Exam 2 Flashcards
(16 cards)
physical restraint policies
- Type of restraint
- Justification
- Criteria for removal
- Never a PRN
Fire: Nurses’ action
RACE
Rescue and remove all patients from
danger
Activate the alarm
Extinguish the fire with appropriate
extinguisher
Confine the fire by closing doors, turn
off oxygen & equipment
process of med admin
Identify the client
Explain what you are giving: action
and side effects of the medication
Administer the drug: “Rights” of
Medication Administration
Make sure client takes medications
Record the drug administered
Evaluate the client’s response to the
drug
SUBCUTANEOUS
INJECTION
Volume usually less than 1 mL
* Size needle is 3/8 inch to 1 inch (5/8 most
common)
* 25 to 30 gauge needle
* 45 to 90 degree angle
* Heparin: only in ABD. Avoid the area 2′′
around the umbilicus and the belt line.
Intramuscular
Injection
- Volume: 1 ml in deltoid, up to 5 ml
in large muscle (VG) - Needle size: 5/8- 1 ½ inch; most
common is 1 inch - Gauge: 18-25 gauge (18 gauge for
thick/oil-based medications) - 90-degree angle
- Z track may be used
- No aspiration
subq sites
Posterior upper arm
Abdomen (2” away from umbilicus)
Anterior thigh
Upper back
Upper ventral/dorsogluteal
IM sites
Deltoid
Vastus lateralis
Ventrogluteal
Blended
Competencies
for Nursing
Cognitive Competencies
Technical Competencies
Interpersonal Competencies
Ethical/Legal Competencies
Maslow’s
Hierarchy
of Human
Needs
self actualization
self esteem
love and belonging
safety and security
physiological needs
Components of Nursing Diagnosis
P: The Problem - Nursing Diagnosis
E: Etiology - Cause of the problem
S: Signs and Symptoms (or D: Defining
Characteristics)
nursing assessments
Comprehensive Initial
Focused
Emergency
Time-Lapsed
Patient-Centered Assessment
Types of
Nursing
Diagnoses
Problem-focused
Risk
Health promotion
LEARN
L: Listen actively to what patients say with empathy and understanding, without imposing your
own values and beliefs.
E: Explain your perception of the problem and express your understanding that perceptions of
illness vary by culture.
A: Acknowledge and discuss the differences and similarities in perspectives. Be careful not to
devalue the pt’s perspective and privilege yours.
R: Recommend nursing care that respects pt preference and integrate aspects of cultural
health beliefs (herbal med, traditional healers, cultural rituals)
N: Negotiate agreement as authentic partners (not as superior authority figure) in developing,
implementing, and evaluating the plan of care
Effects of Heat
- Reduces muscle tension
- Relieve muscle spasm and joint
stiffness. - Used to treat infection,
arthritis, joint and muscle pain,
dysmenorrhea, chronic pain
Effects of Cold
- Reduces muscle spasms
- Promotes comfort (reduces
release of pain-producing
substances) - Reduces edema and
inflammation - Direct trauma, muscle spasms,
sprains and some chronic pain
Complications Related
to Use of Central
Venous Access Devices
Pneumothorax
Thrombo-embolism
Air Embolism
Infection and sepsis
◦ Tubing change: use sterile
technique
◦ Sterile dressing change
Blood glucose, fluid, & electrolyte
imbalances
