FINAL FUNDAMENTALS

identify factors which affect a persons perception and reaction to pain

Ethnic and cultural values Developmental stage Environment and support people Previous pain experiences Meaning of current pain Spiritual Social

What evaluation do you do for a patient with a sleep problem?

-observe for s/s of REM/NREM deprivation -observe duration of sleep -ask how they feel when waking -effectiveness of interventions including goals set: .ex. relaxation, med, ingesting milk products, rituals

nursing interventions associated with TPN

daily weights are the best way to assess efficiency. see if pt is gaining or mantaining weight. important to assess blood glucose levels. assess insertion site for swelling/ redness/ drainage / pain

melena

dark sticky feces containing partly digested blood

What is coping?

dealing with change looking for adaptation. It can be successful or unsuccessful

Increased water in take is necessary when

hyperventilation - rapid breathing diaphoresis - profuse sweating from heat, exercise or fever diarrhea & vomiting

apical pulse

-Prepare the patient Locate the apical impulse - PMI - point of maximal intensity (fifth intercostal space, mid-clavicular line) Auscultate and count the heart beats Assess the rhythm and strength of the heart beat Document and report Normally the apical pulse and the radial pulse are identical When the heart or vasculature is diseased, a difference between apical and radial pulse may occur - known as a Pulse Deficit Apical and radial pulse taken simultaneously A full 60 second count In no instance is the radial pulse greater than the apical pulse Pulse deficit can the result of CHF where the heart is weak and does not pump enough blood Or tachycardia where not enough time to fill the heart with blood

preventing injury in the health care agencies

ALL OF THE ABOVE : orient to surroundings explain call system -assign at risk pts near to the nurses station -place personal items within reach -keep bed in low position, wheels locked and side rails up -lock all beds, wheel chairs and stretchers

Nursing Interventions for Client with Fever

Monitor VS Assess skin color and temperature Monitor labs Remove or provide blankets Provide nutrition and fluids Measure I&O Reduce physical activity Antipyretics Provide oral hygiene Tepid sponge bath Dry clothing and linens Remove heavy blankets cover Blood consists of three basic blood cell types: red blood cells, white blood cells, and platelets. Blood cells are produced from specialized cells in the bone marrow and are regularly released into the circulatory system. A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia A complete blood count test measures several components and features of your blood, including: Red blood cells, which carry oxygen White blood cells, which fight infection Hemoglobin, the oxygen-carrying protein in red blood cells Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in your blood Platelet count 150-450 billion/L (150,000 to 450,000/mmol****) Fever with high counts may suggest infection. Common sites where infection can occur in children are throat, ear, chest urine or some other site An elevated white cell count and/or a fever generally indicate that there is an infection somewhere in the body. See your doctor for a thorough check up and locate the cause of infection and have it treated asap. Once the treatment is complete, temperature and blood count should return to normal

General Guidelines for Transferring a Client

Plan what to do and how to do it Obtain essential equipment before starting Remove obstacles Explain transfer to client and assistive personnel Support or hold client rather than equipment

therapeutic techniques

SILENCE: Pause Being silent EXAMPLE: sitting quietly, walking and waiting until the client is able to relate his thoughts and feelings into words PROVIDING GENERAL LEADS: statements used to encourage the patient to verbalize EXAMPLE - Would it help to discuss your feelings? "Where would you like to begin?" "Perhaps you would like to talk about..." USING OPEN ENDED QUESTIONS: asking broad questions that lead or invite the patient to explore feelings invites answers that are longer than one or two words EXAMPLES - "Tell me about..." "I'd like to hear more about that." "What brought you to the hospital." USING TOUCH: appropriate form of touch to reinforce caring RESTATING/PARAPHRASING: actively listening then repeating in a similar way EXAMPLE- Client - "I did not get any sleep last night." Nurse - "You had difficulty sleeping last night?" SEEKING CLARIFICATION: making a patients broad overall meaning of their message more understandable restate basic message confess confusion or poor understanding EXAMPLE - "Would you please say that again?" "I'm not sure I understand that." OFFERING SELF: offering of one self without demands EXAMPLE- "I will help you to get dressed if you would like." " I will stay with you until your family arrives." GIVING INFORMATION: simple and direct EXAMPLE - "Your surgery is scheduled for 9:00 a.m. tomorrow." "I don't know the answer to that but I will find out for you from the doctor." ACKNOWLEDGING: giving recognition without judging EXAMPLE- "I notice that you keep squinting your eyes. Are you having difficulty seeing?" "You took a shower and combed your hair."

common artery used to access BP

brachial artery

characteristics in respiratory assessment

rate depth rhythm quality sound effectiveness -count respirations for 30 sec. and timed (x) by 2; for very sick pt. 1 full minute.

older adults

need reular vision tests and hearing tests

Anions

negatively charged electrolytes Cl-, HCO3-, HPO4-, SO42-

total incontinence

no pee no poop at all ._. complete loss of urinary or fecal control.

eupnea

normal quiet breathing

what is pain?

"Pain is whatever the experiencing person says it is, and exists whenever he/she says it does" (McCaffery). An unpleasant sensory (physical) and emotional (psychological) experience associated with actual or potential tissue damage Meaning that pain usually indicates a problem

What is the information needed for the nurse to complete a history dealing with fecal elimination?

-defecation pattern -description of feces and any changes -fecal elimination problems -factors influencing elimination -presence and management of ostomy

Differrence between a Complete & Incomplete Protein

- Complete Proteins has a High biological value. It closely resembles amount & combination of amino acids in the human body. Animal sources are most often a complete protein. i.e., meat, fish, poultry, milk, cheese - Incomplete Proteins - Plant Sources, have a lower biological value (can be made complete in the right combo of food at the same meal)

Enteral feeding

- Feeding through the GI tract for patients with swallowing difficulties or at risk of aspiration, unable to ingest foods, impaired upper GI tract - Suction stomach contents: gastric decompression to prevent gastric distention, nausea & vomiting

Inserting a Nasogastric tube

- High, Fowlers position - measure from tip of nose to the tip of the earlobe to the tip of the sternum (xiphoid process) - Check for correct placement by stomach aspiration for nasogastric larger gauge as well as ausculate air by insufflation ( instill 30-50cc bolus of air)

describe nursing interventions to support clients spiritual beliefs and religious practices

*Recognition and encouragement of the body/body/sprit in promotion of health* • Identifying and validating client's inner resources: − Coping methods − Humor − Motivations/Attitude/Optimism − Self-determination • Providing Presence • Support religious practices • Assist in prayer/meditation • Converse about spirituality • Refer client for spiritual counseling if needed or requested Examples of encouragement for clients' healthy spiritual : - Needing to leave behind a legacy (storytelling, recording life stories) - Encouraging creative expression (writing, art, and/or music) - Fostering need for client to be in touch with nature/maintain a sense of wonder BEING PRESENCE: Definition: • Being present • Being there • Being with the client FEATURES OF PRESENCING: • Giving of self in the moment • Being available with one's whole self • Active listening with full awareness • Being present in a meaningful way to the other Four Levels of Presencing: • Presence: − Physically present but not focused on client. • Partial presence: - Nurse present, doing a task on client, superficial relation with client. • Full presence: - Nurse is physically, mentally, and emotionally present - Intentionally focusing on client • Transcendent presence: - Nurse is physically, mentally, emotionally, and spiritually focused on client - A transpersonal/transforming experience REMEMBER: • Assist with prayer - Ask client: • What do you want to say in your prayer? - Participate if appropriate, provide privacy, quiet environment •Refer patients for spirituality counseling as needed - Community/clergy

Normal weight gain on infant

- 1 to 2 lbs a month - double by 6 months - triple by 10 mth to 1 yr - increases hight 9-10 inches

Toddlers

- 13 months to 3 yrs - can learn to feed themselves - hot dogs are dangerous - avoid stews and casseroles

Calorie requirement for lactation

- 500 plus per day

Rules for PPN and TPN

- Always run through control pump if TPN runs out hang an IV of D10W until the pharmacy delivers the next bag - Non IV certified LPN's cannot hang by Florida Law - Never run anything together in the same IV line gradually discontinue - Assess for fluid overload (SOB, wet respirations, chest pain, disorientation or confusion) - Report wet, soiled or non-occlusive dressings

ABCD nutritional assessment

- Anthropometic measures - Biochemical data - serum protein, serum albumin, tranferrin, TIBC: total protein intake & use. - Clinal signs - Dietary history- allergies, chewing, swallowing See page 29 through 31

Filtration

- fluid & solutes move together across a membrane from one compartment to another - movement is from an area of higher pressure to one of lower pressure i.e., fluid & nutrients move from capillary membranes to the surrounding tissues

Describe fecal incontinence

- Loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter - At specific times (after meals), or irregularly - Two types--- Partial (cannot control flatus or minor soiling) or Major (cannot control feces of normal consistency) - Causes Emotional distress and/ or social isolation -Dysfunction of anal sphincters .Vaginal delivery, surgical procedures ( repair or colostomy), trauma, tumors .Decreased Rectal Compliance .Impaired rectal sensation -Diabetes mellitus, multiple sclerosis, dementia, meningomyelocele, spinal cord injuries -Fecal Impaction .Impaired mental function, immobility, rectal hyposensitivity, inadequate intake of fluids and dietary fiber -Idiopathic

Role of the Nurse in TPN/PPN Nursing Interventions

- Report sudden fevers immediately - assess for phlebitis (inflammation of leg or arms) - sterile dressing changes every 3 days - I&O, weight every day - Check Labs, especially blood sugars as ordered or q6h - * change bag and tubing q24h - Non IV certified LPN's cannot hang by Florida Law

Nursing Diagnoses electrolyte imbalance

- Risk of fluid volume imbalance - Fluid volume deficit related to poor intake/vomiting/diarrhea - High Risk for fluid deficit related to diuretic therapy/poor intake - Fluid volume excess related to sodium & water retention - Impaired gas exchange related to hypoventilation

Define TPN

- a tailored solution that includes the use of dextrose, fats, proteins, electrolytes, vitamins, minerals & trace elements - it's a hypertonic solution - usually infused through a Central Venous access device (CVAD)

Characteristics of NREM Sleep

- activity is RAS is inhibited -slow-wave sleep: on deg waves maybe long continuous -deep/restful: most of sleep during night (nrem)

How the DRI is Calculated

- age - sex - height & weight - for calories: energy expenditure

Total vegan diet

- all animal food sources are excluded including dairy and eggs - this diet is low/inadequate in vit. B12, FE, Ca, and vit. D

What does Full Liquid Diet mean

- all clear liquids plus Milk, ice cream, strained soups, fruit & vegetable juices, custard, pudding, creamed cereals, yogurt, food liquid at room temperature

Soft liquids/- pureed

- all liquids - used for patients with difficulty swallowing thin fluids - usually low on residue (fiber)

Primary regulator of Fluid Intake

- body's thirst mechanism-(hypothalamus) - changes is osmotic pressure, vascular volume and angiotensin (hormone released in response to decreased blood flow to the kidneys)

Identify normal characteristics of feces

- brown/yellow - formed, soft, semisolid, moist - cylindrical - 100-400 g/day - aromatic - small amounts of undigested roughage

Water loss

- can not be stored - sensible water loss; measurable loss, urine output, emesis - insensible water loss; not measurable, respiration, perspiration, feces, diarrhea

Age affecting fluid & electrolytes

- children have greater needs than adults because of immature kidneys, greater surface area & higher metabolic rate, higher respiratory rate, rapid turnover of fluids - elderlies thirst response blunted, nephrons are less able to preserve water in response to ADH, heart disease, increased levels of atrial natriuretic factor, impaired renal failure, multiple drugs - higher risk of dehydration

Factors affecting nutritional status of the elderly

- chronic illness; 85 % of elders have one or more diseases, osteoporosis, DM, atherosclerosis, HTN, cancer - elderly patients alter their diets to prevent complications, due to chronic disease - poor dentition - diminished capability to shop and prepare meals

Identify abnormal characteristics of feces

- clay/white, black/tarry, red, pale, orange/green - hard/dry, diarrhea - narrow, pencil-shaped, string like stool - pungent (sharp) - pus, mucus, parasites, blood, fat, foreign objects

Clinical measurements used in patients with fluid & electrolyte imbalance

- daily weight (1 kg = 1 Liter of fluid) take before breakfast & after 1st void, similar clothing, same scale - vital signs - intake & output

Nursing interventions for heartburn (2nd & 3rd trimester)

- decrease fats, spices, caffeine - small frequent meals - drink fluid between meals

Bottle feeding teaching

- do not feed propped up with a pillow or towel; risk of aspiration, gas or colic - do not leave milk out over 2 hrs - do not store milk in fridge more than 48 hrs - do not reuse formula not completely consumed (bacterial growth from babies saliva) - do not put older babies to bed with a bottle other than water

Strategies on how to improve weight loss

- don't skip meals to avoid becoming ravenous - eat breakfast - eat 3 meals, slowly - set realistic goals (1 to 2 lbs wk) - eat a variety in moderation - exercise & sleep

Electrolyte

- electrically charged particles that are part of the body's fluids and play an important role in cell function - measured in miliequivalent (mEq/L), chemical combining power of an Ion - milligrams per 100 milliliters (mg/mL), referes to weight of an Ion - Calcium levels usually reported in milligrams per deciliter (1dL=100mL)

Temperature Affecting Fluid & Electrolytes

- excessive heat causes sweat production, which in turn causes an increase in the demands for fluids - water and salts lost through sweating, salt depletion causes fatigue, weakness, headache, GI symptoms (anorexia or heatstroke) - risk of heat exhaustion or heatstroke

Gender & Body Size Affecting Fluid & Electrolytes

- fat cells have little or no water - muscle/lean tissue has more water concentration Male - 60% of weight is water Female - 52% of weight is water

How to improve eating habits in child

- finger foods - avoid mixtures of food; stews & casseroles - switch to 2% milk - have them eat breakfast - become a role model since parents and peers eating habits are an influence - never force them to eat - do not use foods as a reward - do not routinely offer sweets

dietary patterns

- habits begin in infancy - child should be allowed to eat based on his own hunger and satiety

What can premature intro of food lead to

- inadequate enzymes to digest complex CHO: fill up before getting adequate milk to meet nutritional needs. - immature GI tract can result in food allergies - inadequately anatomic readiness: tongue thrust - inadequately sociological readiness; open mouth

Nursing interventions electrolyte imbalance

- increase fluids - decrease fluids - Dietary changes to prevent further imbalances - oral electrolyte supplements - Administer electrolytes as ordered - Parenteral Fluid & Electrolyte replacement (IV)

What are the types of coping strategies depending on duration?

- long-term coping strategies: .is constructive .helps with more permanent coping .example: change in lifestyle -short-term coping strategies: .temporary .ineffective to deal with reality on a permanent basis

What leads to Anorexia

- loss of appetite due to the decreased metabolic rate and the increased catabolism that accompany immobility - Nitrogen Imbalance - refusal to eat, rapid weight loss, and emaciation of person who believes they are fat, may induce vomiting and use laxatives to stay thin

Carbohydrates

- macronutrient: needed in large amounts - Composed of carbon, hydrogen, oxygen: CHO - easily digested - all digestible CHO is broken down into glucose; normal serum glucose level is 70-100mg/dL

Carbohydrates

- macronutrient: needed in large amounts - Simple sugars, to complex CHO (starches & Fiber_ - Composed of carbon, hydrogen, oxygen: CHO - easily digested - all digestible CHO is broken down into glucose; normal serum glucose level is 70-100mg/dL

Care for patients with Iron Deficiency Anemia

- most commonly seen in preschoolers 3- 5 yrs old. If the have problems chewing meats --> - have them eat non-meat sources of iron with vit. C rich foods to enhance absorption i.e., raisins, spinach, beets, beans, peanut butter, whole grains, iron fortified cereals, eggs

Snacks

- most snacks are empty & high in fat & sugar - if well planned they can add to the nutrient value of growing child or active adult as well as add to the reducing diet

When should you not breast feed

- mothers who use street drugs - prescribed drugs for some chronic illness - mother becomes pregnant - mother has HIV or other infectious disease communicable through breast milk - vegan may produce milk deficient in vit. D and B12

What is a certification of death?

- only done by physician, coroner or nurse if authority is granted -certificate is signed by attending physician

Describe diarrhea

- passage of liquid feces - increased frequency of defecation - caused by rapid peristalsis - ingested irritants cause diarrhea (defensive mechanism) - loss of electrolytes SYMPTOMS - spasmodic cramps - increased bowel sounds - irritation of anal region - fatigue - weakness - malaise - emaciation CAUSES - psychological stress - medications - antibiotics - iron - cathartics - food allergies - food intolerance - diseases of the colon (mal absorption of syndromes; Crohn's disease)

Diet for pregnant women

- protein - Folic Acid 122% - decrease risk of neural tube - Vit. D - Iron - Calcium - calories increase by 300/day in the 2nd and 3rd trimester (1 glass of milk per meal) - prenatal vitamins - 6-8 glasses of fluids

Nitrogen Balance

- protein metabolism - the status of protein nutrition in the body. It is the measure of degree of protein anabolism and catabolism. - When Nitrogen intake = Nitrogen output, a state of Nitrogen balance exist. - A negative Nitrogen Balance is using more than you have.

Advantages of breast feeding

- provides antibodies - protectant against developing food allergies - decrease incidence of some chronic diseases later in life, NIDDM, chrohn's disease, obesity - infants feed on demand

Soft liquids

- pureed - all liquids - used for patients with difficulty swallowing thin fluids rather than thick liquids and semi solids - usually low on residue (fiber)

Diet in elderly

- reduce caloric needs yet keep nutrition needs and nutrition value unchanged - lean meats, bake or broil, use low fat milk , cheese, ect. - increased Ca to 1200mg & vit. D for risk of osteoporosis - Mg for cardiac rhythm - B12 supplement because as people age diminished intrinsic factor reduces the ability to absorb

What is loss of muscle tone?

- relaxation of facial muscles -difficulty speaking -difficulty swallowing and gradual loss of gag reflex -decreased activity of the GI tract -possible urinary and rectal incontinence -diminished body movement

changing habits

- slow step by step process - education - motivation - desire, willingness, conviction

Nursing interventions for morning sickness (1st trimester)

- smaller more frequent meals, don't leave stomach empty - decrease fat, increase complex CHO - low fat protein snack before bed i.e., cheese or yogurt - dry toast, crackers before arising

What should vegans add to their diet

- soy products fortified with B12 & Iron (Fe) - soy milk is fortified with Ca

Types & Sources of CHO

- starches are insoluble ( can not dissolve in water) - their main function is satiety (fullness) and assist in assisting the digestive tract eliminate waste products.

Signs of a well nourished infant

- steady weight gain (1-2lbs/month) - 8 to 12 feedings per/24hrs - 6 or more wet diapers/24 hrs - 1 BM/day (more but not less) - moist mucous membrane - happy & vigorous - sleeps well * breast fed babies have more BM's

Normal changes that occur in pre-schoolers

- strong preference of certain food types - general disinterest in foods - finger foods are most enjoyable

Nursing assessment of a patient with fluid & electrolyte

- take a good nursing history - obtain clinical measurements - assess skin turgor - perform physical exam - review lab tests

What does Clear Liquid Diet mean

- temporary - 400-500 k cal i.e., ginger ale, gelatin without fruit, ices, hard candy, anything you can see through

characteristics of NI

-1st site is UTI, respiratory tract -1st cause iss lak of hand washing

what is the amount of fluid administered for a cleansing enema?

