET BS, hard abd

Age and developments effect on pt learning ability (6cats)

infant/newborn: teach parents tod/presch: direct at parents, include child life specilists to teach role-play (play dr, vAnx), read books c pics, sing songs, short simple explainations schoolage: book, videos hands-on learning -often eager to learn, offer time to answer qs adolscents: -limit distractons: put away phone -concise, expectations clear Adults: books, videos, return demonstration -dont assume they understand older adults: -focus on strengths -dont rush instructions: take longer to process -relate to life experience: best way

Post-op complications: wound care

infection: ~3-6 days post op -redness, edema, pain, heat, loss of fxn dehiscence evisceration

QSEN EBP

integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care leads to safe and effective care

Skin

integrity, wounds, color, rashes. assess pts backside during bath, walking to BR, getting up to chair. assess coccyx, heels, elbows, other body prominences for erythema

Antihypertensives ixn c anesthesia

interact c anesthetics to cause deeper bradycardia, HOTN, impaired circulation

IM

intramuscularly

IV

intravenously

5 characteristics of culture

learned dynamic diverse observable: rituals as expression of culture ethnocentric -viewing ones own culture as the only correct standard by which to view ppl of other cultures

sleep latency

just prior to SI, the period of time between lights out trying to sleep and being asleep usually lasts 10-15: longer or shorter indcts a problem

KVO

keep vein open

Organs/systems that manage fluid and electrolyte balance: list

kidneys heart and vascular lungs nervous system gi

kg

kilogram

introduction

knock introduce self hand hydiene ID pt with 2 identifiers AND allergy band (cross check c chart) (how would you like me to address you) acknowledge visitors explain provide privacy

if you have two injectables that need to go in 2 syringes, what must you do (ie one subcue, one IM

label your syringes so you know which med goes in each sharpie the barrel or write on tape

post op normal return of bowel function flow

lack of peristalsis > return of peristalsis > BS > flatus > gradually resume diet

Ensure pt safety Remove unnecessary items Answer questions Address unmet needs Tell when youll return Hand hygiene

last 6 steps after any interaction

how do parenteral meds come

liquid or powder form powder must be reconstituted ampules vials cartridges: pre-filled, can be IM SubQ or IV pens: insulin pen pre-filled syringes

ABD Assessment: RUQ organs

liver, gallbladder, duodenum, head of pancreas, R kidney, R adrenal gland, portions of ascending and transverse colon

Furosemide pre-adm assessment, monitor what, caution, toxicity

loop diuretic PRE-ADMIN ASSESS bp, lytes, excess fluid MONITOR lytes, fluid status (I&O, daily wt) CAUTION risk for falls TOXIC ototoxicity >> tinnitus, hearing loss

osteoporosis what is it, how to screen

loss of bone mass, deterioration of bone tissue >> risk of breaks screen for risk factors screen @40-60 years old DXA: bone densometry test BMD: bone mineral density test -ultrasound of heel or xray of spine or hip to det mineralization, loss of bone mass

Pt saftey c bed and room

low and locked pt psnt safe bed electrically fxning properly side rails (3) raised if indicated pt has call button uncluttered walking space temp ventilation etc to pts preferance

in generic name of drug how do you write it

lower case first letter

circle with arrow above

male

Neck

masses, skin, trachea midline, JVD (+)/(-)

when would you use other arm for a bp (4)

mastectomy lumpectomy injury (burn) IV

post void residual measured with what, how, high number indicates what

measured with bladder scanner, get measurement before and after urinating, could indicate bladder retention

head

mental status (calm, cooperative, etc), eyes (PERRLA), mouth, nose (NG, O2-nc, mask) Follow any tubing to machines

mEg

milliequivalent

mL

milliliter

DONT USE MEDICAL JARGON

okay !!

MAE

moves all extremities

abduction

mvmt away from midline

Factors effecting sleep (13)

need environment: noise, light, temp, electronics relationships: dont go to bed angry, sense of security shift work nutrition and metab elimination patterns: enuresis, nocturia exercise: helps, but stop 3hrs before thermoregulation: hot flashes c menopause, obesity vigilance: parenting, awareness interupts cycles lifestyle, culture: when to sleep, what to wear illness: pain, n/v/d, anx about illness mood: dif to falls asl c extreme emos, coping hard pm meds/chemicals

what do you do if you need a bp on a pt w a bilateral mastectomy

need an order from physician

- (circled)

negative

neg

negative

net ratio of I&O how to get it and what does a (+) ratio mean and what does a (-) ratio mean

net ratio = I-O should be small (+)#:maybe not a problem, probably a problem for a HF, RF, DM pt (-)#: behind in volume

whats unique about the female urethra

no portion of it is exterior to the body

do you always go through all the stages of sleep

no!

should you let a pt put their arm around your waist or shoulder if youre assisting them with ambulation?

no! theyll take ya down

pulse defintion

number of L ventricular contractions that occur in 1 minute

who determines the frequency of vs taking

nurse and physician collab depending on pts condition/ floor rules NURSE responsible for judging if more freq assessment is needed

whats one way to stat utd on current EBP

nursing organizations

what should be done about cracked/dry hands

oil-FREE lotion glove up

Sensory Overload: def, s.s., causes, interventions

one or more of the senses are overloaded s/s: agitation, racing thoughts, confusion C: INTERNAL STIM: pain, anx, nausea C: EXTERNAL STIM: roomate, envi, weather C: OTHER: taking in new information I: V or tx internal stimuli (id them reduce them) I: elim any unec stimuli I: cluster nursing care I: break tasks into 1 or 2 step directions

what additional items are used in isolation rooms

one-time use vital signs equipment (steth, bpcuff)

when can you take telephone and verbal orders, how to document

only in case of emergency always WRITE DOWN AND READ BACK 11/22/20 0715 Tylenol 650mg po x1 now *TO/VO* Dr. Smith/P.Romano, RN

what assessment steps do we use in MSK exam

only inspection and palpation

Stage II pressure injury characteristics, intervention

partial-thickness SKIN LOST, shallow wound, OPEN area, present as ABRASION or BLISTER Interventions -check all at risk spots -reposition -re-eval -keep skin clean -moisture barrier cream (if area ef'd by incontinence). -protective foam dressing to prevent further breakdown -consider hydraulic lift when lifting out of bed -pressure relieving devices (boot, cushin)

Ostomy def, created for what, 6 types (loc of them, stool consistancy), temp or permanent

opening created in sx when diseased portion of digestive tract is removed and reroutes fecal elimination to the skin to a wearable pouch to collect elimination -sigmoid colostomy -descending colostomy: l side, stool hard -transverse colostomy: middle, stool harder -ascending colostomy: r side, stool liquid -ileostomy -ureterostomy *may be temp or permanent

nurses primary role with patients with cognitive impairement

optimize functioning to minimize deficits, restore function through compensatory means, provide nursing support and care

PMH

past medical history

PCA

patient controlled analgesia

whats more important than societal norms when collecting and interpreting data

patient norms

PR

per rectum

orientation

person, place, time, situation (A&O x 3 or 4) (broad with time; year, month, day)

values

personal beliefs on what is right or wrong

pain txs (7)

pharmaceutical intervention repositioning distraction relaxation exercises guided imagery massage music therapy

ABD Assessment: LLG

portion of L kidney, portion of descending colon, sigmoid colon, left ovary and fallopian tube/ left spermatic cord, L ureter

+ (circled)

positive

lb

pound

purposful rounding 4 ps

pstn, pain, personal surroundings, potty make each round purposeful: use these 4 if nothing else

malignant hyperthermia

rare, genetic, life threatening rxn to anesthetic agents >> acclrtd muscle metab S/S *EARLY: jaw muscle rigidity, conc urine color *LATE/SERIOUS: fever -vent dysrhythmias, tachypnea, cyanosis, unstable bp >> all r/t rhabdomyolosis

factors effecting pulse oximeter (8)

really anything effecting coloring of skin/nail -peripheral vascular disease: thick discolored nails -nail polish, fake nails -hypotension: vCirc volume > cyanosis > discoloring -hypothermia: ^^ what she said - peripheral edema: excess fluid alters light -outside light interference -carbon monoxide: tix becomes reddish -jaundice: discoloring of skin

what is the 3 step process of sensory input and what manages it

reception (stimulus registering with brain) > perception (interpretation of the stimuli) > reaction (to stimuli) Reticular Activating System (RAS)

red reflex

red glow that fills the pts pupil when visualized through the ophthalmoscope normal = red = retina intact

Antidysrhythmic ixn c anesthesia

reduce cardiac contractility and impair cardiac conduction dangerous during anesthesia

interventions for stress

reduce stressors address perfections: set realistic expecatations positive self talk assertiveness lifestyle change exercising relaxation techniques environmental modification crisis intervention

r/t

related to etiology, cause of problem cant be meddx its the context, the tx, or the pathology

Types of Debriedment (5), what used for

removal of necrotic tix for wound staging and healing process 1. autolytic - easiest, best in shallow wounds, 3-7days -use of hydrocolliod of foam dsg over wound -bodies own enzymes loosen/liqify necrotic tix 2. biosurgical -use of surgical grade/sterile fly larvae (maggots) -larvae secrete enzyme that liqifies necrotic tix, then consume liquid and inf material in wound 3. enzymatic -apply prescribed and commercially prep'd enzymes to wound bed 4. sharp/surgical -use of scalpal or sx scissors by physc or APRN -full sx sometimes required 5. mechanical -use of external force: H2O2, irrigation, wet to dry dsg -painful

3 nursing interventions that matter to pain

remove or alter source of pain alter factors that contribute to pain tolerance >>fatigue, anxiety est. trusting rlxn (dont forget to give their meds!)

Legs

remove socks, SCDs skin assessment, pedal pulses (DP, then PT at same time), edema, movement (symmetry and strength), sensation (close eyes, which foot am i tickling), cap refill

documentation definition

reporting the pt status and care written or electronically or both the process of recording vital information that is communicated to others -specific precise facts and figures -all pertinent care and ixn c pt -contains correct language, med terms and abbreviations

when use alcohol-based hand rub

routine hygiene when NOT: 1. when hands visibly soiled 2. exposure to spore formers (c.diff, norovirus) 3. high risk clients 4. ^ likelihood to virulent pathogens

how do you decrease the risk of developing a blood clot ascd with IV site

routine removal and rotation of sites

Altered cognition: planning

safety dignity compensatory mechanisms

Altered cognition: implimentation

safety health promotion orientation to surroundings communication methods

SCD

sequential compression device: massage for lower legs to prevent DVT

What neurotransmitters play a role in ability to sleep (5)

serotonin dopamine histamine acetylcholine norepinephrine

culture

set of beliefs values and customs passed down from generation to generation provides a sense of idenification and belonging

STD

sexually transmitted disease

Communication: posture

standing >> open posture get to eye level, sit with them - to be equals remove any objects between you two 2'-4' away, lean forward, uncross limbs

SL

sublingual

Sensory Deficit: def, types and their considerations, interventions

temporary or permanent impairment or lack of senses -Visual: announce presence, orient to time and place, may need assistance with meals -Auditory: use stronger side, face pt so they can see your lips, grab their attn before you start talking -Tactile: teach about protective footwear, inspect feet regularly, set heat limit on water at home -Smell: can be safety hazard (smoke or spoiled), new alarms and ensure food safety I: eval and suggest compensatory techniques

Urine pH how tested, why high, why low

tested w dipstick in lab (also looks at ketones, glucose) high: -drugs (sodium bicarbonate) vegetarian, UTI, alkalosis low: -drugs (ammonium chloride), diabetics, acidosis

what does therapeutic communication focus on

the client and their concerns goal driven on helping the pt keep the ball in their court

tid

three times a day

Hormonal control of fluid and electrolyte balance: thyroid gland

thyroxine secretion >> ^B.flow > ^GFR > ^ Urinary output

X

times

when changing someones O2 level or equipment, what must you do

titrate level of O2 slowly dont leave the room use pulseox during titration and until they tolerate the new level and/or equiptment

what is an incentive spirometer used for, whats the reps

to exercise the lungs and alveoli encourages deep breathing measures inspiratory volume (tidal volume)a to tx/prevent ateletasis, pneumonia 10x/hr

4 process of pain list

transduction transmission perception modulation

Rx

treatment

Tx

treatment

TF

tube feeding

chest tube placement, use, notable

tube in intercostal spave may drain blood from a hemothorax, etc ANY DRAINAGE CONSIDERED OUTPUT

eversion

turn foot away from midline

walker use, size, gait

used to increase balance and support body weight a walker, not a getter upper handles should be at crease of wrist when pt in middle of walker arms down gait: walker, weak leg, strong leg dont use to help get up

goal of aseptic technique

v#moos vLikelihood of spread protect ourselves, our families, and clients

what phsiological changes happen when you stay up all night

vGH and Prolactin ^cortisol ^BP ^seizure risk for pts c epilepsy ^insulin resistance ^early morning cardiac events ^r.f obesity if sustained (espc in children)

altered mobility manifestations

vMuscle strength and tone lack of coordination altered gate falls vJoint flexibility pain on movement

renal regulation of a-b balance: normal process

when pH low, kidneys excrete H+ and retain HCO3- retaining HCO3- >> pH ^^ when pH high, kidneys excrete HCO3-, retain H+ retaining H+ >> pH vv may take up to 3 days

pain definition

"whatever the person says it is, and it exists whenever the person says it does" bodys defense mechanism to indicate a problem universal and mysterious

Major nursing theorists: Peplau ct, tool

-CT: intrapersonal rlxn bt pt, nurse, pt fam -Tool: therapeutic communication

NEURO: Sensory function assessment (7), 2 reminders

*assess both sides of body *have pts close their eyes for all non visual tests 1. pain: nail bed push back, sternal rub 2. temperature 3. positioning: close eyes, can they tell where you moved their hands to 4. vibration: tuning fork 5. numbness/tingling -radiculopathy: nerve disease causes tingling -stenosis: narrowing of spinal cord >> tingling 6. crude/fine localized touch (dull v sharp test) 7. dermatome test: use dermatomes to assess sensation r/t specific spinal locations >>2pt discrimination index: if two sensations are on the same dermatome, body cant descriminate

Info recording in a sleep diary

*collect for ~14days to estblish trends* *can synth with data from bed partner* -time pt retires -time pt attemps to fall asleep -aprx time they fall asleep -time of any abn awakening and time of resumption of s -time of AM awakening -presence of any stressors affecting sleep

6 interventions for colostomy care, specialty role to help

*enterostomal therapist or wound ostomy continence nurse = resource for you and pt 1. privacy and reassurance -like going to bathroom, close curtain to empty pouch 2. keep pt free of odors as possible -empty more than you think: ~1/4-1/3 full 3. inspect stoma regularly -size will stabilize in 6-8wks -surrounding skin: soap and water to clean, keep dry, clean from fecal matter 4. I&O 5. Teach each aspect of care to pt 6. Encourage pt care for and looking at ostomy/stoma

Major nursing theorists: Henderson ct

-CT: pt is an individual who requires help to regain independence >> = health and recovery

Cardiac assessment hx questions

-CP (oldcart) -palpitations: fluttering feeling -fatigue -dynpnea/DOE -orthopnea: +3 pillows or sitting in chair to sleep -pedal edema -syncope -smoking -meds: heart, bp, anticoag meds -alcohol, street drugs -exercise -dietary habits: caffeine -stress -family hx: >Heart disease, CHF, CAD >high chol >DM >HTN >CVA >Rheumatic heart disease: caused by strepto infect >dysrhythmia >murmurs

QSEN: Pt centered care def, goal, ex

- recognize pt as source of control and full partner in providing compassionate and coordinated care based on respect for the pts preferences, values, needs -goal: involve pt in care of themselves -pt advocate for self >> reduction in errors >>ex: bedside report: allows pts to participate, correct, ask qs, promotes continuity of care

general asepsis guidlines (6)

- use right glove for job -never reuse gloves -use nonpermeable gown/apron -use appropriately fitting mask: snug, not moist -keep nails short, natural, clean -no jewelry thatll tear gloves, harbor MOOs

Back Massage

-3-5 minute intevetnio, just after wash and dry -se as relaxant -side lying psnt -use warm lotion -slow gliding strokes: EFFLEURAGE STROKE -affects: mood, pain, musc tens, bp, depth of resp

Guidelines for nursing practice: Standards of Nursing Practice who dev'd, goal, def, notable

-ANA developed -goal: improve health and wellness of individuals, communities, and populations thru nursing useing standard-based practice -def: competent level of nursing care thru the critical thinking model of the Nursing Process -medical model (tx disease) vs nursing model ( tx soc, emo, edu of the PT)

Immobility interventions: msk

-Change positions gradually -Joint mobility maintenance/ ROM exercises >>Automatic ROM equipment >>>Types of ROM: active/passive -Devices: foot board, high top sneakers, boots to prevent plantar flexion (foot drop), hand rolls, trochanter rolls -Early and progressive mobilization · Transfer/gait belts -Pt can perform isometric exercises in bed -Dangling

