NU322 Exam 1

Foundations

factors affecting vital signs

age, gender, genetics, weight, circadian rhythms, state of health, environmental temp, stress, meds, disease states, fever

BP: emotional state & body position

sites for assessing temp

oral

tympanic

temporal

rectal

axillary

sites for assessing pulse

temporal

carotid

apical

brachial

radial

femoral

popliteal

posterior tibial

dorsalis pedis

sites for assessing BP

brachial artery most common

popliteal

forearm

ankle

assessing temp

thermometers

which one & where depends on age, cooperation, accessibility of location

assessing pulse

count beats per 30 sec x2 bpm

assessing respirations

1 resp = 1 full inhalation + 1 full exhalation

count # resp in 30 sec x2 rpm

assessing BP

palpate brachial artery

apply cuff

palpate radial artery & pump cuff until no longer felt

position stethoscope over location of brachial artery & release cuff at rate of 2-3 lines/sec

1st korotkoff sound = systolic

loss of sound = diastolic

quickly release cuff & record

normal temp values

96\.4-99.5

35\.8-37.5

normal pulse values

60-100

80 avg

normal respiration values

12-20

normal BP values

120/80 or less than

pulse deficit & what it indicates

difference between apical & radial pulse rates

apical (felt at heart)

radial (felt at wrist)

if unequal, listen to each for 1 min & measure difference (apical – radial)

deficit > 10 needs further investigation, call physician

major classification of hypertension

increased BP

“silent killer”

can lead to hemorrhagic stroke, embolism, heart attacks

Primary/Essential: increase in both BP #s w/out known cause

Secondary: increase in both BP #s w/ known cause

factors affecting hygiene practices

culture

socioeconomic status

spiritual practices

developmental levels

health status

personal preferences

disease/illness status

bed baths

complete: all areas covered

partial: genital, perineum, hands, face

therapeutic: long-term care

shower

tub

bath in bag

oral care

2x/day or 1x/shift

pt lying on side if performing on unconscious pt

nail & foot care

typically done by podiatrist depending on facility

cut nails across & file sides

always dry thoroughly

don’t soak if pt has diabetes or neuropathy

perineal care

decreases risk for infection especially in pt’s w/ catheters, given birth, had rectal surgery, or uncircumcised males

hair & scalp care

wash & comb

shower cap if needed

shaving

get pt input what they’d like done

use warm towel 1st to soften area

be careful w/ pts on anticoagulants, blood thinners, etc.

considerations when assisting pts w/ hygiene

whether or not pt is diabetic

whether or not pt uses dentures

whether or not pt can assist w/ hygiene care

assessments done while assisting pts w/ hygiene

odors

lesions

heart sounds

skin integrity

tolerance

any other abnormal findings

nursing interventions associated with assisting pts w/ hygiene

when documenting, nurse should include what’s done, pt’s level of involvement, findings, pt’s response to care, & any education provided

aims of nursing

promote health

prevent illness

restore health

facilitate coping w/ disability/death

roles of a nurse

caregiver

communicator

teacher & educator

leader

counselor

researcher

advocate

collaborator

professionalism in nursing

standards of ethics

culturally congruent practice

communication

collaboration

leadership

education

EPB

research

practice quality

professionalism evaluation

resource utilization

4 concepts common to all nursing theories

describes, explains, predicts, controls desired outcomes of nursing care practices

4 metaparadigms

4 metaparadigms

person/pt

environment

health

nursing (relationship between pt & nurse)

quantitative research

involves concepts of basic & applied research

\#s based

what rather than why

measurable & countable

tells us how much, how often, how many

data is objective (factual)

qualitative research

conducted to gain insight by discovering means

why rather than what

focus on change over time

seek in depth understanding of social phenomenon

basic research

designed to generate & refine theory

findings aren’t often directly useful in practice

basic purpose is to acquire infromation

advance knowledge w/out any immediate goal in mind or use of practice in mind

applied research

designed to directly improve/influence clinical practice

seen in nursing

look at pain managements

influences of nurses as far as length of pt’s hospital stay

evidence-based practice in nursing care

provides problem-solving approach to making clinical decisions using best evidence available collected from reputable sources

steps (form clinical question, gather best evidence, analyze evidence, apply evidence to clinical practice, assess results)

elements (integration of best practices to guide current practices, viewing clinical expertise as component in care efficacy, & considering pt’s preferences/values/engagement in decision making)