-500 - 1000 mL [adult] hypotonic, isotonic, soap 70-130mL [if Hypertonic] 150-200mL prepackaged [fleet enema] oil

analyze key factors in painmanagement

-Acknowledge and Accept Client's Pain Are you in pain? What does it feel like? Where is the pain? -Listen Attentively: Restate what the patient tells you, and add "how can I help you?" Explain the importance of asking questions to define the pain as unique and ask if they have any other feelings of discomfort - Encouragement of Pain Diary for clients with chronic pain: Records pain, its characteristics, and associated situation/factors which assist improve pain management. Attend to the client promptly and keep them informed. 84 -Assist support persons: Provide accurate information Teach about the disease, medications, and non-drug relieving techniques Provide emotional support Give opportunities for them to discuss their emotional reactions. 85 - Reduce Misconceptions: Pain is an individual experience Address patients fear of addiction - Reduce fear and anxiety: Allow the client to talk about pain and verbalize feelings Provide accurate information -Prevention of pain: Preventative pain management Before/after surgery Before/after procedures

Characteristics of REM Sleep

-Around 20% of sleep is REM in an adult -recurs about every 90 minutes and lasts 5-30 minutes -not as restful as NREM -difficult to arouse -most dreams occur in REM (thats why you can remember some if you awaken at the end of REM) -brain highly active (its metabolism increases 20%) -acetylcholine & dopamine increase. acetylcholine highest levels in REM -Eye movement occur -tone of voluntary muscles decreases -deep tendon reflexes are absent -may arouse spontaneously -gastric secretions increase -HR & RR are irregular -areas of learning, thinking, organizing info is stimulated

care for a closed and open drain

-CLOSED: drain connected to either an electrical suction or a portable drainage suction. Eliminates the possibility of entry of microorganisms into wounds through the drain and are sutured in place. Ex: hemovac, Jackson, pratt -OPEN: inserted in surgery to permit drainage of excessive fluid, promotes wound healing of underlying tissue from the inside to outside

Cultural accommodation and negotiation

-Considered clients viewpoint on health care and negotiates the plan of care(nurse-client negotiation) as a collaborative process. -Shows differences between nurse and client on health, illness and treatment -Negotiation considers harm or benefit that clients cultural health practices may bring into health care. If danger or harm, nurse must educate client on scientific view

Discuss nursing interventions to assist clients who have difficulty with fecal elimination

-Constipation: .increase fluid intake .drink hot liquids .fruit juices (prune juice) .fiver (raw fruit, bran products, whole grain cereals, and bread) -Diarrhea: .increase fluids and bland foods .small amounts (easier absorption) .avoid excessively hot or cold fluids (increase peristalsis) .spiced foods and high fiber foods can aggravate diarrhea -Flatulence: .limit carbonated beverages, drinking straws, chewing gum .gas forming foods: cabbage, beans, onions, cauliflower .exercise, moving in bed, ambulation .rectal tube

What is depression?

-Grief over what happened and what cannot be. -May talk freely

types of exercise

-Isotonic (dynamic) -Isometric (static or setting) -Isokinetic -Resistance -Aerobic -Anaerobic

signs of healing

-No bleeding and appearance of a clot that binds wound edges -Swelling wound edged to 1-3 days -Reduction of inflammation and new tissue -wound closes 7-10 days -Scar formation -Diminished scar size

Identify essential aspects involved in assessing a patient's stress and coping patterns.

-Nursing history: .ask about perceived stressors/duration .past/present coping strategies .explore with patient .data collected from client communication would be subjective date. -physical examination (objective data): verbal, motor, cognitive signs .examples: nervousness, biting nails, changes in blood pressure, increase work of breathing (dyspnea) .remember if coping is effective, the nurse may not observe signs and symptoms

Develop nursing diagnoses related to fecal elimination

-Risk for deficient fluid volume r/t .prolonged diarrhea .abnormal fluid loss through ostomy -Risk for impaired skin integrity r/t .prolonged diarrhea .bowel incontinence .bowel diversion ostomy -Low self esteem r/t .ostomy .fecal incontinence .need for assistance -Deficient knowledge(bowel training, ostomy management) .r/t lack of previous experience -Anxiety r/t .lack of control of fecal elimination secondary to ostomy .response of others to ostomy

Cultural models of nursing care

-Transcultural nursing(madeleine leininger): focuses on providing care within differences and similarities of beliefs, values and cultural patterns -health traditions model(rachel e. spector): based on concept of holistic health and explains what people do from a traditional perspective.

Describe sleep and biorhythms:

-Two types of sleep: 1 REM Sleep 2 NREM Sleep -Circadian Rhythms: 1)another name for biorhythm: .the biologic clock that exists in all living things .rhythms are controlled from within the body .synchronized with: .the environment .gravity .light/darkness .electromagnetic forces .circadian: from Latin circa dies meaning "about the day" .The cyclic nature of sleep: . controlled by the reticular formation in the brain stem .integrates sensory information from the peripheral nervous system (PNS) and relays it to the cerebral cortex .cerebral cortex and reticular formation must be intact for regulation of sleep and wake .Circadian regularity: .begins by the 6th week of life .by the age of 3-6 months, most infants have a regular sleep/wake cycle .Circadian Synchronization: .when a persons biological clock coincides with the sleep/wake cycle .awake when body temp is highest .asleep when body temp is lowest ( sleep neurotransmitters) .Serotonin: thought to lessen the response to sensory stimulation .Gamma-aminobutyric acid (GABBA): .Shuts off activity of the reticular activating system (RAS) .Darkness and sleep preparation causes a decrease in stimulation of RAS .Pineal Gland: .Begins secreting melatonin (decreases alertness) -During sleep: .growth hormone is secreted .cortisol is inhibited -With daylight: .melatonin is at its lowest .cortisol is at its highest -Wakefulness is also associated with high levels of : .acetylcholine .dopamine .noradrenaline

Grief

-a complete response to the emotional experience due to loss and may be exhibited by behaviors, thoughts, and/or feelings associated with sorrow or having overwhelming distress. -bereavement: loved ones subjective responses to experience of loss or death -Mourning: behavioral process in which the grief is revolved or changed. Influenced by spiritual beliefs, cultures and customs -Grieving assists the individuals to cope with the loss slowly and to accept the loss as part of reality

Identify the cultural concepts

-acculturation: involuntary process through which people incorporate behaviors/ideas traits from another culture -assimilation: when a person develops a new/different cultural identity -race:classification of people according to shared biologic characteristics, genetic markers, features. (white, black, asian indian) -discrimination -culture shock: disorder that occurs from one cultural setting to another -heritage: things passed down from previous generations -heritage consistency: clients identify with their traditional cultural system -heritage inconsistency: clients have acculturated into the new dominant culture of the modern society in which they now reside

What are the types of coping depending on appropriateness?

-adaptive/effective coping: .effective to deal with stressful events .minimizes stressful events -maladaptive/ineffective coping: .leads to unnecessary distress for the person and others around

how to promote wound healing

-adequate nutrition -prevent stress on wound -frequent position changes -ambulation -monitor fluid and electrolytes

identify major factors contributing to Health Disparities

-age -poverty -access to care -poor health literacy -provider biases/prejudices -poor provider-client communication -some minority groups

Factors affecting the grief process: (8)

-age -significance of loss -culture -spiritual beliefs -gender -socioeconomic status -support system -cause of loss

factors increasing susceptibility to infection

-age: infants and elderly -medical therapies

What is autopsy?

-an examination of body after death -sudden death or occurring within 48 hours of admission to determine cause of death - learn more about disease and collecting statistics

passive immunity

-antibodies are produced by another source, animal or human [are required]. -natural: antibodies transferred from immune mother to her baby through placenta or breast milk; lasts months to 1 yr

care and purpose of an AE hose

-antiemboli (elastic stockings) : are firm elastic hose that compress the veins of the legs and thereby facilitate the return of venous blood t the heart. -Should be removed once each shift so that a thorough assessment of the legs and feet can be made

s/s of grieving (9)

-anxiety/depression -lack of concentration/communication -weight loss or gain/difficulty swallowing/vomiting -fatigue/sleep disturbances - blurred vision/ dizziness/ fainting/headaches -excessive sweating -palpitations/chest pain/ dyspnea -crying/sobbing -menstrual disturbance/ alteration in libido

blood pressure sites

-arm: most common -thigh: auscultate over the popliteal surface -leg: auscultate over posterior tibial/dorsalis pedis -forearm: auscultate over brachial artery

Describe the physiology of sleep

-arterial blood pressure falls -pulse rate decreases -peripheral blood vessels dilate -cardiac output decreases -skeletal muscles relax -basal metabolic rate decreases 10% - 30% -growth hormone levels peak -intracranial pressure decreases

properties of antiseptic and disinfectives

-bactericidal: destroys bacteria -bacteriostatic: reduces the growth and reproduction of some organisms

factors affecting heat production

-basal metabolic rate [BMR] -muscle activity increase BMR -thyroxin output: increase BMR -epinephnrine, norepinephrine = sympathetic nervous system -fever

How do family patterns affect cultural care?

-basic unit of society -important role in cultural influences on health -cultural values determine: .communication within the family group .norm for family size .role of specific family members .value placed on a ember of family (elder) -family values: .older relatives living with other family members .nursing home or not .family visiting patient -cultural gender-role behavior: .taking instruction from male nurse rather than female nurse or vice versa -naming systems: .Japanese and Vietnamese family name first and ends in -san which means Mr. Mrs. Miss. -Decision making (matriarchal or patriarchal society) -disclosing information

What actions do you take for a patient with a sleep problem?

-bed-linen clean and dry -clean/dry gown -encourage own/thicker clothes -provide sufficient blankets -relaxation -administering sleep meds -tach about side effects of meds and caution with ETOH -assess need for and the use of meds with elderly

Ways to manage urinary incontinence

-bladder training: involves resisting the urge to void and patient voids on timetable; the goal is to gradually lenghten the intervals between voids, stabilize bladder, drecrease urgency. -habit training: a imed but not to avoid the urge to voidor delay voiding -pelvic muscle exercises (kegel) -maintain skin integrity (meticulous skin care) -external catheters(condom catheter):better than foley catheter because prevents UTI

What is sensory impairment?

-blurred vision -impaired senses of taste and smell -research found hearing is the last to go

How do you asses a patient with a sleep problem?

-brief sleep history .use of medications .sleep environment .recent changes in sleep patterns and/or difficulty in sleeping .sleep diary -physical exam .facial appearance .behavior .energy level .diagnostic tests .polysomnography (sleep study)

Sodium (Na) (mineral)

Sources: table salt, MSG, Soy sauce Functions: muscle contraction and heart beat

What are physiological indicators of stress?

-caused by stimulations of sympathetic sf neuroendocrine systems -depends on personal perception of events -clinical manifestations: .pupils dilate to increase vision .diaphoresis (increased sweat production) .tachycardia and increased cardiac output .increased production of mineralocorticoids (retention of Na+ and H2O which leads to increased blood volume) .rate/depth in respiration increased .mouth may be dry .urinary output decreased

how to place ice/heat on wound

-check if not contraindicated in the patient ex. Bleeding, 20-30 minutes interval, check every 15 minutes, remove heat/cold, assess skin for burns

Common sleep Disorders:

-chronic insomnia -insomnia -acute insomnia -hypersomnia -parasomnias -narcolepsy -sleep deprivation (result, not disorder)

Common type of urine specimens collected by the nurse

-clean voided specimen (routine analysis) -timed speciment (1,2,12,24hrs): if collecting for 24 hrs, first have them void and dispose that void; and after that you will start collecting and documenting -straight catheter

Describe the care involved in a supra pubic catheter

-clean/wash around catheter daily -assess

types of enemas

-cleansing enemas: intended to remove feces -soapsuds: irritates mucosa, distends colon -oil: mineral,olive,cotton seed oils, lubricates feces and mucosa -carminative enemas: given to expelflatus, solution release gas, ditention of colon and rectum, stimulates paristalsis -retention enema [oil or med]: retained 1-3 hrs, oil softens feces, antibiotics enema, nutritive enemas -return flow enemas: expelflatus, alternating flow 100- 200 ml of fluid in and out of rectum stimulates paristalsis, repeat 5 to 6 times until flatus expelled and abdominal distension is relieved.

list the four criteria needed for adequate ventilation

-clear airways -intact CNS -intact thoracic cavity capable of expanding and contracting -for adequate pulmonary compliance and recoil need: tidal volume, lung compliance, lung recoil, surfactant

identify essential nursing assessments and interventions during the ongoing postoperative phase

-collecting data -reviewing specific data to determine needs pre /post op - physical, psychological & social needs begins with the admission to PACU and ends when healing is complete, NURSING ACTIVITIES: assess the pt's physiological and psychological responses to surgery, perform interventions to promote healing and prevent complications, pt teaching to patients/ family, planning home care. GOAL: optimal health status possible.

What is acceptance?

-comes to terms with death/loss of loved one -may have decreased concern in surroundings and support people -may desire to begin making plans

delays of healing

-complications: obesity, multiple trauma, failed sutures excessive coughing/vomiting, dehydration -developmental: children and adult heal faster than older adults -nutrition: protein, fats carbs. Malnourished pt take longer to heal -lifestyle: pt who exercise heal faster -medications: anti-inflammatory interfere with healing, prolonged use ^ susceptibility to infections -infection: contamination and colonization of organisms in the wound

What is feces?

-composition: normally 75% water, 25% solid materials -consistency: soft but formed -color: normally brown (stercobilin and urobilin, which derive from bilirubin) -odor: affected by bacteria, type of diet .Escherichia coli and staphylococci affect odor and color

How do you implement for a patient with a sleep problem?

-create a restful environment .reduce environment distractions/noises -support bedtime rituals -promote comfort/relaxation -schedule medications to prevent nocturnal awakeness

Identify the characteristics need to provide culturally responsible care

-culturally sensitive: possess some basic knowledge of an constructive attitudes toward health traditions observed among culturally diverse groups in the clinical setting -culturally appropriate: application of the background knowledge to provide a client with the best possible health care -culturally competent: being capable of understanding, respecting, and attending to the total context of the clients situation and use a complex combination of knowledge, attitudes and skills to deliver effective care

What is algol mortis?

-decrease in body temperature

contact precautions

-dedicate use of non critical patient care equipment to a single room -private rooms are used for isolation because they maintain a negative pressure and have special vents to the outside -avoid transporting patients outside of isolation room if possible

guidelines for standard precautions

-designated for all patients in the hospital -apply to blood, all bodily fluids, excretions and secretions except sweat non intact skin and mucous membranes -handle, transport and process soiled linen in manner to prevent contamination of clothing and transfer of microorganisms

Identify factors affecting voiding

-developmental factors -psychosocial factors -fluid and food intake -medications -muscle tone -pathological conditions -surgical and diagnostic procedures

What is the slowing of the circulation?

-diminished sensation -mottling and cyanosis of the extremities -cold skin, first feet then hands, ears and nose -decelerated and weaker pulse -decreased blood pressure

What is liver mortis?

-discoloration from breakdown of RBC in tissue -located in dependent areas of body

Ways to prevent urinary tract infections

-drink eight 8-ounch glasses of water daily -frequent voiding (every 2-4hrs) -void immediately after sex -avoide bubble bath, harsh soaps, powderor sprays to the perineal area -avoid tight fitting pants -wear cotton clothes for ventilation of perineal area -women wipe from front to back -increase acidity of urine by taking vitamin C daily

What is chronic insomnia?

-duration greater than one month -main causes: .Women: hormonal changes .Most common in America

Past

-emphases on tradition -things are done the way they have always been done -historical power plays a part

Present

-emphasis on here and now -future arrives on its own

Future

-emphasis on progress and change -whats new - technology, breakthroughs

What is hypersomnia?

-enough sleep at night but cannot stay awake during the day -causes: usually organic/functional problems, metabolic disorders

bathing

-excellent opportunity for nurses to assess psychological and learning needs, orientation to time/place/person -its the best time to do a head to toe assessment

What are the interventions to help patient's minimize and manage stress?

-exercise -nutrition -sleep/rest -time management -have patient breath before injection -explain procedures -massage to help patient relax -offer support -listen attentively -educate client -convey atmosphere of trust, empathy and caring -eliminate environmental/situational stressors (noise, many visitors) -use short/clear sentences

s/s of systemic function

-fever -increased pulse and respiratory rate -enlargement / tenderness of lymph nodes

Nursing interventions associated with retention cath.

-fluid intake : 3,000mL/day if not contraindicated -dietary : acidify the urine(helps reduce UTI) foods thatll increase the acidity are eggs, cheese, meat and poultry, whole grains, cranberries, plums, drunes and tomatoes -routine changing of cathether not recommended, only if there is an obstruction -when removing assess for voiding. they may need bladder re-training. if voiding after removal is less than 100mL per void, then considered dysfunctional

What is an organ donation?

-for medical/dental education, research or transplantation -donor can be a living person or a cadaver

What is a DNR order?

-for terminally ill -signed when no resuscitation wanted in the event of a respiratory or cardiac arrest -patient or health care surrogate/proxy make this decision -must be signed by physician

ways to prevent skin breakdown

-frequent position changes, ambulation, adequate nutrition

active immunity

-host produces its own antibodies - artificial antigen [vaccine]blasts many years but may need reinforcement by boosters

Factors affecting normal sleep:

-illness .sleep/awake cycles disturbed .people need more sleep .dyspnea, peptic ulcers -Lifestyle .irregular schedules .exercise late in day .doing activities before bedtime -environment .noise .temperature .light/darkness .presence of unusual stimuli .absence of usual stimuli -Nocturia .excessive urination at night -doing activities before bedtime -exercise late in day -stress -alcohol and stimulants

What is insomnia?

-inability to fall asleep/remain asleep -people awaken tired -most common in america

identify four factors affecting oxygenation

-innefective airway clearance -ineffective breathng pattern -impaired gas exchange -altered tissue perfusion, decreased output cardiac,, activity intoleance, anxiety, fear, powerlesness, sleep pattern disturbance, social isolation

care of a patient with NGT

-inspect nostril for discharge/irritation -clean nostril and tube w/ moistened, cotton tipped applicators -apply water soluble lubricant to the nostril if it appears dry or crusted -change adhesives tape as required -give frequent mouth care [due to presence of tube pt may be breathing through mouth]

body defenses against infection

-intact skin and mucous membranes are first line of defense unless broken -normal secretions of skin - acidic -nasal passages - cilia -GI tract

How can a nurse convey cultural sensitivity?

-introduce yourself and explain your role -address clients by the last name until they give permission to use other names -respect and support the clients culture, wishes, requests -be authentic and acknowledge your lack on knowledge about their culture -use language that is culturally sensitive -assist with language limitations -find out clients thoughts/concerns about illness or condition -try to develop nurse-client trust if possible -do not make assumptions about clients. ask when in doubt -show respect for clients support people

specific [immune] defenses

-involves the immune system response to foreign proteins from bacteria or other transplanted tissues [antigens]

inflammatory response

-it is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of injury and promotes repair of damaged tissue -characteristics: impaired function of the part (if severe)

identify the nurses role in assisting with replacement of a chest tube

-keep rubber tipped clamps, sterile occlusive dressings, bottle of sterile water -use standard precautions and PPE -assess and medicate for pain as needed -reposition q2 hrs -ROM exercises for affected for affected shoulder -encourage deep breathing and breathing exercises as ordered

Nursing interventions associated with collecting urine specimens

-label date, time and how obtained -place in biohazard bag and in bag of transport -take to the lab: must transport to lab ASAP or store specimen in a regrigerator. if left out for more than 1 hour, itll break down and test is innefective. **clean voided sample should be collected in the morning (it's more uniform and higher pH, 10mL)

What are advanced directives?

-legal documents to make medical decision for patients when they are unable -all hospitals must provide patients with information about this right to declare their personal wishes about treatment and give them opportunity to make a decision. (living will, health care proxy or power of attorney, health care surrogate)

Discuss ways to reduce flatulence

-limit carbonated beverages, drinking straws, chewing gum -gas forming foods -- cabbage, beans, onions, cauliflower -exercise, moving in bed, ambulation -rectal tube

How do you plan for a patient with a sleep problem?

-maintain/develop a sleep pattern that provides sufficient energy for daily activities -create short patient goals related to main long term goal

foot/nail care

-make sure to wash and dry feet well, especially between the toes for pts with diabtes, and peripheral vascular disease -file nails, DO NOT CUT NAILS

goal of the patient immediate post operative goals

-mantain comfort -promote healing -prevent associated risks [respiratory, cardiac complications] -prevent other complications of surgery -restore highest level of wellness -plan for home care [continuity of care]

Nutritional Value

-most cultures have staple foods that are plentiful and accessible in the environment .rice, wheat, corn, pineapple, etc -cultural practices related to food .food preparation and serving .steam vs. fried .kosher; dairy and meat separate meals .food related: breast feed vs. bottle-feed .remedy or treatment for illness - hold/cold .religious practices .roman catholics - no meat on Fridays during lent .orthodox jews and islams, no pork

Identify ways in which to assess urine

-normal urine : 96% water and 4% solutes -color : straw(yellow), amber, transparent -odor : faint/mildly aromatic -sterility : no microorganisms -pH : 4.5-8.0 (average 6) -normal output : 1,200-1,500mL in 24 hrs -glucose : absent -ketone bodies (acetone) : absent -blood : absent

apical radial pulse

-normally apical and radial are identical -when the heart or vasculature is diseased, a difference between the 2 may occur: pulse deficit [CHF] -taken simultaneously -full 60 sec count -radial is NEVER greater than apical pulse

What is acute insomnia?

