Final Exam Blueprint Flashcards
Nonrebreather mask (low flow)
Amount delivered FIO2:
- 10-15 L/min - 80-95%
nursing interventions:
- maintain flow rate so reservoir bag collapses only slightly during inspiration
- check valves and rubber flaps are functioning properly (open during expiration and closed during inhalation)
- monitor SaO2 w/ pulse ox
stress management techniques (class notes)
- relaxation
- meditation
- anticipatory guidance
- guided imagery
- biofeedback
- humor
- crisis intervention
Transmission precautions
used in addition to standard precautions for pts with suspected infection that can be transmitted by: airborne, droplet, or contact routes
Sepsis (IV) s/s
- red, tender insertion site
- fever, malaise, other vital changes
Delegating pain management to UAP’s
Do not delegate:
Pain assessment
Monitoring of patient’s response to pain management
Evaluation of pain management plan
(everything else we can delegate)
Hypotonic fluid: what is it? example?
Lesser concentration of particles than plasma
- should be administered slowly to prevent cellular edema
– causes cells to swell - used for dehydration
- definition: solutions that are more dilute or have a lower osmolality than body tissues
Example: 0.45% NSS
Air embolus s/s
- respiratory distress
- increased HR
- cyanosis
- decreased BP
- change in level of consciousness
Causes of hypoxia?
Often caused by hypoventilation, atelectasis
Foley catheter
needs to be sterile
Female:
- sterile gloves
- graps corners of drape and unfold without touching nonsterile areas
- sterile tray on drape between patient thighs
- open all supplies; attach syringe to inflation port for balloon
- antiseptic swabs or cotton balls: prepare
- lubricate 1-2 inches of catheter tip
- spread labia and identify meatus – keep one hand there until catheter is inserted
- use dominant hand to pick up swaps or cotton balls and clean one labial fold top to bottom, discard, and use clean one for each following stroke
- slowly insert catheter into urethra with dominant hand and advance until return of urine
- once urine drains, advance catheter another 2-3 inches
- rotate slightly if needed
- use dominant hand to inflate catheter balloon with sterile water from syringe attached to port
- pully gently after inflation to make sure in place
- attach catheter to drainage bag if not preattached
- remove gloves; secure catheter tubing to patient’s inner thigh with securing device
- secure drainage bag below level of bladder; ensure tubing is not kinked or clamped
What is the reticular activating system (RAS)
- basically your drive
- is a poorly defined network
- extends from hypothalamus to medulla
- mediates arousal
– optimal arousal state of RAS: general drive - monitors and regulates incoming sensory stimuli
Chronic stress
exercise helps to lessen stress
from internet:
Chronic stress can lead to a range of negative effects on both mental and physical health,
- including increased risk of anxiety,
- depression,
- heart disease,
- high blood pressure,
- digestive issues,
- headaches,
- muscle tension,
- sleep problems,
- weakened immune system,
- memory impairment,
- and difficulty concentrating,
essentially impacting nearly every system in the body due to prolonged elevated stress hormones
What is the therapeutic action of a drug
The intended effect of the drug; the physical effect
Can have more than one
6 actions: palliative, curative, supportive, substitutive, chemotherapeutic, restorative
Ex: giving antihypertensive -> therapeutic effect is lower BP
What are stressors
anything perceived as challenging, threatening, or demanding; anything that causes a person to experience stress
What is oliguria
low urine output, or when someone is producing less urine than normal
Care of a patient with an indwelling foley catheter
- keep bag below bladder
- have it strapped
- check for kinks; move tubing if not draining
- make sure everything is connected
- make sure with placement that it is correct and balloon accurately inflated
- replace catheter and urine bags that become disconnected
- cleaning with soap and water
- empty collection bag
- make sure sterile technique
how long can it be in there?
Complications of IV therapy (list)
- phlebitis
- thrombus
- infiltration
- sepsis
- fluid overload
- air embolus
Respiratory medications
Expectorants, suppressants, nebulizer, inhaler, bronchodilators, corticosteriods???
Deep Tissue Pressure Injury
purple or maroon intact skin or blood-filled blister
Types of assistive devices in activity
patient confined to bed:
- wedges and pillows
- mattresses
- adjustable beds
- trapeze bar
- high-top sneakers
- hand splints
assistive devices in activity:
- walker
- cane
- crutches
T or False: A urine specimen from a patient with an indwelling catheter should be obtained from the collection receptacle.
False-should be obtained from the sampling port on the catheter tubing, not the collection receptacle (drainage bag) to ensure a fresh, uncontaminated sample.
