Fundamentals Flashcards
Preventative Healthcare focuses on
education
-why you should use your seatbelt, or here are some stress management techniques
Primary Healthcare is
prenatal care or well child visits
Secondary Healthcare deals with
diagnosis and treatment
Tertiary Healthcare is
acute care
ICU, burn center, oncology center…something more specialized
Restorative Healthcare focuses on
getting you back to your basic level of functioning
Home health centers, rehab facilities, skilled nursing facilities
Continuing Healthcare is
something you will need indefinitely
end of life care, palliative care, hospice care, assisted living facilities
Occupational Therapy focuses
on a client’s actives of daily living
Physical Therapy focuses on
gross motor skills
Speech-Language pathologist
evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing
Advocacy means that we will
support and defend our client
Responsibility means that we will
respect our obligations and follow through on promises
Accountability means that we will
answer for our actions
Confidentiality is the
protection of privacy
Beneficence means that we will
promote good for others, without any self-interest
Fidelity is a
fulfillment of your promise
Justice is
fairness and care delivery and use of resources
Nonmalefeficence means a
commitment to do no harm
Veracity is a
commitment to tell the truth
Unintentional torts
Negligence
Malpractice
Quasi-intentional torts (some intent)
Breach of confidentiality
Defamation of character
Intentional torts
Assault
Battery
False Imprisonment
The 5 elements necessary to prove negligence
Duty to provide care as defined by a standard
Breach of duty by failure to meet standards
Foreseeability of harm
Breach of duty has potential to cause harm
Harm occurs
Responsibilities for informed consent
Provider obtains informed consent
Client gives informed consent
Nurse witnesses the informed consent
Informed consent means the client understands
The reason for the procedure/treatment
How the procedure/treatment will benefit the client
The risks
Other options
What do you need to document?
Factual
Complete
Organized
Current
When taking a telephone order
WRITE IT DOWN
then read it back
Incident reports are NOT documented
in the client’s chart, they are documented internally for auditing
PIE
Problem
Intervention
Evaluation
DAR
Data
Action
Response
RN may NOT delegate
ANY part of the nursing process
5 Rights of Delegation
Task
Circumstance
Client
Direction and Communication
Supervision and Evaluation
Virulence
the ability of a pathogen to invade and injure host
Stages of Infection
Incubation - pre symptoms
Prodromal stage - more distinct findings; early stage of symptoms
Illness stage - more severe symptoms
Convalescence - acute findings disappear
When client is having a seizure
NEVER put anything in their mouth
STAY with them
Call for help, possibly RRT
Administer any PRN meds
Take note of duration/type of seizure
Take VS after seizure subsides
Hard Lock Restraints may be applied for (time)
4 hrs - adult
2 hrs - 9-17 y/o
1 hr - under 9 y/o
Soft Lock Restraints may be applied for (time)
24 hrs
Field Triage
Disaster is larger than the resources available
Class 1 - RED - Emergent/Immediate
Life-threatening injury
i.e. arterial bleed, severe burn, head injury, airway issue
Class 2 - YELLOW - Urgent/Delayed
Major injuries that are not life-threatening
i.e. open fracture (won’t kill you within the next 30 min to 2 hrs)
Class 3 - GREEN - Minor/Nonurgent
Minor injuries not life-threatening
i.e. laceration (also called the walking wounded)
Class 4 - BLACK - Expectant
Lowest priority, will not survive; provide “field hospice” care
i.e. exposed brain matter, pulses, impaled
Active Shooter
Run
Hide
Fight
Primary level of Prevention
Healthy clients
Immunizations, using car seats/seatbelts, exercise, health ed
Secondary level of Prevention
Identify Illness
Disease screening, early detection of DM, physical activities of exercise for elderly clients
Tertiary level of Prevention
Preventing long term consequences of illness/injury
Preventing of pressure ulcers, independence after traumatic brain injury, rehab centers
