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Nurs 3201 Test 1

Need to know in Patient Safety Developmental levels Mobility, sensory, and cognitive status Lifestyle choices Special risks found in health care setting
Patient Safety according to QSEN Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Patient Safety according to IOM New standard for quality care—care that is free of unintended injury from acts of commission or omission, in any setting in which it is delivered.
Patient Centered Care according to QSEN Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.
Purpose of the National Patient Safety Goals (TJC website) The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
Risks for Infant, Toddler, and Preschooler Injuries, lead poisoning, accidents due to particular stage of growth--such as oral activity and children possibly ingesting dangerous substances or choking
Risks for the School-Age Child Different environments outside of the home, such as school, school transportation, after school activities, etc. Strangers, sports activities, bicycle related injuries.
Risks for the Adolescent greater independence and separate emotionally from family; tension associated with physical and psychological changes and peer pressures can lead to risk-taking behaviors (smoking or drugs); motor vehicle accidents
Risks for the Adult lifestyle habits: alcohol/drug use, and smoking; stress leading to accidents or illnesses, such as headaches, gastrointestinal disorders, and infections
Risks for the Older Adult physiological changes leading to greater fall risk and other types of accidents such as burns and car accidents
Risks within the Healthcare Setting Medical errors: infection, bed sores, and failure to diagnose and treat in time; medication errors; falls, client-inherent accident; procedure-related accidents; equipment-related accidents
Inflammation A protective reaction Can be caused by nonliving agents i.e. heat, trauma Always present with infection Infection occurs only through superimposed evasion of microorganisms It establishes an environment for healing
Infection Involves invasion of tissue or cells by microorganisms (bacteria, fungi, or viruses) Always has inflammation present Often reveals altered lab values ( i.e. WBCs, positive cultures)
Infection and Inflammation can be local, systemic, acute or chronic
Recognizing Infection Local or systemic Patient information, clinical appearance (objective and subjective) Vital signs Lab values CBC (Complete Blood Count) Culture reports
Recognizing Inflammation Swelling Redness --hyperemia Heat Pain/Tenderness Loss of Function
Functions of red blood cells (erythrocytes) carry oxygen from the lungs to body tissues and transfer carbon dioxide from the tissues to the lungs. Oxygen transfer is accomplished via the hemoglobin contained in RBC's. Hemoglobin combines readily with oxygen and carbon dioxide.
Normal values white blood cells (leukocytes) normally 5000 to 10,000/microliter, can rise up to 15,000 to 20,000/mm3 and higher during inflammation, high wbc count can indicate infection
Functions of white blood cells involved in cellular response of inflammation upon arrival at site; WBC pass through blood vessels and into the tissues; through phagocytosis, neutrophils and monocytes ingest and destroy microorganisms and other small particles
High red blood cell count (polycethemia) increases in the RBC count occur at high altitudes because less atmospheric weight pushes air into the lungs, causing a decrease in the partial pressure of oxygen and hypoxia. With strenuous physical training, increased muscle mass demands more oxygen.
Normal values of red blood cells 4-6 million/microliter
Low red blood cell count (anemia) can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. Red blood cells live for approximately four months in the bloodstream
Normal levels of platelets 150,000-400,000/microliter
Functions of platelets (thrombocytes) prevent bleeding
Chain of Infection Infection occurs in a cycle that depends on the presence of: Infectious agent or pathogen, Reservoir or source for pathogen growth, portal of exit from the reservoir, mode of transmission, portal of entry to a host, susceptible host
Infectious agent microorganisms include bacteria, viruses, fungi, and protozoa; can cause disease when there is sufficient number, adequate virulence, ability to enter and survive the host, and susceptibility of the host
Reservoir place where a pathogen can survive but may not multiply, may be in food, oxygen, and water; factors that affect bacteria growth are temperature, pH, and light (organisms can thrive in the dark)
Portal of Exit for microorganisms to grow and multiply they must exit their host, portals of exits include blood, skin, and mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
Modes of Transmission the specific way a disease is transmitted, most common: (unwashed hands) direct (person-person), physical contact, indirect (susceptible host to inanimate object), droplet (large particles that travel up to 3 ft), airborne, vehicles, vector (mosquitos)
Portal of Entry organism enter the body through the same routes they use for exiting
Susceptible Host depends on the individual degree of resistance to a pathogen (immune response). Factors that influence susceptibility are age, nutritional status, presence of chronic disease, trauma, and smoking
