Transition study guide (Kaplan)

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Maslow’s hierarchy of needs
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5 basic levels of needs: physiological, safety, love & belonging, self esteem, self actualization. -Client progresses up the hierarchy when attempting to satisfy needs -Low level needs must be met first
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Nursing Process
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problem solving systematic approach used to meet actual & potential healthcare needs of clients. -Steps: assessment, diagnosis, planning, implementation, evaluation -purpose: to diagnose + treat client’s responses to actual/potential health problems -provides common language + step by step process for nurses to care for clients
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Scope of practice
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Extent + limits of medical interventions that healthcare provider may perform
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Delegation to nursing assistive personnel
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Unlicensed staff; AKA CNA, technicians, etc -Can assist with direct client care activities [bathing, transferring, ambulating, feeding, toileting, obtaining VS, height, weight, I&O, housekeeping, transporting, stocking supplies
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Therapeutic communication
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listening to and understanding client while promoting clarification and insight Goals: -to understand client’s message -to facilitate client’s verbalization of feelings -to communicate nurse’s understanding + acceptance -to identify problems, goals, + objectives **using silence, using general leads of broad openings, clarification, + reflecting
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Restraints
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prevents clients from harming themselves or others by using chemical or physical means -informed consent required -physician’s order required specifying duration, + circumstances under which restraints should be used **remove Q2H, assess for redness or excoriation nursing care includes: -assessing + documenting needs for restraints -considering + documenting use of alternative measures
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Orthostatic vital signs
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measurement of bp + pulse in supine, and standing positions *positive test when: -client becomes dizzy or loses consciousness -pulse increases by 20bpm -SBP drops by 20mmHg or more 2 mins after changing position from lying to sitting or sitting to standing **indicates hypovolemia or dehydration
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Bronchoscopy
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visualization of trachea + mainstream bronchi to: -obtain tissue biopsy -apply medication -aspirate secretions for lab exam -aspirate mucous plug causing airway obstruction -remove aspirated foreign objects Nursing responsibilities pre-test: -explain procedure -maintain NPO 6-12hrs -inspect mouth for infection -administer pre medication -remove dentures -prepare for sore throat after procedure Nursing responsibilities post-test: -instruct to sit or lie on side -remain NPO til gag reflex returns -observe for respiratory difficulties
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Herbal supplements
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botanical meds, vitamins, + minerals regulated as dietary supplement with statements of how supplement affects structure + function of body -can interact with convention medication -St John’s wort: accelerates metabolism of many drugs -Gingko biloba, feverfew, + garlic: suppresses platelet aggregation + increases risk of bleeding when given with anti-coag meds -Ephedra: elevates BP, heart, and CNS **dietary supplements include: echinacea, garlic, ginseng, black cohosh, feverfew, ginger, saw palmetto
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State boards of nursing
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state govt agencies responsible for regulation of nursing practice -accredit/approve nursing education programs in schools + universities -develop standards, rules, + regulations **each state has nursing practice act + board’s responsibility to enforce nursing practice act includes: -qualification for licensure -nursing titles -scope of practice -outcomes that may happen if nurses dont adhere to practice act
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Informed consent
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client’s agreement to have procedure performed after explanation of risks, benefits, expectations, + alternatives to procedure *can be withdrawn at any time *nurse ensures consent form is signed + attached to chart
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Furosemide [lasix]
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loop diuretic that inhibits absorption of sodium + chloride in loop of henle + distal renal tubes -S/E: hypotension, hypokalemia, GI upset, weakness nursing considerations: -monitor BP, pulse rate, I&O, potassium -weight daily -do not give at hour of sleep -encourage potassium containing foods *after oral dose, diuresis can occur within 30 mins
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Incident report
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accurate + comprehensive report on any unexpected/unplanned occurrence that affects or can possibly affect a client, family member, or staff person -don’t include reference to incident report in charting -don’t use words like “error” or “inappropriate”, inflammatory words, or judgemental statements needed for: -medication errors -complications from diagnostic or tx procedures -incorrect sponge count in surgery -failure to report change in client’s condition -falls -burns -break in aseptic technique -medical/legal incident [client or family refusing tx as ordered, refuses to sign consent] -client or family dissatisfied with care + situation can’t be or has not been resolved
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Apical pulse
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where impulse of left ventricle [L 5th intercostal space @ midclavicular line] felt most strongly; point of maximal impulse [aka PMI] -pulse deficit: difference b/t apical + radial pulse ->radial usually slower d/t ineffective contractions failing to send pulse waves to periphery; cardiac dysrhythmia may be present
