Exam 1 Flashcards
Normal Blood Pressure
<120/<80
Normal Pulse Range
60-100 bpm
Normal Respiratory Rate Range
12-20 breaths/min
Normal Temp Range
96.4 - 99.5 F
Normal Pain Rating
0
Oral Temp Range
97.7 - 99.5 F (accurate)
Rectal Temp Range
98.7 - 100.5 F (1 degree more than oral)
Axillary Temp Range
96.7 - 98.5 F (1 degree less than oral)
Tympanic Temp Range
98.2 - 100 (not accurate)
Radiation
diffusion of heat by electromagnetic waves
ex: remove blanket
Convection
fan/cold shower/AC
Evaporation
sweating (liquid to vapor)
Conduction
transfer of heat to object w/ direct contact
ex: ice pack
Factors that Affect Body Temperature
circadian rhythms, age & gender, physical health, state of health, environmental temperature
Pulse
regulated by the autonomic (automatic) nervous system through cardiac sinoatrial (SA) node
Parasympathetic Stimulation
rest and digest (decrease HR)
Sympathetic Stimulation
fight or flight (increase HR)
Dysrhythmia
irregular HR
Characteristics of Peripheral Pulse
rate, amplitude & quality, rhythm, volume
quality of perfusions: 0, 1+, 2+, 3+
Diffusion
exchange between alveoli and blood
Perfusion
exchange between blood and tissue cells
Rate/Depth of Respirations
shallow breaths/fast
anxiety, exercise, asthma, infections
Rhythm of Respirations
steady rhythm
sleep apnea, fear, before death, heart failure
Orthopnea
breath better sitting up
Eupnea
normal breathing
Dyspnea
difficult/labored breathing
Pulse Pressure
difference between systolic and diastolic
Factors Affecting Blood Pressure
age, stress, exercise, obesity, emotions, fluid volume (dehydration), outside temp, infection (sepsis), hemorrhage, meds, food intake
Orthostatic Hypertension
temporary fall in BP (usually positional/changing position)
When to Assess Vital Signs
- on admission to any health care facility
- based on the facility/institutional policy
- any time there is a change in patient’s condition
- any time there is a loss of consciousness
- pre-op/post-op surgical or invasive diagnostic procedure (test) [post-op: check for complications every 15 min]
- before and after activity that may increase risk, such as ambulation after surgery
- before administering meds that affect cardiovascular and respiratory function [check 30 min before giving BP meds and cardiovascular meds]
Apnea
periods in which there is no breathing
Pyrexia
another name for “fever”
Bradypnea
decrease in respiratory rate
Hyperthermia
high body temp exposed to extreme heat
Pulse Deficit
difference between apical and radial pulse
Korotkoff Sounds
series of sounds which nurse listens for when assessing blood pressure with stethoscope
Tachypnea
increase in respiratory rate
Febrile
person with a fever
Hypothermia
low body temp exposed to extreme cold
Maslow’s Hierarchy of Needs
physiological needs
safety and security
love and belonging
self-esteem
self-actualization
Physiological Needs
oxygen, water, food, elimination, homeostasis, rest, sexuality
Prioritize ABC
A-airway
B-breathing
C-circulation
Nursing Care to Meet Physiological Needs
Oxygen: evaluate by assessing skin color, vital signs, anxiety levels, responses to activity, restlessness, and mental responsiveness
Intake & Output of Fluids: measure intake and output, test resiliency of skin, check condition of skin and mucous membranes, and weigh patient help assess a patient’s water balance
Food & Elimination: assessed w/ indiactors including weight, muscle mass, strength, and lab values
Safety and Security
physical components: security & protection, potential or actual harm
emotional components: involves trusting others and being free of fear/anxiety
Nursing Care to Meet Physical Safety
nurses meet needs by using proper hand hygiene and sterile techniques to prevent infection, using electrical equipment properly, administering meds knowledgable, skillfully moving and ambulating patients, teaching parents about household chemicals that are dangerous to children
Nursing Care to Meet Emotional Safety
encourage spiritual practices that provide strength and support, by allowing as much independent decision-making and control as possible, and by carefully explaining new and unfamiliar procedures and treatments
Love & Belonging
feeling of inclusion, acceptance, and belonging (giving and receiving love)
families, peers, friends, neighborhood, community
unmet needs can lead to isolation and loneliness
Nursing Care to Meet Love & Belonging Needs
include family and friends in care of patient, establish nurse-patient relationship based on mutual understanding and trust (by demonstrating care, encouraging, communication, and respecting privacy) and referring patients to specific support groups (such as cancer support groups or AA)
