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452 Cards in this Set

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  • Back
Nursing defenition
according to the American Nurses Assoc. nursing is the diagnosis and treatment of human responses to actual or potential health problems
Nursing process
systematic method of assessing, diagnosing, planning, implementing and evaluating the care required by any patient in any setting. nursing process is a clinical framework and themeans by which the majority of the Nurse Practyice Acts in the US define practice of nursing
process by which nurse collects and analyzes data about the client
may include any of these activities, intervening, delegating, and coordinating
the process of determining both the clients progress toward the attaining of expected outcomes and the effectiveness of nursing care
Standard of clincial nursing practice
established by American Nurses Assoc. divided into two subsets standars of care adn standards of professional performance
standards of care
1. assessment, 2.diagnosis, 3. outcome ID 4. planning, 5. implementation, 6. evaluation
Standards of professional performance
1. quality of care, 2. performance appraisal, 3. education 4. collegiality, 5. ethics 6. collaboration 7. research, 8. Resource Utilization
focused health assesment
performing selected portions of the history and examination. - primary tool by which nurses nurture and sustain life and contribute to the success of the health care team
emergency nursing assessment
referrs to the data collection process that occurs in a life threatening situation
Time lapsed nursing assessment
repeated assessment obtained to compare data collected at one or more points in time with baseline data
primary data
nurse derives directly from the patient, can be subjective or objective
secondary data
data derived from all other sources. the sum of all primary and secondary data is the patients database
Baseline data
data taken at the time of the first encounter
objective data
data capable of being verified
secondary data
sources include the patients family and friends, other nurses and professionals
Gordon's typology of Functional Health patterns
method to organize data
valid data
only valid data is documented, to be valid data must be accurate, complete, and factual. ie recording slept well is an assumtion that may or may not be factual.
nursing diagnosis
are derived from assessment. are also called conclusions. the subject of the dx may be a patient, family or community. may be health or life problem. nursing dx directs the planning of patient goals and the selection of appropriate nursing interventions
components of a nursing dx
consists of a dx label, the defenition of the dx and its defining characteristics, related factors and risk factors. the dx label is the name of the diagnosis, each dx has its own defenition.
defining characteristics
part of each nursing dx. defining characteristics are like manifestations of the diagnosis or signs or symptoms
related factors
part of each nursing dx. show some sort of pattern in relationship to the dx. factors may be causative, antecedent to the dx, are associated with a dx are contributing to the dx or are abetting a dx
risk factors
refer to those variables that increase a patients vulnerability to developing an actual nursing dx
types of nursing dx
actual, risk and wellness
actual diagnosis
refers to a human response to a health condition or life process that is happening now at the present time
risk diagnosis
refers to a diagnosis that is likely to occure in a vulnerable person
wellness diagnoses
refer to human responses to achieve even greater levels of welleness. the dx name or label includes the words potential for enhanced or readiness for enhanced
formulating nursing diagnoses
dx may be documented in one of 3 ways, 1. using the dx name or label alone 2. along with its related factors 3. using the name related factor and defining characteristics
prioritizing nursing diagnosis
1. physiological needs 2. safety needs 3. social needs 4. esteem needs 5. self actualization needs
ANA standard of care on Diagnosis
Anurse analyzes the assessment data in determining diagnoses
dx are validated with the patient, family etc. dx are documented in a menner that facilitates the determination of expected outcomes and plan of care
Nursing dx outcomes
must be time measurable, and attainable.
Nursing dx goals
patient centered future oriented and action / direction oriented. always expressed in terms of patients goals to be achieved. most often use the very will do not refer to a nurses to do list, not statements of what tx are to be performed
statements of reportable observable, or measurable results expected to occur as a reslt of nursing interventions
Discharge planning
begins at the time the patient is admitted. involves active participation from the pt. family etc. is faciliated by an interdisciplinary team approach and requires teaching so taht the patient or family is capable of managing post discharge care
handwritten care plans
handwritten onto kardex which includes patients id and background info, listing of patients dx's and listing of problem specific interventions
Standardized care plans
Joint Commission for the Accrediation of Healthcare Organizations supports the use of standardized plans. they are specific for dx, allow for addl or deletion to accomodate agency policies, sprovide space to tailor, are included in the patients chart
written instructions designed to address a commonly occurring problm in an institutionally approved manner
are institutionally approved `preprinted detailed instructions on how to perform specific clinical tasks
standing orders
are institutionally and departmentally approved instructions granting the nurse the authority to act in the bsence of a physician
independent nursing intervention
include repositioning a patient in bed who is at risk of impaired skin integrity.
dependent nursing intervention
ordered by a Dr. or carried out under a physicians supervision for the treatment of a medical dx.
Terminal evaluation
evaluation of outcomes which occurs prior to the discharge of a patient from the hospital or prior to a case being closed in a community setting.
Quality of nursing care evaluation
looks at structure, process and outcomes
the setting or the environment in which the care is given
the appropriateness of the care given and wheterh policies and procedures were followed to maximize patient safety, minimize medication error, minimize infections , and insure patients and families feel welcome
outcome evaluation
examines such quality indicators as number of patient falls, number of new pressure ulcers formed, number of postoperative wound infections and number of tube fed patients developing aspiration pneumonia
a record or chart review
concurrent audit
uses interview, obersravtion and a chart reviwe to evaluate ongoing practice.
peer review
is an audit perfomred by one's colleagues, using standards of practice or other standardized criteria to evaluate performance
first step is to identify expected outcomes for each of the actual diagnoses and frame them in terms of patient goals
ineffective airway clearance
any patient with thick sputum production, especially a smoker, has the possiblity of developing ineffective airway clearance
high fever
any patient with high fever is likely to become dehydrated unless adequate hydration or rehydration occurs
nursing assistant tasks
those that address ADL's
LPN tasks
include the performance of a number of procedures
eduemosnistic model of health and wellness
focuses on health as well beign, self fulfillment and self actualization
adaptive model of health and wellness
views health as adaptation to the physical and social world in which a person lives, and views disease as maladaption
role performance model of health and wellness
views health in functional terms, if I can function, I am healthy
clinical model of health
views health as the absence of disease. emphasis on disease treatment outweighs emphasis on health promotion and diease pervention. also called a traditional defenition of health.
florence Nightengale's defenition of health
being well and using every power the individual possesses to the fullest extent
world health organizations defenition of health
state of complete physical mental and social well being and not just the absence of disease
Roy's adaptation model
developed by sister callista roy, defines health as adaptation and of illness as maladaptation
role performance model of health
the ability to function within one's role
websters defenition of health
a condition of being sound in minde, body and spirit, especially freedom from physical disease or pain.
