Nursing 111

  1. ventilation 
    "movement of air in and out of the airways"
  2. Fungi
    plantlike organisms present in air, soil, and water
  3. Virus
    smallest of all microorganisms
  4. Bacteria
    most significant and most prevalent in hospital settings
  5. Infectious agent
    bacteria, viruses, fungi
  6. Reservoir
    natural habitat of the organism
  7. Portal of exit
    point of escape for the organism
  8. Means of transmission
    direct contact, indirect contact, airborne route
  9. Portal of entry
    point at which organisms enter a new host
  10. Susceptible host
    must overcome resistance mounted by host’s defenses
  11. Factors Affecting an Organism’s Potential to Produce Disease
    • Number of organisms
    • Virulence
    • Competence of person’s immune system
    • Length and intimacy of contact between person and microorganism
  12. Classification of Bacteria
    • Spherical (cocci), rod shaped (bacilli), corkscrew shaped (spirochetes)
    • Gram positive or gram negative—based on reaction to Gram stain
    • Aerobic or anaerobic—based on need for oxygen
  13. Possible Reservoirs for Microorganisms
    • Other humans
    • Animals
    • SoilFood, water, milk
    • Inanimate objects
  14. Common Portals of Exit
    • Respiratory
    • Gastrointestinal
    • Genitourinary tracts
    • Breaks in skin
    • Blood and tissue
  15. Means of Transmission
    • An organism may be transmitted from its reservoir by various means or routes.
    • Direct versus indirect contact
  16. Portal of Entry
    • The point at which organisms enter a new host
    • Often the same as the exit route from the previous reservoir
  17. Susceptible Host
    • Microorganisms can continue to exist only in a source that is acceptable (a host)
    • ANDIf they overcome any resistance by the host’s defenses
    • Hospitalized patients in a weakened state of health-thus more susceptible to infection.
  18. Incubation period
    organisms growing and multiplying
  19. Prodromal stage
    person is most infectious, vague and nonspecific signs of disease
  20. Full stage of illness
    presence of specific signs and symptoms of disease
  21. Convalescent period
    recovery from the infection
  22. Laboratory Data Indicating Infection
    • Elevated white blood cell count—normal is 5,000 to 10,000/mm3
    • Increase in specific types of white blood cells
    • Elevated erythrocyte sedimentation rate
    • Presence of pathogen in urine, blood, sputum, or draining cultures
  23. Body’s Defense Against Infection
    • Body’s normal flora
    • Inflammatory response
    • Immune response
  24. Factors Affecting Host Susceptibility
    • Intact skin and mucous membranes
    • Normal pH levels
    • Body’s white blood cells
    • Age, sex, race, hereditary factors
    • Immunization, natural or acquired
    • Fatigue, climate, nutritional and general health status
    • Stress
    • Use of invasive or indwelling medical devices
  25. –Medical asepsis
    —clean technique
  26. Surgical asepsis
    —sterile technique
  27. Transient
    attached loosely on skin, removed with relative ease
  28. Resident
    found in creases in skin, requires friction with brush to remove
  29. Evolution of Specialized Infection Control Precautions
    • Early CDC guidelines
    • Specific isolation techniques
    • Disease-specific isolation
    • Universal precautions
    • OSHA regulations for universal precautions
    • Body substance precautions
    • Current CDC guidelines
  30. Standard precautions
    • used in care of all hospitalized patients
    • Apply to blood, body fluids, secretions, excretions, nonintact skin, mucous membranes
  31. Transmission-
    • used in addition to standard precautions for patients with suspected infection
    • –Include airborne, droplet, or contact precautions
  32. DAME
    • D – Drug and alcohol use
    • A – Age-related physiologic status
    • M – Medical problems
    • E – Environment
  33. Hendrich II Fall Risk Model
    • Fall Scene Investigations (FSI)
    • Hourly patient rounding
    • Root cause analysis (RCA)
  34. Safety Event Reports
    • Must be completed after any accident or incident in a health care facility that compromises safety
    • Describes the circumstances of the accident or incident
    • Details the patient’s response to the examination and treatment of the patient after the incident
    • Completed by the nurse immediately after the incident
    • Is not part of the medical record and should not be mentioned in documentation
  35. Oral
    –Capsule, pill, tablet, extended release, elixir, suspension, syrup
  36. Topical
    –Liniment, lotion, ointment, suppository, transdermal patch
  37. elixir
    is a medication in a clear liquid containing water, alcohol, sweeteners, and flavor.
  38. suspension
    contains finely divided, undissolved particles in a liquid medium.
  39. solution
    is a drug dissolved in another substance.
  40. syrup
    is medication combined in a water and sugar solution.
