Nursing Final 20020 Kent State Bacha

primary source

information from the patient (symptoms, medications, ect.)

secondary source

information from family members, close friends, PCP, or medical records

subjective data

verbal statements from the patient (ex: rate your pain 1-10)

objective data

signs detected by the nurse during the physical examination (what nurse measures or sees) ex: vital signs, rash, lab results

abdominal assessment

inspection

auscultation

percussion

palpation

normal assessment

inspection

palpation

percussion

auscultation

the diaphragm

used for high pitched sounds (taking blood pressure, abdominal sounds, heart sounds, and lung sounds)

the bell

used for low pitched sounds (vascular sounds and heart murmers)

asepsis

the practice that minimize or eliminate organisms that can cause infection and disease

medical asepsis

clean technique (reduces the number and transfer of pathogens, depends on the nurses rigorous practice) always best to assume every patient is infected with an organism that can be transmitted to others

surgical asepsis

sterile technique (renders and keeps objects or areas free of microorganisms) used in surgery, catheter insertion, and some dressing changes

most common nosocomial infections

surgical site infections (SSI)

ventilator - associated pneumonia (VAP)

catheter - associated UTI (CAUTI)

central line- associated bloodstream infection (CLABSI)

iatrogenic infections

treatment acquired caused by treatment they got (chemotherapy, c-diff, or thrush)

handwashing

#1 practice to decrease spread of organisms, friction is the most effective component

latex gloves

check for allergies, molds to hands easier, better for precision, cheap

synthetic latex free gloves

used most often at point of care

vinyl gloves

use if allergic to latex or powder, readily available

chemotherapy gloves

heavier than vinyl or latex, resist tearing, do not use with allergies

rubber household gloves

used for household cleaning & instrument cleaning

therapeutic communication

benefits the patient with stress, coping, and help the patient make decisions. A trusting relationship with you and your patient

intimate zone

0-18 inches from pt

personal zone

18 inches to 4 feet from pt

social zone

4-12 feet from pt

public zone

12 feet and beyond

SBAR

Situation - explain who you are and what is going on

Background - history

Assessment - give a brief overview of what's going on

Recommendation - meds, care

open ended questions

allows the pt to continue the conversation and express. start with what, how, tell me...

validating

what the nurse believes that the pt has said is truee

clarifying

offers back to the speaker the essential meaning

reflective

focuses on pt feelings based on verbal/nonverbal cues

silence

allows the client time to think

positive stress

eustress, may lead to constructive change, progress

negative stress

distress, may lead to illness or death

stress

the experience in which the person experiences changes in normal balances state

stressor

is any event or stimulus that caused the individual the experience stress

behavioral stress

sleep disturbances, use of alcohol, drugs, absenteeism

physiological stress

increase in B/P and HR, muscle tension, dry mouth

biochemical stress

increased metabolic rate, altered hormone levels, altered endorphin levels

cognitive stress

lack of concentration, negative thoughts, worrying, poor memory

emotional stress

depression, anxiety, irritability, crying, suicide

developmental stress - erikson

infant - learning to trust others

toddler - learning to control elimination

school age - making friends

adolescent - driving for identity and independence

middle aged adult - accepting the signs of aging

older adult - reflecting on past experiences with satisfaction

situation stress

may be caused by external events and may demand a change in behavior (death in family, divorce, second child)

coping

the process of managing external and internal demands that are appraised as taxing or exceeding the resources of the person

compensation

overachievement in one area to offset deficiencies in another area. (good athlete but bad at school)

denial

refusing to admit the reality of the situation. (don't believe a poor diagnosis)

displacement

transfers and emotional reaction from one source of stress to an unrelated person or object (employee disciplined and goes home and yells at children)

projection

contributing indesirable feelings to another person. (if you don't like someone bc you thing they do not like you)

rationalization

a person tries to give a logical or socially more acceptable explanation for questionable behavior (an alcoholic who says they only drink with their friends to be social)

