Fundamentals of Nursing

closed drainage system

-Jackson-pratt drain -hemovac drain may be connected to an electrical suction or built-in reservoir

color classification of open wounds

-R: red-protect -Y: yellow-cleanse -B: black-debride -mixed wound: contains components of RY&B wounds

water

-accounts for between 50% and 60% of adults total weight -2/3 of body water is contained within the cells (ICF) -the remainder of body water is extracellular fluid, body fluids -acts as solvent, aids digestion

factors affecting body temp

-circadian rhythms -age and gender -physical activity -state of health -environmental temperature

Nurse Practice Acts

-define legal scope of nursing practice -create state board of nursing to make and enforce rules and regulation -define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs - established criteria for the education and licensure of nurses

phases of wound healing

-hemostasis-vessels constrict and clotting begins -inflammatory-white blood cells move to wound -proliferation-granulation tissue is formed -maturation-collagen is remodeled, forms scar

goals of nursing research

-improve care in clinical setting -study ppl and nurse process: education, policy development, ethics, nursing history -develop greater autonomy and strength as a profession -provide evidence-based nursing practice

wound complications

-infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation

minerals

-inorganic elements found in all body fluids and tissues -some function to provide structure in the body, others help regulate body processes -contained in ash that remains after digestion -macrominerals include calcium, phosphorus, magnesium -microminerals include iron, zinc, manganese, and iodine

fats

-insoluble in water and blood -composed of carbon, hydrogen, and oxygen - 95% of lipids in diet are triglycerides -most animal fats are saturated -most vegetable fats are unsaturated -digestion occurs largely in small intestine -most concentrated source of energy in diet -RDA not established, 20-35% total calorie intake

nursing process for bowels

-inspection -auscultation -percussion -palpation (deep palpation is performed by advanced medical personal)

assessing blood pressure

-listening for korotkoff sounds w/ stethoscope -first sound is systolic -change or cessation of sound occurs: diastolic pressure - brachial artery and popliteal artery are commonly used

The Nursing Process

-one of major guidelines for nursing practice -helps nurses implement their roles -integrates art and science of nursing -allows nurses to use critical thinking and clinical reasoning -defines the areas of care that are within the domain of nursing

Vitamins

-organic compounds needed by the body in small amounts -most are active in form of coenzymes -classified as water soluble or fat soluble -absorbed through intestinal wall (small intestine) directly into bloodstream -needed for metablolism

major classifications of hypertension

-primary (essential): characterized by an increase above normal in both systolic and diastolic pressures -secondary : caused by another disease condition like kidney disease, aorta disorders, or adrenal cortex disorders

heat production

-primary source is metabolism -hormones, muscle movements, exercise increase metabolism -thyroid hormone and shivering also increase heat production - energy production decreases and heat production increases

establishing an effective nurse-patient relationship

-reduce anxiety through therapeutic communication, teaching, and acceptance -remember that the patient has concerns and needs other medical ones -communicate with the patient as an individual -take time to learn about the patient being admitted -provide for the family participation in all aspects of care

protein

-required for formation of all body structures -based on amino acid composition -animal proteins are complete, plant proteins are incomplete -RDA for adults is 0.8g/kg

types of knowledge

-science (observing, identifying, describing, investigating, and explaining events and occurences that are perceived in world) -philosophy (the study of wisdom, fundamental knowledge, and the processes used to develop and construct on perception on life) -process (a series of actions, changes, or functions intended to bring about a desired result)

measurement of pressure ulcer

-size of wound -depth of wound -presence of undermining, tunneling, or sinus tract(all on wound bed)

stages of pressure ulcers

-stage1: nonblanchable erythema of intact skin -stage2: partial-thickness skin loss -stage3: full-thickness skin loss; not involving underlying fascia( epidermis and dermis) -stage4: full-thickness skin loss with extensive destruction (epidermis, dermis, and subcutaneous) -unstageable: base of ulcer covered by slough and/or eschar in wound bed

carbs

-sugars and starches -organic compounds composed of carbon, hydrogen, and oxygen -lactose is an animal source -most abundant and least expensive -classified as simple or complex sugars -converted to glucose for transport through blood -50-100g needed daily to prevent ketosis

sources of knowledge

-traditional ( passed down from generation to generation) -authoritative- comes from an expert, accepted as truth based on person's perceived expertise -scientific (obtained through the scientific method-research)

Nursing is recognized as profession based on what criteria

-well defined body specific and unique knowledge -strong service orientation -recognized authority by a professional group (ANA) -code of ethics -professional organization that sets standards -ongoing research -autonomy and self-regulation

