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236 Cards in this Set
- Front
- Back
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Why do we measure Vital Signs?
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- to detect important physiologic changes
- to obtain a baseline (stable) vitals |
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What Vital Signs do you take?
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- Temperature
- Pulse - Respiration - Blood Pressure - Pulse Oximetry - Pain |
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When would you as the Nurse want to assess Vital Signs?
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- Upon admission to any healthcare agency (hospital, clinic)
- At the beginning of a shift (for inpatients) - Any time there is a chg in condition (ex every 5 - 15 mins) - Before & after surgical or invasive diagnostic procedures - Before & after activity that may increase risk - Before administering medications that affect cardio or respiratory functioning |
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What are the normal temperature ranges r/t site?
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Oral 98.6
Rectal 99.5 Axillary 97.6 Tympanic 99.5 Forehead 94.0 Core 97-100.8 |
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How is temperature regulated?
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Hypothalmus: center receives messages from cold and warm thermal receptors in the body. The center initiates responses to produce or conserve body heat or increase heat loss. Metabolism: hormones, muscle movements, and exercise increase metabolism
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What are the types of thermometers?
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Fahrenheit/Centigrade
Electronic & Digital Glass Disposable/single use (strip) Tympanic Rectal |
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What are the sites where to take temperatures?
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Oral
Axillary Tympanic (ear) Temporal (forehead) Rectal Skin |
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What factors can influence temperature?
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Age
Environment (room-temp, weather) Gender Exercise Stress Circadian Rhythm Smoking Hot or Cold Liquids *Women have higher temp that men (ovulating, menses, hormonal) |
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What are the signs & symptoms of hyperthermia? (increased body temp)
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Weakness
Nausea & Vomitting Syncope (fainting) Tachycardia (fast pulse) Headache Diaphoresis (sweating) *temp above 109 can result in brain damage and sometimes death |
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What are the interventions for someone with hyperthermia?
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Determine the cause
Continue to monitor Rx with antipyretics or antibiotics Observe S&S Provide oral or IV fluids (prevention of dehydration) Change damp linen Mouth care Adequate nutrition Cooling blankets Evaluation |
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What are the signs & symptoms of hypothermia? (low temp)
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Early signs
-shivering -cyanosis lips/fingers -pale, cool skin -bradycardia (slow pulse) Late signs -stops shivering -irregular pulse & respirations -shock *70-75 degrees - if body falls to that temp death usually occurs |
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What interventions as a Nurse would you do for hypothermia?
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-Determine the cause
-Continue to monitor -Observe signs & symptoms -Warm clothing/blankets -Warm drinks -Increase room temp -Heating pads -Warm IV fluids -Evaluate *if the body temp is low, the circulation is vaso-constricted so the patient may not be able to sense hot/cold at extremities |
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What are the sources of heat loss?
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Radiation
-Skin (primary source). Uncovered skin is warmer than the air. Heat is coming off our skin and warming the air -Convection*-through currents of air or water. Cool air from a fan can reduce temp. Warm bath can increase temp -Evaporation (sweating) Loss through mucous membranes. Comes out in breath -Conduction: transfer heat from warm to a cool surface *Body temp can almost drop one full degree within one hr through convection |
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What are the chemical effects of anti-pyretic meds? (acetaminophen/Tylenol, asprin/Salicylates, ibuprophen/Motrin)
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They act in the hypothalamus to relieve fever & pain; inhibits prostaglandin production*
*prostaglandins go right to the injury site to cause inflammation. When giving anti-inflammatory med - it blocks prostaglandins at site |
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What is the therapeutic effect of anti-pyretic meds? (acetaminophen/Tylenol, asprin/Salicylates, ibuprophen/Motrin)
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Reduces fever
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What is the onset of Tylenol?
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Works within 15-30 minutes
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aspirin/Salicylates
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anti-coagulant & anti-inflammatory
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acetaminophen/Tylenol
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not anti-inflammatory
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ibuprofen/Motrin
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anti-inflammatory
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How is a pulse measured?
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It's measured in beats per minute (bpm)
Normal: 60-100 bpm Average: 70-80 bpm |
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How is the pulse regulated?
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The pulse is regulated by the autonomic nervous system through cardiac sinoatrial node.
The parasympathetic stimulation decreases the heart rate. The sympathetic stimulation increases the heart rate. Ease pulse occurs at the left ventricle of the heart. It's contraction and relaxation. The pulse rate is the number of contractions over a peripheral artery in 1 minute (or over the apical pulse using a stethoscope) |
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What factors influence the pulse?
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-Variation in hear rate
-Changes in elasticity of the arterial walls -Interference with heart function -Age (newborn-higher older - lower) -Gender (women - faster rate) -Stress (increase) -Food (increase) -Fever (increase) -Diseases (ex: hyperthyroidism - increase, hypo- decrease) -Blood loss (slight decrease if small loss. If hemorrhage, increase) -Position changes (sitting to standing increases) -Medications (epinephrine - increase, narcotics - decrease) |
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What are the sites for palpating and auscultating?
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Palpating: peripheral arteries with fingers
Auscultating: apical pulse with stethoscope Pulse deficit (assessing apical-radial pulse) *Assessing heart function and heart irregularities |
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What is lub? What is dub?
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Lub is the contraction - S1
Dub is the relaxation - S2 lub-dub is ONE beat |
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What do you assess when measuring the pulse?
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-Rate
-Rhythm* -Quality -Tachycardia (BPM rate over 100) -Bradycardia (BPM rate under 60) *Rhythm - is it rhytmic? skipped beats? double beats? |
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What is respiration?
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Respiration is the exchange of O2 and CO2 in the body.
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What is pulmonary ventilation?
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Pulmonary ventilation is the movement of air in and out of the lungs.
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How does respiration work?
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Respiratory center
Autonomic nervous system regulates breathing Central chemorecepters: sensitive to changes in O2 & CO2 Thoracic muscles and diaphragm: inspiration & expiration Breath in - Breath out = one respiration Breathing should be effortless |
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What are you assessing & measuring when looking at respirations?
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Rate
Tidal Volume Rhythm Effort Color Difficulty breathing Shortness of breath Prolonged expiration Breathing evenly spaced (regular or irregular) |
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What influences the respirations?
