Essential Exam 1.txt

Interdependent

Saw nurding as an art and science. Supported education. Said the environment directly affects one's health. Cleanliness, Light, Pure air and water.

Defined the nurse-client relationship. Stranger, Resource person, Teacher Leader Surrogate, and Counselor

Defined nursing as assisting a person in the performance of acitivites that will contribute to health or a peacful death. Stressed independence of client

Conservation theory- Energy, Structural Intergrity, Personal Intergrity, and Social Integrity.

I am Nursing. Looked at action by the nurse client and family and said those things are integrated together. Important that the patients do what they can on their own.

Stressors- Intrapersonal, Interpersonal, and Extrapersonal

stresses within (fear of flying)

Between 2 individuals (getting into with someone)

Outside the individual (raining)

Culrture care and culture belief. Accomodation or negotiation (We respect cultural beliefs).

Aaptation model- Nursing attempts to alter the environment when the person in not adapting well (i.e. if patient has a problem getting out of the bed, get them a walker). Use of coping systems-Nursing attempts to assist hte client in coping mechanisms.

Human caring. Care and love are the basis for humanity.

• Unitary human beings
• Nursing as an art and science. Energy fields. Looked at humans as structures that cannot ve seperated into pieces.

• Improve accuracy of client identification
• Reduce risk of health care associated infection
• Improve effectiveness of communication
• Improve safety of usig high-alert med
• Prevent errors in surgery
• Improve safety of infusion pumps
• Effectiveness of clinical alarm systems
• Reduce the risk of patient harm resulting form falls

Burns/poisonings, Self inflicted cuts

• Medication errors
• Client transfer falls
• Contamination

• Fire
• Electrocution
• Osygen Tank

Always there. Hands washing alone will not get rid of it. Must use friction by rubbing the hands and scrubbing the nails.

Brief can get rid of with hand-washing.

Viruses, bacteria, fungi, protozoa, Rickettsia

Pesticides, food additives, medications, and industrial chemicals

Machine, heat, light, noise, radiation, and machinery

Person who lacks resistance to an agent and is vulnerable to disease

• Contact
• Airborne
• Vehicle
• Vectorborn

Sexually transmitted diseases

Host contacts droplet nuclei or dust particles suspended in the air

Contaminated inanimate objects such as water, food, drugs and blood

mosquitoes, fleas, ticks, lice and other animals

• Incubation
• Prodromal
• Illness
• Convalescent

Time interval between entry of an infectious agent in the host and the onset of symptoms.

Non specific symptoms

Specific Systems

Disappearance of acute symptoms until the client returns to the previous state of health

• SARS
• Hepatitis
• West Nile Virus/Hantavirus
• Viral hemorrhagic fevers (ebola)
• HIV

• GI
• Urinary
• Skin
• Lower Respiratory
• Conjunctiva

• Fall risk every shift
• Infection (local or systemic)

• Knowledge
• Asses prior to patient's discharge

10,000

Increase in acute sever infection (bacterial)

Increase in chronic bacterial infections

increased in protozoan and rickettsial infections and tuberculosis

Unaltered in an infectious process

Elevated in infection

Elevated in infection

less time, more distance, and more shielding

infection control practice used to reduce number, growth and spread of microorganisms.

Gloves, changing linens daily, cleaning floors, hospital furniture and hand hygiene

Eliminates microorganisms and spores

Sterile technique, donning sterile gloves,donning surgical attire, surgical hand antisepis, gowning and closed gloving

• Gloves
• Gown
• Protective Eyewear
• Hand Hygiene

• In addition to standard
• Gloves
• Gowns
• Disposable equipmemt

LAST

• In addtion to standard
• Eye protection
• Fluid resistant procedure mask

• Keep door closed
• N95 respirator mask

MRSA, VRE, C.difficile, major wounds with significant damage

Tuberculosis,measles,chickenpox, disseminated herpes zoster

Influenza, respiratory MRSA,rubella, meningoccocal meningitis, mumps, pertussis

• Client is free injury
• Client is free from
• Self-care needs are met

• Upon admission
• Every few hours
• Anytime there is a change in the patients condition
• Before procedures (compare when they return)
• Prior to discharge

Every 8hrs

Every hour

Every 4 hours

May not take them

98.6 F

97.6 F

99.6 F

• Patient at risk for perforation
• Patients who have extremely slow heart rate because it stimulates vegus nerves and can slow the heart rate

• Metabolism
• Shivering (body's own mechanism)
• Excessive muscle activity
• Fever
• Thyroxine production

• Radiation
• Conduction
• Convection
• Evaporation

Loss of heat to object in contact with the body

Using Air

12-20 breaths per minute

During cardiac arest, shock, blood pressure very low

1 minute

Circulation problem, the heart is not pumping efficient enough to reach extremeties

