Exam 1 Flashcards
critical thinking is the foundation for
effective communication
domains of nursing
nursing learning health individuals
7 core concepts
caring, professionalism, role competence, communication, cultural sensitivity, critical thinking, research and evidence based medicine
Caring
reflects valuing of others, nurses commitment to concern of self and others, theorist Jane Watson
professionalism
commitment to following core values, ethics, values and standards of nursing including advocacy, leadership, accountability, responsibility, and life long learning
Role Competence
application of specialized nursing knowledge, values, and skills necessary to provide safe care to people in different settings
Communication
exchange of facts, theorist Hildegard Peplau
Cultural Sensitivity
process of recognizing accepting and respecting different world views, informed interaction with others
Critical thinking
process that includes questioning, analysis, interpretation, inferences, and synthesis, that informs independent and interdependent nursing practices.
Research and evidence based practice
research- purpose to generate new knowledge
evidence based- existing knowledge utilized for nursing
nurse from the Latin word
nutrix meaning nourish
no longer true that ‘a nurse is a nurse’
area oriented can blindly go to a different floor
Virginia Henderson’s definition of nursing
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.
nursing is both a
science and an art
four broad aims for nursing practices
promote health, prevent illness, restore health, and facilitate coping
major goal for nursing is
client advocacy- speech for client when they are unable to for them self
nursing is now recognized as a
profession
criteria for a profession
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
career
person’s major life work
job
group of positions that are similar in nature and skill, can be taught to anyone with similar skills
power
ability or capacity to exert influence over another person or group
sources of power
referent, expert, reward, coercive, legitimate, and collective
referent
power from close personal relationship with someone, parent or spouse
expert
power from knowledge, skills, or expertise…. professional such as doctor or manager
reward
power from the ability of one person to give another some type of reward for behaviors, job rewards
coercive
power from ability to punish or withhold reward, jobs
legitimate
power from legal act that gives them right to make decisions,, political
collective
power of a large group with similar beliefs, desires or needs… nursing is the largest group in healthcare
ways to increase powers in nursing
professional unity, political activities, accountability and professionalism, networking
5 vital signs
temperature(T), pulse (P), respirations (RR), blood pressure (BP)
baseline vital signs
tell us usually state of health for comparison
vital signs are a quick way to
monitor condition, identify problems, evaluate response to interventions
Alteration in vital signs indicates
change in condition
who can take vital signs?
nurse aide, medical assistants, family, pt, RN (responsible for the meaning and making sure its done)
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
body temperature
heat produced- heat lost
core body temperature
in deep tissues, rectal tympanic esophagus pulmonary artery and urinary bladder
surface temperature
oral or axillary
normal range for temperature
36C-37.5C, 97F-99.5F, mean of 98.6F or 37C
temperature is regulated by
the hypothalamus
mechanism for heat production
metabolism, muscular activity, piloerection, hormones, fever, temperature
mechanism for losing heat
sweating
processes of losing heat
radiation, conduction, convection, evaporation
fever
pyrexia, rise in body temperature (100.4), can be from bacterial or viral, also from tissue injury
febrile
have fever
afebrile
without fever
FUO
fever of unknown origin
neurogenic fever
caused by damage to the hypothalamus
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
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)
axillary temperature
average 97.7F or 36.5C, safe inexpensive, long measurement time and can be effected by position or environment
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
pulse caused by
contraction of the left ventricle
pulse is regulated by
SA node
parasympathetic NS
slows down HR
sympathetic NS
speeds up HR
normal pulse rate
60-100 bpm
tachycardia
HR >100 bpm
Bradycardia
HR < 60 bpm
pulse amplitude and quality
reflects volume of blood being ejected against the arterial wall 0-4(absent to bounding)
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
inspiration
act of breathing in (active)
expiration
act of breathing out (passive)
respirations average between
12-20 per minute in an adult
tachypnea
increased RR (over 24/min)
bradypnea
decreased RR (less than 10/min)
Apnea
absence of breathing
dyspnea
difficult or labored breathing
characteristics of respirations
depth-deep normal or shallow, rhythm-labored irregular or regular
blood pressure
force of blood against the arterial walls, provides tissue perfusion (pushes blood through the tissue)
BP=
cardiac output x peripheral resistance (smaller lumen)
arterial dilation
decreased BP
arterial constriction
increased BP
CO=
(cardiac output)= HR x stroke volume
BP is determined by
Cardiac output, vascular resistance, volume of blood, viscosity, and elasticity of arterial walls
systolic BP
peak of maximum pressure when ejection of blood from LV occurs, top #
diastolic BP
minimum pressure exerted against the arterial walls, when the LV relaxes, bottom #
measure of BP
in mm/Hg
normal range of BP
<120/80
prehypertension range
120-139/ 80-89
stage 1 hypertension range
140-159/ 90-99
stage 2 hypertension range
> 160/>100
orthostatic hypotension
low blood pressure when rise position, SBP drops 20 points, caused by peripheral vasodilation w/o rise in CO, may be dizzy
which vital signs are routinely measured?
