Exam 1 Flashcards
Theory-based nursing practice helps you to?
design and implement nursing interventions that address individual and family responses to health problems.
Nurses develop theories to explain?
relationships among variables by testing the theory through research and applying it in practice. Throughout this process new information often comes to light that indicates the need to revise a theory, and the cycle repeats
Novice: Advanced beginner: Competent: Proficient: Expert:
Novice: Beginning nursing student or any nurse entering a situation with no previous experience. Learns via set of rules/procedures that are step wise and linear.
Advanced beginner: Some experience may only be observational, able to identify meaningful aspects or principles of nursing care.
Competent: Been in same position for 2-3 yrs. Able to anticipate nursing care & establish long range of goals. Experience w/all psychomotor skills
Proficient: More than 2-3 yrs. Perceives patient clinical situation as whole, able to assess entire situation, readily transfer knowledge gained from mult. previous experiences. Focused on managing care.
Expert: Diverse experience, intuitive grasp of clinical problem. Zero in on problem & mult. dimensions. Skilled at identifying both patient-centered problems & problems related to the health care system.
A theory: Helps explain an event by
- Defining ideas or concepts
- Explaining relationships among the concepts
- Predicting outcomes
ANA Standards of nursing practice
1) Assessment
2) Diagnosis
3) Outcomes identification
4) Planning
5) Implementation
a. coordination of care
b. health teaching and health promotion
c. consultation
d. prescriptive authority and Tx
6) Evaluation
ANA Standards of Professional Performance
1) Ethics
2) Education
3) Evidence-based practice and research
4) Quality of practice
5) Communication
6) Leadership
7) Collaboration
8) Professional Practice Evaluation
9) Resources
10) Environmental Health
4 core roles for Advanced practice registered nurse (APRN)
1) Clinical nurse specialist (CNS)
2) Nurse practitioner (NP)
3) Certified nurse midwife (CNM)
4) Certified registered nurse anesthetist (CRNA)
Affects how health care is paid for and delivered
ACA Affordable Care Act
Quality of care is achieved by?
Implementing evidence-based practice
Involve family and friends in care. Elicit patient values and preferences. Provide care with respect for diversity of the human experience. This is an example of?
Patient-centered care
Recognize the contributions of other health team members and patient’s family members. Discuss effective strategies for communicating and resolving conflict. Participate in designing methods to support effective teamwork.
Teamwork and collaboration
Quality and Safety Education for Nurses (QSEN)
Encompasses the competencies of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
-(KSA) each one has targeted knowledge, skills, and attitudes
Touch is relational and leads to a?
connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact.
Knowing the context of a patient’s illness helps you?
choose and individualize interventions that will actually help the patient. Striving to understand an event as it has meaning in the life of the other and knowing the patient are essential when providing patient-centered care. Two elements that facilitate knowing are continuity of care and clinical expertise.
Instilling hope and faith helps increase an individual’s?
capacity to get through an event or transition and face a future with meaning.
Asking permission demonstrates to the patient and family that the nurse?
respects the patient’s rights. Respecting and protecting patient rights is part of “doing for” and “being with” the patient.
Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves?
“being there” and “being with.” “Being there” is not only a physical presence, but also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, wholism, intimacy, vulnerability, and adaptation to unique circumstances.
Factors that may affect vital signs
temp. of environment, patient’s physical exertion, the effects of illness
When vital signs appear abnormal what should the nurse do?
1) Have another nurse/health care provider repeat the measurement to verify readings.
2) Inform the charge nurse/health care provider immediately
3) Document findings in your patient’s record
4) Report vital sign changes to nurses during hand off communication
Acceptable Ranges for Adults: Temperature Range
- Average temp. range: 36-38 C (96.8-100.4 F)
- Average oral/tympanic: 37 C (98.6 F)
- Average rectal: 37.5 C (99.5 F)
- Axillary: 36.5 C (97.7 F)
Acceptable Ranges for Adults: Pulse
60-100 beats/min, strong and regular
Acceptable Ranges for Adults: Pulse Oximetry (SpO2)
Normal: SpO2 > or equal to 95%
Acceptable Ranges for Adults: Respirations
Adult: 12-20 breaths/min, deep and regular
Acceptable Ranges for Adults: Blood Pressure (BP)
Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30-50 mm Hg
Acceptable Ranges for Adults: Capnography (EtCO2)
Normal: 35-45 mm Hg
When to measure vital signs
- On admission to a health care facility
- When assessing a patient during home care visits
- In a hospital on a routine schedule according to the health care provider’s order or hospital standards of practice before, during, and after a surgical procedure or invasive diagnostic procedure
- Before, during, and after a transfusion of blood products
- Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or temperature-control functions
- When a patient’s general physical condition changes (e.g before a patient previously on bed rest ambulates or before a patient performs range of motion exercises)
- When a patient reports nonspecific symptoms of physical distress (e.g. feeling “funny” or “different”)
Body tissues and cells function efficiently w/in a narrow range
From 36-38 C (96.8-100.4 F), but no single temp. is normal for all people
Site of temp. measurement
- Oral
- Rectal
- Tympanic membrane
- Temporal artery
- Esophageal
- Pulmonary artery
- Axillary
- Urinary bladder
Are all just one factor that determines a patient’s temp.
In the elderly population the average core temp. ranges from?
35-36.1 C (95-97 F) as a result of decreased immunity
What are considered core temperatures
Invasive measurements such as with a pulmonary artery catheter
Controls body temperature
The hypothalamus located between the cerebral hemispheres.
- The hypothalamus senses minor changes in body temp. -The anterior hypothalamus controls heat loss, and the posterior controls heat production.