Cognitive Domain of learning
Thinking, Knowledge, Comprehension, Analyzing
Affective Domain of learning
Feelings, Beliefs and Values
Psychomotor Domain of learning
Skills; mental and physical
Infants (0-12 mo)
Erikson: Trust vs Mistrust
Piaget: sensorimotor
Head to Foot in Motor Skills development
Fontanels - posterior closes first 2-3 mo; anterior closes second 12-18 mo
Infants will loose 5-10% of their weight initially, but should gain it back by the second week of life; weight will double by 4-6 mo and triple by 1 yr
Aspiration, Bodily harm, Burns, Drowning, Falls, Poisoning, MV injury, Suffication
Toddlers (1-3 yrs)
Erikson: Autonomy vs Shame/Doubt
Piaget: sensorimotor transitions to pre operational
Motor skills - speaking short sentences by 2 yo,
Aspiration, Bodily harm, Burns, Drowning, Falls, Poisoning, MV injury, Suffication
Preschoolers (3-6 yrs)
Initiative vs Guilt
Piaget: pre operational
Motor skills - lots of language and social development; magical thinking
Bodily harm, Burns, Drowning, MV injury, Poisoning
School-age Children (6-12 yrs)
Industry vs Inferiority
Piaget - concrete operations
Puberty wil start, permanent teeth
Bodily harm, Burns, Drowning, MV injuries, Substance abuse/Poisoning
Adolescents (12-20 yrs)
Erikson: Identity vs Role Confusion
Piaget: formal operations
Puberty will complete by the end of adolescence, determine sexuality
Bodily harm, Burns, Drowning, MV injuries, Substance use disorder, Sexuality, Pregnancy prevention
Young Adults (20-35 yrs)
Erikson: Intimacy vs Isolation
Piaget: formal operations
Done growing
Avoid alcohol, tobacco, and drugs, wearing a seatbelt/helmeet, smoke/carbon monoxide detectors
Middle Adults (35-65 yrs)
Erikson: Generativity vs Stagnation
Piaget: formal operations
Mid-life crisis, body image changes, menopause
Older Adult (65+ yrs)
Erikson: Integrity vs Despair
Piaget: formal operations
Systems changes: skin, cardiopulmonary, neuro, GI, MSK, GU, endo, immune
Delirium (sudden onset caused by something physiological) vs Dementia (slower, progressive, chronic; can’t improve it)
Heat loss through Conduction
transfer of heat from the body directly to another surface
body immersed in cold water
Heat loss through Radiation
transfer of heat from one object to another object without contact between them
sitting in a cold room
Heat loss through Convection
dispersion of heat by air currents
wind blowing across skin
Heat loss through Evaporation
dispersion of heat through water vapor
prespiration
Heat loss through Diaphoresis
visible perspiration on the skin
Oral Temp range
36-38 C (96.8-100.4 F)
Avg 98.6
Rectal Temp
0.5 C higher than oral
Axillary Temp
0.5 C lower than oral
Pulse Strength
0 - absent
1+ - weak
2+ - expected, brisk
3+ - strong
4+ - bounding
PERRLA
Pupils are Equal, Round, and Reactive to Light and Accommodation
Rinne
bone conduction vs air conduction
Weber
right ear vs left ear
Bronchial
loud, high-pitched over the trachea
Brochiovesicular
blowing sounds over the main bronchi
Vesicular
soft, breezy over the periphery of the lungs
Crackles
Fine or coarse bubbly, fluid in the alveoli
Wheezes
high-pitched, musical
Ronchi
coarse, loud, low-pitched rumbling
Pleural friction rub
dry, grating, or rubbing sound
Normal heart sounds
S1 and S2
Gallop is heard by
S3
Strong atrial contraction heard by
S4
Systolic murmurs occur after
S1
Diastolic murmurs occur after
S2
Thrill is a
palpable vibration that accompanies murmur or a cardiac malformation
Bruit is a
blowing, swishing sound heard with stethoscope
Cyanosis
bluish tint in skin
Pallor
loss of color in skin, paleness
Jaundice
yellowish color in skin
Erythema
redness in skin
Macule
non palpable, skin color change; <1cm
freckle
Papule
palpable, circumscribed, solid elevation of skin; <1cm
elevated nevus
Nodule
palpable, deep, firm; 1-2cm
wart
Vesicle
serous fluid-filled; <1cm
herpes simplex, blister, varicella
Pustule
pus-filled; size varies
acne
Tumor
solid mass, deep; >1-2cm
epithelioma
Wheal
palpable, irregular borders, edematous
insect bite
Atrophy
thinning of skin with loss of normal skin furrow
Erosion
lost epidermis, moist surface, no bleeding
ruptured vesicle