Autonomic control of ventilation: 4 autonomic factors that control ventilation

-Chemical makeup of blood >>pH, O2, Co2: alt'd levels lead to HYPOXIC RESP drive >>mechanical sensors and pressure sensors -Pain: may ^breathing, vIf thorax/abd pain w breath -Emotions -Medications: opioids vv ventilation

Impact of immobility: GI/metabolic

-Decreased metabolic rate d/t vO2 demand (-) nitrogen balance:other factors-fever, trauma, illness—cause increased metabolic rate and tissue breakdown occurs faster than can be replaced -Constipation d/t vPeristalsis -Anorexia

Post-op interventions: evisceration

-FLAT or semifowler -call for help, notify md -cover intestines c SNS moist dsg -monitor vs -medicate as ordered -prep for sx

Impact of immobility: Physiologocal/self perception,concept

-Helplessness -Body image disturbance -exaggerated emotional responses

illness def, chronic illness def, objective or subjective, what does the nurse tx

-Illness: a state in which a persons physical, emotional, intellectual, social, development, or spiritual functioning is diminished or impared compared w previous experience -Chronic illness: permanent irreversable change of structure and functions that require life long care - illness if subjective, its a personal response to disease -nurses tx illnesses, providers tx disease

Immobility interventions: GI/metab

-Increase fluids -offer frequent toileting -oob for meals and elimination -Progressive mobility

factors effecting pulse (7)

-age: young ^ -exercise: tachycardic -fever: tachy-to ^temp, muscles need to move, only muscle your body can move when laying down is heart -pain: ^^ fight or flight response for acute pain -anxiety: ^ -caffeine: ^ -medication: ^ OR v depending on med

Immobility interventions: psychological, self perception/concept

-give choices -encourage even limited self care -Mobilize

Impact of immobility: GU

-Urinary stasis >> Urinary tract infection -Renal calculi d/t diuse osteroporsis (^ca in body)

pressure injury risks, 3 comorbid conditions

-age -nutrition -moisture -friction, shearing forces >>prevent shearing forces: HOB <30*, raise knees so they dont slide comorbidities: -alt'd level of conciousness -sensory impairment -impaired mobility

factors effecting bp (10)

-age: rise w age (athero/arterio) -gender: F usually lower until menopause, then higher -race: HTN ^ and more severe in AfAm, 2x risk of complication (heart attack, stroke) HM MAYBE has to do with systemic stressors and envi -weight: ^htn:^wt -medications: can directly OR indirectly ^v -diurnal variations: bp daily pattern lowest in AM rises throughout the day -hemorrhage: vVol:vBp -anx,fear,emostress: ^Bp -pain: ^Bp if acute -exercise: ^bp during, but lowers baseline w time

Pt assessment that must be done before ambulating your pt (11)

-recent VS, pain -history of falls -activity tolerance -use of assertive devices -ROM and muscle tone, strength, mass -body alignment and posture -gait and balance -cognition, memory, judgement: can they follow direct -motivation -body size -activity orders

Elements of Documentation: Content 3

-reflect nursing process -specific and descirptive wording (not "normal") -maintain professionalism: avoid subjective comments

Hormonal control of fluid and electrolyte balance: parathyroid gland

-regulates Ca2+ and Phosphate thru PTH -PTH influences Ca2+ bone reabsorption, GI absorption, kidney reabsorption - ^PTH: ^ Ca , vPhos ... VPTH: VCa, ^Phos (indirect

2 blood tests to eval kidney function

1. BUN -blood urea nitrogen 10-20 mg/dL -measures urea and nitrogen in blood -by products of liver metab -^^BUN: ineffective filtering (renal failure, HF, dehyd) 2. Creatinine -Cr+ 0.7-1.4 mg/dL -more sensitive than BUN -byproduct of skeletal muscle Bv -^^Cr+ : damage to kidneys, obstruction, skeletal muscle damage

types of transfers based on 2 variables, 3 types within each category

1. Based on patient ability -independent: capable of moving on own, no help -assisted: needing any form of help -total: completely depended on us 2. Based on destination -lateral: one bed to another, or onto a cart -bed to chair/chair to bed -boost up in bed: when theyve slid down

DYSPHAGIA neuromusclar causes(4) , traumatic causes (3), easy to swallow foods (3 cats)

1. CVA: 50% have dysph, 1/3 of those develop aspirational pneumon>>leading killer in CVA pts -recent CVA = NPO until safe swallowing 2. ALS: amylotrophic lateral sclerosis (louegherigs) 3. PD 4. MG 1. oral/throat sx 2. CA therapy 3. Injection of caustic substances 1. thickened liquids -anything necture, pudding, honey consistancy -"thicken up" a substance put in thin liquid (h20, coffee) that makes it thickened consistancy for safe swallowing 2. pureed/smooth foods -pudding, mashed potato 3. other easy to swallow foods -cooked veggies, ground meat, creamed soup, iced fruit

10 purposes of pt records

1. Communications: continuity of care 2. Diagnostic and therapeutic orders 3. Careplanning: baseline and ongoing 4. Legal: didnt chart it didnt happen, chart EVERY thing 5. Historical documentation: previous hospitalizations 6. Research: data repositories, promotes EAB 7. Education: learn about pt, illnesses 8. Credentialing: compliance c standards of care 9. Reimbursemnt: not charted not paid 10. Quality Improvement: measure performance

documentation of catheterization 6

1. date and time 2. type and size 3. if specimen obtained, sent to lab 4. amt of urine drained 5. description of urine 6. pts response

interventions for fluid and electrolyte imbalance: tx(3)

1. Fluid management -^ORv PO fluid intake -^:offer preffered fluids, set goals, always fluids avail v:restrict, set goals, use small cups, ice chips, avoid salty foods, keep fluids out of site, good oral hygiene **IV fluids as prescribed 2. Electrolyte management -admin ordered lyte replacements *beware admin instruction, often diluted and slow drip, some are vesicant 3. Medication management -diuretics may be ordered to assist management of fluid and electrolytes

Health Assessment: 3 frameworks of PE (list)

1. Head-to-Toe Framework 2. Body Systems Framework 3. Functional Health Patterns Framework

3 post op circulatory complications

1. Hemorrhage -EARLY post op prob -1st sign = low UOP -BPv, HR^, thready pulse -^drainage -cool clamy pale skin 2. Thrombophlebitis -d/t dvt or iv 3.DVT -DEV 7-10 DAYS POST OP

2 flows of O2 administration

1. Low Flow O2 System -provides only PART of total inspired air -more comfortable -O2 delivery varies w breathing pattern 2. High Flow O2 System -provides TOTAL inspired air -O2 delivery does NOT vary with breathing pattern

4 pt safety issues in the hospital, what can they cause

1. problems c equiptment 2. procedural errors 3. patient impairments >>>>>fires, falls, adverse med errors 4. sentinel event -serious safety error that leads to serious injury or death -facility must conduct root cause analysis -"Never event" should be mostly preventable

Health Assessment: collection of data, 2 types

1. Subjective data -verbal statements ONLY from pt -includes feelings, perceptions, self report of symptoms 2. Objective data -signs detected by the nurse during PE; hears sees measures -vs, apperence, rashes, bp, dx imaging

Factors (pt sepcific) effective ventilation (6)

1. age: vElasticity of alveoli w age 2. gender: males tend to have ^thorasic space so vResp rate bc of ^resp volume 3. metabolism: more muscle mass >> ^resp rate 4. stress: sick>> ^resp rate, anx >> ^ 5. medication 6. environment: bad air qual: nursing home, prison

alterations in CVC fxn (5)

1. vCo -MI, stenosis, dysrhythmia 2. alt'd blood flow -shock, polycethemia, vascular dysfxn 3. vTix perfusion -ischemia, thrombus, hypvolemia 4. impared vavle fxn -stenosis of valves 5. myocardial ischemia -angina, MI

MSK Assessment: Osteoporosis last 11 risk factors

11. race: white, asian 12. blonde or red hair, freckles: vCollagen 13. light body frame, thin 14. family hx of osteoporosis 15. nulliparous: never given birth (chml change to bones 16. constant dieting: vCal, vProt, vCa2+, AN 17. scoliosis, R.arthritis: low mineralization, RA meds=roid 18. metabolic disorders: DM, hyperThy: malabs of Ca2+ 19. poor teeth 20 previous fractures 21. drugs that vBone strength

IV solutions: hypertonic solution examples, tx what

5% dextrose in LR (D5LR) others: D10LR, 3% NS, TPN -replaces lytes, provides cals, shifts fluids into vascular space to expand vascular volume

Health Assessment: Functional health patterns (last 7) (usually a def and then some questions youd ask in an assessment)

7. Pain and Discomfort -ability to control/maintain discomfort -any pain? rate, use anything to control it? 8. Respirations -ability to provide and use O2 to meet physio needs -breathing ok? lung sounds? 9. Safety and Protection -ability to provide safe, growth promoting environment -@risk for fall? inj? pressure injury? 10. Role relationship / Social Interactions -the cxns or acns bt people or groups -how does change in health status interfere w person ability to fulfill their role expectations 11. Sexuality -sexual identity, sexual fxn, reproduction -satisfied/dis? reprofxn? STIdx? breast cancer? 12. Life Principles/Values/Beliefs -spiritual assessment, may focus on religious beliefs and values -assess any rituals, rules, create time to pray if necc 13. Teaching/Learning -ability to incorporate and use info to achieve healthy lifestyle and *optimal wellness* -regular check ups, what do they do to try to achieve optimal wellness

Chloride value range, what test measures, low and high value indications

95-105 mEq/L Cl- level, may indicate acid-base balance, hydrtn status LOW indicates: hypovolemia HIGH indicates: dehydration

Essential non-nursing theories: Maslow's Heirarchy of Needs Ct, goal, needs

CT: persons more basic needs must be met before they can proceed to or achieve higher needs -goal: rank pts priority problems, strive for max potential - physiological, saftey, love, self-esteem, self-actualization ( = peak experience: intense awe and joy >> inspiration, reform)

Major nursing theorists: Newman and Roy's theories CT, Nurses r

CT: pt response to stress Nurses r: help pt adapt to illness, strengthen their line of defense

Hair assessment (9)

Assess clients hair for: I. Color II. Distribution III. Quantity IV. Thickness V. Texture VI. Sheen VII. Hirsutism VIII. Alopecia IX. Assess scalp

Skin assessment (9)

Assess clients skin for I. Color II. Moisture III. Temperature IV. Texture V. Turgor VI. Vascularity/Petechiae/discolorations to the extremities VII. Edema (pitting, non-pitting) VIII. Lesions/rashes/abrasions IX. Body piercings/tattoos

Skin - Teach a patient how to identify an abnormal mole - ABCDE.

Asymmetry Border: irregularity Color: blue or black, should be 1 or 2 colors Diameter >6mm (pencil eraser head) Evolution: changing

Benefits (2) and Risks (2) or oral route for meds

BENES -easy to use, easy for self-admin -wide variety of meds RISKS -aspiration >>check gag reflex, sit up pt, sip before try, admin 1 @ time as needed -GI Side effects w many oral meds >>n/v/d/constipation

Anticoagulants ixn c anesthesia

BIGGEST RISK causes increase intra- and post- op bleeding d/c 5-12 days pre-sx, start back same day

what is red bag for

BIOHAZARD any items that have contacted bodily fluid

Pre-op diagnosis screening possible tests 4

BLOOD WORK cbc bmp coagulation studies blood type and cross hcg CXR EKG MRI/SCANS

Neuro - Assess deep tendon reflexes - Patella and Brachial. Demonstrate Romberg Test

BRACHIAL -medial to tendon -use fingers or thumb to hit -rest arm on lap or down -response: draw arm upward slightly PATELLA -soft spot posterior to the knee cap -watch your placement -reponse: kick ROMBERG -stand c arms down and feet hip distance -I stand to side of pt, ready to catch -instruct to close eyes and stand as still as possible for 30 seconds -normal: slight swaying -if start to fall, open eyes -one legged ~5-10 seconds -walk tenderly

Essential non-nursing theories: Lewin's Change Theory Ct, defs, ex

CT: describes how ppl struggle with change 1. Unfreeze -recognition of need for change -ex: dx w lung cancer 2. Movement -bx change toward helpful pattern -ex: tx for nicotine addiction 3. Refreeze -permanent healthy change -ex: stop smoking

Respiratory - Demonstrate chest excursion and vocal/tactile fremitus

CHEST EXCURTION -measurement of proper ventilation -hands at end of exhalation, placed under scapulae with thumbs touching -ask pt to breath w maximal inhalation, thumbs should spread -NORM: equal spread -ABN: one hand doesnt move COULD INDCT lung not filling w air VOCAL/TACTILE FREMITUS -vibrations felt on hands on scapulae, between scapulae, below scapulae -"99" should feel vibration -lack of vibration: accum of mucus, lung collapse, lesion

5 things to work on when youre developing therapeutic communication skills

CONVERSATION SKILLS -be flexable, follow pts lead LISTENING SKILLS -active listening facilitates communication -dont EVER interrupt pt -be quiet, listen, and observe pt -posture: face pt, observe, lean toward, est and maintain eyecontact, relax USE OF SILENCE -useful when ppl confronted by decisions w a lot of thought -espc therapeutic during times of profound sadness THERAPEUTIC TOUCH -esp therapeutic during times of profound sadness -"caring touch" -one of the most powerful forms of communication -during procedure, assesment, hold hand of vulnerable pts HUMOR -coping strategy that adds perspective -helps adjust to stress, build rlxn -goal: bring hope and joy to situation, enhance wellbeing

Coping and adaptation

COPING -managing events perceived as stressful -adjusting to circumstances, environmental change, challenges -R.Role: assess need for interention, when coping mech fail ADAPTATION -outcome of coping -capacity to survive and flourish in the face of adversity -goal: achieve homeostasis, balance **HELPING pts manage stress = impt to health promotion and illness prevention

Liver biopsy: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: tix sample obtained from liver P: dx diseases of liver E: d.c bleeding RX, NPO 6hr, avoid lifting post P: PTT, PLT count pre, emtpy bladder imdtly before P: RIGHT SIDE LYING, NPO 2hr post

Arthroplasty: def, nursing actions

D: total joint replacement N: infection, impd mobility, neurovasc dysfxn, pain

Intubation: def, nursing actions

D: tube thru trachea to assist w breathing N: airway patency, suction, o2, bronchodilators

Holter monitor: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: wearable device that keeps tract of heart rhythyms P: worn long time to detect more ryhtym abn E: non invasive, teach how to wear P: make sure device on and working P: remove monitor

Pancreatiocoduodenectomy: def, nursing actions

D: whipple, remove head of panc, gallb, part of s.int N: pre/post, monitor drains, cath, i&O

Sleep apnea def, types

DYSSOMNIA -lack of airflow thru nose and mouth for 10sec-2min during sleep -SNS takes over when ^HR and ^BP d/t lack of O2 1. Obstructive sleep apnea -when soft tix (tounge) doesnt maintain patent airway, falls back and narrows or occuldes airway 2. Central sleep apnea -problem in respiratory centers in brain, doesnt send correct signals to breath 3. Mixed sleep apnea -combo of 1+2

Sleep apnea s/s, 3 concerns, tx,

DYSSOMNIA -s/s: excessive sleepiness, fatigue, depressed mood, difficulty concentrating, poor memory -concern: use of opiods (depressed resp) -concern: public health - fatigue at wheel -concern: strong link to CVdis - htn, stroke, cad -TX: cpap overnight (46-83% dont use bc uncomfy)

Sleep deprivation qualification

DYSSOMNIA >30hrs of no sleep

Restless leg syndrome

DYSSOMNIA periodic limb movements 15% pop in SI or SII: sensation in legs, jerk >> chronic sleep issues

define constipation, whats it ususally d/t, 6 pt groups at risk for constipation

Def: persistently difficult passage pf dry hard stool >> NOT about timing since last bm d/t vGI mot, longer in l.int, more h2o abs, harder stool pts on cbr pts on constipating meds pts w vFluid or bulk in diet pts who are depressed pts w CNS disease pts w local lesions >> pain when deficating

3 D's of mental status change and 3 defining characteristics

Delirium -acute, sudden, reversible Dementia -gradual onset, progressive, irreversible Depression -rapid delcline, A&O, reversible

Source-oriented Record def, adv, disadv

Documentation method -handwritten narritive notes of pts activities ADV -used c flow sheets (add note to box) -chronological data quickly documented -familiar form -used in all types of settings -inexpensive DISADV -requires time to handwrite -may be illegible, hard to read -may lack info (no boxes to check) -quality assurance monitoring hard: hard to find -relevant data found in different places: many pgs -confidentiality difficult to protect (no passcode on a piece of paper)

HEENT: Ears assessment (9)