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Confidentiality
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code of ethics safeguarding client’s right to privacy -client has right of records -info about client can be used only for purposes of diagnosis + tx -info can’t be released to others w/o permission
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Oxygen therapy
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when using nasal canula: -assess patency of nostril -apply water-soluble jelly to nostrils q3-4hrs -perform good mouth care If using face mask: -remove mask q1-2hrs -wash, dry, apply lotion to skin -provide emotional support to decrease feeling of claustrophobia with partial non rebreather mask: -adjust oxygen flow to keep reservoir bag 2/3 full during inspiration
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Priorities
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establishing priorities enables nurse to attend to client’s most important needs + helps nurse organize care *situations if left untreated, can cause physical harm to clients have highest priority *use maslow’s hierarchy of needs to establish priorities
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Culturally competent care
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planning + implementing care that’s sensitive to the needs of individuals, groups, and families from diverse cultures -requires cultural sensitivity + cultural awareness When nurse from different culture than client interacts with them, include: -their culture, expectations, and beliefs of healthcare -context of interaction -amount of agreement b/t 2 person’s set of beliefs and values
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Assessment
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1st step of nursing process; establishes database includes: -collection, validation, organization, initial references, + communication of data of client or healthcare situation -subjective data from client’s point of view -objective data from nurse’s point of view -dynamic process, not ending up with initial contact or impressions
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Delegation
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responsibility and authority for performing a task transferred to another individual that accepts responsibility and authority -can delegate only tasks for which nurse is responsible steps include: -defining task to be delegated -determining who should receive delegated task -identifying what the task involves -matching task to individual by assessing their skills and abilities -providing clear communication about expectations regarding task -answering q’s
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Delegation to LVN/PN
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LPN/LVN assist with implementation of defined plans of care -perform procedures according to protocol -differentiate normal from abnormal -care for physiologically stable clients with predictable conditions -has knowledge of asepsis + dressing changes -ability to administer meds varies with educational background + state nurse practice act
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Chain of command
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person or organizational chart who is above the nurse -nurse reports to this person -is responsible to the person above the nurse **nurse reports variances, problems, + concerns to next person with authority in direct line in their area
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Negligence
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unintentional failure of individual to perform act that a reasonable person with same knowledge, experience, + background would or would not perform in similar circumstances -can be acts of omission or commission **failure to act causes injury to client -4 elements of negligence: duty owned, breach of duty or standard care -connection b/t breach of duty + damage
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Client goals
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statements reflecting highest level of independence for client -goals are client centered, measurable, and time limited -if goal short term, client expected to achieve in hours up or upto less than a week -long term goals take matters of several days, weeks, or months
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Right to refuse Tx
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patient self determination act + ethical doctrine of autonomy gives patients right to refuse tx -if patient refuses tx, must be informed of harmful consequences of refusal
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Culture
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beliefs, values, attitudes, customs, languages, ceremonies, symbols, behaviors, artifacts shared by group of ppl and passed on from one generation to next -needs to be considered in all health care situations -different cultures have different ways of perceiving, defining, understanding, expressing, responding to, and treating illness *cross cultural difference can be problematic if not understood, accepted, + responded to appropriately
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Influenza vaccine
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given yearly, preferably in october to november recommended for: -ppl of 65yrs or older -ppl younger than 65 with heart disease, lung disease, DM, immunosuppression, or living in chronic care facility *contraindication: previous anaphylactic reaction to vaccine or eggs
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Standards of practice
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established by american nurses associatio -standards of profession performance include quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, + leadership **include utilization of steps of nursing process [ADPIE] as basis of clinical decision making
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Assault and battery
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assault: threat or attempt to touch a person in a way that’s intimidating, insulting, offensive, or harmful battery:actual touching of a person w/o authorization to do so ** any nursing, medical, or surgical procedure performed w/o consent of patient is viewed legally as battery
