NURS 509 Exam 1

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  1. Gordons Functional Health Patters Purpose
    direct nurse to: the kind of information to obtain, the order in to which collect it( what to obtain), how detailed the assessment

    provide objectives to evaluated and diagnose status of INDIVIDUAL, FAMILIES< and COMMUNITIES

    identifiy issues, prevention
  2. Functional Health Patters List:
    • 1) Health perception-health management pattern: how individual perceives own health and how they manage (provides individuals perception on tx, discover needs for education)
    • 2) nutrition-Metabolic pattern: food and fluid intake and elimination
    • 3) Elimination: waste removal, characteristics
    • 4) Activity-Exercise Pattern: exercise and  ADL and IADL
    • 5) Sleep-Rest pattern: describe disturbances and deprivation, quality of sleep
    • 6) Cognitive-Perceptual Pattern: ability to make decisions and consider environment (cognitive and perceptual status), pain, nonverbal cues
    • 7) Self-Perception-Self-Concept: self concept, body image, self-worth, mood
    • 8) Role-Relationship Pattern: functional role, loss of relationships, social support
    • 9) Sexuality-Reproductive Pattern: sexual identify and relationship satisfaction
    • 10) Coping-Stress Pattern: strategies, response
    • 11) Value-Belief Pattern: beliefs guide decisions, provide comfort
  3. Care plan
    tool that represents meaningful structure... with a focuses questions

    what is important to the patient is in the middle

    ideas branch out

    • used to problem solve, help generate interventions
    • need ADPIE first
  4. ADPIE
    • Assessment (physical assessment, history, medical records and diagnostic tests)
    • Diagnosis (PES)
    • Plan (SMART)
    •      Maslows Hierarchy
    • Intervention
    • Evaluation

    • Note: PES 
    • problem (NANDA-I) Etiology (related to) symptoms (as evidence by)

    medical diagnosis can be secondary
  5. Stress Incontinence
    Sudden loss with increased abdominal pressure due to exertion, laughing, coughing. Involuntary leakage

    • cause: poor sphincter, increased urethral mobility
    • Risk factors: obesity,pregnant,chronic constipation
  6. Overflow Intcontinence
    Urinary leakage associated with bladder distention

    • cause: obstruction, muscle weakness or neuro
    • symptoms: dribbling, weak urinary stream
  7. Urge Intontinence
    • Involuntary leakage accompanied by urgency (overactive bladder)
    • sudden overwhelming urge to urinate

    • cause: contraction muscles
    • Risk factors many UTIs
    • symptoms: frequency, nocturia
  8. Reflex Incontinence
    • spinal injury above 3rd sacral
    • unaware of bladder fullness
  9. Mixed Intcontinence
    • stress and urge
    • involuntary leakage
  10. Functional Incontinence
    • inability or lack of motivation to reach toilet on time
    • cognitive impairment
  11. Nonsocomial Infection
    Hospital acquired infection
  12. Chain of Infection
    Image Upload
  13. Signs and symptoms of local infection
    • erythema
    • swelling
    • drainage
    • tenderness
  14. Signs and symptoms of systemic infection
    • fever
    • chills
    • malaise
    • anorexia (loss of appetite)
    • nausea and vomiting
    • decreased energy
    • increase pulse and respirations
  15. Urinary Tract Infections: Adults
    • cystitis or urehritis
    • at risk >75 yrs, men older 50 with enlarge prostate, 

    Symptoms: urinary urgency and frequency, dysuria (pain when pee), burning, bladder cramps, noctouria, fever, hematuria

    General symptoms: low back pain, malaise, confusion, chills, flank pain,n/v, low abd pain

    Tx: med, antibiotics, modify diet: acidify urine (vit c), decrease caffeine, alcohol, tomatoes, spicy

    prevention: keep closed catherter system, remove catheter asap, appropriate peri hygiene
  16. Pyelonephritis in Adults
    • Inflammation of kidneys
    • Acute: sudden bacterial infection into kidneys
    • chronic: persistent infection
    • S&S: fever, chills, flank pain, urgency and frequency, dysuria, burning, nocturia, hematuria, anemia, general fatigue,  and leukocytes in urine
  17. Alterations of Urinary Tract: Cystectomy
    Cancer of bladder, prostate

