final exam Flashcards
sentinel event:
unexpected event leading to death
or serious injury to a patient
purpose of nursing care:
health promotion, illness prevention, health restoration, and end-of-life care
professional organizations:
ANA: National professional organizations
NLN: Establishes and maintains a universal standard of education
ICN: Federation of national nursing organizations
NSNA: Represents nursing students
state board of nursing:
nurse practice acts and licensure
Florence Nightingale:
pioneer in using data analysis in healthcare. She used statistical data to create her famous “rose chart”, one of the first pie charts, to show that preventable diseases were the leading cause of death among British soldiers in the Crimean War, “the act of utilizing
the environment of the patient
to assist him in his recovery,” she is the founder of modern nursing
nursing is:
helps the public understand the value of nursing, helps differentiate activities of nursing from those of medicine, helps students understand what is expected of
them
urinary words to know:
-polyuria: excessive urination
-ketonuria: ketones in urine
-anuria: pus in urine
-proteinuria: protein in urine
-oliguria: decreased urine output
-glycosuria: glucose in urine
-nocturia: peeing at night
-dysuria: painful urination
-pyuria:absence of urine
different types of incontinence:
-stress: coughing, sneezing, laughing, or physical activity that increases pressure on the bladder
-urge: strong urge to urinate, but leaking occurs before getting
to the toilet
-reflex: urinary leakage as a result of nerve damage
-overflow: incomplete bladder emptying which results in the bladder overfilling when full
-functional: physical inability to reach the toilet in time
-bedwetting
urinary retention: and how does it occur
occurs when the bladder is not able to fully empty.
-symptoms of urinary retention include the inability to urinate, pain,
abdominal distention, urinary frequency, urinary hesitancy, weak or slow
urine stream, and urinary leakage
uti:
-bacteria entering the urinary tract
-more common in women, shorter urethra
-if left untreated can cause a kidney
infection called pyelonephritis
kidney stones:
(also called renal calculi, nephrolithiasis, or urolithiasis) are hard formations of
minerals and salts that collect in
the kidneys
kidneys, ureters, bladder:
-two bean shaped organs
-average filter 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine
-kidneys, urine is transported to the bladder by ureters, or thin tubes of muscle, there is one ureter from each kidney
-a bladder can hold up to 2 cups of urine
what are three sets of muscle to help prevent unwanted urination
-urethra
-bladder neck which is composed of the internal sphincter
-pelvic floor
diuretic and antidiuretic
-antidiuretic: minimize fluid loss by preventing urine production in the kidneys
-diuretics: increase urination by increasing urine production in the kidneys
urinary tract:
-primary function is to eliminate waste and excess fluid from the body in the form of urine
-regulated levels of electrolytes, produces hormones that are important for blood pressure regulation, develops red blood cells, and helps to keep bones strong
-urine travels through the urinary system or urinary tract, which consists of the kidneys, ureters, bladder, and urethra
hygiene:
as actions and practices that decrease the
spread or transmission of pathogens, thereby lessening the occurrence of illness
how long do you rub hands together after hand sanitizer? and when can it not be used?
20 seconds , contact with bodily fluid, visibly dirty/greasy, around diseases and parasites
how far up the arm do we wash ?
1 inch above the wrist
which way do we open the top flap of a sterile field? whats the maximum border around a sterile drape that is considered unsterile?
away from your body, one inch
skin:
largest organ, epidermis:outer layer, dermis: under epidermis, hypodermis: beneath dermis, acts as cushion
Body temp regulation
Vitamin D production
Immunologic
Absorption
Elimination
chain of infection: and the steps
sequence of infection to occur infectious agents, reservoir, portal of exit, mode of transmission
1) infectious agent: contains bacteria, fungi, virus, parasite
2) reservoir: habitat of infectious agent, lives, grows, reproduce
3) portal of exit: agent leaves
4)mode of transmission
5) portal of entry: body orifice, be thru skin
6) susceptible host: take hold and become a reservoir/infection, not every host is susceptible
modes of transmission:
-contact: occurs when microorganisms move from an infected person to
another person.
~direct contact: microorganisms are
directly moved from the infected
person to another person without
having a contaminated object
~indirect contact: microorganisms are
moved from the infected person to
another person with a
contaminated object
-droplet: occurs when airborne droplets from the respiratory tract of a client
travel through the air and into the mucosa of a host.
-airborne: occurs when small particulates move into the airspace of another
person
when should you not put a catheter in ?
when a pt is incontinent
specific and nonspecific immunity
specific: antibodies (also called
immunoglobulins) and lymphocytes
nonspecific: neutrophils and macrophages and their work as phagocytes
stages of infection:
-incubation: An infection enters host
and begins to multiply.
-prodromal: The client begins
having symptoms.
-acute illness: Manifestations of the
specific infectious disease process
are obvious and may become
severe.
-decline: Manifestations begin to
wane as the degree of infectious
disease decreases.
-convalescence: The client returns
to a normal or a “new normal” state
of health.
systemic vs local infections
systemic: start as local infections and then spread to the bloodstream to infect the entire body
local: confined to one area of the body
medical asepsis vs sterile asepsis
medical: clean technique, reducing the number of microorganisms
sterile: sterile technique, free of all microorganisms
nursing process:
key to helping nurses make clinical
judgments that are appropriate for
clients
-assessment: Assess the objective
and subjective data that pertains to
the client.
