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M6 Nursing Concepts

Phase 2 test 1 'Basic Nursing Concepts'

Antiseptic substance that tends to inhibit the growth and reproduction of microorganism and can be used on humans
Antisepsis free of pathogenic organisms
Carrier individual who harbors in the body the specific organisms of a disease without manifesting its symptoms, thus acting as a transmitter of the infection
Contaminate make unsterile or unclean
Cycle of Infection chain of events necessary for an organism to survive and to continue to grow, multiply, and possibly do injury to human life
Disinfectant use of a chemical that can be applied to objects to destroy microorganisms
Double Bagging infection control practice that involves placing a bag of contaminated items into another clean bag that's held outside an isolation room by other personnel
Endogenous growth within the body
Exogenous growth outside the body
Fomite inanimate vehicle capable of carrying pathogens, such as a stethoscope, thermometer or bandage that may carry pathogens
Host person, group, or animal that may be susceptible to a disease or illness
Infectious Agent pathogen
Infection Control consists of policies and procedures of the hospital or other health care facility to minimize the risk of nosocomial or community-acquired infections spreading to patients and other staff members
Isolation Precautions guidelines designed to reduce the link of transmission of blood-borne pathogens and pathogens from moist body substances
Body Fluid that Isolation Precautions doesn't Apply to sweat
Medical Asepsis clean technique; consists of techniques that inhibit the growth and spread of pathogenic microorganisms
Microorganism organism that cannot be seen by the naked eye, but can be seen with a microscope
Types of Microorganisms bacteria, viruses, fungi, protozoa
Mode of Escape means or avenues by which the organism leaves the reservoir
Health Care-Associated Infection infection acquired during hospitalization which was not present or incubating at the time of hospital admission
Reservoir place that organism needs to live in order to grow and multiply
Spore bacteria form a specialized when conditions are unfavorable for growth of the bacterium
Standard Precautions combines universal precautions and body substance isolation
Sterilization methods used to kill microorganisms
Surgical Asespsis sterile technique; destroys microorganisms
Universal Precautions (standard precautions)precautions established by CDC in an effort to control the spread of diseases
Vector living vehicle that's carrying a pathogen about
Vehicle means by which organisms are carried about
Virulent pertaining to a highly pathogenic or rapidly progressing disease
ATP produced in the mitochondria from nutrients capable of releasing energy that enables cells to work
Active Transport force that moves molecules into cells without regard for their positive and negative charge and against concentration gradients requires energy moves fluid and electrolytes from an area of lower concentration to an area of higher concentration
Examples of Substances Actively Transported sodium potassium calcium iron hydrogen amino acids insulin provides transport for glucose
Passive Transport movement of substances through the cell membrane doesn't require energy
Diffusion movement of particles in all directions through a solution solutes move from area of higher concentration to an area of lower concentration
Osmosis movement of water from an area of lower concentration to an area of higher concentration
Filtration transfer of water and dissolved substances from an area of higher pressure to an area of lower pressure force behind it is hydrostatic pressure
Hydrostatic Pressure force of fluid pressing outward on a vessel wall pumping action of the heart determines the amount of pressure
Isotonic solution of same osmotic pressure as that of blood solution with same amount of solutes as blood
Hypertonic solution of higher osmotic pressure as that of blood contain more solutes that blood
Hypotonic solution of lower osmotic pressure solutions that contain less solutes than extravascular fluids
Homeostasis balance
Intracellular larger of the 2 fluid compartments fluid inside the cells within the body
Extracellular any fluid outside the cells interstitial and intravascular
Interstitial fluid between cells or in the tissues
Intravascular fluid within the vessels, plasma