EARS 1. size 2. shape 3. position 4. symmetry 5. discharge 6. define otoscope 7. different inspection techniques for adults v children 8. cerumen 9. whisper test

how do we measure sleep

EEG: electroecephalogram (brain waves) EOG: electrooculogram (eye movment) EMG: electromyogram (muscle contractions) Polysonogram: "sleep study"

ET Tube and ventilator

ET Tube endotracheal tube intubation, attached to ventilator placed down throat w millers blade to deliever O2 directly to lungs Ventilator mechanical ventilation used to breath air for pt unable to breath independently

Health Assessment: PE examination techniques (4) brief description and order

EVERY ASSESSMENT EXCEPT ABD 1. Inspection: looking 2. Palpation: touch, feel 3. Percussion: tap to det size, borders, fluids, airs 4. Auscultation: listening with stethoscope ABDOMINAL EXAM: so we dont create sound that wasnt present before due to touching 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

korotkoff sounds

I -clear, rhythmic thumping -1st sound heard -systolic, record as top # II -blowing or whooshing sound -audible as vessels distend w blood III -softer thumping IV -distinct muffling sound V -disappearance of sound -diastolic, record as bottom #

Cardiovascular and Peripheral Vascular - Verbalize 6 questions you would ask regarding this assessment

Hx of heart disease Discoloration of the fingers or toes Any swelling, lateral, bilateral Do you check your BP regularly, what is it Notice any pulsating in your abdomen Do you experience chest pain

Skin assessment (9) and whats normal for each

I. Color -no normal, but should be symmetrical throughout II. Moisture -normal = dry III. Temperature -normal = symmetrically warm IV. Texture -normal = smooth V. Turgor - normal = no tenting (use forearm or sternum to test) VI. Edema -pitting vs non-pitting -bilateral vs unilateral -dependent vs independent VII. Vascularity/Petechiae/Extremity Discoloration -normal = symmetrical (if you can see it) -abn: varicose veins, petechiae (small hemorrhages) VIII. Lesions/Abrasion/Rashes -macule, papule, pustule IV. Tattoos/Piercings -document skin condition (redness, intact, etc)

ISBARR

IDENTIFY/INTRODUCE: name, unit, status, pt SITUATION: what is happening at present time >why are you communicating BACKGROUND: circumstances that led up to situation ASSESMENT: what do I think the problem is RECOMMENDATION: what should we do to correct the problem >what tests and procedures should we do right now READ BACK: restate orders

mixing injectable meds procedure

IE mix 30unit NPH and 12 unit R insulin 1. roll vial in hand 2. w/d 30 unit air, inject into NPH. DO NOT TOUCH SOL 3. take out, w/d 12 units air, inject into R 4. invert R vial, draw up 12 units, ok to get extra 5. w/d 30 unit NPH, CANNOT OVERDRAWAL 6. w/d, engage safety mechanism w one hand

HEENT: Eyes assessment (16)

II. EYES 1. shape 2. shape 3. position 4. symmetry 5. discharge 6. PERRLA 7. visual acuity 8. visual fields 9. extraocular eye movement in 6 cardinal directions 10. exophthalmos 11. strabismus 12. lacrimal glands 13. tear ducts 14. conjunctiva 15. sclera 16. define ophthalmoscope

3 Phases of General Anesthesia

INDUCTION -from admin of anesthesia to ready for incision -usually started via inhalation MAINTENANCE -from incision till near completion of procedure EMERGENCE -starts when pt emerges from aneths and is ready to leave OR

normal fluid intake and output causes and amounts

INTAKE ingested water ----------- 1300ml ingested food -------------1000ml metabolic oxidation ------- 300ml TOTAL ---------------------2600ml OUTPUT kidneys ------------1500ml skin------------------600ml lung -----------------300ml gi--------------------200ml TOTAL--------------2600ml

Post-op interventions: metabolic and urinary

IV fluids, oral fluids for fluid volume deficit progressive dietary intake of fluids >sips>clear liq>full liq>soft diet acurate and strict I&O assess serum electrolytes

equiptment

IV pump, feeding pump, oxygen, BiPAP, CPAP, PCA, SCD's, foley catheter, NGT follow all tubes and assess any details (O2 amount, fluid type, rate) make sure to turn everything back on as ordered before leaving

direct and indirect measurements of SaO2

Indirect: light emitting probe on pts finger or earlobe for 10-30s indirect, noninvasive Direct: arterial blood gas (ABG) take blood out and run analysi direct, invasive

Magnesium normal value, role, hypo name, causes (5), s/s (5), tx (4)

Magnesium Mg2+ 1.3-2.3 mEq/L important for metab of carbs, proteins, neuromuscular fxn Hypomagnesemisa Cause -choronic alcoholism, intestinal malabsorption, diarrhea, NG suction, drugs S/S -neuromuscular irritability, coarse temors, seizures, tachyarrhythmias, disorientation TX take seizure precautions, monitor airway, replace magnesium, edu on Mg rich foods

Topical Medications: Nasal examples (4), administration

Nasal Antihisthamines, steroids, decongestants, moisturizers Administration -Put gloves on -pt blow nose, provide them tix -pt tilt head back -occlude other nostril, insert tip into other -instruct pt to breath in if required -release one spray toward the septum -keep container compressed, remove from nares -instruct pt to hold breath for few secs, then breath out slowly through the mouth -repeat if ordered or indicated -wipe outside of nose piece with clean dry tix -avoid blowing nose for 5-10 minutes

Professional nursing organizations: NSNA who, goal

National Student Nurses Association -org for students -goal: run by students, advocate for student and pt rights, take collective action on social/political issues

Medication dose response terms: Peak, Pleateau

PEAK time it takes to reach highest effective concentration in blood impt in insulin PLATEAU maintained level of concentration c repeated fixed doses

Topical Medications: Ophthalmic examples (2) and administration

Ophthalmic Lubricant, antihistamine Administration -Put on gloves -offer pt tissues -clean eyelid/lashes w cotton or gauze moistened w water or NS, use each once from inner to outer canthus -tilt head back, or onto pillow, can situate to prevent med from rolling to opposite eye -remove cap, invert container -pt focus on object -lower to expose lower conjunctival sac -squeeze container for prescribed #drops into lower conjunctival sac, NOT cornea (injury, unpleasant) -release lid, pt close eyes -apply gentile pressure over inner canthus -replace cover -pt no rub eye **AVOID TILTING HEAD IF PT LIMITED ROM

Topical Medications: Otic examples (2) and admin

Otic Lubricant, antibiotic Administration -Put on gloves -clean ear with water or NS soaked gauze as needed -pt on unaffected side, straighten ear canal -keep lid and dropper tip sterile -invert dropper, instill drops on SIDE of canal, avoid instilling onto tympanic membrane -release pinna, pt stays for 5 minutes -gently press on tragus few times to move med down canal -if ordered, place cotton to prevent leakage

4 opioid concerns

PHYSICAL DEPENDENCE -physcial w/d symptoms c d/c, vDose, antidote TOLERANCE -req ^dose for same efect PSEUDOADDICTION -bx suggestive of addiction, caused by undertx of pain ADDICTION/PSYCHOLOGICAL DEPENDENCE -psych disorder characterized by compulsive continuous use despite harm -use for non-prescriptive purposes

Medication Administration: Polypharmacy and Misuse Noncompliance

POLYPHARMACY use of multiple meds ~1/3 of nation taking >5meds a day -more chronic conditions >> more polypharm likely -hard to det how 5 meds will ixn w each other MISUSE taking prescribed med any other way than prescribed -includes dc, ^dose, vDose NON-COMPLIANCE many pts noncompliant in one way or another our job: investigate (pts will talk, we can find solutions) -may be knowledge deficit, economic reason, psych reason, may be innocent> dont know about pill box

3 Phases of perioperative nursing, when do they begin and end, what do they include

PREOPERATIVE -from pts FIRST decision to get sx until theyre transfered to OR or procedural bed -can be preop teaching for years -dx, options, plans, schedule, informed consent INTRAOPERATIVE -begins when pt transfered to OR or prodedural bed and until theyre transfered to PACU -whole time procedures being done POSTOPERATIVE -lasts from adminssion to recovery room until complete recovery and last f/u with physician -lots of assessments during this time

Coagulation studies (4) and values

PROTHROMBIN TIME (PT) 9.5-12 seconds INTERNATIONAL NORMALIZED RATIO (INR) not anticoag'd: 0.76-1.27 anticoag'd: 2.0-3.0 ACTIVATED PARTIAL PROTHROMBIN TIME (aPTT) 20-39 seconds ANTI-FACTOR Xa ASSAY 0.3-0.7 units/mL

QSEN Competencies and safe medication administration

PT CENTERED CARE -pay atn to patient rights -advocate for your pt TEAMWORK AND COLLABORATION -many HCP collab to create safety -know your role and others to work competently and efficently EBP -in how we admin, how we prevent errors QUALITY IMPROVEMENT -r/t timliness of admission, vErrors, ^workflow SAFETY culture of saftey, open communication of errors and near misses INFORMATICS use eMAR, Barcode scanning

what stages get about 10% of sleep

SIII, SIV (deep/delta sleep)

Pain process: Transduction

STEP 1 activation of pain receptors pain receptors = sensory afferent receptors = nociceptors conversion of noxious stim to electrical impulses and sending the impulse from the periphery (nociceptors) to the dorsal horn of spinal cord

Pain process: Transmission

STEP 2 two processes happening at same time 1. reflex arc: reflex to pain, remove body from stimuli 2. dorsal horn decides pain is important enough to let brain know, bring msg to SPINOTHALMIC tract to THALAMUS (sensory center of brain) and CEREBRAL CORTEX (determines intensity of pain) >>A-Delta fibers are initial gate opening at dHorn and cause immeditate pain >>C Fibers overpower AD, close down the gate, sub the immediate pain for continuous constant pain

Pain Process: Modulation

STEP 4 controlling the pain, regulation or inhibition of sensation Neuromodulators (endogenous opioid compounds) >endorphins: block at dHorn, work @brain to vSensatn >enkaphlins: same and they decrease Subst P

short term goal sentence ex, intervention sentence example

STG ex: "pt will ______ by ______" intervention ex: "nurse will _____ by ______"

Respiratory - Identify lung sound on manikin and cause - Stridor

STRIDOR CAUSE -severe contraction of upper airway -obstruction, 2* to croup in children

Most important part of communication we have

Silence give it time, both know theres silence maintain eye contact, open position, lean in DONT interrupt the silence

CVC system Electric (pace maker)

Sinoatrial node (SA node) pacemaker of the heart specialized cells receive signals to regulate the contraction of the heart -initiates electrical signaling path SA node > AV node > bundle of His > bundle branches > purkinje fibers

urine tests: list 4 common tests

Urine analysis specific gravity C&S (sterile) 24 collection

structures of the respiratory system(3 categories and subcats)

Upper airway nose, pharynx, larynx, trachea Lower airway Left lung (2lobes), Right lung (3 lobes) Thoracic cavity ribcage, muscles, diaphragm

VARK

VISUAL -pictures maps graphs to explain things AUDITORY/AURAL -hear things, discuss things outloud -recorder, dicsussions, lectures, tutorial, study groups READERS/WRITTERS -anything in print -manuals, lists, books, ppts, notes, -words words words KINESTHETIC -experience, use their senses, practice -field trips (clinical), simulations, real life examples, labs, trial and error, case studies, videos of real things

Medication Administration: Triple Check

VISUALLY CONFIRMING MED 3X 1. when nurse reaches for med 2. when dose is in nurses hand 3. one last time before admission

Ventilation, Diffusion, and Perfusion def, how measure,

Ventilation measure w incentive spirometer breathing: moving air in and out of lungs Diffusion -indirectly measured with pulse oximeter -O2 and CO2 movement bt alveoli and blood Perfusion -indirectly measured by pulse oximeter -circulation of blood thru an area of the body

what makes oral thermometer not suitable for use? then what

pt had something to eat or drink, smoked, or chewed gum in 30 mins use another method or wait 30 min

Aspirin indications, toxicity symptoms, GI side effects

antipyretic, non-opioid analgesic INDICATIONS -pain, inflammation, fever, prevention of MI or CVA TOXICITY tinnitus, hyperventilation, confusion, lethargy, agitation, sweating, diarrhea GI SIDE EF irritaiton, bleeding

what is noise in a conversation

anything distracting you from communication processes eliminate noise common: pain, BR needs, odors, literal noise

Digoxin pre-admin assessment, toxicity

anti-arrhythmic, inotropic PRE-ADMIN ASSESSMENT apical HR (60sec) TOXICITY bradycardia, vision changes (halo), GI symptoms

Nitroglycerin adverse effect, ixn

antianginal ADVERSE EF h/a and hotn IXN potentially fatal ixn c ED meds (phophodiesterase inhibitors [PDEIs]

Diltiazem Action, caution

antianginal, antiarrhythmic, antihypertensive ACTION vasodilaters - lower bp CAUTION position changes OHOTN

METOPROLOL use, preadmin

antianginal, antihypertensive USE decrease bp and HR PREADMIN HR and BP

Prednisone administration caution, side ef

antiasthmatic, corticosteriods CAUTION titrate down from high doses SEF many sefs: hyperglycemia requires urgent mgmt

Enoxaparin administration specifics

anticoagulant ADMINISTRATION pre filled syringe, do not expel air from syringe, retain bubble

Warfarin lab, antidote, sef

anticoagulant LAB monitor INR level: Therapuetic range = 2-3 seconds ANTIDOTE Vit K SEF increased risk of bleeding

Sertraline onset, bbw, ixn

antidepressant ONSET up to 4 weeks BBW suicidal ideations IXN cannot be taken within 2 weeks of MAOIs

Metformin when use, monitor what labs, contraindication

antidiabetic WHEN after lifestyle change in diabetic pt, continue to reinforce it LABS monitor bg, HbgA1C to det improvement of blood sugar CONTRAI lab contrast >> renal failure if pt also taking metformin

Naloxone use

antidote for opioids USE opioid antagonist, reversal for morphine, hydromorphone, heroine, etc

Promethazine admin caution, sef

antiemetic, antihistamine, sedative/hypnotic ADMIN IM injection-z-track SEF causes drowsiness, sedation

normal arterial blood ph, regd by what mechanisms, measured how

arterial blood ph = 7.35-7.45 reg'd by -respiratory mechanisms: rapid pH changes d/t quick diffusion of CO2 (minutes to hours) -renal mechanism: reg H= excretion or rtn and formation and excretion of HCO3- (slower, 3 days) measured thru abgs arterial blood sample taken from artery sent to lab partial pressure of gasses reflect overall effectiveness of gas exchange

when to record vitals, what order

asap, in room TPR, B/P, 0-10 HEY STUDENT NURSE USE UNITS DONT BE LAZY

hearts function, equation

blood flow regulation CO = HR x SV SV = amt of blood ejected from L vent w each contraction

pulmonary ciruclation

blood moving to the alveoli in capillaries for gas xchange to occur

BP

blood pressure

orthostatic hypotension def, numbers def, method of testing, two causes

blood pressure dropping with change in position vBp >20mmHg with position change method -measure bp laying down, sitting, standing with 1-3 min of rest bt measurements causes -volume deficit : vBp + ^pulse -inadequate sympathetic response: vBp + vPulse

respiratory regulation of a-b balance: normal process

body metab yeilds H2CO3 (carbonic acid H2CO3 >> H2O and CO2 as CO2 ^^ in blood, respiratory rate increases this >> vH2CO3 >> Blood pH ^ as Co2 vv in blood, respiratory rate decreases this >> ^^H2CO3 >> blood pH v

Anticonvulsants ixn c anesthesia

can alter metabolism of anesthetic agents

Dyssomnias: def, 6 types

characterized by either insomnia or excessive sleepiness Insomnia Hypersomnia Restless leg syndrome Circadian ryhthm sleep disordrs Sleep deprivation Sleep apnea

Post-op interventions: psychological

provide privacy maintain hygeine deep drainage devices empty when possible allow pt to discuss feelings encourage family support, visits

what if pulse strength isnt symmetrical/equal

concerning could be vascular occlusion from fracture, clot, etc

conciousness, attention, memory, learning, communication

conciousness: awareness, responsiveness. requires an intact RAS attention: req'd to aquire and express info, focus attention on some stimuli and ignore others memory: serves as filter. associate with sensory experiences learning: stimuli must be meaningful, link learning to previous knowledge, reqs storing and recall of knowledge, comprehension, application, analysis, synth, eval communication: both verbal and nonverbal

clinical judgement

conclusions and opinions about patients health drawn from patient data the DECISIONS you make

Sensory Alterations: Planning

determine if the alteration is temporary or permanent. plan could either be for coping with a temporary loss or completely adapting

Medication error definition , stat, when can errors occur, what are 2 reasons why

def: a preventable event that can cause or lead to inappropriate med use or pt harm while the med is in the control of the HCP incidences of meds >> harm ~1.5mil errors can occur at each phase ordering transcibing dispensing administering*** >>our most likley (MINIMIZE INTERUPTIONS) errors can be d/t human error or system ineffectiveness

