Final Flashcards
vital signs: how are vital signs obtained
via palpation of pulse, inspection of respiration, and obtaining blood pressure, oxygen saturation levels, temperature, and pain levels
vital signs: why are vital signs obtained
it provides:
- info. of pt.’s health status
- baseline data
- monitoring of pt.’s condition
- identification of problems
- evaluation of pt.’s response to intervention
vital signs: physiology of normal regulation of body temperature
regulated by:
- neural and vascular control
- heat production [post. hypothalamus], i.e.:
- by-product of BMR
- voluntary movements
- shivering
- non-shivering thermogenesis [brown fat in neonates]
- heat loss [ant. hypothalamus], i.e.:
- radiation: indirect loss from surface to surface
- conduction: direct loss from surface to surface
- convection: loss by air movement
- evaporation: heat/fluid loss by diaphoresis
vital signs: physiology of normal regulation of pulse
it is affected by stroke volume (it is the amount of blood your heart pushes into the artery every time it contracts), cardiac output and compliance (how elastic an artery is which allows blood to flow more easily
vital signs: physiology of normal regulation of respiration
involves three processes:
- ventilation: the mechanical movement of gases in and out of the lungs
- diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
- perfusion: the distribution of red blood cells to and from the pulmonary capillaries
vital signs: physiology of normal regulation of blood pressure
regulated through:
- cardiac output: the amount of blood coming from heart
- peripheral vascular resistance: resistance of blood flow
- blood volume: circulating volume
- blood viscosity: thicker blood causes more pressure to be made which increases blood pressure
- artery elasticity or “compliance”
vital signs: physiology of normal regulation of oxygen saturation
accuracy is dependent upon light transmission and adequate arterial pulsations
vital signs: normal vital signs
temperature - 36-38 degree Celsius (96.8-100.4 degree Fahrenheit) pulse - 60-100 bpm respiration - 12-20 bpm blood pressure - <80 oxygen saturation - 95-100% pain - absence of pain
vital signs: abnormal vital signs
temperature - hypothermia [mild, moderate, severe] - frostbite pulse - tachycardia - bradycardia - dysrhythmia respiration - bradypnea - tachypnea - hyperpnea - apnea - hyperventilation - hypoventilation - cheyne-strokes, kussmaul's [hyperventilation] blood pressure - hypotension - orthostatic hypotension - hypertension
vital signs: abnormal vital signs interventions
- review, analyze, decide if further investigation is necessary/notify the physician
- proper functioning equipment
- equipment appropriate for pt.
- know the pt.’s baseline; educate pt. to know their baseline
- medical Hx and medications
- have a routine for taking vital signs
- frequency of measurement dependent on diagnosis
- indication for medication administration
- analyze and interpret significant changes
- communicate significant changes
infection control: interventions to prevent the spread of infection
Hand hygiene before and after all pt. contact
- When to use hand hygiene: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a pt., after touching pt. surroundings
- Alcohol-based hand sanitizer: 20-30 seconds
- Soap and water: 40-60 seconds
Visibly soiled
Coming into contact with a pt. that has spore-forming microorganisms
Proper use of supplies
Proper disposal of certain supplies
Good technique of donning and removing PPE
Critical thinking
Artificial nails (don’t have, get them)
infection control: types of isolation
Tier I
- Standard precautions: Don gloves when in contact with bodily fluids or mucous membranes
Tier II
- Contact precautions Ie. Rhino virus, c. diff., MRSA, VRE, MDRO (multi-drug resistant organisms); Don gown and gloves
- Droplet precautions Ie. Pneumonia, bacterial meningitis, shingles, influenza; Don gloves, gown, face mask
- Air-borne precautions Ie. Chicken-pox, tuberculosis; All PPE + N95 mask (Mask is specifically fitted to fit an individual’s face)
infection control: donning and removing PPE
Donning - Gown - Mask - Goggles - Gloves Removing - Gloves - Cap - Goggles - Gown - Mask
infection control: medical asepsis
- Clean technique
- Practices/procedures that assist in reducing the number of organisms present and prevent the transfer or organisms
- Used when coming into contact with mucous membranes or skin Ie. Bedpans, food utensils, blood pressure cuffs, endotracheal tubes
infection control: surgical asepsis
- Sterile technique
- Procedures used to eliminate all microorganism (pathogens & spores) from an object or area
- Used when there will be intentional perforation of the pt.’s skin Ie. IV insertion, catheters
mobility: purpose of body mechanics
to maintain coordinated efforts of the musculoskeletal and nervous system to maintain balance, posture, and body alignment
to facilitate activities of lifting, bending, moving, and performing ADL’S
to achieve balance via a relatively low center of gravity balanced over a wide base of support
mobility: proper body mechanics
equilibrium maintained as long as center f gravity aligns with base of support
facing direction of movement prevents abnormal twisting of the spine
balanced use of arms and legs reduced risk of back injury
leverage, rolling, and turning and pivoting requires less work than lifting
less friction equals less force needed to move an object
