NURS 344 Exam 1 Blueprint

Flashcards for NURS 344 Exam 1 Blueprint

Vital Signs

Factors that interfere with vital sign readings, accurate vital signs, abnormal vital signs nursing interventions, clinical presentation of abnormal vital signs, causes of hypertension, orthostatic vitals

Normal Pulse

60-100

Alteration in apical pulse

Dyspnea, chest pain, increased cap refill time, dizziness, confusion, or fatigue

Tachycardia

100

Bradycardia

<60

Normal Temperature

36° C to 38° C (96.8° F to 100.4° F)

Oral Temperature Measurement

Ensure the client has not smoked or consumed hot or cold food or drinks in the previous 30 minutes - can alter the temperature of oral mucosa = inaccurate measurement

Normal Blood Pressure

90/60 - 119/79

Blood Pressure Cuff Size

Ensure the cuff width encircles 80% of limb

Hypotension

<90/60

Hypertension

<130 (systolic) <80(diastolic)

Alterations in Blood Pressure

Nausea, visual changes, headache, dizziness, neurologic changes, SOB, chest pain

Normal Oxygen Saturation

95-100%

Oxygen saturation Site Selection

Choose a site that has adequate perfusion = cap refill less than 2 seconds

Hypoxemia

SOB, ↑HR, irritability, and confusion

Normal Respiratory Rate

12-20

Tachypnea

20

Bradypnea

<12

Hypoxia

Restlessness, irritability, dizziness, tingling in the hands, confusion, impaired coordination, and cyanosis

Causes of Hypertension

In adults, thickening of arterial vessels’ walls and a decrease in elasticity = increased peripheral resistance

Hyperthermia Nursing Considerations

Moving the client to a cooler environment and removing excess clothing, apply cold packs to the client’s neck, axillae, and groin, fan blowing air over, administer IV fluids to decrease temperature and maintain hydration

Hand Hygiene

Washing hands with antimicrobial hand soap (15-30 seconds), At least 60% alcohol hand sanitizer (15-30 seconds of rubbing until dry)

Airborne Diseases

TB, rubeola (measles), varicella-zoster virus (chickenpox), COVID-19

Incubation Stage of Infection

Client may not feel ill or have any visible symptoms (symptom has not showed yet)

Prodromal Stage of Infection

Nonspecific symptoms appear (e.g. fever, aches, poor appetite, malaise)

Acute Stage of Infection

The “peak”; manifestations become specific to disease process

Period of Decline Stage of Infection

Less symptomatic; client regains strength and function

Period of Convalescence Stage of Infection

Client returns to previous or new, balanced state

Body Mechanics

Keep back straight, chin level, and tighten abdominal muscles, create wide space by spreading feet shoulder-width apart and flex knees, Stand as close to object/client as possible, Bow hips slightly and squat, Do not twist torso; always pivot or side step, Push up from knees

Order for Using Cane

Cane, Weak Leg, Strong Leg

Preventing Pressure Injury

Daily skin assessments, Remember Braden Assessment!, Turn at least every 2 hours, booties, pillows, waffle cushions, pressure redistribution devices, moisturize dry skin, keep skin free from moisture, ensure intake of adequate calories, protein, and micronutrients (vitamin C, zinc)

Preventing DVT and complications of DVT

Lower leg exercises, antiembolism stockings (ted-hose), SCD, encourage fluid intake, ambulation, administer anticoagulants

Disuse osteoporosis

Bones have become thinner and weaker as a result of prolonged bed rest

Joint contractures

Abnormal fixations of the joints that occur as a result of changes to muscles and connective tissue

Foot drop

A type of joint contracture that results in a partial or total inability to pull the toes up toward the head (dorsiflexion)

Signs/Symptoms of Urinary tract infections

Burning or painful urination (dysuria), frequent urgency to urinate despite not having a lot of urine to pass, cloudy or foul smelling urine, fever

Urostomy “ileal conduit”

