Exam 1 Fundamentals Flashcards
semi-fowlers
30-45 degrees, normally 30
Used for feeding, lung expansion, cardiac or respiratory conditions, for pts with a nasogastric tube
hypokalemia
symptoms: muscle weakness, chronic fatigue, and cardiac dysrhythmias
Leukopenia
condition where a person has a reduced number of white blood cells. This increases their risk of infections
leukocytosis
high WBC count
Z-track method of drug injection
for intramuscular injections to prevent leakage of medication into the needle track into subcutaneous tissue, thus minimizing discomfort.
procedure: attach a clean needle to the syringe after the syringe is filled with the medication to prevent the injection of any residual medication on the needle into superficial tissues. Pull the skin down or to one side 1 to 2cm (Yilmaz et al., 2016; Karch, 2020), spread the skin taut at the injection site, and hold in this position with the nondominant hand. Insert the needle and inject the medication slowly. After 10 seconds, withdraw the needle steadily and release the displaced tissue to allow it to return to its normal position. Massage of the site is not recommended because it may cause irritation by forcing the medication to leak back into the needle track. However, gentle pressure may be applied with a dry sponge.
gr (grains) to mg conversion
__ gr x 64 (conversino factor)= mg
ELISA test stands for and detects
Stands for: enzyme-linked immunosorbent assay
Uses what? Antibodies to detect the presence of a disease agent (bacteria, virus, or parasites) in your blood or body fluid
Thrombophlebitis typically develops in patients with which of the following conditions?
An impaired or traumatized blood vessel wall
The three factors of Virchow’s triad include intravascular vessel wall damage, stasis of flow, and the presence of a hypercoagulable state.
Immobility impairs bladder elimination, resulting in such disorders as:
Urine retention, bladder distention, and infection
Sources of Pain
cutaneous, somatic, visceral, referred, nociceptive, neuropathic
Cutaneous pain
superficial pain to the epidermis, dermis, or subcutaneous (burn, paper cut)
somatic pain
pain originating in structures in the body’s external wall
nerve, tendon, bones, muscles
visceral pain
pain originating in the internal organs in the thorax, cranium (migraine), or abdomen
poorly localized –> generalized
referred pain
the pain you feel in one part of your body is actually caused by pain or injury in another part of your body
heart attack causes pain in arm/shoulder/back
Nociceptive pain
type of pain caused by damage to body tissue
pain from a normal process that results in noxious stimuli being perceived as painful
feels like sharp, aching, throbbing
ex. stubbing your toe, sports injury, dental procedure
Neuropathic pain
my definition: abnormal processing of pain message
pain that results as a direct consequence of a lesion or disease affecting abnormal functioning of the peripheral nervous system (PNS) or central nervous system (CNS)
ex. phantom pain
described as burning, electric, tingling or stabbing
origins of pain
physical- can be identified
psychogenic- cause cannot be identified
the pain process
receive pain stimulus- activate the receptors(transduction)-
send a message via nerve fibers (transmission) to the thalamus- sensory center- heat, cold, pain, and touch are first perceived.
Then the cerebral cortex identify the intensity and location of the pain (perception)
brain messages to release endorphins & neuromodulators which are sent to diminish pain messages(modulation).
