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236 Cards in this Set

  • Front
  • Back
What is the procedure for mixing Reg & NPH insulin?
*Air into NPH without touching needle to solution, then air into Regular
*Draw Regular
*Draw NPH
Name the last stage of "GAS" (General Adaptative Syndrome).
Exhaustion
Which type of social isolation may a pt experience after having a colostomy?
Presentational
As a nurse with geriatric clients, what is the meaning of reminiscence?
Ability of older adults to recall their past for the purpose of assigning new meaning to past expreriences.
What does JVD mean and how to you assess it?
*Jugular Vein Distention-distended only if pt has rght-sided heart failure
*Assess in Supine position, when standing, and when sitting at a 45 degree angle.
How should the carotid arteries be palpated?
Low and separately
Which of the following physiological changes occur as a person nears death?
*decreased peristalsis
*need to add more
HTN categorized as mild at what level?
140 Systolic & 85 Diastolic
Congruent communication means?
Verbal and non verbal communication disagree. Say they are fine but their face looks upset.
What nursing diagnosis is used when there is widespread disturbance involving self esteen and body image?
Altered Self-Concept
Pt says, "Only in my country can the hospital make my stay comforatable." What is this an example of?
Ethnocentrism
Surgery performed to restore function lost or reduced by a congential deformity.
Constructive
Which is the most basic need?
Love & Belonging
What is the treatment for respiratory acidosis?
Provide airway??????This is caused by acid base imbalance...so is that all you do?
Administering an injection is of meical or surgical asepsis?
Surgical
Is the following correctly or incorrectly stated? "Ineffective airway clearance R/T lung cancer AMB diagnosis secondary to bronchitis?"
Incorrect?????Why
List four components of legal consent:
*Responsiblility
*Legal Age
*Witnessing
*Time
What is the usual high limit of O2 for those with COPD?
2-3 l/m Hightest=4 l/min
What is this acid-base disturbance? pH=7.14, CO2=67, HCO3=?
Respiratory Acidosis
What type of wound drainage is clear?
Serous
Is the following correctly or incorrectly stated? "Ineffective airway clearance R/T lung cancer AMB diagnosis secondary to bronchitis?"
Incorrect?????Why
List four components of legal consent:
*Responsiblility
*Legal Age
*Witnessing
*Time
What is the usual high limit of O2 for those with COPD?
2-3 l/m Hightest=4 l/min
What is this acid-base disturbance? pH=7.14, CO2=67, HCO3=?
Respiratory Acidosis
What type of wound drainage is clear?
Serous
What is the normal capillary refill time?
<3 seconds
In Nursing Diagnosis Fluid Volume Deficit (FVD) related to diarrhea and vomiting AMB mucous membrane...True or Rals, diarrhea and vomiting are signs & symptions?
False. It is the etiology.
When performing PA (Physical Assessment) on the abdomen, what techniue is preferred after insprection?
Ascultation (Palpation may stimulate activity & cause misleading results)
What is the 2nd stage of the grief process?
Anger
What is the name of a hospital -acquired infection?
Nosocomial
True or Flase. Pt is anxious, Best way to provide support for him is to leave him alone.
False
All of the following are correct except which one? A patient is dying:
Freedom from decision making
Are S & S objective or subjective?
Objective
4 issues Plaintiff must prove for malpractice?
Duty owned
Duty breached
Harm occurred
Breached duty cause harm
What is atrophy?
Wasted or reduce size or physiological activity of a part of the body caused by disease or other influences. Muscle wasting
When charting descriptive, objective information, you should include what you?
See, hear, feel and smell
Which is higher in Maslow's hierarchy, food or self-actualization?
Self-actualization
_______ preventive care focuses on the client who has existing health problems?
Secondary
What is the treatment for metabolic alkalosis?
Reverse cause
The priority setting takes place in assessment phase? T ot F
False, planning phase
When male clients act out sexually to female nurse, the nurse should first:
Redefine the nurse-pt relationship to the client
Rational why distraction is effective for mile-moderate pain?
Decreased perception of pain
In planning care, the most important factor in preventing dying client's sense of loneliness and isolation is?
Visits by family members
Normal lab values for K:
3.5 - 5
Respiratory assessment produced findings of bilateral high-ptiched musical sounds produce?
