question

Human Beings

answer

Unique biopsychosocial, cultural, and spiritual individuals Respond to external and internal cues in the physical and social environment Mind, body & spirit continuously interact with each other

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Individual

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Has personal rights Deserving of respect with regards to Customs, Beliefs, and Needs Right to actively participate and collaborate with health care provider in his/her plan of care Right to be cared for & cared about to reach maximum level of wellness

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Caring

answer

Universal phenomenon Its expression varies among culture Central to nursing profession Knowledge of caring values, beliefs & practices Support communication Promote adaptation Reduce Stress Meet psychosocial needs of patient Nurse patient relationship is foundation for caring practice Protecting & enhancing patient dignity Morally responsible action Provide safe & competent care when patient unable to care for self Physical care of the body that promotes comfort and healing, health and medication teaching, listening, and psychological & spiritual support

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Nursing

answer

A service to mankind Focus on diagnosis and treatment of human responses to actual or potential health problems Promotes, maintains, and restores health throughout life cycle

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Practice of Nursing

answer

Consists of 2 major components Nurse - patient relationship Environment

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Environment

answer

Culture of environment complex Inpatient, outpatient, home care Need collaboration between health care disciplines & services Multidisciplinary approaches to plan & manage patient needs Cost-effective framework

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Nurse-Patient Relationship

answer

Foundation for a caring practice Creates a health promoting and healing environment Nurse presence, being there in time of need Utilizes critical thinking skills Patient advocacy Maintain standards of professional ethics and accountability Morally responsible action Balance of promoting patients' independence & supporting their dependence

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Health

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Dynamic state Physical well being Social interactions Emotional conditions Spiritual being

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Health Promotion

answer

Domain of Nursing Directs individuals and groups toward lifestyle practices Valuing of health Enhances wellness of mind, body, and spirit Enables one to partake & enjoy all life has to offer

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Education

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Life long process Learner develops personally, socially & intellectually Active process Involves cognitive, affective, psychomotor activities Student is proactive participant Applies theory to nursing practice Previous life experiences foundation for new learning experiences Learning is evidenced by gradual change in behavior

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Critical Thinking

answer

Focused Reasoning used to solve problems Self-reflective Involves discernment & judgment Use nursing process, functional patterns of behavior, evidence based nursing practice & supportive sciences

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Educational Process

answer

Shared experience based on caring, respect, communication & collaboration Utilize sciences, nursing arts, legal & ethical principles Reason through complex clinical problems & apply knowledge, competencies & experience to clinical practice

question

Nursing Program

answer

Provides articulation From Practical nurse to Associate Degree, and to Baccalaureate Degree Scope and application of nursing principles widens with each successive degree

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Associate Degree Nursing

answer

First level of preparation for professional nursing Focus on critical thinking skills and technical competencies ADN graduates prepared to manage, teach, & provide direct care Various clinical settings Delegate care provided by LPN and Assistive Personnel

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Practical Nursing

answer

Differs primarily in degree of responsibility Assists RN by providing the emotional, physical, & spiritual comfort of patients Documents signs & symptoms to indicate change in patient condition Administers care utilizing patient's care plan

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Conceptual Framework

answer

Conceptual Framework Interrelated concepts on which the nursing curriculum is based. It is a frame of reference that provides a map for all curriculum matters.

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Nurse - Patient Relationship

answer

Central focus on the dynamic process of caring Nurse-patient relationship is dynamic, central to every nursing activity Focus on the patient Purpose to help the patient Therapeutic, purposeful, & goal directed Promotes patient advocacy Communication & interpersonal skills

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Caring begins where

answer

Begins with caring about self & other nurses Learned by experiencing caring practices Comfort, compassion, concern, empathy, helping behaviors, nurturance, support, involvement, and sharing "Caring for" Providing for or being responsible for another in a competent manner

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Nursing Process

answer

Critical thinking tool Provides structure for caring action Needs assessed per Maslow's Hierarchy of needs Gordon's Functional Health Patterns Dynamic and continuous Assessment Analysis - Nursing Diagnosis (NANDA) Planning Nursing Outcomes Classifications (NOC) Nursing Interventions Classifications (NIC) Implementation Evaluation

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Man

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Unique Responds to cues in environment

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Nursing

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Values to guide standard nursing behavior Ethics Legal decision making Students directly accountable or their behavior

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Maslow's Hierarchy of Needs Principles

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Individuals have unique needs Everyone has same basic human needs (BHN) necessary for survival & health Person's position on Health-Illness continuum depends on degree of needs met

