R.A.C.E.
Rescue those in danger, Activate alarm system, Confine by closing doors, Extinguish or evacuate as needed.
Nursing Diagnoses related to behavior change
Ineffective health maintenance, Health seek behaviors, noncompliance, Knowledge deficit, Decisional conflict, Ineffective management of therapeutic regimen
Physiological responses to pain
GI distress, tachycardia, chest pain, dizziness, tachypnea, dry mouth, tremors, diaphoresis, change in B.P.
Benner’s Theory
Bottom: Novice (nursing student) 2nd: Advanced beginner (1st yr RN) 3rd: Competent (2-3 yr. RN) 4th: Proficient (Charge Nurse) Top: Expert (preceptor)
List critical thinking indicators
Self aware, genuine, effective communicator, curious, alert, analytical, logical and insightful, confident and resilient, autonomous, careful and prudent, realistic, proactive, courageous
T.H.I.N.K.
Total recall, Habits, Inquiry, New ideas, Knowing
Nursing Diagnoses for immobility
Activity intolerance, risk for inactivity, impaired mobility, risk for pressure ulcers, self-care deficit, risk for impaired skin integrity
Disuse Syndrome
deterioration of body systems as a result of prescribed or unavoidable inactivity.
stress incontinence
described as “little dribbling” due to decrease in bladder muscle tone, stimulus (laughing)
urge incontinence
feels the urge to go but is not able to get to the bathroom in time due to immobility or decreased bladder muscle control
functional incontinence
sudden, unpredictable voiding; often related to dementia or impaired cognition
reflex (overflow) incontinence
not aware that bladder is full; common with neurological impairment or spinal cord injury
total incontinence
unknown, constant voiding; as soon as urine is produced, it is voided.
Bactrim use and side effects
Bacteriostatic - Used to treat UTIs; side effects: N, V, D, cough, SOB, Steven-Johnson’s
Pyridium use and side effects
Analgesic - Used to relieve pain related to UTI; side effects: orange urine, headache, GI distress, jaundice
This is defined as distended abdomen, anal leakage, with no BM for 3 or more days
fecal impaction
7 Elements of Critical Thinking
clinical judgment, clinical reasoning, deliberate informed thought, controlled and purposeful, uses strategies, analyzes data, makes changes
List 5 barriers of critical thinking
overuse of the habit mode, anxiety, working under deadlines, overcommittment to principles, lack of confidence
List personal characteristics that affected one’s stress response.
hardiness, sense of coherence, resilience, attitude
List the 3 Stages of GAS (general adaptation syndrome)
Alarm Reaction - fight/fight
Resistance - mobilize reserves, body coping
Exhaustion - energy expended, illness or fatality occur
Nursing Diagnosis for coping, defined as a positive or negative coping mechanism.
ineffective denial
Nursing Diagnosis defined as coping by masking issues with negative habits or behaviors.
ineffective coping
Labs of importance when assessing for altered physical mobility
calcium, phosphorus, alkaline phosphatase, creatinine, lactate dehydrogenease
List Primary preventions for immobility
nutrition, regular activity, ideal body weight, rest
List Secondary preventions for immobility
fall risk assessment, skin integrity assessment (Braden Scale), screening for mobiliy
Vision disturbance brought on suddenly with excruciating pain, N&V, red eye and vision change.
Primary Angle Closure Glaucoma
Vision disturbance that develops over time, presents as tunnel vision.
Primary open-angle Glaucoma
Normal Creatinine range
Female: 0.5-1.1 mg/dL
Male: 0.6-1.2 mg/dL
BUN normal values
10-20 mg/dL
Test to deter if there is backflow of the urine into bladder
Urodynamics
Typically the last sensory system to disappear in the end of life.
hearing
Pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing.
Cheyne-Stokes respirations
Vision disturbance presenting as decrease in vision, abnormal color perception, glare, poor night vision
Cataracts
Anticholinergic agent used postoperatively to dilate the pupil
Cycloplegia
Alpha adrenergic agonist that produces pupilary dilation and reduces inflammation in the eye; typically used postoperatively
Mydriatic
It is important to teach patient using cycloplegics and mydriatics to do what?
Wear dark glasses to minimize photophobia and monitor for signs of systemic toxicity (tachycardia, CNS effects)
Visual disturbance typically presenting asymptomatic; due to increased or decreased IOP and decrease peripheral vision
Glaucoma
List of foods that may block an ileostomy
celery, coconut, coleslaw, mushrooms, corn, nuts, popcorn, raisins, seeds, stringy meats
Sufficient oral intake range for adults
1200-1500 mL
Normal values for RBCs in Urinalysis
Females: no more than 5
Males: no more than 3
Normal lab value for pH of urine
4.5-7.8
Immune-mediated disease; body’s T cells attack and destory pancreatic beta cells. Manifests as polydipsia, polyuria, polyphagia.
Type I Diabetes
What does SPICES stand for when assessing older adults?
Sleep disorders, Problems with eating/feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown
An emotional, physical, cognitive or behavioral response to bereavement, separation or loss
Grief
Known as complicated grief; overly intense or lasting longer than normal
Pathological grief
Occurs when relationship with deceased was ambivalent. Initally not showing pain but feels sadness and guilt about the relationship later.
Conflicted grief
No grief present, may occur later when loss is realized.
Absent grief
Engaging in detrimental activities during a phase of prolonged grief.
Maladaptive/Dysfunctional grief
Using adaptive behaviors to deal with grief
Adaptive grief
Involves the intellectual and emotional responses and behaviors by which individuals, families, and communities attempt to work through the proess of modification based on perception of potential loss.
Anticipatory grief
Encompasses grief and mourning and demotes emotions and behaviors of a person, group or community suffering a loss
Bereavement
Defined as an irreversible loss of all brain function; coma, unresponsiveness, absence of brainstem reflexes and apnea.
Brain death
Condition preventing the body from converting certain fats to energy. Mainfests in early childhood as vomiting, lethargy, hypoglycemia.
MCAD deficiency
Sign of stress effecting decision making and memory.
Cognitive sign
Sign of stress causing increase or decrease in appetite or other coping mechanisms (ETOH, drugs, sex)
Behavioral sign
Sign of stress resulting in decreased immune system and an increased risk for cardiovascular disease
Physical sign