Wheezes
A client care summary with certain information for daily care and that the client can readily access is:
Kardex
A jacke restraint must be removed q4h?
False, all restraints must be checked for circulation q 30 min.
3 techniqus that hinder communication
Belittle feelings
Agreeing
Sterotypical comments
(Any non-therapuetic communication technique)
Before teaching pt, nurse should first...?
Determine level of knowledge about subject
Which pase of nurse-pt relationship may the nurse and pt experience fellings of loss?
Termination
Movement of particles from high level to lower level of concentration?
Diffusion
Recall 2 principles of sterile technique:
Don't turn back on sterile field
Sterile can touch sterile
Contamination can occur thru capillary action
edges of the field are contaminated
Describe 24 hr urine collection.
Discard 1st urine.
Begin collection all urine for 23 hrs.
Pase of nursing process that involves data collection?
Assessment
Nurse walks into the room and the client is on the floor. What step is necessary at this time?
Assessment (find out if pt is breathing)
Pt had amputation. What disturbance may occur?
Disturbance of body image
Loud, low-ptiched coarse sounds heard in the lungs?
Ronchi or gurgles
Pain in claf on dorsiflexion, what action should the nurse take?
Call MD, Positive Homan's signs
2 signs of venous insufficiency:
Edema
Brown pigmentations around ankles
Color, cyanotic to normal
Temp & pulse Normal
Action of drug Versed.
Sedation
The way a microorganism leaves the source?
Portal of Exit
Identification of a client's problems occur during which phase of nurse-pt relationship?
*Orientation
*4 phases are:
-Pre-Interview
-Orientation
-Working
-Termination
4 purposes for Pre-Op Meds:
*Sedation
*Reduce pain
*Reduce GI & Respiratory secretions
*Reduce nausea
Skills are an example of what type of learning?
Psychomotor
What type of therapeutic technique is being used? "What would you like to talk about today?'
Broad Opening Statements
2 factors that influence susceptibility of host:
Nutritional Status
Age
Virulence
2 means to prevent infections in a catheterized pt:
Increase fluid intake
Cath care
Keep the bag below bladder level
Maintain a closed system
Name the type of solution equal to body's pressure.
Isotonic
________ preventive care focuses on a client with no current health problem or illness?
Primary
Wound drainage is pink...what is this drainage called?
Serosanguenous
What acid-base disturbance is... pH=7.54, CO2=27, HCO3=26 and how is it treated?
Respiratory Alkalosis, because CO2 is low, you want to increase CO2 so breath into paper bag
1st stage of grieving.
Denial
Treatment for metabolic acidosis?
Sodium bicarb IV (Tums)
Normal adult pulse rate.
60-100 beats p/min
Wound drainage that is a sign of infections?
Purulent
What is the propose for the end of shift report?
Continuity of care
What cranial nerve is associate with pupil cnstriction/dilation?
Cranial nerve III
What is the type of infection received from a medical procedure or diagnostice test?
iatrogenic
How would you assess a pt with pulse deficit?
Apical & radial pulse for 1 min.
What is the purpose of Atropine?
Reduce secretions
Which range would indicate Hypernatremia? Na=125, K=2, Na=155, K=6
Na=155 (Range is 135-145)
An unconscious, involuntary forgettng of painful events -What defense mechanism is this?
Repression
What acid-base disturbance? pH=7.21, ????
Metabolic acidosis
2 signs of poor nutrition:
*Thin brittle nails, hair
*Gums swollen and bleeding
What does PERRLA stand for?
Puipls Equally Round & Reactive to Light with Accommodation
Respiratory pattern gradually fater, deeper slowing with alternating periods of apnea?
Cheyne-Stokes
In most states, what is the legal age for consent?
18
_____ preventive care focuses on helping clients achieve high levels of function reducing disability.
Tertiary
6 Righs of Meds
Right medication
Right dose
Right route
Right patient
Right time
Right documentation
Pt expries at 10 am, it is now 11 am. Rigor mortis has sent in. T or F
False, 2-3 hours before it sets in and leaves after 96 hrs
In planning nurse care, what is the least priority: FVE, High risk for injury, Loneliness, Disturbed body image.
Disturbed body image
An IM injections of 1.66 cc, which sites can be used?