Subjective mobility assessment

det normal pattern r/t mobility determine if impaired mobility is 1* or 2* to something do they have access to assistive devices ID risk: falls, bedrest risks

5 factors that effect spirituality

developmental considerations family ethnic background formal religion life events

Whats true of every patient and fall risk

every patient in the hospital is at an increased risk for fall

Culturally competent nursing: concerns impacting pt care (9)

gender roles disease susceptabilit: incidence in certain groups food: preferences, religious timing of eating (ramadan) spiritual/relig needs: items, time with leader rxn to pain: some cultures expressive, some suppressive socioeconomic personal care patters: bathing, deodorant use folk and traditional care: ixns? orientation to space and time: african/arabic norm = less personal space

what suppliment is contraindicated with insulin and why

ginseg may increase hypoglycemia w insulin therapy

sequence for removing PPE

gloves, googles/faceshield, gown, mask, wash hands OR gown with gloves, goggles/faceshield, mask, wash hands

Scalp assessment (10)

i. lesions ii. bruises iii. hair loss: alopecia iv. dandruff: over use of soap v. psoriasis vi. lice (pediculus humanus capitis) vii. ticks: deer tick = lyme disease viii. tingworm ix. lumps x. tenderness

sentinel alert regarding sleep

impact of fatigue on HCP, changes to rules about hours of calls, shift lengths changed

HEENT focused assessment

introduction ask 3 questions I. HEAD 1. size 2. shape 3. position 4. symmetry 5. TMJ for crepitus II. EYES 1. shape 2. shape 3. position 4. symmetry 5. discharge 6. PERRLA 7. visual acuity 8. visual fields 9. extraocular eye movement in 6 cardinal directions 10. exophthalmos 11. strabismus 12. lacrimal glands 13. tear ducts 14. conjunctiva 15. sclera 16. define ophthalmoscope III. EARS 1. size 2. shape 3. position 4. symmetry 5. discharge 6. define otoscope 7. different inspection techniques for adults v children 8. cerumen 9. whisper test IV. NOSE 1. size 2. shape 3. position 4. symmetry 5. patency 6. discharge 7. excoriations 8. sinuses for tenderness V. THROAT 1. mouth: size shape position symmetry color 2. tonsils 3. uvula 4. soft palate 5. neck size shape position symmetru 6. lymph nodes 7. trachea alignment 8. thyroid gland IV. ALL PIERCINGS R/T HEENT

bp bladder size percentages of arm

length 80-100 width 45%

Interviewing techniques

open-ended questions -" what, how, tell me more" -prevents y/n response close-ended questions -elicit 1 word answer (y/n), limited response -"are you allergic to anything" validating -validate to nurse what was heard or observed -"I see youve been taking 1 pill a day, is that correct?" clarifying -offer back to speaker estl meaning as understood by listener -"i dont think i understood, could you tell me again?" reflective -focus on pt identified feelings based on verbal or nonverbal cues -"you seem upset" sequencing -used to place events in chron order or det cause/eff -" you get tired at 3pm... after you take your medicine" direct question (focused) -used to get more info on a topic from earlier, narrow in providing information -your BP is 132/82 sharing observations -sim to refelctive, observe cues, share obs

A Delta Fibers and C Delta fibers role in pain

operate during Transmission >>A-Delta fibers are initial gate opening at dHorn and cause immeditate pain >>C Fibers overpower AD, close down the gate, sub the immediate pain for continuous constant pain

Hydromorphone antidote, preadmin assess, sef in geri, common sef and its assesment

opioid analgesic ANTIDOTE naloxone PREADMIN LOC, RR, BP, HR SEF IN GERI may cause confusion of excessive sedation in elderly COMMON SEF constipation, last BM?

morphine antidote, preadmin assess, sef in geri, common sef and its assessment

opioid analgesic ANTIDOTE naloxone PREADMIN LOC, RR, BP, HR SEF IN GERI may cause confusion of excessive sedation in elderly COMMON SEF constipation, last BM?

temperature celsius

oral 37 temporal 37 tympanic 37.5 axillary 36.5 rectal 37.5

OOB

out of bed

Common sensory alterations: visual (5)

presbyopia: age rlt'd nearsighted loss (age 40) cataracts: clouding of lens, sx, 50% of 80+ have glaucoma: ^IOP>>optic nerve dmg, irrvsble, tx c meds retinopathy: dt dm, non-inflam damage to retina maculardegen: loss of vision in center of field

how does a bp cuff work

pressure in bp cuff occludes artery, as cuff matches arterial pressures, youll hear sounds (or lack of sound) of turbulent blood

Universal Protocol

prevent wrong site, wrong procedure, and wrong surgery verify pt c 2 id necessary assements, doc, procedure (preop checklist) "TIME OUT" in OR: regroup, double check

personal hygeine for the nurse

professional appearance clean and neat styled hair away from face excellent oral and skin care minimal makeup minimal jewelry no perfumes clean shoes clean wrinkle free uniform

Last 5 teaching sessions

programmed instruction: send home w material, be proactive c evaluation printed material: brochure, keep in mind languge/literac role playing: kids playing dr to vAnx role model: actions speak loud, nurse who quit smoking web-based instruction: easy, accessable 24/7, webmd

4 main roles of the intraoperative nurse

provide emotional support -advocate for pt ensure safe environment and prevent injury -technique, needle and sponge count maintain asepsis -call out break in sterility promote wound healing -psnting, vs, sx timlines

where/how take radial pulse, where/how take apical pulse

radial inner wrist thumb side lightly compress with index&middle finger 30sec x 2 if regular, 60sec if not apical bt 4th and 5th intercostal space and midclavicular line pt with breasts must displace, or you w BACK of hand auscultate with stethescope 60 sec : ONE lub&dub = ONE pulse count

ROM

range of motion

Scrub Nurse main job 4

scrubs in: sterile PPE assists surgeon c instruments and equiptment maintains sterility equiptment mgmt: count, dual verification

Pharmacological tx for dyssomnias

sedatives hypnotics

Communication: pacing

slow down for now cause youll be nervous hah

at what stage of sleep do we see parasomnias

slow wave sleep/deep sleep (SIII, SIV)

what will be ordered often w a foley

specimen collection to determine baseline if UTI present IF THEY DONT, ASK THEM

Objesctive and subjective assessment of spirituality in pt

sub -tell me about beliefs that are important to youy" -"do you have a spiritual person i can notify" obj -general apperance, cry, body posture

what 3 people have a say in pt psnt during surgery

surgeon anesthesiologist circulating nurse

4 never events in surgery

sx performed on wrong pt sx performed on wrong body part wrong sx performed on pt unitended rtn of a foreign object in pt after procedure

7 types of oral medication, procedure type,

tablets, capsules, powder, liquid, time release, buccal, sublingual clean procedure: do not need to wear gloves EXCEPT if contacting MM (buccal, sublingual), then wear gloves

hypothermia temp, signs symptoms

temp: <35 C SS: -uncontrolled shivering: to ^BMR -memory loss -depression -poor judgement: ^last 3 due to physio dpress -vPulse vResp vBP -cyanosis 3 KINDS >>1. perpheral cyanosis: fingers, toes, lil concerning >>2. circumoral cyanosis: around mouth, concerning >>3. core cyanosis: thoracic cavity, VERY CONCERNING YOUR ORGANS ARE IN THERE and getting no perfusion -loss of consciousness

who determines your scope of practice

the state you live in

thermoregulation equation, variables causes, bodies control center

thermoregulation = heat produced - heat lost HEAT PRODUCED -BMR: measured when sleeping -Voluntary movements: move around, vulner pops cant -Shivering: contrai with trying to cool a hyperthermic, will cause BMR to ^x5 HEAT LOST -Radiation: heat lost to envi -Conduction: heat lost thru direct contact -Convection: heat lost thru air movement -Evaporation: heat lost thru diaphoresis (sweating) CONTROL CENTER -Nervous and vascular control center = HYPOTHALAMUS (controls vasodia/constr

steryotyping

to develop a fixed idea about a person or group

occult blood testing def, process

to test stool sample for presence of hidden blood use solution of Guaiac to test >> spread stool of testing slide >> dropper onto control spot, then over fecer spot >> if area or rim turn blue = (+)blood

respiratory physiology: ventilation, diffusion, perfusion defs and what measures them

ventilation -movement of gas in and out of lung -measured by respiratory rate diffusion -movement of O2 and CO2 bt alveoli and RBCs -assessed by SaO2 perfusion -distribution of oxygenated RBCs around the body -assessed by SaO2

communication congruence

verbal and nonverbal communication needs to be consistant with one another -avoid confusion -prevents sending mixed signals

who can take vitals, interpret vitals

vs assessment COLLECTION may be delegated vs INTERPRETATION and INTERVENTIONS CANNOT BE DELEGATED "you take the vitals q4h, tell me if its outside x-x range"

Major nursing theorists: Rodger ct, ex

-CT: hymans have rlxn w environment thru energy fields -wellness achieved thru cxn of energy fields >> psych, phys, soc, intrapersonal fields -ex: toufh arm, can tell how they feel

Nursing theory (5)

-describes nursing -"theory": a set of concepts, definitions, statements, and research that attempts to explain things -used to describe, explain, and predict human behavior which can control for desired pt outcomes -very specific theory that provides rational, knowledge of care -directs care at common goal: improved pt care

Sleep Assessment (6)

-understand characteristics of any sleep patten -obtain pt current sleep habits -obtain sleep hx -usual bedtime, awakening time -sleep hygiene -sleep subjective like pain

Early morning Care

-usually before breakfast -assist to BR BSC bedpan or urinal -provide supplies for hand/face washing, mouth care, comb hair -asses c glasses, dentures, hearing aid insertion

urinary irrigations 2 kinds

1. catheter -use to cleanse the lumen of the cath -promotes patency of tube 2. bladder -removes mucus, blood clots, other tix -can introduce medication to bladder -CBI: Continuous Bladder Irrigation >>empty bag often, sometimes run til clear

kidney and ureter function (2)

1. filter and excrete blood constituants not needed, keep those that are needed 2. excrete waste product (urine) -nephrons remove waste products, regulate fluid balance

factors influencing urination (14)

1. fluid intake: dont forget NPO, IV 2. loss of body fluid: may cause kidneys to rtn some 3. nutrition: adkins >> ketones in urine 4. body position: hard to urinate laying down 5. cognition 6. obstruction of urine flow: stone, bph 7. infection: pus odor color changes 8. medication: make sure pt on diuretics isnt dyhydrated 9. hypotension: vOutput 10. neurologic injury 11. decreased muscle tone 12. pregnancy: ^urgency 13. sx: I&O, <30ml/hr notf phys 14. urinary diversion: catheter

MSK Assessment: Palpation assessment (3)

1. joints -temp, pain, ability to MAE -listen for crepitus 2. muscles -spasm: look during ROM. cause=dehyd, lyte imbal 3. bones

HEENT: Mouth assessment (11)

1. lips -pallor: anemia -cyanosis: resp or cv disfunction -cherry colored: carbon monoxide poisoning 2. texture: normal=smooth 3. hydration: normal=moist 4. contour 5. lesions -irritaions, skin cancer, infection (HSV=cold sores) 6. Mucous membranes -color, hydration, texture -lesions : ulcers, abrasions, cyst 7. buccal mucosa -hyperpigmentation: common in older adults, afameric -check for jaundice, pallor -thick white patches: leukoplakia >> heavy smok, alcholic 8.gums -pale in older adults -patchy pigmentation common in african americans 9. teeth -cavities, odor, #, abn pattern 10. tongue -color, coatings (thrush), lesions, mobility 11. palate -color, inactness

MSK Assessment: osteoporosis risk factors first 10

1. little to no exercise, activity >>any wt bearing good, walk run dance, wt lift 2. low Ca2+ intake (<500mg/day): vDensity, ^fractures 3. excessive caffiene or ETOH intake 4. smoking 5. **steriod use: major cause. an Rx for severe allergies 6. for women: low E levels (E bone protector, strongest RF) 7. postmenpausal women NOT on ERT: 80% dx women 8. menopause before age 45 9. postmenopause 10. age: women >70, men >80

manifestations of altered integument fxn (4)

1. pain : from trauma 2. pruritus: itching r/t tox build up or histamine response 3. rash : histamine response 4. legions: melanoma, ABCDEs of moles

NEURO: behavior and appearance assessment (5) when to assess this, and reasons for abnormalities

assess as soon as they walk in abn >> grandiose event, dementia, manic behavior mood hygiene grooming choice of dress

NGT

nasogastric tube

physical assessment of rectum and anus when do we do it, what type of assessment, are we looking for and where

not routine, only if theres problems -inspection and palpation -lesions, ulcers, fissures, inflam, external hemorrhoids -ask pt to bear down as if having a bm to look for internal hemorrhoids, fissures, fecal massess -inspect perineal area for skin irritaiton 2* diarrhea/incontinance

hourly rounds 4 Ps

pain position personal belongings potty

auscultory gap ascd with, def, when it typically happens, how long what to do

ascd with HTN, atherosclerosis, elderly temp disappearance in sound when bp assessment typically bt 1st and 2nd korotkoff sounds can be as long as 40mmHg gap recorded as follows: "195/90, ausculatory gap from 176-158"

hand hygiene: whats it good for, most effective component, types

#1 practice to v spread of moos FRICTION: most effective component hand washing, alcohol-based hand rub

how do organisms move around (5)

-air currents: air residue, droplets shortly -direct contact -gravity: closer to ground, more pathogens (surgeon holding hands up -released in droplets: cough, talk -move quick in wet material, slow on dry (chg moist dsg)

iatrogenic infection def, 2 ex

-tx acquired inf, benefit of tx outweighs inf risk ex: chemo > vWBC >vImsys, > (iatrogenic) infection ex: antibx > vmicroflora > opportunistic C.diff (iatrogen) **PS: C.diff = ^^infectious, so can be HAI or iatrogenic

what detects if a pulse is reg/irreg, what can distinguish dysrhythmias

detect: stethoscope distinguish disrhythmias: ECG/EKG

Standards of legal care

-minium requiremnet for safe patient care -formal = legal, informal = guidelines by organizations

QSEN: Quality Improvement def, how

-monitoring outcome of care to continually improve quality and safety -done by quality departments and nurses at point of care

Voluntary control of ventilation: 2 times

-breathing exercises >>yoga breathwork, incentive spirometer -holding breath >>voluntary and invol work together

large intestine primary organ for what, 6 parts, 3 fxn

-primary organ for bowel elimination - ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus -Fxns >>absorption of water (up to 1L a day) >>formation of feces * >>expulsion of feces

MDI

metered dose inhaler

Sx based on risk

1. Major risk -may be elective, urgent, or emergent 2. Minor -usually elective, often outpatient -possbily a sx is minor bc of advancement in techology and techniques

Impact of immobility: Neurological

-Sensory deprivation -Altered sleep/wake cycle

what thermometers require probe covers

ALL BUT temporal can just have an alcohol swab

adduction

mvmt toward midline

Sv

without

Bed Time Care

* most helpful for bedridden pts, make a ritual to signify that its time to sleep soon* -assist c elimination -assist c washing hands and face -oral care -skin care -straighten or change linens prn

5 nursing intervention for pts w fecal incontinence, what the goal w incontinence

*goal: correct incontinence, maintain skin integ *incontinence is very disabling 1. targeted toileting -easiest, can delegate -attempt to toilet at expected times 2. Pericare w barrier cream 3. Keep skin and linens clean 4. Freq skin assessment 5. Rectal tubes/incontinence devices -only w severe incontinence or large skin irritation, or sig card/resp/neuro disorders >>only if dangerous to care for incontinence episodes -cxn to drainage pouch around anus, emptied

Leg, foot, nail care

*often unable to self care: immobile, pain -wash feet c lukewarm water -dry thoroughly espc bt toes -apply lotion to dry areas -remove teds and scd before bath, replace after -avoid massage of redned areas, ok to wash and lotion -provide diabetic foot care, assess wounds, education is imperative, request consult if indicated

Amulatory/Activity orders (6), note

*order may be higher than capability, goal is to movept to highest level of fxning 1. bedrest (BR) -ie card pt: to reduce O2 demands on body, after invasive procedure 2. BR c BRP 3. dangle -elevate head, swing legs to side, support pt -OHOTN, if it doesnt go away, back to BR -can be an order or a nursing judgement 4. up to chair 5. up w assistance or w/ assistive devices 6. unrestricted/ up ad lib -up as tolerated

ureterostomy, ileoloop, ileoconduit: who would have these, purpose of each, what is being diverted, adv of ileoloop/conduit

*pts w damage, trauma, CA of bladder -uterer diversion 1. ureterostomy -permanent fistula for drainage of ureter thru abdl wall -pouch worn 2. ileoloop/ileoconduit -ureter drains into portion of ileum -sxn forms a pseudobladder out of discxnd s.int with a small opening into abdl wall -straigh cath placed >> no external pouch

COPD respiration differences, conditions (3), respiratory drive

*respiratory drive driven by low O2, unlike normal ppl who are driven by high CO2 COPD pt body has compensated for high CO2, densed to it COPD normal Pulse Ox ~92-94%, may have a high baseline resp rate 1. Asthma bronchoconstriction d/t allergen 2. Chronic bronchitis -"blue bloaters" -usually look cyanotic, pulmonary edema -inflam of bronchi d/t allergen, pollen, infe -chronic cough for 2 months for 2 years -barrel chest (1:1) 3. Emphysema -"pink puffers" -pink glow to skin, puff to breath -incomplete inflation of alveoli sacks: vvDiffusion -collapsing alveoli: loose elasticty d/t smoking -PEEP: (+) end expiratory pressures: compensation so alveoli dont collapse during exhalation -pts skinny: energy to breath, priority breathing than taking bites of food

Guidelines for nursing practice: Nursing Practice Act def, protects, content, who ensures complience

- state-based law that defines responsibilities of the nurse and their scope of practice -protects: PTS from harm from unsafe/unqual/incompetent nurses -describes what constitutes unprofessional conduct, misconduct, and investigates and disciplines for complaints against nurses -compliance ensured by state board

How to convey cultural sensitivity

-Spend time with your patient and convey a genuine desire to learn about their culture, values and beliefs. -Ask anything you don't understand -Show respect for your patient and their support system -Assess need for interpreter -Assess dietary needs/restrictions - consult dietician if needed.

