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NRSG 225- Intro > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

normal temp values

A

96.4- 99.5

> 100.4 = concern

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2
Q

methods to take temp

A

temporal, tympanic, artery, oral, axillary and rectal

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3
Q

effectors for temp

A

age, sex, environ temp, health and circadian rhythm

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4
Q

hypothermia/ hyperthermia

A

<95

> 106

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5
Q

normal pulse rate values

A

60-100

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6
Q

pulse r methods

A

radial, brachial and carotid

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7
Q

pulse r effectors

A

physical act, fever, meds/stress and age/sex

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8
Q

bradycardia/ tachycardia

A

<60 bpm

> 100bpm

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9
Q

apical pulse

A

measure if giving cardiovas meds

hold stethoscope over heart for one min

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10
Q

norm resp. rate

A

16-20

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11
Q

resp. rate effectors

A

exercise, diet, trauma, meds, infection, pain, emotion and acid-b bal.

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12
Q

hyper v hypotension

A

hyper >130/80

hypo< 90/60

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13
Q

auscultatory gap

A

avoid missing systolic p
pump until cannot hear pulse
go 30mmhg above when taking actual bp

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14
Q

orthostatic hypotension

A

laying-5 min
sitting- 1 min
standing- 3 min
take it first time in morning when get up
have = if S dec. 20 points and D dec. 10 points w/in 3 min position change

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15
Q

norm oxygenation values

A

> 90 ok >95 ideal

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16
Q

oxygenation is a measure of

A

arterial blood

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17
Q

oxygen. effectors

A

meds, disease, hemogl lvls, air quality and lifestyle

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18
Q

hypoxemia

A

< 90%

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19
Q

special populations for pain

A

children, cog. impaired, older adults

*have to look at body language/ changing vital signs

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20
Q

effectors for pain

A

cul values and beliefs, past exper. environ and support

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21
Q

procedure when talking about pain

A

ask abt goals and expetations

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22
Q

purpose for taking vitals

A

get baseline

measure hemodynamic stability

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23
Q

when take vitals

A

admission, change in pat. condition, loss of concisouness, after fall, b/d/a invasive procedures, b/d/a meds (opioids) + orthostatic hypo

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24
Q

time frame for taking vitals if norm

A

every 4 hours

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25
Q

reasons for abdnorm vitals

A

stress, coffee, temp outside

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26
Q

pot. for microo to cause dis. depends on

A

number of organ. virulence, imm. system function, length/ intimacy btw person and microo

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27
Q

steps in infection cycle

A

organism, reservoir, portal of exit, transm., portal of entry, vulnerable hosts

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28
Q

incubation stage

A

time from infection till appearance of sympt

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29
Q

prodromal stage

A

non-specific sympt.

* most infectious

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30
Q

full stage

A

recogniz and specific sympt

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31
Q

convalenscence

A

final recovery stage of infection

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32
Q

portals of exit in body

A

respir. GI, GU, Blood and tissue

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33
Q

ways to reduce spread

A

id signs infection, give adeq nutrition, proper disposal infecti. items, clean, get immunized, reduce stress and hand hygiene

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34
Q

hand hygiene times

A

b/a touching pat. a touching pat surface, after fluid exposure, before clean procedure

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35
Q

hand hygiene- when is soap needed

A

if hands visibly soiled
bodily exposure
a/ bathroom and before eating

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36
Q

transient bac

A

low #
aquire from exposure
not normal

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37
Q

resident bac

A

normal
high #, always present
*varies from person to person

38
Q

HAI

A

hospital aquired infection

39
Q

cauti

A

catheter ass. tract infection

40
Q

ssi

A

surgical site infec

41
Q

clabsi

A

central line ass. bloodstream infec

42
Q

vap

A

ventilator ass. pneumonia

43
Q

sterilization considerations

A

some dis. require diff procedure

ex. c-diff

44
Q

standard precautions for PPE

A

use gloves for all fluid ex. sweat

use mask for spinal canal procedure

45
Q

airborne precautions

A

keep door closed, room neg. pressure
wash hands b+a
N-95 mask

46
Q

droplet precautions

A

mask, eyewear, gown and gloves

ex. influenza

47
Q

contact precautions

A

ex. mrsa
patient specif. equip
gown and gloves

48
Q

enteric/special

A

ex c-diff
patient specific equip
gown and gloves

49
Q

aseptic tech

A

any activity to prevent/ stop chain infection

50
Q

medical tech v sterile tech

A 
med= clean (reg)
sterile= cath, nicu, invasive procedures
51
Q

possible self-care diagn

A

feeding
bathing/ hygiene
dressing and grooming
toileting

52
Q

factors affecting hygiene

A 
culture
socioecon class
spiritual practices
dev. level
health state
personal perf
53
Q

early morning care

A

wash hands and face
mouth care
toileting
comfort measures

54
Q

morning care am (1)

