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What is the most important assessment to be aware of?
Knowing the patient's baseline for comparison
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What are the five parts of the Nursing Process?
- Assessment
- Nursing Diagnosis
- Planning of Patient's care
- Implementation of care
- Evaluation
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What is the normal range for HR?
60-100
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Normal rate for RR?
12-20
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Normal PO (Oral temp)?
97.6-99.6
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What can be an early warning sign that complications are developing?
Vital signs
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What are some factors affecting temperature?
- age
- exercise
- hormones
- sleep cycles
- stress
- smoking
- eating
- medications
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What is core temperature?
The heat generated by organs and tissues inside the body, and controlled by the hypothalamus
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What is skin temperature?
The quick rise and fall of heat in response to environmental conditions
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Heat lost to the external environment is dependent on what?
blood flow to the skin
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What is the normal core temp?
96.2 - 100.4
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Why do we shiver during fever?
it's an early response of the body to generate heat and regulate temp
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When would you measure VS every 15 min?
- Post cardiac catheterization
- Beginning blood transfusion
- After surgery
- Beginning chemotherapy
- Neurovascular checks/MS changes
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When would you measure VS every 30 min?
- After first set of cardiac cath VS
- If a change in status
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Which pts do you measure VS every hour?
ICU and critical care pts
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What is pyrexia?
Temp greater than 100.4
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What is hyperpyrexia?
Temp greater than 106 (med emergency, leads to heat stroke)
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What is hypothermia?
Core temp below 95 degrees
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What can happen as a result of hypothermia?
- Uncontrolled shivering
- Loss of memory
- Decreased level of consciousness
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What is a pulse?
Left ventricle contracts and blood surges through the arteries
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What three things do we assess related to pulse surge?
Rate, rhythm, and strength
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What is the gold standard for assessing pulse?
Apical
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What is a normal pulse rate?
60-100 BPM
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What is Bradycardia? Tachycardia?
- Less than 60 BPM
- More than 100 BPM
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Inhaling and exhaling are automatic responses controlled by what?
the medulla
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What is Eupnea?
normal breathing rate (12-20 resp per minute)
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What is tachypnea?
greater than 24 breaths per minute
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What is it called when a person has difficulty breathing?
dyspnea
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What is orthopenia?
difficulty breathing while lying flat
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Which side should a cane be on for a pt?
Contralateral (strong side)
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Which side should a crutch be used on?
- Actual = ipsilateral (Pt's weak side)
- HESI = contralateral
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What is alopecia?
hair loss
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What is pediculosis?
Lice
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What is stomatitis?
Oral inflammation (ulcer or sore)
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What is cheilosis?
- abnormal lip condition - dry & scaly
- usually from vitamin B-2 deficiciency
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What is glossitis?
tongue inflammation (swollen, discolored, sore)
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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
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How do you clean the eyes during a bed bath?
Using a wet, warm cloth (no soap) - from inner to outer canthus
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What do you use on a pt's eyes if their blink reflex is absent?
artificial tear solution every 4 hours
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Swelling in the sacral area is indicative of what?
Congestive heart failure
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Excessive _______ predisposes the skin to breakdown.
perspiration
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When assisting with hygiene, changing linens, or assisting with a bed pan, consider ______ and ______ which could cause pressure ulcers.
pressure, friction
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_____ or _____ forces tear or injures blood vessels which can cause pressure ulcers.
friction, shearing
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When providing oral care of an unconscious patient, irrigate with a 60 ml syringe and suction with a ______.
yaunkauer
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What is the trendelenburg position?
head down
-
What is reverse trendelenburg position?
feet down
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What is fowler's position?
sitting up 40-60 degrees
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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?
1-2 inches
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Never use what two things to id a pt?
room number, physical location
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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)
- Recommendation
- Repeat
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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?
- alcohol
- betadine
- chlorahexadine
-
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)
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Deaths linked to ________ now representsthe fourth leading cause of death among Americans.
hospital germs
-
If it's wet, it's _________.
infectious
-
What percent of nurses suffer from chronic back pain?
52%
-
What percent of nurses have a lifetime prevalence of back pain?
80%
-
What percent of nurses report having occupational-related back pain?
38%
-
What are the five L's for lifting?
- Load
- Lever
- Lordosis
- Legs
- Lungs
-
What do injuries to the lumbar spine result from?
- posture/position
- wt or size of object
- repetitiveness
- physical condition of spine
- sustained flexed spine
-
Dependent patients should be repositioned how often?
every TWO hours
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Repositioning dependent pt prevent?
contractures
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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.
Bony prominences
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What is another word(s) for a decubitous ulcer?
pressure sore
-
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?
prone
-
What should you avoid with a transtibial (below knee) amputation pt?
- prolonged hip and knee flexion
- do not elevate residual limb on pillow
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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
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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?
45 degrees
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Collecting, validating, and communicating of patient data.
Assessing (part of nurse process)
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Analyzing pt data to id pt strengths and problems.
diagnosing
-
Specifying pt outcomes and related nursing interventions.
planning
-
Carrying out the plan of care.
Implementing
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Measuring extent to which pt achieved outcome.
Evaluating
-
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
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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?
7-8 in
-
How long is the female urethra?
1.5-2.5 in
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What are some factors that affect urinary elimination?
- aging
- food & fluid intake
- psych conditions
- activity & muscle tone
- Pathologic conditions
- meds
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What are some factors that affect bowel elimination?
- mobility
- diet
- meds
- intestinal diversions
- ostomies
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