Manifestations of altered cognitive functioning: impaired thought process (5)

-disorganized thinking -alt'd level of arousal (somnolent, hypervigilant) -alt'd attn -memory impairment impaired communication

Respiratory assessment history questions

-allergies -family hx (lung cancer, TB, COPD) -persistant cough (prod/nonprod, sputum char) -unexplained weight loss: 2* to emphysema, cancer -night sweats: 2* to Tb -fever: inf/pneu -chest pain -SOB/DOE/activity intolerance/orthopnea: -chronic hoarseness: smoking -persistant/rescurrant respiratory infections -smoking hx (yrs, packs a day, age started) -environmental pollutants: 2nd hand, coal dust -known or suspected HIV infection: TB risk -substance abuse: any smoking -SES: low chance for fresh air -residency in extended care facility/prison -recent US immig: detention centers, spread via plane -shape/symmt of chest: barrel -abnormal contours: scoliosis/kyph can ef breathing -splinting of chest wall -use of accessory muscles -breathing rate, rhythm, depth

O2 tank safety (6)

-always upright in holding device -if no holding device, lay flat, do NOT fall over -make sure tank full, 1/2 before leaving room -sign on door: O2 in Use -10ft from open flame -MRI: tank must stay outside, O2 in the room

Respiratory assessment: auscultation assessing for what, four types of breath sounds, procedure

-assess for air movement, ID areas of mucus or obstruct -bronchial: throat sounds (ant only, over trachea) >>deep, low pitched -bronchiovesicular: ant/post below clavical, bt scapulae >> higher pitched (narrower structures) -vesicular: below scapulae, follow ridge of ribcage >>quieter, diminished, shorter (less air gettin there) -adventitious: abnormal -use DIAPHRAGM of steth -ask pt to breath slowly and deeply >>in thru nose out thru mouth -us step-latter pattern to do side to side comparison

Mouth and oral care

-assist c brushing and flossing > blood thinners - soft brustles or use toothette -use swabs for pts c stomatitis (inflam of oral mm) >swab = toothette, look slike lolipop -pt c dentures >remove c sponge or gauze, plave in cup >clean mouth c toothette and mouthwash > clean dentures over sink c brush, TOWEL on bottom, use gloves > dentures in cup if not in mouth, dont put on food tray -unconcious pt >req more oral care, mgmt of secretions >lower HOB, SIMS, tilt head well toward side >use kidney basin, suction to prevent aspiration** >oral care c toothette, suction out *Aspriation biggest risk for unconcious pt*

6 rationales for using EBP

-better pt outcomes, better pt care experience -care practice based on outcome, not tradition -leads to ^satisfaction among nurses -^quality:vCost -engage nurses in research process -contributes to evolution of nursing practice

Health Assessment: Health History: components (6), when do you start, importance, exception

-can begin after pt is oriented to room (show tv, call light, menu) OR during nursing assessment - 1st step in est'ing a trusting rlxn: HOW? listen to them! 1. Chief complaint: what brought you here 2. Details of present illness 3. Pain assessment: address early so you can avoid positions or techniques that can be uncomfortable 4. Have client describe pain 5. Acknowledge pain: maybe tx if severe b4 continuing 6. Past health history: has this happened before etc **exception, if pain is extreme, may have to limit questions about health history until later

suprapubic catheter where, in what cases, how, advantages

-cath inserted in bladder thru abdl wall above pubis symphysis -long term solution -may be stitched in place -advantages >> VVinfection rate >> ^pt comfort

eye care

-clean from least contam to most -clean from inner canthus to outer -use wet cloth or cotton ball or compress -use new area of cloth on each eye -assis removal/insertion of contacts/artificial eye -clean glasses, assist c placement

osmolarity def, 3 categories of body fluid

-concentration of particles in a solution (its pulling power) relative to cells 1. isotonic -when osmolarity is equal to plasma -remains in the intravascular space 2. hypertonic -when osmolarity > plasma -pull water from cells into intravascular space -cells shrink 3. hypotonicity -when osmolarity < plasma -fluid move from intravascular space into cells -cells swell

pressure injuries akas, primary interventions, causes, classification/naming of injury

-decubitus ulcers, bed sores, pressure ulcer -Primary intervention: PREVENTION -causes: >>pressure intensity >>duration -classified by depth of tissue distruction -named for boney prominance its over

Adventitious lung sounds: Pleural friction rub sound, when heard, where heard, why heard, clear with coughing?

-dry grating sound -heard best during INSPIRATION -heard best over LATERAL ANTERIOR lung fields -2* to inflamed pleural linings (inf, trauma, blood), pareital and visceral pleura rubbing together -CANNOT be cleard by coughing

ileostomy function, 2 concerns, stool consistancy

-empties from end of s.int, completely bipasses l.int -concern: water not absd, pt very prone to dehydration, malabs. ALSO pt more likely to exp irritation around stoma d/t liquid nature of stool -stool is liquid

Risk factors for infection (9)

-envi exposure: schools, milbases, crowds, winter -tix distruction: skin=best protector, broken=poEntry -invasive procedures: IV, surgery -malnurish: vProt=vImmsys -ef of pharm agents: chemo vImmsys, antibx ef GI -age: elderly, neonates/infant (breastfed do better) -stress: young/mid age adults stress >> vImmsys -heredity: genetic immunocomprimise -existing disease: many chronic ill > vImmsys (cancer, diabetes, HIV)

Health Assessment: PE Palpation what assessing for, 3 ways how, watch for

-feel for presence of lumps, masses, rigidity, spasticity, texture of skin -use fingertips for fine touch (pulse, lymphnodes) -use dorsum finger/hand for skin warmth, texture -use palmar or ulnar edge to assess vibrations

Elements of documentation: Timing 4

-follow agency and procedure protocol r/t frequency of documentation -always document ANY change in status -document ASAP, avoid batch charting -NEVER doc before intervention carried out

ABD Assessment: body systems found in the abd (7)

-gi system -urinary tract -reproductive system -parts of cv system -parts of the nervous system -blood forming organs -immune system

Adventitious lung sounds: Stridor sound, when heard, where heard, why heard, clear with coughing?

-harsh honking wheeze -heard during INSPIRATION -heard in BV SOUNDS, UPPER AIRWAY -d/t severe airway constrct, croup, swallowed object -CANNOT be cleared by coughing

health definition, subjective/objective, passive or active

-health: state of complete physical mental and social well being, not merely the absense of disease or infirmary -indv define their health based on values, beliefs: subjective -passive, not a choice

Reticular Activating System and Bulbar Synchronizing Region

-help regulate sleep/wake cycle in brain -facilitates reflex and voluntary movement -controls cortical activities r/t state of alertness -extends thru meduall, pons, midbrain, hypothalamus

Elements of documentation: Confidentiality

-hipaa -no actual pt names in edu reports -breach = loss of records, loss of electronic record device -ALL INFO about pt on paper, aloud, on computer -name, pmh, reason for illness, tx, -HIPAA >provides protection of data privacy for HC consumers and provisions for safegaurding medical information -PROTECTION FOR PT

QSEN: Evidence-Based Practice def, goal

-integrates current best practice evidence into delivery of care -includes clinical expertise, research evidence, pt preference -goal: optimum pt care

characteristics of normal cognition

-intelligence: objective measure = IQ -reality perception: everyone had their own -orientation: 1st to go is time, last is ID of self -judgement: interptn and apprte rxn to stim -recall and recognition -language: word choice, sentence construction

Incident report def, purpose, when, who fills it out

-internal document of unusual occurance or accident -NOT on health record -PURPOSE: id areas of staff development, so it doesnt happen again -falls, med errors, near misses, needle stick, incorrect tx, loss of belongings, injury to visitors -ONLY nurse who witnessed or discovered event completes it -focus on client before filling this out

Health Assessment: PE percussion def, use, sounds (5)

-involves tapping the body w fingertips -used to evaluate size and border of organs, presence of air or fluid in body tix -different sound waves heard at different sites 1. tympany: low drum like, common over bowels 2. resonance: low pitched, air filled with lungs 3. hyperresonance: overinflatted air filled tix (emphys) 4. dullness: thud-like, muffled: over dense organs 5. flatness: soft and short: common over musc, bone

Foley catheter timeline, how it stay in, type of drainage system, procedure technique

-left in place to drain urine over period of time -balloon maintain catheter placement within bladder, blocks urine from coming out -CLOSED DRAINAGE SYSTEM: bad (leg or bed) -sterile procedure

Health Assessment: PE Auscultation def, why, define sides of steth

-listening with stethoscope -used to evaluate sounds created by CV, resp, GI systs -the diaphragm: high pitched sounds (bp, lung sounds) -the bell: low pitched sounds (vascular sounds, murmurs)

Adventitious lung sounds: Crackles sound, when heard, where heard, why heard, clear with coughing?

-loud bubbly sounds -END of INSPIRATION, can be other times too -VESICULAR (lower airway) where its typically heard -d/t fluid in the lungs: pneumonia, L-side HF -typically NOT cleared w coughing

Adventitious lung sounds: Ronchi sound, when heard, where heard, why heard, clear with coughing?

-low pitched rumbling sounds -heard THROUGHOUT breathing cycle -heard THROUGHOUT lung fields -2* air moving over large amt of mucus/fluid in airway d/t bronchitis, HF, smoking -CAN be cleared with coughing

Health Assessment: 6 polite (and necessary) things to consider during PE

-make sure pt has sensory aids avail (glasses, hearaids) -invite pt to use restroom before exam: espc abdexam -be aware of verbal and nonverbal cues: grimace, moan -be genuine, open, honest, sincere -respectful: pref'd names, any honors, avoid "honey"s -show empathy: put self in shoes to get thru together

Elements of documentation: Format 4

-make sure you have correct chart/pt before charting -use standard terminology, abbrv, symbols -NEVER skip lines -draw single line thru blank space

Hormonal control of fluid and electrolyte balance: pituitary gland

-manages ADH ADH increased when -hypovolemic -ecf osmotic pressure > cell osmotic pressure ADH decreased when -hypervolemic -ecf osmotic pressure < cell osmotic pressure **inhb by caffeine, ETOH, ^w stress

QSEN: Teamwork and collaboration def, goal, how

-nurses working other HCPs -goal: best pt care -how: foster open comm, share decision making, work in unity, efficiency, strength of other professionals

Skin vascularity assessment (3)

-observe or inspect for redended, pink, pale areas -varicose veins: vein valve failure, pooling blood -petechiae >> pinpoint red or purple spots = small hemorrhages >> may indct blood clotting disorder, drug rxn, liver disease

Skin edema assessment (5)

-observe/inspect/palpate for fluid build up in tix -edema may be 2* to direct trauma (independent of gravity, usually unilateral) impaired venous return -more common in dependent areas (on gravity: legs, ankles, feet) usually will be bilateral -Pitting edema >> indentation lasting >5 sec >> +1 = 2mm deep >> +2 = 4 mm deep >> +3 = 6 mm deep >> +4 = 8+ mm deep -some practitioners may use time-to-fill as measurement of edema severity

Hair Care

-often overlooked -id pts usual hair and scalp care practices and styling preferences -not hx of problems: c scalp, dandruff, hairloss -comb or brush hair at minimum -wash as apropriate >shamp + water/ waterless shamp > shampoo caps: disposable, massage hair, take off towel dry >> theyre heated up, check the temp of them TX any infestations ie pediculosis or ticks

Medication and cognitive alteration (3)

-opioid >> sedation -polypharm: ixn c unexpected reactions -Beers criteria (american geriatric society) >>meds not used or careful 65+ d/t ^r/f tox

aspiration def, leads to what, s/s

-passage of food or fluid from esophagus to trachea -can lead to aspirational pnuemonia (death) S/S OFTEN SILENT!!! -coughing, watery eyes, trouble breathing, cyanosis

Dressing and grooming

-personal preferences >we rec gown: ease of access, protects clothing -more likely to AMB if offered pants, two gowns -hair grooming

texas/condom catheter placement, what type of drainage system, adv/disadv

-placed over penis Leave 1-2" at tip of penis -closed drainage system, bag attached -adv >> low risk for UTI >> good for incontinence, no urine on body -dizadv >>potential for decreased cirulation

Implementation of sleep interventions (in hospital)

-prep a restful envi: lights, shades -promote bedtime rituals: espc in bed bound -offer bedtime snacks and bevs: carbs -promote relaxation and comfort: blankets -respect normal sleep/wake patterns -sched/cluster nursing care -use meds to produce sleep -teach about rest and sleep -use CPAP for apnea pts -ask if they want you to wake them, some do -anticipate problems, alarms on night shift

bathing rationales 7

-provides opportiunity for thorough skin assessment -elim perspiration, oils, dead cells, bact, prev odor -enhances circulation and conditions skin -stim resp rate and depth -provides sensory input -allows for pt teaching, therapeutic touch and communication -hygiene can be dignity promoting

Nursing implications for altered cognition: physiological (5)

-pvnt and mgmt of disease -nutrition needs: forget to eat, overeat -encourage exercise: mng anx, beware fall wander risk -assist c sensory impairements: devices, compensatry -medication use: as ordered

Safeguards to competent practice

-respect legal boundries of practice -follow institutions policies and procedures -own personal strengths and weaknesses -evaluate proposed assigments -keep current knowledge and skills -respect pt rights -careful documentation

tell me more about concious or moderate sedation

-safer: no need for intubation cause pt can maintain a patent airway -pt moderately sedated with a hypnotic, often wont remember -pt can still respond to verbal or tactile stim (can be roused)

Hormonal control of fluid and electrolyte balance: adrenal gland

-secretes Aldosterone >> Na+ RTN, therefore water rtn, >>K+ LOSS -excess cortisol can have same effect

MSK Assessment: what loss of fxn should we assess (2)

-single sided weakness: pull/push hands at same time -below the neck/waist weakness

Fluid and lyte balance assessment: physcial exam (5)

-skin: turgor, mm -cardiac: edema, HR, rhythm, bp, jvd, ohotn -respiratory: lung sounds (crackles) -neurological: mental status, reflexes, seizure -msk: muscle tone (tonicity)

2 things patients cant know were doing when were doing them

1. counting respirations 2. watching them walk

environmental assessment that must be done before ambulating you patient (7)

-slipper socks or shoes -wheels locked of what theyre getting off -clear path -tubes managed -assistive devices available -enough help: in doubt, get more ppl than u think -opportunities for rest period

Adventitious lung sounds: Wheezes sound, when heard, where heard, why heard, clear with coughing?