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Age (newborns higher - 40 to 90 breaths per min)
Exercise/position change Pain Anxiety Smoking (increases the resting respirations) Infection (increases) Respiratory and cardiovascular disease Fluid, electrolyte, and acid/base imbalances & hemoglobin level |
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What are considered normal respirations?
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12-20 breaths per minute
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When would the respiratory rate increase?
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When the patient is trying to get more oxygen
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What are abnormal lung sounds? (adventitious = abnormal)
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Wheeze
Rhonchi Crackles Stridor Stertor |
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What is wheezing?
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It's a high-pitched continuous musical sound, usually heard on expiration (asthma)
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What is rhonchi?
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It's low-pitched continuous sounds caused by secretions in the large airways (bronchiolitis)
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What are crackles?
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Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds (CHF; pneumonia)
Sounds like rice krispies |
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What is stridor?
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It's a piercing, high-pitched sound heard heard primarily during inspiration (Croup, Respiratory distress)
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What is stertor?
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It's labored breathing that produces a snoring sound.
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What are abnormal deviations in respirations? (adventitious = abnormal)
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Apnea - stop breathing (breathing and stopping...breathing and stopping) If it continues for more than 4-6 minutes, brain damage could occur
Dyspnea - increased effort to breathe - labored breathing Bradypnea - low resp. rate Tachypnea - higher resp. rate Hyperpnea - increased resp. rate that's deeper. It's normal with exercise but not normal with heart problems |
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What interventions as a Nurse would you do regarding respirations?
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-Monitor rate & effort
-PO2 -Observe color -Assess lung sounds -Assess retractions (with every inspiration, muscles are pulling in accessory muscles near intercostal spaces -Pain Deep breath/passive coughing Elevate head of bed/sit up O2 Medication Respiratory treatments Evaluate/Reassess |
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What are you assessing when measuring blood pressure?
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Blood pressure is an indicator of overall cardivascular health
The normal BP is 120/80 Systolic is the top # and diastolic is the bottom # |
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How does blood pressure work?
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-Force of the blood against arterial walls
-Controlled by a variety of mechanisms to maintain adequate tissue perfusion throughout the body -Pressure rises as ventricle contracts and falls as heart relaxes Systolic pressure Diastolic pressure Other factors: Constricted arteries Blood viscosity |
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What is systolic pressure?
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It's the highest pressure when ventricles contract.
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What is diastolic pressure?
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It's the lowest pressure when the heart is at rest.
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What factors influence blood pressure?
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-Age, gender, race (babies & younger kids have lower BP: men BP higher than women: African Americans higher BP - predisposition for hypertension)
-Family history -Lifestyle (high salt, smoking, sedentary) -Body position - higher BP when standing -Emotional state -Pain (increase BP. If continuous pain over long period of time - decrease BP) -Obesity -Medications -Diseases (kidney disease can alter BP) |
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What happens if the blood pressure cuff (sphygmomanometer) is too big or too small?
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Too small BP cuff could have higher BP reading
Too big BP cuff could have lower BP reading |
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How do you assess the blood pressure?
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-brachial artery
-listen to Korotkoff sounds (first sound you hear is the systolic and the change or cessation of sound occurs is the diastolic - last sound you hear) *The brachial artery and popliteal artery are commonly used |
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What are deviations can occur with hypertension (high blood pressure)?
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Hypertension is blood pressure above 140/90.
It can cause heart attack, heart failure, PVD, kidney damage, stroke Primary hypertension is where there is no known cause. Secondary hypertension is when you know what the cause is. |
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What can cause hypertension?
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Over the counter meds
Herbal supplements Cocaine Thickening of arteries Loss of arterial muscles *above makes the heart work harder |
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What interventions as a Nurse would you use for a patient with hypertension?
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-Cause
-Monitor BP -Lifestyle change -Dietary changes -Anti-hypertensive medications -Evaluation |
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What are the deviations that can happen in blood pressure with hypotension (low blood pressure)?
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Systolic 100 mm HG or less
Associated symptoms (dizziness, shortness of breath) Hemorrhage & heart failure Orthostatic |
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What is orthostatic hypotension?
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When BP drops suddenly when moving from a lying to sitting or sitting to standing position. (quick change in position)
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How do you measure orthostatic BP?
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BP lying down
BP sitting up BP standing up Assess the patient (1-3 mins in between orthostatic pressures). Looking for decrease in BP usually delta 10 mm HG |
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What interventions would you do as a Nurse for a patient with hypotension?
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Monitor BP
Etiology Evaluation |
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What is SpO2?
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The measurement of oxygen saturation in the arteries
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What is Pulse Oximetry?
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Monitoring the respiratory status with a device that measures the O2 saturation.
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What is an epidemic?
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It's an outbreak of a disease that suddenly affects a large number of people.
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What's a pandemic?
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It's an outbreak of a disease in a country or worldwide.
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What are emerging infectious diseases?
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Newly identified diseases caused by unrecognized or known micro-organism (viruses not common).
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Why is infection control important?
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To the patient
To the staff Standardized protocols & guidelines To decrease healthcare costs |
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What is a local or systemic infection??
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It's an infection spread throughout the body.
*Septicemia is a systemic infection spread via the blood |
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What is a primary infection?
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It's the first time you acquired the infection.
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What is a secondary infection?
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It's the next exposure to the infection.
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What is an exogenous infection (from healthcare)?
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It's a pathogen acquired through healthcare personnel.
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What is an endogenous infection (from own body r/t treatment)?
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It's from the patient's normal flora.
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What is an acute infection (rapid onset)?
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It's an infection that comes on suddenly.
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What is a chronic infection?
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It's an infection that develops slow, but lasts weeks, months, years.
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Who is at risk for infection (susceptibility)?
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Those with
-inadequate hand hygiene -immuno-compromised -indwelling devices -surgery -breaks in the skin -poor oxygenation and poor circulation (oxygen/blood not circulating to the area needed to heal) -chronic or acute illnesses -poor nutrition or hygiene -caregivers with poor hand hygiene -crowded conditions/environments/poor sanitation -older adults -poor lifestyle choices (drugs, unsafe sex, smokers) |
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What is an inflammatory response?