alternating period of rest and activity helps to reduce fatigue and injury
mobility: devices used for positioning
foot boots/splints trochanter rolls wedge pillow side rails trapeze bar hand rolls/splints pillow bed boards
mobility: assessment of mobility
range of joint motion gait activity tolerance - exercise - activity body alignment pain associated with activity
mobility: nursing interventions on musculoskeletal system mobility
perform ROM exercises to improve strength
skin integrity
perform skin assessment, turn patient q2h
mobility: nursing intervention on elimination system mobility
keep pt. hydrated via either drinking or IV fluids
gastrointestinal
provide a high-fiber diet, it encourages digestive movement
mobiity: nursing intervention on psychosocial system mobility
encourage social interactions, regulate sleep-wake cycles
developmental changes
maintain normal development (young)
prevent falls via strength build-up, encourage
mobility: nursing interventions on respiratory system mobility
promote expansion of the chest and lungs
- use incentive spirometer
prevent stasis of pulmonary secretions
mobility: nursing interventions on cardiovascular system mobility
monitor pulse, blood pressure (especially before performing movements)
encourage pt. to breath out during movement
- discourages valsalva maneuver which leads to syncope
mobility: nursing intervention on metabolic system mobility
increase intake of protein and vitamins
consider tube-feeding for pt.’s with a lack of appetite
mobility: nursing interventions on prevention of blood clots
encourage movement
increase circulating fluids
administer blood-thinners
promote circulation with SED’s or ted stockings
oxygenation: oxygen level of room air
21% O2 on room air
oxygenation: nasal cannula
1L = 24 O2 on nasal cannula 2L = 28 3L = 32 4L = 36 5L = 40 6L = 44 humidification may be added for comfort (prevents nares drying) may only administer 6L or less
oxygenation: simple mask
5-6L = 40% O2 on simple mask
7-8L = 50
10L = 60
ranges exist because the pt. is breathing in room air as well as the prescribed oxygen
oxygenation: partial rebreather mask
6-10L = 40-70% O2 on partial rebreather
should not run below 5L
the reservoir bag should never be fully collapsed
oxygenation: non-rebreather mask
delivers 60-80% O2 on non rebreather
should not run below 10L
the reservoir bah should never be fully collapsed
oxygenation: venturi mask
delivers a specific amount of oxygen
oxygenation: airway maintenance techniques
hydration - 1500-1600 mL/day (unless contraindicated) humidification - add sterile water to the O2 supply nebulization - adds medication to the humidification chest physiotherapy - removes secretions or mobilizes them through: -- postural drainage -- chest percussion -- chest vibration coughing techniques artificial airways - oropharyngeal - nasopharyngeal - endotracheal - tracheostomy suctioning techniques - oropharyngeal - nasophaaryngeal - orotrahceal - nasotracheal - traccheostomy ambulation - ROM positioning - at a 45 degree semi-fowler's position chest tubes - removes air or fluid from pleural space
skin integrity and wound healing: inspection and palpation of skin
skin color distribution skin turgor presence of edema characteristics of any skin lesions particular attention paid to areas that are most likely to break down hyperemia - areas of redness - perform blanching of that area -- if it turns white then back to red, that is normal and indicates short-term injury it is abnormal if it remains red which indicates long-term injury and the first stage of a pressure ulcer incontinence skin around dressings
skin integrity and wound healing: untreated vs. treated wound assessment
untreated:
- skin color distribution
- skin turgor
- presence of edema
- characteristics of any skin lesions
- particular attention paid to areas that are most likely to break down
- hyperemia
– areas of redness
– perform blanching of that area
– if it turns white then back to red, that is normal and indicates short-term injury
it is abnormal if it remains red which indicates long-term injury and the first stage of a pressure ulcer
- incontinence
- skin around dressings
treated:
- appearance
- size
- drainage
- presence of swelling
- pain
- status of drains or tubes
- wound base
skin integrity and wound healing: pressure site assessment
inspect pressure areas for discoloration and capillary refill or blanch response
inspect pressure areas for abrasions or excoriations
palpate the surface temperature over the pressure area sites
palpate bony prominences and dependent body areas for presence of edema
skin integrity and wound healing: interventions to prevent skin breakdown
provide nutrition maintain skin hygiene for stage I ulcers to prevent further ulcerification - reduce irritants - reduce pain avoiding skin trauma - semi-fowler's position - frequent weight shifts - exercise and ambulation providing supportive devices prevent entry of microorganisms prevent transmission of pathogens minimize direct pressure over bony prominence's improve circulation schedule and record position changes clean and dress the ulcer using medical asepsis obtain C&S, if infected teach the pt. check for blanching color guide for wound care - if it is red, protect - if it is yellow, cleanse - if it is black, debride
skin integrity and wound healing: hemorrhage
an escape of blood through ruptured or unruptured vessel walls
