Nurs1111 - Final Study Cards

Front 1

Apothecary System
Rules & Measurements

Back 1

- Roman numerals for any number less than10
- Numbers less than 1 will be in fraction form
- Used to be system of choice
~ changed to metric

- does not use decimals ~ only fractions or Roman numerals (lower-case) or ounces

- Measurements
* Weight = Grains
* Volume = Ounces

Front 2

What is medication?

Back 2

A substance used in the diagnosis, treatment, cure, relief, or prevention of health alterations

Front 3

4 types of names of Drugs

Back 3

Chemical
Generic
Official
Trademark

Front 4

4 Classifications of Drugs

Back 4

This is classified by:
- Body system
- Therapeutic Use – ex. infections, nausea
- Physiologic action – ex. beta blocker, ACE inhibitor, etc
* what it does for the body – “makes me urinate”
- Prescription or Non-prescription
* OTC

Front 5

3 Sources of Information on Drugs

Back 5

Package Inserts
PDR
Drug Guide for Nurses

Front 6

Federal Food, Drug, & Cosmetic Act

Back 6

- enforced by the FDA (Food & Drug Administration)
▪ determines the safety of drugs before marketing to ensure labeling specifications and standards in advertising are met

Front 7

Federal Food, Drug, & Cosmetic Act
Amendments:
1. 1938
2. 1952 - Durham-Humphrey amendment
3. 1962 - Kefauver-Harris Drug Amendment

Back 7

Which amendment (name & year) for 1,2 & 3?

1. drugs were required to be or have: safe, labeling & advertisement
2. tightened restrictions for refilling prescriptions
- prescription or non-prescription
3. brought about by the thalidomide tragedy – provides greater control and surveillance of the distribution and clinical testing of investigational drugs and requires that a product be proven safe and effective before release for sale
▫ effective as well as safe

Hint 7

dates/names of amendments:

-1952 - Durham-Humphrey amendment

or

- 1938

or

- 1962 - Kefauver-Harris Drug Amendment

Front 8

Controlled Substance
Schedule I

Back 8

What schedule is described?
- high potential for abuse; no currently accepted medical use in the US; lack of accepted safety for use under medical supervision
▪ ex. LSD (lysergic acid diethylamide); marijuana, peyote, STP, heroin, hashish

Front 9

Controlled Substance
Schedule II

Back 9

What schedule is described?
- high potential for abuse; currently acceptable medical use in the US; abuse potential may lead to severe psychological or physical dependence
▪ ex. Secobarbitol, pentobarbital, amphetamines, morphine, meperidine, methadone, Percodan, methylphenidate

Front 10

Controlled Substance
Schedule III

Back 10

What schedule is described?
- high potential for abuse; currently accepted medical use in the US; abuse potential that may lead to moderate or low physical dependence or high psychological dependence
▪ ex. Empirin w/codeine; Lortab; Fiorinal; Tylenol w/codeine

Front 11

Controlled Substance
Schedule IV

Back 11

What schedule is described?
- low potential for abuse; currently accepted in the US; abuse potential may lead to limited physical or psychological dependence
▪ ex. Phenobarbital, propoxyphene, chloral hydrate, paraldehyde, chloridiazepoxide, diazepam, flurazepam, temazepam, valium, xanax

Front 12

Controlled Substance
Schedule V

Back 12

What schedule is described?
- low potential for abuse; currently accepted in the US; abuse potential of limited physical or psychological dependence liability; prescription may not be required b/c of low abuse potential
▪ ex. Lomotil, Robitussin A-C

Front 13

Controlled Substance
Act of 1970

Back 13

- enforced by the DEA (Drug Enforcement Agency)
- basic structure consists of 5 classifications or schedules of controlled substances which requires degrees or conditions of control of record-keeping, order forms required; other regulations depend on these classifications

Front 14

Route of administration
- Enteral

Back 14

What route is described?
- administered directly into the gastrointestinal (GI) tract by oral, rectal, or nasogastric routes.
- Meds mostly administered orally
- Special considerations needed for pediatric & geriatric because: tablets & capsules are too big, or they cannot chew chewable pills
- Gastrointestinal absorption influenced by many things such as: gastric pH, emptying time, GI tract motility, enzymatic activity, blood flow of mucous linings, permeability & maturation of mucosal membranes, and concurrent disease processes

Front 15

Route of administration
- Percutaneous

Back 15

What route is administered by:
- Topical - usually effective in infants b/c out layer of skin (stratem corneum) is not fully developed & more fully hydrated so that water-soluble drugs are absorbed more readily
- Inhalation
- Sublingual
* Inflammation of the skin (diaper rash) also increases absorption
* In geriatric patients, difficult to predict - dermal thickness decreases w/age & can enhance absorption
* But can be decreased from: drying, wrinkling, & decrease in hair follicles

Front 16

Route of administration
- Parenteral

Back 16

- by injection thru Intradermal, Subcutaneous, Intramuscular, Intravenous Routes
- Pediatric & geriatric need special considerations for medication administration due to: muscle mass, muscle inactivity (for bedridden patients)

Front 17

2 factors that affect
- Absorption of medication

Back 17

These 2 factors affect what?
1. Blood Flow - from each route of administration can vary

2. Dissolvability - liquids absorbed faster, solids need to dissolve b/f absorption occurs

Front 18

Pharmacokinetics
- Distribution of Medication

Back 18

- how drugs are transported by the circulating body fluids to the sites of action (receptors), metabolism & excretion
- Usually thru blood or lymphatic system
- Dependent on: pH, body water concentrations (intra/extra-cellular and total body), presence & quantity of fat tissue, protein binding, cardiac output, & regional blood flow
- Affected by: subcutaneous tissue b/c it is not as vascular

Front 19

Pharmacokinetics
- Metabolism/ Biotransformation

Back 19

- drugs broken down into metabolites (inactive compounds)
- Controlled by: genes, diet, age, & maturity of enzyme systems
- Affected by: condition of the liver & genetics (present at birth, but matures at different rates)
- Also affected at all ages by genetics, smoking, diet, gender, other medicines & diseases
□ No way to measure liver function - can only assess renal function to adjust dosages
§ Liver - primary sites of enzyme systems

Front 20

Types of Drug Action
- Side Effect

Back 20

what type of drug action?
- ex. cenepril - causing coughing
- When the drugs affect more than one body system simultaneously
- Symptoms that occurs other than their intended symptom
- Symptoms that can be alleviated or prevented by actions of the nurse or educate the patient

Front 21

Types of Drug Action
- Adverse Effect

Back 21

what type of drug action?
- ex. cenepril rarely causes impotence
- According to WHO: any noxious, unintended, and undesired effect of a drug which occurs at doses in humans for prophylaxis, diagnosis, or therapy
- "Right drug, right dose, right patient, bad effect"
- Severe side-effect
- Should not be confused w/medication errors or Adverse Drug Events (ADE's)

Front 22

Types of Drug Action
- Toxic Effect

Back 22

what type of drug action?
- amount of drug in the body - too much can be deadly
- When adverse effects are severe

Front 23

Types of Drug Action
- Idiosyncratic Effect

Back 23

what type of drug action?
- RARE - happens in 1/100,000people
- Ex. taking prednisone and it causes the hip bone to dissolve
- When something unusual or abnormal happens when a drug is first administered - an over-response to the action of the drug
- Happens usually b/c patients inability to metabolize a drug b/c of a genetic deficiency of certain enzymes

Front 24

Types of Drug Action
- Allergic Reaction

Back 24

what type of drug action?
- hypersensitivity reactions - occurs in 6-10% of patients taking meds
- Only occurs in patients who have been previously exposed to a drug and have developed antibodies to it, then upon re-exposure a reaction is caused

Front 25

Examples of Increased Action of drug interaction

Back 25

These are examples of what?
- Ex. taking an antihistamine w/caffiene causes the effects of the antihistamine to work faster
- Ex. taking an antacid w/aspirin causes faster dissolving & absorption

Front 26

2 types of Increased Action of drug interaction

Back 26

These 2 terms are types of what?

1) Additive effect - 2 drugs w/similar actions are taken for a doubled effect

2) Synergistic effect - combined effect of two drugs is greater than the sum of the effect of each drug given alone

Front 27

2 types of Decreased Action of drug interaction

Back 27

These 2 terms are types of what?

1) Antagonistic effect - one drug interferes w/the action of another

2) Displacement - displacement of the 1st drug by a 2nd drug increases the activity of the 1st drug

Front 28

Incompatible
- type of drug interaction

Back 28

What type of drug interaction?