Provider order interpretation
- be sure to compare meds to original order
medication orders:
- standing order (routine)
- prn: as needed
- single order (one time)
- stat order: immediately given, emergent
- standing protocols - like diabetic and sugar levels; based on number values or symptoms like chest pain
- telephone/verbal/faxed
Work-life balance
no idea; try to have a good work life balance? make sure to make time for yourself to do things like exercise, see family
Sources of stress (4)
- developmental stressors (childhood, adolescence)
- situational stressors (car accident, exams)
- physiologic stressors (medical)
- psychosocial stressors (bullying, breaking up)
HIPAA
All information about patients written on paper, spoken aloud, saved on computer
Name, address, phone, fax, social security
Reason the person is sick
Treatments patient receives
Information about past health conditions
Types of isolation
Contact precautions
Droplet precautions
Airborne precautions
Transmission precautions
Also just standard precautions: apply to blood, all body fluids, secretions, excretions (except sweat!), non-intact skin, and mucous membranes
Pain with GI/GU/Peri-op (CA means colon cancer)
CA warning signs (idk what CA means)
- change in bowel pattern
- blood in stool
- rectal/abdominal pain
- change in stool
- sensation of incomplete post bowel movement
Alternatives for drugs for comfort/pain
Distraction
Humor
Music
Imagery
Relaxation/Meditation
Cutaneous
- Stimulation
Acupuncture
Hypnosis
Biofeedback
Therapeutic Touch
Animal-facilitated therapy
What are some things you can recommend to a spouse that is a caregiver and has symptoms of chronic stress
social worker, techniques to deal with stress like meditation and exercise
safety: prioritization
nurse assessment for safety
- individuals
- environment
- specific risk factors
– falls
– impaired vision or balance
– medications
– confusion
our job for safety:
- assess
- diagnose
- plan
- implement
- preventing
- educating
What is role overload
unmanageable expectations and responsibility of that role
Intradermal injection: gauge, angle, length, sites
1/4 to 1/2 inch needle
gauge: 25-28
dose small, less than 0.5 mL
angle: 5-15 degrees
sites: inner surface of forearm, upper arm, upper back (no hair)
What do you want to accomplish with teaching after a teaching session
want to evaluate goals and learning objectives
Types of Urine specimen collection
- Routine urinalysis
- Clean-catch or midstream specimens
- Sterile specimens from indwelling catheter
- urinary specimen from urinary diversion
- 24hr urine specimen
Droplet precautions
- precautions for patients with an infection that is spread by LARGE-PARTICLE droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children
- Use a private room, if available; door may remain open
- Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the pt’s environment (mask and don PPE when entering pt room)
- Transport patient out of room only when necessary and place a surgical mask on the patient if possible
- Nurse should also wear mask when transporting pt
- Keep visitors 3 ft from the infected person
- Ex. influenza (flu); bronchitis (Anything with someone coughing)
- Masks are to be worn for protection against potential exposure to infectious agents when the client is on droplet precautions
TPN
Total parenteral Nutrition
Nutritional support, highly concentrated
Infused through central line
Used with clients who can’t meet nutritional needs PO or enteral.
Complications; infection, f/e imbalance.
REM sleep and vital signs
Stage 4: REM. Dream and brain activity. Most dreaming occurs. Body cannot regulate its temperature you may begin to feel hot or cold.
Heart and respiratory rates increase
Limb muscles paralyzed
Increased brain activity
Sleep apnea
impaired Gas
Exchange
- high BMI
-snoring
-diabetes
Fluid overload s/s
- increased BP
- distended jugular veins
- rapid breathing
- dyspnea
What is airborne transmission
Small particles (<5 μm) spread through the air.
Ex: tuberculosis requires a N95 respirator mask and negative air pressure room. <5 micrometers; door should remain closed
What is somatic pain
tendons, ligaments,
muscles, bones,
blood vessels
What is the expected response of vital signs to infection? **not sure what she wants here tbh
Fever (pyrexia)- increase above normal in body
temperature due to a change of thermoregulatory
set point
Temperature above 100.4 F (orally)
-
-
Malaise
Chills, shivering (pt c/o being cold)
Aches, pains, fatigue
Headache, drowsiness, confusion
Nausea, decreased appetite
Hot, dry, flushed skin
Increased pulse and respirations
Dehydration, thirst
Diaphoresis (sweating)
Susceptible Host
-Susceptibility: degree of resistance
-Compromised: a person at increased risk of
infection
Who would you be worried about using a nonrebreather mask
COPD patients because they have low oxygen as the drive to breathe and worry about them losing the drive to breathe
What are the 3 checks of medication administration
when you reach for container
before pouring
upon replacing container
What should you do after a general acute injury-RICE
Rest
Ice
Compression
Elevation
First 48 hours you do ice for acute injury and then switch or alternate
What is adaptation
change in response to a stressor in an effort to restore balance
Joint Commission guidelines for pain management
Staff must be oriented and competent
Oral analgesics must be evaluated in 45-60 minutes
IV analgesics must be evaluated in 15 to 30 minutes
Discharge planning must include pain management needs
—–
Teach patients
Determine pain rating goals
Provide appropriate care
24 hour urine
First, you discard urine
If you empty the urine at 0600, you’ll collect the urine 24 hours later at 0600
Foley - i think you have the bag on ice
Discard first urine
Collect for 24 hours
At the end, ask patient to void and add to collection
Devices for oxygen therapy
nasal cannula
simple mask
nonrebreather mask
partial rebreather
venturi mask
Stage 1 pressure ulcer
non-blanchable erythema of intact skin
Stage 2 pressure ulcer
partial-thickness skin loss - shallow, open ulcer
Simple mask (low flow)
Amount deliver FIO2:
- *Simple-A low-flow system that delivers 35–50% oxygen with a flow rate of 6–10 L/min (from slides)
nursing interventions:
- monitor frequently to check placement of mask
- support patient if claustrophobic
- secure nasal cannula (prescribed) to be used during meals
DVT prevention
- compression socks
- keeping patients mobile; not resting in bed too long
Values and beliefs in culture
- can influence type of health care received
- can influence medications receive
- can influence hygiene practices
- can influence dietary practices
Cold applications for skin - effects?
constricts peripheral blood vessels
decreases muscle spasms
promotes comfort
reduces blood flow to tissues
decreases local release of pain producing substances
decreases edema and inflammation
alters tissue sensitivity - numbness
What are the 11 rights of medication administration
right patient
right medication
right dose
right route
right time
right reason
right assessment
right education
right refuse
right response
right documentation: drug, dose, route, time, initials, full signature, site of injection, clinical info
GI/GU/Peri-op: male hygiene
Male assessment:
- lesions, swelling, excoriation, tenderness, discharge
make sure to clean foreskin if uncircumcised
- anal area:
– cracks, nodules, distended veins, masses, polyps
perineal care:
- clean from tip of penis toward pubic area
- if uncircumcised, retract foreskin, wash, rinse, and put foreskin back in place
- wash and rise scrotum and dry
Stage 3 pressure ulcer
full-thickness skin loss - subcutaneous fat may be visible
Hoyer lift (2 types)
Hoyer lifts: allow person to be lifted and transferred with a minimum of physical effort
– sit-to-stand hoyer lift
– manual and powered hoyer lifts
Techniques for assessing vital signs (temperature)
Equipment:
Tympanic (ear)
Electronic, digital
Temporal artery – right or left side of forehead
What are factors contributing to pulmonary disease?
factors affecting oxygenation:
-sedentary activity patterns
-exercise
-smoking
Smoking!!! (have to offer smoking cessation to any patient that smokes)
Environmental - pollution
Working with chemicals
Safety with oxygen therapy
No open flames
No smoking
No gas stoves or fireplace
Monitor for skin breakdown around ears with cannula; around nose with CPAP
Sterile gloves - how to put on and off?
