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Describe thermoregulation in the body
the hypothalamus controls body temp
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Explain why it is so important to take a patients vital sign pattern rather than relying on a single reading:
- to create a baseline
- then to check for accuracy
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What is the normal oral temperature range for adults?
98o
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Explain the physiological mechanisms of fever:
- abn high body temp ( >100.4oF or 38o C)
- occurs b/c of pyrogens (bacteria)
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What is the method of finding a peripheral pulse & an apical pulse?
- use 2-3 fingers (no thumbs)
- apical - 60 sec
- peripheral -30 sec x 2
- apical - 5th intercostal space mid-clavicular line
- peripheral - carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
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What are the abnormal findings for a pt given their age, pulse rate, rhythms, quality & symmetry?
- bradycardia: rate <60bpm
- tachycardia: rate >100bpm
- quality: bounding (easy to feel) thready (hard to feel)
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What is a normal pulse rate for healthy adults?
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How are respirations regulated in the body?
exchange of oxygen & carbon dioxide in the body
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Define: arterial oxygen saturation
amt of oxygen in your blood
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Define: hypoxia
inadequate cellular oxygenation
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Define: hyperventilation
rapid & deep breathing resulting in excess loss of CO2
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Define: hypoventilation
rate & depth of respirations are decreased & CO2 is retained
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What are the abnormal findings of a pt given their age, respiratory rate, depth. rhythm, chest movement, & associated clinical signs?
- apnea: cessation of breathing
- bradypnea: abnormally slow 1-12
- tachypnea: abnormally fast > 12
- deep/shallow
- reg/irreg rhythm
- dyspnea: labored breathing
- hypoxia
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What is the normal respiratory rate for adults?
12-20/min
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Describe the physiology of blood pressure:
- pressure of blood as its forced against arterial walls during cardiac contraction
- measured in millimeter of mercury (mm Hg)
- pulse pressure: the difference between systolic & diastolic pressures
-
Describe the process for taking a brachial blood pressure reading:
- apply BP cuff
- find radial pulse
- pump cuff up till can't feel radial pulse, release cuff, then add 30 to your #
- apply steth diaphram to brachial pulse, put in ears
- pump up to your number
- slowly release listening for the systolic(first sound) and diastolic (last sound)
- remove cuff
- chart findings
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What is the importance of cuff size when obtaining a blood pressure reading?
- should be 2/3 length of upper arm or 40% of arm
- wrong size cuff could result in measurement error
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Define: hypotension
systolic blood pressure <100 mm Hg
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Define: hypertension
- systolic bp >140 mm Hg OR
- diastolic bp >90 mm Hg on 2 or more seperate occasions
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Define: essential hypertension
diagnosed when there is no known cause for the increase in bp
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Define: secondary hypertension
when there is a clearly identified cause for the persistent rise in bp
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What is the nursing process when interpreting vital signs results?
taking vital signs as part as the assessment data
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What is the rapid response team?
called for respiratory distress , chest pain etc
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What is code blue?
called when someone is breathless, &/or pulseless (respiratory/cardiac arrest)
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What are the basic elements of airway management including placement of oral and nasal airways:
- endotrachial airways are pliable tubes inserted into the trachea through:
- oral: in mouth to trachea
- nasal: in nose to trachea
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Define: Pain
unpleasant sensory/emotional experience
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Classify pain according to origin:
- cutaneous or superficial pain (near surface)
- visceral pain (deeper pain)
- deep somatic pain (body, ligaments, bones)
- radiating pain (from one spot and branches out)
- referred pain (pain diff location from where actually is)
- phantom pain ( amputee's)
- psychogenic pain (np physical cause)
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Classify pain according to cause:
- nociceptive pain (aching) (muscles/joints, organs)
- neuropathic pain (burning, numbness, itching, & "pins & needles")
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Classify pain according to duration:
- acute pain: brief duration
- chronic pain: longer than 6 months
- intractable pain: chronic & highly resistant to relief
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Classify pain according to quality:
- sharp or dull
- throbbing
- stabbing
- burning (nerve)
- ripping
- searing (nerve)
- tingling (nerve)
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What are the physiological changes of pain?
- transduction
- transmission
- perception
- modulation
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What are some factors that influence pain?
- emotions
- developmental stage
- sociocultural factors
- communication impairments
- cognitive impairments
- vital signs
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What are some nonpharmacological pain relief measures?
