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Describe thermoregulation in the body
the hypothalamus controls body temp
Explain why it is so important to take a patients vital sign pattern rather than relying on a single reading:
- to create a baseline
- then to check for accuracy
What is the normal oral temperature range for adults?
Explain the physiological mechanisms of fever:
- abn high body temp ( >100.4oF or 38o C)
- occurs b/c of pyrogens (bacteria)
What is the method of finding a peripheral pulse & an apical pulse?
- use 2-3 fingers (no thumbs)
- apical - 60 sec
- peripheral -30 sec x 2
- apical - 5th intercostal space mid-clavicular line
- peripheral - carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
What are the abnormal findings for a pt given their age, pulse rate, rhythms, quality & symmetry?
- bradycardia: rate <60bpm
- tachycardia: rate >100bpm
- quality: bounding (easy to feel) thready (hard to feel)
What is a normal pulse rate for healthy adults?
How are respirations regulated in the body?
exchange of oxygen & carbon dioxide in the body
Define: arterial oxygen saturation
amt of oxygen in your blood
inadequate cellular oxygenation
rapid & deep breathing resulting in excess loss of CO2
rate & depth of respirations are decreased & CO2 is retained
What are the abnormal findings of a pt given their age, respiratory rate, depth. rhythm, chest movement, & associated clinical signs?
- apnea: cessation of breathing
- bradypnea: abnormally slow 1-12
- tachypnea: abnormally fast > 12
- reg/irreg rhythm
- dyspnea: labored breathing
What is the normal respiratory rate for adults?
Describe the physiology of blood pressure:
- pressure of blood as its forced against arterial walls during cardiac contraction
- measured in millimeter of mercury (mm Hg)
- pulse pressure: the difference between systolic & diastolic pressures
Describe the process for taking a brachial blood pressure reading:
- apply BP cuff
- find radial pulse
- pump cuff up till can't feel radial pulse, release cuff, then add 30 to your #
- apply steth diaphram to brachial pulse, put in ears
- pump up to your number
- slowly release listening for the systolic(first sound) and diastolic (last sound)
- remove cuff
- chart findings
What is the importance of cuff size when obtaining a blood pressure reading?
- should be 2/3 length of upper arm or 40% of arm
- wrong size cuff could result in measurement error
systolic blood pressure <100 mm Hg
- systolic bp >140 mm Hg OR
- diastolic bp >90 mm Hg on 2 or more seperate occasions
Define: essential hypertension
diagnosed when there is no known cause for the increase in bp
Define: secondary hypertension
when there is a clearly identified cause for the persistent rise in bp
What is the nursing process when interpreting vital signs results?
taking vital signs as part as the assessment data
What is the rapid response team?
called for respiratory distress , chest pain etc
What is code blue?
called when someone is breathless, &/or pulseless (respiratory/cardiac arrest)
What are the basic elements of airway management including placement of oral and nasal airways:
- endotrachial airways are pliable tubes inserted into the trachea through:
- oral: in mouth to trachea
- nasal: in nose to trachea
unpleasant sensory/emotional experience
Classify pain according to origin:
- cutaneous or superficial pain (near surface)
- visceral pain (deeper pain)
- deep somatic pain (body, ligaments, bones)
- radiating pain (from one spot and branches out)
- referred pain (pain diff location from where actually is)
- phantom pain ( amputee's)
- psychogenic pain (np physical cause)
Classify pain according to cause:
- nociceptive pain (aching) (muscles/joints, organs)
- neuropathic pain (burning, numbness, itching, & "pins & needles")
Classify pain according to duration:
- acute pain: brief duration
- chronic pain: longer than 6 months
- intractable pain: chronic & highly resistant to relief
Classify pain according to quality:
- sharp or dull
- burning (nerve)
- searing (nerve)
- tingling (nerve)
What are the physiological changes of pain?
What are some factors that influence pain?
- developmental stage
- sociocultural factors
- communication impairments
- cognitive impairments
- vital signs
What are some nonpharmacological pain relief measures?