    -Continent vesicostomy: urine diverted to reservoir formed by part of bladder-empty with catheter

    -Ileal conduit (urostomy): ureters anastamosed to ileal segment

    • Management: keep urine acidic, drink 3-4L/day
    • drain pouch when 1/3 full
  18. Suprapubic Catherization
    Temp urinary diversion: transcutanous insertion of catheter through suprapubic area into bladder

    urinary retention: upper motor neuron-reflex intonctinence, lower motor neuron-urinary retention
  19. Urinary calculi (Urolithiasis)
    • kidney stones
    • Primary cause: urianry statis, increases concentration of solute, urine pH, meds, high vitamin C
    • Risk factors: immobility,dehydration, metabolic acidosis/alkalosis, high mineral in water, UTI

    • Types: calcium (common), oxalate
    • S&S: sharp pain deep lumbar rediates to front, n/v, diaphoresis, elevated BP and HR

    Management: increase liquids,reduce pain, prevent stones, let pass 
  20. Kegel Exercises
    strengthen the pelvic floor muscles, lead to improvement of control over urine incontinence. 

    • find muscle first (make sure not abdominal)
    • practice holding for 0 seconds set of 10 several times a day.
  21. Obstipation
    fecal impaction
  22. Alteration in bowel elimination lead to...
    • abdominal distention
    • flatulence
    • diarrhea
    • constipation
    • obstipation
    • incontinence
    • bowel diversions
  23. Urostomy
    This is a general term for a surgical procedure which diverts urine away from a diseased or defective bladder. Ileium is surgically removed and relocated as a passageway (conduit) for urine to pass from the kidneys to the outside of the body through a stoma.
  24. Ileostomy
    A surgically created opening in the small intestine, usually at the end of the ileum. The intestine is brought through the abdominal wall to form a stoma. Ileostomies may be temporary or permanent, and may involve removal of all or part of the entire colon.
  25. Colostomy
    The surgically created opening of the colon (large intestine) which results in a stoma. A colostomy is created when a portion of the colon or the rectum is removed and the remaining colon is brought to the abdominal wall.
  26. Clean technique
    • routine hand washing
    • use clean technique if staff or objects will touch intact skin, intact mucous membrane, dirty items

    When? blood pressure, examine, feed
  27. Aseptic Technique
    • For short invasive procedures
    • hand washing, sterile gloves, antiseptic skin 
    • When? urinary catheter, IV

    • sterile field yes, skin prep yes
    • dedicated area
  28. Sterile Technique
    • used for surgery
    • surgical hand scrub, hands dried with sterile towel, sterile gow, sterile suppleis, skin prep,

    • hand hygiene and skin prep: surgical scrub
    • dedicated room
  29. Standard Precautions
    Assume blood and any body fluids of ANY patient could be infectious

    PPE: specialized clothing or equipemtn worn by an employee profect against infectious materials
  30. Isolation Precautions
    • Contact
    • Droplet
    • Airborne
    • Reverse
  31. PPE Dressing sequence
    • gown
    • mask/respirator
    • goggles
    • gloves
  32. Using PPE Safely
    • Keep gloved hands away from face
    • avoid touching or adjusting other PPE
    • Remove gloves if they become torn
    • Perform hand hygiene before donning new gloves
    • limit surface and items touched
  33. PPE Removal
    • Contaminated versus clean
    • gloves
    • face shield/goggles
    • gown
    • mask/respirator

    When: at door way, respirator outside
  34. Causative Agent
    bacteria, virus, fungi, parasites, prions

    control: clean, disinfection, sterilization
  35. Reservoir
    any person, animal, insect, plant, soil, or substance in which an infectious agent lives and multiplies

    need food, moisture, ideal temperature, oxygen, pH, light
  36. Portal of Exit
    • Blood
    • Mucus
    • Breast Milk
    • Urine
    • Feces
    • Semen
    • Vomit
    • Other secretions

    control: handling of feces, urine, blood, lab specimens, cover mouth when cough/sneeze, mask 
  37. Mode of Transmission
    • Direct
    • Indirect
    • Droplet (6 ft)
    • Airborne
    • Vector
  38. Direct Contact
    • touching an infected person, draining wounds, dressings, patient supplies and secreations,  including sexual contact
    • transplacental