-analysis: Determine the client
problems.
-planning: Create a plan to address
client problems.
-implementation: Take action to
provide care as outlined in planning.
-evaluation: Evaluate the
effectiveness of the interventions
provided and document the client’s
response
they go in order for the most part, but can go back to center ones
critical thinking vs clinical reasoning:
critical: skill of learning to analyze and
interpret data to solve a problem to
achieve a desired outcome
clinical: mental process used when
analyzing all the data of a clinical
situation to make a decision based
on that analysis
(clinical reasoning and judgment cannot be delegated)
SMART:
S: specific
M: measurable
A: attainable/ achievable
R: relevant/ realistic
T: timely
clinical judgement measurement model:
1)recognize cues: data gathering phase, validating the information you are collecting. NEVER ASSUME (vital signs)
2)analyze cues: create meaning from the information, cluster into groups, distinguish relevant and irrelevant
3)prioritize hypotheses: ABCs, after its judgement call, biggest risk
4)generate solution/ expected outcomes: providing quality patient care is to improve the client’s health
5)take action/ interventions: how you plan to accomplish your goal, assess, teach, tasks
6)evaluate outcomes: early and often, reduce errors, assessment, what improved/declined, any modifications
this is not the same as the nursing process!
six medication rights:
right dose, route, time, patient, documentation, medication
additional rights:
right to refuse, right assessment, right education, right response/evaluation
medication reconciliation:
preformed every time the patient is transferred from one healthcare professional to another (readmissions or transfer within hospital), involves reviewing current medications and addressing omissions and duplications
Pharmacodynamics:
the study of how a drug effects the body, relationship to drug concentrations, how body responds
drug doses:
-therapeutic range: concentration of drug in the blood serum that produces the desired effect without causing toxicity
-half-life: amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body
-peak: when a drug is at its highest concentration, does not mean it is at its most therapeutic level
-trough: the lowest levels of concentration of a medication that correlates to the rate of elimination
-duration:
different medications admin:
-afferent: sensory neurons, travel ack towards the CNS
-efferent: motor neurons, travel outward from CNS
-antagonist: blocks target receptor site
-agonist: stimulates target receptors site
-teratogenic: cause fetal defects
-anaphalaxysis: severe, life threat, reaction due to histamine release
-black box warning:issued on medications
that may produce lethal and iatrogenic
results
-iatrogenic: a state of ill health or adverse effect
-idiosyncratic: an unusual or abnormal response
-prodrugs: inactive chemicals that are transformed through metabolism to become active before they have therapeutic effect
types of ways medication can be given:
-enteral – administered directly into the GI
tract
-topical – applied directly to skin, eyes,
nose, respiratory tract, vagina, rectum, or
urinary tract
-parenteral – administered by
injection using a needle and syringe or
catheter (IV: vein, IM: intramuscular, subq: subq tissue, intradermal: under epidermis, intraosseous: bone)
-sublingual: under tongue
-buccal: placing drug between tongue and cheek
subcutaneous injection:
-layer: adipose layer just below the epidermis and dermis
-angle: 45º
-sites: outer aspect of upper arm, abdomen, anterior aspects of thigh,
upper back, upper ventral or dorso gluteal area
-length: 3/8” - 5/8”
-gauge: 25-27 gauge
-max dose: 1.5 mL
-example: insulin
important: do NOT massage
intramuscular injection:
-layer: muscle
-angle: 90º
-sites: ventrogluteal, vastus lateralis, deltoid (1 inch for deltoid)
-length: 1”-1 1/2”
-gauge: 22-25
-max dose: up to 1 mL for deltoid
-example: most vaccines
important: do NOT massage
intradermal injection:
-layer: dermis
-angle: 5º-15º (go in middle 10º)
-sites: inner surface of arm, upper back, under scapula
-length: 1/4” - 1/2”
-gauge: 25-27 gauge
-max dose: 0.5 mL
-example: TB test
important: do NOT put band-aid over
create a wheel
pharmacokinetics:
Study of the absorption, metabolism, distribution, and excretion of drugs in the human body, ADME
ADME
absorption: drug being absorbed through way it was taken
distribution:
metabolism: biotransformation, liver metabolizes most, but kidney and small intestine also
excretion: kidneys excrete most, process of moving drugs from body, skin, lungs,
exocrine glands, and intestines also excrete but lesser, toxicity
develops when the body is unable to
metabolize and excrete a drug
types of medication orders:
-standing order – routine, carried out until it is cancelled by another order
-PRN order – as needed
-Single or one-time order
-STAT order – carried out immediately
high risk drugs:
A: anti-infective, P: potassium/ other electrolytes, I: insulin, N: narcotics, C: chemotherapeutic agents, H: heparin/ anticoagulants
time and non time critical medications:
-time critical medications are those administered either 30 minutes after the scheduled time that can cause harm to the client or have less than desired effects
-non-time critical medications are defined as medications that can be administered between one or two hours early or late without causing harm
bones classified by shape
-long bones: upper and lower extremities
-short bones: wrist and ankle
-flat bones: ribs and skull bones
-irregular bones: spinal column and jaw
positioning patients:
fowlers, supine or dorsal recumbent, side-lying or lateral position, sims position, prone position