Crust
dried blood, serum, or pus
scab
Scale
flakes of skin that exfoliate
dandruff, eczema
Fissure
linear crack
tines pedis
Ulcer
loss of epidermis and dermis with possible bleeding, scarring
pressure injury
General Adaptation Syndrome
Alarm - “fight or flight”
Resistance - body functions normalize back to homeostasis
Exhaustion - no longer able to maintain a response; recovery or death
Stages of Grief
Denial
Anger
Bargaining
Depression
Acceptance
Types of Grief
Normal
Anticipatory
Complex - delayed, chronic, exaggerated, masked
Disenfranchised - not culturally acceptable or cannot be publicly shared
Diabetic foot care
Lotion feet, but NOT between toes
Wear close-toed, hard sole shoes
Clean cotton socks
Nails are filed straight accross
Foot care by podiatrist
NO soaking feet, use of heat
Hypersomnolence
excessive daytime sleepiness lasting at least 3 mo
Factors that Interfere with Sleep
Physiologic disorders
Current life events
Emotional stress or mental illness
Diet
Exercise
Fatigue
Sleep environment
Medications
Substance use
Clear Liquid Diet
anything you can see through when held up to the light
broth, jello, popsicles, coffee
Full Liquid Diet
clear liquid plus liquid dairy products
yogurt, milkshake, creamy soups (no particles of food)
Pureed Diet
full liquid plus pureed meats, fruits, and eggs
Mechanical Soft Diet
clear and full liquids plus diced or ground foods
Soft/low-residue Diet
foods that are low and fiber and easy to digest
eggs, dairy products, bananas
High-fiber Diet
whole grains, raw and dried fruits
Low Sodium Diet
no added salt, or 1-2 g sodium
Low Cholesterol Diet
no more than 300 mg/d of dietary cholesterol
Diabetic Diet
balanced intake of proteins, fats, and carbs; ~1800 calories
Dysphagia Diet
pureed food and thickened liquids
Regular Diet
no restrictions
Idiopathic Pain
chronic pain without a known cause, or pain that exceeds typical pain levels associated with the client’s condition
Nociceptive Pain
arises from damage to or inflammation of tissue
Somatic
Visceral
Cutaneous
Somatic Pain
bones, joints, muscle, skin, or connective
Visceral Pain
in internal organs; described as cramps, squeezing, or heavy
Cutaneous Pain
in the skin or subcutaneous tissue
Neuropathic Pain
abnormal or damaged nerves
pins/needles, shooting, burning, tingling, electric-like, and numbness
Opioid analgesic adverse effects
Sedation
Respiratory depression
Orthostatic hypotension
Urinary retention
Nausea/vomiting
Constipation
Aloe
wound healing
Chamomile
anti-inflammatory
Echinacea
enhances immunity
Garlic
inhibits platelet aggregation (aspirin)
Ginger
antiemetic
Ginkgo Biloba
improves memory
Ginseng
increase physical endurance
Valerian
promotes sleep and reduces anxiety
Bowel control starts at
about 2-3 yrs
Fluid requirement for bowel elimination
2L - women
3L - men
Tyramine Interaction
do not eat when taking MAOI’s - monoamine oxidase inhibitors
hypertensive crisis
Vitamin K Interaction
decrease therapeutic effects of warfarin
Dairy Interaction
with tetracycline
Grapefruit Interaction
with Calcium Channel Blockers
Caffeine Interaction
with theophylline (asthma control agent)
excessive CNS excitation
Antacids/Vit C Interaction
taking aluminum-containing antacids with citrus beverages can result in excessive absorption of aluminum
Pregnancy Risk Categories
A - no evidence of risk
B - no evidence of risk to animal fetus; no studies of humans
C - adverse effects on animals but not on humans
D - adverse effects on humans, but benefits may outweigh risks
X - should not be used
Nasal Cannula
24-44% at a flow rate 1-6 L/min
provide humidification for flow rates 4 L/min and greater
Simple Face Mask (oxygen delivery)
35-50% at a flow rate 6-12 L/min
more comfortable than nasal cannula
Partial rebreather mask (oxygen delivery)
60-75% at a flow rate 6-11 L/min
allows for easy humidification of oxygen and client is able to rebreathe up to 1/3 of exhaled air together w/room air
Non-rebreather mask (oxygen delivery)
80-95% at a flow rate 10-15 L/min
delivers highest O2 concentration (other than intubation)
Venturi mask (oxygen delivery)
24-50% at a flow rate 4-12 L/min
