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NR I 224 IFinal IExam IReview
- Bulimia INervosa - Recurrent Iepisodes Iof Ibinge Ieating I(rapid Iconsumption Iof Ia Ilarge Iamount IofIfood I in Ia Idiscrete Iperiod Iof Itime) - A Ifeeling Iof I lack Iof Icontrol Iover Ieating Ibehavior I during Ieating Ibinges - Recurrent Iinappropriate Icompensatory Ibehaviors Ito Iprevent Iweight Igain, Isuch IasI self-induced Ivomiting, Iuse Iof Ilaxatives Ior Idiuretics, Istrict I dieting Ior Ifasting, IorIvigorous Iexercise - Binge Ieating Iand Iinappropriate Icompensatory Ibehaviors Ithat Iboth Ioccur, IonIaverage, I at Ileast Ionce Ia Iweek Ifor I 3 Imonths - Self-evaluation Iunduly Iinfluenced Iby Ibody Ishape Iand Iweight
- To Iprevent I hypoglycemia , I do Inot Iabruptly Idiscontinue I TPN Ibut I taper Irate Idown I to Iwithin I10% Iof Iinfusion Irate I 1 Ito I 2 Ihours I before Istopping.
- Assess Ifor Isigns Iof I medical Itoxicity Iin Iolder Iadult I because: I re duced IglomerularIfiltration
- Majority Iof Iabsorption: Ismall Iintestine
- Indicate Ithe Iuse Iof I z-track: I last Ishot Iturned Iskin Ito Icolors
- GI Itract o mouth, Iesophagus, Istomach, Ismall Iintestine, Ilarge Iintestine, Irectum,Ianus o small Iintestine: Iduodenum, I jejunum, Iileum o large Iintestine: Icecum, Iascending Icolon, Itransverse Icolon, IdescendingIcolon, Isigmoid Icolon, Iand Irectum
- Dose Iis Iincorrectly Iinte rpreted: INURSE I is Iat Ifault
- if Ipt. I refuses I medication: I explain Ipurpose/ Ieducate Iwhy Ithey Iare IgettingIit/ Iask Iwhy Ithey Idon’t I want Ito Itake Iit
- excrete Igaseous Imedication: Icough Iand Itake Ideep Ibreaths
- expired Imedication: I call Iphysician
- Nurse Iis Igoing Ito Iadminister Ipain Imedication Ifor Ipt Iwith I pe ripheral IIV. INotices I red Istreak, Iwarm Iand Itender Ito Itouch I= IPhlebitis-iv Isite Ithat Iis Iblown/bust, Iand Ithe Ifluid I just Istarts Ito Ipuddle: I DO INOT Igive Ipain Imedication.
- Nurse Iis Ipreparing Imedication Ito Ipatients Iwith I same Ilast Iname Iand IdidINOT Icheck Iidentification Ibefore Iadministering I medication: I return Ito Iroom Ito Icheck Iand Iassess Ipt.
- Pt Idid I not Itake Idaily Iallergy Imedication I in Ithe Imorning Ibc Ifelt ItooIdrowsy: I change Itime Ito I9PM I so Idrowsiness Ioccurs Iwhen Ipt Iis Isleeping
- Successful Igoal Iof Iconstipation: Isoft Istool
- Pt Iasks Iif Ishe Iwill Ibe Ineeding Ito Ihave Ithe Ibag I(ostomy) Ion Iat I all Itime: IyesIbc Iit Iby-passes Ithe Ilarge Iintestine Iand Iconstantly Ioozes Iliquid
- Concerned I if I stoma Iis Iblue/purple/black
- REE: I consumed Iover I 24 Ihour I period I for Ibody Ito Imaintain Iall Iof Iits internal I working
- Pain I meds. ICause Iconstipation. I 3 Idays Iwithout IbowelImovement=constipated
- MajorIsource Iof Ienergy: Icarbohydrates
- Black Istool: Iiron Iingestion-women Itake Iiron Isupps. IAIlot
- Meet Inutritional Ineeds: Ido Inot Igain Ior Ilose Iweight I- Initrogen Ibalance- Inegative Iis Imalnutrition, Ipositive-healing
- Breastfeeding I is Inecessary Ifor Ithe I first I4-6 Imonths Iof Ilife Cow’s Imilk Ican Ibe Idrank Iafter I 1 Iyear
- PoorInutrition: Ishort Iattention Ispan; Idry, Ibrittle Ihair; Idry, Irough IandIpale Iskin
- Colorectal Icancer o African-americans I are Iat I highest Irisk o Risk Ifactors: Ihigh Ianimal Ifats Iand Ired Imeat; Iobesity, Itype I 2 Idiabetes,Ismoking, Iand Iheavy Ialcohol o Causes Iof Igyno ----obesity, Ialcohol, IliverIcirrhosis o Warning Isigns: Ichange Iin Ibowel Ihabits; Irectal Ibleeding; Iincomplete Ievacuation Iand Iunexplained Iabdominal Ior Iback Ipain o Colonoscopy: Ievery I 10 Iyears Iafter I 50 Iyears o Sigmoidoscopy: Ievery I 5 Iyears IafterI 50 o Pap Ismears: Iwomen Iget Ithis Itest Ievery Iyear
- C. Idiff: I wash Ihands Iwith Isoap Iand I water
- Infectious Iagent, Ireservoir, Iportal Iof Iexit, Imode Iof Itrans mission, Iportal IofIentry, Isusceptible Ihost
- Measure I for I NG Itube: Itip Iof Inose, Iearlobe, Ixiphoid Iprocess
- AdministerIeardrops o Children: Ipull Iauricle Idown Iand Iback o Adult: Ipull Iauricle Iupward Iand Ioutward o Cotton o Apply Igentle Ipressure Ito Itragus Iof Iear
- Toxicity: Ikidney Ifailure
- BMI Iof I28: Ioverweight
- Opioids: Iconstipation
- Alcohol I with Iopioids Iwould Imake Ithe Ieffect Iwork Ifaster=synergisticIaffect
- Deltoid Ineedle: I22- 25 Iand I1-1 Iand Ia Ihalf Iin
- Valsalva Imaneuver: Idon’t Ihave Ia Iaging Iadult Ido Ithis IbecauseIintracranial I pressure
- Inserting Ia Isuppository: ILeft-side Iwith I(right) Iknee Ibent
- Feeding:
- Too Imany Imedications, Iconcerned Iwith I clogging: I (what Idoes Inurse Ido?) o use Iliquid Iforms Iof Imedication , Iif Ipossible o flush Itube Iwith I 30 Ito I 50 ImL Iof Iwater Ior Inormal Isaline Ibefore Iand IafterImedication Iadministration Iand Ibefore Iand Iafter Ibolus Ifeeding o flush Iwith Iwater Ievery I 4 Ihours Ifor Icontinuous Ifeeding o answer: Icall Ithe Ipharmacy Iand Iask Ithem Ito Isend Iyou Iliquid Iform IofImedications
