Final Study Guide PDF

Normal vital signs: 1. Respirations are between 12-20 BPM (can be slightly higher in older patients) 2. Tempurature is between 96.8- 100.4 farenhite 3. Pulse is 60 -- 100 BPM 4. Blood pressure is less than 120/80 Pulse pressure is the diastolic pressure minus the systolic pressure Do n...

Normal vital signs: 1. Respirations are between 12-20 BPM (can be slightly higher in older patients) 2. Tempurature is between 96.8- 100.4 farenhite 3. Pulse is 60 -- 100 BPM 4. Blood pressure is less than 120/80 Pulse pressure is the diastolic pressure minus the systolic pressure Do not do an oral temperature on: 1. Consufed patients 2. Infants 3. Patients with shortness of breath 4. Anyone who cannot keep the thermometer in their mouth While performing a physical assessment make sure 1. The capillary refill is less than 3 seconds 2. The anteroposterior chest diameter is 2-1 3. The pupils react to light 4. There are bowel sounds every 5-15 seconds 5. The patient doesn't display symptoms of presbyopia 6. The patient doesn't display symptoms of presbycusis PERRLA: Pupils are Equal, Round, Reactive to Light, and Accommodate Presbyopia is farsightedness usually due to aging Presbycusis is the inability to hear S and CH sounds due to aging During a fecal occult test the indicator will turn blue if positive Broccoli, red meats, and cabbage can cause a false positive in a fecal occult test For restraints: 1. Tie to non-movable part of the bed 2. The RN must do any assessments 3. Allow for as much movement as possible 4. Use a slip knot Physical restraints are - ties, straps, mitts Chemical restraints are sedatives Exceptions to HIPAA are: 1. Some infectious diseases 2. Abuse 3. Legal proceedings Types of incontinence: 1. Urge incontinence- inability to make it to the bathroom in time 2. Reflex incontinence- incontinence due to nerve damage 3. Overflow incontinence- left the toilet too early 4. Functional incontinence- a physical disability making it difficult to wipe or use the bathroom properly- examples being wheelchair bound patients and patients with hand arthritis 5. Stress incontinence- leakage or early restroom usage as a result to a bodily stress, like sneezing, coughing, or laughing The Hendrich 2 Fall Risk assessment assesses if a patient is a fall risk. Anything over 5 is a high risk for falling. Criteria for The Hendrich 2 Fall Risk Assessment: - Confusion/Disorientation/Impulsivity - Symptomatic Depression - Altered Elimination - Dizziness/Vertigo - Gender (Male) - Any Administered Antiepileptics (anticonvulsants): - Any Administered Benzodiazepines - Get-Up-and-Go Test: "Rising from a Chair" SBAR is the technique used when relaying over information about a patient to another healthcare employee. It stands for: 1. **S- S**ituation- what is happening to the patient now 2. **B-** Background- pertinent patient information 3. **A-** Assessment- what you think is happening-your assessment of the situation 4. **R-** Recommendation- your recommendation about what should happen next To avoid a pressure injury, turn and position a patient at least every two hours and give frequent and meticulous skin care in cases of incontinence. Risk factors for pressure injuries are: 1. Shearing 2. Malnutrition 3. Moisture 4. Sensory loss Subjective symptoms are symptoms that are needed to be told to you by the patient. Objective symptoms are symptoms that are able to be seen by the nurse or providor. Examples of subjective symptoms are: 1. shortness of breath 2. pain 3. nausea 4. dizziness Examples of objective symptoms are: 1. vital signs 2. a rash 3. vomiting Using positioning devices is an independent nursing intervention, meaning one nurse does it on their own without help. Examples of position devices and their purposes are: - Foot boards and high-top sneakers- are used to prevent foot drop/plantar flexion - Hand rolls- are used to prevent contractures - Cradle boots- are used to prevent skin breakdown on the heels - Trochanter rolls- are used to keep the hip in internal rotation Advance Directives are legal care plannings designed to instruct medical staff on how to care for a patient. There are two types of advance directives: - The first type is a living will, which is a document where a client can clearly state which life-sustaining treatment(s) they wish to have performed if they become incapacitated and are unable to make decisions for themselves. - The second type of advance directive is the durable power of attorney for health care. In this document, a client can appoint an individual to make health care decisions on their behalf if they are unable to do so.  The five steps of the nursing process are: 1. **Assessment**: The first step, where the nurse gathers information about the patient\'s health, including their medical history, medications, and allergies.  