Test 2 Study Guide Flashcards
1
Q
The nursing process is an organized sequence of
A
problem-solving steps used to identify and manage the health problems of client
2
Q
Be able to identify the steps of the nursing process and what is done during each step.
Assessment
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1st step
3
Q
When does the assessment begin?
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Assessment begins with the nurse’s first contact with a client and continues as long as a need for health care exists. During assessment, the nurse collects information to determine areas of abnormal function, risk factors that contribute to health problems, and client strengths
4
Q
observable and measurable facts and are referred to as signs of a disorder. An example is a client’s blood pressure measurement
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Objective Data
5
Q
information that only the client feels and can describe, and these are called symptoms. An example is pain.
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Subjective Data
6
Q
Diagnosis is what step
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2nd step
7
Q
What are we identifying with diagnosis?
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The identification of health related problems
8
Q
A Nursing Diagnosis is a health issue
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is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility
9
Q
Nursing Diagnoses are written to describe _____ nurses can ________.
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Nursing Diagnoses are written to describe ___patient problems__ nurses can __solve______.
10
Q
R/T
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Related to
11
Q
AEB
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As evidence by
12
Q
RF
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Risk for
13
Q
4th step of nursing process
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Planning
14
Q
To determine priorities nurses use
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Maslow’s Hierarchy of Human Needs
Self actualization
Esteem needs
Social needs
Safety needs
Basic needs
15
Q
Define Goals for planning
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outcome criteria, identify specific evidence for each nursing diagnosis that a client’s problem is trending towards resolution or has been resolved
16
Q
Explain short term goal
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(outcomes achievable in a few days to 1 week) more often in acute care setting because most hospitals stays are only a few days or no longer 1 week
17
Q
5 Characteristics: of planning
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1 Developed from the problem portion of the diagnostic statement
2 Client-centered, reflecting what the client will accomplish, not what the nurse will accomplish
3 Measurable, identifying specific criteria that provide evidence of goal achievement
4 Realistic, to avoid setting unattainable goals, which can be self-defeating and frustrating
5 Accompanied by a target date for accomplishment (the predicted time when the goal will be met), which establishes a timeline for evaluation
18
Q
Implementation is the _______ of nursing process
A
5th step
19
Q
It means carrying out a
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plan of care
20
Q
Evaluation is the _____ step of nursing process
A
6th step
21
Q
On evaluation has you patient reached________
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Reached their goal
22
Q
Are ideals that a person feels are important knowledge, wealth, financial security, martial fidelity, health
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Values
23
Q
Are concepts that a person holds to be true. Beliefs and values guide a persons actions
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Beliefs
24
Q
Means a full and balanced integration of all aspects of healthcare
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Wellness
25
the aum of physical, emotional, social, and spiritual health. Determines how “whole” or well a person feels
Holism
26
What is Maslow’s Hierarchy of human needs? How do nurses use this tool? And Why?
( factors that motivate behavior) Physiologic ( first level), safety and security ( second level), love and belonging ( third level), esteem and self esteem ( fourth level) , and self actualization( fifth level)
27
is a state of being unhealthy when disease, deterioration, or injury impairs a person's well being.
Illness
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one that comes on suddenly and lasts a short time) is one method for classifying a change in health
Acute Illness: Onset
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Sequelae ill effects that result from permanent or progressive organ damage caused by a disease or its treatment
Lasts
30
one that comes on slowly and lasts a long time) risk increases as people age
Chronic Illness: Onset
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(one in which there is no potential for cure) is one that eventually is fatal. The terminal stage of an illness is one in which a person is approaching death.
Lasts Terminal Illness
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(Incidence of a specific disease, disorder, or injury) refers to the rate or the number of people affected.
Morbidity: refers to the
33
Incidence of deaths) denotes the number of people who died from a particular disease or condition
Mortality: refers to the number of people who
34
one that develops independently of any other disease
Primary Illness
35
disorders that develop from a pre-existing condition.
Secondary Illness
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is the disappearance of signs and symptoms associated with a particular disease
Remission
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(reactivation of a disorder , or one that reverts from a chronic to an acute state) can occur periodically in clients with long standing diseases
Exacerbation
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( disorder acquired from the genetic codes of one or both parents) may or may not produce symptoms immediately after birth.
Hereditary
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(those present at birth but which are the result of faulty embryonic development) cannot be genetically predicted.
Congenital
40
is an illness of unknown case. Treatment focuses on relieving the signs and symptoms because the etiology is unknown
Idiopathic
41
Define the word VITAL
absolutely necessary or important; essential.
42
When should vital signs be taken?