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Needs

answer

Needs may be: Met / Unmet / Partially met Healthy people have all needs met If one or more needs unmet Person unhealthy in one or more aspect Theory can be applied in general but individuals have different priorities Healthy adults able to meet most needs Old & young, ill & disable Unable Client entering health care system may have one or > unmet needs NSG care addresses all client's needs Life-sustaining needs Essential They take priority RN assesses needs & prioritizes according to their position on the pyramid Client's wishes also taken in consideration At times many needs carried out at same time

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Basic Human Needs

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For Survival and Health Food Water Safety Love

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Physiological Needs

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Highest Priority Essential for life Oxygen - Sexuality Water - Physical Activity Food - Rest Temperature Elimination

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Safety & Security Needs

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Physical Safety Protected from actual or potential harm Psychological Safety Trusting others Being free of fear, anxiety and apprehension experiences

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Love & Belonging Needs

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Giving and receiving affection Feel loved by family Feel accepted by peers & community Meaningful relationships with others Illness or injury leaves little time or energy to meet these needs

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Self-Esteem Needs

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Self-Esteem Desire for strength, achievement, adequacy, competence, confidence, and independence Esteem from Others Recognition, respect & appreciation from others Illness or injury may change client's self-concepts

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Self-Actualization Needs

answer

Achieve their fullest potential Learn, create, understand & experience one's potential Mature, multi-dimensional personality Balance client's needs, stressors & ability to adapt Strong need for privacy

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Applying Maslow's Hierarchy

answer

Focus on needs of the individual Must understand the relationship among different needs for the individual Individualize nursing care plan to provide for unique needs & desires Emergency physiological needs take precedence over higher level needs Needs not always fulfilled in hierarchical order For each client, needs on different levels may be related in various ways

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Factors Influencing Need Priorities

answer

Life-threatening situations priority Unmet physiological needs Personality & Mood Client's health Socioeconomic & cultural groups Family structure Needs interrelated in unique ways

question

A nurse who focuses attention on the strengths and abilities of his patients rather than their problems is helping them to achieve which of Maslow's basic human needs?

answer

Answer: A. Self-actualization Rationale: To meet patient self-actualization needs, nurses provide a sense of direction and hope and maximize patient potential.

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Effects of Stress

answer

Stress can be a stimulus or a barrier Stress response is individual Failure to meet needs results in illness Affects physical status Increases risk for disease or injury Compromises recovery and return to normal function Is associated with specific diseases

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Family Stressors

answer

Changes in family structure and roles Anger and feelings of helplessness and guilt Loss of control over normal routines Concern for future financial stability

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Factors Affecting Stress and Adaptation

answer

Sources of stress Types of stressors experienced Personal factors

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Types of Stressors

answer

Physiologic Chemical agents, physical agents, infectious agents, nutritional imbalances, hypoxia, genetic or immune disorders Psychosocial Includes real and perceived threats

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Categories of Stress

answer

Developmental stress Occurs when person progresses through stages of growth and development Situational stress Does not occur in predictable patterns

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Stressful Activities in Nursing Profession

answer

Assuming responsibilities for which one is not prepared Working with unqualified personnel Working in environment in which supervisors are not supportive Caring for patient in cardiac arrest or dying person Experiencing conflict with peers

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Definition of Nursing

answer

"Diagnosis and treatment of human responses to actual or potential problems

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Aims of Nursing

answer

Promote health Prevent illness Restore health Facilitate coping with disability

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ANA Standards of Clinical Practice(organized around steps of nursing process)

answer

Standard I: ASSESSMENT Standard II: DIAGNOSIS Standard III: OUTCOME IDENTIFICATION Standard IV: PLANNING Standard V: IMPLEMENTATION Standard VI: EVALUATION Standard IX: LEADERSHIP

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Standards of Professional Performance

answer

Standard I: Quality of Care Evaluates quality and effectiveness Standard II: Performance Appraisal Nurse evaluates own practice Standard III: Education Maintains current knowledge Standard IV: Collegiality Contributes to professional development Standard V: Ethics Acts in ethical manner Standard VI: Collaboration Client, SO, HC Providers Standard VII: Research Uses research findings in practice Standard VIII: Resource Utilization Standard IX: Leadership

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Accountability in Nursing Practice

answer

Nurse assumes responsibility & accountability for nursing care provided Nurse acts according to professional code of ethics Nurse practice within code of the profession Nurse evaluates performance in providing nursing care