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It's a vascular or cellular response to injury.
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What is an antigen?
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It's a bacteria or virus - invading/foreign organism.
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What is an antibody?
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It's a defender to fight infection. An antibody binds to the antigen to destroy it!
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What is phagocytosis?
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It's the process of how to engulf and destroy.
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What are leukocytes (WBC's)?
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They are white blood cells that are made in the bone marrow.
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What are the different exudate (fluid that filters from the circulatory system into lesions or areas or inflammation)?
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Serous - clear
Sanguineous - red blood cells Sero-sanguineous - combination of serous and sanguineous Purulent - pus (leukocytes & bacteria) |
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What are the stages of acute inflammatory response?
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1st stage - inflammatory response
2nd stage - proliferation/granulation 3rd stage - maturation/ epithelialization |
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What are the signs & symptoms of an infection?
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Fever
Increased pulse & respiratory rate Malaise (weakness) Nausea & vomitting, anorexia (loss of appetite) Enlarged lymph nodes |
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Why would you want a laboratory analysis for an infection?
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To determine if the infection is bacterial or viral.
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What does "culture" refer to in laboratory results?
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It's measure the presence of micro-organisms in tissues, body fluids, blood
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What does "sensitivity" refer to in laboratory results?
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To determine the effect of an antibiotic on the organism to see if resistant or sensitive.
*Antibiotic therapy should not be started until after the culture is obtained |
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What are tier-two precautions?
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They are transmission-based precautions.
It consists of contact, droplet and airborne. |
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What are contact precautions?
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Contact precautions are used for patients known or suspected to have an infection transmitted by direct contact or contact with items in the environment.
(ex: patients with MRSA or VRE. patients with lice, c-diff, skin infections or gastrointestinal infections) |
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What are droplet precautions?
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The patients are known or suspected to have infections transmitted by droplets (organisms in droplets can travel 3 ft!!) but are not suspended into the air for long periods of time.
(ex: patients with influenza, mumps, pertussis, meningitis, pneumonia) |
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What are airborne precautions?
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Patients known or suspected to have infections transmitted by airborne transmission (organisms are tiny & suspended in the air for long periods of time)
(ex: patients with TB - tuberculosis, chicken pox - varicella or measles - rubeola) |
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What are drug or multi-drug resistant organisms (MDRO)
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Micro-organisms (bacteria) resistant to one or more antimicrobial drugs that are serious & significantly challenging.
Ex: MRSA, VRE, C-diff |
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What is MRSA?
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It's methicillin-resistant Staphylococcus Aureus.
So..what happened? 1. Penicillin 2. Over time, penicilling could not eradicate all staph (resistance) 3. Methicillin was invented & effective against resistant staph 4. MRSA learned to evade most antibiotics over time 5. There are some antibiotics that kill MRSA but it is formidable (now they don't kill) |
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What types of wounds are there?
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Incision
Laceration - torn open with jagged edges Abscess - collection of pus Penetrating - an open wound in which the agent causing the wound lodges in the body tissue Puncture - caused by sharp object Tunnel - a wound with an entrance and exit site |
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What is a chronic wound and what causes them?
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A chronic wound is one that has not healed within the proper time frame.
Causes include infection, ischemia (inadequate blood supply), continued trauma and edema |
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What are the classifications of wounds?
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Clean (uninfected)
Contaminated (open, traumatic, high risk for infection Superficial (epidermal layer) Full-thickness (from sub-cutaneous tissue & beyond) Penetrating (involves internal organs) *Wound depth is a major determinant of healing time: the deeper the wound, the longer the healing time. |
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How would you as a Nurse assess a wound?
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Inspect: evaluate skin color, integrity (open or closed?), temperature, texture, turgor, moisture, drainage.
Evaluate: tenderness, edema, discoloration, bony prominences Documentation: describe the wound location, characteristics, any intervention/treatment, if dressing was changed and how the patient tolerated the procedure. |
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What are complications of wound healing?
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Hemorrhage (internal or external)
Infection Dehiscence (rupture/separation of one of more layers of the wound) Evisceration (total separation of the layers & internal viscera protrude) Fistula (connecting 2 body cavities or a cavity & skin) |
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What are the causes of pressure ulcers? (bedsores, decubitus ulcers, pressure sores)
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Unrelieved pressure over time
Shearing force Vigilant nursing care can prevent!! Ischemic lack of blood flow to area (tissue ischemia leads to tissue anoxia and cell death) Imobility |
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What are the stages of pressure of ulcers? (classified by degree of tissue involvement)
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Stage 1 - localized, intact skin
Stage 2 - open, shallow; partial thickness Stage 3 - Deep crater, full thickness, damage or necrosis of subcutaneous tissue Stage 4 - Full thickness, tissue necrosis, damage to bone, muscle, tendons *Staging is not for all wounds, just for pressure ulcers. They are always classified at the highest stage even if changes (ex: Stage 3 to Stage 1...will be classified as Stage 3) |
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What is growth?
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Growth is an increase in size and a change in body cell structure, function or complexity
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What is development?
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Development is an orderly progression in structure, thoughts, feelings or behaviors resulting from maturation, experiences and learning.
Development is -orderly -predictable -cephalo - caudal (head to toe) -proximal - distal (core to outer) -nature vs. nurture |
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What theories are there in Nursing?
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- attempt to explain a certain concept
- provide an organized framework - help one to understand - allows nurses to plan to care for patient - basis for nursing interventions and clinical decision-making - multiple (a theory doesn't fit all sizes. Take the individual and assess) |
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What is the name of the theorist for developmental?
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Robert Havighurst
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What theories of development does Robert Havighurst represent?
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- Learning is a lifelong process
- Stages to pass through; if fail, there is imbalance within |
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What is the name of the theorist for psychoanalytical?
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Sigmund Freud
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What theories of psychoanalytical does Sigmund Freud represent?
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- Motivation for human behaviors and personality development
- Id, ego and supergo *Id is more impulsive - instinctual urges Ego is a balance between Id and superego Superego is the conscience - devil on one shoulder and the angel on the other |
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What is the name of the theorist for cognitive?
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Piaget
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What theories of cognitive does Piaget represent?
