Fundamentals Test #1

Healing

The replacement of tissue by regeneration or repair. • Regeneration is replacement of damaged cells w/ identical or similar cells. Not all cells can regenerate. • Repair occurs when scar tissue replaces original tissue. Most injuries heal by repair.

Diastole

The trough or resting phase of the heart.

Purulent

Yellow, contains pus (protein-rich fluid filled with WBCs, bacteria, & cellular debris) • Thick, malodorous drainage seen in infected wounds. • Caused by infection from pyogenic (pus-forming) bacteria (streptococci/staphylococci) • Pus is yellow in color, but it may take on blue-green color if the bacterium Pseudomonas aeruginosa is present.

True or False: Not getting enough sleep can impede the healing process.

True.

REM Sleep

• A stage of sleep characterized by rapid eye movements and a high level of brain activity. • Essential for mental and emotional restoration.

Hyperpyrexia

• Abnormally high body temperature • Fever >105.8°F (41.0°C)

Intentional Torts

• Assault and battery • False imprisonment • Fraud • Invasion of Privacy

Planning interventions

• Choose interventions to help the patient achieve stated goals. • Developing a list of possible interventions based on nursing knowledge & choosing those most likely to help pt achieve stated goals. • Best interventions are evidence-based.

Stress-Induced Psychological Responses

• Crisis • Burnout • Post-traumatic stress disorder (PTSD)

Tort Law

• Dealing with duties and rights among individuals • Involves claims for damages.

Signs of infection for nurses to look out for:

• Fever • Cough • Redness/swelling of wound • Elevated WBC count

Exhaustion Stage of GAS

• If adaptive mechanisms become ineffective/nonexistent. Physical adaptive resources & energy are depleted. • Vasodilation, decrease BP, elevated pulse & respiration. • Usually ends in disease or death. • Body is unable to defend itself & can't maintain resistance against continuing stressors --> ends in injury, illness, or death.

Sedentary Lifestyle

A habit of life that is characterized by a low physical activity level.

Stridor

A piercing, high-pitched sound heard primarily during inspiration. • Heard without a stethoscope. • Primarily during inspiration. • In infants who are experiencing respiratory distress. • In someone with an obstructed airway.

Abrasion

A scrape of the superficial layers of the skin; usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces.

Protective Isolation

"Protective environment" which protects patient from organisms. Used in special situations with immune-compromised patient population. Precautions include: • Private room w/ special ventilation & air filters; no carpeting; daily wet-dusting • Special cleaning or disposal of pt's equipment & supplies • Avoiding standing water in the room • Nurse not assigned to other pts with active infection • Restricting visitors • Standard & transmission-based precautions, plus mask & PPE (to protect pt)

Pulse

"Wave" that begins when left ventricle contracts and ends when ventricle relaxes.

Lipid screening guidelines

*1. Adults aged 20 years or older:* • Have a fasting lipid panel at least once every 5 years. • Total cholesterol is 200 mg/dL or greater—or high-density lipoprotein (HDL) is less than 40 mg/dL— frequent monitoring is required *2. Children aged 9 to 11 years:* • Universal screening is recommended, regardless of risk factors for CVD *3. Children aged 2 to 8 years:* • Screening is recommended if a parent, grandparent, aunt/uncle, or sibling has a history of MI, angina, stroke, coronary artery bypass, graft/stent/angioplasty, or hyperlipidemia

Elevated

• Systolic BP of 120 to 129 mmHg • Diastolic BP of >80 mmHg

Nonmaleficence

• Twofold duty to do no harm & to prevent harm.

4 Determining Factors in Infection

• Virulence (how severe or harmful a disease is). • Organism's ability to survive in host's environment. • Number of organisms. • Host's defenses.

Pulse Pressure

• Volume output of the left ventricle. • Difference between the systolic and diastolic pressures. • Should be no greater than one-third of the systolic pressure. Ex: a BP of 120/80, with a pulse pressure of 40 (1/3 x 120 = 40).

Diagnosis

2nd phase: Identify patient's health needs. Usually stated in form of a problem based on careful review of assessment data. Need to analyze all data, synthesize & cluster information, & hypothesize about patient's health status.

Recovery Stage of GAS

3rd stage, if adaptation is successful. • For example, after a miscarriage, a couple participates in a support group & begins to focus more deeply on their relationship with each other. They are able gradually to resolve their grief.

Wound Closures

1. Adhesive strips: Steri-Strips are used to: • Close superficial low-tension wounds • Close the skin on a wound that has been closed subcutaneously to aid in healing and reduce scarring. • Give additional support to a wound after sutures or staples have been removed. • Adhesive strips are often kept in place until they begin to separate from the skin on their own. 2. Sutures: • Traditional wound closures are sutures • Suturing creates small puncture wounds along the track of the laceration or incision. • Absorbent sutures are used deep in the tissues; for example, to close an organ or anastomose (connect) tissue. Because they are made of material that will gradually dissolve, there is no need to remove absorbent sutures. • Nonabsorbent sutures are placed in superficial tissues and require removal, usually by the nurse. 3. Surgical staples: • Made of lightweight titanium, surgical staples provide a fast, easy way to close an incision. • Lower risk of infection & tissue reaction than sutures • Some wound edges are more difficult to align. • Most common sites are arms, legs, abdomen, back, scalp, or bowel. • Wounds on the hands, feet, neck, or face should not be stapled. 4. Surgical glue • Is safe for use in clean, low-tension wounds • Wound closure method for skin tears

3 general approaches for coping, depending on the situation:

1. Alter the stressor: Person takes actions to remove or change the stressor. 2. Adapt to the stressor: Adapting involves changing one's thoughts or behaviors r/t the stressor. 3. Avoid the stressor: For instance when a certain person is stressful for you, even though you have tried many times to change the dynamics of the relationship.

Nurse's Role in Hygiene

1. Assess self-care abilities 2. Provide assistance with ADLs 3. Promote self-care in ADLs 4. Delegate appropriate parts of hygiene care. Remember: You are responsible for anything you delegate. *With personal hygiene, you need to respect a client's cultural and personal preferences while also addressing the medical necessity for care*

BP is influenced by 3 factors:

1. Cardiac Function: • Cardiac output: volume of blood pumped by the heart per minute. 2. Peripheral Vascular Resistance: • Arterial & capillary resistance to blood flow as a result of friction between blood & vessel walls. 3. Blood Volume (about 5 liters or 5000 mL) • Too high of a volume = BP increases • Too low of a volume = BP decreases

Dressing**

1. Gauze: some impregnated with antimicrobial, meds, or moisture & others contain petrolatum to keep wound moist. Gauze can be used in combination with amorphous hydrogels, NS, or meds. 2. Transparent film: exchange air & water vapor between wound & environment preventing external bacterial contamination Ex: Indicated for partial-thickness wounds with little or no exudate, wounds with necrosis and as both a primary or secondary dressing. Also used to cover IV sites, donor sites, lacerations, abrasions and second-degree burns. 3. Hydrocolloid: wafers, pastes, powders contain hydrophilic (water-loving) particles. When applied, particles interact with exudate to form gel that keeps wound moist & protective layer against friction & bacteria • These dressings can rehydrate necrotic tissue and assist with autolytic debridement. Thus, these types of dressings are useful for sacral pressure injuries that need to be protected from urine or feces. 4. Hydrogels: sheets, granules, gels with high H2O content, create jelly consistency does not adhere. Soft, cooling texture promote pt comfort. Enhance epithelialization by providing moisture. To soften slough/eschar in necrotic wounds & used in infected wounds. • They are a good choice for dry or dehydrated wounds, abrasions, mild burns, or radiation skin damage (eg, after radiation therapy).

Progression from Novice to Expert

1. Novice 2. Advanced Beginner 3. Competent 4. Proficient 5. Expert

Classification of Wounds

1. Open/closed: • Open: break in skin or mucous membranes (abrasions, lacerations, puncture, & surgical). • Closed: no breaks in the skin (Contusions (bruises) or tissue swelling from fractures). 2. Acute/chronic: • Acute: short duration, heal through 3 phases of healing (inflammation, proliferation, maturation). • Chronic: exceed expected length of recovery. 3. Clean/contaminated/infected • Clean: uninfected wounds with minimal inflammation • Clean-contaminated: surgical incisions enter GI, resp, or GU tracts. Increased risk • Contaminated: open, traumatic/surgical, major break in asepsis. Risk of infection is high. • Infected: when bacteria+100,000 org/gm. Presence of B-hemolytic strept, in any number, is infection. 4. Superficial/partial or full-thickness • Superficial involve only epidermal layer, from friction, shearing, or burning. • Partial-thickness: extend through the epidermis but not through the dermis. • Full-thickness: extend into the subcutaneous tissue and beyond 5. Penetrating: Involve internal organs (ex: when you're stabbed).