STEPS TO PUTTING ON FIRST STERILE GLOVE (ALWAYS DOMINANT HAND FIRST)
- Use the thumb and forefinger of your non-dominant hand to grasp the cuff of the sterile glove for your dominant hand.
- Touch only the inside surface of the glove.
- Lift the glove above your waistline.
- Place your dominant hand into the glove and pull on the glove.
STEPS TO PUTTING ON SECOND STERILE GLOVE (NONDOMINANT HAND)
- Hold the thumb of your gloved hand outward, and place your fingers inside the cuff of the remaining glove.
- Lift it from the wrapper.
- Place your non-dominant hand into the glove and pull it on, taking care not to touch your skin with the outer surface of the glove.
STEPS TO EXTENDING CUFF ONCE STERILE GLOVES ARE ON
- Slide the fingers of one hand under the cuff of the other.
- Fully extend the cuff down your arm, being careful to only touch the sterile outside of the glove.
- Repeat for the other hand.
- Adjust gloves as needed
STEPS FOR REMOVING STERILE GLOVES
- Use your dominant hand to grasp the other glove near the cuff end on the outside of the glove. Contaminated surface does not come in contact with wrist.
- Remove the glove by inverting it as it is pulled off, to keep the contaminated area (the outer surface of the glove) on the inside. Remove the gloves in a safe manner to prevent the spread of microorganisms that may be on the outside of the gloves.
- Hold the removed glove in your gloved hand. Contaminated area does not come in contact with hand or wrist.
- Slide the fingers of ungloved hand inside the remaining glove, between the glove and your skin. Do not touch the outside of the glove. Contaminated area does not come in contact with hand or wrist.
- Grasp the glove on the inside and remove it by turning it inside out, over the hand and the other glove. Contaminated area does not come in contact with hand or wrist.
- Perform hand hygiene. Wearing gloves does not eliminate the need for hand hygiene. It reduces the spread of microorganisms.
Cold applications for skin - types?
Moist
- cold compresses
Dry/cold
- ice bags/packs
- cold packs (freezer)
- hypothermia blanket or pad
Priority nursing issue/nursing diagnosis (unsure)
ADPIE
safety first
UTI - signs, symptoms, how to treat
From internet:
A urinary tract infection (UTI) can cause a variety of symptoms, including:
A burning sensation or pain while urinating
A strong urge to urinate, especially at night
Cloudy, red, or bloody urine
Urine with a strong odor
Pain in the lower abdomen or pelvis
Fever or feeling hot and shivery
Nausea and/or vomiting
Tiredness
Pain in the back or side, below the ribs
treated by antibiotics
Stool specimen collection
Medical aseptic technique
– hand hygiene before and after glove use
– disposable gloves
– do not contaminate outside of container w stool
– obtain sample, package, label, and transport according to policy
Patient guidelines:
- void first so urine is not in stool sample
- defecate into container rather than toilet
- do not place toilet tissue in bedpan or specimen container
- notify nurse when specimen available
Factors affecting learning
- education
- knowledge deficit
– need to teach about medications, oxygen therapy, assistive devices, catheter care, NGT care - reading proficiency
- ability to communicate
– language barrier
– medications
– sensory loss - physical health state
– health and disease process
– illness - mental status
- psychosocial health state
– stress and depression (decreased concentration, lack of judgment and decision making, lack of motivation in learning)
in class review:
Intellectual ability
Health literacy
Language
Support systems
Level of consciousness; mental status
Financial status
Types of responses to pain (voluntary..involuntary..)
Physiologic (involuntary)
Behavioral (voluntary)
Affective (psychological)
Long-term stress (class notes)
ability to adapt is lessened; becomes chronic
- increased duration, intensity, and number of stressors
increased risk for disease or injury; recovery and return to normal function is compromised
Stages of Infection #2
Prodromal Stage:
Interval from the onset of nonspecific until
specific symptoms appear
Client is usually the most contagious
Fatigue in hygiene/ADL
- patient can get tired or unable to complete hygiene for themselves or able to do ADLs
Adult learning
- only 12% of adults have proficient health literacy
- health literacy: ability to understand instructions, navigate health care system, and communicate needs, and engage in self-care and chronic disease management
might be affected by
- intellectual ability
- health literacy
- language
- support systems
- level of consciousness
- financial status
assess patient learning with teach-back method
always confirm understanding
Incontinence and skin
- fecal incontinence
- urinary incontinence
watch for skin breakdown due to moisture exposure
What is neuropathic pain
Nerve pain
Some effects of NREM sleep
decreased respiratory, BP and pulse
decreased vital signs and eye movements
Pulse oximetry - normal values, when to take
measures the arterial oxyhemoglobin saturation (SaO2 or SpO2)
Be aware of patient’s hemoglobin level as well
95 – 100% normal
< or = 90% abnormal
Metabolic rate
basal metabolic rate (BMR): energy (# of calories) required to fuel the involuntary activities of the body at rest after 12 hours; energy needed to sustain metabolic activities of cells and tissues
males have a higher BMR due to larger muscle mass, generally
factors that increase BMR:
- growth, infections, fever, emotional tension, extreme environmental temps, elevated levels of certain hormones
factors that decrease BMR:
- aging, prolonged fasting, sleep
Means of Transmission (5)
A. Contact
Direct
Indirect
B. Airborne Transmission
C. Droplet transmission
D. Vehicle Transmission
E. Vector Transmission
What is drug toxicity
- Occurs from cumulative effect due to poor metabolism/excretion (one dose cannot be metabolized prior to the next dose)
- Impairing an organ; bad effects
endangers health - risk for permanent damage or death
Thrombus s/s
- IV infusion sluggish or may cease
- heat, redness, tenderness at site
Sterile field
- You cannot take your eyes off the sterile field once it is set up
– If you have to leave the room → the sterile field must be reset up - If out of your range of vision or below your waist, it is considered contaminated
- A wet field is contaminated
- Prolonged exposure to the air will contaminate
Basic Principles of Surgical Asepsis:
- Touching Sterile Objects: Only sterile objects should touch other sterile objects. Any unsterile contact contaminates the sterile object.