Health Status
refers to a person health state or condition at one particual point in time.
health beliefs
the aymara of Bolivia believe that loss of blood is associated with loss of the persons spirit. health beliefs reflect the influence of a persons culture
health behaviors
refer to actions taken to promote health, protect health or prevent illness and disease
internally controlled person
self motivated or self directed in effecting healthy behavior changes
externally controlled person
requires external motiators
self efficacy theory
developed by Bandura, means that if a person believes they can do it, they do it.
health belief model
Rosenstock and Becker
examines motivational influences on health behavior chagne as it relates primarily to compliance with treatment regimn for a disease.
Health promotion model
Pender. emphasis is on health promotion behavior change only. it examines cognitive perceptual factors, modifinying factors and participation in health promoting behavior
Stages of behavior change
prochaska and DiClementes, examinies any kind of behavior change. therefore it may be applied to health promotion, protection or disease prevention
stages of behavior changes 1-5
1 precontemplation
2 contemplation
3 preparation
4 action
5 maintance
piaget infant behaviors
progression cognitively form a stage where most action is reflexive to a circular phase in which the infant perceives other objects and persons as an extension of the self, that is everything returs to the self
flouride levels
if less than 0.7 parts per million, then use a supplement
Eriksons toddler theory
autonomy versus shame development .
Freuds toddler stage
anal stage
Piagets toddler stage
12-18 months olds seek new goals and develop rituals
Havighurst toddler theory
children in this age group progress in language development, learn urine and bowel control, begin to learn right from wrong
Kohlbergs toddler theory
preconventional stage of moral development, distinguishing right from wrong on the basis of reward and punishment.
Fowler's toddler theory
spiritual development remains undifferentiated
westerhoffs toddler theory
toddler is guided by parents in a simple prayer and ritual
toddler Dr. info
recommends visits at 15 & 18 months
Early childhood
3-6 years, time of play play is motor development oriented. play is also group oriented imaginative and creative
Erikson's early childhood theory
3-6 yo. initiative versus guilt
freud's early childhood theory
end anal stage by 2-3, and begin pallic stage 4-5. Oedips complex. Genitals become focus of attention
Havinghurst's early childhood theory
3-6 yo child learns to identify sexual differences becomes sexually modest, relate emotionally to parents
Piagets early childhood theory
preconceptual phase 2-4 year olds, manifested by egocentrism and begin the intuitive thought phase 4-7 yo which is manifested by decreased egocentrism and kidea formation.
kohlbergs early childhood theory
child learns to share and to be kind, helpful etc. this behavior begining around age four is called presocial an dis performed for adult approval. Child is developing a capacity for moral thinking but would not as yet place the child at the level where moral thought occurs
fowler's early childhoood theory
childs imagination and experience combine with the images and beliefs transmitted by others to form an intuitive projective spirituality
westerhoff's early childhood theory
the child experiences faith within the context of those with whom the child lives
12-18 years, pubertal development, self concept change, falue testing, stress and conflict.
Erikson's adolescence theory
this stage of identity and repudiation versus identity confusion is know for increasing independence in and responsibility for values, choices, and actions
Freud's theory of adolescents
genital stage aimed at attainign mature sexual relationship. pregenital stages may be reactivated and then repressed when moving to the genital stage
havighurst's adolscense stage
tasks are to establish new relationships with members of both sexes, develop masculine or feminine social roles, accept one's physique , attain emotional independence from parents and other adults
Piaget's adolescents stage
this is the formal operations phase, rational deductive and future thinking
Kohlberg's adolescents stage
most continue at the conventional level - golden rule or law and order morality. some may proceed to Kohlbergs postconventional stages, where laws and rules are questioned and right and wrong decisions are reached on the basis of one's internally developed value system
Fowler's adolescent stage
spiritual development focuses on fashioning a world and envrinment built on others expectations. reject the other people or grous because of differences
young adulthood 20-40
20-40 yo. recommended to have a cmplete health exam every one to three years for emales and every five years for males.
monthly testicular self examins or males and breast exams for females. pap smear for all over 18. clinical breast exam q 3 years by a Dr.
Erikson adulthood stage
does not examine the 25-40 age range per se. limited to 18-25 year olds who face the task of achieving intimacy or facing isolation. those in this tage perceive sexual behavior as a desirable expression of intimacy.
Freud young adulthood
believes development concludes with the genital stage, entered into in adolescence
Harvingston young adulthood stage
developmental tasks are selecting a mate and learning to live together, starting a family, rearfing children, managing a home, becoming established in a occupation
Fowlers young adulthood stage
spiritually people between 18 - 30 develope an individuating and reflexive spriituality, meaning they construct their own highly self conscious approach to spirituality
Westerhoffs young adulthood stage
young adult enters a faith searching period after questioning and doubting, the young adult develops a cognitively grounded and effective faith.
Middle Adulthood 40-65
mid career and lifestyle changes. should have annual heath exams for females and 2-3 years for males. yearly mammograms, pelvic and prostate screenings. TD booster every ten years
Eriksons view of middle adulthood 40-65
generative versus stagnation years continue
Havighursts view of middle adulthood
tasks are to assist children in transition to adulthood, relateo to spouse as a person, maintane adult civic and social responsibilities
Fowlers middle adulthood view
after 30 years of age the person is aware of spiritual truth from a number of different perspectives
Westerhoff's view of middle adulthood
indicates that middle adult years are characterized by an owned faith put into action personally and socially. the middle aged adult acts ont he basis of his or her belief
Older adulthood - young old
65-74 task of adapting to retirement and accepting changes in physical ability.