Self-Esteem
a need to feel good about oneself
sense of pride and accomplishment
positive self-esteem = confidence
Nursing Care to Meet Self-Esteem Needs
respect their values and beliefs, encouraging patients to set attainable goals, and facilitating support from family or significant others
Self-Actualization
the need for people to reach their full potential through development of their unique capabilities
each lower level need must be met first
process is lifelong
purposeful life
Nursing Care to Meet Self-Actualization Needs
focus on person’s strengths and possibilities rather than on problems
interventions are aimed at providing a sense of direction and hope and providing teaching that is aimed at maximizing potential
Verbal Communication
exchange of info using words, including both written and spoken word
this communication depends on a prescribed way of using words so that people can share info effectively known as language
Ex: oral reports, email/text professionally, calling, speaking w/ patients/families
Non-Verbal Communication
AKA body language
can help the nurse notice subtle and hidden meanings in what the patient is saying verbally
Ex: eye contact, touch, facial expressions, posture, sounds (signs, moans), appearance, gesture, dress/grooming, silence
Rapport
feeling of mutual trust experienced by people in a satisfactory relationship
Factors Influencing Communication
developmental level
biological sex
sociocultural differences
roles and responsibilities
physical/mental/emotional state
space and territory
environment
values
Purpose of SBAR
to eliminate the breakdowns in communication and potential adverse effects
Hand-Off Communication
occurs between nurses in other departments in the facility during nurse-to-nurse reports, or in nurse to physician/health care provider discussions
I-S-B-A-R-R
I - identify (self and patient)
S - situation
B - background (medical history)
A - assessment (thorough)
R - recommendation
R - readback
Phases of the Helping Relationship (Nurse-Patient Relationship)
orientation, working, termination
Orientation Phase of Nurse-Patient Relationship
introductions
establishing trust
setting the tone
provide info
establish routine
Working Phase of Nurse-Patient Relationship
LONGEST PHASE
assisting patient in physical/mental needs
motivate to learn, implement health promotion
caring and providing reassurance throughout day
Termination Phase of Nurse-Patient Relationship
conclusion
leaving for day
patient going home
review goals
satisfying feeling
introduce new nurse
Assertive Communication
stand up for self or others using open, honest, and direct communication
Nonassertive Communication
not stand up for self or others
Aggressive Communication
asserting one’s rights in a negative manner that violates the rights of others
Communication Blocks
failure to perceive patient as human being
failure to listen
changing the subject
giving false assurance
gossip and rumor
disruptive interpersonal behavior and communication
impaired verbal communication (elderspeak)
Nontherapeutic Comments & Questions
cliches (stereotyped, trite, pat answer)
yes or no questions
questions containing words Why & How
questions that probe for info
leading questions
comments that give advice
judgmental comments
Therapeutic Relationships w/ Patients
control tone of voice
be flexible, clear, and concise
be truthful
keep an open mind
take advantage of available opportunities
Incivility
rude, intimidating, and undesirable behavior directed at another person
Horizontal Violence
anger and aggressive behavior between nurses or nurse-to-nurse hostility
Bullying
negative, often repetitive, disruptive behavior; also referred to as horizontal violence, lateral violence, and professional incivility
Acute Illness
rapidly occurring illness that runs its course, allowing a person to return one’s previous levels of functioning
Chronic Illness
irreversible illness that causes permanent physical impairment and requires long-term healthcare
Disease
pathologic change in the structure or function of the body/mind
Exacerbation
period in chronic illness when the symptoms of the disease reappear
Health
state of optimal functioning or well-being
Health Disparity
a specific difference that is closely linked to social, economic, and/or environmental disadvantage
Health Equity
attainment of the highest level of health for all people
Health Promotion
behavior of an individual motivated by a personal desire to increase well-being and health potential
