NU 313 Exam I

What are the five types of nursing diagnoses?

1. Actual nursing diagnosis (problem is present) 2. Risk (potential) nursing diagnosis (problem may occur) 3. Possible nursing diagnosis (problem may be present) 4. Syndrome nursing diagnosis (several related diagnosis are present) 5. Wellness nursing diagnosis (no problem is present)

Identify the factors that affect skin integrity

1. Age 2. Mobility status 3. Nutrition 4. Hydration 5. Sensory and cognitive status 6. Circulation 7. Medications, tobacco 8. Exposure to moisture 9. Exposure to harmful microorganisms 10. Fever 11. Lifestyle

List the steps in the diagnostic process.

1. Analyzing and interpreting data (this includes identifying significant data, clustering cues, and identifying data gaps and inconsistencies) 2. Drawing conclusions about health status (this includes making inferences and identifying problem etiologies) 3. Verifying problems with the patient 4. Prioritizing the problems 5. Recording the diagnostic statements (it could be argued that this is not really a part of the diagnostic process) You might also include "reflecting critically about your diagnostic reasoning," although it comes after the diagnostic process, strictly speaking.

List and explain three ways to incorporate caring theory into your nursing care.

1. Holistic nursing care. This is the basis of contemporary nursing. It allows nurses to examine the entire person and the person's world when making healthcare decisions. It goes beyond "just" giving the medication or dressing a wound. These are important tasks, but try to see nursing as giving care to the entire person and all that entails (e.g., family, friends, fears, and cultural beliefs). 2. Honoring personhood. None of the three caring theorists refers to the person in the healthcare system as a patient unless they need to for clarification. They firmly believe that the "patient" is someone who deserves to be honored for individuality in behavior as well as needs. If you accept the need to honor personhood, you will learn the names of the people in your care and will refer to them by name instead of "Room 331," or "the kidney infection down the hall." Honoring personhood takes time, as you need to look at, talk to, and touch the person to understand what his personhood is. It requires you to control the rush and fast pace of nursing and take the time to experience the person. 3. Transpersonal caring moments. Watson says the concept of transpersonal caring is a moral ideal rather than a task-oriented behavior [think about Mr. Wilkey in the chapter's Meet Your Patient scenario]. Transpersonal caring moments occur when an actual caring occasion occurs or an authentic caring relationship exists between the nurse and the person. This can be a challenge! In the current healthcare environment, people are moved rapidly through the system. How can you find the time to develop authentic caring relationships? The first step is to make a commitment to be a caring nurse—to go to work with the thought, "Today I will be authentic with the people in my care." The word authentic simply means to be genuine or real. Or you might think, "I will focus on creating transpersonal caring moments instead of rushed and harried ones." Think back to Mr. Wilkey in the Meet Your Patient scenario. Where did the transpersonal caring moments occur? It was a stressful situation, yet the nurse found within herself the ability to use that nursing skill. As a student, you might go to clinicals thinking, "Today I will practice changing sterile dressings or starting IV solutions or giving intramuscular injections." However, developing the ability to have transpersonal caring moments is just as important. 4. Personal presence. This is another phrase for being authentic and "in the moment." If the person in the bed is fearful, you should be fully present, recognizing the fear and supporting the person experiencing it. Your support may be in the form of answering simple questions or providing more in-depth education. It may simply be staying with the person for 2 or 3 minutes while quietly listening and holding the person's hand. The concept denotes that you, the nurse, are totally with the person for the time you are there. You are not thinking about a medication pass or medical orders you need to get. Instead, you are with the other person emotionally and physically. 5. Comfort. Most nurses think of comfort as the relief of pain, but it is much more. For example, is the person comfortable with you as the caregiver? For example, think about an older woman having a young male CNA assigned to bathe her. She may not be comfortable with that. Other examples involve comfort with the room light, the temperature, or the availability of a window. Some people like a dark room, and others need really bright lighting to see well. For the most part, comfort has to do with the emotional well-being of the person. Other questions to consider are the following: Is the patient's modesty being respected? Is there too much or too little environmental stimuli? Does the patient need more rest periods to heal? Does the patient need someone to spend a transpersonal caring moment with her so she can express fears and anxiety? This is the complex picture of comfort. 6. Listening. You should begin to put all of these concepts of caring into one "package" of behavior. All of them complement each other. For example, if you are fully present in the moment, you will be listening, you will be authentic, and you will experience a transpersonal caring moment. Listening requires you to quiet your mind and truly listen with your mind and heart. The caring theorists also talk about listening "from within yourself." Some call that type of listening intuition. Benner indicates it is intuition that allows the expert nurse to know when it is the right time to extubate a person on a ventilator. As a novice, you should not rely too heavily on your intuition. 7. Spiritual care. Spirituality is a critical aspect of holistic nursing care. Humans consist of body, mind, and spirit. Gone is the era when nurses avoided talking about spirituality for fear of offending someone. You need to know what an individual's spiritual needs are and make appropriate plans to meet them. If the person does not want to talk about or deal with his spirituality, you will listen and follow his instructions. However, generally the opposite is true. People who are ill often want to talk about their spiritual needs but may be uncomfortable doing so. Helping someone to meet spiritual needs may be as simple as calling a clergy person or as personal as praying with the person who is sick. Providing spiritual care is a critical aspect of caring (see Boxes 8-1 and 8-2 in your textbook). Chapter 16 provides more information about spiritual care. 8. Caring for the family. All nurses who base their practice on caring theories recognize the importance of including the family of the person who is receiving care. That the family structure may not be traditional is not a reason to withdraw support. Family structures that previously have been hidden no longer are, in most situations. If you are giving care to a gay or lesbian couple, be respectful of the relationship between the two people. If you are working with a developmentally disabled person, be sure to explain all procedures to the person as well as the family. Sometimes in the rush of the day, this can be challenging. What about an older family member with dementia? He deserves to know what is happening to his loved one even though he most likely will forget the information. If he does forget, patiently repeat what he needs to know. Families are challenging, as they have had years to develop their own communication patterns and miscommunication patterns. Respect the need for the family, all of the family, to be part of your responsibility based on the principles of holistic nursing care. You will find more information about family care in Chapter 14. 9. Cultural competence. This was discussed in the explanation of Leininger's cultural care theory. Please refer to it at the beginning of this section and in Chapter 15, if you need additional information.

According to the text, why has nursing research been slow to develop?

1. Nightingale schools used authority-style education, which does not lead to the critical thinking needed for conducting research. 2. Nursing research has been traditionally associated with higher education, which had been slow to develop in nursing. However, this is rapidly changing with nursing's present professional commitment to evidence-based practice.

Describe a five-step process for generating and choosing nursing interventions.

1. Review the nursing diagnosis. Nursing orders should flow from the etiology and sometimes from the problem side of the diagnosis. 2. Review the desired patient outcomes. Outcomes suggest nursing strategies that are specific to the individual patient. 3. Identify several interventions/actions that might achieve the desired outcomes for the nursing diagnosis. 4. Choose the best interventions for this patient— those expected to be most effective in helping to achieve client goals. 5. Individualize the standardized interventions to meet the unique needs of the patient.

List the phases of the research process.

1. Select and define the problem. 2. Select a research design. 3. Collect data. 4. Analyze data. 5. Use the research findings.

List the six risk factors that are assessed on the Morse Fall Scale.

1. Whether the patient has a history of falling 2. Whether the person has more than one medical diagnosis 3. Whether the person uses ambulatory aids, such as crutches or a walker 4. Whether the person has an IV or a heparin lock 5. Whether the person's gait is normal, stooped, or otherwise impaired 6. The person's mental status

What part(s) of a sterile field are considered to be unsterile?

A 1-inch margin around the edges of the field and any material that hangs over the horizontal plane are considered unsterile. You may also recall that a field is no longer sterile if it becomes wet, if you turn your back on it, or if someone not wearing sterile garb comes within 1 foot of the field.

Why is a chest tube inserted?

A chest tube is inserted to remove air or fluid from the pleural space so that the lungs can fully expand.

What are some reasons that a client may not follow a recommended treatment regimen?

A client may not follow a treatment regimen because of the following reasons: • Might not understand the treatment. • Might not understand the reasons for/importance of the treatment. • May have cultural objections to the treatment. • Lifestyle may interfere; he may not be willing to change his lifestyle. • Fear of failure. • Reluctance to ask questions because of fear that the nurse/physician will think he should know the answers or reluctance to bother a busy professional. • Lack of resources (e.g., money to buy medications, access to transportation to a clinic).

Why does a clinical practice guideline provide better support for an intervention than does a single study?

A clinical practice guideline provides better support because it includes more data and multiple studies. A single study may have included only a few patients and may not be reliable because of that or for other methodological reasons. Considering many studies removes some of the bias

When is a cough significant? What aspects of a cough should be assessed?

A cough generally becomes significant when it persists, is recurring, or is productive. A persistent or recurring cough is indicative of ongoing or recurring airway irritation. A cough that lasts more than 3 weeks and cannot be explained should be medically evaluated. The following aspects of a cough should be evaluated: • Type of cough (e.g., dry, productive, hacking) • Duration of cough • Timing of cough • Appearance of sputum (if any) • Exacerbating factors • Alleviating factors • Types of treatments used to date and their effects • Associated symptoms • Type, amount, and timing of sputum produced

What is the difference between a cue and an inference?

A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. You can observe a cue directly, but not an inference. You cannot directly check the accuracy of an inference.

What are three ways you can recognize a cue?

A cue is recognized by the presence of data representing (1) a deviation from population norms, (2) a change in usual health patterns that is not explained by developmental or situational changes, (3) an indication of delayed growth and development, (4) a change in usual behaviors in roles or relationships, or (5) a nonproductive or dysfunctional behavior.

What type of cane should a patient with significant balance problems use?

A multipronged cane should be used by a patient with a balance problem.

How is the nursing assessment different from the medical assessment?

A nursing assessment is holistic and focuses on client responses to disease, pathology, and other stressors. A medical assessment focuses on disease and pathology.

How is a paradigm different from a theory?

A paradigm is broader than a theory. It includes the philosophy, values, knowledge, theories, and research processes of a discipline. It is the shared "worldview" of the community of scholars within a discipline.

How does a portable chest drainage system compare with a water-seal drainage system?

A portable chest drainage system is smaller and lighter, so it makes ambulation easier than with a water-seal system. A portable system is a single chamber, whereas a water-seal system can be one, two, or three chambers. The portable system is dry seal and drains by gravity (although it can be connected to wall suction). However, it holds a maximum of 500 mL, so it is not practical for those with large amounts of drainage.

What is the advantage of a three-chamber system (compared with a one-chamber or two-chamber system)?

A three-chamber system provides controlled negative pressure, a place for fluid collection, and a water seal. It does not increase the work of breathing. The three-chamber system also allows for drainage of larger amounts of fluid than does a one- or two-chamber system.

Briefly describe a process for creating a comprehensive, individualized care plan that incorporates collaborative care and standardized planning documents.

A process for creating such a care plan should include the following steps: • Perform a comprehensive patient assessment. • Make and prioritize a working problem list. • Decide which problems can be managed with standardized care plans or critical pathways. • Individualize the standardized plan as needed. Mark off any instructions that do not apply to the patient; add or adapt nursing orders as appropriate. • Transcribe medical orders to appropriate documents. • Write activities of daily living (ADLs) and basic care needs in special sections of the Kardex, care plan, or computer. • Develop individualized care plans for problems not addressed by standardized documents. Write outcomes and nursing orders for each nursing diagnosis not addressed by standardized documents.

If you needed to disinfect a sink in a client's home, what would you use?

A solution of 1 part household bleach and 50 parts water

What is the difference between a strain and a sprain?

A sprain is a stretch injury of a ligament that causes the ligament to tear. • A strain is an injury to muscle caused by excessive stress on the muscle.

• Identify the most appropriate device for the following activities: • Transferring an obese patient from a bed to a stretcher Assisting an immobile patient to a recliner chair • Helping a weak patient from bed to chair

A transfer board should be used when transferring an obese patient from a bed to a stretcher. A mechanical lift should be used when assisting an immobile patient to a recliner chair. A transfer belt should be used when helping a weak patient from a bed to a chair.

Explain the primary assessment approach

ABCs We're just getting on board with the idea that nurses should be thinking in this way so that changes in pts health would be addressed sooner and potential life threats would be avoided.

What nutritional components are essential to maintain skin?

Adequate intakes of five nutritional components are essential to maintain skin: 1. Protein 2. Calories 3. Fluid 4. Vitamin C 5. Minerals

How does absorption differ in children and older adults?

Absorption differs in children and older adults in the following ways: • Children, because of their smaller body mass, must have their dosage adjusted. Infants, in addition, have immature body systems. Infants and children experience more rapid absorption because of the lack of gastric acidity in their stomach and the shorter length of intestines through which the drug passes. In addition, limited muscle mass decreases children's ability to absorb parenteral medications. • Older adults, because of a decrease in gastric pH, have a delayed, but more complete, absorption of medications in the stomach. Absorption of parenteral medications varies because of the loss of muscle mass. Declining function in organs (e.g., liver and kidneys) affects the metabolism and excretion of drugs and can lead to toxicity.

Mrs. King has several of the signs and symptoms (defining characteristics) of the nursing diagnosis: Ineffective Coping.