- TPN Itotal Iparenteral Inutrition-through Ithe Icentral Iline
- HTN Imedication Iand Iorange Istool: Iquestion: Iwhat Imedications Ihave IyouItaken Irecently
- Laxative: Ilong-term Ican Icause Iconstipation
- Older Iadult: Icalcium Iand Ivitamin ID
- Candidate Ifor Itube: I throat Icancer
- nurse Ineeds Ifurther Iteaching: I(always Iprepare Ithe Iregular Iinsulin Ifirst) o Draw IRegular Iinsulin Ifirst, Ithen Ithe INPH Iin Ithe Isyringe o NPH Iis Iintermediate o insulin Igarglane I(Lantis) I- Ialways Idrawn Iin Iits Iown Isyringe I(drawn Ialone) o Regular Iinsulin Iis Ithe IONLY Iinsulin Ithat’s Igiven IIV
- IV Iis Ithe Ifastest Iabsorption
- Topical Iis Ithe Islowest
- Enteral Ifeeding: Icannot Iingest Ifood I but I can Idigest Iand IabsorbInutrients
- Stop Iusing IET Iwhen I75% Iof Ibody Ineeds Iare Imet, Itapering I method
- Inserted Iright Iinto Ithe Idigestive Itract Ilike Ia IJ-tube, IG-tube, ING Itube o Candidates: Ifunctioning IGI
- Parenteral Ifeeding: Icannot Idigest, Iabsorb ----- proble m Iwith Ithe IGI Iso you Ihave Ito Iget Ia Icentral Iline Iclose Ito Ithe Iheart o Candidates: I NON Ifunctioning IGI
- Side Ieffect: Iunavoidable, Ipredictable
- Idiosyncratic Ieffect: Iover/under-reactionIorIdifferent Ireaction IfromInormal, Iunpredictable Iex: Ilike Iif ICNS Istimulator Iand Iinstead Iof Ibecoming I restless Iand Ihave Ienergy Ithe Ipatient Ifalls Iasleep
- At Irisk: Imotorcycle Iaccident Ivictim
- Surgery: Iprimary Iintention, Iclean Iincisions, Iapproximated Iedges
- Burn: Isecondary Iintention, Iburns, Ipressure Iulcers, ISCARRING
- Tertiary Iintention: Ileft Iopen Ifor I 7 Idays Iuntil Inecrotic Istuff Iis Igone, Iand Ithen IitIcloses- Ibecause Iyou Idon’t Iwant Ito Itrap Ibacteria Iin Ithe Iwound **- Shallow Iopening: IStage III
- Nonblanchable: IStage II**
- Nectrotic: IUnstageable, Ineed Ito Iremove I(debridement)
- Wound Ican’t Ibe Istaged Iuntil Iit’s Idebrided
- Classification Iof IPressure IUlcers o Stage II: Iintact Iskin Iwith Inonblanchable Iredness o Stage III: Ipartial-thickness Iskin Iloss I(epidermis, Idermis, Ior Iboth) o Stage IIII: Ifull-thickness Itissue Iloss Iwith Ivisible Ifat o Stage IIV: Ifull- thickness Itissue Iloss Iwith Iexposed Ibone, Imuscle, Ior Itendon,IEschar
- First Isign Iof Ihypoxia: Irestlessness
- the Ilast Isign Iof Ihypoxia Iis: Icyanosis I(turning Iof Ithe Iskin Iblue)
- Administer Ianalgesic Iwithin I 30 Ito I 60 Iminutes o Dressing Ichange: Iprovide Ianalgesic Imeds
- Acute Idistress Isyndrome: Igive Ibronchodilator
- Atelectasis: Ibreathing Iexercises I- Ievery I1-2 Ihours Imake Ithem Icough IandIdeep Ibreath Iand Iincentive Ispirometer Iis I 10 Iper Ihour Iand Imake Isure Ito Iinspire Inot Iexpire I(use Iaccessory Imuscles)
- Calcium: Irenal Istones I(hype rcalce mia)
- Know Ihow Ito Iread Ilabel: Iwhat Iis Ithe Igeneric Iname
- Nasal Icannula: Imost Icommon I2-6L/min Iof Ioxygen
- most Icommon IHAIs I(nosocomial): IUTI I(why?) ILOOK IUP E. Icoli IisIthe Icommon Icause Ifor IUTI’s o I Catherterization: IE.Coli I?? IIatrogenic? - UTIs Iare Ione Iof Ithe Imost Icommon Ihealth Icare–acquired Iinfections o Escherichia Icoli, Ia Ibacterium Icommonly Ifound Iin Ithe Icolon, Iis Ithe ImostIcommon Icausative Ipathogen o risk Ifor Ia IUTI Iincreases Iin Ithe Ipresence Iof Ian Iindwelling Icatheter, Iany Iinstrumentation Iof Ithe Iurinary Itract, Iurinary Iretention, Iurinary Iand IfecalIincontinence, Iand Ipoor Iperineal Ihygiene Ipractices. o Symptomatic Iinfection Iof Ithe Ibladder Ican Ilead Ito Ia Iserious Iupper IUTI I(pyelonephritis) Iand Ilife-threatening Ibloodstream Iinfection I(bacteremia IorIurosepsis) Iand Ishould Ibe Itreated Iwith Iantibiotics. ISymptoms Iof Ia Ilower IUTI I(bladder) Ican Iinclude Iburning Ior Ipain Iwith Iurination I(dysuria); Iirritation Iof Ithe Ibladder I(cystitis) Icharacterized Iby Iurgency, Ifrequency, Iincontinence, Isuprapubic Itenderness; Iand Ifoul-smelling Icloudy Iurine. IOlder Iadults Imay Iexperience Ia Ichange Iin Imental Istatus Icalled Idelirium. IInIsome Icases Ithere Iwill Ibe Iobvious Iblood Iin Ithe Iurine I(hematuria). IIf Iinfection Ispreads Ito Ithe Iupper Iurinary Itract I(pyelonephritis), Ipatients Imay Ialso Iexperience Ifever, Ichills, Idiaphoresis, Iand Iflank Ipain - Catheter-associated IUTIs I(CAUTIs)
- Strong Ineed Ito Ivoid: Iurgency
- Indwelling I-sterile
- Intermittent-sterile
- Palpate Ibladder Ifor Idistention - Urine Iassessment: IColor, IOdor, IConsistency, IAmount
- Decrease Iin Iurine Ivolume: Iobstruction Ipossibility
- Signs Iof Iinfection I(5-10, I 000 Ifor IWBC Icount) I!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! - Why Ido Iyou Iget Iurine Isample Imidstream? IBc Ifirst Ifew Idrops Imay IhaveIbacteria
- Diabetes Imellitus Iat Irisk Ifor Itissue Iperfusion, Isugar Iis Ia Igood Imedium IforImicrobes Ito Igrow
- Evisceration: Ian Iinternal Iorgan Iis Isticking Ioutside Iof Ithe Ibody
- Dehiscence: Iseparation Iof Ithe Iwound Iand Ilayers Iof Iskin Iand Itissue Iseparate, IGIVING IWAY
