Funds Final Exam Review

Maslow's Hierarchy of Needs

• Levels and order of importance:

  • Physiological: Basic survival needs (e.g., air, water, food, shelter, sleep).

  • Safety: Security, stability, freedom from fear.

  • Love/Belonging: Intimacy, affection, relationships.

  • Esteem: Self-respect, confidence, achievement.

  • Self-Actualization: Reaching one's full potential.

• Prioritizing Care: Use the hierarchy to address the most fundamental needs first.

Clinical Manifestations of Stress

• Sympathetic Nervous System:

  • Fight-or-flight response.

  • Increased heart rate, blood pressure, and respiratory rate.

  • Pupil dilation.

  • Decreased digestion.

• Parasympathetic Nervous System:

  • Rest and digest response.

  • Decreased heart rate, blood pressure, and respiratory rate.

  • Increased digestion.

Effects of Stress and Stress Related Disorders

• Cardiovascular: Hypertension, coronary artery disease.

• Gastrointestinal: Ulcers, irritable bowel syndrome.

• Immune: Weakened immune response, increased susceptibility to infection.

• Mental Health: Anxiety, depression.

Levels of Prevention

• Primary: Preventative measures to avoid the onset of disease (e.g., vaccinations, healthy diet, exercise).

• Secondary: Early detection and intervention (e.g., screenings, mammograms).

• Tertiary: Managing and rehabilitating established disease to minimize complications (e.g., physical therapy after a stroke).

Common Defense Mechanisms

• Denial: Refusing to acknowledge reality.

• Displacement: Transferring emotions to a less threatening target.

• Projection: Attributing one's own feelings or thoughts to others.

• Regression: Reverting to childlike behaviors.

• Rationalization: Creating false justifications for unacceptable behavior.

Nursing Process

• Assessment: Gathering subjective and objective data.

• Diagnosis: Identifying the patient's problem based on the assessment data.

• Planning: Setting goals and developing interventions to address the problem.

• Implementation: Carrying out the planned interventions.

• Evaluation: Assessing the effectiveness of the interventions in achieving the goals.

Confidentiality with Computer Documentation

• Protect patient privacy.

• Follow HIPAA guidelines.

• Do not share passwords.

• Log off when leaving a computer.

General Guidelines for Documentation

• Accurate and factual.

• Complete and concise.

• Objective.

• Timely.

• Legible.

• Use standard terminology.

ISBAR

• Introduction: Identify yourself, your role, and the patient.

• Situation: Briefly state the reason for the communication.

• Background: Provide relevant history and context.

• Assessment: Share your assessment findings.

• Recommendation: Suggest a course of action.

• Used for: Communication between healthcare providers.

Culture

• Personal Space: Varies among cultures; be aware of and respect personal boundaries.

• Other Cultural Aspects: Communication styles, beliefs about health and illness, dietary practices, family roles.

Hand Hygiene

• Importance: Prevents the spread of infection.

• Methods:

  • Hand washing with soap and water.

  • Using alcohol-based hand sanitizer.

Medical vs. Surgical Asepsis

• Medical (Clean) Asepsis: Reduces the number and spread of pathogens.

• Surgical (Sterile) Asepsis: Eliminates all microorganisms.

Standard Precautions

• Used with all patients, regardless of diagnosis.

• Includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices.

Donning and Doffing PPE

• Donning (Putting On):

  1. Gown

  2. Mask

  3. Goggles/Face Shield

  4. Gloves

• Doffing (Taking Off):

  1. Gloves

  2. Goggles/Face Shield

  3. Gown

  4. Mask

• Hand hygiene after removing PPE.

Logrolling

• Definition: Technique used to turn a patient in bed while keeping the spine in alignment.

• Why Use It: To prevent spinal injury or further complications in patients with spinal issues.

Active vs. Passive Range of Motion (ROM) Exercises

• Active ROM: Patient performs the exercises independently.

• Passive ROM: Healthcare provider moves the patient's joints through the range of motion.

Safe Use of Wheelchairs

• Check for proper fit and condition of the wheelchair.

• Lock the brakes before transferring the patient.

• Use a gait belt to assist with transfers.

