H356- Exam 1 (Med Surg)

What are the stages of the nursing process (ADPIE) ?

Assessment, diagnosis, planning, implementation, and evaluation

What is done in each stage of the nursing process (ADPIE) ?

Assessment: collect data, organize data, and validate data

Diagnosis: analyze data, and identify health problems, risks and strengths

Planning: prioritize problems, formulate goals, select nursing interventions

Implementations: carry out nursing interventions

Evaluations: collect data related to goals, compare data, and draw conclusions

When are smart goals used?

When making goals for patients

What does SMART goals stand for?

Specific/single action, measurable, achievable, relevant, timely

Whats the difference between nursing and medical diagnosis?

Nursing diagnosis are within a nurses scope of practice and medical diagnosis are made by a Dr, physician assistant, or NP

Examples of nursing diagnosis…

risk for unstable blood glucose levels

deficient fluid volume

ineffective breathing patterns

Examples of medical diagnosis…

hypoglycemia

dehydration

respiratory failure

right leg ischemia

What is clinical reasoning?

“thinking it through”

nurses collect cues, process info, come to an understanding, plan, implement, and evaluate

What is clinical judgement?

“action you take”

the outcome and action that is took after collecting info and observing clues

What are the NCSBN clinical judgment measurement model steps?

Step 1: recognize clues (what’s going on? what are you seeing?)

Step 2: analyze cues (is there a reason what’s happening is happening?)

Step 3: prioritize hypothesis (what’s most likely happening?)

Step 4: generate solutions (what is the desired outcome?)

Step 5: take action (which intervention is priority to do? How will this be accomplishes?)

Step 6: Evaluate outcomes (was the goal achieves? Does anything else need changed?)

What is osteoporosis?

decreased bone density which increases the risk for fractures

What nutritional therapy is needed for osteoporosis?

increase calcium rich foods (dairy, veggies, sardines, salmon)

increase vitamin D intake (fish, mushrooms)

What are fortified calcium rich foods?

fruit juice, cereal, bread, rice, soy, and tofu

what are fortified vitamin D foods?

milk, OJ, yogurt, cereal, and bread

What does calcium do for osteoporosis and what does it need to work?

Calcium foods prevent or treat osteoporosis and calcium does nothing without vitamin D

Why do calcium and vitamin D need each other?

Vitamin D supplements are needed to absorb calcium from GI tract into blood stream

What diagnostic testing is needed for a pt with osteoporosis?

DXA scan (most effective)

Serum calcium and Vitamin D3 (done annually)

conventional x-rays

what does a DXA scan do for a pt with osteoporosis?

measures bone mineral density (decreased bone density is how it is diagnosed)

what does serum calcium and vitamin D3 do for a patient with osteoporosis?

to determine possible needs of supplements

what do conventional x-rays do for a patient with osteoporosis?

used if a fracture is present, but does not diagnose osteoporosis

what are complications and risk factors of osteoporosis?

fracture, spinal/skeletal deformity, pain, decreased mobility, trouble with ADL’s, depression, insomnia, poor self esteem, and fear of falling

what do most patients with osteoporosis have?

kyphosis (hunchback)

calcitonin

\*selective estrogen receptors modulators (SERM’s)

stops breakdowns of the bone

available as a nasal spray or IM injection

give IM injection at night to minimize effects

alternate nostrils when using nasal spray

side effects: nasal irritation (nasal form), nausea/vomiting (IM injection)

calcium carbonate and calcium citrate

\*calcium supplements

often took preventively by postmenuposal women

should not be took within 1-2 hours of other meds

should be took orally with meals or an hour after meals

side effects: constipation, cardiac arrhythmia

requires vitamin D also since its calcium for absorption

calcitrol

\*vitamin D supplement

reduces bone resorption

taken orally with or without food

protect capsules from sunlight

side effects: possible increase in calcium levels

alendronate, risedronate, ibandronate

\*bisphosphonates (ends in “dronate”)

slows breakdown of bone

increases bone density which decreases risk for fractures

take orally with a full glass of water

take 2 hours before meals on an empty stomach

remain in upright position for at least 30 mins

side effects: nausea, vomiting, esophageal irritation, abdominal pain

raloxifene

\*selective estrogen receptors modulators (serm’s)

