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Nursing theory, research, and practice are
Saw nurding as an art and science. Supported education. Said the environment directly affects one's health. Cleanliness, Light, Pure air and water.
Defined the nurse-client relationship. Stranger, Resource person, Teacher Leader Surrogate, and Counselor
Defined nursing as assisting a person in the performance of acitivites that will contribute to health or a peacful death. Stressed independence of client
Conservation theory- Energy, Structural Intergrity, Personal Intergrity, and Social Integrity.
I am Nursing. Looked at action by the nurse client and family and said those things are integrated together. Important that the patients do what they can on their own.
Stressors- Intrapersonal, Interpersonal, and Extrapersonal
stresses within (fear of flying)
Between 2 individuals (getting into with someone)
Outside the individual (raining)
Culrture care and culture belief. Accomodation or negotiation (We respect cultural beliefs).
Sister Calista Roy
Aaptation model- Nursing attempts to alter the environment when the person in not adapting well (i.e. if patient has a problem getting out of the bed, get them a walker). Use of coping systems-Nursing attempts to assist hte client in coping mechanisms.
Human caring. Care and love are the basis for humanity.
- Unitary human beings
- Nursing as an art and science. Energy fields. Looked at humans as structures that cannot ve seperated into pieces.
National Patient Safety Goals
- Improve accuracy of client identification
- Reduce risk of health care associated infection
- Improve effectiveness of communication
- Improve safety of usig high-alert med
- Prevent errors in surgery
- Improve safety of infusion pumps
- Effectiveness of clinical alarm systems
- Reduce the risk of patient harm resulting form falls
Client behavior accident
Burns/poisonings, Self inflicted cuts
Therapeutic procedure accidents
- Medication errors
- Client transfer falls
- Osygen Tank
Always there. Hands washing alone will not get rid of it. Must use friction by rubbing the hands and scrubbing the nails.
Brief can get rid of with hand-washing.
Biological Agents (chain of infection)
Viruses, bacteria, fungi, protozoa, Rickettsia
Chemical agents (chain of infection)
Pesticides, food additives, medications, and industrial chemicals
Physical agents (chain of infection)
Machine, heat, light, noise, radiation, and machinery
Person who lacks resistance to an agent and is vulnerable to disease
Compromised host- a person whose normal defenxe mechanims are impaired and is susceptivle to infection
Modes of transmission
Sexually transmitted diseases
Host contacts droplet nuclei or dust particles suspended in the air
Contaminated inanimate objects such as water, food, drugs and blood
mosquitoes, fleas, ticks, lice and other animals
Stages of infection
Time interval between entry of an infectious agent in the host and the onset of symptoms.
Non specific symptoms
Disappearance of acute symptoms until the client returns to the previous state of health
Emerging Infections- Don't know where they are at or going
- West Nile Virus/Hantavirus
- Viral hemorrhagic fevers (ebola)
Nosocomial Infections (most common infection sites greatest to least)
- Lower Respiratory
Assesing client in inpatient setting
- Fall risk every shift
- Infection (local or systemic)
Assesing client in home
- Asses prior to patient's discharge
Magic number for leukocytes
Increase in acute sever infection (bacterial)
Increase in chronic bacterial infections
increased in protozoan and rickettsial infections and tuberculosis
Eosinophils and basophils
Unaltered in an infectious process
Erthrocytes Sedimentation rate (ESR)
Elevated in infection
pH in urine, gastric or vaginal secretion
Elevated in infection
Three things to focus on to reduce exposure to radiation.
less time, more distance, and more shielding
infection control practice used to reduce number, growth and spread of microorganisms.
Examples of medical asepsis
Gloves, changing linens daily, cleaning floors, hospital furniture and hand hygiene
Eliminates microorganisms and spores
Examples of surgical asepsis
Sterile technique, donning sterile gloves,donning surgical attire, surgical hand antisepis, gowning and closed gloving
- Protective Eyewear
- Hand Hygiene
- In addition to standard
- Disposable equipmemt
Perform areas with contaminated areas when?