All except Deltoid.
Others are:
Vastus lataralis
Ventrogluteal
Dorsogluteal
Who is responsible for obtaining a consent signature?
The doctor
Name 2 of the 4 modes of transmission:
Contact
Air
Vector
Vehicle
2 signs of arterial insufficiency
Temp cool
Decreased or absent pulse
Thin, shiny skin
Pale extremity, dusky red when lowered
The statement "Asian women are stoic" is an example of what...
Stereotyping
2 factors of healthy bowel elimination
Increase fluids
Activity
Body's normal defense against infections
Normal flora
Inflammations
Body system defense
Immune response
Fever ?
Which is a higher priority: Safety or Love
Safety
What is the normal lab value for Na?
135-145
Romberg's sign accesses?
Balance
__________ Time is takes a drug to reach maximum level of effectiveness.
Peak
Name an illness prevention activity.
Vaccination
Screening Tests
Way which microoganisms leave host...
Portal of Exit
Normal range WBC...
5,000-10,000
5 techniques that facilitate communication
Any therapeutic communication technique
Broad Opening Statement
General lead
Giving information
Offering self
Encouraging Evaluation
Exploring
How long to you auscultate before determining there are no bowel sounds?
5 min
Which phase is more infectious?
Prodromal
What acid base disturbance..pH=7.64, CO2=37, HCO3=36
Metabolic Alkalosis
Holding dirty linens away from the body is _____ _____?
Medical Asepsis
A grandparent is always allowed to give medical consent for their minor grandchildren. T or F
False
2 types of aphasia
Expressive
Receptive
Systematic, scientific problem solving method of plannin and providing nursing care.
Nursing process
Acceptable way to correct a charting error.
Draw line through and initial
Includes those activities that motivates individual to avoid negative outome n health.
illness prevention
The time it takes a drug to reach a minimm level of effectiveness.
Onset of action
2 physical responses to stress
Increased heart rate
Sweaty palms
You check client restrants every shift. T or F
False, every 30 min for circulation
Which is least restrictive? Posey Belt, Writ Restraint, Jacket restraint, Mitt Restraint?
Mitt restraint
Black, tarry stools may be indicative of?
UGI Bleeding (as LGI bleeding would see fresh blood)
Health Promotion-Vaccines
Vaccines-
*Annual flue shotes for 65 and older
*pts with chronic illness reguardless of age
Health Promotion-Environment
Avoiding secondhand smoke; patients with cardiopulmonary illness
Health Promotion-Dyspnea
Dyspnea-(Difficult to measure and treat) Admin following therapies...MOPP
*Medications-steroids, bronchodilators
*O2 Therapy as indicated
*Physical techniques-breathing techn., cough control
*Psychosocial techniques-relaxation techn., biofeedback, meditation
Mainenance of patent airway
Coughing techniques
Suctioning
Artifical airways (Oral and tracheal)
Mobilization of pulmonary secretions
*Hydration-Promotes mucocilliary clearance
*Humidification-Pts with moree than 4 ml/min of 02.
*Nebulization-Aerosol principle, with water particles; improves clearance
Maintenance or promotion of lung expansion
*Positioning-Turn, activity, gradually increace of time OOB
*Incentive spirometers-encourages voluntary deep breathing. Prevention or treatment of atelectasis.
*Check physiotherapy-Chest percussion, vibration, postural drainage, group therapies
*Chest Tubes-Keep below the level of the chest
*Pneumothorax-Air or other gases in the pleural space
Maintenace and promotion of O2.
*Goals-prevention or relief hypoxia. *Safety-Water bases lubricant on nostirls and lips. *Supply-O2 tanks or permanent wall piped systems. *Nasal cannulas-not removed for daily activity. *nasal catheter-Must be alternated every 8 hrs, not desirable. *Transtracheal-small iv cath inserted into trachea. *Masks-Simple face masks usually used. *Always humidify 02 if flow rate is greater than 4 ml/min. * Trach-collar, *CPAP and BiPAP, *Ventilator-breaths for you
Maintenance or promotion of lung expansion
*Positioning-Turn, activity, gradually increace of time OOB
*Incentive spirometers-encourages voluntary deep breathing. Prevention or treatment of atelectasis.
