NURS205 Midterm

what is med surg nursing?

looking after people who have had surgery and help them go home, acute care typically, any nursing setting, diverse pt population

what is critical thinking?

process used to examine and analyze patient issues at point of care.

identifying a change in patient status and taking into account the context and concerns of the patient and deciding what to do about it

what is evidence-informed practice?

continuous interactive process involving the explicit, conscientious and judicious consideration of best available evidence to provide care

improves patient outcomes

best possible evidence: systematic or integrative reviews

translate to clinical practice guidelines

what is a clinical practice guideline?

single conclusion about state of science based on summaries of the literature

ex. registered nurses association of ontario

what should you consider during clinical decision making?

your clinical expertise, patient’s preferences or values and what the evidence tells you; research, clinical findings

what does clinical expertise entail?

clinical state, setting & circumstance

patient preferences and actions

health care resources

research evidence

what is the nursing process?

way of thinking that nurses use

what nurses do when planning and providing care

problem solving approach

basic framework that uses unique combination of knowledge, skills, and caring that makes the art & science of nursing

what are the 5 parts of the nursing process?

assessment

diagnosis

planning: outcomes and interventions

implementation

evaluation

what are the comparisons between medicine and nursing?

what are human responses?

reactions to events or stressors like disease, injury, or life changes

can be actual or potential health problems

what are the 4 types of human responses?

biological

psychological

social

spiritual

what does phase 1 of assessment include?

systematic gathering of relevant and important data on patient’s present health status

uses date to identify health problems, plan nursing care, evaluate patient outcomes

how do we collect data

interview

observation

physical examination

collateral information; patient chart, other nurses or HCPs

how do we validate data?

ensure assessment is complete, accurate and factual before making a diagnosis

eliminate own biases and misconceptions of data

avoid jumping to faulty conclusions about data

what does diagnosis include?

sorting, clustering analyzing data to identify patient’s present health status

writing precise statement to describe patient status and contributing factors

prioritize the diagnoses

decide which diagnoses will respond to nursing care and which must be referred to another healthcare professional

what is the format for writing diagnostic statements?

problem (p) related to/caused by etiology as evidenced by/resulting in signs & symptoms

ex. pain related to surgical incision as evidenced by swelling, pt immobility

how do we plan outcomes?

identify goals that are patient-centered and mutually set if feasible

important to identify short and long-term goals

smart criteria

how do we plan interventions?

identify independent and dependent nursing interventions to accomplish the desired patient outcomes

being specific with who, what, where, when and how

what should you consider when choosing an intervention

desired patient outcomes, rationale, feasibility of successfully implementing the intervention

what do we incorporate into clinical decision making?

research, clinical expertise, preferences, other available resources

what does implementation include?

communicating the plan of care to other members and carry out interventions

recording the care given & the client’s responses

what does evaluation include?

what were the outcomes of pt care? evaluating long term and short term goals, if the interventions worked, do the plan of care need to be continued or revised and evaluation data becomes new assessment data

what are the two types of documentation?

charting by inclusion (narrative); assessments, interventions, outcomes in progress notes in chronological order

charting by exception (focused): completed when assessments, interventions or outcomes vary from established norms or standards of care

why do we use focus charting?

focus on patient/client concern or behavior

change in patient condition

significant treatment event

what does DARP stand for

D - data

A - analysis and action

R - Response

P - Plan

what is SOAPier charting?

S - subjective

O - objective

A: assessment

P: plan

I: implementation

E: Evaluation

R; Revision

what is clinical reasoning?

collecting cues

weighing evidence

using intuition

recognizing patterns

selecting from alternatives

what are cues?

physiologic or psychosocial changes

how do we communicate your concerns?

s - situation

b - background

a - assessment

r - recommendations

what is homeostasis?

set point that the body is trying to balance itself to

range that the body allows us to stay in equilibrium for adaptive responses

maintain composition and volume of body

how much % of the adult body weight is water content?

60

what are the body fluid compartments?

ecf and icf

where is extracellular fluid found?

between clls in the interstitial and lymph

where is intracellular fluid found?

located within cells

1L of water weight weighs __kg

1

what are electrolytes?

substances whose molecules dissociate into ions when placed into water

what are examples of cations

sodium, potassium, calcium, magnesium

what are examples of anions?

biocarbonate, chloride, phsophorus

what are the major electrolytes in the ecf and icf?

ecf: sodium and calcium

icf: potassium and phosphorus

what are the mechanisms for controlling fluid and electrolyte movement?

diffusion, facilitated difficusion, active transport, osmosis, hydrostatic pressure, oncotic pressure

what is diffusion

movement of molecules from high to low concentrationw

what is facilitated diffusion?

movement of molecules from high to low concentration without enery but using specific carrier molecules to accelerate diffusion

what is active transport?

moelcules move against concentration gradient from high to low which requires external energy

what is osmosis?

movement of water between two compartments by a membrane permeable to water but not to solute from low solute to high solute and requires no energy

what is osmotic pressure?

amount of pressure required to stop osmotic flow of water

determined by concentration of solutes in solution

what is osmolality?

measure of osmotic force that is the concentration of molecules per weight of water - measure for evaluating concentration of urine, body fluids and plasma

what is the major colloid in the vascular system that contributes to toal osmotic pressure?

