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Assessment:

collecting vital signs, pain levels, other signs/ symptoms

Diagnosis:

nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis

Planning:

nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks)

Implementing:

following through with plan that was developed for the patient

Evaluation:

goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient

Normal range for temperature

96.8-100.4

Normal range for pulse

60-100

Normal range for respirations

12-20

Normal range for BP

100/60-140-90

Normal range for pulse ox.

>95%

SOLER

sit close, observe, lean forward, eye contact, relax

Types of pain

acute, chronic, cancer, by inferred pathology, idiopathic

Pain threshold

level of stimulus needed to produce the perception of pain

Pain tolerance

amount of pain a patient endures without its interference of ADLs

Factors influencing pain

age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors

Behavioral responses to pain

clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction

Pharmacological pain relief

analgesics (NSAIDS & non-opioids, opioids, adjuvants)

NSAIDS & non-opiates

has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction, possible liver failure

Opioids

pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status

Naloxone (Narcan)

opiate antagonist, reverses opioid induced resiratory depression

Patient Controlled Analgesia (PCA)

client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses

Anesthetics

depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local

Basal metabolic rate (BMR)

energy needed to maintain life

Carbohydrates

main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey

Proteins

essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance

Fats

triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential

Water

comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids

Vitamins

essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight

Minerals

inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport

Free Radical Theory

presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products

Erikson's 8 stages of development

trust vs mistrust
autonomy vs shame and doubt
initiative vs guilt
industry vs inferiority
identity vs identity confusion
intimacy vs isolation
generativity vs stagnation
integrity vs despair

Pharmacokinetics

the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions

Medication absorption

the passage of medication molecules into the blood from the site of administration

factors that affect med absorption

route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication

meds are excreted through:

kidney, liver, bowel, lungs, exocrine glands

medication interactions

when one med modifies the action of another

Obese

increased weight for height by 10% or more

Morbid Obesity

100% over weight for height

Measurements for obesity

waist size, BMI, ideal weight for height

causes of obesity

corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone

management of obesity

decreased food intake, increased physical activity

definition of nursing

an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems

evidence based practice

interventions nurses do that are based on evidence

roles of nurse

caregiver, advocate, educator, communicator, manager, autonomy and accountability

definition of health

state of complete physical, mental, and social well being not merely the absence of disease or infirmity

communication-

process by which people affect one another; exchange of info, ideas, feelings; basic component of human relationships; fundamental element of nurse-client relationship

intrapersonal communication

occurs within, self verbalization, self awareness, self talk, guided imagery

interpersonal communication

one on one interaction; most frequently used; exchange of idea, problem solving, decision making

transpersonal communication

persons spiritual domain; higher power; prayer, meditation, guided reflexion

small group communication

small number of people meet; committees; group meetings

public communication

with an audience; speaking at conferences; leading class

elements of communication

referent sender; message, receiver, channels, feedback, interpersonal

forms of communication

verbal, non-verbal

factors influencing communication process

developmental level, gender, values/ perception, personal space, territoriality, roles/ relationships, environment, congruence

teaching

interactive process that promotes learning

purpose of teaching

gaining new knowledge, change attitudes, adopt new behaviors, preform new skills,

learning

purposeful acquisition of new knowledge, attitudes, behavior, or skills

need for nurse to teach client

clarify info given by doc or other health care providers; has to be complete, accurate, and relevant; should be based on patient's needs and learning ability

cognitive learning

includes all intelectual behavior/ requires thinking

affective learning

expression of feelings and acceptance of attitude, opinion, values

psychomotor learning

acquiring skills that require the integration of mental / muscular activity

motivation to learn

person's desire/ willingness to learn

ability to learn

developmental / physical ability

learning environment

privacy, room temperature, lighting, noise, furniture, ventilation

infection

invasion of a susceptible host by pathogens or microorganisms. resulting in disease

colonization

occurs when a microorganism invades the host but doesn't cause infection

communicable disease

the infectious process transmitted from one person to another

symptomatic infection

when the infection has signs and symptoms like fever, cough, etc

asymptomatic infection

when the infection does not cause any signs or symptoms, making the diagnosis difficult

hand hygiene

the most important technique used in preventing and controlling transmission of infection

chain of infection

infectious agent/ pathogen > reservoir/ source for pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host

4 stages of infection

incubation period, prodromal stage, illness stage, convalescence

Latrogenic HAI

from a procedure in a hospital

Exogenous HAI

from microorganisms outside the individual ( Salmonella)

Endogenous HAI

when patient's normal flora becomes altered (C.diff)

factors influenceing infection

age, stress, disease process, treatment/ condition that compromise the immune system

disinfection

eliminates many or all microorganisms with exception of spores from inaminate objects

sterilization

complete elimination or destruction of all microorganisms including spores

social patterns affecting hygiene

ethnic, social, and family influences on hygiene patterns

personal preferences affecting hygiene

dictates personal hygiene practices for individual patients

body image affecting hygiene

a person's subjective concept of his/her body appearance

socioeconomic status affecting hygiene

influences type and extent of hygiene practice used

health beliefs and motivation

motivation is the key factor in hygiene

cultural variables in hygiene

people from diverse cultures practice different hygiene rituals

developmental stage in hygiene

affects the patient's ability to preform hygiene care

physical condition in hygiene

may lack physical energy / dexterity to preform self-care

safety guidelines in hygiene

communicate with team members; incorporate patient's priorities; move from cleanest to less clean areas; use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood; test tempo of water or solutions; use principles of body mechanics and safe patient handling; be sensitive to invasion of privacy

autonomy

commitment to include clients in decisions

beneficence

taking positive actions to help others

non-maleficence

avoidance of harm/ hurt

justice

being fair

fidelity

agreement to keep promises

professional nursing code of ethics

a set of guiding principles that all members of a profession accept; helps professional groups settle questions about practice or behavior; includes responsibility, accountability, and confidentiality

