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213 terms

Fundamentals of Nursing Study Guide

collecting vital signs, pain levels, other signs/ symptoms
nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis
nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks)
following through with plan that was developed for the patient
goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient
Normal range for temperature
Normal range for pulse
Normal range for respirations
Normal range for BP
Normal range for pulse ox.
sit close, observe, lean forward, eye contact, relax
Types of pain
acute, chronic, cancer, by inferred pathology, idiopathic
Pain threshold
level of stimulus needed to produce the perception of pain
Pain tolerance
amount of pain a patient endures without its interference of ADLs
Factors influencing pain
age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors
Behavioral responses to pain
clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction
Pharmacological pain relief
analgesics (NSAIDS & non-opioids, opioids, adjuvants)
NSAIDS & non-opiates
has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction, possible liver failure
pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status
Naloxone (Narcan)
opiate antagonist, reverses opioid induced resiratory depression
Patient Controlled Analgesia (PCA)
client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses
depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local
Basal metabolic rate (BMR)
energy needed to maintain life
main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey
essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance
triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential
comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids
essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight
inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport
Free Radical Theory
presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products
Erikson's 8 stages of development
trust vs mistrust
autonomy vs shame and doubt
initiative vs guilt
industry vs inferiority
identity vs identity confusion
intimacy vs isolation
generativity vs stagnation
integrity vs despair
the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions
Medication absorption
the passage of medication molecules into the blood from the site of administration
factors that affect med absorption
route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication
meds are excreted through:
kidney, liver, bowel, lungs, exocrine glands
medication interactions
when one med modifies the action of another
increased weight for height by 10% or more
Morbid Obesity
100% over weight for height
Measurements for obesity
waist size, BMI, ideal weight for height
causes of obesity
corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone
management of obesity
decreased food intake, increased physical activity
definition of nursing
an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems
evidence based practice
interventions nurses do that are based on evidence
roles of nurse
caregiver, advocate, educator, communicator, manager, autonomy and accountability
definition of health
process by which people affect one another; exchange of info, ideas, feelings; basic component of human relationships; fundamental element of nurse-client relationship
intrapersonal communication
occurs within, self verbalization, self awareness, self talk, guided imagery
interpersonal communication
one on one interaction; most frequently used; exchange of idea, problem solving, decision making
transpersonal communication
persons spiritual domain; higher power; prayer, meditation, guided reflexion
small group communication
small number of people meet; committees; group meetings
public communication
with an audience; speaking at conferences; leading class
elements of communication
referent sender; message, receiver, channels, feedback, interpersonal
forms of communication
verbal, non-verbal
factors influencing communication process
developmental level, gender, values/ perception, personal space, territoriality, roles/ relationships, environment, congruence
interactive process that promotes learning
purpose of teaching
gaining new knowledge, change attitudes, adopt new behaviors, preform new skills,
purposeful acquisition of new knowledge, attitudes, behavior, or skills
need for nurse to teach client
clarify info given by doc or other health care providers; has to be complete, accurate, and relevant; should be based on patient's needs and learning ability
cognitive learning
includes all intelectual behavior/ requires thinking
affective learning
expression of feelings and acceptance of attitude, opinion, values
psychomotor learning
acquiring skills that require the integration of mental / muscular activity
motivation to learn
person's desire/ willingness to learn
ability to learn
developmental / physical ability
learning environment
