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- assess patient
- collect and label correctly
- assess results and notify physician
What does the liver do during digestion?
When do you get the most REM sleep?
serves as “body’s natural biological cover”. Scab like cover over pressure ulcers and does not need to be removed, unless ordered by physician.
smallest known agents that cause disease, reproduce rapidly, interrupt cell activities and use cell as their own, most run their course and then recover (leave quickly)
Types of Infection- infection that affects the entire body instead of just a single organ or body part
Types of Infection- in one area. Proper care controls the spread and minimizes the illness. Hope is to keep them localized with no spreading
An infection that is contracted outside of the health care setting or present upon admission
In addition to standard precautions, you will use this for persons known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patients’ environment. Examples of illness to use this for.
Standard precautions & persons known or suspected to have serious illnesses transmitted by airborne droplet nuclei.
Examples of illnesses to use this for. (TB, Varicella, measles)
Precautions for serious illness transmitted by large droplets. Examples of illness o use this for.
Bio-rhythms are known as a body clock. This is the cyclic pattern of body ______.
Within bio-rhythms, the fluctuations can occur when?
What is the body’s every hour or minute cycle rhythm?
Which stage of sleep (REM or Non-REM) provides more efficient rest?
- mental as your brain prepares for the next day.
Sleep disorder where pt gets too much sleep. What can it lead to?
Bowel sounds that are infrequent and soft.
Bowel sounds that are loud, high pitched, and frequent (q 3 seconds)
virus infections that don’t run their course, but stay in the body
Examples of Virus
An infection that manifests at least 48 hours after hospitalization or contact with another health agency
Reverse Isolation- protecting the patient from what is outside
Joint Commission & medicare & medicaid require that pts be given a ______.
Moving a pt from one unit to another w. in facility
Protection, promotion, & optimization of health & abilities, the prevention of illness & injury, the alleviation of suffering through the diagnosis & treatment of human response & advocacy in the care of individuals, families, communities, & populations
Systematic problem solving approach to nursing care
Type of assessment that is lengthy, but reviews all body systems. Always done upon admission for someone that stable & not acute.
Type of assessment that provides detail about certain problems. Done with all nurse-pt contact. Briefly and frequently done.
Sources of data (2)
Methods of data collection
What are the 3 things an actual nursing diagnosis requires?
An actual nursing diagnosis is a condition that is ______.
Maslow’s Hierarchy of Needs
Types of goal- achieved in 7-10 days or before d/c from a facility
Activities that are chosen by the nurse to lead to the accomplishment of pt’s goal. Needs to be clearly stated, agree w/ other disciplines (such as physical therapy), be realistic, needs a time frame (how often to do this), needs to match the goal.
Directed & purposeful mental activity by which ideas are evaluated, plans are constructed, & desired outcomes are decided
Types of patient records- organized according to the source of documented info. Divided into sections (physician, lab, nurse, respiratory, etc.)
Types of patient records- based on scientific problem solving. Organized according to health problem of the pt rather than source of info. Contains a database (admitting info & assessment), problem list, plan of care, progress notes (where everyone charts)
Methods of charting- recording pt care in descriptive form. More in traditional records.
Methods of charting- subjective info, objective info, assessment, plan, intervention, evaluation, revision. Mostly in problem-oriented charts.
Methods of charting- similar to SOAPE. Problem, intervention, evaluation
Methods of charting- only charting during abnormal assessment findings or care that deviates from the standard
Methods of charting- electronic med record, electronic health record. Computerized.
The _____ regulates body temp.
surface and core
Temperature taken by mouth. Sometimes contraindicated by mouth breathers. Normal is 98.6.
Temperature taken by inserting thermometer into rectum. Most accurate & reliable. Normal is 99.6.
Temperature taken by placing thermometer in axillary (arm pit). Safest & most non-invasive, but does not give the most accurate reading. Normal is 97.6.
