NPN-118 Midterm Review

Nursing Process

five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating

Nursing Assessment

systematic and continuous collection and analysis of information about the client; begins at first interaction with client

Nursing Diagnosis

describes a health problem that can be treated by nursing measures; a step in the nursing process

Nursing Planning

an organized nursing care plan based on the nursing Dx, goals and interventions are set by both patient and nurse

Nursing Implementation

Formally begins after a plan of care is developed. The nurse initiates interventions that are designed to achieve the goals and expected outcomes needed to support or improve the patient's health status.

Nursing Evaluation

Determines whether, after application of the nursing process, the patient's condition or well-being improves.

Narrative charting

a descriptive record of client data and nursing interventions, written in sentences and paragraphs

SOAP charting

subjective, objective, assessment, plan; problem oriented record

Focus charting

Charting methodology for structuring progress notes according to the focus of the note (e.g., symptoms and nursing diagnosis). Each note includes data, actions, and patient response.

PIE charting

problem, intervention, evaluation

Charting by exception

uses standardized forms that identify norms and allows selective documentation of deviations from those norms; quick access to abnormal findings

Objective data

what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination; things we can measure; signs (vitals)

Subjective data

things a person tells you about that you cannot observe through your senses; symptoms (pain, nausea)

Patient education

process of influencing the patient's behavior to effect changes in knowledge, attitudes, and skills needed to maintain and improve health; ensure that patient understands by assessing for language barriers, cultural differences, and motivation

Inspection

general observation of the patient as a whole, progressing to specific body areas

Palpation

an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts, temperature and moisture

Percussion

a diagnostic procedure designed to determine the density of a body part by the sound produced by tapping the surface with the fingers

Auscultation

listening to sounds within the body

Prone

lying face down

Supine

lying on the back

Dorsal recumbent

lying on the back with knees up and feet flat on the table

Lithotomy position

lying on back with legs raised and feet in stirrups, hips and knees flexed, thighs abducted and externally rotated; used to observe the reproductive organs

Sim's position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back; used when someone can not abduct their hips or for procedures like an enema

knee-to-chest position

patient is lying face down with the hips bent so that the knees and chest rest on the table

Military time

time based on a 24 hour clock

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization

Maslow's Physiological Needs

Oxygen, water, food elimination, temperature, sexuality, physical activity, and rest.

Maslow's Safety and Security

Protection from injury, promote feeling of security, trust in nurse-client relationship

Maslow's Relationships, Love and Affection

Meaningful relationships with others, need for affection

Maslow's Self-esteem

The individual seeks self-respect and respect from others, works to achieve success and recognition in work, and desires prestige from accomplishments.

Maslow's Self-actualization

the ultimate psychological need that arises after basic physical and psychological needs are met and self-esteem is achieved; the motivation to fulfill one's potential

Sleep cycle

one of these consists of the progression through sleep stages 1-4 in sequence followed by an ascension from 4 back to 1 and then a transition into REM sleep; typically takes about 90 min

Average sleep

7-9 hours for adult

Latex sensitivity

response to latex proteins in gloves and other medical equipment that usually leads to contact dermatitis; can also be seen in patients with allergies to certain fruits and vegetables (bananas, kiwi, avocado); nurses should take care to use non-latex gloves and equipment when caring for these patients

RACE for fire

R- rescue those in immediate danger of fire

A- activate the alarm

C-contain fire (close all doors)

E- extinguish (pull, aim, squeeze, sweep)

Intake and Output (I&O)

a record that notes all fluids taken in or eliminated by a person in a given period of time; includes all liquids taken in including foods that are liquid at room temperature (jello, ice cream) (oral, IV, g-tube, etc.) and put out (vomit, urine, diarrhea, etc.)

NPO

nothing by mouth

Clear liquid diet

a diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello, coffee without cream, tea

Patient assessment

Reassess patient immediately anytime they complain of feeling differently, include vital signs, physical assessment, and collection of both objective and subjective data

Normal Adult Vital Signs

Temperature: 96.8-100.4 oral

BP: 100-120/60-80

Pulse rate: 60-100 BPM

RR: 12-20 resp/min

Pulse ox: >90%

Pain assessment should be assessed every time vitals are taken

Phantom pain

sensation of pain without demonstrable physiologic or pathologic substance; commonly observed after the amputation of a limb

Interventions for abnormal vital signs

*Important to determine cause first!

