Nurs Foundations

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  1. What is the most important assessment to be aware of?
    Knowing the patient's baseline for comparison
  2. What are the five parts of the Nursing Process?
    • Assessment
    • Nursing Diagnosis
    • Planning of Patient's care
    • Implementation of care 
    • Evaluation
  3. What is the normal range for HR?
    60-100
  4. Normal rate for RR?
    12-20
  5. Normal PO (Oral temp)?
    97.6-99.6
  6. What can be an early warning sign that complications are developing?
    Vital signs
  7. What are some factors affecting temperature?
    • age
    • exercise
    • hormones
    • sleep cycles
    • stress
    • smoking
    • eating
    • medications
  8. What is core temperature?
    The heat generated by organs and tissues inside the body, and controlled by the hypothalamus
  9. What is skin temperature?
    The quick rise and fall of heat in response to environmental conditions
  10. Heat lost to the external environment is dependent on what?
    blood flow to the skin
  11. What is the normal core temp?
    96.2 - 100.4
  12. Why do we shiver during fever?
    it's an early response of the body to generate heat and regulate temp
  13. When would you measure VS every 15 min?
    • Post cardiac catheterization
    • Beginning blood transfusion
    • After surgery
    • Beginning chemotherapy
    • Neurovascular checks/MS changes
  14. When would you measure VS every 30 min?
    • After first set of cardiac cath VS
    • If a change in status
  15. Which pts do you measure VS every hour?
    ICU and critical care pts
  16. What is pyrexia?
    Temp greater than 100.4
  17. What is hyperpyrexia?
    Temp greater than 106 (med emergency, leads to heat stroke)
  18. What is hypothermia?
    Core temp below 95 degrees
  19. What can happen as a result of hypothermia?
    • Uncontrolled shivering 
    • Loss of memory
    • Decreased level of consciousness
  20. What is a pulse?
    Left ventricle contracts and blood surges through the arteries
  21. What three things do we assess related to pulse surge?
    Rate, rhythm, and strength
  22. What is the gold standard for assessing pulse?
    Apical
  23. What is a normal pulse rate?
    60-100 BPM
  24. What is Bradycardia? Tachycardia?
    • Less than 60 BPM
    • More than 100 BPM
  25. Inhaling and exhaling are automatic responses controlled by what?
    the medulla
  26. What is Eupnea?
    normal breathing rate (12-20 resp per minute)
  27. What is tachypnea?
    greater than 24 breaths per minute
  28. What is it called when a person has difficulty breathing?
    dyspnea
  29. What is orthopenia?
    difficulty breathing while lying flat
  30. Which side should a cane be on for a pt?
    Contralateral (strong side)
  31. Which side should a crutch be used on?
    • Actual = ipsilateral (Pt's weak side)
    • HESI = contralateral
  32. What is alopecia?
    hair loss
  33. What is pediculosis?
    Lice
  34. What is stomatitis?
    Oral inflammation (ulcer or sore)
  35. What is cheilosis?
    • abnormal lip condition - dry & scaly
    • usually from vitamin B-2 deficiciency
  36. What is glossitis?
    tongue inflammation (swollen, discolored, sore)
  37. What should you offer before a bath?
    bedpan or urinal
  38. Which type of people are more susceptible to skin infections?
    Very thin and very obese
  39. How do you clean the eyes during a bed bath?
    Using a wet, warm cloth (no soap) - from inner to outer canthus
  40. What do you use on a pt's eyes if their blink reflex is absent?
    artificial tear solution every 4 hours
  41. Swelling in the sacral area is indicative of what?
    Congestive heart failure
  42. Excessive _______ predisposes the skin to breakdown.
    perspiration
  43. When assisting with hygiene, changing linens, or assisting with a bed pan, consider ______ and ______ which could cause pressure ulcers.
    pressure, friction
  44. _____ or _____ forces tear or injures blood vessels which can cause pressure ulcers.
    friction, shearing
  45. When providing oral care of an unconscious patient, irrigate with a 60 ml syringe and  suction with a ______.
    yaunkauer
  46. What is the trendelenburg position?
    head down
  47. What is reverse trendelenburg position?
    feet down
  48. What is fowler's position?
    sitting up 40-60 degrees
  49. What is semi-fowler's position?
    head elevated 30 degrees
  50. what is high fowlers position?
    head elevated greater than 80 degrees
  51. How much space between tip of penis and end of condom sheath for catheter use?
    1-2 inches
  52. Never use what two things to id a pt?
    room number, physical location
  53. 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
  54. 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
  55. What antiseptics can be used on skin?
    • alcohol
    • betadine
    • chlorahexadine
  56. What is disinfection?
    Destruction of pathogens other than SPORES
  57. What are disinfectant solutions/chemicals used on?
    OBJECTS, not people
  58. What is surgical asepsis?
    practice that destroys ALL microorganisms and their spores
