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Maslow's Hierarchy pyramid
- Basic Physiological Needs - airway, respiratory effort, heart reate, rhythm, strength of contraction, nutrition, elimination.
- Safety & Security: Protection from injury, promote feeling of security, trust in nurse-client relationship
- Love & Belonging: Maintain support systems, protect from isolation.
- Self-esteem: Control, competence, positive regard, acceptance/worthiness
- Self-Actualization: hope, spiritual well-being, enhanced growth
- Assessment: subjective & objective data, confirming data, communicating and documenting data.
- Analysis: interpretation of data,
- Planning: prioritize nursing diagnosis, determing goals & outcome criteria for goals of care, developing plan of care,
- Implementation: organizing & managing care, counseling, teaching, providing care, supervising and coordinating care
- Evaluation: comparing outcomes with expected outcomes of care, clients response to care.
What is autonomy?
Respect for an individual's right to self-determination.
What is nonmaleficence?
The obligation to do or cause no harm to another.
What is Beneficence?
Duty to do good to others and to maintain a balance between benefits and harms.
What is justice?
The equitable distribution of potential benefits and tasks determining the order in which lient's should be cared for.
What is veracity?
The obligation to tell the truth.
What is fidelity?
The duty to do wha one has promised.
What is HIPAA?
Health Insurance Portablity and Accountability Act.
What needs to be included in telephone orders from Doctor's?
- Date and time of entry.
- Repeat the order tothe physician and record the order.
- Sign the order: begin with t.o. (telephone order), followed by nurses signature.
- Physician needs to countersign the order within agency time frame.
What are the components of a medication order?
- Date and time the order was written.
- medication name.
- Medication dosage.
- Route of administration.
- Frequency of administration.
- Physician's or health care provider's signature.
What is an advanced directive?
A written document (living will) that provides directions concerning provision of care when a client is unable to make his or her own treatment choices. Attach a copy to the medical record.
What information should be included in transfer reports?
- Client's name, age, physician, and diagnosis.
- Current health status & plan of care.
- Client's needs & priorities of care.
- Any assessment or interventions that need to be performed after transfer (lab tests, med admin, dressing change)
- Need for any special equipment.
- Additional: allergies, resusitation status, precautionary considerations, family issues.
- Bone formation, coagulation of blood, excitation of cardiac and skeletal muscle
- Normal level: 8.6-10.0
Found in: cheese, collard greens, milk, spinach, yogurt
- Required for ATP, neuromuscular activity, clotting mechanism.
- Normal level: 1.6-2.6
Found in: Peanut butter, avocado, canned tuna, green leafy veggies, milk
- Principle electrolyte of intracellular fluid, nerve conduction, mulcle function, acid-base balance, osmotic pressure, controls rate & force of contraction of the heart, cardiac output
- Normal level: 3.5-5.0
Found in: Bananas, carrots, fish, strawberies, tomatoes
- Generation of body tissue, metabolism of glucose and lipids, acid-base balance, storage and transfer of energy.
- - Has an inverse relationship w/calcium
Normal level: 2.7-4.5
Found in: fish, nuts, whole grain breads & cereals
Maintains osmotic pressure, acid-base balance, transmits nerve impulses.
Normal level: 135-145
Found in: bacon, butter, canned food, lunch meats, processed food, table salt, white & whole wheat bread
What is the intravascular space?
The space inside a blood vessel.
What is the intercellular space?
Refers to the fluid inside the cell.
What is the extracellular space?
The fluid outside the cell. (includes interstitial fluid, blood, water)
What is edema?
- Excess accumulation of fluid in the interstitial space. (Swelling)
- Generalized edema
What is an Isotonic solution?
- Fluid that has the same osmolality as other body fluids.
- (0.9% sodium chloride, normal saline NS, ringers lactate, 5% dextrose in water)
What is a hypotonic solution?
- A fluid that has a lower concentration of salt or solute. (0.45% sodium chloride)
- Draws fluid from the cell thru osmosis.
What is a hypertonic solution?
- A fluid that has a higher salt or solute concentration. (3% or 5% sodium chloride, 10% dextrose in water)
- Used to draw water from vascular space into the cell.
What is the average amount of urine produced in a day?
Tests for hypocalcemia?
