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Sodium Levels

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135-145 mEq/L

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Sodium Function

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It helps regulate the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Is also important in how nerves and muscles work.

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Potassium Levels

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3.5-5.0 mEq/L

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Potassium Function

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Crucial to heart function and plays a key role in skeletal and smooth muscle contraction, making it important for normal digestive and muscular function.

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Calcium Levels

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8.6-10.2 mEq/L

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Calcium Function

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Nerve impulse, blood clotting, muscle contraction, B12 absorption

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Magnesium Levels

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1.3-2.3 mEq/L

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Magnesium Function

answer

protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation

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Tube feeding aspirate

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Less than 5.5 pH

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ICF

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70% of total body water and 40% of adults weight

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ECF

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30% of total body water and 20% of weight

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Most prone to fluid volume deficit

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Infants

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Infant total body weight water

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77%

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Men total body weight water

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60%

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Women total body weight water

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50%

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Elderly total body weight water

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45%

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Potassium imbalance signs and symptoms

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Muscle weakness, cardiac arrhythmia, paresthesia, nausea, diarrhea

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Respiratory alkalosis

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Increased pH, decreased PaCO2, normal HCO3

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Respiratory acidosis

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Decreased pH, Increased PaCO2, Normal HCO3

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Metabolic alkalosis

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Increase pH, Normal PaCO2, Increased HCO3

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Metabolic acidosis

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Decreased pH, Normal PaCO2, decreased HCO3

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Normal pH range

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7.35-7.45

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Normal PaCO2 range

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35-45mmHg

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Normal HCO3 range

answer

22-26mmol/L

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Autologous transfusion

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When a person knows ahead of time that they may need a blood transfusion and can donate their own blood for the transfusion. This eliminates the danger of transmitting cross-infection from donor to recipient and decreases the risk for complications from mismatched blood. It must be done at least 5 weeks prior to procedure and infections are still possible.

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Infiltration

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The escape of fluid into the subcutaneous tissue that is caused by a dislodged needle or penetrated vessel wall. S/S: Swelling, pallor, coldness, or pain around the infusion site; significant decrease in the flow rate. Nursing interventions include: Check the infusion site every hour, discontinue the infusion if symptoms occur and restart the infusion at a different site.

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Phlebitis

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Inflammation of a vein that is caused by mechanical trauma from needle or catheter and chemical trauma from solution. S/S Local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. For an intervention the nurse should: Discontinue the infusion immediately, apply warm, moist compresses to the affected site, avoid further use of the vein and restart the infusion in another vein.

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Fluid Overload

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Condition caused when too large a volume of fluid infuses into the circulatory system. S/S Engorged neck veins, increased blood pressure, and difficulty in breathing (dyspnea). Nurse interventions would consist of: If symptoms develop, slow the rate of infusion and notify the primary care provider immediately. Monitor vital signs.Carefully monitor the rate of fluid flow. Check the rate frequently for accuracy.

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Embolus

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Detached blood clots, clumps of bacteria, fatty deposit or any other material that floats and obstructs or blocks blood flow in a blood vessel.

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Sepsis

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When chemicals are released into the bloodstream to fight the infection and trigger an inflammatory response throughout the body. This causes changes and failure to multiple organs and systems in the body, thus leading to death.

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Pneumothorax

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a collapsed lung due to air leaking from the lungs into the space between the lungs and the chest wall. This can be caused by a blunt puncture to the lungs or underlying lung disease.

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Cigarette smoking

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Most common cause of COPD

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Prioritizing respiratory problems

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airway, breathing, circulation

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Pursed lip breathing

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Helps patient gain control of breathing pattern, improves ventilation, releases trapped air in the lungs, keeps airways open longer, decreases the work of breathing, relieves DIB, prolongs exhalation, promotes relaxation.

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Pneumonia

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infection that causes inflammation in the air sacs of the lungs.

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Hypervolemia

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excessive retention of water and sodium in ECF

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Overhydration

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above normal amounts of water in extracellular spaces

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Edema

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excessive ECF accumulates in tissue spaces

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Interstitial-to-plasma shift

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movement of fluid from space surrounding cells to blood

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ANA Standards of Practice

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1). Assessment 2). Diagnosis 3). Outcomes identification 4). Planning 5). Implementation 6). Evaluation

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International Council of Nurses

answer

Founded in 1899 First International organization of professional women Provides a way for national nursing organizations to work together

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American Nurses Association

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For RNs Membership is comprised of the state nurses' associations Involved in public education, clinical nursing standards and lobbying state a federal lawmakers

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National League of Nurses

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Open to all people interested in nursing Fosters the development and improvement of all nursing services and nursing education Conducts one of largest professional testing services in the united states Serves as primary source of research data about nursing education

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American Association of College of Nursing

answer

National voices for baccalaureate and higher degree programs Establishing quality educational standards, influencing the nursing profession to improve health care and promoting public support of BSN and graduate education. Provides national accreditation for nursing programs.