    MRSA, Hep B and C, HIV, Chlamydia, C. Diff
  39. Indirect Contact
    • contact with fomites
    • usually by touching soil contamination or a contaminated surface, air, food, water

    MRSA, Hep A, C. Diff, Clostridium botulinum
  40. Droplet Contact
    coughing or sneezing, talking on another person

    six feet distance

    Avian Influenza A, smallpox, diptheria, moningococcal disease
  41. Airborne Contact
    • if the microorganism can remain in the air for long periods
    • Ventilation, sweeping floor, shaking sheets

    Measles, TB, varicella, SARS

    Need Airborne infection isolation room (AIIR) with negative pressure or High efficiency particualte air (HEPA) filtration
  42. Vector Contact
    A vector is an organism, usually an arthropod, which transmits an infectious agent to a new host.

    Dengue, Lyme disease, west nile virus
  43. Portal of Entry
    • Respiratory
    • GI
    • Urinary
    • Gyno
    • Blood
    • Tissue

    Control: maintain skin integrity, clean/dry linen, safe needle disposal, manage IV, catheters, wound care, aseptic technique
  44. Susceptible Host
    • who is at risk
    • children, pregnant, elder, immunocompromised.. continue on bottom

    protection: hygiene (include oral), adaquate fluid intake, good nutrition, prevent skin breakdown, monitor visitors, standard precautions, isolation as needed

    breaks in first line of defense, illness or injury, tobacco use, substance abuse (typically poor diet), multiple sex partners, environmental factors, chronic diseases, meds (that reduce immune response)
  45. Control of Infection Transmission
    • Handwashing
    • Keep soiled items from touching uniform
    • Do not wear uniform in community
    • Do not go to work ill
    • Label personal items, basins, urinals
  46. Hand washing...when??
    • before touch newborn, immunocompromised
    • before invasive procedures
    • before enter intensive areas
    • before/after work, food prep, restroom, sneeze/cough
    • before and after gloves use
    • after patient contact

    Antiseptics: alcohol based, chlorhexidine, triclosan, iodine compounds
  47. Medical Asepsis
    • Decrease potential for the spread of infections.
    • Clean technique
    • handwashing
    • glove use (non sterile)
    • clean environment
    • standard percautions
  48. Surgical Apsesis
    Sterile technique: procedure used to eliminate all microorganisms (not 100% effective)

    • sterile object contaminated if touched by non-sterile object
    • sterile objects placed on sterile field
    • objects become contaminated when exposed to air for long period
    • edges of sterile field are contaminated
  49. CDC standard precautions
    • handwashing
    • gloving
    • gown
    • mask
    • appropriate device handling
    • appropriate handling of laundry
    • patient placement
  50. Contact Precautions
    • PPE:
    • gloves when touch patient, immediate environment, belongings; 
    • gown when suspect substantial contact with patient or environment anticipated

    hand washing if visibly dirty or after care patient who has or is suspected of having C. Diff, norovirus
  51. Droplet Precautions
    • PPE:
    • face mask before enter room
    • Gown, goggles and gloves if spraying of respiratory fluids is anticipated

    patient use mask when exit exam room, avoid close contact with other patients, proper cough/sneeze hygiene

    place patient in closed room ASAP, if not available isolate in waiting area
  52. Airborne Precautions
    • PPE:
    • N-95 mask before enter room
    • Gown and gloves and goggles if substantial spraying anticipated 

    • Separate entrance if possible
    • Airborne infection isolation room (AIIR) or HEPA
    • if not available: provide face mask and place in separate room, arrange for transfer to another facility
  53. JCAHO
    • Joint commission on the accreditation of hospital organization
    • guidelines for the prevention of infection
    • guidelines for control of infection
    • reporting infections
    • hospital inspections
  54. Bed bath
    • use bath sheet
    • if IV remove arm with IV first, when putting on gown put arm with IV first
    • eyelids wash from innrer canthus outward (no soap)
    • Clean to dirty
    • pat dry
    • Distal to proximal
    • hands and feet us basin with water
    • do no massage calves
    • backrub (stimulates circulation)

