Nursing 101 Final Study

nurse practice act

the _ determines the scope of the professional nurse in a specific state; distinguishes between nursing and medical practices; defines expanded nursing roles; sets educational requirements

negligence

the unintentional failure to act or perform an act that a reasonable person in the same role would or would not do and results in injury to another

elements of negligence

the are duty, breach of duty, and injury

duty

the legal relationship between nurse and patient

breach of duty

failure of a nurse to complete duty

injury

reasonable casual connections between the nurse's conduct and the injury (physical, emotional, or financial)

malpractice

failure to follow standards of care, use equipment in a responsible manner, assess & monitor, communicate, or documentsl

slander

oral defamation of character

libel

written defamation of character

informed consent

nurse's role is to witness the patient's signature, ask client if they understand procedure

HIPAA

confidentiality is the right of the patient; patients are allowed to inspect and copy their medical record; use and disclose protected health information

durable power of attorney

the _ is the person that makes health care decisions for the patient, particularly regarding end of life care

autonomy

self-determination; being independent and self-governing

beneficence

principle of doing good

justice

process that distributes benefits, risks, and costs fairly

fidelity

keeping promises and commitments made to others

nonmaleficence

principle of avoiding evil

virtues

human excellences, cultivated dispositions of character and conduct that motivate and enable us to be good human beings

good Samaritan law

law designed to protect those who aid victims in emergencies outside of a facility. Varies from state to state. Must be an emergency, provided free of charge, in good faith, and cannot willingly or intentionally harm the victim. Once aid is offered, must stay with the victim until he or she is stable or another provider of equal or greater training can take over for you. Offers legal immunity.
Samaritan lawc

cognitive learning

involves the storing and recalling of new knowledge in the brain

affective learning

includes changes in attitudes, values, and feelings

psychomotor learning

learning is a physical skill involving the integration of mental and muscular activity

teach back method

assess health literacy, seeking to confirm that the learner understands the health information received from a health professional

portal of entry

the point at which the microorganisms enter a new host; often the same as the exit route (skin, urinary, respiratory, and gastrointestinal tracts)

reservoir

where microorganisms grow and multiply; ex. other people, animals, soil, food, water, milk, and inanimate objects

portal of exit

the point of escape for the microorganism from the reservoir; ex. respiratory, gastrointestinal, genitourinary tracts, breaks in the skin, blood, and tissue

susceptible host

microorganism must be able to overcome any resistance mounted by the host's defenses; hospital patients are often in a weakened state of health

infectious agent

Bacteria
Virus
Fungi
Parasites

direct contact

Requires close proximity between the susceptible host and an infected person or carrier
Includes activities like touching, kissing, and sexual intercourse

vector

A living creature that transmits an infectious agent to a human (ex: insect)

fomite

An inanimate object (ex: equipment or countertops)

WBC

range for these is 5,000-10,000 (use abbreviation)

erythrocyte sedimentation rate

men up to 15 mm/hr, women up to 20 mm/hr; test when inflammatory process is happening

urinalysis

nitrites & leukocytes

standard precautions

Applies to all patients

Used to prevent exposure to bloodborne pathogens, such as HIV, Hep B and Hep C

Private room recommended if patient is at risk for contaminating the environment with blood, body fluids, secretions, or excretions

Utilize mask and eye protection when there is a likelihood of splashing or spraying of blood, body fluids, secretions, or excretions

Utilize a gown when they is a likelihood of splashing or spraying of blood, body fluids, secretions, or excretions, or when soiling of clothing is likely

Utilize gloves when touching mucous membranes, non-intact skin, blood, body fluids, secretions, excretions, and contaminated linens

Handle equipment with caution and clean before use with other patient if soiled

airborne precautions

Droplet nuclei <5 microns
Diseases include TB, varicella (chicken pox), rubeola (measles), COVID

Use a private room that has monitored negative air pressure in relation to surrounding areas, at least 6 air changes per hour, and discharge of room air to outdoors or special filtration system. Keep door closed.

Wear respiratory protection when entering room.

Wear a gown during procedures when there is a likelihood of splashing or spraying of blood, body fluids, secretions, excretions, or soiling of clothing.