Surgically created diversion using small intestine - urine drains via stoma

Nephrostomy

Tube that drains directly from kidney into an external pouch

Causes of constipation

Dehydration, opioids, decreased mobility, low fiber intake

Physiological changes in the GI tract with aging

Esophageal contractions decrease, altered stomach lining, stomach elasticity decreases, decreased peristalsis, decreased muscle tone

Increased Fall Risk Factors

Meds: diuretics, opioids, benzodiazepine, post-op anesthesia, decreased mobility, decreased LOC

Fall Prevention

Bed in lowest position, Call light within reach, Bedside table within reach, Bed alarm, Hourly rounding and toileting schedule, Nonskid footwear, Adequate lighting, Assistive devices

Critical Thinking

Skill of learning to analyze and interpret data to solve a problem to achieve a desired outcome

Critical Reasoning

Mental process used when analyzing all the data of a clinical situation to make a decision based on that analysis

Clinical Judgment

Clinical reasoning across an expanse of time that happens repetitively and improves with practice

Nursing Process

Assess the objective and subjective data that pertains to the client. Analysis/Diagnosis: Determine the client's problems. Nursing Diagnoses. Planning: Create a plan to address client problems. Implementation: Take action to provide care as outlined in planning. Evaluation: Evaluate the effectiveness of the interventions provided and document the client’s response.

SMART Goals

Specific, Measurable, Achievable, Relevant, Time limited

Independent Nursing Interventions

Enacted based on nursing judgment and experience (ex. Fall precaution, education)

Dependent Nursing Interventions

Originate from provider’s orders (ex. meds)

Collaborative Nursing Interventions

Require cooperation among HCPs and UAPs (ex. Speech language pathology)

Motivational Interviewing

Form of therapeutic communication that allows the nurse and client to develop plans to promote client’s health by using several techniques: OARS

OARS

Open-ended questions “Tell me more about how you exercise or eat in a week”, Affirmations “You did very well with your food diary this week”, Reflective listening “So you are worried that you will get diabetes like your mother”, Summarizing “Your mother also had diabetes”

Passive Communication

Avoids conflict; a nurse is constantly asked to stay late but doesn’t want to. She says nothing and continues to stay late, even though it causes burnout.

Assertive Communication

Honest and clear communication that does not violate the rights of others; a nurse feels overwhelmed and speaks up about needing help during a busy shift.

Aggressive Communication

Verbally and/or physically abusive; A nurse yells at a CNA for not completing a task on time.

Passive-Aggressive Communication

Passive on surface, aggressive in subtle or secretive way; A nurse agrees to switch shifts, then complains about it to other coworkers or intentionally shows up late.

Communication with Hearing Impaired

Guiding clients away from background noise, Do not exaggerate your words or raise your voice, Make appropriate eye contact, Do not turn away or walk around while communicating, Provide a sign language interpreter if necessary

Rights of Delegation

Right task, Right circumstance, Right person, Right directions and communication, Right supervision and evaluation

Critical (CURE)

Emergent, life-threatening situations

Urgent (CURE)

Situations in which the client could suffer harm of discomfort if there is a delay in addressing the client’s needs

Routine (CURE)

Associated with client care

Extras (CURE)

Tasks that are not essential to client care but promote comfort

Rights of Med Admin

Right client, Right medication, Right dose, Right route of administration, Right time of delivery, Right documentation, Right to refuse, Right assessment, Right education, Right response

Safety Checks during Medication Administration

1. Checking the medication against the Medication Administration Record (MAR) or medication information device upon removal of the drug from the dispensing device (Pyxis). 2. Checking the drug upon preparation. 3. Checking the drug just prior to administration.

Medication Reconciliation

Performed any time the care of the client is transferred from one health care professional to another.Involves reviewing the client’s current medications, then addressing omissions and duplications. Ensures continuity of care.