- therapeutic touch
What are pharmacological measures for pain including opiod analgesics?
- used to treat moderate to severe pain
- ex: oxycodone
What are pharmacological measures for pain including nonopioid analgesics?
- NSAIDS, centrally acting agents or acetaminophen
- used for mild to moderate pain
- Ex: advil, tylenol
What are pharmacological measures for pain including adjuvant analgesics?
- used to treat chronic pain that is neuropathic in nature
- ex: fentanyl
Why should pain be considered a 5th vital sign?
pain management is essential for quality patient care
What is the nursing process in the care of a patient with pain?
assess for pain then diagnosis
How is critical thinking used in the nursing process?
- for nurses to apply knowledge to provide holistic care
What are the 6 steps of the nursing process?
- assessment: data gathering
- diagnosis: identify pt health needs by analyzing data
- planning: -outcomes: pt focused goals -interventions: nurse focused goals
- implementation: carry out planned actions
- evaluation: determine if interventions were effective
Describe the relationship of assessment to the other steps in the nursing process
- diagnosis: helps identify pt actual/potential health problems & strengths
- planning outcomes & interventions: helps formulate realistic goals, helps choose interventions most acceptable & effective for client
- implementation: conti to gather assessment data by observing clients response as you implement interventions
- evaluation: indicate whether or not goals have been met
What is subjective data?
what the pt (or family) tells you
What is objective data?
- what nurse sees, hears, smells, feels or another nurse
What is primary data?
- obtained from client
- your own assessment
What is secondary data?
- "second hand"
- medical record
What are 3 circumstances you would validate data?
- subjective/objective data do not agree or make sense
- clients statements differ at different times in the interview
- data are far outside normal range
What is the difference between cue and inference?
- cue: what the pt says & what you observe
- inference: judgements
What is a nursing diagnosis?
statement of client health status that nurses identify, prevent, or treat
What is a medical diagnosis?
focus on disease, illness, and injury
What are collaborative problems?
always a potential problem... if becomes "actual" now its a med diagnosis
What are the 5 types of nursing diagnoses?
- actual (prob is present, has signs & symptoms)
- risk (prob may occur)
- possible (prob may be present, not enough data to support diagnosis)
- syndrome (several related prob are present)
- wellness (no prob, in transition to higher lvl wellness, no cause or etiology)
Why is etiology always an inference?
b/c you can never really observe the link between etiology and problem
How do you know which of the NANDA labels to use to describe a pt's problems?
identify the topic that fits the your assessment data
Clairfy the relationship between nursing diagnosis and outcomes/interventions:
- the prob suggests the outcome/goal
- the etiology suggests interventions
State at least 5 criteria for judging the quality of a diagnostic statement:
- incl. both problem & etiology
- descriptive and specific
- state the prob as a pt response
- nonjudgemental lang
- avoid legally questionable lang
What is the importance of a written care plan?
to help the nurse provide individualized goal-directed client centered care
What is the difference between short and long term goals?
- Short term- to be achieved in hours, days
- long term -a week, month, or more
Give an example of an outcome statement
- Client will take part in self care activites such as personal hygiene daily.
- Client will identify 2 resources available to help in giving care such as babysitters, husband switching roles, within 1 month after discharge.
How is an outcome derived from a nursing diagnosis?
based on what our desired result of care will be
What does SMART stand for?
make sure u write all these in the outcome that dont conflict w. the med diag.
How do theories and research influence the choice of nursing interventions?
- theories - how you define a prob
- research - looking at studies, protocols
Explain how nursing interventions are determined by problem status
- goals met
- goals part met
- goals not met
What must be on your nursing order?
- subject ("the nurse")
- action verb (tells nurse what action to take)
- times and limits
What are "5 rights" of delegation?
- think critically about:
- the task
- the circumstance
- the person
- the direction or communication
- supervision & evaluation
How are standards and criteria used in evaluation?
- RN evalu progress toward outcomes
- documents results of evalu
- uses ongoing assessment data to revise diagnosis
What is ongoing evaluation?
