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nur 111 final

final exam

maslow's hierarchy of needs 1: physiological 2. safety 3. love/belonging 4. esteem 5. self-actualization
trust vs. mistrust infant, dependence on mother, need body & sensory stimulation, have a routine, attend to needs promptly
autonomy vs. shame & doubt toddler, mastery of body and environment, stress of separation from mother,
initiative vs. guilt preschool, beginning of peer involvement, accept child as they are, allow independence
industry vs. inferiority school age,competitiveness, puberty, provide intellect stimulation
identity vs. role confusion adolescence, independence from family, choosing life goals, peer pressure to conform
intimacy vs. isolation young adult, carrying out life plans, choosing work & mate, depression over interruption of plans
generativity vs. stagnation middle aged adult, ideas for next generation, carrying out life goals, assessment of life
integrity vs. despair older adult, life review, dec. physical function, unhappiness due to dec. independence
types of abuse physical, emotional, sexual, financial, violation of rights
barriers to obtaining help from elder abuse fear of reprisals, question of injury occurred, cultural traditions make it difficult to determine abuse
ANA code of ethics pt dignity & advocate, commitment to pt, nurse responsibility for own practice, character & professional growth, quality health care, collaboration with other health care professionals, maintain nurse values
primary healthcare health promotion and illness prevention
secondary healthcare diagnosis and treatment
tertiary healthcare rehabilitation and health restoration
AIDET acknowledge, introduce, duration, explanation, thank
QSEN pt centered care, team work, evidence based practice, quality improvement, informatics, safety
TEAMSteps from military, pt safety, promote team leadership, situation monitoring, support communication
TCAB transforming care at the bedside
HIPPA protected & kept private, allows pt access & the ability to amend their health info, pt has right to refuse or approve release of health info, pt has right to view info unless MD feels it is harmful, info may be revealed to friend/family identified by pt
payment sources medicare, medicaid, SSI, private, canada, cobra, military/va
5 steps to the nursing process 1. assessment 2. nursing diagnosis 3. planning 4. implementation 5. evaluation
characteristics of a GOAL realistic, measurable, time frame, pt centered, positively stated
purpose of documentation communication, education, assessments & planning, research, auditing, legal documentation, agency accreditation, reimbursement
source orientated medical records each person or department makes notation in a separate section or sections of clients chart
problem orientated medical records data is arranged according to problems the pt rather than source of the info
charting by exception only abnormal or significant findings or exceptions to norms are recorded
computerized charting use computers to stare pt database, add new data, create and revise care plans and document pt progress
info found in Kardex medical diagnosis, MD orders, plan of care, nursing orders, test & procedures, diet/activity, safety precautions, written in pencil
4 factors influencing response to stress 1. nature of stress 2. # of stressors to be coped with at one time 3. duration of exposure to stressor 4. past experiences with comparable stressor
negative stress rejection, guilt, negative body image, embarrassment, breaking off relationship
nursing diagnosis for stress hopelessness, ineffective coping
anxiety response to unobservable internal danger, source not identifiable, r/t future or anticipated event, vague, psychological/ emotional conflict
fear response to observable external danger in proportion to danger, source in identifiable, r/t present event/happening, definite & clear, result of direct or psychological entity
4 levels of anxiety mild, moderate, severe, panic
nursing intervention with angry patient recognize pt is angry, ask direct questions, accept anger for what it is, assist pt to recognize they are angry, encourage pt to verbalize anger and their feelings, allow time to relax
stages of dying 1. denial and isolation 2. anger 3. bargaining 4. depression 5. acceptance
effect of dying process: senses in sweating, impaired taste/smell, blurred vision, hearing is last to go
effect of dying process: skin loss of sensation
effect of dying process: respiratory system rapid, shallow, irregular, abnormal, gurgling, mouth breathing, dry mucous membranes
effect of dying process: CNS mobility & reflexes dec., dec. muscle tone, changes in consciousness
effect of dying process: circulatory system dec. circulation, dec. pulse, poor circulation=edema
effect of dying process: GI & GU system dec. activity of GI tract, constipation, incontinence
signs of brain death exclude hypothermia as cause of coma, rule out residual drug/alcohol, confirm absence of brain stem function
biological half life time required for body's elimination process to reduce concentration by half life
peak drug level highest blood or plasma concentration
what absorbs the drugs kidneys
what breaks the drugs down liver
onset of action time after administration when body initially responds to drug feels effect of med
how do you check for placement of a g-tube insert 5-10mls of air and listen for pop, aspirate content, check pH (normal range is < or equal to 5)
adverse reactions to medications allergy, idiosyncracy, cumulative, iatrogenic, teratogenic
idiosyncracy unexpected, individualized, under/over responsiveness to med, unexplainable
iatrogenic disease caused unintentionally by med therapy
variables influencing drug action age, gender, weight, illness/disease
how does heart diseases effect drug action distribution problems
how does liver disease effect drug action metabolism problems (accumulation of drug)
wound assessment redness, edema, ecchymosis, drainage, approximation
contaminated wounds pathogenic organism with no signs of infection
colonized wounds body carries pathogen but no S/S of disease
infected wounds S/S of disease are present
infection cycle reservoir, portal of exit, common modes of transmission, portal of entry, host
