Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
235 Cards in this Set
- Front
- Back
Steps of the Nursing Process
|
ADPIE
Assess Diagnose Plan Implement Evaluate |
|
Systematically collect patient data, health history, and physical assessment portion of nursing process
|
Assess
|
|
Clearly identify patient strengths and actual or potential problems - nursing process
|
Diagnose
|
|
Individualized care with goals and time frames. Select nursing interventions and communicate plan.
|
Plan
|
|
Goals must be
|
Measureable, Time sensitive, and specific. Outcomes will be better when pt is involved in the goal setting process.
|
|
Execute, continue to collect data, modify plan of care as needed
|
Implementation
|
|
Evaluate effectiveness of plan, measure how well pt has achieved goals. Identify factors that have contributed to pt success or failure
|
Evaluation
|
|
Establishes Standards of Practice, Code of Ethics, encourages and conducts research, and represents nursing in legislative action
|
ANA - American Nurses Association
|
|
Main focus is education. Provides testing and also provides accredidation of schools; develops NCLEX testing for nurse licensing.
|
NLN - National League of Nurses
|
|
Issues licenses and educational criteria. Sets up Nurse practice act. They answer to state legislature, define and enforce rules, regulations, and titles
|
State Board of Nursing
|
|
This person..
Identified personal needs of patient-established standards of hospital management-established education-respectable career for women-recognized and identified health and illness-established and maintained records for research |
Florence Nightingale (Crimean War)
|
|
Superintendent of the Female Nurses of the Army during the Civil War; was given the authority and the responsibility for recruiting and equipping a corps of army nurses; was a pioneering crusader for the reform of the treatment of the mentally ill
|
Dorothea Dix
|
|
Founded American Red Cross. Volunteered to care for wounds and feed union soldiers during civil war.
|
Clara Barton
|
|
The state of optimal functioning or well-being. It includes physical, social, and mental components and is not merely the absence of disease or infirmity.
|
HEALTH
|
|
genetic inheritance
cognitive abilities educational level race and ethnicity culture age and gender developmental level lifestyle environment socioeconomic status |
A person's level of health can be affected by these things
|
|
Nursing care is both a _ _ _ and a _ _ _ _ _ _ _
|
art and science
|
|
Caregiver must meet
|
physical, emotional, intellectual, sociocultural, and spiritual needs.
|
|
Communicator, teacher, counselor, leader, researcher, advocate
|
Nurse acts in all of these roles
|
|
Promote wellness, prevent illness, restore health, facilitate coping
|
Nursing goal is to
|
|
The use of effective interpersonal and therapeutic communication skills to establish and maintain helping relationsips with patients of all ages in a variety of healthcare settings
|
Communicator
|
|
The use of communication skill to assess, implement, and evaluate individualized teaching plans to meet learning needs of patient and their families
|
Teacher/Educator
|
|
The use of therapeutic interpersonal communication skills to provide information, make appropriate referralsm and facilitate the patient's problem solginv and decision making skills
|
Counselor
|
|
The assertive, self confident practice of nursing when providing care, effecting change, and functioning with groups.
|
Leader
|
|
The participation in the conduct of research to increse knowledge in nursing and improve patient care
|
Researcher
|
|
The protection of human or legal right and the securing of care for all patients based on the belief that patients have the right to make informed decision about their own health and lives
|
Advocate
|
|
Facilitates decisions about lifestyle that enhance quality of life and encourage acceptance of responsibility for one's own health - accomplish through pt education
|
Promote health
|
|
Increses health awareness by teaching that the state of health is more than no being ill
|
Promote health
|
|
Teaches self care activities to maximize achievement of goals that are realistic and attainable; serves as role model
|
Promote health
|
|
encourages health promotion by providing information and referral
|
Promotes health
|
|
By teaching and personal example - educational programs (prenatal care, smoking cessation, stress-reduction), community programs to encourage healthy lifestyles
|
Prevent Illness
|
|
Preforming diagnostic assessments that may detect illness (vitals), reporting abnormals, direct physical care for ill, collaborating with other healthcare providers, planning, teaching, carrying out rehabilitation for illness
|
Restore health
|
|
Facilitate an optimal level of functioning through maximizing the person's strengths and potentials through teaching and community referrals
|
Facilitate coping with disability and death
|
|
How to write a nursing dx statement
|
1-Nursing dx based on assessment 2-r/t (reason for the dx) 3- objective finding that justify your nursing dx AEB _______rt________AEB_______
|
|
Nursing is
|
human response to actual or potential health problems
|
|
Delegation
|
Know state and institutional policies, know training and background of any licensed assistive personell, assess what tasks can be safely delegated
|
|
Ericksons theory of development
|
based on freuds work but was expanded to include cultural and social influences in addition to biologic processes.