• Ensure the patient's feet are supported.

Safe Use of a Slide Board

• Position the board between the surfaces.

• Ensure the board is stable and secure.

• Use proper body mechanics to prevent injury.

Safe Use of a Gait Belt

• Apply the belt snugly around the patient's waist.

• Use proper body mechanics when assisting the patient.

• Do not use the belt to lift the patient.

Hygiene

• Bathing Preferences: Respect the patient's preferences for bathing.

• Other Factors: Cultural considerations, mobility limitations, cognitive impairments.

Risk Factors for Pressure Injuries

• Immobility.

• Incontinence.

• Malnutrition.

• Dehydration.

• Sensory loss.

Stages of Pressure Injuries

• Stage 1: Non-blanchable erythema of intact skin.

• Stage 2: Partial-thickness skin loss with exposed dermis.

• Stage 3: Full-thickness skin loss with damage or necrosis of subcutaneous tissue.

• Stage 4: Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.

• Unstageable: Full-thickness skin and tissue loss where the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

• Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration.

Pressure Injury Prevention

• Reposition the patient frequently.

• Use pressure-reducing devices (e.g., specialty mattresses, cushions).

• Keep the skin clean and dry.

• Ensure adequate nutrition and hydration.

Back Massage

• Promotes relaxation.

• Improves circulation.

• Reduces muscle tension.

Falls Risk Assessment

• History of falls.

• Medications.

• Gait and balance.

• Cognitive impairment.

• Visual impairment.

• Environmental hazards.

Protective Devices

• Types: wrist restraints, vest restraints.

• Why Used: To protect patients from injury.

• Precautions: Monitor frequently, ensure proper fit, release regularly for range of motion.

Vital Sign Norms

• Temperature: 97.6-99.6°F (36.4-37.5°C)

• Pulse: 60-100 beats per minute.

• Respirations: 12-20 breaths per minute.

• Blood Pressure: Less than 120/80 mm Hg.

• Oxygen Saturation: 95-100%.

Factors Affecting Pulse Rate and Blood Pressure

• Pulse Rate: Age, exercise, stress, medications.

• Blood Pressure: Age, weight, race, diet, stress.

Physical Exam Techniques

• Inspection: Visual examination.

• Palpation: Touching to assess texture, temperature, and tenderness.

• Percussion: Tapping to assess underlying structures.

• Auscultation: Listening with a stethoscope.

Heart Auscultation Areas

• Aortic: 2nd intercostal space, right sternal border.

• Pulmonic: 2nd intercostal space, left sternal border.

• Tricuspid: 4th intercostal space, left sternal border.

• Mitral: 5th intercostal space, midclavicular line.

Abnormal Curvatures of the Spine

• Scoliosis: Lateral curvature of the spine.

• Kyphosis: Excessive outward curvature of the thoracic spine (hunchback).

• Lordosis: Excessive inward curvature of the lumbar spine (swayback).

Abnormal Lung Sounds

• Wheezes: High-pitched whistling sounds.

• Crackles (Rales): Crackling or bubbling sounds.

• Rhonchi: Coarse, snoring sounds.

• Stridor: High-pitched, crowing sound.

Measuring Pitting Edema

• Press firmly on the skin and note the depth of the indentation.

• 1+ = 2mm

• 2+ = 4mm

• 3+ = 6mm

• 4+ = 8mm

Abdominal Assessment

• Inspection: Observe for distention, scars, and pulsations.

• Auscultation: Listen for bowel sounds in all four quadrants.

• Percussion: Assess for tympany (air) and dullness (organs).

• Palpation: Lightly palpate to assess tenderness and masses.

Neuro Assessment

• Pupil Assessment:

  • Size: Measure pupil diameter in millimeters.

  • Shape: Pupils should be round.

  • Reactivity: Assess response to light (direct and consensual).

  • Accommodation: Assess pupil constriction when focusing on a near object.

Normal Lab Values

• White Blood Cell (WBC): 5,000-10,000/mm^3

• Red Blood Cell (RBC):

  • Male: 4.7-6.1 million/mcL

  • Female: 4.2-5.4 million/mcL

• Hemoglobin (HGB):

  • Male: 14-18 g/dL

  • Female: 12-16 g/dL

• Hematocrit (HCT):

  • Male: 42-52%

  • Female: 37-47%

Stool Tests

• Ova and Parasites: Detects the presence of parasitic infections.

