Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
133 Cards in this Set
- Front
- Back
|
Evidence-based practice
|
– nursing practice based on the best available evidence.
|
|
|
Example of Evidence based practice
|
using saline flush instead of heparin in peripheral lines
|
|
|
ADPIE
|
Assessment, Diagnosis, Planning, implementation, and evaluation
|
|
|
Nursing diagnosis
|
Using patient data and critical thinking skills to identify and validate appropriate nursing diagnosis
|
|
|
What are the 3 parts to nursing diagnosis
|
Problem
Etiology Symptoms |
|
|
Problem
|
Problem – label (NANDA list)
|
|
|
Etiology
|
related to – cause of contributor of the problem
|
|
|
Symptoms
|
– as evidenced by – defining characteristics or symptoms identified during nursing assessment
|
|
|
Planning
|
Phase consisting of writing measurable patient outcomes and nursing interventions to accomplish the outcomes.
|
|
|
Priority
|
Maslows Hierarchy of needs
|
|
|
Maslows hierarchy order
|
1. PHysiological needs (breathing/food)
2. Safety and security (health, employment) 3. Love and belonging (friendship/family( 4. Self esteem (confidence/ achievement) 5. Self actualization (morality/creativity) |
|
|
Look for measurable outcomes like
|
Pt doesnt wake as much during the night, awakens refreshed
|
|
|
Implementation
|
take your plans and do them
|
|
|
DAR
|
Data, action, response
|
|
|
Sometimes the best action is to
|
call the doc
|
|
|
What are the goals of communication (3)
|
1. COnfidential
2. Accurate 3. Timely |
|
|
Therapeutic nurse-patient relationship is
|
1. Foundation of nursing care
2. Patient centered communication and goal directed 3. Professional 4 goal directed 5. empowers them to make decisions |
|
|
Goal directed communication
|
promote wellness and personal growth in patients
|
|
|
3 phases of therapeutic relationship
|
1. Orientation
2. Working 3. Termination |
|
|
Orientation (therapeutic relationship)
|
Learning about the patient and needs, clarifying roles, establishing rapport, collecting data, establishing goals and clarifying misunderstandings
|
|
|
Working (therapeutic relationship)
|
Work toward effective goal attainment
|
|
|
Termination of therapeutic relationship
|
evaluation and summary of progress toward goals
|
|
|
Nosocomial infection
|
infection resulting from being at hospital
|
|
|
6 elements of infection
|
1. infectious agent
2. reservoir or source for the growth 3. Portal of exit from the reservoir 4. Mode of transmission (cough, touch) 5. Portal of entry (open wound) 6. Susceptible host (immunocomp) |
|
|
Working (therapeutic relationship)
|
Work toward effective goal attainment
|
|
|
Termination of therapeutic relationship
|
evaluation and summary of progress toward goals
|
|
|
Nosocomial infection
|
infection resulting from being at hospital
|
|
|
6 elements of infection
|
1. infectious agent
2. reservoir or source for the growth 3. Portal of exit from the reservoir 4. Mode of transmission (cough, touch) 5. Portal of entry (open wound) 6. Susceptible host (immunocomp) |
|
|
Medical Asepsis
|
clean technique. hand washing, routine environmental cleaning
|
|
|
Surgical Asepsis
|
Sterile technique. (invasive procedures)
|
|
|
Most common means of transmitting infections btw pts
|
hand hygiene
|
|
|
Standard precautions
|
used for all patients
|
|
|
Airborne precautions
|
private room with negative airflow respirator or mask....measles, varicella, tb
|
|
|
Droplet precautions
|
private room r room with patient who has the same problem, mask within 3 ft of patient (FLU, meningitis, mumps)
|
|
|
Contact precautions
|
private room or share room with patient with the same problem, gloves, gown (GI, resp, skin infections)
|
|
|
What is the purpose of sterile technique?
|
To make or maintain objects and areas that are free from pathogenic microorganisms (also called surgical asepsis)
|
|
|
How big is the border of a sterile area?
|
1 inch
|
|
|
What equipment is necessary for sterile technique?
|
surgical mask, surgical cap, and eyewear protection
|
|
|
Possible nursing diagnosis for applying and removing cap, mask, and protective eyewear
|
1. Ineffective protection
2. risk for infection |
|
|
When inspecting sterile equipment packaging look for
|
integrity, exposure, and expiration dates
|
|
|
When removing a mask what order do you go in?
