Studied by 8 peoplenurse 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
Note
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