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Fundamentals of Nursing > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

Nursing Assessment

A

assessing is the systematic and continuous collection, analysis, validation, and communication of patient data, or information. Assessment is the first of six nursing standards; collecting patient data is a vital step in the nursing process because the remaining steps depend on purposeful, prioritized, complete, systematic, accurate, and relevant data.

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2
Q

Nursing Diagnosis

A

the second step in the nursing process. The purposes of diagnosing are to identify how a person, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths that the person, group or community can draw on to prevent or resolve problems.

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3
Q

Nursing Implementation

A

During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. Nursing intervention as “any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes”. Direct and indirect care.

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4
Q

Nursing Evaluation

A

The fifth step of the nursing process, evaluating, the nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care.

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5
Q

Full Health Assessment

A

Involves gathering information about the health status of the patient. The nurse plans appropriate nursing interventions based on this data and evaluates patient outcomes to deliver the best possible care for each patient.

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6
Q

NANDA - North American Nursing Diagnosis Association

A
  • Gather information and disseminate it through the Clearinghouse for Nursing Diagnosis
  • Encourage educational activities at regional and state levels to promote the implementation of nursing diagnosis
  • Promote and organize activities to continue the development, classification, and scientific testing of nursing diagnosis.
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7
Q

Importance of Coughing and deep breathing

A
  • A cough is a cleansing mechanism of the body. It is a means of healping to keep the airway clear of secretions and other debris. A cough that is dry is termed a non-productive cough. A cough that produces respiratory secretions is termed a productive cough.
  • Deep-breathing exercises can be used to overcome hypoventilation. Instruct the patient to make each breath deep enough to move the bottom ribs.
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8
Q

Pursed-lip Breathing

A
  • Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing.
  • Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration.
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9
Q

Crackles

A

intermittent sounds occurring when air moves through airways that contain fluid. Classified as fine, medium or coarse.

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10
Q

Rhonchi

A

Sonorous or coarse; snoring quality, low-pitched, continuous sounds, auscultated during inspiration and expiration, coughing may clear the sound somewhat, and air passing through or around secretions.

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11
Q

Wheezing (musical sounds)

A

continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors. Classified as sibilant or sonorous.

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12
Q

Gas exchange and CO2 within respiratory system

A
  • Oxygen is carried in the body via plasma and red blood cells
  • Most oxygen is carried by RBCs in the form of oxyhemoglobin
  • Hemoglobin also carries carbon dioxide in the form of carboxyhemoglobin.
  • Internal respiration between the circulating blood and tissue cells must occur
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13
Q

Normal values for Respirations

A

under normal conditions Respirations should be 12-20 breaths a minute

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14
Q

Normal Pulse Oximeter Levels

A

95-100% SpO2

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15
Q

S&S Respiratory Distress

A
  • Rapid, Shallow breathing
  • Sharp pulling in of the chest below and between the ribs with each breath
  • Grunting sounds
  • Flaring of the nostrils
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16
Q

Cyanosis

A

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood

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17
Q

Dyspnea

A

difficulty breathing or labored breathing

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18
Q

Anemia

A

condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness.

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19
Q

Pallor

A

an unhealthy pale appearance

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20
Q

Apnea

A

temporary cessation of breathing, especially during sleep

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21
Q

Tachypnea

A

abnormally rapid breathing

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22
Q

Bradypnea

A

decrease in respiratory rate

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23
Q

Nursing diagnosis’s for various respiratory conditions

A

Impaired gas exchange, ineffective airway clearance, risk for deficient fluid volume, risk for decreased cardiac output, anxiety and risk for injury.

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24
Q

S&S of hypoxia

A

hypoxia is a condition in which an inadequate amount of oxygen is available to cells, skin can turn blue to cherry red, confusion, cough, increase HR and Respirations, SOB, sweating and wheezing.

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25
Q

Respiratory Depression

A

Opitate analgesics (Narcotics)

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26
Q

Method of Auscultating breath sounds

A

back and forth from left to right sides of lungs, front: collar bone, 3rd intercostal space, 5th intercostal space, lower side. Back: top of shoulder blades, middle of should blade, under shoulder blade, and side.