- 1st drug is chemically conflicting w/the 2nd drug, causing deterioration when both drugs are mixed in the same syringe or administered together at the same site
- Signs are: haziness, a precipitate, or a change in color of the solution when the drugs are mixed
- Never give conflicting drugs together! - can cause death
- ALWAYS check drug interactions

Front 29

Peak drug levels

Back 29

- level of drug in serum
- Highest level after administration
- Some drugs take 1/2 hr to 2 hrs to reach this hi level

Front 30

Trough drug levels

Back 30

- drawn 30 minutes b/f next scheduled dose
- Must be drawn at this time!
- Lowest amount of serum in system

Front 31

A Factor that Influences Drug Action
- Cumulative Effect

Back 31

How does this influence drug action?

- a drug may accumulate in the body if the next dose is administered b/f the previously administered dose has been metabolized or excreted.
- May result in drug toxicity
- Ex. excessive drinking of alcohol

Front 32

6 Types of Medication Orders

Back 32

Standard order - aka standing order
PRN order
One time order
STAT order
Verbal order
Automatic stop order

Front 33

What you should know about Drugs during medication administration

Back 33

Why ordered
Expected actions
Usual dosing
Correct route
Side effects
Contraindications
Compatibility

Front 34

What to do if Patient refuses medication?

Back 34

1) First ask patient why?
* could be a simple reason such as:
- not wanting to drink it with water;
- it doesn't look the same as their medication currently prescribed;
- they don't understand how it will help them

2) Teach patient & show medication information if needed

3) If patient still refuses, call the Dr & inform him

4) document patient refusal and response from call to Dr., time of call/refusal, patient's reason for refusal

Front 35

Intradermal Injection
- location
- needle size
- volume injected
- injection angle

Back 35

- Angle: 15 degrees
- location: Inner aspect of forearm
- Make a bleb
- Maximum volume 0.1 mL

** Needle Size
- 26 gauge
- Length: 1/4,3/8, or 1/2 inch

Front 36

Subcutaneous Injection
- angle
- max volume
- needle size

Back 36

- Angle 45 or 90 degrees
- Grasp skin
- Aspirate- pull back on plunger to check for blood
* EXCEPT FOR:
- Insulin & Heparin
- Maximum volume 2 ml

- Needle Size
* 25-29 gauge
* Length: 3/8, 5/8 inch

Front 37

Intramuscular Injection
- angle
- max volume
- needle size

Back 37

- Angle 90 degrees
- Pull skin taunt
- Aspirate
- Maximum volume 3 ml
**Deltoid 2 ml or less
- Needle Size
* 20 - 22 gauge
* length: 1 to 1-1/2 inch

Front 38

4 Intramuscular Injection Sites

Back 38

Ventrogluteal
Dorsogluteal
Vastus Lateralis
Deltoid

Front 39

Vastus Lateralis IM Injection Site
- location
- landmarks

Back 39

- Location of injection: Vastus Lateralis muscle

- Landmarks:
* Greater trochanter
* Knee
- inject into lateral side of anterior thigh near the midline of the thigh
* in the middle of the anterior thigh
- Preferred site for children

Front 40

Ventro-gluteal IM Injection Site
- location
- landmarks

Back 40

- location of injection: Gluteus medius muscle

- Landmarks:
* Greater trochanter
* Anterior superior illiac spine
* Posterior iliac crest

- this site has the least amount of risk for injecting into major veins/arteries/nerves

Front 41

Dorso-gluteal IM Injection Site
- location
- landmarks

Back 41

- location of injection: Gluteus maximus muscle

- Landmarks:
* Greater trochanter
* Posterior superior iliac spine

- Not recommended for children under 3 years

- site rarely used now because of risk to sciatic nerve - can cause permanent injury & chronic pain

Front 42

Deltoid IM Injection Site
- location
- landmarks

Back 42

- location of injection: Deltoid muscle

- Landmarks:
* Acromion process
* Two fingers breadths below

Front 43

Z-track Injection
- location of injection
- steps
- why used?

Back 43

- not intended for injections into exposed sites (arm)
- Usually administered in the dorsogluteal site
- When used?
* If meds harm/stain skin
* Ex. Iron

- REQUIRES Air lock- pull back on plunger­ 0.2 mL
- Stretch skin (displace about 2 in. & hold in place)
- Aspirate (check for blood.. remember use caution for Right Route)
- Count for 10 seconds
- Release skin immediately after removing needle

Front 44

How Illness influences drug action

Back 44

what factor is being described to influence drug action?

- pathologic conditions may alter the rate of absorption, distribution, metabolism & excretion
- when you don't feel well the body metabolizes drugs differently than when you're well b/c its not at its normal function
- Ex. vomiting - may not be able to retain meds in the stomach long enough for dissolution & absorption

Front 45

How Psychological Aspects influences drug action

Back 45

What type of factor described is influencing drug action?

- attitudes & expectations play a major role in patient's response to therapy and willingness to take prescribed meds
- always be therapeutic & positive with your patients
- Nurses' attitude & comments can impact patient inner thoughts & feelings

Front 46

Historical Development People

- Florence Nightingale

Back 46

Which one of the Historical Development People is described?

- est. the 1st Nursing Philosophy based on health maintenance and restoration
- Views from a spiritual philosophy that developed during adolescence and adulthood that reflected the changing needs in society
- Developed the first organized program for training nurses "Nightingale Training School for Nurses" at St. Thomas's Hospital in London
- She was the 1st practicing nurse epidemiologist
- Brought about major reforms in hygiene, sanitation, and nursing practice
- Brought the mortality rate in a Turkish hospital from 42.7% down to 2.2% in 6 months

Front 47

Historical Development People

- Clara Barton

Back 47

Which one of the Historical Development People is described?

- founder of the American Red Cross - tended soldiers on the battlefields, cleansing their wounds, meeting their basic needs, and comforting them in death

Front 48

Historical Development People

- Harriet Tubman

Back 48

Which one of the Historical Development People is described?

- influence nursing during the Civil War - was active in the Underground Railroad movement
- Assisted in leading over 300 slaves to freedom

Front 49

Historical Development People

- Mary Mahoney

Back 49

Which one of the Historical Development People is described?

- 1st professionally trained African American nurse
- Concerned w/relationships between culture and races
- Brought forth an awareness of cultural diversity and respect for the individual, regardless of background, race, color or religion

Front 50

Historical Development People

- Isabel Robb

Back 50

Which one of the Historical Development People is described?

- helped found the Nurses' Associated Alumnae of the US and Canada in 1896 - later became the ANA
- Authored many nursing textbooks
- One of the original founders of the American Journal of Nursing

Front 51

Historical Development People

- Lillian Wald & Mary Brewster

Back 51

Which one of the Historical Development People is described?

- opened a clinic that focused on the health needs of poor people who lived in tenements in NYC
- Nurses in this clinic were some of the first to demonstrate autonomy in practice b/c they frequently encountered situations that required quick thinking w/o supervision or direction of a health care provider.
- 1st to offer Nursing rewards to schools
- 1st to practice independently

Front 52

7 Historical Development People

Back 52

- Florence Nightingale
- Clara Barton
- Harriet Tubman
- Mary Mahoney
- Isabel Robb
- Lillian Wald & Mary Brewster

Front 53

4 Professional Nursing Organizations

Back 53

- American Nurses Association (ANA)
- National League for Nursing (NLN)
- International Council of Nursing (ICN)
- National Student Nurses Association (NSNA)

Front 54

Responsibilities of the Professional Nurse

- Caregiver

Back 54

What type of nursing responsibility?

- manage and care for the community's health
- Also teaches wellness
- Ensure appropriate, individualized nursing care for specific clients and their families
- help build a healthy community which enables people to achieve and maintain high quality of life and function

Front 55

Responsibilities of the Professional Nurse

- Educator

Back 55

What type of nursing responsibility?

- a nurse who provides educational support for: prenatal classes, infant care, child safety, and cancer screenings

Front 56

Responsibilities of the Professional Nurse

- Communicator

Back 56

What responsibility of a nurse is being described?

- is essential for all nursing roles and activities
- Routinely connect with clients and families, other nurses and health care professionals, resource persons, and the community
- Without this, it is impossible to give comfort and emotional support, give care effectively, make decisions with clients and families, protect clients from threats to well-being, coordinate and manage client care, assist the client in rehabilitation, or provide client education

Front 57

Responsibilities of the Professional Nurse

- Case Manager

Back 57

What responsibility of a nurse is being described?

- establishes plan of care & resources
- Delegating tasks & follow-up on patient care
- the ability to establish and appropriate plan of care based on assessment of clients and families and to coordinate needed resources & services for the client's well-being
- Assumes responsibility for the case supervision of multiple clients who are usually at the greatest risk for needing extensive coordination of health care services.
- Ex. of types of health-care services: neurological disease, trauma victims, or clients w/complex medical or psychiatric conditions

Front 58

Professional Standards Review Organizations (PSROs)
- how they help to control health-care cost

Back 58

- this organization reviews the quality, quantity, and cost of hospital care

Front 59

Prospective Payment System (PPS)
- how they help to control health-care cost

Back 59

- this organization is one of the most significant factors that influenced payment for health care
- Established by Congress in 1983, they eliminated cost-based reimbursement.
- Hospitals serving clients who received Medicare benefits were no longer able to charge whatever the clients care cost.