- Cleaning: Inormal Isaline
- If Ithere Iis Ievisceration-put Imoist Idressing Iover Iit Iand Ithen Icall Ithe Iteam - Prevention: Ielevate Ihead Iof Ibed I 30 Idegree Iand Imaybe Ielevate Ithe Iknees Islightly, Ireposition Ievery I 2 Ihours, Iuse Itransfer Ilift Idevice Ifor **Ipressure Iulcers
- Nursing IDiagnosis IforIimmobile** o Skin Iintegrity: Irotate Ievery I 2 Ihours
o Fall: Ilower Ibed, Ibedrails I(up Ito I3), Icall-light Iat Ireach, Inon-skid Isocks,Iproper Ilighting Iand Ino Iclutter
- Wound Ihealing: Inutrition, Itissue Iperfusion, Iinfection, Iage, IandIpsychosocial Iimpact Iof Iwounds
- Monitoring IStage IIII Ipressure Iulcer: IHealing IStage IIII Ipressure Iulcer
- Moist Iwound: Iresurface Iat I 4 Idays; Iopen Iwound: I 6 Ito I 7 Idays
- Full- thickness Irepair: Igranulation
- Most Iimportant Iassessment Idata Ito Iwound Ihealing: Ipulse Iox Iassessment - Stage IIII Iulcer Iwith Ipurulent Idischarge Iand Iodor: Icomplete Ihead ItoItoe Iassessment, Icurre nt Itreatment, Ivital Isigns Iand Ilab Iresults
- Decrease Irisk Iof Ipressure Iulcers Iand Iincrease Imobility: Isit Iup Iin Ichair
- Immobile Ipatient-watch Irespiratory Isystem
- Decrease Ianxiety: Iexplain Iprocedure - Who Iis IatIrisk IforIpressure Iulcer: IdecreasedImobility, IdecreasedIsensory Iperception, Ifecal IorIurinary Iincontinence Iand Ipoor **Inutrition
- Urinary Iincontinence I(UI) Iis Idefined Ias Ithe I“complaint Iof** IanyIinvoluntary Iloss Iof Iurine o urge Ior Iurgency IUI I(involuntary Ileakage Iassociated Iwith Iurgency) o stress IUI I(involuntary Iloss Iof Iurine Iassociated Iwith Ieffort Ior IexertionIon Isneezing Ior Icoughing o reflux-most Idangerous Ione o transient-from Ia Imedical Icondition
- Collapsed Ialveoli: Iatelectasis
- Fever Iincreases Imetabolic Idemand Iand Iheart Irate!!!!! IUseIantipyretics!!!!!!!!!!!!!!!!!!!!!!!!!! - Nurse Isees Ipatient Iunconscious Iin Isidewalk, InumberIone Ipriority o When Iout Iin Icommunity: Iassess Ithe Iscene Iand Icall I 911 o If Ialone: Icall I911; Inot Ialone: Istart Icompressions o If Iat Ihospital: Ipush Ibutton Ifor Icode Iand Istart Icompressions
IncubationI
Prodromal
Contact Iprecautions-blood Ithat Igets Ion Iyou, Iclean Iit Iquickly ----- varicella-chicken Ipox
Droplet-up Ito I3ft. Iflu
- Components Iof Icritical Ithinking
I. Specific Iknowledge Ibase Iin Inursing
Underlying Idisease Iprocess, Inormal Igrowth Iand Idevelopment, Inorma l Iphysiology Iand Ipsychology, Inormal Iassessment Ifindings, Ihealth Ipromotion, Iassessment Iskills,Iand Icommunication Iskills
II. Experience
Previous Ipatient Icare Iexperience, Ivalidation Iof Iassessment Ifindings I& IobservationIof Iassessment Itechniques
III. Critical Ithinking Icompetencies
A. General Icritical Ithinking: Iscientific Imethod, Iproblem Isolving Iand IdecisionImaking
B. Specific Icritical Ithinking: Idiagnostic Ireasoning, Iclinical Iinference Iand IclinicalIdecision Imaking
C. Specific Icritical Ithinking Iin Inursing: Inursing Iprocess
IV. Attitudes Ifor Icritical Ithinking
Confidence, Iindependence, Ifairness, Iresponsibility, Irisk Itaking, Idiscipline,Iperseverance, Icreativity, Icuriosity, Iintegrity, Ihumility
V. Standards IforIcritical Ithinking
A. Intellectual Istandards Clear—Plain Iand Iunderstandable I(e.g., Iclarity Iin Ihow Ione Icommunicates).
Precise—Exact Iand Ispecific I(e.g., Ifocusing Ion Ione Iproblem Iand IpossibleIsolution).
Specific—To Imention, Idescribe, Ior Idefine Iin Idetail
Accurate—True Iand Ifree Ifrom Ierror; Igetting Ito Ithe Ifacts I(objective IandIsubjective)
Relevant—Essential Iand Icrucial Ito Ia Isituation I(e.g., Ia Ipatient's IchangingIclinical Istatus)
Plausible—Reasonable Ior Iprobable IConsistent—
Expressing Iconsistent Ibeliefs Ior Ivalues
Logical—Engaging Iin Icorrect Ireasoning Ifrom Iwhat Ione Ibelieves Iin Ia IgivenIinstance Ito Ithe Iconclusions Ithat Ifollow
Deep—Containing Icomplexities Iand Imultiple Irelationships
IBroad—Covering Imultiple Iviewpoints I(e.g., Ipatient Iand
Ifamily)IComplete—Thoroughly Ithinking Iand Ievaluating ISignificant—Focusing Ion Iwhat Iis Iimportant Iand Inot Itrivial
Adequate I(for Ipurpose)—Satisfactory Iin Iquality Ior IamountIFair—Being Iopen- minded Iand Iimpartial
B. Professional Istandards
- Ethical Icriteria Ifor Inursing Ijudgment
- Criteria Ifor Ievaluation
- Professional Iresponsibility
Steps Iof INursing IProcess
Infectious IProcess I(pg I443)
If Ian Iinfection Iis Ilocalized I(e.g., Ia Iwound Iinfection), Ia Ipatient Iusually IexperiencesIlocalized Isymptoms Isuch Ias Ipain, Itenderness, Iwarmth, Iand Iredness Iat Ithe Iwound Isite. IUseIstandard Iprecautions, Iappropriate IPPE, Iand Ihand Ihygiene Iwhen Iassessing Ithe Iwound. ITheIuse Iof Ithese Iprecautions Iand Ihand Ihygiene Iblocks Ithe Ispread Iof Iinfection Ito Iother Isites Ior Iother Ipatients. IAn Iinfection Ithat Iaffects Ithe Ientire Ibody Iinstead Iof Ijust Ia Isingle Iorgan Ior Ipart Iis Isystemic Iand Ican Ibecome Ifatal Iif Iundetected Iand Iuntreated.
