Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
121 Cards in this Set
- Front
- Back
|
Average Oral & Tympanic temperature
|
37 C
98.6 F |
|
|
Average Rectal Temperature
|
37.5 C
99.5 F |
|
|
Average Axillary temperature
|
36.5 C
97.7 F |
|
|
When to measure vital signs
|
- Admission
- Assessing clients in home setting - In hospital, on routine schedule per orders - Before and after invasive procedure - Before, during and after blood transfusion - Before during and after therapies that affect cardio, respiratory and temp control functions - When physical condition changes - Before and after nursing interventions influencing vital signs - When client reports non specific symptoms of physical distress |
|
|
Thermoregulation
|
Balance between heat loss and heat produced
|
|
|
Hypothalamus
|
Regulates body temperature
|
|
|
Radiation
|
Transfer of heat without direct contact
|
|
|
Conduction
|
Transfer of heat with direct contact
|
|
|
Convection
|
Transfer of heat by way of air movement
|
|
|
Diaphoresis
|
Visible perspiration
|
|
|
Core temperature measurement sites
|
Rectum
Tympanic membrane Temporal artery Esophagus Pulmonary artery Urinary bladder |
|
|
Surface temperature sites
|
Skin
Oral Axillary |
|
|
Determination of fever
|
Physical signs and symptoms of infection
- Several elevated temperature readings at different times of day when compared to usual values for that person |
|
|
How fever fights infection
|
WBC production is stimulated; increased temp decreases iron available in blood plasma, which suppress bacterial growth. Interferon in released to fight viral infection.
|
|
|
Patterns of Fever
|
Sustained - continuously greater then 38C
Intermittent – spikes with boats of normal tempRemittent – Fever spikes and falls without return to normal Relapsing- febrile episodes and period of normal temp alternating > 24 hours |
|
|
Celsius to Fahrenheit
|
C = (F-32) x 5/9
|
|
|
Fahrenheit to Celsius
|
F = (9/5 x C) + 32
|
|
|
Cardiac Output
|
Volume of blood pumped by the heart in one minute
|
|
|
Adult Resp rate
|
12-20/minute
|
|
|
Child Resp. Rate
|
20-30 /minute
|
|
|
Infant Resp Rate
|
30-60/minute
|
|
|
Vital Signs
|
Temperature
Pulse BP Resp Rate Pain |
|
|
Factors that Influence Vital Signs
|
- Individual metabolism
- Time of day - Age - Gender - Medications - Exercise - Emotional State |
|
|
Hypotension
|
<90/<60
|
|
|
Normal BP
|
90-120/60-80
|
|
|
Prehypertension
|
121-139/81-89
|
|
|
Stage 1 hypertension
|
140-159/90-99
|
|
|
Stage 2 hypertension
|
>160/>100
|
|
|
Pulse Rate Normal Child
|
70-100 bpm
|
|
|
Pulse Rate Normal Adult
|
60-100 bpm
|
|
|
PRN
|
As needed
|
|
|
Ventilation
|
Movement of gases in and out of lungs
|
|
|
Defusion
|
Movement of O2 and CO2 between alveoli and RBC
|
|
|
Perfusion
|
The distribution of RBC to and from the pulmonary capillaries
|
|
|
Respiration
|
The mechanism the body uses to exchange gases between the atmosphere and the blood
|
|
|
Pulse pressure
|
Systolic - Diastolic
|
|
|
Palpation
|
Use hands to touch body parts
|
|
|
Why assess hair and scalp
|
To determine SaO2
|
|
|
Why assess nail beds
|
Circulation, self-care, lifestyle
|
|
|
Fever
|
- Variable # per MD orders
- Technical definition of >102.2 |
|
|
Arterial Oxygen Saturation
|
Indirect measure of oxygen saturation
|
|
|
Family durability
|
Interfamilial system of support and structure that may extend beyond the walls of the household
Resources available to family |
|
|
Family resiliency
|
The ability to cope with expected and unexpected stressors
Family’s ability to withstand turmoil |
|
|
Family diversity
|
The attention to uniqueness
Acknowledgement of individuality, and refrain from stereotyping |
|
|
Concept of family
|
Any diverse group that relies upon one another for emotional, physical and financial support
|
|
|
Family
|
Family is defined biologically, legally, or social network with personally constructed ties and ideologies
|
|
|
Trends in American families
|
Smaller
Delayed childbirth Couples having no children Remarriage results in blended families Homosexual couples leading families Divorce rates tripled since 1950s Prevalent single families Aging of population |
|
|
Current Healthcare areas for concern
|
Changing economic status
Homelessness Family violence Acute or chronic illness |
|
|