Front 60

Capitation-Hospitals
- how they help to control health-care cost

Back 60

- in this organization the providers received a fixed amount per client or enrollee of a health care plan
- The aim is to build a payment plan for select diagnoses or surgical procedures that consist s of the best standards of care, including essential diagnostic and treatment procedures at the lowest cost
- Most health care providers (e.g., health care networks or managed care organizations) now receive capped payments

Front 61

Managed Care
- how they help to control health-care cost

Back 61

- this type of organization describes health care systems in which there is administrative control over primary health care services for a defined client population
- The provider or health care system receives a predetermined capitated payment for each client enrolled in the program

**Examples
- Only paid for a 24hr stay for vaginal deliveries, 48hrs for c-section
- Mastectomies were outpatient procedures

Front 62

Preferred Provider Organization (PPO)
- how health care cost is paid

Back 62

- An organization that limits an enrollee's choice to a list of "preferred" hospitals, physicians, and providers.
- An enrollee pays more out-of-pocket expenses for using a provider not on the list.
- Characteristics:
* Contractual agreement exists between a set of providers and one or more purchasers (self-insured employers or insurance plans).
* Comprehensive health services at a discount to companies under contract
* Focus on health maintenance.

Front 63

Medicare
- how health care cost is paid

Back 63

- A federally administrated program by the Commonwealth Fund or the Centers for Medicare and Medicaid Services (CMS)
- a financially funded national health insurance program in the United States for people 65 years and older.
- Characteristics:
* Payment for plan deducted from monthly individual Social Security check.
* Covers services of nurse practitioners.
* Does not pay full cost of certain services
* Supplemental insurance encouraged.

Front 64

Medicaid
- how health care cost is paid

Back 64

- Federally funded, state-operated program that provides:
1. health insurance to low-income families;
2. health assistance to low-income people with long-term care (LTC) disabilities
3. supplemental coverage and LTC assistance to older adults and Medicare beneficiaries in nursing homes.
- Individual states determine eligibility and benefits
- Characteristics:
* Finances a large portion of maternal and child care for the poor
* Reimburses for nurse-midwifery and other advanced practice nurses (varies by state).
* Reimburses nursing home funding.

Front 65

Private Insurance
- how health care cost is paid

Back 65

- Traditional fee-for-service plan.
- Payment computed after client receives services on basis of number of services used.
- Characteristics:
* Policies typically expensive.
* Most policies have deductibles that clients have to meet before Insurance pays

Front 66

Levels of Health Care
- Primary Care

Back 66

What level of Health care?

- this care focuses on health services provided on an individual basis.
- Health Promotion Programs lower the overall costs of health care by reducing the incidence of disease, minimizing complications, and thus reducing the need to use more expensive health care resources.

Front 67

Levels of Health Care
- Preventive Care

Back 67

What level of Health care?

- care is more disease oriented and focused on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs.
- ex. Screenings, wellness, prenatal, exercise classes, internal medicine, hotlines, primary care

Front 68

Levels of Health Care
- Secondary and Tertiary Care

Back 68

What level of Health care?

- Usually connected to a medical school
- The ability to think critically and to identify clients changing problems quickly and accurately is essential.
- Nurses in this setting need to apply evidence-based information when selecting nursing interventions to improve client outcomes.

Front 69

Levels of Health Care
- Restorative Care

Back 69

What level of Health care?

- help individuals regain maximal functional status and to enhance quality of life through promotion of independence and self-care.
- Clients recovering from an acute or chronic illness or disability often require additional services to return to their previous level of function or reach a new level of function limited by their illness or disability.
- Nurses in these settings recognize that success is dependent on effective and early collaboration with clients and their families
- Clients and families require a clear understanding of goals for physical recovery, the rationale for any physical limitations, and the purpose and potential risks associated with therapies

Front 70

Levels of Health Care
- Continuing Care

Back 70

What level of Health care?

- a variety of health, personal, and social services provided over a prolonged period.
- Services are for persons who are disabled, who never were functionally independent, or who suffer a terminal disease.
- Nurses in this setting need to be creative in meeting the needs of clients, especially older adult clients, who need ongoing care

Front 71

6 Preventive and Primary Care Settings

Back 71

School health services
Occupational health services
Physicians offices
Clinics
Nursing centers/nurse managed clinics
Block and parish nursing

Front 72

6 Secondary and Tertiary Care Settings

Back 72

Hospitals/medical centers
Emergency departments
Medical units
Intensive care
Psychiatric facilities
Rural hospitals

Front 73

3 Restorative Care Settings

Back 73

Home health care
Rehabilitation centers
Extended care facilities

Front 74

5 Continuing Care Settings

Back 74

Agencies on aging
Nursing facilities
Assisted living
Adult day care centers
Hospice

Front 75

5 types of Vulnerable Populations

Back 75

Poor & Homeless
Abused (Psychological and Physical)
Substance Abusers
Severely mentally ill
Older adults/infants/children

Front 76

6 Competencies of Community-Based Nursing

Back 76

Case Manager
Collaborator
Educator
Counselor
Advocate
Change Agent

Front 77

4 Components of the Nursing Paradigm Theory model

Back 77

nursing
person
health
environment/situation

Front 78

Environment/situation component of the Nursing Paradigm Theory model

Back 78

What component of the Nursing Paradigm Theory model?

- all possible conditions affecting the client and the setting in which health care needs occur
- Continuous interaction b/t the client & setting
- can be (+) or (-) on person's level of health & health needs
- Ex. an adolescent girl w/Type 1 diabetes needs to adapt her treatment plan to physical activities of school, demands of a part-time job, and time of social events (prom).

Front 79

Nursing Theorist

- Florence Nightingale

Back 79

Which Nursing theorist?

- Initial model for nursing
- Environment was the focus of nursing care & nurses do not need to know all about the disease process
- Nursing was not limited to the administration of medicines and treatments but rather as oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition
- Her "descriptive theory" provides nurses w/a way to think about clients and their enviornments
- She taught that "vital observation… [was for] the sake of saving life and increasing health and comfort."

Front 80

Nursing Theorist

- Hildegard Peplau (1952)

Back 80

Which Nursing theorist?

- focuses on the individual, the nurse, and the interactive process. - result is the nurse-client relationship
- The client is an individual with a need, and nursing is an interpersonal and therapeutic process
- this nurse's theory is unique: the collaborative nurse-client relationship creates a "maturing force" through which interpersonal effectiveness meets the client's needs. When the client's original needs are resolved, new needs sometimes emerge.
- Phases of the nurse-client interpersonal relationship:
- Orientation, identification, explanation, and resolution

Front 81

Nursing Theorist

- Martha Rogers (1970)

Back 81

Which Nursing theorist?

- considers the individual (unitary human being) as an energy field coexisting within the universe
- The individual is a unified whole, continuously interacting with the environment, possessing personal integrity and manifesting characteristics that are more than the sum of the parts
- The unitary human being is a "four dimensional energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from the knowledge of parts."
- The four dimensions of this theory are:
(1) energy fields
(2) openness,
(3) pattern and organization, and
(4) dimensionality—aid in the development of principles related to human development.

Front 82

Nursing Theorist

- Leininger

Back 82

Which Nursing theorist?

- cultural care diversity and universality theory (1991)
- States that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing.
- Human caring varies among cultures in its expressions, processes, and patterns.
- Social structure factors, such as the client's religion, politics, culture, and traditions are significant forces affecting care and influencing the client's health and illness patterns.
- The goal is to provide the client with culturally specific nursing care.

Front 83

Nursing Theorist

- Sister Callista Roy

Back 83

Which Nursing theorist?

- adaptation theory (1980) - views the client as an adaptive system.
- The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness
- Individuals must adapt to the following demands:
- Meeting basic physiological needs
- Developing a positive self-concept
- Performing social roles
- Achieving a balance between dependence and independence
- The nurse determines what demands are causing problems for a client and assesses how well the client is adapting to them.

Front 84

Nursing Theorist

- Jean Watson

Back 84

Which Nursing theorist?

- Philosophy of transpersonal caring (1979) - defines the outcome of nursing activity in regard to the humanistic aspects of life
- Designed the model around the caring process, which requires the nurse to be knowledgeable about human behavior and human responses to actual or potential health problems.
- The nurse also needs to know individual needs, how to respond to others, and strengths and limitations of the client and family, as well as those of the nurse.

Front 85

6 Nursing Theorists

Back 85

Nightingale
Hildegard Peplau
Martha Rogers
Leininger
Sister Callista Roy
Jean Watson

Front 86

Beneficence
- ethics in nursing

Back 86

What ethical term is described?

