Test 1 Flashcards
Acceptable temperature range for adults
36-38 C (96.8 to 100.4 F)
Average oral/tympanic temp for adults
37 C (98.6 F)
Average rectal temp for adults
37.5 C (99.5 F)
Average axillary temp for adults
36.5 C (97.7 F)
Acceptable Pulse range for adults
60 to 100 beats/min
Acceptable Respirations for adults
12 to 20 breaths/min
Acceptable Pulse Pressure range for adults
30 to 50 mmHg
Who are more at risk for heatstroke?
Very young, very old, those with cardiovascular disease, hypothyroidism, diabetes, alcoholism, those who work or exercise strenuously, and those taking certain medications
What are signs and symptoms of heatstroke?
*Body temp of 104F or more, sometimes as high as 113F *Increase HR, decrease BP *Giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and incontinence; HOT, DRY SKIN
What is the treatment of heat exhaustion?
Transporting patient to cooler environment and restoring fluid and electrolyte balance.
Classification of hypothermia
Mild - 93.2-96.8 F
Moderate - 86.0-93.2 F
Severe - <86 F
What is bradycardia?
Pulse below 60 beats per min in adults
What is tachycardia
Pulse above 100 beats per min in adults
What is dysrhythmia
abnormal pulse rhythm
What is hypertension?
Often asymptomatic-silent killer Thickening of walls Loss of elasticity (heart pumps harder and blood flow to organs is decreased)
What is orthostatic hypotension and nursing implications?
Orthostatic/postural - low blood pressure when rising to upright position NURSING IMPLICATIONS: obtain BP and pulse with patient supine, sitting, & standing, taking readings 1-3 min after position change and observe for other symptoms of hypotension: fainting, weakness, light-headedness
Patient conditions not appropriate for electronic blood pressure measurement
*irregular heart rate *Peripheral vascular obstruction *shivering *seizures *excessive tremors *inability to cooperate *Blood pressure less than 90 mmHg systolic
Blood Pressure Classification adults
Normal - 120/80
Prehypertension - 120-139/80-89
Stage 1 - 140-159/90-99
Stage 2 - >160/>100
Acceptable blood pressure range for adults
Six Critical Thinking Skills
- Interpretation
- Analysis
- Inference
- Evaluation
- Explanation
- Self-Regulation
Concepts for a Critical Thinker
- Truth Seeking
- Open-mindedness
- Analytic approach
- Systematic approach
- Self-confidence
- Inquisitiveness
- Maturity
Five Components of Critical Thinking
- Knowledge base
- Experience
- Nursing Process Competencies
- Attitudes
- Standards
Nursing Process Competencies
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
ADPIE
Common Errors in Blood Pressure Assessment
ERROR
EFFECT
Bladder or cuff too wide
False-low reading
Bladder or cuff too narrow or short
False-high reading
Cuff wrapped too loosely or unevenly
False-high reading
Deflating cuff too slowly
False-high diastolic reading
Deflating cuff too quickly
False-low systolic and false-high diastolic reading
Arm below heart level
False-high reading
Arm above heart level
False-low reading
Arm not supported
False-high reading
Stethoscope that fits poorly or impairment of examiner’s hearing, causing sounds to be muffled
False-low systolic and false-high diastolic reading
Stethoscope applied too firmly against antecubital fossa
False-low diastolic reading
Inflating too slowly
False-high diastolic reading
Repeating assessments too quickly
False-high systolic reading
Inadequate inflation level
False-low systolic reading
Multiple examiners using different Korotkoff sounds for diastolic readings
False-high systolic and false-low diastolic reading
Cardiovascular response to hemorrhage
- Increases pulse rate
- Decreases BP
Sites for and Causes of Health Care-Associated Infections
- Impoper hand hygiene increases patient risk for HAI
- Urinary & respiratory tracts
- Surgical and traumatic wounds
- Bloodstream
Tier One Precautions
Standard precautions for use with all patients
Tier Two-AIRBORNE Precautions
INFECTION/CONDITION
BARRIER PROTECTION
Measles, chickenpox, disseminated varicella zoster, pulmonary or laryngeal TB
Private room, negative-pressure airflow via HEPA, mask or respiratory protection device, N95 respirator
Tier Two-DROPLET Precautions
INFECTION/CONDITION
BARRIER PROTECTION
Diphtheria, rubella, streptococcal pharyngitis, pneumonia, scarlet fever, pertussis, mumps, Mycoplasma pneumonia…
Private room or cohort patients; mask or respirator required
Tier Two-CONTACT Precautions
INFECTION/CONDITION
BARRIER PROTECTION
Colonization or infection with VRE, MRSA, or C. difficile, shigella, major wound infections, herpes simplex, scabies, varicella zoster
Private room or cohort patients, gloves, gowns
Tier Two-Protective Equipment
INFECTION/CONDITION
BARRIER PROTECTION
Allogeneic hematopoietic stem cell transplants
Private room, positive airflow, HEPA filtration, mask to be worn by patient when out of room
Principals of medical asepsis and when they are used
Medical asepsis - clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms.