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National Student Nurses Association

answer

National organization for students enrolled in nursing education programs. Voluntary participation Students practice self-governance, advocate for student and patient rights , and take collective, responsible action on social and political issues.

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Possible Nursing Dx

answer

when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence. Additional date is used to confirm or rule out the suspected problem

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Actual Nursing Dx

answer

problems that have been validated by the presence of major defining characteristics. Has four components.

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Risk Nursing Dx

answer

Clinical judgements that a person, family, or community is more vulnerable to develop the problem than other in the same or similar situation.

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Wellness Nursing Dx

answer

Clinical judgements about a person, group, or community in transition from a specific level of wellness to a high level or wellness. Wilnes diagnoses are often more applicable in nursing settings that deal with primarily healthy people. One part statement that contains the label Readiness for Enhanced, followed by the desired high level wellness. Related factors are not included.

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Syndrome Nursing Dx

answer

Comprises a cluster of actual or risk nursing diagnoses that are predicted to present because of a certain event or situation; for example. Rape-Trauma Syndrome or Post-Trauma Syndrome.

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Cognitive Outcome

answer

increases in patient knowledge or intellectual behavior

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Psychomotor Outcome

answer

Learning new skills

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Affective Outcome

answer

Changes in patient's values, beliefs, and attitudes

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Physiological Outcome

answer

Physical change

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Never Events

answer

things that should have never happened. For example: Surgery on the wrong body part, leaving a tool in the body, discharging infant to wrong person.

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Sentinel Events

answer

unexpected occurrences involving death or serious injury. Common have been wrong-side surgery, suicide, and operative and postoperative complications.

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SOAP charting

answer

used to organize entries in the progress notes of the POMR (problem-oriented medical record). Caregivers select numbered problems from the master list on the front of the patient record and then work up the problem or "soap it" on the progress sheet.

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Ethnocentrism

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viewing one's own culture as the only correct standard by which to view people of other cultures.

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Stereotyping

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preconceived and untested beliefs about people. They are exaggerated descriptions of character or behavior that are commonly reiterated in mass media, idiomatic expressions, and folklore.

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Culture Shock

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occurs when a person is immersed in a different culture that is perceived as strange. The person may feel foolish, fearful, incompetent, or humiliated, and these feelings can lead to frustration and anxiety.

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Cultural Assimulation

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when one begins to assume some characteristics of a culture outside of one's own

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Cultural blindness

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when cultural differences are ignored

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Cultural imposition

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when one pushes his or her beliefs onto another person.

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Body Language

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S- sit squarely facing pt O- observe an open posture L- lean forward toward pt E- Eye contact R- Relax

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Teaching

answer

Summary of the learning need The plan The implementation of the plan Evaluation results

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CT scan /C oral contrast

answer

an oral contrast is consumed before the study if the upper gastrointestinal tract is to be examined. Intravenous iodine contrast is usually administered. Assess for patient allergies to iodine, IV contrast, and/or shellfish. Prestudy preparation may be required if allergies are present. Assess for renal impairment; check lab values for evaluated BUN and creatinine levels. Patient should be NPO for at least 4 hours before study. Pregnant women should not get CT scans. An informed consent is required. Metformin (Glucophage) must be discontinued prior to study and held after surgery to prevent renal failure.

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Diabetic Neuropathy

answer

have a hard time feeling things in their extremities. If you are giving someone a shower, make sure that the water is not too hot. Make sure that they wear proper footwear at all times. Assess heels and legs for decubitus formation. Be sure to clean feet well. PROPER FOOT CARE. Also, only Podiatrists should be cutting their toe nails.

question

Pressure Ulcer Stage 1

answer

area of intact skin with nonblanchable redness,

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Pressure Ulcer Stage 2

answer

partial thickness loss of dermis and presents as a shallow open ulcer

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Pressure Ulcer Stage 3

answer

full thickness tissue loss, subcue fat may be present does not obscure depth of tissue loss

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Pressure Ulcer Stage 4

answer

full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present.

question

Unstageable Pressure Ulcer

answer

when base of ulcer is covered by slough and eschar in the wound bed

question

Dehiscence

answer

surgical complication in which a wound ruptures along a surgical incision

question

Evisceration

answer

is the protrusion of the internal organs (usually abdominal) through an incision.

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High Fowler's

answer

(60-90 degrees) = easier to breathe, used for excretion, best position for eating and swallowing, also easier to take x-rays in this position

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Semi-Fowler's

answer

(35-45 degrees) = Tube feeds, labor

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Low Fowler's

answer

(15-30 degrees)= Patient rest

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Torticollis

answer

Inclining of head to affected side

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Lordosis

answer

exaggerated anterior convex curvature of the spine)

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Scoliosis

answer

lateral curvature of the spine

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Kyphosis

answer

increased convexity in the curvature of the thoracic spine

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QSEN competencies

answer

Patient-Centered Care: recognize the patient as the source of control and partner in providing compassionate and coordinated care based on respect for patient's preferences, values and needs. Teamwork and Collaboration: function effectively within nursing and interprofessional teams, fostering mutual respect and shared decision making. Evidence-based Practice (EBP): integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Quality Improvement (QI): Use data to monitor the outcome of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems. Safety: minimize risk of harm to patients and providers through both system effectiveness and individual performance. Informatics: use information and technology to communicate, manage knowledge, mitigate error and support decision making.