The Icourse Iof Ian Iinfection Iinfluences Ithe Ilevel Iof Inursing Icare Iprovided. IThe Inurse Iis Iresponsible Ifor Iproperly Iadministering Iantibiotics, Imonitoring Ithe Iresponse Ito Idrug Itherapy I, Iusing Iproper Ihand Ihygiene, Iand Istandard Iprecautions. ISupportive Itherapy
includes Iproviding Iadequate Inutrition Iand Irest Ito Ibolster Idefenses Iof Ithe Ibody Iagainst Ithe Iinfectious Iprocess. IThe Icourse Iof Icare Ifor Ithe Ipatient Ioften Ihas Iadditional Ieffects Ion IbodyIsystems Iaffected Iby Ithe Iinfection. Course Iof IInfection Iby IStageIIncubation IPeriod Interval I between I entrance I of I pathogen I into I body I and I appearance I of I first I symptoms (e.g., Ichickenpox, I 14 Ito I 16 Idays Iafter Iexposure; Icommon Icold, I 1 Ito I 2 Idays; Iinfluenza, I 1 ItoI 4 Idays; Imeasles, I 10 Ito I 12 Idays; Imumps, I 16 Ito I 18 Idays; IEbola I 2 Ito I 21 Idays Prodromal IStage Interval Ifrom Ionset Iof Inonspecific Isigns Iand Isymptoms I(malaise, Ilow-grade I fever, Ifatigue) Ito Imore Ispecific Isymptoms. I(During Ithis Itime Imicroorganisms Igrow I and Imultiply, Iand Ipatient Imay Ibe Icapable Iof Ispreading Idisease Ito Iothers.) IFor Iexample, IherpesIsimplex Ibegins Iwith Iitching Iand Itingling Iat Ithe Isite Ibefore Ithe Ilesion Iappears. Illness IStage Interval Iwhen Ipatient Imanifests Isigns Iand Isymptoms Ispecific Ito Itype Iof Iinfection. IFor Iexample, Istrep Ithroat Iis Imanifested Iby Isore Ithroat, Ipain, Iand Iswelling; Imumps Iis Imanifested Iby Ihigh Ifever, Iparotid Iand Isalivary Igland Iswelling. Convalescence Interval Iwhen Iacute Isymptoms Iof Iinfection Idisappear. I(Length Iof Irecovery Idepends Ion Iseverity Iof Iinfection Iand Ipatient's Ihost Iresistance; Irecovery Imay Itake Iseveral Idays Ito Imonths.)
Standard Iprecautions: I Apply Ito Iblood, Iblood Iproducts, Iall Ibody Ifluids, Isecretions,Iexcretions, Ino Iintact Iskin, Iand Imucous Imembranes.
- Perform Ihand Ihygiene Ibefore, Iafter Iand Ibetween Idirect Icontact Iwith Ipatients. IAfterIremoving Igloves. IHands Iare Ivisible Isoiled.
- Do Inot Iwear Iartificial Ifingernails.
- Wear Igloves
- Wear IPPE Iwhen Ianticipated Ipatient Iinteraction Iindicates Ithat Icontact Iwith Iblood IorIbody Ifluids Imay Ioccur.
- Discard Iall Icontaminated Isharp Iinstruments Iand Ineedles Iin Ia Ipuncture IresistantIcontainer.
- Have Ipatient Icover Itheir Imouth Iwhen Icoughing. IUse Itissue Iand Iperform IhandIhygiene.
Contact Iprecautions : I Used Ifor Idirect Iand Iindirect Icontact Iwith Ipatients Iand Itheir Ienvironment. IDirect Icontact Irefers Ito Ithe Icare Iand Ihandling Iof Icontaminated Ibody Ifluids.IContact Iprecautions Irequire Ia I gown Iand Igloves. IAn Iexample Iincludes Iblood Ior Iother Ibody Ifluids Ifrom Ian Iinfected Ipatient Ithat Ienter Ithe Ihealth Icare Iworker's Ibody Ithrough Idirect Icontact Iwith Icompromised Iskin Ior Imucous Imembranes. IIndirect Icontact Iinvolves Ithe Itransfer Iof Ian Iinfectious Iagent Ithrough Ia Icontaminated Iintermediate Iobject Isuch Ias Icontaminated Iinstruments Ior Ihands Iof Ihealth Icare Iworkers. IThe Ihealth Icare Iworker Imay
transmit Imicroorganisms Ifrom Ione Ipatient Isite Ito Ianother Iif Ihand Ihygiene Iis InotIperformed Ibetween Ipatients I (Varicella) Droplet Iprecautions : IFocus Ion Idiseases Ithat Iare Itransmitted Iby Ilarge Idroplets I(greater Ithan I 5 Imicrons) Iexpelled Iinto Ithe Iair Iand Iby Ibeing Iwithin I 3 Ifeet Iof Ia Ipatient. IDroplet Iprecautions Irequire Ithe I wearing Iof Ia Isurgical I mask Iwhen Iwithin I 3 Ifeet Iof Ithe Ipatient ,Iproper Ihand Ihygiene, Iand Isome Idedicated-care Iequipment. IAn Iexample Iis Ia Ipatient IwithIinfluenza Airborne Iprecautions: I Focus Ion Idiseases Ithat Iare Itransmitted Iby Ismaller Idroplets, IwhichIremain Iin Ithe Iair Ifor Ilonger Iperiods Iof Itime. IThis Irequires Ia Ispecially Iequipped Iroom Iwith Ia Inegative Iair Iflow Ireferred Ito Ias Ian I airborne Iinfection Iisolation Iroom. IAir Iis Inot Ireturned Ito Ithe Iinside Iventilation Isystem Ibut Iis Ifiltered Ithrough Ia Ihigh-efficiency Iparticulate Iair I(HEPA) Ifilter Iand Iexhausted Idirectly Ito Ithe Ioutside. IAll Ihealth Icare Ipersonnel Iwear Ian I N95 Irespirator Ievery Itime Ithey Ienter Ithe Iroom. I (TB) Protective Ienvironment : I Focuses Ion Ia Ivery Ilimited Ipatient Ipopulation. IThis Iform Iof Iisolation Irequires Ia Ispecialized Iroom Iwith Ipositive Iairflow. IThe Iairflow Irate Iis Iset Iat Igreater Ithan I 12 Iair Iexchanges Iper Ihour, Iand Iall Iair Iis Ifiltered Ithrough Ia IHEPA Ifilter. IPatients Imust Iwear Imasks Iwhen Iout Iof Itheir Iroom Iduring Itimes Iof Iconstruction Iin Iarea.