Wear gloves when touching mucous membranes, non-intact skin, blood, body fluids, secretions, excretions, and contaminated items

Handle equipment with caution and clean before use with other patient if soiled

contact precautions

Diseases include MRSA, MDRO, impetigo, pediculosis, scabies, clostridium difficile, VRE, RSV

Keep patient in private room
Wear mask and eye protection during procedures when there is a likelihood of splashing or spraying blood, body fluids, secretions, or excretions

Put on a gown before entering the room or you may have contact with the patient or environment

Wear gloves when entering the room if you may have contact with the patient or environment. Remove gloves before leaving the room.

Dedicate the use of all noncritical patient care equipment to a single patient. Clean and disinfect any common equipment between uses by different patients.

droplet precautions

Droplets >5 microns

Being within 3 ft of patient

Diseases include: rubella, mumps, diphtheria, adenovirus, influenza, meningococcal meningitis, pertussis

Keep patient in private room. If private room is not available, maintain 3 feet between infected patient and others.

Wear a mask when working within three feet of patient

Wear a gown during procedures when there is a likelihood of splashing or spraying of blood, body fluids, secretions, excretions, or when soiling of clothing is likely

Wear gloves when touching mucous membranes, non-intact skins, blood, body fluids, secretions, excretions, and contaminated items

Handle equipment with caution and clean before use with other patients if soiled.

medical asepsis

basic technique that breaks the chain of infection

surgical asepsis

sterile procedure

hand hygiene

Hands are visibly soiled
Contact with blood or body fluids
Before eating
After using restroom

Before touching a patient
Before a clean/aseptic procedure
After a body fluid exposure risk
After touching a patient

vehicle transmission

Contaminated items
Water
Drugs/solutions
Blood
improperly handled food

vector-borne transmission

External mechanical transfer (ex: flies)
Internal transmission (ex: parasitic conditions)

newborn

vital signs ranges for a(n) _ :

Temp: 35.9-36.9 (96.7-98.5)
Pulse: 70-190
Resp: 30-40
BP: 73/55

infant

vital signs ranges for a(n) _ :

Temp: 37.1-38.1 (98.7-100.5)
Pulse: 80-160
Resp: 20-40
BP: 85/37

toddler

vital signs ranges for a(n) _ :

Temp: 37.1-38.1 (98.7-100.5)
Pulse: 80-160
Resp: 25-32
BP: 89/46

child

vital signs ranges for a(n) ____ :

Temp: 36.8-37.8 (98.2-100)
Pulse: 70-115
Resp: 20-26
BP: 95/57

preteen

vital signs ranges for a(n) :

Temp: 35.8-37.5 (96.4-99.5)
Pulse: 65-110
Resp: 18-26
BP: 102/61

teen

vital signs ranges for a(n) _ :

Temp: 35.8-37.5 (96.4-99.5)
Pulse: 55-105
Resp: 12-22
BP: 112/64

adult

vital signs ranges for a(n) _ :

Temp: 35.8-37.5 (96.4-99.5)
Pulse: 60-100
Resp: 12-20
BP: 120/80

aged adult

vital signs ranges for a(n) _ :

Temp: 35.8-36.8 (96.4-98.3)
Pulse: 40-100
Resp: 16-24
BP: 120/80

6 rights of medication administration

the are:

Right medication
Right patient
Right dosage
Right route
Right time
Right documentation

intramuscular

injection site: injection deep into the muscle tissue, usually of the buttock, thigh, or upper arm

90 degree angle depending on the BMI of patient

Possible sites include the ventrogluteal, vastus lateralis, deltoid

intradermal

injection site: injection placed just below the epidermis

5-15 degree angle, create a wheal with fluid
Typically used for allergy testing or TB test

Sites include inner surface of the forearm and upper back, under the scapula

intravenous

injection site: injection of a solution into the vein

subcutaneous

injection site: tissue that lies between the epidermis and the muscle

Consider folding the skin while injecting
45-90 degree angle

Sites include upper outer arm, abdomen, anterior aspect of thighs, the upper back, upper ventral or dorsogluteal area

palliative care

Consists of interdisciplinary team and therapists

Practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease of treatment at the end of life when a cure is no longer an option