- taking positive actions to help others
- Encourages the urge to do good for others
- Requires that the best interests of the client remain more important than self-interest
- Ex. a child asks for a pill to be crushed and mixed w/favorite food or drink even though they are able to swallow the pill. The nurse complies even if busy.

Front 87

Nonmaleficence
- ethics in nursing

Back 87

What ethical term is described?

- avoidance of harm or hurt
- Ex. bone marrow transplant procedure offers a chance at cure but the process involves some suffering
- Health-care providers consider the associated discomforts and take into consideration the suffering the disease causes and suffering the treatments could cause
- The commitment to provide least harmful interventions is illustrated by this term

Front 88

Justice
- ethics in nursing

Back 88

What ethical term is described?

- refers to fair distribution of resources
Ex. Liver transplants - making every effort to ensure fairness by ranking recipients according to need.

Front 89

Fidelity
- ethics in nursing

Back 89

What ethical term is described?

- agreement to keep promises
▪ Supports the reluctance to abandon clients, even when disagreement occurs about decisions that a client make
▪ Also includes an obligation to follow through with care offered to clients
▪ If you assess a client for pain and then offer a plan to manage the pain, this standard encourages you to monitor the client's response to the plan
- Includes revision of the plan as necessary to try to keep the promise to reduce pain

Front 90

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Back 90

in the Code of Ethics:

- a type of Federal legislation that mandates the confidential protection of clients' personal health information
- defines the rights and privileges of clients for protection of privacy w/out diminishing access to quality care.
- establishes fines for violations.
- Ex. you cannot copy or forward medical records without a client's consent.
- You cannot share health care information, including laboratory results, diagnosis, and prognosis, with others without specific client consent, unless the information is necessary in the course of providing care.
- When medical records are computerized, computer security measures such as special access codes for all authorized users and computer "firewalls" protect systems from unauthorized access

Front 91

Veracity in the Nursing Code of Ethics

Back 91

This term in the Code of Ethics reflects:

- conformity to truth
- Do not say things like: "this won't hurt" or "it will be alright" - always be as truthful as possible
- Everyone feels pain at different degrees, and you can't predict what will happen

Front 92

Patient Advocacy in the Nursing Code of Ethics

Back 92

a nursing action in the Code of Ethics:

- support of a cause such as: health, safety, and rights of the client
- You safeguard the client's right to physical and auditory privacy.
- Follow institutional policies and procedures to report any occurrence of incompetent, unethical, illegal, or impaired practice by any health care member that has the potential to affect client health or safety.

Front 93

7 steps for Processing an Ethical Dilemma

Back 93

1. Is this an ethical dilemma?
2. Gather Data - from patient, physicians, patients family
3. Examine your own values- but always know that it is the patient's final decision and you should not push yours on them
4. Verbalize the problem
5. Consider possible actions
6. Negotiate the outcome - "if we do this… this could happen"
7. Evaluate the action - response of the patient

Front 94

What are Values?

Back 94

- A personal belief about the worth of a given idea
- Attitude, custom, or object that sets standards that influence behavior
- Clarification
* Choosing ones own beliefs and behaviors
* Prizing ones beliefs and behaviors
* Acting on ones beliefs

Front 95

How are Values formed? 4 steps

Back 95

1. Begins in childhood - shaped by experiences w/in the family unit
- Variations in child rearing result in variations in values and behaviors as the children grow up.
2. Schools, governments, religious traditions and other social institutions also play a role in the formation of values, reinforcing or sometimes challenging family values
- Depends on the nature of the institution.
- Over time, an individual acquires values by choosing some that the community holds strongly and perhaps discarding or transforming others
3. Individual experiences - the unpredictable twists and turns that occur in life, influence value formation.
- A person who suffers great loss early in life sometimes grows to value things differently than someone whose life has been free of suffering.

Front 96

Where are the standards of care for nursing defined? (list 4)

Back 96

Nurse Practice Acts
Federal and State laws
Professional Organizations
Institutional Policies and Procedures

Front 97

How the Nurse Practice Acts define standards of care

Back 97

What is described by this?

- this national policy has Nursing standards of care are set out in every state,
- federal and state laws regulating hospitals and other health care institutions,
- by professional and specialty nursing organizations
- by the policies and procedures established by the health care facility where nurses work
- Est. educational requirements for nurses, distinguish between nursing and medical practice, and generally define the scope of nursing practice

Front 98

How the The Joint Commission (TJC) define standards of care

Back 98

- this organization requires that accredited hospitals have written nursing policies and procedures.
- These internal standards of care are quite specific and should be accessible on all nursing units.

Front 99

How the American Nurses Association (ANA) define standards of care

Back 99

- this organization developed standards for nursing practice, policy statements, and similar resolutions

Front 100

How the American with Disabilities Act (ADA) define standards of care

Back 100

- This Act protects the rights of disabled people. It is also the most extensive law on how employers must treat health care workers and clients infected with the human immunodeficiency virus (HIV).
- this has regulations that protect the privacy of infected people by giving individuals the opportunity to decide whether to disclose their disability However, several cases have held that the health care provider has to disclose the fact that he or she has HIV.

Front 101

How the EMTALA (Emergency Medical Treatment and Labor Act) define standards of care

Back 101

- This act provides that when a client comes to the emergency department or the hospital, an appropriate medical screening occurs within the hospital's capacity.
- If an emergency condition exists, or if a woman is pregnant and in labor, the hospital is not to discharge or transfer the client until the condition stabilizes,
- Exceptions to this include if the client requests transfer or discharge in writing after receiving information on the benefits and risks or if a physician or health care provider certifies that the benefits of transfer outweigh the risks.

Front 102

How the Mental Health Parity Act define standards of care

Back 102

- forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits.
- Admission of a client to a psychiatric unit occurs involuntarily or on a voluntary basis.
- Potentially suicidal clients are admitted to psychiatric units. If the client's history and medical records indicate suicidal tendencies, the client must be kept under supervision

Front 103

Advance Directives
- Durable Powers of attorney for health care

Back 103

- legal document that designates a person or persons of one's choosing to make health care decisions when the client is no longer able to make decisions on his or her own behalf.
- This agent makes health treatment decisions based on the client's wishes
- ex. DNR order - "do not resuscitate" or "no code." should be written, not verbal.

Front 104

Advance Directives
- living wills

Back 104

- written documents that direct treatment in accordance with a client's wishes in the event of a terminal illness or condition.
- With this legal document the client is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state.
- Often difficult to interpret and not clinically specific in unforeseen circumstances.
- Each state has its own requirements for executing them.

Front 105

Uniform Anatomical Gift Act

Back 105

- An individual who is at least 18 years of age has the right to make an organ donation
- Donors need to make the gift in writing with their signature.

Front 106

Administrative Law (regulatory law)

Back 106

- reflects decisions made by administrative bodies such as State Boards of Nursing when they pass rules and regulations.
- Ex. is the duty to report incompetent or unethical nursing conduct to the State Board of Nursing.

Front 107

Standards of Care

Back 107

- legal guidelines for nursing practice and provide the minimum acceptable nursing care.
- Reflect values and priorities of the profession

Front 108

State Boards of Nursing

Back 108

- define the practice of nursing more specifically.
- With the increased use of assistive personnel they have defined the registered nurse's responsibilities specifically and developed position statements and guidelines to help licensed nurses delegate safely
- Ex. They develop rules regarding intravenous therapy.
- All nurses are responsible for knowing the rules and regulations enacted by this and other regulatory administrative bodies

Front 109

Licensure

Back 109

- this permits persons to offer special skills to the public, but it also provides legal guidelines for protection of the public,
- Requirements: vary among states, but most states have minimum education requirements and require an examination to receive this
- All states use the National Council Licensure Examinations for registered nurse and licensed practical nurse examinations.

Front 110

an example of a situation in which a nurse may be found negligent.

Back 110

- hanging the wrong intravenous solution for a client
- allowing a nursing assistant to administer a medication

Front 111

The Joint Commission (TJC) -
Specific guidelines regarding use of restraints

Back 111

1. only to ensure the physical safety of the resident or other residents
2. when less restrictive interventions are not successful
3. Only on the written order of a physician or health care provider
- Written orders include a specific episode with start and end times.
- Dr. cannot call-in a restraining order - they must see the patient & assess before writing the order

Front 112

Assault example

Back 112

- use of words
- a nurse to threaten to give a client an injection or to threaten to restrain a client for an x-ray procedure when the client has refused consent.

Front 113

Battery examples

Back 113

- if the nurse actually gives an injection to an unconsenting patient, after threatening to without the client's consent,
- If the health care provider performs a procedure that exceeds the client's consent
- If the client gives consent for an appendectomy and the health care provider performs a tonsillectomy

Front 114

False imprisonment example

Back 114

this occurs when nurses restrain a client in a bounded area to keep the person from freedom without a doctor's order

Front 115

libel example

Back 115

- Charting false entries
- inclusion of false or injurious information on the client's medical record
- written defamation

Front 116

Slander example

Back 116

- if a nurse tells people erroneously that a client has venereal disease and the disclosure affects the client's business
- spoken defamation

Front 117

4 types of Invasion of privacy

Back 117

1. Appropriation of name or likeness
2. Publication of private or embarrassing facts
3. Publicity placing one in a false light in the public's eye
4. Intrusion on seclusion

Front 118

What is the nurse role in informed consent?