Actual diagnosis

Explain the difference between an acute and a chronic wound.

Acute and chronic wounds have different durations and causes. • Acute wounds are expected to be of short duration. Acute wounds may be intentional (surgical incisions) or unintentional (trauma). • Wounds are classified as chronic when they exceed the anticipated length of recovery. Chronic wounds include pressure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with bacteria, and healing is very slow because of the underlying disease process. A chronic wound may linger for months or years.

What are some indirect indicators of tissue oxygenation?

Adequacy of tissue oxygenation can be indirectly assessed by determining whether organs are functioning normally. For example, hypoxic central nervous system tissue causes abnormal brain functioning (e.g., altered level of consciousness), whereas hypoxic renal tissue causes abnormal kidney functioning (e.g., poor urine output), and hypoxic limb tissue results in abnormal muscle functioning (e.g., muscle weakness and pain with exercise).

What does the term parenteral mean?

Although the term parenteral actually means all routes other than oral or rectal, many people use the term parenteral to mean only injectable drugs—by the intradermal, subcutaneous, intramuscular, or IV routes.

Which two nursing organizations have been responsible for making diagnosis a part of the professional nursing role?

American Nurses Association and NANDA Internationa

What type of interaction occurs when one drug interferes with the action of another?

An antagonist drug reaction results when one drug interferes with another.

Explain the difference between analytic reading and research appraisal.

Analytic reading is a broad examination of what you are reading, in which you ask general questions of the reading so that you can truly understand it: What is the reading about as a whole, what is being said, and how are the details being delineated? Is it true in whole or part? And what of it? In a research appraisal, you examine each part of the article (e.g., researcher qualifications, title, problem statement), thinking critically and answering more specific questions about each section.

Explain what is evaluated in each of the following types of evaluation (i.e., the focus of each type of evaluation): structure, process, and outcomes: • Structure evaluation focuses on the setting in which care is provided. It explores the effect of organizational characteristics on the quality of care. It requires standards and data about policies, procedures, fiscal resources, physical facilities and equipment, and the number and qualification of personnel. • Process evaluation focuses on the manner in which care is given—the activities performed by nurses (and other personnel). It explores whether the care was relevant to patient needs, appropriate, complete, and timely. • Outcomes evaluation focuses on demonstrable ("measurable") changes in the patient's health status that result from the care given. 1. In the Emergency Department, the time from patient sign-in to assessment by a healthcare worker will be less than 15 minutes.

Answer: Process 2. A fire extinguisher is located in an accessible spot on each unit. Answer: Structure 3. No patients with indwelling urinary catheters will develop urinary tract infection. Answer: Outcomes

What effect does aging have on skin?

As adults age, aging has the following effects on the skin: • The activity of the sebaceous and sweat glands diminishes, resulting in drier skin. • The subcutaneous tissue layer thins, giving the individual a sharp, angular appearance. Excess caloric intake and weight gain can offset this change of appearance. • The strong bond between the epidermal and dermal layers decreases as the dermal layer loses elasticity. • These changes make the skin prone to breakdown and slow the healing of a wound.

What are the four features common to all definitions of assessment?

Assessment involves data collection, use of a systematic and ongoing process, categorizing of data, and recording of data.

Identify the four components of body mechanics

Body mechanics, a term used to describe the way we move our body, includes four components: body alignment, balance, coordination, and joint mobility

Where can you go to use CINAHL?

CINAHL is the Cumulative Index to Nursing and Allied Health Literature. It is found in the library as a set of large books in the reference section or on the World Wide Web.

The level of which gas (oxygen or carbon dioxide) is the primary stimulant for breathing?

CO2

After giving birth, all women are at risk for developing postpartum hemorrhage.

Collaborative problem (potential complication of childbirth: postpartum hemorrhage) Rationale: This is a potential problem that the nurse can help to prevent (e.g., by fundal massage); but if fundal massage is not effective, the physician must prescribe medication to prevent hemorrhage. This is a potential physiological complication associated with a medical diagnosis (childbirth).

What is the main disadvantage of computerized and standardized care plans?

Computerized and standardized care plans may cause you to lose some creativity, intuition, insight, or caring because it is tempting, when you are busy, to accept the "easy answer" provided by the computer and not go further to think about the unique needs of a particular patient.

How are critical pathways different from other standardized care plans?

Critical pathways focus on care for a particular medical diagnosis or diagnosis-related group (DRG); they are organized on a timeline to meet recommended lengths of stay; instructions for nursing interventions are usually less specific/ detailed.

Why does a clinical practice guideline provide better support for an intervention than does an agency's critical pathway?

Critical pathways may not always be evidence based, but clinical practice guidelines are always evidence based. Critical pathways are developed by the agency's practitioners, who may be reluctant to change some of the traditional practices that they believe to be effective. Some institutions may omit interventions they do not consider to be cost effective.

What types of dressing may be used for wounds with a large amount of exudate?

Gauze, foam, alginates, or absorption dressings are best used for a wound with a large amount of exudate.

To help you fix them in your mind, list at least 10 questions to ask yourself when evaluating your diagnostic reasoning.

Data Analysis • Did I identify all the significant data (cues)? • Did I omit any important cues from the cluster? • Did I include unnecessary cues that may have confused my interpretation? • Did I try more than one way of grouping the cues? • Did I consider the patient's social, cultural and spiritual beliefs and needs? • Did I identify all the data gaps and inconsistencies? Drawing Inferences and Interpretations of the Data • Did I consider all the possible explanations for the cue cluster? • Is this the best explanation for the cue cluster? • Did I have enough data to make that inference? When there are insufficient data, you should suspend judgment until you gather more data. • Did I look at patterns, not single cues? • Did I consider behavior over time, not just isolated incidents? • Did I jump to conclusions? Always take the time to carefully analyze and synthesize the data. Critiquing the Diagnostic Statement (Problem + Etiology) • Is the diagnosis relevant and does it reflect the data? • Does the diagnostic statement give a clear and accurate picture of the patient's problem or strength? • When identifying the problem and etiology, did I look beyond medical diagnoses and consider human responses? • Did I consider strengths and wellness diagnoses, as well as problems? • Can I explain how the etiology relates to the problem—that is, how it would produce the problem response? • Does the complete list of problems fully describe the patient's overall health status? Verifying the Diagnosis • Did the patient verify this diagnosis? • When I verified the diagnosis, did I explain clearly? Am I certain that the patient understood my description of his health status? • Did I obtain feedback from the patient, or did I just assume that he agreed? • Did I keep an open mind, realizing that all diagnoses are tentative and subject to change as I acquire more data? Prioritizing • Considering the whole situation, what are the most important problems? • What aspects of the situation require the most immediate attention? • Did I consider patient preferences when setting priorities? If not, was there a good reason?

List the five components of a nursing order

Date, subject, action verb, times and limits, signature

Differentiate between dehiscence and evisceration.

Dehiscence and evisceration have the following differences: • Dehiscence is the separation of one or more layers of the wound. • Evisceration is the total separation of the layers of a wound with internal viscera protruding through the incision.

Why is the diagnosis step so critical to the other phases of the nursing process?

Diagnosis is critical because it links the assessment step, which precedes it, to all of the steps that follow it. Assessment data must be comprehensive and accurate in order to make an accurate nursing diagnosis. The nursing diagnosis must be accurate because it is the basis for the goals and interventions you will plan and implement for your patients.

What purpose does each part of the nursing diagnosis serve for directing the care of the client?

Diagnostic label: Succinct expression that symbolizes a pattern of associated cues; usually reflects the problem response Definition: Imparts a distinctive explanation, which distinguishes the label from similar nursing diagnoses Defining characteristics: Recognizable indications that when organized into groups reflect an actual or wellness nursing diagnosis; patient data; similar to signs and symptoms Related or risk factors: Description of clinical cues, conditions, and circumstances associated with the problem in some way (i.e., causing, contributing to the problem); usually a part of the problem etiology

How do diuretics affect oxygenation?

Diuretics increase removal of sodium and water from the body through increased urine output. By reducing the volume of circulating blood and preventing accumulation of fluid in the pulmonary circulation, gas exchange (carbon dioxide and oxygen) is improved.

What factors affect absorption?

Drug absorption depends on the route of administration, drug solubility, effects of pH at the site of absorption, blood flow to the area, body surface area, and form of the drug. • The route of drug administration affects both the rate at which onset of action occurs and the extent of the therapeutic response. • Solubility refers to the ability of a medication to be transformed into the appropriate form for administration via the route chosen and absorbed into the bloodstream. • Medications are absorbed rapidly in areas where blood flow to the tissue is greatest. When a medication is applied to a larger surface area, the rate of absorption is faster.

From which route is medication absorbed more rapidly: subcutaneous or IM? Why?

Drug absorption is more rapid from the intramuscular route. Absorption is more rapid because it is more richly supplied with blood vessels.

Define absorption.

Drug absorption is the movement of drug particles from the site of entry into the blood.

Define distribution

Drug distribution is the delivery of the medication from the site of administration to the various organs in the body through body fluids, primarily the blood.

What is drug incompatibility?

Drug incompatibilities are drug interactions occurring when two or more drugs are mixed together that cause a chemical deterioration of the drug

Define drug metabolism.

Drug metabolism is the deactivation of the drug in the body. Drugs are chemically deactivated or changed into an inactivated form in preparation for excretion.

How are drugs absorbed?

Drugs are absorbed through the membrane of the blood vessel into the bloodstream.

What is the importance of diastole to perfusion of the heart?

During diastole, the coronary arteries are the only arteries in the body that fill.

When should you use sterile technique when performing otic instillations?

During otic instillations, use sterile technique when the ear drum has been ruptured or opened surgically (to prevent an infection). Bacteria can harbor inside the ear canal and flourish because it is a moist, warm, and relatively closed area.

What are three uses for siderails?

Ensure patient safety • Provide a grip for the patient who is able to reposition himself in bed • Provide a sense of security for the patient in bed

A patient who complains of being claustrophobic and requires low-flow humidified oxygen

Face tent

What is a typical cause of fire in healthcare facilities?

Fire in healthcare facilities is typically related to anesthesia or electrical causes.

What measures should you take, and in what order, if a fire occurs in the hospital?

First rescue the patient—move the patient(s) away from the area. Then sound the alarm and attempt to confine the fire, if that is practical.

Identify five types of wound complications.

Five types of complications can occur with wounds: • Hemorrhage • Infection • Dehiscence • Evisceration • Fistula

What does the P wave, QRS complex, and T and U waves of an ECG complex represent?

For an ECG complex, • The P wave represents the firing of the SA node and conduction of the impulse through the atria. • The QRS complex represents ventricular depolarization and leads to ventricular contraction. • The T wave represents the ventricles returning to an electrical resting state so they can be stimulated again (ventricular repolarization). • The U wave is not always seen on the ECG, but may be detected with electrolyte imbalance, such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain medication (e.g., digitalis, epinephrine). An inverted U wave may occur with ischemia to the cardiac muscle.

For an "average" adult, what is the standard needle length for IM injections?

For an average adult, the standard needle length for IM injections is 11 /2 inches.

Which syringe would you use for an intramuscular injection, as a rule: tuberculin, 50-mL, 5-mL, or 3-mL syringe?

For intramuscular injections, you will usually use a 3-mL syringe. Even if the dosage is only 1 mL, it is difficult to manipulate a 1-mL syringe that has a 1-mL dose in it because the plunger is pulled all the way back.

You need to irrigate a wound. Which syringe size do you need: 0.5 mL, 3 mL, 5 mL, or 50 mL?

For irrigations, you will usually need a 50-mL syringe, unless the wound is very small. However, to irrigate an eye, you would, of course, use a smaller size.

As a rule, what gauge and length of needle would you use for a subcutaneous injection?

For subcutaneous injections, as a general rule, use a syringe with a short (3 /8- to 5 /8-inch) and small (25- to 30-gauge) needle.

Explain comprehensive vs focused assessment

Gathering data about everything you can and using to establish what may be going on with a pt vs gathering data from a specific body system r/t a previous medical diagnosis like Afib or asthma.

Describe oxygenation and perfusion.

Getting oxygen into blood as it flows through the lungs is only the first step in tissue oxygenation. The oxygenated blood must be transported to the tissues so that oxygen is available to them. • Oxygenation refers to how well cells, tissues, and organs are supplied with oxygen. • Perfusion refers to the circulation of blood to all body regions.

In which age-groups are you more likely to see health concerns that affect mobility?

Health concerns that affect mobility may occur throughout the life span. Congenital problems (e.g., hip dysplasia, club foot) are usually identified and treated in infancy. In contrast, degenerative problems (e.g., osteoporosis) are more likely in older adults.

How long should heat or cold be applied to an area?

Heat or cold should be applied intermittently, leaving either on for no more than 15 minutes at a time to avoid tissue injury.

What is the title of Dr. Watson's theory?

Human caring theory (or the science of human caring)

What form of dressing is appropriate for a wound with an eschar that needs to be eliminated?

Hydrogel is most appropriate for a wound with an eschar that needs to be eliminated. You may state that a wet-to-wet dressing is also appropriate, but this dressing type is difficult to maintain and may cause damage to surrounding tissue.