- Opening Sterile Packages: Open packages so that the first edge of the wrapper is directed away from the worker to prevent contamination.
- Avoiding Spills: Do not spill solutions onto cloth or paper fields as moisture can cause contamination.
- Handling Sterile Objects: Hold sterile items above waist level to keep them in sight and prevent contamination.
- Avoiding Contamination: Do not talk, cough, or sneeze over sterile fields, and never turn your back on or walk away from a sterile field. Do not reach over sterile fields.
- Edge Contamination: The outer 1-inch margin of a sterile field is considered contaminated.
- Doubtful Sterility: Consider any object contaminated if there is doubt about its sterility.
Diet for clients based on bowel health
high or low fiber diets
idk eat fruits and veggies
What is vehicle transmission
transmitted through food or water
Assisting patients with sensory deficits
- use clock face language to tell a patient where something is.
- making sure they dont trip on the IV line
- clearing paths
- clear communication
Normal and abnormal values: RR
12-20
Bradypnea: slow breathing; regular rate that is less than 10 rpm
-Tachypnea: rapid breathing; regular rate that is more than 24
-Apnea: period without breathing
- Dyspnea: difficult or labored breathing
- Hyperventilation: increased rate and depth
-Hypoventilation: decreased rate and depth
-Orthopnea: difficulty breathing in any position
except upright sitting or standing
-Cheyne Stokes: regular pattern, alternating
hyperventilation with apnea
Heat application for skin - effects?
dilates peripheral blood vessels
– increases local blood flow
– increases supply of oxygen and nutrients to area
increases tissue metabolism
decreases blood viscosity
increases capillary permeability
decreases muscle tension
helps relieve pain
Documentation/reporting/informatics - pain
Ask on scale 0-10
PQRST or OLDCARTS
Unsure on this just guessing
Clear vs Full Liquid
Clear liquid: juice, broth, water, coffee
Full liquid:
“Clears” plus:
- milk
- pudding and custard
want pourable
liquid supplements
What are complications with tube feedings
aspiration
Types of restraints
- wrist restraint (cloth, leather)
- jacket or body restraint
- geriatric chairs
- bed rails
- medications as well
Bacterial Reservoir
(Common reservoirs)
What does bacterial need?
Common reservoirs:
- Human body, animals, insects
- Fomites (inanimate objects ex. soil)
Must provide microorganism-specific
environment to survive:
- food, oxygen, water, temperature, ph, light
Powered full body lift
designed for patients who cannot bear any weight
Older adult comfort/pain
Approximately 80% suffer with chronic illness accompanied by varying degrees of discomfort
Many myths surround pain management
What is vector transmission
transmitted through insect or fomite
Confidentiality with documentation/reporting
Cannot have any identifying information in writing yourself notes
Do not speak about patients in common, public areas
What is something you should always check for patients as general safety
call bell in reach, bed lowered, and personal belongings within reach
7 components of a medication order
- patient’s full name
- date and time order is written
- drug name
- dosage
- route of administration
- time and frequency
- signature of person writing order
What is pneumonia? When does it develop? How to prevent? idk
Can be a respiratory complication peri/post-op
Can develop from lack of movement in bed? - is bacterial or viral
Prevent by moving patient around using breathing exercises
Alcohol vs soap and water for hands
Alcohol-Based Hand Rubs: Preferred when hands are not visibly soiled. They are effective in reducing bacterial counts quickly.
Soap and Water: Necessary when hands are visibly dirty or after contact with C. difficile spores since alcohol-based rubs are ineffective against these spores.
Portals of Exit
When the human body is the reservoir
When the human body is the reservoir -
-Skin & mucous membranes
-Respiratory tract
-Genitourinary tract
-Gastrointestinal tract
-Blood & tissue
Powered Stand lift (can patient assist)
Powered Stand-assist and repositioning lifts: for patients with weight-bearing ability, able to follow directions, and cooperation
Venturi mask (high flow)
Amount delivered FIO2:
- 4-6 L/min - 24-40%
nursing interventions:
- requires careful monitoring to verify FIO2 at flow rate ordered
- check that air intake valves are not blocked
Central venous sites
Subclavian, jugular, PICC line
she noted: IV in hand is not a central line
How to use crutches
Top of crutches should be 1-2 in below armpit, weight should be on hands not armpit. handgrips should be even with top of hips.
Navigating Stairs
Up Stairs: Lead with your uninjured leg, moving it to the next step first, then move your crutches and injured leg to the same step. Remember the phrase: “Up with the good.”
Down Stairs: Place the crutches on the lower step, move your injured leg down next, and then follow with your uninjured leg. Remember: “Down with the bad.”