- In addtion to standard
- Eye protection
- Fluid resistant procedure mask
- Keep door closed
- N95 respirator mask
When to use contact precaution
MRSA, VRE, C.difficile, major wounds with significant damage
When to use airborne precaution
Tuberculosis,measles,chickenpox, disseminated herpes zoster
When to use droplet precaution
Influenza, respiratory MRSA,rubella, meningoccocal meningitis, mumps, pertussis
- Client is free injury
- Client is free from
- Self-care needs are met
When to take vital sighns
- Upon admission
- Every few hours
- Anytime there is a change in the patients condition
- Before procedures (compare when they return)
- Prior to discharge
How often you take vital signs for med surge?
How often do you take vital signs for ICU?
How often do you take vital signs for Progressive care?
Every 4 hours
How often do you take vital signs for Hospice?
May not take them
Normal adult value for oral temperature?
Normal adult value for axillary?
Normal adult value for rectal(most accurate)?
When shouldn't you take a rectal temperature?
- Patient at risk for perforation
- Patients who have extremely slow heart rate because it stimulates vegus nerves and can slow the heart rate
Meatabolic heat production
- Shivering (body's own mechanism)
- Excessive muscle activity
- Thyroxine production
Loss of heat to object in contact with the body
Normal respirations for an adult
12-20 breaths per minute
When do you check the carotid pulse?
During cardiac arest, shock, blood pressure very low
How long do you check the apical pulse?
If apical pulse is larger than radial, what may be the problem?
Circulation problem, the heart is not pumping efficient enough to reach extremeties
What two pulses should you find in every patients besides the normal pulse?
Posterior tibial and Dorsalis Pedis
measure of blood that enters the aorta with each ventricular contractiondiac output
volume of blood pumped by the heart in one minute
Cardiac out put for men?
Cardiac output for women?
Repolarization- Most important heart not resting doesn't get oxygen and doesn't allow blood to flow to tissues
Pulse pressure equals
- 120/80= 40
Orthostatic Blood pressure
- Lay flat, take BP
- -Wait 5 minutes
- Sit, take BP
- -Wait 5 minutes
- Stand up, take BP
How does fever affect pulse?
- It is expected to go up
- peripheral vasodilation and increased metabolic rate
Digoxin increase or decrease pulse?
Epinephrine increase or decrease pulse?
Hypovolemia affect on pulse?
Increases pulse in attempt to raise BP
Position changes affect pulse how?
Blood pooling causes lower BP and increase in heart rate
Most accurate way of measuring Vital signs?
Mercury manometer (no longer used)
When is the electronic sphygmomanometer used?
For frequent vitals, used to see if any changes in BP
What must always be the same when measuring daily weight for fluids?
Time of day, Same scale, and same clothing
Absence of fever
Which site does not require a sheath when doing thermoregulation assessment?
Pulmonary artery (PAT)
What temp is classified as hyperpyrexia?
Greater than 105.8
Some of the signs associated with hyperthemia?
Chills, Fever, pyrogens, diaphoresis, elevated pulse and respiration rate.
Signs associated with hypothermia
Pallor, shivering, cyanotic nail beds, decrease in BP and pulse
What is ineffective thermoregulation
fluctuation between hypothermia and hyperthermia
Why do you have to be careful when using ice packs to bring down temperature?
If the patient is shivering (body's own mechanism) the temperature will go up
What will you instruct the patient to do during a fever?
- Reduce external coverings and keep clothing and bed linen dry
- Limit physical activity
- Increase rest periods
- Increase oral fluids of choice
If unable to palpate the pulse what do you use?
Doppler (ultrasound) with gel
What is meant by pulse deficit?
Apical pulse and radial pulse not the same
quality and rate
- 0- Absent
- 1- Weak
- 2- Normal
- 3- Strong/bounding
portable cardiac monitor worn 24 hours used to determine if certain activities such as walking are associated with abnormal transmission of impulses.
normal rate and depth
10 or fewer breaths per/minute
more than 24 breaths per minute
sit or stand to breathe
gradual increase in depth of respiration followed by gradual decrease in depth of respiration
What muscles are involved in costal breathing?
External intercostal muscles and accessory muscles
What to do for a patient experiencing costal breathing
They are going into respiratory distress, place them in an upright position. This helps them breath easier
diaphargm contraction and relaxation observed in the abdomen
- labored breathing or forced respirations
- use accesory muscles and neck to breathe
Normal respirations for a newborn
Normal respirations fora an infant (6 months)
Normal respirations for a toddler (2 year old)
Normal respirations for an adolescent?