Bicarbonate (HCO3) main anion of the extracellular fluid alkaline electrolyte whose major function is the regulation of acid base balance acts as a buffer to neutralize acids
Organ the Regulates HCO3 How? kidneys selectively retaining or secreting it
Buffer blood buffers are one of the 3 systems that work to keep the body's pH within the narrow range of normal chemical sponges that circulate through the body in pairs and neutralize excessive acids or bases by contributing or accepting hydrogen ions
Purpose of DA 3888-3 facilitates summarizing the patient's status at the time of discharge
Preparation of DA 3888-3 3-part carbonless form RN responsible for completing and reviewing it with patient ensure patient receives copy prior to leaving unit
Where the Parts of the DA 3888-3 Go original part of the permanent inpatient treatment record second reviewed with patient and family, then given to them third placed in patient's health record
Part of Body that Maintain Balance Between Heat Production and Loss, Regulating Body Temperature hypothalamus
Type of body temperature that remains relatively constant core
Temperature above 105 F can damage body cells
Death can occur if temperature falls below 93.2 F
Using tympanic thermometer for child, nurse should pull the ear pinna Adult downward and back upward and back
To ensure optimum reception from a stethoscope, the nurse should place the earpieces pointing toward the face
Diaphragm of stethoscope used to best assess Bell lung sounds low-pitched sounds, peds, cardiac, vascular
Pulse in produced by contraction of left ventricle
Pulse of 120 called tachycardiac
When peripheral pulse needs to be assessed quickly, nurse should choose the carotid
Apical pulse 88, radial pulse 70 difference termed pulse deficit
Patient with severe head injury of occipital lobe has respiratory rate of 10 which may indicate injury to the medulla oblongata
Temporal artery scanner on neonate is 99.5 F, nurse should record the findings
Respirations of a patient who is demonstrating pursed-lip breathing, flared nostrils and retractions are described as dyspnea
Pedal pulse difficult to feel and not palpable when only slight pressure is applied, nurse should document this finding as thready pulse
Dorsalis pedis pulse not palpable when light pressure applied, document as weak pulse
Dorsalis pedis pulse easily felt but not palpable when moderate pressure applied normal pulse
Dorssalis pedis pulse feels full and springlike even under moderate pressure thready pulse
When instructing primary caregiver about keeping a daily log of BP readings, nurse should include what instructions? apply cuff approximately 2 inches above AC fossa apply cuff snugly
5th vital sign pain
Axillary temperature 96.2 F, true temperature is 97.2 F
Factors that may influence patient's pulse rate age, sex, emotion, temperature, physical activity
Pulse 56 is termed bradycardia
Bradycardia is when pulse less than 60
Pulse rate greater than 100 tachycardia
Abnormally rapid rate of breathing that is seen in many disease conditions is known as tachypnea
Signs of Inflammation redness pain loss of function of affected body part heat swelling
Stages of the Infectious Process incubation period prodromal stage illness stage convalescence
Chain of Infection infectious agent reservoir exit route method of transmission entrance host
Factors Affecting Immunologic Defense Mechanisms age, stress, nutrition, hereditary, disease processes, environmental factors, medical therapy, chemotherapy, radiation, lifestyle, occupation, diagnostic procedures, travel history, trauma
Normal Defense Mechanisms Against Infection skin, mouth, respiratory tract, urinary tract, GI tract, vagina
Fever, chills, headache, fatigue, anorexia, rapid pulse, hypotension, shivering, and marked leukocytosis are signs and symptoms of what type of infection? systemic infection
Nursing Interventions to Prevent Spread of Infections hand washing, PPE, never recap needles, pest control, thorough skin assessment, keep closed systems closed, immunizations
Patient Teaching r/t Infection Control well-balanced diet, current medications, proper technique for tube feedings, contaminated dressings, aseptic principles, soiled linen, signs and symptoms of infection, safe ways to prepare and store food
Patient Teaching r/t Isolation disease and pathogen, transmission and transmissions precautions, hand washing and waste disposal, explain to significant others