transduction
activation of pain receptors
transmission
conduction along pathways (A-delta and C-delta)
perception of pain
awareness of the characteristics of pain
modulation
inhibition or modification of pain
Bradykinin
a powerful vasodilator that increases capillary permeability and constricts smooth muscle
prostaglandins
important hormone like substance that sends additional pain stimuli to the CNS
substance P
sensitizes receptors on nerves to feel pain and also increases the rate of firing nerves
gate control theory of pain
describes the transmission of painful stimuli and recognizes a relationship between pain and emotions
sedation scale
S: sleep, easy to arouse: no action necessary
1: awake and alert; no action necessary
2: occasionally drowsy, but easy to arouse; no action necessary
3: frequently drowsy, drifts off to sleep during conversation; reduce dosage
4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone
sources of knowledge
traditional- passed down from generation to generation
authoritative- comes from an expert, accepted as truth based on persons perceived expertise
scientific- obtained through scientific method
deductive reasoning
examines general ideas and considers specific actions or ideas
inductive reasoning
builds from specific ideas or actions to conclusions about general ideas
nursing process follows this
general systems theory
theory for universal application; break whole things into parts to see how they work together in systems
adaptation theory
adjustment of living matter to other living things and environment (fluid)
developmental theory
orderly and predictable growth and development from conception to death
types of quantitative research
Descriptive
Correlational
Quasi-experimental
Experimental
qualitative research method
Phenomenology
Grounded theory
Ethnography
Historical
PICOT
P = patient, population, or problem of interest
I = intervention of interest
C = comparison of interest
O = outcome of interest
T = time
the helping relationship
orientation phase- establish goal of relationship, location frequency and length of contract, duration of relationship
working phase- longest phase, pt actively participates , works towards achieving mutually acceptable goals, pt will express feelings and concerns
termination phase- begins at hello, pt will participate in identifying the goals accomplished and progress made towards goals
aims of teaching and conseling
Maintaining and promoting health
Preventing illness
Restoring health
Facilitating coping
three learning domains
Cognitive: storing and recalling of new knowledge in the brain
Psychomotor: learning a physical skill, integration of mental and muscular activity
Affective: changing attitudes, values, and feelings
Knowles Assumptions about Adult Learners
most adults orientation to learning is that material should be useful immediately, rather than at some point in the future
teaching plans for older adults
Identify learning barriers.
Allow extra time.
Plan short teaching sessions.
Accommodate for sensory deficits.
Reduce environmental distractions.
Relate new information to familiar activities or information.
cognitive domain examples
lecture, panel, discovery, written materials
affective domain
role modeling, discussion, audiovisual materials
psychomotor domain
demonstration, discovery, printed materials
nursing process
ADPIE
A- assess
D- diagnosis
P- plan
I- implementation
E- evaluation
vital signs
Temperature (T)
Pulse (P)
Respiration (R)
Blood pressure (BP)
Pain (often included as fifth sign)
oral temp
35.8-37.5 C (or 96.4-99.5 F)
types of fever
intermittent, remittent, sustained or continuous, relapsing or recurrent
intermittent
temperature returns to normal at least one every 25 hours
remittent
temp does not return to normal and fluctuates a few degrees up and down
primary source of heat
metabolism
heat production
metabolism
hormones, muscle movements, exercise (all increase metabolism)
epi and norepi
thyroid hormone and shivering (increase heat production)
sources of heat loss
skin (primary source)
evaporation of sweat
warming and humidifying inspired air
eliminating urine and feces
transfer of body heat to external environment
radiation, convection, evaporation, conduction
radiation
Loss of heat by indirect contact
ex. placing a cold object inside incubator.
convection
Loss of heat from warm body to cooler air currents.
evaporation
Loss of heat due to conversion of water to vapor.
ex. sweating
conduction
Loss of heat by direct touch.
ex. ice pack on knee
pulse rate
number of contractions over a peripheral artery in 1 minute
pulse is regulated by
the autonomic nervous system through cardiac sinoatrial node
ventilation
movement of air in and out of lungs
diffusion
exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood
perfusion
exchange of oxygen and carbon dioxide between circulating blood and tissue cells
most powerful respiratory stimulant
increase in carbon dioxide
Tachypnea
increased respiratory rate; may occur in response to an increased metabolic rate
eupnea
normal, unlabored respiration
most common blood pressure spot
brachial artery and popliteal artery
primary hypertension
characterized by an increase above normal in both systolic and diastolic pressure
secondary hypertension
caused by another disease conditions
commonly: kidney disease, adrenal cortex disorders, and aorta disorders
diuretics
decrease fluid volume (and blood pressure) by helping the body eliminate sodium and water through the urine. However, some diuretics can also cause the body to eliminate more potassium in the urine.
