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105 Cards in this Set

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Temperature Normal value
96.6 - 99.3F or 35.9 - 37.4C
Pulse Normal Value
Adults 60-80bpm
Infants 120-160bpm
Respirations Normal Value
Adults 12-18 breaths per min
Infants 40-60 breaths per min
Blood Pressure Normal Value
Young and mid Adult 120/80

older Adult 140/80
transfer of heat from one object to another object without contact b/w them
(e.g.heat lost from the body to a cold room)
Radiation
transfer of heat from the body to another surface
Conduction
Dispersion of heat by air currents
Convection
When water vaporizes heat, energy is used to change it from a liquid to a gas
Evaporation
to convert C to F?
Multiply by 9/5 and add 32C
to convert F to C?
Subtract 32c and Multiply by 5/9
Client interview
Describe its purpose?
-introduction to client,
-establish caring
-therapeutic relationship
-insight on clients concerns
-set goals and expectations
History taking process what is the objective?
Identify patterns of health and illness
-risk factors for physical
-behavioral health problems
-deviations from normal
-available resources for adaptation
What is included in History taking process?10
1.biographical info
2.Reason for seeking H.care
3.Client expectations
4.Present illness/concerns
5.Health History
6.Family History
7.Environmental History
8.Psychosocial History
9.Spiritual Health
10.ROS
Soft, breezy, low pitched
3:1 ratio
best heard over lung fields
VESICULAR
blowing sounds, med.pitched
1:1
heard over scapula,sternum,1st and 2nd intercostal space
BRONCHOVESICULAR
loud, high pitched
2:3
heard over trachea
BRONCHIAL
heard over dependent lobes,at bases
caused by:disruptive psg of air
NOT CLEARED WITH COUGH
Fine:High pitched,short interrupted crackling sounds.

Medium:lower,moist sounds,heard mid inspiration

Coarse:loud bubbly sound
ausc:trach,bronchi
cause: muscular spasms
fluid/mucus in lg.airways
-rumbling sound
-clears with cough
Rhonchi
High velocity air flow through narrowed airways
-high pitched
-Musical sounds
Wheezes
Inflamed pleura:rubbing of pleura against visceral pleura
-DRY GRATING SOUND ON INSP
-DOES NOT CLEAR WITH COUGH
Pleural Friction Rub
clients perceptions about their Health problems
(e.g. feelings of anxiety,pain,mental stress)
Subjective data
Observations, measurements made by nurse.
Observe(e.g. clients wound)
Measure(e.g. V/S temp,pulse)
Objective data
Requires that accredited hospitals have written nsg.policies and procedures.
-details how nurses are to perform their duties
-Establish Natl safety goals
-Reduce risk of med errors
JCAHO
The process a nurse goes through to get a license revoked?
DUE PROCESS:Nurse must be notified of the charges brought against them and that the nurse have an opportunity to defend against the charges in a hearing.
Name 2 reasons a nurse can have her license revoked?
-incompetent practice