How does hypoventilation affect risk for hypoxemia and hypoxia?

Hypoventilation occurs when a small amount of air is moved into and out of the lungs, which is caused by a decreased rate and/or depth of breathing. Hypoventilation increases the risk for problems with oxygenation (hypoxemia) and perfusion (hypoxia).

How is PCO2 related to oxygenation?

Hypoventilation severe enough to cause hypercarbia is usually associated with hypoxemia because inadequate amounts of oxygen are inhaled. Hyperventilation may or may not be associated with adequate oxygen levels.

What action should you take if a patient begins to fall when ambulating?

If the patient begins to fall, do not attempt to hold the patient up independently. Instead, do the following: • Protect the patient as you guide him to a seated or lying position. • Create a wide base of support and project the hip closest to the patient forward. • Assist the patient to slide down your leg as you call for help. • Protect the patient's head as his body descends.

Explain the special steps required when administering enteral medications to a patient who is receiving continuous tube feedings.

If the patient is receiving a continuous tube feeding, (1) disconnect the tube, (2) flush with water before and after giving the medications, and (3) leave the tube clamped for a few minutes after administering the medication according to agency protocol.

If a patient's lab work reveals that IgM, but not IgG, is present in the blood, what could you conclude about this infection?

IgM is present the first time an individual is exposed to a particular pathogen. If IgG is not present, you can conclude that the exposure occurred less than 10 days ago.

Why might immobility be referred to as a stressor?

Immobility might be referred to as a stressor because it triggers the release of epinephrine and norepinephrine, thyroid hormones, adrenocorticotropic hormone from the pituitary gland, and aldosterone from the kidneys. These changes in hormone levels are the same as the stress response, letting us see that immobility can be a stress in itself.

What are three effects of immobility on the GI system?

Immobility slows peristalsis, which often leads to constipation, gas, and difficulty evacuating stool from the rectum. In extreme circumstances, a paralytic ileus (cessation of peristalsis) may occur. With peristalsis slowed, appetite diminishes and food that is consumed is digested slowly. The net effect is usually decreased caloric intake and inability to meet the protein demands of the body. Body muscle is broken down as a fuel source, and further wasting occurs.

What factors affect excretion?

Impaired renal function has the biggest influence on excretion because most drugs are excreted through the kidneys. If renal function is decreased, the patient runs the risk of medication toxicity because less of the drug is excreted and more remains in the circulating blood. For patients with renal disease, the dosage of the medication should be reduced. Inactivity, poor diet, and decreased peristalsis may also delay excretion.

Define in a brief conceptual form or title the nursing theory of each theorist listed below: • Florence Nightingale • Virginia Henderson • Hildegard Peplau

Improving the environment to enable the patient to heal himself Definition of nursing Interpersonal relationships

What is the preferred IM injection site for adults? Why?

In adults, the ventrogluteal is the preferred site for intramuscular injections. This site is preferred for four reasons: • There are no major vessels or nerves in that area. • It is a large muscle mass that can hold 3-4 mL of medication. • There tends to be less pain at this site. • It is less likely to be contaminated when the client is incontinent.

What changes occur in the cardiovascular system with aging?

In general, the number of cells and the efficiency of the organs decline gradually as a person ages. Keep in mind, though, that endurance training and regular exercise slow the rate of these changes. In fact, an older person who is physically conditioned by regular exercise may have better heart and circulatory function than a younger adult who is not well conditioned. Cardiac efficiency gradually declines as the heart muscle loses contractile strength and heart valves become thicker and more rigid. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. As a result of these changes, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. For example, in response to exercise, an older adult's heart rate does not increase as much as a younger person's, but it will remain elevated longer. Thus, older adults have lower exercise tolerance and need more rest after exercise

What effect does ventilation have on arterial PCO2?

In hyperventilation, large amounts of carbon dioxide diffuse into the alveoli and are exhaled into the air, causing arterial PCO2 values to fall. • In hypoventilation, less carbon dioxide diffuses into the alveoli for exhalation, leaving more carbon dioxide in the arterial blood, which causes PCO2 values to rise.

What does the nurse do in the planning phases of the nursing process?

In the planning phases, the nurse chooses outcomes/goals based on assessments and nursing diagnoses, chooses nursing interventions, and writes the plan of care.

List three errors in technique that can occur when giving parenteral injections. State their possible consequences.

Injecting a large volume of medication into a small muscle causes pain and may damage the tissues. • Injecting into the wrong tissue (e.g., giving an intramuscular medication too shallowly into the subcutaneous tissue) may (1) accelerate or delay the rate of absorption and (2) cause tissue injury and pain. • Incorrectly locating an injection site may result in bone or nerve injury when you insert the needle. • Failing to hold the needle and syringe steady while injecting the drug may cause pain and tissue trauma.

Identify and describe four types of exercise

Isometric exercises involve muscle contraction without motion. They are usually performed against an immovable surface or object. For example, when pressing the hand against a wall, the muscles of the arm contract but the wall does not move. Each position is held for 6 to 8 seconds with 5 to 10 repetitions. Isometric training is effective for developing total strength of a particular muscle or group of muscles. It is often used for rehabilitation because the exact area of muscle weakness can be isolated and strengthening can be administered at the proper joint angle. This kind of training requires no special equipment, and there is little chance of injury. Bedridden patients can use this form of exercise to maintain or regain muscle strength. • Isotonic exercise involves movement of the joint during the muscle contraction. A classic example of an isotonic exercise is weight training with free weights. As the weight is moved throughout the range of motion, the muscle shortens and lengthens. Calisthenics, such as chin-ups, push-ups, and sit-ups, all of which use body weight as the resistance force, are also isotonic exercises. • Isokinetic exercise utilizes machines that control the speed of contraction within the range of motion. Isokinetic exercise attempts to combine the best features of both isometrics and weight training by providing resistance at a constant preset speed while the muscle moves through the full range of motion. Specialized machines available at health clubs and physical therapy departments are used for this form of exercise. • Aerobic exercise acquires energy from metabolic pathways that use oxygen—the amount of oxygen taken into the body meets or exceeds the amount of oxygen required to perform the activity. Aerobic exercise uses large muscle groups, can be maintained continuously, and is rhythmic in nature. It increases the heart and respiratory rate, thereby providing exercise for the cardiovascular system while simultaneously exercising the skeletal muscles • Anaerobic exercise occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity. Therefore, the muscles must obtain energy from metabolic pathways that do not use oxygen. Rapid, intense exercises, such as lifting heavy objects or sprinting, are examples of anaerobic exercise.

What criteria determine whether your patient should be logrolled when he is repositioned?

Logrolling is a special turning technique used when the patient needs to maintain the spine in straight alignment.

What is the purpose of mechanical ventilation?

Mechanical ventilation assists a patient to breathe. It can merely assist breathing or breathe entirely for the patient.

A patient has signs and symptoms of appendicitis, which must be treated with surgery and antibiotics.

Medical diagnosis: appendicitis (actual problem; nurse cannot treat independently; requires surgery and antibiotics)

How is medication quality managed?

Medication quality is managed through federal and state legislation: • Federal legislation mandates that certain qualitycontrol guidelines be in place for all medications manufactured, marketed, and sold in the United States. These regulations ensure the safety and efficacy of medications available to the public. • Individual state legislation also mandates certain quality-control regulations when a medication is sold only within that state's boundaries

Goal: By 8/24/18, will walk, unassisted, to the end of the hall without pallor or shortness of breath. Reassessment data: 8/23/18. Walked, unassisted, to end of hall. Skin color pink; respirations 14 breaths/min; no dyspnea observed; states no shortness of breath.

Met. All desired outcomes were seen.

What is the main cause of injuries during the adolescent period?

Motor vehicle accidents are the most common cause of serious and fatal accidents during adolescence, especially if alcohol or drug use is involved.

What is the role of normal flora?

Nonpathogenic microorganisms that help to control the growth of pathogenic microorganisms are referred to as normal flora. Normal flora in the intestine aid digestion and, when they die, release vitamins important to human health.

Name the oxygen delivery method that is appropriate for the following patients: A patient prescribed to receive 2 L/min of oxygen

Nasal cannula

Trace the path of normal electrical impulses in the heart.

Normal electrical impulses in the heart follow this path: • The sinoatrial (SA) node initiates impulses that trigger each heartbeat. • Each impulse travels rapidly down the atrial conduction system so that both atria contract as a unit. • There is a slight delay at the atrioventricular node (AV) node. • From the AV node, impulses pass into the left and right bundles of His and into the Purkinje fibers.

Define nebulization.

Nebulization is the production of a fine spray, fog, powder, or mist of a liquid drug

What is the preferred method of wound culture that may be performed by a registered nurse (RN)?

Needle aspiration of a wound is the preferred method for a culture obtained by nursing staff. Nurses can culture wounds by swabbing and aspirating with a needle, but not biopsy, unless certified as advanced practice.

Does poor peripheral perfusion increase risk for hypoxemia (a low level of oxygen in the blood)?

No, poor peripheral perfusion increases the risk for tissue hypoxia.

Open ended questions are most essential for which type of interview?

Non-directive.

Goal: By 8/24/18, will walk, unassisted, to the end of the hall without pallor or shortness of breath. Reassessment data: 8/25/18. Walked halfway to end of hall before becoming pale and short of breath.

Not met. It is 1 day past the target time of 8/24/18, and the patient was unable to walk the desired distance; both pallor and shortness of breath occurred.

What data can you obtain through smell?

Numerous answers are possible, including the following: body odor, smell of breath, and odor from wound secretions, drains, urine, or vaginal secretions.

What data can you obtain through hearing?

Numerous answers are possible, including the following: breath sounds, coughing, heart sounds, blood pressure, spoken words.

What data can you obtain through touch?

Numerous answers are possible, including the following: firmness or mobility of lesions (e.g., masses, nodules), firmness of uterine fundus after childbirth, edema, skin temperature, pulse rate and rhythm, crepitus in joints, liver enlargement.

What data can you obtain through vision?

Numerous answers are possible, including the following: general appearance (e.g., height, weight, posture, grooming), skin color, condition of equipment, readings from monitors and pumps, gait.

A client is at risk for constipation because he postpones defecation and also does not consume enough dietary fiber and fluids.

Nursing diagnosis Rationale: The problem can usually be prevented by independent nursing interventions, such as patient teaching. Medication is sometimes prescribed, but not always.

Define nursing research.

Nursing research is the systematic, objective process of analyzing phenomena of importance to nursing.

You see in Sami's health record that her breast exam was normal.

Objective data (Someone other than Sami made the observation; it was not from Sami's perspective.)

The nurse tells you that Sami is anemic.

Objective data (This is observed by someone other than the patient; not told to you by the patient. It isn't the verbal reporting of data that makes them "subjective"; it is the verbal reporting by the patient that does.) • Secondary data for you (You did not get the data from Sami.) Actually, anemia is a diagnostic conclusion made by the nurse practitioner, not data. But when you receive the information, it is, for you, data.

You check the result of the Pap smear in her electronic health record and see that it is normal

Objective data (This was observed by someone other than the patient.) • Secondary data (You did not get the information directly from the patient. It would be primary data for the pathologist.)

How are oxygen and carbon dioxide transported in the blood?

Oxygen (O2) is carried in the blood bound to hemoglobin (97%) or in a dissolved state (3%). At the tissue level, oxygen leaves the hemoglobin, becomes dissolved in the blood, and passes through the capillary membrane. Only the dissolved form of oxygen can pass through capillary membranes. Oxygen bound to hemoglobin serves as a reservoir, holding oxygen until it is needed in the dissolved state. • Carbon dioxide (CO2) can be carried in the blood in three ways: a dissolved state, bound to hemoglobin, or as a bicarbonate ion. It leaves the cells by passing through the cellular- capillary membrane in the dissolved state. In the blood, about 7% remains dissolved in plasma, 23% attaches to hemoglobin, and 70% is converted into bicarbonate ions. At the alveolar-capillary membrane, dissolved carbon dioxide diffuses into the alveoli for exhalation from the lungs.

Why is oxygen humidified?

Oxygen is humidified to prevent drying of the airway mucosa and to keep secretions thin.

Using the following outcomes and reassessment data, determine whether each goal has been met, partially met, or not met: Goal: By 8/24/18, will walk, unassisted, to the end of the hall without pallor or shortness of breath. Reassessment data: 8/24/18. Walked, unassisted, to end of hall; states no shortness of breath, but skin color was noticeably pale.

Partially met. Two desired responses were seen, but one (no pallor) was not.

What is a pathogen?

Pathogens are bacteria, viruses, fungi, and other organisms that cause disease.

What are the parts of a PICOT question?

Patient population, or Problem; Intervention; Comparison intervention; Outcome; and Time

• How often should you turn and reposition a patient?

Patients should be turned at least every 2 hours to protect their skin and prevent problems associated with immobility. Turning is often done at the same time the patient is moved up in bed.

What changes in mood might be seen with immobility?

Patients who are in bed (immobile) for long periods of time can suffer depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities, as well as disorientation and apathy.

What effect does immobility have on skin?

Patients with impaired mobility often cannot reposition themselves, leading to pressure over bony prominences, which can lead to skin breakdown.

What are the risks involved for patients who engage in polypharmacy?