Family health system
|
A holistic model used to assess and care for families
|
|
|
Developmental stages
|
Each stage has its own challenges, needs and resources
|
|
|
Attributes if families
|
Structure is based on organization
Relationships are numerous and complex |
|
|
Family and health
|
- Many factors influence health
- Class ad ethnicity produce different access to the health care system - The family beliefs values and practice influence health behaviors |
|
|
Family context
|
Who are the players
What are the roles and belief systems |
|
|
Family as client
|
Caregivers must be offered care
|
|
|
Family as a system
|
Facilitate care within the family
|
|
|
Nursing process for the family
|
Assessing the needs
Family-focused care Challenges for family nursing Implementing family – centered care |
|
|
Family assessment
|
Indentify data
Family composition Family history and developmental stage Environmental data Family structure Family functions Health beliefs, values, and behaviors Family stressors and coping Abuse and violence within family Family communications patterns Family coping processes |
|
|
Confidentiality
|
Providers must obtain separate client authorization for disclosure for drug and alcohol treatment, mental health, & HIV
|
|
|
Standards
|
All clients must have an assessment of physical, psychosocial, environmental, self-care, client education and discharge planning
|
|
|
Documentation
|
Systemic, continuous, accessible, communicated, recorded and readily available to all members of the health care team
|
|
|
Records
|
Client identification and demographics
Informed consent Admission nursing history Record of nursing care treatment and evaluation Medical history Medical diagnosis Therapeutic orders Medical and health disciplines progress notes Reports of physical examination Reports of diagnostic studies Client education Summary of operative procedures Discharge plans |
|
|
Reports
|
Oral, written or audio taped exchanges of information between multidisciplinary team
|
|
|
Consultations
|
Form of discussion in which formal advice is exchanged
|
|
|
Guidelines for quality documentation and reporting
|
Factual
Accurate Complete Current Organized |
|
|
Methods of recording
|
- Narrative (traditional)
-Problem oriented medical record (POMR) - Database - Problem list - Nursing care plan - Progress note - SOAP (Subjective, Objective, Assessment, Plan) - SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation) - PIE – Problem, Intervention, Evaluation - Focus Charting (DAR- Data, Action, response) -Source Records (A separate section for each discipline) - Charting by exception (CBE - focus on deviation from norm) - Case Management and critical pathways |
|
|
Kardex
|
Basic demographic info
HIPPA code word MD, or HCP name Primary medical diagnosis Medical and surgical history Current treatment orders from HCP Nursing care plan Nursing orders Scheduled tests and procedures Safety precautions necessary Factors related to ADL Nearest relative/guardian in case of emergency Emergency code status Allergies |
|
|
Home care documentation
|
Quality control and justification for reimbursement
|
|
|
Four types of reports
|
Change-of-shift
Telephone Transfer Incident |
|
|
Omnibus Budget Reconciliation Act of 1987
|
Medicare and Medicaid legislation for long term care documentation
|
|
|
Nursing information systems Advantages
|
Increased time with clients
Better access to information Enhanced quality of documentation Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with accrediting agencies Development of clinical database |
|
|
Absorption
|
Route of administration
Ability of medication to dissolve Blood flow to the site of administration Body surface area Lipid solubility of medication |
|
|
US Drug legislation
|
Sets official drug standards
Defines prescription drugs Regulates controlled substances Requires proof of efficacy |
|
|
Nurse Practice Acts
|
Identify nursing responsibilities for administration and client monitoring
|
|
|
Types of medication systems
|
Stock supply
Unit dose Automated dispenser Self administration |
|
|
Stock supply
|
Bulk quantity
Central location Not client specific |
|
|
Unit dose
|
Individually packaged
Client specific drawers 24 hour supply |
|
|
Automatic dispenser
|
Password-accessible locked cart