binds to estrogen receptors

reduces breakdown of bone

increases bone density which decreases risk for fractures

take with or without food

increases risk for VTE (formation of blood clot)

side effects: hot flashes, leg cramps, weight gain

what is health promotion

behavior that Is motivated by desire to change

important so pts can achieve highest goal of optimal goal/self actualization

what is primary prevention

preventions before a disease is established

ex/ educating pt about sunscreen or influenza vaccine

what is secondary prevention

screenings during early stages to identify sooner

ex/ annual mammogram, pt has a colonoscopy to scan for colon cancer

what is tertiary prevention

treatment or rehab stage

ex/ physical therapy after hip replacement, taking amlodipine for hypertension, chemo for lung cancer

a client is prescribed alendronate at 0800 for the treatment of osteoporosis. how should the nurse administer this medication?

give on an empty stomach with a full glass of water and instruct the pt to sit upright for 30 mins

annual eye exams are an example of which type of prevention?

secondary

a nurse is providing education to a client who has been diagnosed with osteoporosis. which client statement indicates that the client understands the education?

“it is a disease that causes progressive bone loss, which can result in bone fractures”

the nurse is providing diet education to a pt who has been diagnosed with osteoporosis. what should the pt include in the meal plan?

orange juice

a nurse applied oxygen to a client who has difficulty breathing and an oxygen saturation of 86%. which step of the NCSBN clinical judgement measurement model does this represent?

take action

a nurse is performing health screenings at a health fair. what type of pt is at risk for osteoporosis?

a 40 year old pt who has been taking prednisone for 6 months

(long term prednisone use affect the absorption and metabolism of calcium and places the client at a risk for osteoporosis

what do the kidneys do?

balances bodies fluids

is the kidneys aren’t working what can happen

fluid overload

bun and creatine levels increase

electrolyte levels increase

define renal calculi

kidney stone

define hydronephrosis

kidney build up with urine

hydroureter

ureter enlarges due to back up of the urine

pyelonephritis

kidney infection

dysuria

painful urination

what are some interventions that promote urinary health

wipe front to back (women)

hygiene care

fluid intake (cranberry juice helps UTI)

regular physical activity

don’t hold urge to urinate (stretches bladder)

proper foley care

strict sterile technique when placing foley

kegel excercises

regular medical screenings

how do you access a pt with an issue with urinary issues

mental status

I and O

characteristics of urine

urine culture

uranalysis

abdomen assessment

CVA assessment

look at perineal area (vaginal prolapse)

pain

urinary symptoms

voiding patterns

general appearance

skin color and temp

general appearance

genitourinary assessment (GU)

palpapte bladder for distention

diagnostic testing for urinary issues

urinalysis

BUN and creatine (renal function)

bladder scan

CT scan

ultrasound

IVP (intravenous pyelogram)

urine culture and sensitivity (48-72 hours to get results)

metabolic panel-BMP (basic metabolic panel), CMP (complete metabolic panel)

cystoscopy (uses a camera, can increase risk for infection)

ureterscopy (uses a camera, can increase risk for infection)

IV flow rate formula

volume (mL) / time (hour) = Y (flow rate)

IV flow rate-units/hour

\*determine concentration first

D (desired amount) / H (dose you have) x V (volume) =dose

IV drip rate forumla

volume (mL)/ time (hours) x 60 mins x drip factor (get/mL)= IV drip rate

what are characteristics of effective interprofressional collaboration

clear goals, clarity on roles, clinical competence, effective communication, call and respecting each other, trust, cooperative relationships, participative leadership

how do you collaborate with pts and their support systems

communicate, educate in a way they understand, be honest, allow them to be involved in decisions

define incivility

disrespectful or rude comments made towards you, can be from a pt or other employee

define horizontal violence

when another nurse is bullying you

what should happen if you're experiencing incivility or horizontal violence?

