Term 1 Fundamentals Flashcards by Jordan Turner

The pts right to make their own decisions regarding their care even if the nurse disagrees

autonomy

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What are the 5 components of swansons Theory of caring

Knowing, being with, doing for, enabling, and maintaining belief

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A communication tool used to ensure accurate and concise information for transfer of patient

Isbar

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What is nurses role in advocacy

To protect patient rights, support their decisions, advocate for them to the provider

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Why is perineal care important for patients bedridden

To prevent infections skin breakdown, and promote comfort, and hygiene

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Define clinical judgement in nursing

Ability to assess patient conditions and make decisions about care interventions

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What is critical thinking in nursing?

Process of analyzing information, and making evidence-based decisions in patient care

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5 steps of the nursing process

Assessment, diagnosis, planning, implementation, evaluation

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Results inclient death or permanent severe harm

sentinel event

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What are the modes of transmission?

Contact (touch), droplet(respiratory, coughs sneeze), airborne(tuberculosis)

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What are the 5 rights of delegation?

Right task, right circumstance, right person, right direction & communication, right supervision & evaluation

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What are stages of pressure injury

Redness, skinloss, subcutaneous layer exposed, bone

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What does systolic represent in blood pressure

How hard heart is working

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What does the diastolic number in blood pressure represent

When the heart is relaxed

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What is normal pulse

60 -100bpm

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Where can you find pts aypical pulse.

Left, 5th intercostal space(between ribs), true pulse

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Requires 2 nurses radial and aypical pulse taken at same time

Pulse deficit

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What are the grading pulses

O( absent/ nonpalble), +1 weak/ diminished, +2 normal, +3 increased, strong, +4 bounding

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How should you document pulse taking.

Location of pulse, left or right , and grading number

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Actions guided by compassion and kindness

beneficence

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Telling the truth

veracity

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Keeping promises

Fidelity

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To do something or act for the sake of benefiting someone.(ex. Holding door open, donating money)

altruism

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Individual carries out an act or fails to carry one out and results in injury or harm to patient.(ex. Nurse forgets to give seizure medication

Tort law

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What is infectious agent?

Bacteria, fungi, virus, parasite

Where infectious agent lives and grows(ex.food/water, people, dirty surfaces & equipment)

Reservoir

Susceptible host

A person. Required for infectious agent to take hold

Type of white blood cell that help the body fight infection & disease by engulfing pathogen (pacman)

Phagocytes

Protective protein produced by immune system and attatch to bacteria To destroy them

Antibodies

Incubation

Bacteria enters host and begins to multiply

Prodromal stage

Pt begins having symptoms

Acute illness

Sickness is obvious and severe

Decline stage

When symptoms start to decrease and host feels a little better

Convalescence

Client returns to normal state of health

What color should mucous membranes be?

Pink & moist

Epidermis

Top layer of skin

Dermis

Middle layer of skin

Subcutaneous layer

Beneath dermis, made up of fat

Acuity

Complexity of patients condition (stable to highrisk)

Ideal discharge planning

Include, discuss, educate, assess, listen

Main type of sugar in the blood and is major source of energy for body's cells

Glucose

Glycogen

Stored sugar/ stored glucose

Normal blood pressure

120/80

Normal body temp

97 to 99 (98.6 is normal)

Respiratory rate

12-20bpm

O2 level

95% to 100%

Triage

Prioritization (level 1 most urgent, level 5 least urgent )

Acute pain

Last seconds to 6 months

Indicators of pain

Elevation in vitals, veins pop out, pallor

Severe pain

Decrease in bp,decrease in heart rate, nausea & vomiting fainting, restlessness

Nonpharmological pain interventions

Positioning, heat/cold therapy, massage, acupuncture, hypnosis, tens unit

Opioid analgesics

Morphine, hydrocodone, oxycodone, fentanyl codeine

Circadian rhythm

Cycle in body controls sleep-wake cycle

Stage I sleep

Light sleep, lasts 5-10 minutes

Stage 3 sleep

Deep sleep difficult to wake up stage is crucial for physical recovery and overall health.

REM sleep brain becomes active dream stage breathing irregular, heart rate B blood pressure increase

Stage 4 sleep

Surfactant

Lines the lungs keeps lungs from collapsing on itself. Mucousy substance

Hypoxemia

Low oxygen in blood

Hypoxia

Low oxygen in tissues

Macronutrients

Protein, carbs, and fat, provide energy to function

Micronutrients

Vitamin and minerals

COPD

Chronic airflow obstruction - decrease in oxygen increase in carbon dioxide

6 rights of medication administration

Right client,right medication,right dose, right route, right time of delivery, right documentation

Poritis

Itchy

Hormone made by pancreas, helps sugar from food you eat move into body's cells where its used for energy

