Exam 1 Flashcards
1
Q
critical thinking is the foundation for
A
effective communication
2
Q
domains of nursing
A
nursing learning health individuals
3
Q
7 core concepts
A
caring, professionalism, role competence, communication, cultural sensitivity, critical thinking, research and evidence based medicine
4
Q
Caring
A
reflects valuing of others, nurses commitment to concern of self and others, theorist Jane Watson
5
Q
professionalism
A
commitment to following core values, ethics, values and standards of nursing including advocacy, leadership, accountability, responsibility, and life long learning
6
Q
Role Competence
A
application of specialized nursing knowledge, values, and skills necessary to provide safe care to people in different settings
7
Q
Communication
A
exchange of facts, theorist Hildegard Peplau
8
Q
Cultural Sensitivity
A
process of recognizing accepting and respecting different world views, informed interaction with others
9
Q
Critical thinking
A
process that includes questioning, analysis, interpretation, inferences, and synthesis, that informs independent and interdependent nursing practices.
10
Q
Research and evidence based practice
A
research- purpose to generate new knowledge
evidence based- existing knowledge utilized for nursing
11
Q
nurse from the Latin word
A
nutrix meaning nourish
12
Q
no longer true that ‘a nurse is a nurse’
A
area oriented can blindly go to a different floor
13
Q
Virginia Henderson’s definition of nursing
A
assist sick or well, contributing or teaching about health or recovery (or peaceful death) that would be preformed unaided if they had the strength, will, or knowledge, and to help them regain independence as quickly as possible.
14
Q
nursing is both a
A
science and an art
15
Q
four broad aims for nursing practices
A
promote health, prevent illness, restore health, and facilitate coping
16
Q
major goal for nursing is
A
client advocacy- speech for client when they are unable to for them self
17
Q
nursing is now recognized as a
A
profession
18
Q
criteria for a profession
A
according to Bixler: High intellectual level (critical thinking), high level of individual responsibility and accountability, authority, specialized knowledge, higher education, public service, code of ethics, have license
19
Q
career
A
person’s major life work
20
Q
job
A
group of positions that are similar in nature and skill, can be taught to anyone with similar skills
21
Q
power
A
ability or capacity to exert influence over another person or group
22
Q
sources of power
A
referent, expert, reward, coercive, legitimate, and collective
23
Q
referent
A
power from close personal relationship with someone, parent or spouse
24
Q
expert
A
power from knowledge, skills, or expertise…. professional such as doctor or manager
25
reward
power from the ability of one person to give another some type of reward for behaviors, job rewards
26
coercive
power from ability to punish or withhold reward, jobs
27
legitimate
power from legal act that gives them right to make decisions,, political
28
collective
power of a large group with similar beliefs, desires or needs... nursing is the largest group in healthcare
29
ways to increase powers in nursing
professional unity, political activities, accountability and professionalism, networking
30
5 vital signs
temperature(T), pulse (P), respirations (RR), blood pressure (BP)
31
baseline vital signs
tell us usually state of health for comparison
32
vital signs are a quick way to
monitor condition, identify problems, evaluate response to interventions
33
Alteration in vital signs indicates
change in condition
34
who can take vital signs?
nurse aide, medical assistants, family, pt, RN (responsible for the meaning and making sure its done)
35
How often should vitals be taken?