privacy, room temperature, lighting, noise, furniture, ventilation
invasion of a susceptible host by pathogens or microorganisms. resulting in disease
occurs when a microorganism invades the host but doesn't cause infection
communicable disease
the infectious process transmitted from one person to another
symptomatic infection
when the infection has signs and symptoms like fever, cough, etc
asymptomatic infection
when the infection does not cause any signs or symptoms, making the diagnosis difficult
hand hygiene
the most important technique used in preventing and controlling transmission of infection
chain of infection
infectious agent/ pathogen > reservoir/ source for pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host
4 stages of infection
incubation period, prodromal stage, illness stage, convalescence
Latrogenic HAI
from a procedure in a hospital
Exogenous HAI
from microorganisms outside the individual ( Salmonella)
Endogenous HAI
when patient's normal flora becomes altered (C.diff)
factors influenceing infection
age, stress, disease process, treatment/ condition that compromise the immune system
eliminates many or all microorganisms with exception of spores from inaminate objects
complete elimination or destruction of all microorganisms including spores
social patterns affecting hygiene
ethnic, social, and family influences on hygiene patterns
personal preferences affecting hygiene
dictates personal hygiene practices for individual patients
body image affecting hygiene
a person's subjective concept of his/her body appearance
socioeconomic status affecting hygiene
influences type and extent of hygiene practice used
health beliefs and motivation
motivation is the key factor in hygiene
cultural variables in hygiene
people from diverse cultures practice different hygiene rituals
developmental stage in hygiene
affects the patient's ability to preform hygiene care
physical condition in hygiene
may lack physical energy / dexterity to preform self-care
safety guidelines in hygiene
communicate with team members; incorporate patient's priorities; move from cleanest to less clean areas; use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood; test tempo of water or solutions; use principles of body mechanics and safe patient handling; be sensitive to invasion of privacy
commitment to include clients in decisions
taking positive actions to help others
avoidance of harm/ hurt
being fair
agreement to keep promises
professional nursing code of ethics
a set of guiding principles that all members of a profession accept; helps professional groups settle questions about practice or behavior; includes responsibility, accountability, and confidentiality
personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior
defines actions as right or wrong
proposes that the value of something is determined by its usefulness
feminine ethics
focuses on the inequality between people
ethic of care
emphasizes the importance of understanding relationships, especially as they are revealed in narratives
JCAHO's ethical standards
mandate that health care institutions provide multidisciplinary ethics committees or similar structures to write guidelines and policies, provides education, counselling, and support for staff on ethical issues
how to process an ethical dilemma
1. ask if this is an ethical dilemma
2. gather all relevant info
3. clarify values
4. verbalize problem
5. identify possible courses of action
6. negotiate a plan
7. evaluate plan
quality of life
central to discussions about futile care, cancer therapy, physician assisted suicide, DNR
futile care
interventions unlikely to produce benefit for the client
allocating scares resources
a key issue in discussions about access to care
the nursing shortage
produces difficult working conditions and affects client outcomes
source of laws
legal guidelines that come from statutory, regulatory, and common law
standards of care
legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care
a signed form required for all routine treatment, hazardous procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language clients
what does mobility mean?
allows ability to move freely about; musculoskeletal and nervous systems working together to make movement; decreases risk for injury
labs for obesity
electrolyte/sodium/potassium, blood glucose, triglycerides, hemoglobin, serum albumin
lap band reduction; gastric bypass
lap band reduction
removable, premanent life cange; can cause dehydration, electrolyte problem, backup into esophagus, blockage
gastric bypass
malabsorption surgery; can cause dehydration and electrolyte problems; overeating can cause dumping syndrome-food deposits into small intestines too quickly
kidney/ renal disease
not enough RBCs; anemia; metabolizes calcium and Vitamin D; ADL intolerance; risk for hyper/hypotension, anemia, soft bones, and fractures; caused by diabetes; patient has to out out at least 30mls per hour