*Check physiotherapy-Chest percussion, vibration, postural drainage, group therapis
*Chest Tubes-Keep below the level of the chest
*Pneumothorax-Air or other gases in the pleural space
Maintenace and promotion of O2.
*Goals-prevention or relief hypoxia. *Safety-Water bases lubricant on nostirls and lips. *Supply-O2 tanks or permanent wall piped systems. *Nasal cannulas-not removed for daily activity. *nasal catheter-Must be alternated every 8 hrs, not desirable. *Transtracheal-small iv cath inserted into trachea. *Masks-Simple face masks usually used. *Always humidify 02 if flow rate is greater than 4 ml/min. * Trach-collar, *CPAP and BiPAP, *Ventilator
Nursing Diagnosis
Five components of the Nursing process (ADPIE) Assessment, Diagnosis, Planning, Intervention, Evaluation
For a complete Goal statement you need:
*Subject- pt
*Verb- Action
*Condition - Under what circumstances
*Criteria- How well
*Specific time - Target date
Components of an intervention
Action verb
Content
Time element
Scientific rational
Types of Care Plans
Kardex- Card filing system that allows quick ref to the particular needs of the client.
Standardized/Compterized-Gives basic standard of care, saves nurse time, part of permanent record
Individualized NCP's
Na (Cation) Normal Lab Value
135-145 mEq regulated by diet and aldosterone
K (Cation) Normal Lab Value
3.5-5 mEq controls metabolic activity and body doesn't conserve well
Magnesium (Cation) Normal Lab Value
1.5-2.5 mEq
Chloride (Anion) Normal Lab Value
95-108 mEq
BUN Normal Lab Value
8-20 general for renal failure
Creatinine Normal Lab Value
.05-1.3 very specific for renal failure
Dextrose
5% in water-Isotonic
10% in water-Hypertonic
Half Normal Saline
.45% Hypotonic
Normal Saline
.9% Isotonic
Dextrose 5% and Normal Saline
Both Isotonic but when comined form a hpertonic solution
RBC
4-6 Million
WBC
5-10 thousand
Therapeutic Effect
The intended or desired response
Side Effect
A predictable and unavoidable secondary effect produced as a Usual Therapeutic Dose
Adverse Reaction
Undesired, upredictable, unintended responses to medication. (You didn't know med could cause
Toxic Effect
Prolonged intake of durg or accumulation of drug in system
Idiosyncratic Reaction
Unpredictable reation from what is expected
Alleric reaction
pt becomes immunologically sensitized to a med after taking the first dose
Anaphylatic Reaction
Hypersensitive condition induced by contact with certian antigens
Synergistic
an effect resulting from 2 drugs, the effect of the two drugs combined is greater than the effect of them given separately
Antagonistic drug action
Therapeutic or non therapeutic. One drug abolishes, or reduces the effect of another drug. Morphine and Narcan, Vit K and Coumadin
Signs and Symptons of an infection
Redness, heat, pain, swelling, decreased function of the affected body part, fever, nausea, vomiting, lymph node enlargement
Sugical Consents
*All consent forms need to be signed before admin of any pre op meds.
*Doc must get sign.
*If pt is confused the doctor must re-explain
Nursing Diagnosis Evaluation measures
*Review the OC
*Collect the subjective and objective data r/t OC
*Evaluate if the goal is met, unmet or partially met.
*if pts status has change, may need to id new nsg dxes
*Modify if necessary
Immobility-Proper nursing actions
ROM-maintains joint mobility. *Splints-Helps prevent contractures. *Exercise-About 2 hours total pr day. *Ambulation-If allowed. *I pt has paralyzed limb-teach them to perfomr passive ROM on that limb. *High top shoes to prevent foot drop. *Turn pt every 2 hrs. *Instruct patient not to massage legs. *Use TED hose. *Keep foot of bed elevated. *Ankle circles. *Encourage fluid, fruits and veg.
Antagonistic drug action
Therapeutic or non therapeutic. One drug abolishes, or reduces the effect of another drug. Morphine and Narcan, Vit K and Coumadin
Signs and Symptons of an infection
Redness, heat, pain, swelling, decreased function of the affected body part, fever, nausea, vomiting, lymph node enlargement
Sugical Consents
*All consent forms need to be signed before admin of any pre op meds.