|
|
Ericksons psychosocial theory is based upon 4 major organizing concepts
|
1-stages of development
2-developmental goals/tasks 3-psychosocial crises 4-process of coping |
|
Infancy - infant learns to rely on caregivers to meet basic needs of warmth, food, and comfort, forming trust in others. Mistrust is result of inconsistent, inadequate, or unsafe care
|
Erickson - Trust vs mistrust
|
|
Toddler 1-3, learns from environment and gains independence thru encouragement vs too high expectations and overprotectiveness
|
Erickson - Autonomy vs Shame and doubt
|
|
Preschooler 4-6, toddler seeks out new experiences and explores how and why. restrictions and reprimands child hesitates for new experiences
|
Erickson - Initiative vs. Guilt
|
|
School age children, focusing on end result of acheivement, child gains pleasure from finishing projects and recieving recognition. Child not accepted/rewarded inferiority results.
|
Erickson - Industry vs Inferiority
|
|
Young adult, task for young adult is to unite self-identity with identities of friends and to make commitments to others.
|
Erickson - Intamacy vs Isolation
|
|
Adolescent, hormonal changes, transition from childhood to adulthood. Trying on roles and rebellion normal behaviors. Role confusion occurs when adolescent is unable to establish identity/sense of direction
|
Erickson - Identity vs Role Confusion
|
|
Middle Adulthood, time of concern for next generation, Desire to make contribution to the work, if this not met person becomes self absorbed and regresses to earlier level of coping.
|
Erickson - Generativity vs Stagnation
|
|
Later Adulthood, reminiscence about life events provides sense of fulfillment. Despair if feelings of failures or missed directions
|
Erickson - Ego Integrity vs Despair
|
|
Increase in size and changes in body cell structures (anatomy changes in growth)
|
Growth
|
|
An orderly pattern of changes in structure or behaviors resulting from maturation, experiences, and learning
|
Development
|
|
Both ______ and _____ are results of genetics and environment
|
Growth and Development
|
|
In aging process abilities from development are generally lost __________ of the order in which they are acquired
|
opposite
|
|
Healthy fetal development dietary - prevent fetal megaloblastic anemia and neural tube defects
|
Folic acid
|
|
Healthy fetal development dietary - ensure adequate bone calcification
|
Calcium and vit d
|
|
Healthy fetal development dietary - to prevent hypothyroidism
|
Iodine
|
|
Healthy fetal development dietary - to provide amino acids necessary for Growth and development of fetus
|
Protein
|
|
Mother of fetus should increase calorie intake by ____ calories per cay
|
300 calories
|
|
Alcohol, nicotine, excessive caffeine, some OTC (aspirin, ibuprofin, antihistamines), radiation, pesticides, certain environmental chemicals
|
Aviod during pregnancy
|
|
Interventions when communicating with the elderly
|
Allow longer response and reaction time and make sure pt has hearing aid in and turned on if they have one
|
|
Kubler-Ross's 5 stages of grieving
|
1-Denial and Isolation
2-Anger 3-Bargaining 4-Depression 5-Acceptance |
|
Kubler Ross - Pt denies that he or she will die, may repress and isolate self. May think doctor has records mixed up or mistaken diagnosis
|
Stage 1 - Denial and Isolation
|
|
Kubler Ross - Pt expresses rage and hostility and adopts a "Why me" attitude
|
Stage 2 - Anger
|
|
Kubler Ross - pt tries to barter for more time. Many pt's put personal affairs in order, make wills, and fulfill last wishes.