EBP

evidence-based practice

HAI

hospital-acquired infection

homeostasis in wound healing

activation of coagulation cascade

inflammation in wound healing

may experience low-grade fever

proliferation in wound healing

repair phase

granulation begins to appear

adequate nutrition important

maturation in wound healing

starts about 3 wks post-surgery

collagen production forms scar

classification of wounds

intentional vs unintentional

open vs closed

acute vs chronic

factors affecting skin health & wound healing

age (skin thins w/ age leading to tears, less collagen production, decreased peripheral circulation, slower tissue regeneration)

state of health (obese are more susceptible to skin injury, dehydration, excessive perspiration, jaundice, eczema/psoriasis, smoking, chronic disease, meds)

pts at risk for pressure ulcer development

immobile

elderly

suffer from malnutrition

incontinent

altered level of consciousness

spinal cord/brain injuries

neuromuscular disorders

stages of pressure ulcers

nonblanchable

partial-thickness

full-thickness

full-thickness w/ extensive destruction

unstageable

nonblanchable

stage I

redness to area, stays red when press on it

partial thickness skin loss

stage II

blister, shallow-crater appearance, involves epidermis

full thickness skin loss

stage III

damage to epidermis & dermis

full thickness skin loss w/ extensive destruction

stage IV

involves destruction through all skin layers & some part of tendon, muscle, or bone

unstageable

base of ulcer covered by slough &/or eschar

assessing wounds

inspect: sight & smell

palpate: swelling

exudates: serous, sanguineous, serosanguineous, purulent

sutures/drains/tubes: S&S of infection

measurement: length x width x depth

serous exudate

clear, watery

sanguineous exudate

bloody

serosanguineous exudate

light pink, watery

purulent exudate

yellow/green, thick

pus

nursing interventions preventing pressure ulcer

mobility: turn q 2 hrs

nutritional status: safe swallow, pre-surgery, eating well

moisture & incontinence: always change pt quickly, be sure to dry well after bath

appearance of PU if already existing: monitor & change dressings

assess pain

proper wound management

clean wound every dressing change, use careful motions to minimize trauma, use 0.9% normal saline solution, document/report drainage or necrotic tissue

dressings, bandages, binders

dressings

telfa

gauze

transparent

bandages

typically roller bandages

circular turn, spiral turn, figure-8 turn, recurrent stump

binders

straight

t-binder

sling

straight binder

abdomen/chest

usually to support surgical incision

t-binder

rectum, perineum, groin

usually to secure dressings

sling

support arms

infection cycle & how hand hygiene can break it

infectious agent, reservoir, portal of exit (blood/GI/genitourinary/nasal/drainage/breaks in skin), means of transmission, portal of entry, susceptible host

hand hygiene can eliminate transmission of infectious agents from 1 pt to another or to staff

stages of infection

incubation period

prodromal stage

full stage

convalescent period

incubation period

from pathogen entry to S&S

prodromal stage

non-specific symptoms

most infectious

full stage

specific S&S of disease

convalescent period

starting to feel better but typically categorized by fatigue

factors increasing risk for infection

breaks in skin

abnormal pH levels

low WBC count

age, gender, race, genetics

immunization (natural or acquired)

nutrition

general health status

stress

indwelling/invasive medical devices

healthcare-associated infections & how healthcare providers can prevent

infections acquired in healthcare facility

CAUTI, SSI, pneumonia, bloodstream infections, MRSA, VRE, C diff

prevent by using standard & surgical aseptic/sterile techniques, wash hands between pts, frequent pt monitoring especially of indwelling medical devices

standard precautions

used in all hospital settings & will at pts

regardless of diagnosis

apply to blood, body fluids, secretions/excretions, respiratory etiquette

transmission-based precautions

used in addition to standard when infectious pathogen suspected whose transmission is airborne, droplet, or contact