older adulthood middle old
74-84, have task of adapting to a decrease in swiftness of movement, reaciton time,
oldder adulthood old old
85-up, have the task of adapting to increasing physical problems and phychosocially coping with multiple losses
Erikson's older adulthood view
integrity versus despair
freud's view of older adulthood
genital stage of development remains operative
Havighursts view of older adulthood
defines tasks for the elderly as adjustment to retirement, decrease in income, decline in physical health and strength and death of spouse. tassks also include establishing an affiliation with ones age group
fowler view of older adulthood
universalizing stage of spirituality in which a person is permeated by and permeats love and justice. this stage may never occure
westerhoff's view of older adulthood
faith that is owned continues inot older adulthood
Prevention of constipation
dr45ink at least 6 eight ounces of water daily, exercise and include roughage
health illness continuum
health illness status of a person is not an absolute state, but a relative placement along a continuum of health and illness
Travis' illness wellness continuum
wellness is differentiated from the term health because according to Travis and Ryan, wellness is a choice a philosophy or way of life, the intergration of body mind spirit and high level self acceptance. in the wellness model the person chooses healthy lifestyles and makes healthy choices
Dunn's high level wellness grid
looks at two dimensions. one is environment varying form favorable to unfavorable the other is the wellness death diminsion. dunn does not ephasize distinctions between health and wellness as Travis did. Dunn looks at the person within the context of the family, community and society
Ecological or Epidmiological model of health and illness
disease is due to a interaction between the disease causing agent, the person or host and the environment. three rings. looks at the agent, host and environment within an interactive system where each componet is interdependnt on the other. epidemiologic means it looks at the cause of and influences on disease
Ecological model example
nurse or health educator (agent) who brings people (hosts) concepts and practices that prevention illness within homes and community (environment)
specific pathologic state with defined signs and symptoms
a unhealthy state or condition of the mind or body in which physical social emotional intellectual or spiritaul functioning is compromised
is the opposite of wellness, a state of not being well, but it has also entered the vernacular to mean discgust
Talcott Parsons sick roll
sickness which begins with the experience of signs and symptoms of illness and the assumption of the sick role carrries with it responsibilities that include a search for the health care needed to recover, dependence on health care providers for recovery and participation in recovery. in other words patient is expected to assume responsibility for getting well quick
sometimes it refers to the forces or stimul that impinge upon an individual, - stressors. When streass is deffined as a stimulus the resulting model is called a stimulus based stress model
response based model
stress is used to describe a persons response.
general adaptation syndrome
bodily organs and systoms involved in GAS are the adrenal lymphatic structures and teh GI tract. if only one organ reacts alone, the the resulting syndrome is called a local adaptation syndrome,
general adaptation syndrome (GAS) and local adaptation syndrome (LAS) typical pattern
the stressor yields an alarm response, which is followed by a resistance phase, if resistance fails, exhaustion occurs leading to rest recovery or death.
physiological response to sterss
shock phase begins, epinephrine and cortisone are released, body prepares for fight or flight
Fight or flight
detrusor muscle of the bladder relax, urethral sphincter contracts allowign for greaater bladder capacity without voiding. sympathetic release also stimulates hypothalamus to release corticotrophins
effect the release of pituitary adrenocorticotropin. which acts on the adrenal cortex and the adrenal medulla adrenal cortex releases glucocorticoids are released causing an anti inflamm response. increased blood sugar for energy.
adrenocortical stimulation
also causes a release of mineral corticoids which conserve sodium, retain water, increase blood volume, and increase blood pressure.
stimulation of adrenal medula
nor epinephrine is released decreasing renal blood flow and increasing renin release, renin is a potent vasoconstrictor. also secretes epinephrine which starts the cycle again.
shock phase
first part of alarm reaction. may endure as long as 24 hours
2nd part of alarm reaction
countershock phase physiiologic changes reverse themselves. resistance sets in
3rd phase of alarm reaction
resistance phase. body attempts to cope, if coping is unsuccesssful, the body becomes exhausted
final phase of alarm reaction
exhaustion phaser, either the body rests or you die.
Stimulus based model negatives
the stimulus based model does not fully explan why the same stimul are perceived differently.
response based model of stress - negatives
doesn ot explain why some people are more inclined to stress than others
Transaction based model of stress
Lazarus - four factors operating in streass and adaptation theory. They include the sensitivity of th eperson to stress, the person's vulnerability at any one point in time,
Summary of Lazarus stress theory
needs to consider the presence or absence of these orther transactional factors over and above the interaction between environmental stimulus and the individuals respones. . (interpretation of the stimuli)
Brief of transaction based model of stress
cognitive (interpretive) affective (mood) and adaptive mechanisms that influence the relationship between an environmental stimulus and a persons response.
psychologic indicators of stress
include anxiety fear, anger depression and unconscious ego defense mechanism.
is a vague and uneasy discomfort stemming from a source that is not easily identifiable. it is an alerting signal of an ill defined threat or danger. As such it is future related..
anxiety classification
mild,moderate,severe or panic
severe anxiety
characterized by inability to focus except on the anxiety itself. because severe anxiety interferes with a patients ability to function, it requires intervention.
an overwhelming anxiety in which the patient loses contrl of self and in whih distortions of reality may occure
physical effects of anxiety
no increased heart rate with mild anxiety. moderate anxiety may have a increased heart and respiratory rate. severe = impaired communication, wide eyed & apprehensive, tachycardia & hypervent.
in anxiety there is no clear cut object causing the anxiety. the object of fear on the other hand is known
a negative response associated with a feeling of animosity or strong displeasure
is more than a passing blue mood. it may be endogenous (stemming from inside) or exogenous (situational or reactive.
Characteristics of depression
diminished interest in usual please outlets, change in appetite, change in sleep habits, restlessness, sense of hopelessness, sense of worthlessness, decreased ability to concentrate
mild depression
may accompany grief and resemble grief but should not be confused with normal grief reactions that occure with the loss of a loved one.
defense mechanism - compensates for a weakness by overachieving or overcompensating in another area
transfers emotions from one person animal or object to another
defense mechanism - imitating the behvior of a feared or respected individual in order to relieve anxiety
defense mechanism. distance one's self from an emotionally painful event by subjecting tyhe incident to intellectual analysis
defense mechanism - assuming and accepting the values or norms of others as ones own.
reaction formation
defense mechanism. reacts in the opposite manner
defense mech. turning of aggressive or sexual drives or energy into socially laudable or praiseworth behavior.
simply means thinking
problem solving
ability helps a person think through a stress generating problems and find solutions
helps establish a routine yielding a decreased need for change and decreased sterss. extremem structuring creates rigidity and may represent obsessive compulsive tendencies
self control
helps a person to assume a I am in control demeanor.
is consciously willing oneself to think of the stressful events at another time.
another way of responding to stress . if fantasy focuses on practical solution then it can be useful if a persons fantasy focuses on escape, like living alone on a tropical island then it delays problem solving.