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27
Q

Interventions for Dyspnea

A

pursed-lip breathing exercises, and upright - Orthopnea position

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28
Q

S&S Infection

A
  • Cough, inflammation, localized pain, urinary frequency/urgency/dysuria, malaise, fever, GI complaints, and local inflammation with drainage, heat, redness, pain
  • Increased temp, pulse, resp. rate
  • Enlarged lymph nodes.
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29
Q

Cycles of Infection

A

Infectious agent, Reservoir, Portal of exit, Mode of transmission, Port of entry, and Susceptible host.

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30
Q

Infectious Agent

A

Bacteria - most significant and most commonly observed infection - causing agents in health care institutions.

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31
Q

Reservoir

A

For growth and multiplication of microorganisms is the natural habitat of the organism

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32
Q

Port of Exit

A

The point of escape fro the organism enter a new host

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33
Q

Mode of Transmission

A

An organism may be transmitted from its reservoir by various means or routes

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34
Q

Port of Entry

A

is the point at which organisms enter a new host

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35
Q

Susceptible host

A

Microorganisms can continue to exist only in a source that is acceptable and only if they overcome any resistance mounted by the host’s defenses.

36
Q

Potential to produce infections

A
  • Integrity of the skin and mucous membranes
  • pH levels of GI/GU tracts and skin
  • Integrity and number of WBC
  • Age, sex, race, hereditary
  • Immunizations
  • Stress level
  • Level of fatigue, nutritional and general health status
  • Invasive or indwelling medical devices
37
Q

Stages of Infection

A

incubation, prodromal, full stage and convalescence

38
Q

Incubation

A

is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection

39
Q

Prodromal

A

a person is most infectious during this stage. This period lasts from several hours to several days

40
Q

Full Stage

A

the presence of specific S&S indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations

41
Q

Convalescence

A

is the recovery period from the infection

42
Q

Signs of Inflammation

A

Redness (Hyperemia), swelling, heat, pain, and loss of function

43
Q

Indications of Infections - Lab Data

A
  • CBC with diff – WBC values normal range 5,000-10,000, Increased Neutrophils and Lymphocytes = acute infection
  • Culture of body fluids – blood, sputum, exudate from wounds, urine and stool, spinal fluid throat
  • Specific blood tests to detect virus
  • Spinal fluid
  • ESR
44
Q

Obtaining core body temp

A

Orally, Axillary, Temporal artery, Tympanic, Rectal, etc.

45
Q

Normal Temperature Range

A
  1. 9 - 38 degrees Celsius

96. 7 - 100.5 degrees Fahrenheit

46
Q

Infection on a patient’s Vital Signs

A

Increased Temperature, Pulse and Respiratory Rate

47
Q

Conduction

A

The transfer of heat to another object during direct contact. Ex: the body transfers heat to an ice pack, causing the ice to melt

48
Q

Convection

A

The dissemination of heat by motion between areas of unequal density. Ex: an oscillating fan blows currents of cool air across the surface of a warm body.

49
Q

Radiation

A

The diffusion or dissemination of heat by electromagnetic waves Ex: the body gives off waves of heat from uncovered surfaces

50
Q

Evaporation

A

The conversion of a liquid to a vapor. Ex: body fluid in the form of perspiration and insensible loss is vaporized from the skin

51
Q

ADPIE related to fever

A

Assess temp, diagnosis type of fever and onset of fever, plan of action to lower fever - medications, nonpharmaceutical actions, implement plan and evaluate fever after taking action

52
Q

Wound Drainage - Serous

A

clear drainage, typically clear yellowish

53
Q

Wound Drainage - Sanguineous

A

bloody drainage, can’t be seen through

54
Q

Wound Drainage - serosaguineous

A

Bloody but clear drainage

55
Q

Wound Drainage - Purulent

A

pus drainage

56
Q

Factors involved in affecting would healing

A
  • A variety of factors affect wound healing, local factors that occur directly in the wound.
  • Desiccation (Dehydration): is the process of drying up
  • Maceration (Overhydration): softening and breakdown of skin, results from prolonged exposure to moisture.
  • Trauma, edema, Infection, excessive bleeding
  • Necrosis: dead tissue present in the wound delays healing
  • Biofilm: wound biofilms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins
  • Systemic Factors: age, circulation and oxygenation, nutritional status, medications and health status and immunosuppression.
57
Q