Lines of Defense Against Infection:

1. Primary Defenses: Anatomical features limit pathogen entry • Intact skin: surface of skin is tough & resilient & prevents entry of many pathogens • Mucous membranes: nares, trachea, bronchi are covered with mucous membranes that trap pathogens, then expelled • Tears: lacrimal glands produce tears that contain lysozyme. • Normal flora in GI tract: acidic environment; small intestine face the antimicrobial action of bile. • Normal flora in urinary tract: epithelial cells lining the urethra & anus secrete mucus; excretion through urine & stool; urine is highly acidic & contains lysozyme. 2. Secondary Defenses: Biochemical processes activated by chemicals released by pathogens . • Phagocytosis: Phagocytes (specialized WBCs) engulf and destroy pathogens directly. Phagocytic WBCs include neutrophils, monocytes, and eosinophils. • Complement cascade: A set of blood proteins (complement) triggers release of chemicals that attack cell membranes of pathogens, causing them to rupture. • Inflammation: When histamine & chemicals are released from damaged cells or from basophils being activated by complement. Blood vessels dilate & more permeable, increases flow of phagocytes, antimicrobial chemicals, O2 & nutrients to the affected area. • Fever: A rise in core body temperature that increases metabolism, inhibits multiplication of pathogens, & triggers specific immune responses. 3. Tertiary Defenses: • Humoral immunity: B-cell production of antibodies in response to an antigen producing specialized WBCs (leukocytes) to seek out and destroy invaders by any of the following methods. • Cell-mediated immunity: Direct destruction of infected cells by T cells. 4 types of T cells play a role in fighting infection: • Cytotoxic (killer) T cells directly attack & kill body cells infected with pathogens. • Helper T cells play supportive role in cell-mediated responses by secreting interleukin, which attracts infection-fighting WBCs. • Memory T cells. When antigen invades body, T cells form that respond to that specific antigen. With subsequent infections, memory T cells are able to increase speed & amount of the T-cell response. • Suppressor T cells stop immune response when infection has been contained.

Primary vs. Secondary Infection

1. Primary: can practically be viewed as the root cause of an individual's current health problem. 2. Secondary: Occurs during or after treatment for another infection. It is a sequela or complication of the root cause. Ex: An infection (secondary infection) due to a burn or penetrating trauma (the root cause or primary infection).

Wound Healing Processes

1. Regeneration • In epidermal and dermal wounds • No scar • Refers to when doctors close a wound using staples, stitches, glues, or other forms of wound-closing processes. 2. Primary intention • Clean surgical incisions heal by this method. • Minimal scarring. 3. Secondary intention • Wound edges not approximated • Tissue loss • Heals from inner layer to surface • May leave scar • Pressure ulcers & infected wounds heal by 2nd intention because they cannot be stitched up. Doctors will leave the wound to heal naturally in these cases. 4. Tertiary intention • Granulating tissue brought together • Delayed closure of wound edges • An example would be an abdominal wound that is kept open in order to allow drainage, and then later closed.

5 Rights of Delegation

1. Right task: Examples of tasks you might assign to nursing assistive personnel (NAP) are bathing a stable patient, ambulating steady patients, obtaining routine VS, changing linens, assisting patients with meals, clerical duties, and transporting non-acute patients and specimen. 2. Right circumstance: Before deciding to delegate, assess your patient to be certain that her needs match abilities of the NAP/LPN. 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

The Alarm Stage has which 2 phases?

1. Shock: • Begins when cerebral cortex 1st perceives a stressor & sends out messages to activate endocrine & sympathetic nervous systems • Epinephrine & other hormones prepare body for fight or flight • Does not last long— < 24hrs, & sometimes only 1-2 minutes 2. Countershock: • All the changes produced in shock phase are reversed, & the person becomes less able to deal w/ immediate threat.

Safe, effective nursing care includes what?

1. Teamwork and Collaboration 2. Patient-Centered Care 3. Quality Improvement (QI) 4. Informatics 5. Safety 6. Evidence-Based Practice (EBP)

The Nurse's Role in Caring for Immobile Patient

1. Transferring 2. Positioning 3. Moving 4. Ambulating *When doing any of these the nurse should seek assistance or use assistive devices to prevent personal injury*

Flora

1. Transient Flora: Normal microbes that a person picks up by coming in contact with objects or another person. You can remove these with hand washing. 2. Resident Flora: Live deep in the skin layers, where they live and multiply harmlessly. Are permanent inhabitants of skin and cannot be removed with routine handwashing.

Assessment

1st phase: Gather data that you will use to draw conclusions about the patient's health status.

Contusion

A closed wound caused by blunt trauma. It is the medical term for a bruise.

Abscess

A localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen.

Tunneling Wound (Sinus Tract)

A narrow channel or passageway underneath the skin that can extend in any direction from the base of the wound. This results in dead space with a potential risk for abscess formation.

Activity Intolerance

A state in which a patient has insufficient physical or psychological energy to carry out daily activities.

Medical Asepsis

A state of cleanliness that decreases the potential for the spread of infections.

Crushing Wound

A wound caused by force leading to compression or disruption of tissues. Often associated with fracture.

Tunnel Wound

A wound with an entrance and exit site.

Bradycardia

<60 bpm

Developmental Stress

Associated with life stages.

Is systolic or diastolic on top?

BP is recorded as systolic pressure over diastolic pressure (120/80 mmHg).

Clara Barton

Barton served in the battlefields of the Civil War, bringing necessary supplies, comfort, and food to the wounded. She created a center to locate missing soldiers and started the American Red Cross.

Supporting/Immobilizing Wounds

Binders/bandages: hold dressing in place, apply pressure to wound to impede hemorrhage and support + immobilize injured area, promoting healing and comfort.

Hemorrhage

Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the body, called external bleeding. • Risk is greatest in 24-48hr post-op or injury • Swelling of affected body, pain, & changes in VS (decreased BP, elevated HR) indicate internal bleeding/hematoma: red-blue collection of blood under skin, bleeding cannot escape to surface. • External hemorrhage: see bloody drainage on dressing & drainage devices.

Safety

The condition of being safe from undergoing or causing hurt, injury, or loss. It is a basic human need, only second to survival needs.

Expert

The expert nurse has extensive experience and knowledge to draw from when responding to complex client conditions. At this stage, nurses have self-confidence and trust their intuitive sense of a situation. Expert nurses know what needs to be done and are able to perform it well.

Debriding

Removal of tissue and foreign material to aid healing. • Removes cells that are alive but not functioning (senescent) from wound bed & edges. Removes necrotic tissue, exudate, & infective material helps stimulate wound healing & prepare wound bed for advanced therapies/biological agents • Sharp: Use sharp instrument to remove devitalized tissue, providing immediate improvement of wound bed & preserves granulation tissue. • Mechanical: performed via lavage, use of wet-to-dry dressings, or hydrotherapy (whirlpool) • Enzymatic: use proteolytic agents to break necrotic tissue without affecting viable tissue. Clean wound with NS, apply thin layer of cream, & cover with moisture-retaining dressing. • Autolysis: use occlusive, moisture-retaining dressing & body's enzymes & defense mechanisms to break necrotic tissue; Takes more time than others but tolerated better. Dressing is normally changed q72hr & wound is cleansed before new dsg is applied • Biotherapy (Maggot therapy): use of medical-grade larvae of green bottle fly to dissolve dead & infected tissue from wounds. Larvae secrete enzymes that liquefy dead tissue & create alkaline environment. Larvae digest bacteria from wound.

Dehiscence

Rupture of 1 or more layers of wound. • Most likely in inflammatory phase of healing, before collagen is deposited in the wound to strengthen it. • Most common causes: poor nutritional status, inadequate closure of muscles, infection.

Endorphins

Secreted by hypothalamus and posterior pituitary, act like opiates to produce sense of well-being and reduces pain.

Thyroid-Stimulating Hormone (TSH)

Secreted by pituitary gland to increase efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. Ex: Patients with thyroid problems do not have a stable metabolism.

Endogenous healthcare-related infection

The pathogen arises from the patient's normal flora when some kind of treatment causes the normally harmless microbe to multiply and cause infection. Ex: A patient with a compromised immune system, such as after chemotherapy, may become sick from a bacteria already present in their body that grows unchecked.

Sims' Position

The patient is lying on the left side with the right knee and thigh drawn up with the left arm placed along the back. • Used for enema delivery and if rectal medications need to be given.

Lateral Position

The person lies on one side or the other; side-lying position. • Used during back surgery and posterior skin breakdown. • Lateral recumbent position is side-lying with legs straight.

Proficient

The proficient nurse is able to understand the bigger picture or the desired outcome of situations, which facilitates improved decision making. Proficient nurses are able to respond to changing situations and modify plans in the face of different events.

Pulse Quality

The rhythm and force of the pulse. For example, it may be bounding or thready.

Consequentialism (Ethical Framework)

The rightness or wrongness of an action depends on the consequences of the act rather than on the act itself.