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-Adaption (adjusting to the environment)
-Assimilation (Taking in and integrating new experiences with what you came in with) - Accommodation (change in ones knowledge that produces new knowledge) |
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Who is the theorist for psychosocial?
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Erikson
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What theories of psychosocial does Erikson represent?
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-Negotiate through the eight stages through life
- Person can regress if a person doesn't navigate through a stage in life - Failure to achieve can lead to maladaptation (may have to take a step backward before can move forward) |
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Who is the theorist for moral development?
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Lawrence Kohlberg
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What theories of moral development does Kohlberg represent?
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-Moral reasoning is related to age
-Moral development is based on one's ability to think at progressively higher levels |
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Who is the theorist for Spiritual Development?
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James Fowler
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What theories of spiritual development does Fowler represent?
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Faith is a universal human concern
*We give up control to what is bigger (i.e. God - spiritual) |
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What is aging?
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-a gradual process
-development and maturation continue -normal even not pathologic (because we have something wrong with us) -no universally accepted theory of aging |
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What is health?
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-Balance
-Absence of illness -Something to strive for -Prevention of disease |
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What is illness?
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-Patients will tell Nurses how illness makes them fell versus our utilization of a nursing diagnosis
-Nurses attempt to honor patient's understanding of illness *absence of disease *how I'm feeling when I'm sick |
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What is the health-illness continuum?
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-Personal
-Dynamic (changes every day) -Based on physiologic changes, lifestyle choices and is a result of various therapies |
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What experience is health & illness based on?
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-biology
-nutrition -activity -sleep & rest -finances -lifestyle choices -personal relationships -religion & spirituality -environmental factors -meaningful work |
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What disrupts health?
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-disease
-injury -pain -imbalance -isolation -mental illness -impending death -competing demands -the unknown -loss |
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What is the concept of self?
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-body image
-role performance -identity -self esteem -anxiety or depression |
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What are the stages of adulthood?
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-young adult (20-35 yrs of age)
-middle adult (35-65 yrs of age) -older adult (65 and older) |
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Who is the young adult?
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-Commitment
Risk for -substance abuse -unplanned pregnancies -STD's -infertility -work related injuries Problems with -nutrition (obesity/anorexia) -relationships -safety |
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Who is the middle aged adult?
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-still feel young
-sense of generativity (generous, love to give back) vs. stagnation (self absorbed) - create and produce (Erikson) -concern for others -wonder about next generation -adjust to changes (to older people and younger people - i.e. your parents, your children, your grandchildren) |
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How does the middle aged adult physically change?
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Begin to lose
-height -body mass -calcium in bones -vision and auditory loss -greying of hair |
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What changes occur in the middle aged adult?
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-Menopause
-Changes in sexuality -Depression -Job performance -Marital changes |
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What are some of the major health problems in the middle aged adult?
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-Cancer
-Rheumatoid arthritis -Obesity -Cardiovascular and pulmonary changes |
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Who is the older adult?
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-baby boomers: ready to retire, largest population
-Integrity vs despair -Many physical losses and decreases -Cognitive decline -3 D's *Depression *Delirium *Dementia |
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What are the 3 D's?
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Depression - could be acute or chronic or situational (ex: loss of spouse)
Delirium - acute & temporary state. Could be the sign of an infection (ex: UTI) Dementia - chronic illness. >4 million people in the United States have dementia. There isn't a cure. The most common form of dementia is Alzheimer's |
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What health risks occur in older adults?
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-cardiovascular disease
-mobility challenges -mental health changes -chronic disabilities |
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What is ageism?
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It's a myth of older adults
-most are in nursing homes (5% in nursing homes 71% are fine and functioning in their homes) -older adults are sick and mentally deficient -not interested in sex -form of prejudice -older adults are stereotyped -outlived their usefulness -bladder problems are a problem of aging |
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What is antimicrobial therapy?
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It's a treatment that destroys or prevents the development of micro-organisms.
Using medications to treat infections caused by bacteria, viruses or fungi |
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What is a superinfection?
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It's a type of resistance when normal flora is killed by overuse of antibiotics and a new infection is difficult to eliminate (ex: MRSA, VRE, C-diff)
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What is antibiotic resistance?
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It's the ability of microorganisms to survive in the presence of antibiotics.
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How would you assess the patient to be able to select an antimicrobial?
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-identify causative organism
-site of infection -age of the patient: the young & the older (infants have immature livers and kidneys. The kidneys filter & metabolize then excrete medications. Oder adults have same problem as infants with metabolizing and excreting meds) -pregnant patient -allergies -combination therapy (use of more than one med or therapy) -prophylactic therapy (preventative) |
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What is antibiotic/anti-infective therapy?
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It's a medication that destroys micro-organisms or inhibits their growth.
Must use selective toxicity to kill microbes without destroying host cells (good cells) Works with host defense system to suppress organisms. |
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How are antibiotics/anti-infective therapies classified by?
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1. Which are susceptible to each medication or 2. the mechanism of action - how they work in the body
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What is the general use, action and considerations for anti-infective/antibiotic therapy?
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General Use
-treatment & prophylaxis of various bacterial infections Chemical Action -Kills (bactericidal) or inhibit growth of (bacteriostatic) susceptible bacteria -Not active against viruses or fungi Considerations -Culture & Sensitivity testing -Prolonged use may lead to superinfection |
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What is the chemical action for bacteria by using antibiotic therapy?
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It's chemical action is to bind to the bacterial cell wall, resulting in cell death
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What is a broad-spectrum antibiotic?
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It's an antibiotic that acts against a wide range of disease causing bacteria.
It acts against gram positive (ex: staph) and gram negative (ex: e-coli, salmonella) bacteria *a commonly used broad-spectrum antibiotic is ampicillin |
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What is a narrow-spectrum antibiotic?
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It's an antibiotic that's effective against specific families of bacteria.
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What is penicillin?
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It's a broad spectrum antibiotic that is used against a wide variety of infections.
The contraindication is if there's a hypersensitivity to penicillin, then you may be hypersensitive to cephalosporins. The therapeutic effect is bactericidal against susceptible bacteria |
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What are the adverse reactions/side effects to penicillin?