Makes sure that patient with advanced chronic illness or those near death receive care that is as free of avoidable pain and suffering as possible

hospice

For individuals with limited life expectancy

Indicators include: poor performance status, declining cognitive status, advanced age, poor nutritional intake, pressure injuries, comorbidities, previous hospital admissions for acute decompensation

Provides services for patients who typically have less than 6 months to live

Can provide care in home, hospital, or extended care facilities

Provides physical, emotional, and spiritual care for patients and family members

Focuses exclusively on palliative care interventions to relieve symptoms and burdens of illness or treatment and help patients live as fully as possible until death

immobility

effects of _ :

Decreased metabolic rate
Decreased GI motility
Decreased nutrients/fluid intake
Decreased appetite
Decreased O2 availability/ischemia
Decreased cardiac output
Increased oxygen demand
Increased dependent edema
Increase clot formation
Muscle atrophy
Decreased strength/flexibility/endurance

torticollis

inclining of head to affected sidek

kyphosis

increased convexity in the curvature of the thoracic spine

scoliosis

lateral curvature of the spine

foot drop

the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, patient experiences extreme difficulty in walking

transfer

safe of patients

Canes should be used on the strong side of a person’s body, 15-30 degree bend in elbows

Walkers: person’s elbow should bend comfortably - 15-30 degree while holding it, do not advance walker further than 12-18 inches from body when in use

Crutches: crutch should be 3-4 finger widths from axilla, elbows slightly flexed 20-25 degrees, could be 4 point/3 point/2 point gait

restraints

guide lines for use of

Use only as a temporary mean to maintain client safety

Not a solution to client problems

Used to:
Reduce the risk of client injury from falls
Prevent interruption of therapy
Prevent the confused or agitated patient from removing life support
Reduce risk of injury to others
Should be removed every two hours
Always consider alternatives first

Include:
Side rails
Bed restraint
Jacket or best
Belt or waist
Extremity

Need an provider’s order, but may first implement them without is their is an imminent threat of harm

Increase supervision (use family or nurse’s aid)

Assign pts to rooms with higher supervision
Provide meaningful visual/auditory stimuli

Eliminate bothersome therapies as quickly as possible

Use relaxation therapies

Maintain a toileting routine to decrease risk of falls

Use a quick release tie and leave space for two fingers under

hygiene

rules for ____ include

Clean to dirty

Allow patients to complete as much bathing as they can independently

Cannot cut//trim patient nails!

How to assist different patients (with impairments, cultural preferences, etc.)

Promote as much of the patient’s independence as possible

Assess their ability to perform hygiene care
Ensure privacy

Convey respect

Foster a level of safety & comfort

Differences based on:
Age, skin, culture, socioeconomic class, spiritual/religious practices, developmental level, health state, personal preferences

oxygen promotion

tips for :

apply supplemental oxygen, positioning (semi-fowler’s, turn q1-2 hours, decrease anxiety, humidification, nebulization, hydration, dyspnea management (pursed-lip breathing, quad coughing, cascade coughing, huff coughing, medications (bronchodilators, mucolytics, anti-anxiety), cardiopulmonary reconditioning, primary suctioning techniques, chest physiotherapy,

incentive spirometer

encourages voluntary deep breathing, place patient in semi-fowlers position, hold device with one hand and mouthpiece with the other, exhale then place lips around mouthpiece, inhale slowly and as deeply as possible, count to 3, check position of the gauge, exhale normally

hypoxia

inadequate tissue perfusion; brain, heart, pulmonary vessels, and liver are most sensitive

Lowered O2 carrying capacity, diminished concentrations of inspired O2, inability of tissues to extract O2 from blood, poor perfusion, failure of hemoglobin to release O2 to tissues

hypoxemia

Abnormal deficiency in the concentration of O2 in arterial blood

Decreased diffusion of O2 from the lung into the blood, high altitudes, shunting of blood from right side to the left side of the heart without exchange of gasses in the lungs

hypoventilation

Inadequate breathing to meet the O2 demands at the alveolar level and may lead to hypercapnia

Impaired ventilation, pain, infection, obstructive disease, fluid volume overload, alteration in neurological regulation or chemical regulation of breathing