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Health System Management The Nursing Process

answer

A systematic problem-solving method by which nurses individualize care for each client Assessment Analysis/nursing diagnosis Planning Implementation Evaluation

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What does the Nursing Process do?

answer

An approach to problem solving Enables nurses to organize and deliver nursing care An element of critical thinking Allows nurses to make judgements and take action Organized structure and framework

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Characteristics of critical thinker

answer

Creative, systematic, humility Integral, goal-directed Intellectual, courageous Thinks independently

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Assessment

answer

Process of: Gathering data Verifying data Communicating data Purpose: Establish a data base

question

Components of data collection (Assessment)

answer

Nursing health history Physical exam Lab data Diagnostic data Information from the health team, family

question

Nursing Health History

answer

Subjective data Gordon's functional health patterns (domains) System of organization Directs nurse to: Positive functioning Altered functioning At-risk functioning

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Components of Nursing HistoryCCRI Nursing Assessment Form

answer

Biographical data Chief complaint Client expectations History present illness Past health history Family history Environmental history Spiritual history/cultural considerations Review of systems (Gordan's Functional patterns)

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Sources of Data Collection

answer

Patient/Client Family/SO Health team members Medical & other records Literature Diagnostic testing

question

Types of Data

answer

Subjective Provided by patient Objective Obtained by nurse Observations Physical exam Vs Lab data

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Methods of Data Collection

answer

Interview Specific purpose Focused or comprehensive Nursing health history Obtained during interview First step assessment Objective identify patterns of health and illness Many formats Interview (Nursing Health HX) Physical exam Gathering objective, observable data Includes V/S, general survey, physical assessment, documentation Diagnostic & lab data Nurse reviews Identify alterations

question

Approaches to Data Collection(Assessment)CCRI Nursing Assessment Forms

answer

Gordon's Functional health patterns (Domains) Health perception Nutrition Elimination Activity Cognition Sleep/rest Self perception Role perception Sexuality Coping stress Value/belief

question

Focused Assessment

answer

We use preliminary data, labs/diagnostic tests information, and medication information to form our focused assessments

question

What is a Focused Assessment?

answer

A group of manifestations that tell the nurse where to focus care Can fall into four main categories Medical or surgical diagnosis Pneumonia, appendicitis A complication of a diagnosis DVT, PE A high risk treatment TPN, chemotherapy, anticoagulation, dialysis A system Respiratory system, M/S system

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Clinical Preparation

answer

The night BEFORE clinical Gather preliminary data (in clinical institution) Write focused assessments The FIRST day of the clinical experience Assess the client Use Gordan's Functional Patterns Fill in functional patterns Circle abnormalities--Cluster Defining Characteristics Identify etiologies and develop ND for Prioritize ND—Maslow Write NCP for each ND developed The Second day of the clinical experience Implement the NCP

question

Formulating Nursing Judgements

answer

Data interpretation Critical thinking Problem solving Data clustering Nurse organizes data Focus on functions needing support Forms nursing diagnosis (NANDA human response patterns

question

Nursing Diagnosis Definition

answer

A statement that describes a clients actual or potential response to a health problem Taxonomy Developed by NANDA Accepted ND

question

Nursing Diagnosis Types

answer

Actual Clinical judgement validated by presence of defining characteristics High-risk Clinical judgement of vulnerability to develop a problem Wellness Clinical judgement of a client in transition to a higher level of wellness Possible Nurses option to indicate that some data are present for a diagnosis but are insufficient (secondary source) Syndrome A cluster of actual or risk ND that are predicted to be present due to a specific situation Rape-trauma syndrome; Post-trauma syndrome

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Process of Determining ND

answer

Analysis & interpretation of data Recognize significant data Defining characteristics Data clusters Identification of patient needs Actual High risk Possible Reach conclusion Nursing diagnosis

question

Component of Actual Nursing Diagnoses

answer

3 part statement Problem (label) Name of the ND Taken from NANDA list Prioritized using Maslow Etiology (R/T) Cause, related factors Contributing factors Symptoms (M/B) or (Evidenced by) Defining characteristics Signs & symptoms Subjective & objective

question

Outcome Identification/Planning

answer

Third step in nursing process Actual NCP developed Establish priority of needs Utilize Maslow's Hierarchy of needs to prioritize ND For each individualized nursing diagnosis: Expected outcome (NOC) Nursing interventions (NIC) Evaluation statements Consider patient preferences Consider MD plan