these actions should be reported immediately (depending on protocol), depending on severity you can confront the person. these issues can lead to more problems such as poor pt outcomes, job dissatisfaction, or a high turn over

what is perioperative surgery

the three stages of surgery

what is preoperative surgery

phase before surgery

what is intraoperative

during surgery

what is postoperative

care after surgery

What are the 4 layers of the NCSBN clinical judgement model

layer 0-the observation layer

layer 1- the first cognitive layer

layer 2-the second cognitive layer

layer 3-the third cognitive layer

define health

state of complete physical, mental, or social well being

define wellness

a process of self-care achieved by making choices leading to a healthy life

define illness

an abnormal process in which aspects of the social, physical, emotional, or intellectual condition and function of a person are diminished or impaired

define acute illness

abrupt onset: short duration (less than 6 months)

define chronic illness

characterized by a loss of abnormality of body function that lasts longer than 6 months and requires ongoing long-term care

define remission

periods of wellness

define exacerbation

worsening of clinical manifestations, which could be life-threatening

define health protection

intentional behaviors to overcome illnesses

define preventative action

involves lifestyle change and information gathering about a health topic that leads to a change in behavior

define self actualization

highest level of optimal functioning, it involves the integration of cognitive abilities

what are factors that affect health

age, gender, genetics, lifestyle, environment, attitudes and emotions, support system, beliefs and values, and access to healthcare

what is secondary osteoporosis

results from other diseases, treatments, or meds

what is osteoporosis often called

the silent disease

what is osteoporosis caused by

an imbalance of bone resorption and bone remodeling which leads to decreased skeletal mass and decreased bone density

what is bone resorption

the process by which bones are broken down and absorbed by the body

what is bone remodeling

the process of constant change that bones undergo as living tissues

who is most at risk for osteoporosis

postmenopausal women and men 70 or older are most at risk

non modifiable risk factors for osteoporosis

over 50 years of age

menopause or hx of total hysterectomy

parental hx of osteoporosis

eating disorders

rheumatoid arthritis

hx of low trauma fracture after age of 50

modifiable risk factors for osteoporosis

low body weight

chronic low calcium or vitamin D intake

estrogen or androgen deficiency

smoker

high alcohol intake

poor nutrition

lack of physical exercise

prolonged decreased mobility

clinical manifestations of osteoporosis

pain-often in back or spine

fracture-often vertebral

progressive curvature of the spine-kyphosis

decreasing height

what is included in assessment for a pt with osteoporosis

observation: gait, ability to perform ADL’s, ROM

patient interview: hx of current illness (all the questions)

physical examination (inspect and palpate): general appearance, height/weightBMI, musculoskeletal (spinal curvature, evidence of fracture), ability to perform ADL’s

what is the treatment goal for a pt with osteoporosis

prevent or decrease bone loss, fractures, and manage risk factors

define elimination

secretion and excretion of waste products from kidneys and intestines

where is urine excreted from

the urinary system

where is stool excreted from

the gastrointestinal system

what are the jobs of the urinary systems

filter the blood, removes fluid and electrolytes, reabsorbs nutrients, maintains desired concentration of electrolytes and nutrients, helps maintain proper neuronal, muscular, bone and cellular strength and function, helps maintain BP to ensure adequate circulation of oxygen and nutrients

what are the parts of the upper urinary system

kidneys and ureters

what are the parts of the lower urinary tract

urinary bladder, urethra, pelvic flood muscles

what strengthens the pelvic floor muscles

kegels

what are the functions of these organs

aorta, renal artery, kidney, ureters, bladder, urethra

aorta-brings blood to the renal artery

renal artery- supplies blood to the kidneys to be cleaned

kidney-organ filters the bloods toxins and wastes, transferring them to urine

ureters-tubes that transfer the urine to the bladder

bladder-storage of urine, contain stretch receptors

urethra-transfers urine from bladder to outside of body

\
what is urine also called

micturition, voiding

what is the normal pattern for voiding

5-6 times daily (depends on person)

what amount of urine output indicates adequate renal functioning

30mL/hr or greater is adequate renal functioning

define anuria

failure of kidneys to excrete/produce urine (can indicate kidney failure)

define oliguria

reduced urine volume

define polyuria

excessive amount of urine formed and excreted

define dysuria

painful urination (seen commonly with UTI’s)

define Urinary Incontinence

inability to control passage of urine

define urinary retention

inability of bladder to empty (often an obstruction or neurological)

what factors affect urinary elimination

developmental factors/lifestyle considerations, physchosocial factors, fluid and food intake, medication, surgical and diagnostic procedure, pathological conditions, impaired mobility, pregnancy