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Adverse reactions
-seizure, anaphylaxis, pseudomembranous colitis Side effects -diarrhea, epigastric distress, local: pain at IM site, rashes, urticaria (hives, itching) eosinophilia (abnormally high eosiniphils - WBC's) |
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What are cephalosporins?
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They are capable of bacteriocidal action against gram positive or gram negative bacteria.
They are classified in "generations" |
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What are the generations of activity of cephalosporins?
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1st generation: work against gram positive bacteria; skin/soft tissue, uncomplicated resp. or surgical wound prophylaxis
2nd generation: similar to the 1st in addition to some gram negative, UTI's, intra-adominal, gynecological infections, some gram negative infections 3rd generation: work against gram negative. Hospital acquired infections, pneumonia, meningitis 4th generation: works against gram positive and negative |
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What is tetracycline (Sumycin)?
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It's an anti-infective antibiotic that treats various infections caused by unusual organism (ex: acne, lyme disease, chlamydia)
It works with penicillin allergic patients and against gram positive and negative pathogens It's bacteriostatic so inhibits bacterial protein synthesis and uses the bacteriostatic action against susceptible bacteria |
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What are the nursing implications of tetracyclines (Sumycin)?
|
-yellow/brown discoloration to teeth
-Avoid in children < 8 years old -Not used in pregnancy -take tetracycline on an empty stomach with water -if minocycline/doxycline, needs to be taken with meals |
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What are aminoglycosides?
|
The are anti-infective antibiotics used to treat serious gram negative bacteria and staphlococci.
It inhibits protein synthesis and is bactericidal Used in staph infections, E coli and streptomycin |
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What are the nursing implications for aminoglycosides?
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-Most IM/IV only
-peak and trough levels to establish effectiveness -peak 1 hr after; trough right before next dose (<1 hr) -assess for hearing loss/ringing in ears -pregnancy Category D; high risk to fetus |
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What does peak mean in regards to medications?
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Peak shows how well the medication is working. It works approximately 30-60 minutes after medication is administered.
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What does trough mean in regards to medications?
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Trough is when the medication is least effective. It is generally one hour prior to the next dose.
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What is Fluroquinolone?
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It's an anti-infective antibiotic. It's a class of antimicrobial agents that inhibit DNA synthesis.
It's bactericideal and is indicatied in UTI's GYN infections, resp. tract infections, diarrhea, bone/joint, otitis media (ear infections)/gram negative and positive staphs, streps etc... (ex: Cipro - don't give to kids because can stunt bone growth) |
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What are the nursing implications for Fluroquinolone?
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-not used in pregnancy
-FDA "black box" warnings alerting doctors and patients -Cipro/Levaquin may cause tendon rupture/tendonitis -These may be the patients best drug of choice: careful watching and monitoring |
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What are Sulfonamides?
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Sulfonamides are anti-infective/anti-protozoals antibiotics.
Compounds of sulfanilic acid (sulfa drugs) Used on gram negative and positive bacteria. It inhibits the metabolism of folic acid (needed for cells to make DNA) in bacteria It's bactericidal against susceptible bacteria and is indicated for UTI's, pneumonia, travelers diarrhea, bone & wound infections, etc.. |
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What are the nursing implications for Sulfonamides?
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Allergic reactions
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What are antibiotic misuse and resistance?
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-use of antibiotics to treat viral infections or fungal infections
-inadequate pathogen coverage -excessive use of broad-spectrum agents -sub-optimal dosing (not high enough dose to kill bacteria) -poor adherence to antibiotic therapy -retaining unfinished antibiotic for later use |
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What is vancomycin?
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It's an anti-infective/bactericidal antibiotic.
It's used for the treatment of potentially life threatening infections when less toxic anti-infectives are contraindicated. Indications: MRSA, gram positive staph, group B strep, meningitis, septicemia, VRE (organism that is becoming resistant to vancomycin) |
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What are the nursing implications for vancomycin?
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-vancomycin doesn't get along with other antibiotics. It needs it's own IV bag/line
-infuse over 60 min to decrease the risk of thrombophlebitis, tissue irritation & necrosis -vanco levles (peak & troughs) |
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What is anti-viral therapy for viruses?
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It's to prevent viral replication. Viruses invade and take over the host.
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What is the chemical action for anti-viral therapy?
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It interferes with viral DNA synthesis.
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What is the therapeutic action for anti-viral therapy?
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It reduces time to heal lesions, reduced transmission, inhibit viral implication
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What are the chemical and therapeutic actions for anti-fungal medication?
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Chemical
-binds to fungal cell membrane, allowing leakage of cell contents Therapeutic -fungistatic or fungicidal *Commonly used for yeast infections |
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What are the nursing implications/assessments antibiotic therapies?
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-assess patient for signs & symptoms of infection prior to and throughout therapy (to make sure antibiotic is working)
-determine previous hypersensitivies (allergic reaction) -obtain culture & sensitivity specimens prior to initiating therapy *The first dose may be given before the results. WHY? You don't want to wait to start the antibiotic as it may take up to 72 hours to get final results and would be too long of a wait. -get specimen first for culture & sensitivity -send to lab -can start antibiotic prior to receiving results |
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Discuss the roles and responsibilities of a student nurse.
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-health maintenance
-teaching -counseling -collaborative planning -restoration of optimal health -comfort & dignity of death |
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Define some of the concepts that were discussed during the legal/ethical lecture.
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-Morals - personal beliefs (wrong & right)
-Ethics - systematic study of right and wrong -Nursing ethics - subset of bioethics - application & principle of ethics |
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What are 5 reasons for a student nurse to study ethics?
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-better decision making
-responsibility to be advocate -ethics is central to Nursing -necessary for nursing credibility -encounter ethical problems frequently |
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Discuss the nursing Professional Code of Ethics, and identify key concepts inherent in all codes.
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-human dignity
-patient centered -advocacy -accountability/delegation -continued learning -nursing rules -keep clean/provide care -integrity/safety -continued learning |
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Define the following: autonomy, beneficence, nonmaleficence, fidelity and justice
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Autonomy
-right to informed consent Beneficence -to do good and not cause harm to people Nonmaleficence -preventing intentional harm, act in ways that does not inflict evil or cause harm to others Fidelity -concept of keeping a commitment Justice -obligation to be fair to all people |
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Compare ethical decision making with the nursing process.