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Teaching/learning
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-consider specific knowledge needed + whether type of learning needed is cognitive, psychomotor, and/or effective -assess motivation, anxiety level, attitudes + beliefs, cultural + environmental influences of patient -best to set realistic goals [preferably with mutual agreement] and priorities -be nonjudgmental and empathetic -supplement verbal w/ nonverbal instruction -use demonstration and return demo for teaching skills -allow for practice periods -give positive feedback -ensure by observation that knowledge has been incorporated
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Abdominal assessment
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assessed for symmetry, contour, umbilicus, bowel sounds, arteries [aorta, renal, iliac, femoral], peritoneal friction rub, liver + spleen size, inguinal lymph nodes, rebound tenderness, kidneys, abdominal reflexes -done in order of inspection, auscultation, percussion, and palpation -ensures progression from least to most disruptive or invasive technique to prevent bowel sounds from being altered -bowel sounds evaluated for intensity, pitch, + frequency [usually 5-30per minute] **to determine bowel sounds are absent, nurse must listen for total of 5 mins in each quadrant
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Nosocomial infection
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when hospitalized clients acquire infections as result of hospitalization can be classified as: -iatrogenic infection: c/b diagnostic or therapeutic procedures -exogenous infection: c/b microorganisms outside of client and isn’t part of normal flora -endogenous infection: when client’s normal flora is altered *common sites: urinary tract, wounds, respiratory tract, bloodstream **standard precautions are primary strategy for nosocomial infection control
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Postural drainage
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uses gravity to facilitate removal of bronchial secretions -client placed in variety of positions to facilitate drainage into larger airways from lungs and bronchi into trachea -secretions may be removed by coughing or suctioning *prevents complication of stasis of respiratory secretions
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Self breast exam
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begin at 18-20yrs of age, examine monthly, 1 week after menstrual period begins or at a routine time [ex: first day of month if non-menstruating] -begins with inspection of breasts in mirror -examine first with arms at sides, second with arms above head, third with hands on hips -while lying down, use finger pads of 3 middle fingers to palpate breasts to detect unusual growths -look for dimpling or retractions -examine nipples for discharge, changes, + swelling
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Pain management
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5th VS, whatever person says it is and exists whenever person says it does -can be acute or chronic -cultural and past experiences with pain major factors influencing pain experiences -indications: increased BP + pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprehension + irritability, grimacing, guarding, verbalizations of pain -interventions: establish therapeutic relationship, establish 24 hr pain profile, teach patient about pain + its relief, reduce anxiety + fears, provide comfort measures, administer pain medication, refer to alternative methods of pain relief **with regard to pain medication: use preventive approach, which states if pain is expected to occur throughout most of a 24hr period, a regular schedule is better than prn, usually takes smaller dose to alleviate mild pain or prevent occurence of pain
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Case management
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identifies, coordinates, monitors implementation of services needed to achieve desired outcomes within specified period of time -involves principles of continuous quality improvement -promotes professional practice case manager : ->usually has advanced degree and considerable experience ->doesn’t provide direct client care ->supervises care provided by licensed and unlicensed personnel ->coordinates, communicates, collaborates, solves problems ->facilitates client care for group of clients [10-15] ->follows client through system from admission to discharge ->notes variances from expected progress
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Living will
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advance directive that tells healthcare providers of life sustaining tx’s [ex: surgery, cpr, respirator, tube feedings] an individual doesn’t want initiated or wants if they develop a terminal condition or persistent vegetative state *implemented only if terminal or irreversible state develops
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Nursing licensure compact
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mutual recognition nurse licensure that allows nurse to have one license in state of residency + to practice in other states [both physical + electronic] -subject to each state’s practice law and regulation -each state must enact legislation or regulation authorizing the NLC *includes RN’s, LN/PN’s but doesn’t include advance practice nurses
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Interviewing q’s
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important to establish effective nurse-client relationship before proceeding to actual initial interviewing process -introduce self + purpose, time frame -elicit concerns of client -inform about confidentiality -convey competence + acceptance -use therapeutic communication techniques ->silence ->general leads or broad openings when possible ->reflection ->rephrasing ->clarification ->focusing ->summarizing ->offering info prn **sequence of interview: -greet client -elicit why client seeking healthcare -determine topics of interview -expand + clarify client’s story -discuss shared understanding of client’s problem -discuss a plan -determine the f/u
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Ginger