    if use packaged bath heat pack in microwave for one minute
  55. denture care
    • use cold water
    • wash all surfaces
    • inpect dentures for sharp edges, rough, worn
    • inspect mouth for redness, irritation, lesions or infections
  56. Applying Bandages
    • distal to proximal: improves venous return and helps prevent edema
    • overlap by 2/3 the width
  57. Antiembolism Stockings: TED
    assess for S&S of severe peripheral arterial disease: weak pulse, discoloration, cyanosis, gangerene

    recumbent position for at least 15 minutes, prevents trapping of pooled veneous blood 

    measure circumference of thigh (if exceed 100 cm do not apply), calf and distance from gluteal fold to base of heel
  58. Sequential compression Device (SCD)
    leave two fingerbreaths between sleeve and extremity
  59. Swallowing and Choking Precautions
    • alert
    • sit 90 degrees, head erect
    • watch swallow
    • swallowing disorder: smaller bites, more time
  60. Swallowing and Choking Precautions: Pocketing
    • alternate between solids and liquids, textures and temp
    • downward pressure of spoon
    • lemon juice with ice
    • fingersweep
    • no straw
  61. Swallowing and Choking Precautions: delayed swallowing
    • Chin tuck (if appropriate)
    • lemon ice
    • massage of cheeks, shin and throat (see speech)
  62. Swallowing and Choking Precautions: poor bolus manipluation
    • (chew/move food back in mouth)
    • place food further back
    • provide easy to chew foods
    • liquid wash or alternate solids and liquids
  63. Swallowing and Choking Precautions: signs and symptoms of problems/aspiration
    • Facial weakness (facial droop, drooling, poor lip closure)
    • apraxia (difficultly with lip and tongue)
    • decreased sensation
    • choking
    • coughing before/during swallow
    • decreased cognition
    • ineffective throat clear or cough
    • need for multiple swallows
    • feeling of something stuck in throat
    • weight loss
    • temp spikes
    • change in lung status
  64. Swallowing and Choking Precautions: 
    Thickened Liquids

    need for thickened liquids: decreased movement of adams apple during swallow, delayed swallow or sings of aspiration
  65. Factors Affecting Oxygen Delivery
    • Altitude
    • Diffusion
    • Carrying Capacity
    • Cardiac Output
    • Metabolism
  66. Oxygen Indicators
    • Acute MI
    • Pain
    • Hypoxemia
    • Smoke inhalation
  67. Oxygen Administration
    • oxygen is a medication
    • need order for adminiatration and anytime change in rate
    • usually in liters per minute (lpm)

    • Note: O2 vs Air flow
    • 02 is green flowmeter
    • airflow is yellow flowmeter
  68. Oxygen: E cylinderImage Upload
    • E cylinders
    • 2200 PSI=full
    • 500 PSI=empty
  69. Oxygen Safety
    • 1) no free standing tanks
    • 2) store in secured area
  70. Nasal Cannula
    • 0-6 lpm
    • 24-40% oxygen
    • <2 lpm for infants

    application: connect device, put on in nares and behind ears, move fastener then turn on oxygen to ordered rate.
  71. Simple 02 Mask
    • 6-10 lpm
    • must be run at >6lpm otherwise may rebreathe CO2

    • FiO2 range is 35-55%

    application: connect, turn on to ordered rate, place under chin then over nose, adjust then put strap on 
  72. Venturi Mask
    • High flow (COPD)
    • dial in % of O2
    • dial in rate: 3-15lpm
  73. Non-Rebreather Mask
    • reservoir bag 2/3 full
    • one way valves
    • no CO2 rebreather
    • FiO2 70-100% (6-15lpm)
  74. Pulse Oximetry
    • measure oxygen level
    • reflects % of hemoglobin molecules carrying oxygen
    • 95-100% normal
  75. Incentive Spirometer
    An incentive spirometer is a medical device used to help patients improve the functioning of their lungs