Phlebitis s/s
- local acute tenderness
- warmth, redness, edema above insertion site
Oxygenation: positioning
Promoting comfort with oxygenation - positioning allows free movement of the diaphragm and expansion of the chest wall
How to use walker
stand between the back legs of the walker with arms relaxed at the side
top of walker should align w/ the crease on inside of patient wrist
grip top of the walker at the handles with elbows slightly bent
lift walker and position about one step ahead; keep back upright
place one leg inside the walker (ensure doesn’t roll away if wheels)
push straight down on grips of walker and step forward with remaining eg
repeat process
How to use cane
Widen a person’s base of support, should not be for bearing weight
hold cane on stronger side
cane about 4 inches to side of foot and extend to wrist crease
elbow slightly bent; flexed 15 degrees
teach patients to stand erect and not lean on it
patient stand w/ weight evenly distributed
cane on stronger side and advance one small stride ahead
supporting weight on stronger leg and cane, patient advances the weaker foot forward to parallel to the cane
supporting weight on weaker leg and cane, patient brings stronger leg forward to finish the step
Stages of infection #4
Convalescence: period when acute symptoms disappear
What nutrients provide energy
Protein, fat, carbs
What is an adverse reaction
effects that are not intended
Portals of Entry
- Often the same as exit routes
** Gain entrance into host
Skin & mucous membranes
Respiratory tract
Genitourinary tract
Gastrointestinal tract
Blood & tissue
Subcutaneous injection: gauge, angle, length, sites
length: 3/8 to 1 inch (based on subcutaneous tissue)
25-30 gauge (dose no more than 1 mL)
angle: 45-90 degrees (based on needle length/adipose tissue)
sites: upper arm, anterior thigh, abdomen, upper back and upper dorsogluteal
be sure to rotate sites
How do you describe to a patient what PRN pain controlled meds mean
they need to tell you when they need the meds, but to tell you before the pain is severe. if you wait until it is terrible, it will take more meds or longer to go away
What is role strain
frustration when one feels inadequate in performing tasks the role is assumed to be responsible for
Vital signs: delegation of tasks to UAP, best practice
Delegation of vital signs based on:
patient situation
abilities of unlicensed personnel; sufficient
knowledge to perform task delegated, can
perform accurately
RN is responsible for validating and
reporting/acting on findings
How do you test for food poisoning
stool sample culture is only official way to diagnose
COPD considerations
teaching w patient and measures to recommend:
-Reduce anxiety
-Eat a high-protein/high-calorie diet
-Maintain a high fowlers position when possible/
tend to sit in tripod position
watch for barrel chest and clubbing
Venturi mask good for these patients
Diet orders (therapeutic, modified)
Therapeutic diets:
- consistent carbohydrate
- fat or sodium restricted (cardiac)
- high or low fiber (GI)
- renal (monitor potassium)
Modified consistency diets:
- clear liquid (juice, broth, water, coffee)
- pureed (usually for swallowing issues)
- mechanically altered (finely chopped, thickener in liquids)
Normal values and locations you can take: pulse ox
ear, finger, toes
normal range: 95-100%
Enteral nutrition
Techniques:
- bolus feeding (delivering a large volume of formula at once using a syringe),
- continuous feeding (administering a steady stream of formula over a long period using a pump),
- cyclic feeding (delivering a large volume of formula over a shorter period, often several hours, using a pump),
- intermittent feeding (giving smaller volumes of formula at regular intervals, usually with a pump or gravity) depending on the patient’s needs and the placement of the feeding tube (stomach vs. small intestine)
Monitoring:
Enteral feeding
- Feeding schedule and formulas, and pumps
- monitor for tolerance
– gastric residual volume (GRV)
- promote patient safety
- monitor for complications
- provide comfort measures
- provide education
What is the expected response of vital signs to exercise?
core temp increase
pulse rate increase
RR increase
bp increase
Communicating with a patient who is confused
- use frequent face to face contact
- speak calmly, simply, and directly to patient
- orient and reorient patient
- orient patient to time, place, and person
- offer explanations
Heat applications for skin - types?
Dry heat:
- hot water bottles
- electric heating pads
- aquathermia pads: water is enclosed
- hot packs (instant)
- warming blankets
Moist heat:
- warm moist compresses
- sitz bath
- warm soaks
Direct vs indirect contact
Direct Contact:
Close proximity between host and carrier (e.g., touching, kissing).
Indirect Contact:
Via vectors (e.g., insects) or fomites (e.g., contaminated equipment).
Stages of infection: #1
INCUBATION
The interval between the entrance of the pathogen into the body and the appearance of the first symptoms
The organisms are growing and multiplying
Prior knowledge in client/patient teaching (unsure)
dispel any misconceptions learned from internet or other sources
assess prior knowledge before teaching
How to use an incentive spirometer? What is it good for?
They are supposed to exhale air and then inhale through the incentive spirometer.
The goal is to keep the ball between arrows on the side and see how high the patient can get and/or reach the level marker. When inspiration increases, they are improving.
Good for: encourages maximizing lung inflation and preventing/reducing atelectasis
What is sensory overload
- patient experiences so much sensory stimuli that brain unable to respond meaningfully or ignore stimuli
- patient feels out of control and exhibits manifestations observed in sensory deprivation
- nursing care focuses on reducing distressing stimuli and helping the patient gain control over the environment
Intramuscular injection: gauge, angle, length, sites
5/8 to 1 1/2 inches (based on site and patient age)
needle gauge: 18-25
angle of insertion: 72-90 degrees
sites: Vastus lateralis (thigh) - 4mL max
Deltoid (upper arm) - 1mL max
Ventrogluteal (hip area) - 4mL max
Exercise - effects on sleep? how long to do before going to bed?
2 hours before
CDC guidelines for handwashing
Hands are washed between client contacts; after contact with blood, body fluids,
secretions, and excretions and after contact with equipment or articles contaminated
by them; and immediately after gloves are removed.
WHO’s 5 Moments for Hand Hygiene:
- Before touching a patient.
- Before a clean or aseptic procedure.
- After body fluid exposure risk.
- After touching a patient.
- After touching patient surroundings.
What is the teach-back method
patient literally teaches if back to you after you teach them
What are side effects of a drug
effects from medication, but are not the desired effect
some are expected like headache, weight loss, hair growth
What is dermatomal pain (?? had to google)
pain that occurs in a specific area of skin, called a dermatome, that is connected to a single spinal nerve. Dermatomal pain can be caused by damage or dysfunction to the spinal nerve, which can be due to infection, compression, or injury.