Side Effects

Excessive expressions of known pharmacologic effects that occur at recommended doses

Drug overdose or toxicity

Exaggerated, but characteristic pharmacologic effect produced at supratherapeutic doses

Drug interactions

Unusual effects due to the combined pharmacologic activity of two or more drugs

Teratogenesis

Known to cause fetal defects

Allergic Reaction

Body perceives a foreign substance as an allergen, producing antibodies to counteract allergen

Adverse Drug Reactions

Unintended and nontherapeutic effects, which can range from tolerable to harmful and sometimes to irreversible damage or death

Serious Adverse Drug Event

Life-threatening reaction that requires medical intervention to prevent death or permanent disability, or congenital anomaly

Black Box Warning

Medications that produce lethal and iatrogenic results

High-Alert Medications

Associated with increased risk of causing considerable harm when they are administered in error

Meds for preventing clot formation

Warfarin, heparin, apixaban

Meds for decreasing blood pressure

-lol, -pril, -sartan, diuretics (furosemide, spironolactone, hydrochlorothiazide), amlodipine, diltiazem, verapamil

CBC

Red blood cell count (RBC) (4.35-5.65), Hemoglobin (13-18 mg/dL), Hematocrit (HCT) (36-50), White blood cell count (WBC) (4500-11000)

Coagulation Studies

Platelet count (150,000-450,000)

Troponin (<0.05)

Tells us if there has been cardiac muscle damage/ischemia within 2-3 hours

BNP (brain natriuretic peptide) (<100)

Hormone released by the ventricle during times of increased pressure or overload

Hemoglobin A1c (less than 5.7%)

Evaluates the blood sugar levels over a period of 2-3 months

Kidney Function Tests

Blood urea nitrogen (BUN) 10-20 mg/dL, Creatinine (0.5-1.3 mg/dL)

Lipid Profile

Total Cholesterol, Low-density lipoprotein (LDL) “bad cholesterol”, High-density lipoprotein (HDL) “good cholesterol”, Triglycerides

Liver function tests--Liver profile

Albumin, ALT, AST, Bilirubin

Endoscopy

Anyone who has a GI concern on the upper part of the GI tract.

Colonoscopy

Anyone who has a GI concern on the lower part of the GI tract.

Causes of Hyponatremia

Excessive Gl fluid loss (vomiting, nasogastric suctioning, draining fistulas), Excess diuresis, Excessive water ingestion or administration of nonelectrolyte IV fluids, Conditions that cause the body to hold onto fluids (CHF, cirrhosis, liver failure, etc)

Treatment of Hyponatremia

Sodium containing fluids (0.9% NaCl or 3% NaCl), Oral administration of NaCl tablets or high sodium foods

Causes of Hypernatremia

Excessive salt intake without adequate fluid intake, Decreased water intake, Watery diarrhea, High fever, Severe burns

Treatment of Hypernatremia

Fluid replacement, Hypotonic fluids (0.45% NaCl), Diuretics may sometimes be used to facilitate sodium excretion

Causes of Hypokalemia

Gl losses (vomiting/diarrhea), Loop diuretics, Inadequate intake of potassium, Renal losses

Hypokalemia Treatment

Oral or parenteral potassium Diet high in potassium, Balanced electrolyte solutions Pedialyte/Sports drinks

Causes of Hyperkalemia

RENAL FAILURE, Potassium-sparing diuretics, Excessive potassium intake, Burns

Hyperkalemia Treatment

In extreme cases, hemodialysis, Shift potassium into the cells with IV insulin, calcium gluconate

Causes of Hypomagnesemia

Chronic alcoholism, Diabetic ketoacidosis, Impaired absorption, Renal disease, Pancreatitis

Hypomagnesemia Treatment

Oral or parenteral magnesium replacement

Causes of Hypermagnesemia

Severe metabolic acidosis, Renal failure, Tissue trauma

Hypermagnesemia Treatment

Discontinue magnesium-containing medications, Hemodialysis may be needed for severe cases, Calcium gluconate is antidote to magnesium sulfate

Causes of Hypocalcemia

Lack of weight bearing

Hypocalcemia Treatment

Oral (calcium carbonate) or parenteral (calcium gluconate or calcium chloride)