Polypharmacy increases the potential for adverse reactions and dangerous drug and food interactions.

Alicia Hernandez seems anxious, but you are not sure whether she actually is. You would like to have more data in order to diagnose or rule out a diagnosis of Anxiety.

Possible diagnosis

Sami tells the nurse that she experiences cramping with her menstrual cycle.

Primary data (The nurse obtained the information from Sami.) • Subjective data (This is Sami's perspective, told directly to the nurse practitioner by Sami.)

What does a pulse oximetry reading tell you?

Pulse oximetry is a noninvasive estimate of arterial blood oxygen saturation (SaO2). SaO2 reflects the percentage of hemoglobin molecules carrying oxygen. The normal value is 95% to 100%.

Describe activities that can promote a patient's readiness for ambulation.

Quadriceps and gluteal drills. The quadriceps muscle group and the gluteal muscles are the largest muscles of the body. When practicing good body mechanics, you use these muscles to lift objects to protect your back. Patients who have been confined to bed can perform isometric muscles in bed to increase muscle tone and facilitate the transition to ambulation. Ask the patient to tighten her thigh muscles by pushing downward with her knees and flexing her feet. Hold the position for a count of five and then relax. Repeat this process two to three times per hour during the waking hours. To exercise the gluteal muscles, ask the patient to pinch her buttocks together. Repeat this exercise when the patient exercises the quadriceps muscles. Instruct the patient not to hold her breath as she exercises. • Arm exercises. The arm muscles are used when getting out of bed and for crutch walking. To prepare the patient for ambulation, install a trapeze bar. The trapeze bar exercises the biceps muscles. To exercise the triceps muscles, ask the patient to lift his upper body off the mattress by firmly pressing down with the palms. Push-ups can also be done from a seated position at the side of the bed or from a stationary chair or wheelchair. • Dangling. Dangling is a seated position at the side of the bed. The patient can rest his feet on the floor or a footstool. This position readies the patient to get up in a chair, to stand, or to ambulate. Patients who have been bedridden frequently become lightheaded or develop orthostatic hypotension when first getting up. Dangling allows the patient to experience being upright with limited risk of falling. As a result, patients should not be moved further unless they are comfortable and stable in the dangling position. • Daily activities. Encourage your patient to be active in bed and get out of bed into the chair prior to attempting to walk. Performing ADLs exercises many of the muscle groups used in ambulation. Getting up to the chair readies the patient for an upright posture and is an important predictor of success with ambulation.

List at least three reasons for noncompliance with a medication regimen.

Reasons for noncompliance with a medication regimen include the following: • Inability to afford the cost of the medication • Visual and motor deficits that limit the ability to read labels and manipulate bottle caps, syringes, and so on • Inability to tolerate side effects • Forgetfulness • Impaired mental capacity • No symptoms of disease • Does not believe in the medication regimen

When is rectal instillation of a drug preferred over oral administration?

Rectal instillation is preferred over oral administration in the following situations: • When a drug has an unacceptable taste or odor • When it is not safe to use the oral route, as with a patient who is vomiting or unconscious • When the patient is nauseated or vomiting

When, as a rule, are rectal medications contraindicated?

Rectal medications are contraindicated when there is active rectal bleeding. (Note that a disadvantage of this route is possible pain and embarrassment, but those are not contraindications.)

List two things a person who works around workplace toxins can do to prevent bringing them into the home.

Remove work clothing and shower, preferably in an open-air shower, before leaving work. If facilities for showering are not available, patient advocacy may be appropriate. Before entering their homes, exposed workers who have not showered should remove their clothing. Then they should shower immediately. When handling contaminated clothes or objects, they should wear gloves to reduce the risk of skin transmission. Laundering may not be effective in removing certain toxins in clothes.

Charles Oberfeldt has no symptoms of constipation. However, he reports that he does not include many fiber-rich foods in his diet and drinks few liquids. In addition, he is now fairly inactive because of a back injury. These are all risk factors for a diagnosis of Constipation.

Risk diagnosis

What nursing diagnosis is most appropriate for a patient at risk for pressure injury development?

Risk for Impaired Skin Integrity

Identify the type of wound healing (primary, secondary, or tertiary intention): • A wound that heals from inner layer to the surface • A wound with approximated edges • A wound that heals by approximating two surfaces of granulation tissue • A wound that is sutured and has minimal or no tissue loss

Secondary intention Primary and tertiary intention Tertiary intention Primary intention

What is a cue?

Significant data (also called cues) are data that influence your conclusions about the client's health status (or that influence your choice of nursing diagnoses). A cue should alert you to look for other cues that might form a cluster (pattern) representing a nursing diagnosis.

What is the relationship between arterial PO2 and SaO2 levels?

Small changes in SaO2 are associated with large changes in PO2. However, the levels rise and fall together.

What happens to inhaled air in the airways? How does this occur?

The airway structures moisten, warm, and filter inhaled air. This is accomplished in three ways: • A moist mucous-membrane lining adds water to inhaled air. • Blood flowing through the vessels of airway walls transfers body heat to the inhaled air. • Tiny hair-like projections from the wall of the airways (cilia) move rhythmically to carry trapped debris up and out of the airway.

Identify five crutch gaits.

The five crutch gaits are the two-point gait, threepoint gait, four-point gait, swing-to gait, and swingthrough gait. • Two-point and four-point gaits are used for partial weight-bearing. • Three-point gait is used for non-weight-bearing. • Swing-to and swing-through are used when weight-bearing is permitted.

Caring processes are critical to her theory. What is the purpose of the caring processes?

The purpose of the caring process is to improve the health of the patient (this concept is central to her theory).

What types of injuries are most likely to cause oxygenation problems?

Three types of injuries are most likely to be associated with oxygenation problems: • Injuries to the chest wall • Injuries to the CNS that may affect regulation of breathing • Injuries that may be associated with embolus formation

How would you verify data that was provided on an intake sheet?

Through interviewing and during the physical examination.

List three sources of noise pollution.

Sources of noise pollution include road traffic, jet planes, garbage trucks, construction equipment, lawn mowers, and loud music.

Under what circumstances are standard precautions used?

Standard precautions are used on all patients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions and secretions, mucous membranes, and any break in the skin.

In the following predicted outcomes, identify the subject, action verb, performance criterion, target time, and special conditions (if any). State which components are assumed, if any: (Client) will walk to the doorway with the help of one person by 12/13/18.

Subject: client (assumed) • Action verb: will walk • Performance criterion: to the doorway • Target time: by 12/13/18 • Special conditions: with the help of one person

Which data are most likely to need validation?

Subjective.

What does surfactant do for alveoli?

Surfactant is the substance that lowers the surface tension inside alveoli and prevents their walls from being drawn together. Adequate surfactant levels are key to preventing alveolar collapse and allowing alveolar expansion during breathing.

What interactions occur when one drug has an additive effect on another drug?

Synergistic drug reactions occur when one drug has an additive effect on another.

A patient has a respiratory rate of 30 breaths/min that is rhythmic and moderate in depth. What term would you use to describe this breathing pattern?

Tachypnea

Which assessment tool would you use for a slightly confused home care client to assess her ability to safely live alone and perform activities of daily living?

The Safety Assessment Scale (SAS) primarily evaluates whether the cognitively impaired person is capable of cooking, taking her own medicines, shopping, and performing other activities of daily living.

What legislation defines controlled substances in the United States?

The United States has enacted the Controlled Substances Act of 1970 that defines which medications are controlled substances that require a prescription and which drugs can be signed over the counter. These are usually based on the dependence and addictive properties.

What is the effect of adding moisture to heat or cold treatments?

The addition of moisture amplifies the intensity of the treatment.

What are some ways that the aging process makes the older adult more prone to injury?

The aging process can result in physiological changes that can create changes in strength and gait stability. Some adults experience sensory losses, particularly hearing and vision.

How can you control the amount of force applied for wound irrigation?

The amount of force applied during wound irrigation is controlled by the size of the syringe and angiocatheter used. Ideal irrigation pressures range from 4 to 15 pounds per square inch (psi). Pressures below 4 psi may not adequately cleanse the wound. Pressures above 15 psi increase the risk of impaling bacteria into the tissues and causing mechanical damage. Current recommendations are to use a 36-mL syringe with a 19-gauge angiocatheter attached. This will deliver the solution at approximately 8 psi. Commercial irrigation systems are available. Closely evaluate the amount of pressure delivered before you use these devices.

How is the cardiovascular system regulated?

The cardiovascular system is regulated by the autonomic nervous system through its influence on heart rate, cardiac muscle contractility, and vascular tone. • Sympathetic fibers, through branches at the thoracic level of the spinal cord, stimulate the heart, resulting in an increased heart rate and increased myocardial contractility. Parasympathetic fibers innervate the heart through the vagus nerve. • Parasympathetic stimulation of the heart results in a slowed heart rate with no influence on myocardial contractility. • All blood vessels are innervated by sympathetic fibers that maintain them in a baseline state of partial contraction, even during rest. This baseline state maintains blood pressure and blood flow even when a person is resting or asleep. Sympathetic stimulation above and beyond this baseline varies in response to body needs. Increasing sympathetic stimulation causes constriction of some vessels (e.g., skin, gastrointestinal tract, and kidneys) and dilation of other vessels (skeletal muscle). This serves to shunt blood flow to the skeletal muscles for a fight-or-flight response. The parasympathetic nervous system has no significant control over blood vessels. • Brainstem centers regulate cardiovascular function and blood pressure in response to baroreceptors and chemoreceptors. The vasomotor center controls sympathetic heart and vascular stimulation. The cardioinhibitory center controls parasympathetic slowing of the heart rate. • Chemoreceptors located in the aortic arch and the carotid arteries are sensitive to changes in blood pH, oxygen, and carbon dioxide levels. Their main function is to regulate ventilation, but they can send information to the vasomotor center in response to lack of oxygen. The vasomotor center will respond by activating sympathetic stimulation.

• What is the chief danger when administering oral medications to children?

The chief danger when administering oral medications to children is that they may aspirate or choke.

In addition to care related to the patient's basic needs, what other types of information does a comprehensive care plan contain?

The comprehensive care plan also contains information about the medical/multidisciplinary plan of care, information about care related to nursing diagnoses and collaborative problems, and information regarding special teaching and/or discharge planning needs.

Describe how the diaphragm, accessory muscles, and pressure changes within the lungs create inhalation and exhalation.

The diaphragm is the major muscle of breathing. Inhalation begins when the diaphragm contracts and the chest cavity is pulled downward. The lung bases descend with the chest cavity, significantly enlarging the lungs. Intercostal muscles, the small muscles around the ribs, also contract and pull the ribs slightly outward, expanding the chest cavity and lungs. The overall effect is to enlarge the chest cavity and subsequently the lungs. The negative pressure created in the lungs draws air in through the only opening to the outside, the trachea. Exhalation occurs when the diaphragm and intercostal muscles relax, allowing the chest and lungs to return to their normal resting size. The reduction in size causes a rise in pressure inside the chest and lungs to above atmospheric pressure, which causes air to flow out of the lungs. Exhalation requires no energy or effort.

What are the most common poisonous agents ingested by children?

The following poisonous agents are most commonly ingested by children: • Household cleansers, including oven cleaner, drain cleaner, toilet bowl cleaner, and furniture polish • Medicines, including cough and cold preparations, vitamins, pain medications, antidepressants, anticonvulsants, and iron tablets, which to children may look like candies • Indoor house plants, including poinsettia, dieffenbachia, philodendron, and many others • Cosmetics, hair relaxer, nail products, mouthwash • Pesticides • Kerosene, gasoline, lighter fluid, paint thinner, lamp oil, antifreeze, windshield washer fluid, lighter fluid, and other chemicals • Alcoholic beverages • Wild plants and mushrooms • Pesticides, rodent poisons

What precautions should you take before using heat or cold therapy?

The following precautions should be taken before heat or cold therapy: • Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a washcloth, towel, or fitted sleeve. • Apply hot or cold intermittently, leaving either on for no more than 15 minutes at a time in an area. This helps prevent tissue injury (e.g., burns, impaired circulation). It also makes the therapy more effective by preventing rebound phenomenon: At the time the heat or cold reaches maximum therapeutic effect, the opposite effect begins. • Check the skin frequently for extreme redness, blistering, cyanosis (turning blue), or blanching. When heat or cold is first applied, the thermal receptors react strongly and the person feels the temperature intensely. During about 30 minutes, the receptors adapt to the new temperature, and the person notices it less. Caution clients not to change the temperature when this occurs because this can cause tissue injury

In addition to organizing your work, what other preparations should you make before implementing care?

The following preparations should be made before implementing care: • Establish feedback points. • Check your knowledge/skill to see whether you are qualified to perform the intervention. • Organize/prepare supplies and equipment. • Prepare the patient (e.g., assure that the intervention is still needed, check for readiness, tell the patient what she will experience and what she is expected to do, and provide privacy).

Identify four pathophysiological conditions that affect pulmonary function. How are they similar? How are they different?