If you’re teaching someone, what is one of the first things you should do before teaching
assess prior knowledge (what they already know)
What is metabolic syndrome
This was pulled from my prereq notes
Metabolic syndrome: have been linked to high fat diets;
cluster of symptoms that include excess abdominal fat, high blood glucose levels, high triglycerides, low HDL and hypertension
If one has three or more → diagnosed with metabolic syndrome aka Syndrome X
Risk of mortality increases related to diabetes, obesity, and cardiovascular disease
What is visceral pain
body organs in thorax,
cranium, and abdomen
Emotional responses to stress: defense mechanisms
- compensation
- denial
- displacement: taking stress out on others
- rationalization: trying to rationalize what’s happening
Stages of infection #3
Full stage of illness: the presence of specific
disease symptoms
Patient assisted moving devices
o Wedges and Pillows
o Mattresses
o Adjustable Beds
o Trapeze Bar
o High-top Sneakers
o Hand splints
prolonged stress effects (class notes)
- affects physical status
- increases risk for disease or injury
- compromises recovery and return to normal function
- associated with specific diseases (cancer, anything with breathing or SOB, anything life threatening or severe like MI)
Patient getting tired during ADLs - what can you recommend?
Taking breaks; doing it in steps
Symptoms of hypoxia?
S & S: dyspnea, increased BP, increased pulse, pallor, cyanosis, anxiety, restlessness, confusion, and drowsiness
Infection prevention (cleaning)
asepsis, cleansing, disinfecting
Medical Asepsis (clean technique): activities that
reduce the number and transfer of pathogens
.
.
Cleansing: the removal of visible foreign material
from objects (soap/water)
.
Disinfecting: destroying pathogens * use when
risk for infection is high
Stage 4 pressure ulcer
full-thickness skin loss with exposure bone, tendon, or muscle
When do you have to use an electronic pump for IV?
medication that has to be controlled on a pump like TPN
Contact precautions
- precautions used for patients who are infected or colonized by a multidrug-resistant organism (MDRO)
- Place the pt in a private room, if available
- Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient’s environment (gloves, gown, don PPE when entering pt room)
– Change gloves after having contact with infective material
– Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent
– Limit movement of the patient out of the room
– Avoid sharing patient-care equipment - Do not need to apply a face mask, N-95 respirator, goggles, or face shield to prevent contamination through contact with the client or equipment
What is droplet transmission
Larger particles (>5 μm) spread through activities like coughing.
generally need to be 3ft or more away from patient
Example: influenza
Infiltration s/s
- edema, pain and coolness at site
- significant decrease in flow rate
What is polyuria
Frequent urination
Interpretation of vital signs
(im gonna add ranges in the next cards)
What is anuria
very little urine output; 24 hour urine output is less than 50 mL (maybe the key here is “less than”)
HOWEVER, online it says when kidneys aren’t producing urine. which makes sense because of the prefix
Isotonic fluid: what is it and example
Same concentration of particles as plasma
Definition: solutions with the same osmolality as body fluids
- do not enter the cells because there is no osmotic force to shift the fluids
- increases ECF volume
Example: 0.9% NS, Lactated ringer
What is tolerance?
A condition that occurs when the body gets used to a medicine so that either more medicine is needed or different medicine is needed
Unstageable Pressure Ulcer
base of ulcer covered by slough and/or eschar in wound bed
Pump vs gravity infusions
pump can be set to a ml/hr
gravity - set to specific height
Using a gait belt
When to avoid using them?
used to steady patients, not to lift them
avoid using them on patients with abdominal or thoracic issues
When getting a medication history, you should check if they are also taking…
OTCs, herbal meds, supplements
What is referred pain
originates in one part of the body but is perceived in an area distant from its point of origin; transmitted to a cutaneous site different from its origin
Focused assessment in oxygenation (just typing from memory from studying exam 3 so flagging this in case wrong)
Pattern of respirations
Meds
Health history
Recent changes
Lifestyle and environment
Interpreting orders/conferring verbal orders
Repeat verbal orders back
Effects of stress (class notes)
symptoms:
- dilated pupils
- dry mouth
- headache
- backache
- constipation or diarrhea
- increased pulse
- increased BP
- increased respirations
- increased gastric acid production
- nausea
- sleep disturbances
- increased perspiration
- chest pain
- weight gain or loss
- decreased sex drive
psychological responses:
- anxiety, anger, depression
Medication administration: health history
- previous and current drug use
- allergies, response to drugs
- compliance with regimen
- attitude/understanding of drugs
- perceptual/coordination problems related to administration
Other assessments:
- MAR
- diet and fluid orders
- lab values
- ability to swallow
- muscle mass
- GI motility
- venous access
- body system assessment
- pt’s health status
Healthy vs. unhealthy adaptation/coping
- personal habits like drugs and alcohol, illicit or street drugs
- activity and exercise
- nutrition and elimination
- interpersonal relationships and resources
- spiritual resources
- lack of eye contact
- limiting relationships to those with similar values and interests
- attack behaviors
- compromise behaviors
- withdrawal
need to consider coping mechanisms for the adult especially dealing with careers and family
nasal cannula (high flow) - was asked specifically if this was on exam and it was not
amount delivered FIO2 (fraction inspired oxygen):
- maximum flow 60 L/min
- 10 L/min = 65%
- 15 L/min = 90%
nursing interventions:
- monitor respiratory status
- often better tolerated by children than other noninvasive delivery methods
Insomnia (3 types)
Most common sleep disorder
-Transient insomnia - Less than one month.
* Short-term insomnia – Between one and six
months.
* Chronic insomnia – More than six months.
