Unit/Exam 1 Foundations of Nursing

Cardiac Output (CO)

amount of blood pumped into the circulatory system by the heart within one minute

Stroke Volume (SV)

is the amount of blood ejected by the ventricle during one heart contraction (60-100 normal)

Blood Viscosity

The resistance of a liquid to flow, aka “thickness” of blood

atherosclerosis

hardening of the arteries

Peripheral vascular resistance

PVR = how hard it is for blood to flow through the blood vessels

Think of it as how tight or relaxed the vessels are.

• High PVR → vessels are narrow/tight

• Low PVR → vessels are wide/relaxed

Contractility

The force required to eject blood from the left ventricle and if the heart can do this efficiently or not.

Preload

the amount of blood inside the ventricles before they contract. (this can effect stroke volume and blood pressure)

Afterload

amount of resistance, or constriction, that the heart must overcome to eject the blood into the systemic circulation

Orthostatic Hypotension

A decrease in blood pressure that occurs upon standing, especially from a lying or sitting position. A significant drop in the blood pressure caused by a change in position.

tachycardia vs bradycardia

• higher then normal range heart rate

• lower then normal range heart rate

apical pulse

The heart rate that is heard or felt at the apex of the heart,

pulse sites in the body

• Temporal – At the temple, just lateral to the eye, above the zygomatic (cheek) bone

• Carotid – On either side of the neck, between the trachea and sternocleidomastoid muscle

• Apical – Left chest at the 5th intercostal space, midclavicular line (auscultated, not palpated)

• Brachial – Inner aspect of the upper arm, between the biceps and triceps (antecubital space)

• Radial – Thumb side of the wrist, just below the base of the thumb

• Ulnar – Little-finger side of the wrist (less commonly used)

• Femoral – In the groin, where the thigh meets the trunk

• Popliteal – Behind the knee, in the popliteal fossa

• Posterior Tibial – Behind and slightly below the medial malleolus (inner ankle)

• Dorsalis Pedis – Top of the foot, lateral to the extensor tendon of the great toe

eupnea

respiratory rate and rhythm that are normal or within range for a specific patient

Cheyenne - Stokes

Irregular respirations beginning with rapid shallow breaths and then deep breaths followed by apnea

Kussmaul Respirations

Deep, rapid respirations (metabolic acidosis)

Normal Vital Signs Range

Pacemaker of the heart

SA node

What would indicate orthostatic hypotension

A decrease of 20 millimeters of mercury ion the systolic pressure with a position change indicates what

Blood Pressure Readings

Pulse Rate Ranges by Age

Respiratory Rate (different ages)

Pulse 4 point scale

A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?

Instruct the client to bear down like they are having a bowel movement. (valsava maneuver can regualte heart rate)

A nurse is assessing a 3-month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse?

Place the stethoscope over the 4th intercostal space to the left of the sternum.

Pulse Deficit

Apical - Radial Pulse = ????

anticoagulant medication

Medications that inhibit the blood's ability to clot

medication reconciliation

The process when the physician assesses the current home medications with the newly prescribed drugs. It must be completed on client admission, transfer, or discharge from the hospital

hospital–associated infections (HAIs)

Nosocomial infections. Infections that occurred while the client was in the hospital.

​​ Jean Watson 10 Caritas Processes

Ten caring processes that provide a common language to guide nurses

1. Embrace – Loving‑Kindness

2. Inspire – Faith‑Hope

3. Trust – Sensitivity to Self and Others

4. Nurture – Helping‑Trusting Relationship

5. Forgive – Expression of Positive and Negative Feelings

6. Deepen – Creative Problem‑Solving

7. Balance – Transpersonal Teaching‑Learning

8. Co‑create – Healing Environment

9. Minister – Basic Needs with Dignity

10. Open – Spiritual‑Existential Care

Jean Watson’s Theory of Human Caring

Theory of client care stemming from holistic mind-body-spirit healing perspective characterized by caring moments in which the nurse and the client have a human-to-human connection

Medically Futile

doing useless treatments that don’t do anything for the patient

palliative care

multidisciplinary care approach that focuses on the management of symptoms for a chronic or life threatening condition while maintaining the highest quality of life possible

4 questions to ask before administering medication

• What Medications is the client currently taking?