The following types of conditions affect ventilation and oxygenation. • Pulmonary system abnormalities, such as structural alterations, inflammation, obstruction, infection, alveolar-capillary membrane disorders, or collapse of alveoli, affect ventilation and gas exchange. • Pulmonary circulation abnormalities, such as pulmonary embolus and pulmonary hypertension, can disrupt gas exchange. • Central nervous system abnormalities can affect gas exchange by interfering with the regulation of breathing or by limiting movement of the muscles involved with breathing. Trauma, stroke, and medications are the most common causes. Neuromuscular disorders that affect the nerves involved in breathing can also depress respiratory function (e.g., Guillain-Barré syndrome, amyotrophic lateral sclerosis, and myasthenia gravis). • Neuromuscular abnormalities can affect gas exchange by interfering with the regulation of breathing or limiting movement of the muscles involved with breathing. Any condition that causes injury to the CNS or alters CNS function can interfere with the regulation of breathing. These conditions are similar in that each of these conditions affects oxygenation. They differ as to whether they affect ventilation, gas exchange, or gas transport. They also differ in that some affect structure of the pulmonary or cardiovascular systems, and others affect function of these systems.

When are forearm support crutches used?

The forearm support crutch is more likely to be used by a patient with permanent limitations.

Why would you auscultate the lungs as a part of your assessment of cardiac function?

The heart and lungs work together to achieve oxygenation of all body tissues. Loss of function in one system (respiratory or cardiovascular) inevitably affects the other system. Adventitious lung sounds may, for example, be a sign of decreased cardiac output.

Where are drugs metabolized?

The kidneys, liver, gastrointestinal tract, lungs, and blood plasma are the primary organs of drug metabolism.

What factors affect drug metabolism?

The majority of metabolism occurs in the liver. Decreases in liver function, such as from liver disease or aging, will decrease the rate at which drugs metabolize. The drug will be eliminated slowly, and accumulation of toxic levels of the medication may result. Preexisting diseases (particularly those affecting the kidney, liver, heart, circulation, and gastrointestinal tract) affect the metabolism of many medications. For example, a patient with diabetes should not be given medications such as elixirs that are high in sugar content; and patients with alcohol abuse problems should not be given medications containing alcohol.

What kinds of microbes favor the human body as a reservoir of infection?

The microbes that are pathogenic to humans thrive at about the same temperature as the human body. These pathogens also must be able to use the body's delicate balance of moisture, nutrients, electrolytes, and pH to support their own reproduction.

How do the muscles and the nerves interact?

The nervous system controls the movement of the musculoskeletal system. When we want to make a conscious decision to move our arm, the thought originates in the motor area of the cerebral cortex. The upper motor efferent nerves communicate with the lower motor neurons that conduct an impulse to the muscle. When the muscle receives sufficient stimuli it contracts, shortening the biceps brachii and bending the elbow. A stimulus to cause a contraction of the biceps generates a stimulus to cause relaxation in the triceps in a process known as reciprocal innervation. Movement also occurs through reflex mechanisms. Reflexes are protective mechanisms. Common reflexes include the knee jerk and corneal reflex.

What is the advantage of the oblique position versus the lateral position?

The oblique position is an alternative to the lateral position that places less pressure on the trochanter. The patient turns on the side with the top hip and knee flexed, but the top leg is placed behind the body.

What is the best way to determine whether a metereddose inhaler is empty?

The only reliable method for determining the number of doses remaining in a canister is to subtract the number of doses used from the number available. Some devices are equipped with counters. Floating MDIs in water is not accurate for assessing remaining doses and often will clog the valve.

What are some important developmental considerations when providing a safe environment for a preschool child?

The preschooler is less prone to falls than the toddler, but other types of injuries increase because preschooler play includes more outside activities. Supervision of outside play, such as on playground equipment, is important. Safety must be stressed when playing near streets.

What factors affect distribution of drugs in the body?

The rate of drug distribution depends on the adequacy of local blood flow in the target area, permeability of capillaries to the drug molecules, and the protein-binding capacity of the drug. To complete distribution, the medication must pass through all membranes, organs, or tissues. Some membranes act as barriers to this medication passage, whereas others act as facilitators. Specialized structures made of biological membranes can serve as barriers to the passage of drugs at certain sites in the body (e.g., the blood-brain barrier and the placental barrier). Drug distribution is affected by a medication's ability to bind to protein in the blood. While bound to protein, the drug molecules are unable to be pharmacologically active, so it is desirable for the drug to remain in the free or unbound state.

What is the function of the stratum corneum, the outermost layer of the skin?

The stratum corneum serves as a barrier, which has three functions: • Restricts water loss • Prevents entry of fluids into the body • Protects the body against the entry of pathogens and chemicals

What is the function of the subcutaneous layer?

The subcutaneous layer, which is primarily connective and adipose tissues, has three functions: • Insulates • Protects • Reserves calories in the event of severe malnutrition

State the components of an exercise program.

The three components of a well-rounded exercise program are flexibility, resistance training, and aerobic conditioning.

Based on your theoretical knowledge and the scant patient data you have, why do you think Teresa's toddler (Meet Your Patients, in your textbook) is at risk for accidents? What about Teresa's grandmother?

The toddler and grandmother have the following risks for accidents: • Toddler. You have the theoretical knowledge that toddlers are typically active and curious and that their motor skills advance faster than their judgment and ability to recognize danger. You have the data that Teresa's toddler is typical in this respect: "into everything." You also have Teresa's statement that it is becoming difficult for her to provide enough supervision for the toddler. • Grandmother. You have the theoretical knowledge that older adults often have motor and sensory losses that increase their risk for accidents. You have the patient data that Teresa's grandmother has a mobility problem (recovering from hip fracture) and that she is afraid of falling.

How do the walls of arteries, veins, and capillaries differ?

The walls have the following differences: • Arteries have thick, elastic walls that allow them to stretch during cardiac contraction (systole) and to recoil when the heart relaxes (diastole). • Veins and venules have thin, muscular, but inelastic walls that easily collapse. Blood flows from the capillaries into venules and then into veins, which return deoxygenated blood to the heart. The muscular wall of veins contract or relax in response to feedback from the sympathetic nervous system. • Capillaries are tiny microscopic vessels that are only one cell thick to facilitate the passage of gases, nutrients, and wastes through them. Billions of capillaries provide blood flow to every cell in the body. Capillaries lie between the arterial and venous systems.

Explain how theory influences your choice of nursing interventions.

Theories influence your perspective: what you notice, what you consider to be a problem, how you define a problem, and what you choose to do about it.

You are to administer the following drugs to Cyndi Early (Meet Your Patients, in your textbook): (1) insulin subcutaneously for her diabetes and (2) morphine intravenously to relieve her pain. For which primary effect is each of these drugs being given?

These drugs are being given for the following primary effects: • Insulin for substitutive effects • Morphine for palliative effects

What kind of dysrhythmia would describe a heart rate of 140 beats/min that originates in the ventricles?

This would be a ventricular tachydysrhythmia (often called ventricular tachycardia).

How can you be sure that patients are not spitting out their medications after you leave the room?

To be sure a patient takes his medications, stay with the patient until you see that he has swallowed the medication. You can also discuss with the patient his perception of the need for the medication and provide education as needed.

Why is it important to organize your work before implementing care?

To ensure efficiency. In today's work environment, nurses have heavy workloads and cannot afford to waste time. Making good use of time helps the nurse to prevent errors and to provide the best possible care for patients.

As a nurse, what can you do to help prevent injuring your back?

To prevent injury to your back, consistently use assistive devices when moving patients in and out of bed, use good body mechanics, and get help when moving patients or lifting heavy objects.

How does smoking affect the cardiovascular system?

Tobacco use is a major risk factor in several chronic cardiovascular conditions: stroke, peripheral arterial disease, aortic aneurysm, and heart disease. Smoking is implicated in atherosclerosis (fatty buildups in the arteries), hypertension, and decreased HDL (good) cholesterol—all of which lead to coronary heart disease and heart attack. Other factors contribute to coronary heart disease (e.g., obesity, diabetes, physical inactivity). However, cigarette smoking is such a significant risk factor that the U.S. Surgeon General has called it the leading preventable cause of disease and deaths in the United States. Cigar and pipe smoking are also implicated, but not to the extent of cigarettes (American Heart Association, 2011a).

Why should you use a cotton swab, tongue blade, or gloved finger to apply corticosteroid creams and other topical medications?

Topical medications should be applied with an apparatus or gloved finger so that you will not absorb them systemically.

Most of the following routes are used for both local and systemic effects. Which one is used only for medications intended for systemic absorption (i.e., which one is not used for local effects): lotions, creams, ointments, transdermal patches, or irrigations?

Transdermal patches are used only for medications intended for systemic absorption.

True or False: Some procedures require both standard precautions and sterile technique.

True Healthcare providers use sterile technique to perform a variety of procedures. Some of the procedures require full surgical attire; others do not. The following procedures, for example, use both sterile technique and principles of medical asepsis: administering an injection, starting an IV line, and performing a sterile dressing change. To clarify, when administering an injection, you prepare the patient, cleanse the injection site, and remove the needle cap using standard precautions. You do not don sterile gloves, but for the rest of the procedure you observe sterile technique by taking care not to touch or otherwise contaminate the exposed needle.

In which structures of the lung does gas exchange take place?

Type I alveolar cells

How should you screen older adults to see whether they need a comprehensive falls evaluation?

Use the Get Up and Go test, and possibly the Timed Up and Go test if indicated.

Why should people rotate injection sites when they must have repeated injections over a long time?

Using the same site can cause scarring and hardening of fatty tissues for subcutaneous sites. Thus, when people must have repeated injections over a long period of time, they should rotate injection sites to promote absorption of the medication and to minimize tissue damage.

A patient with chronic obstructive pulmonary disease with an order for oxygen at an FIO2 of 24%

Venturi mask

Determine the type of nursing diagnosis for each of the following: a. Jane Thomas regularly engages in exercise but tells you she would like to increase her endurance.

Wellness diagnosis

• What instructions should you give to a patient who is taking a sublingual medication?

When a patient is taking a sublingual medication, instruct him (1) to hold it under his tongue until it is dissolved and (2) not to chew or swallow it whole.

What should you consider when choosing a dressing?

When choosing a dressing, ask yourself these questions: Will the dressing provide a moist wound environment? Will it contain all the wound drainage and keep it off the surrounding skin? Can it be removed without damaging fragile skin or the wound itself? Will it protect the wound from outside contamination or infection? How long should it stay in place, or how often does it need to be changed?

When using the vastus lateralis to give an intramuscular medication to a person with small muscle mass, how can you ensure the medication reaches muscle tissue and the needle does not penetrate to the underlying bone?

When using the vastus lateralis to give an intramuscular medication to a person with small muscle mass, grasp ("pinch up") the body of the muscle during injection to be sure that the medication reaches muscle tissue and the needle does not penetrate to the underlying bone.

Give an example of a closed question

When was your last physical exam? Are you having pain? Where does it hurt?

How does wound depth affect healing?

Wound depth is a major determinant of healing time. As wound depth increases, healing time also increases.

Describe the wound categorization system based on the level of contamination.

Wounds are categorized based on four levels of contamination: • Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tract (these systems frequently harbor bacteria). There is very little risk of infection for these wounds. • Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tract. There is an increased risk of infection for these wounds, but there is no obvious infection. • Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds. • Infected wounds are wounds with evidence of infection, such as purulent drainage or necrotic tissue. Wounds are considered infected when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue or in which there is the presence of beta-hemolytic streptococci in any number.

What are the possible conclusions you can draw about a client's health status (e.g., that no problem exists)?

You might conclude that there is a patient strength, no problem, a wellness diagnosis, a possible problem, an actual nursing diagnosis, a risk (potential) nursing diagnosis, a collaborative problem, or a medical diagnosis.

When will you need to don sterile gloves using the closed method?

You need to don sterile gloves when you are performing an activity that requires you to wear a sterile gown. The gloves must cover the gown cuffs.

A patient who wants to avoid intubation but requires an FIO2 of 100%

nonrebreather mask

Short-term Long-term

under a week more than a week

Identify three types of laboratory data that may be associated with a delay in wound healing.

• A low WBC count • A low serum protein, albumin, or pre-albumin level • Prolonged coagulation times • Needle aspiration result indicative of infection

Describe a focused assessment for a patient experiencing mobility concerns.

• A nursing history focused on activity and exercise assesses past and current activity, as well as future plans. The history addresses the following topics: • Usual activity • Fitness goals • Mobility concerns • Underlying health concerns • Lifestyle • External factors • A physical examination focused on activity and exercise assesses the musculoskeletal system and activity tolerance. Important data include vital signs, pain assessment, height, weight, body mass index, body alignment, joint function, gait, and activity tolerance.

Define the following movements: abduction, adduction, flexion, extension, circumduction, internal rotation, supination, and pronation.

• Abduction is moving away from midline. • Adduction is moving toward midline. • Flexion is bending, decreasing the joint angle. • Extension is straightening, increasing the joint angle. • Circumduction is moving in a circular fashion. • Internal rotation is turning toward midline. • Supination is turning upward. • Pronation is turning downward.

Differentiate between the different categories of dressings.

• Absorption dressings are used to soak up drainage from a wound. • Alginate dressings are highly absorbent dressing made of fibers from brown seaweed and kelp. • Antimicrobial dressings are topical antifungal and antibiotic agents that are available as ointments, impregnated gauzes, pads, gels, foams, hydrocolloids, and alginates. • Collagen dressings are made from bovine or porcine sources and made into sheets, pads, powders, and gels to absorb wound drainage. • Gauze dressings absorb wound drainage with woven and nonwoven fibers of cotton, rayon, polyester, or a combination of these.