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herbal supplement used for nausea, vomiting, indigestion, gas, lack of appetite -S/E: minor heartburn, dermatitis -c/i with gallstones -may potentiate antiplatelet + anticoagulation meds, antidiabetic meds, and herbs that increase bleeding time
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Certification
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verifies expertise in specialty areas of clinical practice -most certification programs require clinical experience in related field plus successful completion of written exam -ANA + multiple nursing specialty organizations have exams + procedures for certification in a specialty area *nurse practice act regulates the practice of RN and advance practice nursing
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Blood Pressure
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exerted by circulating volume of blood on walls of arteries, veins, & chambers of heart -cover 50% of limb from shoulder to olecranon with cuff -check both arm for comparison, difference of 5-10mmHg normal -difference of 30-40mmHg b/t systolic and diastolic is normal Normals: – newborn: 60 to 80/40 to 50mmHg -child 1-4: 90 to 99/60 to 65mmHg -child 5-12: 100 to 110/56 to 60mmHg -adult: 90 to 140/60 to 90mmHg
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Documentation
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-promotes communication -maintains legal record -meets requirements of regulatory agencies -required for 3rd party reimbursement -is legible, accurate, timely, thorough, concise, well organized, uses proper grammar, spelling, & authorized abbreviations
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Incentive spirometer
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used to maximize lung expansion by opening closed alveoli + mobilizing secretions -instruct to breathe in & exhale normally -seal lips around mouthpiece -inhale slowly & deeply -hold breath for at least 3sec while keeping ball/cylinder elevated -exhale -take several normal breaths & repeat procedure 4-5 times **client should cough after procedure to facilitate secretion removal
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Contact precautions
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for clients requiring physical skin to skin contact, occurring b/t nurse + client or 2 clients; can occur by contact w/ contaminated objects in client’s environment, private room or w/ another client w/ same infection but no other infection -wear clean nonsterile gloves when entering room -change gloves after client contact w/ fecal material or wound drainage -remove gloves before leaving client’s environment + wash hands w/ antimicrobial agent **wear gown when entering room if clothing has contact with client, environmental surfaces, or if client is incontinent, has diarrhea, an ileostomy, colostomy, or wound drae
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Evidence based practice
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problem solving approach based on using very best available evidence from disciplined research findings, -used for making clinical judgements, & best decisions about client care
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Postop care
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Requires full assessment because anesthesia, immobility, + surgery can affect any system in body -Neuropsychosocial: stimulate client postanesthesia + monitor loc -Cardiovascular: monitor VS q15mins x4, then q30mins x2, then qhr or prn: check potassium levels, monitor CVP -Respiratory: check airway + breath sounds: turn, cough, & deep breathe unless c/I such s with brain, spinal, or eye surgery; splint wound, offer pain meds, teach to use incentive spirometer (hold mouthpiece in mouth, exhale normally, seal lips & inhale slowly + deeply, keep balls or cylinder elevated, exhale + repeat) -GI: check bowel sounds in all 4 quadrants for 5 mins, keep NPO until bowel sounds present, provide good mouth care while NPO, provide antiemetics for n+v, check abdomen for distention, check for passage of flatus + stool -Genitourinary: monitor I&O, encourage to void, check for bladder distention, notify MD if unable to void within 8hrs, catheterize prn -Extremities: evaluate + promote circulation -Wounds: evaluate and manage dressings, drains, + incision itself -GI tubes: check placement -Musculoskeletal: get oob asap, ambulate as much as possible **monitor for complications: hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infections of wound, dehiscence, evisceration, DVT, + psychosis
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Meningitis
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Inflammation of meninges of brain or spinal cord 5 types of meningitis viral bacterial parasitic non infectious fungal -viral: spreads from person to person through fecal contamination, can occur when changing diaper or using toilet and not properly washing hands after ->caused by common viruses, & mumps, herpes, stomach problems and etc -bacterial transmission: through respirator throat secretions (kissing) ->bacterial meningitis caused by three bacteria with complex code names: 1. Haemophilus influenzae type b 2. Pneumococcus 3. Meningococcus *Spreads when someone has close contact with an infected person—like real close conversation, or kissing. Also thru touching infected surfaces, like a doorknob, and then touching your mouth or nose Bacterial meningitis can cause brain damage, hearing loss, or learning disabilities -vaccines and antibiotic are best defense -CDC recommends 11-12yr olds entering high school to get vaccinated Viral meningitis normally does less damage than bacterial meningitis. -can’t be treated with medicine -immune system can usually knock out viral meningitis without any help
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Neurological assessment
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consists of: interview, levels of consciousness, pupillary assessment, vital signs, motor function, sensory function, + tone Interview the presence of: -headache -difficulty with speech inability to read or write -alterations in memory -altered consciousness -confusion or change in thinking -disorientation -decreased sensation tingling or pain -motor weakness or decreased strength -decreased sense in smell -changes in vision -difficulty with swallowing -decreased hearing -altered gait or balance
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Healthcare provider’s orders
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