Holistic Healthcare
health care that takes into account the whole person interacting in the environment
Illness
abnormal process in which any aspect of the person’s functioning is altered (in comparison to the previous condition of health)
Morbidity
frequency that a disease occurs
Mortality
number of deaths
Remission
period in a chronic illness when the disease is present, but the person doesn’t experience symptoms
Risk Factor
something that increases a person’s chance for illness or injury
Social Determinants of Health
conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks
Vulnerable Population
disadvantaged subsegment of a community requiring utmost care, specific ancillary considerations and augmented protection in research; includes those living in poverty, women, children, older adults, rural and inner-city residents, new immigrants, homeless, mentally ill patients, and people w/ disabilities and special health care needs
Wellness
an active process in which an individual progresses toward the maximum possible potential, regardless of current state of health
Examples of Acute Illness
COVID-19, strep throat, appendicitis
typically need treatment (let it run its course)
Examples of Chronic Illness
cancer, heart disease, stroke, hypertension, diabetes, CHF
People of all ages
Example of Exacerbation
COPD (Chronic Obstructive Pulmonary Disease)
Factors Affecting Health & Illness
basic human needs
human dimensions (physical, emotional, intellectual, environmental, sociocultural, spiritual)
Modifiable Risk Factors
diet, alcohol consumption, and smoking
Non-Modifiable Risk Factors
age, family history, gender, ethnicity, race
Primary Level of Health Promotion and Illness Prevention
promoting health and preventing development of disease process or injury
Secondary Level of Health Promotion and Illness Prevention
focus is on screening for early detection of disease with prompt diagnosis and treatment of any found
Tertiary Level of Health Promotion and Illness Prevention
begins after an illness is diagnosed and treated with the goal of reducing disability and helping rehabilitate patients to a max level of functioning
Airborne Transmission
spreading of microorganisms that are less than 5 mcm when an infected host coughs, sneezes, or talks, or when the organism becomes attached to dust particles
coughs, sneezes, talks, becomes attached to dust particles
Ex: TB, COVID-19
Antibody
immunoglobin produced by the body in response to a specific antigen
Antigen
foreign material capable of inducing a specific immune response
Antimicrobial
antibacterial agent that kills bacteria or suppresses their growth
Asepsis
absense of disease-producing microorganisms; using methods to prevent infection
Bacteria
most significant and most commonly observed infection-causing agents
Bundles
evidence-based best practices that have proven positive outcomes when implemented together to prevent infection
Colonization
presence of an organism residing in an individual’s body but w/ no clinical signs of infection
Direct Contact
way for organisms to enter the body that involves proximity between the susceptible host and an infected person or a carrier, such as through touching, kissing, or sexual
Ex: HIV/AIDS, E. coli, Hepatitis B
Disinfection
process used to destroy microorganisms; destroys all pathogenic organisms except spores
Droplet Transmission
transmission of particles > 5 mcm
Ex: common colds, influenza, strep, pneumonia
Endemic
occurs w/ predictability in one specific region or population and can appear in a different location
Endogenous
infection in which the causative organism comes from microbial life harbored w/in person
Exogenous
infection in which causative organism is acquired from outside the host
Fungi
plant-like organisms (molds & yeasts) can cause infections
Health Care-Associated Infection (HAI)
infection not present on admission to health care institution and develops during course of treatment for other conditions (nosocomial)
Host
animal/person on or w/in which microorganisms live
Iatrogenic
infection that occurs as a result of a treatment or diagnostic procedure
Indirect Contact
personal contact w/ either a vector, living creature that transmits an infectious agent to a human, usually an insect; or an inanimate object (fomite) like equipment
Infection
disease state resulting from pathogens in or on body
Isolation
protective procedure designed to prevent transmission of specific microorganisms; aka protective aseptic techniques and barrier techniques
Medical Asepsis