A 
*after breakfast
make plan for day
toileting
oral care
bathing 
back massage
skin considerations
hair care/ cosmetics
55
Q

morning care am (2)

A

dressing
positioning for comfort
changing bed linens
tidying up room

56
Q

afternoon care (pm)

A 
*after lunch
toileting
handwashing/ oral care
make bed
reposition in bed or chair
57
Q

hour of sleep care (hs care0

A

toileting, washing and oral care
change soiled clothing/ bed
position comfortably
lower bed and place call light

58
Q

as needed care (prn)

A 
hygiene measures (bathroom and bath)
change clothing and bed
oral care every 2 hours
59
Q

purpose bathing

A 
cleanse skin
promote circulation 
   relaxes person
musculoskeletal exercise
stim rate/ depth respir.
60
Q

physic. assess oral cavity

A

look for oral problems
id approp. nursing measures
carry out care plan

61
Q

five steps in nursing process

A 
ADPIE
assessing
diagnosing
planning
implementing
evaluating
62
Q

assessing

A

collecting, validating, and comm w/ pat

63
Q

diagnosing

A

analyzing pat data to id strengths, problems

*diff. than usual med diagnosis

64
Q

planning

A

id pat outcomes and plan interventions

65
Q

implementing

A

carrying out plan

66
Q

evaluating

A

measuring extent outcomes achieved

67
Q

characteristics of nursing process (SDIOU)

A 
systematic
dynamic
interpersonal
outcome oriented
universally applicable
68
Q

systematic

A

ordered sequence of act

69
Q

dynamic

A

interaction and overlap of five steps

70
Q

interpersonal

A

comm/ interaction with pat

71
Q

outcome oriented

A

nurse and pat work together to id outcomes

72
Q

universally applicable

A

framework used

73
Q

benefits of process for pat

A

scient based, holistic/ indivii care
continuous care
clear, efficient cost-effective plan

74
Q

benefits of process for nurse

A

opportunity collab w/ o/ healthcare workers
satisf. making diff in lives of o
opp grow professionally

75
Q

in action

A

thinking on feet

76
Q

on action

A

after the fact

thinking through situation

77
Q

for action

A

think about future/ how actions could display diff results

78
Q

reason for critical thinking

A

determ credibility
analyze norm from abnorm
distinguish relevant data from irrel
id bias, assumptions or inconsis

79
Q

characteristics of assessment

A

ppcsfrr

purposeful, priorit, complete, systematic, factual, relevant, recorded standard manner

80
Q

purpose of assessment

A

create database
id health problems, health status
makes diagn and planning easier

81
Q

nursing v med assessments

A

nursing- analyze coping measures (comparing data)

med- diagn. pathological condition from data

82
Q

comprehensive assessment

A

when- admission
why- create datab adn id problems
who- prim nurse

83
Q

focused assessment

A

when- every 12 hrs w/ shift change

why- gather data about old problem or address new

84
Q

emergency assessment

A

when- physical or emotional change (ex. level conciousne)

85
Q

time lapse assessment

A

when- on floor
why- compare current status to baseline
ex. checking pain after med

86
Q

phases of nursing interview

A

preparatory
intro
working
termination

87
Q

sources of pat info

A

patient (primary)
family/ sig o
pat record, med history, physical exam, consultations, lab reports, reports from o/ healthcare

88
Q

observe what in interview

A

ability manage care
current responses, emot and physical
immediate/ larger environ

89
Q

objective data

A

observed and measureable

ex. bp and skin appear.

90
Q

subjective data

A

emotion pat. is feeling

record in “quotations”

91
Q

do’s for document.

A

use pat own words
avoid non-spec terms
summarize sub/obj data
give verbal report w/ critical change in pat health status

NRSG 225- Intro (5 decks)

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