- relaxation/imagery
- meditation
- distraction/laughter
- heat/cold
- massage
- TENS
- acupressure/acupuncture
- therapeutic touch
- biofeedback
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What are pharmacological measures for pain including opiod analgesics?
- used to treat moderate to severe pain
- ex: oxycodone
-
What are pharmacological measures for pain including nonopioid analgesics?
- NSAIDS, centrally acting agents or acetaminophen
- used for mild to moderate pain
- Ex: advil, tylenol
-
What are pharmacological measures for pain including adjuvant analgesics?
- used to treat chronic pain that is neuropathic in nature
- ex: fentanyl
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Why should pain be considered a 5th vital sign?
pain management is essential for quality patient care
-
What is the nursing process in the care of a patient with pain?
assess for pain then diagnosis
-
How is critical thinking used in the nursing process?
- for nurses to apply knowledge to provide holistic care
- theoretical
- practical
- personal
- ethical
-
What are the 6 steps of the nursing process?
- assessment: data gathering
- diagnosis: identify pt health needs by analyzing data
- planning: -outcomes: pt focused goals -interventions: nurse focused goals
- implementation: carry out planned actions
- evaluation: determine if interventions were effective
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Describe the relationship of assessment to the other steps in the nursing process
- diagnosis: helps identify pt actual/potential health problems & strengths
- planning outcomes & interventions: helps formulate realistic goals, helps choose interventions most acceptable & effective for client
- implementation: conti to gather assessment data by observing clients response as you implement interventions
- evaluation: indicate whether or not goals have been met
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What is subjective data?
what the pt (or family) tells you
-
What is objective data?
- what nurse sees, hears, smells, feels or another nurse
- observation
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What is primary data?
- obtained from client
- your own assessment
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What is secondary data?
- "second hand"
- medical record
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What are 3 circumstances you would validate data?
- subjective/objective data do not agree or make sense
- clients statements differ at different times in the interview
- data are far outside normal range
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What is the difference between cue and inference?
- cue: what the pt says & what you observe
- inference: judgements
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What is a nursing diagnosis?
statement of client health status that nurses identify, prevent, or treat
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What is a medical diagnosis?
focus on disease, illness, and injury
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What are collaborative problems?
always a potential problem... if becomes "actual" now its a med diagnosis
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What are the 5 types of nursing diagnoses?
- actual (prob is present, has signs & symptoms)
- risk (prob may occur)
- possible (prob may be present, not enough data to support diagnosis)
- syndrome (several related prob are present)
- wellness (no prob, in transition to higher lvl wellness, no cause or etiology)
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Why is etiology always an inference?
b/c you can never really observe the link between etiology and problem
-
How do you know which of the NANDA labels to use to describe a pt's problems?
identify the topic that fits the your assessment data
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Clairfy the relationship between nursing diagnosis and outcomes/interventions:
- the prob suggests the outcome/goal
- the etiology suggests interventions
-
State at least 5 criteria for judging the quality of a diagnostic statement:
- incl. both problem & etiology
- descriptive and specific
- state the prob as a pt response
- nonjudgemental lang
- avoid legally questionable lang
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What is the importance of a written care plan?
to help the nurse provide individualized goal-directed client centered care
-
What is the difference between short and long term goals?
- Short term- to be achieved in hours, days
- long term -a week, month, or more
-
Give an example of an outcome statement
- Client will take part in self care activites such as personal hygiene daily.
- Client will identify 2 resources available to help in giving care such as babysitters, husband switching roles, within 1 month after discharge.
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How is an outcome derived from a nursing diagnosis?
based on what our desired result of care will be
-
What does SMART stand for?
- specific
- measurable
- attainable
- realistic
- timely
make sure u write all these in the outcome that dont conflict w. the med diag.
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How do theories and research influence the choice of nursing interventions?
- theories - how you define a prob
- research - looking at studies, protocols
-
Explain how nursing interventions are determined by problem status
- goals met
- goals part met
- goals not met
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What must be on your nursing order?
- date
- subject ("the nurse")
- action verb (tells nurse what action to take)
- times and limits
- signature
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What are "5 rights" of delegation?
- think critically about:
- the task
- the circumstance
- the person
- the direction or communication
- supervision & evaluation
-
How are standards and criteria used in evaluation?
- RN evalu progress toward outcomes
- documents results of evalu
- uses ongoing assessment data to revise diagnosis
-
What is ongoing evaluation?
