Nursing Exam II

accreditation agencies such as ____ ____ ____ specify guidelines for documentation

requires disclosure or requests regarding health information

the joint commission requires each client have an assessment (6 steps)

federal and state regulations, state statutes, standards of care, and accreditation agencies......

confidential permanent legal document

oral, written, audiotaped exchange of information

a professional caregiver providing fomal advice to another caregiver

arrangement for services by another care provider

purposes of records

guidelines for quality documentation and reporting

tradition method of recording

what the patient says

i.e. symptoms

something observable
i.e. signs

focuses on documenting deviations....only chart whats not normal

incorporates a multidisciplinary approach to care....gets people out as quick as possible

includes medicare and medicaid legislation for long term care documentation

governs the frequency of written nursing records

S
O
A
P

not permanent in patients file

occurs when a microorganism invades the host but does not cause infection

infectious process transmitted from one person to another

chain of infection

three stages of the infection process

most microorganisms preer an environment within a pH range of

do not usually cause disease when residing in their usual area of the body but instead participate in maintaining flora

fluid and cells that are discharged from cells or blood vessels

pus and serum

process that involves the destruction and absorbtion of bacteria

increase in number of circulating blood cells

clear like plasma

containing red blood cells

contains WBCs and bacteria

not as strong as tissue collagen and assumes the form of scar tissue

type of HAI from a diagnostic or therapeutic procedure

post operative infection that is present outside the body

occur when pard of the clients flora becomes altered and an over growth occurs

absence of pathogenic microorganisms

writes guidlines in infection control and prevention

has a thicker cell wall and holds the violet stain

thinner cell wall and does not hold violet stain

bacteria shaped like a rod

bacteria shaped like a sphere

bacteria shaped like a spiral

anerobic bacteria infections are usually found where in the body

anti-infectives are broken into what two classes

bacteriocidal medications are used to

these type of infections interrupt growth

affects bacterial cell wall, gram +

affects bacterial cell wall, gram -

affects bacterial cell wall, both gram + and -

two unclassified drugs that affect bacterial cell wall

major considerations for medications that affect the bacterial cell wall

can cause hypotension and be ototoxic

affects bacterial protein synthesis, gram + and -

affects bacterial protein sythesis, gram +

affects bacterial protein synthesis, gram -

effective against MRSE and VRE

major considerations for medications that affect bacterial protein synthesis

causes tooth discoloration

are ototoxic and nephrotoxic

interferes with DNA replication, gram + and -

effective against c-diff

effective against TB

commonly used antibiotic ointment

major considerations for medications that interfere with DNA replication

most common medications used to interfere with DNA replication

new and effective against anarobes

the awareness of the postion of the body and its parts

fit closely together and are fixed

removal of waste products

one day of full bed rest takes how many days to recover

what are the three factors that contribute to venous thrombus formation

muscles break down into _____

contractor can start as soon as ___ hours and is not reversable

atelectasis means

immobitiliy affects the cardio system in what way compared to the other systems

changes in mobility alter what changes to the metabolic changes

when the client is immoble, the clients body often excretes more nitrogen then it ingests in proteins, resulting in _____ ______ _______

inflammation of the lung from stasis or pooling of secretions

the most common respitory complications from immobility are ______ and ______

accumulation of platelates, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery

what are the changes on the musculoskeletal due to immobility

effects on the muscles due to immobility

what are the effects on the skeletal system due to immobility

what are the effects on urinary elimination due to immobility

effects on the integumentary system due to immobility

whats the acute care implementation for metabolic immobility

implementation of acute care for the respiratory system due to immobilty

stored in bronchi trees, GI tract and skin

reduces prostaglandin synthesis
lowers body temperature
causes centrally mediated peripheral vasodilation and sweating

this class of drug can increase blood sugars

assess the prothrombin time and international normalized ratio with concurrent anticoagulant use

report ringing in the ears, impaired hearing, dizziness, unusual bruising or bleeding that is slow to stop with this medication

analgesic
anti-inflammatory
antipyretic

this NSAID blocks cox-2 but not cox-1; causes less GI bleeding and ulcer formation;anti-inflammatory

this medications serious adverse effects include MI that can be fatal and stroke

used to reduce fever and relieve pain but is not a NSAID of anti-inflammatory

which medicine do you take for tylenol poisoning?

used to treat transplant rejection
inhibit immune response bia several different mechanisms

what is the specific drug of choice for transplant rejection
diminishes the activity of T cells and B cells and suppresses the immune response

when on this immunosuppressant avoid direct sunlight, and causes renal impairment and hepatic impairment

this immunosuppressant causes reduced urine flow, hypertension, tremor, hair growth in women, elevated hepatic enzymes, infections, anaphylaxis

on this immunosuppressant avoid crowds
take the same time everyday
see dentist before to ensure good dental hygeine

immunosuppressant that inhibits DNA synthesis and is metabolized in the liver

immunosuppressant side effects:
bone marrow suppression
serious infections
hepatotoxicity
skin and lymphoid malignancies

when on this immunosupp. nursing respons. include:
obtain baseline lab tests and perform CBCs
monitor kidney and liver function, input/output ratio, and characteristics of urine, abnormal bleeding signs, use protective isolation to reduce infections

used to prevent transplant rejection, autoimmune disorders, malignancies....harvested from antibodies produced by a single B cell, very specific targeting a single type of target cell or receptor

drug of choice for short term therapy of severe inflammation

corticosteroids lymphocyte effect

corticosteroids monocyte effect

corticosteroids neutrophil effect

what are the other effects of cortiocosteroids

the four types of immunosuppessants

the skin has a ____ pH and receives approximately _____ of the blood supply

what are the four functions of the skin

what are the four assessment steps for the skin

helps indentify patients at risk, has been known to decrease pressure ulcer rates, pt. assessed in 6 areas of functions and scored, the lower the number the higher the risk

the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues

partial thickness loss of skin layers involving epidermis and possibly penetrating into, but not thru the dermis...may appear to be blistering with erythema; wound base is moist and pink

full thickness tissue loss extending thru the dermis to involve subQ tissue...presents as shallow crater unless covered by eschar...may include necrotic tissue, exudate or infection

full thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present on some parts of the wound..often undermining and tunneling

skin intact, discoloration of skin, deep red to purple color, may have recesed area, may be dark blister

full thickness tissue loss in which the base of the ulcer is covered by yellow, tan, gray, green, or brown tissue and eschar in the wound bed

factors that impact wound healing include (6)

transparent dressing that is used to reduce friction, and protect small areas

only insulates and protects wound...stages 1-3...agressive skin sealant..can stay on up to 7 days...NOT to be used on infection

provides and maintains moisture to the wound bed, easy to apply, requires external dressing

tolerates minimal damage, very comforting on wounds, insulates wounds....used for burns

can be used on most wounds, moderate to heavy drainage, can be left in place for 3 or more days, requires outer dressing, made from seaweed, high absorbancy

made from seaweed
used for heavy drainage
turns into gel when moistened

large dressings
heavy draining wounds
non-stick layer

adaptic
non-stick layer
used for skin tears
layer on wound vac

alldress
wound covering
gentle tape
non-stick dressing