Four most basic techniques in performing a physical
percussion, inspection, palpation, and ausculation
use the pads of your fingers best at sensing vibrations or at discriminating changes in texture. to palpate light, use3 dominant hand aprallel to the part examines. Deep = fingers of dominant hand are placed on top of fingers of other hand
performing a physical exam, order
inspect, palpate, persuss, auscultate. Except for GI inspect the palpate.
lightly but sharply. tape of the fingers may be direct. middle finger tap the frontal mxillary sinuses. percussion is indirect when the nurse uses the middle finger of the dominant hand to tap the middle finger of the other had in an intercostal space or abd.
general survey of a patient
includes age, gender , general appearance, behavior, relevance and organization of thought and vital signs resp. rate and temp.
idea weight of women
assign 100 #s for the first 5 ft. of height. Add 5 #'s for each addl inch. add 10% if large body frame, subt. 10% if small.
Mens idea weight
100#'s for first 5 feet. add on six pounds for every addl inch. add 10% for lg frame, subt 10% for a small frame
Body mass index
takes into consideration both weight and height.
To calculate BMI
divide weight in Kilograms by height in meters squared. when measuring wt in kids, remember that infants are weighed without clothing. When measuring kids ht, kids up to 2 must be in a recumbent position with knees fully extended.
techniques used in the physical assessment of the neurological system
include assessments of crain nerves, deep tendon reflexes, sensory and motor function and level of consciousness
cranial nerves
forehead for alignment of eyebrows and the patients ability to wrinkle the forehead and raise the eyebrows first and then symmetrically - cranial nerve V, trigiminal branch of the forehead and cranial nerve VII , facial
cranial nerve III
oculomotor eyelids for ptosis or drooping
Cranial nerve II
optic, inspect the eyes for visual acuity using the Snellen chart. peripheral vision in the uncovered eye by testing the visual fields
Cranial nerve VI
abducens, ask if there is any double vision
cranial nerve III
oculomotor, assess they pupils for symmetry
cranial nerve IV
trochlear, eye movement in all six directions up down out
cranial nerve VII
close eyes tightly (fascial nerve)
Nerve I
olfactory nerve, assess smell
Cranial nerve VIII
vestibulocochlear by teating hearing
cranial nerve IX
glossopharyngeal,ask patient to identify foods quality of swallowing with small amounts of water
cranial nerve XII
hypoglossal, extend tongue without deviating, talk without slurring words
cranial nerve XI
spinal assessory, inspect symmetry of shoulders or the drooping of one more than the other by the patients ability to move head side to side even when opposed with mild pressure.
Deep tendon reflexes
five deep tendon reflexes biceps, triceps, brachioradialis, patellar and the achilles
biceps deep tendon reflex.
spinal cord level c3 and c6. Rest patients arm & place thumb over the biceps tendon
triceps deep tendon reflex
level C7/C8find the tendon 1-2 inches above the elbow
patellar deep tendon reflex
spinal cord level L2L3 and L4kneecap. use percussion hammer, , kick up = quadricep muscle contracts
achilles deep tendon reflex
spinal cord level S1/S2 support the patients foot in your nondominant hand and dorsiflex it . this mvmt stretches the Achilles tendon slightly, observe plantar flexion (jerking downward)
Plantar deep tendon reflex
superficial - not a deep tendon reflex. Moving from heel to the ball of the foot and then moving across the ball to the great toe wihle observing a bending downward of the toes. negative babinski = normal. in a abnormal response, the toes flare and move upward. an infant normally has a positive babinski until 6 months old.
brachioradialis deep tendon reflex
spinal cord level C3-C6, two to five cms above the wrist.
sensory function
may be performed bu ysing a wisp of rolled cotton. Perform lateral and medial assessments
perform motor function tests
pt. sits on table - finger to nose, finger to nurses finger, finger to finger, finger to thumb, alternating supinatyion/pronation of hand on thighs test
motor function tests - lying down
heel down thin test, toe to nurses finger test
motor performance tests - standing
walking gait test, romber test, stand on one foot with eye closed, heel to toe walking test, toe walking heel walking tests
rombergs test
facing the patient so that you may steady or catch the patient, ask patient to close eyes, observe sway or its absence. if sway occures document the direction . observation of sway or moving the legs apart to maintain balance is abnormal.
level of consciousness assessment
fully alert and oriented to comatose. a score of 15 is the bet possible, a score of 7 or less indicates coma, the lowest possible score is 3.
respiratory sytem assessment
inspection, palpation, percussion, ascultation
resp. system inspection
inspect for normal size and shape. in the infant the shape is like a round cylinder, the A-P diameter = the transverse. by six yo the shaqpe is less round because the AP diameter is decreasing. adulty ap = tx's transverse.
respiratory system palpation
for chest excursion - equal bilateral mvmt on inspiration and expiration. expansion 3-5 cm or 1.5-2 inches. remitus - bilaterally symmetrical, tactile sensations in palmar surface of fingertips upon patients vocalization of words
normal breath sounds
are called bronchial, bronchovesicular and vesicular.