most precise oxygen concentration
Aerosol mask (oxygen delivery)
24-200% at a flow rate at least 10 L/min
useful for clients with facial trauma, burns, and thick secretions or ones who don’t tolerate masks well
Oxygen Toxicity can result from
high concentrations of oxygen; >50%
long duration of therapy; >24-48 hr
Chest Physiotherapy is used
on clients who cannot clear airways of thick secretions
NG Tube Indications
Decrompression
Feeding
Lavage
Compression
Collection (Data)
Large-bore tubes are used for
Lavage
Decompression
Aspiration
Orogastric Tubes are
large-bore tubes with wide proximal ends to be used for lavage and gastric emptying
Double lumen tube is the
most common NG tube used; mostly for decompression but sometimes for irrigation
major advantage is that it can be used with continuous suction
Salem sup tube
Triple lumen tube
Used for upper GI bleed from esophageal varices used only in emergencies when endoscopy is unavailable
Sengstaken-Blakemore
When inserting an NG tube, and encountering resistance, _______ or ________ , and attempt to readvance.
rotate
withdraw it slightly
When removing an NG tube, inject ________, ____________, or ________ to clear the tube of fluid and make sure it is free of debris.
10mL water
10mL 0.9% NS
30-50mL of air
When removing an NG tube, ask the patient to ______________ to prevent aspiration.
take a deep breath and hold it
During enteral feedings, client should be elevated
at least 30 degrees, and stay that way for at least 30 min after feeding
Types of formulas for enteral feedings: Modular and Polymeric
Single-nutrient and whole-nutrient formulas and require a functioning gastrointestinal tract that can absorb whole nutrients.
Types of formulas for enteral feedings: Elemental
Contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb
Types of formulas for enteral feedings: Specialty
meet specific nutritional needs for clients who have a conditions such as HIV, liver failure, or clients who have pulmonary disease.
When measuring a nasointestinal tube for insertion
measure from the nose to the clients earlobe, and from the earlobe to the xiphoid process plus 20 to 30 cm more
Wound Dressings: damp to damp
used to mechanically decried a wound until granulation tissue starts to form in the wound bed
Wound Dressings: hydrocolloid
promote healing in stage 2 pressure injuries by creating a moist wound bed
Wound Dressings: hydrogel
composition is mostly water
for infected, deep wounds or necrotic tissue
Wound Dressings: alginates
used for stage 3 and 4 pressure ulcers to absorb exudate
Wound Dressings: collagen
powders, pastes, sheets, gels
helps stop bleeding and promotes healing
Dehiscense
partial or total rupture of a sutured wound
Evisceration
dehiscence involves protrusion of visceral organs
Dehydration signs and symptos
Tachycardia
Tachypnea
Hypotension
Hypoxia
dizzy, confused, weak, thirsty, fatigue, decreased urine output, diminished skin turgor, flat veins, seizures
elevated hemoglobin and hematocrit
elevated sodium level
Fluid Volume Overload signs and symptoms
Tachycardic
Bounding pulse
HTN
Tachypnea
confused, paresthesia, seizures, crackles, ascitis, dyspnea, pitting edema, weight gain, cool skin
hemoglobin and hematocrit is decreased
sodium decreased
BUN decreased
Nonpharmacologic Interventions
Basic Comfort Measures - proper positioning and therapeutic environment
Cutaneous Stimulation- heat/cold, TENS
Cognitive and Behavioral Strategies - changing the way a client percieves pain
Distraction - prayer, music, deep breathing, games
Relaxation - meditation, yoga
Imagery - focusing on pleasant thoughts
Acupuncture and Acupressure
Chronic Pain
chronic/persistent is lasting longer than 6 months; sometimes categorized as cancer pain or noncancer pain
Acute Pain
protective, temporary, usually, self-limiting, has a direct cause, and resolves with tissue healing
lasting less than 6 months
No-one should judge another pain experience
“Pain is whatever the person says it is occurring whenever the person says it does” - Margo Mccaffery
Four Phases of Nociceptive Pain
Transduction
Transmission
Perception
Modulation
Why do depression and pain coexist?