Psychological Aspects r/t Isolation patient stimulation, encourage visits esp at mealtime, warm caring attitude, avoid negative behavior/attitude, listen to patient's feelings, positive comments
Temperature for a Patient's Room 68-74 F
Humidity for Patient's Room 30-50%
Other Physical Factors Affecting Patient's Environment Lighting, Ventilation, Odor, Noise, Interior Design, Neatness, Privacy, Comfort
Psychological Factors Affecting Patient's Environment provide hope, cheer, and ease grief explain procedures/disease processes provide distractions allow expression of fears/concerns patient participation in care privacy
Factors Affecting Sleep physical illness anxiety/depression drugs and substances lifestyle sleep patterns stress environment exercise/fatigue nutrition
Nursing Interventions to Promote Rest and Sleep develop plan limit interruptions provide quiet environment comfortable room temperature limit visitors and length of stay timely procedures decrease environmental stimuli early evening ambulation milk 30 min before bed procedures before 2100 mas
Nursing Responsibilities Affecting Bed Making ensure cleanliness and comfort make post-op bed before pt returns make unoccupied bed whenever possible make occupied bed when required
Who completes and documents the nursing assessment? When it must be completed? RN (others may contribute) within 24 hours
4 Techniques to Perform Physical Assessment Inspection, Observation, Auscultation, Palpation
Most Frequently used Technique for Physical Assessment Inspection
Least Frequently used Technique for Physical Assessment and Why Percussion most people don't know how to do it right
Considerations for when doing a Physical Assessment on the Elderly aging occurs at different rates, allow adequate time, fatigue, comfort measures, explain what you're doing in a way they can understand, be patient and listen
Physiological Considerations for Older Adults may have memory difficulty, skin less elastic and drier, develop lesions, actinic keratoses, skin sensation and sensory function diminish with age, muscle strength and joint flexibility may decrease
Preventive Health Topics routine physical exams, immunizations, periodic diagnostic tests, cancer warning signs, self breast/testicular exam
Focused Assessment performed when change in condition
Admission Assessment formal head-to-toe done when admitted
Shift-to-Shift Assessment performed at the beginning and end of each shift
Purpose of DA 3888 documents baseline nursing history and assessment
Purpose of SF 510 provides chronological record of nursing care, patient status, and response to nursing interventions reflects any change in condition and results of treatment
Form used as a Discharge Form DA 3888-3 (noted on SF 510 "Patient Discharged, see DA Form 3888-3)
Notes on SF 510 end with Signature, Rank, Title of person making the entry
Minimal Entries on SF 510 Category 4,5,6 patients - 1 per shift Category 2,3 - once a day Category 1 - once a week
True/False Documentation can absolve RN of responsibility. Which one(s)? False professional supervision, review of nursing care, appropriateness of documentation
Parts of an Initial Assessment that LPN Performs vital signs, HT/WT, brief history, psychological preparation, test prerequisites completed?, informed consent necessary?
Different Positions used for Assessments sitting, lithotomy, dorsal recumbent, lateral recumbent, sims (left-lateral recumbent), prone, knee chest
Describe Draping may be cloth or paper prevents unnecessary exposure helps client relax provides warmth and prevents chilling
Chaperone patient's right to request must be provided
Female Preparation Needs assist into lithotomy position as needed drape kept over lower half of body during positioning expose exam area only when necessary
Male Preparation Needs prepare for occult blood testing rectal exam of prostate for men over 40
Common Equipment used for Exams gloves, opthalmoscope, otoscope, sterile safety pin, tuning fork, cervical spatulas, tongue depressor, cotton-tip swab, lubricant, vaginal speculum, reflex hammer, tape measure, penlight, specimen cup, BP cuff, stethoscope, eye chart, gown, biohazard cont
Nursing Responsibilities during Exam pass supplies and restock position patient adjust lighting
How to position child during exam use parent as much as possible allow parent to hold child
What does ID band do? provide positive means of identification of patient
Where admission procedure usually begins admission department