Name and define the four pharmacokinetic processes

• Absorption is the movement of a drug from the site of administration into the bloodstream. • Distribution is the transportation of a drug in body fluids (usually the bloodstream) to the various tissues and organs of the body. • Metabolism (or biotransformation) is the chemical inactivation of a drug by converting it into a more water-soluble compound or into metabolites that can be excreted from the body. Once a medication reaches its site of action, it is metabolized or changed into the inactive form in preparation for excretion. • Excretion is the ultimate removal of drug molecules from their sites of action and elimination from the body. A drug continues to act in the body until it is excreted.

What actions improve host ability to prevent infection?

• Adequate nutrition and hydration, including vitamins, minerals, and water, are essential for combating infection. Nutrients are required to form the components of the immune response. • Hygiene is a crucial aspect of maintaining skin integrity. Intact skin is one of the best defenses against infection. • Both rest and physical activity are necessary to rejuvenate the body. • Stress, whether physical, mental, or emotional, decreases the body's immune defenses. • For some diseases, immunizations have been developed. Immunizations expose the body to weakened or killed pathogens and stimulate the body to produce IgG. At a later date, if the natural pathogen is encountered, IgG and specialized T cells are available to ward off an infection.

Describe four types of wound closures.

• Adhesive strips (Steri-Strips) are used to close superficial low-tension wounds, such as skin tears or lacerations, or to close the skin on a wound that has been closed subcutaneously. They may also be used to give additional support to a wound after sutures or staples have been removed. The strips extend at least 2 to 3 cm on either side of the wound to ensure closure and are placed 2 to 3 cm apart along the wound. • Sutures are the most traditional wound-closure technique. They are available in a variety of sizes and materials. Absorbent sutures are used deep in the tissues. They may be used to close an organ or anastomose (connect) tissue. Absorbent sutures are made of material that will gradually dissolve; there is no need to remove these sutures. Nonabsorbent sutures are placed in superficial tissues. These sutures require removal. Nurses often remove sutures. • Surgical staples are made of lightweight titanium and may be used as an alternative wound-closure technique. Staples are easy to use and provide a rapid way to close an incision. Removal requires a staple remover. • Surgical glue is a relatively new method for wound closure. It is safe for use in clean, low-tension wounds. It is an ideal wound-closure method for skin tears. • Negative-pressure wound closure uses a piece of open-cell foam in the wound that is attached with a tube to a negative-pressure pump to remove wound drainage, provide subatmospheric pressure for improved wound healing, create a clean and moist environment, and form a barrier to bacterial infection. The negative-pressure device is computerized and can be programmed for continuous or intermittent negative pressure. • Compression stockings are used with venous stasis ulcers on the lower extremities. They apply continuous pressure to the veins, which facilitate venous return and helps the ulcers to heal.

Name two reasons for giving an intradermal injection.

• Allergy tests • Tuberculosis screening test

Identify and describe six positioning devices.

• An adjustable bed, sometimes known as a hospital bed, assumes a variety of positions. The head can be elevated or lowered below the level of the feet, and the foot of the bed can be elevated. Often the bed breaks, or "catches," at the knee to prevent the patient from sliding down when the head is elevated. The height of the bed is also adjustable. • Pillows expand the weight-bearing area by molding to the body and are the most common device used to assist with positioning. Pillows provide support and elevate body parts. • A trapeze bar is a triangular bar that is attached to an overhead bed frame. The patient can use the base of the triangle as a grip bar to move up in bed, turn, pull up in preparation for getting out of bed, or pull up to get on and off the bedpan. • A footboard is a device placed at the end of the bed that prevents plantar flexion. • A foot cradle is a metal or plastic device that is secured at the foot of the bed to prevent bedding from constricting the movement of the lower extremities. • Sandbags are small fabric bags filled with sand. They are used in the same manner as pillows, but they provide firm support. • Trochanter rolls are made from tightly rolled towels or foam pads. They are usually 12 to 18 inches in length. The rolls are placed adjacent to the hips and thighs to prevent external rotation of the hips. • Splints may be premade or fashioned from rolled wash clothes. The purpose of a splint is to hold the wrist and hand in a natural position and prevent claw-hand deformities.

Identify at least three nursing interventions to promote optimal respiratory function in a hospitalized patient with chronic lung disease.

• Annual influenza vaccination • Annual pneumonia vaccination • Frequent position changes to keep all areas of lungs well ventilated • Incentive spirometry 10 to 20 times per hour • Positioning upright for meals • Other activities in Clinical Insight 37-2 in your textbook

List at least four things you could do to promote client participation in care or adherence to recommendations for treatment.

• Assess the client's knowledge about her illness and the treatments and provide the necessary information. • Assess the client's supports and resources. • Be sensitive to the client's cultural, spiritual, and other needs and viewpoints. • Realize and accept that some attitudes cannot be changed. • Determine the client's main concerns. • Determine the client's priorities. • Help the client to set realistic goals.

Name the five building blocks of a theory.

• Assumptions • Phenomena • Concepts • Definitions • Statements (or propositions)

How many times, and when, should you check the medication against the MAR?

• Before you pour, mix, or draw up a medication, you check its label against the entry on the MAR, ensuring that the name, route, dose, and time match the MAR entry. • After you prepare the medication and before you return the container to the medication cart or discard anything, you check the label against the MAR entry again. • At the bedside, you check the medication before you actually administer the medication.

List one adverse reaction for each of the following systems: blood, gastrointestinal, neurological, cardiovascular, hepatic, and renal.

• Blood—aplastic anemia, thrombocytopenia, agranulocytosis, or leukopenia • Gastrointestinal—abdominal pain, nausea, vomiting, abdominal distention, diarrhea, constipation, or changed stools • Neurological—drowsiness, syncope, vertigo, decreased level of consciousness, insomnia, nervousness, dizziness, irritability, or extrapyramidal symptoms • Cardiovascular—hypotension, hypertension, bradycardia, tachycardia, arrhythmia, dizziness, headache, or shock • Hepatic—jaundice, petechiae, dark urine, or uremia • Renal—anuria, oliguria, hematuria, albuminuria, or fluid or electrolyte imbalance

Identify the effects of immobility on the cardiovascular, musculoskeletal, and integumentary systems.

• Cardiovascular system. Immobility increases the workload of the heart and promotes venous stasis. When you are active, the skeletal muscles of the legs assist with pumping blood back to the heart. Recall that the veins are thin-walled vessels with valves. Muscular activity propels blood toward the right side of the heart, and the valves prevent backflow of blood. Without muscular activity (immobility), blood pools in the periphery. To compensate, heart rate and stroke volume increase to maintain blood pressure. In addition to venous pooling, immobility leads to compression and injury of the small vessels in the legs and decreased clearance of coagulation factors, causing the blood to clot faster. These three changes—stasis, activation of clotting, and vessel injury—make up what is known as Virchow's triad, a trilogy of symptoms associated with a greater chance of thrombus formation in the effected blood vessels. An immobile person is also more prone to orthostatic hypotension. Bedrest causes inactivation of the baroreceptors involved with constriction and dilation of the vessels. As a result, when a patient who has been immobilized changes position, he is unable to maintain his blood pressure. The patient complains of feeling dizzy and light-headed and may be unable to support his own weight. • Musculoskeletal system. Inactivity causes significant wasting of the gastrocnemius, soleus, and the leg muscles that control flexion and extension of the hip, knee, and ankle. Confinement to bed leads to a 7% to 10% loss of muscle strength (atrophy) per week. Immobility also causes the joints to become stiff. The strongest muscles, usually the flexors, pull the joints in their direction, leading to contractures or joint ankylosis (fusion of the joints). Immobility affects parathyroid function, calcium metabolism, and bone formation. The result of these changes is osteoporosis, calcium depletion in the joints, and renal calculi (stones) due to increased excretion of calcium. These changes place the patient at risk for pathological fractures with minimal trauma. • Integumentary system. External pressure from lying in one position compresses capillaries in the skin, obstructing skin circulation. Poor circulation causes tissue ischemia and possible necrosis (tissue death). Nursing interventions include frequent turning and skin care to prevent the formation of wounds, known as pressure ulcers.

As an RN, how could you establish that a NAP is competent to perform a task?

• Check facility records for documented proof that the person has demonstrated competence. • Find out how often the NAP has performed the task. • Find out whether the NAP has worked with patients with similar diagnoses. • Observe and evaluate the NAP's performance.

List at least four ways a drug could be named.

• Chemical name • Generic (nonproprietary) name • Official name • Brand (trade, proprietary) name It is usually most important to know the brand name and the generic name.

Describe two ways in which breathing is controlled.

• Chemoreceptors located in the medulla of the brainstem, the carotid arteries, and the aorta detect changes in blood pH, O2, and CO2 levels, and they send messages back to the central respiratory center in the brainstem. In response, the respiratory center increases or decreases ventilation to maintain normal blood levels of pH, O2 (PO2), and CO2 (PCO2). Normally the blood CO2 level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. • A secondary, though important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to get more oxygen into the lungs. • In addition, lung receptors, located in the lung and chest wall, are sensitive to breathing patterns, lung expansion, lung compliance, airway resistance, and respiratory irritants. The respiratory center uses feedback from the lung receptors to adjust ventilation. • Voluntary control from the motor cortex can override the involuntary respiratory centers, but only temporarily.

What are the major risks to oxygenation related to developmental factors?

• Children. Incomplete development of the lungs and immune system place infants and young children at increased risk for problems with oxygenation. Increasing motor skills that are not accompanied by knowledge of risks also place young children at risk for aspiration and drowning. • Older adults. The effects of aging also influence oxygenation. Costal cartilage begins to calcify, making the chest wall gradually less mobile and more rigid, reducing chest wall movement during breathing. The lungs have less recoil ability, and the alveoli lose elasticity. These changes result in reduced lung expansion and less alveolar inflation, especially in the bases of the lungs. The cough reflex is less effective, and the number of cilia in the airways decline with aging, making it more difficult to expel mucus or foreign material. Exhalation becomes less efficient, causing progressive air trapping, which decreases the ability to increase ventilation when oxygenation demands increase (as with exercise). The immune response declines with aging, especially cell-mediated immunity, T-cell activity, and the inflammatory response. All of these changes put elders at risk for respiratory infections.

Name three ways a drug may be classified.

• Clinical use (clinical indication) • Chemical or pharmacological traits • Body system affected by the drug

What types of disorders limit activity or mobility?

• Congenital abnormalities of the musculoskeletal system • Disorders of bone formation, integrity, metabolism, or joint mobility • Disorders of the central nervous system or other body systems that produce fatigue, shortness of breath, or impaired circulation

What areas should you include in a nursing history for a patient with oxygenation concerns who is undergoing a comprehensive assessment?

• Demographic data • Health history • Respiratory history • Cardiovascular history • Environmental history • Lifestyle

What are the components of a NANDA-I nursing diagnosis?

• Diagnostic label • Definition • Defining characteristics • Related or risk factors

What are some of the symptoms you will see in an anaphylactic reaction?

• Difficulty breathing, which progresses to gasping for air • Wheezes when you auscultate the lungs; later, you will be able to hear them without your stethoscope • Cool, clammy skin • Falling blood pressure • Increasing heart rate

When administering eye drops, how can you prevent injury to the cornea?

• Do not place any medication in the eye unless the label on the bottle or tube states, "For ophthalmic use only." • Do not place medications directly onto the eyeball. • Take care to not touch the tip of the dropper or tube to the eye or conjunctiva to prevent bacterial growth on the container.

Identify three strategies that prevent clot formation.

• Elevate the legs above the level of the heart. • Apply antiembolism stockings (TED hose) or sequential compression devices (SCDs). • Turn patients frequently to prevent vessel injury from prolonged pressure in one position. • Use scrupulous sterile technique when inserting or handling IV lines. • Provide adequate dilution of IV medications. • Provide adequate hydration to keep the blood from becoming viscous (I&O, teach to drink plenty of fluids). • Promote smoking cessation. • Prescribe anticoagulant therapy. • All of the following measures promote circulation: elevating the patient's legs above the level of the heart, frequent ambulation, teaching patients not to sit with legs crossed, range-of-motion exercise, and antiembolism stockings or sequential compression devices.

List at least three ways to help ensure that the NAP will understand clearly what she needs to do when you delegate a task.

• Explain exactly what the task is, including what to do and what not to do. • Include specific times and methods for reporting. • Explain the purpose or objective of the task. • Describe the expected results or potential complications to expect. • Be specific in your instructions.

Identify four principles to be followed when performing PROM.

• Explain to the patient the purpose of PROM. You should also teach family members and caregivers about the importance of range-of-motion exercises and enlist their help in exercising the patient when they visit. • Observe the patient as you perform PROM. You may need to perform PROM in several short segments when the patient easily fatigues. • Support the patient's limb above and below the joint that is to be exercised. • Move the joint in a slow, smooth rhythmic manner. Avoid fast movements, as they may cause muscle spasm. • For a guide to move each joint through the range of motion it is able to attain, Go to Chapter 33, Table 33-1, Range of Motion at the Joints, in your textbook. • Never force a joint. Some patients may have limited range of motion. Move each joint until there is resistance, not pain. • Perform PROM at least twice daily. Move each joint through its range of motion three to five times with each session. Consider incorporating PROM into care activities—for example, while bathing or turning the patient. • Return the joint to a neutral position when exercise is complete. • Encourage active exercise whenever possible.