pathogenicity the ability of a pathogen to produce an infectious disease in an organism
localized infection localized symptoms (wound infection) pain and tenderness and redness at the wound site
systemic infection infection that affects the entire body instead of just a single organ or part, can become fatal if left untreated
inflammatory response protective reaction that serves to neutralize pathogens and repair body cells
nursing actions that control or eliminate infections in the clinical setting properly administering antibiotics, monitoring response to drug therapy, and using proper hand hygiene and standard precautions; supportive therapy would include proper nutrition and rest
Role of nurse in infection control Assess patient’s defense mechanisms (age, nutritional status, stress, disease process), susceptibility and knowledge of infections “Risk for Infection” (lab data and clinical appearance) Consult Infection Control Practitioner (clients with infection)
Nursing Care Handwashing Use gloves Elevate foot Aseptic technique for dressing change Discard contaminated dressing, linens, etc. properly Administer medications Management of fever Rest Maintain glucose within normal Healthy diet Teach of infection contro
Acute/Transient Pain protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response
Chronic/Persistent Pain not protective and serves no purpose, lasts longer than anticipated, does not always have an identifiable cause, and leads to great personal suffering, can be cancerous or noncancerous)
Chronic/Episodic pain that occurs sporadically over an extended duration of time, may last for hours, days, or weeks (migraine headaches)
Cancer pain can be acute and/or chronic, sometimes nociceptive and/or neuropathic; usually due to tumor progression and its related pathological process, invasive procedures, toxicities or treatments, infection , and physical limitation--at actual site or referred
Inferred pain by pathological process Nociceptive pain--somatic and visceral and neuropathic pain
Nociceptive Pain Damage to bone, soft tissue, or internal organs Usually responsive to nonopioids and/or opioids Types of nociceptive pain: somatic pain and visceral pain
Somatic Pain Arises from bone, joint, muscle, skin or connective tissue Usually aching or throbbing in quality and is well localized
Visceral Pain Arises from viscera, such as the GI tract and pancreas Described as squeezing, cramping pain, shooting May be due to obstruction of hollow viscous, which causes the cramping and poorly localized pain
Neuropathic Pain Abnormal processing of sensory input by the peripheral or central nervous system Treatment usually includes adjuvant drugs A physical cause for reports of excruciating pain may not be evident on examination
Idiopathic Pain chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
factors that influence pain physiological factor (age, fatigue, genes, neurological function), social factors (attention, previous experience, family and social support), Spiritual factors, psychological factors (anxiety, coping style), Cultural Factors ( meaning of pain, ethnicity)
Pain Assessment Factors influencing the pain experience Location Intensity Quality Pattern Aggravating/relieving factors Medication history
Pharmacological Measures: Nursing Responsibilities Assess pain Determine when to administer analgesics Select the appropriate analgesic Evaluate effectiveness of the analgesics Monitor and manage medication side effects Suggest changes Consider the needs of special populations
nursing role in pain management Direct clinical care Patient/family teaching Education of colleagues Indentify system barriers
Factors Affecting Oxygenation physiological, developmental, lifestyle, environmental
Physiological Factors affecting oxygenation*** reduced oxygen carrying capacity, reduced inspired oxygen concentration, hypovolemia, higher metabolic rate, impaired chest wall movement-pregnancy, obesity, musculoskeletal abnormalities, trauma, neuromuscular diseases, central nervous system alterations
Developmental Factors affecting oxygenation infants and toddlers (upper respiratory tract infection), school age children and adolescents (smoking-respiratory infections), young and middle age adults (lifestyle factors-affect cardiopulmonary health)
The older adult and oxygenation** trachea & large bronchi become enlarged from calcification of the airways; alveoli enlarge, reducing the surface are available for gas exchange; the number of cilia is reduced, causing a decrease in the effectiveness of the cough mechanism-respiratory inf
Lifestyle factors affecting oxygenation habits such as cigarette smoking or unhealthy diets; nutrition, exercise, smoking, substance abuse, stress
environmental factors affecting oxygenation pulmonary disease is higher in smoggy, urban areas than in rural areas; patient's workplace --occupational pollutants include asbestos, talcum powder, dust, and airborne fibers
Alterations in Respiratory Functioning Atelectasis Aspiration Hyperventilation Hypoventilation Hypoxia
Atelectasis collapse of alveoli which prevents normal exchange of oxygen and carbon dioxide
Aspiration occurs when fluids are breathed into the lungs or airways leading to the lungs
Hyperventilation a state of ventilation in excess of that required to eliminate the carbon dioxide produced by cellular metabolism