  41. Drug Classifications
    • Effect on body system
    • Chemical composition
    • Clinical indication or therapeutic action
  42. Pharmacokinetics (Effect of Body on Drug)
    • Absorption
    • Distribution
    • Metabolism
    • Excretion
  43. Intravenous Administration of Medication
    • Delivers the drug directly into the bloodstream
    • Medication has an immediate effect and cannot be recalled or actions slowed
    • Route most often used in emergency situations
  44. Subcutaneous injections
    • Administered into the adipose tissue layer just below the epidermis and dermis.
    • –Outer aspect of the upper arm
    • –Abdomen (from below the costal margin to the iliac crests)
    • –The anterior aspects of the thigh
    • –The upper back
    • –The upper ventral or dorsogluteal area
  45. Intradermal Injections
    • Administered into the dermis, just below the epidermis.
    • Has the longest absorption time of all parenteral routes.
    • Used for sensitivity tests and local anesthesia.
    • Body’s reaction to the substances is easily visible.
    • Sites commonly used are the inner surface of the forearm and the upper back, under the scapula.
    • A 1/4″ to 1/2″, 25- or 27-gauge needle is used and the angle of administration is 5 to 15 degrees.
    • The dosage given intradermally is small, usually less than 0.5 mL.
  46. Preparing Medications for Injection
    • Ampules
    • Vials
    • Prefilled cartridges or syringes
    • Mixing medication in one syringe
    • Mixing insulins in one syringe
    • Reconstituting
    • powdered medications
  47. The recommended intramuscular site for an adult is the
    ventrogluteal or deltoid
  48. Sites for Intramuscular Injections
    • Ventrogluteal site
    • Vastus lateralis site
    • Deltoid muscle site
    • Dorsogluteal site is no longer recommended.
  49. intramuscular angle
  50. subcutaneous angle
  51. intradermal
  52. Criteria for Choosing Equipment for Injections
    • Route of administration
    • Viscosity of the solution
    • Quantity to be administered
    • Body size
    • Type of medication
  53. sites
    • Intradermal injection: corium under epidermis
    • Intraperitoneal injection: peritoneal cavity
    • Intravenous injection: vein
    • Intra-arterial injection: artery
  54. Oral medication
    • Oral route: having patient swallow drug
    • Enteral route: administering drug through an enteral tube
    • Sublingual administration: placing drug under tongue
    • Buccal administration: placing drug between tongue and cheek
  55. oral medications
    • Solid form: tablets, capsules, pills
    • Liquid form: elixirs, spirits, suspensions, syrups
  56. 3 checks of medications
    • Read the label:–When the nurse reaches for the container or unit dose package
    • –After retrieval from the drawer and compared with the CMAR, or compared with the CMAR immediately before pouring from a multidose container
    • –Before giving the unit dose medication to the patient or when replacing the multi-dose container in the drawer or shelf
  57. medications orders
    • Standing order (routine order): carried out until cancelled by another order
    • PRN order: as neededSingle or one-time orderStat order: carried out immediately
  58. Therapeutic range
    concentration of drug in the blood serum that produces the desired effect without causing toxicity
  59. Trough level
    the point when the drug is at its lowest concentration, indicating the rate of elimination
  60. Adverse Drug Effects
    • Allergic effects: anaphylactic reaction
    • Drug tolerance
    • Toxic effect
    • Idiosyncratic effect
    • Drug interactions: antagonistic and synergistic effects
  61. Pharmacodynamics
    • Pharmacodynamics is the process by which drugs alter cell physiology and affect the body.
    • Drugs turn on, turn off, promote, or block responses that are part of the body’s processes.
    • Drug–receptor interaction occurs when the drug interacts with one or more cellular structures to alter cell function.
    • Drugs may also combine with other molecules in the body to achieve their effect. Other drugs act on the cell membrane or alter the cellular environment to achieve their effect.
  62. Factors Affecting Absorption of Medications
    • Route of administration
    • Lipid solubility
    • pH
    • Blood flow
    • Local conditions at the site of administration
    • Drug dosage
  64. APNEA
    Temporary cessation of breathing
    Subjective experience that describes difficulty breathing or shortness of breath
    Inability to breath easily except in an upright position
    Abnormally rapid respirations
    Decrease in oxygen supply to the tissues and cells
    Percentage of hemoglobin that is bound to oxygen
    Soft, high-pitched, discontinuous popping sounds during inspiration
    Low-pitched wheezing or snoring sound associated with partial airway obstruction; heard on chest auscultation
    Continuous musical sounds associated with airway narrowing or partial obstruction
  73. respiratory system
    • šDelivers oxygen
    • šWarms and filters air
    • šGas exchange
  74. ventilation breathing exchange
    • šThoracic cavity is an airtight chamberš
    • Diaphragm is the floor of this chamber  šInspiration
    • šExpiration
    • š1 respiration =  inspiration, 1/3 of the respiratory cycle; and expiration, 2/3 of the respiratory cycle
  75. oxygen transport
    • šCarries oxygenated blood to all body tissues.š
    • O2 diffuses from areas of higher partial pressure to areas of lower partial pressure.
