Fundamentals Test 1 Flashcards
What is the nursing process?
ADPIE: Assessment, Diagnosis, plan, implementation, evaluation
Medical-surgical nursing
Adult health nursing: To promote health and prevent illness or injury in patients from 18 to >100.
Physical restraints
Check every 30-60 min. Remove every 2 hours.
Physiological changes when aging
- Medications aren’t absorbed
- Everything Slows down
- Higher risk for toxicity
Delirium
An ACUTE state of confusion. Short-term and reversible.
Dementia
A slow progressive cognitive decline. CHRONIC confusion.
Depression
A mood disorder that can have cognitive, affective, and physical manifestations.
Young old
Middle old
Old old
Elite old
65-74
75-84
85-99
100+
Neglect
Failure to provide basic needs.
Physical Abuse
Use of physical that results in bodily injury.
Financial Abuse
Mismanagement or misuse of property or resources.
Emotional Abuse
Intentional use of threats, humiliation, intimidation, and isolation.
Autosomal Dominant
- Gene alleles controlling trait
- A dominant gene allele is expressed only when one allele of the pair is dominant.
- Appears in every generation with no skipping.
- Risk 50%
- Equal in males and females
Autosomal Recessive
- Required to be an autosomal chromosome
- Only expressed when both alleles are present
- May not appear in all generations
- only 25% of a family will be affected
Genetic Testing
- Sickle cell disease
- Hemophilia
- Hereditary hemochromatosis
- Cystic Fibrosis
- Beta thalassemia
- Tay-Sachs disease
- Huntington disease
Purpose of rehab
- The continuous process of learning to live with chronic and disabling conditions, often those resulting from trauma.
- Aims to help patient return to best possible physical, mental, social, vocational, and economic capacity.
Cultural competence
Respecting all differences and not letting one’s own biases influence others.
Nursing intervention anxiety and post-op care
Physical signs of anxiety include; restlessness, increased pulse, BP, respiratory rate, and crying.
Pre-op intervention
- remove most clothes & wear hospital gown
- valuable w/ family or locked up
- tape rings in place if cannot be removed
- patient wears identification band
- dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.
Prevent DVTs
- antiembolism stockings (TED hose)
- pneumatic compression device
- leg exercises
- mobility
General anesthesia
Patient is unconscious
Local anesthesia
Applied to skin or mucous membrane, affects nerve impulse.
Regional anesthesia
Blocks multiple peripheral nerves, used when general can’t be used.
Epidural
Waist down
Conscious
Patient is not awake, in a sleepy state.
Allergy that gives increased risk to allergy to iodine
Shellfish
Incentive spirometer
Encourages patient to take deep breaths. Seal lips around mouthpiece, inhale spontaneously, & hold breath for 3-5 sec. for effective lung expansion. Atelectasis: collapse of alveolar
Discharge planning
Begins in pre-op phase.
Urine output
30 mL/hr
Sickle cell
Recessive
Huntington’s
Dominant
How many chromosomes?
23
Creatine level
0.5-1.2
Peristalsis
A series of muscle contractions that occur in your digestive tract. Up to 24 hours after surgery.
Respiratory system assessment
- patient airway and adequate gas exchange
- note artificial airway, when applicable
- rate, pattern, and depth of breathing
- breath sounds
- snoring and stridor
- respiratory depression or hypoxemia
Cardio assessment
- vital signs
- heart sounds
- cardiac monitoring
- peripheral vascular assessment
Neurologic system assessment
motor function- simple commands; patient to move extremities.
Renal/ urinary system
- check for urine retention
- consider other sources of output like sweat, vomitus, or diarrhea stools
- report urine output of <30 mL/hr
Gastrointestinal system
- 30% experience n/v after general anesthesia
- peristalsis may be delayed up to 24hrs
- monitor bowel sounds
Skin assessment
- normal wound healing
- ineffective wound healing can be seen most often between the 5th and 10th days after surgery
Dehiscence
A partial or complete separation of the outer wound layers.
Evisceration
A total separation of all wound layers and protrusion of internal organs through the open wound. `
Rapid response
Save lives and decrease risk for harm by providing care to patients before a respiratory or cardiac arrest occurs.