Autoimmune Ideficiency
Normal IRanges Ifor Ivitals: IAcceptable IRanges IforIAdults
Temperature IRange Average Itemperature Irange: I 36° Ito I38° IC I(96.8° Ito I100.4° IF) Average Ioral/tympanic: I 37° IC I(98.6° IF) Average Irectal: I 37.5° IC I(99.5° IF) Axillary: I 36.5° IC I(97.7° IF) Pulse I 60 Ito I 100 Ibeats/min, Istrong Iand Iregular Pulse IOximetry I(SpO 2 ) I Normal: ISpO 2 I≥95% no Ioxygen Iuntil Iits Iat I88% Respirations IAdult: I 12 Ito I 20 Ibreaths/min, Ideep Iand IregularIBlood IPressure Systolic I <120 Imm IHg Diastolic I <80 Imm IHg Pulse Ipressure: I 30 Ito I 50 Imm IHg Capnography I(EtCO 2 ) I Normal: I35-45 Imm IHg
Acceptable IRanges Iof IRespiratory IRate Age Rate I(breaths/min)
Newborn 30 - 60 Infant I( months)
30 - 50
Toddler I(2 Iyears) 25 - 32 Child 20 - 30 Adolescent 16 - 20 Adult 12 - 20
- respiration o rate, Idepth I(deep/shallow) o labored I(using Iaccessory Iorgans) o lung Isounds ▪ normal: Ivesicular/ Iclear ▪ crackles: I(fluid) Ipneumonia ▪ rhonchi: Iirregular ▪ wheezing: I musical Iswishing ▪ asthma
o check Iblood Ipressure Iif Itheyre Ibreathing Ifast Ibut Ieverything Ielse IisInormal
- orthostatic Iblood Ipressure-laying, Istanding, IsittingIsystolic>20 Idrop, Idiastolic Idrop I>
Average IOptimal IBlood IPressure IforIAge Age Blood IPressure I(mm IHg) Newborn I(3000 Ig [6.6 Ilb])
40 I(mean)
1 Imonth 85/ 1 Iyear 95/ 6 Iyears 105/ 10 - 13 Iyears 110/ 14 - 17 Iyears 119/ 18 Iyears Iand Iolder <120/<
Assessing Ithe IRisk Iof IInfection IinIAdults Risk IFactor Causes Outcome Chronic disease
COPD, Iheart Ifailure, Idiabetes Pneumonia, Iskin Ibreakdown, Ivenous stasis Iulcers Lifestyle— Ihigh-risk Ibehaviors
Exposure Ito Icommunicable/infectious diseases, Iuse Iof IIV Idrugs IandIother Idrugs/substances
STIs, IHIV, IHBV, IHCV, IopportunisticIinfections, Iviral Iinfections, Iyeast Iinfections, Iliver Ifailure Occupation Health Icare Iworker; Iminer, unemployed, Ihomeless
Exposure Ito Iblood Iand Ibody Ifluids increase Irisk Iof Iinfection; Iblack Ilung
disease, Ipneumonia, ITB, Ipoor Inutritional Iintake; Ilack Iof Iaccess Ito medical Icare; Istress Diagnostic procedures
Invasive Iradiology, Itransplant Multiple IIV Ilines, immunosuppressive Idrugs Heredity Sickle Icell Idisease, Idiabetes Anemia, Idelayed Ihealing Travel history
West INile Ivirus, ISARS, Iavian flu, I Hantavirus
Meningitis, Iacute Irespiratory Idistress
Trauma Fractures, Iinternal Ibleeding Sepsis, Isecondary Iinfection Nutrition Obesity, Ianorexia Impaired Iimmune Iresponse
PPE
1. GOWNS: I Prevent Isoiling Iclothes Iduring Icontact Iwith Ipt. IGowns Iused Ifor IbarrierIprotection Iare Iusually Ifluid Iresistant Imaterial. IIsolation Igowns Iusually Iopen Iat ItheIback Iand Ihave Ities Ior Isnaps Iat Ithe Ineck Iand Iwaist Ito Ikeep Ithe Igown Iclosed Iand Isecured. 2. MASK: I provide Irespiratory Iprotection 3. Eye IProtection : IWhen Iperforming Iprocedures Ithat Iwill Isplash Ior Isplatter. 4. Gloves: I Help Iprevent Ithe Itransmission Iof Ipathogens Iby Idirect Iand Iindirect IcontactI When Ifull IPPE: Ifirst Iperform I hand I hygiene, Ithen Iapply Ia Igown, Iapply Imask Iand Ieyewear Ior Igoggles, Iand Iend I with Iapplying Igloves.
Orthostatic Ihypotension, Ialso Ireferred Ito Ias Ipostural Ihypotension, Ioccurs Iwhen Ia Inormotensive Iperson Idevelops Isymptoms Iand Ia Idrop Iin Isystolic Ipressure Iby Iat Ileast I 20mm IHg Ior Ia Idrop Iin Idiastolic Ipressure Iby Iat Ileast I 10 Imm IHg Iwithin I 3 Iminutes I of Irising Ito Ian Iupright Iposition. IWhen Ia Ihealthy Iindividual Ichange Ifrom Ia Ilying–to Isitting– toIstanding Iposition, Ithe Iperipheral Iblood Ivessels Iin Ithe Ilegs Iconstrict. IWhen Istanding, Ithe Ilower-extremity Ivessels Iconstrict, Ipreventing Ithe Ipooling Iof Iblood Iin Ithe Ilegs Icaused Iby Igravity. IThus, Ian Iindividual Inormally Idoes Inot Ifeel Iany Isymptoms Iwhen Istanding. IIn Icontrast, Iwhen Ipatients Ihave Ia Idecreased Iblood Ivolume, Itheir Iblood Ivessels Iare Ialready Iconstricted. IWhen Ia Ipatient Iwith Ivolume Idepletion Istands, Ithere Iis Ia Isignificant Idrop Iin IBP Iwith Ian Iincrease Iin IHR Ito Icompensate Ifor Ithe Idrop Iin Icardiac Ioutput. IPatients Iwho IareIdehydrated, Ianemic, Ior Ihave Iexperienced Iprolonged Ibed Irest Ior Irecent Iblood Iloss Iare Iat Irisk Ifor Iorthostatic Ihypotension, Iparticularly Iin Ithe Imorning. ISome Imedications Icause Iorthostatic Ihypotension Iif Imisused, Iespecially Iin Iolder Iadults Ior Iyoung Ipatients. IAlways Imeasure IBP Ibefore Iadministering Isuch Imedications.
