Nursing 111

"movement of air in and out of the airways"

plantlike organisms present in air, soil, and water

smallest of all microorganisms

most significant and most prevalent in hospital settings

bacteria, viruses, fungi

natural habitat of the organism

point of escape for the organism

direct contact, indirect contact, airborne route

point at which organisms enter a new host

must overcome resistance mounted by host’s defenses

• Number of organisms
• Virulence
• Competence of person’s immune system
• Length and intimacy of contact between person and microorganism

• 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

• Other humans
• Animals
• SoilFood, water, milk
• Inanimate objects

• Respiratory
• Gastrointestinal
• Genitourinary tracts
• Breaks in skin
• Blood and tissue

• An organism may be transmitted from its reservoir by various means or routes.
• Direct versus indirect contact

• The point at which organisms enter a new host
• Often the same as the exit route from the previous reservoir

• 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.

organisms growing and multiplying

person is most infectious, vague and nonspecific signs of disease

presence of specific signs and symptoms of disease

recovery from the 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

• Body’s normal flora
• Inflammatory response
• Immune response

• 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

—clean technique

—sterile technique

attached loosely on skin, removed with relative ease

found in creases in skin, requires friction with brush to remove

• Early CDC guidelines
• Specific isolation techniques
• Disease-specific isolation
• Universal precautions
• OSHA regulations for universal precautions
• Body substance precautions
• Current CDC guidelines

• used in care of all hospitalized patients
• Apply to blood, body fluids, secretions, excretions, nonintact skin, mucous membranes

• used in addition to standard precautions for patients with suspected infection
• –Include airborne, droplet, or contact precautions

• D – Drug and alcohol use
• A – Age-related physiologic status
• M – Medical problems
• E – Environment

• Fall Scene Investigations (FSI)
• Hourly patient rounding
• Root cause analysis (RCA)

• 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

–Capsule, pill, tablet, extended release, elixir, suspension, syrup

–Liniment, lotion, ointment, suppository, transdermal patch

is a medication in a clear liquid containing water, alcohol, sweeteners, and flavor.

contains finely divided, undissolved particles in a liquid medium.

is a drug dissolved in another substance.

is medication combined in a water and sugar solution.

• Effect on body system
• Chemical composition
• Clinical indication or therapeutic action

• Absorption
• Distribution
• Metabolism
• Excretion

• 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

• 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

• 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.

• Ampules
• Vials
• Prefilled cartridges or syringes
• Mixing medication in one syringe
• Mixing insulins in one syringe
• Reconstituting
• powdered medications

ventrogluteal or deltoid

• Ventrogluteal site
• Vastus lateralis site
• Deltoid muscle site
• Dorsogluteal site is no longer recommended.

72-90

45-90

5-15

• Route of administration
• Viscosity of the solution
• Quantity to be administered
• Body size
• Type of medication

• Intradermal injection: corium under epidermis
• Intraperitoneal injection: peritoneal cavity
• Intravenous injection: vein
• Intra-arterial injection: artery

• 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

• Solid form: tablets, capsules, pills
• Liquid form: elixirs, spirits, suspensions, syrups

• 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

• Standing order (routine order): carried out until cancelled by another order
• PRN order: as neededSingle or one-time orderStat order: carried out immediately

concentration of drug in the blood serum that produces the desired effect without causing toxicity

the point when the drug is at its lowest concentration, indicating the rate of elimination

• Allergic effects: anaphylactic reaction
• Drug tolerance
• Toxic effect
• Idiosyncratic effect
• Drug interactions: antagonistic and synergistic effects

• 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.

• Route of administration
• Lipid solubility
• pH
• Blood flow
• Local conditions at the site of administration
• Drug dosage

GAS EXCHANGE BETWEEN ATMOSPHERIC AIR AND THE BLOOD AND BETWEEN THE BLOOD AND CELLS OF THE BODY

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

• šDelivers oxygen
• šWarms and filters air
• šGas 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

• 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.

• carbon dioxide is the end product of metabolic combustion
• co2 crosses the alveolar-capillary membrane
• c02 diffueses more easily than o2

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.

• noninvasive
• Does not replace ABGs
• Normal level is 95% to 100%.
• May be unreliable

• Symptoms include:šsubsternal discomfortš
• Paresthesias
• šDyspneaš
• Restlessness
• šFatigue
• šMalaiseš
• progressive respiratory difficulty

• 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

—nursing process term used by Hall

—specific steps delineated

—Yura and Walsh published first comprehensive book on nursing process

—ANA Congress for Nursing Practice developed Standard of Practice

—State board examinations for professional nursing uses nursing process as organizing concept

–Scientifically based, holistic individualized patient care–Continuity of care–Clear, efficient, cost-effective plan of action

collecting, validating, and communicating of patient data

analyzing patient data to identify patient strengths and problems (or potential problems)

• 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.

specifying patient outcomes and related nursing interventions

—carrying out the plan of care

—measuring extent to which patient achieved outcomes

The systematic and continuous collection, validation, and communication of patient data. Involves analyzing data about a client, the first step in delivering nursing care.

Collection of patient data is a vital step in the nursing process because the remaining steps depend on complete, accurate, factual, and relevant 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

• –Information perceived only by the affected person
• –e.g., pain experience, feeling dizzy, feeling anxious

• –Subject
• –Verb
• –Conditions
• –Performance criteria
• –Target time

• –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

–actions performed by a nurse without a physician’s order

—actions initiated by a HCP in response to a medical diagnosis but carried out by a nurse under doctor’s orders

–treatments initiated by other providers and carried out by a nurse

• –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

• –Interdependent
• –Performed jointly by nurses and other members of the healthcare team

• Dependent nursing actions
• Carrying out HCP prescribed orders
• Nurses are still accountable
• Responsible for clarification of any questionable order