Pain and depression use the same neural pathways and the same neurotransmitters
Analgesics, or pain killers
medications that relieve different types of pain
Opioids
Non opioids
Adjuvant analgesics
Allodynia
when things that shouldn’t cause pain, do cause pain (feather’s touch or clothing)
Opioids
Exogenous: morphine, fentanyl, codeine, oxycodone
Endogenous: endorphins, enkephalins, and dynorphins
Non opioids
acetaminophen and NSAIDS
Adjuvant Analgesics
primary indication is not pain; antidepressants, anti epileptics, antiemetics, glucocorticoids
Absorption
Process by which medication enters the blood stream
Distribution
Process by which medication is delivered to the target cells and tissues
Metabolism (Drug Binding)
Process by which drug is chemically changed in the body
Excretion
Process of removing the drug or its metabolites from the body
Pharmacokinetics
The process by which a drug moves through the body and is eventually eliminated; consists of absorption, distribution, metabolism, excretion
Pharmacodynamics
The physiologic and biochemical effects of a drug on the body
May be systemic or local
Medication Interaction
When a medications effects are altered by the concurrent presence of other medications or food
Synergism- increases drug’s effects
Antagonism - decreases a drug’s effects
[In]Compatability
In some cases, a drug will precipitate from solutions, or chemically inactivate, if mixed with other medications
Drugs known to cause birth defects
Teratogenic
Some drugs are immediately absorbed in the liver
First pass metabolism
Enteroheptic Cycling
When drugs pass through the liver and are secreted back into the small intestine in the bile
Entry rate of a drug into the tissue depends on:
- The rate of blood flow into the tissue
- The tissue mass
- The rate at which entry/exit of the drug molecules between blood and tissue equlibriate
Three Checks of Medication Administration
- Read the eMAR and select the proper medication from the supply system
- After retrieving the medication, compare it to the eMAR
- At the bedside after verifying the pt recheck again against eMAR
Six Rights of Medication Administration
Right Patient
Right Drug
Right Dose
Right Route
Right Time
Right Documentation
Insulin is injected [with and into]
With 1-mL syringe with 26-30 gauge
Into upper arm, anterior or lateral aspects of thigh, buttocks, or abdomen
100U = 1 mL
IM injections are given [with and into]
With 3 mL syringe and a 20-25 gauge, 1-3 in needle
Into deltoid, rectus femoris, ventrogluteal, vastus lateralis (infant)
ID injections are given with
1 mL syringe with a short, half-inch small gauge 26-28
kg to lb
Multiply by 2.2
1 kg = 2.2 lb
oz to mL
Multiply by 30
1 oz = 30 mL
Tablespoons to mL
Multiply by 15
1 tbsp = 15 mL
Teaspoons to mL
Multiply by 5
1 teaspoon = 5 mL
Inches to centimeters
Multiply by 2.54
1 in = 2.54 cm
Cups to ounces
Multiply by 8
1 cup = 8 oz
Pints to cups
Multiply by 2
1 pint = 2 cups
Cups to milliliters
Multiply by 240
1 cup = 240 mL
Pounds to ounces
Multiply by 16
1 lb = 16 oz
Fahrenheit to Celsius
-32
x5
/9
Celsius to Fahrenheit
x9
/5
+32
Airborne precautions for _______, __________, and __________
MTV
measles, tb, varicella
Purulent
Thick, opaque and odorous build up from infection
First Phase of Wound Healing
Hemostasis; vasoconstriction, aggregation, and clot formation
Second Phase of Wound Healing
Inflammatory; vasodilation and phagocytosis
Third Phase of Wound Healing
Proliferation; rebuilding new tissue
Fourth Phase of Wound Healing
Maturation; scar tissue is formed
pH needed for wound healing
7.0-7.6
Progress of an Infection: Phase 1
Incubation: time between the pathogen’s entrance into the host and the appearance of symptoms
Progress of an Infection: Phase 2
Prodromal: nonspecific symptoms such as nausea, fever, general weakness, or aches and pains
The functional part of the kidney is the
Nephron
How many nephrons does each kidney have?