inspiratory ration
1-2 (short inspiration, long expiration) at bronchial level, 1-1 at bronchovesicular, 5-2 at at vesicular (long inspiration short expiration
lung sounds
high pitched and harsh at the bronchial level, moderately pitched and softening at the bronchovesicular level, low pitched and softtly sighing at the vesicular level
bronchial sounds
apex of the lungs
bronchovesicular sounds
correspond to the area between the apex and the base of the lungs
vesicular sounds
correspond to the base of the lungs
adventitious sounds
include wheezing, gurgles (rhonchi) and crackles (rales)
a high pitched whistling sound heard especially over the anterio posterior bronchial areas. caused by bronchoconstriction due to bronchial edema and secretions or bronchial obstruction . not usually relieved by coughing
gurgles - rhonchi
low pitched gurgling sounds heard best on expiration and frequently cleared on coughing. these sounds are usually emitted by secretions in the bronchi and hence are heard best over the bronchial areas
crackles - rales
sound like noise emitted when salt is thrown into fire or like th enoise that occurs when you use your finger to rub a lock of hair.harshly and quickly near your ear. heard at the bse of the lungs, rales may or may not be cleared on coughing
pleural friction rub
heard best along the lateral or anterior chest, sounds like the noise that occurs when you use your fingers to rub a lock of hair back and forth slowly and gently near your ear. occurs throughout inspiration and expiration and is not cleared by coughing
cardiovascular system assessment
move head to toe, neck, jugulars, carotids then heart, then peripheral vascular system
assessment of jugular veins
inspect the vein with patient lying at a 45degree semi fowlers position. if no distention lower head of bed to 30 deg. and check again. distention over 3 cm above the sternal angle is abnormal
assessment of the carotid arteries
inspect for visible pulsating masses palpate gently only one at a time (brain blood flow). to avoid a carotid sinus response, and injurious bradycardia never massage nor apply pressure to the carotid artery, listen to carotid - bruit (murmer like sound)
assessment of heart inspection
aortic area (second intercostal space to the right of the sternal border) the pulmonic area (2nd intercostal space to the left of the intercostal border) tricuspid or right ventricular area (5th IC space left of SB) apex 5-6th IC space along the mid clavicular line
heart assessment - auscultate
semiflowers 30-45degree angle. s1 and s2 (lub dub) S1 = systole s2 = diastole
heart sound s3
left ventricular failure. if failure is suspected but not heard, put patient in the supine position and ask the pt. to turn ot the left side.
s4 heart sound
abnormal in the child or adult although it may be present in a healthy appearing older adult. sound occurs immediately before the first heart sound r/t decreased flexibility of LT vent. - hyerptension.
s3 + s4
= gallop rythem
swooshing noises that occure during systole, diastole or throughout the cardiac cycle they are casued by turbulent blood flow though one or more heart valves.
peripheral vascular system assessment
nails - clubbing, capillary return, buergers test, rubor (rubby redness) find pulses bilaterally head to toe
Buerger's test
arterial adequacy test
brachial radial, femoral posterior popliteal, posterior tibial and dorsalis pedis
indicates turbulent flow caused by a partial femoral obstruction, requiring prompt notification of the MD>
abdominal assessment inspection
inspect for contour symmetry in supine and semi flowers and standing positions
abdominal assessment, auscultate
gurgling sounds q 5-20 seconds. before saying they're absent listen 3-5 minutes
abdominal assessment percuss
beginning in the right lower quadrant persuss in a straing line up until the sounds of tympany change to dullness. this is the lower rt margin of the liver. beginnin at umbilicus, go up until chagnes - this is lower left margin of liver. begin at rt midclavicular line, persuss down, - upper rt margin of liver. begin at sternal border - percuss down = upper lt margin of the liver
abdominal assessment palpation
ileosecal area to right lower quadrant, progressing up over the ascending colon, across over the transverse colon, and down over the descending colon, rt uq = liver or gallbladder
ADL assessments
performed upon admission of a clinet to the hospital or health care agency and at those points in time when changes are expected
instrumental activities of daily living (IADL)
refers to tasks involving the basic tolls or instruments of daily life needed to live independently. including use of a phone, meal prep, laundry, meds, and handle finances
mental status assessment
involves attention span, baility to calculate, memory, and assessment of speech and language and assessment of orientation
Speech and language assessment
sensory ability is either visual or auditory. loss of the ability to interpret both writtend and spoken words is sensory aphasial
visual aphasia
loss of ability to interpret written words
motor or expressive aphasia
loss of ability to use words appropriately
immediate recall test
ask person to repeat 3 to 8 digits. the ability to repeat 5-8 is considered normal
recent memory test
ask patient to recall todays events
remote memory test
ask patient to recall and describe an event from the past, also called long term memory
attention span assessment
ask patient to count backwards from 100 or to recite the alphabet
calculation assessment
ask patient to subtract seven or three form one hundred then continue sub. 7s these test are called the serial threes or seral sevens .normal - completion in 90 seconds
primary prevention
aims at preventing illness and disease before it occurs. techniques include teaching health promotion
secondary prevention
intended to detect and treat disease and health problems in the earliest stages . techniques include, screenings, nursing assessments, neruo checks, administration of meds
tertiary prevention
designed to restore maintain and maxamize health & optimize functioning in the later stages of illness. ie referring patients to support groups
Breast cancer
most common cancer among women in the US and second leading cause of cancer related deaths. only skin cancer is more common than prostate cancer amont men. prostate cancer is 2nd only to lung CA as leading cause of CA deaths in men
Orthodox jews circumcision
done on 8th day after birth
four catagories of inteventions
stress reducing, alternative/complementary therapies, research derived interventions, research derived interventions and clinical practice guidelines
stress reducing interventions
also called mind/body therapies. incl. progressive relaxation techniques, biofeedback, imagery, yoga, mediation, prayer, musical therapy and hypnosis
progressive relaxation
in quiet place, progressively tense and relax each muscle group. to complete this exercise it takes at least 10 minutes.
process by which the body learns to bring autonomic nervious system responses under its control. these responses incl. heart rate, rhythm, blood pressure, peristalsis and skin temp.
process imagery
may be used to prepare a patient for an anxiety provoking prcedure by mentally rehearsing the procedure process with the patient in a calm atmosphere
end state imagery
find healed state.
altered state of consciousness in which the mid is focused in passive attention and quiet resulting in an experience of transcendence. focus on object and repeat mantra
system of belief and practices aimed at the union of the individual self with the universal self. takes 8 stages to get to this union
method of altering consciousness by focusing attention on one thought thereby distractign consciousness from other thoughts
National institute of health office of alternative
studies the use of complementary and alternative medicine (CAM).
complementary and alternative therapy
touch therapy, massage, reflexology, accupressure, aromatherapy, chiro,
research derived interventions
many interventions address the objective of Healthy people 2000
healthy people 2000
the nations disease prevention and ehalth promotion agenda. coordinated by US dept of Health and human services office of disease prevention. now HP 2010.