- immed after intervention
- at ea pt contact
- while implementing
-
What is intermittent evaluation?
- at specified times
- goals should be designate times
-
What is terminal evaluation?
clients progress at time of discharge
-
Describe a process for evaluating client health status (outcomes)?
- review outcomes
- collect reassessment data
- determine progress towards goals
- record evaluative statement
- evaluate collaborative problems
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Describe a process for evaluating the effectiveness of a nursing care plan
- relate outcomes to interventions
- draw conclusions about problem status
-
What is the definition of communication?
process of sending and receiveing messages
-
What are the 3 basic levels of communication?
- intrapersonal- self talk
- interpersonal- 2 or more people
- group- public speaking
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What are the 5 components of the communication process?
- encoder (sender)
- message
- channel (way you send msg)
- decoder (receiver)
- feedback
-
What are some verbal communication characteristics?
- use of spoken/written words to send a message
- vocab & language
- meaning
- pace
- tone of voice
- clarity
- timing
- relevance
- credibility
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What are some nonverbal communication characteristics?
- body language
- facial expression
- posture
- gait
- personal appearance
- gestures
- touch
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What are some factors that influence the communication process?
- environment
- gender
- devl lvl
- age
- personal space
- roles & responsibilities
-
How do relationships and roles influence communication?
- rapport and trust established
- effects all phases of therapeutic relationship
- effectiveness determines quality of nurse-client relationship
-
Describe the role of communication in each of the 4 phases of therapeutic relationship
- stage 1: pre-interaction (no communication)
- stage 2: orientation phase (client and nurse meet)
- stage 3: working phase (nurse & client work together to meet clients needs)
- stage 4: termination phase ( concl of relationship)
-
Compare and contrast techniques that enhance communication to those that hinder communication.
- enhance:
- active listening
- establish trust
- be assertive
- restate
- clarify
- validate
- observe body language
- explore issues
- use silence
- hinder:
- asking too many ??
- asking why
- changing subj inapprop
- failing to listen
- offering advice
- stereotyping
-
What is the purpose of documentation?
- communication
- education
- legal documentation
- quality assurance
- reimbursement
- research
-
What are the different types of documentation?
- Narrative (chronological "story")
- SOAP (subj, obj, assess, plan)
- SOAPIE & SOAPIER (interv, eval, revision)
- PIE (problem, interv, eval)
- Focus (Data, Action, Response/Eval)
- Charting by exception (streamlined doc)
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What are the 7 different charting forms & their purposes?
- Admission Database (when pt enters HC system)
- Flowsheets & Graphic Record (checklists: rout care,assess, VS, wound care, trtmt, IV flu adm)
- Medication Admin Rec ( list of all ordered meds)
- Kardex (brief summ pt POC)
- Integrated IPOC (combo charting & car plan form)
- Event report ( incident report)
- Discharge Summary
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What are the key elements to include when giving an oral report about a client?
progress, change of status, any tests given or will get, therapies, teaching
-
How do you verify or question a medical order?
- contact whomever wrote the order
- if they dont change the order, you may refuse to carry it out
- inform charge nurse
-
What are federal laws regulating the nursing practice?
- Bill of Rights
- Emerg Medical Trtmt & Active Labor Act
- Health Care Quality Improvement Act
- American Disabilities Act
- Pt Self-Determ Act
- Newborns' & Mothers Health Prot Act
- National Labor Relations Act
- HIPAA
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What are state law regulating the nursing practice?
- Mand. reporting laws
- Good Samaratin Law
- Nurse Practices Act (credentialing, licensing, discipline)
-
What are some basic principles of criminal law controlling nursing practice?
- offense against society
- under jurisdiction of state & federal courts
- lead to fine, imprisonment, or death
- misdemeanor or felony
-
What are some basic principles of civil law controlling nursing practice?
- protect rights of indiv
- pymt of monetary damages
- plaintiff or defendant
- Contract law (agreem btw indiv)
- Tort Law ( breach of civil duty)
-
What are the major legal issues that arise within nursing practice?
- failure to assess & diagnose
- failure to plan
- failure to implement a plan of care
- failure to evaluate
-
What are some measures to take that would decrease the likelihood of committing nursing malpractice?
- observe mand stand of care
- use nursing process & follow prof stand
- avoid med and trtmt errors
- report & document accurately
- obtain informed consent
- maintain confidentiality
-
What are the basic elements of informed consent?
- completeness
- clarity & comprehension
- voluntariness
- competence
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