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SBAR

answer

-Introduction, Situation, Background, Assessment, Recommendation, Response/Repeat

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Autonomy

answer

self-determination; respect the rights of patients to make decisions

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Nonmaleficence

answer

do no harm

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Beneficence

answer

benefit the patient and balance benefits against risks and harm

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Justice

answer

act fairly

question

Fidelity

answer

keep promises

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Ethics

answer

formal inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil as they relate to human conduct and human flourishing

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Morals

answer

refers to personal or communal standards of right and wrong.

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Deception

answer

Not being truthful

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Advocacy

answer

protection and support of another's rights

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Veracity

answer

obligation to tell the truth

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Ethical distress

answer

when someone wants to do the right thing but is not able to

question

NG Tube

answer

Measure tube from tip of the nose to the ear lobe and from the earlobe to the xiphoid process the add 8 to 10 inches for intestinal placement. Check tube for proper placement before administering any fluids and pH of aspirate. Position patient head of bed at least 30-45 degrees while feeding. Monitor for CO2 to make sure tube is not in the patient's airway instead of the stomach.

question

Daily fluid intake to facilitate defication

answer

2,000-3,000 mL

question

High fiber foods

answer

whole grains, beans, fresh fruits and vegetables

question

Foods that can cause constipation

answer

processed cheeses, lean meat, eggs and pasta.

question

Stoma

answer

should be dark pink to red and moist, size should maintain the same after 6-8 weeks of surgery, keep skin around site dry and clean.

question

Fecal Impaction

answer

Prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum that cannot be passed.

question

Stoma Assesment

answer

Inspect the patient's stoma regularly. Note the size, which should stabilize within 6 to 8 weeks. Keep the skin around the stoma site clean and dry.

question

Overflow incontinence

answer

Urethral blockage, unable to properly empty bladder

question

Stress incontinence

answer

weakened pelvic floor muscles and tissues. It can happen when pressure on your bladder increases -- such as when you exercise, laugh, sneeze, or cough.

question

Urge Incontinence

answer

urgent need to go to the bathroom and may not get there in time.

question

Functional Incontinence

answer

Mental or physical problems such as dementia or arthritis prevent you from getting to the bathroom in time.

question

PCA

answer

computerized, portable infusion pump that is prefilled with a syringe containing an opioid analgesic Usual dose is on a 6-8 minute lock out Can be programed to give a dose at specific times regardless of patients The patient is typically more satisfied and uses less medication

question

Bronchial

answer

sounds heard over the larynx and trachea are high pitched, harsh, blowing sounds. Expiration being heard longer than inspiration.

question

Bronchovesicular

answer

sounds are heard over the mainstem bronchus and are moderate blowing sounds with inspiration being equal to expiration.

question

Vesicular

answer

sounds are heard over most of the lung fields and are soft, low-pitched, whispering sounds with inspiration being longer than expiration.

question

Wheeze

answer

high-pitched, musical like (air passing through narrow airways)

question

Rhonchi

answer

low-pitched, continuous sounds that may be cleared by cough (air passing through or around secretions)

question

Crackles

answer

low to high-pitched discontinuous sounds, bubbling or popping, crackling. (air passing through fluid in the airways)

question

Stridor

answer

harsh, loud, high-pitched sounds heard on inspiration. ( narrowing of upper airway or presence of foreign body in airway)

question

Pleural Friction Rub

answer

rubbing or grating sounds (inflamed pleura rubbing against chest wall)

question

Atelectasis

answer

partial or complete collapse of a lung due to the alveoli becoming deflated and unable to exchange gases. Causes: complications from sx, cystic fibrosis, inhaled foreign objects, lung tumors, fluid in the lung, respiratory weakness.

question

Pneumothorax defintion

answer

A collapsed lung due to air leaking into the space between the lungs and the chest wall. The air pushes on the lungs to collapse them. Causes: chest puncture or injury, underlying lung disease.

question

Hypoxia

answer

inadequate amount of oxygen available to the cells

question

Hypoxemia

answer

an abnormally low concentration of oxygen in the blood.

question

Hypoventilation

answer

Breathing at an abnormally low rate, resulting in an increased amount of carbon dioxide in the blood.

question

Hypoxia Signs and Symptoms

answer

Changes in the color of your skin, ranging from blue to cherry red. Confusion. Cough. Fast heart rate. Rapid breathing. Shortness of breath. Sweating. Wheezing.

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