labs for kidney/ renal disease
BUN, creatinine, GRF, Rennin, EPO
patient has some form of renal failure; not producing as much urine as regular patient; strict I&Os
irreversible renal disease; need kidney transplant or dialysis; not producing urine; increased phosphorus in system
excessive urine; sign of diabetes or hormone issue
blood in urine; not a good sign
voiding at night; early sign of hypertension; pressure on bladder during pregnancy
peritoneal dialysis
shunt placed in peritoneum; diasolate poured in peritoneum, about 1hr later diasolate, nitrogenous waste, fluid, electrolytes removed
3 days out of week, 3-4 hr long process; blood circulated through the machine and nitrogenous waste, fluid, electrolytes removed; BP before and after treatment; weight before and after; can be used for drug overdose
UTI causes
E. coli, young and old women at risk; uncircumcised men (smegma); frequent sexual intercourse/ unprotected/ multiple partners; poor hygiene; HAI; med/surg related
UTI s/s
frequency/ urgency; burning pain when voiding; hematuria; fever; chills; nausea; vomiting; pyelonenephritis; malaise
UTI treatment
antibiotic- Siproflaxin; cranberry juice for prevention
functional incontinence
can't make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule
stress incontinence
usually in women who didn't do kegels during labor
reflex incontinence
on urge to go; it just comes out
irreversible damage to kidney tissue
uremic syndrome
increase in nitrogenous wastes in the blood
urinary incontinence
can be temporary; affects everyone especially elderly
causes of urinary incontinence
urethral obstruction, surgical trauma, alterations in sensory/ motor innervation, medication side effects, anxiety
pain or burning on urination
urinary diversion; bypasses the ureters, bladder, urethra; used in patient with kidney stones, cancer, ureter problem, any GU problem
pH; protein; glucose; ketones; blood; specific gravity; WBCs; bacteria
factors affecting bowel elimination
age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics
stool gets lodged in the intestines; a symptom not a disease
result of unrelieved constipation; leaky drainage
liquid stool; associated with disorders affecting digestion, absorption, and secretion in GI tract
inability to control passage of feces or gas through rectum
loose stool
chunks of stool
pressure ulcers
tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis
stage 1 ulcer
intact skin; red/irritation; unblanchable
stage 2 ulcer
broken skin; partial thickness; blister epidermis and dermis; can ooze
stage 3 ulcer
epidermis, dermis, and subQ tissue; oozing, signs of infection; full thickness loss
stage 4 ulcer
full thickness loss; can see organs/ bones; very painful
granulation tissue
healing tissue; looks beefy
dead tissue; yellowish, brownish; makes wound unstageable; has to be debritied
necrotic/black; surgically removed
dry skin; becomes reddish; low humidity; frequent washing
chemical, allergic, physical agent; drugs, food, sweat-act on nerve fibers, releases histamine and affects itch receptors; insect bites, scabies, medication (opioid) , systemic effect
reddish, whitish, plaques edematous; usually show up on torso; usually caused by drugs, histamine, bed linen detergent
health care delivery system
complex, dynamic, constantly changing; past 10-15 yrs managed care, primary care provider; services provided by a wide variety of licensed/ non-licensed staff
new philosophy of health care
manage health; wellness and prevention
old philosophy of health care
manage illness; disease management
school health
support educational success by enhancing health
occupational health
health promotion, accident or illness prevention
MD, APRN office
annual PE and screening/ preventative education
screening to comprehensive care
nursing centers
focus on health promotion/ health education, disease prevention, chronic disease management, support for self-care and caregivers
block and parish nursing
services based on need vs availability of reimbursement; religous involvement
primary care in community
health professionals, community members, govt
hospital and med centers
inpatient services, diagnostic and treatment services
psych facilities
focus on clients with emotional / behavioral problems
close monitoring; 1:2 staffing; equipped with most advanced technology; staff educated in critical care principles/ techniques
purpose unclear; physiological and psychological restoration; maintenance of biological function; regulated by reticular activating system > regulates sleep cycle in hypothalamus
occur in NREM and REM; REM in color; important for learning, memory, and adopting to stress
stage 1 of sleep
4-5%; light sleep; muscle activity slows
stage 2 of sleep
45-55%; breathing and heart rate slow
stage 3 of sleep
4-6%; deep sleep
stage 4 of sleep
12-15%; very deep sleep; rhythmic breathing
stage 5 of sleep
20-25%; REM; brainwaves speed up and dreaming occurs; increased heart rate; rapid and shallow breathing