- immed after intervention
- at ea pt contact
- while implementing
What is intermittent evaluation?
- at specified times
- goals should be designate times
What is terminal evaluation?
clients progress at time of discharge
Describe a process for evaluating client health status (outcomes)?
- review outcomes
- collect reassessment data
- determine progress towards goals
- record evaluative statement
- evaluate collaborative problems
Describe a process for evaluating the effectiveness of a nursing care plan
- relate outcomes to interventions
- draw conclusions about problem status
What is the definition of communication?
process of sending and receiveing messages
What are the 3 basic levels of communication?
- intrapersonal- self talk
- interpersonal- 2 or more people
- group- public speaking
What are the 5 components of the communication process?
- encoder (sender)
- channel (way you send msg)
- decoder (receiver)
What are some verbal communication characteristics?
- use of spoken/written words to send a message
- vocab & language
- tone of voice
What are some nonverbal communication characteristics?
- body language
- facial expression
- personal appearance
What are some factors that influence the communication process?
- devl lvl
- personal space
- roles & responsibilities
How do relationships and roles influence communication?
- rapport and trust established
- effects all phases of therapeutic relationship
- effectiveness determines quality of nurse-client relationship
Describe the role of communication in each of the 4 phases of therapeutic relationship
- stage 1: pre-interaction (no communication)
- stage 2: orientation phase (client and nurse meet)
- stage 3: working phase (nurse & client work together to meet clients needs)
- stage 4: termination phase ( concl of relationship)
Compare and contrast techniques that enhance communication to those that hinder communication.
- active listening
- establish trust
- be assertive
- observe body language
- explore issues
- use silence
- asking too many ??
- asking why
- changing subj inapprop
- failing to listen
- offering advice
What is the purpose of documentation?
- legal documentation
- quality assurance
What are the different types of documentation?
- Narrative (chronological "story")
- SOAP (subj, obj, assess, plan)
- SOAPIE & SOAPIER (interv, eval, revision)
- PIE (problem, interv, eval)
- Focus (Data, Action, Response/Eval)
- Charting by exception (streamlined doc)
What are the 7 different charting forms & their purposes?
- Admission Database (when pt enters HC system)
- Flowsheets & Graphic Record (checklists: rout care,assess, VS, wound care, trtmt, IV flu adm)
- Medication Admin Rec ( list of all ordered meds)
- Kardex (brief summ pt POC)
- Integrated IPOC (combo charting & car plan form)
- Event report ( incident report)
- Discharge Summary
What are the key elements to include when giving an oral report about a client?
progress, change of status, any tests given or will get, therapies, teaching
How do you verify or question a medical order?
- contact whomever wrote the order
- if they dont change the order, you may refuse to carry it out
- inform charge nurse
What are federal laws regulating the nursing practice?
- Bill of Rights
- Emerg Medical Trtmt & Active Labor Act
- Health Care Quality Improvement Act
- American Disabilities Act
- Pt Self-Determ Act
- Newborns' & Mothers Health Prot Act
- National Labor Relations Act
What are state law regulating the nursing practice?
- Mand. reporting laws
- Good Samaratin Law
- Nurse Practices Act (credentialing, licensing, discipline)
What are some basic principles of criminal law controlling nursing practice?
- offense against society
- under jurisdiction of state & federal courts
- lead to fine, imprisonment, or death
- misdemeanor or felony
What are some basic principles of civil law controlling nursing practice?
- protect rights of indiv
- pymt of monetary damages
- plaintiff or defendant
- Contract law (agreem btw indiv)
- Tort Law ( breach of civil duty)
What are the major legal issues that arise within nursing practice?
- failure to assess & diagnose
- failure to plan
- failure to implement a plan of care
- failure to evaluate
What are some measures to take that would decrease the likelihood of committing nursing malpractice?
- observe mand stand of care
- use nursing process & follow prof stand
- avoid med and trtmt errors
- report & document accurately
- obtain informed consent
- maintain confidentiality
What are the basic elements of informed consent?
- clarity & comprehension