2. **Diagnosis**: The nurse analyzes the assessment data to determine the patient\'s actual or potential health issues. A nursing diagnosis is a way for nurses to communicate with each other about their patients. \*at this stage we prioritize patients problems\* 3. **Planning**: The nurse identifies the patient\'s goals, both short-term and long-term, and plans the steps to achieve them.  4. **Implementation**: The nurse provides direct and indirect care to help the patient reach their goals. \*At this stage is when nurses do their interventions\*. It is important to note about the nursing process that: 1. Signs and symptoms support or give evidence to you problem statements. 2. Risk for diagnostics will not contain the signs and symptoms as they did not happen yet. 3. Care plans should be individualized and done with the patient. Ethical Principles and their Definitions: - **Autonomy**- respect the client's right to make their own decisions regarding their health care, including the right to refuse care - **Beneficence-** the nurse's obligation to minimize harm and practice in a way that benefits the client. - **Nonmaleficence-** the nurse's obligation to do no harm. Doing no harm, or the least amount of harm to the client, while trying to achieve the best possible outcome - **Veracity-** the nurse's obligation to provide truthful and accurate information to the client - **Fidelity-** the nurse's obligation to demonstrate loyalty, to keep promises, and to uphold commitments- Keeping promises or commitments - **Justice-** the nurse's obligation to provide treatment, care, and resource allocation that is impartial, fair, and equitable to all clients regardless of age, sex, race, or economic status. In a normal urinalysis: - The specific gravity- is 1.002- 1.030 - Color is - pale yellow to amber - The clarity is- clear - glucose- negative - ketones- negative - hemoglobin- negative (under microscope less than 5 per high powered field) - nitrite- negative - leukocyte esterase- negative (under microscope less than 5 per high powered field) - bacteria, yeast, parasites- none Self Concept types and their definitions: - **Self-awareness-** the ability to see oneself clearly and objectively through reflection and introspection. - **Body-image-** one's feelings, perceptions, and thoughts about one's body and is typically conceptualized by perceptions related to body shape, size, and physical attractiveness. - **Self-efficacy-** refers to a person's perceived ability and aptitude to successfully complete a task - **Role Performance-** A role is a set of expected behaviors determined by family, culture, and societal norms. Roles are influenced by one's upbringing, education, relationships, occupation, and life experiences.-​​​​​​​Role performance includes the specific behaviors that a person displays within each role and the perceptions of their ability to successfully fulfill the roles. EMTLA stands for Emergence Medical Treatment and Labor Act. It is a law forbidding a hospital emergency room to turn away patients without insurance and enforcing Emergency rooms to provide equal care to all patients regardless of their insurance or financial status. All clients must have a medical screening evaluation (MSE), meaning if an ER feels the need to transfer a client to different facility they must verify and sign off transfer, clearly indicating that the benefits of transfer outweigh the risks of transferring an unstable client. MSE was enacted because of "patient dumping"- hospitals would turn away patients who had no insurance leading to patient deaths. With Good Samaritan Laws: - Protect medical professionals who *choose* to intervene in medical emergencies outside of work - A nurse does not have a legal obligation to provide care to anyone outside of their employment obligations. - laws were enacted to encourage health care professionals to render aid outside of work - you cannot receive compensation for any care given, **you cannot be negligent or provide care outside your scope of practice.** Four key elements in Good Samaritan laws are: - Permission of ill/injured person when possible. - Care given inappropriate (non-reckless) manner. - The person covered by good samaritan laws was NOT the one who caused an accident. - Care was being given because it was an emergency and trained help had yet to arrive. Vitamins: - Water-soluble vitamins- B, C, B complex - Fat-soluble vitamins- A, D, E, K- needed in the diet to absorb fat Trans fats- hydrogen is added to make oils harder and more shelf-stable. They raise cholesterol in the blood. Aspiration- occurs when something enters the lungs other than air, including food, liquid, or other materials. Two types are: 1. **Overt aspiration-** presents with noticeable symptoms such as - sudden cough, - wheezing, - trouble breathing, - congestion, - heartburn, - throat clearing, - chest discomfort, - decreased O2 saturation as the body recognizes a foreign object going into the airway and attempts to clear it 2. **Silent aspiration-** has no obvious symptoms- look for - fever, - low O2 sat., - tachypnea- signs