Back 118

- The nurse's signature witnessing the consent means that the client voluntarily gave consent. The nurse does not have to prove that the patient was anything but willing to sign
- the client's signature is authentic,
- that the client appears to be competent to give consent
- Nurses must ask the clients if they understand the procedure for which they are giving consent. It is the physician's responsibility to explain medical procedures patient is consenting to
- Nursing students Cannot be and should not be responsible for or asked to witness consent forms due to the legal nature of the document.

Front 119

Risk Management system

Back 119

- A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs

Front 120

Risk management steps (4)

Back 120

1. identifying possible risks
2. analyzing them
3. acting to reduce the risks
4. evaluating the steps taken.
5. document an incident report

Front 121

5 levels of Communication

Back 121

Intrapersonal
Interpersonal
Transpersonal
Small-group
Public

Front 122

Denotative meaning

Back 122

– definition: use a common language
- Ex. baseball has the same meaning for everyone who speaks English

Front 123

Connotative meaning

Back 123

- shades of interpretation
– influenced by the thoughts, feelings, or ideas people have about the word.
- Carefully select words, avoiding easily misinterpreted words, especially when explaining a client’s medical condition or therapy
- Ex. medical abbreviations can be interpreted wrong.
* SOB = short of breath
* BS - bowel sounds

Front 124

3 phases of a Nurse-Patient Relationship

Back 124

1) Orientation Phase
2) Working Phase
3) Termination Phase

Front 125

Orientation Phase description of the Nurse-Patient Relationship

Back 125

- When the nurse and client meet and get to l- Set the tone for the relationship by adopting a warm, empathetic, caring manner
- Begin to make inferences and form judgments about client messages and behaviors
- Assess the client’s health status
- Prioritize the client’s problems, and identify the client’s goals
- Form contracts with the client that specify who will do what
- Let the client know when to expect the relationship to be terminated

Front 126

Working Phase description of the Nurse-Patient Relationship

Back 126

- When the nurse and client work together to solve problems and accomplish goals:
- Use therapeutic communication skills to facilitate successful interactions
- Use appropriate self-disclosure and confrontation

Front 127

Termination Phase description of the Nurse-Patient Relationship

Back 127

- During the ending of the relationship:
- Remind the client that termination is near
- Evaluate goal achievement with the client
- Separate from the client by relinquishing responsibility for his or her care
- Achieve a smooth transition for the client to other caregivers as needed

Front 128

nonverbal skills facilitate attentive listening
S O L E R

Back 128

S—Sit facing the client
O—Observe an open posture
L—Lean toward the client.
E—Establish and maintain intermittent eye contact.
R—Relax. It is important to communicate a sense of being relaxed and comfortable with the client.

Front 129

NON-Therapeutic Communication Techniques

Back 129

Asking Personal Questions - not relevent to the situation
Giving Personal Opinions
Changing the subject - implies avoidance or inattention to patient
Automatic Responses - can reflect poor nursing judgement
False Reassurance - reassurance not supported by facts or based in reality will do more harm than good.
Sympathy - Not as therapeutic as empathy.
Asking for explanations - "Why" questions can make patient feel defensive
Approval or disapproval
Defensive Responses - Becoming defensive in the face of criticism implies the other person has no right to an opinion.
Passive or aggressive responses
Arguing - implying that the other person is lying, misinformed or uneducated. Do not Argue!

Front 130

8 characteristics of Critical Thinking

Back 130

1. An active process
2. Organized
3. Using cognitive processes to carefully examine one’s own thinking
4. *Recognizing an issue – client problem
5. *Analyzing Information – clinical data about the client
6. *Evaluating Information – reviewing assumptions and evidence
7. *Making Conclusions
8. Reflection – looking back
* Ask yourself: did it work? Did I do it right?

Front 131

3 Levels of the Critical Thinking Model

Back 131

1. Basic Critical Thinking Level
2. Complex Critical Thinking Level
3. Commitment Critical Thinking Level

Front 132

Basic Critical Thinking Level description

Back 132

- Concrete thinking based on a set of rules or principles, not from own experience
- Right and wrong answers – because you do not have enough experience to anticipate how to individualize procedures
- Basic critical thinkers accepts diverse opinions from instructors and staff nurses
- Inexperience, weak competencies & inflexible attitudes restrict next step.

Front 133

Complex Critical Thinking Level description

Back 133

- Analyze and examine more independently – separating yourself from authorities
- Realize there may be more than one right answer – learning that there are alternatives and conflicting solutions do exits
- Weigh the benefits & risks of following procedures word for word or adjusting to meet specific needs as long as still abiding the procedures & rules
- Thinking is complex – more creative and innovative
- Willing to consider alternatives when complex situations develop

Front 134

Commitment Critical Thinking Level description

Back 134

- Anticipates the need to make choices without the assistance from others (autonomy)
- Accountable for decisions
- Choose an action based on your knowledge, and take responsibility for those actions
* Not taking dangerous risks

Front 135

Inference

Back 135

- a term that describes judgment or interpretation of cues from a patient
- Ex. Pain is severe, Pain limits client’s ability to move normally

Front 136

Data Validation description

Back 136

describes what process?

– putting pieces together that are related – to avoid making incorrect inferences
- The comparison of data with another source to determine data accuracy
- opens the door for gathering more assessment data because it involves clarifying vague or unclear data.

Front 137

Analysis & Interpretation description

Back 137

- organizing the information into meaningful and usable clusters, keeping in mind your client’s response to illness.
- Focus attention on client functions needing support or assistance for recovery.

Front 138

What is a Nursing Diagnosis?

Back 138

- a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. -
- What nurses can do something about
- describes actual or potential problems that a nurse is LICENSED & COMPETENT to treat.
- consists of Collaborative problems – what nurses monitor to detect changes
- An actual or potential physiological complication that nurses monitor

Front 139

5 STANDARDS of NANDA-I

Back 139

Provides common language
Allows efficient communication
Distinguishes nurses
Focuses nursing practice
Encourages nursing knowledge

Front 140

NANDA-I Steps (5)

Back 140

1. Look at data, cluster around themes
2. Analyze objective/subjective data
3. Critically think about diagnosis
4. Identify, test, re-evaluate
5. Finalize nursing diagnosis

Front 141

4 types of Nursing Diagnoses

Back 141

Actual Diagnosis
Risk Diagnosis
Wellness Diagnosis
Health Promotion Diagnosis

Front 142

NANDA-I

- Two Part Diagnosis

Back 142

1. Diagnostic label – the name of the nursing diagnosis
- Ex. Impaired physical mobility
- Impaired - is used to describe the nature or change in mobility that best describes the client’s response.

2. Related Factors - a condition or etiology identified from the client’s assessment data.
- the related factor related to lack of exposure to instruction
- ex. related to pressure on spinal nerves – always the related to the nursing domain practice & responds to nursing intervention

Front 143

Planning step of the Nursing Process

Back 143

- is a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and prepares nursing interventions.
- Requires critical thinking, applied through deliberate decision making and problem solving.
- Is to set priorities for a client.
- dynamic - will change as you meet the client’s needs or identify new needs

Front 144

Planning stage - determining High Priority

Back 144

- Diagnoses that if untreated would cause harm to patient or others
- For example: nursing diagnoses that drive the priorities of safety, adequate oxygenation, and adequate circulation.
- Impaired Gas Exchange
- Decreased Cardiac Output
- Risk for Other-directed Violence
- Acute Pain or Acute Anxiety – Are they harming themselves? – this could lead to many problems

Front 145

Planning stage - determining Intermediate Priority

Back 145

- Involves non-emergent, non-life threatening needs of the patient.
- For example:
- Deficient Knowledge
- Bowel Incontinence
- Sleep pattern disturbance
- Potential nursing diagnoses (at risk for…)

Front 146

Planning stage - determining Low Priority

Back 146

- still important but not ranked high
- May not be specific to illness, but usually affect long term goals and wellness
- For example:
- Impaired physical mobility – can move to a higher priority at any point
- Social isolation
- Altered nutrition: more than body requirements

Front 147

3 phases of the Planning stage

Back 147

1. Initial – involves development of preliminary care following admission assessment and initial selection of nursing diagnoses.
- Important in addressing nursing diagnoses and collaborative problems to hasten problem resolution.

2. Ongoing – involves continuous updating of the client’s care.
- As the client’s condition changes, you assess new information about the client and evaluate the client’s status.
- you sometimes revise the initial plan of care and further individualize your interventions

3. discharge – the last phase
- involves the critical anticipation and preparation for meeting the client’s needs after discharge.