Community-Acquired Pathogens Prevention

There are food-borne, vector-borne, and water-borne pathogens. Preventions: proper storage, cleaning, and cooking of foods, clean cooking surfaces, attention to folk remedies, drain standing water, insect repellents, protect skin from contact with insects, and wipe out breeding areas.

Novice

This initial stage covers nursing students and new students who have no previous experience. Novices cannot yet draw on their own judgment. The novice struggles to decide which tasks are most relevant in real-life situations.

The American Nurses Code of Ethics

This is not a law but a standard of professional responsibility. It describes the obligation for safe, compassionate, nondiscriminatory, and quality care while defining commitments to self, the patient, the employer, and the profession. Violation of the Code of Ethics can be used in court to justify whether the nurse functions at the level expected by the professional.

Primary Prevention

Those preventive measures that prevent the onset of illness or injury before the disease process begins. • Examples include immunization and taking regular exercise.

Who is at risk for developing pressure ulcers?

Those with immobility, friction and shear, moisture, incontinence, poor nutrition, perfusion, age, skin conditions, and altered LOC.

CRH

Together with messages from cerebral cortex, directs pituitary gland to release adrenocorticotropic hormone (ACTH) & antidiuretic hormone (ADH).

Braden Scale

Tool for predicting pressure ulcer risk. 6 categories graded from 1 (worst) to 4 (best). *<18 = at risk* 1. Sensory perception 2. Activity 3. Mobility 4. Nutrition 5. Moisture level 6. Friction and shear

Evisceration

Total separation of wound layers, which internal viscera protrude through incision. • Rare complication & a surgical emergency! • Immediately cover with sterile towels or dressings to prevent organs from drying out & becoming contaminated with bacteria. • Pt stay in bed with knees bent to minimize strain on incision

Conduction

Transfer of heat from a warm to a cool surface by direct contact. Ex: Patient's temperature is 98.6°F (37°C) while he is fully dressed in the exam room. If he dresses in a thin, hospital gown & lies on a cool metal radiology table, his temperature will drop, perhaps as much as a full degree Fahrenheit in the first hour

Convection

Transfer of heat through currents of air or water. Ex: Immersion in a warm bath may raise body temperature for a hypothermic patient. Ex #2: Currents of cool air produced by a fan can help reduce a fever. • Processes of convection & conduction account for ≈ 15% to 20% of all heat loss to the environment.

Secondary Prevention

Trying to detect a disease early and prevent it from getting worse. • Examples include screening for high blood pressure and breast self-examination.

Tertiary Prevention

Trying to improve your quality of life and reduce the symptoms of a disease you already have. Ex: Managing disease post diagnosis to slow or stop disease progression through measures such as chemotherapy, rehabilitation, and screening for complications. Ex #2: Screening of patients with diabetes for diabetic retinopathy to prevent progression to blindness through prompt treatment.

Non-REM Sleep

Typically the restful phase of sleep where physiological function slows.

Maladaptive

Unhealthy style, temporary fix. Possibly other harmful effects. Ex: Patient with lung cancer continues to heavily smoke.

Communicator

Using interpersonal and therapeutic communication skills to address the needs of the client and facilitate communication in the healthcare system. Ex: Counseling a client, discussing staffing needs at a unit meeting, and providing HIV education at a local school.

Counselor

Using therapeutic communication skills to advise clients about health-related issues. Ex: Counseling a client on weight-loss strategies.

How often are vital signs taken?

Varies by setting: • Hospital: every 4 to 8 hr • Home health setting: each visit • Clinic: each visit • Skilled nursing facilities (SNFs): weekly to monthly

Fowler's Position

Semi-sitting body position in which a person's head and shoulders are elevated 45 to 60 degrees. • Used for eating, socializing, and breathing difficulty. • High Fowler's would be 90 degrees.

Evaporation

Water is converted to vapor & lost from the skin (perspiration) or mucous membranes (through breath). Ex: Insensible loss, which is water loss by evaporation (through sweating). • Affected by relative humidity (moisture in environment).

Wheels of Wellness

Wellness is broken down into seven major categories, as demonstrated by the Wellness Wheel: Physical, Spiritual, Social/Family, Mental, Emotional, and Occupational. All pegs of the wheel need to be working--the more pegs you have the better your overall wellness is.

Sleep vs Rest

Sleep: Cyclical state of decreased motor activity and perception characterized by altered consciousness. Rest: Mild to no activity.

Cellular Response

Specialized WBCs (phagocytes) migrate to site of injury & engulf bacteria, other foreign material, & damaged cells & destroy them. They form a "wall" around invading pathogen. Accumulation of dead white cells, digested bacteria, & other cell debris in presence of infection is called pus.

Pressure Ulcer Stages

Stage 1: sores are not open wounds (it's just at the surface). The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose colour briefly when you press your finger on it and then remove your finger). Stage 2: partial thickness loss. The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Stage 3: the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. Stage 4: the pressure injury is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur. Eschar = UNSTAGEABLE

ACTH

Stimulates adrenal cortex to produce and secrete glucocorticoids.

Serous Exudate

Straw colored • Clean wounds typically drain serous exudate. • Watery in consistency & contains very little cellular matter. • Consists of serum, the straw-colored fluid that separates out of blood when a clot is formed

Pallor

Paleness of skin when compared with another part of the body.

Transmission-Based Precautions: Contact Precautions

Pathogen is spread by direct contact. Precautions include: • Possible private room • Clean gown and glove use • Disposal of contaminated items in room • Clean hands, including before entering and when leaving the room • Double-bag linen and mark • Ex: Norovirus, rotavirus, MRSA, and clostridium difficile (c-diff).

Transmission-Based Precautions: Airborne Precautions

Pathogen is spread via air currents (ex: Ventilation systems, shaking sheets, sweeping). Precautions include: • Same as those for contact, with addition of special room, special mask (fit-tested N-95 or higher level respirator before room entry), & mask for pt when transported. • Remove respirator after exiting the room and closing the door. • Door to room must remain closed. • A negative pressure isolation room is commonly used for patients with airborne infections. • Ex: Measles, mumps, rubella, TB, covid, and the chicken pox.

Transmission-Based Precautions: Droplet Precautions

Pathogen is spread via moist droplets. Spread through coughing and sneezing then touching contaminated objects. Precautions include: • Same as those for contact • Addition of mask & eye protection within 3ft of patient. • Remove face protection before room exit. • Ex: pneumonia, influenza, whooping cough!

Take-home Toxins Prevention

Pathogenic microorganisms, asbestos, lead, mercury, arsenic, pesticides, and caustic farm products. Contamination can occur via arthropod vectors (like ticks giving you lyme disease), dust particles, and skin-to-skin contact or direct contact with contaminated clothing. Preventions: be aware of workplace preventive measures, remove work clothing, shower if appropriate, and use gloves.

Hardiness

People who thrive despite overwhelming stressors tend to have a quality that has been termed hardiness.

Client Advocate

Supporting clients' right to make healthcare decisions when they are able to voice their opinions and protecting clients from harm when they are unable to make decisions. Ex: Helping a client explain to his family that he does not want to have further chemotherapy.

Sleep Apnea

Periodic breathing cessation for 10 seconds during sleep; absence of air flow through nose or mouth during sleep.

Hypochondriasis

Person is preoccupied w/ idea that he is or will become seriously ill. Pt is abnormally concerned w/ his health & interprets his real or imagined symptoms unrealistically, fearing that they will get worse or become incurable.

Maslow's Hierarchy of Needs

Physiological needs, safety needs, belonging and love needs, esteem needs, cognitive needs, aesthetic needs, self actualization, and transcendence.

Hypertension (HTN)

Physiologically HTN is related to thickening of the arterial walls and decreased elasticity of the arteries. • Diagnosed when BP is persistently higher than normal. • Diagnosed when BP is >140 mmHg systolic or > 90 mmHg diastolic on 2 or more separate occasions.

Semi-Fowler's Position

Position is the position of a patient who is lying in bed in a supine position with the head of the bed from approximately 30 degrees to 45 degrees.

Carbon Monoxide (CO) Poisoning Prevention

Prevention: Carbon monoxide detector Treat: 100% humidified oxygen

Firearm Injuries Prevention

Preventions: Firearms safety education for parents and children, proper locked storage, and keep ammunition separate.

Scalds and Burns Prevention

Preventions: Guardrails by fireplace, turning pot handles, care with candles, sunscreen, and care when warming food in microwave.

Poisoning Prevention

Preventions: Keep cabinets locked, store poison high, keep poison control telephone # available Treat: Depends on the type of poison ingested; antidotes, charcoal

Fires Prevention

Preventions: Smoke alarms, caution with cigarettes, fire extinguisher, no candles unattended, safety with holiday lights, and care with electrical cords.

Motor Vehicle Accidents Prevention

Preventions: avoid distractions in the car, use designated driver, use seat belts appropriately, and proper age-dependent restraints for children.

