exam 1 (all topics)

What is the goal of Healthy People 2030?

promote quality of life, healthy development, and healthy behaviors across all life stages
-access to health services
-injury/violence prevention
-health for all ages
-health of communities affects overall health of nation

Illness perceptions

beliefs about illness; may be brought on by cultural, spiritual, or ethical factors

what does holistic care consist of

paying attention to the mind, body, and spirit of the client

what is the normal range for a child temperature

96.8-99 F.

what is the normal range for adult temperature (tympanic/oral)

98.6 F.

what is the normal range for adult temperature (rectal)

99.5 F.

what is the normal range for adult temperature (axillary)

97.7 F.

pyrexia

fever

afebrile

without fever

hyperpyrexia/hyperthermia

very high fever (103-105.8 F. or above)

hypothermia

low body temperature (95 F. or lower)

factors affecting temperature

developmental level, environment, sex, exercise, emotions/stress/hormones, circadian rhythm

when should you not use the oral method of obtaining a client's temperature

if the patient has a problem with their mouth or if their mouth is in use by medical equipment

what is the normal range for adult pulse

60-100 bpm; strong, regular

systole

peak of the wave; contraction of the heart

diastole

trough of the wave; resting phase of heart

stroke volume

the amount of blood ejected from the heart in one contraction.

Cardiac Output (CO)

total quantity of blood pumped per minute

factors affecting pulse

exercise, temperature, acute pain, emotions, meds, hemorrhage, postural changes, pulmonary conditions

what is something to consider about older adult's pulse?

it may take longer for the HR to rise. heart sounds may also sometimes be muffled due to an increase in air space in the lungs

what is something to consider about older adult's temperature?

it runs low

when should you take the apical pulse

when the radial pulse is irregular, if a patient is taking cardiac meds, or in assessment of infants to children up to 3 years old

what is the normal range for adult blood pressure

120/80

peripheral resistance

arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls

hypotension

systolic pressure less than 100mmHg

prehypertension

BP of 120-139 systolic or 80-89 diastolic, obtained with 2 readings, 6 minutes apart with patient sitting

hypertension

BP above 140 systolic or 90 diasolic

primary hypertension

high BP where the cause is unknown

secondary hypertension

high blood pressure caused by the effects of another disease

what is the normal range for adult respirations

12-20

apnea

absence of breathing

dyspnea

difficulty breathing

orthopnea

difficulty breathing when lying down

rhonchi

low-pitched gurgling caused by secretions in large airways; can often clear with coughing

crackles

discontinuous popping sounds heard over inspiration; high-pitched popping or low-pitched bubbling sounds caused by fluid in alveoli

stridor

strained, high-pitched sound heard on inspiration when an individual experiences respiratory distress or has an obstructed airway

stertor

Labored breathing that produces a snoring sound

factors that affect respirations

exercise, pain, stress, smoking, fever, hemoglobin, disease, meds, position, neurological injury

signs of hypoxia

cyanosis, restlessness, apprehension, confusion, dizziness, fatigue, decreased level of consciousness, tachycardia, and BP changes

what is the normal range for adult O2 saturation

95% or more

factors that affect oxygen saturation

anxiety, infection, shock, hypoxia, drugs, acid-base imbalance, disease

what is something to consider about oxygen saturation levels in older adults with disease

they may have a lower oxygen saturation level and may require supplemental oxygen

disease definition

Infection is the invasion of a susceptible host by pathogens or microorganisms. Infection will develop if the Chain of Infection stays intact. This infection will ultimately result in disease.

chain of infection

-infectious agent/pathogen
-reservoir: place where microorganism survives, multiplies, and waits to be transferred to a susceptible host.
-portal of exit
-mode of transmission
-susceptible host

HAI

an infection that develops in a person cared for in any setting where health care in given. the infection is related to receiving health care

iatrogenic HAI

from a procedure

exogenous HAI

from microorganisms outside the individual (Salmonella)

endogenous HAI

when patient's normal flora becomes altered (C.diff)

body's response to stress

Basal metabolic rate increases as the body uses energy stores. Adrenocorticotropic hormone increases serum glucose levels and decreases anti-inflammatory responses. If this lasts a while, it can cause decreased resistance to infection.

inflammation

protective vascular and cellular reaction to eliminate pathogens and necrotic tissues.

serous exudate

Watery exudate: indicates early inflammation

sanguinous exudate

bloody

purulent exudate

Pus: indicates a bacterial infection (made up of bacteria, neutrophils, monocytes, and WBCs)

