Midterm Flashcards
1
Q
Assessment
Primary and secondary source
A
Collection of data from primary source (patient) and Secondary source (family, other health pros, med records, med lit).
2
Q
Assessment
A
Deliberate and systematic collection of data. Interpretation of data. Documentation of data.
3
Q
Diagnosis
A
The clinical judgement concerning the patient’s response to health conditions/life processes.
An analysis and synthesis of data put into focus notes and charting
4
Q
Maslow’s hierarchy of needs
A
Helps prioritize the components of nursing diagnosis. Physiological needs Safety Love/belonging Esteem Self-actualization
5
Q
What comes first with diagnosis?
A
ABCs
6
Q
Planning
A
Collaborates with pt and healthcare team to determine urgency of identified problems.
Prioritizes patient’s needs.
Design goals.
7
Q
Goals should be what?
A
SMART Specific Measurable Attainable Relevant Time bound
8
Q
Different types of nursing interventions
A
Independent, collaborative, and dependent.
Independent require no order
Collaborative are in conjunction
Dependent require an order
9
Q
Implementation
A
The execution of the care plan.
Any treatment the nurse performs to enhance pt outcomes
10
Q
Evaluation
A
Examining results according to data collected.
Comparing achieved outcomes with goals.
Recognize errors.
A continuous review.
11
Q
Correct order of nursing process
A
Assessment Diagnosis Planning Implementation Evaluation
12
Q
Three parts of a diagnosis
A
The problem
The etiology
The defining characteristics
13
Q
Problem:
A
The diagnostic label
Ex imbalanced nutrition
14
Q
Etiology
A
What is causing or contributing to the problem? Described as related to (RT)
Ex. Less than body requirements RT chronic diarrhea, nausea, and pain
15
Q
Defining characteristics
A
Evidence of the problem. As evidence by (AEB) or as manifested by (AMB)
Ex AEB he aight 5’5” weight 105 lbs
16
Q
Three types of nursing diagnoses
A
Actual/problem focused
Risk
Wellness/health promotion
17
Q
Appropriate documentation
A
Succinct Avoid generalizations Subjective data: symptoms Objective data: signs Observe, verify, infer
18
Q
Verify
A
Confirming something
19
Q
Validate
A
Comparison of data with another source to determine data accuracy
20
Q
Observation
A
Patient’s nonverbal and verbal behaviors
21
Q
Observation of cues
A
See if your observations of the patient matches what the patient is verbally describing
22
Q
Inference
A
Your judgement or interpretation of a cue
23
Q
Inductive reasoning
A
Cognitive process where one identifies a specific idea or action, then makes conclusions about general ideas
24
Q
Seductive reasoning
A
Cognitive process where one examines a general idea and then considers a specific action or idea
25
Proper documentation of an incident
An incident report.
| Provides a database for further investigation in an attempt to determine any deviation from standards of care
26
Safe body mechanics when lifting
Assess weight - determine if assistance needed
Use safe patient handling equipment if patient is unable to help
Use lift teams of two
27
Meaning if colonized organisms
Colonization occurs when a microorganisms invades a host, but does not cause infection
28
Safety risk factors: fetal
Maternal smoking
Alcohol consumption
Addictive drugs
X ray first trimester
29
Safety risk factors: infant
Falling, suffocation, choking, burns, car accident, crib injury, electric shock, poisoning
30
Safety risk factors: toddler
Physical trauma, falling, cuts, car accident, burn, poisoning, drown, electric shock
31
Safety risk factors: school age
Injury, choking, suffocation, obstructed airway or was, poisoning, drowning, fire, burns, harm from people or animals
32
Safety risk factors: adolescent
Car accident, Rec injuries, firearms, substance abuse
33
Safety risk factors: older adults
Falls, burns, car accidents, pedestrian injuries
34
Which nursing procedures require sterile techniques
Wound dressing
| Foley catheter
35
Behavior restraints:
Written restraint orders following evaluation are okay but only for 4 hours. Pt must be continually monitored
36
Medical restraints:
Can be used up to 12 hours after dr orders. Order must be renewed daily. Must state reason and time.
37
Which patients are most at risk for infections?