- Trousseau's: hand/fingers contract when blood pressure cuff is applied.
- Chvostek's: facial muscle contration when lightly tap on cheek.
What is the Allen's test?
Used for collateral circulation. The hand is checked for patency of the radial and ulnar arteries. Both arteries are occluded (closed off), then one is released to see if hand regains color. Then test the other.
What are some causes of respiratory acidosis (too much acid)?
Kidneys will compensate.
- Asthma, atelectasis, brain trauma, bronchitis, CNS depressants, HYPOventilation, Pulmonary edema (PE), pneumonia.
- ANYTHING THAT INTERFERS WITH YOUR BREATHING.
What are some causes of respiratory alkalosis (too much alkaline)?
Kidneys will compensate.
Fever, HYPERventilation, hypoxia, hysteria, pain, overventilation of mechanical ventilators.
What are some causes of metabolic Alkalosis?
Lungs will compensate.
DM, DKA, aspirin overdose, high-fat diet, malnutrition, renal insuffidiency or renal failure, severe diarrhea.
What are some causes of metabolic alkalosis?
Lungs will compensate.
Diuretics, excessive vomiting, or GI suctioning, too much sodium bicarbonate ingestion, massive transfusion of whole blood.
What are the normal ranges for
- pH = 7.35 (acidic) to 7.45 (basic)
- PCO2= 35-45
- HCO3= 22-27
- PO2= 80-100
What is the normal fundal height during pregnancy for
- 16 weeks = approx halfway between symphysis pubis and umbilicus.
- 20-22 weeks = approx at the umbilicus
- 36 weeks = at the xiphoid process
Examples of true labor?
Contractions occur regularly, become stronger, last longer, occur close together, cervical dilation, and effacement progress. Walking does not relieve contractions.
Signs of false labor?
No dilation, effacement or descent, contractions are irregular w/o progression, Walking relieves
When does a babies fontanel typically close?
- Anterior: between 12-18 months of age
- Posterior: between birth and 2-3 months of age
What is the correct order to insert a Foley catheter?
- 1) Check integrity of Foley balloon (not always done now)
- 2) Spread the labia
- 3) Cleanse meatus
- 4) Insert the Foley
- 5) Attach drainage bag to bed
- 6) Send urine speciment to lab
What are the five rights of delegation?
- 1) the right task
- 2) the right circumstance
- 3) the right person
- 4) the right direction/communication
- 5) the right supervision
What are the six rights of medication administration?
- 1) right drug
- 2) right dose
- 3) right route
- 4) right client
- 5) right time
- 6) right documentation
What are the colors of the following IV gauges?
16, 18, 20, 22, 24
- 16- gray
- 18- green
- 20- pink
- 24- yellow
What is the term used when an IV is kept in place but nothing is running thru it?
What is the placement for a 5 lead ECG?
- White on right
- Snow on top of grass (white over green on right side)
- Smoke over fire (black over red on left side)
- Brown in the middle
Normal temperature of an adult?
- 35.8 - 38.1 C
- 96.4 - 100 F
What is the normal pulse rate for an adult?
Pulse = 60 to 100 bpm
What is the normal Respitorary rate (RR) for an adult?
Respirations= 12 to 20 bpm
What is the normal BP of an adult?
BP= 120 (systolic) over 80 (diastolic)
What is the normal pulse O2 for an adult?
What is the normal cerebral perfusion pressure for an adult?
What is the normal lab value for Sodium (NA+)?
What is the normal lab value for Chloride?
What is the normal BUN level?
What is the normal blood glucose level?
What is the normal Potassium (K+) level?
3.5 - 5.0
What is the normal BICARB level?
What is the normal Creatinine level?
0.6 - 1.2
What is the normal WBC level?
5,000 - 10,000
What is the normal hemoglobin level?
12 - 16
What is the normal Hematocrit level?
35 - 47
What is the normal platelet level?
150-450 x 10(9)
What is the normal magnesium level?
1.2 - 3
What is the normal calcium level?
What is the normal phosphorus level?
1.2 - 3
What is the normal Prothrombin time (PT) and what drug does it coincide with?
- 9.5 - 11.8 seconds
What is the normal APTT time?
What drug does it coincide with?