Aims of Nursing

1. To promote health 2. To prevent illness 3. To restore health 4. To facilitate coping with disability or death

respirations for healthy adult

12 to 20 breaths/min

average blood pressure for healthy adult

120/80

anuria

24-hour urine output is less than 50mL; complete kidney shut down or renal failure

albumin normal lab values

3.5-5

forehead temp

34.4 C, 94.0 F

axillary temp

36.5 C, 97.7 F

oral temperature for healthy adult

37.0 C, 98.6 F

rectal temp

37.5 C, 99.5 F

tympanic temp

37.5 C, 99.5 F

pulse rate for healthy adult

60-100 (80 average)

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

afferent nervous system conveys info to the

CNS; going to your brain

To restore health

Nurse's responsibility to assess & teach levels of prevention

To facilitate coping w/ disability or death

Nurse's role to provide "comfort" care

RACE

R: rescue anyone in immediate danger A: activate the fire code and notify appropriate person C: confine the fire by closing doors and windows E: evacuate patients and other people to a safe area

stages-of-illness behaviors

Stage 1: experiencing symptoms Stage 2: assuming the sick role Stage 3: assuming a dependent role Stage 4: achieving recovery and rehabilitation

To promote health

State of optimal functioning or wellbeing. not just absence of disease

steps in implementing EBP

Step 1: ask a question about a clinical area of interest or an intervention Step 2: collect the most relevant and best evidence Step 3: Critically appraise the evidence Step 4: integrate the evidence w/ clinical expertise, patient preferences, and values in making a decision to change Step 5: evaluate the practice decision or change

wound

a break or disruption in the normal integrity of the skin and tissues

sinus tract

a cavity or channel underneath the wound that has the potential for infection

suppository

a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature

total incontinence

a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation

dialysis

a mechanical way of filtering waste from the blood

evidence-based practice (EBP)

a problem-solving approach to making clinical decisions, using the best evidence available; blends both science and art of nursing so best outcomes are achieved; may consist of specific nursing interventions or use guidelines established for the care of patients

health

a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

paralysis

absence of strength secondary to nervous impairment

Maslows level 5: Self-Actualization

acceptance of self and others as they are; each lower level must be met; focus of interest on problems outside oneself; respect for all people; focus on strengths and possibilities vs problems

tertiary health promotion

after an illness is diagnosed and treated; example: teaching a patient with diabetes how to recognize and prevent complications, refer woman to support group after removal of breast due to cancer

ileostomy

allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma

wellness

an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health

fistula

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

unintentional wound

are accidental; occur from unexpected trauma

when does discharge planning start?

as soon as the patient comes in the door

pulse is regulated by what?

autonomic nervous system through cardiac sinoatrial node

nonmaleficence

avoid causing harm

nocturia

awakening at night to urinate

proliferation phase

begins 2-3 days of injury and may last up to 2-3 weeks, new tissue is built to fill wound space through action of fibroblasts, capillaries grow across wound, thin layer of epithelial cells form across wound, granulation tissue forms a foundation for scar tissue to develop

beneficence

benefit the patient; balance benefits against risks and harms

sanguineous drainage

blood cells present; looks like blood

occult blood in stool

blood that is hidden in the specimen or cannot be seen on gross examination

Maslows level 2: safety and security needs

both physical and emotional components; being protected from potential or actual harm

scale used for predicting pressure sore risk

braden scale

orthopnea

changes in breathing when sitting or standing

overflow incontinence

chronic retention of urine, the involuntary loss of urine associated

cleaning a pressure ulcer

clean w/ each dressing change, gentle motions (patting), use 0.9% normal saline solution to irrigate and clean, report any drainage or necrotic tissue

serous drainage

clear and watery

subjective

coming from that subject

psoriasis

common skin condition that speeds up the life cycle of skin cells, cells build up rapidly on surface of skin and extra skin cells form scales and red patches that are itchy and sometimes painful; chronic, comes and goes

indirect studies

commonly performed through radiography ex. abdominal ultrasound, MRI, abdominal CT scan, small bowel series, barium enema