Signs of inflammation

redness, heat, swelling, pain, tenderness, loss of function, increased WBCs

localized infection

infection limited to a specific part of the body; has local symptoms

systemic infection

infection spreads to several sites and tissue fluids usually in the bloodstream

how can you ensure quality and safety in client care

Apply standard precautions, use clean gloves, use proper PPE, keep bedside tables clean, clean all equipment, ensure patient is covers nose and mouth when coughing and/or sneezing

mode of transmission: airborne

carried in droplet nuclei, need to wear N95, special equipped room with negative air flow

mode of transmission: droplet

sneeze or cough creates droplets carrying germs short distances, wear a surgical mask within 3 feet, proper hand hygiene, some dedicated-care equipment

mode of transmission: direct contact

requires gowns and gloves; ex. Staphylococcus aureus, rhinovirus

mode of transmission: indirect contact

involves contact with contaminated inanimate objects (needles, utensils, hospital equipment, etc)

mode of transmission: vehicle

contaminated items such as water, drugs, solutions, blood, food

mode of transmission: vector

transmission from parasites such as mosquitos, louse, flea, tick

importance of safety in client based care

-patient centered care: center the patient's care on their beliefs, values, etc.
-teamwork/collaboration: shared decision making for quality care
-evidence based practice: include current evidence with clinical skills
-quality improvement: use data to monitor patient outcome and use methods to test changes
-safety: minimize risk of harm by following safety precautions

vulnerable populations

individuals with limited access to health care, those who depend on others for care, those with low social support, those with limited financial clearance

standard precautions for infection control

-hand hygiene
-educate about infection prevention
-cover mouth and nose
-use surgical masks, gowns, gloves when necessary
-use fluid-resistant linen bags
-explain risks of depression when a patient enters isolation
-private rooms can provide negative-pressure airflow to prevent spread of disease

Assessing the Environment

replacement of equipment, furniture, bed position, bedside table and call light in reach, ambulation level, appropriate lighting

What age is the respiratory system considered fully developed?

by 20 years old

when does the respiratory system begin to decline

at 25 years old

health belief definition

a person's ideas, convictions, and attitudes about health and illness

illness behavior

how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system

Transtheoretical Model of Change

1. Precontemplation: not considering making a change/denial phase
2. Contemplation: considering making a change
3. Preparation: planning their change to carry out on specific timeline
4. Action: undergo the change process
5. Maintenance: sustained change over time; new behaviors adopted

according to the transtheoretical model of change, during which stage of change would the nurse help a patient integrate lifestyle changes

maintenance

primary prevention

Efforts to prevent an injury or illness from ever occurring; health promotion (immunizations)

secondary prevention

Early diagnosis and prompt treatment before disease becomes advanced and disability severe

tertiary prevention

actions taken to contain damage once a disease or disability has progressed beyond its early stages; restoration and rehabilitation

what symptom is associated with elevated temperature

diaphoresis

what symptom is associated with hypoxemia

cyanosis

what symptom is associated with abnormal blood pressure

chest pain

health belief model

Addresses the relationship between a person's beliefs and behaviors

Maslow's Hierarchy of Needs

physiological, safety, love/belonging, esteem, self-actualization

what environment would limit bacterial growth (be bactericidal)

pH of 3.0 because most bacteria prefer an environment with a pH from 5.0-7.0

which microorganisms are associated with exogenous infection

salmonella, staphylococci, enterococci, and streptococci

what disease is communicable and can be asymptomatic

hepatitis C virus

what disease is communicable and symptomatic

Tb

what patients would be at high risk for hypothermia

patients with cardiovascular problems, the homeless, and patients who have ingested excess drugs or alcohol

major reservoirs of HIV

blood, semen, vaginal secretions, breast milk (vehicles)

major reservoir of hepatitis A

feces

A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating?

tertiary

A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices?

difficulty paying his bills and family practice of not routinely seeing a doctor

When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model?

holistic

normal adult capnography

35-45mmHg

chills are caused by

vasoconstriction, piloerection, epinephrine secretion, shivering

patterns of fever

sustained, intermittent, remittent, relapsing

Korotkoff phases

Phase 1- A sharp thump
Phase 2- A blowing or whooshing sound
Phase 3- A crisp, intense tapping
Phase 4- A softer blowing sound that fades
Phase 5- Silence

host characteristics influencing susceptibility to disease

age, sex, ethnicity, socioeconomic status, marital status, lifestyle, heredity, nutritional status, occupation, immunization status, therapeutic procedures, meds, pregnancy, trauma

Lab tests to screen for infection

WBC count, cultures of urine and blood, iron level

Airborne precautions

precautions: private room, negative pressure airflow, mask or respirator

airborne diseases

measles, varicella, tuberculosis, disseminated herpes zoster, rubeola

Droplet precautions

Private room, mask