Very young and the elderly
38
Older adults susceptibility to infection
```
Immune senescence: age related functional deterioration
Decreased lymphocyte production
Increased risk of HAIs
Recommend flu and pneumonia vaccines
Educate hand hygiene
```
39
Risk of infection: chronic disease
Cause pneumonia, skin breakdown, and venous stasis ulcers
40
Risk of infection: lifestyle
STIs, HIV, HBV, infections, or liver failure
41
Risk of infection: occupation
Black lung disease, pneumonia, TB, poor nutrition, or excess stress
42
Risk of infection: diagnostic procedures
Cause multiple iv lines and immunosuppressive drugs
43
Risk of infection: travel
Meningitis or acute respiratory distress
44
Risk of infection: trauma
Sepsis or secondary infection
45
Risk of infection: improper nutrition
Impaired immune response
46
Factors affecting: pulse rate
```
Exercise
Temp
Emotions
Medications
Hemorrhage
Postural changes
Pulmonary conditions
```
47
Factors affecting: respiratory rate
```
Exercise
Acute pain
Anxiety
Smoking
Body position
Medications
Neurological injury
Hemoglobin function
```
48
Factors affecting: temperature
```
Age
Exercise
Hormone level
Circadian rhythm
Stress
External environment
```
49
4 ways to transfer body heat
Radiation: one surface to another without direct contact
Convection: transfer by air movement
Evaporation: transfer of heat energy by liquid changing to a gas
Conduction: one object to another through direct contact
50
Factors affecting: blood pressure
```
Age
Stress
Ethnicity
Gender
Daily variation
Medications
Activity
Smoking
```
51
Patient conditions that require specific nursing actions: temperature
Risk for imbalanced body temp, hyperthermia, hypothermia, ineffective thermoregulation
52
Patient conditions that require specific nursing actions: pulse
Risk for activity intolerance, anxiety, decreased CO, deficient fluid volume, impaired gas exchange, acute pain, ineffective peripheral tissue perfusion
53
Patient conditions that require specific nursing actions: blood pressure
Risk for hypotension, hypertension, orthostatic hypotension, activity intolerance, anxiety, decreased CO, deficient fluid volume, risk for injury, acute pain, ineffective tissue perfusion
54
Patient conditions that require specific nursing actions: respirations
Risk for activity intolerance, ineffective airway clearance, anxiety, ineffective breathing pattern, impaired gas exchange, acute pain, ineffective peripheral tissue perfusion, dysfunctional ventilators weaning response
55
Most accurate temp?
| Most used?
Rectal - 37.5
| Oral - 37
56
How often do you check vitals after a procedure?
```
On arrival
After 30 min
Every hour the first 3 hours
Every 4 hours for 72 hours
Every shift after 72 hours
```
57
What are SCDs?
Sequential compression devices
Provide intermittent compression to lower extremities to promote venous return and prevent DVT
Need a provider order and remain on
58
Who is at the greatest risk for complications due to bedrest?
People who have prolonged br due to surgery, serious illness, or pregnancy complications
Those who are immobilized due to stroke, fracture, spinal cord injury, chronic conditions
At risk for osteoporosis, ulcers, and have a fracture
59
How can you prevent br complications?
Fall wristband
No slip socks
Ted hose wrinkle free
Cal button for nurse when need to use bathroom
60
Isotonic solution
A solution with the same osmolarity as plasma
0.9% NaCl
D5W
61
Hypertonic solution
```
When a solution has a greater osmolarity than plasma
Causes the water to move out the cells
Causes them to shrink
>295 mOSm/L
D10W
```
62
Hypotonic solution
When a solution has less osmolarity than plasma
Causes cells to swell and potentially burst
<275 mOSm/L
0.33 NaCl
0.45 NaCl
63
Hyperosmolarity
Higher solute concentration outside the cell
Cell shrinks
Water leaves cell
64
Hypo-osmolarity
Higher solute concentration inside the cell
Cell swells
Water enters, sometimes explodes
65
Who is most at risk for dehydration/fluid overload?
Elderly
| Young children
66
What IV solution can be given with blood?
Normal saline 0.9% NaCl
67
What is a saline lock?
| A heparin lock?