Assess Ifor Iorthostatic Ihypotension Iduring Imeasurements Iof Ivital Isigns Iby Iobtaining IBP Iand Ipulse Iin Isequence Iwith Ithe Ipatient Isupine, Isitting, Iand Istanding. IObtain IBP Ireadings Iwithin I 3 Iminutes Iafter Ithe Ipatient Ichanges Iposition. IIn Imost Icases, IorthostaticIhypotension Iis Idetected Iwithin Ia Iminute Iof Istanding. IIf Iit Ioccurs, Ihelp Ithe Ipatient Ito Ia Ilying Iposition Iand Inotify Ithe Ihealth Icare Iprovider Ior Inurse Iin Icharge. IWhile Iobtaining Iorthostatic Imeasurements, Iobserve Ifor Iother Isymptoms Iof Ihypotension Isuch Ias Ifainting, Iweakness, Iblurred Ivision, Ior Ilight-headedness. IOrthostatic Ihypotension Iis Ia Irisk Ifactor Ifor Ifalls, Iespecially Iamong Ielderly Ipatients Iwith Ihypertension. IWhen Irecording Iorthostatic IBPImeasurements, Irecord Ithe Ipatient's Iposition Iin Iaddition Ito Ithe IBP Imeasurement I(e.g., I140/80 Imm IHg Isupine, I132/72 Imm IHg Isitting, I108/60 Imm IHg Istanding).
Methods Iof IHeat ILoss
- Conduction : ITransfer Iof Iheat Iwith Idirect Icontact.
- Radiation: I transfer Iof Iheat Ifrom Ithe Isurface Iof I 1 Iobject Ito Ianother Iwith IdirectIcontact Ibetween Itwo.
- Convection: I transfer Iof Iheat Iaway Iby Iair Imovement.
- Evaporation: I transfer Iof Iheat Ienergy Iwhen Iliquid Iis Ichanged Ito Igas.
Infants Ilose Itheir Iheat Ithrough Itheir Ihead!!!!
Aseptic Ivs ISterile ITechnique Aseptic Itechnique: IProcedures Ithat Ihelp Ireduce Ithe Irisk Ifor Iinfection.
- Medical IAsepsis: IHand Ihygiene, Iroutine Ienvironmental Icleaning Iand IbarrierItechniques. IKilling Imicrobes Ibut Inot Ispores. IClean Itechnique
- Surgical Iasepsis: Isterile Itechnique
- Sterile ITechnique: Ieliminates Iand Idestroys Iall Iforms Iof Imicrobial Ilife Iincluding Ispores. ISterilization Imethod Iinclude Iprocessing Iitems Iusing Isteam,Idry Iheat, Ihydrogen Iperoxide Iplasma, Ior Iethylene Ioxide.
- Nurse Iwith Ipost-partum Ipatient. IWhat Ito Ido Iwith Ibaby: Ikeep Icap Ion Ihead
- Nurse Iis Idoing Iassessment Iirregular Iradial Ipulse: Ido Iapical Ipulse Ifor Ione Iminute
- Med ICal: IPt Iis Iordered I 30 ImL. Ihow Imany Itablespoons: I 2 Itbsp
- Baby Iweight I7.3 Ikg Iis I16.1 Ilbs - Using IPPE Iin Ireverse: Iremove Igloves Ifirst, Ithen Igoggles, Ithen Igown, IthenImask
- Nurse Iis Iquestioning Ipatient Iinadequate Ipain Imanagement o I1. IGuarded Iabdomen, I2. Irefuse Ito Iturn Ior Ido Ibreathing Iexercises, I4. IpatientIhas Ipain Iand Iswelling Iin Ilower I(last Ianswer I#5 Iis Icorrect Itoo)
- Nurse Iis Iassessing Ipatient Iwith Ihypertension. IWhat Iare Ithe IcontributingIfactors? o Smoking, Iobesity, Iexcessive Idrinking
- Patient Iis Isusceptible Ito Iinfection. IWhat Ishould Ihe Ido? o Stop Iexcessive Idrinking
- Nurse Iis Iremoving IIV. IDrop Iof Iblood Ion Iintact Iskin o Stop, Iwash, Ireglove Ithen Istart Ireassessing
- Maternity Ipatient. IVital Ialarm Igoes Ioff. IWhat Ido Iyou Ido Inext? o Continue Ito Iassess. IWash Ihands Iand Ithen Iattend Ito Ivital Ialarm
- UTA. IBP Iis I90/52. IWhat Idoes Ithe Inurse Ido? o Go Icheck Iit Iyourself o I 3 Imain Icomponents Iof Ipulse: Irate, Irhythm, Istrength, Iequality
- Normal Ipulse Ifor Iadult: I60-100 Ibpm
- Normal Irespirations Ifor Iadult: I12-20 Ibreaths
- 59 Iyo Iolder Igentleman. IWhat Iis Iconsidered Inormal Itemperature? I95- 97 ⁰FIor I35-36.1⁰C Ias Ipeople Iget Iolder, Icore Itemp Idrops
- Asking Ian Iopen-ended Iquestion.
- Nurse Iwants Ito Icheck Ienvironment Ifor Irisks: ICheck Ihealth Ihistory
- Nurse Iheard Ipatient Idemand Iother Ifood. IAsked Idoctor: IBasic Ilevel o Patient Iis Ion Ibed-rest Iand Ineeds Ito Igo Ito Ibathroom: Itake Ipatient Ifrom IlyingIto Isitting Iand Ilet Ifeet Idangle - Levels Iof ICritical IThinking o Level I 1 Iis I Basic : IAt Ithe Ibasic Ilevel, Inurses Ithink Iconcretely Ion Ithe Ibasis IofIa Iset Iof Irules Ior Iprinciples, Ifollowing Ia Istep-by-step Iprocess Iwithout Ideviation Ifrom Ithe Iplan. IFollowing Ia Iprocedure Istep Iby Istep Iwithout Iadjusting Ito Ia Ipatient’s Iunique Ineeds Iis Ian Iexample Iof Ibasic Icritical Ithinking. o Level I 2 Iis I Complex: I Complex Icritical Ithinking Ianalyzes Iand Iexamines Ichoices Iindependently. INurses Ilearn Ito Ithink Ibeyond Iand Isynthesize Iknowledge. IIn Icomplex Icritical Ithinking, Ia Inurse Ilearns Ithat Ialternative IandIperhaps Iconflicting Isolutions Iexist - start Ito Idifferentiate Iyourself Ifrom other Ipeople o Level I 3 Iis I Commitment : ICommitment Iis Ithe Ithird Ilevel Iof Icritical Ithinking. INurses Ianticipate Ineeds Iand Imake Ichoices Iwithout IassistanceIfrom Iothers.
- Patient Iis Iin Iisolated Iroom. IWhat Ishould Ithe Inurse Itell Ipatient’s Ifamily: ICannotIhave Iflowers o I no Iuncooked Ifoods, Ino Ichildren
- What Idoes Iconvalescence Imean: Iacute Isymptoms Iof Iinfection Idisappears
- Patient Ihas Ihad Ichemo Iand Iradiation Ifor Icolon Icancer -- would Iprob Ibe immunocompromised Iwhich Iyou Iwould Ineed Ito Iput Ithem Iin Ia IPOSITIVEIPRESSURE Iroom o Use Istandard Iprecaution
- Patient Ihad Ian Iopen Iappendectomy. IThe Inurse Iinferred Iabout Iher IgoingIhome Iand Ithe Ipatient Iis Iscared Ito Igo Ihome, Iwhy?: Ianxious Iabout IgoingIhome
- Radial Ipulse: Iuse Imiddle Iand Iindex Ifinger
- Easiest Iway Ito Iget Itemperature Iwithout Ibothering: Itympanic o rectal: Imost Iaccurate Ibc Iclose Ito Icore Itemperature o tympanic: Ibabies, Iseizures I(not Igoing Ito Istay Istill)
- For Ifever: Iantipyretics!