Nurse's Responsibilities for Admission prepare room, greet patient, check ID band, assess for immediate/life-threatening needs, orient patient
Social History Includes language spoken and understood family members and significant others home situation interests and abilities ADLs occupation
Intra-agency Transfer moving of patient from one unit to another
Interagency Transfer transfer to another hospital or agency
Nursing Steps in Patient Transfer check physician's orders inform patient and family notify receiving unit gather patient's belongings assist with transport document transfer
Purpose of Discharge Planning teach patient and the family about patient's illness and its effect on his or her lifestyle; provide instructions for home care; communicate dietary/activity instructions; explain purpose, adverse effects, and scheduling of medication treatment
Risk Factors for Disease genetic and physiologic, age, environment, lifestyle
Nursing Responsibilities for Patient Discharge coordinate referrals and transportation verify discharge orders ensure orders complete ensure client and family understand discharge instructions
Describe what happens during patient leaving AMA notify charge nurse and physician immediately request patient sign release don't restrain client document thoroughly
Who is to convince patient to stay? physician
Who signs release when patient refuses? nurse and at least 2 witnesses and documented that patient refused to sign
Barium enema highlights how Barium swallow bottom-up top-down
Most basic test ever done CBC
Culture what microorganism is
Sensitivity what will work against microorganism
Echocardiogram mechanical function of heart
Electrocardiogram electrical function of heart
Electroencephalogram brain waves
What MRI used to examine tissue damage muscle tendon ligaments (like football player tears ACL)
LPN's role in specimen collection patient preparation prepare supplies and equipment patient care during procedure post procedure care
Patient rights in specimen collection informed consent verifies written consent verifies oral consent withdrawl of consent
CBC with diffifferential includes neutrophils lymphocytes monocytes eosinophils basophils RBC HGB HCT MVP platelet count
BMP previously known as CHEM-7 BUN Ca CO2 Cl creatinine glucose K Na
CMP previously known as CHEM-12 albumin AST bilirubin BUN CO2 Ca Cl creatinine glucose K sodium ALP total protein
Globulin functional proteins (enzymes)
CPK found predominately in heart, skeletal muscle, and brain elevated whenever injury occurs rise within 4-8 hours after heart attack reach peak around 12-24 hours return to normal by 3-4 days
LDH found in cells of many body tissues, esp heart, liver, RBC, kidneys, skeletal muscle, brain, lungs after heart attack begin to rise 24-72 hours peak 2-5 days remain elevated for as long as 14 days
LDH-1 mainly from heart
LDH-2 primarily from reticuloendothelial system
LDH-3 from the lungs and other tissues
LDH-4 from the kidneys, placenta, pancreas
LDH-5 from the liver and striated muscle
Cholesterol main lipid associated with arteriosclerotic vascular disease required for production of steroids, sex hormones, bile acids, and cellular membranes
Lipid Profile total cholesterol - <200 triglycerides - unsaturated & saturated fat HDL - 30-80 LDL - 60-180
Prothrombin Time (PT) evaluates the adequacy of the extrinsic system and common pathway in the clotting mechanism measures clotting ability of factors 1 (fibrinogen), 2 (prothrombin), V, VII, and X
INR (international normalization ratio) designed to standardize values best lab value for monitoring anticoagulation therapy
aPTT (activated partial thromboplastin time) used to monitor heparin therapy
Acid-Fast Bacilli (AFB) test for organism responsible for TB of the lung
UA routinely includes appearance, color, odor, pH, protein, ketones, RBCs, WBCs, specific gravity, glucose, drugs (when you're in the military)
24 hour urine collection tests of renal function and urine composition requires the entire volume of urine from a 24-hour period be collected
Guaiac (Hematest stools) presence of blood in body waste is abnormal
Acquired Bacteria salmonella, shigella, campylobacter, yersinia, pathogenic E. coli
Common parasites which affect the stool ascaris (hookworm) strongyloides (tapeworm) giardia (protozoans)
Death Certificate required by U.S. laws prepared for each person who dies sent to local health departments physician declares and signs
Organ Donation organ donor consent card family consent in many states, back of driver's license