*Doc must get sign.
*If pt is confused the doctor must re-explain
Nursing Diagnosis Evaluation measures
*Review the OC
*Collect the subjective and objective data r/t OC
*Evaluate if the goal is met, unmet or partially met.
*if pts status has change, may need to id new nsg dxes
*Modify if necessary
Immobility-Proper nursing actions
ROM-maintains joint mobility. *Splints-Helps prevent contractures. *Exercise-About 2 hours total pr day. *Ambulation-If allowed. *I pt has paralyzed limb-teach them to perfomr passive ROM on that limb. *High top shoes to prevent foot drop. *Turn pt every 2 hrs. *Instruct patient not to massage legs. *Use TED hose. *Keep foot of bed elevated. *Ankle circles. *Encourage fluid, fruits and veg.
O2 Therapy and COPD
Normal persons increas CO2 level is their drive to breath, but a person with COPD constantly has increasec co2 level, therefore their decreased o2 level is their drive to breath. o2 rand for a person on o2 with copd 2-3 ml/min.
Ear Drops
*Down and inward for child
*Up and outward for an adult
Physical Assessment-Normal findings
*Temp 96.8-100.4 (oral 98.6)
*Resp 12-16
*Pulse 60-100
*BP 120/80
*Eupnea Regular in Depth and Rate
Physical Assessment-Abnormal Findings #1
*Orthopnea-breath easier upper right
*Dyspnea-Difficulty breathing, SOB
Tachypnea-faster rate of RR
*Cyanosis-turning blue
*Apnea-Absence of respiration
Cheyne-Stokes-Death Rattle-Gradually becomes faster and deeper than normal, then slower alternating with periods of apnea.

*Bradypnea-slower rate of RR
Physical Assessment-Abnormal Findings #2
*Kussmaul's-faster and deeper resp. with pauses, usually labored, occurs in diabetic acidosis
*Kyphosis-hunchback
*Lordosis-swayback
*Scoliosis-curvature of the spine
*All sounds caller "adventitious" are sounds that can not be differentiated in the lungs
*Petechiae-pin point red or purple spots caused by small hemorrhages
Physical Assesment-Abnormal Findings #3
*Alopecia-Baldness
*Clubbing-nail abnormalitities
*Tinnitus-ringing in the ears
*Postiive Homans sign-pain in claf on dorsiflexion
*Positive Rombers sign-porblem with balance
Older Adult Avoiding Falls
*Exercise daily to help musculoskeletal system
*
Maslow's Hierarchy
*Physiologic-Most basic need; Most important
*Safety and Security-Includes both physical and psychological security
*Love and Belonging-Need love, friendship and social relationships
*Self-Esteen-Feelings of confidence, usefulness, achievement and self worth
*Self-Actualization-A state in which one is fully achieving one's potential and is able to solve problems and cope
Wound Healing
*Primary Intention-heals from side to side, less scarring
*Secondary Intention-heals from inside out, more risk of enfection, takes longer to heal, more scar tissue
Specimen Collection-Urine
*Clean voided urine or mid stream (clean catch)-after cleaning with antiseptic wipes, collect mid stream into sterile cup
*Sterile Speciments-can be obtained by cathing or indwelling cath
*24 hr urine-starts after 1st speciment, collect all urine in 24 hrs, last voiding should be close to end of 24 hr
Specimen Collection-Feces
*Guaiac test/Hemoccult. Detects blood in stool
*testing for fat in feces, do same test for 3-5 days
Chain of infection transmission
*Infections Agent
*Reservoir
*Portal of Exit
*Means of Transmission
*Portal of Exit
*Susceptible Hose
Cultural Conflicts
*Avoid Steryotyping
*Know and understand patients religion
Symptoms vs Signs
*Subjective-Symptoms-Have to be told, apparent only to the pt, the feelings, thoughts, ideas, of the pts.(hunger, anxiety, depression, pain nausea, etc)
*Objective-Signs-Can be seen, heard, felt and smelled (fever, bp, IV fluids, swelling, inflammation, etc)
Pt safety during care
*Provide safe, caring enviroment
*Foster Autonomy
*Always avoid restraints when possible; restrain then get order
*Best way to calm pt down, reorientation
*Do circulation checks every 30 min, take off rest. every 2 hrs do ROM
*Use the least amount of restraints necessary when they must be used
*Side rails up by 2
Domains of Learning-Cognitive Learning
Involes changes in the person's level of understanding or knowledge. It includes intellectual behaviors (learning the principle of why an injection must be IM as opposed to SQ, pt learns the rationale for checking his heart rate prior to taking a med. Evaluation is by testing.