• Interaction with prescription?

• Allergies?

• Physical assessments needed?

Nursing Process

5 step sequential process that allows nurses in prioritizing care for clients

1. assessment

2. analysis

3. planning

4. implementation

5. evaluation

Controlled Substances

Medication with the potential for addiction, misuse, and physical or mental injury regulated Drug Enforcement Administration. (NOT FOUND IN CLIENTS CABNIET)

Troche

a flat, round tablet also called a lozenge that is designed to be dissolved in the mouth and not swallowed. No food 5 min before or after

Sublingual/Buccal Administration

Under the tongue/Inside of the cheek

• DO NOT CHEW or eat until fully dissolved

Elixirs and Syrup

Elixir - contains water, alcohol, sweeter and medication

Syrup - contains water, concentrated sugar and medication

Suspension

A liquid medication prepared when the drug doesn't dissolve but is crushed into fine particles.. Shake or stir IMMEDIATELY before administration

First Step of Clinical Judgment Model

Assessment, recognize and analyze cues

General Survey, Lab/Assessment Results, Diagnostic material … ect

Recognize Cues

When you identify problems from the information you have gathered and you put them together to form a hypothesis or multiple

Analyze Cues

After your cues have been grouped together this is where you break down the reasoning behind the different hypothesis(s) you have formed

Time Management Matrix

A tool that divides activities into four quadrants: important, not important, urgent, not urgent.

EMRGENT - NOWWWWW

SMART Goals

• S: Specific

• M: Measurable

• A: Attainable

• R: Realistic

• T: Timely

SBAR Tool

(situational, background, assessment and recommendation)

helps relay client information systemically and concisely making sure no critical details are missed

SOAP Note

• S: Subjective

• O: Objective

• A: Assessment

• P: Plan

A acronym used for how nurses should document things in the clinical setting

Acuity Level

How much the requirement of nursing services is needed and the amount of nursing time to meet those requirements. AKA the complexity of a client's condition.

Client Assignment Types

• Direct: one nurse → specific client(s)

• Area: one nurse → specific location/zone

• Group: one nurse → group of clients

IDEAL Discharge Planning

• I: Include the client and caregivers.

• D: Discuss the five key areas—medications, home life, warning signs, test results, and follow-up.

• E: Educate the client on the condition, the discharge process, and next steps.

• A: Assess the effectiveness of the education.

• L: Listen to the client’s goals and preferences.

Teach-Back Method

• Nurse teaches → client explains it back

• Confirms understanding

• Used during education & discharge

5 Rights of Delegation

• Right Task: within role; no critical thinking

• Right Circumstance: client is stable

• Right Person: competent to do task

• Right Directions/Communication: clear instructions given

• Right Supervision/Evaluation: nurse supervises & evaluates

OUD: Steps of Care

1. Prevention – education, safe opioid use, risk screening

2. Identification – recognize misuse, assess risk factors

3. Treatment (1-2 years) – MAT (buprenorphine, methadone, naltrexone) + counseling

4. Recovery – long-term support, relapse prevention

Maslows Hierarchy of Needs

1. Physiological – food, water, oxygen, sleep

2. Safety – security, shelter, stability, protection

3. Love & Belonging – relationships, family, friends

4. Esteem – self-worth, confidence, respect

5. Self-Actualization – reaching full potential

ABCDE Priority of care Framework

A: Airway

B: Breathing

C: Circulation

D: Disability (neurological)

E: Exposure (environment safe? Expose patient to inspect)

Triage

To sort and rank clients based on their urgency of their need for care.

emergent (red) - needs treatment ASAP

urgent or delayed (yellow) - needs treatment in the next 30 min to 1hr

non-urgent or minimal (green) - can be okay without treatment for a few days

expectant (black) - probably going to die

Acuity Level

Used in the ED. Nurses focused client data when assigning an acuity level to each client. The acuity level helps with deciding which clients can wait to be seen and which clients should be seen immediately. (level 1 urgent - level 5 less urgent)

Increased fever can indicate

increased metabolism