    It is provided to patients who have had any surgery to the lungs, patients recovering from cardiac or other surgery involving extended time under anesthesia and prolonged in-bed recovery.
  76. Common Wounds:
    • Traumatic: injury that require closure either by primary or secondary intention
    • Pressure sore: wounds or pressure ulcers
    • wound secondary to: health problems such as arterial, venous or diabetic ulcers
  77. Types of Healing:
    • Primary intention: occurs when margins of wound approximate, such as surgical wound
    • Secondary intention: occur from trauma, infection or ulceration. Wound edges are not approximated and healing occurs from the edges and bottom up. 
    • Tertiary intention:  wound is left open intentionally  and is not sutured until granulation fills in, sutured later. 
  78. Healing Phase: Inflammation Phase
    • Inflammation phase (2-5 days): stimulate fibroblast cells to produce collagen. WBC part of this. 
    • -vascular phase: vasoconstriction, platelet aggregation. later vessels dialate. Allows movement of plasma protein. Fibrinogen to allow for blood clot from platelets.
    • -Cellular response: neutrophils and monocytes phagocytize bacteria and other material. Macrophages assist in phagocytosis. Lymphocytes arrive later with humoral and cell-mediated immunity
  79. Healing Phases
    • 1. Inflammation Phase (vascular phase, cellular response)
    • 2. Proliferation Phase (granulation)
    • 3. Maturation/remodeling
  80. Healing Phase: Proliferation Phase
    • 2 days-3 weeks
    • Granulation: fibroblasts synthesize and secrete collagen. New blood vessels. Gradnular tissue: soft, pink, fragile, bleeds-later develops with collagen for foundation of  scar tissue
  81. Healing Phase: Maturation or remodeling
    • 2 weeks- 2 yrs
    • remodeling or collagen occurs, shrink scar tissue through collagen lysis increasing tensile strength of scar about 80% original 
  82. Necrotic:
    Dead cells that can appear a pale white or black, adherent to viable tissue
  83. Gangrenous Necrosis
    • dry gangrene: dry shriveled, darkened area
    • wet gangrene: liquefied underlying necrotic tissue
  84. Slough
    creamy white, stringy issue, adhering wound
  85. Exudate:
    cellular fluid and cell material that slowly discharged form cells or blood vessels. provides positive environment for wound healing. Lysosomal enzyme, WBC, Lymphokines, growth factor. 
  86. Assessment of Wounds
    • vital signs/lab work
    • wound (location, size and level of tissue)
    • circumference
    • depth
    • level of tissue injury
  87. Staple/suture removal
    • gather equipment
    • wash hands, don gloves
    • remove dressing and discard, change gloves
    • remove staple/suture
    •     pick up forcep with nondominant hand
    • cleanse area and place dressing 

    Note: alternate staple removal
  88. Regulations and Recommendations for PPE
    • OSHA: health and safety regulations at work. Provide PPE and ensure disposal
    • CDC: recommend when, what, how to use PPE
  89. Glove Use
    • work from clean to dirty
    • do'nt touch yourself, face, don't adjust PPE with contaminated gloves
    • Don't touch environment surfaces except as necessary during patient care. 
    • change gloves: torn, heavily soiled, after patient
  90. Respiratory Protection
    • powered air purifying respirators (PAPR)
    • protect from inhalation of infectious aerosols (Mycobacterium TB)
  91. Don Particulate Respirator
    • Select fir tested respirator
    • perform fit check
    • inhale-respirator should collapse
    • exhale: check for leakage
  92. PPE: contaminated vs clean
    • contaminated: outside, front
    • clean: inside, outside back, ties on head and back
  93. PPE Removal
    • gloves (turn inside out, bundle)
    • goggles (grasp ear or head pieces, away from face)
    • gown (untie, peel away from shoulders, turn inside out, bundle)
    • mask (untie bottom then top0
  94. Levels of communciation
    • intrapersonal: self-talk
    • Interpersonal: between two or more ppl
    • Group
    • Public Speaking
  95. Factors influencing communcaion and Environment
    • learned ways of thinking: social status and role, cutlure, religion
    • gender
    • age and developmental level
    • environment of communcation