antihypertensive medications
diuretics, beta-adrenergic blockers, vasodilators and calcium channel blockers, ACE inhibitors
beta-adrenergic blockers
to block sympathetic stimulation and decrease cardiac output
vasodilators and calcium channel blockers
to relax smooth muscles of arterioles and decrease peripheral vascular resistance
ACE inhibitors
to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production
safety assessments
review EMR, watch their gate, fluidity of movement, weakness on one side
morse fall rating
tool to assess risk for fall
includes: history of falling
ambulatory aids
more than one diagnosis/mental status
Among adults older, falls are the leading cause of injury fatality
true
chain of infection
● Infectious agent: bacteria, viruses, fungi
● Reservoir: natural habitat of the organism
● Portal of exit: point of escape for the organism
● Means of transmission: direct contact, indirect contact, airborne route
● Portal of entry: point at which organisms enter a new host
● Susceptible host: must overcome resistance mounted by host’s defenses
quantitative research: descriptive
To explore and describe events in real-life situations, describing concepts and identifying relationships between and among events; often used to generate new knowledge about topics with little or no prior research
quantitative research: Correlational
To examine the type and degree of relationships between two or more variables; the strength of the relationship varies from a –1 (perfect negative correlation, in which one increases as the other decreases) to a +1 (perfect positive correlation, with both variables increasing or decreasing together)
quantitative research: Quasi-experimental
To examine cause-and-effect relationships between selected variables; often conducted in clinical settings to examine the effects of nursing interventions on patient outcomes
quantitative research: experimental
To examine cause-and-effect relationships between variables under highly controlled conditions; often conducted in a laboratory setting
qualitative research method: Phenomenology
Analysis of data provides information about the meaning of the experience within each person’s own reality (e.g., the experience of health or of having a heart attack).
qualitative research method: Grounded theory
how people describe their own reality and how their beliefs are related to their actions in a social scene. (e.g., coping with a seriously ill child).
qualitative research method: Ethnography
Developed by the discipline of anthropology, ethnographic research is used to examine issues of a culture that are of interest to nursing.
qualitative research method: historical
Historical research examines events of the past to increase understanding of the nursing profession today. Many historical studies focus on nursing leaders, but there is increasing interest in the historical patterns of nursing practice.
example of affective learning
Pt expresses renewed self confidence after physical therapy
Pt values good nutrition and hydration and rest at home
ex of cognitive learning
Pt can list the signs of thrush
Pt describes measures to prevent nipple cracking
Pt describes the correct procedure for breastfeeding
Pt describes how salt intake affects blood pressure’s
ex of psychomotor learning
Pt begins protective measures immediately
Pt demonstrates correct procedure for breastfeeding
Pt demonstrates how to change dressing using clean technique
eriksons theory
Trust vs mistrust (infant)
- need warmth food comfort and trust
Autonomy vs shame and doubt (toddler)
- ages 1-3 years
- gains independence but feeding, dressing and toileting themselves
Initiative vs guilt (pre-school)
- ages 4-6 years
- seeks out new experiences and explores the how and why
Industry vs inferiority (school-aged children)
- gains pleasure by finishing projects and receiving recognition
Identity vs role confusion (adolescence)
- hormonal changes
- acquires sense of self and decides what direction to take in life
Intimacy vs isolation (young adult)
- establish close honest loving relationships
Generativity vs stagnation (middle adulthood)
- involvement in family friends and community
- desire to make contribution to the world
Ego integrity vs despair (late adulthood)
- reminiscence about life provides sense of fulfillment
- fear of dying
maslows hierarchy
1 Physiologic needs
2 Safety needs
3 Love and belonging needs
4 Self-esteem needs
5 Self-actualization needs
cultural assimilation
When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different, and they may take on the values of the dominant culture.
ie. when people immigrate and encounter a new dominant culture as they work, go to school, and learn the dominant language, they often move closer to the dominant culture. The process and the rate of assimilation are individualized.
culture shock
when placed in a different culture they perceive as strange.