Weather Hazards Prevention

Preventions: be aware of weather events, develop a disaster plan, during a storm seek the lowest spot possible, seek shelter in a large building that is away from water, and do not use metal objects.

Pollution Preventions

Preventions: proper disposal and recycling of solid wastes, environmentally safe products, carpool, public transportation, and ear plugs.

Suffocation/Asphyxiation Prevention

Preventions: watch for small, removable parts, cut food into tiny pieces, pay attention to mobiles, strings, cords, and plastic bags, apply a barrier to a pool, and know the Heimlich maneuver.

Morals

Private, personal, or group standards of right and wrong. Ex: Stealing is wrong.

Delegation

Process of directing another person to perform a task or activity. You cannot delegate any intervention that requires independent, specialized nursing knowledge, skill, or judgment.

ADH

Promotes fluid retention by increase reabsorption of H2O by kidney tubules.

Good Samaritan Laws

Provide liability protection to those providing emergency care with good intentions. In this situation, a nurse is expected to initiate emergency services and stay with the person until care is transferred to an equally competent professional. He or she should not accept compensation.

Americans with Disabilities Act of 1990

Provides protection against discrimination of individuals with disabilities. This covers physical and mental impairments that substantially limit life activities. The employer must provide reasonable accommodations within the work setting to allow employees with disabilities perform their jobs.

Stroke Volume

Quantity of blood pumped out by each contraction of the left ventricle. • Averages 70mL in most healthy adults. • If stroke volume decreases, the body tries to maintain the same cardiac output by increasing pulse rate.

Situational Stress

Random, unpredictable.

Hypoventilation

Rate & depth of respirations are decreased & CO2 is retained.

Malpractice (4 Elements)

The 4 elements necessary to collect damages: • Existence of a duty: Nurse-patient relationship creates this obligation. • Breach of the duty: Occurs when nurse fails to meet standards of care. • Causation: Breach of duty or deviation from acceptable standards of care by nurse must be direct and proximate cause of injury suffered by patient. Causation is established based on testimony of experts (physicians, APNs) who can clearly show connection between nurse's action or omission & resulting injury to the patient. • Damages: Remedy for the harm the patient suffered is money. Plaintiff may be awarded punitive damages for grossly negligent or wrongful behavior by the healthcare provider.

Advanced Beginner

The advanced beginner has been involved in enough real-world situations to be able to recognize patterns and recurrent situations. A problem at this stage is that the focus is on remembering and following the rules and guidelines that have been taught. The advanced beginner needs clinical support to set priorities so that clients receive the care they need.

The Patient Self-Determination Act of 1991

Recognizes the patient's right to make decisions regarding his or her own health care, based on predetermined decisions. Two types of documents are addressed in this act: the living will and the durable power of attorney (DPOA) for health care. The living will is prepared when the individual is competent to make decisions and address his or her personal preferences about end-of-life care. The DPOA identifies a person who will make the decisions should the patient be unable to do so.

Personal Hygiene

Refers to the activities of daily living (ADLs) that not only help prevent disease but also promote comfort and a positive self-image. Care of the body includes bathing, hair and nail care, shaving, and oral hygiene. *It is important to have cleanliness bc of the risk of infection plus it makes them feel refreshed*

Hypothalamus

Releases corticotropin-releasing hormone (CRH).

Distress

Can threaten health.

Narcolepsy

Chronic disorder caused by brain's ineffectiveness in regulating sleep-wake cycles normally. Patients experiences sudden, uncontrollable episodes of sleep during the day.

Cleaning and Irrigating Wounds

Commonly use irrigation (lavage) to cleanse gently by flushing. • Remove debris: introduce irrigation solution with mild amount of force (pressure range 4lbs/square inch (psi) to 15 psi). • Caring for a drainage device, such as a Jackson-Pratt or Hemovac

Nurse Practice Acts

Contain provisions that regulate the practice of nursing within each state. They include information on the authority of the board of nursing, boundaries of nursing practice, standards for nursing education programs, licensure requirements, and grounds for disciplinary action.

Purosanguineous Exudate

Contains pus and blood

Manager

Coordinating and managing the activities of all members of the team. Ex: Charge nurse on a hospital unit (e.g., assigns clients to staff nurses).

Case Manager

Coordinating the care delivered to a client. Ex: Coordinator of services for clients with tuberculosis.

Hypothermia

Core temperature below normal (<95°F or 35°C)

Scope of Practice

Defines nursing at various levels. Violation of the scope of practice can violate a state's nursing practice act, causing loss of nursing privileges.

Temperature

Degree of heat maintained by the body. A normal temperature is 98.6ºF (37ºC).

Florence Nightingale

Demonstrated what is now called evidence-based practice through her data collection, documentation, and reporting of findings connecting unclean conditions to infection. She observed that overall cleanliness and hand washing between caring for soldiers reduced infection rates.

Active ROM

Describes movement of extremities and joints that clients perform independently.

Crackles

Discontinuous sounds heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds (sign of pneumonia).

Restless Leg Syndrome

Disorder in CNS characterized by uncontrollable movement of legs during sleep/rest.

Fidelity

Duty to keep PROMISES. Ex: If you promise to get a patient ice cream, do it. Even breaking a small promise like that can make a patient not trust you with bigger promises.

Mandatory Reporting Laws

Duty to report physical, sexual, or emotional abuse or neglect of vulnerable individuals (e.g., children, older adults, the mentally ill), whether you suspect it or have actual evidence of it.

Veracity

Duty to tell the TRUTH.

Ildaura Murillo-Rohde

Earned her doctorate in nursing in the 1970s and founded the National Association for Hispanic Nurses (NAHA).

Somatoform Pain Disorder

Emotional pain that manifests physically. Pain is main focus of person's life. Level of pain the person states is inconsistent w/ physical condition; that is, physical cause is either disproportionate to pain or cannot be found at all. The pain does not change location.

When applying heat and cold to a wound, how often do you take it off?

Every 15 minutes

How often do you change the position of clients in order to prevent skin breakdown, muscle discomfort, and damage to superficial nerves and blood vessels?

Every 2 hours

Exudate Formation

Fluid & WBCs that move from circulation to site of injury are exudate. Nature & quantity of exudate depend on severity of injury & tissues involved.

Transtheorectical Model of Change

Focuses on universal aspects of an individual's decision-making process and how the individual progresses through stages to make a change in behavior. There are 6 stages: 1. Precontemplation (no intention of change) 2. Contemplation (seriously thinking about making a change) 3. Preparation (intending to take action + small behavioral changes aka baby steps) 4. Action (implementation of plan) 5. Maintenance (allows the changed behavior to be reinforced) 6. Termination (a person who enters this stage has changed the behavior and is not in danger of relapse)

Cortisol

Has glucose-sparing effect. Increases use of fats and proteins for energy and conserves glucose for use by the brain.

The American Nurses Association Standards of Practice

Has three components: 1. Professional standards of care 2. Professional performance standards 3. Practice guidelines

Adaptive

Healthy choices. Involves adjusting to the stress/stressor (aka COPING). Ex: Patient who has recently been diagnosed w/ hypertension may react by modifying diet & exercising to lower BP & prevent complications.

Insomnia

Inability to fall/remain asleep or go back to sleep.

Classifications of Infections By Duration

1. Acute: Rapid onset of short duration. 2. Chronic: Slow development, long duration. 3. Latent: Infection present with no discernible symptoms (like latent TB).

Factors that support host defenses:

1. Adequate nutrition (ex: patients who are dehydrated are at a risk of UTIs) 2. Balanced hygiene 3. Rest and exercise 4. Reducing stress 5. Immunization *Nurses should try enhancing natural defenses though prevention of skin breakdown, regular oral care, bun expansion with cough and deep breathing, regular ambulation, and minimization of invasive lines*

Nursing Theorists

1. Florence Nightingale believed that a clean environment would improve the health of patients. 2. Virginia Henderson believed that nurses deserve to know what it means to be a nurse. 3. Hildegard Peplau believed that health could be improved for psychiatric patients if there were a more effective way to communicate with them. 4. Patricia Benner believed that caring is the central concept that each person is unique, so that caring is always specific and relational for each nurse-person encounter. 5. Madeleine Leininger: caring as cultural competence. 6. Jean Watson described what caring means from a nursing perspective.

Somatoform Disorders

1. Hypochondriasis 2. Somatization 3. Somatoform Pain Disorder 4. Malingering

Effects of Immobility

1. Muscle atrophy 2. Joint dysfunction 3. Atelectasis/pneumonia (respiration depth decreases and secretions pool in airways). 4. Venous stasis (compression and injury of small vessels in legs and decreased clearance of coagulation factors cause blood to clot faster). 5. Orthostatic hypotension 6. Glucose intolerance 7. Pressure ulcers (external compression of capillaries in skin, obstructing circulation. Causes tissue ischemia or a lack of blood flow. 8. Constipation (slows peristalsis). 9. UTI (laying supine inhibits urine drainage from renal pelvis and bladder). 10. Renal Calculi (immobility triggers rise in calcium, contributes to stone formation). 11. Depression 12. Disorientation

Circadian Rhythm

Internal clock/biorhythm based on day-night pattern in 24 hour sleep/wake pattern. Affects overall level of functioning.