of pneumonia Tube feedings- 1. keep the head of the bed raised 30 degrees 2. when doing care or lying patient flat- pause the feeding Urinary catheterization- urinary catheter is placed into the bladder to allow urine to drain. This flexible tube can be placed into the bladder through the urethra or through a surgically created opening in the lower abdomen. Indications for urinary catheterizations are: 1. Urinary retention 2. Incontinent patients with **large wounds** that are having difficulty healing because of the presence of urine 3. Operative procedures - Regulated as food NOT medication - Doses/strengths can vary between brands - Can cause dangerous drug interactions - Should be included in the patient's medication list State Boards of Nursing: - Determine scope of practice - Administers licensing exam- tests for minimum competency - Licenses nurses to protect the public from unsafe practitioners - Compact licensure- allows nurses to work under one license in multiple states - Reciprocity- nurses can apply for licensure in another state without taking another exam Occurrence/ Incidence reports: - Used when something out of the ordinary occurred or almost occurred - Help to track incidents to prevent them from happening again - Never document about an incident report in a patient's chart Kubler-Ross Five Stages of Grief: - Denial - Anger - Bargaining - Depression - Acceptance Types of Stressors: - **Situational stressors** created by personal, family, or work-related issues. Examples of personal stressors include being diagnosed and living with a chronic illness, financial strain, and being a victim of a motor vehicle accident, death of a family member etc... - **Developmental stressors** occur as an individual moves through the stages of life.  - **Adventitious stressors-**also called **disaster** **events**, because they are generally rare and unexpected. Such stressors can result from natural disasters such as floods, earthquakes, and war, or from interpersonal disasters such as physical or sexual assault. Acts of terrorism may also be considered adventitious events since previous methods of coping may not be sufficient for dealing with the magnitude of the stress. - **Socioeconomic stressors-**Stress that occurs from factors such as poverty, socioeconomic status (SES), and homelessness. - **Cultural stressors-**Stress that individuals may experience by living within a society in which they do not culturally fit and/or receiving care that ignores their cultural beliefs. Complementary VS Alternative Treatment: - Complimentary- treatment done in conjunction with western medical treatment - Alternative- treatment done instead of western medical treatment A "Shared governance" is a shared-decision structure that gives nurses control over their own practice. Shared Governance is based on the premise that nurses will have access to resources, information, data, and growth opportunities by being a contributing partner in the decisions that influence nursing practice. Parenteral Nutrition: - Dietary intake that is administered intravenously (IV). - Prevents malnutrition in clients or, if the client is already malnourished, can help correct it. - Provides liquid nutrients such as proteins, fats, carbohydrates, minerals, electrolytes, and vitamins. - Clients with a digestive system that cannot absorb or tolerate adequate food eaten by mouth can utilize parenteral nutrition - Parenteral nutrition, in the form of IV fluid, is administered into a large vein through a venous access device - Partial parenteral nutrition supplies a client with only part of their nutritional requirements, allowing for supplemental oral intake. In contrast, total parenteral nutrition gives the client their total daily nutritional requirements. - For clients without a functioning GI tract, total parenteral nutrition may be the only option A mission statement is a statement about the purpose of an organization Pressure Injury/ Skin Breakdown: - **Stage 1 Pressure Injury: Non-blanchable Erythema** - **Stage 2 Pressure Injury: Partial-Thickness Skin Loss** - **Stage 3 Pressure Injury: Full-Thickness Skin Loss** - **Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss** - Note- blanchable redness is not considered a pressure injury Types of Learning: - Cognitive- learning facts, remembering - Affective- changing emotions and feelings - Psychomotor- based on action. It involves physical movement, skills, coordination, and use of the senses (e.g., touch). Nurses include the psychomotor domain in client education because they often teach clients hands-on skills. Bowel Elimination: - Constipation- dry, hard stool that is difficult to pass - Diarrhea- watery, liquid stool - Fecal impaction- can present as diarrhea Other Team Members: - Physical therapist- gross motor skills- walking, stair climbing - Occupational Therapist- fine motor skills- using utensils, writing, ADL's - Speech Therapist- speaking (communication) and swallowing