Autopsy examination performed after a person's death to confirm or determine cause of death physician's responsibility to obtain consent
Who can consent to autopsy? family client coroner in special circumstances
Preparing the Body Post-Mortem gather equipment, wash hands, gloves, close patient's eyes and mouth, remove all tubing, replace soiled dressings, bathe patient, clean gown, valuables
Who becomes patient after death? the family
Role in Caring for the Family of the Deceased continue care contact someone for survivor express sympathy remain nonjudgmental notify mortician
Deaths on the Battlefield spot report KIA's ID recover remains 10 digit coordinate quartermaster function medical units establish only temporary morgues
Composition of Body Fluids water electrolytes non-electrolytes blood
Normal Daily Fluid Intake 2500mL
Sensible Fluid Loss fluid loss that can be measured
Insensible Fluid Loss fluid loss that cannot be measured
Kidneys filter ____mL of fluid an hour. minimum 30
Causes of Hypovolemia inadequate intake severe diarrhea or vomiting severe burns hemorrhage profuse perspiration or urination
Signs and Symptoms of Hypovolemia thirst, thick saliva, dry mucous membranes weakness postural hypotension dizziness dark concentrated urine poor skin turgor flat neck veins weak thready pulse elevated temperature weight loss
Nursing Care for Hypovolemia monitoring I&O urine concentration daily weights vital signs offer oral fluids monitor hematocrit
Causes of Hypervolemia taking in more fluid than can excrete renal failure CHF Cushing's syndrome corticosteroid therapy
Signs and Symptoms of Hypervolemia weight gain crackles in lungs: pulmonary edema ascites slow, bounding pulse elevated blood pressure distended neck veins diluted urine edema
Nursing Care for Hypervolemia urine concentration edema vital signs weight monitor lung sounds hematocrit
Risk for Fluid Volume Imbalance very young obese older adults
mEq measure of chemical activity
Sodium normal range - 134-142 most abundant electrolyte in body regulates water balance & muscle contractility
Causes of Hyponatremia vomiting and diarrhea GI or billary drainage via NG tube fistulas small bowel obstruction diaphoresis large open lesions burns massive edema
Signs and Symptoms of Hyponatremia headache apathy muscle weakness fatigue postural hypotension abd cramps nausea vomiting
Nursing Interventions for Hyponatremia monitor I&O observe for abnormal GI, renal, skin losses replace fluid loss with fluids containing NA, not plain water
Causes of Hypernatremia more water than sodium lost large intake of sodium
Signs and Symptoms of Hypernatremia dry mucous membranes decreased urine output tissue turgor changes
Nursing Interventions for Hypernatremia monitor I&O encourage fluid intake decrease sodium intake monitor water loss
Potassium normal range 3.5-5 dominant intracellular cation intracellular water and electrolyte balance hydrogen ion control
Causes of Hypokalemia decreased K intake increased aldosterone activity GI losses lasix trauma/burns/fistulas excessive sweating conditions that cause very large urine output
Signs and Symptoms of Hypokalemia skeletal muscle cramps decreased bowel sounds constipation anorecia nausea/vomiting diminished deep tendon reflexes cardiac dysrhythmias*
Nursing Interventions for Hypokalemia diets high in K watching for digitalis toxicity adminisiter IV replacement monitor: bowel sounds EKG, I&Os
Chloride normal range 96-106 chief anion in intersititial and intravascular fluid formation of hydrochloric acid, osmotic pressure regulation, acid base balance
Hypochloremia decreased chloride in body usually occurs when sodium is lost most common causes: vomiting, prolonged NG tube, fistula drainage
Causes of Hyperkalemia excess K intake renal failure medications
Signs & Symptoms of Hyperkalemia nausea and vomiting diarrhea/colic cardiac dysrhythmias numbness/tingling muscle weakness
Nursing Interventions for Hyperkalemia decrease K intake monitor telemetry I&Os labs
Hyperchloremia increased chloride in body rarely occurs chloride anons attempt to compensate to maintain equal number of cations in body fluids bicarbonate levels fall
Chloride Imbalances rarely occur independently of other electrolyte imbalances no specific signs and symptoms to identify chloride imbalance
Calcium normal range 9-11 bones and teeth, blood clotting, cell membranes
Causes of Hypocalcemia inadequate intake of Ca surgical removal of parathyroid gland burns pancreatic disease