-squeaking high pitched musical sounds -heard THROUGHOUT breathing cycle -heard in VESICULAR d/t LOWER airway CONTRICT -d/t LOWER airway constriction, obstruction, r/t asthma -CANNOT be cleared w coughing

Administrative law

-state legistalatures give power to State Boards of N -rules, regulations, restrictions, revocations of licence -PROTECT THE PUBLIC

Rest defintion

-state of mental, physical, spiritual activity that leaves a person feeling REFRESHED -individualized, does not imply inactivity -person awake, aware, can interact with their environment

Skin Turgor assessment test for what, how

-test for elasticity >> ef'd by edema, dehydration, age -pinch skin, release fold of skin on formarm or sternum >>tenting : poor skin turgor (dehydration) -more accurate assessment: weight, I&O, serum osmolarity

Nursing implications for altered cognition: psychosocial (6)

-therapeutic communication: listen beyond what is said -touch: bring into reality -reality orientation: always ok, not always priority #1 -validation therapy: meet them where they are -reminiscence: comforting to share old memories -body image interventions: hygiene assistance, dignity

what are defense mech, why do we use them,. when helpful, when not first 5 defense mechanisms

-unconscious reaction to stress -protect ones self esteem -useful in mild/mod anx, distorts reality in severe COMPENSATION -attempt to overcome weakness by emphasizing more desirable trait or overachieve in a more comfortable are DENIAL -refuse to aknow presence of condtion that is disturbing DISPLACEMENT -transfere emo rxn from one obj/person to another INTROJECTION -person incorporates values of another into own structure, important for dev of kids PROJECTION -attribute thoughts or impulses to someone else

standard precautions 1996

-use as standard -replaced "universal precations" -primary method to prevent infectious transmission -wash hands, wear gloves, goggles, gown

Toileting

-use of toilet, BSC, bedpan -may have hat for collection (no tp) -urinal: container c handle for male pt >can be used for I&O gathering >keep off over-bed table >if full, assess urine, I&O, empty -freq asociated c falls >#1 reason pts fall >proactive: prompt to go to BR -assess ability to assist: a&o? msk? ohotn? amb orders? -check AMB orders > always ask for help if in doubt > may be ordered above their ability, so always assess

Restraints: physical

-used only when all other less restrictive ivnts have fail -have to be ordered BUT if harm happening, use and then get an order -can cause skin damage, nerve, perfusion impair -always at least 2 contralateral, even if paralyzed >>Death from retraint -psychological truama ascd w restraint -req much freq assessemtn and doc

AM/Morning care

-usually after breakfast -assist w partial or complete bath, shower or baths in a bag >>disposable wipes, each pckg = one bath or soap and water c basin -provide privacy except from us -maintain saftey -keep H2O warm, change it prn -wash top to bottom, front to bath -use gentle firm strokes -dry throroughly: skin folds, crack >> skin dmg, maceratn -promote independence: wash face good place to start **Shower needs order, still make need help, IV lines covered

when to wear non-sterile gloves

-when in doubt -when you/pt has nonintact skin -touching mms or and body fluids -ONLY TIME OUTSIDE ROOM: when transporting contaminated material (dirty linens)

4 types of GI visualization studies (endoscopies) how its preformed, what its looking for, sedation level and prep for pt

1. EGD: Esophagogastroduodenoscopy -scope thru mouth, look at E, G and D -look for ulcers, bleeding, retrieve foreign bodies -concious sedation, NPO before and until gag reflex return after procedure 2. Colonoscopy -scope thru rectum, WHOLE L.intest -look for growths, narrowing, bleeding -conscious sed, NPO and Bowel Prep until clear 3. Sigmoidoscopy -scope thru rectum until end of sigmoid colon -look for rectal or sigmoidal disease: diverticulitis, rectal cancer -conscious sedation, bowel prep less, maybe just enema 4. Wireless Capsule Endoscopy -camera inside capsule! single use and $$$ -look at S.intestine, usually after (-)colon-, sigmoidoscopies -While cap is in, NPO for 24-48hr, wear pouch w bluetooth to record

Sx based on urgency categories

1. Elective -planned -may be pts choice -tonsilectomy, hernia repair, plastic 2. Urgent -necessary, done in 24-48 hr -used to preserve health -malignant tumor removal 3. Emergent - necessary STAT -done to preseve life -trauma repair

Complications in wound healing (5)

1. Hemorrhage -bleeding, check dsg, under pts, cant heal >>hematoma: mass, eval if growin, may need sx 2. Dehiscence -wound edges separate, stiches glue wont hold -typic due to stress from infct, edema, wt, coughing -tech pt splint: hold pillow to wound when coughing 3. Evisceration -EMERGENCY: most serious complication, ERSx - abd wound, organs protrude thru incision - dont push, cover w moistened sterile gauze and call surgeon 4. Infection -usually within 2-7 days -sepsis: multisystem infection -looks like a prolonged/pronounced inflamm stage 5. Fistula -abnormal connection bt two passageways or organs -rectovaginal, enterocutaneous -r/t injury, infection, congenital, cancer

Administration of IM med 13 steps

1. ID pt, hh, provide privacy (exposure for sites 2. review allergies, order, med expiration 3. verify 6 rights 4. don clean gloves 5. select injection location (depd on volume) 6. clean skin c antiseptic swab, allow to dry 7. remove cap from needle 8. stabilize skin (spead, 1 inch pinch, z-track) 9. inject needle into skin 10. inject medication 11. w/d needle, immedietly activate safety w one hand 12. dispose of syringe and needle in sharps container 13. doc administration location

Communication: space, 4 zones, where do we spend out time w pt

1. Intimate Zone: 0-18" -we'll spend our time here -get comfy w it 2. Personal Zone: 18"-4' 3. Social Zone: 4'-12' 4. Public Zone: 12'+

6 things you do first when starting a health assessment

1. Introduce Yourself -knock on door, ASK to come in -"name, KSU student nurse, ill be with you until 2PM 2. Use of Standard Precautions -contact precations: ppe will be listed outside room -depends on pt case, but always assume infection -ALWAYS foam in foam out 3. ID Pt with Two Identifiers -Name, Birthdate -always LOOK at band when confirming to ALSO confirm they have the right band on -may have allergy band, if not ASK if they have allergies -NO band? check w anyone caring for pt, ask family, then double check w whiteboard 4. Provide Privacy -pull close door, curtain -if visitors: explain what your about to do and allow pt to give or deny consent for visitors to stay 5. Explain Procedure to Client -explain everything and always get consent BEFORE touching pt -refuse? explain why important, find out why (can i come back later?) ** document and not'f doctor 6Make use of Teaching Opportunities -each ixn can be teaching moment -gain insight on pt, -be prepped to answer qs, never make up answer

Abnormal breathing pattersn (3)

1. Kussmaul's respirations -type of hyperventilation -exaggerated, deep, regular, rapid breathing >>exercise breathing -may be present w ASA od, pain, fever, panic/hysteria, cardiac/pulm disease, DKA 2. Cheyne-Stokes respirations -alternating periods of kussmauls and apnea -ascd w end of life 3. Biot's respirations -irrg patten: varying shallow breaths (panting) then apnea -ascd w ICP (intracranial pressure) and respiratory comprimise

postural abnormalities (3)

1. Kyphosis -exaggeration of posterior THORACIC spine curvature -hump-back appearance -can be caused by osteoporosis -see in elders more -caused by shortening of vertebral column >>ave ht loss = 2cm/yr after 50 yrs 2. Lordosis -often seen in children -^ in LUMBAR curvature above buttocks -aka sway back -tx: exercise, PT -causes: congenital, poor posture, neuromuscular, hip problems 3. Scoliosis -LATERAL curvature of spine (s) -begin screening at at 11-14 during growth spurts -look if one shoulder or hip higher than other -complications: resp, mobility problems -tx: braces, harrington rods (sx) if curve >40%

Altered CO (2 HFs s/s)

1. Left-sided heart failure -fluid volume back up in lungs - SOB, crackles, dizziness (low O2 sat), activity intolerance 2. Right-sided heart failure -fluid volume back up in body -wt gain, JVD, peripheral edema >>dependent 2/3+ pitting edema in lower extremities

4 goals of pt education

1. Maintain and Promote Health -exercise programs -Ex: Heart Disease and Cardiac rehab -healthy eating -ex: DM edu about ADA diet 2. Prevent illness -Vxs -Teaching high risk individuals how to avoid illness -ex: chemo pts: avoid crowds, sick ppl, HH frequently 3. Restore Health -post op teaching to get back to ADLs -ex: post hip replacement discharge instructions 4. Facilitate Coping -help a pt deal with permanent health alterations -ex: mastectomy support group

5 signs of localized infection

1. Red: not pink 2. Heat: not warm 3. Edema 4. Pain: abn for context 5. Altered fxn

Skin temperature assessment dependent on what, how assess, what compare, alert for what

1. dependent on amount of blood circulating dermis 2. best assessed thru palp: dorsum of hand 3. compare symmetrical body parts (2 hot hands vs 1) 4. be alert to areas of warm and erythema (PI) >> over bony prominence? test for blanching >> NOT over bony prominence? DTI

First 7 steps for All Nursing Skills

1. Verify active order if appropriate or necessary 2. Introduce yourself by name & role 3. Perform hand hygiene 4. ID pt 5. Explain procedure or action 6. Gather equipment and PPE 7. Provide privacy as appropriate

Systemic factors effecting wound healing (4)

1. age -infants: poor adher bt derm/epiderm -elderly: vCirc, comorbidities 2. nutrition -big wounds often need suppliements to aid healing -protein: poor >> slow healing - Vit A and C: epithelialization, collagen synthesis -zinc: proliferation 3. circulation/oxygen -delivers nutrients, rids wastes, O2 needed for epithelialization and collagen synthesis 4. health status -diabetes: ^risk inf, vCirc -shock: vPerpheral circ -immunosupression: rt disease, med, age >>delay healin -obesity: ^wound stress (vEdge approx), vCirc to adipose tix:vCirc to skin -smoking: vHb:vO2 to tix, V.constrict:vCirc

factors effecting temperature (6)

1. age: v old, v young cant vasodia/cont like adults, poor regulation 2. exercise: young and old cant voluntarily move to prod heat 3. hormones: hot flashes during menopause 4. circadian rhythm: normal sleep/wake = warmest at 1800, coolest bt 0300-0400 (2*C flux) 5. stress: ^temp (ex: face red during test) 6. environment: nursesR: referee of envi in dual occupancy rooms, another Ex: cool in OR so surgeon doesnt sweat into pt

ABD Assessment: abdominal hx questions (13)

1. appetite, wt changes 2. dysphagia, difficulty chewing 3. pain/tenderness (OLDCART) 4. n/v 5. any food intolerance 6. ETOH abuse or IV drug use: organ damage 7. HC occupation: exposure to body fluids 9. Hepatits B exposure: exposure to body fluids 10. usual bowel habits: x/day or week 11. rectal problems: pain, hemorrhoids 12. past abd sx, trauma, diagnostic dyes 13. current Rx >>NSAIDS: irrt mucosa >> ulcers, blood in stool >>Steriods: lower gi bleeds = blood in stool >>Antibx: n/v/d/dehydration >>Bloodthinners: >>blood in stool 14. current nutrition >>assess diet over last 24 hours (r/o food poision)

10 things to chart

1. assessment at start of shift 2. changes in mental, psych, physical conditions 3. rxns to procedures and medications 4. teaching: what was taught, pt response, plan 5. physician visits: when you called when they came 6. time pt left and returned to unit including transportation and destination 7. meds: time dose route site effect 8. tx: all interventions 9. late entry: out of sequence, thats ok dont squeeze in 10. communication c others: ALL OF IT CYA CHARTING COVER YA BOOTY

Nursing process steps, single sentence explaination

1. assessment: gather info about pts condition 2 diagnosis: id the patients problem 3. planning: (outcome identification) set goals of care and desired outcomes, id appropriate nursing actions 4. implementation: perform the nursing actions identified in the planning 5. evaluation: det if goals and expected outcomes are acheived

Assisted falls (3)

1. assume wide base support and attempt to slow pt descent -wide base to protect yourself -dont try to hold a pt up, try to help lower them slowly 2. call for help -complete an assessment and VS while on floor -id precipitating incident 3. attempt to protect pt from injury as they fall

ABD Assessment: auscultation (4), documentation

1. auscultate lightly to not alter bowel sounds 2. use Diaphragm to assess bowel sounds 3. use bell to assess for vascular sounds over aorta 4. begin next to painful area, go clockwise, painful last "BSx4" "BSx4 hyperactive"

4 strategies in avoiding errors in writing a nDx

1. avoid using medical dx within a nDx statment >>>impaired gas exhg r/t COPD = WRONG 2. use only official NANDA nDx 3. address only 1 problem at a time 4. avoid writing legally inadvisable statement >>>imprd skin integrity r/t not being turned q2h WRONG

responsibilities of the professional nurse (8)

1. caregiver -part of collaborating team for hands on care 2. communicator -central to all roles, connects all parties -critical to meet all of pts needs 3. counselor -therapeutic comm to help pts solve problems 4. collaborator -organization, communication, advocacy, to help all HCPs work together 5. advocate -protect pt, speak on behalf of pts 6. educator -health promotion, disease prevention education - explain tx and procedures, answer qs -evaluate pts progress 7. researcher -conduct or participate in research 8. leader -every nurse reflects mission and values of their HC org

Foley catheterization process 20 step

1. check order 2. wash hands 3. select cath size 4. collect equiptment, 2 kits, 2 gloves 5. id and assess client 6. set up equipt 7. set up sterile field 8. don sterile gloves 9. open cleansing sol 10. open lubricant 11. attach prefilled syringe to cath 12. expose meatus w non dom hand (now dirty) -retract forskin, separate labia 13. clean meatus using sterile hand and swab -male: cirular motion -female: one side, other side, middle -USE swab only once 14. with sterile hand, insert cath until urine appears 15. insert 2 more inches 16. inflate balloon 17. attach bag to bed 18. clean pt to remove lubricant 19. gather and discard used equiptment 20. remove gloves, HH

Skin integrity: developmental considerations (children, elderly)

1. children under 2 years old -skin thinner and weaker r/t poor adherence bt dermis and epidermis -becomes increasingly resistant to injury and inf 2. eldery -maturation of epidermal cells is prolonged, circulation and collagen formation impaired >> Thin, easily damaged skin >> vElasticity and ^risk for tix damage from pressure >> v sensetivity to pain >> v sebacious and sweat gland fxn >> dryness, itching

3 urine collection techniques

1. clean catch or midstream -use saniwipe to clean perineal area -initiate stream, stop, then collect spec -used for a UA 2. catheter collection -sterile collection of pt with cath -aspiration port w syringe or needle -get at least 5-10ml, 20 for a C&S 3. straight catheter -for sterile collection for a pt w/o an indwelling catheter -collect spec, send to lab within 15-20 min

4 large categories of enemas , 4 subcats in one, tell me all about em

1. cleansing 2. retention -oil: lube stool, intestinal mucosa, ease defication -carminative: helps expel flatus from rectum -medicated: provides meds absd thru rectal mucosa -anthelmintic: destroys intestinal parasites 3. large volume -"tap water enema", "soap suds enema" -500-1500mL of body temp water, soap if ordered, hang, 18" up, SIMS postn, lube and insert ~3", run for 5-10, hold for at least 20 min -ensure clear path to br, probably a bsc 4. small volume -SIMS postn, ~240mL sol, nozzle in rectum, squeeze in fluid, hold fluid as long as possible, -ensure clear route to br, bsc best

ABD Assessment: characteristics of stool (6)

1. consistency: infl by food, fluid intake, gastric motility 2. amt: diarrhea 3. shape: normal = cylindrical 4. odor 5. presence of unusual matter: parasites, foreign body 6. color >>black: iron (supp, ^iron diet) , upper gi bleed >>red: lower gi bleed or hemrrhoids >> black tarry akak melena: blood in gi tract >>white/clay: lack of bil, inj of contrast dye, liver disease, pt who eats dirt >>brown: normal ** dont flush! visualize, abn findings sent to lab

ABD Assessment: alterations in bowel fxn (6)

1. constipation: -improper diet, vFluid, exercise, meds, -s/s: diff bm, <2x/week, excessive straining 2. diarrhea -^#bm in liquid form -ascd w dig, abs, secretion disoder in gi = vNuts,lyte abs 3. incontinence -inability to control passage of stool -neuromuscular, spinal cord trauma> lack control of sphincter 4. flatulance -large amts >> gastric distension >>pain -may need to insert rectal tubve to remove gas 5. fecal impaction -results from unrelieved constipation -collection of hard stool wedged in rectum -severe>>intestinal obstruction -tx:oil retention enema, suppositories, stool softeners -Manual disimpaction: double glove, lube, remove stool stuck in passage way 6. distension -gas, exessive fluid, tumor in abd cavity -skin may look stretch, shiney, may bulge laterally

factors that effect oral intake (7)

1. developmental considerations 2. state of health: illness cause ^ need for nuts 3. alcohol abuse: Alt'd absorb, ^need for vit B 4. medications: alt'd absorb of nuts or other meds 5. economic factors: healthier foods cost more 6. religion: some fasting, certain food forbid practices 7. culture: dictates what is edible, how its prepared, etc

inspiration, expiration process (3steps each)

1. diaphragm and intercostal muscles contract which enlarges the thorax and vInterthoracic pressure 2. lungs pull outward 3. the pressure in airway drops and air rushes in 1. diaphragm and intercostal muscles relax causing thorax to get smaller, ^pressure in chest 2. lungs push in 3. air forced out thru lungs

Nursing Process: Planning identifies nursing strageties that (4)

1. direct pt care (hands on) 2. promote continuity of care: thru shift changes 3. focus charting on the particular problem 4. provide delegation of specific pt care activities

Cardiac assessment: abnormal heart sounds (2)