- ADPIE-assess, Idiagnose, Iplan, Iimplement, Ievaluate
- Implementation Iand IEvaluation Ifor INursing IProcess
- The Ilast Ithing Ishe Idid Iwas Iimplement. IExample Iof Iimplementation o Know Idefinition:
- Patient Iwith IInfectious IDisease. Ihow Ido Iyou Iassess: o What Itype Iof Idisease Iand Ihow Ilong Ihave Iyou Ihad Iit? I* o Religion Iand Ibeliefs?
- Alcohol I pump: I 3 Itimes I→ Isoap Iand Iwater o If Ihands Iare Inot Ivisibly Isoiled, Iuse Iof Ian Ialcohol-based Ihand Iproduct Ior Ihandwashing I with Isoap Iand I water Iis Iacceptable Ifor Idisinfecting Ihands Iof Ihealth Icare Iworkers. IHand Ihygiene Iis Ithe Imost Ieffective IwayIto Ibreak Ithe Ichain Iof Iinfection
▪ If Ihands Iare Inot Ivisibly Isoiled I(WHO, I2009), Iuse Ian Ialcohol- Ibased, Iwaterless Iantiseptic Iagent IforIroutinely IdecontaminatingIhands Iin Ithe Ifollowing Iclinical Isituations:
**- Before, Iafter, Iand Ibetween Idirect Ipatient Icontact I(e.g., ItakingIa Ipulse, Ilifting Ia Ipatient)
- Before Iputting Ion Isterile Igloves Iand Ibefore Iinserting Iinvasive Idevices Isuch Ias Ia Iperiphe ral Ivascular Icatheter Ior Iurinary Icatheter
- After Icontact I with Ibody Ifluids Ior Iexcretions, Imucous Imembranes, Inonintact Iskin, Iand I wound Idressings I(even IifIgloves Iare Iworn)
- When Imoving Ifrom Ia Icontaminated Ito Ia Iclean Ibody IsiteIduring Icare
- After Icontact I with Isurfaces IorIobjects Iin Ithe Ipatient's IroomI(e.g., Ioverbed Itable, IIVIpump)
- AfterIre moving Igloves**
- Transmission: I 3 Ifeet Iaway - 4 Istages Iof Iinfection
- Incubation IPeriod: I Interval Ibetween Ientrance Iof Ipathogen Iinto Ibody Iand I appearance Iof Ifirst Isymptoms I (e.g., Ichickenpox, I 14 Ito I 16 Idays Iafter Iexposure; Icommon Icold, I 1 Ito I 2 Idays; Iinfluenza, I 1 Ito I 4 Idays; Imeasles, I 10 Ito I 12 Idays; Imumps, I 16 Ito I 18 Idays; IEbola I 2 Ito I 21 Idays
- Prodromal IStage : IInterval Ifrom Ionset Iof Inonspecific Isigns Iand Isymptoms I(malaise, Ilow-grade Ifever, Ifatigue) Ito Imore Ispecific Isymptoms. I(During Ithis Itime Imicroorganisms Igrow Iand Imultiply, Iand Ipatient Imay Ibe Icapable Iof Ispreading Idisease Ito Iothers.) IFor Iexample, Iherpes Isimplex Ibegins Iwith Iitching Iand Itingling Iat Ithe IsiteIbefore Ithe Ilesion Iappears.
- Illness IStage : IInterval Iwhen Ipatient Imanifests Isigns Iand IsymptomsIspecific Ito Itype Iof Iinfection. IFor Iexample, Istrep Ithroat Iis Imanifested Iby Isore Ithroat, Ipain, Iand Iswelling; Imumps Iis ImanifestedIby Ihigh Ifever, Iparotid Iand Isalivary Igland Iswelling.
- Convalescence: I Interval Iwhen Iacute Isymptoms Iof Iinfection Idisappear. I(Length Iof Irecovery Idepends Ion Iseverity Iof IinfectionIand Ipatient's Ihost Iresistance; Irecovery Imay Itake Iseveral Idays Ito Imonths.) - chain Iof Iinfection
- An Iinfectious Iagent Ior Ipathogen
- A Ireservoir Ior Isource Ifor Ipathogen Igrowth
- A Iport Iof Iexit Ifrom Ithe Ireservoir
- A Imode Iof Itransmission
- A Iport Iof Ientry Ito Ia Ihost
- A Isusceptible Ihost
- Pt Ihad Ia Isurgery I 24 Ihours Iago. IIt Iis Ired Iand Ioozing. IHas Ilow-grade Ifever: InotifyIthe Iphysician
- Immobility: IDepression Irisks - Canes I(806) o Keep Icane Ion Istronger Iside Iof Ithe Ibody o Place Icane Iforward I 6 Ito I 10 Iinches, Ikeeping Ibody Iweight Ion Iboth Ilegs o Weaker Ileg Iis Imoved Iforward, Idivide Iweight Ibetween Icane Iand IstrongerIleg o Stronger Ileg Iis Iadvanced Ipast Icane; Idivide Iweight Ibetween Icane IandIweaker Ileg
- Crutches I(pg I806) o weight Ibearing Ion Igood Ileg o The Iaxillary Icrutch Iis Ithe Imore Icommon Icrutch Iused. o Measurements: Ipatient’s Iheight, Ithe Iangle Iof Ielbow Iflexion, Iand ItheIdistance Ibetween Ithe Icrutch Ipad Iand Ithe Iaxilla. o When Icrutches Iare Ifitted, Iensure Ithe Ilength Iof Ithe Icrutch Iis Itwo Ito Ithree Ifinger Iwidths Ifrom Ithe Iaxilla Iand Iposition Ithe Itips Iapproximately I 2 IinchesIlateral Iand I 4 Ito I 6 Iinches Ianterior Ito Ithe Ifront Iof Ithe Ipatient’s Ishoes o Position Ithe Ihandgrips Iso Ithe Iaxillae Iare Inot Isupporting Ithe Ipatient’s IbodyIweight. o Pressure Ion Ithe Iaxillae Iincreases Irisk Ito Iunderlying Inerves, IwhichIsometimes Iresults Iin Ipartial Iparalysis Iof Ithe Iarm. o Determine Icorrect Iposition Iof Ithe Ihandgrips Iwith Ithe Ipatient Iupright, Isupporting Iweight Iby Ithe Ihandgrips Iwith Ithe Ielbows Islightly Iflexed Iat I 20 Ito I 25 Idegrees. o Elbow Iflexion Imay Ibe Iverified Iwith Ia Igoniometer. o When Iyou Idetermine Ithe Iheight Iand Iplacement Iof Ithe Ihandgrips, IverifyIthat Ithe Idistance Ibetween Ithe Icrutch Ipad Iand Ithe Ipatient’s Iaxilla Iis Iapproximately I 2 Iinches I(two Ito Ithree Ifinger Iwidths). ▪ Canes Iand Icrutches: Ifalling Irisks Iand Iskin Ibreakdown - crutch Igait: ▪ basic: Itripod Iposition ▪ crutches Iare Iplaced I 15 Icm I(6 Iinches) Iin Ifront Iof Iand I 15 IcmI(6 Iinches) Ito Ithe Iside Iof Ieach Ifoot ▪ improves Ithe Ipatient's Ibalance Iby Iproviding Ia Iwider Ibase IofIsupport. ▪ body Ialignment: Ierect Ihead Iand Ineck, IstraightIvertebrae, Iand Iextended Ihips Iand Iknees. - Four-point Ialternating, Ior Ifour-point - gives Istability Ito Ithe Ipatient Ibut Irequires Iweight Ibearing Ion Iboth Ilegs. IEach Ileg Iis Imoved Ialternately Iwith Ieach Iopposing Icrutch Iso Ithree Ipoints Iof IsupportIare Ion Ithe Ifloor Iat Iall Itimes - Three-point Ialternating, Ior Ithree-point, Igait - requires Ithe Ipatient Ito Ibear Iall Iof Ithe Iweight Ion IoneIfoot. IIn Ia Ithree-point Igait Ithe Ipatient Ibears Iweight Ion Iboth Icrutches Iand Ithen Ion Ithe Iuninvolved Ileg, Irepeating Ithe Isequence
- The Iaffected Ileg Idoes Inot Itouch Ithe Iground Iduring Ithe Iearly Iphase Iof Ithe Ithree-point Igait. IGradually ItheIpatient Iprogresses Ito Itouchdown Iand Ifull Iweight Ibearing Ion Ithe Iaffected Ileg.