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ADPIE (nursing process)
MORAL (ethical decision making) M-massage the dilemma O-outline options R-resolve dilemma A- act on option L- look back and evaluate |
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List the four elements that need to be present for a law suit to be filed
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-duty
-breach of duty -causation -damages |
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Discuss ways to avoid legal repercussions
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-fact
-nursing process -informed consent -document -avoid medication errors -maintain patient safety |
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Reflect on the scope of practice; compare/contrast between a LPN, a RN and the CNA
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RN
LPN CNA |
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In determining the location, size and density of the liver, the nurse uses the assessment skills of auscultation. True or False?
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False. You use percussion.
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Assessing a client's nails and hair is often not a critical assessment. But these items are important to include a complete physical exam for which of the following reasons?
a) abnormal assessment findings may indicate a self-care deficit b) changes in the distribution of hair and/or color of nail beds may indicate the presence of a more serious disease c) alterations in assessment findings related to hair and nails may represent underlying malnutrition d) all of the above |
d.) all of the above
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In completing a nursing assessment of the skin, the nurse knows to instruct the client to seek medical attention for which of the following?
a) aches on face and back b) crusts that formed over pustules c) striae found on a patients abdomen (female) d) a mole that has become asymmetrical |
d) a mole that has become asymmetrical
A change in size, shape, color or elevation above the skins surface of a mole could indicate the presence of a malignant lesion |
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Which of the following data would you likely obtain during a general survey of the client during a physical exam? Check all that apply.
a) bowel sounds present x's 4 quadrants b) BP 130/70 mm Hg c) Speech appropriate for development d) gait steady |
B, C, and D
Bowel sounds would be done during a head to toe or focused assessment |
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Which type of assessment is best suited for use in an emergency or urgent patient situation?
a) ongoing b) focused c) psychosocial d) comprehensive |
b) focused
It allows the nurse to quickly gather system specific data related to a presenting problem |
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The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally and if there are no contraindications, how should the nurse position the patient for this portion of admission assessment?
a) sitting upright b) lying flat on back knees flexed c) lying flat on back with arms and legs fully extended d) side-lying with knees flexed |
a) sitting upright
rationale: allows for full lung expansion and is preferred position for measuring blood pressure |
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For all body systems, except the abdomen, what is the preferred order for the nurse to perform the following exam techniques
a) palpation b) auscultation c) inspection d) percussion 1) D, B, A, C 2) C, A, D, B 3) B, C, D, A 4) A, B, C, D |
2) C, A, D, B
Inspect, Palpate, Percuss, Auscultate EXCEPT when abdominal assessment. Auscultation should be performed before palpation and percussion to prevent altering bowel sounds |
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The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining the patients rectal area?
a) Sim's b) Supine c) Dorsal recumbent d) Semi-Fowler's |
a) Sim's
Rationale: Sim's is typically used to examine the rectal area. However, the position should be avoided if patient underwent hip surgery |
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The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical exam?
a) dorsal recumbent b) semi-fowlers c) lithotomy d) sim's |
b) semi-fowler's (laying flat with head of bed elevated)
Dorsal recumbent - on back with knees flexed and soles of feet flat on bed Lithotomy-female pelvic exam position Sim's - left side with right knee flexed against abdomen and eft knee slightly flexed |
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The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
a) heart murmurs b) jugular venous hums c) bowel sounds d) carotid bruits |
c) bowel sounds
Rationale: the bell of the stethoscope should be used to hear low pitched sounds such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs and abdomen |
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A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
a) ongoing b) comprehensive c) focused d) psychosocial |
c) focused
Rationale: focused assessment is done to obtain data about identified problem (ex: shortness of breath) |
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For a physical assessment of the older adult (65+ yrs old), what does the acronym SPICES mean?
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Sleep disorders
Problem with eating or feeding Incontinence Confusion Evidence for falls Skin breakdown |
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What are the types of health assessments?
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Comprehensive
System specific Focused On-going |
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What is the purpose of a physical assessment?
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1) to obtain a baseline for comparison
2) to identify nursing dx (to establish risks and problems and wellness dx) 3) establish a plan of care & patients needs 4) to monitor the status of a previously identified problem 5) to screen for health problems |
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What is a comprehensive health assessment?
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It includes a health history and head to toe assessment
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What is a system specific health assessment?
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Limited to one body system
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What is a focused physical assessment?
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To obtain data on an identified actual or potential problem.
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What is an on-going physical assessment?
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As needed assessment...continuing to monitor.
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What date should you collect to help plan for the physical assessment? (hint: think of NCP)
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1) diagnosis
2) chief complaint/reason for admission 3) past medical history 4) medications 5) past surgeries 6) allergies 7) limitations 8) lab results or diagnostics 9) employment/socio-economic concerns 10) living arrangements prior to hospitalization 11) spriritual/cultural practice 12) shift report from prior nurse |
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How should you plan and prepare for physical assessment besides data collection?
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-prepare environment
*adequate lighting and comfortable room temp -positioning *remember to use body mechanics -gather all supplies *what equipment do I need? (reflex hammer, pen light?) |
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How would you conduct a physical assessment so it really flows?
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cephalo-caudal (head to toe)
- review of body systems |
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What technique should you use when performing a physical assessment?
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Inspection, Palpation, Percussion, Auscultation
EXCEPT abdominal assessment Inspection, Auscultation, Percussion, Palpation |
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What would you inspect/observe during a physical assessment?
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1) overall impression
2) assessments for deviations from normal 3) general appearance 4) any distress? 5) mood/behavior 6) orientation to time, person, place: oriented x 3 7) level of consciousness 8) gait/posture 9) hygiene 10) symmetry (compare & contrast) 11) speech/hearing/vision 12) vital signs, height and weight |
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What would you inspect for when performing a physical assessment for skin?
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1) color: flesh? pale? cyanotic? jaundice? flushed petechiae (little red dots), rashes, dry?
2) lesions: none notes? moles? bruises? 3) palpate temp: warm? dry? cool? moist? 4) skin integrity: intact? open areas? scars? 5) turgor: <3 seconds? tenting? 6) edema? |
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What would you inspect for when performing a physical assessment for hair?