Culture shock may result in psychological discomfort or disturbances, because the patterns of behavior a person found acceptable and effective in their own culture may not be adequate or even acceptable in the new culture.
The person may then feel foolish, fearful, incompetent, inadequate, or humiliated. These feelings can eventually lead to frustration, anxiety, and loss of self-esteem
cultural imposition
the belief that everyone else should conform to your own belief system
7 rights
Right medication
Right patient
Right dosage
Right route
Right time
Right reason
Right documentation
cycle of infection
how to break cycle of infection
hand washing
PPE in isolation
keeping skin intact
disposing of sharps properly
immunization
sterilization
3 checks for medication administration
When the nurse reaches for the container or unit dose package
After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container
Before giving the unit dose medication to the patient or when replacing the multi-dose container in the drawer or shelf
what is included in a physician order (7)
Patient’s name
● Date and time order is written
● Name of drug to be administered
● Dosage of drug
● Route by which drug is to be administered
● Frequency of administration of the drug
● Signature of person writing the order
how to clip toenails
straight across, do not clip a diabetic pts toenails
stages of infection
incubation period
prodomal period
full stage illness
convalescent
incubation period
Organisms growing and multiplying
prodomal period
person is most infectious, vague and
nonspecific signs of disease
full stage illness
presence of specific signs and symptoms of disease
convalescent period
period of recovery from infection
types of knowledge
traditional
authoritative
scientific
instinctive
general system theory (nurse report)
This theory describes how to break whole things into parts and to learn how the parts work together in a system
Emphasizes relationships between the whole and the parts and how they function and behave
developmental theory
Outlines the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death
isotonic
Muscle shortening and active movement (tone)
Ex. Squats, lunges, push ups
isometric
Muscle contraction without shortening (no movement)
Ex. Planks and wall sits
isokinetic
Muscle contraction with resistance
Ex. Bicep curls
stages of sleep
Non rapid eye movements (NREM)
rapid eye movement (REM)
deepest stage of sleep
Stage 4
obstructive sleep apnea
Too much relaxation of muscles cause disruption of air flow
The absence of breathing (apnea)
Diminished breathing efforts (hypopnea)
Fowlers position
Bed angle between 45-60 degrees
Low fowlers
15-30 degrees
High fowlers
60-90 degrees
CPAP in obstructive sleep apnea
Continuous positive air pressure
Holds airway open
Cultural blindness
occurs when one ignores differences and proceeds as though they do not exist
Common portal of exit
● Respiratory
● Gastrointestinal
● Genitourinary tracts
● Breaks in skin
● Blood and tissue
Adaptation theory
Defines adaptation as the adjustment of living matter to other living things and to environmental conditions
Human adaptation occurs on three levels: self, social (others), and the physical (biochemical rxns)
Reticular activating system
Facilitates reflex and voluntary movements
Controls cortical activities related to state of alertness
Control center for sleeping and waking
Hypothalamus
Non rapid eye movement (NREM)
Four stages
Stages I and II: light sleep, 5%-50%
Rapid eye movement (REM)
Deepest sleep
20-25% of nightly sleep
HR, RR, BP, metabolic rate, and body temp increases
Skeletal muscle tone and deep tendon reflexes depressed
Dreaming is essential to mental and emotional health
Amount of sleep in aging adults
Less sleep needed
Narcolepsy
Excessive daytime sleepiness
70% of people with narcolepsy also experience cataplexy (involuntary loss of skeletal muscle tone lasting from seconds to minutes)
what happens if a person is deprived of REM sleep for multiple nights
REM rebound- person will spend more time in REM sleep on successive nights, allows the total amount of REM sleep to remain fairly constant over time.
more deep sleep occurs in the delta stage (NREM stages III and IV) in the first half of the night, especially if one is tired or has lost sleep
average amount of sleep for adults
8 hours
how many REM cycles occur in one night sleep
4-5 cycles typically lasting for 90-100 mins
recommended amount of sleep time for adults
more than 7 hours
amount of sleep for older adults and sleep patterns
recommendation: 7 to 8 or 9 hours
less sound sleep occurs- shortened periods of REM sleep
stage IV is decreased or absent completely
percent of REM sleep in sleep cycle
20-25%
factors affecting sleep patterns
enlarged prostate- may have to urinate more frequently
caffeine
nicotine
alcohol
A person’s cultural beliefs and practices can influence rest and sleep
excessive exercise or exhaustion can decrease the quality of sleep.