1. dysrhythmias: irregular heart beat -AFib: -atira beating irregularly, fluttering, out of rhythm w ventiricals -life sustaining rhythm (only 20% COv) -PRONE TO BLOOD CLOTS -VFib: -ventricals beating irregularly, fluttering -lift-threathening (accnt for 80% CO)\ 2.Extra heart sounds -S3, S4: when valves arent closing correctly -murmurs: lil back flow -clicks; mechanical heart valve rubs: layers of heart tix rubbing together

4 methods hcp can use to empty colon of feces and what are they

1. enemas -instillation of fluid into rectum -for elimination or to instill meds 2. rectal suppositories -topical, placed against rectal wall 3. oral intestinal "lavage" -AKA bowel prep for scope procedure -drink till clear 4. digital removal of stool -last line for severe impaction -be aware of cardiac status (vasovagal response) -gloved hand, b^ feces or remove blocking one -happens w vNervefxn, long term opioids, immobility

Positioning function (4)

1. ensures natural alignment of body and extremities -once situated in bed, make sure theyre positioned naturally: can use pillows to supp natural postn 2. promotes circulation and improved respiratory fxn 3. reduces continuous pressure on bony prominances -fowl/semifowl/supine: pillow under calves to suspend heels 4. appropriate positioning can prevent complications -skin integrity, resp, gi complications

Peripheral Vascular Assessment: what are you lookin at (4)

1. eval bp 2. monitor health and b flow of arteries and veins 3. assess effectivness of circulation thru out body 4. reeval eftvness of heart to pump blood to peripher

NEURO: sneaky ways to integrate neurological assessment into your head to toe (3)

1. evaluate the cranial nerves when evaluating head and neck during HEENT assessment 2. assess mental and emotional status during intake interview through behavior and apperance 3. focus the neuro assessment to patient health status and patient concerns

ABD Assessment: factors effecting urinary elimination (4)

1. fluid intake -change color odor quantity 2. age -loss of bladder muscle tone in older adults 3. health status -dehyd: vOutput, kidfxn, cardiacdis, kidstones 4. emotional state -stress: peroneal muscles and sphincter cause urge to urinate but emptying is difficult

Hand washing process (11 steps)

1. gather necessary supplies and stand in front of sink without clothes to touch sink 2. remove jewelry, plain wedding band ok 3. turn on warm water, adjust pressure so no splash 4. wet hands and wrists keeping hands lower 5. use soap and cover all areas of hands with it 6. firm rubbing and circular motions wash palms, back of hands, each finder, in between fingers, knuckles, wrists, forearms @ least 1" above contamination, if not visibly soiled, 1" above wrists 7. continue friction motion for at least 20 seconds 8. use fingernails or clean orange-wood stick to clean under fingernails 9. rinse thoroughly from wrist ~> fingers 10. pat dry hands from fingers to arms, throw away towel, use new towel to turn off sink 11. use oil free lotion if desired

Placement procedure of NGTube (12)

1. gather supplies, id pt, provide instructions, wash hands, provide privacy 2. pt in FOWLERS 3. det length of NGT (nose to helix to xyphoid) 4. mark tubing 5. glove, lube tube 3-4" 6. det more patent nostril 7 . instruct pt procedure will be uncomfortable 8. lean head back, aim toward ear 9. have pt tilt head forward 10. advance tube while pt swallowing 11. secure to nose 12. follow hospital policy on placement verification

HEENT: common eye/visual pathology (11)

1. hyperopia: farsightedness, can only see far 2. myopia: nearsightedness, can only see close 3. presbyopia: impaired near vision w age 4. astigmatism: lens of eye football shaped >> light not focused on retina >> blurry vission 5. retinopathy: disease of retina, noninflam eye disorder r/t lack of O2 supp to retina (DM), leading cause of blindness 6. strabismus: crossing eyes (often congenital) 7. cataracts: opacities/clouds in eyes, fast sx 8. glaucoma: ^interoccular pressure, glucose in eye overpulling in h2o (DM) 9. exophthalmos: bulging usually r/t thyroid issue 10. macular degeneration: blurred central vision usually r/t degen of retina, progressive w rapid onset 11. diplopia: double vision

4 errors in writing nDx

1. incomplete or inaccurate data collection 2. misinterpretation or analysis of data 3. incorrect or incomplete clustering of data 4. addressing problem that is outside the scope of nursing practice

indications for catheterization (4)

1. incontinence -less common now -if wound in perineal area, cath needed 2. urinary retention -if shown during post void residual 3. accurate assessment of output needed -strict I&Os -ICU, CCU 4. sx, trauma -post surgery -strict I&Os for trauma patients

ABD Assessment: alterations in urinary elimination (15)

1. incontinence: invol loss of urine control 2. stress incontinence: cough, preg >> incontinence 3. enuresis: bed wetting 4. noturia: awakening to go 3-7x/ night 5. oliguria: diminished output <400ml/24hr 6. polyuria: aka diuresis exes output >2500-3000mL 7. retention: blad not empty fully, dribbling 8. dysuria: diff urin maybe due to UTI 9. urgency: gotta go now or incontinence 10. pyuria: pus in urine UTI foul odor 11. anuria: no urine, usually d/t renal failure 12. hematuria: blood in urine, UTI bladder CA, stone 13. reflex incontinence: spec vol triggers voiding 14. fxnl incont: knew had to go but blocked physclly br 15. total incont: continuous, involuntary, unpredictable

when to do musculoskeletal assessment (4)

1. integrate w neuro assessment 2. observe pt walking: gait shuffle limp 3. assess movement in bed: can turn self, get oob? 4/. note movement during any physical activity -any assistive devices -and assistance needed with ADLs

3 classes of alterations in integumentary structure

1. intentional vs unintentional -intnl: break skin for therapeutic purposes (IV) -unintnl: abrasion, laceration, puncture 2. open or closed -brake in skin vs bruise (soft tix damage under intact skin) 3. acute or chronic -acute: heal quicker and easier -chronic: remains in inflamm stage, ^risk inf

ABD Assessment: nutritional disorders (4)

1. kawshikor -more common in children -malnut when bbs weaned off bmilk, not getting enough PROTEIN -vAlbumin>> fluid leaves blood enter cells > edema 2. marasmus -more often in babies -syndrome 2* to def in both CALS and PROTEIN -gradual starvation, may be 2* to acute illness 3. Cachexia -malnut/wasting -most often 2* to CA, severe infections 4. AN/BN

factors that EF oxygenation(6)

1. level of health -cvc, resp, obestiy, trauma, renal (fluid rtn>>vPerfusion) 2. developmental considerations -infants = high resp rate, abdl breathing -elder 16-24 resp rate, thorasic breathing 3. medication: narcotics vResp rate 4. lifestyle: exercise, smoking 5.environmental: residence, occupation, pollution 6. psychological: stress/anx > prone to hyper vent

6 rules to follow for oral med administration

1. measure poured liquids at eye level to miniscus 2. dont open packages until just before admin @bed 3. must be present while pt takes med -may need to do oral cavity inspection 4. dispose of any open, unused meds per admin policy 5. hold meds needed and consult prescriber 6. beware meds ability to be crushed or chewed -any time you crush, you loose some med

stool collection method (5) and instructions for pt with 4 steps

1. medical asepsis technique 2. b/a hand hygiene 3. wear disposable gloves (double) 4. do not contam outside of contatiner w stool 5. package, label, and transport to lab instructions 1. urinate first, dont let ixn w stool 2. deficate into container 3. no tp into toilet/bedpan 4. notify asap when specimen available (preserves parasites, ova)

5 nursing responsibilities for enteral tubes

1. monitor I&O 2. provide nasal and oral care 3. always assess tube placement before use 4. maintain patency of tube and its opening: irrigate 30-60ml warm water several times a day 5. if ordered maintain suction: decompression >>**SHUT OFF FOR ABDL ASSESSMENT, 30 MIN POST MED ADMIN

HEENT: Neck assessment (4)

1. muscles -watch movment u/p s/s (flexion and extension -asymmetry 2. lymph nodes -normally not visable -symmetry, edema, erythema, red streaks 3. thyroid gland -normally symetrical and not visable: test with swallow -if you can feel it indcts somethings wrong -massess, edema 4. trachea -midline, in line with sternal notch = normal -shifted to one side = huge emergency

ABD Assessment: palpation (6)

1. note size psnt mobility consistancy and tension of major organs or masses 2. areas of disention: feel if soft or firm 3. tenderness/ gaurding 4. examine tender areas last 5. light palpation -press ~1/2" -systematically assess 4 quad -localize areas of pain, massess, tenderness 5. deep palpation -press 1-3" -use 1-2 hands, push down on opposite hand -check for rebound tenderness: pain when hands come off could indct swelling, organs reboudning on eachother -to delineate abn organs, enlarged organs, abd massess

Implimentation of pt teaching, 5 considerations

1. nurse attitude/effective communication -non-threatening, warm, accepting -interactive, interesting, enjoyable -show respect 2. evironment: decrease noise 3. timing: ask when is best for them 4. Session length: 15-30min 5. Pt comfort level: pain, sob, reduce noise

MSK Assessment: inspection (8)

1. observe gait -slow, steady, unsteady -foot drop/dragging (fd usuall >> dragging -shuffling -limping 2. posture -anterior posterior lateral 3. upper body position 4. parallel alignemnt of hips, shoulders (uneven ft in bed = dislocated hip) 5. level scapula, iliac crests 6. head alignment 7. extremity -symmetry -size -length -circumforance -deformities:fractures -bone enlargment -alignment -posnt -skin folds 8. spinal alignment

nursing aims and competencies (4)

1. promote health -motivated by desire to increase wellbeing -nurses role: i.d, analyze, maximize each pts strengths 2. Prevent illness -tool: edu, lead by example -ex: health assesments, smoking cessation group 3. Restore Health -nurses role: perform assessment to detect illness, plan, teach, carry out rehab for illness 4. Facilitate coping with disability or death -"altered fx": v In pts ability to perform daily tasks -nurses r: maximize pts strength thru teaching, refferals -end of life care

Skin functions (7) and descriptions

1. protection -from phys, chml, infection -sebum: gives skin acidic pH to kill some moos -normal flora: indigenous moos, inhibit pathogens 2. metabolism -vit d: precursor in skin + UV = vit d -Vit d absorbs Ca2+ and Phophorus 3. thermoregulation -dilation and constriction of blood vessels -regs temp to envi fluxs, goosebumps, sweating 4. elimination -water electrolytes wastes thru diaphoresis -adults loose > 400mL sweat/day 5. sensation -nerve endings on skin provide info and protection -touch pain pressure temp 6. psychosocial -facial expressions, hair distribution 7. absorption -substances absd due to vascularity of skin

HEENT: Ear assessment (13)

1. size: nomal = symmetrical 2. shape: normal = symmetrical 3. symmetry: auricles usually level w each other 4. postion >> low set>>chromos abn: usually down syndrome 5. color: lesions, inflamm 6. integrity: piercings (doc intactness, infection) 7. discharge: CERUMEN, drainage 8. ear pain: us indcts int or ext ear infect (seperated by tympanic memb) if pressing tragus hurts >> ext 9. itching 10. vertigo: dizziness, punctured tymp memb 11. tinnitus: constant bzzin, damage CN8 12. hearing acuity: whisper test, refer to audiologist 13. ototoxicity -injury to auditory nerve -medications can cause: ASA, streptomycin, furosemide, aminoglycocides

ABD Assessment: inspection (7)

1. skin -scars -striae: stretchmarks -rash/lesions/massess 2. contour -normal: slightly convex or flat -obese: round, protruberant -abn: swelling, distended, bluging 3. muscle tone/symmetry 4. unbillicus -color, contour, location 5. visible peristalsis 6.pulsations -ABN: check for"Bruit" turbulance w bell of steth >> AAA 7. signs of pain -gaurding: protecting, leaning away, grabbing hand away, splinting

5 interventions for promoting regular bowel habits

1. timing -gastrocolic reflex: food in stomach causes peristalsis -help pt elim regularly after meals 2. positioning -squating/proping feet up easier than just sitting -legs infront of you in bed = very difficult -bsc or toilet > bed pan 3. Privacy/Dignity -except from nurse! "you get privacy from the world but not from your nurse, ive seen it all before" 4. Nutrtion/hydration -pt need to change habits? 5. Exercise -activity and movement promote bm -abdl, quad, postural muscle training may improve control over bowel elimination

purpose of health assessment (5)

1. to collect objective and subjective data pertinent to pts health status 2. to identify deviations from normal 3. to discover pts strengths, limitations, and coping resources 4. to pinpoint actual and potential problems 5. to build rapport/therapeutic rlxn with pt/family *bonus: accurate assessment provides an estl foundation of care for pt

HEENT: Throat assessment (6)

1. uvula -CN 10 -should be midline -say ahh >> if floats to side, sympt of stroke 2. soft palate: intact? 3. tonsils: swelling, tonsil stones, erythema 4. pharyngeal tissue -edema -ulcerations -inflammation: inf, abnormal lesions 5. drainage -clear: chronic sinus problem (ie allergies) -yellow/green: inct inf 6. odor -sweet/fruity: diabetic ketoacidosis -ammonia: kidney issue

2 normal findings in bp that seem odd

1. variation in bp from one arm to another BUT if greater than 10mmHG > poss cardiac abnormality 2. slight change in bp with body position

HEENT: Eye assessment first 5

1. visual acuity -Snellen eye chart -tests CNII -pt test w bad eye first, then good eye, then both WITH CORRECTIVE LENSES ON -stand 20 ft away (numerator), denom det'd by how far a normal sighted person could be to see that row (20/200 = pt 20' away, societal norm could see that from 200' away) 2. Extraocular movement -tests CN III, IV, VI -6 cardinal fields of gaze - follow object making H 12-18" away, no move head -testing muscles and nerves are in cxn and working 3. Parallel eye movement -at extent of lateral muscular effort, eye will beat 1-2 times -Nystagmus: uncontrolled shaking, indct intox, stroke 4. Visual Fields -periphery test -failure indcts: detached retina, severe cataracts 5. External eye structure -position and alignment >> be in same plane, parallel >> bulging = EXOPHTHALMOS (can indct thyroid issue) >> crossing = STRABISMUS -eyebrows: dist, postn, alignment, movement (CN7) -eyelashes: dist, direction -eyelids >>color >>motility >>position: PTOSIS (eyelid ptosis re:boxers) >>alignment >>edema >>lesions

Post-op complications: metabolic and urinary

1.dehydration -d/t exposed organs 2.fluid overload -swelling, ^UOP, crackles, dyspnea 3.difficulty voiding -expect to void 8hrs post cath removal -could rtn d/t edema, trauma, meds, inability to AMB -minimum UOP 30mL -may need to bladder scan, re-cath

types of meds administed via injection (7) how admin'd

ANTICOAGGULANTS: some IM some subcue enoxaparin = prefilled syringe c airbubble for subcue ANTIBX: some IM some sub cue ANTIEMETICS: some IM some subcue ANTIPSYCHOTICS: some IM some subcue IMMUNIZATIONS: usually IM INSULINS: usually subcue OPIOIDS: usually IM, sometimes subcue (peds)

Angiography: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: imaging using contrast dye and catheter, allowing for direct x-rays of blood vessels P: helps id blocked blood vessels E: contri for preg, renal insuffiecy, bleeding P: enforce NPO 2-4 pre P: VS E&O, assess catheter site

Diverticulitis: def, nursing actions

D: inflam/infd pouches of digsys >> blockage, fistulas N: monitor gi, diet, give antibx, NPO if acute

Bone Marrow Biopsy: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: need inserted into bone and marrow, tix removed P: test tix for problems making blood cells E: NPO 6hrs pre P: dsg 24hrs

CSF anaylsis/Lumbar puncture/Spinal tap: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: collection of CFS for analysis P: assist dx of infection or hemm of brain, assess MS P: assess baselines P: VSE&O, administer fluids to replace CFS, pt maintain horizontal psnt, assess puncture site

Endoscopic Retrograde Cholangiopancreatography (ERCP): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: contrast endosc pancreatic ducts, hepatobiliary tree P: eval cause of obstruction, jaundice, dx abn E: NPO midnight, sedative P: suction, P: cholangitis/pancreatisis, laryngospasm, check gag

Barium enema/Lower GI series: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: contrast used for radiological examination of colon, small bowl, appendix P: assist dx bowel disease E: Vresidue diet, NPO 8hr pre, stools will be light post P: admin laxitive to clear barium, monitor fluid/lyte

Brochoscopy: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: direct vis larynx, trachea, bronchial tree c light scope P: vis structure for diseases E: NPO 2hrs pre, no anticoagulant P: VS E&O, assess breathing, airway

Cystoscopy: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: direct vis of urethra, bladder, ureters, obtain spec P: visualize and remove tumors, stones, E: P: NPO 6hr P: hematuria, encourage fluids, difficulty urinating

Arthroscopy: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: direct visualization of specific joint bia endoscope P: inspect structure, biopsy, surgical repair E: h&c therapy, refrain from pain, crutchwalking P: 5-6" hair shaved around joint, NPO P: monitor circ and sensation, elevate, avoid soaking