Phases involved in Wound Healing

A

Hemostasis, Inflammatory phase, Proliferation phase, and maturation phase

58
Q

Hemostasis

A

immediately after the initial injury - involved blood vessels constrict and blood clotting begins through platelet activation and clustering

59
Q

Inflammatory Phase

A

WBCs move to the wound

60
Q

Proliferation Phase

A

new tissue is built to fill the wound space, primarily through the action of fibroblasts

61
Q

Maturation Phase

A

collagen that was haphazardly deposited in the wound is remodeled, making the healing wound stronger and more like adjacent tissue

62
Q

Interventions required with performing wound care

A
  • Cleansing and draining
  • Skin assessment
  • Assessing wound length, width, and depth, tunneling, etc.
  • Assessing for infection, nutritional status, mobility, moisture and incontinence,
  • Pain assessment
  • Packing wounds and Changing dressings
63
Q

4 Stages of pressure ulcers

A

Stage 1, stage 2, stage 3, stage 4, and unstageable

64
Q

Stage 1 Pressure Ulcer

A

Intact but discoloration of epidermis

65
Q

Stage 2 Pressure Ulcer

A

Discoloration which involves partial-thickness of dermis

66
Q

Stage 3 Pressure Ulcer

A

Deep crater with full-thickness skin loss with damage or necrosis

67
Q

Stage 4 Pressure Ulcer

A

Involves full-thickness with extensive destruction, tissue necrosis or damage to muscle, bone or support structures

68
Q

Unstageable

A

covered in black eschar, unable to stage. Heel and Scalp are typical

69
Q

Braden Scale scores that are at risk

A

Very high risk score of 9 or less
High risk score of 10-12
Moderate Risk score of 13-14
Mild Risk score 15-18

70
Q

Nursing Diagnosis for impaired skin integrity

A

• Impaired Skin Integrity r.t. any condition that alters the dermis and/or epidermis, such as a surgical incision or traumatic wound; moisture, physical immobilization a.e.b presence of intentional or unintentional wound; disruption of skin surface or presence of a pressure ulcer; destruction of skin layers.

71
Q

Nutritional status and wound healing

A
  • Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues.
  • Vitamins A and C are essential for epithelialization and collagen synthesis.
  • All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional status and fluid balance.
72
Q

Acute Infection

A

rapid onset and brief period of symptoms and resolves within days.
Cardinal signs are redness, heat, swelling, pain and loss of function, usually appearing at the site of injury or inflammation

73
Q

Chronic infection

A

long-term, persistent ex: hepatitis or herpes

74
Q

Jaundice

A

a medical condition with yellowing of the skin or whites of the eyes arising from excess of the pigment bilirubin and typically caused by obstruction of the bile duct, by liver disease, or by excessive breakdown of red blood cells

75
Q

Pallor

A

an unhealthy pale appearance

76
Q

Erythema

A

superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilation of the blood capillaries

77
Q

Cyanosis

A

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood

78
Q

Subjective Data

A

gathered from the patient telling you something that cannot be measure. Pain is subjective

79
Q

Objective Data

A

is another type of information this is collected from patients. Heart Rate, Blood Pressure, Temperature, Respirations, Wound Appearance, and Ambulation description

80
Q

Assessment Techniques

A

Norm order - inspect, palpate, percuss, and ausculate.

Abdomen - inspect, ausculate, palpate and percuss

81
Q

Inspection

A

Performing deliberate, purposeful observations in a systematic manner. Assess smell, hearing, appearance, behavior and movement.

82
Q

Auscultation

A

is the act of listening with a stethoscope to sound produced within the body

83
Q

Palpation

A

uses the sense of touch. Hands and fingers are sensitive tools that can assess skin temp, turgor, texture and moisture

84
Q

Percussion

A

is the act of striking an object against another to produce sound.

85
Q

Normal Blood Pressure

A

120/80

86
Q

Normal Heart Rate

A

60-100 beats per minute - for an adult.

Fundamentals of Nursing (1 decks)

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