Temperature: administer antipyretics, cool cloths, ice

Pulse: decrease activity level, relaxation

BP: Orthostatic: encourage slow movement, increase fluid intake, encourage pt to ask for help prior to movement, utilize assistive devices, use night lights

Pulse ox: apply oxygen per physician's order, raise the HOB,

Pain: administer analgesics and assess their effectiveness

gate control theory of pain

The theory that pain is a product of both physiological and psychological factors that cause spinal gates to open and relay patterns of intense stimulation to the brain, which perceives them as pain; can be disrupted by stimulating other areas of the body (back rub, tens unit)

Opioid Analgesics

Synthetic pain-relieving substances that were originally derived from the opium poppy, Naturally occurring opium derivatives are called opiates; used for moderate to severe pain

Opioid Analgesics: Adverse Effects

SEDATION; RESPIRATORY DEPRESSION; postural hypotension; flushing; N/V; constipation; urinary retention; pupil constriction

Apical Pulse

the pulse on the left side of the chest, just below the nipple

Bowel sounds

Abdominal sounds caused by the products of digestion as they move through the lower gastrointestinal tract, usually heard on auscultation. Hyperactive: greater than 34x/minute; hypoactive: occur after long intervals; absent: no sounds heard for 3-5 minutes

Lung sounds

lung sounds are referenced as crackles (rales), wheezes (rhonchi), and stridor

heart sounds

Lub-dub. 1st- a-v valves close. 2nd- aortic and pulmonary valves close

dyspnea

difficulty breathing, sit the patient upright, administer oxygen as needed

SOB

shortness of breath

Sentinel event

an accident or incident that results in grave physical or psychological injury or death; unexpected

Infection control

Procedures to reduce transmission of infection among patients and health care personnel.

Restraints

to physically restrict voluntary movement or use chemicals to revise/restrict resident behavior; SRD (soft restraints)

Patient restraints

Used only for patients who are violent or potentially violent, or who may harm self or others. Document:

1-Reason restraints were needed

2-type of restraint used, extremity(ies) restrained, time

3-which agency applied the restraints

4-information/data regarding PMS

5-information regarding respiratory status

Chains of Infection

6 links

1. infectious agent

2. reservoir of source

3. portal of exit (respiratory and GI concerns)

4. mode of transmission

5. portal of entry

6. susceptible host

Transmission Based Precautions

special precautions implemented on the basis of how the disease spreads

Contact Precautions

Methods of infection control that must be used for patients known or suspected to be infected with epidemiological microorganisms that can be transmitted by either direct or indirect contact. (c-diff, MRSA, VRE)

Airborne Precautions

Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei. (TB, Measles, Chicken Pox)

Droplet Precautions

Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by large particle droplets expelled during coughing, sneezing, talking, or laughing. (Influenza)

PPE for droplet precautions

gloves, gown, mask

PPE for airborne precautions

N95 mask

PPE for contact precautions

gloves and gown

Number one way to prevent the spread of infection

handwashing

medical asepsis

practices designed to reduce the number and transfer of pathogens; synonym for clean technique

surgical asepsis

techniques used to destroy all pathogenic organisms, also called sterile technique

susceptible host

a person likely to get an infection or disease, usually because body defenses are weak (poor nutrition, lack of sleep, diabetics, multiple sexual partners without protection, IV drug users, chemotherapy patients, etc.)

nosocomial infection

an infection acquired during hospitalization; could be caused by not using proper PPE, staff wearing acrylic nails, poor handwashing procedures

Poisoning

to cause injury, illness, or death by chemical means; keep chemicals locked up and out of reach of children, have Poison Control number readily available

Drowning

The process of experiencing respiratory impairment from submersion or immersion in liquid; avoid leaving toddlers unattended during baths, keep pool gates locked and pools covered when not in use

IV Solutions

Isotonic: solution remains in extracellular space and increases volume (0.9 NS, LR, D5W

Hypotonic: into cell- shift from intravascular→intracellular, DKA/HHMS (0.45NaCl, D2.5W)

Hypertonic: out of cell water from intracellular→extracellular increases volume, cerebral edema (3%NaCl, D10W)

Colloids: Blood and blood products

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, skin warm and dry

Blood transfusions

the introduction of blood, blood products, or a blood substitute into a patient's circulation to restore blood volume to normal levels; Assess vitals prior to starting and every 5 minutes for first 15 minutes: STOP transfusion for any signs of a reaction and notify health provider; send blood and tubing back to lab

Nutrition

the process of providing or obtaining the food necessary for health and growth.

People at risk for poor nutrition

Low income, elderly on fixed income, pregnant teenagers, people with substance abuse issues,

Nurse's role in procedures

-ensure preprocedural prep was completed and report to provider ASAP if not

-ensure that the patient ID band is in place

-ensure that the consent has been signed

-answer any questions/explain procedure as needed

-prepare exam room and gather supplies

-assist provider during procedure

-provide comfort and support to patient during procedure

-monitor patient progress postprocedure

Glucose Monitoring

60-110 mg/dL

check blood glucose using the side of the fingers for puncture

assess before meals and at bedtime

Clean catch urine

a midstream urine sample collected after the urethral opening and surrounding tissues have been cleansed; instruct patient to wipe from front to back three times with supplied wipes, while separating the labia allow the first urine to flow into the toilet, catch the mid-stream urine in the cup, then finish urinating in the toilet

Nursing interventions for constipation

Increased fluid and fiber in diet, ambulate, exercise, avoid laxatives/enemas, establish regular time to defecate

Nursing interventions for dizziness

Encourage patient to change positions slowly, ask for help, use assistive devices, bed in lowest position, use of side rails