question

Expected outcome Planning

answer

Expected outcome Statement of client behavior that the nurse expects from nursing care May be called "GOAL" by some sources Goal- Commonly broader statement Expected Outcome- Offers specific criteria for measuring results Derived from the problem statement (ND) If achieved must resolve the problem

question

Expected Outcome Guidelines

answer

Patient oriented (the patient or some part of the patient will:) Measurable & observable (2x3 cm pressure ulcer on planter aspect of the left heel will heal 0.5 cm) Time frame is realistic (within one week) Put this together to form a sentence The patient's 2x3 pressure ulcer on planter aspect of the left heel will heal 0.5 cm per week

question

Guide to Planning Care

answer

Nursing Outcomes Classification system (NOC)--list of expected outcomes that allows you to determine if the client problem is resolved (Section III A & L) Research based NOC system from IOWA outcomes project (Standardized) One-two word generalizations describing the results of nursing care f/b measurement criteria for each one Offers a beginning list of measured expected outcomes responsive to nursing interventions Individualized for each developed ND

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NOC Example

answer

Nursing Diagnosis Impaired skin integrity R/T pressure & immobilization manifested by a 3x2cm open area on the planter aspect of the left heel Suggested outcome (NOC) Wound healing Client outcome (measurement criteria) Regains integrity of skin by 0.5CM /week Reports altered sensation of pain Demonstrates understanding of plan to heal skin and prevent re-injury

question

Guide to Planning Care

answer

Nursing Intervention Classification System (NIC) Research based NIC system (Standardized taxonomy of nursing interventions) Describes nursing interventions Standardized nursing universal language useful in documentation Classify nursing interventions into broad categories NIC taxonomy describes the scope of nursing practice

question

NOC & NIC

answer

Advantages Understandable to all HC professionals NOC (Define client outcome in measurable terms) NIC (Provides appropriate nursing interventions and rationales)

question

Planning Care utilizing NP, NOC & NIC

answer

Information from assessment Pressure ulcer 2x3CM Look up pressure ulcer/skin integrity in section II of A & L Pick appropriate ND Impaired skin integrity Look up Impaired Skin Integrity in section III of A & L Match defining characteristics with patient S&S Determine related factors The nurse can now make the appropriate ND (Impaired skin integrity) Nursing Outcome Classification (NOC) Wound healing Client outcome (measurement criteria) Regains integrity of skin by 0.5 CM/ week Reports altered sensation of pain Demonstrates understanding of plan to heal skin and prevent re-injury Nursing Intervention Classification (NIC) Wound Care Client interventions Assess site of skin ulcer to determine etiology... Determine that skin impairment involves skin only Assess nutrition...

question

Writing Nursing Interventions

answer

Nursing intervention is a strategy to achieve an outcome Derived from etiology (i.e. Pressure) Guidelines Clearly describe nursing action Date and sign Tailor to patient Compatible with other Rx Consistent with standards

question

Purpose of NCP

answer

Guideline for care Individualized care Coordination of care Enhances continuity of care Framework for evaluation Teaching tool Communication tool

question

Format of NCP

answer

Institutionalized care plans Varies with same purpose Written guide for care Kardex care plans Written guide for care Contains interventions, MD orders Critical pathways Allow staff from all disciplines to develop care plan for clients with a specific diagnosis Student care plans Format differs so student can learn Systematic, creative, practical approach

question

Student Nursing Care Plan

answer

Must be accompanied by: preliminary data sheet completed assessment form Develop each nursing diagnosis to complete one individualized NCP for each patient

question

Implementation/Intervention

answer

4th step in the nursing process Begins with development of the NCP Focus on: Initiation of interventions to achieve expected outcomes

question

Types of Interventions

answer

Dependent MD/NP/PA prescribed orders Independent Nurse prescribed orders (turn every two hours) Interdependent Actions performed jointly by nurses and other HCW RN responsible and accountable for ALL nursing interventions carried out

question

Nursing Interventions

answer

Patient condition can change dramatically in a matter of seconds Reassess before initiating care Interventions should be supported by evidenced based (EB) practice Consistent with professional standards of care Consistent with protocols, policies & procedures of institution Are nursing actions safe for this patient? Clarify unclear orders For each nursing diagnosis Dedicated EB interventions Student nurse finds these is A&L section III Choose all that are appropriate for the individual client

question

Implementation/Intervention Process

answer

Five steps 1. Reassess (is the wound healing?) 2. Review/modify NCP 3. Identify areas needing assistance 4. Implement EB nursing strategies via three skills Cognitive (Critical thinking) Interpersonal communication skills Psychomotor skills 5. Communicate EB nursing strategies Written NCP, Verbal, documentation