    • intimate=0-18"
    • personal=18-48"
    • social: 4-12 ft
    • public= >12 ft
  96. Components of communication
    • Content: words, gestures, substance of message
    • Process: sending (encoding), receiving and interpreting (decoding), reacting (feedback)
  97. Verbal vs. Nonverbal
    • Verbal: spoken, written, word selection, conscious
    • Nonverbal: less conscious, body language, emerges from feelings of sender, typically convey meaning of message (facial expression, tone of voice, appearance, movement, eye contact, gesture, posture)
    • inclding eye (contact, downcast, daring, staring) eyebrows (raised, furrowed), smiling
  98. Therapeutic Relationships
    A relationship between a nurse and a client for the purpose of assisting to improve a the clients health or to manage health related problems
  99. Phases of Therapeutic Relationship
    • Stage 1: Pre-interaction (gather information)
    • Stage 2: Orientation (create trust, how to address, expectation, assessment information, identify problems, set goals, develop care plan)
    • Stage 3: Working (problem solving, continue to evaluate, clarification, maintain trust)
    • Stage 4: Termination (conclusion, consider feelings)
  100. Non-Therapeutic Communication Techniques
    • Excessive questioning (close ended)
    • Advising/offering advice
    • Agreeing
    • Challenging
    • Changing the topic
    • Denying
    • Interpreting
    • Making stereotypical comments
    • Passing judgment
    • Probing
    • Reassuring
    • Rejecting
  101. Therapeutic Communication Techniques
    • Using silence
    • Accepting
    • Observing
    • Offering self
    • Asking open-ended questions
    • Encouraging
    • Clarifying time or sequence
    • Encouraging descriptions
    • Restating
    • Reflecting
    • Focusing
    • Exploring
    • Seeking clarification
    • Identifying themes
    • Giving information
    • Summarizing
  102. Developmental Factors Urinary
    • 8-10 wet diapers normal
    • toilet training at 18-36 months
  103. Renal Calculi
    • Kidney Stones
    • Risk factors: immobility, sedentary lifestyle, dehydration, metabolic acidosis/alkalosis, previous hx, UTI's neurogenic bladder, high mineral content in drinking.
  104. Kock pouch
    continent ileostomy, internal pouch to collect ileal draininage
  105. clean vs disinfect vs sterilize
    • clean: remove visible soil
    • disinfect: remove pathogens by physical or chemical means
    • sterilize: remove all microorganism (except prions)
  106. Fomite vs vector
    • fomite: object
    • vector: arthropod

    indirect contact
  107. Model of health and Illness
    • psycho
    • socio
    • bio

    HEALTH in middle
  108. Maslow Psychosocial Theory
    Basic needs first

    need physiological (food, water, shelter, warmth)

    • Safety
    • Belonging-Love
    • Self-Esteem
    • Self-Actualization
  109. Eriksons Psychosocial Theory
    Erikson's stages of psychosocial development, as articulated by Erik Erikson, explain eight stages through which a healthily developing human should pass from infancy to late adulthood.  Each stage builds upon the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future.

    • Trust vs Mistrust
    • Autonomy vs Shame
    • initiative vs. guilt
    • industry vs. inferiority
    • identity vs confusion (12-20 yrs)
  110. Holistic View of Humans
    • Gordons Health Patterns
    • +
    • physical, spiritual emotional, social, intellectual
  111. Duke University Wheel of Health
    • outside: meds/supplements, preventative meds, conventional tx
    • inner: personal growth and spirituality, mind-body, exercise, nutrition, relationships, physical environment
    • inside: mindfulness
  112. Self Concept definition? dimensions?
    • how one things/feels about oneself
    • -body image
    • -role performance
    • -personal identity
    • -self-esteem

    affected by history of success/failure, relationships, developmental level, locus of control, socioeconomics, illness, sexual dysfunction
  113. Self-Concept: Body Image
    how person perceives the size, physical appearance, sexuality and function of body and its parts. attitudes
  114. Self-Concept: Role Performance
    Way in which a person perceives his/her abilty to carry out significant roles. Student, parents, nurse, friend, etc.
  115. Self-Concept: Personal Identity
    • view of oneself as unique human being
    • Age, race, ethnic origin, culture
    • sexuality, occupation, beliefs, values, pesonality
  116. Self-Concept: Self-Esteem
    • Overall judgment of one's worth or value
    • relationship between ideal self (expectations) and real self (current skills)
  117. Stress
    • physical or psycho challenge that threatens or has potential to threaten, interfere homeostasis.
    • coping response: voluntary/involuntary reaction
    • adaptations: changes we make in response to stress
  118. Stressor
    a stimulus that the person perceives as a challenge or threat. unique to each person