• Occult Blood: Detects hidden blood in the stool, which may indicate gastrointestinal bleeding. Use a fecal occult blood test (FOBT) test.

Hypervolemia vs. Hypovolemia

• Hypervolemia: Fluid overload. Body regulates fluid volume through kidneys and hormones.

• Hypovolemia: Fluid deficit. Body regulates fluid volume through kidneys and hormones.

Electrolytes

• Sodium (Na):

  • Normal Range: 135-145 mEq/L

  • Functions: Regulates fluid balance, nerve and muscle function.

• Potassium (K):

  • Normal Range: 3.5-5.0 mEq/L

  • Functions: Nerve and muscle function, cardiac function.

• Calcium (Ca):

  • Normal Range: 9.0-10.5 mg/dL

  • Functions: Bone health, blood clotting, nerve and muscle function.

Signs and Symptoms of Dehydration

• Thirst.

• Dry mucous membranes.

• Decreased urine output.

• Dark urine.

• Dizziness.

• Weakness.

Fat Soluble vs. Water Soluble Vitamins

• Fat Soluble: A, D, E, K. Stored in the body.

• Water Soluble: B vitamins, C. Not stored in the body; excess is excreted.

Full Liquid vs. Clear Liquid Diets

• Clear Liquid: Clear broths, gelatin, clear juices. No pulp.

• Full Liquid: Clear liquids plus milk, pudding, ice cream, vegetable juices.

Measuring Oxygen Saturation

• Method: Pulse oximetry.

• Reasons for Inaccurate Readings: Poor circulation, nail polish, cold extremities.

Postural Drainage

• Definition: Using gravity to drain secretions from the lungs.

• Why Use It: To improve respiratory function in patients with conditions such as cystic fibrosis or pneumonia.

Oxygen Safety Considerations

• No smoking.

• Keep oxygen away from open flames.

• Ensure proper storage.

Infection in Older Adults

• Changes: Confusion, weakness, loss of appetite, incontinence.

Abnormal Characteristics of Urine

• Color: Dark, bloody, concentrated, or cloudy.

• Odor: Strong, foul.

• Clarity: Cloudy, sediment.

Abnormal Characteristics of Stool

• Color: Black, red, white, or clay-colored.

• Consistency: Hard, watery, or mucus-filled.

• Odor: Foul.

Medications Contributing to Constipation

• Opioids.

• Anticholinergics.

• Iron supplements.

Non-Medicinal Methods of Pain Control

• Heat or cold application.

• Massage.

• Distraction.

• Relaxation techniques.

• Therapeutic touch.

Commonly Used Herbs in Herbal Therapy

• Echinacea.

• Ginseng.

• Garlic.

• Ginger.

• St. John's Wort.

Six Rights of Medication Administration

• Right patient.

• Right medication.

• Right dose.

• Right route.

• Right time.

• Right documentation.

Phases of Wound Healing

• Hemostasis: Blood clotting.

• Inflammation: Redness, swelling, pain.

• Proliferation: Tissue regeneration.

• Maturation: Collagen remodeling.

Types of Wounds and Their Characteristics

• Abrasion: Superficial wound to the epidermis.

• Laceration: A cut in the skin.

• Puncture: A small hole in the skin.

• Surgical: Incision made during a surgery.

• Pressure injury: injury to skin from prolonged pressure.

Ways Wounds Heal

• Primary Intention: Wound edges are approximated (e.g., surgical incision).

• Secondary Intention: Wound is left open to heal from the bottom up (e.g., pressure ulcer).

• Tertiary Intention: Wound is left open for a period of time and then closed (delayed primary closure).

Effects of Immobility on the Body

• Musculoskeletal: Muscle atrophy, contractures.

• Cardiovascular: Decreased cardiac output, blood clots.

• Respiratory: Pneumonia, atelectasis.

• Gastrointestinal: Constipation.

• Integumentary: Pressure injuries.

• Genitourinary: Kidney stones, urinary tract infections.