Malingering

It is a conscious effort to escape unpleasant situations. Patient merely pretends to have symptoms for personal or tangible gain.

What is BP measured in?

It is measured in millimeters of mercury (mmHg).

Hypoxia

Lack of oxygen in the body tissues.

Impaired Physical Mobility

Limitation of independent purposeful movement of the body.

Radiation

Loss of heat through electromagnetic waves emitting from surfaces that are warmer than surrounding air. If uncovered skin is warmer than the air, body loses heat through the skin. Ex: A cool room warms by radiation when it is filled w/ many people • A person can acquire heat by turning on heat lamp or in sunlight. • This is why you put a cap on a newborn. • Radiation accounts for almost 50% of body heat loss.

Rhonchi

Low-pitched continuous sounds caused by secretions in large airways

Liability

Means that the person is financially or legally responsible for something.

Diastolic Pressure

Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest.

Serosanguineous

Mix of bloody and straw-colored fluid

Parasomnia (Category of Sleep Disorders)

1. Sleepwalking 2. Bruxism: grinding and clenching of teeth. 3. Night terrors: sudden arousals when patient (child) is physically active, often hallucinatory and express strong emotion (terror). 4. REM Sleep Behavior Disturbances: Sleeper violently acts out dream injuring self or others. 5. Enuresis: night incontinence past stage when toilet training is well established.

Source-Oriented Documentation System

documentation system in which each health care group/discipline records data on its own separate form

Other Reports to Know About:

• Integrated Plans of Care (IPOCs): a combined charting and care plan form. Maps out patient outcomes, interventions, treatments for a specific diagnosis, lab work, diagnostic testing, meds, and therapies. Can help administrators predict length of stay, monitor costs of care, and can assist with staffing. •Occurrence Reports: formal record of unusual occurrence or accident (ex: incident report). • Handoff Report: change-of-shift report or handover report; alerts the next caregiver about patient's status or reset changes in patient's condition and to discuss planned activities, tests, procedures, or concerns that require follow-up. Written usually as SBAR (situation, background, assessment, and recommendation). • Transfer Reports: when patients are being transferred, you should include your contact info, patient demographics, diagnoses, and reason for transfer, family contact info, summary of care, current status, meds (when next due), treatments, any tubes, presence of wounds, special directives, code status, preferred intensity of care, or isolation required, and ask if the receiver has any questions. • Discharge Summary: completed when the patient is transferred within the same organization, transferred to another facility, or they go home.

Ability to adapt depends on:

• Intensity of the stressor • Effectiveness of coping skills • Personal factors

Infection

• Localized swelling • Redness • Heat • Pain • Fever (higher than 38°C (100.4°F) • Foul-smelling/purulent drainage •Change in color of drainage may indicate infection

What to check for during a wound assessment:

• Location: describe wound location in anatomical terms • Size: length (head to toe), width, and depth • Appearance: look for color, maceration, undermining, blistering, slough, and eschar (which is unstageable). • Drainage: assess for amount, color, odor, tissue pain, and nutrition status. • Redness • Swelling • Pain • Nutritional Status

Developmental Factors Affecting Safety in Older Adults

• Loss of muscle strength • Joint mobility • Slowing reflexes • Decreased ability to respond to multiple stimuli • Sensory losses (hearing and vision) • These changes increase the older adult's risk for falls, burns, car accidents, and other injury. • *FALLS* are the most common cause of accidental death for adults age 50 and older. Physiological changes are what create the risk for falls.

Developmental Factors Affecting Safety in Adults

• May be exposed to injury in the workplace. • Lifestyle choices impact health • Poisoning (from alcohol or other drugs) is the major cause of death and injury, followed by MVAs. • Other injuries are related to lifestyle, stress, carelessness, abuse, and decline in strength and stamina. • Work and family responsibilities often leave little time for regular physical activity, increasing risk of musculoskeletal injury in the "weekend athlete."

Pulse Rate

• Measure in beats per minute (BPM) • If pulse is regular, count for 30 seconds, then multiply that number by 2. • Normal range for healthy adults = 60 to 100 bpm • Average = 70 to 80 bpm

Vital Signs

• Measure the body's basic functions. • Gives clues to possible illness. • Shows progress toward recovery. • Indicate deterioration in condition.

Negative Pressure Wound Therapy (Wound Vac)

• NPWT uses a closed system that applies suction (negative pressure) to the wound surface. • Wound surface is packed with a foam or gauze dressing and sealed using an occlusive drape. • Wound dressing is connected to a vacuum pump that provides either continuous or intermittent suction. • Liquid waste is collected in a waste container. • It is used to treat chronic wounds, such as pressure injuries.

Diabetic Foot Ulcer

• Narrowing of the arteries leads to reduced oxygenation to the feet, resulting in delayed wound healing and tissue necrosis. • Often painless; often with drainage, swelling, redness, ulceration. • Occurs primarily on plantar surfaces and toes (ball of the foot or underside of the toes). • Highly susceptible to wound infection because of the poor sensation, circulation, and immune protection.

Reticular Activating System (RAS)- Reticular and Cortical Neurons

• Neurotransmitters with excitatory and inhibitory sleep mechanisms include catecholamines, acetylcholine, serotonin, histamine, and prostaglandins. • L-Tryptophan and adenosine promote feelings of sleepiness.

Malpractice (Definition)

• One source of legal liability. • It means that a professional person has failed to act in a reasonable and prudent manner. • If someone is harmed the professional may be held liable.

Problem-Oriented System Documentation System

• Organized around client problems • Four components: database, problem list, plan of care, and progress notes • Promotes greater collaboration

Exogenous Healthcare-Related Infection

• Pathogen acquired from healthcare environment. Ex: Patient with hip surgery gets MRSA in the wound 2nd to exposure to contaminated equipment or persons with poor hand washing skills.

Positioning Devices

• Pillows • Side rails • Adjustable belts • Trapeze bar • Footboards • Splints • Rolls • Boots Each help nurses best position clients to avoid complications or injury. These are primarily used for patients who cannot get out of bed.

Developmental Factors Affecting Safety in Preschoolers

• Play extends to outdoors • More adventurous • Major cause of accidental death is motor vehicle injuries followed by drowning, fire, and poisoning • Falls are primary cause of nonfatal injuries • After age 3, less prone to falls because gross and fine motor skills, coordination, and balance have improved. • Playing in an outside environment also creates additional safety concerns.

Cyanosis

• Presentation of a lack of oxygen. • Bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood.

Whistleblowing

• A person who reveals information about practices of others that he/she reasonably believes is corruption; mismanagement; fraud; abuse; illegal; or harmful to health, safety, & welfare of general public. • Consider the nature of the action, the likelihood of immediate harm, the accuracy, & the completeness of your data. • If it involves an immediate threat to the health, safety, & well-being of others, you should report it immediately.

What needs to be collected during a health history/physical examination?

• A thorough health history, review of body systems, and physical exam. • Ask patient about family history of various health disorders and cause of death of family members. • Exams should include: VS, weight, BMI or weight circumference, auscultation and palpation of chest and abdomen, inspection of skin, and palpation of peripheral pulses. • Exam may be accompanied by laboratory studies.

Full Spectrum Nursing

• A unique blend of thinking, doing, and caring for the purpose of effecting good outcomes from a patient situation.

Implementation

• Action phase when you carry out or delegate actions you previously planned. • Carry out actions that you previously planned & document your actions & patient's responses

Physiological Stress

• Affects the body: structure/function • Chemical—poison, medications, tobacco • Physical or mechanical—trauma, cold, joint overuse • Nutritional—vitamin deficiency, high-fat diet • Biological—viruses, bacteria • Genetic—inborn errors of metabolism • Lifestyle—obesity, sedentary lifestyle

What affects skin integrity?

• Age: the skin of an older adult is more susceptible to skin breakage. • Mobility Status: increased pressure, shearing, and friction can lead to breakdown. • Nutrition/Hydration: for instance, dehydration can cause poor skin turgor. • Sensation Level: diminished sensation leads to increased risk for pressure and breakdown. • Impaired Circulation: impaired arterial and venous circulation can negatively affect tissues in the body. Both forms of circulatory impairment delay wound healing too. • Medications • Moisture: Exposure to moisture (for instance, due to incontinence) leads to maceration. • Fever: leads to sweating, which can cause maceration and increases skin breakdown. • Infection • Lifestyle: tanning, frequent bathing (can lead to drying of skin), and piercings and tattoos.

Professional Organizations

• American Nurses Association (ANA): National professional organization. • National League for Nursing (NLN): Establishes and maintains a universal standard of education. • International Council of Nursing (ICN): Federation of national nursing organizations. • National Student Nurses' Association (NSNA): Represents nursing students. • Sigma Theta Tau International: National honor society for nursing.