COPD

hyperventilation

An increase in respiratory rate that results in excess amounts of CO2 elimination

Causes hypocapnia & respiratory alkalosis

Caused by severe anxiety, infection, head injury, medications & acid base imbalance

pulse ox

normal values are 95% to 100%

Measures the saturation of oxygen in a person’s blood
Short-term findings: s/s of acute hypoxia
Long-term findings: s/s of chronic hypoxia (ex: clubbing of fingers)
C

CPR

30 compressions for every 2 breaths
5 cycles should take about 2 minutes
CABD - circulation, airway, breathing, defibrillation

chest physiotherapy

A type of respiratory care performed to promote coughing and the removal of lung secretions through percussion (clapping) and vibration on the affected areas, postural drainage, and breathing exercises

Includes percussion, vibration, and postural drainage

Cup hand for chest percussion

Mobilizes secretions

Indications: patients with large amounts of secretions or ineffective cough, use with patients who have cystic fibrosis

Contraindications: children with pneumonia, adults with COPD, postoperative adults

pursed lip breathing

inhales through the nose, slowly exhales out of the mouth – prolonged exhaling (increases exhalation of CO2)

huff coughing

more natural. Sit with HOB at 45 degrees inhale through the mouth while breathing slowly through the diaphragm – forcefully exhales with mouth open creating a huff sound.

cascade coughing

takes a slow, deep breath and holds it for 2 seconds while contracting the expiratory muscles. Then exhales with a series of coughs – coughing at a progressively lowered lung volume. Promotes airway clearance in pt with large volumes of sputum

infants

_ should sleep on their backs, 16 hours a day, average of 4 hour increments

Eye movements, grimacing, groaning, and moving are all normal

Should sleep alone without items in their cribs

toddlers

_ Should have a regular bedtime routine
Child may wander out of bed - consider a folding gate across door

May begin resisting naps and going to bed at night

Sleep 11-14 hours daily on average
p

preschoolers

_ Sleep average of 11-13 hours

Sleep patterns becoming more similar to adults

Nightmares and night terrors are more common, may want to consider a night light

school age

_ children sleep 10-12 hours nightly, increases when growth peaks

School may interrupt normal sleep patterns

teenagers

_ Sleep needs varies widely, average require 8-10 hours

Growth spurt at this age may require more

Tend to go to bed late - may result in insufficient sleep

Excessive daytime sleepiness is common, may cause a decrease in school performance and make them more vulnerable to accidents

young adults

Average required sleep 7-9 hours
Physical health, occupation, and exercise impact sleep

May use relaxation techniques to assist in sleeping before considering medications

middle aged adults

_ Total sleep time begins to decrease, more aware of disturbances of sleep patterns

Encourage adults to avoid consistently using sleep-inducing medication

elderly

____ need 7-8 hours of sleep

Sleep is less sound and poorer in quality

More difficulty falling and staying asleep

Should discuss sleep problems with health care provider to determine solutions

clear liquids

diet composed only of clear fluids or foods that become fluid at body temperature

Includes: clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, commercially prepared clear liquid supplements
f

full liquid

diet : Thin, nectar, honey, or spoon thick consistencies

mechanical soft

regular diet with modifications for texture
Excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits.

Foods are chopped, ground, mashed, or soft

fiber restricted

Fiber is limited to <10g/day

high fiber

emphasis on increased intake of foods high in fibers

diabetic diet

Total daily carb content is consistent; emphasizes general nutritional balance.

Calories based on attaining and maintaining healthy weight.

High fiber and heart health fats are encouraged.

Sodium and saturated fats are limited.

dash diet

Sodium limit may be set at 500-3,000 mg/day; approaches to stop hypertension

low cholesterol

diet intended to lower the patient's total intake of fat

gluten free

diet that avoids all wheat productsd

dysphagia diet

diet:

Level 1: pureed
Level 2: mechanically altered
Level 3: advanced - closest to a normal diet, transitional step

BRAT diet

bananas, rice, applesauce, and toast; helps diarrhea

anemia

iron deficiency

hypertension

caused by high sodium, DASH diet helps

cardiac

lower cholesterol, avoid trans fats and saturated fats