Saline: capping off an IV with a short tube in which normal saline is injected to maintain patency
Heparin: similar but a concentration heparin solution is injected to prevent clogging of blood within the line
68
What is KVO?
Keep vein open
An order indicating the patency of the IV needs to be maintained for later use
This is done using lowest possible infusion rate
69
Sodium: below normal
Hyponatremia
| CHF, burns, diarrhea, diuretics
70
Sodium: above normal
```
Hypernatremia
Licorice (raises bp), dehydration, higher salt
```
71
Chloride: below normal
Hypochloremia
| Prolonged vomiting, excessive sweating
72
Chloride: normal
101-111 mg/dL
73
Chloride: above normal
Hyperchloremia
| Hormonal treatments, overactive PT gland
74
Potassium: below normal
Hypokalemia
| Diarrhea, vomiting, diuretics
75
Potassium: normal
3.7-5.2 mg/dL
76
Potassium: above normal
Hyperkalemia
| Impaired renal excretion, hemolysis
77
Magnesium: below normal
Hypomagnesium
| Malabsorption, sever diarrhea
78
Magnesium: normal
1.8-3.6 mg/dL
79
Magnesium: above normal
Hypermagnesemia
| Uremia, dehydration, Mg poisoning
80
Calcium: below normal
Hypocalcemia
| Eating disorder, osteoporosis, renal failure, prolonged vomiting
81
Calcium: normal
9-11 mg/dL
82
Calcium: above normal
Hypercalcemia
| Bone disease, parathyroid tumor, renal failure, immobilization
83
Phosphorus: below normal
Hypophosphatemia
| Hepatic failure, alcohol abuse, malabsorption
84
Phosphorus: normal
3.0-4.5 mg/dL
85
Phosphorus: above normal
Hyperphosphatemia
| Tumor lysis, vitamin d intoxication, laxative abuse
86
Mechanisms for regulation of body fluids
Intake
Output
Homeostasis
Intake: thirst
Output: urine, insensible loss, feces
Homeostasis: kidneys, adh, renin-angiotensin-aldosterone system, atrial natriuretic system
87
Osmosis:
Movement of a pure solvent through a semipermeable membrane from a solution with a lower solute concentration to one with a higher
88
Diffusion:
Movement of molecules from an area of higher concentration to lower
89
Filtration:
Straining of fluid from membrane
90
Active transport:
Movement of materials across the cell membrane using atp to admit particles what wouldn’t have otherwise made It through
91
How do body fluids maintain a pH of 7.35-7.45
Buffers
Respiratory system
Renal system
Lungs regulate acid base balance by eliminating/retaining co2
Kidneys regulate by selectively excreting/conserving bicarbonate and hydrogen ions slower to respond to change
92
Role of buffers in regulating acid-base balance
Prevent excessive changes in pH
Major buffers: bicarbonate and carbonic acid
Other buffers: plasma proteins, hemoglobin, and phosphates
93
Normal urine output per hour
At least 30 mL
94
Respiratory alkalosis
Increased pH above 7.45
Decreased PaCO2
Normal HCO3 (low in compensation attempt)
95
Respiratory acidosis
Decreased pH below 7.35
Increased PaCO2
Normal HCO3 ( high in compensation attempt)
96
Metabolic alkalosis
Increased pH above 7.45
Increased HCO3
Normal PaCO2 (low in compensation attempt)
97
Metabolic acidosis
Decreased pH below 7.35
Decreased HCO3
Normal PaCO2 (low in compensation attempt)
98
Veins for IV placement
Cephalon
Median
Basilic
(Larger, easy to puncture, less likely to rupture)
99
Steps for initiating IV
Arm in dependent position
Apply tourniquet (4-6 in above site)
Look for distal veins and move proximal
Make sure placement doesn’t interfere with ADLs
100
If you can’t find a vein for IV?
Gently stroke extremity
Place warm blanket over
Avoid rubbing vigorously or flicking - May cause vein to constrict or hematoma to form
101
If you don’t get blood return with Iv?