albumin

what is the role of albumin?

keep vascular fluid in vascular space

what is a hypotonic fluid?

fluid where solute is less concentrated than the cells they are in

what is a hypertonic fluid?

fluid where solute is more concentrated than the cells they are in

normally ecf and icf are ______ to one another

isotonic

what is hydrostatic pressure?

force within fluid compartment

pushes water out of vascular system at capillary level

what causes edema?

plasma leading to interstitial fluid shift

an elevation of venoushydrostatic presure

what are the type of fluid spacings

first spacing (normal distribution of fluid ICF and ECF

second spacing (abnormal accumulation of interstitial fluid) - edema

third spacing (third space syndrome): fluid accumulation in part of body where not easily exchanged with ecf (ascites, burns, pleural effusions, bowel obstructions

what is sodium content

135-145mmol/L

what is normal potassium content

3.5-5.0mmol/L

what is normal chloride content

95-105mmol/L

what is normal bicarbonate content

21-28 mmol/L

urea nitrogen content

2.5-6.4 mmol/L

creatine content

71-106 umol/L

what does insensible loss mean?

nonmeasurable

what does hypovalemia mean?

ecf volume deficit

what is hypervolemia

ec volume xcess

who are at risk for hypovolemia and why

children (greater bsa, immature kidneys, higher metaolic rate and immature endocrine system)

elderly (chronic medical conditions, decreasedd thirstand mobility, medication effects)

what type of solution is isotonic

0.9 sodium chloride and lactated ringers

what type of iv solution is hypotonic

0.45 sodium chloride

what type of solution is hypertonic

3% sodium chloride

normal saline changes icf volume true or false

false

dextrose moves into icf true or false

true

does dextrose provide electrolytes

no

what can dextrose be used for

replace water losses

what are the 3 categories of cbc?

leukocytes, erythocytes and platelets

what is heamtocrit

percentage of rbc in volume of whole blood

what is hemoglobin

protein/iron compound on red blood cells that bind with xygen

what is hemoglobin volume

female: 7.4-9.9 mmol/L or 12-16 g/dL

male: 8.7-11.2 mmol/L (14-16 g/dL)

hat is normal hemtocrit

female 0.35-0.47 volume

male: 0.42 -0.52

is osmolality affected in hypervolemia?

no b/c fluid and solutes are gained in equal proportion

who is at risk for hypervolemia?

pt with impaired renal or elderly patient

what are some interventions for hypervolemia?

treating primary cause with diuretics or fluid restriction or sodium intake

measure intake and output

measure daily weights

good skin care

elevation of edematous extremities

monitor patient

what level is sodium at for hyponatremia?

<135 mmol/L

severe: <125mmol/L

what can we give for severe symptoms of hypernatremia?

3% NaCl to cause water to hift out of the cells

why must we be careful giving 3% nacl solution?

• fluid can rush out and cells can die, must do it at rate of 100ml/hr

• depletion of cells

  • overwhlem the pt with fluid volume - must give through IV and central line infusion preferred

what is the numbers for hypernatremia?

>145mmol/L

lifethreatening >155mmol/L

death: >180mmol/L

hypernatremia causes hyperosmolality - true or false

true b/c hyperosmolality causes shift water out of cells, causing celular dehydration

what are the interventions for hypernatrium

oral flui replacement

receieve salt-free solution like dextrose to return serum levels to normal

but careful becasuse too much fluid can cause cerebral edema

hypokalemia occurs when…

levels below 3.5 mmol/L

what is the primary route for potassium loss

kidneys

what are the clinical manifestations of low potassium

cardiac issues, fatigue, muscle weakness, leg cramps, nausea vomiting

ileus

soft flaby muscles

paresthesias, decreased reflexes

weeak irregular pulse

rate of adminstration of kcl should not exceed ____ to prevent hyperkalemia

10-20mmol/hour

can you administer potassim throughIV push or bolus?

no

what is the max amount of potassium given in 24 hours?

200mEq/L

how do we increase elimination of potassium

diuretics

dialysis

ion-exchange resins like kayexalate

increase fluid intake

how do we force potassium from ecf to icf?

iv insulin with glucose to prevent hypoglycemia

iv sodium bicarbonate

blood pressure is equal to what

cardiac output x stroke volume times heart rate

what are baroreceptors

specialized nerve cells in carotidsinus and aortic arch that relay info

what are the sns receptors responsible for

a1: vasoconstriction

a2: vasoconstriction

B1: increase contracitility, hr, conduction and renin

B2: dilate bronchial passages

how does the raas system lead to vasoconstriction?

juxtaglomerular apparatus release renin

renin converts angiotensin —> angiotensin 1

angiotensin 1 goes to lungs wehere ACE makes angiotensin ii leading to vasoconstriction and secrete aldosterone to retain sodium and water

what is stage 1 hypertension

SBP 140-150 or DBP 90-99 mmHg

what is stage 2 hypertension

SBP 160mmHg or DBP 100mmHg

what are some lifestyle modifications for hypertension?

dash diet

weight reduction

alcohol consumption - nomore than 2 drinks/week

30-60min physical activity 4-7x week

avoid tobacco

stress management