What are the disadvantages of the deltoid site?

• In many adults, the deltoid muscle is not well developed, so you should use it only for injecting small amounts (1 /2 to 1 mL) and when other sites are inaccessible. • In infants and children, the deltoid site should not be used because the muscle is small and lies close to the radial nerve and brachial artery. Its use increases the risk for injury to these structures.

List at least eight questions you could ask to critically evaluate the quality of your goal/outcome statements.

• For each nursing diagnosis: Is there at least one goal that, when met, would demonstrate problem resolution? That is, does at least one goal flow from the problem clause? • For each nursing diagnosis: Are the predicted outcomes adequate to completely address the nursing diagnosis? For each expected outcome: • Is the outcome appropriate for the nursing diagnosis? • Is each outcome derived from only one nursing diagnosis? • Does each outcome describe only one patient response or behavior? • Is the outcome stated as a patient behavior, not a nurse activity? • Is the outcome stated in positive, rather than negative, terms? • Is the outcome measurable or observable? • Are the performance criteria specific and concrete? Avoid words like normal, sufficient, enough, more, less, adequate, increased. • Does each goal include all the necessary parts? • Is the expected outcome realistic and achievable by this patient, given the available resources? • Does the outcome conflict with the medical or other collaborative treatment plan? • Does the patient, family, or community value the outcome? • Does the goal conflict with any religious or cultural values?

Name three purposes of the skeletal system.

• Forms the framework of the body • Protects the internal organs • Produces red blood cells • Serves as a storage site for calcium • Works with the muscles to cause movement

Describe the following positions: Fowler's, lateral, prone, Sims', and supine.

• Fowler's position is a semi-sitting position. The head of the bed is elevated 45° to 60°. • Lateral position is a side-lying position with the top hip and knee flexed and placed in front of the rest of the body. • Prone position is a position in which the patient lies on his stomach, with his head turned to one side. • Sims' position is a semiprone position. The lower arm is positioned behind the patient and the upper arm is flexed. The upper leg is more flexed than the lower leg. • Supine position, also known as the dorsal recumbent position, is a position in which the patient is placed on his back with the head and shoulders elevated on a small pillow. The spine is aligned and the arms and hands comfortably rest at the side.

Describe three methods for disguising the taste of objectionable tasting drugs

• Have the patient drink a liberal amount of flavored liquid (e.g., juice) or water to dilute the medication. • Have the patient suck on ice chips for several minutes before taking the medication, which numbs the taste buds. • Store the medication in the refrigerator, unless contraindicated. The smell and taste are less objectionable when chilled, especially for oily liquids. • Use a syringe to place the medication on the back of the patient's tongue, because there are fewer taste buds there. • Offer oral hygiene immediately after giving the medication, regardless of method.

Identify at least five reservoirs of infection.

• Human body • Animals • Insects • Food • Floors in healthcare facilities • Bathrooms • Raw sewage • Stagnant water • Garbage • Diapers • Used wound dressings

How are hyperventilation and hypoventilation related to carbon dioxide levels?

• Hypoventilation causes an excess of dissolved carbon dioxide in the blood, called hypercarbia (also called hypercapnia). • Hyperventilation causes a low level of dissolved carbon dioxide in the blood, called hypocarbia (also called hypocapnia).

What are the major causes of injuries from MVAs?

• Improper use of seat belts and car seats • Injury from air bags deployed when children are riding in the front seat

What are two disadvantages of the parenteral route?

• Infection is more likely if aseptic technique is not used because the route bypasses the skin barrier. • Tissue damage may result if the pH, osmotic pressure, or solubility of the medication is not appropriate to the tissue where the medication is given. For example, medications intended for injection into muscle may damage subcutaneous tissue. • The onset of action is relatively rapid, and the medications, once given, cannot be retrieved. This means that if an incorrect drug or dosage is given, you will not have very much time to recognize and remedy the error.

Identify the six links in the chain of infection.

• Infectious agent • Reservoir • Portal of exit • Mode of transmission • Portal of entry • Susceptible host

What is the purpose of initial planning? Ongoing planning? Discharge planning?

• Initial planning is done for the purpose of identifying patient problems and creating the care plan. • Ongoing planning allows you to revise and individualize the patient's care plan as new data are obtained. • Discharge planning is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency.

How can you ensure that the suction catheter enters the trachea and not the esophagus?

• Insert the catheter into the pharynx. • Advance it into the trachea during inspiration. • Once the suction catheter enters the trachea, it will stimulate coughing. If the catheter is not advanced on inspiration, it will enter the esophagus and may trigger gagging or vomiting.

To maintain sterile technique, which parts of a syringe must you not touch?

• Inside of the barrel • Hub • Shaft of the plunger • Needle

Identify the assessment methods (inspection, palpation, percussion, and auscultation) used when performing a physical examination focused on mobility concerns.

• Inspect each joint for swelling, erythema, asymmetry, or obvious deformity. Compare the size of the muscles above and below the joint and on each side of the body. • Palpate the joint for temperature and crepitus. Warmth over a joint indicates inflammation or infection. Be sure to compare body temperature over several joints and right to left. As you palpate the joint, move it through its range of motion. • Auscultation is part of the physical assessment for mobility and range of motion. Listen for crepitus, which is a grating sensation when the joint is moved. It can often be heard as well as felt.

Identify the major interventions for preventing pressure injury

• Inspect skin daily • Manage moisture • Adequate nutrition and hydration • Frequent position changes • Use of therapeutic mattresses and cushions to minimize pressure • Adjunctive wound care therapies • Patient and family teaching

What specific safety measures would you discuss with a mother to prevent choking in her 9-month-old child?

• Inspect toys for small, removable parts. • Store plastic bags away from young children in a secure place. • Avoid giving the child large, round chunks of meat, such as whole hot dogs. • Refrain from giving child hard candy, chewing gum, nuts, popcorn, grapes, marshmallows, or peanuts.

In the NIC system, what is the difference between interventions and activities?

• Interventions are broad, general, two- or three word labels (names); they are the standardized part of the language. • Activities are the more specific actions the nurse performs in carrying out the intervention; they are not standardized.

How can you help a person who has some difficulty swallowing oral medications?

• It may help to crush tablets (if not contraindicated) or give drugs in liquid form. • Gently massaging the area just below the chin may help to initiate swallowing. • You may also wish to collaborate with a speech therapist for other suggestions.

Name four theories that nurses "borrow" from other disciplines.

• Maslow's hierarchy of basic human needs • Validation theory • Developmental theories (Erickson, Piaget, family theories, Kohlberg's and Gilligan's moral development theories) • Selye's theory of stress and adaptation • System theory

Compare mechanistic and holistic nursing. Select one of these concepts and describe a scenario in which it is used.

• Mechanistic nursing is getting the tasks done. • Holistic nursing is meeting the needs of the whole person. • An example of mechanistic nursing is taking vital signs without any input from the patient to determine how she is feeling. Holistic nursing calls for the vital signs to be taken while talking to and assessing the patient, observing the family, and in general examining the "whole" picture of the patient's needs.

List at least three things you should do when providing supervision to an unlicensed caregiver.

• Monitor the person's work to be sure it complies with agency policies and procedures and standards of practice. • Intervene, if necessary. Perhaps demonstrate caregiving activities. • Obtain feedback from and provide feedback to the worker. • Give positive, as well as negative, feedback often. • If the NAP's performance was not acceptable, communicate that privately with the NAP. • Evaluate client outcomes. • Ask the client for input after the care is given. • Ensure proper documentation.

Identify three nursing responsibilities when caring for a client with a wound drain.

• Monitor wound drains. The surgeon will describe the number and type of drains present. • Describe drain placement using the positions on the clock face. Consider the patient's head to be at the 12 o'clock position (e.g., "Penrose drain at 3 o'clock"). • Label the drains numerically with a marker or by placing tape on the collection apparatus, so that each caregiver provides consistent care. Some patients have more than one drainage device in a wound. • When removing dressings or irrigating wounds, take care to avoid dislodging drains. Remember, many drains are not sutured in place. • Monitor the amount and character of the drainage and the condition of the collection apparatus. Record this information in your nursing notes and on the I&O record. • Report to the surgeon any change in the amount or character of the drainage. • If you suspect that a drain is occluded, check the drain line from the insertion site to the collection device. Remove any kinks in the tubing. If this does not correct the problem, notify the physician of the blockage. • Empty the collection apparatus at a designated volume to maintain suction. As the device fills, suction pressure decreases. If there is significant drainage, you may need to empty the device several times during your shift.

Name and describe three standardized intervention vocabularies recognized by the ANA.

• NIC. Consists of more than 500 interventions with associated activities. Can be used in all specialties. Does not include nursing diagnoses and patient outcomes. Designed for home healthcare. Has more than 800 interventions in Version 2.5; also includes diagnoses and outcomes. • Clinical Care Classification (CCC). Designed for home healthcare. Has more than 800 interventions in Version 2.5; also includes diagnoses and outcomes. • Omaha System. Designed for community health. Includes diagnoses and outcomes. Has 75 "targets" for intervention that are combined with four "categories" to make the intervention statement.

Identify at least five signs that you may observe in a patient experiencing dyspnea.

• Nasal flaring • Head bobbing • Retractions • Use of accessory muscles during inspiration • Grunting • Orthopnea • Inability to speak complete sentences without stopping to breathe (conversational dyspnea) • Paroxysmal nocturnal dyspnea • Stridor • Wheezing

List at least three tips for preventing food poisoning.

• Never eat any food that has an odor or that might be spoiled. • Never use a cutting board, knife, or other object that was used to prepare meat, poultry, or fish for any other purpose until it has been thoroughly washed in hot, soapy water. • Eat only meats that are fully cooked. • Refrigerate foods promptly after meals. • Observe sanitation reports for selection of eating establishments in the community. • Don't store food in decorative containers unless labeled safe for food; some crystal and pottery have a high lead content. • Imported folk remedies, such as greta, used by some Hispanic patients for colic, may be contaminated with lead.

What are some specific activities that reduce the possibility of fires in the home?

• Never leave burning candles unattended. • Store matches and cigarettes in a locked area. • Install smoke detectors and carbon monoxide detectors throughout the house. • Place extinguishers in the kitchen and workshop area.

What are the four essential concepts in a nursing theory?

• Nurse • Person • Health • Environment

In what circumstances would you use an oropharyngeal airway? A nasopharyngeal airway?

• Oropharyngeal airways should be used only in unconscious patients because they are likely to trigger gagging, vomiting, or laryngospasm when airway reflexes are intact. • Nasopharyngeal airways should be used on patients who are semiconscious; they can tolerate nasal airways because they do not stimulate the gag reflex.

What are two of the undesired effects of selfadministered nasal decongestants?

• Overuse. Clients usually self-administer "nose drops" and nasal sprays. Because many nasal medications are available without prescription, caution the patient regarding overuse. Long-term use of decongestants may cause a rebound effect; that is, they will be effective immediately after being administered, but the nasal congestion will recur and even increase when the effects of the drug wear off. Thus, you must continue to use it to get the desired effect. • Systemic side effects. Frequent use or swallowing excess decongestant can also cause systemic side effects, such as increased heart rate and increased blood pressure. This can be serious in children; saline drops are safer for them.

Identify normal PO2, SaO2, and PCO2 levels.

• PO2, 80 to 100 mm Hg • SaO2, 95% to 100% • PCO2, 35 to 45 mm Hg

What are the essential parts of a medication prescription?

• Patient's full name • Date and time the prescription was written • Name of the medication • Dosage, including the size, frequency, and number of doses • Route of administration • Signature of the prescriber

What type of patient is most likely to experience an allergic reaction?

• Patients on multiple medications • Patients with a history of allergic reactions to other medications • Patients who are older adults • Patients with a past sensitivity to other antibiotics

For which patients are oral medications contraindicated?

• Patients who cannot swallow fluids, because the risk for aspiration is too great • Patients who have nausea or vomiting, because the medication would be lost in the emesis • Patients who are NPO

Describe the difference between pharyngeal and tracheal suctioning.

• Pharyngeal suctioning clears secretions that have collected in the back of the throat. • Tracheal suctioning clears secretions that have entered the lower airways.

What are the five original levels of Maslow's basic human needs (not including cognitive needs, aesthetic needs, and transcendence)?

• Physiological • Safety and security • Love and belonging • Self-esteem • Self-actualization

What environmental and lifestyle factors that influence ventilation can be avoided or minimized?

• Poor nutrition • Obesity • Sedentary lifestyle • Smoking • Substance abuse To a lesser extent, exposure to poor air quality, altitude, temperature extremes, and stress can be minimized.

Differentiate between primary and secondary effects of medications.

• Primary effects (or therapeutic effects) are those that are predicted, intended, and desired. Basically, the effect is the reason the drug was prescribed. • Secondary effects (or unintended and nontherapeutic effects) are all other consequences. Both primary and secondary effects are dose related, so increasing the dose will increase these effects.