-not longer than one month -caused by personal stressors

Discuss the functions of sleep

-not totally understood -physiological effects on nervous systems and body -restores normal activity and balance in nervous system -necessary for protein syntheses (repair process) -important for psychological well-being -sleep deprivation causes deterioration in mental functioning -poor sleep causes: .emotional irritability .poor concentration .difficulty making decisions

What are nursing measure to care for the body after death?

-notify family asap -prepare body to look as natural as possible -close eyes -put denture in mouth -clean environment (Especially after a code) -hygiene/clothing change/clean linen -positioning: supine/pillow behind head and shoulders ; arms to the side or across abdomen ; remove jewelry -allow family to view body -allow to visit up to 2 hours -identification and wrapping: ID band behind wrist; labels on toe and outside of shroud; muslims place the body facing their special temple Mecca -Body taken to morgue to be picked up by funeral home. Storing body in cool temperature to prevent fast tissue softening and liquefying -embalming: injection of chemical to kill bacteria and prevent fast decomposition. not all religious practices embalm

What is labeling of the deceased?

-nurses complete the labeling of body -legally important for as go on the body and on the shroud -name, hospital number and physician name

assessing body temperature

-oral: adv: most accessible & convenient Disad: mercury in glass thermometers can break.could injure mouth following oral surgery, inaccurate [did pt. drink?] -rectal: adv: most reliable measurement, disad: could injure rectum, presence of stool could interfere, could result in ulcerations and rectal perforations in infants and newborns -AXILLARY: underarm, -adv: safest and most noninvasive -disad: thermometer must be left in position for a long time to obtain a more accurate reading TYMPANIC: ear, adv: readily accessible, reflects core temp, very fast, place in ear and click button. disadv: can be uncomfortable and risk of damaging membrane, right and left measurements can differ, cerumen cam affect reading

Instructions of oxygen therapy and safety

-oxygen is classified as a nonflammable gas but it supports combustion -a fire that will burn in air will bun explosively in pure oxygen. the burning of flammable materials is accelerated in the presence of oxygen. the metal from the oxygen cylinder will burn very well in the presence of pure oxygen -oxygen is stored at high pressures; a typical cylinder of gaseous oxygen will be pressurized to 2000 psi. if oxygen is released suddenly, as when a valve is broken off, there is enough power to drive a heavy cylinder through a concrete wall. .can be piped into walls or can be found in tanks .usually attached to a humidifier

korotkoffs sounds

-phase 1: first faint, clear tapping or thumping sounds (systolic pressure) -phase 2: muffled, whooshing or swishing sound -phase 3: blood flows freely; crisper/ more intense -phase 4: muffled and have a soft, blowing sound -phase 5: period of silence (diastolic pressure)

two ways to measure pain intensity

-physical: pain receptors and nerves -emotional: feelings and beliefs

diastolic

-pressure of blood when the ventricles are at rest -difference between the two is pulse pressure (40mmHg)

Discuss nursing interventions used to maintain normal fecal elimination patterns

-privacy -timing urge -nutrition and fluids -exercise .in supine, tighten abdominal muscles (pull in), gold for 10 seconds, repeat 5-10 min x4/day .in supine, contract the thigh muscles and hold for 10 seconds repeat x4/day -positioning .squatting; leaning forward .elevated toilet sit, bed side commode, bed pants (fracture, regular) . regular bedpan (high back) regular bedbound clients .slipper or fracture bedpan- for clients unable to raise buttocks (fracture)

What are the types of coping strategies depending on focus?

-problem-focuses coping: .seeks improvement by making changes or taking actions -emotional-focused coping: .thoughts and actions to relieve emotional distress .does not improve situation, but person feels better

4 phases of respiration

-pulmonary ventilation: ventilation or breathing [the movement of air in and out of the lungs while we inhale and exhale -alveolar gas exchange: capillary exchange which involves the diffusion of CO2 between the alveoli and the pulmonary capillaries -transport of CO2: transport of CO2 between the tissues and the lungs -systemic diffusion: movement of CO2 and O2 between systemic capillaries and the tissues

characteristics included when assessing pulses

-rapid [tachy] slow [brady] cardia -volume: weak or strong -rhythm: regular or irregular

What is changed in respiration?

-rapid, shallow, irregular or abnormally slow: cheyne-strokes respirations -noisy breathing, referred to a death rattle due to collection of mucous in throat

What is denial?

-refuses to believe that the loss is happening -not ready to deal with practical problems -may assume artificial joyfulness to prolong denial -behaves inappropriately

Space orientation

-relative concept involving relationships between the individual, body and objects and persons within that space -intimate zone, personal zone, and social/public zone -nurse moves through all 3 zones and needs to be aware of the differences and respecting the culture -nurses must ask permission and explain procedure/reasos before entering client's spouse

identify potential post-operative complications and describe nursing interventions to prevent them.

-respiratory [pneumonia] -circulatory [hypovolemia, hemorrhage] -urinary [urinary retention, UTI] -GI [N?V, constipation, tympanites, post-op ileus] -wound [infection, dehiscence, evisceration] -psychologic [post-op depression] *interventions to prevent and promote post op complications: view Flashcard #7. we teach the same in peri and post op.

give examples of pertinent nursing diagnoses for surgical patients

-risk for aspiration -altered protection -impaired skin integrity -risk for perioperative positioning injury -altered body temp -altered tissue perfussion -risk for fluid volume deficit

Discuss the process of digital removal of a fecal impaction

-risk of vagal response sometimes, cardiac arrhythmia -oil retention enema suggested 30 min before -after procedure - cleansing enema or suppository -lidocaine (xlocaine) gel 5 minutes before (if permitted in institution) .obtain assistance from second person if needed .right or left lying position, knees flexed, back toward nurse .absorbent pad' bed pan under client; bedpan nearby .avoid unnecessary exposure .clean gloves, lubricate index finger .remove stools in small pieces/help clean .assess patient (HR, facial pallor, diaphoresis) .assist pt to commode/bedpan/toilet

types of exudates

-serous: serum, watery with few cells -purulent: thicker with presence of pus that contains leukocytes, dead tissue debris and bacteria [pus=bad] -sanguineous: large amount or RBC -serous sanguineous: clear and blood tinged *course of drainage : sanguineous -> serous sanguineous -> serous

How do you diagnose a patient with a sleep problem?

-sleep pattern disturbance -others .high risk for injury .self-esteem disturbance .ineffective individual coping .fatigue .impaired social interaction .high risk for impaired gas exchange .altered thought processes .anxiety .activity tolerance

What is rigor mortis?

-stiffing occurs 2-4 hours after death -starts in involuntary muscles (heart, intestine, etc) -progresses to head, neck, trunk and extremeties

differentiate between straight cath. and retention catheter

-straight catheter is removed after collection of pee -retention catheter: also known as indwelling cath. remains in place until the MD orders it to be D/C. it contain a balloon so that it remains in place and its attached to a closed drainage

wound drain and suction

-surgical: drains are inserted in surgery to permit the drainage of excessive fluid [serosanguinous] to promote wound healing of underlying tissue from the inside to the outside -closed: drainage system consists of a drain connected to either an electrical suction or portable drainage suction. the closed systems eliminate the possibility of entry of microorganisms into wounds through the drain and are sutured in place.

body temperature regulating system

-temperature is regulated by 3 main systems: heat and cold sensors are found in - [the shell core], Hypothalamus: which signals to increase/decrease body temp. Effector system: adjusts the production of heat.

What are the cognitive indicators of stress?

-thinking responses to find a solution -coping: dealing with change looking for adaptation. It can be successful or unsuccessful -coping strategy (or coping mechanisms): natural/learned way of responding to a changing environment, specific problem, or specific situation.

What are the 4 s/s of death?

-total lack of response to external stimuli -no muscular movement, especially breathing -no reflexes -flat encephalogram (eeg) for 24 hours in instance of artificial support

Two forms of iv orders

-total volume to infuse in a number of hours/ 1000cc D5W run in 8 hers. -volume per hr / 500 D5 1/2 NS at 50cc/hr

Pain

-unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage -perception not a sensation -multifactoral phenomenon -unique to individual -difficult to communicate -high priority problem -bodys defense indicating a problem -can be normal in certain situation [labor] -highly subjective [personal] -presents physiologic and psychological dangers to health and recovery

abnormal lab data

-urine, blood, sputum or other drainage cultures.

how to clean a wound

-use a physiological solution such as saline (betadine & alcohol have a caustic effect on the wound and should not be used) -warm the solution (unless contraindicated) body temperature -if the wound is very contaminated clean the wound at every dressing change -if the wound appears clean and healthy do not do any unnecessary cleaning (delays healing) -avoid drying a wound after cleaning -always clean from clean to dirty (from wound outward to skin) -clean main incision first then the sides

How does culture affect communication?

-use professional/official interpreters -avoid non-professional interpreters and family members as interpreters -gender/age differences: embarrassment about certain topics to be interpreted -consider political or social incompatibility -speak directly to client (not the interpreter) -speak slow and distinctly - do not use metaphors -observe facial expressions and body language

how to bandage a wound

-use tape and place appropriately -type of dressing used depends on: location, size and type of wound -Are applied for protection, prevention, splint or immobilize, prevention

Describe colostomy irrigation

-used only with sigmoid or descending colostomy -distend bowel and stimulate evacuation -not routinely utilized for most patients -300-500 ml (some 1000 ml) -long-term use: may cause perforations, peristomal hernias

implementation strategies / to prevent infection

-using meticulous medical and surgical asepsis techniques -implement measures to support the defense of a susceptible host -teaching pt about protective measures to prevent spread -immunizations -hand washing

indirect transmission

-vehicle born: substance that serves as an immediate means to transport and introduce an infectious agent. ex: toys, handkerchiefs, soiled clothes, surgical instruments/dressings -vector born: animal / insect that serves as an immediate means to transport and introduce an infectious agent

Steps in inserting a urinary catheter

-wash hands, provide privacy, adequate lighting, open kit, don gloves, drape patient, poour solution over cotton balls, check the balloon, lubricate tip, clean meatus, insert the catheter until urine flows, collect urine specimen if needed. -straight catheter: continue to drain until urine flow stops, then D/C, 750-1000mL to be drained at any 1 time -indwelling catheter: insert one more inch after start of urine flow, inflate balloon, pull out until resistance is felt to ensure balloon has inflated -attach tube to drainage and secure to thigh/leg to prevent trauma to the bladder -hang bag below level of baldder -assess flow of urine and document

airborne precautions

-wear a respiratory device -susceptible people should not enter the room

Nurses need to be aware of what time to a patient. Most cultures have all 3, but one is always more dominant

.

Nursing interventions associated with fluid volume issues

... assessing fluid and electrolyte imbalance take a good nursing history, obtain clinical measures, assess skin turgor, perform a physical exam, review lab tests.

bronchovesicular

... Relating to the bronchial tubes and alveoli.

extravasation

... a discharge or escape, as of blood, from a vessel into the tissues; blood or other substance so discharged.

wheezes

... a whistling type pf continuous sound

bronchial

... bronchi: The larger air passages of the lungs arising from the terminal bifurcation of the TRACHEA. They include the largest two primary bronchi which branch out into secondary bronchi, and tertiary bronchi which extend into BRONCHIOLES and PULMONARY ALVEOLI.

identify outcome criteria by which to evaluate the effectiveness of perioperative nursing interventions

... cant find this either ._.

vesicular

... composed of or relating to small, saclike bodies. [alveoli]

discuss the importance of documentation with reference to preoperative, intraoperative, and post operative recording.

... could not find this one but i would answer that it is important to document before, during, and after a prodcedure to make sur ethat the pt understands what the procedure will be doing, and what the pt has to do after the surgery to recover. nursing interventions are needed, and also this should all be recorded to keep track of what the pt understands and what nursing interventions have been taken.. does it make sense or am i rambling? ._. help me find this answer . JC

crackles

... fluid in the lungs i.e: bubbles in water

phlebitis

... inflamation of a vein

care of the central line

... inserted most often in the subclavian or jugular vein the distal tip of the catheter should terminate in the superior vena cava just above but not in the right atrium.

rub

... sounds like grinding cheese, very bad sign.

infiltration

... the pathological diffusion or accumulation in a tissue or cells of substances not normal to it or in amounts in excess of the normal.

nursing interventions associated in promoting healing and preventing complications

.adequate nutrition .prevent stress on wound .frequent position changes .ambulation .monitor fluid and electrolytes

What are the characteristics of sleep?

.minimal physical activity .variable levels of consciousness .changes in body's physiological processes .decrease response to external stimuli

What is a health traditional model:

.views health holistically, complex, interrelated .considers balance of body and spirit .based on concept of holistic health and explains what people do from a traditional perspective -holistic/traditional perspective: .maintain health .proper diet .wearing proper clothing .using the mind .practicing religion .protect health: .wearing protective objects .restore health .herbal remedies, exorcism, healing rituals

pulse measurement

0 - absent 1- thready and weak 2- normal 3- bounding

describe the spiritual development of the individual across the life span

0-3 yrs acquiring qualities of trust, mutuality, courage, hope, love 3-7 yrs fantasy filled, imitative phased child realtes existence to stories, images, and fusion of facts and feelings 7-12 yrs (even into adulthood) demands proof or demonstration of reality able to learn beliefs and practices of culture and religion ADOLESCENCE: spiritual beliefs help understand extended environmental beyond family generally conforms to beliefs of those around them begins to examine beliefs objectively YOUNG ADULTHOOD: self identity differentiating beliefs from those of others develops personal meaning for symbols of religion and faith MID ADULTHOOD: respect for past and ones inner voice more awareness of differences because of social background attempts to reconcile contradictions in mind and experience open to others truths MID LATE ADULTHOOD: believes in, live with, participate in community works to resolve problems in society embraces life

What are three nursing diagnoses related to stress?

1) anxiety: -uneasy feeling of discomfort or dread -apprehension feeling caused by anticipation of endangerment -generates an automatic response -source nonspecific/unknown -helps the client to prepare to face threat 2)caregiver role strain: -difficulty in accomplishing the family caregiver role 3)ineffective coping: -inability to do proper evaluation of stressors -inadequate choice of responses -inability to use appropriate resources

What are 5 defense mechanisms?

1)compensation 2)denial 3)displacement 4)minimization 5)projection

Five concepts that lead to cultural competence:

1)cultural desire: motivation to engage in culturally competent care 2)cultural awareness: examination of ones own prejudices, biases, cultural/ethic background 3)cultural knowledge: education about other cultures 4)cultural skills: ability to collect culturally relevant data about clients health in a sensitive matter 5)cultural encounters: engage in face-to-face cultural interactions from different backgrounds, learning to modify own beliefs and prevent stereotypes

What are the 4 C's of culture in culturally responsive nursing care:

1)what do you CALL your problem? 2)what do you think CAUSED your problem? 3)how do you COPE with your condition? 4)what are your CONCERNS regarding the condition and/or recommended treatment?

two ways to evaluate pain

1-10 scale, COLDERR

Different types of vegeterians

Lacto-ovo- no meat, but dairy and eggs are acceptable Lacto - dairy is acceptable, no eggs, meat Total Vegan - all animal food sources are excluded including dairy and eggs

Composition of Proteins

1. Amino Acids are the building blocks of Protein 2. C,H,O and N (nitrogen) combined to form protein and are considered essential and non essential 3. 22 Amino Acids: 9 are essential - can not be synthesized by the body; must be obtained from diet 13 non-essential: most are synthesized by the liver

Vitamins

1. Can not be manufactures in the body 2. Are essential for regulation of body process

Functions of Fat

1. Concentrated source of energy - 9C/g therefor 2. Slow Digestion, thereby retarding hunger - giving satiety, and adding flavor 3. Promote absorption and storage of fat soluble Vitamins A, D, E, K)

Characteristics of Good Nutrition

1. Correct weight for height, bone size, age 2. Straight bones (not bowed or curved) i.e. rickets & kyphosis 3. Firm Muscles, flat abdomen 4. smooth, clear, moist skin (good color) 5. bright, alert expression, good vision 6. smooth glossy hair

What are the 3 types of movements that occur in the large intestine?

1. Haustral churning: back and fort, mixing contents, aids in absorption of water, propels content 2. Peristalsis: sluggish wavelike movement which moves the chime forward and slowly 3. Mass peristalsis: waves caused by powerful muscular contraction after food ingestion (occurs a few times a day)

Normal sleep patterns through the life span:

1. Normal sleep patterns throughout the lifespan - Children a. Usually have some more hours of sleep b. 3 year olds need 12-14 hours c. Range covers between 10-18 hours including from newborns to school-age children - Adolescents a. Require 9-10 hours of sleep - Elderly a. Disturbed sleep leading to lower quality of life b. Awaken around 6 times at night c. Needs of sleep is the same as when younger

Sources of Fat

1. Plants and Animals

Role of MD in Nutritional Planning and the Nurse

M.D. writes prescription Nurse, assesses appetite, likes & dislikes, feedings, reinforce teaching

Role of Cholesterol

1. Production of Vit. D 2.UV light on the skin plus cholesterol = Vit. D 3. Good Fats contain essential fatty acids and are obtained from plant sources 4. Bad Fats are low density lipoprotein of L.D.L.; excesses deposit in artery walls leading to atherosclerosis. 5. Medications are given for high cholesterol

Ways to maintain normal urine elimination

1. Promote adequate fluid intake: normal adult should be 1,500mL/day, if they have UTI then 2,000-3,000mL 2. Maintain normal voiding habits: POSITIONING, assist to normal position (female:sitting, male:standing) if unable to ambulate bedside comode or urinal. RELAXATION and TIMING 3. Assisting with toileting

What can happen with too much fiber

1. Diarrhea, fluid & electrolyte imbalances 2. Binding & elimination of FE and ZE

Vitamin A

Retinol, precursor - carotene Sources: dark yellow & orange vegetables Functions: improves resistance to infection; vision

What are the basic protocols for hygiene?

1. Early morning care - provided as client awakens - providing urinal, bedpan, washing face, hands and oral care 2. Morning care - before or after breakfast - elimination needs, shower/bath, perineal care, oral, nail or hair care - bed making 3. Afternoon care - bedpan/urinal - washing hands and face, oral care 4. Hour of sleep (HS) care / PM care - occurs before the patient retires - elimination needs, washing face and hands, oral care, back massage 5. As needed (PRN) care - as required by client (i.e., diaphoretic)

s/s of impending death? (4)

1. Loss of muscle tone 2. Slowing of the circulation 3. Changes in respiration 4. Sensory impairment

Role of Protein

1. Macronutrient - needed in large amounts 2. Repair or replace worn out tissue, leading to tissue growth anabolism vs catabolism & nitrogen balance, especial wounds, surgical incisions, burns 3. Can supply energy in an emergency 4C/g (same as CHO, 4 calories per gram)

How do you take care of the mouth?

1. Needed equipment and supplies 2. Curved basin (emesis basin or kidney basin) 2. Preparing the patient—assisting the client to a sitting position if possible 3. Preparing the equipment—wear gloves to prevent transmission of microorganism between nurse and client. Moistened toothbrush and apply toothpaste. 4. Brushing—at a 45 degree angle (sulcular technique) 5. Dentures—assess health status of gums, oral mucosa and tongue; condition of dentures; fit and comfort of dentures. Important to clean to remove food particles and microorganisms form artificial teeth Always provide a labeled denture cup and store in safe place when not in use. When cleaning dentures, line the sink with a towel to prevent breakage; tepid water

How do you care for the hearing aid?

