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What is the most important assessment to be aware of?
Knowing the patient's baseline for comparison
What are the five parts of the Nursing Process?
- Nursing Diagnosis
- Planning of Patient's care
- Implementation of care
What is the normal range for HR?
Normal rate for RR?
Normal PO (Oral temp)?
What can be an early warning sign that complications are developing?
What are some factors affecting temperature?
- sleep cycles
What is core temperature?
The heat generated by organs and tissues inside the body, and controlled by the hypothalamus
What is skin temperature?
The quick rise and fall of heat in response to environmental conditions
Heat lost to the external environment is dependent on what?
blood flow to the skin
What is the normal core temp?
96.2 - 100.4
Why do we shiver during fever?
it's an early response of the body to generate heat and regulate temp
When would you measure VS every 15 min?
- Post cardiac catheterization
- Beginning blood transfusion
- After surgery
- Beginning chemotherapy
- Neurovascular checks/MS changes
When would you measure VS every 30 min?
- After first set of cardiac cath VS
- If a change in status
Which pts do you measure VS every hour?
ICU and critical care pts
What is pyrexia?
Temp greater than 100.4
What is hyperpyrexia?
Temp greater than 106 (med emergency, leads to heat stroke)
What is hypothermia?
Core temp below 95 degrees
What can happen as a result of hypothermia?
- Uncontrolled shivering
- Loss of memory
- Decreased level of consciousness
What is a pulse?
Left ventricle contracts and blood surges through the arteries
What three things do we assess related to pulse surge?
Rate, rhythm, and strength
What is the gold standard for assessing pulse?
What is a normal pulse rate?
What is Bradycardia? Tachycardia?
- Less than 60 BPM
- More than 100 BPM
Inhaling and exhaling are automatic responses controlled by what?
What is Eupnea?
normal breathing rate (12-20 resp per minute)
What is tachypnea?
greater than 24 breaths per minute
What is it called when a person has difficulty breathing?
What is orthopenia?
difficulty breathing while lying flat
Which side should a cane be on for a pt?
Contralateral (strong side)
Which side should a crutch be used on?
- Actual = ipsilateral (Pt's weak side)
- HESI = contralateral
What is alopecia?
What is pediculosis?
What is stomatitis?
Oral inflammation (ulcer or sore)
What is cheilosis?
- abnormal lip condition - dry & scaly
- usually from vitamin B-2 deficiciency
What is glossitis?
tongue inflammation (swollen, discolored, sore)
What should you offer before a bath?
bedpan or urinal
Which type of people are more susceptible to skin infections?
Very thin and very obese
How do you clean the eyes during a bed bath?
Using a wet, warm cloth (no soap) - from inner to outer canthus
What do you use on a pt's eyes if their blink reflex is absent?
artificial tear solution every 4 hours
Swelling in the sacral area is indicative of what?
Congestive heart failure
Excessive _______ predisposes the skin to breakdown.
When assisting with hygiene, changing linens, or assisting with a bed pan, consider ______ and ______ which could cause pressure ulcers.
_____ or _____ forces tear or injures blood vessels which can cause pressure ulcers.
When providing oral care of an unconscious patient, irrigate with a 60 ml syringe and suction with a ______.
What is the trendelenburg position?
What is reverse trendelenburg position?
What is fowler's position?
sitting up 40-60 degrees
What is semi-fowler's position?
head elevated 30 degrees
what is high fowlers position?
head elevated greater than 80 degrees
How much space between tip of penis and end of condom sheath for catheter use?
Never use what two things to id a pt?
room number, physical location
What is I-SBAR-R?
- Introduction (name, unit)
- Situation (what triggered conversation)
- Background (what's been done)
- Assessment explain problem, signs, symptoms, what you think might be wrong)
What is asepsis?
- The state of being free of living pathogenic microorganisms;
- The process of removing pathogenic microorganisms or protecting against infection by such organisms
What antiseptics can be used on skin?
What is disinfection?
Destruction of pathogens other than SPORES
What are disinfectant solutions/chemicals used on?