question

Implementation Methods

answer

Assist with ADL's Counseling Teaching Provide care to achieve expected Outcomes Preventive measures Routine measures Lifesaving care Supervising and evaluating others work Delegate appropriate tasks

question

Delegation

answer

Unlicensed assistive personnel (UAP) Reduce healthcare cost Function is an assistive role ARE NOT IN CHARGE—YOU ARE if you as a LPN or RN delegated a task to the UAP, you are responsible for that task! You must evaluate and determine if the task was done properly You are responsible for all tasks delegated Med technician Certified nursing assistant

question

Evaluation

answer

Definition: Continuous process whereby we determine patient's progress toward the expected outcome (professional must evaluate) Steps: Compare outcome statement to patient response Make judgement Goal met (wound healed)-discontinue plan of care Goal partially met (wound partially healed)-continue plan of care Goal not met (wound unchanged or worse-reassess and change plan of care Based on outcome RN determines further actions: D/C NCP Continue NCP as is Reassess and modify NCP

question

Reporting & RecordingCommunication within Health Care Team

answer

Important function in providing quality care Documentation—Individualized patient record Written/typed/computerized legal record of all interactions with the client Joint Commission on Accreditation of healthcare Organizations (JCAHO) requires Nursing Process permanently integrated into patient record according to local policies and professional standards

question

Purposes of Documentation

answer

Legal documentation Communication Financial billing Education Assessment Research Auditing Evidence of quality care

question

Guidelines for Reporting & Recording

answer

Consistent with professional and agency standards Complete Factual Accurate Concise Through Current/timely Organized Confidential Legally prudent Legal guidelines: No erasures No correction fluid No blanks Ink Acceptable abbreviations Chart only for yourself Begin every entry with date and time End every entry with signature and title

question

Reporting

answer

Oral, written, computerized communication of patient data: Face-to-face Telephone reports/conversations Telephone orders Change of shift report Transfer/discharge reports (family) Always Confidentiality Incident reports Variance or occurrence report Tool used to document out of ordinary situation with harm potential to patient, visitor, staff. Used for Quality Improvement Belongs to institution not patient record

question

Methods of Recording

answer

Source records Traditional Each discipline has own section to record data (nursing, medicine, etc.) Problem Oriented Medical Record (POMR) 4 sections Data base Problem list Care plan Progress notes Usually integrated & according to a specific format (SOAP, PIE)

question

Health Insurance Portability and Accountability Act of 1996 (HIPPA

answer

Violators fined and or jailed Follow agency policies Responsibility to hold patient information in confidence All information in patient record confidential and private Do not: Discuss pt info in public Leave info unattended (paper or computer) Fail to log out Share/expose password Improperly release pt info

question

Role of the nurse while providing hygienic care

answer

Assess physical & emotional states Enhance therapeutic communication Consider client values, beliefs & habits Promote client teaching opportunities Enhance patient privacy Promote client independence Assess client's developmental level

question

Factors influencing hygiene

answer

Body image Social practices Socioeconomic status Knowledge level Cultural variables Personal preferences Physical condition

question

Purpose of bathing

answer

Cleansing the skin Stimulate circulatory processes Improve one's self image Reduce body odors Promote range of motion with joints Promote comfort & muscle relaxation

question

Types of therapeutic baths

answer

Hot water bath Warm water bath-43-46C [110-115F] Cool water bath Soak Sitz bath

question

Types of cleansing baths

answer

Complete bed bath Partial bed bath Tub bath- physician order required Shower- physician order required Bag bath

question

Time of hygienic care

answer

Early morning care AM care Afternoon care PM care

question

Nursing responsibilities of hygienic care

answer

Provide privacy Offer toileting opportunities Maintain safety Promote physical warmth Promote client independence Communicate respect for client

question

Anatomy & physiology of the skin

answer

Epidermis-outer layer contains melanocytes & layers of epithelial cells Dermis-thicker layer contains collagen & elastin fibers; nerve fibers, sweat & sebaceous glands; & hair follicles Subcutaneous-inner layer contains blood vessels, nerves,lymph glands & loose connective tissue with fat cells

question

Functions of the skin

answer

Protection Secretion Excretion Temperature regulation Sensation Production & absorption of vitamin D

question

Risks for skin impairment

answer

Immobilization Decreased sensation Nutrition/hydration alterations Secretions/excretions Vascular problems External devices Lifestyle variables