Combining foods that are high in tryptophan (small protein-containing snack) with healthy, complex carbohydrates improves sleep.
large quantities of alcohol reduce rem and delta sleep
T/F: lack of sleep is a safety concern
true
Barbiturates, amphetamines, and antidepressants decrease REM sleep.
people with depression are more likely to develop insomnia
illnesses associated with sleep disturbances
Gastroesophageal reflux (GERD)
Coronary artery diseases
Epilepsy
Liver failure and encephalitis
Hypothyroidism
End-stage renal disease
insomnia is chronic when lasting for
over 6 months
drugs that affect sleep
Diuretics
antiparkinsonian drugs,
some antidepressants
antihypertensives
steroids
decongestants
caffeine
asthma medications
Barbiturates,
amphetamines
sleep diary key points
*Time patient retires
*Time patient tries to fall asleep
*Approximate time patient falls asleep
*Time of any awakenings during the night and when sleep was resumed
*Time of awakening in the morning
*Presence of any stressors the patient believes are affecting their sleep
*A record of any food, drink, or medication the patient believes has positively or negatively influenced their sleep (include time of ingestion)
*Record of physical activities—type, duration, and time
*Record of mental activities—type, duration, and time
*Record of activities performed 2 to 3 hours before bedtime, bedtime rituals, changes in sleep environment
*Presence of any worries or anxieties the patient believes are affecting their sleep
sleep hygiene methods
dark room, no night light,
cool temp
Quiet,
go to bed same time,
avoid taking diuretics/stimulation meds/foods/coffee/monster or lots of fluids- drink after certain time of day
Avoid napping during the day
treatment for dyssomnias: nonpharm therapy
Cognitive Behavioral Therapy (CBT):
Progressive muscle relaxation measures
Stimulus control
Sleep restriction; sleep hygiene measures
Biofeedback and relaxation therapy
tools to assess sleep disturbances
The Epworth Sleepiness Scale
The Pittsburgh Sleep Quality Index (PSQI)
Sleep Disturbance Questionnaire
lab data indicating infection
elevated WBC count- norm is 5,000-10,000
increased lymphocytes and neutrophil levels
increase eosinophils= allergic response or parasitic infection
elevated ESR= inflammation is present
5 moments of hand hygiene
before touching patient
before a clean or aseptic technique
after a body fluid exposure risk
after touching a patient
after touching pt surroundings
four common hospital acquired infections
Nocicomial time frame- 48 hours
catheter-associated UTI (CAUTI)
Surgical site infection (SSI)
central-line associated bloodstream infection (CLABSI)
ventilator-associated pneumonia (VAP)
infections that require contact isolation
vancomycin-resistant enterococci (VRE)
C. Diff
MRSA
infections that require airborne precautions
TB
varicella
rubeola
covid
infections that require droplet precautions
influenza
ubella,
mumps,
diphtheria
adenovirus infection
body’s defense against infection
body’s normal flora
inflammatory response
immune response
C Diff is not killed by alcohol-based handrubs, so soap and water are required.
correct order to DON PPE
gown
mask
glasses/face shield
gloves
correct order to doff PPE
untie gown
remove gloves
remove goggles
remove gown
remove mask
Freuds developmental stages
oral stage- 0 to 18 months
anal stage- 8 m to 4 years
phallic stage- 3-7 years
latency stage- 7 to 12 years
genital stage- 12-20 years
