-
Admission- HIPPA
What is mandated?
- Health Insurance or Health Information Will be shared.
- Hilllary Clinton made it happen (GOVERNMENT).
-
DRG (Diagnostic Related Group)
They Determine stay of patient and the money they get for a certain illness.
-
Assessment
Respiratiory
- 12-20 Adult
- 30-60 Children
- Slower respiration- with older adult.
-
Blood Pressure-
- Blood loss, dehydration, stress, age groups, illness, medication, etc.
- Can change with age differences.
- Older adults hardening of arteries.
- Higher Older/ Younger Lower.
-
Musculoskeletal-
- Hand grip, foot pushes up and down, Bilateral strength, document, deficits can be a falls risk, labs.
- Close to call button, person, walker, on strond side of body for a cane and we stand on the weak side when ambulating.
-
Pulse-OX
- Measure arterial O2 in the blood.
- ABG is more accurate for reading.
- Check O2 if looking blue or gray in color, make sure its on, and in the nose.
-
Skin-
- Color, Turgor, Moisture, no break down on inspection, & temperature.
- Check Tedd hose no wrinkles. Check circulation in popliteal and dorsal pedal pulse, or posterior tibeal pulse.
-
Medications-
- Topical Creams- Apply with gloves.
- Injections- 5 rights, 3 checks, supplys need and syringe with medication, air in vial with draw medication, clean skin alcohol, land mark on patient, dispose of needle and syringe in sharps.
- P.O.- Enteric coated medications cannot crush or chew. If coating is gone, possible overdose, stomach irritation, etc.
- Sublingual dissolve meds- Don't eat for a 1/2 hour.NG Tube- Aspirate check ph and residual, flush/ give /flush.
-
How to verify Orders or RX-
Look are Dr. Order and the MAR. Its the nurses responsibility to check, they are the 3rd check Person.
-
Peak-
taken 1 hr. after the medication if given.
-
Trough-
Drawn 1/2 hour before medication is given usually on 3rd dose.
-
Side Effect-
- An extension or secondary effect of a drug.
- EXP. Hives, weeze, Palpitation, N/V, Constipation, rash, etc.
- Constipation- Push fluids, ambulate, increase fiber.
- Dirrhea- eat yogert with live cultures in it.
-
Meds that change urine color-
- Pyridum- Orange/red UTI.
- Anticoagulants- Red
- Iron-Brown/Dark
- Riphampin-Orange/Red/Pink
- Dilantin-Orange/Red/Pink
- Beets-red or pink
- Elavil-Blue/Green
- Levodopa-Black/Brown blood pressure
- Diuretics- pale yellow/Clear
-
Bronchodilators-
- Inhalers, metered dose, or Nebulizer.
- Inhale through mouth.
- Increase B/P and Heart Rate only temporary with go away.
-
Medications for Cardiovascular Complications
- Ace Inhibitors
- Beta blockers- Antihypertensives
- Anticoagulants-Cumarin, Heprin, SCD, Tedd Hose, to prevent thrombis.
- Causes-Postop surgery, bedrest, not moving or amulating much.
-
Labs
Hct (male, female)
- male = 40-54%
- female = 38-47%
- WBC5,000-10,000
- Na135-145 mEq/L
- Platelets150,000-400,000
- BUN10-20 mg/dL
- ABG: pH PaO2 PaCO2 HCO3 SaO2
- pH = 7.35-7.45
- PaO2 = 80-100 mmHg
- PaCO2 = 35-45 mmHg
- HCO3 = 22-26 mEq/L
- SaO2 = 94-100%
- PT11.0-12.5 seconds
- AST (=SGOT)0-35 u/L
- ALT (=SGPT)4-36 u/L
- Ammonia10-80 mg/dL
- Total Protein6.4-8.3 g/dL
- Bilirubin: Total? Indirect? Direct?
- Total = 0.3-1.0 mg/dL
- Indirect = 0.2-0.8 mg/dL
- Direct = 0.1-0.3 mg/dL
- Lithium0.6-1.2 mEq/L therapeutic
- Albumin3.5-5 g/dL
- Urinalysis: albumin pH WBC glucose
- albumin = 0-8 mg/dL
- pH = 4.6-8.0
- WBC = 0-4
- Glucose = negative
- LDL60-180 mg/dL
- HDL (men, women)
- men = 45-50 mg/dL
- women = 55-60 mg/dL
- Total Cholesterol122-200 mg/dL
- Magnesium1.3-2.1 mEq/L
- HgbA1C
- Good control = 2.5-5.9%
- Fair control = 6-8%
- Poor Control = >8%
- Bleeding Time1-9 minutes
- Digoxin0.5-2 ng/mL
- RBC (male, female)
- Male = 4.7-6.1 million/mm^3
- Female = 4.2-5.4 million/mm^3
- Hgb (male, female)
- male= 14-18 g/dL
- female = 12-16 g/dL
- Potassium3.5-5.0 mEq/L
- Glucose70-110 mg/dL
- Phosphorous/Phosphate3.0-4.5
- ESR (male, female)
- male = 0-10 mm/hr
- female = 0-20 mm/hr
- INR1.3-2.0
- aPTT (=PTT)20-36 seconds
- Creatinine (male, female)
- male = 0.6-1.3 mg/dL
- female = 0.5-1.0 mg/dL
-
K+
3.5-5 year olds like bananas.