Fraingham heart study
1948 - over 5k residents in Framingham MA. studies relation btw dietary fat and blood cholesterol levels, & tobacco, wt, and HBP and heart disese
Nurses health study
1976 Dr. Frank Speizer of Harvard began a large study into risk factors for major chronic disease in women.
Nurses Health study II
by Dr. Walter Willet also of Harvard. RN's were chosen for the study because of their ability to respond to brief, technically worded questions and becausei t was assumed they would be willing participants. This is still ongoing
agency of healthcare research and quality AHRQ
leading federal agency on quality research. one of its tasks has been to develop and disseminate clnical practice and provide organization
National Guidelines Clearinghouse
includes its own clinical practice4 guidelines as well as those developed by health professional organizations foundations and other government agencies
the conclusions drawn form the assessment process, and they are listed in their order of priority
freedom from the risk of injury
temp. comfort zone
18.3 to 23.9 Celsius (65-75 F)
Avoid inducing vomitting for the following
oils b/c r/o aspiration, acid, alkalines -esophageal damage
overexposure to radiation in adults may result immediately in radiaation sickness. if the patient survives the initial then = great risk of CA
Traditional rememdies
some contain lead. Greta and azarcon are mexican tx for disgestive issues & have lead in them
Contains mercury!
some Latin Americans use to tx dirrhea
coining and cupping
practices that require theapplication of aheated coin of the heated mouth of a cup to the back or neck.
Topical garlic
traditional remedy for Yemenite Jews placed on wrist to tx infectious disease. may resul in the formatino of blisters or garlic burns
poisonous plants
have become one of the nations leading substances causing toxic ingestion
Regional Poison Control Center
located at cardinal Glennon Childrens hospital in St. Louis Missouri
bicycle related head injuries
cause 67% of bicycle related deaths each year.
rear facing car seat
birth to 20 pounds or as close to one year as possible
fire safety
R- rescue
A - Alarm
C - Confine
E. extinguish
to operate a extinguisher correctly. P=pull pin, A = aim, s = squeeze handle, s = sweep the fire from side to side.
ultraviolet A waves
are longer waves responsible for photosensitivity, photoallergic, or phototoxic reactions. a = allergy
Ultraviolet B rasy
shorter and are responsible for burning, tanning, and skin cancer. B = burn. Max exposure = btw 10am and 3pm.
Para Amino Benzoic acid (PABA)
frequently found in sunscreens. it increases the efectiveness of the screen.
Parsons 1789
only sunscreens with this in it are effective against UVA and UVB radiation . Do NOT apply sunscreen to infants less than six months of age.
Carbon monoxide detectors
must be approved by underwriters laboratory
physical restraint alternatives
leg bands. Bed/chair exit safety monitor = position sensitive
Rogers and Bocchino
outlined restraing avoidance or restrain substitute strategies
IV lines
capped IV lines are much preffered to Keep Open IV lines.
Document the following on all restraint interventions
your assessment and DX. Alternative interventions attempted, time physician was notified, order given, reason for the restraing. client/guardian permission for restraing. time applied, pts response q 30 min, time given joint exercise and skin care
use of restrains
must be per physician approval. within 24 hours if emergency
MD order for restraints
must say why and length of time to be used.
mummy restraing
blanket wrapped ina special way to enclose a childs body to prevent mvmt during a procedure
1976 Omnibus udget Reconciliation Act (OBRA)
states nursing home residents have the righ tto be free from physical or chemical restraints that are not required to treat specific medical conditions
safety research for restraints
research has shown the restraints double hospital length of stay. restrained patients are 8 x more likely to die than unrestrained.
refers to the gathering of health data
medical asepsis
refers to biological safety techniques used during daily routine care to prevent infection or control its spread
surgical asepsis
refers to those techniques a nurse uses to establish and maintain a field free of all organisms, including spores. used for IM injections, starting IVs, chaning surgical dressings,
medical asepsis chain of infection
infections agent,2. reservoir, 3 portal of exit, 4. mode of transmission. 5. entry portals 6. susceptible host,
methods used to control or eliminate infectious agents
cleaning - , disinfection and sterilizing.
removal of all foreign material from objects by cleansing, which inhibits the growth of organisms. six steps rinse, hot water, clean grooves, rinse, towel dry, clean sink bursh etc.
removes all but spores. May be bactericidal or bacteriostatic
destroys all MO's including spores. moist heat (autoclaves), free steam, gas, boiling radiation.
Stage one of a inflammatory response
1. vascular and cellular response, histamine release causing vasodilation altered capillary permeability causes leakage of leukocytes which stimulates an increase in leukocyte producti8on resulting in high white blood cells.
Stage II of a inflammatory response
exudative stage. fluid that seeped through blood vessels, dead phagocytes & dead tissue cells form exudate.
exudate catagories
serous-clear, serum like
purulent-pus, containing drainage
sanguinous - dark or bright red bloody drainage
serosanguineous-thin, bloody drainage diluted by serous fluid
stage III of a inflammatory response
reparative phase. regeneration of tissue.fibrous tissue formation = 2 stages, 1st=fragile granulation tissue laid down 2. firm tissue called cicatrix tissue develops.
antibody mediated response (AKA humoral circulating immunity
resides in the b lymphocytes and the antibodies produced in B cells mediate the response. B cells acitvated by FB which activates ATB's
another word for antibody
when present, indicates the client is currently or actively infected. 1st Immunogobulin produced during a response
when present, indicate the client was infected by this specific pathogen in the past. Crosses placenta to provide protection to baby
located in external secretions and in the resp. tract and plasma
function unknown
produce the typical signs and symptoms of allergy and anaphylaxis
cell mediated defense (aka cellular immunity)
resides in T cell system. on exposure lymphoid tissue released large amt of T cells.
stages of a infectious process
incubation, prodromal, illness and convalescence
incubation period of a infection
time btween the invasion and the first sign or symptom
prodromal stage of infection
time between onset of nonspecific signs and symptoms of infection to more disease specific signs and symptoms
illness stage of infection
during which the disease specific signs and symptoms are present
convalescence stage of infection
the time period between the disappearance of the acute signs and sumpts of the disease and full recovery
wound healing phases
inflammatory, destructive, proliferative, maturation
inflammatory phase of wound healing
hemostasis occurs- vessels constrict platelets form making a fibrin matrix. injured tissue and cells secrete histamine - vasodilation - increased permeability which allows serum and WBC to pass forming exudate. s&s redness, etc.