- When nerve cells in the anterior become heated beyond the set point, impulses are sent out to reduce body temp.
Posterior hypothalamus
If it senses the body temp. is lower than the set point, body initiates heat conservation mechanisms.
- Vasoconstriction (narrowing) of blood vessels reduces blood flow to skin/extremities.
- Compensatory heat production is stimulated through voluntary muscle contraction and muscle shivering.
- When vasoconstriction is ineffective in preventing additional heat loss, shivering begins.
- Disease or trauma to hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temp. control.
Heat production occurs during?
Rest, voluntary movements, involuntary shivering, nonshivering thermogenesis
Nonshivering thermogenesis
Occurs primarily in neonates, because neonates cannot shiver, a limited amount of vascular brown tissue, present at birth, is metabolized for heat production.
Radiation
The transfer of heat from the surface of one object to the surface of another w/out direct contact between the two
Conduction
The transfer of heat from one object to another w/direct contact.
Factors affecting body temp.
- Age
- Exercise
- Hormone level
- Circadian rhythm
- Stress
- Environment
- Temperature alterations (fever, hyperthermia, heat stroke, heat exhaustion, hypothermia)
Newborn’s body temp. is usually w/in
35.5-37.5 C (95.9-99.5 F)
The older adult has a narrower range of body temps.
- Oral temp.: 35 C (95 F)
- Average body temp: 35-36.1 C (95-97 F)
Pyrogens
Bacteria and viruses that elevate body temperature
If the body cannot meet the demand for additional oxygen what happens?
Cellular hypoxia (inadequate oxygen) occurs
Myocardial hypoxia (inadequate oxygen) produces?
Angina (chest pain)
Cerebral hypoxia produces
Confusion
Interventions during a fever include?
Oxygen therapy & maintaining optimum fluid volume
When water loss through increased respiration and diaphoresis is excessive, the patient is at risk for?
Fluid volume deficit
A serious problem for older adults and children with low body weight and experiencing a fever
dehydration
Patterns of fever: Sustained: Intermittent: Remittent: Relapsing:
Sustained: A constant body temp. continuously above 38 C (100.4 F) that has little fluctuation
Intermittent: Fever spikes interspersed with usual temp. levels (temp. returns to acceptable value at least once in 24 hours)
Remittent: Fever spikes and falls w/out a return to acceptable temp. levels
Relapsing: Periods of febrile episodes & periods w/acceptable temp. values (febrile episodes & periods of normothermia are often longer than 24 hrs)
Classifications of hypothermia
Mild: 34-36 C (93.2-96.8 F)
Moderate: 30-34 C (86.0-93.2 F)
Severe: <30 C (<86 F)
Fever is an upward shift in the set point, hyperthermia results from?
An overload of the thermoregulatory mechanisms of the body.
Malignant hyperthermia
A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
Heat stroke
Body temp of 40 C (104 F) or more
Patients at risk of heat stroke include
- very young or very old
- those who have cardiovascular disease
- hypothyroidism
- diabetes
- alcoholism
- those who take medications that decrease ability of the body to lose heat (e.g. phenothiazines, anticholingergies, diuretics, amphetamines, beta adrenergic receptor antagonists)
- those who exercise or work strenuously ( athletes, construction workers, farmers)
Signs and symptoms of heat stroke
- Giddiness
- confusion
- delirium
- excessive thirst
- nausea
- muscle cramps
- visual disturbances
- incontinence
Vital signs of heat stroke
- body temp of 45 C (113 F)
- increased HR
- Lowered BP
- most important sign is hot, dry skin because they can’t sweat due to severe loss of electrolytes and hypothalamic malfunction
Nursing diagnostic process: ineffective thermoregulation related to aging and inability to adapt to environmental temperature
Assessment activities & defining characteristics
This is an example
1) Assessment: Obtain vital signs, including temp., pulse, respirations, SpO2
Defining characteristics: Increased body temp. above usual range, tachycardia, tachypnea, hypoxemia
2) Assessment: palpate skin
Defining characteristics: warm, dry skin
3) Assessment: Observe patient’s appearance and behavior while talking and resting
Defining characteristics: restlessness, confusion, flushed appearance
4) Review medical history
Defining characteristics: found in unventilated apartment during heat wave; 85 yrs old with history of dementia
Nursing interventions for patients with a fever
Interventions (unless contraindicated)
- Obtain blood cultures (before beginning antibiotics) if ordered. Obtain blood specimens to coincide w/temp. spikes when the antigen-producing organism is most prevalent
- minimize heat production: reduce frequency of activities that increase oxygen demand such as excessive turning and ambulation; allow rest periods; limit physical activity
- maximize heat loss: reduce external covering on patient’s body w/out causing shivering; keep patient, clothing, and bed linen dry
- satisfy requirements for increased metabolic rate: provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells; provide measures to stimulate appetite and offer well-balanced meals; provide fluids (at least 8-10 8oz glasses for patients w/ normal cardiac & renal function) to replace fluids lost through insensible water loss and sweating
- promote patient comfort: encourage oral hygiene because oral mucous membranes dry easily from dehydration; control temp. of the environment w/out inducing shivering; apply damp cloth to patient’s forehead
- identify onset and duration of febrile episode phases: examine previous temp. measurements for trends
- initiate health teaching as indicated
- control environmental temp. to 21-27 C (70-80 F)
Acceptable ranges of heart rate
1) infant 120/16 beats/min
2) toddler 90-140
3) preschooler 80-110
4) school-aged child 75-100
5) adolescent 60-90
6) adult 60-100