|
Stage 3 - Bargaining
|
|
Kubler Ross - pt goes through a period of grief before death. Grief is often characterized by crying and not speaking very much
|
Stage 4 - Depression
|
|
Kubler Ross - the patient feels tranquil. Pt has accepted death and is prepared to die
|
Stage 5 - Acceptance
|
|
Qualification for eligibility of hospice
|
Pt has a diagnosis of terminal illness with 6 months or less to live.
|
|
Threating to kill/hurt self, looking for ways to kill self (finding weapons etc), increased substance abuse, no reason for living/sense of purspose, anxiety/agigation, unable to sleep, hopelessness, withdrawing from friends/family/society
|
signs of suicide
|
|
Highly concentrated, hypertonic solution. Provides calories, restores nitrogen balance, replaces essential fluids vitamins, electrolyes, minerals, and trace elements intravenously.
|
TPN - total parenteral nutrition
|
|
a pliable single or double lumen tube that is hollow allowing for removal of gastric secretions and instillation of solutions into the stomach.
|
NG tube - nasogastric tube
|
|
tube passed through the nasopharynx into the stomach
|
NG tube
|
|
To check placement of NG tube
|
visual assessment/aspiration gastric contents and measure ph of aspirate, tube length in comparison to initial placement should be assessed
|
|
surgically inserted tube through the abdomen wall into the stomach
|
G tube
|
|
surgically insterted through the abdomen wall into the stomach and down into the jejunum or small intestine
|
J tube
|
|
Small intestine placement aspirate check of ph should be
|
>7
|
|
Recommendations are made for feeding pattern/schedule by
|
the nutritionist or dietician
|
|
Intestinal feeding
|
always continuous delivered through a pump
|
|
Stomach feedings
|
intermittent feedings are preferred. these are delivered at regular intervals in equal portions. This allows for the formula to be introduced gradually
|
|
What is checked before each feeding or q4-6 hours during continuous feeding
|
Residuals in the stomach.
|
|
Foods high in Na
|
Salt and processed foods - meat, poultry, processed cheese,
|
|
Foods high in K
|
whole grains, leafy vegetables, bananas, tomato juice
|
|
Vit C and B-Complex vitamins (ascorbic acid, thiamin, riboflavin, niacin, pyridoxine, biotin, folate)
|
Water soluble
|
|
Vit A, D, E, and K
|
Oil Soluble
|
|
How many calories is 1lb of body fat
|
3500 calories. Therefore, to gain or lose 1 lb in a week, dail calorie intake should be increased or decreased by approx. 500 calories
|
|
inability to effectively maintain homeostasis is
|
characteristic of elderly
|
|
wrinkling and sagging of skin, balding common in men, hair loses pigmentation, nails thicken becoming brittle and yellow
|
elderly characteristic
|
|
Decrease in subQ tissue and weight common, muscle mass and strength decrease, bone demineralization, joint stiffening, overall mobility commonly slows
|
Elderly characteristic
|
|
CNS responds more slowly to multiple stimuli. rate of reflex response decreases, temp regulation and pain perception less efficient, loss of sensation in extremities, difficulty with balance, coordination, fine movements, sleep at noc shortens
|
Elderly characteristic
|
|
diminished visual acuity (presbyopia) and hearing acuity, senses of taste and smell decreased.
|
Elderly characteristic
|
|
blood vessels less elastic and often rigid and tortuous. venous return less efficient. less able to ^hr and co with activity, electrolyte balance fragile
|
Elderly characteristic
|
|
Maslows Heirarchy of Needs
|
1-Physiologic 2-Safety 3-Love and Belonging 4-Self-esteem needs 5-Self-actualization needs
|
|
What needs must be met before a person can progress on the heirarchy
|
basic physiological needs must be met before all others.
|
|
Episode of pain that lasts from seconds to less than 6 months
|
Acute pain
|
|
Episode of pain that lasts for 6 months or longer; may be intermittent or continuous
|
Chronic pain
|
|
Pain that is categorized as cutaneous, deep somatic, or visceral in nature
|
Nociceptive pain
|
|
pain that results from an injury to or abnormal functioning of peripheral nerves or the central nervous system
|
Neuropathic pain
|
|
pain originating in the internal organs in the thorax, cranium, or abdomen
|
Visceral pain
|
|
Pain originating in structures in the body's external wall
|
Somatic pain
|
|
Pain in an area removed from that in which stimulation has it's origin
|
Referred pain
|
|
Three different ways to measure pain
|
Numerical scale
FLACC (face,legs,activity,cry, consolability) Wong-Baker (faces 1-5) |
|
abbreviation for the World Health Organization 3step analgesic ladder. Idea is to start low and go slow
|
WHO ladder
|
|
What function does pain have for the body
|
Pain is a warning sign that something is going on in the body. Pain is the 5th vital sign
|
|
Educational factors patient need to know about pain
|
They do not need to be in pain. Also, addiction will not occur if there actually is pain in the body. The drugs will work on the nerves.