microorganisms need... warm, dark, moist, nutrients, oxygen, pH, immune response
local S/S of infection redness, heat, edema, pain, drainage
systemic S/S of infection fever, malaise, fatigue, anorexia, elevated wbc, diaphorsesis, irritability
4 stages of infection 1. incubation 2. prodromal 3. illness 4. convalescence
drives infection control practices OSHA
sets standards and guidelines CDC
mechanical debridement of wound Surgical: cut away dead tissue Non-specific: pull off dead and healthy tissue
autolysis debridement of wound let body own chemicals try to debride
transparent film and non-adherent autolytic debridement, minimal drainage wound
hydrocolloid dressings not infected wounds, autolytic debridement
hydrogel absorbs small amount of exudate, autolytic debridement, partial/full thickness wounds, infected wounds
foam dressing light to heavy drainage, not for dry eschar
what stage pressure ulcer is used for impaired SKIN integrity stage 1 and 2
what stage pressure ulcer is used for impaired TISSUE integrity stage 3 and 4
___ blood glucose ___ rate of wound healing increased; decrease
serosanguineous serum and blood in drainage
sanguineous bloody drainage
purulent pus drainage
partial thickness wounds involve only epidermis and dermis
full thickness wounds involve complete destruction of the epidermis and dermis and extend into deeper tissues
human body regulates temperature by... sweating, shivering, vasoconstriction, vasodialation, avoidance of external heat/cold
body's heat production is influenced by... BMR, muscle activity, thyroxin, epi/norepinephrine, fever
pyrexia fever
S/S of hypothermia dec. body temp, shivering pale cold skin, dec. urine output, confusion, dec. muscle coordination
normal temperature ranges oral: 97.6-99.6 Rectal: 98.6-100.6 Axillary: 97-98.6
the most accurate measurement of frequency and rhythm of the heart apical pulse
can radial pulse be > apical pulse no
normal pulse range for older adult 70(60-100)
respiration consist of what 3 interrelated procedures 1. ventilation 2. diffusion 3. perfusion
normal respiratory range for older adult 16(15-20)
eupnea normal resp. rate
cheyne strokes rapid and shallow resp. with periods of apnea
4 determinants of BP 1. pumping action of heart 2. peripheral vascular resistance 3. blood volume 4. blood viscosity
orthostatic hypotension BP falls when pt sits or stands with S/S of vertigo
pulse pressure difference between systolic an diastolic pressure
hygiene nursing diagnosis self care deficit
how are microorganisms are transmitted direct, indirect, vector-borne, droplet, airborne
pressure ulcer risk factors dec. mental status, dec. sensation, excess body heat, circulatory problems, older person
stage 1 pressure ulcer intact skin, reddened area
stage 2 pressure ulcer loss of epidermis, partial thickness, blister
stage 3 pressure ulcer full thickness, tissue visible, may include undermining/tunneling
stage 4 stage ulcer full thickness, exposure of bone/tendon/muscle
unstageable pressure ulcer full thickness, base of ulcer covered by slough or eschar
squeezing on muscles that surround veins dec. venous pooling, inc. venous return, inc. cardiac output, dec. dizziness
functional level 1 requires equipment/device
functional level 2 help from another person
functional level 3 help from another person and equipment
functional level 4 is dependent and doesn't participate in movement
nursing diagnosis for activity impaired physical mobility
cataracts buildup of protein in the lens that makes it cloudy, prevents light from passing clearly through the lens causing some loss of vision
glaucoma damage to the optic nerve
6 F's of distended abdomens flatus, fetus, foreign matter, feces, flat, fluid
opioid morphine, demerol, acts in CNS, moderate-severe pain
side effects of opioid (narcotic) constipation, resp. depression therefore check respirations
non opioids-acetaminophen Tylenol, mild-moderate pain, can cause hepatotoxicity
factors affecting pain experiences fear, lack of knowledge, culture, ethnic values, environment, support, psychological
developmental consideration for older adults: pain may not report due to dec. sensations or perceptions, seen as a weakness to admit pain
delirium sudden, altered mental state caused by a disturbance in brain function
nursing intervention for delirium remove causative agent, prevent further damage, mild sedation with MD order, hydrate, provide quite environment, measure I&O
symptoms of dementia cognitive impairment, functional losses, behavior changes, anxiety, depression, hallucinations
nursing intervention for dementia safe & structured environment, inc. sleep, proper nutrition, support family
drugs for dementia cognex, namenda, aricept, haldol, depakote
NREM non rapid eye movement, divided into 4 stages, 75% of sleep during night
meds affecting sleep Lasix: inc. urination Beta-blockers: causes nightmares Bronchodilators: CNS stimulant
nursing diagnosis for sleep sleep pattern disturbance
stages of sleep Pre-sleep->NREM stage 1->NREM stage 2->NREM stage 3->NREM stage 4-> NREM stage 3-> NREM 2
conduction direct touch transfer of heat/cold
convection loss of heat by air
diathermy use of high frequency current to generate heat
nursing intervention for INEFFECTIVE TISSUE PERFUSION PERIPHERAL (arterial) keep extremity below level of heart, eliminate pressure pointd, discourage leg crossing, assess SPO2
nursing intervention for INEFFECTIVE TISSUE PERFUSION PERIPHERAL (venous) assess for edema, remove venous pressure points, HT moving legs QH, do not massage leg, administer diuretics, apply antiembolism stockings
arterial assessment pain, pallor, absent pulse, paresthesis, cold temp.
venous assessment warm temp., edema
atelectasis collapse of lung tissue, air sacs aren't completely filled
oxygen therapy assessment 1. breathing 2. airway 3. circulation
incentive spirometer measure how much pt can breath in with force, helps with lung expansion, improve ventilation, helps with collapsed aveoli
chronic hypoxia fatigue, clubbing fingernails
hypoxia dec. O2 in cells/body
4 requirements essential for adequate ventilation 1. adequate atmospheric O2 2. clear air passage 3. adequate stretch ability and recoil 4. intact CNS
3 functions of resp. system gas exchange, fluid balance, acid-base balance pH
Created by: kamia2010