Tortilla wrap With avacado, banana, and spinach, or green leafy vegtables.
Tetiny if to much.
-
NA+
- 135-145 Weight of hot Girl LOL!
- Low sodium-Old people especially dehydration, dry mucus membranes, low out put, increased heart rate, skin turgor tents, decreased B/P, confusion, dry mouth, loss of thirst for water, etc.
- Document skin tents, or not, don't put with normal limits.
-
ABG-
- Drawn by nurse, seen in COPD broad umbrella category.
- Change in PAO2.
-
Pain-
- Patient determines pain.
- PCA- Patient controlled Analegesic device. Patient is only one who can push it.
-
Types of Pain-
- Nerve-Pain from Nerves. Like Cyatica.
- Chronic-Lasting longer than 6 months.
- Acute- Shorter than 6 months.
- Cutaneous- Pain from Skin, bones, organs(Visceral), etc.
- Phantom-pain for nonexistent part of body that has been removed or lost.
- Reffered pain- hurting in chest(heart) and it manifests in the arm.
-
Misconpetions About Pain Medications-
- Side effects, addiction, wait til pain is high, natural to have pain, Etc.
- Rate pain intensity of pain from patient 0-10.
-
Nursing Diagnosis-
Problem/Cause/Defining characteristics!!!
-
Maslow's Hierachy of Human Needs
- Physiological
- Saftey
- Love and Belonging
- Self-Esteem
- Self-Actualization
-
Interventions-
- Colaborative Care-Patient, family, Dr., Nurse. Contunity of care, Pain meds given by dr. Orders.
- Nurse initiated care- a care plan of patient. Don't need dr. order to do these.
- EXP. give drink of water, bathroom, etc.
-
Legal
- Purpose of Documentation- document really well its to cover you if your sued, if its not documented it didn't happen.
- Deligation- Make sure that they can do it. Right task, right circumstance, right person, & right supervision.
-
Who Accredits a school of Nursing?
The State or State Board
-
Damages, Causation, Duty, Breach of Duty
- Damages- To cause harm or injury to a person.
- Causation- Anything that produces an effect, cause to effect, action of causing.Duty-Something that one is expected or required to do by moral or legal obligation.
- Breach of duty-Unexcused failure to fulfill one duty.
-
Nursing Theories 4 Concepts-
- Patient-Most important of all 4 concepts.
- Enviroment-Things that surround us, conditions, influences, and Milieu(atmosphere or environment).
- Health- General condition of the body and mind:good health of bad health.
- Nursing-A person educated and trained to care for the sick and afflected.
-
Focus of Nursing
Is on the Patient!
-
Self Concept-
- Idea of mental image one has on themselves and one strengths, weaknesses, or status.
- Their self image.
-
Self-Actualization-
The achievement of one's full potential through creativity, independence, sponiatety, and grasp of the real world.
-
Self-Esteem-
- Strength, values, beliefs help them with self-esteem.
- Exp. Shower, shave, apply makeup, & etc.
-
Who influences children?
Culture, parents, and friends(peer pressure).
-
Values-
Recognition of whats Valuable-
- Ask ?'s, give them value that they are a person, care, talk, and listen.
- Ask routeins!
- Native American/ Hispanic
-
Culture-
- Characteristics- Lack of eye contact, not being touched, called by right name, & etc.
- Foods- How its prepared, eaten, who eats with whom, and eat it with what.
Herbs can react with medications.
-
Culture awearness-
Ask how they would do it, if you don't know.
-
Culture Sensitivity-
Don't sterotype, ethnocentrism, racism, prejudice, and discrimination.
-
Loss, Grief, Death
- Loss- Percieved, physical, Situational, anticipatory, actual, & Maturational loss-is experienced as a result of natual developmental process.
- Grief- Mental suffering of distress from afliction or loss, and is necessary to maintain emotional and physical well being.
- Death-The end of life, occurs when all vital organs and systems cease to function, no breathing, and no brain activity.
-
Kubler Ross 5 stages of Grief
Denial, anger, barganing, depression, and acceptance.
-
Palliative care-
Is care aimed a symptoms rather that curative treatments. End of life care, comfort care.
-
Bereavement-
Is an individual's response to the loss of a significant other.