Domains of Learning-Psychomotor Learning
Involves a change in a person's ability to perform a skill. Depends on muscle and neuo coordination/intergration. (a diabetic leaning how to give self insulin, learning how to palpate and count a radial pulse) Evaluation-demostrate ability. Practice is the key
Domains of Learning-Affective Learning
A change in a learners expression of feelings related to his/her opinions, values, and attitudes. (accepting a diagnosis of an illness, accepting the need for injections by overcoming fear for performing the task). Evaluation is done by role modeling and discussion.
Promote Normal Voiding
*Assist with normal position
*Provide sensory stimuli
*Povide for privacy
*Maintain intake of 2-3,000 ml/24hrs
Promote Complete Bladder Empting
*Kegal exercises
*Credes' compression (manual bladder compression
*Medications
*Catheterization
*Cath alternatives (Suprapublic cath, condom cath, underpads)
Promote normal defecations (fecal impactions)
*Check for MD order
*Avoid forceful pressure as it can cause irritaion and bleeding
*Monitor VS
Promote Normal Defecation (Diarrhea)
*Answer call light promptly
*Remove cause of diarrhea if possible
*If there is an indication of impaction, exam will be needed before giving meds
*Maintain the pt's fluid and elect balance
*Give special care to the region around anus.
*Avoid toilet tissue when it irritates
*Once the diarrhea stopes, promote a return to normal flora
Interventions in pain mngt.
*Analgesic Admin. *PCA pumps. *Epidural analgesic. *Local analgesic. *Placebo.
*Distraction-pt is able to ignore or become less aware of the pain. Works best for short, intense pain.
*Imagery-pt creates an image in the mind
*Relaxation-ability to relas physically promotes mental relaxation
*Cutaneous Stimulation-stimulation of the skin, heat or cold, massages, warm bath
*Acupuncture-needs in certain points
*Hypnosis-Decreases perception of pain
Definition of the Nursing Process
A method for oganizing and delivery nursing care. It focuses on identification and treatment of unique responses of individuals or groups of actual or potential alterations in health.
Choosing best communication
Know Therapeutic techniques
Restraints
*Used as a last resort
*Restrain then get MD order
*If using write restraints, use on both wrists
*Check for circ. every 30 min
*Completely remove and do ROM every 2 hours
Congruent vs incongruent communication
Verbal and nonverbal communication should congruent. If a person is talking about a horrible event in their life, but laughing, this would be incongruent
Older Adult-Assisting pt to adjust
*Some pt may deny retirement-Feel like an aging person.
*Therapeutic Communication-Shows trust
*Touch
*Reality Orientation
*Resocializtion
*Reminiscence
*intervetions to improve body image
REM Sleep
For metal, emotional, physiological well being.
*More difficult to awaken someone
*Vivid, full color dreaming
*Begin 90 min after falling asleep
*Fluctuating heart rhythm & RR
*BP flucuates
*Loss of skeletal muscle tone and gastric secretions increase
*Duration of REM increased with each cycle, aver 20 min
Stage I Non-REM
(10-30 mins)
All non REM good for physical well being
*Lightest level of sleep
*Stage lasts a few min
*Gradual vall in VS and Metab.
*Muscle twitching
*Sensory stimuli can arouse
*If awakens pt feels as if daydreaming has occurred
Stage II Non-REM
(10-20 mins)
*Stage is sound sleep
*Relaxation in progress
*Arousal is still easy
*body functions continue to slow
Stage III Non-REM
(15-30 mins)
*Initial stages of deep sleep
*Difficult to arouse sleeper and rarely moves
*Muscels are completely relaxed
*VS decline but remain regular
Stage IV Non-REM
(15-30 mins)
*Physical functioning is thought to be restored
*Deepest level
*Very difficult to arouse sleeper
*If sleep loss has occurred, then sleeper will spend a lot of time in this stage
*VS are significantly lower than during waking hours.