-conviction of a crime
any intentional threat to bring about harmful or offensive contact
ASSAULT
any intentional touching without consent
Battery
professional negligence
Malpractice
A Nurse can be found liable if ? 4 steps
1.The nurse owed a duty to the client
2.The nurse did not carry out the duty
3.The client was injured
4.The nurses failure to carry out the duty caused the injury
How to avoid Malpractice?5 steps
1.Follow standards of care
2.give competent Health care
3.communicate w/other H.care
4.develop caring rapport w.pt
5.document assess,interv,evaluat, fully
Name the basic elements of communication? 8
1.REFERENT
2.SENDER
3.RECEIVER
4.MESSSAGES
5.channels
6.feedback
7.interper.var
8.ENVIRONMENT
motivates one perosn to cummunicate with another
(e.g.sights, sounds, odors)
REFERENT
person who encodes and delivers the message?
SENDER
THE CONTENT (IDEA)
(E.G VERBAL,NONVERBAL, SYMBOLIC LANGUAGE
MESSAGES
MEANS OF CONVEYING AND RECEIVING MESSAGES
(e.g. VISUAL,AUDITORY,TACTILE SENSES)
CHANNELS
THE MESSAGE RETURNED BY THE RECEIVER
-indicates whether the meaning of the senders message was understood
FEEDBACK
FACTORS THAT INFLUENCE COMM
-PERCEPTION
-EDUCATIONAL/DEVELOPMENTAL
-VALUES/BELIEFS
INTERPERSONAL VARIABLES
Settin for interaction
ENVIRONMENT
NAME ELEMENTS OF PROFESSIONAL COMM?6
-COURTESY
-USE OF NAMES
-PRIVACY/CONFIDENTIALITY
-TRUSTWORTHINESS
-AUTONOMY/RESPONSIBILITY
-ASSERTIVENESS
SIT FACING CLIENT
OPEN POSTURE
LEAN TOWARDS CLIENT
EYE CONTACT
RELAX
ACTIVE LISTENING
"YOU LOOK TIRED"
"i SEE YOU HAVENLT EATEN ANYTHING"
SHARING OBSERVATIONS
"IT MUST BE VERY FRUSTRATING TO KNOW WHAT YOU WANT AND NOT BE ABLE TO DO IT"
SHARING EMPATHY
"I BELIEVE YOU WILL FIND A WAY TO FACE YOR SITUATION, BECAUSE I HAVE SEEN YOUR COURAGE AND CREATIVITY IN THE PAST"
SHARING HOPE
"THE FOOD WAS NASTY, THE COOKS AT THIS HOSPITAL CANT COOK"
SHARING FEELINGS
HOW HAS YOUR PAIN AFFECTED YOUR LIFE AT HOME?
ASKING RELEVENT QUESTIONS
"YOUR BLOOD SUGAR IS ELEVATED TODAY, I'LL LET YOUR DOCTOR KNOW"
PROVIDING INFORMATION
'IM NOT SURE I UNDERSTAND WHAT YOU MEAN BY SICKER THEN USUAL, WHAT IS DIFFERENT NOW?
CLARIFYING
WE'VE TALKED ALOT ABOUT YOUR MEDICATIONS BUT LETS LOOK MORE CLOSELY AT THE TROUBLE YOU'RE HAVING TAKING THEM ON TIME"
FOCUSING
THAT HAPPENT TO ME ONCE TO......
SELF DISCLOSING
TEACHING TO AND INFANT
-KEEP ROUTINES CONSISTENT
-HOLD INFANT FIRMLY,SMILE,SOFT VOICE=TRUST
-HAVE INFANT TOUCH DIFF TEXT
TEACH A TODDLER
-USE PLAY
-PICTURE BOOKS OF HOSPITAL
-SIMPLE WORDS "CUT"
TEACH A PRESCHOOLAR
-ROLE PLAY,IMITATION
-ENCOURAGE QUESTIONS,OFFER EX
-ENCOURAGE TO LEARN TOGERTHER
TEACH SCHOOL-AGE CHILD
-TEACH PSYCHOMOTOR SKILLS
-OFFER OPPORT. TO DISCUSS HEALTH PROBLEMS AND ANSWER QUESTIONS
TEACH ADOLESCENT
-HELP LEARN ABOUT FEELINGS AND NEES FOR SELF-EXPRESSION
-USE TEACH AS COLLABORATIVE
-LET THEM MAKE DECISIONS
-USE PROBLEM-SOLVE (CHOICES)
TEACH YOUND AND MID ADULT
-ENCOURAGE PARTICIPATION IN SETTING GOALS AND TEACH PLANS
-" INDEPENDENT LEARNING
-OFFER INFO TO UNDERST.EFF.OF H. PROBLEMS
TEACH OLDER ADULT
-TEACH WHEN ALERT/ORIENTED
-INVOLVE IN DISCUSSION/ACTIV
-FOCUS ON WELLNESS,STRENGTH
-KEEP SESSIONS SHORT
NAME 5 STAGES OF KUBLER-ROSS STAGES OF DYING
1.DENIAL
2.ANGER
3.BARGAINING
4.DEPRESSION
5.ACCEPTANCE
ACTS AS THOUGH NOTHING HAS HAPPENED AND MAY REFUSE TO BELIEVE OR UNDERSTAND THAT A LOSS HAS OCCURRED
DENIAL
RESISTS THE LOSS AND MAY STRIKE OUT AT EVERY ONE AND EVERYTHING
ANGER
POSTPONES AWARENESS OF THE REALITY OF THE LOSS AND MAY TRY TO DEAL IN A SUBTLE OR OVERT WAY AS THOUGH THE LOSS CAN BE PREVENTED?
BARGAINING
A PERSON FINALLY REALIZES FULL IMPACT AND SIGNIFICANCE OF THE LOSS. FEELS LONELY AND WITHDRAW FROM INTERPERSONAL INTERACTION
DEPRESSION
ACCEPTS THE LOSS AND BEGINS TO LOOK TO THE FUTURE
ACCEPTANCE
ALTERNATIVE CARE DELIVERY MODEL FOR THE TERMINALLY ILL
-CLIENT HAVE LESS THAN 6 MTS TO LIVE
-DESIGN FOR COMFORT AND MAINTAIN SATISFACTORY LIFESTYLE UNTIL DEATH
HOSPICE
NURSES ROLE IN HOSPICE CARE
TO MEET THE PRIMARY WISHES OF THE DYING CLIENT AND TO BE OPEN TO INDIVIDUAL DESIRES OF EACH CLIENT
SIGNS OF LOCALIZED INFLAMMATION?
-SWELLING
-REDNESS
-HEAT
-PAIN
-TENDERNESS
-LOSS OF FUNCTION TO AFFECTED BODY PART
SIGNS OF SYSTEMIC INFLAMMATION?
-FEVER
-LEUKOCYTOSIS
-MALAISE
-ANOREXIA
-NAUSEA
-VOMITING
-LYMPH NODE ENLARGEMENT
LOCAL VASODILATION DELIVERS BLOOD AND WBCS TO INJURED TISSUES(EDEMA)
VASCULAR RESPONSE OF INFLAMMATION
WBCS ARRIVE AT SITE
PHAGOCYTOSIS INGEST/DESTROY BACTERIA
CELLULAR RESPONSE OF INFLAMMATION
ACCUMULATION OF FLUID AND DEAD TISSUE CELLS AND WBCS FORMS AT SITE
EXUDATE
SEROUS(CLEAR,LIKE PLASMA)
SANGUINEOUS(RBCS)
PURULENT(WBCS/BACTERIA)
DAMAGED CELLS REPLACED WITH NEW CELLS
TISSUE REPAIR
WBC?
5000-10000
HIGH:ACUTE INFECTION
LOW:VIRAL INFECTION
ESR?
15 MEN
20 WOMEN
HIGH:PRESENCE OF INFLAMMATION
IRON LEVEL?
60-90G/100ML
LOW CHRONIC INFECTION
NEUTROPHILS?
55%TO 70%
HIGH: ACUTE SUPPURATIVE INF
LOW: BACTERIAL INFECTION
LYMPHOCYTES?
20% TO 40%
HIGH:CHRONIC BACTERIAL/VIRAL
LOW:SEPSIS
MONOCYTES?
2% TO 8%
HIGH:PROTOZOAL,RICKETTSIAL,TB INFECTIONS
EOSINOPHILS?
1% TO 4%
HIGH: PARASITE INFECTION
BASOPHILS?
0.5% TO 1%
NORMAL DURING INFECTION
LAB VALUES
HYPONATREMIA
< 135
280mOsm/kg
urine specific gravity < 1.010
Hypernatremia
>145
295mosm/kg
urine specific gravity 1.030
hypocalcemia
<4.5 or 8.5
Monitor serum albumin
calcium, blood clotting levels
hypercalcemia
>5.5 or 10.5
BUN >25mg/100ml
creatine >1.5
hypochloremia
<95
ph >7.45 (met alkalosis)