Take It out
Clean area
Try again in different location up the arm
102
Normal sodium
135-145 mEq/L
103
Bicarbonate normal
20-29 mEq/L
104
Normal hemoglobin
13-18 g/dL (m)
| 12-16 g/dL (f)
105
Hematocrit normal
40-50% (m)
| 38-48% (f)
106
What’s a CBC
```
Complete blood count
RBC count
Hemoglobin
Hematocrit
Platelets
WBCs
```
107
Normal RBC count
4.2-5.2 million/mm3
108
Normal platelets
100,000-400,000 /mm3
109
Normal WBC
5,000-10,000 / mm3
110
What’s a BMP?
```
Basic metabolic panel
Sodium
Chloride
Potassium
Bun
Creatinine
Glucose
Bicarbonate
```
111
Supine vs prone
Supine: lying down, face up
Prone: lying down, face down
112
Sims patient position
Patient is on left side and chest
Right knee and thigh drawn up
Left arm along the back
113
Orthopneic patient position
| Tripod
Enables pt to breathe comfortably
| Pt is sitting up and bent forward with arms supported
114
Trendelenburg
Pt is supine in a surface inclined 45 degrees
| Head at lower end and legs flexed over upper end
115
Catheter sizes are scaled by what?
French (F)
| According to lumen size
116
Catheter size for long term adult use
14F to 16F
With a 5-10 mL balloon
Smaller than this takes too long to drain and larger can distend urethra
117
Catheter size for children
5F to 8F for infants and young
| 8F to 12F for older children
118
Routine urinalysis technique
Collect urine during normal voiding, an indeed long catheter, or urinary collection bag
Must be freshly voided
119
Clean catch/midstream
Pt cleans area
Voids and discards a small amount of urine
Catches 30-60 mL in a sterile cup
Finishes void in toilet
120
Sterile urine collection technique
May be obtained by catheterizing pt or taking specimen from an already placed in dwelling catheter
121
Factors affecting circulation
```
Age
Heredity
Gender
Hypertension
Smoking
Obesity
Serum lipid levels
Diabetes
Temperature
Stress
Diet
Alcohol
```
122
Blood flow through the heart
```
Blood from systemic circuit
To vena cava
To RA through TV
To RV through PV
To pulmonary trunk
To pulmonary arteries
To lungs
To pulmonary veins
To LA through MV
To LV through AV
To aorta
To systemic circuit
```
123
Preventing venous stasis
```
Positioning - in chair legs up
Leg exercises
Antiembolic stockings
SCDs
Foot pumps
```
124
Measures to promote vascular circulation
Encourage leg exercises
Promote ambulatory
Avoid pillows under knees more than 15 degrees
Encourage frequent position change
125
Measures to promote cardia circulation
Positioning pt
Monitor i&o’s
Fluid restriction if necessary
126
Factors affecting oxygenation
```
Activity intolerance
Ineffective airway clearance
Ineffective breathing pattern
Potential for aspiration
Impaired gas exchange
Imbalanced nutrition
Deficient knowledge
```
127
Eupnea
Normal breathing
128
Tachpnea
Rapid breathing
129
Bradypnea
Slow breathing
130
Apnea
Stopped breathing
131
Hyperventilation
Fast shallow breathing
132
Hypoventilation
Slow shallow breathing
133
Kussmaul’s breathing
Deep and steady breathing
Presence of diabetic acidosis
Fruity sugary breath
Low ph
134
Cheynes-stokes
Periods of apnea followed by labored breathing
| Sign of dying
135
Biot’s respiration’s
Neurological disorder
| Erratic breathing due to damage of brain stem (medulla)
136
Orthopnea
Breathing changed by body position
| Associated with pulmonary disease
137
Dyspnea
Any type of unusual breathing
138
Signs of altered breathing
Tachycardia: heart beating faster, not enough oxygen in the blood
Anxiety: facial expression
Restlessness or confusion: not enough oxygen to the brain
Use of accessory muscles
Change in level of response: more confused than before
Increased bp
139
Oxygenation promotion
```
Changing position (high Fowler’s)
Ambulatory/exercising
Promote comfort - pain meds
Deep breathing and coughing
Bronchodilators and expectorants
Incentive spirometers
Postural drainage (head lower than bed)
Oxygen therapy
```
140
Oxygen delivery systems
Nasal cannula
Face tent
Face mask
141
Liter increase in O2
Room air is 21% increase 3-4% with each liter
1L/min 24%
2L/min 28%
3L/min 32%