1. Remove and turn off the aid 2. If the aid is not to be used for several days - remove the battery (corrosive) and store in a place avoiding heat and moisture 3. Detach (if possible) the ear mold and soak in soapy water 4. If the aid is not detachable - do not soak. Instead wipe with a damp cloth 5. DO NOT USE ALCOHOL TO CLEAN A HEARING AID 6. Remove any excess debris with a cotton-tipped applicator or a pipe cleaner 7. Reattach the ear mold and reinsert with the battery in and volume on low 8. Correct problems associated with proper functioning -weak or no sound = check volume and make sure it is not clogged -constant whistling sound = functioning well -make sure ear canal is not blocked with wax -whistling sound or squeal after insertion= turn volume down; make sure it is properly attached and reinsert

Composition and Types of Fats

1. Saturated fats have the most hydrogen atoms and are most often solid or semisolid at room temperature. i.e., butter, bacon, lard 2. Good Fats contain essential fatty acids and are obtained from plant sources

Functions of CHO

1. Spares Protein for energy (protein has more important functions) 2. Aids complete oxidation (burning) of fats for energy

Role of Fiber

1. aids elimination and some soluble forms may help to reduce serum cholesterol 2. requirements 25 - 30g/day

What are the 5 stages of the grieving according to Kugler-Ross?

1. denial 2. anger 3. bargaining 4. depression 5. acceptance

Identify the factors that affect defecation

1. development 2. diet 3. fluid intake/output 4. activity 5. psychological factors 6. lifestyle 7. defecation habits 8. medications 9. medical procedures 10. anesthesia and surgery 11. diseases 12. pain

Steps of how to administer tube feedings

1. introduce yourself and verify clients identity, explain to client what you are going to do, why it is necessary and how they can participate. Advise the client that it should not cause discomfort but may cause a feeeling of fullness 2. Perform hand hygiene and observe infection control procedure. 3. Provide privacy 4. Assess tube placement: - Apply gloves - Aspirate and check ph; should be higher than 6 (allow 1 hour to elapse before testing the ph for a pt that has received medications) 5. Assess residual eating contents - if the tube is in stomach, aspirate all contents and measure the amount before administering feeding. (if 100mL or more than 1/2 of the last feeding is withdrawn, check with the nurse in charge or refer to agency policy before proceeding) - Reinstill gastric contents into the stomach if its agency policy or provider's orders. (if on continuous feeding check gastric contents every 4-6 hours) 6. Administer the feeding: - check expiration date of feeding - warm to room temperature - if Feeding Bag (open system) clean the top of the feeding container with alcohol before opening - apply a label with date, time of start of feeding, initials - hang bag 30cm (12 inches) above the tubes point of insertion - clamp the tubing and add formula to bag - open the clamp, run the formula through the tubing and reclamp the tube - attach the bag to the feeding tube and regulate the drip if not placed on a pump

Role of the DRI (Dietary Reference Intake)

1. recommended daily allowance 2. guidelines for food labeling 3. exceptions to the DRI include: premature birth, metabolic disorders, infections, surgical procedures, chronic disease states, use of certain meds. 4. required if a nutrient is added or a nutritional claim is made 5. used as a guide to determine food stamp allowance 6. evaluating food consumption, planning and to aquire of supplies 7. designing nutritional programs

What are 3 body changes that occur after death?

1. rigor mortis 2. livor mortis 3. algor mortis

Water

1. the Most essential nutrient 2. a principal constituent of the body, approx. 60% of the body on average 3. regulates body temperature 4. lubricates moving parts

What are the functions of the lower intestinal tract?

1.ABSORPTION of water and nutrients function. -Most waste products are excreted within 48 hours of ingestion -Chyme (waste product from stomach and small intestine) enters the large intestine from the small intestine through the ileocecal valve (1500 ml daily; only 100 ml of fluid are eliminated in feces; rest is reabsorbed in proximal colon) 2.PROTECTIVE FUNCTION(MUCUS): -mucous contains large amounts of bicarbonate ions -stimulated by parasympathetic nerves -mucous protects intestinal wall from chemical trauma (acids within feces) -serves as an adherent for holding fecal material together -mucous protects intestinal wall from bacterial activity 3.FECAL ELIMINATION: -transports flatus and feces -flatus: is air and byproducts of digestion of carbohydrates

Differentiate four levels of anxiety

1.Mild anxiety: - slight arousal that enhances perception, learning and productivity -prompts to seek information 2.Moderate anxiety: -person expresses feelings of tension, nervousness or concern -perceptual abilities are narrowed -attention focuses on particular aspect of situation 3.Severe anxiety: -consumes most of person's energy -requires intervention -perception is even more decreased -person unable to focus on real event -focuses only on specific detail of event 4.Panic:(least frequent) -overpowering -frightening level of anxiety causing the person to lose control -perception severely affected and person distorts -fear -anger -depression -ego defense mechanism

What are the nurses legal responsibilities regarding patient death? (6)

1.advanced directives 2.autopsy 3.organ donation 4.DNR orders 5.Certification of death or pronouncing someone dead 6.labeling of the deceased

19

1/3-1/2

when to change a colostomy

1/3-1/2

how many cc are needed to fill up a ballon?

10 cc

describe factors that influence the rate of diffusion gases

factors that affect the rate of O2 transport. cardiac output, NUMBER OF ERYTHROCYTES [RBC], hematrocit [% of RBC in total blood volume, execrcise.

Fluid Intake

1500 - 3000 cc/day (food & liquids) 750 from food

what size foley catheter is normally used to insert in a patient?

16 French

biggest inhibitor in communication

failing to listen

Daily CHO Requirements

45 - 65% of Kcal @ 4C/g thats, 200-330g/day for men 180-230g/day for women * spares protein & fats from being used to supply energy

Nursing interventions associated with fluid volume deficit

increase fluids

Constipation intervention in pregnant women

increase fluids, fiber, avtivity

cardiovascular exercise

increase heart rate, increase strength of heart muscle contraction,, increase cardiac output 30L/min - 5L/min

serum osmolality

indicator of total solute concentration or number of particles dissolved in serum or urine.

What is anger?

individual or family may direct anger to staff or nurse about things that normally wouldn't trouble them

when do most people feel the urge to void?

250 - 450 mL

how many inches do you insert the enema tubing into the rectum?

3-4 inches

contractures

permanent shortening of the muscle, develops when the elastic tissues are replaced with inelastic fiber like tissue, makes it hard to stretch area and prevents normal movement

Fast food diet

quick, convenient, relatively low cost

heat loss

radiation conduction convection vaporization

isotonic exercise

Characteristics Increase muscle strength Muscle shortens produce muscle contraction and active movement Example: Running, walking, swimming, cycling, ADL's (activity of daily living) Active ROM (range of motion) Increases muscle tone and mass Increase heart rate and cardiac output, increased general blood flow

Vitamin B

Sources: whole grains, enriched breads, cereals Functions: energy metabolism, stress - Specific Vit. with known DRI B6 - pyridoxine must be supplemented for patients receiving INH - isoniasid TB B9 - folacin or folic acid - very important for pregnant women

Food group changes in lactation

4 or more servings of low fat milk to meet Calcium (Ca) requirements, increase fluids 2-3 qts/day

Foods to reduce intake

reduce daily sodium to less than 2300 mg/day

Diffussion

the movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration

osmosis

the movement of water across cell membranes, from less concentrated solution to the more concentrated solution.

What to Avoid in a Bland Diet (low residue, roughage)

6 S's String: celery, green beans Seeds: tomato, cucumber, squash, okra, eggplant, Kiwi, strawberries Skins: corn, grapes, peas, tomato, beans, berries Spices: pepper, garlic, etc. Stimulants: coffee, tea, ETOH, nicotine Smoking

carbohydrates serum level

70-10mg/dL

Essential Nutrients

9 Essential Amino Acids; Cannot be made by the body, must be obtained from diet

rectal temp

99.1F-99.6F The average normal oral temperature is 98.6°F (37°C). A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.

s/s of UTI

A burning feeling when you urinate A frequent or intense urge to urinate, even though little comes out when you do Pain or pressure in your back or lower abdomen Cloudy, dark, bloody, or strange-smelling urine Feeling tired or shaky Fever or chills (a sign the infection may have reached your kidneys)

orthostatic hypotension

A drop in blood pressure which occurs when patient rises from lying to sitting :or from sitting to standing Patient at risk are those who are immobilized and are on prolong bed rest Assess BP and P in the supine position, then sitting position, then standing - when possible. Wait for one minute between positions before taking BP and P. A rise in pulse of 15-30 beats per minute or a fall in pressure of 10-20 mm Hg indicates abnormal orthostatic vital signs

Provitamin or Precursor

A substance which is used by the body to convert into a Vitamin. i.e., Cholesterol and Sunlight = Vit. D Carotene = Vit. A

Fat Soluble Vitamins that can be stores in the body

A, D, E, K

Skills needed for developing self-awareness ASKED

A- Awareness: am I aware of my prejudices, biases, racism ideas and/or any other "isms"? S- Skills: do I have the skills to conduct a cultural assessment in a sensitive matter K- Knowledge: am I knowledgeable about the worldviews of diverse cultural and ethnic groups? E-Encounters: Do I see face-to-face and other types of interactions with people who are different from me D- Desire: Do I really "want" to become culturally competent?

log rolling

Spinal injury, spinal surgery, or hip surgery Pull patient to the side of the bed All staff move together to keep pt's alignment Using pull sheet Use head to support head It is necessary to move patient body as one unit post spinal surgery

Which patients are at risk for problems with the mouth?

A. Seriously ill B. Confused / comatose / depressed C. Dehydrated D. NGT/O2-have dry oral mucous membranes E. Oral/Jaw surgery-need meticulous oral care to prevent infection F. Heavy smokers / alcohol use G. Medications (diuretics; laxatives; Valium) tend to cause dryness of oral mucous membranes. Some chemotherapeutic agents used to treat cancer also cause oral dryness and lesions. H. Radiation (head/neck) permanent damage to salivary glands- results in dry mouth

purpose of T,C,DB

turn cough deep breath pt does on their own it helps eliminate mucus

Define urination (micturition)

Act of emptying the urinary bladder

factors affecting blood pressure

Age Exercise Stress Race Gender Medications Obesity Diurnal variations Disease process AGE: Aging tends to diminish arterial elasticity (hardening) EXERCISE: increases cardiac output, therefore BP is increased Note: a good nursing interventions would be to wait 20-30 minutes after any activity to take VS to get the most accurate results STRESS: causes stimulation of sympathetic nervous system which causes an increase in cardiac output and vasoconstriction of arterioles - an increase in BP RACE: African American males older than 35 have higher blood pressures than European American males of the same age group. OBESITY: pressure is increased do to the increased resistance. GENDER: Females have a lower BP than males (on average) until menopause - then it equals out MEDICATIONS: may increase or decrease blood pressure DIURNAL VARIATIONS: BP is lowest in the morning - metabolic rate is slowest BP is higher in evening hours along with metabolic rate Temperature: Because of increase metabolic rate, fever can increase BP. However, external heat causes vasodilation and decreases blood pressure. Cold- causes vasoconstriction and elevated blood pressure. DISEASE PROCESS: Any condition affecting cardiac output, blood volume, blood viscosity, and/or arterial compliance can increase or decrease blood pressure DIET: high fat/high salt can increase BP

factors affecting pulse

Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology AGE: as age increases, the normal resting pulse rate gradually decreases GENDER: after puberty, males have a slightly slower pulse rate than females. . EXERCISE: Pulse rate normally increases with activity - to meet the demands for the increasing need for oxygen. . FEVER: Elevated body temperature leads to peripheral vasodilation that leads to lowered blood pressure and increased heart rate. Increased metabolic rate due to fever also increases pulse. . MEDICATION: Increases or Decreases pulse rate depending on Medication. Cardiotonic (e.g., digitalis preparations) decrease the heart rate Epinephrine increases heart rate HYPOVOLEMIA: Will increase the pulse (i.e. hemorrhage) 7. STRESS: Increases pulse due to stimulation of the of the sympathetic nervous system (fear/anxiety/pain) POSITION CHANGES: Sitting or standing can cause blood to pool in dependent areas of the body - resulting in temporary decrease in blood pressure and an increase in the pulse rate.

factors affecting body temperature

Age Time of Day Exercise Hormones Stress Environment Medication AGE : young vs. Old The elderly have decreased thermoregulatory controls. (Inadequate diet, loss of subcutaneous fat, lack of activity, reduced thermoregulatory efficiency). TIME OF DAY DIURNAL VARIATION (Circadian Rhythms) Changes in body temperature throughout the day Highest between 1600 and 1800 and lowest during sleep between 0400- 600. EXERCISE: increases body temperature HORMONES: certain hormones affect heat production ex: progesterone @ ovulation STRESS: stimulates the sympathetic nervous system ENVIRONMENT: extremes in temperature

erroneously low BP

An abnormally low blood pressure A consistently low systolic reading between 85 and 110 mm Hg in an adult whose normal pressure is higher than this E.G.: 90/60

2 processes that are compromised in the body

Anabolism: building tissue Catabolism: breaking down tissue

Sources Protein

Animal Sources: - High Biological value: closely resembles amount and combination of amino acids in human body; most often are complete proteins i.e., meat, fish, poultry, eggs, milk, cheese Plant Sources: - can be made complete if eaten in the right combination at the same meal i.e., corn & beans, lentils & rice, peanut butter & bread, macaroni & Cheese (animal protein)

What is a vector transmitted infection?

Animal/insect that serves as an immediate means to transport and introduce an infectious agent. Can include an insect, animal, etc that transports the infectious agent

charting errors

Are all entries legible? Are there grammatical or spelling errors? Is the language objective? Are abbreviations approved by the agency? Are entries signed correctly? Are entries dated and timed? Is the chart free of erasures and other alteration Are all entries made in black ink? Are known allergies highlighted? Are all necessary flow sheets in the patient's medical record? Are flow sheets filled out completely?

assessment before moving patients

Assess degree of exertion permitted Physical abilities Muscle strength, Presence of paralysis Ability to understand instructions Degree of comfort Clients weight Presence of orthostatic hypotension Assess nurse's strength and ability Pain medications Prepare supportive equipment Obtain require assistance Explain procedure to the patient Safe practice for moving and turning Pt Before moving, assess If indicated, use pain relief modalities Prepare any needed assistive devices Plan around encumbrances Be alert to the effects of any medications Obtain required assistance Explain the procedure to the client Provide privacy Wash hands Raise bed/Lock wheels Lower side rail if turning toward nurse/Raise side rail if opposite Face in the direction of the movement Broad stance of support Lean trunk forward by flexing hips, knees and ankles Tighten your gluteal, abdominals, leg and arm muscles before movement Weight shift from one leg to the other when pulling or pushing Assess patient (comfort, alignment, tolerance (HR, RR), safety precautions Head of bed flat as to tolerance Elicit patient's help (flexing hips and knees, using over head trapeze) Two nurses using forearm interlock or Two nursed using turn sheet

pulse locations

BRACHIAL:, at the inner aspect of the biceps muscles of the arm or medially in the antecubital space RADIAL:, where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist FEMORAL, where the femoral artery passes alongside the inguinal ligament POPLITEAL:, where the popliteal artery passes behind the knees POSTERIOR TIBIAL: on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus. PEDIAL: (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line

color of normal stoma

Beefy Red

Discuss the purpose of digital removal of a fecal impaction

Breaking fecal mass and removing it in pieces. Order needed in some institutions.

Water Soluble Vitamins that can not be stored in the body

C, ascorbic acid, B complex

isometric exercise

Change in muscle tension No change of muscle length No change in movement Used with immobilized muscles (casts, traction), endurance Examples: Quadriceps sets, gluteal sets Moderate increase in heart rate and cardiac output

differentiate between cheyne stoke and biots breathing

CHEYNE STOKES: marked a rhythmic waxing and warning of respiration from very deep to very shallow breathing and temporary apnea [ cessation of breathing] BIOTS BREATHING: shallow breaths interrupted by apnea

therapeutic diets in specific disorders

CHO 50-60% protein 10-20% fat 20-30%

Hyperchloremia

CL greater than 108 mEq/L Clinical signs: weakness, lethargy, metabolic acidosis

Hypochloremia

CL less than 95 mEq Clinical signs: alkalosis, which causes muscle twitching/tetany, tremors

Routine preoperative tests

COMPLETE BLOOD COUNT [CBC]:used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia. A complete blood count test measures several components and features of your blood, including: Red blood cells, which carry oxygen. MRI: Magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. In many cases, MRI gives different information about structures in the body than can be seen with an X-ray, ultrasound, or computed tomography (CT) scan. UPPER GI SERIES: a radiographic (X-ray) examination of the upper gastrointestinal (GI) tract. The esophagus, stomach, and duodenum (first part of the small intestine) are made visible on X-ray film by a liquid suspension. This liquid suspension may be barium or a water-soluble contrast. ELECTROENCEPHALOGRAM [EEG]: a test that detects electrical activity in your brain using small, flat metal discs (electrodes) attached to your scalp. Your brain cells communicate via electrical impulses and are active all the time, even when you're asleep. This activity shows up as wavy lines on an EEG recording.

What do vegans have the must difficulty consuming

Ca & B12

Hypercalcemia

Ca greater than 10.5 mg/dL lethargy, weakness, urinary calculi, depressed deep tendon reflexes, anorexia, nausea, vomiting, constipation, polyuria, cardiac dysrhythmias (heart block)

Hypocalcemia

Ca less than 8.5 mg/dL numbness, tingling, muscle crampsm tremors leading to tetany (sustained contraction) cardiac dysrhythmias, confuison, anxiety, psychosis, Positive Trousseau's (hands) Positive Chvostek's (nerve 7)

What are psychological indicators of stress?

Can be helpful or harmful depending on situation and length of action: -anxiety

Essential Nutrients

Cannot be made by the body Water Carbs fats proteins minerals vitamins

What are energy foods

Carbohydrates i.e., grains, fruits, vegetables, legumes, sugar, syrups, root vegetables

What is sleep?

Considered an altered state of consciousness. The individual perception of and reaction to the environment are decreased. -The individual during sleep displays: .minimal physical activity .variable levels of consciousness .changes in body's physiological processes .decrease response to external stimuli

Sputum for culture and sensitivity

Culture and sensitivity [C&S]: looks for abnormal growth cytology: looks for abnormal cells acid fast bacillus [AFB]: looks for TB

describe the influence of spiritual and religious beliefs about diet, dress, prayer, meditation, birth, and death on health care

DIET/NUTRITION many religions have dietary needs/restrictions considerations healthcare providers need to prescribe diet plans with awarness of the patients dietary and fasting beliefs including food and beverages, fasting examples: msulim: during ramadan no eating food during daylight hours, judaism: during yom kuppir, catholicism: for good friday examples: catholics choose not to consume meat on fridays jews/orthodox jews: may require kosher diet, food prepared according to jewish laws, no mixing of dietary and meat in the same meal. no shellfish/fish with scales or pork muslims: no alcoholic beverages or pork mormons: no caffeine or alcohol DRESS: -orthodox jewish: married women must cover their head with wig/scarf. Men: wear yarmulke/hats to cover head -islam: women cover body -some religions: women: conservatively dress: cover arms to elbows and skirts to cover knees. PRAYER: human communication with divine and spiritual entities. different types include thankfulness, requests, and reflection. examples for christians the lords rayer, for muslims first sutra [attributed to mohammed] MEDITATION: focusing ones thoughts or engaging in contemplation and self reflection examples: slow deep breathing, short meaningful, self selected mantras, extraneous thoughts or noise that interrupts. ill peaople usually increase prayer and/or meditation **provide uninterrupted quiet time** BIRTH: important event giving cause to celebrate, specific rituals a part of the celebration. examples: christians: christening/baptism anyone can do even when a child is very ill muslims: call to prayer recited in the childs ear jews: boys: mohel completes ritual circumsision on the 8th day after birth. Girls: named in the synagogue on the sabbath after birth DEATH: catholics: scarament of the sick, anointing [last rites] jewish: bury within 24 hrs muslims: turn head or body toward mecca hindu: cremate body within 24 hrs to release soul -religious symbols objects should be treated with respect and kept with the body. nurseshould provide environment conducive to clients familys performance of religious rituals.

identify 2 phases of alveolar gas exchange

DIFFUSION: movement of particles from an area of greater pressure or higher concentration to an area of lower pressure or concentration OSMOSIS: movement of H2O from an area of lower concentration to an area of higher concentration to equalize the concentration

Dependent and Non dependent Edema

Dependent Edema is found lower body parts. In supine position you will find in sacrum and buttocks, and when standing you will find in legs and feet. Non-dependent Edema is not focus on dependent body areas. Usually there is a specific cause or an illness

Life Style Affecting Fluid & Electrolytes

Diet, inadequate nutritional intake - decrease in protein including albumin, disrupts the body's ability to regulate effective water balance - high risk = anorexia, bulimia, laxative abusers Stress, affects the body's demand - increase production of ADH decreases urine production, results in increased cellular metabolism, increased blood volume Exercise - fluid and sodium loss occurs with perspiration - weight bearing exercises are beneficial for calcium balance

Difference between Fluid volume deficit and Dehydration

In FVD you loose both water & electrolytes, with Dehydration you loose water but electrolytes are retained, particularly sodium is retained.