-
Grief
Reactions-
- Shock and disbelief
- developing awareness
- restitution
- resolving loss
- idealization
- outcome
-
Spirituality/ Limits in Health Care
- Jehovah witness- no blood, no holidays beliefs, etc.
- Lds- limits of not to health care.
- Prayer- If they need spritual support and they ask you.
- Intervention- Call someone from outside, ask staff, prayer, help with blessing if asked, etc.
-
Infection
Nursing Diagnosis-
Risk for infection R/T chronic disease, altered skin integrity, effects of medication, malnutrition, lake of immunizations, and indwelling medical device.
-
Nosocomial-
- Hospital acquired infection.
- Due to lazyness, not following protocol, not washing hands, etc.
-
Viral-
- Is smallest microorganisms. Causes common cold, and many other diseases like, AIDS, herpes, etc. Antibotics don't effect them, need antivirals to effect and kill.
- Raised white blood cells with infection, immune system fights them off.
-
Latrogenic-
not intentional infection you just get it, catheter, IV, surgery, from a medical precedure.
-
Body Defense- Immune System-
- 1st- Normal body Flora.
- 2nd-Inflamatory Response
- 3rd- Immune response
-
Local Infection-
An infection involving microorganism that invaded the bidy at a specific site and remain there until they are eliminated.
-
Systemic Infection-
An infection in which the pathogen is distrubuted through out the whole body, rather than one spefic spot.
-
Wound
Heat
- Pain relief, improved blood circulation, comfort, speeds inflamitory responce, and etc.
- Rational for healing- heat speeds healing.
- Time Frame-20 minutes on, 40 off, check with in 10 minutes of applying.
-
Pressure Ulcer Staging- 1-4
- 1-Tomato, red non-blanching.
- 2-Potato, epidermis is gone, shallow crater, partial thickness.
- 3-Apple, epidermis and dermis are gone, big crater, partial to full thickness.
- 4-Peach, full thickness, bone/muscle/ tendon/adipose tissue are showing.
-
Sexaulity
Post Menopause
Cercival cancer
Masterbation
- Post Menopause- Absense of menstrual cycle, falling estrogen levels, leads to weaken bones, osteoprosis, hair loss, facial hair, and vaginal dryness.
- Cercival cancer- HPV, STD, more that 1 sex partner, impared immune system, and birth control pills taken over 5 years.
- Masterbation- discuss if brought up by patient.
-
Gas- General Adaptation syndrome-
- Alarm, resistance, exhaustion.
- It is the bodys general response to stress.
- Alarm-Race fight or flight.
- Restistance- Mobilize resources and adapt to stressor.
- Exhaustion- All adaptive mechanisms are exhausted.
Physical changes- Sympethetic nervous system increases, digestion decreases, hormone level increases, Which increases HR, B/P, and increased respirations.
-
Preoperative
- Explain procedure to decrease anxiety.
- Teach about what to expect- dry mouth, medications dry them up, can have sore throat, deep breath, etc.
-
Discharge teaching-
Follow up on medications, don't drive, follow up care, don't sign legal documents, and demonstrate selfcare.
-
Aging Adult- Erickson's
- Life review or reminisent, the wholeness perspective.
- Middle adult- like to feel useful and benificial to society, or be worthless.
-
Respite care-
elderly care for a week or short time so family or care provider can have a break.
-
Sensory-
Hearing loss prevention-
Wear ear protection, lower volume on tv music, blow your nose gently can cause damage to ears, avoid noisy situations, etc.
-
Non-Pharmacological interventions to promote Relaxation
- Distraction
- Humor
- Music and Relaxation
- imagery
- theraputic touch
- hot and cold application
- cutaneous stimulation
- acupuncture
- hypnosis
- biofeedback
-
Ways to facilitate sleep-
Music, relaxitation, darkness, little or no noise, don't work out before bedtime, etc.
-
Sensory Deprivation-
- Loss of vision and hearing.
- Reduction of environmental stimuli by physical isolation and loss of eye sight.
-
Sleep disorders-
Most common- Insomnea, Sonombulism, narcolepsy, sleep apnea, hypersomnia, restless leg syndrome, and sleep deprivation.
-
Nutritional lab used to determine nutritional status?
Serium Albumin
-
Pyramid Food Guide
- Grains 6 oz daily
- Vegtables 2 1/2 cups daily.
- Fruits 2 cups daily.
- Milk 3 cups daily.
- Meat and beans 5 1/2 oz daily.
- Moderate physical activity daily.
- Fluids (water).
-
Communication
Closed ended ?'s or statements-
- Leaves persons with limited choices that re answered in one or two words, like yes or no.
- Non-Verbal ways to Communicate- Body language, gate, touch, appearence, eye contact, gestures, and facial expressions.
|
|