|
|
Prepare restful environment, promoting bedtime rituals, offering appropriate dedtime snack and beverages, relaxation, comfort
|
facilitate rest and sleep for patients
|
|
physical discomfort, pain, emotional discomfort, anxiety, stress, changes in bedtime rituals or sleep environment
|
Factors that can affect sleep pattern
|
|
Signs of insufficient sleep in a patient
|
decreased energy level, facial characteristics (narrowing or glazing eyes), behavioral characteristics (yawning, rubbing eyes, slow speech), physical data( obesity, enlarged neck)
|
|
Questions you need to ask to assess pain
|
Characteristic
Onset Location Duration Intensity Symptoms that accompany pain |
|
Distraction, humor, music, imagery, relaxation, cutaneous stimulation, accupuncture, hypnosis, biofeedback, therapeutic touch
|
non-medication treatments for pain
|
|
a drug that produces stupor or narcosis Opium or opium derivative
|
Narcotic
|
|
Medication that blocks receptors in the CNS so that the perception of peripheral pain is blocked
|
Narcotic
|
|
(aspirin, ibuprofen) anti-inflammation, analgesic, and antipuretic effects
|
NSAIDs
|
|
Medication that inhibits prostaglandins by blocking cyclooxygenase
|
NSAIDs
|
|
Acetominophen and NSAIDs in this category - These block peripheral pain impulses by inhibition of prostaglandin synthesis
|
Nonnarcotic analgesics
|
|
An antagonist used to counteract the effects of narcotics (especially to counteract the depression of respiration) (ex Narcan). These drugs produce their opioid antagonistic activity by competing with opioids for CNS receptor sites
|
Narcotic antagonist
|
|
(Flumazelin) acutely reverses the actions of benzodiazepines (sedative/hypnotic) on the CNS by directly competing for binding sites in CNS
|
Versed antagonist
|
|
Information percieved ONLY by the affected person; information can not be verified by another (nervousness or pain)
|
Subjective Data
|
|
Observable and measureable data that can be seen, heard, or felt by someone other than the person experiencing it
|
Objective data
|
|
A medical term meaning there is a pathological change in the structure or function of the body or mind
|
Disease
|
|
The response of the person to a disease; an abnormal process in which the person's level of function is changed
|
Illness
|
|
Phases of infection (4 stages)
|
Incubation
Prodromal stage Full stage of illness Convalescent |
|
Illness phase - interval between the pathogens invasion of the doby and the apperance of symptoms of infection
|
Incubation
|
|
Phase of infection - stage when a person is most infectious. Early signs and symptoms of disease are present, symptoms vague and nonspecific.
|
Prodromal Stage
|
|
Phase of illness - presence of specific signs and symptoms. The type of infection determines the length and severity of illness's manifestations.
|
Full stage of illness
|
|
Phase of illness - Recovery period from an infection. Varies according to severity of infection
|
Convalescent period
|
|
Phases of wound healing
|
Hemostatis
Inflammation Proliferation Maturation |
|
Phases of wound healing - occurs immediately after the initial injury, blood vessels constrict, clotting. beginning of healing process
|
Hemostatis phase
|
|
phase of wound healing - lasts 4-6days. WBC's move to wound. Leukocytes and macrophages.
|
Inflammation phase
|
|
Acute inflammation is characterized by
|
pain, heat, reness, and swelling at site of injury
|
|
Phase of wound healing - fibroblastic, regenerative or connective tissue phase. O2 is important at this time.
|
Proliferation phase
|
|
Phase of wound healing - final stage of healing, begins about 3 weeks after injury and can continue for months or years
|
Maturation phase
|
|
Well approximated, skin edges tightly together. Usually after intentional wounds such as a surgical procedure without much loss.