*Sleep walking and enuresis occur in this stage
Care of the dying
*Promotion of comfort
*Mouth care
*Proper positioning for relaxation and sleep
*Touch
*Maint. of independence; encourage pt participation in decision making
*Conservation of energy
*Prevention of loneliness and isolation
*Provide meaningful environment stimulation
*Promotion of spiritual well being
*Support the grieving family
Priority Setting in Nursing Process
*High Priority-ugent and immediate-acute pain-anything to do with breathing
*Intermediate priority-not life threatening-safety, love, etc
*Low priority-not directly related to specific illness or prognosis-for well being or quality of life
Preventing falls
*Foster autonomy with caution
*Side rails x2, adequate lighting, hazardous environmental precautions, (removing cords from walkways, removing throw rugs) organize attached equipemnt (iv poles, chest tubes etc)
*
Kardex, progress notes, etc. Where to find certain information
*Kardex-A client care summary with certain information for daily care that the client can readily access.
*Progress notes-Notes in the chart made by nurse and doctor collaboratively
*Information on client diagnoses-chart information on client meds-MAR
Pre-Op Procedures
*Skin prep (anti micorbial soap)
*Check med record to make sure all lab tests have been done, check consent forms, complete pre op check list. Check nurse's notes.
*Assess VS. If not normal tell surgeon
*Remove all hair pieces, cosmetics. leave dentures in until after intubations. Do not remove hearing aids, eye glasses, or contacts until just before surgery.
*Appliction of TED hose
*Any specific procedures (IV, foley, NG tube
*Administer pre op meds
Post Op Assessment
*Biggest job nurse has-Look for the little signs
*General survey-LOC, VS-VS every 15x4, every 30x2, every hourx4
*Check distal side of the surgey pulses
*Circulation-Monitor pulse, rhythm, continuous ECG, assess for signs of continuous hemorrhage.
*Respiratory-moniroty rate, rhythm, depth and quality of airway. Patency is top priority. Observe chest wall movement, color oskin, mucous membranes. Auscultate for breath sounds.Pulse ox. Gag reflex, reflexes, hand grips, and ROM
*Observe the wound. Check fluid status.
*Pain and comfort. Gastrointestinal. Normal bowel sounds should return within 24 hrs.
Purpose of different phases of nursing process
*Assessment-establish a database
*Diagnosis-Develop a diagnostic statement
*Planning-Priorities are set, client-centered goals are set, outcomes developed, NCP is formulated.
*Implementation-Carrying out of plane of care
*Evaluation-effectiveness of goals and interventions evaluated.
Safety and patient care
*Falls assessment
*Restraints
*Pathogen transmission
*Wheelchair safety, berails upx2
Post Op care and drains
*Wound clensing (removing surface bacteria, bandages and binders, heat and cold therapy, dressing, drains (check tube drain below the chest)
*Penrose-operates by gravity
*Hemovac & Jackson Pratt-Operates by suctioning. Hemovac looks like an accordion
Different types of infection
*Nosocomial-originates in a hospital or other medical facility
*Latrogenic-received from a medical procedure or a diagnostic test
Correct interventions on a care plan
Nurse will....
Interpretation of blood gases and causes and nursing interventions #1
Normal blood gas values (arterial blood)
*pH-7.35-7.45
*pCO2-35-45 mm Hg
*HCO3-22-26 mEq/L
*pO2-80-100
Interpretation of blood gases and causes and nursing interventions #2
Know signs, symptoms and interventions of acid base
*Normal pH-7.35-7.45
*Acidic pH-less than 7.35
*Alkaline pH-More than 7.45
Metabolic-Excess of H and adeficit of HCO3. Regular HCO3 -22-26. If off, metabolic
*Resp-carbonic acid. Regular carbonic acide 35-45. If off Respiratory
Types of surgery #1
*Major-usually inpatient. potentially life threatening (bypass)
*Minor-can be either inpatient or outpatient (hysterectormy)
*Elective-pt chooses to have (facelift, hernia repair)
*Urgent-Not life threatening but needs to be done (cancerous tumor, vascular repair)
*Emergency-life saving surgery (perforated appendix, repair of traumatic amputation)
Types of surgery #2
*Diagnostic-exploratory (biopsy)
*Ablative-amputation
*Palliative-comfort measure (colostomy)
*Reconstructive_restores function (scar revision)
*Constructive-Building something for the first time, congential (cleft palate)
*Procurement-removal of organs and or tissues
*Cosmetic
Charting
*If you don't chart it, it didn't happen
*To correct a mistake, draw a single line throuch error and intial
Normal Changes with Older patients
*Mental deterioration is not a normal part of aging.
