Exam 1 Flashcards
normal temp values
96.4- 99.5
> 100.4 = concern
methods to take temp
temporal, tympanic, artery, oral, axillary and rectal
effectors for temp
age, sex, environ temp, health and circadian rhythm
hypothermia/ hyperthermia
<95
> 106
normal pulse rate values
60-100
pulse r methods
radial, brachial and carotid
pulse r effectors
physical act, fever, meds/stress and age/sex
bradycardia/ tachycardia
<60 bpm
> 100bpm
apical pulse
measure if giving cardiovas meds
hold stethoscope over heart for one min
norm resp. rate
16-20
resp. rate effectors
exercise, diet, trauma, meds, infection, pain, emotion and acid-b bal.
hyper v hypotension
hyper >130/80
hypo< 90/60
auscultatory gap
avoid missing systolic p
pump until cannot hear pulse
go 30mmhg above when taking actual bp
orthostatic hypotension
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
norm oxygenation values
> 90 ok >95 ideal
oxygenation is a measure of
arterial blood
oxygen. effectors
meds, disease, hemogl lvls, air quality and lifestyle
hypoxemia
< 90%
special populations for pain
children, cog. impaired, older adults
*have to look at body language/ changing vital signs
effectors for pain
cul values and beliefs, past exper. environ and support
procedure when talking about pain
ask abt goals and expetations
purpose for taking vitals
get baseline
measure hemodynamic stability
when take vitals
admission, change in pat. condition, loss of concisouness, after fall, b/d/a invasive procedures, b/d/a meds (opioids) + orthostatic hypo
time frame for taking vitals if norm
every 4 hours
reasons for abdnorm vitals
stress, coffee, temp outside
pot. for microo to cause dis. depends on
number of organ. virulence, imm. system function, length/ intimacy btw person and microo
steps in infection cycle
organism, reservoir, portal of exit, transm., portal of entry, vulnerable hosts
incubation stage
time from infection till appearance of sympt
prodromal stage
non-specific sympt.
* most infectious
full stage
recogniz and specific sympt
convalenscence
final recovery stage of infection
portals of exit in body
respir. GI, GU, Blood and tissue
ways to reduce spread
id signs infection, give adeq nutrition, proper disposal infecti. items, clean, get immunized, reduce stress and hand hygiene
hand hygiene times
b/a touching pat. a touching pat surface, after fluid exposure, before clean procedure
hand hygiene- when is soap needed
if hands visibly soiled
bodily exposure
a/ bathroom and before eating
transient bac
low #
aquire from exposure
not normal
resident bac
normal
high #, always present
*varies from person to person
HAI
hospital aquired infection
cauti
catheter ass. tract infection
ssi
surgical site infec
clabsi
central line ass. bloodstream infec
vap
ventilator ass. pneumonia
sterilization considerations
some dis. require diff procedure
ex. c-diff
standard precautions for PPE
use gloves for all fluid ex. sweat
use mask for spinal canal procedure
airborne precautions
keep door closed, room neg. pressure
wash hands b+a
N-95 mask
droplet precautions
mask, eyewear, gown and gloves
ex. influenza
contact precautions
ex. mrsa
patient specif. equip
gown and gloves
enteric/special
ex c-diff
patient specific equip
gown and gloves
aseptic tech
any activity to prevent/ stop chain infection
medical tech v sterile tech
med= clean (reg) sterile= cath, nicu, invasive procedures
possible self-care diagn
feeding
bathing/ hygiene
dressing and grooming
toileting
factors affecting hygiene
culture socioecon class spiritual practices dev. level health state personal perf
early morning care
wash hands and face
mouth care
toileting
comfort measures
morning care am (1)
*after breakfast make plan for day toileting oral care bathing back massage skin considerations hair care/ cosmetics
morning care am (2)
dressing
positioning for comfort
changing bed linens
tidying up room
afternoon care (pm)
*after lunch toileting handwashing/ oral care make bed reposition in bed or chair
hour of sleep care (hs care0
toileting, washing and oral care
change soiled clothing/ bed
position comfortably
lower bed and place call light
as needed care (prn)
hygiene measures (bathroom and bath) change clothing and bed oral care every 2 hours
purpose bathing
cleanse skin promote circulation relaxes person musculoskeletal exercise stim rate/ depth respir.
physic. assess oral cavity
look for oral problems
id approp. nursing measures
carry out care plan
five steps in nursing process
ADPIE assessing diagnosing planning implementing evaluating
assessing
collecting, validating, and comm w/ pat
diagnosing
analyzing pat data to id strengths, problems
*diff. than usual med diagnosis
planning
id pat outcomes and plan interventions
implementing
carrying out plan
evaluating
measuring extent outcomes achieved
characteristics of nursing process (SDIOU)
systematic dynamic interpersonal outcome oriented universally applicable
systematic
ordered sequence of act
dynamic
interaction and overlap of five steps
interpersonal
comm/ interaction with pat
outcome oriented
nurse and pat work together to id outcomes
universally applicable
framework used
benefits of process for pat
scient based, holistic/ indivii care
continuous care
clear, efficient cost-effective plan
benefits of process for nurse
opportunity collab w/ o/ healthcare workers
satisf. making diff in lives of o
opp grow professionally
in action
thinking on feet
on action
after the fact
thinking through situation
for action
think about future/ how actions could display diff results
reason for critical thinking
determ credibility
analyze norm from abnorm
distinguish relevant data from irrel
id bias, assumptions or inconsis
characteristics of assessment
ppcsfrr
purposeful, priorit, complete, systematic, factual, relevant, recorded standard manner
purpose of assessment
create database
id health problems, health status
makes diagn and planning easier
nursing v med assessments
nursing- analyze coping measures (comparing data)
med- diagn. pathological condition from data
comprehensive assessment
when- admission
why- create datab adn id problems
who- prim nurse
focused assessment
when- every 12 hrs w/ shift change
why- gather data about old problem or address new
emergency assessment
when- physical or emotional change (ex. level conciousne)
time lapse assessment
when- on floor
why- compare current status to baseline
ex. checking pain after med
phases of nursing interview
preparatory
intro
working
termination
sources of pat info
patient (primary)
family/ sig o
pat record, med history, physical exam, consultations, lab reports, reports from o/ healthcare
observe what in interview
ability manage care
current responses, emot and physical
immediate/ larger environ
objective data
observed and measureable
ex. bp and skin appear.
subjective data
emotion pat. is feeling
record in “quotations”
do’s for document.
use pat own words
avoid non-spec terms
summarize sub/obj data
give verbal report w/ critical change in pat health status