|
Primary Intent Healing
|
|
Edges aren't well approximated. Large or open wounds from burns or major trauma
|
Secondary (Tertiary) Intention healing.
|
|
Basic Steps for wound change
|
1-Check physician order
2-Gather all neccessary supplies 3-Identify pt, explain proc 4-Verify whether analgesia needs to be given 5-Assist pt to comfortable position 6-Comfort and lighting 7-Keep trash can close 8-Remove tape and old dressings carefully 9-Note any drainage and characteristics of it |
|
Cardiovascular side effects of immobility
|
excessive workload, risk for orthostatic hypotension, risk for venous thrombosis
|
|
Respiratory side effects of immobility
|
depth of resp, rate, pooling of secretions, impaired gas exchange
|
|
Gastrointestinal effects of immobility
|
disturbance in appetite, altered protein metabolism, altered digestion and utilization of nutrients
|
|
Unrinary effects of immobility
|
increased urinary stasis, increased risk for renal calculi, decreased bladder tone
|
|
Musculoskeletal effects of immobility
|
decreased muscle size, tone, and strenth, decreased joint mobility and flexibility, bone demineralization, decreased endurance stability, increased risk for contractures
|
|
Metabolic system effects of immobility
|
increased risk for electrolyte imbalance, altered exchange of nutrients and gases
|
|
Integument effects of immobility
|
increasesd risk for skin breakdown and formation of pressure ulcers
|
|
Psychological well being effects of immobility
|
increased sense of powerlessness, decrease in self-concept, decrease in social interaction, decrease in sensory stimulation and altered sleep/wake pattern
|
|
Intervention to prevent conditions caused by immobility
|
exercise(in bed or ambulating), breathing exercises (IS/deep breathing), monitor dietary intake, fowlers position, kaegel exercises, repositioning
|
|
COPD, pneumonia, bronchitis, RSV, Apnea, anxiety related disorders, asthma
|
Respiratory disorders
|
|
Rapid breathing, change in pulse, bluing around mouth and lips, dry lips, deep cough, lightheadedness, dizziness
|
S&S of respiratory distress
|
|
COPD nursing dx
|
Ineffective airway clearance. Interventions - pursed lip breathing, fowlers position
|
|
FX ribs nursing dx
|
Ineffective breathing pattern. Interventions - monitor resp pattern, splint painful areas
|
|
Potassium (K)
|
3.5-5.3
|
|
Sodium (Na)
|
135-145
|
|
Blood Urea Nitrogen (BUN)
|
5-25
|
|
Creatinine
|
0.5-1.5
|
|
Hemoglobin (hgb)
|
Males 13.5-17
Females 12-15 |
|
Hematocrit (Hct)
|
Males 40-54%
Females 35-46% |
|
Albumin
|
3.5-5
|
|
Chloride (Cl)
|
95-105
|
|
WBC (White Blood Cell)
|
5000-10,000
|
|
Fasting Blood Sugar (FBS)
|
60-100
|
|
Platelets
|
100,000-400,000
|
|
Co2
|
21-32
|
|
PT
|
9.5-12sec
|
|
PTT
|
20-45sec
|
|
Assessment of patients learning needs is vital to develop a ______ __ _____ with which the patient can comply
|
Plan of Care
|
|
Occurs when patients ignore instructions or do not folow them appropriately
|
Noncomplaince
|
|
____________ can be associated with lack of learning rediness and motivation, confusion, disappointment, misunderstanding, fear, inability to learn, or inadequate finances
|
Noncompliance
|
|
To promote compliance
|
be sure instructions are understandable and designed to support patient goals, include patient and family as partners in the teaching-learning process
|
|
strengthen pelvic floor muscles and sphincter muscles.
|
Kegel Exercises
|
|
Fluid intake averages ______ml/day
|
2600ml - 1300 from ingested water, 1000ml from ingested food, 300ml from metabolic oxidation.