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1) inspection: color & cleanliness = general survey
2) texture 3) distribution: alopecia (hair loss), hirsutism (excessive hair over body) 4) pediculosis: lice |
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What would you inspect for when performing a physical assessment for nails?
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Inspection: color: pink? blue?
Texture: smooth? oval? brittle? thick? Palpate: capillary refill < 2 seconds Clubbing: > 180 degree angle. Clubblng is an indication of poor oxygenation |
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What are you looking for when assessing the head?
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Inspection: round & symmetrical?
Eyebrows, nose aligned? lesions? Palpate: tender? masses? |
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What are you looking for when assessing the eyes?
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1) Inspection: color: sclera: white? icterus? glistening? blood vesles? conjunctiva: clear?
2) Pupils: PERRLA Compare and contrast each eye (brisk? sluggish? equal? measure in mm before and after) 3) Blink: symmetry? 4) Tearing? Drainage? 5) Vision? distance with Snellen chart. Reading? Color? Accommodate: (constrict equally?) 6 cardinal fields of gaze? convergence? 6) Palpate: bony structures: tender? 7) Palpate & percuss: for sinus congestion. Headaches? post nasal drip? |
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What are you looking for when assessing the nose?
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Inspection: straight
Breathing effort: quiet? Drainage? Blood? Palpate: Tenderness? Lumps? |
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What are you looking for when assessing the ears?
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Inspection: symmetrical?
Smooth, non tender? Drainage/ Blood? Hearing? Bilateral? Palpate: tenderness/pain? masses? |
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What are you looking for when assessing the neck?
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Inspection: symmetrical/straight? alignment? color, scars?
Swallow: equal rise & fall Thyroid: straight, midline? enlarged? tender? Palpate: enlargement? lymph nodes? Auscultate & Palpate: carotid artery 1 at a time Observe: jugular vein: in semi-fowler's position for pulsations |
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What are you looking for when assessing the mouth?
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Inspection: symmetry? open/close? jaw/lip movement: frown? smile?
Palpate: lips: moist, dry, cracked, lesions? Gums/Mucous Membranes: pink, moist? lesions? Teeth: condition/dentures? decay or missing? Tongue: moist? pink? movement symmetry? lesions? Tonsils? Uvula? lesions? (0 - +1 is normal, 4 is when tonsils touching) |
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What are you looking for when assessing the chest/thorax?
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Inspect, palpate & auscultate anterior & posterior
Color: flesh? pale? blue? jaundice? scars? bruises? Moisture: dry? sweating? Palpate: masses? Respirations: symmetrical rise and fall? effortless? bilateral? dyspnea? shortness of breath? Auscultate: lung sounds: compare and contrast apices to bases: clear & rhythmic bilateral? 8-10 points on thorax. Wheezing? diminished? smoker? asthma? cough? AP: anterior/posterior: diameter 2:1 ratio - barrel chest? |
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What are you looking for when assessing the heart?
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Inspect: any visible pulsations
Palpate: for abnormal vibrations Auscultate: at 5 points Sounds of valves: opening and closing S1=lub (systolic) S2= dub (diastolic) lub dub = one beat Rate & Rhythm: irregular? skipped beats? extra beats? |
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What is a good mnemonic to know for the 5 points for auscultating the heart?
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Apes to Man
Aortic Valve Pulmonic Valve Erb's Point Tricuspid Valve Mitral Valve |
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What are you looking for when assessing the abdomen?
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Inspection: color, scars, moles, flat or distended?
Umbilicus: flat? protruding? Auscultate: 4 quadrants (RLQ, RUQ, LUQ, LLQ) Bowel Sounds: 1+ to 5 every 15 seconds. Absent? hypo or hyperactive (just after eaten, gastroenteritis, diarrhea). Document bowel sounds in each quadrant Palpate: 4 quadrants. Tender? Taut? Guarding? Pain Percussion- 4 quadrants to detect fluid, gas, masses |
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What angle/degree should you at least set the bed at when performing an abdominal assessment?
|
At least 30 degrees
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What are the pulse points?
|
Carotid
Temporal Brachial Radial Apical Femoral Popliteal Posterior tibial (inner ankle) Dorsalis pedis (top of foot) |
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What do you look for when assessing the musculoskeletal?
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Inspection: posture straight? slumped? gait? muscle mass? joints = arthritis?
Palpation: full ROM (ROJM)? active/passive ROM? joints red? edematous? Assess muscle strength: head, shoulders, extremities. Scale 0-5. 5 is the strongest |
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What do you look for when assessing the neurosensory?
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Full exams done with signs and symptoms of neurological problems. Not a test for cognitive functioning.
Inspection: gait/posture? Assess: LOC/oriented x 3, PERRLA, muscle strength, deep & tendon reflexes (DTRs= rapid, involuntary response at a certain level of the spinal cord - rated 0 to +4 where 0= no response and +4 = hyperactive, very brisk) Cranial nerve functioning (smell, vision, hearing, motor sensory) |
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What are you looking for when assessing vascular & peripheral circulation?
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Inspection: any varicose veins? skin: redness, edema? pale? cold? nail beds: cap refill?
Edema: trace (minimal) to +4 (deep depression lasting 2-3 minutes - pitting) Palpate: peripheral pulses: regular/strong? weak? absent? bilateral? Arteries: pulses to assess Veins: one way valves to prevent backflow Implications: PVD (peripheral vascular disease) DVT (deep vein thrombosis) diabetes, sores that don't heal |
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How do you assess GU & GI? and what questions would you ask the patient during this assessment?
|
Assess
What was the % of intake? 50%? 100% Any specific diet? diabetic? Accurate documentation of fluid intake? Restricted fluid intake? Questions: When did you last urinate? Any pain or burning? How often do you go to the bathroom? When was your last BM? Any difficulties or anything unusual such as difficulties stopping or starting the stream of urine? Any blood in the stool? |
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How do you assess for sensory perception?