Personal factors affecting adapatation
- physiologic makeup
- genetic inheritance
- very young
- very old
- altered physical or mental health
- inadequate nutrition
- sleep deficits
- poor support systems and relationships
What is role conflict
a person must assume opposing roles with incompatible expectations
Ex: adult daughter now caregiver and medical decision maker for elderly parent
Normal values and locations: temperature
Axillary: 36.5°C, 97.7°F
Oral: 37.0°C, 98.6°F
Rectal: 37.5°C, 99.5°F
Tympanic: 37.5ºC, 99.5°F
Temporal: 37.5°C, 99.5°F
Patient teaching about oxygenation
Teaching those with altered oxygenation from COPD or asthma:
-Reduce anxiety
-Eat a high-protein/high-calorie diet
-Maintain a high fowlers position when possible
Increase activity levels and exercise; no smoking; have adequate fluid intake levels to thin secretions
What is sensory deprivation
- environment with decreased/monotonous stimuli
- impaired ability to receive stimuli
- inability to process stimuli
Who is at higher risk for toxicity
those with impaired kidney or liver function depending on what the drug is and how it is excreted
What is stress
condition in which the human system experiences changes in its normal balanced state
Priority patient
Acute vs chronic
ABC
Emergent > urgent
Objectives/goals in client/patient teaching
oral, written, interview
Oral:
- avoid medical terminology
- avoid jargon
- teach back
Written:
- use pictures
- use handouts in person’s language
- confirm ability to read
Always confirm patient understanding
The interview:
- purpose is to obtain subjective data to complete a health history
- establish trust
- teach about health state
- build therapeutic relationship
- health promotion
Cultural competence
- services to meet unique diverse needs of patients with consideration to culture
- recognize that culture matters in certain clinical encounters
- recognize limits of knowledge of a patient’s situation
- avoid generalizing assumptions
- be aware of provider and patient biases
- ensure mutual understanding through patient centered communication
- respectfully asking open ended questions about patient’s circumstances and values when appropriate
- understand health related behaviors resulting from cultural beliefs
- recognize values stemming from individual experience and cultural background
Infectious Agent - 3 types
*Bacteria
Shape – cocci, bacilli, spirochete
Gram stain – negative or positive
Need for oxygen – anaerobic or aerobic
*Fungi molds and yeasts
*Parasites
Viruses – smallest microorganisms
Multicellular
Diets for clients with diarrhea
BRAT: banana, rice, applesauce, toast
Nasal cannula (low flow)
Amount delivered FIO2 (fraction inspired oxygen):
- 1-2L/min = 24-28&
- 3-5L/min = 32-40%
- 6L/min = 44%
nursing interventions:
- check frequently is in both nares
- chronic lung disease: limit rate to minimum needed to raise ox sat to 88-92%
Normal and abnormal ranges: BP
=
<120/80 mm Hg (Adults ages 18 and older)
Hypertension -Systolic pressure >130 mm Hg or diastolic
>80 mm Hg
-
-
Hypotension-<90/diastolic pressure <60 mm
Hg or pressure 20-30 mm Hg lower than usual
-
-
Orthostatic-abnormal
drop in blood pressure that occurs upon standing
up from a sitting or lying down position
- Increase of 40 beats in pulse rate or decrease of 20
mm Hg in blood pressure
What patients are most susceptible to opioid effects like decreased respirations, constipation and nausea
very young and very old
What are the types of pain?
Referred
Visceral
Somatic
Dermatomal
neuropathic
Legal issues with documentation/reporting/informatics
Legally, it didn’t happen because it wasn’t documented.
You can document late - remember to go back to document; it is your only defense
Humidification with oxygenation
Provides comfort with oxygenation
protects against irritation and infection
Patient reliability in communication
- use stages of cognitive development
- consider that health care crisis can lead to regression as common response
- be alert to nonverbal behaviors
older adults:
- pace appropriately
- may need increased response time to process
- physical limitations
considerations when interviewing people with special needs
overcome communication barriers
consider health literacy; help clients understand
What is hypoxia?
inadequate amount of O2 available to cells
Kegel exercises
From internet: Kegel exercises are a way to strengthen the pelvic floor muscles, which can help with bladder control
Verbal communication
Avoid these “traps” to effective interviewing:
1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions
assist the narrative
- patient leads and reactions obtained from interviewer
– facilitation, silence, reflection, empathy, clarification
- interviewer leads and expression of own thoughts based on obtained information
– confrontation, interpretation, explanation, summary
Nursing documentation - documentation/reporting/informatics
formats, conferring, nursing informatics
Use the nursing process to document: ADPIE
Formats for nursing documentation:
- nursing care plans (NANDA)
- critical/collaborative pathways
- patient care summary (kardex)
- flow sheets/graphic records
Conferring
- consultation
- referral
- conference
- nursing care rounds
Nursing informatics
- specialty integrating nursing science, computer science, information science
- developing and implementing cutting age tech
- providing more knowledge to nurses to improve patient safety and quality of care
Patient transfers types
Gait belt
Sit-to-stand
Lateral assist (mechanical)
Transfer chair
What is the sick role
expectations of how one should behave when sick, not likely to be reality, different for each person
Opioid use (sedation)
Common Side Effects:
Sedation, nausea, and constipation
-Sedation usually precedes opioid-induced respiratory depression
-Must assess level of sedation and take action if necessary:
…..If asleep, but easily arousable – no action necessary
…..If frequently drowsy and drifts off to sleep mid-conversation then dose should be decreased
……If somnolent with minimal or no response to stimuli then discontinue opioid and consider reversal agent (narcan)
Concepts of types of ADL: self care
(thinking of in hygiene with self care)
patient able to do everything themselves
Skin: pressure prevention
-assess skin daily
-cleanse skin routinely and as needed
-moisturize dry skin
avoid massage of bony prominences
-minimize friction and shearing
-use appropriate support surfaces
-administer nutritional supplements as needed
-improve mobility/activity and use ROM
-frequent position changes
-document prevention measures and results
What nutrients regulate body processes
vitamins, minerals, water
Sleep and adaptation
Discussing adaptation Monday too
sleep deprivation lowers ability to adapt
immobility: sleep pattern disturbance
Good mobility: better sleep
factors affecting sleep
- developmental considerations
- motivation to be awake
- culture
- physical activity
- shift work
- stimulating activities
- dietary habitrs
- tobacco use
- alcohol use
- environment
- psychological
- health condition
- meds
insomnia most common sleeping disorder
CA (colon cancer) warning signs
Change bowel pattern
Blood in stool
Rectal/abdominal pain
Change in stool
Sensation of incomplete emptying p bowel movement
Nutrients: six classes
carbohydrates, protein, lipids, vitamins, minerals, water
Fire safety - RACE?
R - rescue
A - alarm
C - contain
E - extinguish/evacuate
- have a fire plan
- fire alarm and CO alarm
- check electrical equipment and cords
- no smoking in hospitals
Hypertonic fluid: what is it and example
Greater concentration of particles than plasma. causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink.