OBJECTS, not people
What is surgical asepsis?
practice that destroys ALL microorganisms and their spores
What is "antimicrobial"?
destroying or inhibiting the growth of microorganisms
What is "aseptic"?
Being free from infection or disease producing microbes
What is "contaminated"?
To soil, stain, corrupt, or infect by CONTACT or association - bacteria contaminated my hands.
What is a pathogen?
A disease producing organism (germ)
What is a specimen?
a sample (of blood, tissue, or bodily fluid, an excretion or secretion such as semen, urine or feces, etc)
Deaths linked to ________ now representsthe fourth leading cause of death among Americans.
If it's wet, it's _________.
What percent of nurses suffer from chronic back pain?
What percent of nurses have a lifetime prevalence of back pain?
What percent of nurses report having occupational-related back pain?
What are the five L's for lifting?
What do injuries to the lumbar spine result from?
- wt or size of object
- physical condition of spine
- sustained flexed spine
Dependent patients should be repositioned how often?
every TWO hours
Repositioning dependent pt prevent?
Repositioning a dependent pt every 2 hrs can also decrease the risk of?
skin breakdown and pressure ulcers
Repositioning a dependent pt every 2 hrs promotes what?
normal circulatory, neural, and lymphatic systems function
What is a contracture?
Shortening of tightening of the skin, muscle, fascia, or joint capsule that prevents normal movement of a joint.
_____________ have the highest risk for skin breakdown.
What is another word(s) for a decubitous ulcer?
What is stage 1 of a pressure sore?
nonblanchable area (does not turn white or purple when you press on it)
What is stage 2 of a pressure ulcer?
partial thickness loss of dermis
What is stage III of a pressure ulcer?
full thickness tissue loss
What is stage IV of a pressure ulcer?
full thickness involving bone
What should you avoid with a transfemoral amputation pt?
- prolonged hip flexion
- do not elevate residual limb on pillow
- hip abduction
With a transfemoral amputation pt, limit the amount of sitting to what?
no more than 40 min of every hour
With a transfemoral amputation pt, what position is recommended periodically?
What should you avoid with a transtibial (below knee) amputation pt?
- prolonged hip and knee flexion
- do not elevate residual limb on pillow
Which side of a hemiplegia pt is the most therapeutic?
The affected side
What are the THR (total hip replacement) precautions?
- Hips greater than 90 degrees
- hip adduction-crossing midline
- hip internal rotation
What positions do you avoid with split-thickness burns and grafted burn areas?
positions of comfort
A benefit of PROM is to enhance _______ and movement of ______.
cartilage nutrition, synovial fluid in joint capsule
What is a minimum assist?
Pt performs 75% or more of activity but requires some assistance
What is a moderate assist?
Pt performs 50-74% of activity
What is a max assist?
Pt performs 25-49% of activity
What should you avoid doing to a patient with hemiplegia?
avoid pulling on the involved extremity
When transfering a patient, what type of angle should there be from surface to surface?
Collecting, validating, and communicating of patient data.
Assessing (part of nurse process)
Analyzing pt data to id pt strengths and problems.
Specifying pt outcomes and related nursing interventions.
Carrying out the plan of care.
Measuring extent to which pt achieved outcome.
What is the nursing process used to do?
- identify needs
- establish priorities of care
- maximize strengths
- resolve actual or potential alteration in responses to health and illness
What are 3 important reasons to monitor I's and O's?
- Keep track of a pt's fluid balance
- Ensure that pts are meeting caloric needs
- Assess elimination status
Assessing a pt's elimination status enables you to assess ______ function, ____ function, and _______.
kidney, GI, medication side effects
What are the main components of the urinary tract?
kidneys, ureters, bladder, urethra
How long is the male urethra?
How long is the female urethra?
What are some factors that affect urinary elimination?
- food & fluid intake
- psych conditions
- activity & muscle tone
- Pathologic conditions
What are some factors that affect bowel elimination?
- intestinal diversions