Temperature taken by placing special thermometer in the ear. Closest correlation to core temp. Very quick & easy. Excellent for critically ill, pediatrics, & elderly. Norm is 98.6.
Who should you not obtain an oral temperature on?
If temperature is greater than ____ it can destroy normal body cells.
Words meaning fever
If temperature reaches ___ or lower, death can occur.
Normal pulse rate for adult
Normal pulse rate for child
Normal pulse rate for infant
Normal pulse rate for newborn
Difference between apical pulse & radial pulse. Need 2 nurses to do this. Use same clock & same time frame. If heart action is abnormal, will see a ↑apical rate (closer to heart) & ↓radial rate (farther from the heart)
Normal respiratory rate for newborn
Normal respiratory rate for infant less than 3 years old
Normal respiratory rate for adult
↑respiratory rate, greater than 20/minute in an adult
↓respiratory rate, less than 12/minute in an adult
Fast & deep respiration, followed by a period of apnea. Usually in terminally/chronically ill pts
Fast & deep respirations with no pauses. Diabetic coma pts.
Difference between systolic & diastolic pressure. Norm 30-50
Pulsating sounds heard while taking BP
Temporary disappearance in sound of BP.
% of room air that is O2
↓ O2 @ cellular level
↓ O2 in blood
↑ CO2 in blood
During _____, the diaphragm contracts and moves ↓, intercostal muscles move chest outward (lung expansion). Diaphragm relaxes & moves ↑, intercostal muscles return to normal, air flows out of lungs.
Molecules moving from an area of ↑ concentration to ↓ concentration. Breathe in O2 which diffuses into the blood, goes to cells, CO2 diffuses into blood back to lungs.
Movement of solutes from areas of high concentration to lower concentration
Where fluid passes through spaces. Blood travels through vessels to all of the body.
People with respiratory disorders respond to ___ aka ____.
DO NOT increase O2 in people with _____.
Slow, shallow breathing where CO2 is retained.
Sitting up to breathe
Respond to strong physical stimuli
Unresponsive to verbal/physical stimuli
Un-arousable, no response to painful stimuli
When looking at neck veins, what are we looking for?
Instructing pt to take 2-3 deep breaths, exhale slowly followed by deep breath in & cough on exhalation
Instrument used to measure flow of inhaled air
drains by gravity.
Types of oxygen administration
Normal concentration of O2 with nasal cannula. % of O2 with every L/minute
Mask that gives a very accurate % of O2. Color coded for % needed.
All exhaled air leaves mask. Not breathing in any CO2. Average is 12-15 L/minute. Has a reservoir bag attached. If bag is not inflated, then they are breathing in CO2 and not enough O2 is getting into the bag.
Fits loosely under chin to deliver O2. O2 delivery is inconsistent. Mostly for pts not wanting to leave O2 masks on.
For pediatric pts. Deliver cool, humidified O2. Sprays fine mist & provides constant temperature. O2 delivered in % not L.
Continuous positive airway pressure. Different from bi-pap, does not use O2. Keeps alveoli partially inflated during expiration. Keep alveoli saturated with O2 when apnic.
Artificial airway- in the mouth. Different sizes. For sedated ppl or unconscious ppl, not for someone awake.
Artificial airway- in the nose. Aka nasal trumpets. Nostril to pharynx, lays by epiglottis.
Artificial airway- used when someone is under general anesthesia. Mechanical ventilation. Lies in trachea. Inflated bulb to close system & hold in place. Aka ET tube. Physician or RT places. Tape in place to prevent slips. Not a permanent use.
Artificial airway- provides permanent airway for pt. tube through a stoma into the trachea. Has an outer cannula (tube), inner cannula and an obturator(used to guide tube in, do not throw this away)
Nursing intervention for trach tubes
Body fluid is made up of (3 elements)
Fluid inside the cell
Fluid outside the cell
Area between or surrounding the cells
Serum portion of blood
Why are the elderly at risk for fluid imbalances?