Signs and Symptoms of Hypocalcemia tingling muscle spasms nausea/vomiting diarrhea hyperactive DTRs osteoporosis muscle irritability
Causes of Hypercalcemia immobilization metastitic bone cancer antacids containing calcium increased dietary intake increased PTH
Signs and Symptoms of Hypercalcemia thirst, polyuria decreased muscle tone decreased DTRs lethargy decrease GI motility renal stones
Phosphorus normal range 4 support/maintenance of bones and teeth acid/base buffer
Causes of Hypophosphatemia dietary insufficiencies impaired kidney function
Signs and Symptoms of Hypophosphatemia muscle weakness, especially respiratory confusion/seizures/coma numbness
Nursing Interventions for Hypophosphatemia assess for vitamin D deficiency or hyperparathroidism educate overuse of aluminum containing antacids
Causes of Hyperphosphatemia renal insufficiency increased intake of phosphate or vitamin D
Signs and Symptoms of Hyperphosphatemia tetany numbness, tingling around mouth deep muscle spasms anorexia/nausea/vomiting
Nursing Interventions for Hyperphosphatemia monitor muscle spasms monitor electrolyte levels
Magnesium normal range 1.5-2.4 enzyme activation, regulation of serum calcium, phosphate, and potassium
Causes of Hypomagnesemia decreased intake impaired absorption from GI tract a decrease in Mg often parallels decrease in K
Signs and Symptoms of Hypomagnesemia anorexia/nausea/vomiting/dysphagia mental status change hyperactive deep reflexes paresthesia/twitching/tremors positive Chevostek and Trousseau sign (hypocalcemia) vertigo
Nursing Interventions for Hypomagnesemia monitor vital signs, I&O, EKG, respiratory status administer replacements increase Mg in diet insititute seizure precautions
Causes of Hypermagnesemia impaired renal function excessive Mg administration severe water loss associated with DKA
Signs and Symptoms of Hypermagnesemia hypotension sweating/flushing/thirst nausea/vomiting loss of deep tendon reflexes respiratory depression severe: coma, cardiac arrest
Nursing Interventions for Hypermagnesemia promote urine excretion avoid overuse of laxatives and antacids containing Mg monitor I&O monitor VS
Range and Functions of Bicarbonate 22-26 regulates acid/base balance buffer neutralize acids in the body and maintain homeostasis
Acid increased hydrogen ion concentration (positive)
Base decrease in hydrogen concentration (negative)
Body Balance Systems blood buffers respiratory system kidneys
Normal ABGs pH 7.35-7.45 PaCO2 35-45 PO2 80-100 O2 saturation 95-100% HCO3 22-26
Describe Respiratory Acidosis retention of CO2 occurs with resultant pH decreases shallow respirations result because of retained CO2 depressin of CNS occurs
Causes of Respiratory Acidosis compromise pneumonia respiratory failure atelectasis traumatic injuries to thorax or brain obesity airway obstruction
Signs and Symptoms of Respiratory Acidosis CNS cardiopulmonary musculoskeletal
Mode of Compensation for Respiratory Acidosis kidneys retain increased amounts of bases
Describe Respiratory Alkalosis loss of excessive amounts of CO2 (hyperventilation) results in low carbonic acid in the blood pH rises due to carbonic acid being blown off
Causes of Respiratory Alkalosis anxiety/fear anemia head injuries infections aspirin overdose asthma/pneumonia inappropriate ventilator settings
Signs and Symptoms of Respiratory Alkalosis anxious/irritable appearance fainting/dizziness muscle weakness
Mode of Compensation for Respiratory Alkalosis kidneys will excrete increased amounts of base to lower pH
Metabolic Acidosis gain of hydrogen ions or loss of HCO3
Causes of Metabolic Acidosis starvation dehydration diarrhea DKA renal failure (most common) drugs
Signs and Symptoms of Metabolic Acidosis headaches cardiopulmonary anorexia N/V/D cushmol respirations (rapid, shallow)
Mode of Compensation for Metabolic Acidosis lungs blow off CO2 to raise pH
Metabolic Alkalosis significant amount of acid is lost from the body or an increase in the HCO3 level occur depresses CNS
Causes of Metabolic Alkalosis excessive vomiting (most common) prolonged gastric suctioning electrolyte disturbances Cushing's disease: hyperaldosteronism (increased cortisol) drugs (steroids, overdose baking soda, diuretics)
Signs and Symptoms Metabolic Alkalosis headaches, decreased LOC cardiopulmonary nausea/vomiting musculoskeletal
Mode of Compensation for Metabolic Alkalosis lungs retain CO2 to lower pH
Created by: ealongo