Posterior tibial and Dorsalis Pedis

measure of blood that enters the aorta with each ventricular contractiondiac output

volume of blood pumped by the heart in one minute

5000ml

4500ml

Depolarization

Repolarization- Most important heart not resting doesn't get oxygen and doesn't allow blood to flow to tissues

• Systole/Diastole
• 120/80= 40

• Lay flat, take BP
• -Wait 5 minutes
• Sit, take BP
• -Wait 5 minutes
• Stand up, take BP

• It is expected to go up
• peripheral vasodilation and increased metabolic rate

Slows it

Increases

Increases pulse in attempt to raise BP

Blood pooling causes lower BP and increase in heart rate

Mercury manometer (no longer used)

For frequent vitals, used to see if any changes in BP

Time of day, Same scale, and same clothing

Absence of fever

Pulmonary artery (PAT)

Greater than 105.8

Chills, Fever, pyrogens, diaphoresis, elevated pulse and respiration rate.

Pallor, shivering, cyanotic nail beds, decrease in BP and pulse

fluctuation between hypothermia and hyperthermia

If the patient is shivering (body's own mechanism) the temperature will go up

• Reduce external coverings and keep clothing and bed linen dry
• Limit physical activity
• Increase rest periods
• Increase oral fluids of choice

Doppler (ultrasound) with gel

Apical pulse and radial pulse not the same

quality and rate

• 0- Absent
• 1- Weak
• 2- Normal
• 3- Strong/bounding

portable cardiac monitor worn 24 hours used to determine if certain activities such as walking are associated with abnormal transmission of impulses.

normal rate and depth

10 or fewer breaths per/minute

shallow respirations

more than 24 breaths per minute

sit or stand to breathe

gradual increase in depth of respiration followed by gradual decrease in depth of respiration

External intercostal muscles and accessory muscles

They are going into respiratory distress, place them in an upright position. This helps them breath easier

diaphargm contraction and relaxation observed in the abdomen

• labored breathing or forced respirations
• use accesory muscles and neck to breathe

30-60

30-50

25-32

16-19

Increase respirations

restlessness

Cyanosis

If a person is wearing polish or there is swelling

Indirect

Direct

• Phase 1-First faint tapping SYSTOLIC
• Phase 2-during deflation muffling quality
• Phase 3-period crisp thumb
• Phase 4-softer blowing, muffled that fades
• Phase 5-silence DIASTOLIC

It fades then return during diastolic

• Systolic blood pressure less than 90mmHg
• 20-30 mmHg below the clients normal systolic pressure

No. Must be confirmed on 2 seperate visits

<130 and <85

decrease

decrease

increase

increase

4 hours

• Cuff too narrow
• arm unsupported
• Insufficient rest before assesment
• cuff wrapped too loosely
• deflating cuff to slowly
• patient talking
• assesing after meal, smoking, or while in pain
• repeating assesment too quickly

• Cuff too wide
• deflating cuff too quickly
• arm above level of the heart
• failure to identify auscultatory gap

• Check the BP again in 15 minutes
• continue to reassess
• review list of medications to see if there is anything available prn

Compare the data against esablished norms

The ability of a test to correctly idenfiry those individuals who DO NOT have the disease

The ability of a test to correctly idenfify those individuals who have the disease

The ablility of a screening test results to correctly identify the disease state. Dont want a lot of false positives or false negatives.

Dehydration

13-18

12-16

37-49%

36-46%

Brain damage

damage to the heart

Damage to skeletal muscle

plain films and mammography

pyelograph and bronchography

• Noninvasisve study
• Uses high frequency sound waves
• Visualise deep body structures

• Abnormal structure or motion of the heart wall and thrombi
• Radiofrequency ablation

reveals blood clots and peripheral vascular disease

From the sternum or illiac crest

Fowler's position

Dyspnea, pallor, tachycardia, vertigo, and chest pain

• Impedes moisture less surface friction
• Used mostly fo IV sites
• Tegaderm (brand name)

No moisture in the wound

In patients with neuro sensory impairment, impaired circulation, skin integrity, very young and old, impaired mental status

Patient sliding down in bed

A nurse pulling a patient up in bed

• Stage- Nonblanchable erythema of intact sking
• Treat- remove pressure, prevent moisture, shear, and friction; promote nutrition and hydration

• Stage- Partial thickness skin loss, involves epidermis or dermis, appears as blister, abrasion, or shallow crater, an open break in skin
• Treat- Clean with sterile saline, semi-permeable occlusive dressing

• Stage- Full-thickness skin loss,includes subcutaneous tissue, deep crater, may have undermining
• Treatment- Debridment, topical teatment to promote granulation of tissue, surgical interventions like skin grafting

• Stage- Full-thickness skin loss, Extensive damage to muscle, bone, or supporting structures, may have undermining
• Treatment- Same as Stage III

Autolytic