|
Untie bottom first then untie top
|
|
|
Type IV hypersensitivity
|
Cell mediated allergic rxn. Redness, itching, hives, local swelling, red and itchy nose, cough
|
|
|
Type I allergic rxn
|
True allergic rxn. hives, edema, itching, rash, wheezing, brochospasm, dyspnea
|
|
|
People at risk for latex allergy (7)
|
1. Spina bifida. 2. Congenital or uogenital defects. 3. History of indwelling catheter or repeated catheterizations 4. hx of condom catheter use 5. high latex exposure
6. hx of multiple childhood surgeries 7 hx of food allergies |
|
|
Complete BLood count
|
CBC
|
|
|
RBC
|
Male- 4.7-6.1
Female- 4.2-5.4 |
|
|
High RBC caused by
|
high altitude, polycythemia, dehydration (false high)
|
|
|
Low RBC caused by
|
Hemorrhage, hemolysis, diet deficiencies, genetics, marrow failure, drugs, chronic illness, and organ failure
|
|
|
White Blood cell
|
Adult/child >2yo 5000-10000. Critical value <2500 or > 30000
|
|
|
Protective Isolation
|
Wash hands, wear mask, gown and gloves, restrict visitors, prohibit visits by sick
|
|
|
Avoid bacteremia from pts own flora
|
No rectal temps, exams or enemas. no flossing. Avoid IM injections
|
|
|
Avoid bacteria from food
|
only foods from newly opened packages, avoid fresh fruit, vegs and cook all food
|
|
|
skin
|
largest human organ, protects body
|
|
|
Complete bed bath
|
dependent patient
|
|
|
Partial bed bath
|
dependent pt or pt unable to reach parts of body
|
|
|
Sponge bath at the sink
|
basin or sink, pt able to perform all or part of bath
|
|
|
Tub bath
|
immersion into tub, pt may need help or may be independent
|
|
|
shower
|
pt stands or sits, may need help or may be independent
|
|
|
disposable bed bath/cloths
|
premoistened, no rinse
|
|
|
Sitz bath
|
decrease pain and inflammation in perianal and rectal areas (hemorrhoids, after childbirth)
|
|
|
Medicated bath
|
relief of skin irritiation and creates antibacterial and drying effect
|
|
|
Perineal care
|
Thorough cleansing of pt external genitalia and surrounding skin (eg incontinence and catheters, rectal or genital surgery)
|
|
|
Nursing Diagnosis for bathing and hygiene
|
- activity intolerance
- bathing/hygiene self-care deficit -knowledge deficit r/t skin care -impaired physical mobility- -impaired skin integrity - risk for infection |
|
|
Fowlers position
|
45-90degrees
|
|
|
SemiFowlers position
|
30-40 degrees
|
|
|
Trendelenburg
|
bed frame tilted head down
|
|
|
Reverse Trendelenburg
|
bed frame tilted feet down
|
|
|
Supine
|
bed frame horizontal
|
|
|
Common causes of constipation
|
1. Irregular bowel habits
2. Chronic illnesses 3. LOw fiber diet 4. Lengthy bedrest - lack of exercise 5. Laxative misuse 6. Slowed peristalsis 7. Neurological Conditions (SCI, tumor) 8. Organic illnesses 9. Meds that slow colon action (anticholergics) |
|
|
foods that promote peristalsis
|
high fiber, whole grains, fruits, green leafy veges
|
|
|
Tap water (hypotonic) enema
|
danger of water toxicity and fluid overload if repeated
|
|
|
Normal Saline
|
isotonic
|
|
|
Hypertonic enema
|
useful for pt who cant tolerate lots of fluid
|
|
|
Harris flush enema
|
expels gas by stimulating perstalsis
|
|
|
soapsuds enema
|
castile soap
|
|
|
Oil retention
|
softens stool
|
|
|
Carminative soluntion enema
|
relieves gas distention
|
|
|
SCD
|
Sequential Compression Devices
|
|
|
Elastic Stocking
|
reduce blood stasis and venous wall injury; promote venous return and prevent venous pooling; prevent passive venous dilation
|
|
|
Goniometer
|
instrument for measuring angles
|
|
|
Risks for falls
|
1. History, 2. Older than 60, 3. postop 4. smoker
|
|
|
Seizure
|
hyperexcitation of neurons in the brain that leads to suddent, violent, involuntary muscle contractions
|
|
|
Define platelet count
|
Acutal count of the number of platelets per cubic militler of blood
|
|
|
What are the causes of Thrombocytopenia
|
1. dec production of platelets
2. Sequestration of platelets 3. Destruction of platelets |
|
|
Prothrombin Time (PT)
|
INternation Normalized ratio (INR)
Normal 11-12.5 sec 2-3.5 INR Critical value >20 sec |
|
|
What does INR measure
|