Values

personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior

deontology

defines actions as right or wrong

utilitarianism

proposes that the value of something is determined by its usefulness

feminine ethics

focuses on the inequality between people

ethic of care

emphasizes the importance of understanding relationships, especially as they are revealed in narratives

JCAHO's ethical standards

mandate that health care institutions provide multidisciplinary ethics committees or similar structures to write guidelines and policies, provides education, counselling, and support for staff on ethical issues

how to process an ethical dilemma

1. ask if this is an ethical dilemma
2. gather all relevant info
3. clarify values
4. verbalize problem
5. identify possible courses of action
6. negotiate a plan
7. evaluate plan

quality of life

central to discussions about futile care, cancer therapy, physician assisted suicide, DNR

futile care

interventions unlikely to produce benefit for the client

allocating scares resources

a key issue in discussions about access to care

the nursing shortage

produces difficult working conditions and affects client outcomes

source of laws

legal guidelines that come from statutory, regulatory, and common law

standards of care

legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care

consent

a signed form required for all routine treatment, hazardous procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language clients

what does mobility mean?

allows ability to move freely about; musculoskeletal and nervous systems working together to make movement; decreases risk for injury

labs for obesity

electrolyte/sodium/potassium, blood glucose, triglycerides, hemoglobin, serum albumin

bariatrics-

lap band reduction; gastric bypass

lap band reduction

removable, premanent life cange; can cause dehydration, electrolyte problem, backup into esophagus, blockage

gastric bypass

malabsorption surgery; can cause dehydration and electrolyte problems; overeating can cause dumping syndrome-food deposits into small intestines too quickly

kidney/ renal disease

not enough RBCs; anemia; metabolizes calcium and Vitamin D; ADL intolerance; risk for hyper/hypotension, anemia, soft bones, and fractures; caused by diabetes; patient has to out out at least 30mls per hour

labs for kidney/ renal disease

BUN, creatinine, GRF, Rennin, EPO

oliguria

patient has some form of renal failure; not producing as much urine as regular patient; strict I&Os

anuria

irreversible renal disease; need kidney transplant or dialysis; not producing urine; increased phosphorus in system

polyuria

excessive urine; sign of diabetes or hormone issue

hematuria

blood in urine; not a good sign

nocturia

voiding at night; early sign of hypertension; pressure on bladder during pregnancy

peritoneal dialysis

shunt placed in peritoneum; diasolate poured in peritoneum, about 1hr later diasolate, nitrogenous waste, fluid, electrolytes removed

hemodialysis

3 days out of week, 3-4 hr long process; blood circulated through the machine and nitrogenous waste, fluid, electrolytes removed; BP before and after treatment; weight before and after; can be used for drug overdose

UTI causes

E. coli, young and old women at risk; uncircumcised men (smegma); frequent sexual intercourse/ unprotected/ multiple partners; poor hygiene; HAI; med/surg related

UTI s/s

frequency/ urgency; burning pain when voiding; hematuria; fever; chills; nausea; vomiting; pyelonenephritis; malaise

UTI treatment

antibiotic- Siproflaxin; cranberry juice for prevention

functional incontinence

can't make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule

stress incontinence

usually in women who didn't do kegels during labor

reflex incontinence

on urge to go; it just comes out

ESRD

irreversible damage to kidney tissue

uremic syndrome

increase in nitrogenous wastes in the blood

urinary incontinence

can be temporary; affects everyone especially elderly

causes of urinary incontinence

urethral obstruction, surgical trauma, alterations in sensory/ motor innervation, medication side effects, anxiety

dysuris

pain or burning on urination

nephrostomy

urinary diversion; bypasses the ureters, bladder, urethra; used in patient with kidney stones, cancer, ureter problem, any GU problem

urinalysis

pH; protein; glucose; ketones; blood; specific gravity; WBCs; bacteria

factors affecting bowel elimination

age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics

constipation

stool gets lodged in the intestines; a symptom not a disease

impaction

result of unrelieved constipation; leaky drainage

diarrhea

liquid stool; associated with disorders affecting digestion, absorption, and secretion in GI tract

incontinence

inability to control passage of feces or gas through rectum

loose stool

chunks of stool

pressure ulcers

tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis

stage 1 ulcer

intact skin; red/irritation; unblanchable

stage 2 ulcer

broken skin; partial thickness; blister epidermis and dermis; can ooze

stage 3 ulcer

epidermis, dermis, and subQ tissue; oozing, signs of infection; full thickness loss

stage 4 ulcer

full thickness loss; can see organs/ bones; very painful

granulation tissue

healing tissue; looks beefy

slough

dead tissue; yellowish, brownish; makes wound unstageable; has to be debritied

eschar

necrotic/black; surgically removed

xerosis

dry skin; becomes reddish; low humidity; frequent washing

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