Exam 1 Flashcards
The Nursing Process : ADPIE
A- Assessment
D- Diagnosis
P- Planning
I- Implementation
E- Evaluation
Assessment
Patient, family, and community all takes part of assessment. Collecting data from this groups with both subjective and objective data.
Diagnosis
Analyzing and interpreting data from assessment, Identifying meaningful patterns and identifying nursing diagnosis. Prioritizing the problems
Planning
Identifying outcomes and developing plan. SMART goals are used: Specific, Measurable, Achievable, Realistic, Timely.
Implementation
Put the plan to action, interventions, considers patient specific adaptations to interventions
Evaluation
Evaluating outcomes and progress. Did it improve patient well being and help move them toward the goal?
Maslow’s Hierarchy of Needs
physiological needs- Safety and Security- Love and Belonging- Self-esteem- Self-actualization
Physiological need
Breathing, food, water, shelter, clothing, sleep
Safety and Security
health, employment, property, family and social stability
Love and Belonging
friendship, family, intimacy, sense of connection
Self-esteem
confidence, achievement, respect of others, the need to be a unique individual
Self-actualization
morality, creativity, spontaneity, acceptance, experience purpose, meaning and inner potential
When should vital signs be obtained?
-Admission
-Assessment in clinic or home care
- Per order in hospital
- Before, during, and after invasive procedures or surgery
- Blood transfusion protocol
- As needed
Heat production
Shivering, Exercise, Emotional stress or anxiety, Infection or illness
Heat Loss
Sweating, Vasodilation, Environmental factors
Fever
hypothalamus elevates body temperature
Hyperthermia
body temperature is elevated, not initiated by hypothalamus
Hypothermia
prolonged exposure to cold
Frostbite
ice crystals form inside vessels
Tachycardia
elevated pulse: Exercise, fever, pain, emotional distress, medications, postural changes, poor oxygenation, hemorrhage, cardiac dysrhythmias
Bradycardia
decreased pulse: athletic condition, medications, hypothermia, cardiac dysrhythmias
BP Elevated
Emotional distress, Caffeine, Nicotine, Medications or illicit substances, Atherosclerosis, hypertension
BP Decreased
Low blood volume, Cardiac dysfunction, Medication, Orthostatic or postural hypotension
Infection
Pathogen invades tissues and begins growing with the host. Can cause damage or alteration in the tissue
Colonization
Presence of microorganisms within a host but without tissue invasion or damage
Infectious disease
A disease that can be transmitted to humans
Chain of Infection
Pathogen-Reservoir-Portal of Exit- Mode of transmission- Portal of entry- Susceptible host
Pathogen
The thing that causes infection like bacteria, viruses, fungi, or parasites.
Reservoir
The habitat of the infectious agent. Lifes within a host and can survive because of food, water, temp, light, oxygen, and pH
Portal of Exit
How it leaves the host and moves to another person.
Coughing, bodily secretions, feces
Mode of Transmission
Direct contact, Indirect contact, Blood borne, Droplet, Airborne, Vectors like insects
Portal of Entry
How the infection gets into the host. Mouth, eyes, nose, cuts in skin.
Susceptible host
Elderly, Infants, Immunocompromised
Barrier defenses in humans
Skin is a physical barrier, body systems, inflammatory response, Mucus
Stages of infection
Incubation: Introduction of the pathogen to the body, no symptoms yet.
Prodromal: Non-specific symptoms to Specific symptoms
Illness: Display of specific symptoms
Convalescence
Standard Precautions
All patients. Hand hygiene and medical aseptic practices. Wear PPE when needed
Isolation Precaution
Likely require private rooms
Contact Precaution
Gown and gloves always. Used with Drug-resistant organisms. MRSA, VRE, CRE, ESBL, Scabies
Contact Enteric Precaution
Gown and Gloves always, SOAP AND WATER, and Bleach wipes. Used when dealing with the GI system. -CDIF, Norovirus
Droplet Precaution
Surgical mask always and may need N95. Used for: mumps, rubella, influenza, rhinovirus
Airborne Precaution
N95 mask required with a negative pressure room. Used with: TB, Measles, chickenpox, and shingles
Protective Precautions
Require HEPA filtration, you can’t enter the room if you are sick. Often called reverse isolation. Used for immunocompromised patients
Isolation Precautions
PPE, isolation environment, specimen collection, Bagging trash and linen.
Informed Consent
The RN’s role is to witness the signature of consent after the provider has discussed and obtained consent. Answer clarifying questions.
Standards of Nursing Practice: ANA
Reflects the knowledge and skill ordinarily possessed and used by nurses. Often developed by professional organizations such as ANA
Legal Scope of Nursing Practice: Nurse Practice Act
Outlines what you can/ can’t do, obligations, and educational requirements. Each state has its own.
Assessing, Recording/Reporting, Planning, Implementing, Evaluations, Teaching, Collaborating
Negligent Acts
Failure to assess or monitor, failure to notify, failure to follow orders, failure to follow the seven rights of medication administration.
Legal Safeguards
Informed consent- Against Medical Advice form- Patient Education- Executing physician’s orders- Documentation- Adequate staffing- Risk management- Incident/Error reporting
Battery vs Assault
Battery: The act of actually hurting someone
Assault: The threat or attempt to hurt someone
Negligence and Malpractice
Care that falls below that of a prudent nurse. Malpractice is a type of negligence committed by a professional
Pharmacokinetics
Absorption, Distribution, Metabolism, Excretion
Pharmacokinetics: Absorption
Site of admin to Blood Stream.
Pharmacokinetics: Distribution
Blood stream to site of action. Circulation, membrane permeability, and protein binding
Pharmacokinetics: Metabolism
Site of action to breakdown/less active.