PPE required, pt-specific tools (stethoscope)

surgical asepsis

requires sterilization of equipment & environment

assessments, hx, & physical findings increasing pt’s risk for safety issues

questions & visual inspection (stairs at home, pt limping, feel safe at home)

pt hx (previous falls/accidents, drug/alcohol use, assistive devices for ambulation, knowledge of family support/home environment)

physical exam (mobility status, ability to communicate, level of awareness, sensory perception, potential safety hazards)

finding suggestive of violence, neglect, or abuse

fall prevention nursing interventions

inspect gait

ask/notice impaired vision/balance

notice any postural hypotension (take BP)

notice slowed reaction time, confusion, or disorientation

violent-behavior restraints

used for aggression when pt is harm to themselves/others

4 point locking

DR order good for 3 hrs (must see pt w/in 1 hr)

documentation required every 15 min (vitals/fluid intake/cognition/skin integrity)

requires enhanced pt monitor/sitter

no orders needed to remove if staff feels no longer necessary

non-violent behavior restraints

behavior threatens pt safety (ex: pt pulls out IVs/ tubes/med devices needed for care)

DR order good for 24 hrs (must see pt w/in 24 hrs)

documentation required every 15 min (vitals/fluid intake/cognition/skin integrity)

enhanced pt monitor not needed

no orders needed to remove if staff feels no longer necessary

chemical restraints

drugs keep pt in calmer state

mitt restraints

not considered restraint but noteworthy

no order needed

velcro always facing outward

interventions keeping pts safe during nursing care

5 R’s of med admin

correct transferring procedures

aseptic wound dressing changes

minimizing wrong-site surgeries & burns by always checking on pt’s w/ heating pad

variables influencing body alignment & mobility

developmental factors (age, cognitive abilities)

physical health (COPD)

mental health (stress, fatigue)

lifestyle (fitness level, job)

external factors (environment, neighborhood)

effects of exercise & immobility on major body systems

decreased circulatory ability

decreased bone density

decreased muscle strength

increased fat

decreased BMR

blood in leg stasis

impaired balance

assessing body alignment, mobility, & activity tolerance

use visual cues - kyphosis, scoliosis, gait, movement patterns, assistive devices or lack thereof but needed

can pt do ADLs on own

gait belts

around waist or chest

depending on abdominal wounds

2 fingers between belt & pt

canes

limits pressure of weight-baring joints

hold in hand OPPOSITE affected limb

moves same time as affected limb

crutches

adjust based on height

should be 2-3 finger space between armpit & top

2, 3, or 4 point gaits

walker

adjust based on height

handles line up w/ wrists

arms 15˚ when in use

2 types: Wheels (2 or 4) & No-Wheel (4-prong)

don’t use on stairs

wheelchair

decreases workload on heart & O2 demands

lead from strong side when transferring

always lock when not in use

lifts

2 kinds: sit to stand (must be able to load-bear at least somewhat) & standing lift (no weight-bearing at all)

nursing interventions preventing complications of immobility

gait belt

safe transferring practices

skin assessment &/or repositioning q 2 h

bed alarms

correct Foley positioning

case management/social work follow-up

key components of nursing process

ADPIE

Assess

Diagnose

Plan

Implement

Evaluate

assess

identify needs & additional required data

objective & subjective

diagnose

identify patterns/trends

compare data w/ expected values

judge significance of data

arrive at conclusions to guide care

plan

create comprehensive poc

modify as assessments come back

discharge planning

SMART

client-centered goals

nurse-initiated vs physician-initiated interventions

implement

use problem solving & clinical judgement skills to select & apply appropriate therapeutic interventions

evaluate

outcomes vs planned goals

continue what’s working & change/discontinue what’s not

problem-focused nursing diagnosis

clinical judgement concerning undesirable human response to health condition or life process existing in individual, family, group or community

risk nursing diagnosis

clinical judgement concerning vulnerability of individual, family, group, or community for developing undesirable human response to conditions or life processes

health promotion nursing diagnosis

clinical judgement concerning motivation & desire to increase well-being & to actualize human health potential

responses expressed by readiness to enhance specific health behaviors & can be used in any health state

responses may exist in individual, family, group, or community

purpose & benefits of nursing process

prioritized, complete, systematic, factual & accurate, relevant, & recorded in timely manner

pt safety, positive therapeutic interventions, holistic pt care