Examples: hand hygiene, barrier techniques, routine environmental cleaning
Principals of SURGICAL ASEPSIS and when they are used
- A sterile object remains sterile only when touched by another sterile object.
- Only sterile objects may be placed on a sterile field
- A sterile object or field out of the range of vision or below waist is contaminated.
- A sterile object or field becomes contaminated by prolonged exposure to air.
- When sterile surface comes into contact with a wet, contaminated surface, sterile object or field becomes contaminated.
- Fluid flows in the direction of gravity.
- The edges of a sterile field or container are considered to be contaminated.
Infectious Process
- Incubation period - time interval between entrance of the pathogen & the appearance of first symptoms
- Prodromal Stage - interval from the onset of nonspecific signs and symptoms to more specific symptoms
- Illness Stage - interval wen client manifests signs and symptoms specific to the type of infections
- Convalescence - interval when acute symptoms disappear (recovery may take several days or months)
Etiology of Hep B, C, and A
- Hep A - Feces
- Hep B - Blood and certain body fluids, sexual contact
- Hep C - Blood and certain body fluids, sexual contact
Nosocomial
Hospital-acquired infections
Iatrogenic
infection from a diagnostic or therapeutic procedure
Endogenous
part of the body’s normal flora becomes altered or an overgrowth results
Exogenous
comes from microorganisms outside of the individual; these do not exist in the body’s normal flora
Chain of Infection
- Infectious Agent
- Resevoir
- Portal of Exit (coughing, sneezing)
- Mode of transmission
- Portal of entry
- Host
Putting on PPE
- Hand hygiene
- Apply gown
- Apply mask and eyewear or goggles
- Apply gloves
Removing PPE
- Remove gloves
- Remove eyewear or goggles
- Remove gown
- Remove mask (outside of patient’s room)
Common bed positions, description and uses
- Flat-entire bed horizontally parallel with floor; vertebral injuries & in cervical tracion
- Reverse Trendelenberg’s-head up, feet down, bed frame tilted; usually surgical
- Trendelenberg’s-feet up, head down, bed frame tilted; shock
- Semi-Fowler’s-head raised 30-40 degrees
- Fowler’s-60 degree; used for SOB
LEVELS OF CRITICAL THINKING
- LEVEL 1 - Basic - concrete thinking, following rules or procedure
- LEVEL 2 - Complex - Nurse realizes that judgement calls sometimes need to be made based on situation
- LEVEL 3 - Commitment - nurses anticipate needs and make decisions without assistance from others
How many mL in One teaspoon
5mL=One teaspoon
How many mL in One ounce
30 mL = one ounce
How many pounds in one kg
one kg = 2.2 lb
How many micrograms in 1 mg
1 mg = 1000 mcg
How many milligram in 1 g
1 g = 1000 mg
How many liter = 1000 mL
1000 mL = 1L
How many mL in One tablespoon
15 mL = 1 tablespoon
How many grams = 1 kilogram
1 kilogram = 1000 g
How many ounces in One cup
8 ounces = 1 c
How many ounces in One quart
32 ounces = 1 qt
How many ounces in One pint
16 ounces = 1 pt