destructive phase of wound healing
2-5 days. macrophages continue to clean wound and stimualte fibroblast which makes collagen - main ingred. in scars. fibroblasts need vitamin B, and c and amino acids and O2
proliferative phase of wound healing
last 3-24 days. characterized by beginning of wound closeure and increasing strength of closure
maturation phase of wound healing
final stage. increased strength of closure, - several months to a year.
healing by primary intention
when sides of wound are closed with bandage of some kind
secondary intention healing
wound is not approximated but allowed to close by filling with scar tissue
sac like accumulation of pus
small red spot
node or aggregation of cells. subq nontender
red elevated are on the skin that is solid. smaller than 0.5cm
pressure ulcer
also called decubitus ulcer. caused by shearing or friction
sac like lesion
spontaneous new unrestrictive growth of tissue
open sore that may be associated with deep loss of skin
stages of pressure ulcers
stage one of pressure ulcer
the skin is intact but a nonblanching erythema is present
stage II of pressure ulcer
partial thickness skin loss that involves the epidermins and may extend into the dermis. the lesions presents as an abraision, blister or shallow crater
stage III of pressure ulcer
full thickness skin loss, including damage to or necrosis of subq tissue but not the fascia lesion looks like a deep crater.
stage IV of pressure ulcer
full thickness skin loss with damage to or necrosis of muscle, bone and surrounding structure
is an abnormal loss of blood
internal hermorrhage
characterized by a iformation of a hematoma
is the partial or complete rupture of a sutured wound usually abdominal and is most frequently accompanied by at least partial seperation of the underlying tissue
is the protrusion of viscera through a dehisced wound
deficiencies in Viatimins B & C
lead to poor wound healing
one who uses magic to cure the sick
directly observed therapy. used for antiTB therapy
empirical therapy
when a Dr. gives a tx prior to C&S being done based on the Dr.s expert knowledge
to minimize gastric irritation, take with food. may cause asthma attack
near absence of microorganisms
soiled or contaminated objects capable of causing infection
three principles needed to obtain medical aespsis
1. items entering the vascular system must be sterile. 2. all items contacting the mucus membrane that is not intact must be free of MOs 3. all items that contact the skin must be clean
10-15 seconds
sterile field
in surgery requires use of mask gloves gown
area of sterile field considered contaminated
2.5 cm edge.
wound healing by proximal intention
wound is usually cleansed daily allowed to dry then redressed. dressings are no longer needed after drainage stops
for wounds healing by 2ndary intention,
the dressing material itself provides a means of removign exudate and debris
five types of dressings
dry gause, wet dressings, nonadherent dressings, self adhesive dressings and hydrocolloid dressings
Hydrocolloid dressings
hydrogen gel. occlusive & contain gel forming agents. form a waterproof barrier. they liquefy debris. used for shallow to moderate skin ulcerations
normal white blood cell count
infection = leukocytosis
ESR - erythrocyte sedimentation rate
nonspecific test that detects the presence of inflammation. rises with autoimmune diseases. 0-15 normal
serum albumin levels
albumin is a resevoir for nitrogen which is needed for tissue growth. when blood vol decreases, SA increases. a high SA level may mean dehydration. low - liver or renal disease 3.4-4.8
Harrison narcotic act
begain in 1914. classsified narcotics and established reulations. later refined under the controlled substance act
drug addict defention
any individual - habitually uses any narcotic drug as to endanger public morals
drug dependent
experiences withdraws
Cough syrup with docein
is a class V controlled substance
distribution of narcotics
only those health professionals registered with the DEA and possessing a registration or DEA number may write a RX for a controlled substance
dispensing narcotics
dose is written in med record and on narcotic inventory sheet
Schedule II drugs
may not be dispensed in the hospital for a period longer than seven days with any single order
Schedule III and IV
limited by the federal government to one hundred dosage units or to 33 days whichever is less
NP and narcotics
can not prescribe them.
drug name
chemically it contains the same therapeutic or active ingredients, but different binding agents
refers to drug absorption distribution biotransormation and excretion
drug absorption
occurs by means of diffusion, active transport or pinocytosis
fat suluble drugs are nonpolar nonionized drugs that passively diffuse back and forth across membranes once they break down
active transport
is the movement of molecules across a cell membrane it is used to move polar ionized drugs cross cell membranes
is a process by which cells ingest smal sac or vacuole
PO meds
bile is needed to facilitate the systemic absorption of fat soluble drugs. food stimulates bile absorption, therefore food helps the absportion of fat soluble drugs, food inhibits the absoprtion of water soluble drugs
the absence of hydrochloric acid in teh stomach inhibits the absoprtion of acid based drugs and inhibits the dissolution of alkaline or basic drugs
PH of drugs
acidic drugs are absorbed more rapidly by the acidic gastric mucosa. basic drugs are absorbed more rapidly by the more alkaline intestinal mucosa
enteric coated drugs
coating stays until it reaches the intestine. absence of bile and pancreatic enzymes inhibits the dissolution of enteric coated agents
subcutaneous injections
subcu tissue damage occurs readily. oils are irritating and are nto give subq maximum subq i one MM.
speedier than subq b/c of the rich blood supply in muscle. up to 2ml are tolerated well massage to the site after injection accelerates absorption
IV meds
usually only water based solutions. deliver IV push very slowly. fat emulsion during parenteral feeding may be administered by IV but central lines are best
drug half life
time needed fo rthe blood level of the drug to decrease by 50%
needed to distribute DNA during gene therapy. 2 = liposome, 2nd = virus
first pass effect
refers to absorption of drugs through the intestinal tract and the drugs entry into the portal circulation before entering the systemic circulation. first pass thru liver - detoxifies before going ststemic
are drugs that upon biotransformation (metabolis) in the liver, produce active metabolites ie heparin after passing through the liver becomes morphine
hepatic isoenzyme syste
performs an important role in biotransformation one major enzyme is P450 system. drugs that inhibit P450 speed it up
half life abbreviation
half life basics
water soluble drugs have short half life(hours) lipid solubles - days. digoxin = 36-48 hours
drug excretion
thru lungs, exocrine glands,kidneys liver and intestine.
