Basic Nursing

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Author:
MarieRN
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171987
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Basic Nursing
Updated:
2012-09-20 10:01:56
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Basic Nursing
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Basic Nursing
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  1. Droplet nuclei smaller than 5 microns; measles; chickenpox (varicella); disseminated varicella-zoster; pulmonary or laryngeal TB
    N95 mask
    airborne precautions
  2. Droplets larger than 5 microns; being within 3 feet of the patient; diphtheria (pharyngeal); rubella; streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children; pertussis; mumps; mycoplasma pneumonia; meningococcal pneumonia or sepsi; pneumonic plague
    droplet precautions
  3. Direct patient or environmental contact; colonization or infection with multi-drug resistant organisms such as VRE and MRSA, Clostridium difficle, or respiraotry syntyial virus; draining wounds if secretions are not contained; scabies
    contact precautions
  4. What is the arterial pressure of a newborn?
    40 mm Hg
  5. What is the arterial pressure of a 1 month old?
    85/54 mm Hg
  6. What is the arterial pressure of a 1 year old?
    95/65 mm Hg
  7. What is the arterial pressure of a 6 year old?
    105/65 mm Hg
  8. What is the arterial pressure of 10-13 year olds?
    110/65 mm Hg
  9. What is the arterial pressure of 14-17 year olds?
    119/75 mm Hg
  10. flat, nonpalpable change in skin color, smaller than 1.0 cm
    macule (freckle)
  11. palpable, circumscribed, solide elavation in skin, smaller than 0.5 cm
    papule (elevated nevus)
  12. elevated solid mass, deeper and firmer than papule, 0.5 - 2.0 cm
    nodule (wart)
  13. solid mass that extends deep through subcutaneous tissue, larger than 1.0 to 2.0 cm
    tumor (epithelioma)
  14. irregularly shaped, elevated area or superficial localized edeam, varies in size
    wheal (hive, mosquito bite)
  15. circumscribed elevation of skin filled with serous fluid, smaller than 1.0 cm
    vesicle (chicken pox)
  16. circumscribed elevation of skin similar to vesicle but filled with pus, varies in size
    pustule (acne)
  17. deep loss of skin surface that sometimes extends to dermis and frequently bleeds and scars, varies in size
    ulcer (venous stasis ulcer)
  18. thinning of skin with loss of normal skin furrow with skin appearing shiny and translucent, varies in size
    atrophy (arterial insufficiency)
  19. normal nail
    approximately 160-degree angle between nail plate and nail
  20. clubbing
    • change in angle between nail and nail base (eventually greater than 180 degrees); nail bed softening, with nail flattening; often enlargement of finger tips
    • Causes: chronic lack of oxygen: heart or pulmonary disease
  21. Beau's lines
    • transverse depressions in nails indicating temporary disturbance of nail growth (mail grows out over several months)
    • Causes: systemic illness such as severe infection; nail injury
  22. Koilonychia (spoon nail)
    • concave curves
    • Causes: iron deficiency anemia, syphilis, use of strong detergents
  23. splinter hemorrhages
    • red or brown linear streaks in nail bed.
    • causes: minor trauma, subacute bacterial endocarditis, trichinosis
  24. paronychia
    • inflammation of skin at base of nail
    • causes: local infection, trauma
  25. fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared with coughing; moist crackles are lower, more moist sounds heard during middle of inspiration, not cleared with coughing; course crackles are loud, bubble sounds heard during inspiration, not cleared with coughing
    crackles
  26. loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration; may be cleared with coughing
    rhonchi (sonorous wheeze)
  27. high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration
    wheezes (sibilant wheeze)
  28. has dry, grating quality heard during inspiration; dose not clear with coughing; heard loudest over lower lateral anterior surface