    • šO2 is transported to the cells of the body.
  76. Carbon Dioxide Transport
    • carbon dioxide is the end product of metabolic combustion
    • co2 crosses the alveolar-capillary membrane
    • c02 diffueses more easily than o2
  77. Auscultation posterior
    When auscultating the lungs you must be on BARE skin not over the shirt. When we are in lab try listening through a shirt then compare to bare skin.You auscultate by zig zagging across the chest…….to compare right and left at the same level.Continue with the same pattern on the posterior (back) side as well.
  78. Pulse Oximetry
    • noninvasive
    • Does not replace ABGs
    • Normal level is 95% to 100%.
    • May be unreliable
  79. Oxygen Toxicity
    • Symptoms include:šsubsternal discomfortš
    • Paresthesias
    • šDyspneaš
    • Restlessness
    • šFatigue
    • šMalaiseš
    • progressive respiratory difficulty
  80. Incentive Spirometry
    • Two types: volume or flow
    • Device encourages patient to inhale slowly and deeply to maximize lung inflation and alveoli expansion
    • Used to prevent or treat atelectasis
  81. 1955
    —nursing process term used by Hall
  82. 1960s
    —specific steps delineated
  83. 1967
    —Yura and Walsh published first comprehensive book on nursing process
  84. 1973
    —ANA Congress for Nursing Practice developed Standard of Practice
  85. 1982
    —State board examinations for professional nursing uses nursing process as organizing concept
  86. Patient
    –Scientifically based, holistic individualized patient care–Continuity of care–Clear, efficient, cost-effective plan of action
  87. Assessing—
    collecting, validating, and communicating of patient data
  88. Diagnosing—
    analyzing patient data to identify patient strengths and problems (or potential problems)
  89. nursing process
    • NP is also Interpersonal: Ensures that nurses are patient-centered rather than task-centered.
    • NP is outcome oriented: Nurse and patient work together to identify specific outcomes related to health promotion, disease and illness prevention, health restoration, and coping with altered functioning. Outcomes are prioritized based on  patient preferences unless an emergency situation.
    • NP is universally applicable in nursing situations: able to use the nursing process to practice nursing with well and ill people, young or old, in any type of practice setting.
    • Summary: NP  provides a framework for all the nurse’s activities. It is the essential core  of practice for the RN to deliver holistic, pt. focused care.
  90. Planning
    specifying patient outcomes and related nursing interventions
  91. Implementing
    —carrying out the plan of care
  92. Evaluating
    —measuring extent to which patient achieved outcomes
  93. Assessing
    The systematic and continuous collection, validation, and communication of patient data. Involves analyzing data about a client, the first step in delivering nursing care.
  94. assessing np
    Collection of patient data is a vital step in the nursing process because the remaining steps depend on complete, accurate, factual, and relevant data.
  95. Objective data
    • –Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
    • –e.g., elevated temperature, skin moisture, vomiting
  96. Subjective data
    • –Information perceived only by the affected person
    • –e.g., pain experience, feeling dizzy, feeling anxious
  97. Parts of a measureable outcome:
    • –Subject
    • –Verb
    • –Conditions
    • –Performance criteria
    • –Target time
  98. Common errors in writing outcomes
    • –Expressing patient outcome as nursing intervention
    • –Using verbs that are not observable or measurable
    • –Including more than one patient behavior or manifestation in short-term outcomes–Writing vague outcomes
  99. Nurse-initiated
    –actions performed by a nurse without a physician’s order
  100. Healthcare Provider-initiated
    —actions initiated by a HCP in response to a medical diagnosis but carried out by a nurse under doctor’s orders
  101. Collaborative
    –treatments initiated by other providers and carried out by a nurse
  102. Nurse initiated interventions
    • –Independent nursing actions based on assessment of patient needs
    • –Actions that nurses initiate without the direction or supervision of another healthcare professional
    • –Nurses are legally accountable for their assessments and their nursing responses
    • –Protocols
    • –Standing orders
  103. Collaborative interventions:
    • –Interdependent
    • –Performed jointly by nurses and other members of the healthcare team
  104. Healthcare Provider-initiated interventions
    • Dependent nursing actions
    • Carrying out HCP prescribed orders
    • Nurses are still accountable
    • Responsible for clarification of any questionable order
Card Set
Nursing 111
nursing 111