Hypoventilation occurs when alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide
Hypoxia inadequate tissue oxygenation at the cellular level, results form a deficiency in oxygen delivery or oxygen utilization at the cellular level-life threatening condition
Signs and symptoms of Hypoxia apprehension, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes, increased pulse rate and increased rate and depth of respiration
Cyanosis blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries-late sign of hypoxia
Objective nursing assessment as related to oxygenation Inspection, Palpation, Percussion, Auscultation; Laboratory and diagnostic tests Hemoglobin Pulse oximetry Arterial blood gases
Arterial blood gas analysis most effective way to evaluate acid-base balance and oxygenation, deviation from normal value will indicate that the client is experiencing an acid-base imbalance; measure of: pH, PaCO2, PaO2, oxygen saturation, and HCO3-
Inspection as related to oxygenation Respiratory rate, rhythm, depth, breathing pattern Skin color Breathing postureMuscles used in breathing Clubbing of fingers Capillary refill Level of consciousness
Diagnostic Tests as related to oxygenation Hemoglobin Levels: 13.5-18g/dl males, 12-16g/dl female Chest x-ray Pulmonary function studies Lung scan Bronchoscopy Throat culture Sputum specimens
Pulse Oximetry Non-invasive Measures arterial oxygen saturation SpO2 Normal is > 95% Ensure accuracy: validate with patient heart rate Ensure accuracy: determine patient’s hemoglobin level Continuous, intermittent, or during ambulation
pH Normal arterial blood pH is 7.35 - 7.45; acidic is less than 7.35 and alkaloid is greater than 7.45
PaCO2 partial pressure of carbon dioxide in arterial blood and is a reflection of pulmonary ventilation; normal range is 35 - 45 mm Hg, hyperventilation occurs when the PaCO2 is less than 35mm Hg; hypoventilation occurs when the PaCO2 level is more than 45mm Hg
PaO2 partial pressure of oxygen in arterial blood; normal range is 80-100mm Hg; less than 60mm Hg leads to anaerobic metabolism, resulting in acidic production and metabolic acidosis; hyperventilation also causes a decrease in PaO2, or respiratory alkalosis
Oxygen Saturation the point at which hemoglobin is saturated by O2, normal range is 95%-99%
nursing action for atelectasis hypoventilation occurs so best action is to help improve tissue oxygenation, restoring ventilatory function, treating the atelectasis, and achieving acid base balance. use of incentive spirometer, deep breathing and coughing, pursed lip breathing
nursing action for hypoventilation same as atelectasis, add diaphragmatic breathing-if possible, check on oxygen therapy
nursing action for aspiration positioning to avoid aspiration, coughing to clear sputum/fluid, maintain a clear airway
nursing action for hyperventilation oxygen therapy, diaphragmatic breathing to relax patient, incentive spirometer
nursing action for hypoxia oxygen therapy, incentive spirometer, diaphragmatic breathing
general nursing actions in regards to oxygenation Auscultate lung sounds - Monitor RR, depth, rhythm - Monitor vital signs - Monitor O2 sat, ABGs - Monitor mental status - Position for best lung expansion, elevate HOB
general nursing actions in regards to oxygenation Reposition regularly - Ambulate patient - Provide oxygen - Provide humidification - Increase fluid intake - Ensure adequate diet - Provide good oral hygiene
general nursing actions in regards to oxygenation Provide emotional support - Utilize incentive spirometry - Administer meds - Provide education - Prevent and recognize complications
Principles of Oxygen Therapy Oxygen should be treated as a drug Expensive Side effects Safety issues Verify 6 Rights of medication administration
Factors that influence the quality and quantity of sleep Physical Illness Drugs/Medications Life Style Emotional Stress Environment Nutrition Sensory Deprivation
hypersomnolence sleep problems from inadequacies in either quantity or quality of nighttime sleep on a daily basis
insomnia a symptom clients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep (most common complaint)
sleep apnea disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep; 3 types: central, obstructive, and mixed apnea
obstructive sleep apnea occurs when muscles or structures of the oral cavity or throat relax during sleep; the upper airway becomes partially or completely blocked, diminishing (hypopnea) nasal airflow or stopping for as long as 30 seconds
central sleep apnea involves dysfunction in the brain's respiratory control center, the impulse to breathe temporarily fails, and nasal airflow and chest wall movement cease
narcolepsy dysfunction of mechanisms that regulate the sleep and wake states (may fall asleep uncontrollably at times)
sleep deprivation result of dyssomnia, causes may be illness, emotional stress, medications, environmental substances, and variability in the timing of sleep due to shift work
parasomnias sleep problems that are more common in children than in adults--may have link to SIDS, in older children: somnambulism, night terrors, nightmares, nocturnal enuresis, body rocking, and bruxism (tooth grinding)
measures to promote sleep Adequate assessment Plan activities to maximize time for rest and sleep Provide comfort measures Establish sleep environment Patient education
