NURS134 Exam 1

• est. American Red Cross in 1882

• cared for/fed Union soldiers during CW

• supt. of female nursing corps of Army (CW)

• reform of treatment for mentally ill pts

• founder of modern nursing

• differentiated nursing from medicine→art & science

• nurse & abolitionist on Underground RR

• later joined Union Army

• define legal scope

• rules & regulations

• est. education standards

• promote health

• prevent illness & restore health

• facilitate coping w/ disability and death

**goals of nursing match goals of pt**

Quality and Safety Education in Nursing

• est. by Institute of Medicine (2003)

• targets for knowledge, skills, and attitude

• 6 competencies

  • patient centered care

  • teamwork and collaboration

  • quality improvement

  • safety

  • informatics

  • evidence based practice (research)

A- assess/analyze

D- diagnose

P- plan

I- intervention

E- evaluate

1. recognize cues

2. analyze cues

3. prioritize hypothesis

4. generate solutions

5. take action

6. evaluate outcomes

• nursing process & nursing tasks are not the same

  • nursing tasks can usually be delegated

• oversee UAP

• know pts needs and what they’re at risk for

**only the RN can TEACH, EVALUATE, & ASSESS**

• infectious agent→ reservoir→ portal of exit→ means of transmission→ portal of entry→ host

transient: attached loosely to skin

resident: found in creases of skin

• spherical (cocci)

• rod shaped (bacilli)

• corkscrew shaped (spirochetes)

1. incubation: growing and multiplying

2. prodromal: most infectious, non specific symptoms

3. full stage: specific symptoms

4. convalescent: recovery

1. before touching a pt

2. before a clean/aseptic procedure

3. after body fluid exposure

4. after touching a pt

5. after touching pts surroundings

• UTIs

• surgical site infections

• bloodstream infections

• pneumonia

gloves and mask (if needed)

• all hospital pts regardless of diagnosis and infection status

• used in addition to standard precautions

• contact

  • hand hygiene, gloves, gown

• droplet

  • hh, mask, goggles/face shield

• airborne

  • N95

1. gown→ mask→ gloves

2. gloves→ gown→ mask

• operating room

• labor & delivery

• bedside: urinary catheter, sterile dressing change, preparing & injecting meds

• nociceptive: actual/threatened damage→ peripheral tissue

• cutaneous: skin/subq tissue

• somatic: og. in tendons, ligaments, bones, bv, nerves

• visceral: poorly localized; og. in body organs

• neuropathic: lesion/disease of central nerves

• physical: cause can be identified

• psychogenic: cause cannot be identified

• referred: perceived in a different area

• physiologic→ increased BP, stronger pulse

• behavioral→ crying

• affective→ anxiety, exaggeration

P- provocation

Q- quantity/quality

R- region/radiation

S- severity

T- time

• analgesics

• nonopioid analgesics

• opioids/narcotics

• adjuvant drugs (anxiety)

• pt controlled analgesics

• epidural

• local

oral temperature: 96.4-99.5 deg. F

pulse rate: 60-100 bpm

respirations: 12-20 breaths/min

blood pressure: 120/80

• intermittent: temp returns→ normal at least once every 24 hours

• remittent: temp does not return→ normal; fluctuations

• sustained/continuous: above normal; no variation

• relapsing/recurring: returns→ normal for days, then back up for days

• regulated by ANS

• PNS→ decreases HR

• SNS→ increases HR

pulse rate: # of contractions over peripheral artery

• pulmonary ventilation: air in/out of lungs

• diffusion: exchange btwn alveoli and blood

• perfusion: exchange btwn blood and tissues

• changes on response→ tissue demands

• respiratory centers→ medulla and pons

  • activated by chemoreceptors

CO2 is the strongest resp. stimulus

• elasticity of arterial walls

• ventricular contraction→ systole

• heart relaxation→ diastole

systole/diastole

• infants: easily damaged and subject→ infection

• children <2: skin is thinner and weaker

  • becomes increasingly resistant to injury & infection

• elderly: prolonged maturation of epidermal cells

  • thin, easily damaged skin

  • circulation & collagen formation dec.→ dec. elasticity→ increased risk for pressure injuries

• R-red→ protect; granulation tissue

• Y-yellow→ cleanse; prevent infection

• B-black→ debride; dead

• aging skin

• chronic illness

• immobility

• malnutrition

• fecal/urinary incontinence

• altered LOC

• spinal cord & brain injuries

• neuromuscular disorders

stage I: redness

stage II: partial thickness; blister

stage III: full thickness; SQ fat

stage IV: full thickness; muscle and bone exposed

• serous: clear

• sanguineous: bloody

• serosanguineous: combination of clear and bloody

• purulent: green/yellow; infected

• protection

• body temp regulation

• psychosocial

• sensation

• vitamin D production

• immunologic

• absorption

• elimination

NREM (75-80%)

• stages I & II: light sleep

• stages III & IV: deep sleep

REM (20-25%)

wake→ NREM I→ N II→ N III→ N IV→ N III→ N II→ REM→ N II…

• restlessness

• sleep postures/activities

• snoring

• leg jerking

• energy level

• facial characteristics

• behavioral characteristics

• physical data

• deep breathing

• using incentive spirometer

• pursed lip breathing

• diaphragmatic breathing

• bed up, proper position, humidified air

S- situation

• describe circumstances

• “I’m calling about…”

B- background

• data about pt

• ex.) mental status, vitals, skin, oxygen

A- assessment

• interpretation

• “I think that…”

R- recommendation

• ask for or provide recommendation

1. orientation phase

   1. tone & guidelines

   2. use names

   3. classify roles

   4. orientation to hc system

2. working phase

   1. work together→ meet pts needs

   2. provide any assistance

   3. provide teaching/counseling

3. termination phase

   1. examine goals

   2. make suggestions

   3. help pt est. a relationship with new nurse or agency

• open

  • “tell me about…”

• closed

  • yes or no

• clarifying

• reflective

• sequencing

• directing (redirect pt)

• mind-body interaction

• anxiety (most common)

• coping mechanisms

• developmental stress: progression→ growth & development

• situational stress: no predictable patterns

• exercise

• rest and sleep

• nutrition

• support systems

• relaxation

• meditation

• anticipatory guidance

• guided imagery

• biofeedback

• crisis intervention

1. identify problem

2. list of alternatives

3. implement a plan

4. evaluate the outcome

5. SAFER-R model

S- stabilization

A- acknowledgement

F- facilitation of understanding

E- encourage effective coping

R- recovery

R- referral