Front 148

Establishing Goals

Back 148

- an aim, intent or end. It is specific and measurable, reflects a patient’s highest level of wellness & independence
- Broad statement that describes the desired change in a client’s condition or behavior.
- diagnoses = acute pain related to pressure on spinal nerves.
- The care target would include “Client achieves improved pain control before surgery.”

Front 149

What is a Goal?

Back 149

- Provide a clear direction for selecting and using nursing interventions .
- Provide a focus for evaluation
* realistic
* contain ONE behavior
* contains a Time frame
- Short vs. long term

Front 150

Expected Outcomes - characteristics

Back 150

- Different than goals.
- specific measurable change in patient’s status.
- Provides focus for nursing care.
- Usually multiple
- In our pain example:
- Patient’s level of comfort will improve after surgery. As Evidenced By (AEB):
- Patient will state pain as 4/10
- Patient will reposition in bed without pain.

Front 151

7 Guidelines for Goals & Outcomes

Back 151

Patient centered
Singular goal or outcome
Observable
Measurable
Time-limited
Mutual factors
Realistic

Front 152

3 Types of Interventions

Back 152

1. Independent Nursing Interventions
2. Dependent Nursing Interventions
3. Collaborative Interventions - (interdependent nursing interventions)

Front 153

2 types of Nursing Interventions

Back 153

1. Direct Care Interventions
- Care provided within interaction with patients.

2. Indirect Care Interventions
- performed away from the patient but on behalf of patients or groups of patients.

Front 154

Evaluation Step of the Nursing Process

Back 154

- crucial to determine whether, after application of the nursing process, the client’s condition or well-being improves.
- determine if you met expected outcomes, not if nursing interventions were completed
- expected outcomes are the standards against which the nurse judges if goals have been met and if care is successful.

Front 155

5 Elements of a Nursing Evaluation
(in sequential order)

Back 155

1) ID evaluative criteria
2) Collect data to determine whether criteria or standards are met
3) Interpret & summarize findings
4) Document findings and clinical judgment
5) Terminate or revise care plan

Front 156

What to consider when developing a Care Plan (4)

Back 156

- What is the intervention?
- When should each intervention be implemented?
- How should the intervention be performed for this specific client?
- Who should be involved in each aspect of intervention?

Front 157

Why is it important to have a Written Plan of Care

Back 157

- to decrease the risk of incomplete, incorrect, or inaccurate care – when another healthcare provider takes over shift and patients – they can see your thought process and back-track any errors
- to direct clinical nursing care
- for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation.

Front 158

What is a Nursing Care Plan?

Back 158

- lists specific nursing interventions needed to achieve the goals of the client
- Include expected outcome criteria used in the evaluation of care,
- it is considered The blueprint for nursing action.
- provides direction for implementation of the plan and a framework for evaluation of the client’s response to nursing actions.

Front 159

Cues

Back 159

- this term refers to the information that you obtain through use of the senses
- Ex. Patient Grimaces when bends over, Has limited range of motion in back, Sits to obtain relief, Reports pain extends down right leg

Front 160

Vital Signs: Acceptable Ranges for Adults
- Temperature
- Pulse
- Respiration
- Blood pressure

Back 160

1. Temperature Range: 36° to 38° C (96.8° to 100.4° F)
- Average oral/tympanic: 37° C (98.6° F)
- Average rectal: 37.5° C (99.5° F)
- Average axillary: 36.5° C {97.7 F)

2. Pulse
- 60 to 100 beats per minute

3. Respirations
- 12 to 20 breaths per minute

4. Blood Pressure
- Average: <120/80
- Pulse pressure: 30 to 50 mm Hg

Front 161

Acceptable V/S ranges for infant
- T
- P
- RR

Back 161

1. Temperature: 97.5 – 99
- updated standard – if an infant’s temp drops below 97.5 the nurse is liable for brain damage caused by the low temp.

2. Pulse: 120 – 160 beats per min.

3. Respiration Rate: 30 – 50 breaths per minute

Front 162

Heat Production

Back 162

- produced by the body as a by-product of metabolism, which is the chemical reaction in all body cells
- As metabolism increases, additional this is produced
- occurs during rest, voluntary movements, involuntary shivering
- Also by non-shivering thermo-genesis – occurs primarily in neonates. Because neonates cannot shiver, a limited amount of vascular brown tissue, present at birth, is metabolized for this

Front 163

Heat Loss thru

- Radiation

Back 163

- this term refers to the transfer of heat from the surface of one object to the surface of another without direct contact between the two.
- Up to 85% of the human body’s surface area transmits heat to the environment in this way
- if the environment is warmer than the skin, the body absorbs heat by this

Front 164

Heat Loss thru

- Conduction

Back 164

- the transfer of heat from one object to another with direct contact.
- Solids, liquids, and gases conduct heat through contact.
- When the warm skin touches a cooler object, heat is lost.
- normally accounts for a small amount of heat loss.

Front 165

Heat Loss thru

- Convection

Back 165

the transfer of heat away by air movement.
- A fan promotes heat loss through this mechanism
- increases when moistened skin comes into contact with slightly moving air.

Front 166

Heat Loss thru

- evaporation

Back 166

- the transfer of heat energy when a liquid is changed to a gas.
- About 600 to 900 mL a day evaporates from the skin and lungs, resulting in water and heat loss.

Front 167

7 Factors that affect pulse rate

Back 167

Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural changes
Pulmonary conditions

Front 168

Characteristics of Radial Pulse

- Rate

Back 168

- count pulse for 1 minute
- acceptable range for Adult: 60-100 (beats/min)
- acceptable range for Infant: 120-160 (beats/min)
- Two common abnormalities for Adult rates:
1) Tachycardia – fast – greater than 100
* Check for other symptoms, may indicate that something is wrong
2) Bradycardia – slow – less than 60

Front 169

Characteristics of Radial Pulse

- Rhythm

Back 169

(same for apical)
- Regular - count for 30 seconds (and mult. # by 2)
- If not regular, count for 1 minute
- abnormal:
- Dysrhythmia – An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm
- described as regularly irregular or irregularly irregular.
- assess the regularity of its occurrence and auscultate the apical rate
- **Document if irregular**

Front 170

Characteristics of Radial Pulse

- Strength (quality)

Back 170

- Strong – can feel the pulse very easily
- Weak – can’t find the pulse very well
- Bounding – can obviously see where the pulse is
- Thready – can barely feel it – feels like a string

Front 171

Characteristics of Radial Pulse

- equality

Back 171

– comparing the left & right side (not on apical pulse)
- Situations for checking this is if patient had surgery on one side of the body, suspecting a clot, or if there is peripheral vascular disease

Front 172

Two characteristics of an:

- Apical Pulse

Back 172

- assess rate and rhythm only
- do not need to assess for strength because you are measuring the source of the pulse (the heart)
- do not need to assess for equality b/c there is only one heart. Nothing else to compare it to. (unlike the radial pulse (there are 2 arms.. 2 radial pulses)

Front 173

What is a pulse deficit?

Back 173

- The term for the difference between the apical and radial pulse rates equals this
- an apical rate of 92 with a radial rate of 78 leaves a discrepancy of 14 beats
- An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site
- assess radial and apical rates simultaneously and then compare rates
- often associated with abnormal rhythms.

Front 174

Difference between apical and radial pulses

Back 174

- An apical pulse will never be lower than the radial pulse.
- Apical is Auscultated with stethoscope
- when auscultating the Apical Listen for two sounds – LUB / DUB

Front 175

8 Factors affecting Respiratory Rate

Back 175

Exercise
Acute Pain
Anxiety
Smoking
Body Position
Medications
Neurological Injury
Hemoglobin Function

Front 176

Characteristic of Respirations

- Rate

Back 176

- Newborn 30-60 breaths/min
- Infant (6 months) 30-50 breaths/min
- Toddler (2 years) 25-32 breaths/min
- Child 20-30 breaths/min
- Adolescent 16-19 breaths/min
- Adult 12-20 breaths/min

- Bradypnea - Rate is regular but abnormally slow (less than 12 breaths per minute).

Tachypnea – Rate is regular but abnormally rapid (greater than 20 breaths per minute).

Front 177

Characteristic of Respirations

- Depth

Back 177

- normal
- shallow - from upper lungs – only a small quantity of air passes thru lungs & ventilary movement is difficult to see
- deep - full lung expansion & full exhalation
* uses ancillary muscles – from asthma or emphyzema

Front 178

Characteristic of Respirations

- Rhythm

Back 178

– regular or irregular
- one breath in & out = one respiration cycle
- Healthy men and children usually demonstrate diaphragmatic breathing.
- Women tend to use thoracic muscles to breathe
- The young child often breathes slowly for a few seconds and then suddenly breathes more rapidly
- Infants tend to breathe less regularly.