Interrelated roles of nurses

communicator, teacher, counselor, leader, researcher, advocate, collaborator

efferent

creates effect and goes to body part from brain

necrosis

death of tissue

bradypnea

decreased respiratory rate; occurs in some pathologic conditions

parasympathetic stimulation on pulse

decreases heart rate

ischemia

deficiency of blood in a particular area

Florence Nightingale

defined nursing as both an art and science, differentiated nursing from medicine, created freestanding nursing education, published books; founder of modern nursing

desiccation

dehydration

nursing theory

differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices

dyspnea

difficult or labored breathing

radiation

diffusion of heat by electromagnetic waves (such as an uncovered head)

primary health promotion

directed towards PROMOTING health and PREVENTING the development of disease processes or injury; example: immunization clinic, family planning services, accident prevention education

chronic wound

do not progress through stages of healing; healing impeded

laxatives

drugs that induce emptying of the intestinal tract

constipation

dry, hard stool; persistently difficult passage of stool; incomplete passage of stool

nurse practice acts

each state has its own; protects public with legal scope of nursing practice

Clara Barton

established red cross; volunteered to care for wounds and feed union soldiers during civil war; served as supervisor of nurses for the army of James

deductive reasoning

examines a general idea and then considers specific actions or ideas

polyuria

excessive output of urine (diuresis)

perfusion

exchange of oxygen and carbon dioxide between circulating blood and tissue cells

diffusion

exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood

reflex incontinence

experience emptying of the bladder w/o sensation of the need to void

pronation

face down; laying on your stomach

supination

face up; laying on your back (spine)

maturation phase

final stage of healing, begins 3 weeks to 6 months after injury, collagen remodeled, new collagen tissue is deposited, scar becomes thin white line

secondary health promotion

focus on SCREENING for early detection of disease with prompt diagnosis and treatment of any found; example: assessing children for normal growth and development and encourage regular medical, dental and vision exams

inflammatory phase

follows hemostasis and lasts 4-6 days, white blood cells move to wound, macrophages enter wound and remain extended time, they ingest debris and release growth factors, pt has generalized body repsonse

origination of the word "nurse"

from the latin word "nutrix" meaning to nourish

direct studies

going inside the body ex. colonoscopy, sigmoidoscopy

paresis

impaired muscle strength or weakness

vitamin c and zinc

important in wound healing

hypoxia

inadequate amount of oxygen available to cells

physiological measures that indicate pain

increased blood pressure and pulse

frequency

increased incidence of voiding

tachypnea

increased respiratory rate; may occur in response to increased metabolic rate

sympathetic stimulation on pulse

increases heart rate

urinary incontinence

involuntary loss of urine

when measuring a wound

measure from left to right and then top to bottom

meaning of healing

mending and getting better from disease

serosanguineous drainage

mix of serum and blood cells; light pink to blood tinged

pulmonary ventilation

movement of air in and out of lungs

isokinetic exercise

muscle contraction with resistance

isometric exercise

muscle contraction without shortening

isotonic exercises

muscle shortening and active movement

Maslows level 4: self-esteem needs

need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments; positive self-esteem facilitates the person's confidence and independence

eupnea

normal, unlabored breathing, one respiration to four heartbeats

coping with disability and death

nurses use optimal function of maximum strengths and potentials, refer to community support systems; provide care to families and patients during end-of-life care, hospice

open wound

occurs from intentional and unintentional trauma; skin surface is broken, providing a portal of entry for microorganisms

hemostasis

occurs immediately after intial injury, blood vessels constrict and clotting begins, exudate(drainage) forms and causes swelling and pain, increased perfusion results in heat and redness, platelets stimulate other cells to migrate to injury to participate in phases of healing

friction

occurs when two surfaces rub against each other

Maslows level 3: love and belonging needs

often called higher-level needs; understanding and acceptance of others in both giving and receiving love; feeling of belonging; unmet needs produce loneliness and isolation

inductive reasoning

one builds from specific ideas or actions to conclusions about general ideas

maceration

overhydration

Maslows level 1: physiologic needs

oxygen, food, water, sex, rest, physical activity; physiologic needs are highest priority

chronic pain

pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period

dysuria

painful or difficult urination

paraplegia

paralysis both legs

quadriplegia

paralysis of both arms and both legs

hemiplegia

paralysis one half of the body

sims position

patient again lies on the side but the lower arm is behind the patient and the upper are is flexed at both the shoulder and the elbow

supine or dorsal recumbent position

patient lies flat on the back with the head and shoulders slightly elevated w/ a pillow

side-lying or lateral position

patient lies on the side and the main weight of the body is borne by the lateral aspect of the lower scapula and the lateral aspect of the lower ilium

open drainage system

penrose drain; promotes drainage passively

apnea

periods when no breathing occurs

colostomy

permits formed feces in the colon to exit through the stoma

prone position

person lies on the abdomen with the head turned to the side; the body is straight in the prone position because shoulders, head, and neck are in erect position, arms are easily placed in correct alignment w/ the shoulder girdle, hips, knees can be prevented from flexing or hyperextending