Methods of bodily fluid & movements

Diffusion, Osmosis, active transport, and filtration

Describe hemorrhoids

Distended veins in the folds because of repeated pressure

two blood test to differentiate between acute and chronic

ESR: erythocyte sedimentation rate [chronic] CRP: C-reactive protein [acute]

Anaerobic Exercise

Endurance training for athletes: Example: weight lifting and sprinting The body uses anaerobic pathways to meet the high demand for oxygen over a short period of time

What is PPE and when should it be worn?

Equipment utilized by health care workers to protect themselves of exposure of potentially infective material.

identify desired outcomes for evaluating the clients spiritual health

Examples of Positive Outcomes: - Assessment clinical manifestations: • Inner peace • Compassion with others • Gratitude • Humor/Laughter - Interaction with spiritual leaders - Participation in spiritual rites - Ability to pray/meditation - Discusses spiritual/religious experiences - Discusses spiritual/religious concerns - Shares feelings about dying (if the case).

Describe flatulence

Excessive flatus (gas) in intestine (causes abdominal distention) -action of bacteria -swallowed air -gas that diffuses between the bloodstream and the intestine -caused by: foods, abdominal surgery, narcotics -rectal tube: inserted in rectum if abdom distension and patient cannot pass flatus

What is scabies?

Excessive growth of body hair. • Acceptance of body hair is largely dictated by culture • The cause of excessive body hair is not always known - may be disease related • Older women may have some on their faces, and women in menopause may also experience this • Could be due to endocrine system disorder • Heredity influences pattern of hair distribution

What is defecation?

Expulsion of feces from the anus and rectum (bowel movement)

Composition of Body Fluids

Extracellular & Intracellular fluids contain: oxygen from the lungs, nutrients from Gastrointestinal tract, waste of metabolism (CO2) Ions - electrolytes

different healings

FIRST INENTION HEALING: when tissue surface has been closed, minimal tissue loss, minimal granulations and scarring occurs SECOND INTENTION HEALING: extensive and involves considerable tissue loss, edges cannot be closed. Ex: pressure ulcer. Repair time longer, greater susceptibility to infection THIRD INTENTION HEALING: is indicated when there is a reason to delay suturing in order for exudate to drain, more scar tissue

positions

FOWLER: Semi sitting position Low Fowler's - Semi Fowler's- 15-45 degrees High Fowler's- up 90 degrees The position of choice for patient who have difficulty to breath allow chest expansion and lung ventilation ORTHOPNEIC: Over head table across the lap Allows maximum chest expansion- problem exhaling DORSAL RECUMBENT: Back lying, supine Comfort and promote healing- spinal surgeries PRONE: Head turned to side Full extension of hip and knees Promote drainage of the mouth Marked lordosis Plantar flexion Might be contraindicated with clients with cardiac and respiratory problems LATERAL: Side lying Hip and knee flexion of upper leg and in front of the body Good for resting and sleeping Pressure relieved from sacrum and heels SIMS: Semi-prone Lower arm behind Prevent aspiration Used for procedures - enemas, and for treatments and examinations of the perineal area TRENDELENBURG: Description Lying on back with arms at sides, bed positioned so that head is higher than the head Purposes During some type of surgeries to shift abdominal contents upward REVERSE TRENDELENBURG: Description: Lying on back with arms at side, bed positioned so that head is higher than foot, but with no flexion at waist Purpose After certain type of angiography procedures, allows head of the bed to be elevated without causing pressure on the femoral artery

Patients most at risk for fluid volume deficit and excess

FVD causes: vomitting/diarrhea polyuria bleeding excessive sweating fever nasogastric suction tissue unjury, abnormal drainage, inability to access fluids. -decreased fluid intake: nausea/anorexia/impaired swallowing. confusion, deprssion, inability to access fluids. FVE causes: also known as edema increased capillary hydrostatic pressure decreased oncotic pressure increased capillary permeability [allergic rxn] obstructed lymph nodes excess Na+ intake [IVF, diet, meds] disease: CHF, RF, cirrhosis of the liver, cushings syndrome

factors affecting pulse oximetry

Factors that affect accuracy include: Hemoglobin level Circulation Activity Carbon monoxide poisoning

Passive Range of Motion

Flexibility Point of slight resistance Never with discomfort Supine Explain procedure to the patient Use firm grip Support the joints (above and below) Avoid hyperextension

differentiate various types of anasthesia

GENERAL ANASTHESIA: loss of all sensation and consciousness, causes amnesia, analgesia, hypnosis, relaxation, cough and gag [protective] reflexes are lost. -administered by IV, inhalation via mask or endotracheal tube, advantages are taht respiratory and cardiac functions can be regulated or adjusted to length of operation, disadvantages are that respiratory and circulatory systems are depressed; anxiety. REGIONAL ANASTHESIA: temporary, interruption of nerve impulses to and from specific area or region of the body, client remains conscious, several different kinds

Aerobic Exercise:

Increase oxygen demand Large muscle groups, continuous, rhythmic Examples: Walking, jogging, running, bicycling, dancing, cross-country training skiing, jumping rope, rowing, swimming, skating Improve cardiovascular conditioning Physical fitness Target heart rate Talk test Borg test

types of solution

HYOERTONIC SOLUTION [enemas] -fleet enemas: exerts osmotic pressure - draws water into colon, volume 90-120ml[sodium phosphate], takes effect 5-10 min, adverse effect: retention of sodium HYPOTONIC SOLUTION lower osmotic pressure, water moves from the colon int the interstitial space, distends colon, stimulates paristalsis, and softens feces, 500-1000 tap water, takes effect 15-20 min. adverse effect: fluid and electrolyte imbalance, water intoxication [danger in cardiac and renal disease] ISOTONIC SOLUTION: same osmotic pressure than tissues, safest enema solution [normal saline]; no fluid movement, stimulates peristalsis, distends colon, softens feces, 500-1000ml, takes effect in 15-20 min. adverse effect is possible sodium irritation

nursing intervention to improve electrolyte deficiencies

HYPONATREMIA: input/output, monitor Na+ lvls, limit water intake, encourage foods with Na+ HYPERNATREMIA: I&O, monitor Na+ lvls, encourage water intake, limit foods with Na+, monitor nehavior HYPOKALEMIA: monitor patients on digoxin because of risk for toxicity, monitor K+ lvls, encourage K+ rich foods, monitor apical pulse HYPOCALCEMIA: monitor respiratory and cardiovascular status, safety measures, Ca+ supplements, diet, exercise to increase bone health and density, estrogen therapy. HYPOMAGNESEMIA: seizure precautions, Mg+ rich foods, alcohol treatment HYPERMAGNESEMIA: monitor VS, lvl of consciousness [ may be faint], monitor DTR. HYPOPHOSPHATEMIA: high phosphorus diet, low Ca+ diet, correct hyopcalcemia, phosphorus HYPERPHOSPHATEMIA: low phosphorus diet, high Ca+ diet, correct hypocalcemia, phosphate binding antiacids [to get rid of, contraindicated in hypophosphatemia] aluminum hydroxide, aluminum carbonate or Ca+ carbonate

differentiate between hypoxia and cyanosis

HYPOXIA: insufficient O2 anywhere in the body, from inspired gas to tissue. CYANOSIS: a physical sign causing bluish discoloration of the skin and mucous membranes, caused by lack of oxygen [hypoxia] in the blood usually a very late sign

What is pediculosis capitis?

Head lice • Different types: 3 common kinds: • 1. Pediculus capitis (head lice) • 2. Pediculus corporis (body lice) • 3. Pediculus pubis (crab lice) • eggs are laid on the hairs - The eggs look like oval particles similar to dandruff • Pustular eruptions can be found on hairlines and behind the ears • Lice are small, grayish white and difficult to see. The difference between head lice and pubic lice is that pubic lice legs are red. • Treatment is with topical pediculicides which are available in lotions, creams, shampoos : pyrethrins (RID) permethrin (NIX)- recommended less toxic lindane (KWELL)

What is a nosocomial infection?

Health care associated infections

Role of the WHO (World Health Organization)

Health: a state of complete physical, mental, social well being, not merely the absence of infirmity

Cultural health related practices

IF YOU HAVE THIS ONE LET ME KNOW

mechanisms of respiration

INHALATIONA: - diaphram contracts and flattens -ribs move up and out -sternum moves outward -thorax enlarges EXHALATION: -diaphram relaxes -ribs move up and inward -sternum moves inward -thorax decreases in size -lungs are compressed

define terms used in the context of pain management

INTRACTABLE: highly resistant to interventions, CA or sickle cell NEUROPATHIC PAIN IN PERIPHERAL CNS: sharp, stabbing. AIDS, diabetes PHANTOM PAIN: percieved in a body part that is missing [amputees], unable to be felt [paralyzed] PAIN TRESHOLD: least amount of stimuli necessary for a person to label a sensation as pain PAIN REACTION: involves the ANS protects body [hot stove] PAIN TOLERANCE: maximum amount of painful stimuli that a person is willing to endure without seeking avoidance/relieve of pain, varies from person to person, varies in the same person, can be influenced by psychosocial and sociocultural factors. HYPERALGESIA AND HYPERPATHIA: heightened response to painful stimuli, disproportionate response ALLODYNIA: pain sensation caused by non painful stimuli, ex: linen touching skin cause pain DYSESTHESIA: unpleasant abnormal sensation, pain that follows a stroke or spinal cord injury. *note EARLY RECOGNITION* prevention of incurable pain syndromes.

Role of Folic Acid

Important for pregnant women

Demographic changes in the population

In 2008: -81.2% white (included 15.4% Hispanic Latino) -13.1% black or african american -4.7% asian/pacific islanders -1% native american indian & alaska native By 2050: -Hispanics/latinos 24% -whites non-hispanic wil decrease from 69% to 50%

Body Fluid Compartments

Intracellular & Extracellular

categories of IV solutions

Isotonic - has the same concentration of solutes as blood plasma Hypertonic - greater concentration of solutes than blood plasma Hypotonic - a lesser concentration of solute than blood plasma

Difference between Fluid volume deficit and Fluid volume excess

Isotonic FVD is when the body looses both water and electrolytes in the ECF in Similar proportions. - fluid is lost from the intravascular compartment (HypOvolemia) FVE occurs when the body retains both water & sodium in the ECF in Equal proportions, aka HypErvolemia (increased blood volume) - both intravascular & interstitial (edema) have an increase in water & sodium

Hyperkalemia

K greater than mEq/L Clinical signs: irritability, confusion, hyperactive GI tract, diarrhea, cardiac dysrhythmias/arrest, muscle weakness/areflexia (absence of reflexes), parasthesias/numbness in extremities Spiked T wave & widened QRS on EKG

Hypokalemia

K less than mEq/L Clinical signs: muscle weakness, leg cramps, cardiac dysrhythmias, anorexia, nausea, vomiting, decreased bowel motility, depressed deep tendon reflexes

levels for K+, Mg+, Ca+, Na+

K+ : 3.5-5.0 mEq/L Mg+: 1.5-2.5 mEq?L Ca+: 8.5-10.5 mEq/L Na+: 135-145 mEq/L

discuss the nurses role in assessing pain

Known as "Fifth" Vital Sign Assess pain as a routine with vital signs Comprehensive Pain Assessment includes: Physiological Psychological Behavioral/Emotional Sociocultural: Integral/holistic pain assessment Extent and frequency of pain assessment depends on organizational policy and situation Pain history Direct observation of behaviors

s/s of local infection and systematic infection

LOCAL INFECTION S/S: redness warmth increased swelling tenderness to touch drainage SYSTEMATIC INFECTION: fever elevated WBC

identify the cahracteristics of pain according to location, origin [etiology], and duration

LOCATION: specific site: head back, chest, knee, etc. -nociceptive pain: 2 categories: somatic and visceral pain: -somatic: originates in skin, muscles, bone, connective tissue examples: sprained ankle, paper cut on finger -visceral pain:results from activation of pain receptors in the organs and/or hollow viscera. characteristics: cramping, throbbing, pressing, aching. examples: labor pain, angina pectoris, irritable bowel -neuropathic pain: associated with damaged or malfunctioning nerves due to illness, typically chronic difficult to treat. examples: post-hepatic neuralgia, diabetic peripheral neuropathy, phantom limb pain, spinal cord injury pain.. neuro pain characteristics include: burning, electric shock, tingling dull, aching, sharp, shooting. -neuro subtyoes: central and sympathetically mantained pain. central is from mafunctioning CNS, while sympathetical is abnormal connections between pain fibers and sympathetic NS. affects circulation, temp., and edema.

effects of immobility

MUSCOSKELETAL: Disuse osteoporosis: without weight bearing the bone demineralize and become spongy Disuse atrophy: decrease in size looses normal function Contractures: permanent shortening of the muscle Stiffness and pain in the joints- ankylosis CARDIOVASCULAR: Diminished cardiac reserve Increased use of Vasalva maneuver Orthostatic (postural) hypo tension Venous vasodilation and stasis Dependent edema Thrombus formation Thrombophlebitis (impaired venous return, hypercoagulability, injury to a blood vessel) Thrombus (clot) Embolus ESPIRATORY: Decreased respiratory movement Shallow respirations and decreased vital capacity Pooling of secretions Hypostatic pneumonia Atelectasis METABOLIC: Decreased metabolic rate Basal metabolic rate Negative nitrogen balance Anabolism/catabolism Anorexia Negative calcium balance URINARY: Urinary stasis: lack of gravity Renal calculi: Increase calcium salt Urine become alkaline Urinary retention accumulation of urine Urinary incontinence: involuntary urine Urinary infections: static in the urine is a source for bacterial growth Escherichia Coli Urinary reflux EXERCISE: Improves the appetite Increases GI tract tone Facilitates peristalsis IMMOBILITY: constipation PSYCHONEUROLOGIC: Apathetic Withdrawn Regression Anger Aggressive Problem solving, decision making

select appropriate nursing diagnoses for patients with pain

Main Diagnostic Labels: Acute Pain Chronic Pain Etilogy/Defining Chraracterstics: Specify the location Related factors, when known, can include physiological and psychological factors Client Examples: Acute vs Chronic Other Nursing Diagnostic Labels related to Pain: Ineffective Airway Clearance Hopelessness Anxiety Ineffective Coping Ineffective Health Maintenance Self-Care Deficit (Specify) Insomnia Impaired physical mobility Deficient knowledge of pain management

Describe fecal impaction

Mass or collection of hardened feces in the folds of the rectum, results from prolonged retention and accumulation of fecal material. - passage of liquid fecal seepage (diarrhea) - non productive desire to defecate - rectal pain - anorexia - abdominal distention - vomiting CAUSES - constipation - poor defecation habits - barium

Hypermagnesemia

Mg greater than 2.5 mEq/L N/V, peripheral vasodilation - flushed, muscle weakness, paralysis, hypotension, bradycardia, depressed of DTR, lethargy, drowsiness, respiratory depression, coma, respiratory & cardia arrest, AV block EKG, prolonges QT interval

Hypomagnesemia

Mg less than 1.5 mEq/L neuromuscular irritability, tremors, convulsions, increased reflexes, tachycardia, hypertension, cardiac dysrhythmias, Positive Trousseau's (hands) Positive Chvostek's (nerve 7), confusion, vertigo

discuss barriers to effective pain management

Misconceptions: Severe pain is only experienced with major surgery Nurse is the authority about patient's pain Giving medications regularly will lead to addiction Extent of tissue injury is directly related to amount of pain Behavioral Signs/Visible Physiological accompany pain and can be utilized to validate pain presence • Other barriers: Inadequate assessment Believing client's report of pain OR not following it Many clients do not voice pain Lack of knowledge about pain management (patient, family)

Therapeutic Nutrition

Modification of the normal diet according to the needs of the individuals treatment of a disease. i.e., can't chew it, puree it

identify different ways to provide O2 therapy for the Pt

NASAL CANULA: can be used while eating or drinking 1-6L/min; 21-24% O2 FACE MASK: simple has no bag the partial breather has a bag for hyperventilating pts. O2 = 40-60%; 6-10L/min. with the bag 1/3 of expired O2 is inhaled as CO2. NONREBREATHER: delivers highest O2 concentration possible 95-100%; 10-15L/min VENTURI MASK: delivers precise O2 concentration 4-10L/min 24-40 or 50% FACE TENT: non invasive pressure ventilation. 30-50% O2; 4-8L/min ARTIFICIAL AIRWAYS: oropharyngeal airways, endotracheal tubes TRACHEOSTOMIES: SUCTIONING: when pt absolutely needs it. delicate tissue CHEST TUBE AND DRAINAGE SYSTEM: keep rubber tipped clamps, sterile occlusive dressing, bottle of sterile H2O

Medical Treatment Affecting Fluid & Electrolytes

NGT/PEG, surgery, medications - diuretics (Lasix) medications that cause seide effects of N&V and diahrrea, chemotherapy, corticosteroids

Need of assessment for swallowing

NPO patients moved to a puree diet

List the stages of sleep

NREM: 4 Stages: 1) Stage 1: relaxed and drowsy, usually lasts only a few minutes, eyes roll from side to side, very light sleep, HR and RR decreased slightly, readily awakened, individual may deny sleeping. 2) Stage 2: lightly asleep, requires touching or shaking to arouse, constitutes 44% to 55% of total sleep. Only lasts 10-15 minutes, process continues to slow down, eyes are still, HR and RR continue to decrease, body temperature falls. 3/4)Stage 3 &4: deeper stages of sleep, different online in % of delta waves, HR and RR drop 20-30% below rates at waking hours, not disturbed by sensory stimuli, difficult to arouse, skeletal muscles very relaxed. Reflexes diminished, snoring most likely, swallowing/saliva production decreased, essential stages for restoring energy and releasing hormones

Hypernatremia

Na greater than 145 mEq/L Clinical Signs: thirst, dry mucous membranes, red swollen tongue, disorientation, restlessness, convulsions, postural hypotention

Hyponatremia

Na less than 135 mEq/L Clinical Signs: lethargy, confusion, anorexia, nausea, vomiting, headache

Average weight gain during pregnancy

Normal - 25-35 lbs Obese women - no more than 15 lbs

When to feed baby

On Demand, when baby is hungry

orthopnea and its nursing interventions

Orthopnea- The inability to breathe easily unless one is sitting up straight or standing erect. Choose a suitable time Observe\ palpate\ count respiration rate 30 seconds and multiply x 2 if regular, for 60 seconds if irregular Assess depth\ rhythm\ character (quality) Document

describe essential perioperative teaching to patients including pain management, how to move, perform leg exercises, coughing and deep breathing exercises.