    pleural friction rub
  29. What is the normal body temperature?
    96.8 to 100.4
  30. core temperature
    temperature of the deep tissues
  31. What controls neural, and vascular temperature?
    hypothalamus
  32. How does the hypothalamus control body temperature?
    lower temperature through sweat and vasodilation and raises temperature through shivering and vasoconstriction
  33. non shivering thermogenesis
    occurs in neonates because they can't shiver - a limited amount of brown adipose tissue present at birth can be metabolized to create heat
  34. shivering
    involuntary response to temperature differences in the body. shivering can increase heat production 4-5 times greater than normal
  35. the transfer of heat between objects without physical contact
    up to 85% of the human's body surface radiates heat to the environment
    radiation
  36. transfer of heat from one object to antoher, when warm skin touches a cooler object, heat transfers from the skin until temps are simliar. conducts through solids, gases and liquids
    conduction
  37. transfer heat away from the body by air movement. heat loss increases when moistened skin comes into contact with slightly moving air
    convection
  38. transfer of heat energy when liquid is changed to a gas - body continuously looses heat by evaporation, about 600-900 mL of water a day evaporates from skin and the lungs
    evaporation
  39. diaphoresis
    perspiration
  40. normal infant heart rate
    120-160
  41. normal toddler heart rate
    90-140
  42. normal preschooler heart rate
    80-110
  43. normal school age heart rate
    75-100
  44. normal adolescent heart rate
    60-90
  45. normal adult heart rate
    60-100
  46. normal infant respirations
    35-40
  47. normal toddler respirations
    30-50
  48. normal preschooler respirations
    25-32
  49. normal school age respirations
    20-30
  50. normal adolescent respiration
    16-20
  51. normal adult respirations
    12-20
  52. Signs of hyperthermia
    giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence
  53. signs of hypothermia
    uncontrolled shivering, loss of memory, depression, poor judgement
  54. dysrhythmia
    a regular interval interrupted by an early beat, late beat, or a missed beat
  55. pathogenic organisms
    microorganisms capable of causing disease
  56. infectious agent
    Microorganism(s) that can make you sick (Pathogenic organisms)
  57. reservoir
    A place where microorganisms survive, multiply, and wait to transfer to a susceptible host.
  58. portal of exit
    Skin, mucous membranes, respiratory tract, etc
  59. modes of transmission
    Airborne, droplets, contact, vesicle, vector
  60. portal of entry
    broken skin, mucous membranes, genitourinary and gastrointestinal tracts, etc.
  61. susceptible host
    any individual. Immune system helps make less susceptible
  62. The 6 steps in the chain of infection are:
    infectious agent, reservoir, portal of exit, modes of transmission, portal of entry, susceptible host
  63. bacteria
    one-celled microorganisms capable of multiplying rapidly within a susceptible host. Bacterial infections are treated with antibiotics.
  64. viruses
    Viruses are small microorganisms that cause significant morbidity.  Because replication of the virus occurs within the host cell, killing the virus without harming the host cell is seldom possible.  Prevention (immunizations, hygiene) is still the best way to combat viral illness.
  65. layers of the skin
    • Epidermis - the most outermost layer.  The base of the epidermis continually produces new cells to replace those at the surface.
    • Dermis - strong connective tissue that contains nerve endings, sweat glands, and hair roots, is well supplied with blood vessels
    • The subcutaneous layer lies beneath the dermis.
  66. how does a corticosteroid work?
    Corticosteroids reduce heat production by interfering with the hypothalamic response. These drugs mask signs of infection by suppressing the immune system. Corticosteroids are not used to treat a fever.
  67. right vs wrong size of BP cuff
    • Cuff too Big: B/P too low (false low reading)
    • Cuff too Small: B/P too high (false high reading)
  68. what are orthostatic hypotension risk factors?
    • Fluid volume deficit from decreased blood volume, Dehydration, Recent blood loss, Prolonged bed rest, Anemia, Antihypertensive meds
    • CANNOT BE DELEGATED TO A CNA!!
  69. antipyretic
    drugs that reduce fever and generally ordere by health care providers if fever is over 102.2 degress
  70. nonsteroidal drugs
    reduce fever by increasing heat loss; these drugs include: Acetaminophen (Tylenol); Salicylates (Aspirin); Indomethacin (nonsteroidal anti-inflammatory); Ibuprophen; Keterolac (nonsteroidal anti-inflammatory)
  71. reflex response
    • 4+ - Very brisk, hyperactive with clonus (Clonus is a repetitive, usually rhythmic, and variably sustained reflex
    • response elicited by manually stretching the tendon), indicative of disease.
    • 3+ - Brisker than average, may indicate disease
    • 2+ - Average, normal
    • 1+ - Diminished, low normal
    • 0  - No response
  72. Prehypertension B/P reading
    120-139 over 80-89
  73. Stage 1 hypertension B/P reading
    140-159 over 90-99
  74. Stage 2 hypertension reading
    greater than or equal to 160 over greater than or equal to 100
  75. s/s of hypotension
    pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increased heart rate, decreased urine output
  76. s/s of orthostatic hypotension
    • lightheadedness
    • dizziness
    • loss of consciousness

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