Front 179

Blood Pressure

- Systolic

Back 179

- top number 120/80
- peak of maximum pressure when ejection occurs
- hearts contraction forces blood under high pressure into the aorta
- when checking for BP using sphygmomanometer – this is the FIRST pulse sound you hear
- **document

Front 180

Blood Pressure

- Diastolic

Back 180

– the bottom number 120/80
- When the ventricles relax, the blood remaining in the arteries exerts a minimum pressure
- The minimal pressure exerted against the arterial walls at all times
- when checking for BP using sphygmomanometer – this is the 2nd sound you listen for in an adult – document the point when you last heard the pulse sound just as its disappearing
- When listening to a child, you listen for a total of 3 sounds. The 2nd sound is when the pulse first sounds as if it is muffled.
- Document

Front 181

Blood Pressure

- Pulse pressure

Back 181

- The difference between systolic and diastolic pressure
- Can indicate vascular problems
- Ex. For a blood pressure of 120/80, the difference between systolic & diastolic is 40.

Front 182

10 Factors that affect Blood Pressure

Back 182

Age
Stress
Ethnicity
Gender
Diurnal
Medications
Exercise
Hypertension
Hypotension
Orthostatic Hypotension

Front 183

A factor influencing Blood Pressure:

- Hypertension

Back 183

– most common alteration in blood pressure - often asymptomatic.
- systolic & diastolic bp is greater than 140/90
- Associated with the thickening and loss of elasticity in the arterial walls.
- Peripheral vascular resistance increases within thick and inelastic vessels.
- Is greater in diabetic clients, older adults, and African Americans.
- It is a major factor underlying deaths from strokes and is a contributing factor to myocardial infarctions (heart attacks)

Front 184

A factor influencing Blood Pressure:

- Hypotension

Back 184

– is present when the systolic blood pressure falls to 90 mm Hg or below.
- For the majority of people it is an abnormal finding associated with illness.
- Occurs because of the dilation of the arteries in the vascular bed, the loss of a substantial amount of blood volume (e.g., hemorrhage), or the failure of the heart muscle to pump adequately (e.g., myocardial infarction).
- If it is associated with pallor, skin mottling, clamminess, confusion, increased heart rate, or decreased urine output it is life threatening and is reported to a health care provider immediately.

Front 185

A factor influencing Blood Pressure:

- Orthostatic Hypotension

Back 185

- , occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position
- Drop of 20 – 30 points & symptoms
- When a healthy individual changes from a lying, to sitting, to standing position, the peripheral blood vessels in the legs constrict which prevents the pooling of blood in the legs due to gravity.
- Assess during vital sign measurements by obtaining blood pressure and pulse with the client supine, sitting, and standing
- Obtain blood pressure readings 1 to 3 minutes after the client changes position.
- In most cases it is detected within a minute of standing.
- record the client’s position in addition to the blood pressure measurement; for example:
** ex. 140/80 mm Hg supine, 132/72 mm Hg sitting, 108/60 mm Hg standing.

Front 186

Common errors in B/P assessment

- false high

Back 186

- Bladder or cuff too wide
- Arm below heart level
- Arm not supported

Hint 186

usually if the bp cuff is too big then the reading will be read incorrectly. so the systolic/diastolic numbers will be higher than they would normally be if using the right size cuff.

Front 187

Common errors in B/P assessment

- false low

Back 187

- Bladder or cuff too narrow or too short
- Cuff wrapped too loosely or unevenly
- Arm above heart level

Front 188

Five basic skills used in physical assessment

Back 188

Inspection
Palpation
Percussion (mainly done by a NP)
Auscultation
Olfaction

Front 189

Type of behavior from a client

- Affect

Back 189

- this term refers to a person’s feelings as they appear to Others.
- Ppl usually express mood or emotional state verbally and nonverbally
- Note if verbal expressions match nonverbal behavior are they using a monotone voice?

Front 190

Eight Aspects of Skin Assessment

Back 190

Color
Moisture
Temperature
Texture
Turgor
Vascularity
Edema
Lesions

Front 191

What to look for when assessing for Lesions

Back 191

- are primary (occurring as initial spontaneous manifestations of a pathological process), such as an insect bite, or secondary (residing from later formation or trauma to a primary wound), such as a pressure ulcer.
a) inspect it for color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized).
b) any exudates? Check for color, odor, amount, and consistency.
c) Measure the size by using a small, clear. Flexible ruler divided in centimeters. Measure in height, width, and depth
d) determines mobility, contour (flat, raised or depressed), and consistency (soft or indurated).
- Certain types present a characteristic pattern.

Front 192

Basic Neurological Check

Back 192

- Level of Consciousness
- Pupils
- Hand Grips
- Follows simple instructions

Front 193

Basic Neurological Check

- Level of Consciousness

Back 193

– exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli.
- Consists of 4 spheres: do not ask close-ended questions.
1) Person – ask: Would you please tell me your full name?

2) Place – “please tell me where you are.” Or “What town are we in?

3) Time – “Can you tell me what (season, month, year) it is?” – know that if the season is changing or there are unseasonable conditions you may get varied answers. Also the same if the new year just passed or a new month just started

4) Situation – “What were the circumstances that brought you to the hospital?”

Front 194

Basic Neurological Check

- Pupillary Checks

Back 194

1) Size
- pinpoint (constricted) – caused by Inflammation of the iris or use of drugs (e.g., pilocarpine, morphine, or cocaine)
* a common sign of opioid intoxication
- dilated could result from glaucoma, trauma, neurological disorders, eye medications (e.g., atropine), or withdrawal from opioids.

2) Shape – round
- May see some odd-shaped pupils, they are indicative of diseases that the patient has

3) Color – black
- cloudy looking indicates cataracts

4) Equality – equal in size (3-7 mm diameter) with iris’s clearly visible

5) Response to light

6) Direct & Consensual - § A directly illuminated pupil constricts, and the opposite pupil constricts consensually (at the same time)

Front 195

Basic Neurological Check

- Pupillary Checks & Response to light

Back 195

- Test reflexes (to light and accommodation) in a dimly lit room. While the client looks straight ahead, bring a penlight from the side of the client’s face, directing the light onto the pupil
- Observe the quickness and equality of the reflex. Repeat the examination for the opposite eye.
- To test for accommodation, ask the client to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 10 cm (4 inches) from the bridge of the client’s nose.
- The pupils normally converge and accommodate by constricting when looking at close objects.
- The pupillary responses are equal.
- If assessment of pupillary reaction is normal in all tests, record the abbreviation
PERRLA (pupils equal, round, reactive to light, and accommodation).

Front 196

Basic Neurological Check

- Hand Grips

Back 196

- Cross your hands in front of your patient so that your right hand (finger) is available to their right hand (the same w/the left)
- Have them grip one finger on each of your hands
- Determine equality of strength in grips

Front 197

Lungs

- what to do during physical assessment

Back 197

1) Inspect – are both sides rising and falling

2) Auscultate - compare lung sounds in one region on one side of the body with sounds in the same region on the opposite of the body.

Front 198

physical assessment of the lungs

- auscultating

Back 198

– systematic pattern
- Go from 1) right to left, down, 2) left to right, down, 3) right to left, 4) down, left to right (which side to start on, right or left, is not important)
1) Anterior – on the chest – location to start is along midclavicular line above the clavicle
* Location of apex of the lung
- Give special attention to the lower lobes, where mucus secretions commonly gather.
- Listen for bronchovesicular and vesicular sounds above and below the clavicles and along the Lung periphery
- bronchial sounds, which are loud, high pitched, and hollow sounding, with expiration lasting longer than inspiration (3:2 ratio). You normally hear this sound over the trachea.

2) Posterior – dorsal side thorax - You normally hear bronchovesicular and vesicular sounds over the posterior thorax
3) Lateral – sides of the chest – the breath sounds you hear are vesicular.

Front 199

Adventitious Lung sounds

Back 199

– abnormal sounds often occur superimposed over normal sounds.
* result from air passing through moisture, mucus, or narrowed airways.
* Also result from alveoli suddenly reinflating or from an inflammation between the pleural linings of the lung.
- types:
1) Crackles
2) Rhonchi
3) Wheezes

Front 200

Abdominal Assessment

- what 3 Nursing skills used?

Back 200

1) Inspection - Always do this first before touching patient!!!

2) Auscultation - Absent sounds indicate a lack of peristalsis, possibly due to late-stage bowel obstruction, paralytic ileus, or peritonitis.