Pharmacokinetics: Excretion
Leftover/inactive med goes out of the body
Medication Effects
Med interaction: increases or decreases effect of another medication
Med tolerance: more meds are needed over time to achieve the same effect
Med dependence: Need the meds to et through the day. Can be psychological or physical
Onset
Time until therapeutic effect
Peak
Time until peak effectiveness
Duration
Length of time of therapeutic effect
Trough
minimum blood concentration reached just before next scheduled dose
Plateau
blood serum concentration maintained after repeated, fixed dose
Biological half-life
time until serum concentration is lowered by half
Around the Clock (ATC)
term for medication that is given at regularly scheduled intervals throughout the day
Routes of administration: Enteral- non oral
Meds entering the GI tract but not through the mouth. PT that can’t swallow or take med orally, administered through NG tube or GT tube. Liquids preferred but solids can be mixed with liquid
Routes of administration: Enteral- Oral
Solid (PO): capsule, table, chewable, enteric- coated
Liquid (PO): Elixirs, suspensions, syrups
Sublingual (SL): solid meds under the tongue
Buccal: solid med between the cheek and gum
Routes of administration: Parenteral
Intradermal: TB test, Subcutaneous: insulin, Intramuscular: vaccinations and antibiotics , Intravenous: IV push and IV PB
Routes of administration: Topical/Transdermal
Topical: Applied to skin: lotion, paste, ointment
Transdermal: disk or patch
Routes of administration: Inhalation
Directly to lungs: Aerosolized/Nebulizer, inhalers
Routes of administration: Ophthalmic
Eye treatment: intraocular disk, drops, ointment
Routes of administration: Nasal
Sprays, drops, Nasal tampon, saline, decongestants, and antibiotics
Routes of administration: Vaginal and Rectal
Inserted via applicator or suppository: can be creams, ointments, foam, or solid pill think
Medication Administration orders
Patients full name, Date, Time, Medication name, Dosage, Route of administration, Frequency, Signature of person that wrote the order
The 7 Rights
Right Patient, Right Medication, Right Dose, Right Time, Right Route, Right Expiration date/ Effect, Right Documentation
Prevention of Medication Errors
7 rights, Perform med rights 3 times, one patient at a time, use two patient identifies, eliminate interruptions, have another RN check
Medication Reconciliation
Obtain, Verify, and Document all at home meds, prescriptions, and over the counter meds including supplements. include date and time last taken. Compare obtained list to current med order
Patients Rights: MEDS
Right to be informed of medication name, purpose, action and effects
Right to refuse a medication
Right to have medication reconciliation and assessment of allergies
Right to be made aware and consent for experimental meds
Right to be made aware if meds are part of a research study
Right to receive no unnecessary meds
Integumentary system functions:
Protection, Body temp regulation, Sensation, Vitamin D production, Immunological, Absorption, Elimination
Closed Wounds
Hematoma (A bruise that has volume) , Contusion ( a flat bruise)
Open Wounds
Surface is not intact
Abrasion
Superficial wound
Laceration
Wound may be deeper then just the epidermis. Edges are not always clean
Puncture
small, circular, deep wound.
Serous wound drainage
Clear, watery plasma. This is normal
Serosanguinous wound drainage
Pale, red, watery drainage. A mixture of serous and sanguineous. Can be normal be is based on the amount of drainage
Sanguineous wound drainage
Bright red, indicates active bleedings.
Purulent wound drainage
Thick, yellow, green, tan, or brown drainage. Can be an indicator of infection
Primary intention
Surgical incision or wound closes through staples or sutures
Secondary intention
Heals on its own through granulation
Types of wound closures
Surgical glue, sutures (in for a week or two), staples, steri-strips. When staples get taken out Steri-strips are placed on closure
Wound healing influencing factors
Nutrition: caloric intake ( increase protein, Serum Albumin) (vitamin A, C, Zinc) , Tissue perfusion (circulation), infection, age
Infection Prevention at the surgical site
Bathe prior to surgery, consider pre-op antibiotics, Glycemic control, Normal temp
Pressure injuries
4 Stages: Stage 1 is intact skin that is non-blanchable, redness or discolored. Stage 2 is partial thickness loss involving epidermis or dermis lost. Stage 3 is full thickness loss with dermis and fat loss. Stage 4 is Full thickness loss with exposed bone, muscle, tendon.
Braden Scale
Mild: 15-18
Moderate: 13-14
High: 10-12
Assessment of wounds
Inspect all surfaces of skin, Utilized Braden scale, note risk factors, assess home care regimen and impact of mobility, assess signs of infections, assess pain and comfort. look at color, location, size, drainage.
Macerated
Soft, Wrinkled skin often caused by moisture
Indurated
Thickened, hardened skin due to inflammation.
Tunneling VS Undermining
Tunneling is when one area of the wound has a narrow channel going deeper into the tissue. Can be caused by dehydration
Undermining is when the wound there is a separation of the wound edge from the underlying tissue. Can be caused by moisture
Planning and outcomes of wound care
Goal is to maintain skin integrity, absence of additional skin breakdown, increase in new tissue growth, increase in caloric intake, improve or get rid of infection, improve mobility, decrease moisture, work as a team.
Implementation of wound care
Turning every two hours, pressure reduction mattress, barrier cream, incontinence care, getting adequate nutrition. Keep wound bed moist and peri-wound dry, keep wound covered, Use normal saline to clean.
Evaluation of wound care
Prevention of injury, Reduce further injury, Promote healing of tissue, Impact on mobility, comfort, infection, Patient and family understanding.