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Assessing sensation
-Do you have any pain? -Keep eyes closed -test on extremities/face 1) light touch (soft/hard) 2) light pain (soft/dull) 3) temperature (cold/warm) 4) position (straight/slouch) |
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What questions would you ask when assessing the breasts or prostate?
|
Breasts
-Do you perform monthly breast exams? yearly mammograms? -Palpate any lumps/masses? -History of breast cancer in family? -Drainage from nipples? -Menopause? Prostate -Do you perform monthly testicular exams? -Difficulty starting or stopping the stream of urine? -Any changes in sexual function? |
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|
What is communication?
|
The process of exchanging information and the process of generating and transmitting meanings between two or more individuals.
The foundation of society Dynamic and reciprocal Human relationships enable us to met our physical and safety needs. Communication assists in meeting psychosocial needs of love, belonging and self-esteem |
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|
What is the communication process?
|
Stimulus
Sender/Source/Encoder Message Channel Receiver Feedback |
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|
What are the levels of communication?
|
Intrapersonal: self talk, within self
Interpersonal: 2 or more people Groups Small groups: must communicate to achieve goals (nutrition project) Organizational: must communicate to meet goals; policies and procedures Group dynamics: how people relate to one another. Success or failure is a function of members behaviors Learn to accept -all are different -not good or bad -each have strengths and areas to strengthen |
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|
What are forms of communication?
|
Verbal - use of language
Non-verbal: facial expressions, body language, general appearance |
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|
What are the factors influencing communication?
|
-developmental level
-gender -sociocultural difference -roles & responsibilities -space and territoriality -physical, mental and emotional state -value (self and others) -environment *Space Intimate (1-18 inches, holding infant) Personal (18 in to 4 ft; teaching, admission history taking) Social (4-12 ft) Public (12 ft and beyond |
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|
What is a therapeutic relationship?
|
Focuses on the health of a patient
The patient gains information and/or knowledge Works through issues, concerns, problems r/t health status, treatments and nursing care |
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|
What is therapeutic communication?
|
Patient-centered communication
Directed at achieving patient goals Used to establish a therapeutic relationship, provide and obtain health care information Expresses interest and concern for the family as well as the patient |
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|
What are some therapeutic communication techniques?
|
Active listening
Conveying acceptance Offering self Empathy Maintaining silence Using touch wisely Open-ended questions Restating/paraphrasing |
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|
What are some non-therapeutic techniques?
|
Offering false reassurance
Showing approval or disapproval Giving an opinion Close-ended questions |
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|
What are some blocks to effective communication?
|
Failure to perceive the patient as a human being
Failure to listen Asking too personal questions Giving personal opinions Being judgmental Automatic responses False reassurance Why and how questions Giving advice Asking for explanations Approval or disapproval Defensive responses Passive or aggressive responses Arguing Changing the subject Gossip and rumor |
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What are helping relationships?
|
Occurs between/among people who provide and who receive assistance in meeting human needs
Sets the climate for participants to move toward common goal to meet needs Quality of relationship is most significant element in determining An unequal sharing of information Based on patient's needs not the helper's needs Professional Helping relationship is NOT a friendship although share some of the same qualities such as care, concern, trust, growth |
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|
What are characteristics of a helping relationship?
|
Intangible
Dynamic Purposeful and time limited Provider person is professional and accountable for outcomes of the relationship |
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|
What are the goals of a helping relationship?
|
Determined cooperatively
Defined in terms of patient's needs Nurse selects the interventions that will help the patient move towards the goal As the patient's needs change, so does interventions Nurse's needs are set aside |
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|
What are the phases of a helping relationship?
|
Are continuous and reciprocal with the nursing process; those phases are
-Orientation (data gathering, guidelines are established) -Working (meet patients needs, nurse provides assistance, interactions, teacher, counselor) -Termination (conclusion of initial agreement, change of shift, transfer/discharge, emotions may be involved especially if + interaction) |
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|
What are the factors promoting effective communication?
|
Disposition
Warmth and friendliness Openness and respect Empathy (remain objective) Honesty/trust/authenticity Caring Competence |
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|
What are some therapeutic communication techniques?
|
Active listening - SOLER
Sit facing patient Open gesture Lean in Establish & Maintain eye contact Relax |
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|
What are some interview techniques?
|
Open-ended vs close-ended questions
Summarizing Validating Clarifying Reflection Direct question/comment *always being with an explanation of the purpose of the interview |
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|
What are the simple deviations of communication?
|
language barrier
speech impairment altered level of consciousness (LOC) impaired hearing decreased cognitive ability |
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|
What is the nursing diagnosis for communication?
|
impaired verbal communication
communication, readiness for enhanced sensory/perceptual disturbed |
|
|
What are the defining characteristics for a communication?
|
absence of eye contact
cannot speak difficulty comprehending usual communication pattern difficulty expressing thoughts verbally difficulty in forming words and sentences difficulty in selective attending difficulty in use of facial or body expressions disorientation to space or time does not speak inability to speak language of caregiver inappropriate verbalization visual deficit |
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|
What could be related to factors for communication?
|
absence of significant others
altered perceptions alteration in self-concept or self-esteem alteration of CNS brain tumor cultural differences |
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|
What would be the outcomes associated with planning for communications?
|
The patient will (be specific for time)
-use effective communication techniques -use alternative form of communication effectively -demonstrate congruency of verbal and non-verbal behavior -demonstrate understanding even if unable to speak |
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|
What would you implement for a patient for communication?
|
-involve family member
-avoid making assumptions -identify the spoken language -request an interpreter -listen, listen and listen some more -assess and refer for consultation re: hearing loss -face the patient when speaking to him/her -speak slowly |
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|
What would be good communication techniques when working with a patient with aphasia (disturbance or loss of ability to comprehend, elaborate or express speech concepts)?
|
-listen attentively
-ask simple questions -allow time for understanding and response -use visual cues -communication aid |
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|
What would be good communication techniques when working with a patient with cognitive impairment?
|
-reduce environmental distractions while conversing
-use simple sentences -be an attentive listener -allow time for patient to respond |
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|
What would be good communication techniques when working with a patient who is unresponsive?
|
-speak to the patient when in the room, as if the patient can hear and respond
-communicate with touch and verbally -provide orientation to person, place and time -do not say anything in front of the patient that he/she should not hear |
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|
What would be good communication techniques when working with a patient who is not English speaking?
|
-be respectful
-use your face to convey warmth -interpretive services -use normal tone of voice -learn some common words/phrases in the patient's language |