    Stressor causes stress
  119. Types of Stress
    • Distress: can threaten health (continual financial worries)
    • Eustress: good stress (kiss)
    • Developmental: associated with life changes/events (graduating)
  120. Situation Stress
    Random, unpredictable (hurricane)
  121. Physiological Stress
    • affect body: structure/function
    • disease, mobility problems
  122. Psychological Stress
    • arise from life events
    • work pressure, family arguments
  123. Stress Response: Approaches
    produce voluntary or involuntary coping response. three approaches:

    • alter: change jobs
    • avoid: end relationships
    • adapt: change thoughts
  124. General Adaptation Syndrome (Selye's)
    • Alarm Stage: fight or flight
    • Resistance: cope with stressor
    • Exhaustion: recovery
  125. Alarm Stage:  general adaptation syndrome
    • stimulates sympathetic system-cortisol-glucose sparing, anti-inflammatory response.
    • Cardio:HR and contraction increase, BP increase
    • Resp: increase depth and tidal volume
    • Unriary: decrease blood flow to kidneys
  126. Resistance Stage: general adaptation syndrome
    Restore cardiac output, blood pressure, respiratory, hormone, if fail to homeostasis move to Exhaustion stage

    Long stage
  127. Exhaustion Stage: general adaptation syndrome
    • -vasodilation, decreased BP, increase pulse and respiration
    • -energy depleted
    • -glucocortisol receptor resistance
    • -ends in injury, illness, death
    • recovery
  128. Styles of coping strategies
    • Adaptive: health choices, reduce negative stress
    • Maladaptive: unhealthy style, temp. fix, harmful effects
  129. Heparin
    • rapid acting anticoagulant
    • Sq or IV

    Lovenox (low molecular weight heparin (LMW)

    • Pulmonary Embolism
    • Massive Deep vein thrombosis
    • Acute MI
    • open heart surgery/dialysis
    • prevent post op venous thrombosis
    • DIC
  130. What two laboratory results do you need to know before giving Heparin and enoxaparin (Lovenox)?
    • Heparin       
    • -aPTT monitoring is essential       
    • -Monitored Platelets

    • enoxaprin (Lovenox)
    • -No aPTT monitoring required
  131. What type of injection is Heparin or enoxaparin (Lovenox) injection?
    • Heparin: IV, subq
    • Enoxaparin: subq

  132. What are the side effectsof Heparin and enoxaparin (Lovenox)?
    • Heparin:   
    • Hemorrhage, Spinal/epidural Hematoma, Heparin-induced Thrombocytopenia (HIT)
    • enoxaparin (Lovenox):
    • ↓ risk of bleeding than Heparin.
  133. What is the antidote of Heparin and enoxaparin (Lovenox)?
    • Heparin: Protamine sulfate
    • enoxaparin (Lovenox): Protamine sulfate
  134. What angle would you position the needle during administration? (heprin and lovenox)
    Subcutaneous: 90 and 45 degrees
  135. Components of Medication Order
    • Clients full name
    • date/time order was written
    • name of med
    • dosage, frequency, number of doses
    • route of administration
    • indication
    • signature
  136. Medication: 6 rights
    • right...
    • drug
    • client
    • dose
    • time
    • route
    • documentation

    other rights: reason, to know, to refuse
  137. Medication: Three Checks
    • check against MAR..
    • -as pull med
    • -after pull med
    • -at bedside

    other consideration: appropriate for ht/wt, allergies, patient's knowledge, anything that can affect absorption, situation reasonable for med.
  138. Meds: routes of administration:
    • oral (buccal, sublingual)
    • enteral (nasogastric, nasoduodenal, gastrostomy jejunostomy, nasojejunal)
    • topical: (optholmpic, otic, nasal, vaginal, rectal)
    • respiratory inhalation:
    • parentral: (IV, subcutaneous, intradermal, intramuscular)
  139. Intramuscular Injections:
    • ntrogluteal
    • deltoid
    • vastus lateralis
    • dorsogluteal