Why are elderly at risk for fluid imbalance?
Body fat contains ____ water
Why are infants at risk for fluid imbalances?
Water is a ____ for transport.
1What does water do? (5)
Movement of H2O from lower concentration to higher concentration (equalizes # of molecules on each side of the membrane)
Solution that have equal concentrations & exert equal pressure. No shifting of fluids from 1 compartment to the next. Used to expand body’s fluid volume & don’t cause a shift between compartments.
Solution of less concentration outside of cells. Decreased # molecules, decreased osmotic pressure. H2O MOVES INTO CELLS & cells expand. If too much, can burst (hemolysis). Used to replace loss of fluids as with vomiting & diarrhea.
1Solution with an increased # of molecules. H2O MOVES OUT OF CELLS & cells shrink (crenation). Give to draw cellular & interstitial fluid into intravascular compartments. To decrease cerebral edema, sodium replacement.
Solutions that are blood & blood products.
Which fluids are isotonic?
Which fluids are hypotonic?
Active transport requires _____ to move substances from lower concentration to higher concentration.
What to observe when assessing fluid balances.
For every kg of weight loss= ____L of fluid
What vital signs tell most about fluid balance?
Who needs strict I&O
You do not count an enema as an intake if ____.
When there is so much fluid present in the body, it begins to go into places such as the abdomen, lungs, becomes trapped & useless.
Medical diagnosis of low fluid volume, nursing diagnosis of low fluid volume.
Medical diagnosis of high fluid volume, nursing diagnosis of high fluid volume
Decreased urine output, less than 400ml/day
Decreased urine output. 100-400 ml/24 hours
Absent urine output or less than 50 ml
Absent, very little urine output. Less than 100ml in 24 hours
S/S of fluid imbalance in infants & children
Why are adolescents & young adults at risk for fluid imbalance?
Compounds that stay bound together- do not have an electrical charge.
Compounds that separate into individual molecules & carry electrical charge of (+) or (-)
S/S of electrolyte imbalances
Low sodium, less than 135 mEq/L
Low potassium, less than 3.5 mEq/L
High sodium, greater than 145 mEq/L
High potassium, greater than 5 mEq/L
Low chloride, less than 96 mEq/L
High chloride, greater than 110 mEq/L
Low calcium, less than 4.5 mg/dl
High calcium, greater than 5.6 mg/dl
Diagnostic tests for electrolytes
How much urine does the bladder hold until the urge to urinate occurs?
Why do elderly have difficulty with urination?
Abnormal large amount of urine output
Need to void perceived with short lived ability to control.
Urine is lost, but no perception of need to void
Control over urination is lost because of compromised ability to use the toilet. Urge is there, but many barriers are in the way of getting to the bathroom
Urine loss with no identifying pattern & no warning. No ability or effort to control, such as with babies
Urine leakage from bladder because bladder is not completely emptied.
Accumulation of urine in bladder & inability to empty bladder. pressure & discomfort, tender when palpated, restless & diaphoretic
Bladder should not be palpable unless it ______.
Pus in urine
____ is the best indicator of urine output
If urine output is ____ notify MD
Different types of external catheters
Types of internal catheters
How often should the drainage bag be emptied on a catheter?
Contraction of muscles causing wave-like movements that move waste products through intestines
How much water is pulled from each stool that passes through the body?
Soft & infrequent bowel sounds
Normal bowel sounds
How far do you insert an enema tubing?
How high up do you hold the enema bag?
How long do you give an enema?
If mild discomfort occurs during an enema, what do you do?
Inability to control the elimination of stool
How do you confirm a rectal impaction?
Distended veins in rectal area
Most common enema. Stimulates peristalsis by irritating & distending colon. Moistens stool. Tap water enema, SSE, saline enema
Enema that introduces oil into rectum to lubricate & soften stool. Fleets enema, mineral oil enema, stays in 30 minutes
Enema used to deliver medications, such as kayexalate to pull potassium from body.
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