pulse ox, BP, P, RR, T
in clinical practice what sites can pulse be measured?
posterial tibial, radial, femoral, carotid
BP can be measured using a cuff _____ and _____
stethoscope and sphygmomanometer
normal arterial blood oxygen saturation is
95-100%
purposes for infection control
reduce or eliminate source of infection and to protect client from disease
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
order in which infection occurs
infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host
standard precautions
used on all clients apply when in contact with blood, fluids secretions, nonintact skin, mucous membranes
transmission based precautions
in addition to standard precautions for clients with suspected infection transmitted by airborne droplet or contact routes
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
droplet precautions
transmitted by large droplet, private room, door may be open, surgical mask within 3 ft, for things like rubella mumps diphtheria flu
contact precautions
spread by direct or indirect, private room, gloves, gown, dedicated equipment, for things like MRSA
types of healthcare associated infections (nosocomial)
exogenous, endogenous, and Iatrogenic
exogenous
causative organism from other people
endogenous
causative organism comes from germs person has
Iatrogenic
occurs as a result of treatment or diagnostic procedure
key factors in disinfection
time, concentration of chemical, temperature of chemical, type of organism
major classes of chemical compounds
chlorine(effective against AIDS), iodine (bactericidal), ethyl/isopropyl alcohol (antiseptic, germicide)
asepsis
absence of disease producing microorganisms
pathogen
disease producing microorganism
medical asepsis
practice to prevent spread of pathogens, clean technique
isolation technique
practice to prevent transmission of microorganisms
assessment process
collection, validation, organization, and recording data
database assessment
comprehensive (all aspects of health)
focus assessment
determine state of specific condition
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
physiological needs
activity and exercise, normal temp, food balance, sexuality, cleanliness, no pain, water-salt balance, o2 and circulation, sleep
safety and security
dependence, stability, protection from harm
love and belonging
love and affection, acceptance, approval from others, unity with loved ones
self esteem needs
usefulness, self reliance, goal achievement, independence, endurence
esteem from others
dignity, attention, importance
self actualization needs
personal growth, awareness, increased learning, religious satisfaction
parts of a rapid assessment
ABC, what’s going into/out of the pt, pain, and safety
nursing goal in wound care
promote tissue repair
intentional wound
planned therapy or treatment, risk of infection is low, surgery IV lumbar puncture
unintentional wound
unexpected trauma, high risk of infection, accidents burns forceful injury
open wound
can be intentional or unintentional, skin surface is broken
closed wound
result of blow, skin surface not broken but soft tissue is damaged
acute wound
recent injury, less than 30 days old
chronic wound
persist beyond healing time, can require serial debridements
abrasion
friction of skin
puncture
penetrating trauma
laceration
open wound or cut, ragged edges with torn tissues
contusion
bruise
avulsion
catching leg on door, skin completely torn away from the body
staging pressure ulcers
1) red nonblanchable 2)actual break in skin, blister 3) beyond dermis into subcutaneous tissue 4) extends to muscle or bone
red wound
needs protection
yellow wound
infection, needs cleaning
black wound
eschar, needs debridement
serous wound drainage
clear and watery
sanguineous
looks like blood
serosanguineous
combination of clear and blood
purulent
yellow/green foul smell
non-stick dressing
prevent dressing from stick to wound, petrolatum or telfa
gauze
most common, also for packing
transparent dressing
applied over small wound protect skin from shearing, Op site
hydrocolloids
absorb drainage, occlusive and adhesive, provides cushioning, Duoderm
hydrogels
o2 permeable, non-adhesive maintains moisture, Aquasorb
hemorrhage
excessive bleeding after first 48 hours of surgery, internal swelling, apply additional dressing and watch VS, DO NOT REMOVE ORIGINAL DRESSING
hematoma
bruise, localized collection of blood
infection
usually 2-11 days, increased drainage (purulent), increased WBC in labs
dehiscence
serious, something gave way, increase serosanguineous post op 4-5 day
Evisceration
organ comes out
fistula
tube like passage way that forms between 2 organs
fight or flight response
arousal of sympathetic NS, prepares body for action
medulla oblongata
controls HR BP and RR
reticular formation
continuously monitors the physiological status of the body through connection with sensory and motor tracts
pituitary gland
produces hormones that adapt to stress, regulates other hormones, feedback mechanism
three stage reaction to stress
1) Alarm stage 2) resistance stage 3) exhaustion stage
GAS
general adaptive syndrome
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
resistance stage
body stabilizes and returns to normal
exhaustion stage
body can no longer resist effects of stress, may result in death
Lazarus theory
transactional stress theory- cognitive affect coping response
psychological indicators of stress
anxiety, anger, depression
cognitive indications of stress
problem solving, self control, suppression, day dreaming