clotting ability of factors i, ii, v, vii and x
|
|
|
Prolonged PT associtate w
|
1. hepatocellular liver disease
2. Obstructive bilitary disease 3. coumarin ingestin |
|
|
What is the nurses role in nutrition
|
1. Screening for malnutrition risk
2. assist w and assess pt intake 3. identify pts at risk for aspiration |
|
|
Nutritional risk factors (16)
|
1. liquid diet for >3days
2. IV or NPO >3days 3. Low intake f prescribed diet 4. Weight 20% above or 10% below desirable 5. Diagnosis that inc or dec nutritional damand (burns) 6. Chronic drug/alcohol use 7. Inadequate nutrition for >7days 8. Alteration in chewing/sawllowing 9. Body temp high>2 days 10. Low hematocrit 11. Dec lymphocyte count 12. Elevated or decreased cholesterol level 13. Low serum albumin 14. Dec appetite, n/v 15 Compromised dentition 16. Change in bowel habits >3 days |
|
|
What score on Mini nutritional assess is at risk of malnutrition
|
11
|
|
|
malnutrition
|
a pathologic state resulting from a relative or absolute deficiency or excess of one or more essential nutrition
|
|
|
aspiration
|
inhalation of oropharyngeal segretions into lower respiratory tract
|
|
|
Albumin
|
protein formed in liver...serum protein Transports drugs, hormones and enzymes, measure of nutrition
|
|
|
WHat is albumin lab used for
|
diagnose, evaluate and monitor cancer pt, intestinal/renal protein wasting states, immune disorders, liver dysfunction, impaired nutrition and chronic edematous states
|
|
|
Prealbumin
|
assist with transport and metabolism of vitamin a
|
|
|
Prealbumin increased levels
|
drugs, nephrotic syndrome, hodgkins disease, pregnancy
|
|
|
Decreased levels of prealbumin
|
drugs, malnutrition, liver damage, burns, inflammation
|
|
|
Hypoxia
|
insufficient oxygen to meet the needs of tissues and cells; caused by hypoxemia
|
|
|
Hypoxemia
|
deficiency of arterial oxygen
|
|
|
Hemoglobin
|
carrier of respiratory gases (O2 and CO2)
|
|
|
3 diseases that require use of oxygen therapy
|
pneumonia, COPD, Cardiovascular disease
|
|
|
Pneumonia
|
fluid in alveoli, decreased gas exchange
|
|
|
COPD
|
CO2 retention and decreased O2
|
|
|
Cardiovascular disease
|
decreased CO, decreased oxygen to tissues and cells
|
|
|
What percentage of oxygen is room air
|
21%
|
|
|
Normal range for pH?
|
7.35-7.45
|
|
|
Normal range for Pco2
|
35-45 mmHg
|
|
|
Normal range for HCO3
|
21-28
|
|
|
Dont do arterial blood gases if
|
no palpable pule, cellulitis or open infection, no ulnar artery, AV fistula, severe coagulopathy
|
|
|
Increased levels of hemoglobin
|
1. Erythrocytosis 2. congenital heart disease 3. COPD 4. Polycythemia vera 5. Severe dehydration
|
|
|
Decreased levels of hemoglobin
|
1. anemia 2. hemoglobinopathy 3. cirrhosis 4. Hemolytic anemia 5. hemorrhage 6. dietary deficiency 7. bone marrow failure . normal pregnancy
|
|
|
hematocrity
|
indirect measure of red blood cell number and volume
|
|
|
Hematocrit used for
|
evaluated pt with bleeding or who is anemic
|
|
|
What are the six rights of medication
|
1. Right patient
2. Right drug 3. Right route 4. Right time 5. Right documentation 6. right dose |
|
|
Extracts
|
obtained by dissolving powder in h20/alchol and allowed to evaporate
|
|
|
Spirits
|
volitile
|
|
|
Emulsion
|
suspension of mixed oils
|
|
|
Liniment
|
ointment like calamine lotion
|
|
|
WhaT does nitro do as sideeffect
|
drop bp and ha
|
|
|
Intradermal
|
26gauge, 1 cm needle
|
|
|
Subcut
|
25 gauge 1.3 – 1.6 cm needle
|
|
|
Therapeutic effect
|
intended effect
|
|
|
side effect
|
may be harmless or cause injury
|
|
|
Idiosyncratic rxn
|
something totally didnt expect
|
|
|
Paradoxical rxn
|
does exact opposite of what supposed to do
|
|
|
Unit dose system
|
minimizes drug dosage errors
|
|
|
MDI
|
Metered dose inhalers
|
|
|
Nebulized drugs
|
add diluent to medication, placed in reservoir
|
|
|
Sites for IM on infants
|
vastus lateralis
|
|
|
Sites for im on toddlers
|
vastus lateralis, ventrolgluteal, deltoid
|
|
|
Children site IM
|
deltoid or ventrogluteal
|
|
|
Adult site IM
|
ventrogluteal or deltoid
|
|
|
IM deltoid
|
small volume <2mL. immunizations
|