Rate

• Apnea: Cessation of breathing • Bradypnea: Abnormally slow (<12 breaths/min) • Tachypnea: Abnormally fast (>20 breaths/min)

ADPIE

• Assessment • Diagnosis • Planning • Implementation • Evaluation

Common Types of Baths

• Assist Bath: patient can do some parts but the nurse bathes areas that are hard to reach. • Partial Bath: bathe only those areas absolutely necessary. A nurse may clean only the axilla and perineum for instance. • Bed Bath: a complete bath. May use prepackaged bathing products.

Ethical Principles

• Autonomy • Beneficence • Nonmaleficence • Veracity • Fidelity • Justice

Safety Hazards for Healthcare Workers

• Back injury • Needlestick injury • Radiation injury • Workplace violence Preventions: body mechanics, sharps awareness and proper disposal, radiation precautions, and environmental awareness of personal safety.

Nursing Diagnoses specific to self-care abilities include:

• Bathing/hygiene deficit • Feeding deficit • Toileting deficit • Dressing/grooming deficit • Self-Neglect

Developmental Factors Affecting Safety in Infants and Toddlers

• Cannot recognize danger • Tactile exploration of environment • Totally dependent • Motor vehicle accidents • Falls, choking, SIDS, and ingesting poisons • Explore environment by putting objects in their mouth • Incidence of choking is highest between 6 months and 3 years of age. • As mobility continues to improve, their curiosity leads them to explore cupboards, stairs, open windows, swimming pools, and other hazards.

Arterial Ulcers

• Caused by inadequate circulation of oxygenated blood to tissue, which leads to tissue ischemia & damage • Ulcer appears "punched out," small & round with smooth borders. • Wound base is usually pale with or without necrotic tissue. • Tend to occur over distal part of leg. • Surrounding skin appears shiny, thin, dry & is cool to touch. • Often there is loss of hair in surrounding area. • Area has delayed capillary refill time & may complain of pain that worsens with increased activity. • This type of ulcer can lead to serious injury & even death.

Venous Stasis Ulcers

• Caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function, resulting in venous pooling, edema, & impaired microcirculation of the skin. • Usually located around inner ankle or in lower part of calf. • Surrounding skin is reddened or brown & edematous. • Wounds are usually shallow, with irregular wound margins. • Wound bed appears "ruddy" or "beefy" red & granular. • Drainage may be moderate to heavy depending on amount of edema. • Pain usually occurs with leg dependence & dressing changes.

Pressure Ulcers

• Caused by pressure, resulting in tissue ischemia & injury • Appearance depends on the stage or tissue layers involved. • Pressure ulcers tend to be located over bony prominences. • Can cause serious tissue damage.

Medication Administration Records (MAR)

• Comprehensive list of all ordered medications. • Provides information on client's medication allergies. • Documents scheduled/routine, PRN, STAT, or omitted doses. • Additional explanation may be required for non-routine or omitted medications.

Stress-Induced Organic Responses

• Continual stress • Is a result of repeated CNS stimulation & elevation of certain hormones • Brings about long-term changes in various body systems. • People who use maladaptive coping strategies create additional stress on body, further contributing to disease • Repeated CNS stimulation • Elevation of certain hormones • Results in long-term changes in body systems

Surgical Asepsis Involves:

• Creation of a sterile environment • Use of sterile equipment/supplies • Sterilization of reusable supplies. • Surgical hand scrub: you modify usual hand washing routine and use bactericidal scrubbing agent. • Surgical attire • Sterile gloves • Sterile field • Use of sterile technique *Used in burn units, labor/birth units, surgeries, ICUs, nurseries, and oncology ward*

Falls Prevention

Most commonly reported incident in hospitals. Prevalent in those older than 65 years old. 1. Environmental Factors: slippery floors, stairs, tubs, low toilet seat, high bed 2. Health issues that increase risk for falls: poor vision, hypotension, history of falls, dizziness, pain, alcohol use, cognitive impairment, poly pharmacy, arthritis, gait or balance deficits, and age greater than 80 years. *Preventions:* nonskid shoes, tidy clothes, proper lighting, grab bars/rails, no scatter rugs, fall risk assessment, clean dry floors, patient education, and environmental safety. *Good to Know:* Risk assessment on admission, for patients at risk repeat risk assessment every 8 hours. Increase frequency of monitoring, have the call light within reach, orient the person to surroundings, identify meds that increase the risk of falls, and teach them fall prevention strategies.

Respiratory Rate

Number of times a person breathes (or completes a cycle of inhalation & exhalation) within 1 full minute.

Delegating Vital Signs

Nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of VS, VS trends, & decisions based on abnormal VS findings.

Deontology (Ethical Framework)

Opposite of utilitarian model in that it considers action to be right or wrong regardless of its consequences.

Planning Outcomes

• Decide goals you want to achieve with your nursing activities. • Making decisions about goals for your care. • Patient outcomes you want to achieve through nursing activities. • These outcomes will drive your choice of interventions.

Effort

• Degree of work of breathing. • Dyspnea: Labored breathing (shortness of breath). • Orthopnea: Inability to breathe when horizontal

Other Types of Screenings

• Dental health • Colon cancer screening • Breast cancer screening • Cervical cancer screening • Testicular cancer screening • Prostate cancer screening • Skin cancer screening (Remember A, B, C, D, and E)

What factors increase infection risk?

• Developmental Stage (young children are vulnerable). • Breaks in the skin (caused by surgical procedure, skin breakdown, insect bite, or insertion of IV device). • Illness/injury, chronic disease • Smoking, substance abuse • Multiple sex partners • Medications that inhibit/decrease immune response • Nursing/medical procedures

Physiological Responses to Stress

• Dilated pupils • Muscle Tension • Stiff Neck • Headaches • Skin Pallor • Nail Biting • Skin Lesions (Eczema) • Diaphoresis, Sweaty Palms • Dry Mouth • Nausea • Flatulence • Weight or Appetite Changes • Increased Blood Glucose • Increased Heart Rate • Cardiac Dysrhythmias • Hyperventilation • Chest Pain • Water Retention • Increased Urinary Frequency or Decreased Urinary Output • Diarrhea or Constipation

Roles of the Nurse:

• Direct Care Provider • Communicator • Client/Family Educator • Client Advocate • Counselor • Change Agent • Leader • Manager • Case Manager • Research Consumer/Researcher

Blood Pressure

• During cardiac contraction, blood is forced out of the heart and against the arterial vessel walls. This force, or pressure, is called blood pressure. • Remember that the body's cells need oxygenated blood to survive. For healthy tissue perfusion, adequate BP is needed.

Types of Scheduled Hygiene Care

• Early morning care: on awakening. Wash face and hands, mouth care. • AM morning care: after breakfast. Bathing, toileting, hair, skin, and bed making. • PM afternoon care: afternoon. Toileting, hand washing, oral care, and readying for visitors. • HS hour of sleep care: prior to sleep. Relaxation activities (such as a back massage), readying environment to facilitate sleep. • Hourly rounding: involves positioning, pain relief, toileting.

Respiration

• Exchange of oxygen and carbon dioxide in the body. • Nurse should count RR after taking the radial pulse. • Patient can alter the rate & pattern of respirations. • RR must be accurate, especially in older adults.

Eddie Bernice Johnson

• Faced segregation as a student, and was the first registered nurse elected to the U.S. Congress, as a representative from Texas. • Created opportunities for minorities, such as the STEM Education Act (which would provide grant awards to minority students), into the U.S. House of Representatives.

Common Malpractice Claims

• Failure to assess and diagnose • Failure to plan • Failure to implement a plan of care • Failure to evaluate

Developmental Factors Affecting Safety in Adolescents

• False confidence; feel indestructible • Risk-taking behaviors • Most lack adult judgment • Leading cause of death is motor vehicle accidents, followed by homicide (and suicide too!)

Fever (Pyrexia)

• Febrile • High body temperature (>100°F or 37.8°C)

Alarm Stage of GAS

• Fight or flight • Involves involuntary body responses: 1. Endocrine System: - Corticotropin-releasing hormone (CRH), Adrenocorticotropic hormone (ACTH), Antidiuretic hormone (ADH). 2. Sympathetic Nervous System: Epinephrine & Norepinephrine 3. Cardiovascular (CV) system: Vasoconstriction, elevated BP 4. Respiratory system: Dilated bronchioles 5. Metabolic: Increased availability of glucose. 6. Urinary: Na+ & water retention 7. Gastrointestinal (GI): Decreased peristalsis 8. Musculoskeletal: Increased blood flow to muscles

Evaluation

• Final phase: Judge whether actions have successfully treated or prevented pt's health problems. • Modification of care plan based on what has been achieved & what yet needs to be achieved.