question

Nursing responsibilities in care of client's skin

answer

Prevention of skin breakdown Inspection of the skin Palpation of the skin Report skin alterations/abnormalities

question

Oral hygiene

answer

Assessment of mouth & teeth Encourage brushing Encourage flossing Assist with denture care Semiconscious client 1. Check for gag reflex 2. Elevate HOB 3. Position client on side 4. Tonsil tip [Yanker] suction mouth care 5. Apply emollient to lips

question

Hair care

answer

Brushing Combing Shampoo

question

Eye care

answer

Assessment of orbital area Care of client glasses Care of client contact lenses Care of unconscious client Care of eye enucleation

question

Ear care

answer

Inspection of outer auricle & external ear canal Cleansing of external ear canal Care of hearing aids

question

Care of nares

answer

Assessment of patient condition Maintain patency of nasal passages Lubrication of nasal passages with irritation/dryness

question

Foot care

answer

Inspection Hygienic care Special foot care for vascular compromised clients

question

Back care

answer

Inspection Back massage

question

Definition of Critical Thinking

answer

A continuous process characterized by open mindedness, continual inquiry and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant Heffner and Rudy2008

question

Critical Thinking and Clinical Reasoning

answer

Is purposeful and outcome focused Is based on the Nursing process and Scientific method Uses both intuition and logic, based on knowledge skills and experience Requires strategies that make the most of human potential Is constantly reevaluating, self correcting, and striving to improve

question

3 Approaches to problem solving

answer

TRIAL AND ERROR INTUITIVE SCIENTIFIC, EVIDENCE BASED, LOGICAL PROBLEM SOLVING

question

4 Blended Skills essential to the Nursing process

answer

Cognitive skills : make sense of the situation and grasp what is necessary to achieve goals Technical Skills: manipulate equipment skillfully Interpersonal skills establish and maintain caring relationships that facilitate achievement and goals Ethical and legal skills personal moral code and professional responsibilities

question

What blended skill does the nurse use when she seeks out special services for a homeless patient with a diabetic foot ulcer? Answer all that apply A. Cognitive B Technical C Interpersonal D ethical legal

answer

Answer A and D Rationale: using ethical /legal skills is the best answer as it involves following a moral code and acting professionally Cognitive skills involve thinking through a situation to achieve outcomes Technical skills relate to the proper use of equipment Interpersonal skills are used to develop caring relationships, involves respect and dignity

question

Attitudes and dispositions required to think critically:

answer

Thinking independently Being fair minded Being intellectually humble Being intellectually courageous Demonstrating integrity Discipline Curiosity Creativity Confidence

question

BARRIERS TO CRITICAL THINKING

answer

Illogical thinking Lack of Information Closed mindedness Erroneous assumptions Bias fear and anxiety impatience

question

Ways to improve critical thinking

answer

Reflection Discussion with colleagues Thinking aloud Reviewing literature Practicing application using patient examples Concept mapping Simulation Writing down key facts

question

To be Critical Thinkers Nursing Students Must

answer

Be active listeners Express your opinions Risk mistakes Transform information into knowledge Apply Knowledge

question

5 vital signs

answer

T.P,R, BP and Pain

question

Core and Surface Temperature

answer

Core temp :Internal Temperature in adults Range 97-99.5 F Measure with rectal and tympanic,temporal method Surface temp measures by oral and axillary

question

Hypothalamus

answer

Center for temperature control ELEVATIONS in temp send signals to the brain Peripheral vasodilation, sweating : transfers heat from core to surface A DROP in temp signals brain to increase heat production Shivering, release of epinephrine, increased metabolism, blood vassals constrict, piloerection

question

How is heat produced?

answer

Metabolism Skeletal Muscle Activity Non shivering thermogenesis (infants)

question

Factors that Influence Body Temperature

answer

Age: infants and adults are most susceptible to temperature changes and may not be able to generate heat.Small elevations may be significant Environment: Extremes temp can lead to hyperthermia , heat stroke and hypothermia Gender:Fem: temp increases .15-.45 within 24hrs of ovulation: Exercise: skeletal musc activity (running)produces heat Emotions and Stress: stimulates sympathetic nervous ,incr BMR and body temp Circadian Rhythm:lowest Temp early AM and highest 4-7pm

question

Terminology related to FEVER

answer

Pyrexia "febrile" : po temp >100F Rectal > 101 F Fever>105.8+ hyperpyrexia Intermittent Remittent Relapsing FUO

question

FEVER: Phases

answer

Onset: may be gradual or sudden Set point: level the body attempts to maintain Crisis lysis