skin integrity and wound healing: infection
invasion off the body by organisms that have the potential to cause disease
skin integrity and wound healing: dehiscence
a bursting open, splitting, or gaping long natural or sutured lines
skin integrity and wound healing: evisceration
protrusion of underlying content through a lesion caused by intentional ie. surgical incision) or unintentional trauma
nursing process: steps of the nursing process
assess
- gather information about the client’s condition
diagnose
- identify the client’s problem[s]
plan
- set goals of care and desired outcomes and identify appropriate nursing actions
implement
- perform the nursing action identified in planning
evaluate
- determine if goals were met and if outcomes were achieved
nursing process: interpreting and analyzing data collection
clustering information into groups using a logical sequence
comparing information to standards of care
identifying patterns that the information hold
make a conclusion about what the information means
nursing process: actual nursing diagnosis
regards a human response
i.e. nutritional imbalance
nursing process: risk nursing diagnosis
a human response that may occur
i.e. risk for fall
nursing process: health promotion diagnosis
pt. wants to improve their well-being
i. e. smoke cessation
nursing process: the diagnostic process
analysis and interpretation
- data validation and clustering
- derived from assessment which includes subjective an objective data and risk factors
identification of pt. health problem
- based on defining characteristics [i.e. pain, ineffective breathing]
formulation of nursing diagnosis
nursing process: developing SMART goals
should be Specific for the pt. should be Measurable - i.e. pain rating from 0-10 should be Attainable should be Realistic should be Timely - i.e. present a specific time frame
nursing process: discharge planning
thought of upon admission to the facility or institution
it is part of the nursing care plan
nursing process: implementation
fourth step of thee nursing process
implements the interventions that have been agreed upon by the pt. and the nurse
implementation process:
- reassessing the pt.
– interventions may have to change depending on the pt.’s status and response to interventions
- organizing resources and care delivery
- anticipating and preventing complications
- communicating nursing interventions
implementation skills
- cognitive, interpersonal, and psycho-motor skills
nursing process: evaluation
it is the final step of the nursing process
measures the pt.’s response to nursing actions and the pt.’s progress toward achieving the goals
it is an on-going process
it requires critical thinking
it requires evaluative thinking
- performing assessments throughout the whole period of care
interpretation and summation of findings occur
remember to document
electronic health records: EHR
electronic record of pt. health information generated whenever a pt. accesses medical care in any health care delivery setting
integrated all pertinent pt. information into one record
enables research and quality of care
provides continuity and quality of care
- pt.’s will not always just go to one facility so this keeps the information for each pt. at the ready
electronic health records: purpose of reccords
communication between different health care professionals and professions
legal documentation to serve a proof that care was given and interventions were done
financial billing which aids the process of reimbursement from insurance companies
education used for research purposes to aid in individual learning and team learning
aids in the navigation of the nursing process
provides readily available information for research
auditing and monitoring which confirms care was given to the pt.
electronic health record: methods of reccording
narrative documentation
- written expressively by the nurse
problem-oriented medical records
- uses a database to document assessment findings
- has a problem list, plan-of-care, and progress notes
source records
charting by exception
- only charting if there is a deviation from the norm
- charting anything that isn’t within normal limits
cases management and critical pathways
electronic health record: legal responsibilities in documentation
standards of documentation are set by federal and state regulations, state statutes, standards of care and accrediting agencies
in the eyes of the law, “if you didn’t document it, you didn’t do it”
electronic health record: maintaining pt. confidentiality
it is the legal and ethical obligation of health care professionals to maintain pt. confidentiality
only staff who have direct involvement in a specific pt.’s care have legitimates access to records
health insurance portability and accountability act [HIPAA] governs all areas of pt. information and the management of their care
electronic health record: guidelines for effective documentation
factual
- describes what is going on, what is the objective, decreases judgment, avoids vague statements [i.e. the pt. seems upset], avoids subjective terms [i.e. the wound is healing “nicely”]
accurate
- requires information to be given verbatim, using appropriate and accepted abbreviations
complete
- requires relevant and specific information, as possible
current
organized
- performed by the nurse/health care professional that gave care and should not be done under the name of someone else and vice versa
