nursing 121 final exam

  1. Admission- HIPPA

    What is mandated?
    • Health Insurance or Health Information Will be shared.
    • Hilllary Clinton made it happen (GOVERNMENT).
  2. DRG (Diagnostic Related Group)
    They Determine stay of patient and the money they get for a certain illness.
  3. Assessment
    • 12-20 Adult
    • 30-60 Children
    • Slower respiration- with older adult.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Peak-
    taken 1 hr. after the medication if given.
  11. Trough-
    Drawn 1/2 hour before medication is given usually on 3rd dose.
  12. 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.
  13. 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
  14. Bronchodilators-
    • Inhalers, metered dose, or Nebulizer.
    • Inhale through mouth.
    • Increase B/P and Heart Rate only temporary with go away.
  15. 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.
  16. 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
  17. K+
    3.5-5 year olds like bananas.

    Tortilla wrap With avacado, banana, and spinach, or green leafy vegtables.

    Tetiny if to much.
  18. 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.
  19. ABG-
    • Drawn by nurse, seen in COPD broad umbrella category.
    • Change in PAO2.
  20. Pain-
    • Patient determines pain.
    • PCA- Patient controlled Analegesic device. Patient is only one who can push it.
  21. 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.
  22. 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.
  23. Nursing Diagnosis-
    Problem/Cause/Defining characteristics!!!
  24. Maslow's Hierachy of Human Needs
    • Physiological
    • Saftey
    • Love and Belonging
    • Self-Esteem
    • Self-Actualization
  25. 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.
  26. 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.
  27. Who Accredits a school of Nursing?
    The State or State Board
  28. 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.
  29. 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.
  30. Focus of Nursing
    Is on the Patient!
  31. Self Concept-
    • Idea of mental image one has on themselves and one strengths, weaknesses, or status.
    • Their self image.
  32. Self-Actualization-
    The achievement of one's full potential through creativity, independence, sponiatety, and grasp of the real world.
  33. Self-Esteem-
    • Strength, values, beliefs help them with self-esteem.
    • Exp. Shower, shave, apply makeup, & etc.
  34. Who influences children?
    Culture, parents, and friends(peer pressure).
  35. Values-
    Recognition of whats Valuable-
    • Ask ?'s, give them value that they are a person, care, talk, and listen.
    • Ask routeins!
    • Native American/ Hispanic
  36. 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.
  37. Culture awearness-
    Ask how they would do it, if you don't know.
  38. Culture Sensitivity-
    Don't sterotype, ethnocentrism, racism, prejudice, and discrimination.
  39. 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.
  40. Kubler Ross 5 stages of Grief
    Denial, anger, barganing, depression, and acceptance.
  41. Palliative care-
    Is care aimed a symptoms rather that curative treatments. End of life care, comfort care.
  42. Bereavement-
    Is an individual's response to the loss of a significant other.
  43. Grief
    • Shock and disbelief
    • developing awareness
    • restitution
    • resolving loss
    • idealization
    • outcome
  44. 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.
  45. Infection
    Nursing Diagnosis-
    Risk for infection R/T chronic disease, altered skin integrity, effects of medication, malnutrition, lake of immunizations, and indwelling medical device.
  46. Nosocomial-
    • Hospital acquired infection.
    • Due to lazyness, not following protocol, not washing hands, etc.
  47. 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.
  48. Latrogenic-
    not intentional infection you just get it, catheter, IV, surgery, from a medical precedure.
  49. Body Defense- Immune System-
    • 1st- Normal body Flora.
    • 2nd-Inflamatory Response
    • 3rd- Immune response
  50. Local Infection-
    An infection involving microorganism that invaded the bidy at a specific site and remain there until they are eliminated.
  51. Systemic Infection-
    An infection in which the pathogen is distrubuted through out the whole body, rather than one spefic spot.
  52. Wound
    • 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.
  53. 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.
  54. Sexaulity
    Post Menopause
    Cercival cancer
    • 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.
  55. 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.
  56. Preoperative
    • Explain procedure to decrease anxiety.
    • Teach about what to expect- dry mouth, medications dry them up, can have sore throat, deep breath, etc.
  57. Discharge teaching-
    Follow up on medications, don't drive, follow up care, don't sign legal documents, and demonstrate selfcare.
  58. Aging Adult- Erickson's
    • Life review or reminisent, the wholeness perspective.
    • Middle adult- like to feel useful and benificial to society, or be worthless.
  59. Respite care-
    elderly care for a week or short time so family or care provider can have a break.
  60. 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.
  61. Non-Pharmacological interventions to promote Relaxation
    • Distraction
    • Humor
    • Music and Relaxation
    • imagery
    • theraputic touch
    • hot and cold application
    • cutaneous stimulation
    • acupuncture
    • hypnosis
    • biofeedback
  62. Ways to facilitate sleep-
    Music, relaxitation, darkness, little or no noise, don't work out before bedtime, etc.
  63. Sensory Deprivation-
    • Loss of vision and hearing.
    • Reduction of environmental stimuli by physical isolation and loss of eye sight.
  64. Sleep disorders-
    Most common- Insomnea, Sonombulism, narcolepsy, sleep apnea, hypersomnia, restless leg syndrome, and sleep deprivation.
  65. Nutritional lab used to determine nutritional status?
    Serium Albumin
  66. 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).
  67. 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.
Card Set
nursing 121 final exam
Final Exam Nursing 121