General Adaptation Syndrome (GAS)

• Hans Selye's theoretical model of physiological responses to stress. • Involves 3 stages: (1) Alarm stage, (2) Resistance Stage, and (3) Recovery/Exhaustion.

Objective Data Collection About Skin

• Inspect each area of the skin in orderly, head-to-toe manner, noting overall cleanliness, condition, color, texture, turgor, hydration, and temperature. • Observe for the following changes in skin color: pallor, erythema, jaundice, and cyanosis. • Assess for common skin problems: pruritus (itchiness), dry skin, maceration (dampness of the skin--caused by excessive perspiration and incontinence of urine or bowel), excoriation, abrasion, pressure injuries, acne, and burns. • *Nursing Diagnosis:* skin integrity alteration as the problem or an etiology • *Planning outcomes/evaluation:* standardized and individualized outcomes • *Planning interventions/implementation:* bathing

Health Promotion Activities

• Promote adequate nutrition. • Help pt establish a routine that includes regular exercise. • Teach pt importance of getting 7-8hr of sleep per day. • Encourage participation in leisure activities. • Help pts to manage time, balance responsibilities, & prioritize tasks. • Advise patients to avoid maladaptive behaviors.

Standard Precautions

• Protect healthcare workers from exposure, decreases transmission of pathogens, and protects clients from pathogens carried by healthcare workers. • The specific elements of standard precautions include hand hygiene, PPE, sharps injury prevention, cleaning and disinfection, cough etiquette, waste disposal, and safe injection practices.

Dorothea Dix

• Pushed for formal training for nurses. • Best known for her advocacy for mental health reform and indigenous rights.

Hyperventilation

• Rapid & deep breathing resulting in excess loss of CO2 (hypocapnea). • Complain of feeling light-headed & tingly.

Autonomy

• Refers to a person's right to choose & ability to act on that choice. • It is based on respect for human dignity.

Rhythm

• Regular or irregular. •Assessment of the pattern of respirations. • Abnormal: Cheyne-Stokes, Biot • Infant breathing rhythms are more likely to be irregular than adult

Oral care facilitates what?

• Removal of food particles and secretions • Improved appetite • Assessment of patient's oral status • Care of dentures • Reduction of incidence of pneumonia • Assessment of the oral cavity (condition of teeth, cavities, gingivitis as well as conditions affecting the mouth, like stomatitis (a general term for an inflamed and sore mouth), glossitis (a problem in which the tongue is swollen and inflamed), and oral lesions/malignancies).

Local Adaptation Syndrome

• Response to stress involving specific body part, tissue, or organ. Short-term attempt to restore homeostasis. • Localized. • Types: 1. Reflex Pain response: When you perceive a painful stimulus in one of your limbs, you immediately & unconsciously withdraw from source of pain (e.g. when you touch something hot and pull away). *Protective reflex.* 2. Inflammatory Response: This is a local reaction to cell injury, either by pathogens or by physical, chemical, or other agents. Produce classic symptoms of inflammation: pain, heat, swelling, redness, and loss of function.

Nursing Interventions for Health Promotion

• Role modeling • Counseling • Health education • Supporting lifestyle changes

Cardiac Output

• Stroke volume × pulse (heart) rate. • Total quantity of blood pumped per minute. • Pulse of 80 beats/min and average stroke volume (70 mL), the cardiac output would be about 5600 mL (or 5.6 liters) per minute - 80 X 70 = 5600 = 5.6 L/min

Ethics

• Systemic study of right and wrong conduct. • Answers the question "what should I do in a given situation?" • Ethics are gray whereas laws are black and white. Ex: Is it wrong to steal if I can't afford food for my children?

Hypertension Stage 1

• Systolic BP 130-139 mmHg • Diastolic BP 80-89 mmHg

Hypertension Stage 2

• Systolic BP 140 mmHg or greater • Diastolic BP 90 mmHg or greater

Most frequent vital signs that will be checked:

• T: Temperature (normal range 97-100.8ºF) • P: Pulse (60-100) • R: Respirations (12-20) • BP: Blood Pressure • Pain (scale 0-10) • O2: Oxygen Saturation (95% to 100%)

Other Types of Baths

• Towel Bath: modification of bed bath in which you place a large towel and a bath blanket in a plastic bag, saturate them with warmed, commercially prepared mixture of moisturizer, disinfectant, and nonsense cleaning agents, and use them to bathe the patient. • Shower • Tub Bath • Therapeutic Bath: given for a specific purpose. For example, to treat a skin condition or relax sore muscles.

Developmental Factors Affecting Safety in School-age Children

• Try new activities without practice • More time outside the home, bone and muscle injuries are common • Stranger danger • Ready to try new skill without practice or training • Leading cause of accidental death in children is motor vehicle accidents. • Leading cause of nonfatal injury is falls • More refined muscle coordination and control, improved decision-making skills • Injuries are related to sports, skateboarding, and bicycle riding • Exposure to wider school and neighborhood environment increases risk for injury inflicted by people outside the home.

Tachycardia

>100 bpm

Fistula Formation

Abnormal passage connecting 2 body cavities & skin. • From infection. • An abscess forms, breaks down surrounding tissue & creates abnormal passageway. • Chronic drainage from fistula lead to skin breakdown & delayed healing. • Most common sites where fistulas form are GI & GU tracts.

Circadian Disorder

Abnormality in sleep/wake times. • May be caused by rapid time-zone changes or working night shifts/rotating shifts.

Unintentional Torts

Accidents or mistakes that are not planned or intended that result in harm to another. Includes: 1. Negligence: Failure to perform as a reasonable, prudent person would. Also failure to follow standards of practice. No intent to harm is present though. 2. Malpractice is a professional form of negligence.

Direct Care Provider

Addressing physical, emotional, social, and spiritual needs of client. Ex: Listening to lung sounds, giving meds, client teaching

Change Agent

Advocating for change on an individual, family, group, community, or societal level that enhances health. The nurse may use counseling, communication, and educator skills to accomplish such change. Ex: Working to improve the nutritional quality of the lunch program at a preschool, providing the nurse manager with information on a more efficient cardiac monitor, and serve on the quality improvement committee.

Puncture Wound

An open wound caused by a sharp object. Often there is collapse of tissue around the entry point, making this wound prone to infection.

Penetrating Wound

An open wound in which the agent causing the wound lodges in body tissue.

Incision

An open, intentional wound caused by a sharp instrument (scalpel).

Somatization

Anxiety & emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, & depression. Pt is unable to control symptoms & behaviors, & complaints are vague or exaggerated.

Stress

Any disturbance in a person's normal balanced state.

What pulse point is most accurate?

Apical

Research Consumer/Researcher

Applying evidence-based practice to provide the most appropriate care, to identify clinical problems that warrant research, and to protect the rights of research subjects. Ex: Reading journal articles, attending continuing education, and seeking additional education.

Psychological Stress

Arises from life events.

Subjective Data Collection About the Skin

Ask the patient about his usual bathing and skin care practices and preferences, as well as the following: • Past and current skin problems • Prescription and OTC or herbal skin remedies being used • Allergic reactions to food, medications, plants, skin care products • History of diseases to cause skin problems

Assault

Assault is the intentional act of making someone fear that you will cause them harm. You do not have to actually harm them to commit assault. Threatening them verbally or pretending to hit them are both examples of assault that can occur in a nursing home. Other examples: Tormenting them by taking away food or medications, objects, isolating them from others, mocking them, even using inappropriate body language (rolling eyes, standing over them yelling) and restricting loved ones can also be seen as a type of psychological or emotional assault.

Delegating Hygiene Care

Assess prior to delegating & instruct NAP regarding: • Client's limitations (ex: he's paralyzed on the left side) • Amount of assistance needed • Use of assistive devices (ex: walker, cane, etc) • Presence and care of tubes (ex: foley's, IV's, central lines) • Observations to make during hygiene care

Client/Family Educator

Assessing and diagnosing the teaching needs of the client, group, family, or community. Once the diagnosis is made, nurses plan how to meet these needs, implement the teaching plan, and evaluate its effectiveness. Ex: Preoperative teaching, prenatal education for siblings, and community classes on nutrition.

Apical Pulse Location

At apex of heart

Battery

Battery is the intentional act of causing physical harm to someone. Slapping, pinching, kicking and pulling hair are examples of battery.

Popliteal Pulse Location

Behind knee

Carotid Pulse Location

Between midline and side of neck (Only for CPR-trained professional & assessing circulation to head).

Know who to calculate celsius:

C = (F-32) / 1.8 OR C = (F-32) x 5/9

Sanguineous

Bloody drainage • Sanguineous exudate with deep wounds or wounds in highly vascular areas. Sanguineous exudate is bloody drainage. It indicates damage to capillaries. Fresh bleeding produces bright red drainage, whereas older, dried blood is a dark, red-brown color. • Indicates active bleeding.

Hygiene

Conditions and practices that help maintain health & prevent the spread of disease.

Undermining Wound

Dead space under the edges of the wound.