interventions to promote sleep Plan activities to maximize time for rest & sleep Provide comfort measures Establish sleep environment Establish sleep routine Avoid stimulants Avoid exercise 2-3 hours before bedtime Pharmacological approaches
sleep apnea treatment Behavioral Therapy -weight reduction -avoidance of alcohol, tobacco, sleeping pills -positional therapy Physical or Mechanical Therapy -dental appliance -positive airway pressure device
nursing process professional nurse's approach to identify, diagnose, and treat human responses to health and illness; 5 steps: assessment, diagnosis, planning, implementation, and evaluation
nursing assessment deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
steps of the nursing assessment 1) collection and verification of data from a primary source, and secondary sources 2) the analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care
database built during assessment, concerns the client's perceived needs, health problems, and responses to these problems
sources of data client, family and significant others, health care team medical records, nurse's experience, other records and literature
subjective data client's verbal description of their health problems, will include feelings perceptions, and self-report of symptoms
objective data observations or measurements of a client's health status
nursing health history data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
data analysis involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.
medical diagnosis the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures
nursing diagnosis clinical judgment about individual, family, or community responses to actual & potential health problems or life processes; statement describing the client's actual or potential response to a health problem that nurse is licensed and competent to treat.
collaborative problem an actual potential physiological complication that nurses monitor to detect the onset of changes in a client's status
North American Nursing Diagnosis Association (NANDA) established to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
defining criteria the clinical criteria or assessment findings that support an actual nursing diagnosis
clinical criteria objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
actual nursing diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community--acute pain
risk diagnosis describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community
health promotion nursing diagnosis a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise
diagnostic label the name of the nursing diagnosis as approved by NANDA International, it describes the essence of a client's response to health conditions in as few words as possible
related factors a condition or etiology identified from the client's assessment data, associated with the client's actual or potential response to the health problem and can change by using nursing interventions
etiology the cause of a disease, and is alway within the domain of nursing practice and a condition that responds to nursing interventions
planning 3rd step of nursing process; a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
priority setting the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
goal an aim, intent, or end; a broad statement that describes the desired change in a client's condition or behavior
expected outcomes measurable criteria to evaluate goal achievement
client-centered goal specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function
short-term goal an objective behavior or response that you expect a client to achieve in a short time, usually less than a week
long-term goal an objective behavior or response that you expect a client to achieve over a longer period; usually over several days, weeks, or months
guidelines for writing goals client-centered singular goal or outcome observable measurable time-limited mutual factors realistic
types of interventions independent nursing, dependent nursing, and collaborative interventions
independent nursing intervention actions that a nurse initiates
dependent nursing intervention physician initiated, actions that require an order from a physician or another health care professional
collaborative intervention interdependent, therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care
scientific rationale the reason that you chose a specific nursing action, based on supporting evidence
implementation 4th step of nursing process; formally begins after the nurse develops a plan of care
nursing intervention any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
Implementation skill of nursing process cognitive skills: application of critical thinking to nursing process interpersonal skills: effective for nursing action-developing a relationship psychomotor skills: integration of cognitive and interpersonal skills
evaluation last step of nursing process; used to determine if after application of the nursing process, the client's condition or well-being improved (used to determine if you met expected outcomes, not if nursing interventions were completed)
standard of care minimum level of care accepted to ensure high quality of care to clients; defines the types of therapies typically administered to clients with defined problems or needs
Created by: nancyms