changes in pattern affecting sleep
illness (cardiac, resp, pain), RLS; food before bed; change in daily pattern
more than 45 min to fall asleep/ trouble staying asleep
falling asleep at inappropriate times
sleep deprivation causes
irritability, cognitive impairment, memory lapses/loss, severe yawning, s/s like ADHA, impaired immune system, risk of type 2 diabetes, increased heart rate variability, decreased reaction time and accuracy, tremors, aches, growth suppression, decreased temp, risk of obesity, hallucinations
night terrors, sleep walking/talking/eating/driving, bed wetting
sleep apnea
lack of airflow through mouth/nose >10sec during sleep; airway collapses, blocking airflow to lungs
left sided failure
blood backing up into lungs; shortness of breath; impaired gas exchange; hypertrophied left ventricle wall; coughing up blood; orthopnea; exertional dyspnea; cyanosis of extremities; paroxymal nocturnal dyspnea
right sided failure
lower extremity edema; dependent edema; HTN; daily weights; increased peripheral venous pressure; distended jugular veins; cyanosis of extremities; asites, GI distress
treating CHF
upright position, high semi fowlers; nitrates- vasodilate coronary arteries and myocardium (dizzy feeling, hypotension); Lasix- diuretic/ urine output; oxygen- when pulse ox. under 95%; ACE inhibitors- Vasotech, Nosinopro (check BP before admin, low potassium or under 60 bpm hold); Digoxin- slows heart rate; apical pulse before admin; nausea and vomiting; toxic if stays in blood for too long; cardiac glycocide- increases contraction, slows heart rate, increases CO and oxygen in blood; decrease fluids to 1500ml; decrease salt to 2000-3000mg; test dig level, ABGs, potassium
myocardial ischemia
chest pain, aching, associated with activity, pain leaves when patient rests
stable angina
unstable angina
spontaneous pain
varient angina/ prinz metals
occurs at rest (sort of constant)
myocardial infarction
pain (sudden onset, substernal, crushing/ tightness/severe; affects back, neck, jaw, arm, shoulder), dyspnea, syncope with low BP, shortness of breath, nausea, vomiting, sweating, increased heart rate, DENIAL
treatment for MI
stent angioplasty or balloon; thrombolytic therapy- breaks clot apart; M-morphine, O-oxygen, N-nitrates, A-aspirin
hyperventillation (kussmaul)
>40 RR; over-breathing, decreased CO2 leads to alkaline; panic attack, stress/anxiety, fever/infection, intense exercise
treatment for hyperventillation
have patient hold one nostril; try to reduce patient;s stress/panic; purse-lipped breathing
decreased ability to remove CO2 from body; pH below 7.35; RR below 12; emphysema/ CVA; hypoxic
treatment for hypoventillation
if narcotic based, reduce/ discontinue; stroke- high fowlers/ oxygen; other meds to increase breathing
decreased tissue oxygenation; restlessness, anxiety, confusion, increased heart rate and RR
irregular breathing; altering rapid/apnea episodes; near death breathing pattern
cardiac panel
sodium, LDL/HDL, potassium, ABG, CKMB, triponin, C-Reactive, protein
stops flu virus multiplication; increases risk for self injury; take within 48 hr of onset
avian flu
H5N1; bird to human trough droppings, saliva, blood; stayed in Asia
swine flu
H1N1; person to person transmission; touching infected surfaces; nose/throat culture; vaccine
inflammation/ swelling of larynx; occurs as single problem or with resp infection; risk/irritant-smoking; dry coughing; voice changes; throat cultures to check for strep; comfort care
hardening of arteries
affects intima of arteries; plaque froms and narrows lumen of arteries; pain when tissues don't get oxygen
causes of atherosclerosis
lifestyle; HTN; smoking; diabetes; genetic
lab work for atherosclerosis
cholesterol; LDL/HDL, homocystine; C-Reactive protein
treatment for atherosclerosis
decreased cholesterol intake; smoking cessation; blood work; exercise
peripheral artery disease
caused by atherosclerosis; usually lower extremities; deprives lower extremities of oxygen; cramps and muscle pain with activity
stage 1 PAD
asymptomatic; Bruit may be present; toes cool to touch; slow capillary bed refill
stage 2 PAD
claudication; muscle pain/ cramping
stage 3 PAD
rest pain
stage 4 PAD
necrosis/ gangrene; loss of oxygen to toes > toes fall off/ need to be removed
treatment for PAD
Statins- help metabolize cholesterol; Crestor, Lipitor- muscle pain, leg pain, cramping, diarrhea
deep vein thrombosis
clots in the veins; usually in the extremities
Virchow's triad
stasis-immobility, bed ridden, car/plane/ train travel
vessel wall injury, fracture, trauma
hypercoagulability- altered coagulation (birth control, hormone therapy, smokers, dehydration)
s/s of PAD
red, inflammed, shortness of breath, coughing, increased heart rate, sweating, anxious feeling
pulmonary emboli
complication of DVT
treatment for pulmonary emboli
prevention- anticoagulant therapy; thrombolytic therapy; surgery to remove thrombus