treat with NaCl or amm.cl
hyperchloremia
>108
ph <7.35 met.acidosis

treat the cause first
Formula to calculate IV solutions?
total # of ml(volume)
--------------------=drip fac
total # of minutes (time)
Physician orders 300ml NS infuse 20minutes
drip factor is 10gtt/min
volume300ml
time 20 min
drip factor 10gtt/min
300/20X10=150gtt/min
what type of IV solution would the anticipate the md to order for a pt who is dehydrated and why?
-.45% NaCl (hypotonic solution)
it will move from the vein into the cells to help hydrate them.
makes renal tubules and collecting ducts more permeable to water; thus more water is return to systemic circulation
Increase in ADH
acts on the distal portion of the renal tubule to increase the reabsorption of sodium, where sodium goes water follows?
Aldosterone
IV fluids that moves fluid into the cells, causig them to enlarge?
.45% hypotonic
expands the bodys fluid volume without causing a fluid shift from one compartment to another
0.9% Na Cl
pulls fluid from cells causing them to shrink
3% Na Cl
When are isotonic fluids more commonly used?
for extracellular volume replacement
(e.g. FVD after prolonged vomiting)
what determines when to use hypertonic or hypotonic soulutions?
specific fluid and electrolyte imbalance
the client with a hypertonic fluid imbalance will receive what type of IV fluid?
Hypotonic solution
-to dilute the ECF and rehydrate the cells
why should hypertonic solutions be given carefully?
because they pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can lead to pulmonary edema.
What clients should the nurse carefully monitor when giving hypertonic IV Solutions?
-Heart or renal failure
Clients with normal renal function who are receiving nothing by mouth shoud have waht electrolyte added to IV solutions and Why?
Potassium
because the body cannot conserve K+, and even when the serum level falls, the kidneys continue to secrete K+ resulting in hypokalemia.
Name Isotonic IV solutions?
D5W in water
0.9%sodium chloride(NS)
lactated Ringers
Name Hypotonic IV solutions?
.45% sodium chloride(1/2 NS)
Name Hypertonic IV solutions?
Dextrose 10% in water(D10W)
3% to 5% sodium chloride
3%-5% Ns
3%-5% NaCl
Dextrose 5% in 0.9% NaCl
D5 0.9% NaCl
D5 0.9% NS
D5 NS
Dextrose 5% in .45% NaCl
D5 .45%NaCL
D5 .45% NS
D5 1/2 NS
Dextrose 5% in lactated Ringers D5 LR
What does Lactated Ringer IV solution contain?
-sodium
-potassium
-calcium
-chloride
-lactate
If a person loses a large quantity of blood from what fluid compartment has the loss occurred?
INTRAVASCULAR (VASCULAR)COMPARTMENT
If a large quantity of fluid had been lost from the vascular bed, what do you think will happen to the hydrostatic pressure?
It will decrease
If fluid moves from the interstitial space to the blood, what would you expect to find when assessing the skin?
-dry skin
-poor turgor