  59. What is "antimicrobial"?
    destroying or inhibiting the growth of microorganisms
  60. What is "aseptic"?
    Being free from infection or disease producing microbes
  61. What is "contaminated"?
    To soil, stain, corrupt, or infect by CONTACT or association - bacteria contaminated my hands.
  62. What is a pathogen?
    A disease producing organism (germ)
  63. What is a specimen?
    a sample (of blood, tissue, or bodily fluid, an excretion or secretion such as semen, urine or feces, etc)
  64. Deaths linked to ________ now representsthe  fourth leading cause of death among Americans.
    hospital germs
  65. If it's wet, it's _________.
    infectious
  66. What percent of nurses suffer from chronic back pain?
    52%
  67. What percent of nurses have a lifetime prevalence of back pain?
    80%
  68. What percent of nurses report having occupational-related back pain?
    38%
  69. What are the five L's for lifting?
    • Load
    • Lever
    • Lordosis
    • Legs
    • Lungs
  70. What do injuries to the lumbar spine result from?
    • posture/position
    • wt or size of object
    • repetitiveness
    • physical condition of spine
    • sustained flexed spine
  71. Dependent patients should be repositioned how often?
    every TWO hours
  72. Repositioning dependent pt prevent?
    contractures
  73. Repositioning a dependent pt every 2 hrs can also decrease the risk of?
    skin breakdown and pressure ulcers
  74. Repositioning a dependent pt every 2 hrs promotes what?
    normal circulatory, neural, and lymphatic systems function
  75. What is a contracture?
    Shortening of tightening of the skin, muscle, fascia, or joint capsule that prevents normal movement of a joint.
  76. _____________ have the highest risk for skin breakdown.
    Bony prominences
  77. What is another word(s) for a decubitous ulcer?
    pressure sore
  78. What is stage 1 of a pressure sore?
    nonblanchable area (does not turn white or purple when you press on it)
  79. What is stage 2 of a pressure ulcer?
    partial thickness loss of dermis
  80. What is stage III of a pressure ulcer?
    full thickness tissue loss
  81. What is stage IV of a pressure ulcer?
    full thickness involving bone
  82. What should you avoid with a transfemoral amputation pt?
    • prolonged hip flexion
    • do not elevate residual limb on pillow
    • hip abduction
  83. With a transfemoral amputation pt, limit the amount of sitting to what?
    no more than 40 min of every hour
  84. With a transfemoral amputation pt, what position is recommended periodically?
    prone
  85. What should you avoid with a transtibial (below knee) amputation pt?
    • prolonged hip and knee flexion
    • do not elevate residual limb on pillow
  86. Which side of a hemiplegia pt is the most therapeutic?
    The affected side
  87. What are the THR (total hip replacement) precautions?
    • Hips greater than 90 degrees
    • hip adduction-crossing midline
    • hip internal rotation
  88. What positions do you avoid with split-thickness burns and grafted burn areas?
    positions of comfort
  89. A benefit of PROM is to enhance _______ and movement of ______.
    cartilage nutrition, synovial fluid in joint capsule
  90. What is a minimum assist?
    Pt performs 75% or more of activity but requires some assistance
  91. What is a moderate assist?
    Pt performs 50-74% of activity
  92. What is a max assist?
    Pt performs 25-49% of activity
  93. What should you avoid doing to a patient with hemiplegia?
    avoid pulling on the involved extremity
  94. When transfering a patient, what type of angle should there be from surface to surface?
    45 degrees
  95. Collecting, validating, and communicating of patient data.
    Assessing (part of nurse process)
  96. Analyzing pt data to id pt strengths and problems.
    diagnosing
  97. Specifying pt outcomes and related nursing interventions.
    planning
  98. Carrying out the plan of care.
    Implementing
  99. Measuring extent to which pt achieved outcome.
    Evaluating
  100. 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
  101. 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
  102. Assessing a pt's elimination status enables you to assess ______ function, ____ function, and _______.
    kidney, GI, medication side effects
  103. What are the main components of the urinary tract?
    kidneys, ureters, bladder, urethra
  104. How long is the male urethra?
    7-8 in
  105. How long is the female urethra?
    1.5-2.5 in
  106. What are some factors that affect urinary elimination?
    • aging
    • food & fluid intake
    • psych conditions
    • activity & muscle tone
    • Pathologic conditions
    • meds
  107. What are some factors that affect bowel elimination?
    • mobility
    • diet
    • meds
    • intestinal diversions
    • ostomies

Card Set Information

Author:
 MeganM
ID:
 255474
Filename:
 Nurs Foundations
Updated:
2014-01-10 01:25:56
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301
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Description:
Nurs
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