trauma

physical injury

human dimensions that compose the whole person

physical, intellectual, environmental, spiritual, sociocultural, and emotional

glycosuria

presence of sugar in the urine

negative-pressure wound therapy

promotes wound healing and wound closure through the application of uniform negative pressure on wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment; results in mechanical tension on wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels

proteinurea

protein in the urine; indication of kidney disease

maslow hierarchy of needs

provides a framework for nursing assessment and for understanding the needs of patients at all levels; many nursing interventions are aimed at meeting patients' basic human needs

pyuria

pus in the urine; urine appears cloudy

acute pain

rapid in onset, varies in intensity and duration, protective in nature

acute illness

rapid onset of symptoms and lasts only a short time; examples: cold, diarrhea, pneumonia, appendicitis

normal stoma

red and moist

eczema

red, itchy inflammation of the skin; usually develops in early childhood, more common in people w/ family history; treatment involves avoiding soap and other irritants and applying creams or ointments if prescribed

To prevent illness

reduce risk for illness. promote good health habits, maintain optimal functioning

debridement

removal of devitalized tissue and foreign material

autonomy

respect rights of patients to make health care decisions

5 vital signs

respirations, pulse rate, blood pressure, temperature, and pain

closed wound

results from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash

negative nitrogen balance

results in muscle wasting and decreased physical energy for movement and work; caused by diseases that are characterized by a larger breakdown of protein than that which is manufactured

shear

results when one layer of tissue slides over another layer

oliguria

scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL

fowlers position

semi-sitting position; head of bed elevated 45 to 60 degrees; used to promote cardiac and respiratory functioning; provides max space in thoracic cavity; high fowlers the bed is elevated to 90 degrees

pale stoma

shows signs of anemia

sources of heat loss

skin (primary source), evaporation of sweat, warming and humidifying inspired air, eliminating urine and feces

chronic illness

slow onset, characteristics: permanent change, caused by change in anatomy, requires special patient education, long period of care or support; examples: heart disease, diabetes, lung diseases, and arthritis

the efferent system conveys via

somatic nervous system

when listening to bowel sounds

start lower right and go up, across and down

suppression

stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h

urgency

strong desire to void

6 classes of nutrients

supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water

ostomy

surgical opening from the inside of an organ to the outside

edema

swelling caused by excess fluid trapped in your body's tissues

sustained or continuous fever

temp remains above normal with minimal variations

relapsing or recurrent fever

temp returns to normal for one or more days with one or more episodes of fever, each as long as several days

remittent fever

temperature does not return to normal and fluctuates a few degrees up and down

intermittent fever

temperature returns to normal at least once every 24 hours

places you can record a pulse

temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

footdrop

the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, and patient experiences extreme difficulty in walking; caused by patients feet being in planter flexion position over extended time

enema

the introduction of a solution into the large intestine, usually to remove feces

pain threshold

the level at which a person experiences pain

pain tolerance

the maximum level of pain that a person is able to tolerate

pulse rate

the number of contractions over a peripheral artery in 1 minute

stoma

the part of the ostomy that is attached to the skin

active exercise

the patient independently moves joints through their full range of motion (isotonic exercise)

passive exercise

the patient is unable to move independently, the nurse moves each joint through its range of motion

intentional wound

the result of planned invasive therapy or treatment ex. surgery, intravenous procedure

illness

the unique response of a person to a disease; an abnormal process involving changed level of functioning

body mechanics

the use of proper body positions to provide protection from the stress of movement and activity

eschar

thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately

purulent drainage

thick, musty or foul odor, varies in color

proprioceptor or kinesthetic sense

this informs the brain of the location of a limb or body part as a result of joint movements stimulating special nerve endings in muscles, tendons, and fascia

beta-adrenergic blockers

to block sympathetic stimulation and decrease cardiac output

ACE inhibitors

to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production

vasodilators and calcium channel blockers

to relax smooth muscles of arterioles and decrease peripheral vascular resistance

inversion

turning foot inward

eversion

turning foot outward

functional incontinence

urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation

standards

used as guidelines for peer review (ANA)

diuretics

used to increase urinary output

acute wound

usually heal within days to weeks

visual or optic reflexes

visual impressions contribute to posture by alerting the person to spatial relationships with the environment

hemiparesis

weakness of half of the body

extensor or stretch reflexes

when extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture

pressure ulcer

wound with localized area of injury to the skin and/or underlying tissue

jaundice causes

yellowish, itchy skin; bilirubin problem and liver not functioning properly

objective

you can see the object