3) Palpation – feeling for abnormalities

Front 201

What to do during an Abdominal Assessment

Back 201

1) Inspection – looking at color, scars, lesions, bruises, bulging, distention/swelling, pulsing, contour

2) Auscultation – umbilicus is the midpoint, divide abdomen vertically & horizontally into 4 quadrants
- Upper left, upper right, lower right, lower left quadrants – listen in this order, it approximates direction of peristalsis
- **the book says to listen to each quadrant for a 5 minutes each for bowels sounds (which indicate peristalsis)
- In reality, it takes too long, inspect all 4 quadrants for a total of 5 minutes.
** If one quadrant (or more) is missing sounds, then you listen to those quadrants for a total of 5 minutes before acting. (call dr)
- Be sure that the stethoscope is not touching clothing (or anything)
- If a person has just had surgery, bowel sounds must be heard BEFORE the patient can eat

3) Palpation - Be sure to palpate above, across and below the umbilicus

Front 202

Palpating the pedis pulse

Back 202

- Located on the dorsal side of the foot
- The artery runs along the top of the foot in line with the groove between the extensor tendons of the great toe and first toe
- place the fingertips between the first and second toes and slowly move up the dorsum of the foot.
- sometimes congenitally absent
- when palpating, hold fingers very lightly over area of pulse, too much pressure can prevent feeling the pulse.

Front 203

Assessing for Pitting Edema

Back 203

- Depth in mm after you press fingers in area of edema for 5 seconds
- Patient has edema – soft or hard
- indention indicates soft edema and how deep (in mm) when pressed on
- Fingerprints can be pressed in just like pushing in on soft butter
- Need to document where it is located, how far it extends, how much of that area it covers
- Ex. starts on the foot and extends up the calf and over the knee

Front 204

5 Other types of assessment data that needs to taken into consideration

Back 204

1) What tubes are connected to your patient and where are they going?
- Name them: ex. gastric feeding tube, urinary output, drainage bags
2) What is going in?
- Describe: what type of iv’s, enteric feeding of what?
3) What is coming out?
- Describe: urine? (document mL excreted); drainage? Colostomy?
4) What is your patient’s Range of Motion (ROM)? limited movement?
5) Are they ambulatory? Do they have a wheelchair, walker, cane?

Front 205

6 Purposes of Health Care Record - AS THEY APPLY TO THE PATIENT ONLY

Back 205

Communication
Legal Documentation
Financial Billing
Education
Research
Auditing/Monitoring

Front 206

5 Characteristics of Documentation & Reporting

Back 206

Factual
Accurate
Complete
Current
Organized

Front 207

What is the purpose & importance of Patient Education?

Back 207

- Purpose - to assist an individual, family or community in achieving optimal health
- Importance – to ensure good patient outcomes, promote health, prevent illness, ethical responsibility.
- Must have a plan, expectations, goals, & outcomes
- Have physical & knowledge base

Front 208

3 Domains of Learning

Back 208

Cognitive (learning) Domain
Affective (learning) Domain
Psychomotor (learning) Domain

Front 209

Cognitive (learning) Domain

Back 209

what learning domain?
– thinking – ­­­­­­knowledge/comprehension
- Can they synthesize info, how easy do they learn, can they breakdown info & organize it better, do they understand the importance of it?
- Includes: Knowledge Comprehension, Application, Analysis Synthesis, Evaluation

Front 210

Affective (learning) Domain

Back 210

what learning domain?
– expression of feelings and acceptance of attitudes, opinions, or values.
- Touchy-feely – attitudes, opinions, values
- What is their value of the things that they should or need to do to improve? Is it important to them?
- This can be indicative of problems teaching them.
- The simplest behavior in the hierarchy is receiving, and the most complex is characterizing

Front 211

Psychomotor (learning) Domain

Back 211

What learning domain?
- involves acquiring skills that require the integration of mental and muscular activity, such as the ability to walk or to use an eating utensil
- Can they read/use a syringe? Can they use a walker when they get to a ledge?

Front 212

3 Basic Learning Principles of Patients

Back 212

Motivation to Learn
Ability to Learn
Learning Environment

Front 213

Teaching Methods Based on Client’s Developmental Capacity

- Adolescent

Back 213

- Help them learn about feelings and need for self-expression.
- Use teaching as collaborative activity.
- Allow adolescents to make decisions about health and health promotion (safety, sex education, substance abuse).
- Use problem solving to help adolescents make choices.

Front 214

Teaching Methods Based on Client’s Developmental Capacity

- Young or Middle Adult

Back 214

- Encourage participation in teaching plan by setting mutual goals.
- Encourage independent learning.
- Offer information so that adult understands effects of health problem.

Front 215

Teaching Methods Based on Client’s Developmental Capacity

- Older Adult

Back 215

- Teach when client is alert and rested.
- Involve adult in discussion or activity.
- Focus on wellness and the person’s Strength.
- Use approaches that enhance sensorially Impaired client’s reception of stimuli
- Keep teaching sessions short.

Front 216

Examples of nursing diagnoses that indicate a need for education

Back 216

- Ineffective health maintenance
- Health-seeking behaviors
- Impaired home maintenance
- Ineffective therapeutic regimen management
- Ineffective community therapeutic regimen management
- Ineffective family therapeutic regimen management
- Noncompliance

Front 217

5 Teaching approaches during Implementation of Patient Education

Back 217

Telling
Selling
Participating
Entrusting
Reinforcing

Front 218

7 Instructional Methods during Implementation of Patient Education

Back 218

One on One
Group Instruction
Preparatory Instruction
Demonstration
Analogies
Role Playing
Simulation

Front 219

Teaching approaches:

- Participating

Back 219

- the nurse and client set objectives and become involved in the learning process together.
- client helps decide content, and the nurse guides and counsels the client with pertinent information.
- opportunity for discussion, feedback, mutual goal, and revision of the teaching plan

Front 220

Teaching approaches:

- Entrusting

Back 220

– provides the client the opportunity to manage self-care.
- The client accepts responsibilities and performs tasks correctly and consistently.
- Ex. Dx'd w/diabetes for 10 yrs.. Pt Managing disease well. New complication happens which requires pt to walk instead of jog during exercise & adjust insulin to prevent hypoglycemia. Nurse instructs pt about new exercise habits & allows pt to adjust insulin independently.

o Nurse remains available to assist without introducing more new information.

Front 221

Teaching approaches:

- Reinforcing

Back 221

- using a stimulus that increases the probability for a response.
- Three types of fortifiers are used to acknowledge a learned behavior
1) Social (e.g., smiles, compliments, or words of encouragement
2) Material (food, toys & music) 3)Activity (doing a more desired activity after completion of task)

- Involves giving careful thought to individual preferences
- By observing behavior, the nurse can determine which type of fortifier to use
- Not always effective
- More effective if there is a therapeutic relationship b/t Nurse & patient

Front 222

Instructional Methods

- One on One

Back 222

- most common method
- Using teaching aids like models or diagrams - depending on learning needs
- Instruction usually given in informal manner which allows client to ask questions & share concerns
- Use unstructured & informal discussions help clients understand the implication of illness & ways to cope with health stressors

Front 223

Instructional Methods

- Group Instruction

Back 223

- economical way to teach a number of clients at one time
- Clients able to interact w/one another & learn from each others experiences
- Also fosters the development of positive attitudes to help meet learning objectives
- Involves both lecture & discussion
- Lectures are highly structured & efficient in helping groups learn standard content
- Discussion & practice are essential b/c lecture does not ensure active thinking
- Sometimes Physical or emotional level of wellness makes participation difficult or impossible

Front 224

Instructional Methods

- Preparatory Instruction

Back 224

– Providing information about procedures often decreases anxiety because clients have a better idea of what to expect during the procedure, which helps to give them a sense of control.
- Guidelines:
- Describe physical sensations during procedure - how a needle feels when puncturing the skin (sticking)
- Describe the cause of the sensation, preventing misinterpretation of the experience - needle stick may burn b/c of alcohol prepping of skin
- Prepare clients only for aspects of the experience that others have commonly noticed - tourniquet may cause tingling & numbness in the hands (when needing to draw blood)

Front 225

Instructional Methods

- Demonstration

Back 225

– when teaching psychomotor skills such as: preparation of a syringe, bathing an infant, crutch walking, or taking a pulse.
- Most effective when learners first observe the teacher & then do a Return Demonstration
- Requires advanced planning

Front 226

Instructional Methods

- Analogy

Back 226

- translates complex language or ideas into words or concepts that the client understands
- Makes the information more real & understandable
- Be familiar with the concept that you are using
- Know client's background, experience & culture
- Keep concept simple & clear

Front 227

Instructional Methods

- Role Playing

Back 227

- people are asked to play themselves or someone else
- Technique involves rehearsing a desired behavior
- Ex. Nurse is teaching a parent how to respond to a child's temper tantrum. The parent responds to the Nurse who is pretending to be the child.
* Nurse evaluates response & determines if alternative approaches are more appropriate

Front 228

Instructional Methods

- Simulation

Back 228

- useful for teaching problem-solving, application, & independent thinking
- Nurse poses pertinent problems during group or individual discussion for patient's to solve
- Ex. Planning a meal for a patient w/heart disease that is low in fat & cholesterol
* Nurse will identify mistakes & reinforce correct info