Quasi-Intentional Torts

Defamation of character. All 4 of the following essential elements must be present: 1. Was false. 2. Was made to another person or persons. 3. Caused the defamed person to experience shame and ridicule and had a negative impact on the person's reputation. 4. Was made as a statement of fact rather than as an opinion. Slander: Oral defamatory statements. Libel: Written defamatory statements.

Pender's Health Promotion Model

Focuses on promoting health and managing stress. It is one of the widely used models to plan for and change unhealthy behaviors and promote health. This model involves: 1) Person desiring to live in a way that promotes health. 2) Utilizing physical exercise, improving diet, nutrition, and stress-management strategies to help person become healthy or maintain health.

Hypersomnia

Excessive daytime sleepiness.

Risk for Disuse Syndrome

Exists when a patient's prescribed or unavoidable inactivity creates the risk for deterioration of other body systems.

The Patient Care Partnership, previously called the Patient's Bill of Rights

Explains that during hospitalization a client can expect high-quality care, a clean and safe environment, involvement in his or her care, privacy protection, help with leaving the hospital, and help with billing claims.

Wheeze

High-pitched continuous musical sounds, usually heard on expiration (asthma). • Caused by narrowing of airways. • Can often be heard without a stethoscope.

Factors that influence pulse rate:

Gender, exercise, stress, fever, disease, blood loss, position change, food intake, developmental level, blood loss, medication

Resistance Stage of GAS

Goal: maintenance of homeostasis. Involves use of coping mechanisms: • Psychological • Physical: return of vital signs to normal. Failure to adapt to or contain stress leads to 3rd phase. If stress is too great, defense mechanisms fail, patient enters 3rd phase.

Eustress

Good stress, for instance getting married may create eustress.

"Never Events"

Many deaths related to medical errors can be attributed to "never events," which are also known as serious reportable events (SREs). Examples of "never events" include: • Foreign objects being left in a patient during surgery. • Serious pressure injuries. • Symptoms resulting from poorly controlled blood sugar levels.

Brachial Pulse Location

Medially in antecubital space

Justice

Obligation to be FAIR.

Vascular Response

Immediately after injury, blood vessels at the site constrict to control bleeding. The following occur: • Response: injured cells release histamine. • Effect: Local vessels dilate, increasing blood flow to the area (hyperemia). • Response: dying cells release kinin. • Effect: Capillaries become more permeable, allowing fluid to move from capillaries into tissue spaces. This results in tissue edema (swelling). • Response: Leukocytes (WBCs) move into the area. • Effect: Localized blood flow again decreases to keep WBCs in the area to fight infection.

Leader

Inspiring others by setting an example of positive health, assertive communication, and willingness to improve. Ex: Florence Nightingale, Walt Whitman, Harriet Tubman, and Malala Yousafzai.

Stertor

Labored breathing that produces a snoring sound. • Common with mouth breathing due to nasal congestion.

Radial Pulse Location

Laterally on anterior wrist

Prone Position

Lying on abdomen, facing downward (head may be turned to one side). • Used for severe back positions and allows for mouth drainage.

Supine Position

Lying on back, facing upward. • In which the patient lies on his or her back with the head flat (it's comfortable after some surgeries).

Emergency Medical Treatment and Active Labor Act

Requires healthcare facilities to provide emergency treatment to patients in the emergency department regardless of their ability to pay, legal status, or citizenship status, until they are deemed stable.

Systole

Peak of the wave, or contraction of heart.

Systolic Pressure

Peak pressure exerted against arterial walls as the ventricles contract and eject blood.

Two types of restraints?

Physical and chemical

Aldosterone

Promotes fluid retention by kidneys to reabsorb more Na+. It helps to increase fluid volume and maintain/increase BP.

Korotkoff Sounds

Series of sounds that correspond to changes in blood flow through an artery as pressure is released.

Laceration

Skin or mucous membranes are torn open, result in wound w/ jagged margins.

Excoriation

Superficial wound due to excessive scratching or mechanical force.

Hypotension

Systolic blood pressure <100 mm Hg

Competent

The competent nurse is able to prioritize tasks by drawing on past experiences. The nurses may not function with the same speed or ease of change as proficient nurses, but they have mastery in multiple areas. Competent nurses recognize patterns in clinical situations more quickly and accurately than advanced beginners.

Beneficence

The duty to do or promote good

Classifications of Infections By Location

1. Local: Occur in a limited region in the body. 2. Systemic: Spread via blood or lymph. Affects many regions (septicemia).

Mechanical vs. Chemical Respiration

1. Mechanical: • Pulmonary ventilation (breathing) • Active movement of air in & out of respiratory system 2. Chemical • External respiration- Exchange of O2 & CO2 between alveoli & pulmonary blood supply • Gas transport- Transport of O2 & CO2 throughout body • Internal respiration- Exchange of gases between capillaries & tissues

Common Types of Charting

1. Narrative: "story" of care in chronological order; tracks the patient's status; can be lengthy and disorganized. 2. PIE: problems, interventions, and evaluation; establishes an ongoing plan of care; does not document the planning portion of the nursing process. 3. SOAP(IER): subjective data, objective data, assessment, plan, intervention, evaluation, and revision. 4. Focus: highlights patient's problems, concerns, or strengths. Uses three columns: • Time and date • Focus or problem being addressed • Charting in a DAR (data, action, response) format 5. Charting by exception (CBE): Chart only significant findings or exceptions to norms. 6. FACT system: flow sheets individualize specific services, assessment with baseline data, concise progress notes, and timely entries. FACT documentation includes only exceptions to the norm or significant information about the patient. 7. Electronic entry format

Kardex (Client Care Summary)

A card file that contains condensed versions of each patient's or resident's medical record

Inflammatory Processes

1. Vascular Response 2. Cellular Response 3. Exudate Formation 4. Healing

Model of Change

1. Contemplation: involves the decision-making process. 2. Determination: stage in which person makes a decision to change a behavior & prepares a plan. 3. Action: the implementation of the plan. 4. Maintenance: allows the changed behavior to be reinforced. Ideally the stages would progress in this order. Realistically, person may progress & regress in any of the stages.

When do you check the apical pulse?

1. If radial pulse is weak or irregular. 2. Rate is less than 60 bpm or greater than 100 bpm. 3. Patient is taking cardiac medications. 4. Patient is an infant or child up to age 3.

Stages of Infection

1. Incubation: From the time of infection until manifestation of symptoms. You can infect others during this stage. 2. Prodromal: Appearance of vague symptoms; not all diseases have this stage though. 3. Illness: Signs and symptoms are present. 4. Decline: Number of pathogens decline. 5. Convalescence: Tissue repair and return to health.

Chain of Infection

1. Infectious agent aka GERMS: Bacteria, viruses, and parasites. 2. Reservoir aka where germs live: People, pets, wild animals, food, soil, and water. 3. Portal of Exit aka how germs get out: Mouth (vomit, saliva), cuts in the skin (blood), during diapering and toileting (stool), and tubes/IV lines. 4. Mode of Transmission aka how germs get around: Contact (hands, toys, sand) and droplets (when you speak, sneeze, or cough). 5. Portal of Entry aka how germs get in: Mouth, eyes, cuts in the skin (e.g. wounds or surgical sites), bite from a vector, and IV/drainage tube sites. 6. Susceptible Host: Person with inadequate defenses. Babies, children, elderly, people with weakened immune systems, unimmunized people

Course of fever:

1. Initial or Febrile Episode: When body temp is rising. You may feel chilly and shiver. 2. Second or Course: When body temp reaches its maximum. You may feel warm and flushed. 3. Third or Defervescence/Crisis: When temp returns to normal. You may experience diaphoresis (sweat excessively).

Types of Exercise

1. Isometric: involves muscle contraction without motion. Ex: planks, squats. 2. Isotonic: involves movement of joint during muscle contraction. Ex: weight training with free weights, walking, running, hiking, swimming, skiing, and dancing. 3. Isokinetic: Combines isometric and weight training providing resistance at constant/preset speed while muscle moves through full ROM. Ex: stationary bike that responds to a constant leg movement by the user.

What is health?

1. Jean Watson: High overall functioning; a state of mind. 2. Betty Neuman: Continuum of energy. 3. Myers, Sweeney, and Witmer: Integration of mind, body, spirit; those w/ disease can be "healthy."

Individual Factors Affecting Safety

1. Lifestyle 2. Cognition 3. Balance, gait, and mobility 4. Ability to communicate 5. Visual acuity 6. Emotional health 7. Safety awareness

Depth

How much air is taken in with each breath. • Normal: falling between shallow and deep. • Deep: taking in a very large volume of air & fully expanding one's chest or abdomen. • Shallow: when the chest barely rises and is difficult to observe.

Femoral Pulse Location

In groin fold

Alarm Fatigue

Occurs when nurses become desensitized to patient care alarms and then miss or delay response to an alarm.

Passive ROM

These exercises are completed by the nurse or nursing assistant.