*Elevated BP is not a normal part of aging.
*Skin color changes, moisture changes, tep devreases, hair thins, decreased renal filtration, dicreased visual acuity, change in sleeping patterns, decreased sense of taste. Decreased testosterone and estrogen, decreased muscel mass, bone demineralization.
Aseptic technique
*Medical asepsis-clean technique
*Surgical asepsis- Steril techique
*Giving an injection is steril
Injection techniques
*IM
*SC
*IV
*ID
Physical response to stress
General Adaptation Syndrome "GAS"
*A-Alarm (fight or flight..every rises)
*R-Resistance (VS stabilize...adaption takes place.)
*E-Exhaustion (death may occur)
Readiness to Learn
*Learning only occurs when a person is ready and willing to learn.
*Interferences can be: Physical (chills, hunger, pain, etc) or Psychological (anxiety, fear)
*Motivation is an internal impulse. Social tasks mastery and physical motives stimulate a person to learn
Pre-op nursing interventions
*Ensure informed consent is signed.
*Health promotion-pre op teaching
*Skin prep
*Measures to reduce vomiting, prevent fecal impaction, and prevent peritoneal contamination
*Promote sleep and relaxation
COPD-Causes of problems and nursing interventions
*
Etiology of problems
How the R/T causes symptons (AMB)
How different forms of med affect delivery
Fastest-IV, IM, SQ, Oral and Topical.
Effects of immobility
Decreases peristalisis, decubitus, metabolic changes, change in sleep cycle, depression. Every body system is affected by immobility.
Safety measures to prevent injury and teaching
*Provide a safe, caring envirionment
*Foster autonomy
*Always avoid restraints when possible
*Always use least restraint necessary
Helping Relationship
POWT
*Pre-interaction phase (review data and Nsg Hx)
*Orientation phase (Set tone for relationship, assess pt's health status, set roles and boundaries, priority setting.
*Working phase (solve problems with pt and accomplish goals, have patient express feelings)
*Termination phase (nurse and patient will experience a loss in this phase)
Defense mechanisms
Repression/dissociation-feelings are unconsciously kept out of awareness.
*Suppression-fellings are consciously kept out of awareness
*Projections-owne feelings and thoughts are attributed to others.
*Denial Blocking out painful or anxiety inducing events or feelings
*Rationalization-Falsification of experience through the construction of logical or socially approved explainations of behavior
*Displacement-discharging pent up feelings on a person less dangerous.
*Compensation-covering up a weekness by over-emphasizing a desirable trait
Nursing interventions for fluid imbalances
*Daily weight, I & O, replacement of fluids, parenteral fluid restrictions, total parenteral nutrition, correct solutions, blood replacement
Incident reports
Do Not go into the chart. For the improvement of entity
*Completed after pt stabilization
Unmet needs and how can lead to illness
A person with one or more unmet needs is considered unhealthy. A person entering the healthcare syste4m generally has unmet needs. If need is not met, this can lead to illness.
Rights of admin
*Right Medication
*Right Dosage
*Right Route
*Right Notes (documentation)
*Right Patient
*Right Time
Preventing Infections
*Control or elimination of infectious agents
*Control or elimination of reservoirs
*Control of portals of exit
*Control of transmission
*Control of portals of entry
*Protection of susceptible host
Malpractice
*Malpractice is professional misconduct or unreasonable lack of skill
*Negligence-conduct that falls below standard ocare.
*For malpractice 4 things must be present: Duty owed, Duty breached, Harm occurred, and breached duty caused harm.
Infection Control, Standar precaustions vs Transmission categories
See Sheet
All types of infection control precautions
See sheet.
Phases of nursing process
See Sheet.
Therapeutic communication techiques
See sheet
Non Therapeutic communication
See sheet