|
|
Fluid output averages ____ to _____ ml per day
|
2500-2900ml/day. approx 1500 from urine, 200-400 insensible loss from skin, 300-500ml sensible loss from skin, 400ml as insensible loss from lungs, 100ml in feces via GI tract
|
|
Mode of transmission of organism determines
|
types of precautions required
|
|
Most serious postoperative wound complicationss
|
Dehiscence and evisceration
|
|
Partial or total seperation of wound layers as a result of excessive stress on wounds that are not healed
|
Dehiscence
|
|
Wound completely seperates with protrusion of viscera through the incisional area
|
Evisceration
|
|
Pt's are at greater risk for dehiscence or evisceration if...
|
they are obese, malnourished, smoke tobacco, use anticog's, have infected wounds, or experience excessive coughing, vomiting, or straining.
|
|
increase flow in serosanguineous fluid from wound between post op day 4,5 is sign of
|
impending dehiscence
|
|
The pt's voluntary agreement to undergo a particular procedure or treatment.
|
Informed consent
|
|
Informed consent means the pt has been given what information
|
description of proc along with alternative therapies, underlying disease process, name and qualifications of person performing proc/treatment, risks of damage/disfigurement, know they have right to refuse, expected outcome and R&R phase
|
|
Informed consent protects...
|
The patient, physician, and healthcare institution.
|
|
Who has the responsibility to secure an informed consent
|
The person who will perform the procedure
|
|
Involves the administration of drugs by inhalation, intravenous (IV), rectal, or oral route to produce CNS depression.
|
General anesthesia
|
|
Desired actions of general anesthesia are
|
loss of consciousness, analgesia, relaxed skeletal muscles, and depressed reflexes.
|
|
Three phases of general anesthesia
|
Induction, Maintenance, and Emergence
|
|
Induction of anesthesia begins________ and goes until __________
|
with administration of the anesthetic agent and continues until the patient is ready for the incision
|
|
Maintenance of anesthesia continues from the end of induction phase until
|
near completion of the procedure
|
|
Emergence of anesthesia starts
|
as the patient begins to emerge from the anesthesia and usually ends when the pt is ready to leave the OR
|
|
It can be used for pt's of any age and for any surgical procedure, with the pt unaware of the physical trauma of the surgery.
|
Advantages of general anesthesia
|
|
Risks of general anesthesia
|
circulatory and respiratory depression, postop nausea and vomiting, and alterations in thermal regulation
|
|
Anesthetic agent is injected near a nerve or verve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to CNS receptors
|
Regional anesthesia
|
|
Pt is awake but loses sensation in specific area or region of the body. In some instances, reflexes may also be lost
|
Regional anesthesia
|
|
Regional anesthesia may be accomplished through
|
Major nerve blocks or spinal (subarachnoid) block, caudal, or epidural blocks.
|
|
Prescreening surgical tests
|
CXR, EKG, CBC, electrolyte levels, and urinalysis
|
|
Prescreening surgical tests provide
|
objective data of normal body function. In cases of abnormalities, such tests provide data for medical intervention to improve the patients physical status and thus decrease the risks for surgical complication
|
|
Abnormal findings - WBC can indicate
|
infection
|
|
Decreased hematocrit and hemoglobin can indicate
|
presence of bleeding or anemia
|
|
hyperkalemia or hypokalemia can indicate
|
increased risk for cardiac problems
|
|
elevated blood urea nitrogen (bun) or creatinine levels can indicate
|
possible renal failure
|
|
abnormal urine constituents can indicate
|
infection or fluid imbalances
|
|
PACU care involves
|
assessing the pt with emphasis on preventing complications from anesthesia or surgery
|
|
PACU assessments are
|
continuous, using preoperative and intraoperative data as bases for system status, fluid status, wound status, and general condition.
|
|
Respiratory function is assessed by monitoring
|
respiratory rate, rhythm, and depth, auscultating breath sounds and by noting SaO2
|
|
Ineffective respiratory function is indicated by
|
restlessness and anxiety, unequal chest expansion with use of accessory muscles, shallow, noisy respirations, cyanosis, and tachycardia
|
|
Most common PACU emergency
|
Respiratory obstruction
|
|
Respiratory obstruction may occur as a result of
|
secretion accumulation, obstruction by the tongue, laryngospasm (sudden violent contraction of vocal cords), or laryngeal edema.