depends on pt condition, change in floor or meds, dr orders, nurse judgment but must at least follow Dr order
36
body temperature
heat produced- heat lost
37
core body temperature
in deep tissues, rectal tympanic esophagus pulmonary artery and urinary bladder
38
surface temperature
oral or axillary
39
normal range for temperature
36C-37.5C, 97F-99.5F, mean of 98.6F or 37C
40
temperature is regulated by
the hypothalamus
41
mechanism for heat production
metabolism, muscular activity, piloerection, hormones, fever, temperature
42
mechanism for losing heat
sweating
43
processes of losing heat
radiation, conduction, convection, evaporation
44
fever
pyrexia, rise in body temperature (100.4), can be from bacterial or viral, also from tissue injury
45
febrile
have fever
46
afebrile
without fever
47
FUO
fever of unknown origin
48
neurogenic fever
caused by damage to the hypothalamus
49
oral temperature
average 98.6F or 37C, need closed mouth, easy accurate comfortable, must wait 30 minutes from eating or drinking, can't use on infants pt with o2 mask or face trauma
50
rectal temperature
average 99.5F and 37.5C, reliable core temp, cant be used on pt with diarrhea rectal surgery cardiac pt (can hit vegas never and decrease HR)
51
axillary temperature
average 97.7F or 36.5C, safe inexpensive, long measurement time and can be effected by position or environment
52
tympanic membrane temperature
average is 99.5F or 37.5C, easy provides core, not accurate in under 3 can also be inaccurate due to positioning
53
pulse caused by
contraction of the left ventricle
54
pulse is regulated by
SA node
55
parasympathetic NS
slows down HR
56
sympathetic NS
speeds up HR
57
normal pulse rate
60-100 bpm
58
tachycardia
HR >100 bpm
59
Bradycardia
HR < 60 bpm
60
pulse amplitude and quality
reflects volume of blood being ejected against the arterial wall 0-4(absent to bounding)
61
respiration
mechanism used to exchange o2 and co2 between the atmosphere and the blood and cells, regulated by the respiratory system in the brain stem
62
inspiration
act of breathing in (active)
63
expiration
act of breathing out (passive)
64
respirations average between
12-20 per minute in an adult
65
tachypnea
increased RR (over 24/min)
66
bradypnea
decreased RR (less than 10/min)
67
Apnea
absence of breathing
68
dyspnea
difficult or labored breathing
69
characteristics of respirations
depth-deep normal or shallow, rhythm-labored irregular or regular
70
blood pressure
force of blood against the arterial walls, provides tissue perfusion (pushes blood through the tissue)
71
BP=
cardiac output x peripheral resistance (smaller lumen)
72
arterial dilation
decreased BP
73
arterial constriction
increased BP
74
CO=
(cardiac output)= HR x stroke volume
75
BP is determined by
Cardiac output, vascular resistance, volume of blood, viscosity, and elasticity of arterial walls
76
systolic BP
peak of maximum pressure when ejection of blood from LV occurs, top #
77
diastolic BP
minimum pressure exerted against the arterial walls, when the LV relaxes, bottom #
78
measure of BP
in mm/Hg
79
normal range of BP
<120/80
80
prehypertension range
120-139/ 80-89
81
stage 1 hypertension range
140-159/ 90-99
82
stage 2 hypertension range
>160/>100
83
orthostatic hypotension
low blood pressure when rise position, SBP drops 20 points, caused by peripheral vasodilation w/o rise in CO, may be dizzy
84
which vital signs are routinely measured?
pulse ox, BP, P, RR, T
85
in clinical practice what sites can pulse be measured?
posterial tibial, radial, femoral, carotid
86
BP can be measured using a cuff _____ and _____
stethoscope and sphygmomanometer
87
normal arterial blood oxygen saturation is
95-100%
88
purposes for infection control
reduce or eliminate source of infection and to protect client from disease
89
client entering hospital are more at risk for infection bc
lower resistance, increased exposure to large number and type of disease organisms, they may have invasive procedures
90
order in which infection occurs
infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host
91
standard precautions
used on all clients apply when in contact with blood, fluids secretions, nonintact skin, mucous membranes
92
transmission based precautions
in addition to standard precautions for clients with suspected infection transmitted by airborne droplet or contact routes
93
Airborne precautions
transmitted by airborne droplet nuclei, private room, monitor negative air pressure(6-12 exchanges per hour), door closed, fitted HEPA mask, for things like TB chicken pox and rubella
94
droplet precautions
transmitted by large droplet, private room, door may be open, surgical mask within 3 ft, for things like rubella mumps diphtheria flu
95
contact precautions
spread by direct or indirect, private room, gloves, gown, dedicated equipment, for things like MRSA
96