question

Hyperthermia

answer

Temp above set point Overexposure to high temps, inadequate fluid replacement HEAT STROKE > 103F s/s delerium, red hot skin dry skin ,dizziness , seizure, coma, unrx >death

question

Hypothermia

answer

abnormally below core Extended exposure to cold, during surgery, weather extremes s/s shivering cyanosis, poor coordination. Pain in extremities, confusion, slow P and R If severe ( below 82.4F) pt becomes unconscious, stops shivering , irreg weak P Temp death RX:rewarm gradually to prevent arrhythmias and shock Warm clothing and drinks and baths

question

Temperature measurement

answer

Fahrenheit and Centigrade scales are used Rechargeable Electronic Oral , Rectal and Tympanic,with disposable sheaths CORE temp are measured by rectal, temporal and tympanic methods Temporal Scanner : measures heat produced at the temporal artery Surface temp measures by PO,Axillary Disposable chemical strips and tapes RECTAL TEMPS ARE THE MOST ACURATE FOR CORE TEMP

question

FEVER

answer

Assess! Assess! follow up in a timely manner , report and document Look for dry ,flushed skin, shallow R CHECK Increased rapid and irregular HR pallor,shivering,loss appetite, H/A, nausea concentrated urine, confusion , seizure,

question

Contraindications to taking temperature

answer

No PO temps after ingesting hot /cold liquids smoking for 20 min, mouth breather, mask O2, confused pt, after oral surgery No Rectals : newborns, after rectal surgery neutropenia,thrombocytopenia,diarrhea. Heart disease.

question

Nursing diagnosis related to temperature

answer

Ineffective thermoregulation Hyperthermia Risk for imbalanced thermoregulation

question

Interventions for fever

answer

Collaborative: Adm antibiotics,antipyretics,replace fluids,IV,cooling blanket Independent: frequent mouth care, encourage fluids, cool cloths (groin, neck , axilla ) tepid bath, alcohol wipe,fans ,cooling blanket Heat stroke will not respond to antipyretics

question

PULSE

answer

Def: reflects contraction of the ventricle, regulated by sympathetic and para sympathetic stimulation Stroke volume :avg is 70ml in healthy adult stroke vol x HR =cardiac output Cardiac output: avg 3.5-8L /min Pulse is felt over peripheral artery or heard over apex of heart.Apical and peripheral pulse is the same in a healthy individual

question

Factors affecting HR

answer

Age Sex Exercise Stress Disease process Position change Medications

question

Pulses assessment

answer

Palpation or auscultation Auscultate with a Doppler Auscultate with a Stethoscope: Diaphragm for AP and Bell for Murmurs and low frequency sounds Listen OVER SKIN, not clothing

question

sites for pulse assessment

answer

Apical , PMI for irregular and hard to palpate radial P Radial for routine VS Carotid for CPR and when AP or radial is not palpable or heard. Peripheral pulses:Tibialis , pedal , popliteal, femoral are most often used to evaluate circulation in extremities Learn location and practice in lab and at home

question

Apical pulse

answer

LOCATED :anterior chest , 4th 5th,6th intercostal site , 3 inches to left of the sternum Lub -dub =one beat Always take an apical pulse if rate is > or < 60, On pt taking cardiac meds, Children up to age 3 To validate abnormal or difficult to palpate pulses

question

Rate, Rhythm, Equality, amplitude

answer

Rhythm , check for one full min Equality : difference between the AP and radial? If so called the PULSE DEFICIT Pulse amplitude (force produced by the blood) absent 0 Thready 1+ Weak 2+ Normal 3+ Bounding 4+

question

Other signs of compromised circulation?

answer

Check for unequal per pulses Check for pallor and cyanosis Check temperature Check for sensation " CSM and Pedal Pulses"

question

Nursing Diagnosis related to pulse

answer

Ineffective Tissue Perfusion Risk for Impaired Skin Integrity Deficient Fluid Volume Excess fluid Volume

question

Planned Interventions related to pulse

answer

Assess activity intolerance Check lab data (K magnesium, calcium) Medications that may affect HR Precipitating factors that may alleviate or precipitate abnormal HR Administer meds at REGULAR intervals Provide emotional support

question

Respirations

answer

Resp Center located in the Pons and the Medulla Responds to concentrations of CO2 and O2 in arterial blood but the primary stimulus for breathing is the CO2 tension in the arterial blood Peripheral chemoreceptors located in the carotid and aortic bodies are sensitive to fall in PaO2. Normal R are quiet effortless , involuntary Inspiration( 1-1.5 seconds) and expiration (2-3 seconds)