|
|
To maintain patent airway and tissue oxygenation
|
position patient, administer humidified oxygen, encouraging pt to deep breathe, suctioning
|
|
Cardiovascular function assessed by
|
taking vital signs, monitoring ekg rate and rhythm, observing skin color and condition. BP finding comparison with baselin data from preop.
|
|
Hypotension post op may be a result of
|
varied factors including anesthetic agents, preoperative meds, position changes, blood loss, resp alterations and peripheral blood pooling
|
|
Oxygen administration, deep breathing, leg exercises, verbal stimulation, and maintaining accurate IV flow rates can increase
|
low BP
|
|
Inadvertent hypothermia (in surgery) can lead to
|
complications of poor wound healing, hemodynamic stress, cardiac disturbances, coagulopathy,delayed emergence from anesthesia, and shivering and it's associated discomfort.
|
|
Assess all pulses for
|
bilateral equality, rhythm, rate, and character.
|
|
Of special significance are post op assessments of
|
ABNORMAL function
|
|
CNS function is assessed through response to
|
stimuli and orientation
|
|
Consciousness returns in ________ order.
|
Reverse
|
|
Consciousness returns in this order (usually)
|
1-unconsciousness
2-response to touch and sounds 3-drowsiness 4-awake but not oriented 5-awake and oriented |
|
Fluid imbalance may result from
|
preop fluid restriction, fluid loss during surgery, wound drainage, or surgical stress response (retention of Na and water)
|
|
Assess fluid status includes
|
skin turgor, vital signs, urine output, wound drainage, and IV fluid intake.
|
|
PACU assesses wound for
|
amount, consistency, and color of drainage as well as for any tubes or drains and the amount and type of drainage by that route
|
|
Pain is both _________ and _________
|
subjective and objective
|
|
The pt is dc'd from PACU when
|
his or her physical status and level of consciousness are considered stable then pt is moved back to their room
|
|
What is the most common degenerative disorder that accounts for 2/3 of all dementia in US
|
Alzheimers disease
|
|
A progressive degenerative neuroligical disorder characterized by bradykinesia, tremor, and rigidity
|
Parkinsons disease
|
|
Aricept, Namenda
|
Medications for Alzheimers
|
|
Selegiline, Levodopa, Ropiniode, Symmetrel, Artane
|
Parkinsons medications
|
|
Rigidity
|
Increased muscle tone
|
|
Bradykinesia
|
Slowness in initial movement
|
|
Tremor
|
Usually noted in hand as a pill rolling tremor
|
|
Diffuse Lewis Body Disease
|
Parkinsons with dementia
|
|
process by which healthcare providers give appropriate, uninterrupted care and facilitate pt's transistion between settings and levels of care
|
Continuity of Care
|
|
Pt's record is the only legal document that details the nurses interactions with the pt and is the nurses best defense if pt alleges nursing negligence. Not documented, didnt happen
|
Documentation is important
|
|
Each healthcare group keeps data on it's own seperate form, chronologically.
|
Source Oriented
|
|
All medical professionals record information on same form, organized around a pts problem.
|
Problem Oriented Medical Record (POMR)
|
|
Used to organize data entries in the progress notes of POMR
|
SOAP (subjective data, objective data, assessment, plan)
|
|
No seperate plan of care. Plan of care is incorporated into the progress notes, and identified by number. Complete pt assessment done at beginning of each shift
|
PIE charting (Problem Intervention Evaluation)
|
|
Focus of care back to pt and pt concerns
|
Focus charting
|
|
Narrative portion of focus charting
|
DAR (data, action, response)
|
|
Shorthanded codumentation, lists only significant findings, or exceptions to standards.
|
CBE (charting by exception)
|
|
Interdisciplinary documentation tool that clearly identify outcomes that select groups of pt's are expected to acheive on each day of care
|
Case Management Model
|
|
Documents pts failure to meet an outcome, or planned intervention
|
Variance Charting
|
|
Used to record routine aspects of nursing care
|
Flow Sheets
|
|
Record specific pt variables, such as temperature or pulse
|
Graph sheets
|
|
Information that is observable and measureable, and that may also be verified by antoher person. It is also called signs or overt data
|
Objective data
|
|
Perceived only by the affected person, cannot be eprceived or verified by another person also called symptoms, or covert data
|
Subjective data
|