reaction formation

a person develops conscious attitude and behaviors that are opposite of their true feelings. (talking about a friend then acting like their bff)

regression

reverting to behaviors consistent earlier stages of development (sucking your thumb as an adult)

repression

storing painful feelings in the unconscious (being abused as a child)

sublimation

the transformation of unwanted impulses into something less harmful (a football player taking anger out on field rather than a random person)

undoing

when a person uses an act to negate a previous unacceptable act. (husband gets wife a gift after a fight he started)

stress management techniques

exercising

relaxation techniques

anticipatory guidance

guided imagery

biofeedback

positive self talk

vital signs

temperature

pulse

respiration (pulse ox)

bp

pain

oral temp

98.6 F, 37 C

tympanic temp

99.5 F, 37.5 C

in the ear, adults is back and up and child is back and down

rectal temp

99.6 F, 37.5 C

do not use on newborns or infants

axillary temp

97.6 F, 36.5 C

under armpit

temporal temp

98.7 F, 37.1 C

forehead

infrared temp

97 F, 36.1 C

no contact, good for large groups of people, the gun looking thermometer

hypothalamus

controls body temp, helps production and serve an an increase in metabolism. releases hormones

radiation

when body is in a cold room and heat radiated out

conduction

a transfer of heat from body to another surface or cold object

convection

dispersion of heat loss, wind blowing exposed skin

evaporation

spursion of heat through water vapors

diaphoresis

means a lot of sweating

normal WBC

4,100 - 11,000

above 11,000 is probably an infection

reyes syndrome

no aspirin is allowed for children under the age of 16 because it may lead to...

heat stroke

hyperpyrexia, temp 106 F or 41 C

hypothermia

temp < 95 F / 35 C

normal pulse rate

60-100 beats per minute in adult

bradycardia

< 60 bpm

tachycardia

> 100 bpm (may cause no complications)

radial pulse

inner wrist / thumb side

apical pulse

point of maximum impulse

fifth intercostal space/midclavicular line

auscultate with stethoscope

count for 60 seconds

dorsalis pedis

top of foot pulse

posterior tibial

inside of ankle, behind ankle bone pulse

doppler

ultrasound device used to asses pulses that are difficult to palpate

brachial pulse

the inner aspect of your arm

carotid pulse

in the neck, only do one at a time bc pt can pass out if you do both at the same time

femoral pulse

around the groin area, used to find circulation in lower extremities

popliteal pulse

behind the knees, used for assessing circulation to leg, also if we cant take a bp in upper extremities

normal rate of respiration

12 -20 respirations/minute

tachypnea

>24 respirations/minute

bradypnea

<10 respirations/minute

dyspnea

difficult breathing

apnea

no breathing

hyperventilation

increase in rate and depth

hypoventilation

decrease in rate in rhythm, narcotic overdose, or anesthesia

orthopnea

someone who cannot breath lying flat

ventilation

movement of gases in and out of the lungs, asses by respiratory rate

diffusion

movement of oxygen and carbon dioxide between alveoli and the red blood cells, assessed by oxygen saturation

perfusion

distribution of red blood cells to and from the pulmonary capillaries, assessed by oxygen saturation

noninvasive

not breaking skin

invasive

breaks skin

OLDCART

pain assessment tool

onset

location

duration

characteristic

aggravating factors

relieving factors

treatment

wong-baker assessment tool for pain

universal pain assessment tool

blood pressure

represent the force exerted by blood against the arterial walls, measures in millimeters of mercury (mmHg)

cardiac output

amount of blood that is pumped out of the heart with each pump, goes against arterial walls which makes bp rise

peripheral vascular resistance

resistance to blood flow within the arteries and it determined by the diameter of blood vessels, the smaller the lumen the greater the resistance to blood flow. This causes bp to rise bc blood in needing resistance. As vessels dilate the resistance falls and bp drops