PAIN MANAGEMENT: pain can have detrimental effects on a post - op patient. pain most significant during the first 12-36 hrs POSITIONING: as needed as appropriate T,C, DB/ INCENTIVE SPIROMETRY: helps remove mucous to improve lung expansion and prevent atelectasis which can lead to pneumonia LEG EXERCISES: prevent venous can lead to stasis and thrombi development. MOVING AND EARLY AMBULATION: prevents respiratory, CV, GI and urinary complications HYDRATION: to replace body fluids lost in surgery DIET: as per doctors orders and the type of surgery [clear liquids and advance as tolerated and bowel sounds return] URINARY ELIMINATION: anesthesia may depress urine WOUND CARE: normal vs abnormal: usually covered by a dressing, need to look for bleeding and if it is dry and intact

Pulmonary function tests

PFT: looks at the following [important in diagnosing pulmonary disease] -tidal volume: volume inhaled and exhaled during normal breathing -inspiratory reserve: amount of air that is inhaled over and above a normal breath -expiratory reserve: amount of air remaining in the lungs after normal exhalation -residual volume: amount of air remaining in the lungs after maximal exhalation -total lung capacity: total volume of the lungs at maximum inflation -vital capacity: total amount of air that can be exhaled after a maximal breath

identify factors associated with spiritual distress and manifestations of it

PHYSIOLOGIC PROBLEMS: illness, loss of function TREATMENT RELATED CONCERN suctioning, amputation SITUATIONAL CONCERNS death or illness of loved one embarrassment inability to appreciate rituals

Hyperphosphatemia

PO4 levels greater than 2.6 mEq/L numbness, tingling around the mouth & fingertips, muscle spasms

Hypophosphatemia

PO4 levels less than 1.8 mEq/L muscle weakness, pain, paresthesias (loss of sensation) mental changes, seizures

identify essential aspects of preoperative assessment

PRE OP ASSESSMENT INCLUDES: collecting data, reviewing specific data to determine needs pre/post op, physical, psychological and social needs. ASSESSMENT IS DONE USING: nursing history, physical assessment, screening tests. ASSESS NURSING HISTORY: current health status, allergies, meds, previous surgeries, mental status, understanding of the surgical procedure and anasthesia, smoking, alcohol and other mind altering substances, coping, social resources, cultural considerations. PHYSICAL ASSESSMENT: attention to systems that may be affected by anesthesia, ability of pt to understand what is happening, hearing, vision, mental status, respiratory/cardiac systems, other systems [GI/GU/MS] SCREENING TESTS: specific test ordered pre-op to assess for abnormalities and possible treatments before surgery. Nursing responsability is to check orders, obtain results, make sure with clients records, inform surgeon of any abnormal/missing labs. [CBC/, blood grouping and cross match, serum electrolytes, fasting blood glucose FBS, BUN and creatinine, urinalysis, chest x-ray, EKG, serum albumin/total protein, ALT,AST, LDH, bilirubin]

describe the phases of the perioperative period

PREOPERATIVE PHASE: begins when the patient decides to have surgery and ends when the patient is trasnfered to the OR table INTRAOPERATIVE PHASE: begins with the ot admission to PACU and ends when healing is complete POSTOPERATIVE PHASE: begins with the admission to the PACU and ends when healing is complete *the goal of all three phases is to promote optimal health status

nursing care of a pt during the peri-operative period

PREOPERATIVE PHASE: begins when the patient decides to have surgery and ends when the patient transfers to the OR table. -Asses the patient -Identify actual or potential health problems - Plan care based on needs -Provide pre-op teaching INTRAOPERATIVE begins when the patient is on the OR table and ends when the patient is admitted to: - Post anesthesia car unit (PACU) - Post anesthetic room (PAR) - Recovery room (RR) *To maintain safe a therapeutic environment for the patient and health care personnel. POSTOPERATIVE PAHSE: begins with admission to the PACU and ends when healing is complete - Asses patients physiological and psychological responses to surgery - Perform intervention to promote healing and prevent complications - Teaching to pt/famly - Planning home care *Goal: optimal health status

identify data to be collected when assessing pain

Pain location Quality Patterns Precipitating factors Intensity (scale) Associated symptoms Alleviating factors

factors that affect pain

Past pain experiences Meaning of Pain Anxiety and Stress

prevent pressure ulcer

Perform pressure ulcer assessment within 24 hours of admission to the unit Develop and post a turning schedule Assess pressure point daily Monitor intake and output Use trapeze and foot boards Protect friction to area prone to pressure ulcer

PPN

Peripheral Parenteral Nutrition - a superficial vein usually in arm

identify medical and nursing interventions in the management of pain

Pharmacologicals: o Non-narcotics/nonopioids (NSAIDS): Over the counter (OTC)/Prescription Common side effect indigestion o Narcotics (opioids): Opioids for mild to moderate pain Opioids for moderate to serve pain Examples: codeine, hydrocodone, tramadol, morphine, codeine, Demerol, dilaudid • Adjuvant analgesic/coanalgesic: medications used for other reasons but can indirectly reduce pain Main Goal: Align proper analgesics with pain intensity Nonpharmacologic Pain Control Interventions • Consists of variety of pain management strategies Physical Cognitive-behavioral Lifestyle pain management Target body, mind, spirit, and social interactions Medical and Nursing Management Non-pharmacological/non-invasive: Physical Interventions: Cutaneous stimulation releases endorphins and block nerve fibers Types: o Massage: o Decrease muscle tension, increase relaxation, increase circulation to the area o Heat/cold application: o Vasodilatation and/or numbing o Cold first 24 hours/Heat used for more chronic pain o Examples: Warm bath, Heating pads, Ice packs, Warm or cold sitz bathes o Acupressure and reflexology: relieve tension -Types: -Immobilization: Restricting movement Transcutaneous electrical nerve stimulation (TENS): Electrical stimulation to the area - Cognitive-Behavioral Intervention: Mind-body intervention o Distraction (Music, TV) o Relaxation, imagery, mediation hypnosis - Spiritual: prayer -Non-pharmacological/non-invasive: Auditory: Music, Humor Visual: Watching TV, Guided Imagery Tactile: Massage (Text: Chapter, p. 1238), Stroking/holding pet or toy, breathing Intellectual: Computer games, card games, puzzles, hobbies -Nerve blocks: Chemical interruption of nerve pathways by injecting local anesthesia Example: dental work - Interrupting conduction pathways: Surgically by serving pain conduction pathways Done as last resort

What are diagnostic procedures used to assess problems with fecal elimination

Physical Examination: .inspection .auscultation (prior to palpation) .percussion .palpation .examination of the rectum and anus (inspection and palpation) Inspection of Feces: .color .consistency .shape .amount .odor .presence of abnormal constituents Diagnostic Studies: .direct visualization (colonoscopy) .indirect visualization (lower GI series) .Laboratory: Hemocult or guaiac (to detect occult blood in feces); C&S (micro)

What are two types of restraints?

Physical and medicational

Pitting edema

Pitting edema is a small depression or pit after finger pressure is applied to the swollen area caused by movement of fluid to adjacent tissue. Non pitting edema, does not pit, fluid is edematous tissue can not be moved to adjacent spaces

Mineral needed in Muscle Contraction

Potassium (K) and Sodium (Na)

Loss

Potential or actual situation/circumstance in which something that is valued is no longer available, is changed and/or is gone

respitory control mechanisms

RESPITORY CENTERS: -medulla oblongata -pons CHEMORECEPTORS: -medulla -carotid and aortic bodies BOTH RESPOND TO: O2, CO2, H+ in arterial blood

isokinetic exercise

Resistive exercise: involves both isometric and isotonic exercise Provides movement or tension against resistance Used for physical conditioning Strengthening/muscle building Includes weight lifting

nursing diagnosis associated with constipation and diareah

Risk for Deficient Fluid Volume r/t Prolonged diarrhea Abnormal fluid loss through ostomy Risk for Impaired Skin Integrity r/t Prolonged diarrhea Bowel incontinence Bowel diversion ostomy Low Self Esteem r/t Ostomy Fecal incontinence Need for assistance Deficient Knowledge (Bowel Training, Ostomy Management) r/t lack of previous experience Anxiety r/t Lack of control of fecal elimination secondary to ostomy Response of others to ostomy

Differentiate between scrub nurse and circulating nurse

SCRUB NURSE: assist surgeon, wears sterile gowns, gloves, caps etc, responsible for handling the needed sterile supplies and equipment to surgeons, ensure accurate sponge, needle and instrument count CIRCULATING NURSE: initiates OR paper work, positions patient, does skin prep, prepares/maintains/ dispenses sterile field/ supplies, administer meds and solutions into sterile field, performs sponge, needle and instrument count, documentation of nursing care/ procedure done and pts response

different types of wound drainage

SEROUS: watery w/ few cells, clear or clear yellow PURULENT: pus (produced by bacteria) color varies SANGUINOUS: bloody appearance SEROUS-SANGUINOUS: clear, blood tinged drainage

what side do you place your client on?

SIMS or left lateral

Normal sleep patterns through the life span:

SOMEONE ANSWER THIS AND SEND IT TO ME SO I CAN PUT IT HERE.

different types of anesthesia

SPINAL ANESTHESIA: lumbar puncture at L2 and S1, anesthetic agent injected into subarachnoid space surrounding the spinal cord CONSCIOUS SEDATION: used alone or in conjunction with regional anesthesia, a minimal depression of the level of consciousness in which the individual retains the ability to maintain a patent airway and respond to verbal and physical stimuli or commands LOCAL ANESTHESIA: injected into specific area, used for minor procedure, suturing small wounds or biopsy ex. Lidocaine or tetracaine EPIDURAL ANESTHESIA: injection into the epidural space, inside the spinal column but outside the dura mater TOPICAL: directly to skin and mucous membranes, readily absorbed, acts rapidly (open skin surfaces, wound, burns) ex. Lidocaine, benzocaine

define the concepts of spirituality and religion as they relate to nursing and health care

SPIRITUALITY: -the part of being human seeking meaningful connections through: intrapersonal relationships, interpersonal relationships, transpersonal awareness. -involves a belief in a relationship with: some higher power, creative force, divine being, infinite source of energy -it includes connecting and relating to others, nature, and universe. transcendence, becoming, hope, meaning, value -feeling alive, purposeful, and fulfilled -happiness through actual personal intentionality not by chance. -nurses should be aware and comfortable with their own spirituality and remove their own biases RELIGION CONCEPTS: faith, transcendence, forgiveness, FAITH -to believe in or to be committed to something or someone -gives life meaning -provides the individual with strength in times of difficulty -HOPE definition: a feeling of expectations and desires for certain things to happen, hope is incorporated into spirituality, in the absence of Hope patients give up, patients lose spirit, patients illnesses are most likely to progress faster.

how to stage an ulcer stage I through IV

STAGE I erythema of intact skin - non blanching, affects epidermis STAGE II partial thickness skin loss, involves the epidermis, dermis, or both, superficial ulcer, abrasion/ blister/ shallow crater. STAGE III full thickness skin loss, involves damage or necrosis to subcutaneous tissue, deep crater STAGE IV full thickness skin loss, extensive destruction tissue necorsis or damage to muscle or supporting structures such as tendons and joints. undermining occurs

nonn therapeutic communication

STEREOTYPING: generalized or oversimplified beliefs about groups of people EXAMPLE- "All confused people are hard to take care of." "All Hispanics are loud." AGREEING/DISAGREEING: judgmental response EXAMPLE- Client- "I don't think Dr. Broad is a very good doctor. He doesn't seem interested in his patients." BEING DEFENSIVE: Being defensive attempting to protect a persons health with negative comments EXAMPLE- Client- "Those night nurses must just sit around and talk all night. They didn't answer my light for over an hour." Nurse- "I'll have you know we run around all night. You are not my only client, you know." CHALLENGING: making a patient prove their statement EXAMPLE Client- "I feel like I am dying." Nurse - "How can you feel that way when you are breathing fine and your pulse is 60." PROBING: Probing asking for information out of curiosity WHY? REJECTING: refusing to discuss certain topics EXAMPLE "I don't want to discuss that. Let's talk about..." PASSING JUDGEMENT: giving ones own opinions or values EXAMPLE "That's good."

list two components of the respiratory system

STRUCTURE: the respiratory system is divided into the upper and lower respiratory system. mouth, nose, pharynx, and larynx are part of the upper system. the lower system includes the trachea which branches into the bronchi and bronchioles, alveoli, pulmonary capillary network and pleural membranes, also the lungs. PROCESS: involves 4 phases. pulmonary ventilation, alveolar gas exchange, transportation of CO2 and O2, systemic diffusion

identify various types of surgery according to the degree of urgency, risk and purpose

SURGERY: -hospital surgeries -ambulatory surgeries -ASC (same day surgeries, day surgeries or outpatient surgery centers): i. 3 phases of perioperative period are shortened ii. post op continues at home PURPOSE: -Diagnostic surgeries: Biopsy -Palliative surgery: relieves/reduces pain or symptoms-does not cure. i.e: nerve root resection -constructive surgery: restores function or appearance that has been lost or reduced i.e: breast implants -ablative surgery: removed a diseased body part -transplant surgery:: replaces malfunctioning structures i.e: hip/knee replacement DEGREE OF URGENCY: -emergency: done immediately to preserve function of life i.e: surgeries to stop internal bleeding; repair a fracture -elective: done when surgical intervention is the preferred treatment for a condition that is not life threatening but may ultimately threaten life or well being. i.e: hip replacement, breast reduction, cholecystectomy, plastic surgeries DEGREE OF RISK: -major surgery-high degree of risk: complicated/prolonged, large blood loss, involves vital organs, post op complication more likely, i.e: organ transplant, open heart, kidney removal -minor surgery: little risk, few complications, often done in "day surgery" i.e: breast biopsy, tonsillectomy, knee surgery. -DEGREE OF RISK AFFECTED BY: clients age, general health, nutrition, medication, and mental status. -AGE: very young and elderly are at greater risk. i.infants: volume depletion, hypthermia, immature organs. ii.elderly: F&E imbalances, malnutrition, decrease hearing and cognition, decrease liver and kidney functions, underlying conditions. iii.General health: least risky when general health is good, health problems that increase surgial risks are: cardiac conditions, blood coagulation, URI/COPD, diabetes mellitus, obesity, renal/liver disease, neurologic disease. -NUTRITIONAL: adequate nutrition required for normal tissue repair. obesity[pneumonia, wound infections and separation], malnutrition [delayed wound healing, wound infection, F&E imbalances] -MEDICATIONS: regular use of certain meds increase risk. anticoagulants -inc. blood coagulation, tranquilizers -+ anasthesia = resp.dep., corticosteroids-wound healing/ risk of infection, diuretics- F&E imbalance. -MENTAL STATUS: any disorder that affects cognitive function, affect the baility of patient to undertand and cope with the stress of surgery, mentall illness, dementia, mental retardation, developmental delay, agitation, extreme anxiety.

Common pathogens that cause Food Bourne Illness

Salmonella - raw/undercooked eggs, cookie dough, salad dressing and mayonnaise and the foods made with them, left at room temperature. E coli - contaminated ground beef, vegetables grown in fields irrigated with contaminated water or manure Listeria - pregnant women are at risk, 20 times more susceptible; can cause miscarriage & still birth. i.e., reheated hot dogs, other liquids from packages drip into other foods, unpasteurized milk & juice, soft cheeses, like brie, feta & blue cheese

Laboratory data used to identify electrolyte imbalance

Serum electrolytes CBC Osmolality Urine PH ABG

Electrolytes

Sodium (Na+) Range 135-145mEq/L Chloride (Cl-) 95-108 mEq/L Potassium (K+) 3.5-5.0 mEq/L Calcium (Ca2+) 8.5-10.5 mg/dL or 4.5-5.5 mEq/L Magnesium (Mg2+) 1.5-2.5 mEq/L Phosphate (PO4-) 1.8-2.6mEq/L Bicarbonate (HCO3-)

Define enema

Solution introduced in the rectum and large intestine -distends the intestine -imitates the mucosa -increasing peristalsis -cause excretion of feces and flatus

identify normal ranges for each vital sign

TEMPERATURE: 98°.6-100°F 36°-37.5°C BLOOD PRESSURE: 120/80 (Typical blood pressure for a healthy adult) PULSE: range: 60-100 PAIN: assesment scales Range: 0-10, Mild- 1-3 range Moderate- 4-6 range Severe- 7-10 range PULSE OX: Normal SpO2 85-100%; < 70% life threatening HEART RATE: 60-100 beats/min RESPIRATORY RATE: 500 (Tidal Volume)

hyperpyrexia

a high fever such as 41c or (105.8F)

definition of transcendence

a persons recognition that there is something other or greater than the self and seeking and valuing of the greater other, wheather it is an ultimate being force or value

identify essential aspects of perioperative preparation:

a planned physical alteration that encompasses three phases which include: -preoperative phase -intraoperative phase -post operative phase together these phases are referred to as perioperative period. the time before, during, and after operation.

laceration

a torn or jagged wound, or an accident cut wound

Fluid Ouput

Urine - 1400 - 1500 or 0.5 ml/kg/hr Insensible lungs & Skin 300-400 mL/day Sweat 100 ml/day Feces 100-200 ml

attentive listening

Using all senses; listen actively Most important technique in nursing Requires energy and concentration Paying attention to total message Nurse focuses on clients needs Conveys an attitude of caring and interest Encourages client to talk Do not interrupt speaker Take time to respond appropriately

Stress Vitamins

Water Soluble vitamins, like Vit. C, ascorbic acid, and B complex

Need for increase in protein in diet

Wound, surgeries, burns

identify the variation in normal body temperature pulse respiration and blood pressure that occur from infancy to old age

TEMPERATURE: -infancy: unstable, newborns must be kept warm to prevent hypothermia -elder: tend to be lower than that of middle aged adults, decreased thermoregulatory controls PULSE: -infancy: newborns may have heart murmurs that are not pathological -elder: often have decreased peripheral circulation RESPIRATIONS: -infancy: some newborns display "periodic breathing" -elder: anatomic and physiologic changes cause respiratory system to be less efficient BLOOD PRESSURE: -infancy: arm and thigh pressures are equivalent under 1 year of age-elder: clients medication affect how pressure is taken.

Potassium (K) (mineral)

Sources: apricots, bananas, oranges, carrots functions: muscle contraction and heart beat

Vitamin C

Sources: citrus fruits, strawberries Function: together with folic acid - RBC formation, improves Iron absorption

Phosphorus (P) (mineral)

Sources: dairy Functions: strong bones & teeth

Vitamin K

Sources: dark green leafy vegetables, and synthesized by intestinal bacteria Function: formation of blood clotting

Magnesium (Mg) (mineral)

Sources: dark green vegetables Functions: regulates heart beat

Vitamin D

Sources: fortified dairy Function: bones & teeth

iron (Fe) (minor mineral)

Sources: lean red meats Functions: component of Hemoglobin

Vitamin E

Sources: legumes, nuts Function: antioxidant

Sulfer (S) (mineral)

Sources: meat products Functions: help with inflammation

Chloride (CI) (mineral)

Sources: table salt Functions: acid-base imbalance

Calcium (Ca) (mineral)

Sources: Dairy Functions: blood clotting, bone & teeth

iodine (I) (minor mineral)

Sources: Saltwater fishes Function: regulates energy metabolism as part of the thyroid hormone thyroxin

Discuss different types of urinary diversons

THERE ARE TWO TYPES : INCONTINENT & CONTINENT INCONTINENT -ureterostomy: ureter connected directly to surface of skin to form small stomas -nephrostomy tubes: from kidneys to stoma -vesicostomy:bladder wall surgically attached to opening in skin forming an incontinenet stoma -ileal conduit(ileal loop):most common, segment of ileum is removed, intestinal ends are re-attached, one end is closed with suture and other end is brought through abdominal wall to create stoma CONTINENT -kock pouch:creation of pouch connected to skin and intermittent catheterization -neobladder: replaces damaged bladder with a piece of ileum; connected to urethra and voiding is contolled by pt.

Discuss bowel diversion ostomies

Temporary: -traumatic injuries -inflammatory conditions of the bowel Permanent: provide means of elimination when rectum or anus is non functional -birth defect -cancer Anatomical Location: -Ileostomy: .opens at distal end of the small intestine .liquid, digestive enzymes, minimal odor, constant elimination -Cecostomy: cecum (constant liquid elimination) -Colostomy: opens into colon Colostomy Type by Location: -Ascending colostomy: .liquid, digestive enzyme presents, odor is a problem, constant -Transverse colostomy: .malodorous, mushy, not control -Descending colostomy: .increasingly solid fecal drainage -Sigmoid colostomy: .formed consistency, can be regulated -Over time stool becomes more formed, residual colon compensates with water re-absorption Surgical Construction of Stoma: a) single b) loop c) divided d) double-barrel colostomies

rectal temp

The average normal oral temperature is 98.6°F (37°C). A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.

