Exam 1 Flashcards
What is included in physical assessment
Subjective and objective data
Subjective data
Reported by patient, family, another member of health team
Objective data
What nurse observes, labs, xrays.
Vital signs
Temp
Pulse
Respiration
Blood presusre
Pain
Oxigenation
What does elevated temp mean
Infection
Is there an infection if body temp is normal
No
What does elevated temp do to immune system
Activates immune systsem
Hyperthermia
High body temp/fever
Hypothermia
Low body temp
Things that affect body temp
Food and fluid consumption, menstrual cycle, age, etc
Normal body temp
98-98.6 F
Pulse
60-100 BPM
Respiration
12-20 breaths per min
Blood pressure
Below 120/80
Elevated
120-129 systolic and below 80 diastolic(double check)
Hypertension 1
130-139 systolic or 80-89 dyastolic
Hypertension 2
140 or above systolic or 90 or above dyastolic
Hypertensive crisis
Above 180 systolic and or above 120 diastolic
MRSA
Surgical site contact staph infection
Caused by poor hand hygiene
CAUTI
Catheter acquired UTI-reportable to the CDC
Indwelling catheter effects
Loss of bladder muscle tone
What can catheters cause
UTI and urinary retention after removal
How log can a catheter stay in
72 hours
Five rights of delegation
Right person
Right task
Right direction
Right curcumstance
Right supervision
Right person
Has to be competent to complete task
Right task
Has to be within scope of practice, job description
Patient centered care
Foundation of nursing. Including patient and all members of treatment team
Should nurses always try to make sure patients are informed about care
Yes
Do nurses function as advocates
Yes
Purpose of nursing process
Identify actual and potential problems
Perform interventions to address those problems
Protect nurses against legal liability
ANA
Nursing organization
Assess
Collect and analyze data
Diagnose
Interpret data and draw conclusions.
Plan
Care plan, goals, outcomes, interventions
Intervention
Executing the care plan
Evaluation
Did the care plan work
Pneumonia
HAI caused by poor hand hygiene
Should we take temp on someone who just drank or ate
No. Wait 15-30 mins.
Radial pulse
On wrist
Apical pulse
Point of Maximum impulse
Fifth intercostal space, midcloviculie
What type of transmission is TB
Airborne and droplet
Ppe for airborne
N95
Ppe for contact
Gloves and gown
Ppe for droplet
Gloves, mask, gown, goggles
Temp routes
Axillary-underarm
Tempanic-in ear
Oral
Rectal
Skin
What kind of patients receive oral and rectal temp
Stable
Dangers of rectal temp
Vagal nerve is affected which can cause cardiac arrest
What route do unstable patients use
Axillary and tympanic
What is considered a fever
99.6 F and above
Hypothermia temp
Below 95 F
All pulses
Instructions for clients before blood pressure
No smoking or drinking 30 mins prior
Record date, time, and pressure
Take multiple readings
Call provider if there are several high readings
Chain of infection
Pathogen
Reservoir
Portal of exit from reservoir
Mode of transmission
Portal of entry
Susceptible host
Types of infection
Local
Systemic
Bacteremia
Septicemia
Local infection
Only one part of body
Systemic infection
Throughout body
Bacteremia
Blood culture shows bacteria/pathogen
Septicemia
Systemic bacteremia
Acute infection
Sudden and short term
Chronic infection
Gradual and long lasting
Nosocomial/HAI
UTI-improper catheter care
Surgery site- staph infections. Poor hand hygiene.
Bloodstream-poor IV care
Pneumonia-poor hand hygiene
Specific defenses
Active
Passive
Active immunity
You create your own antibodies naturally
Passive
Body gets antibodies elsewhere. Vaccines and breast fewding.
Should we investigate cultural preferences
Yes
Durable power of attorney
When a competent individual gives someone else legal ability to make decisions if they are ever incompetent
Duty
Obligation to do something
Injury
Physical or mental harm or violation of a persons rights due to negligence
Malpractice
Deviation from standard
Negligence
Deviation from standard
Example of staph
MRSR and pneumonia
Is TB chronic or acute
Chronic