More than 1 million
Where is urine stored?
The bladder
Where does filtration take place/begin?
The glomerulus
Bowman’s Capsule
Surrounds the glomerulus
Average amount of urine per void
250-400mL
Normal Urine color, clarity, and odor
Light yellow, clear, without sediment, and aromatic
Most common microorganism that causes UTI
E. coli
Altered Urinary Function: polyuria
Brain injury patient
Noninvasive technology that can estimate the volume of urine in the bladder
Bladder scan (ultrasound)
What type of collection do you get if sterile urine is not necessary?
Random urine specimen
24-hr specimen needs to be restarted if:
Any of the urine is discarded
It is contaminated with stool
It is contaminated with toilet paper
T/F: It is normal to have ketones present in the urine.
False
Two most common blood tests to detect kidney disease
BUN and Creatinine
Catheterization performed by RN vs patient
RN: procedure is sterile
Patient: procedure is clean
Intermittent catheterization
Every 6-8 hrs
Altered Urinary Function: nocturia
CHF
Prompted Voiding
Involves the use of regular checks (every 2 hrs) to determine whether the or perceives the urge to void
Bladder Training
Pts suppress the urge to void before scheduled times.
Once foley cath is removed, pt should void when
Within 8hrs
Cystitis
UTI in the bladder
Urethritis
UTI in the urethra
Pyelonephritis
UTI of the ureters, renal pelvis, or renal parenchyma
Urosepsis
Infection spreads to systemic circulation
Common in older adults as the bladder wall thins
CAUTI
Catheter acquired UTI
Fiber recommendations
25-38g of dietary fiber
Fruits and vegetables are high in fiber
To promote soft stool consistency and promote bowel elimination
2L - women
3L - men
Opioids and iron cause
Constipation
Antibiotics cause
Diarrhea
Paralytic ileus (pseudo-obstruction)
Disruption in normal peristalsis, leading to potential blockage of bowel contents
Borborygmi
Loud bowel sounds
Annual fecal occult blood test (FOBT) is recommended for
colorectal cancer screening starting at age 45
What can cause a false positive FOBT?
Red meat
Iron
Bismuth compounds
Steroids
Colonoscopy is recommended
every 10 years
Small-volume enemas are designed to be retained
up to 30 min
Large-volume enemas can be used as
Treatment for constipation
Method of cleansing the bowel before radiologic studies or surgery of the intestines
Return-flow enemas should be placed
12-18in above the rectum
Gastric decompression is indicated for
Bowel obstruction
Paralytic ileus
Some GI surgeries
Gastric lavage is indicated for
Accidental poisoning
Accidental/Intentional drug OD
What is the treatment for fecal impaction?
Digital disimpaction, done by MD
Most common cause of healthcare-acquired diarrhea.
C. diff
Enema should be inserted how far?
Adults - 3-4 in
Children - 2-3 in
The ability to perceive stimulation through the sensory organs that include the nose, eyes, and mouth
Sensation
The process by which we receive, organize, and interpret the internal and external sensations
Perception
Hyponatremia manifestations include
Abdominal cramping
Weakness
Confusion
Lethargyƒ
Headache
Nausea
What is an exogenous HAI?
an infection acquired from pathogens outside the client’s body
When removing PPE consisting of a gown, N95 respirator, gloves, and a face shield, which do you remove first when removing PPE seperately?
Gloves