What does TPN mean

Total Parenteral Nutrition: aka hyperalimenation - a major central vein is used; subclavian or juglar - HIGH ALERT - long term support or high metabolic needs

Identify sources and types of loss:

Types of Loss: 1. Actual - can be identified by others. Such as death and amputation. 2. Perceived - experienced by only one person but cannot be verified by others. Such as loss of independence or freedom. 3. Anticipatory - experienced before the loss actually occurs. Such as when an individual prepares ahead of time for a beloved one's death. 4. Situational - losses caused by unexpected or unusual circumstances. Such as a job loss or a child's death. 5. Developmental - losses that predictably occur during life cycle or process of normal development. Such as death of aged parents or departure of grown children. **Both actual and perceived losses can also be anticipatory because people can live the experiences before it really happens** Sources of loss: **Not always associated with physical death** 1. Loss of an aspect of oneself - body image, trauma, burns, divorce, etc. 2. Loss of an object external to oneself - inanimate: house, job, car, jewelry. Animate: a pet 3. Separation from an accustomed environment: child's first day of school or a new college freshman going away to school. 4. Loss of a loved or valued person: due to illness, separation or death.

Cultural Competence

being capable of understanding, respecting, and attending to the total context of the clients situation and use a complex combination of knowledge, attitudes and skills to deliver effective care

hematuria

blood in the urine

Purpose of Percussion and vibration and when it is done

a forceful striking to the body to mechanically dislodge tenacious secretions for the bronchial wall.

dehiscence

a bursting open or splitting along natural or sutured line. rupture of a wound closure

atelectasis

a collapse of lung tissue affecting a part or all of the lung

hypoxia

a condition where there is insufficient oxygen anywhere in the body, from the inspired gas to the tissue.

eschar

a dense scar type tissue or dark , black, crusted pressure sore

Protein Digestion

broken down into Amino Acids

discuss the procedure of gastrointestinal tube insertion

a. prepare the pt: fowlers position, place towel across chest b. assess the nares c. prepare the tube: if rubber tube place in cold, if plastic put in warm water. d. MEASURE FROM TIP OF NOSE TO THE TIP OF THE EARLOBE, FROM THE TIP OF THE EARLOBE TO THE TIP OF STERNUM [XIPHOID PROCESS] e. mark tube f. insert tubing procedure: gloves, lubricate, inseert tube if resistance met withdraw and relubricate and insert into other nostril, hyperflexion of neck and advance tube downward, once the tube reaches the throat the pt wil feel the tube and gagging may occur so tilt the head forward, pass the tube with swallow of water ice chips. g. check for correct placement: stomach aspiration, auscultate for air, x ray #1 h. secure to nose and gown i. documentation j. plan of care k. suction

abducton and adduction

abduction: Movement of the bone away from the midline of the body adduction: Movement of the bone toward the midline of the body

mobility

ability to move freely, easily, rhythmically and purposefully in the environment

tachypnea

abnormal rapid breathing

different types of wounds

abrassion, puncture, laceration and penetrating -abrasion: surface scrape thats usually unintentional [fall] -puncture: penetration of skin and underlying tissues from a blow with a blunt object

How to identify food allergies or intolerance on infants

add one food every 5 days

list four different conditions that affect respiratory function

age, environment, lifestyle, health status ANEMIA, RESPIRATORY DISEASE, medications, NARCOTICS, DEPRESSED RESPIRATORY CENTER, OPIATES, stress gender.

antiseptic

agents that inhibit the growth of some microorganisms; primarily used on skin or tissue

Dietary problems

allergies, chewing, swallowing

rhonchi

also known as gurgles: secretion in upper airway sounds like snoring

patients at risk for skin breakdown

altered hydration [dehydrated]

12

an ileostomy produces liquid fecal drainage, constant and cannot be regulated. contains some digestive enzymes which are damaging to the skin for this reason clients must wear and appliance continuously to prevent breakdown. colostomy is opening to the colon large bowel

stool from a colostomy vs an ileostomy

an ileostomy produces liquid fecal drainage, constant and cannot be regulated. contains some digestive enzymes which are damaging to the skin for this reason clients must wear and appliance continuously to prevent breakdown. colostomy is opening to the colon large bowel

Overweight/Obesity

an imbalance between food eaten & energy expended

Time orientation

an individuals focus on the past, present or future.

immobility

an interruption of mobility

acute

appear suddenly or last short time

contusion

appears echymotic and occurs from a blow with a blunt object

nursing interventionsassociated with applying heat and cold

application of heat: i. chk if not contraindicated in pt. ex: bleeding ii. 20-30 min intervals, but check every 15 min iii. remove heat if pt feels warm / uncomfortable iv. assess skin for burns application of cold: same as above ---> iii. remove the cold.

nursing care for a patient with a wound hemorrhage

apply pressure dressings to the area and monitor the clients vital signs, in many cases some pts may have to be taken to the OR for surgical intervention

touch and communication

appropriate forms of touch to reinforce caring, it is non verbal, therapeutic touch for pt w/ hearing impaired or AMS or comatose pt to insure message intended is recieved, handshake or touching shoulder,

clean contaminated wounds

are surgical wounds in which the respiratory, GI or genital tract have been entered

guidelines when applying restraints

assess every 30 min remove and do ROM and assess skin every 2-4 hrs if temporarily removed, do not leave unattended

most common work related threat for healthcare providers

back and shoulder injuries

national patient safety goals

based on recent reports, national rganizations [JCAHO] have increased their awareness of the need to improve pt safety. - reconcile medications across the continuum: [ meds pt is taking at home compared to those that the pt is taking while hospitalized]

how to collect a time urine specimen

before collecting empty bladder. then wait to collect in bucket for 24 hrs

how to collect a time urine specimen

before collecting empty bladder. then wait to collect in bucket for 24 hrs also if catheter is in place you may use syringe to collect specimen and then place into cup or tube.

Use of a nasal cannula

can be used while eating or drinking most common and inexpensive low flow device used to deliver O2 delivers 1-6 L/min and a low % of 21-24%

granulation

capillary network that fills the wound bed. a translucent red color and bleeds easily. when the granulation tissue matures, epithelial cells migrate over the wound and fill it

intervention to prevent catheter associated with UTI

catheterize only when necessary aseptic technique sterile equipment mantain closed system dont disconect unless absolutely needed good handwash perineal care prevent cntaminaion in incontinent pt

opportunistic pathogen

causes disease only in a susceptible host. [someone at risk for infection]

COLDERR

character onset location duration exacerbation relief radiation

urge incontinence

characterized by loosing a considerable of urine for no apparent reason after feeling a certain urge need to void. ex: urinating more than 8x a day or 2 times a night. pee alot!

after discontinuing a foley, what is important for you to check?

check for discharge on tip of catheter, make sure they void

11

chk for skin irritation if red around area when stoma is out its bad where you put the actual bag you cut 1/16 to 1/18 bigger than stoma if stoma looks purple or brown report normal is red beefy to empty the pouch from 1/3-1/2

ostomy care

chk for skin irritation if red around area when stoma is out its bad where you put the actual bag you cut 1/16 to 1/18 bigger than stoma if stoma looks purple or brown report normal is red beefy to empty the pouch from 1/3-1/2

how do you obtain a sterile specimen?

clean catheter w/ alcohol swab and then use the correct syringe

behavioral management

client is danger to self and others

stool softening medications

colace and surfak

sign of an infection

cold/pallor hot/red fever

atelectasis

collapse of the air sacs

informed consent

consent by a patient to a surgical or medical procedure or participation in a clinical stusy after achieving and understanding of the relevant medical facts and risks involved

skin

considered first line if defense

Planning/Implementation of diet

consult a dietician, social service

diffusion

continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of molecules

identify the important data that needs to be included in the data collection of the respiratory system

cough, sputum, HEMOPTYSIS: blood in the sputum, family and social history, EXPOSURE TO TOXINS, home or work, inspection of skin color look for cyanosis centra= chest/abdomen/thighs and peripheral bluish at ends like hands and feet, skin condition, thoracic shape, CLUBBING OF FINGERS : THE ANGLE BETWEEN THE NAIL AND THE NAIL BED IS 180 DEGREES OR GREATER, auscultation sounds. normal: vesicular bronchial, bronchovesicular. and adventitious sounds: crackles rubs, wheezes, stridor, gurgles also known ans ronchi.

counting for unstable pt and assessment

count for one full minute

counting pulse for unstable pt and assessment

count for one full minute

toddlers

curious like to feel and touch. you need a toddler proof home

Nursing interventions associated with liquefying secretions

expectorants break up mucous making it more liquid and easier to expectorate.

Describe constipation

decreased activity, low liquid and fiber, muscle weakness - fewer than 3 bowel movements per week - dry, hard stool or no stool - additional re-absorption of water (slow peristalsis) - increased effort or straining - decreased appetite - headache - abdominal pain, cramps or distention - sensation of incomplete bowel evacuation - painful defecation CAUSES OF CONSTIPATION: - insufficient fiber intake - insufficient fluid intake - insufficient activity or immobility - irregular defecation habits - change in daily routine - lack of privacy - chronic use of laxatives or enemas - irritable bowel syndrome - pelvic floor dysfunction or muscle damage - poor motility or slow transit - neurological conditions (stroke, paralysis) - emotional disturbance medications (opiates, iron salts)

kussmaul / hyperpnea

deep and fast [exercise or metabolic acidosis]

large intestine [colon]

defined as a muscular tube lined with mucous membrane. it has muscle fibers that are circular and longtitudonal. it also has Haustra: that are pouches in the large intestine due to the longtitudonal muscles being shorter than the colon the colon main functions include absorption of water and nutrients, mucoid protection of the intestinal wall, and fecal elimination

Purpose of a venturi mask

delivers O2 concentration vaying from 24 - 40 or 50 % through liter flows of 4-10 L/min delivers precise O2 concentration

Purpose of a non re-breather mask

delivers the highest O2 concentration possible 95-100% the pt exhales through a one way valve and breathes nearly pure O2 in the bag. 10-15 L/min

factors that affect wound healing

development, nutritional status, lifestyle, medications, infection

Complication of overweight

diabetes

3

dietary factors play a huge role fiber give fecal vol fluid daily income 2000-3000 activity promotes bowel movement peristalsis

teaching patient about how to mantain normal bowel habit [fluids, activity, diet]

dietary factors play a huge role fiber give fecal vol fluid daily income 2000-3000 activity promotes bowel movement peristalsis

dyspnea s/s

difficult or labored breathing : SOB

dysuria

difficult or painful orination

dyspnea

difficult, labored breathing -[types of dyspnea discussed further in lecture / notes]

define systemic diffusion

diffusion of O2 and CO2 occurs between the capillaries and the tissues and finally the cells. this exchange occurs with pressure differences based on the bodies needs.

Bronchoscopy

direct visualization of the respiratory tract through a scope

identify the essential nursing responsabilities included in planning perioperative nursing care

discahrge planning [begins on or before admission for the planned procedure] -surgical preparation -teaching pre-op/ proedures / treatment, -anxiety reduction -family support -decision- making coping

how does an enema work

distends the intestine irritates the mucosa increasing peristalsis cause excretion of feces and flatus

care of a retention catheter and a condom cath

do not make tight because of circultion reasons

what info do you need before you insert a foley?

doctors orders, and last time voided

Anemia in adolescent girls

due to the start of meneses

4

elders have alot of constipation reduceced activity low liquid and fiber, muscle weakness

physiological changes in the elderly when it comes to fecal patterns

elders have alot of constipation reduceced activity low liquid and fiber, muscle weakness

signs and symptoms of diarrhea and what can occur

electrolyte imbalance, loss of potassium

Junk foods

empty calories; high calorie, low nutrient ratio

purpose of leg exercises after surgery

encourage patient to do every one to two hours while awake. helps prevent clot formation and promote arterial blood flow.

What is narcolepsy?

excessive daytime sleepiness

factors affecting respirations

exercise, stress, environmental temp., medications, increased altitude

Malnourished pregnant woman

fetal & infant morbidity increased

constipated stool

fewer than 3 bowel movemnts per week, dry, hard or no stool -additional reabsorption of water [slow peristalsis -increased effort or straining -decreased appetite -headache -abdominal pain, cramps or distention -sensation of incomplete bowel evacuation -painful defecation

filtration

fluid and solutes move together across a membrane from one compartment to another

Extracellular fluid

fluid found outside the cells 1/3 of all body fluids 15 Liters - responsible for carrying nutrients and waste products to and from the cell - principal electrolytes are Na+ (sodium), Cl- (chloride), and bicarbonate (HCO3-)

Intracellular fluid

fluid found within the cells of the body 2/3 of all body fluids 25 Liters - metabolic processes of cell take place, oxygen, glucose, potassium, magnesium - Principal cations K+ (potassium), Mg+ (magnesium) -Principal anions HPO4- (phosphate), SO42- (sulfate)

exudates [drainage]

fluid that escapes from the blood vessels and include dead phagocytes, dead cells and serious sanguouns fluid

What ETOH intake prevents

food intake, impaired absorption, reduced storage, increased metabolic needs, impaired use of nutrients, especially water soluble vitamins C & B complex

dependent edema

found in the lower body parts [when body is supine sacrum and buttocks; when the body is standing or sitting - legs and feet]

base of support

foundation on which the body rests. widening base of support, spreading feet apart.

how do you clean the perineal area?

front to back

non verbal communication

gestures/ facial expressions/ touch, more widely used, important for nurses to learn

hypertonic solution

has a greater concentration of solutes than blood plasma D5NS [5% dextrose in normal saline] D5 1/2NS [5% dextrose in 1/2 normal saline] D5 LR [5% dextrose in lactated ringers] 3%NS

hypotonic solution

has lesser concentration of solute than plasma 0.45%NS, 0.33%NS volume expanders - used to increase the blood volume loss of blood [hemorrhage] loss of plasma [burns] i.e: albumin, dextran and plasma

isotonic solution

has the same concentration of solutes as blood plasma D5W [5%dextrose in water] 0.9% NS [normal saline] LR [lactaded ringers] balanced electrolyte solution such as Na+, CL-, K+, Mg+]

active ROM exercises

head tilts/ turns shoulder movements [up/down/ side to side/ rotations] wrist bends finger bends hip and knee bends leg lifts and rotations

purpose and how to teach a patient how to use an incentive spirometry

helps remove mucus -helps prevent pneumonia and atelectasis -IS encourage deep breathing -deep breathing usually facilitates coughing reflex result in expectoration of secretions -measures flow of inhaled air -helps prevent pneumonia and atelectasis -encourage atleast every 2 hours while awake in the sitting position

How to assess for anemia

hemoglobin

Nursing diagnosis for morning sickness

high risk for fluid volume deficit

Foods eliminated in High Blood Pressure

high sodium foods

foo drop / prevention

high top sneaker? wtf did she say?

nosocomial infection

hospital acquired

Difference between early signs of hypoxia versus late signs of hypoxia

hypoxia is a condition where there is insuficient O2 anywhere in the body from the inspired gas to the tissue. signs include: rapid pulse, rapid/shallow respiration and dyspnea. increased restlessnes!!! or light headedness. flaring nares. substernal or intercostal retractions. cyanosis! is a very late sign of hypoxia where lips and mucous membranes are bluish.

most common complications of wound healing

i. hemorrhage: escape of blood from a wound thats abnormal ii. hematoma: localized collection of blood underneath the skin and is easily identified as reddish and blue in color iii. infection: the presence of pathogens in a wound iv. dehiscence with possible evisceration: profusion of the internal viscera through an incision from surgery in which the suture line has partially or totally ruptured

describe phases of wound healing

i. inflammatory phase: initiated after injury and last 3-6 days. two parts a) nemostasis - bleeding stops, scab you need this to start healing b)phagocytosis: macrophage activity [WBC eat debris] ii. proliferance phase: extends from day 3 or 4 to 21 days post injury iii. maturation phase: begins about 21 and can extend up to one or two years after the injury. fibroblasts continue to synmesize collagen within become more organized to form a scar/keloid (hypertropic scar)

clinical assessment of wound healing

i. look at appearance of wound and determine progress towards healing ii. size iii. look at the type and amount of drainage iv. look for swelling v. note for patient complaints of any pain vi. look at if more or any drainage is coming from the wound

nursing interventions associated with wound

i. prevent infection ii. cleansing wound iii. dressing wound iv. securing wound

guidelines in removing sutures

i. verify orders ii. explain to the patient iii. remove the dressing iv. don sterile gloves v. use a removal suture kit: -grasp knot with forceps -place the curved tip under suture as close to the skin as possible -cut the suture -pull the suture out in one piece with forceps -look for pieces *follow hospital protocol to who can/cannot remove sutures

guidelines related to bandaging and use of binders

i. when bandaging a joint, make sure the joint is slightly flexed so that it avoids strain on ligaments ii. pad between skin services and over bony prominences to prevent infection iii. bondage body parts from distal to proximal [increases venous return] iv. bandage with even pressure [not tightly] maximizes blood flow v. cover dressings with bondages 2 inches beyond edge of dressing vi. leave the end of the body part exposed for circulation checks vii. face the pt to mantain uniform tension and direction of applying bandage

correct height of a walker

if the handle bars are slightly below the waist and the elbows flexed its a good height

neurogenic bladder

impaired neurological function can interfere with the normal mechanism of elimination

Role immigration plays on culture

in 2007, 38.1 million were foreign born. 12.6% of the U.S. population

contaminated wounds

include open, fresh or accidental wounds and surgical wounds involving a major break in sterile technique

infected wounds or dirty infected wounds

include wounds containing dead tissue and wounds with evidence of clinical infection

the sequence used to examine the abdomen

inspection auscultation [prior to palpation] percussion palpation examination, of the rectum and anus [inspection and palpation]

what contributes to consipation

insufficient fiber intake, insufficient fluid intake, insufficient activity or immobility, irregular defecation habits, change in daily routine, lack of privacy, chronic use of laxatives or enemas, irritable bowel syndrome, pelvic floor dysfunction or muscle damage, poor motility or slow transit, neurological conditions [stroke, paralysis], emotional disturbance, medications such as opiates, iron salts.

define skin integrity

intact skin refers to the presence of normal skin and skin layers uninterupted by wounds. many chronic illness and their treatments affect the skin integrity

what is the purpose of an enema?

intended to remove feces: prevent the escape of feces during surgery, prepare the intestine for certain diagnostic tests, remove feces [constipation, impaction], generally- height: NO higher than 30 cm [12in] above rectum

Define urinary catheterization (indwelling catheter)

intro of catheter through the urethra into the bladder (last resort)

infection

invasion of body tissue by micro organisms and their proliferation [growth] -asymptomati: no evidence of disease no s and s - infectious: presence and evidence of disease

urinary incontinence

involuntary leakage of urine or loss of bladder control

stress

involuntary loss of urina associated w/ activities that increase stress in the abdomen and bladder ex: sneezing, coughing, lifting, sex, laugh, and abs,

stress incontinence

involuntary loss of urine associated w/ activities that increase stress in the abdomen and bladder ex: sneezing, coughing, lifting, sex, laugh etc.

enuresis

involuntary urination in children beyond the age when voluntary bladder control is normally acquired usually 4-5 year of age

nocturnal enurisis

involuntary voiding during sleep [bed wetting]

Nutritional deficiency in preschoolers

iron deficiency anemia

wound irrigation and wound packing:

irrigation: is the washing or flushing out of an area packing: placing gauze into wound to facilitate the formation of granulation tissue and healing by the second intention

cleaning

is chiefly done for hygiene

eupnea

is quiet, rhythmic and effortless breathing

What is sleep deprivation?

itchy eyes, headache, blurred vision, decreased judgment and concentration, difficulty remembering things

define artificial airway

keep airway open, intubation for general surgery or when emergency mechanical ventilation is needed.

Care of a chest tube

keep rubber tipped clamps, sterile occlusive dressings, bottle of sterile water. keep drainage system below chest level, rubber tips go everywhere with pt, disconnect drainage system from suction apparatus before moving pt. make sure vent is open!