question

Factors influencing respirations

answer

Age and gender Exercise trauma, pain, stress ,fear, hemoglobin smoking fever Diseases fluid and electrolyte imbalance Meds caffeine

question

Respiration rate

answer

Normal rate is 12-20 Hyperventilation can result in excessive loss of C02 Hypoventilation can cause CO2 retention. Seen in COPD . anesthesia, resp failure , drug OD

question

Assess clinical signs of hypoxia

answer

Pallor , confusion, cyanosis ( late sign) restlessness, apprension,dizziness, fatigue, decr LOC,tachycardia Note cough ( productive or unproductive) constant , Intermittant Check nail beds , lips nails buccal mucosa and tongue for cyanosis Awareness of underlying disease ( resp or heart

question

Pulse Oximeter

answer

Measures amount of saturated hgb in arterial blood and is expressed in a % SPO2 normally over 95% Place on finger ( no artificial nails,dark nail polish ) or earlobe

question

Assessing respirations

answer

Pt unaware Hold pts wrist to abdomen or chest 60 sec for abnormal or new admission For Routine 30 sec, mult 2

question

Respiration Rate Alone is NOT Enough

answer

Depth ( shallow , deep) Rhythm( reg , irreg), cheyne stokes Kussmaul Biots, bradypnea, tachypnea, Apnea dypnea Effort (effortless) and quiet Pattern and trends : DOE, orthopnea

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BLOOD PRESSURE

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Pressure or force of the blood against the arterial walls during contraction Systolic Diastolic Measured in mm of mercury and recorded as systolic over diastolic

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Pulse pressure

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difference between the systolic and diastolic pressure Pulse pressure is and indicator of the volume of blood in the left ventricle and generally should be no greater than 1/3 of the systolic pressure

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stages of hypertension

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Prehypertension 120- 139 systolic 80-89 diastolic Stage 1 HTN 120-139ystolic, 80-89 diastolic Stage 2 HTN >160 sysytolic >100 diastolic

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3 major regulators of BP

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Cardiac Function Peripheral resistance arterial size , elasticity, and blood volume Blood viscosity

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When taking BP evaluate the following factors

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age Family HX Lifestyle Exercise obesity Body position Stress Pain Race Disease medications

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Equipment for assessing blood pressure

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Stethoscope Sphygmomanometer Cuff size

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Medications that affect BP

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Drugs that may decrease BP narcotics , diuretics, OTC herbal prep Drugs that may increase BP or block the action of antihypertensives: cold preparations, diet pills, steroids, antidepressants,NSAIDS, oral contraceptives,antacids with Na Encourage pt to read labels and talk c Pharmacy

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HYPOTENSION

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Systolic 100mmhg or below Heart failure blood loss medications Dizziness , fatigue, activity intolerance, SOB

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Interventions for Hypotension

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Have pt lie down Orthostatic VS 3 min apart Fluids Doc , report, follow collaborative orders: transfusion, change in meds

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HYPERTENSION>140 systolic > 90 diastolic

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Major cause of illness: stroke , heart Failure, kidney damage, PVD, heart attack Damages lining to blood vessels if untreated PREHYPERTENSION 120-139Systolic 80-89 Diastolic Take 2 readings , 5 min apart Primary HTN Secondary : identifiable cause,ie renal disease

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Primary and Secondary HTN

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Primary or Essential HTN no known underlying medical cause Secondary: disease related: Kidney disease, Endocrine , cardiac Usually no symptoms and Id during screening s/s Headache, lightheadedness, dizzy, tinnitis

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Interventions for hypertension

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Monitor VS Accurate I and O Eval Na intake Weight Eval labs renal function, Hgb,hct,lipids Adm antihypertensive med as prescribed Id pt education needs Educate patient to: Diet Exercise Stress reduction Med management/compliance

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Problems of immobility disuse syndrome

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WEAKNESS MUSCLE ATROPHY CONTRACTURES OSTEOPOROSIS DECUBITI 4 STAGES DECREASED VITAL CAPACITY PNEUMONIA INCREASED WORK LOAD DEEP VEIN THROMBOSIS ORTHOSTATIC HYPOTENSION INCONTINENCE INFECTIONS CONSTIPATION IMPACTION LONLINESS DEPRESSION SADNESS DIFFICULTY SLEEPING DIFFICULTY CONCENTRATING WITHDRAWAL HOSTILITY CONFLICT

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