On admission, when obtaining database assessments
• According to written medical orders
• Once per day when a client is stable
• At least every 4 hours when one or more vital signs are abnormal
• Every 5–15 minutes when a client is unstable or at risk for rapid physiologic changes such as after surgery
• Whenever a client’s condition appears to have changed
• A second time, or more frequently, when there is a significant difference from the previous measurement
• When a client is feeling unusual
• Before, during, and after a blood transfusion
• Before administering medications that affect any of the vital signs and after to monitor the drug’s effect
43
What is considered to be the 5th vital sign?
Pain
44
How is body heat produced?
primarily from exercise and metabolism of food
45
How is it lost? Briefly list the 4 ways body heat is lost.
through the skin, the lungs, and the body’s waste products through the processes of
1.radiation 2. conduction 3. convection 4. evaporation
46
What is a normal shell temp of an adult? (use the Fahrenheit scale)
96.6° to 99.3°F
47
What structure in the brain is the control center for temperature regulation?
Hypothalamus
48
What does the anterior hypothalamus promote?
heat loss through vasodilation and sweating
49
What does the posterior hypothalamus promote?
heat conservation and heat production
50
How is heat conserved?
• Adjusting where blood circulates
• Causing piloerection (the contraction of arrector pili muscles in skin follicles), which stiffens body hairs and gives the appearance of what commonly is described as “goose flesh”
• Promoting a shivering response
• What do temperatures above 105.8F or below 93.2F indicate
• Briefly describe the factors that have an effect on body temp.
51
Both exercise and activity involve muscle contraction. As muscle groups and tendons repeatedly stretch and recoil, the friction produces body heat. Shivering is another example of contractile thermogenesis
Exercise/Activity
52
affect metabolic rate by triggering hormonal changes through the sympathetic and parasympathetic pathways of the autonomic nervous system
Emotions
53
Diseases, disorders, or injuries that affect the function of the hypothalamus or mechanisms for heat production and loss alter body temperature, sometimes dramatically
Illness/Injury
54
Various medications that affect body temperature begin with the prefix “anti.” When a pyrogen (bacterium) is introduced, the body temperature is elevated. Drugs known as antipyretics (such as aspirin, acetaminophen, and ibuprofen) directly lower body temperature by acting on the hypothalamus
Medications
55
What are the four most practical sites to measure temperatures?
Tympanic membrane, mouth, rectum, axillary
56
What are some things that would make an oral temp invalid?
Poor placement, drinking cold beverages, removing too soon
57
What type of client would an oral temp be contraindicated for?
Uncooperative, very young, unconscious, prone to seizures, head oral surgery or are mouth breathers
58
Why isn’t the rectal temp more like a core body temp?
Rapid fluctuations are identified for as long as an hour and retains heat longer than other sites
59
Why is the axillary site the preferred site for taking temps in infants?
Can be injured internally, lose heat through skin are a greater rate
60
What are some symptoms associated with a fever?
Pink/redish flushed skin, warm to the touch, poor appetite, irritability, restlessness, headsche, abnormal pulse rate and respiratory rate
61
Nursing management of a fever would include….
apply cool cloths or ice packs, remove heavy clothing or blankets, provide liberal oral fluids
62
Nursing management of a client with a subnormal temp would include….
Cover if shivering, limit activity , keep humidity low, apply tepid water to skin,
63
What is a pulse?
A wave like sensation that can be palpated in prepherial artery is produced by the movement of body during the heart contraction
64
What is a normal pulse rate in an adult?
80 (60-100 range)
65
When is it considered tachycardia?
100-150 bpm
66
When is it considered bradycardia?
below 60 bpm
67
What are some factors that influence our pulse rates?
Age, gender, body build, excerise and activity, stress and emotions
68
What is a pulse rhythm?
the pattern of the pulsations and the pauses between them
69
What is arrhythmia or dysrhythmia? What should you do with this information?
an irregular pattern of heart beats. you should report promplty if it should become irregular
70
Define pulse volume
the quality of palpated pulsations
71
Describe a normal, thready, & bounding pulse.
N - (Normal Pulse) Pulsation is felt easily; moderate pressure causes it to disappear.
T- (Thready Pulse) Pulsation is not easily felt; slight pressure causes it to disappear.
B- ( Bounding pulse) Pulsation is strong and does not disappear with moderate pressure
72
What is an apical heart rate? Where is the anatomical site?
• an apical heart rate is the number of ventricular contractions per minute
• it is located to the left of the sternum at the interspace below the fifth rib in midline with the clavicle
73
Respiratory rate: What is the normal adult resp rate?