    Absorbed faster than subcutaneous medications because of rich blood supply in muscles
  140. Medication Errors: what do I do
    • —Immediately assess the patient’s vital signs and physical status—
    • Report findings to the primary care provider—
    • Notify the charge nurse/nurse manager & report circumstances—
    • Follow agency’s policy
  141. Diabetes type 1
    • insulin depended diabetes mellitus
    • autoimmune
    • immune system forms antibodies that destroy the beta cells in pancrease
    • need insulin administered
    • Symptoms: hyperglycemia, ketoacidosis
  142. Diabetes Type 2
    • insulin resistance: glucose uptake not happen
    • beta cell dysfunction: pancreas not able to produce enough insulin

    Risk factors: family hx, over 45 yo, overweight, physical inactivity, race
  143. What patient education would you teach? Meds
    • Explain when the patient needs to have intradermal injection read to determine whether result is positive or negative
    •  Explain that mild itching, swelling, or irritation may occur at injection site and is normal
    • Discuss significance of positive or negative skin test result
    • Instruct patient not to scratch
  144. Metabolic Syndrome
    • Waist circumference
    • HDL
    • Triglycerides
    • BP
    • Fasting glucose
    • 100mg/dl: normal
    • 101-125: impaired glucose int.
    • 125 and higher: daibetes
  145. Criteria for Diagnosis of Diabetes
    }Fasting Blood Glucose  >125 mg/dL       or}HbA1C > 6.5 %                   

    • or
    • }Symptoms of diabetes and a random blood glucose >200 mg/dL                       

    or }2 hr blood glucose >200 mg/dL during an oral glucose tolerance test (OGTT)
  146. Signs of Hyperglycemia
    • }Polydipsia
    • }Polyphagia
    • }Polyuria}
    • Weight loss
    • }Blurred vision
    • }Fatigue
  147. Sings of Hypoglycemia
    • }Pallor   
    • }Diaphoresis
    • }Tachycardia
    • }Palpitations
    • }Nervousness
    • }Irritability
    • }Hunger
    • }Weakness
    • }Cold sensation
    • }Trembling
    • }Piloerection

    }Headache}Mental Confusion}Fatigue
  148. Diabetes complications:
    • }Cardiovascular disease
    • }Retinopathy
    • }Nephropathy
    • }Neuropathy
    • }Periodontal disease
  149. Insulin NTK
    •  Insulin is administered subcutaneously by injection or pump.
    • Only regular insulin may be administered intravenous in solution.
    • Insulin must be administered at the correct time.
  150. Types of Insulin
    • Basal - given to cover the body’s energy needs without taking the diet into account. (NPH and long acting) 
    • Prandial/preprandial - given to prevent high blood sugar after eating a meal. Regular insulin.
    • Correction - given to reduce an elevated blood sugar level to a normal range. This type of sliding scale blood sugar management is not the best way to manage diabetes because it achieves damage control more than damage prevention.
  151. What patient education would provide? (diabetes)
    • discuss lifestyle adaptations such as diet and exercise recommendations for managing diabetes mellitus
    • Home Care: 
    • Discuss options for insulin administration to determine best option
    • As long as injection site  is clean pt does not need to cleanse the site with alcohol wipe
    • Do not encourage reusing needles and syringes. If so, teach on how to reuse. 
    • Discuss safety concerns of subcutaneous med administration and disposing of biohazardous material
    • Rotate sites to promote absorption and minimize tissue damage. Usually same time of day  and same body location about 1 inch from previous injection site.
  152. Pyelonephritis
    • Inflammation of kidney, bacteria
    • fever, chills
    • flank pain,
    • urinary urgency, freq
    • dysuria, burning, noturia, hematuria
    • anemia
    • proteinuria, leukocytes in urine
  153. Continent vesicostomy
    • kock poutch
    • urine diverted
  154. Ileal Condiut
    • urostomy
    • ureters anastomosed to ileal segment
  155. Suprapubic catherization
    • temporary diverstion
    • monitor I & O, infection
  156. Urinary Retention
    BPH, neuro injury, rectocele, meds
  157. Crede Meneuver
    milk urinary system
Card Set:
NURS 509 Exam 1
2013-06-11 03:01:14
NURS 509 Exam

NURS 509 Exam 1
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