glomerular filtration rate
as fluid volume increases, the rate of filtration increases and the rate of reabsorption decreases
urine PH
acidic urine pH traps acidic drugs and an alkaline urine pH traps alkaline drugs
Undesired drug effects
may be categorized as iatrogenic effects, side effects adverse effects, toxic effects, allergic and immunological reactions and carcinogenic, chain reaction, cumulative, idiosyncratic and teratogenic reactions
iatrogenic effects
a illnes induced in the client by the drug. ie ace inhibitors can cause a cough
medication side effects
actions or effects of a drug that are not specifically intended. althought usually adverse they may also be beneficial.
bone marrow supression signs and symptoms
anemia, neutropenia, thrombocytopenia,
neurotoxic reactions from medications
CNS-confusion,excitation, sedation, thought distrubances, depression
ANS- constipation, diarrhea
PNS - paresthesias, perpheral neuritis, cranial nerve deficits
Stevens Johnson syndrome
caused by some PCN, sulfa. hydantoins, allopurinol.. progressive and erosive involvement of mucous membranes of the mouth, esophagus nose nasopharynx, trachea bronchial tree and genitalia.
toxic epidermal necrosis
caused by same agent as stevens johnson syndrome. similar reaction, but progresses to 30% loss of epidermis due to necrosis
anticoagulant induced skin necrosis
occlusive thrombi of vessels supplying skin and subq tissue of areas with large amounts of adipose tissue
toxic effect of drugs
those effects secondary to an elevated plasma concentration of the drug
allergic / immunologic reaction drug reaction
account for 10-50% of all adverse drug reactions. 4 types I,II, III, IV
Type I reaction
results from IgE. characterized by uticaria, angioedema and anaphylaxis. first sign = may be difficulty swallowing or breathing.
Type II reaction
IgG and sometimes IgM. s&s those of hemolysis (break down of RBC). FEever. Acute flank pain - RBC affecting Kidneys. . bad blood - clerical error
Type III reaction
antigens interact with antibodies resulting in serum sickness. Fever, arthralgia rash. within a few days of injection. ersolves 7-14 days
Type IV reaction
rash, 2dary to topical agents. mediated by T Cells. rare with systemic drugs
carcinogenic reaction
drug induce3d changes in DNA
chain reaction of medication
ie steroid PT - sodium retention, increased fluid volume, HTN, etc.
cumulative effects of drugs
serum plasma level sof a drug rise or when the amount ingested exceeds that excreted. digoxin can have a cumulative effectt with no S&S.
intradermal agents
a minute amount of agent is injected. producing a tiny buldge in the skin. - TB
eyedrops and ointments
dropped into lower conjunctival sac, never onto the cornea.
ear drop meds
kids pull ear lobe down and back. adults, pull up and back. tepid water to prevent vertigo
metered dose inhaler
do not put all the way in mouth. can use a spacer. driven by a gas propellent.
six general principals of using inhalers
1. allow 1-2 minutes btw puffs 2. after inhaling, hold breath. 3. wash 2qd. 4. rinse mouth 5. have a back up. 6. never use long acting meds for asthma attack.
delivers a fine mist or spray. spinhalers and roahaler accept capsules or powder.
calculating pediatric meds
need ht, wt, and body surface area. if drug is not exceptionally toxic, can use wt as guideline.
IV flow rates
ml x dropss / milileters
how many drops per minute to give 1000 ml in 480 minutes using a drop factor of 15
1000ml x 60 drops/ml
480 minutes = 124.8 = 125
titrating a dose or titratino
refers to adjusting a dowe to achieve a desired effect. oral and iv meds may be titrated.
IV dosage rations
if the ratio is 1:6 then the proportion is 1/6 or 0.167
a proportion multipled by 100 yields a percent
five rights for patients meds
drug, dose, client, route, time.
right drug
medication administration record,Kardex and the drug label must all agree
therapeutic index
a measure of the relative safety of a drug. If 100 animals test the lethal dose / effective dose yields the therapeutic index. Higher T1 = safter
plateu or steady state principal
refers to the fact that when a drug is given at fixed intervals, it takes four or five half lives for its plasma concentration to reach a steady staet or plateau level
trough level
refers to the plasma concentration of the drug prior to the next dose. rising trough level implies increasing risk of toxicity
drugs & pregnancy ratins
A.B.C.D,X. A- least harful to the fetus .
glucose 6 phosphate dehydrogenase. controls level of methaemoglobin. affects drug metabolism.
I & O
under supervision CNA can monitor I & O. Output should be at least 2/3rds of intake. 30-60 ml per hour.
can give up to 3 doses under the tongue
thought disturbance
thought to be associated with a increased dopamine level
motor restlessness, pacing rocking or foot tapping
acute muscle spasms of neck face jaw tongue or hyperarching of the back
tardive dyskinesia
involuntary and abnormal face arm or leg movements. tongue darting, lip smacking
used to tx seizures, long term use causes mouth issues.
medication effects on the automnomic nervious system
r/t effect on adrenergic and cholinergic systems. (sympa / para).
Monomine oxidase - A
A=alpha, means metabolized or degrades nonepinephrine antidepressent
(b - beta) txs parkinson's disease
result from cancer chemotherpay. it is an inflammation of themout and may be accompanied by ulceration and dry mouth
hematologic effects from medication
occur as a resultl of administration of agent sthat alter the production of red blood cells, white blood cells, platelets and or hemoglobin that increases or decreases clotting ability.
folic acid deficiency
may lead to megablostic anemia recommend all wome of child bearing age take .4 mg
pernicious anemia
no intrisnic factor, bitamin B12 cannot be absorbed, which causes abornmal RBC production.
platelet count
overproduction of platelets. polycythemia ver is a disease characterized by an overproduction of platelets
fibrinolytic agents
clot busters
hemostatic agent
used to control bleeding. Vitamin K -
common advic
based on unprofessional opinion
heiarchy of needs
most to least. food basic, air water etc. nest, sex, next safety, love, esteem, self actualization