Benign Prostatic Hyperplasia: def, nursing actions

D: enlargement of prostate, non cancerous N: post op: foley mngmt, tx bladder spasms, no lifting

EKG/ECG (electrocardiogram): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: eval heart electrical status via electrodes on skin P: id conduction abnormalities, asses intvnt performanc E: remain still, electrodes painless NO F/F restrict P: note any cardiac drugs, P: remove electrodes

Stress Test: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: eval heart response to stress P: dx cp cause, fxnlty of heart, screen, id dysryth E: NPO, no smoke 3hr pre, electrodes P: monitor BP, ECG, place ECG leads P: monitor BP, ECG 5-10 post, remove leads, auscultate for S3/S4

Cauterization: def, nursing actions

D: hot cold chem electricity to deliberately destroy tix N: pain, wound care

Magnetic Resonance Imaging (MRI): definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: imaging of bones and soft tix P: eval bones and soft tix E: no metal P: admin sedative, stop all pumps, det any implants P:

Echocardiography: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: non invasive, caridac ultrasound P: dx valve abn, measure size, det abnormalities E: no f/f restrict, P: apply conductive gel P: remove conductive gel

Chest Physiotherapy: def, nursing actions

D: promote deep breath, coughing, IncSpri N: edu, stop smoking, avoid inhaled allergens, observe lung sounds and sputum color

Cytocele: def, nursing actions

D: protrusion of bladder thu vaginal wall N: tach kegels, assess intererance with voiding

Thoracentesis/Pleural fluid analysis: definition, purpose, pt edu, pre-procedure nursing responsibilities, post-procedure nursing responsibilities

D: puncture thoracic wall to obtain spec or relieve press P: provd relief, obtain spec E: no cough, no deep breath, alert if dyspnea P: maintain sterile P: Lab specimen mgmt, pstn of affectd side for 1 hr, VS E&, puncture site

Pilonidal Cyst or Sinus: def, nursing actions

D: small hole/tunnel in skin below coccyx filled with hair N: antibx if infected, wound care, drainage,

Abdominal Perineal Resection: def, nursing actions

D: sx anus rectum sigmoid colon removed N: colostomy bag mgmt

Tacheostomy: def, nursing actions

D: sx incsn to temp or perm create opening for direct airway access to trachea N: patency, inf, suction, skin care, resp status

Nephrectomy:def, nursing actions

D: sx removal of all or part of kidney N: pre/post, UA, cathether care

Craniotomy: def, nursing actions

D: sx remove skull part to expose brain, then replace N: incision, sterile, infection, pain, neuro assess, swallow

Salpingoplasty: def, nursing actions

D: sx repair of fallopian tube N: pre/post considerations

Cesarean Section: def, nursing actions

D: sx to deliever baby thru incsn of abd and uterus N: pain, post op, inf, anx, encourage amb

Hemorrhoidectomy: def, nursing actions

D: sx to remove internal or external hemor that are sevr N: repsnt, sitz/compress, monitor drainage, admin stool softeners, encourage amb,

Salpingo-oophorectomy: def, nursing actions

D: sx to remove ovaries and falloptube (uni/bilateral) N: pre/post, samples may be obtained, lab'd

Hysterectomy: def, nursing actions

D: sx to remove uterus N: pre enema, post assess for hemorrage, infection, discharge, reach perineal care, all post ops

Nursing Process: Implementation definition, types (2), 5 steps in the implementation process

DEF: actual initiation of identified interventions and care activities types: 1. direct intervention: hands on at bedside 2. indirect: for pt not at bedside (call pharmacy, get wheelchair, etc) steps: 1. set priorities (use ABCs and maslow as guide) 2. reassess the client 3. perform nursing interventions 4. record/document interventions *IF YOU DIDNT WRITE IT DOWN, IT DIDNT HAPPEN* no matter how SMALL the intervention 5. reassess the client after every intervention >>review, revise existing care plan

Delirium: 3 characteristics, cause, forms, s/s

DELIRIUM: ACUTE, SUDDEN, REVERSIBLE Cause: usually physiological: alt'd envi, infection, metabolic imbalance Forms: Hypoactive and Hyperactive (motor activity) S/S: changes to motor activity hallucinations paranoia altered reality short term memory loss but INTACT long term memory sleep disturbances (hyper or insomnia)

IM: sites (amt of med, landmarks)

DELTOID -no more than 1mL -landmark: acromion process -2-3 fingers width below -beware radial nerve, brachial artery VENTROGLUTEAL (*pref'd site) -no more than 3 mL -landmark: greater trochanter, iliac crest -contralateral hand on hip, pt side lying, knees flexed, palm of hand on greater trochanter, index finger on anterior/superior iliac spine (ASIS), middle run along iliac crest, makes a V, inject in between VASTUS LATERALIS -no more than 2mL -landmarks: greater trochanter and lateral femoral condyle (knee) -make a goal post, inj in lateral middle 3rd of thigh

Dementia: 3 defining characteristics, def, S/S (x2)

DEMENTIA: GRADUAL, PROGRESSIVE, IRREVERSIBLE -generalized impairment of intellectual functioning -interferes c social and occupational functioning 7As Anosognia: no knldge of illness (d/t frontal lobe dmg) Aphasia: diffclty with or loss of language skills Agnosia: loss of recogntn and process sensory info Apraxia: loss of purposeful physical mvmt even if instructions understood Amnesia: loss of mem or inability to form new mem Alt'd percpt: loss of visual percpt &ability to process (depth) Apathy: loss of interest, lack of of initiation, ADLs anxiety, repeated questions or behaviors, limited short term memory, emotional lability, inappropriate socially or sexually, often wander leave home, aggression c anxiety d/t cognitive dissonance with reality

Types of Dementia

DEMENTIA: GRADUAL, PROGRESSIVE, IRREVERSIBLE 1. Alzheimers -no true test except autopsy, but believed 60-80% of dementia -d/t plaques and tangles of neurons 2. Diffuse Lewy Body Disease 3. Frontotemporal Dementia 4. 2* Dementia (to stroke, parkinsons)

2 sources of stess

DEVELOPMENTAL STRESS -certain tasks must be resolved to vStress (erikson) -infant: trust others -toddler: control elimination -school age: socialize with peers -adolesence: strive for independence -middle age adult: accept phys signs of aging -older adult: reflect on past exp w satisfaction SITUATIONAL STRESS -doesnt occur in predictable patterns -can occur at any time, will ef diff depending on personal developmental level -(+) or (-): marriage, divorce, loss of job, back to school

Nursing interventions for safety (2 broad, sub)

DISASTER PLANS 1. internal disasters: occur in facility that impairs ability to care for pts (fire, internet down) 2. external disasters: occur outside HC setting, impacts the care inside (i.e hurricane) PREVENTATIVE INTERVENTIONS 1. fall prevention -every pt: slipper socks, call light, lights on -high risk: bed alarm, id bracelet 2. self harm protection -suicide, escape (elope) precautions 3. physiologic precautions -aspiration, seizure precautions, isolation during infectious disease

Hypersomnia: sub cat, def, prevelance, s/s

DYSSOMNIA -sleeping too much or too easily -narcolepsy: inability of nervous sys to maintain boundries bt wakefulness and sleep -sleep attacks are disabling -1/2000 in US -s/s: wake disoriented, slow thoughts and speech

Problem Oriented Medical Record

Documentation method SOAP or SOAPIE or SOAPIER data organized based on problems doc 1 problem at a time, then everyone can document on the same problem >>Overall picture can be seen easily SUBJECTIVE: what pt says "8/10 pain" OBJECTIVE: what is observed "grimace, pulse 105" ASSESMENT: "pt having incisional pain" PLAN: "relieve pain from 7 to 3/10 IMPLIMENTATION: repsnt, morphine 2mg q4h EVALUATION: did it work RECOMMENDATIONS

how often does a pt need a bath

EVERYDAY at very least: wash hands, face, new linens, new gown

Expressive Aphasia aka, def, manifestation, intervention

EXPRESSIVE APHASIA/BROCHA'S APHASIA -inability to express words one wants to say (verbal or written) -limited speech, slow or takes great effort, reduced grammar, poor articulation -person KNOWS what they want to say, cant find the words -intervention: use picture cards

Non-Rebreather Mask flow type, rate, O2%, structure

High Flow 10-15L/min 80-90% O2 mask w bag attached at bottom MAKE SURE BAG INFLATES inflates w high con O2, prevents inhal of RA valve largely prevents inhalation of RA or exhaled air

cranial never number, name, s/m/b, function, assessment

I. Olfactory (S) -sense of smell -TEST: close eyes, smell and id something (coffee) II. Optic (S) -visual acuity -TEST: Snellen eye chart III. Oculomotor (M) -extraoccular movement -pupil size -TEST: PERRLA IV. Trochlear (M) -u/d eyeball movement -TEST: 6 fields of gaze V. Trigeminal (B) -sensory nerve to face -motor nerve to jaw -TEST: close eyes "what part of your face am i touching" AND open and close mouth VI. Abducens (M) -s/s eye movement -TEST: 6 fields of gaze VII. Facial (B) -facial expression -taste on front of tongue -TEST: make faces (eyebrow, cheek, mouth movement) AND sugar or salt on tip of tongue "taste?" VIII. Auditory (S) -hearing -TEST: conversation, whisper test IX. Glossopharyngeal (B) -gag reflex/swallow -tast on back of tongue -TEST: swallow AND sugar/salt on back of tongue "taste"? X. Vagus (B) -sallowing -movement of vocal cords -sensation of pharynx -TEST: say ahh XI. Spinal accessory (M) -movement of head/shoulders -TEST: shrug shoulders, head s/s front/back XII Hypoglossal (M) -positioning of tounge -TEST: stick tongue out s/s u/d

Respiratory - Define Cheyne-Stokes Breathing Pattern, Biots Respirations and Kussmal Respirations

KUSSMAL -type of hyperventilation -exaggerated, deep, regular, rapid breathing >>exercise breathing -may be present w ASA od, pain, fever, panic/hysteria, cardiac/pulm disease, DKA CHEYNE-STOKES -alternating periods of kussmauls and apnea -ascd w end of life BIOTS -irrg patten: varying shallow breaths (panting) then apnea -ascd w ICP (intracranial pressure) and respiratory compromise

NREM Stage I name, level, length, body response

NREM SI -transitional stage from wake to sleep -lightest level of sleep, easily awakened -lasts: a few minutes -muscles relax, heart rate and resps slow

NREM Stage III stage, body, length

NREM SIII -1st stage of deep (slow wave) sleep -difficult to awaken -completely relaxed >> snoring -VS continue to decrease but are regular -lasts 15-30 mins

NREM Stage IV stage, occurrences, length, dev consideratiosn

NREM SIV -deepest (slow wave) stage of sleep -REALISTIC DREAMS: hard to tell if real or not -very difficult to awaken -lasts 15-30 mins -newborns spend more time, elderly less time here

IV solutions: isotonic solutions 2 examples, what are they used for

NS (0.9% Nacl) -tx hypovolemia, hyponatremia, hypercalcemia, metabolic alkalosis LR -contains multiple lytes in the same conc as plasma (lacks mg2+) -tx hypovolemia, burns, gi lossess

Potassium normal value, role, hypo name, causes (4), s/s (9), tx (2)

Potassium K+ 3.5-5.0 mEq/L cell enzyme activity, electrical impulses in nerves, heart, muscle, gi, lung tissue Hypokalemia Cause: -v/d/Gi losses, diuretics, poor intake (anorexia, ETOH), polyuria S/S: -fatigue, anorexia, n/v, muscle weakness, vBowel motility, cardiac arryhthmias, paresthesia, OHOTN, EKG changes TX: Replace, diluted PO or IVPB, NEVER pushIV, vesicant, increase serum level by 0.25 mEq w each 20mEg given; encourage potassium rich foods

Cardiac assessment: S1 S2 aka, whats happening,

S1 -LUB -mitral and tricuspid valves (AV valves) closing after contracting/emptying S2 -DUB -aortic and pulmonic valves closing after contracting/emptying

Assessment of pts ability to fxn safely the subjective data and objective data

SUBJECTIVE DATA -pts perception of safety: safe at home -injury hx: last time you fell -concerns about safety: tell me about your smoking -risk identification OBJECTIVE DATA -dx tests and procedures -physcial assessment >>neuro fxn: cog/sensory fxn >> mobility and activity tolerance: msk assess

list the 4 sensory alterations

Sensory deprivation Sensory overload Sensory deficit Sensory processing disorder

Neuro - Identify CN V-CN VIII - names and how to assess

Trigeminal -sensory to face, jaw movement: touch face and open close jaw Abducens -eyeball movement lateral: 6 fields of gaze Facial -facial expression and taste on tip of tongue -smile frown, brows up down, close eyes, salt/sug on tongue Auditory -hearing acuity: conversation, whisper test

Vitamins A D E K roles

VIT A visual acuity, skin, mm, immune fxn VIT D Ca2+, phosphorus metab VIT E antioxidant protects vit a VIT K helps synth enzymes necc for blood clotting

subculture

a group of people within a culture that differentiates itself from the larger culture where it belongs "way of life"

6 anti platetlet suppliments that are contraindicated c sx

anise celery camomile clove ginger red clover

how to communicate with non-english speaking pt

assess need of interpreter (NOT family) never use gestures, get that interpreter universal phones, technology apps

goal of pt education

assist individual, family, community as to how to achieve optimum level of health and wellness pts w more teaching have better health and fewer complication

atheist vs agnostic

atheist: denies existence of higher power agnostic: nothing can be known of existence of higher power, believes its there but not in organized religion

two types of tube feeding administration

bolus nutrition: like a bb bottle, every so many hours give so many oz of formula continous feeding: formula in bag, admin thru feeding pump, given throughout day

pt education definition, whats nurses role

def: the process of influencing pts bx to effect a change in their KSA needed to maintain and improve health we help them develop self care abilities to maximize their self care function and quality of life provide them w edu to promote health, prevent illness

regularly irregular pulse vs irregular pulse

expected, regular pulse rhythm that is NOT normal unpredictable pulse rhythm that is NOT normal

urine tests: specific gravity what measuring, range, high number would indicate what

measures concentration of solutes normal: 1.010-1.025 high number >> dehydration

NEURO: Glasgow coma scale what does it measure, possible scores, categories

measures level of consciousness (LOC) 3/15 - 15/15 : higher#:more conciousness 1. eye response (out of 4) 2. verbal response (out of 5) 3. motor response (out of 6)

why use a ztrack, what 2 meds

meds that need to be sealed in muscle d/t irritation to subcue laterally displaces skin, seals drug as needle is removed EX: compazine, promethazine

MI

myocardial infarction

what does "not tolerated" diet advancement look like

n/v/abdl distention

Transfering pt to PACU: hand off report

name of nurse youre communicating with meds, dosages, time to administration amt of blood lost intubated occurances of complications *use SBAR

interventions for altered spiritual function

obtain spiritual history listen to pt incorparate spiritual practices as appropriate referral to chaplain or spiritual leader maintain respect

populations most likely to have low health literacy

older adults racial and ethnic minorities ppl c <high school degree or GED low income non-native english speakers ppl c comprimised health status

what can you touch with sterile gloves on

only sterile things

which sign isnt vital, why is it included

pain will ef pulse, resp, bp during ACUTE pain (maybe not chronic pain)

did you know this about pain assessment>

pain must be assessed frequently to provide adequate relief!

safe working environement for HC workers

part of safety taking care of ppl at most vulnerable >> risk set boundries of respect allowed and obligated to set boundries wont always protect you if continued disrespect, go up chain of command

PE

physical examination

if you use a pill cutter, what do you do

rinse it out dry upside down, DONT cut self on razer

ethics definition

rlxn bt right and wrong standards of conduct and moral judgement professional ethics involves principles and values with UNIVERSAL application, standards of conduct to be maintained in ALL situations

how do we care for unconscious patients differently than conscious ones

we dont. speak to them normally, assume they can hear you, but just cant respond

Professional nursing organizations why, fx, benefit, (4)

why: set standards for practice and education fx: influence HC policies, legislation benefit to join:network, voice in legislation, keep current 1. American Nurses Association (ANA) 2. National League of Nurses (NLN) 3. American Association of Colleges of Nursing (AACN) 4. National Student Nurse Association (NSNA)

process when collecting urine sample from aspiration port

wipe port w swab, use clean glvoes, LEUR-LOCK syringe = sterile, aspirate urine

when do you want a bm after surgery

within 3 days

5 forms of communication

written/electronic: must be @5th grade level, discharge instructions, consent forms verbal: often interpersonal nonverbal: clothing dress odors body language intrapersonal: with self interpersonal: bt 2 ppl

Fluid and lyte balance assessment: hx

wt changes lab studies: CBC, lytes, BUN, Cr, specific gravity risk factors -illness: DM, RF, HF -abn fluid lossess: v/d, draining wounds -burns -trauma -long sx, big wound (evaporation and bleeding)