16 - 20 Breaths Per Minute (BPM)
74
a rapid respiratory rate
Tachypnea
75
a slower-than-normal respiratory rate at rest
Bradypnea
76
rapid or deep breathing or both
Hyperventilation
77
diminished breathing
Hypoventilation
78
difficult or labored breathing
Dyspnea
79
breathing facilitated by sitting up or standing
Orthopnea
80
the absence of breathing
Apnea
81
What are Cheyne-Stokes respirations?
aka Death Rattle. Occurs near the end of life
82
What is stridor?
a harsh, high-pitched sound heard on inspiration when there is laryngeal obstruction
83
the force the blood exerts within the arteries.
Define blood pressure
84
Age
Blood pressure tends to become elevated with age as a result of arteriosclerosis, a process by which arteries lose their elasticity and become more rigid, and atherosclerosis, a process by which the arteries become narrowed with fat deposits. The rate of these conditions depends on heredity and lifestyle habits such as diet and exercise
85
Gender
Women tend to have lower blood pressure than men of the same age
86
Exercise/Activity
Blood pressure rises during exercise and activity, when the heart pumps more blood. Regular exercise, however, helps maintain blood pressure within normal levels
87
Emotions/Pain
Strong emotional experiences and pain tend to increase blood pressure from sympathetic nervous system stimulation
88
Misc
As a rule, a person has lower blood pressure when lying down than when sitting or standing, though the difference in most people is insignificant. Blood pressure also seems to rise somewhat when the urinary bladder is full, when the legs are crossed, or when the person is cold. Drugs that stimulate the heart such as nicotine, caffeine, cocaine, and methamphetamine also tend to constrict the arteries and raise blood pressure
89
What is systolic pressure/diastolic pressure?
S Pressure within the arterial system when the heart contracts
D Pressure within the arterial system when the heart relaxes and fills with blood
90
Blood pressure is most commonly measure over the brachial artery. In what situations can this site not be used? What is the alternative site?
• When the client’s arms are missing
• When both of a client’s breasts have been removed
• When a client has had vascular surgery (such as that which permits dialysis treatments for kidney failure)
• When plaster or fiberglass casts or dressings obscure the brachial and radial sites
It is also possible to use the lower arm and radial artery, the thigh and the popliteal artery, and the lower leg and the posterior tibial or dorsalis pedal artery
91
How is a palpable blood pressure obtained?
A blood pressure cuff can be substituted for a rubber tourniquet. Whichever technique is used, the radial pulse should be palpable to indicate that arterial blood flow is being maintained.
92
What is hypertension?
Hypertension (high blood pressure) exists when the systolic pressure, diastolic pressure, or both are sustained above normal levels for the person’s age
93
What is white-coat hypertension?
• a condition in which a patient's blood pressure readings are higher when taken at the doctor's office compared to other settings
94
What are some factors associated with HTN?
• unhealthy diets (excessive salt consumption, a diet high in saturated fat and trans fats, low intake of fruits and vegetables)
• physical inactivity
• consumption of tobacco and alcohol
• being overweight or obese
95
What is low-blood pressure usually associated with?
with efficient functioning of the heart and blood vessels. People with low blood pressure, however, should continue to be monitored to evaluate its significance.
96
What else can it indicate?
Low blood pressure measurements may indicate shock, hemorrhage, or side effects from drugs.
Postural or Orthostatic hypotension is…
Postural or orthostatic hypotension is a temporary drop in blood pressure when rising from a reclining position after 3 to 5 minutes of rest
97
What is it associated with?
It is most common in those with circulatory problems—especially common in older adults, those who are dehydrated, and those who take diuretics or other drugs that lower blood pressure.
98
What should you encourage your client to do if they suffer from orthostatic hypotension?
(1) ensure that the client remains seated after rising until dizziness passes, (2) restore adequate hydration if the client’s fluid volume is low, (3) increase consumption of salty foods and those containing sodium providing the client is not hypertensive, (4) apply compression stockings to the lower extremities to reduce pooling of blood upon standing, and (5) administer prescribed medications such as a synthetic mineralocorticoid that mimics aldosterone, an adrenal hormone, to reduce the loss of sodium in urine thus raising blood volume, or a sympathetic nervous system vasopressor, a drug that constricts blood vessels, causing an antihypotensive effect.
99
What do temperatures above 105.8F or below 93.2F indicate?
Hyperperexia and hyperthermia
100
Briefly describe the factors that have an effect on body temp.
smoking, drinking hot fluids,&& chewing gum
101
Which food has the greatest thermic effect?
Protein