How to assess improvements

labs: CBC

anuria

lack of urine production output less than 50mL/day

Food contradictions for infants

large pieces or hard texture (can't chew)

nursing intervention/patient falling while ambulating

let the patient smoothly drop to the floor use your foot. call for help

local infection

limited to the specific part of the body where micro organisms remain

location for apical pulse

listening at the bottom of the heart

incontinence

loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter, at specific times [after meals] or irregularly, there are 2 types: partial and major. partial: cannot control flatus, or minor soiling. major: cannot control feces of normal consistency. causes emotional distress and/or social isolation dysfunction of anal sphincters- vaginal delivery, surgical procedures [repair or colostomy], trauma, tumors. decreased rectal compliance. impaired rectal rectal sensation: diabetes mellitus, multiple sclerosis, dementia, meningomyelocele, spinal cord injuries

What can malnutrition cause in the 2nd and 3rd trimester in a malnourished pregnant woman

low birthrate (LBW) and a higher incidence of complication.

oliguria

low urine output, usually less than 500mL a day or 30mL an hour for an adult

incision

made with a sharp instrument [surgical scapel]

how many inches do you expect to insert the urinary catheter on a male or female?

male: lube 6-7" insert 7-9" female: lube 1- 1 1/2 insert: 2-2 1/2

cheyne-strokes

marked rhythmic waxing and waning of respiration from very deep to very shallow breathing and temporary apnea [cesation of breathing]

impacted stool

mass or collection of hardened feces in the folds of the rectum, results from prolonged retention and accumulation of fecal material

airborne transmission

may involve droplets / dust that contains infectious agent

chronic

may occur slowly over a long period of time and last several months/ years

Food high in iron

meat, raisins, spinach, beets, beans, peanut butter, whole grains, iron fortified cereals, eggs

black tarry stool

most common for newborns

Birth weight

most important predictor of subsequent development

third space syndrome

movement of fluid outside of vascular space and into areas that is non usable

Osmosis

movement of water molecules across a semipermeable membrane, from the less concentrated area to the more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane

legal implications of restraints

must be properly documented by institutions standards

Nursing diagnoses associated with culturally responsible nursing care

nursing diagnoses developed by NANDA are based on western culture. Incorporate clients understanding their diagnoses

Non Essential Nutrients

nutrients than can be made by the body

Nutritional requirement of an adolescent

nutritional needs are higher, including calories, protein, calcium, & vit B to metabolize increase in nutrients eaten

intentional

occur during medical therapy [surgical/venipunctures]

fluid volume excess FVE

occurs when the body retains both water and electrolytes [Na] in the extra cellular fluid in equal proportions.

Nutrients

organic & inorganic substances found in food needed by the body for proper functioning and have three main functions. 1. provide energy for body processes and movement 2. provide structural materials for body tissue 3. regulate body processes

stool for occult blood

originates in upper GI tract, has blood

Pulse oximetry

oxygen saturation

assess the spiritual needs of clients and plan nursing care to assist clients with spiritual needs.

patients assessment data must include spiritual beliefs/practices. -general history and nursing history. clinical observation of patient behavior -questions to ask for obtaining data about spiritual/religious practice: would you like to have someone to visit you for spiritual supporting/counseling? do you have any spiritual or religious concerns that may affect your health care? -* do not assume that the client follows all rituals of their stated belief system. -environment: religious items in room -behavior: prayer before meals / other times, negative towards religious representative/diety -interpersonal relationships: visit from religious advisor -verbalizations in conversations: talks about a higher being, mentions church/synagogue, spiritual leader, and/or religious topics -affect and attitude: mood/anxiety/depression/preoccupation resource for assessment FICA F: faith / beliefs, do you have any spiritual beliefs important to you? I:implications/influence: how does your faith affect your current situation/coping? C: community: is there a group you meet with that you would like to visit you? A: address: how would you like your health care team to support you spiritually?

Who have the most influence on a school age childs nutrition

peers, teachers, yet parents are the most important role model

contractures

permanent shortening of the muscle

Cations

positively charges electrolytes Na+. K+, Ca+. Mg+

Smaller quantities of electrolytes in ECF

potassium, calcium, & magnesium

medical asespsis

practices intended to confine a specific micro organism to a specific area in order to limit number, growth and transmission

surgical asepsis [sterile]

practices that keep an area/object free of all micro organisms

sepsis

presence of infection

systolic

pressure of the blood as a result of contraction of the ventricles

purpose of splinting while coughing

prevent suture from opening

respiration

process of gas exchange between the individual and the environment

sterilizing

process that destroys all micro organisms including spores and viruses

polyuria

production of abnormally large amount of urine by the kidney

intervention to promote urinary eliminaion

promote adequate fluid intake normal adult about 1500mL/day, mantain voiding habits: position, relax, timing. assist w/ toileting: weak or impaired for safecty. for bedbound pts who cant move move head of bed 30-45 degrees or small pillow on back and then flex hips and knee to urinate comfortably.

identify specfic nursing interventions associated with oxygenation

promote oxygenation, C/T/DB, change positions frequently, hydration, medication

role of mucous in the large intestine

protective function: mucous contaions large amounts of bicarbonate ions. stimulated by parasympathetic nerves, mucous protects intestinal wall from chemical trauma [acid within feces], serves as an adherent for holding fecal material together, mucous protects intestinal wall from bacterial activity.

what do you do if you feel resistance?

pull the tube back.

tachycardia

pulse rare of greater than 100, heart not filled with blood quickly enoguh

cathartics

purgative drug: laxative, chiefly of a drug or med tending to facilitate evacuation of bowel

after opening the sterile field and before inserting the catheter into the patient what do you do next?

put on sterile gloves, and clean area with iodine or sterile water

Low protein diet

reduced intake of protein; prescribed to those with liver and kidney disease

Purpose of a face tents

replaces the face mask when pt can not tolerate it. provides various concentrations of O2 = 30-50% O2 at 4-8Liters

Nursing interventions associated with fluid volume excess

restrict fluids

nursing diagnosis associated with wounds

risk for infection, pain, risk for impaired tissue integrity, anxiety, body image disturbance

body mechanics

safe and efficient use of muscle groups mantain balance reduce energy required reduce fatigue decrease risk of injury Center of gravity Lowering the center of gravity Flexing knees and hips (squatting) Base of support Widening base of support Spreading feet apart Avoid rotation (twisting), stooping (bending without bending knees and hips) LIFTING: Use major muscle groups Thighs, knees, upper and lower arms, abdomen, pelvis Keep feet at least 30 cm (12 inches) Keep load close to the body No hazards on the floor, clear path PULLING/PUSHING AND PIVOTING: Pulling and Pushing Enlarged base of support in the direction on movement Pulling weight shift away from the object Pushing weight shift towards the object Pulling is better than lifting, pushing better than pulling PIVOTING: To avoid twisting of the spine Weight on the ball of the feet

clarity

say what is meant

Modifiable risk factors for obesity

sedentary lifestyle

What is bargaining?

seeks to bargain to avoid loss. Patient says "let me live some more days and then I will be ready to go"

signs of fecal impaction

seepage! little things in liquid that cause pain and discomfort. like diarrhea but not diarrhea. something is stuck and tiny bits and pieces are SEEPING through. Seepage! :)

characteristics of spiritual health

sense of inner peace compassion for others reference for life gratitude humor wisdom generosity capacity for unconditional love • Faith - Complete and unquestioning acceptance of a belief that cannot be demonstrated or proved by the process of logical thought • Hope - A concept that incorporates spirituality, that involves the anticipation directed towards a future fulfillment • Value - Having cherished beliefs and standards • Meaning - Having purpose, making sense of life CONNECTING: relating to others, nature, inner self, universe BECOMING: involves refelction, allowing life to unfold and knowing who one is experiencing

Anasarca

severe generalized edema, weight gain, facial/body puffiness, skin is cool and pits when touched

biots breathing

shallow breaths interrupted by apnea -common causes: may be seen in healthy people and in clients with central nervous system disorders.

What is parasomnias?

sleepwalking, sleep terrors, sleep talking, nightmares, broxism, enuresis

provide immediate skin care to incontinent pt

so moisture doesn't increase bacterial growth and irritation

Why is breakfast important in a school aged child (6-12yrs)

so that they don't become inattentive and restless, easily fatigued or have diminished problem-solving abilities

Principal electrolytes of ECF

sodium, chloride, bicarbonate

Foods high in Sodium

soy sauce, pickled foods, processed canned and frozen foods, such as soups, hot dogs, ham, boloney, salami, cheese

Purpose of Prenatal Vitamins

special formulation to meet the essential increase in vitamins especially Iron (FE) and folic acid.

infant baths

sponge baths are suggested and immediately dry after bath once the umbilical cord falls off

systematic infection

spreading of micro organisms damaging different parts of the body -bacteremia: bacteria in the blood -septicemia: bacteria results in systematic infection

identify the most common diagnostic tools utilized in the care of the PT with a respiratory condition

sputum specimens: c&s look for abnormal growth cytology looks for abnormal cells acid fast bacillus looks for TB blood tests: cbc: look at the presence of hemoglobin and hematocrit necessary for O2 transport ABG: looks for O2 saturation and the lvl of O2 and CO2 in the blood bronchoscopy pulmonary function test

principles of surgical asepsis

sterile items that are out of vision or below the waist level of the nurse are considered unsterile

Active transport

substance can move across cell membranes from a less concentrated solution to a more concentrated one using metabolic energy

active transport

substances can move across cell membranes from a less concentrated solution to a more concentrated solution using metabolic energy [ATP]. specific carrier required for each substance [enzymes].

abrasion

surface scrape that is usually un-intentional

urinary diversion

surgical diversion to reroute urine from kidney and bladder

non dependent edema

swelling is not focused on the dependent body areas - usually there is a specific cause or an illness.

What is cultural responsible nursing care?

taking into consideration: -context in which client lives -situations in which clients health problems arise -clients health beliefs and practices -clients cultural needs Allows the nurse to have a proper cultural understanding of client's healthcare beliefs and practices

what types of fluids do you use?

tap water normal saline oil -> enema?

paralytic ileus

temporarily sedation of parastalsis [bowel sounds]

role of the nurse and MD on informed consent

the doctor has legal responsibility that the patient gives informed consent. nurse may witness the signature of the client on the consent form [know the facility policy] by doing this the nurse should make sure that the patient understands the procedure. if not the nurse needs to notify the surgeon before hand.

etiologic agent [microorganism]

the extent to which any microorganism is capable of producing an infectious process; depends on number, virulence, ability to enter body, susceptibility

orthopnea

the inability to breathe except in an upright position [eg: patients cant breathe without using pillows to mantain an upright position]

wound

the injured body part - unintentional and intentional

When is breast milk produced more

the more frequent feedings and complete emptying;supply and demand

Nutrition value

the nutrient content of a specified amount of food

Define culture

the pattern of information composed of thoughts, values, beliefs, actions, attitudes, communications and customs shared by a group of people and passed from one generation to the next

evisceration

the profusion of the internal viscera through an incision from surgery with the suture line ruptured partially or totally

identify the different ways in positioning patient for adequate ventilation

the purpose of changing positions frequently will improve lung expansion and improve ventilation

urgency

the sudden, strong desire to void

Regulation of body fluid

through input and output

describe the regulation of respiration

through neural and chemical controls; the more you need the more increase in your respiration rate. the nervous system of the body adjusts the rate of respiration to meet the body needs

Illness Affecting Fluid & Electrolytes

tissue trauma, renal disorders, cardiovascular disorders, altered level of consciousness, sepsis, burns, diabetes mellitus, chronic obstructive lung disease

correcting charting errors

to correct a charting error simply draw a line across error and initial after.

definition of forgiveness

to give up resentment against offender positive way to deal with an offense that results in reduction of negative emotions and enhancement of positive emtions

Purpose of Couch and deep breathing and when it is done

to remove secretions from the airways and to expectorate secretions

describe the purpose of chest tubes

to restore negative pressure to drain collected fluid or blood

medication that causes constipation

too many laxatives, analgesics like morphine and narcotics

risk assessment tools

tools that are utilized to summarize risk for injury

stool softening medications

tranquilizers [morphine, codeine] for constipation, iron [acts locally] for constipation, laxatives, stool softeners, suppress peristalsis [treatment of diarrhea], appearance of feces [aspirin, iron, antibiotics, antiacids, pepto-bismol]

heat conduction

transfer of heat from one molecule to a molecule of low temperature objects

alternative to restraints

unsafe client close to nursing station. -stay with confused/sedated client when using bedside bathroom

when do individuals get the urge to void

urine collects in the bladder as it fills voiding happen special nerve ending s on the bladder wall called stretch receptors, adult 250-400ml thats when voiding happens. stretch receptors transmit impulse to spinal cord that is called the voiding reflex center. internal sphincter :relaxes and you have the urge to void. external sphincter: relaxes concious brain relaxes voluntary internal sphincter and voiding occurs

residual urine

urine remaining in the bladder following voiding

cane use

use cane on the stronger side

therapeutic communication

use open ended questions, promote understanding, nurse must understand pt. view and feelings before responding, PHYSICAL ATTENDING: mantain good eye contact / face to face, being silent and patient until client ___ <- ._. thanks jaz! promotes understanding and can help establish nurse-client relationship ATTENTIVE LISTENING

working phase

use thought and feelings. what are they feeling? what are their thoughts?

Purpose of Postural drainage and when it is done

using gravity to assist with lung drainage so that secretions may be expectorated.

how to collect a specimen from a wound

using sterile technique simply use a swab or needle syringe to collect specimen. take specimen from center of wound. if there is drainage also take a specimen sample from drainage.

reflex incontinence

variation on urge incontinence in which you feel no need to urinate but urine is lost when bladder begins to contract uncontrolably

procedure for inserting a foley catheter

verify orders verify allergies equipment wash hands provide privacy adequate lighting open package using sterile technique prepare patient open gloves clean patient check balloon insert catheter inflate balloon pull back attach securely to leg obtain specimen check residual

frequency

voiding at frequent intervals that is more than four to six times per day

nocturia

voiding two or more times a night

best assessment for BP if abnormal

wait 15 - 30 minutes before taking blood pressure again

Principles of food safety

wash hands & surfaces often

Important issue in adolescents

weight control and fad diets; an attempt to gain control over a rapidly changing body

Clinical Signs of FVD

weight loss postural hypotension dryness of mucous membranes decreased skin turgor (normal is brisk) weak, rapid pulse sunken eyeballs subnormal temperature decreased capillary refill decreased urine output, Oliguira pale skin increase in specific gravity <1.030 (urine more concentrated) increased HCT increased BUN

Cachexia/cachectic

weight loss and wasting away

message

what is actually said/written, body language that accompanies words, type of medium used [face to face/ writting/ telephone], non verbal: highly effective, touch

Acid - Base balance compensated vs. un compensated

when acid base balance is COMPENSTAED all three levels including PH, CO2, and HCO3 are abnormal and out of range. when acid base balance is UNCOMPENSATED only two of three levels are abnormal and out of range. PH, CO2, and HCO3

osteoporosis

when bones are brittle because of loss of calcium, happens as person ages, demineralizes and becomes spongy

urinary retention

when emptying of bladder is impaired, urine accumulates and the bladder become over distended

when to change a colostomy bag

when the bag is either half full or one third full

What is the difference between active immunity and passive immunity?

• Active immunity: resistance of the body infection. Host produces its own antibodies in response to an antigen. Natural antigen lasts lifespan. Artificial antigen(vaccines) last many years but may need reinforcement by boosters • Passive immunity: antibodies are produced by another source, animal or human. Natural- antibodies transferred from an immune mother to her baby through placenta or breast milk and last 6-12 months. ; artificial - antibodies produced from an animal or another human and is injected and lasts 2-3 weeks

Which patients are most at risk for infection?

• Age • Stressors • Medical therapies • Chronic disease/ preexisting disease process

How do you maintain a sterile field?

• All objects in a sterile field must be sterile • Sterile objects become unsterile when touched by unsterile objects • Sterile items that are out of vision or below the waist level of the nurse are considered unsterile • Sterile objects can become unsterile by prolonged exposure to airborne micro organisms • Fluids flow in the direction of gravity • Moisture that passes through a sterile objects draws micro organisms for unsterile surfaces above or below the to the sterile surface by capillary action • The edges of a sterile field (I inch around) are considered unsterile • The skin cannot be sterilized • Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis

What are the principles of Medical Surgery asepsis?

• All objects in a sterile field must be sterile • Sterile objects become unsterile when touched by unsterile objects • Sterile items that are out of vision or below the waist level of the nurse are considered unsterile • Sterile objects can become unsterile by prolonged exposure to airborne micro organisms • Fluids flow in the direction of gravity • Moisture that passes through a sterile objects draws micro organisms for unsterile surfaces above or below the to the sterile surface by capillary action • The edges of a sterile field (I inch around) are considered unsterile • The skin cannot be sterilized • Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis

Which patients are most at risk for skin breakdown?

• Altered nutritional status • Mobility/immobility • Altered hydration • Altered sensation • Altered venous circulation • Reddened or blanched skin

How do you care for the perineal are of male and females?

• Assessment Focus-Assess for irritation, excoriation, inflammation, swelling, excessive discharge; odor; pain or discomfort; presence of urinary/bowel incontinence/recent rectal or perineal surgery; presence of indwelling catheter; perineal-genital practices and self-care abilities • always wash from clean to dirty • For females always clean form front to back to prevent infection • For males - clean urinary meatus by moving in circular motion from center of urethral opening around the glans

How do you clean the ear?

• Auricles are cleaned during the bath (inner aspect of ear lobe) • Excessive wax should be removed as much as possible • Irrigate as needed - normal saline or other solution • Have the patients head turned to the side • Pull the pinna up and back if older than 4 years old • Use a cotton tipped applicator to clean the auricle and the auditory meatus only.

What is the purpose of a restraint?

• Avoid/prevent purposeful or accidental harm to a resident/client • To do what is required to provide medically necessary treatment that could not be provided through other means

What are the standard precautions?

• Designated for all patients in the hospital • Apply to blood, all body fluids, excretions and secretions, except swear, non intact skin and mucous membranes • Wash hands after contact with blood, body fluids, secretions and contaminated objects whether or not gloves are worn • Handle, transport and process soiled linen in a manner to prevent contamination of clothing and transfer of microorganisms

How do you clean the eye?

• Eyes clean themselves • Soften dried secretions by placing a sterile cotton ball moistened in sterile water or normal saline over the lid • Wipe from the inner to outer canthus (using a different tip of the hand mitt) • For comatose patients use lubricating eye drops / eye patch. Moist compresses

What are 4 different types of restraints?

• Jacket Restraint: vest- straps tied to bed frame • Mitten Restraint: to prevent use of hands/fingers • Mummy Restraint: child to prevent movement. Used during short term procedures when a child is not sedated • Limb Restraint: immobilize a limb

Differentiate between systemic and local infection.

• Local: limited to the specific part of the body where microorganism remains • Systemic: Spreading of microorganisms damaging different parts of the body: bacteremia- bacteria present in the blood ; septicemia- occurs when bacteremia results in systemic infection, medical crisis

How do you care for a patient with a restraint?

• Obtain consent • MD order • Assure that the patient/support person is aware of the reason for the restraint • Leave restrictive but still do the job • Apply securely • Pad pony prominences • Tie the ends to part of the bed that moves to elevate head • Assess every 30 minutes • Remove and do range of motion and assess skin every two to four hours • Put finger under restraint so not too tight • Reassess the need for the restraint every 8 hours • If temporarily removed, do not leave unattended • Report broken/reddened skin • Apply so that it can be removed quickly/tie in a not that will not tighten when pulled • Provide emotional support

What prevents injury in health care agencies?

• Orienting patients to surroundings and explaining the call system • Assign at risk patients near the nurses station • Place personal items within reach • Keep bed in low position, wheels locked and side rails up • Lock all beds, wheelchairs and stretchers

Which patient do you not shave?

• Patients on anticoagulatory meds. Ex: heparin, Coumadin, aspirin

How do you handle airborne isolation?

• Private room • Wear a respiratory device • Susceptible people should not enter the room • Limit movement of patient outside the room • Varicella/TB

How do you handle contact isolation?

• Private room • Wear gloves as described • Wear a gown • Limit movement outside of the room • Dedicate the use of non critical patient care equipment to a single room

How do you apply restraints?

• Restrict as little as possible • Make sure it does not interfere with clients treatments or health problem • Readily changeable • Safe for the client • Least obvious to others

How do you care for soiled linen?

• Roll with soiled part inside, keep away from body and put in linen bag

What are alternatives for a restraint?

• Unsafe clients close to the nursing station • Stay with confused/sedated client when using bedside commode or bathroom