Definition: solutions that are more concentrated or have a higher osmolality than body fluids
- concentrate ECF and cause movement of water from cells into ECF by osmosis
- monitor for fluid overload, but used to treat hypovolemia and replace fluid and electrolyte
don’t want to dehydrate cells - they can shrivel
Example: 5% dextrose in 0.9% normal saline
Example: 5% dextrose in LR
What is pursed lip breathing? What is it good for?
Prolonged expiration to slow down path way resistance. Good for COPD
What are the stages of infection (infection cycle)
-Infectious Agent- Pathogen
-Reservoir Place- where the
organism can grow and multiply, natural habitat
-Portal of Exit- Route of escape
-Means of Transmission- Route of movement from reservoir
-Portal of Entry - Point where the organism enters another host
-Susceptible Host- Person that is acceptable to the pathogen
Nonverbal communication
- when verbal and nonverbal messages are congruent: verbal message reinforced
– when incongruent: nonverbal is viewed as truer
nonverbal skills:
- physical appearance
- posture
- gestures
- facial expression
- eye contact
- voice
- touch
GI/GU/peri-op: female hygiene
female assessment
- color, lesions, masses, swelling, excoriation, tenderness, discharge
cleaning front to back
perineal care:
- spread labia
- wash from pubic area toward anal area (front to back)
- rinse well
- plain soap and water for vaginal water
Patient safety
idk things can prob be added to this? idk specifically what
- risk factors
- fall risk
- psychosocial health state
– stress
– depression - physical health state
– health and disease process
– chronic illness (MI, stroke)
– acute illness (braces, casts, crutches)
T or F: Normal fresh urine has an ammonia odor?
False
Priming IV bags
letting fluid run through the line and getting all the air out before connecting to the patient
What would you expect from someone with increased temperature
increased HR and RR
Infection and skin
Infection:
- immune system fails to control the growth of microorganisms
- microorganisms can invade at the time of trauma, during surgery, or any time after
- usually apparent 2-7 days after injury or surgery
- can lead to other complications
HARPS (heat, affected part loss of function, redness, pain, swelling)
Presence of infection:
- purulent and increased drainage
- pain, redness, swelling
- increased body temperature
- increased WBCs
- delayed healing
- discoloration of granulation tissue
What is dysuria
pain when urinating; difficulty
Types of pain
acute vs chronic
Acute
- Rapid onset
- Varies in intensity: mild to severe
- After cause resolved it disappears
Chronic
- May be limited, intermittent, or persistent
- Lasts beyond the normal healing period
- Can have remission or exacerbation
Patient experience in comfort/pain
(not sure if this is right)
Past experience
Cultural/Ethnic variables
Family
Gender
Age
Religious beliefs
Environment
Support people
Anxiety/Stress
PPE - what are they? order to don and doff?
on- gown, then mask, then goggles, then gloves
doff-remove gloves, then gown, then goggles, then mask, then hand hygiene
Normal and abnormal values: HR
60-100
Concepts of types of ADL: partial care
(thinking of partial bath in hygiene)
nurse assists with some thinks, like untying gown and getting hard to reach areas
SBAR and patient handoff
Identity/Introduction
Situation
Background
Assessment
Recommendation
Concepts of types of ADL: complete care
(thinking of complete bath in hygiene)
patient unable to do activity; nurse does everything
Diet for clients with constipation
high fiber? good fluid intake
What are some things you can do for insomnia
medication
exercise at least 2-3 hours before bed
don’t drink water before bed
keep screens off
avoid caffeine - coffee, tea, chocolate, some sodas
Normal adaptation responses - literally dont know what this is (found a slide on physiologic adaptation in cultural competence ppt)
i think we’re doing this on Monday
physiologic adaptation
- managing and providing care for those w acute, chronic or life-threatening physical health conditions
- knowledge in body systems, f&e imbalances, hemodynamics, infectious diseases, medical emergencies, pathophys, radiation therapy, respiratory care, unexpected response
If you’re adapting to a change or illness, what conditions would have more trouble adapting
chronic illness
sleep deprived person
Safety - restraints
- physician order required
- continuous or very frequent monitoring
- offer use of bathroom or bedpan
- maintain hydration
- maintain nutrition -> feeding patient
- encourage ROM and movement
- assess skin and circulation
- remove ASAP
- be aware of state and hospital guidelines/protocols
Blood transfusions: what to consider, what is different, how long can they be out of fridge
NEED 2 NURSES
Stay with the patient for 15 minutes to watch for reaction
Check blood type and patient band
Can be out of fridge max 4 hours; infuse over 1-4 hours
Consider:
*Typing and cross-matching
*A, B, AB, and O type blood
*Rh factor
*Selecting blood donors
*Initiating transfusion
*Transfusion reactions
Assessment in comfort/pain
OPQRST essentially
Patient’s verbalization and description of pain:
Duration
Location
Intensity
Quality
Chronology
Aggravating factors
Alleviating factors
Airborne precautions
- precautions who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles)
- Place pt in a private room that has monitored negative air pressure in relation to surrounding areas
– 6-12 air changes per hours and appropriate discharge of air outside, or monitored filtration if air is recirculated
– Keep door closed and patient in room - Wear an N95 respirator when entering room of pt with known or suspected tuberculosis
– If pt has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases - Transport pt out of room only when necessary and place a surgical mask on the patient if possible
- Consult CDC guidelines for additional prevention strategies for tuberculosis
- use of N95 respirator mask; negative pressure room
Troubleshooting an IV infusion
No kink in tubing
Iv tower is tall enough
Vein is good condition
Activity: patient transfers
hoyer? friction sheet and board? gait belts?
NREM sleep and vital signs
Stage 1: light sleeping. woken easily
,
Stage 2: light sleeping. HR will slow, body temp will drop, Eye movement stops, brain waves slow down. 50% of sleep is spent here.
.
Stage 3: deeper phase of sleep. Breathing will be deeper, body will regrow and repair tissues, immune system will strengthen. (could feel disoriented if awoken at this time)