Identify the purposes of a wound dressing.

• Protect from contamination and heat loss • Aid hemostasis • Absorb drainage • Débride the wound • Splint the wound site • Prevent drying of the wound bed • Keep the surrounding tissue dry and intact • Provide comfort to the patient • Eliminate dead space • Control odor

Identify goals for wound care before applying a dressing to a wound.

• Protect wounds from further injury and infection. • Cleanse wounds to prevent infection. • Drain wounds to aid in the healing process and prevent infection. • Débride to aid in the healing process and reduce scarring

Identify the major functions of the skin.

• Protection of the internal organs • Thermoregulation • Metabolism of nutrients and metabolic waste products • Sensation • Unique identification of an individual

• Define qualitative research. Name one study presented as an example in this chapter.

• Qualitative research designs are focused on the lived experience of people. The purpose is not so much to generalize data but to share the experience of the person or persons in the study. Data are reported in words, observations, and other non-numeric forms. In some designs, categories and themes are "counted" (usually these are frequency data) and reported as percentages. • The classic study example discussed in the chapter is the Nun Study

Define quantitative research. Name one study presented as an example in this chapter.

• Quantitative designs gather data from enough subjects (people being studied) to be able to generalize the results to a similar population. Researchers control data collection carefully and are very concerned about the objectivity of the research process. Data from a quantitative research project are reported in the form of numbers. • The Framingham studies were given as an example.

What measures can healthcare workers use to reduce exposure to radiation?

• Remember time, distance, and shielding. • Organize nursing care to limit the amount of time with the patient. • Perform near the patient only the nursing care that is absolutely necessary. • Wear protective shielding, if available. • Never deliver care without wearing a film badge.

What are the rights of medication?

• Right medication/drug (right action) • Right patient • Right time • Right dose • Right route (right form) • Right documentation (right response) • Right reason • Right to know • Right to refuse

List the "five rights" of delegation.

• Right task • Right circumstance (patient) • Right person (personnel) • Right direction/communication • Right supervision/evaluation

List four critical concepts that make up informed consent.

• Right to not be harmed • Right to full disclosure • Right to self-determination • Rights of privacy and confidentiality

What solutions are used to cleanse a wound?

• Saline • Water • Dilute antimicrobial solutions • Commercially prepared wound cleansers

• Lungs clear to auscultation at all times.

• Subject: lung sounds (client is assumed) • Action verb: are (Note that "are" is assumed, not stated. "Are" is not an action verb. This is acceptable because we are describing what the lungs are to do, rather than what the patient is to do.) • Performance criterion: clear • Target time: at all times • Special conditions: to auscultation

Describe seven interventions associated with caring for a patient with an endotracheal tube.

• Secure the endotracheal tube with ties, tapes, or a commercial holder to prevent accidental displacement. • Inspect skin around tube or tracheal stoma for redness, drainage, or irritation at least every 8 hours. • Provide skin care around the tube and tape or holder at least daily. • Change the endotracheal or tracheostomy ties every 24 hours. Secure the orotracheal tube to the opposite side of the mouth with each change of tape or ties to prevent skin erosion and breakdown. • Inflate the cuff of the tube with a minimal occlusive volume and monitor cuff pressures to prevent pressure necrosis inside the trachea. (This is a joint responsibility with respiratory therapy.) • Note the centimeter reference marking on the endotracheal tube to monitor for possible displacement. • Minimize pulling and traction on the artificial airway by supporting all tubing connected to the airway and using flexible catheter mounts and swivels. If the patient is conscious, remind him not to pull on the airway. • Use a bite block between the teeth to prevent the patient from occluding an orotracheal tube. • Have emergency equipment immediately available for reintubation if the tube should become dislodged. • Provide 100% humidification of inspired air. • Suction the airway when secretions collect.

What safety measures help reduce equipment-related injuries in the healthcare facility?

• Seek advice if you are unsure how to operate the equipment. • Make sure medical equipment has been properly inspected. • Be alert to signs that the equipment is not functioning properly. • Make sure that rooms are not cluttered with equipment. • Follow agency policies regarding equipment brought from the patient's home (e.g., hair dryers, electric shavers, radios); usually these should be inspected for proper grounding and safe cords.

Describe the five types of wound débridement.

• Sharp débridement is the use of a sharp instrument, such as scalpel or scissors, to remove devitalized tissue. • Mechanical débridement may be performed via the use of wet-to-dry dressings, hydrotherapy (whirlpool), or lavage. • Enzymatic débridement is the application of a topical enzymatic agent to the wound. • Autolysis is the use of an occlusive moistureretaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. • Biotherapy, or maggot débridement therapy, is the use of medical-grade larvae to dissolve dead and infected tissue from wounds.

Identify three types of muscle.

• Smooth muscle, found in the digestive tract and other hollow structures, such as the bladder and blood vessels, produces movement of food through the digestive tract, urine through the urinary tract, and blood through the circulatory system. • Cardiac muscle is a unique form of muscle that possesses the ability to contract spontaneously. It is responsible for the beating of the heart. • Skeletal muscle moves the skeleton.

Give at least five guidelines for good body mechanics.

• Stand in good alignment with a wide base of support. • Minimize bending and twisting. These movements cause an increase in the amount of stress on the back. Instead, face the object and bend at the hips or squat. Avoid bending at the waist. • Squat to lift heavy objects from the floor. Push against the strong hip and thigh muscles to raise yourself to a standing position. • When lifting or moving an object, the closer it is to the center of gravity, the greater the stability. Keep objects close to your body when you lift, move, or carry them. • Use both hands and arms when you lift, move, or carry heavy objects. • Raise the height of the bed and bedside table to waist level when you are working with a patient. • Face objects or persons you are working with rather than twisting. • When possible, keep your elbows bent when carrying an object. • Use the muscles in your legs as the power for lifting. Bend your knees, keep your back straight, and lift smoothly. Repeat the same movements for setting the object down. • If a ladder or stepstool is required to reach an object, make sure it is stable and adequate to position your body close to the object. Do not stand on tiptoes to reach an object. • Push, slide, or pull heavy objects whenever possible rather than lift them. • Make sure you have a good grip on the patient or object you are moving before attempting to move the patient or object. • Work with smooth and even movements. Avoid sudden or jerky motions. • Assess the object or patient you are going to lift. If you have any doubt that you can do it by yourself, get help from a coworker.

• Bowel movements will be soft and formed and of usual frequency.

• Subject: bowel movements (client is assumed) • Action verb: will be (note that this is not an action verb) • Performance criterion: soft and formed, and of his usual frequency • Target time: ("at all times" is assumed if goal is for a potential problem; if for actual Constipation, a date or time should be written) • Special conditions: none

After two teaching sessions, (client) will be able to identify foods to avoid on a low-fat diet by 3/1/18.

• Subject: client • Action verb: (will be able to) identify • Performance criterion: foods to avoid on a low-fat diet • Target time: by 3/1/18 • Special conditions: after two teaching sessions

Describe three signs of internal hemorrhage

• Swelling of the affected body part; • Pain • Changes in vital signs • A hematoma (a red-blue collection of blood under the skin). A hematoma often forms as a result of internal bleeding. The amount of blood in a hematoma varies. A large hematoma causes pressure on surrounding tissues. When the hematoma is located near a major artery or vein, it may impede blood flow.

What are the signs and symptoms of a fracture?

• Tenderness at the site • Loss of function • Deformity of the area • Swelling of the surrounding tissues Diagnosis is confirmed by x-ray. Treatment of a fracture is stabilization until the body can create enough new bone to support function. The type and severity of fracture determine whether casting or surgical repair is necessary.

Briefly describe the Framingham studies and list three diseases for which these studies influenced care.

• The Framingham studies are a longitudinal (50-year) research project conducted in Framingham, Massachusetts, to identify the health and healthcare practices of one specific community. • Healthcare practices pertaining to heart disease, diabetes mellitus, breast cancer, and osteoarthritis have been influenced by the results of these studies.

Name one source of CO (carbon monoxide) poisoning.

• The burning of fuel, such as wood, oil, gasoline, natural gas, kerosene, and coal produces carbon monoxide. • A faulty furnace • Buildup of CO in an unventilated garage when a car is running • Other consumer products include lawn mowers, charcoal grills, gas water heaters, camp stoves or lanterns, and gas ranges or ovens. Many unintentional deaths occur during cold weather among older adults and poor who seek out nonconventional heat sources (e.g., gas ranges and ovens) to stay warm.

Identify and describe the purpose of the body's three major lines of defense against infection.

• The primary defense mechanisms prevent entry of pathogens into the body. Primary defense mechanisms include intact skin, mucous membranes at body openings, normal flora, and a rich vascular supply at potential sites of entry for infection, including the mouth and vagina. They also include processes such as crying, salivating, vomiting, peristalsis, and diarrhea. • The secondary defense mechanisms are activated if a pathogen gains entry into the body. Secondary defense mechanisms include phagocytosis, the complement cascade, inflammation, and fever. • Specific immunity, a third line of defense, protects against specific pathogens and builds immune "memory" in the process. The humoral response produces antibodies that inactivate invading antigens. The cellmediated response results in the production of T cells that destroy body cells infected with invaders.

What facts should you record if a patient is intubated?

• The type and size inserted • The patient's response to the insertion • Once the airway is in place, that breath sounds were heard (to establish that both lungs are ventilated) • Periodic reassessment of breath sounds, as part of airway maintenance

What should be included in a wound assessment?

• The type of wound • Location of the wound • The color of the wound and surrounding skin • The condition of the wound bed and surrounding skin • The color, consistency, amount, and odor of exudate or drainage • Pain or discomfort related to the wound or wound care

Identify four safety measures that decrease the risk of burns in the child.

• Turn pot handles toward the back of the stove. • Place guardrails in front of radiators and fireplaces. • Avoid warming infant formula and food in the microwave. • Always check the temperature of the formula and food carefully before giving it to the child. • Stress the danger of open flames to the child. • Always check bath water temperature for children and set water heater temperature low enough to prevent scalds. • Have children wear protective clothing and sunscreen when outside.

Describe at least four ways to minimize the discomfort of an injection.

• Use the smallest gauge of needle suited for the site and medication. • Use two needles when drawing up medications: one to withdraw the medication from the container and the second for the injection. If the needle is not free of medication, it may irritate tissues as it is inserted. • Do not administer too much solution into an injection site. If the total volume is more than the recommended amount, give it in two injections. • For intramuscular injections, help the client to assume a position that reduces muscle tension. • For intramuscular injections, use the Z-track technique (see Procedures 26-14A and 26-14B). This prevents leakage of the medication up through the needle track after the needle is withdrawn. • Pull the skin taut and insert the needle quickly to avoid pulling of the tissues. Remove it quickly at the same angle you inserted it. • Steady the syringe with one hand while injecting the medication. • Inject the medication slowly, about 10 seconds per milliliter. • Distract the client from the procedure by talking to her. • Apply gentle pressure after injection (not massage) unless contraindicated. • Especially with children, acknowledge that they will feel some pain (e.g., "This may hurt a little bit"). If you deny or minimize the pain, the patient will lose trust in you and be even more anxious about future injections. • After giving an injection to a child, cuddle and speak softly to him and perhaps play with him so that he does not associate you only with pain.

What is the difference between ventilation and respiration?

• Ventilation is the movement of air into and out of the lungs through the act of breathing. • Respiration is gas (carbon dioxide and oxygen) exchange.

Name three sites for giving intramuscular (IM) injections.

• Ventrogluteal • Vastus lateralis • Deltoid

What are the effects of carbon dioxide levels on the nervous system?

• Very high blood levels of carbon dioxide have an anesthetic effect on the nervous system and can lead to somnolence progressing to coma and death, a syndrome known as carbon dioxide narcosis. • Very low blood levels of carbon dioxide have a stimulating effect on the nervous system and lead to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips

What factors increase a client's risk for infection?

• Very young children and older adults are at increased risk for infection. Young children have limited exposure to pathogens and little active immunity. Older adults have declining function of the immune system and limited physiological reserve. • Any break in the skin also increases risk for infection. • Illness and injury, especially chronic disease, limit an individual's ability to fight infection. • Smoking, substance abuse, and multiple sex partners increase the risk of infection. • Some medications inhibit the immune response of the body. • Environmental factors that increase exposure to pathogens, irritate respiratory airways, or cause breaks in the skin increase risk for infection. • Finally, nursing and medical treatments often provide portals of entry and exit or bypass natural defense mechanisms.

List at least three actions clients can take to help avoid infection when they are out in the community

• Wash hands and avoid touching surfaces in public bathrooms. • Carry and use hand sanitizer as needed while in public places • Wash hands upon returning home (e.g., from shopping). • Clients should ask healthcare providers to wash their hands before touching them, if they have not already done so. • Postpone use of public transportation when ill. • Stay home from work if they have a fever or any symptoms of a contagious illness. • Avoid shaking hands with people if they are sick with contagious illness

Describe two ways to ensure an accurate dosage when pouring liquid medications.

• When pouring, hold the bottle so the liquid does not run over the label, making it difficult to read. • Measure the dosage with the calibrated cup at eye level. • Read the dosage where the lowest part of the concaved surface (meniscus) of the fluid is on the line.