Insulin

Not enough insulin

Sugar stays in bloodstream causing high blood sugar

Glycemia

Blood sugar

Alveoli

Air sacs in lungs where exchange of oxygen and carbon dioxide take place

Pain caused by nerve damage or dysfunction

neuropathic pain

Phantom pain

Pain felt in area that has been amputated

Hormone produced by pineal gland that regulates sleep-wake cycle

Melatonin

Pulmonary artery

Artery carrying deoxygenated blood from right ventricle to lungs

Pulmonary vein

Vein carrying oxygenated blood from lungs to left atrium of the heart

Protein in red blood cells that carries oxygen, essential for oxygen transport throughout body

Hemoglobin

Mineral critical for hemoglobin production

Iron

Water soluble vitamin

Vitamin B&C excreted through urine

Prevents neural tube defects, critical during pregnancy

Folic acid

Risk factors for pressure injuries

Poor nutrition immobile, decreased level of conciousness spinal injury, diabetics, urine or stool incontinence, activities that cause pressure injury

Pressure injury sites

Heels, ankles, hips,sacral area, elbows, shoulders , ears, inside of knees

Stage l pressure injury

Nonblanchable redness

Stage 2 pressure injury

Skin visibly damaged, exposed dermis

Stage 3 pressure injury

Full loss of skin through subcutaneous layer

Stage 4 pressure injury

Full loss of skin that exposes bone, muscle, tendon, ligaments

Unstageable pressure injury

Yellow or brown covering full skin loss

Deep tissue injury

Purple,blackish areas over skin, usually when people pass

Too much CO2, shortness of breath, hypoxia

Respiratory acidosis

What is CO2

Acidic/waste product

Respiratory alkalosis

Not enough CO2, hyperventilation

What is normal blood PH

7.35 - 7.45

Too many acids in body, affects kidneys, diarrhea

Metabolic acidosis

Metabolic alkalosis

Tool little acids, kidneys, vomiting

First intention wound healing

Sutured closed

Second intention wound healing

Wound left open to heal

Delayed primary closure wound healing( tertiary intention)

Wound left open 5-10 days then closed with sutures

Penrose drain

Tube inserted into wound that drains on gauze pad

Jackson Pratt drain

drain that collects fluid from wound (like Jessie)

Symptoms of sepsis

Fever(not always),hyperglycemia,hypotension, confused, high WBC , tachycardia, tachypnea

When giving eyedrops what should you do?

Press on lacrimal duct

Peripheral vision loss, pressure build up on optic nerve

Glaucoma

Progressive eye disease that affects the macula of the retina leading to central vision loss

Macular degeneration

Diabetic retinopathy

Vision loss, floaters

Involve the clouding of the lens of the eye, which leads to a decrease in vision clarity

Cataracts

What is PCO2 and range

Respiratory 45-35

HCO3 /bicarb

Metabolic 22-26

Hormone regulates amt of glucose in body Helps with high blood sugar levels , glucose attaches to it and takes inside cell

Insulin

Sugar, body needs it to survive fuels cells in body

Glucose

Diabetes mellitus

Body can not get access to glucose your eating which means no insulin present ( type 1) or body is resistant to insulin(type 2) - overweight sedentary, poor diet, genetic

Elevated blood sugar(glucose) in body that's just hanging out and this affects major organs

Hyperglycemia

Film dressing

Small superficial wounds, non absorbant, iv sites , stitches

Alginate dressing

Made from fibers that turn into gel when it comes into contact with wound exudate, for moderate to heavily exuding wounds, pressure ulcers,venous ulcers, post op wounds

Hydrofiber dressing

Turns into gel when comes into contact with wound exudate. Absorbs more fluid, pressure ulcers, diabetic foot ulcers, venous ulcers

Foam dressing

Soft, absorbent, moderate to heavy exudate pressure ulcers, burns

When bones have become thinner weaker as a result from prolonged bed rest

Disuse osteoporosis

Decrease in blood pressure upon standing , dizziness

Orthostatic hypotension

Acts as physical barrier blocking pathogens from invading the body, moist, inner-lining nose, mouth , lungs, and stomach

Mucous membranes

Medications commonly prescribed for the relief of pain have risk of sedation and respiratory depression

opioids

Used along with other medication help make pain relief move effective, like antidepressants

Adjuvant analgesics

phase where the body responds to the injury by sending blood cells and proteins to the area to control bleeding and prevent infection

Inflammatory phase

New tissue growth occurs as fibroblasts produce collagen to fill the wound and blood vessels form to supply nutrients

Proliferative phase

Collagen fibers model and strengthen, and the wound gradually closes as the tissue matures

Maturation phase

Vitamin C enhances?

Iron

Inflammation of vein, caused by irritation from the IV catheter. Signs include redness warmth, pain, palpable cord along the vein

Phlebitis