Does low hemoglobin increase or decrease respirations?
The earliest sign a patient is having trouble breathing/
Latest sign a person is having trouble breathing?
When would it be hard to measure oxygen saturation of blood using an oximeter?
If a person is wearing polish or there is swelling
Is taking a brachial BP direct or indirect?
Measuring BP by a catheter in a patient heart direct or indirect?
- Phase 1-First faint tapping SYSTOLIC
- Phase 2-during deflation muffling quality
- Phase 3-period crisp thumb
- Phase 4-softer blowing, muffled that fades
- Phase 5-silence DIASTOLIC
It fades then return during diastolic
- Systolic blood pressure less than 90mmHg
- 20-30 mmHg below the clients normal systolic pressure
Can you diagnosis hypertension after one visit to the doctor?
No. Must be confirmed on 2 seperate visits
Normal BP in adults (not optimal)?
<130 and <85
If a person has a hemorrhage you would expect the BP to?
If a person has a heart attack their BP would?
If a person has IV fluid administration their BP would
If a person has a blood transfusion their BP would
How long should a blood transfusion take?
What things cause a false high BP reading?
- Cuff too narrow
- arm unsupported
- Insufficient rest before assesment
- cuff wrapped too loosely
- deflating cuff to slowly
- patient talking
- assesing after meal, smoking, or while in pain
- repeating assesment too quickly
what causes false low BP reading
- Cuff too wide
- deflating cuff too quickly
- arm above level of the heart
- failure to identify auscultatory gap
If BP to high or low what steps do you take?
- Check the BP again in 15 minutes
- continue to reassess
- review list of medications to see if there is anything available prn
First step after collecting data
Compare the data against esablished norms
The ability of a test to correctly idenfiry those individuals who DO NOT have the disease
The ability of a test to correctly idenfify those individuals who have the disease
The ablility of a screening test results to correctly identify the disease state. Dont want a lot of false positives or false negatives.
High hematocrit is a sign of?
Normal hemoglobin for Men
Normal Hemoglobin for Women
Normal hematocrit for men
Normal hematocrit for women
Elevation of BB bands mean?
Elevation of MB bands mean?
damage to the heart
Elevation of UU bands
Damage to skeletal muscle
Non invasive radiography
plain films and mammography
pyelograph and bronchography
- Noninvasisve study
- Uses high frequency sound waves
- Visualise deep body structures
- Abnormal structure or motion of the heart wall and thrombi
- Radiofrequency ablation
reveals blood clots and peripheral vascular disease
Where do you aspirate bone marrow?
From the sternum or illiac crest
What position is used during paracentesis?
What are the symptoms of pnuemothormax you should monitor the patient for during thoracentesis?
Dyspnea, pallor, tachycardia, vertigo, and chest pain
Transparent film (Type of dressing)
- Impedes moisture less surface friction
- Used mostly fo IV sites
- Tegaderm (brand name)
Exudate absorbers (Type of dressing)
No moisture in the wound
When should you not use cold therapy?
In patients with neuro sensory impairment, impaired circulation, skin integrity, very young and old, impaired mental status
An example of shearing
Patient sliding down in bed
An example of friction
A nurse pulling a patient up in bed
Characteristics of Stage I pressure ulcer and treatment?
- Stage- Nonblanchable erythema of intact sking
- Treat- remove pressure, prevent moisture, shear, and friction; promote nutrition and hydration
Characteristics of Stage II pressure ulcer and treatment?
- Stage- Partial thickness skin loss, involves epidermis or dermis, appears as blister, abrasion, or shallow crater, an open break in skin
- Treat- Clean with sterile saline, semi-permeable occlusive dressing
Characteristics of Stage III pressure ulcer and treatment?
- Stage- Full-thickness skin loss,includes subcutaneous tissue, deep crater, may have undermining
- Treatment- Debridment, topical teatment to promote granulation of tissue, surgical interventions like skin grafting
Characteristics of Stage IV pressure ulcer and treatment?
- Stage- Full-thickness skin loss, Extensive damage to muscle, bone, or supporting structures, may have undermining
- Treatment- Same as Stage III
Which debridement is not effective for necrotic tissue?