Computerized tracking Can combine stock and unit doses |
|
|
Self administration
|
Individual containers
Kept at client’s bedside (Nitroglycerin) |
|
|
Pharmacokinetics
|
What happens to the drug in the body
WHAT THE BODY DOES TO THE DRUG |
|
|
Pharmacodynamics
|
How the drug affects the body
|
|
|
Four processes of pharmacokinetics
|
Absorption
Distribution Metabolism Excretion |
|
|
Four factors affecting absorption
|
Route of administration
Drug solubility pH/ionization Blood flow Age (younger metabolize more quickly, aged need lower dose as metabolism is slower) |
|
|
PO absorption rate
|
30-60 minutes
|
|
|
IV absorption rate
|
Immediate
|
|
|
Factors affecting Distribution
|
Circulation
Membrane permeability Protein binding |
|
|
Factors affecting metabolism
|
Liver function
Health/disease status First Pass Effect |
|
|
Factors affecting excretion
|
Organ function especially kidney, liver and lung
|
|
|
Biotransformation
|
Chemical conversion of a drug
|
|
|
Pharmacokinetics
|
Time until onset and peak
Therapeutic range Peak level Trough level Half-life Concentration of active drug |
|
|
Primary pharmacodynamic effects of drugs
|
Therapeutic effects
Predicted Intended Desired |
|
|
Secondary pharmacodynamic effects of drugs
|
Unintended
Non therapeutic Can be: predictable, harmless or harmful |
|
|
Types of secondary effects
|
Side effects
Adverse reactions Toxic reactions Allergic reactions Idiosyncratic reactions Cummulative effect |
|
|
Therapeutic effects
|
The expected and predictable physiological response to medication causes
|
|
|
Side effects
|
Predictable and unavoidable secondary effects
|
|
|
Adverse effects
|
Unintentional, undesirable and unpredictable severe responses to medication
|
|
|
Toxic effect
|
Develop after prolonged intake of medication accumulates in the blood
|
|
|
Idiosyncratic reaction
|
Client over reacts or under reacts to a medication
|
|
|
Drug interactions
|
Antagonistic - opposses the action of another
Synergistic- two drugs together & sum of effects is greater than the two independently Incompatibilities - |
|
|
Synergistic reaction
|
The combined effect of two medications is greater than the effect given separately
|
|
|
Buccal administration
|
Alternate cheeks
Warn client not to chew or swallow |
|
|
Parenteral routes
|
Intradermal (ID)
Subcutaneous (Sub-Q) Intra muscular (IM) Intravenous (IV) |
|
|
Intrathecal
|
Catheter placed in the subarachnoid space or one of the ventricles of the brain
|
|
|
Intraosseous
|
Infusion directly into the bone marrow
|
|
|
Inhalation
|
Meds are readily absorbed and work rapidly because of the rich vascular capillary network
|
|
|
Standing orders
|
Orders carried out until the prescriber cancels or until a prescribed number of days elapse
|
|
|
PRN
|
As needed
|
|
|
STAT orders
|
Single dose to be given immediately (under 1 hour)
|
|
|
Now Orders
|
Single dose to be given quickly, but not STAT
|
|
|
Oral orders
|
Must be read back to MD, and signed within 24 hours
|
|
|
Prescriptions
|
Meds for client to take outside of facility
|
|
|
Process for medication reconciliation
|
Verify
Clarity Reconcile Transmit |
|
|
Six rights of medication administration
|
Right medication
Right dose Right client Right route Right time Right documentation Right to reason Right to know Right to refuse |
|
|
Components of medication order
|
Client’s full name
Data and time order was written Name of medication Dosage size, frequency, number of doses Route of administration Signature of prescriber |
|
|
Three checks of medication administration
|
Before you pour – label against MAR
After you pour – label against MAR At bedside |
|
|
Oral medications
|
Tablets, capsules, pills
Liquids Buccal Sublingual Enteral medications |
|
|
Topical medications
|
Lotions, creams, ointments
Transdermal patches Eye and ear Nasal Vaginal Rectal |
|
|
Respiratory inhalations
|
Atomizers
Aerosol Metered dose inhaler |
|
|
Parenteral medications
|
Intradermal
Subcutaneous Intramuscular Intravenous |
|
|
Equipment preparation for parenteral medication
|
Syringe/needle (size and gauge)
|
|
|
Medication preparation for parenteral medication
|
Vials and ampules
Reconstituting from powder Two medications in one syringe |
|
|
IV medications
|
IV push
IV piggyback Medicated drips |