practices designed to reduce the number of and transfer of pathogens; synonym for clean technique
Nosocomial
something originating/taking place in hospital
Ex: infection
Parasites
organism that lives on/in host and relies on it for nourishment
Pathogens
disease-producing microorganisms
PPE
gloves, gown, mask, and protective eye gear designed to minimize or prevent the healthcare workers exposure to infectious material
Reservoir
natural habitat for growth and multiplication microorganisms
Standard Precautions
CDC precautions used in care of all patients regardless of their diagnosis or possible infection status; combines universal and body substance precautions
Sterilization
process by which all microorganisms, including spores, are destroyed
Surgical Asepsis
practices that render and keep objects and areas free from microorganisms; sterile technique
Transmission-Based Precautions
CDC precautions used in patients known or suspected to be infected w/ pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions
Vector
nonhuman carriers - such as mosquitos, ticks, lice - that transmit organisms from one host to another
Virulence
ability to produce disease
Virus
smallest microorganism, can be seen only using electron microsope
Infection Cycle
1) Infectious agents
2) Reservoir
3) Portal of exit
4) Means of transmission
5) Portal of entry
6) Susceptible host
Stage 1 of Infection Cycle
Infectious Agents: pathogens cause infection/disease
bacteria (most common)
fungi
virus
parasites
Stage 2 of Infection Cycle
Reservoir: natural habitat of microorganisms
people/animals
food/water/milk
soil
inanimate objects
Stage 3 of Infection Cycle
Portal of Exit: point of escape for organisms from the reservoir
respiratory tract
gastrointestinal tract
genitourinary tract
blood
tissue
Stage 4 of Infection Cycle
Means of Transmission: route of an organism takes between transfer from reservoir to susceptible host
Direct: requires close contact/proximity between susceptible host and carrier
Indirect: contact w/ living creature that transmits infectious agent to human or inanimate objects
Stage 5 of Infection Cycle
Portal of Entry: point where organism enters new host
urinary tract
respiratory tract
gastrointestinal tract
SKIN
Stage 6 of Infection Cycle
Susceptible Host: source that provides microorganisms w/ nourishment and shelter
organisms are able to overcome hosts defense systems
Stages of Infection
Incubation Period
Prodromal Stage
Full Stage of Illness
Convalescent Period
Incubation Period
interval between pathogen’s first invasion and the appearance of symptoms
growing and multiplying
Prodromal Stage
most infectious stage
early s/s of disease present, may be mild
continues to be unaware of being contagious
Full Stage of Illness
infection-specific s/s present
acute illness stage
Convalescent Period
recovery from infection
symptoms disappear and person returns to previous health state
Who’s at Risk of Infections
poor skin integrity (wounds, surgical incisions)
age, sex, race (young and old more susceptible)
immunization status
general health status - over-stressed, fatigued, existence of illness
foleys, IV sites, central catheters
immunocompromised - chemo patients
Interventions to Break Chain of Infection
use hand hygiene diligently
carry soiled linens away from the body
avoid raising dust
dispose of waste properly
clean equipment as indicated
use PPE
clean least soiled items first then more soiled
avoid allowing patients to cough/sneeze/breathe directly on to others
Donning PPE
Gown
Mask/Respirator
Goggles/Face Shield
Gloves
Doffing PPE
Gloves
Goggles
Gown
Mask
Factors Affecting Safety
Developmental Considerations
Lifestyle
Environment
Mobility
Sensory Perception
Knowledge
Ability to Communicate
Physical Health State
Psychosocial Health State
Nursing Interventions to Promote Safety
non-skid socks
walkers
answer call lights
bed low to ground
Restraints
physical devices used to limit a patient’s movement
Chemical & Physical Restraints
Physical Restraints
increase possibility of serious injuries due to a fall
Chemical Restraints
drugs that are used to control behaviors and are not included in person’s normal medical regimen
Negative Outcomes from Use of Restraints
falls
skin breakdowns
mental side effects
incontinence
respiratory issues
depression/anxiety
Alternatives for Restraints
3 bed rails
low beds
bed alarm
sitters
distractions/redirection
Sentinel Event
unexpected occurrence involving death, or serious physical or psychological injury, or the risk of death or injury
“never events” because they should never happen