types of healthcare associated infections (nosocomial)
exogenous, endogenous, and Iatrogenic
97
exogenous
causative organism from other people
98
endogenous
causative organism comes from germs person has
99
Iatrogenic
occurs as a result of treatment or diagnostic procedure
100
key factors in disinfection
time, concentration of chemical, temperature of chemical, type of organism
101
major classes of chemical compounds
chlorine(effective against AIDS), iodine (bactericidal), ethyl/isopropyl alcohol (antiseptic, germicide)
102
asepsis
absence of disease producing microorganisms
103
pathogen
disease producing microorganism
104
medical asepsis
practice to prevent spread of pathogens, clean technique
105
isolation technique
practice to prevent transmission of microorganisms
106
assessment process
collection, validation, organization, and recording data
107
database assessment
comprehensive (all aspects of health)
108
focus assessment
determine state of specific condition
109
maslow's hierarchy of needs high priority
at the bottom 1)physiological needs 2)safety and security 3) love and belonging 4)self esteem 5) self actualization
110
physiological needs
activity and exercise, normal temp, food balance, sexuality, cleanliness, no pain, water-salt balance, o2 and circulation, sleep
111
safety and security
dependence, stability, protection from harm
112
love and belonging
love and affection, acceptance, approval from others, unity with loved ones
113
self esteem needs
usefulness, self reliance, goal achievement, independence, endurence
114
esteem from others
dignity, attention, importance
115
self actualization needs
personal growth, awareness, increased learning, religious satisfaction
116
parts of a rapid assessment
ABC, what's going into/out of the pt, pain, and safety
117
nursing goal in wound care
promote tissue repair
118
intentional wound
planned therapy or treatment, risk of infection is low, surgery IV lumbar puncture
119
unintentional wound
unexpected trauma, high risk of infection, accidents burns forceful injury
120
open wound
can be intentional or unintentional, skin surface is broken
121
closed wound
result of blow, skin surface not broken but soft tissue is damaged
122
acute wound
recent injury, less than 30 days old
123
chronic wound
persist beyond healing time, can require serial debridements
124
abrasion
friction of skin
125
puncture
penetrating trauma
126
laceration
open wound or cut, ragged edges with torn tissues
127
contusion
bruise
128
avulsion
catching leg on door, skin completely torn away from the body
129
staging pressure ulcers
1) red nonblanchable 2)actual break in skin, blister 3) beyond dermis into subcutaneous tissue 4) extends to muscle or bone
130
red wound
needs protection
131
yellow wound
infection, needs cleaning
132
black wound
eschar, needs debridement
133
serous wound drainage
clear and watery
134
sanguineous
looks like blood
135
serosanguineous
combination of clear and blood
136
purulent
yellow/green foul smell
137
non-stick dressing
prevent dressing from stick to wound, petrolatum or telfa
138
gauze
most common, also for packing
139
transparent dressing
applied over small wound protect skin from shearing, Op site
140
hydrocolloids
absorb drainage, occlusive and adhesive, provides cushioning, Duoderm
141
hydrogels
o2 permeable, non-adhesive maintains moisture, Aquasorb
142
hemorrhage
excessive bleeding after first 48 hours of surgery, internal swelling, apply additional dressing and watch VS, DO NOT REMOVE ORIGINAL DRESSING
143
hematoma
bruise, localized collection of blood
144
infection
usually 2-11 days, increased drainage (purulent), increased WBC in labs
145
dehiscence
serious, something gave way, increase serosanguineous post op 4-5 day
146
Evisceration
organ comes out
147
fistula
tube like passage way that forms between 2 organs
148
fight or flight response
arousal of sympathetic NS, prepares body for action
149
medulla oblongata
controls HR BP and RR
150
reticular formation
continuously monitors the physiological status of the body through connection with sensory and motor tracts
151
pituitary gland
produces hormones that adapt to stress, regulates other hormones, feedback mechanism
152
three stage reaction to stress
1) Alarm stage 2) resistance stage 3) exhaustion stage
153
GAS
general adaptive syndrome
154
alarm reaction
can last one minute to several hours, increase pupil dilation HR hormone level blood volume blood glucose levels blood flow to muscles o2 intake and mental alertness
155
resistance stage
body stabilizes and returns to normal
156
exhaustion stage
body can no longer resist effects of stress, may result in death
157
Lazarus theory
transactional stress theory- cognitive affect coping response
158
psychological indicators of stress
anxiety, anger, depression
159
cognitive indications of stress
problem solving, self control, suppression, day dreaming
