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NRSG 225- Intro > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

normal temp values

A

96.4- 99.5

> 100.4 = concern

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2
Q

methods to take temp

A

temporal, tympanic, artery, oral, axillary and rectal

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3
Q

effectors for temp

A

age, sex, environ temp, health and circadian rhythm

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4
Q

hypothermia/ hyperthermia

A

<95

> 106

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5
Q

normal pulse rate values

A

60-100

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6
Q

pulse r methods

A

radial, brachial and carotid

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7
Q

pulse r effectors

A

physical act, fever, meds/stress and age/sex

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8
Q

bradycardia/ tachycardia

A

<60 bpm

> 100bpm

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9
Q

apical pulse

A

measure if giving cardiovas meds

hold stethoscope over heart for one min

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10
Q

norm resp. rate

A

16-20

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11
Q

resp. rate effectors

A

exercise, diet, trauma, meds, infection, pain, emotion and acid-b bal.

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12
Q

hyper v hypotension

A

hyper >130/80

hypo< 90/60

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13
Q

auscultatory gap

A

avoid missing systolic p
pump until cannot hear pulse
go 30mmhg above when taking actual bp

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14
Q

orthostatic hypotension

A

laying-5 min
sitting- 1 min
standing- 3 min
take it first time in morning when get up
have = if S dec. 20 points and D dec. 10 points w/in 3 min position change

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15
Q

norm oxygenation values

A

> 90 ok >95 ideal

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16
Q

oxygenation is a measure of

A

arterial blood

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17
Q

oxygen. effectors

A

meds, disease, hemogl lvls, air quality and lifestyle

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18
Q

hypoxemia

A

< 90%

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19
Q

special populations for pain

A

children, cog. impaired, older adults

*have to look at body language/ changing vital signs

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20
Q

effectors for pain

A

cul values and beliefs, past exper. environ and support

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21
Q

procedure when talking about pain

A

ask abt goals and expetations

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22
Q

purpose for taking vitals

A

get baseline

measure hemodynamic stability

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23
Q

when take vitals

A

admission, change in pat. condition, loss of concisouness, after fall, b/d/a invasive procedures, b/d/a meds (opioids) + orthostatic hypo

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24
Q

time frame for taking vitals if norm

A

every 4 hours

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25
reasons for abdnorm vitals
stress, coffee, temp outside
26
pot. for microo to cause dis. depends on
number of organ. virulence, imm. system function, length/ intimacy btw person and microo
27
steps in infection cycle
organism, reservoir, portal of exit, transm., portal of entry, vulnerable hosts
28
incubation stage
time from infection till appearance of sympt
29
prodromal stage
non-specific sympt. | * most infectious
30
full stage
recogniz and specific sympt
31
convalenscence
final recovery stage of infection
32
portals of exit in body
respir. GI, GU, Blood and tissue
33
ways to reduce spread
id signs infection, give adeq nutrition, proper disposal infecti. items, clean, get immunized, reduce stress and hand hygiene
34
hand hygiene times
b/a touching pat. a touching pat surface, after fluid exposure, before clean procedure
35
hand hygiene- when is soap needed
if hands visibly soiled bodily exposure a/ bathroom and before eating
36
transient bac
low # aquire from exposure not normal
37
resident bac
normal high #, always present *varies from person to person
38
HAI
hospital aquired infection
39
cauti
catheter ass. tract infection
40
ssi
surgical site infec
41
clabsi
central line ass. bloodstream infec
42
vap
ventilator ass. pneumonia
43
sterilization considerations
some dis. require diff procedure | ex. c-diff
44
standard precautions for PPE
use gloves for all fluid ex. sweat | use mask for spinal canal procedure
45
airborne precautions
keep door closed, room neg. pressure wash hands b+a N-95 mask
46
droplet precautions
mask, eyewear, gown and gloves | ex. influenza
47
contact precautions
ex. mrsa patient specif. equip gown and gloves
48
enteric/special
ex c-diff patient specific equip gown and gloves
49
aseptic tech
any activity to prevent/ stop chain infection
50
medical tech v sterile tech
``` med= clean (reg) sterile= cath, nicu, invasive procedures ```
51
possible self-care diagn
feeding bathing/ hygiene dressing and grooming toileting
52
factors affecting hygiene
``` culture socioecon class spiritual practices dev. level health state personal perf ```
53
early morning care
wash hands and face mouth care toileting comfort measures
54
morning care am (1)
``` *after breakfast make plan for day toileting oral care bathing back massage skin considerations hair care/ cosmetics ```
55
morning care am (2)
dressing positioning for comfort changing bed linens tidying up room
56
afternoon care (pm)
``` *after lunch toileting handwashing/ oral care make bed reposition in bed or chair ```
57
hour of sleep care (hs care0
toileting, washing and oral care change soiled clothing/ bed position comfortably lower bed and place call light
58
as needed care (prn)
``` hygiene measures (bathroom and bath) change clothing and bed oral care every 2 hours ```
59
purpose bathing
``` cleanse skin promote circulation relaxes person musculoskeletal exercise stim rate/ depth respir. ```
60
physic. assess oral cavity
look for oral problems id approp. nursing measures carry out care plan
61
five steps in nursing process
``` ADPIE assessing diagnosing planning implementing evaluating ```
62
assessing
collecting, validating, and comm w/ pat
63
diagnosing
analyzing pat data to id strengths, problems | *diff. than usual med diagnosis
64
planning
id pat outcomes and plan interventions
65
implementing
carrying out plan
66
evaluating
measuring extent outcomes achieved
67
characteristics of nursing process (SDIOU)
``` systematic dynamic interpersonal outcome oriented universally applicable ```
68
systematic
ordered sequence of act
69
dynamic
interaction and overlap of five steps
70
interpersonal
comm/ interaction with pat
71
outcome oriented
nurse and pat work together to id outcomes
72
universally applicable
framework used
73
benefits of process for pat
scient based, holistic/ indivii care continuous care clear, efficient cost-effective plan
74
benefits of process for nurse
opportunity collab w/ o/ healthcare workers satisf. making diff in lives of o opp grow professionally
75
in action
thinking on feet
76
on action
after the fact | thinking through situation
77
for action
think about future/ how actions could display diff results
78
reason for critical thinking
determ credibility analyze norm from abnorm distinguish relevant data from irrel id bias, assumptions or inconsis
79
characteristics of assessment
ppcsfrr | purposeful, priorit, complete, systematic, factual, relevant, recorded standard manner
80
purpose of assessment
create database id health problems, health status makes diagn and planning easier
81
nursing v med assessments
nursing- analyze coping measures (comparing data) | med- diagn. pathological condition from data
82
comprehensive assessment
when- admission why- create datab adn id problems who- prim nurse
83
focused assessment
when- every 12 hrs w/ shift change | why- gather data about old problem or address new
84
emergency assessment
when- physical or emotional change (ex. level conciousne)
85
time lapse assessment
when- on floor why- compare current status to baseline ex. checking pain after med
86
phases of nursing interview
preparatory intro working termination
87
sources of pat info
patient (primary) family/ sig o pat record, med history, physical exam, consultations, lab reports, reports from o/ healthcare
88
observe what in interview
ability manage care current responses, emot and physical immediate/ larger environ
89
objective data
observed and measureable | ex. bp and skin appear.
90
subjective data
emotion pat. is feeling | record in "quotations"
91
do's for document.
use pat own words avoid non-spec terms summarize sub/obj data give verbal report w/ critical change in pat health status

NRSG 225- Intro (5 decks)

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