- The Itwo-point Igait
- requires Iat Ileast Ipartial Iweight Ibearing Ion Ieach Ifoot
- moves Ia Icrutch Iat Ithe Isame Itime Ias Ithe Iopposing IlegIso Ithe Icrutch Imovements Iare Isimilar Ito Iarm Imotion Iduring Inormal Iwalking. - Critical Ithinking: IA Icontinuous Iprocess Icharacterize d Iby Iopen- Imindedness, Icontinual Iinquiry, Iand Iperseverance, Icombined I with Ia Iwillingness Ito Ilook Iat Ieach Iunique Ipatient Isituation Iand Idetermine Iwhich Iidentified Iassumptions Iare Itrue Iand Irelevant. IRecognizing IthatIan Iissue Iexists, Ianalyzing Iinformation, Ievaluating Iinformation, Iand I making Iconclusions
- Older Ipatient. IWhat Iis Iconsidered Inormal: I(second Ianswer, Ivitals IareIborderline) Ilow IBP, Ibreath Isounds I60, IO2 Isat I94, Ipulse I 62
- 11 Iattitudes Iof Inurse: Ibe Idiscipline Iand Ithorough
- Scientific Imethod I(implementation)
- identify Iproblem
- collect Idata
- formulate Iquestion; Ihypothesis
- test Iquestion
- evaluate
- Build Icritical Ithinking Iskills: Iconcept Imapping-shows Ithe Irelationship IbetweenIdata
- IV: Ihow Ilong Ito Irun o LIbag Iover I 4 Ihrs ▪ 1000 I/ I 4 I= I250/hr Irate
- Know Ihow Ito Iadminister Ioral, IsubQ, IIM
- wound Iinfection: Ired, Idrainage, Iswollen, Ipus, Itemperature, IWBC o call IDr. Ifirst Ito Iget Iorders ▪ antibiotics
- Infection IPrevention Iand IControl Ito IReduce IReservoirs Iof IInfection I(box I29-10) o Bathing ▪ Use Isoap Iand Iwater Ito Iremove Idrainage, Idried Isecretions, Ior IexcessIperspiration. o Dressing IChanges ▪ Change Idressings Ithat Ibecome Iwet Iand/or Isoiled o ContaminatedIArticles ▪ Place Itissues, Isoiled Idressings, Ior Isoiled Ilinen Iin Ifluid- resistantIbags Ifor Iproper Idisposal. o Contaminated ISharps
▪ Place Iall Ineedles, Isafety Ineedles, Iand Ineedleless Isystems Iinto Ipuncture-proof Icontainers, Iwhich Ishould Ibe Ilocated Iat Ithe Isite Iof Iuse. IFederal Ilaw Irequires Ithe Iuse Iof Ineedle-safe Itechnology. IBloodItube Iholders Iare Isingle Iuse Ionly I(OSHA, I2012) o Bedside IUnit ▪ Keep Itable Isurfaces Iclean Iand Idry. o Bottled ISolutions ▪ Do Inot Ileave Ibottled Isolutions Iopen. ▪ Keep Isolutions Itightly Icapped. ▪ Date Ibottles Iwhen Iopened Iand Idiscard Iin I 24 Ihours. o Surgical IWounds ▪ Keep Idrainage Itubes Iand Icollection Ibags Ipatent Ito IpreventIaccumulation Iof Iserous Ifluid Iunder Ithe Iskin Isurface. o Drainage IBottles Iand IBags ▪ Wear Igloves Iand Iprotective Ieyewear Iif Isplashing Ior Ispraying IwithIcontaminated Iblood Ior Ibody Ifluids Iis Ianticipated. ▪ Empty Iand Idispose Iof Idrainage Isuction Ibottles Iaccording Ito IagencyIpolicy. ▪ Empty Iall Idrainage Isystems Ion Ieach Ishift Iunless Iotherwise IorderedIby Ia Ihealth Icare Iprovider. ▪ Never Iraise Ia Idrainage Isystem I(e.g., Iurinary Idrainage Ibag) IaboveIthe Ilevel Iof Ithe Isite Ibeing Idrained Iunless Iit Iis Iclamped Ioff.
- prevent Iinfection Icontrol: o hand Ihygiene o change Idressing Iand Ikeep Idry o adequate Inutrition o shower, I(NO IBATHS, INO ISOAKING) o gauze: Ipat Idry _o pain Imeds Ibefore Idressing Ichange
- pneumonia I (pg I423)_ o immobility I(at Irisk), Irespiratory Iproblems, Ielderly I(age Iis Ia Ifactor), Iheart Ifailure, Ismokers, ICOPD, Iimmunocompromised I(HIV,AIDS), Iproductive Icough, Igreen Isputum, Ipain, Iwheezing o Deep-breathing Iexercises I(1 Ito I 2 Ihours), Iincentive Ispirometry, Icontrolled Icoughing, Iand Ichest Iphysiotherapy Iare Iamong Ithe Inursing Iinterventions Iavailable Ito Iexpand Ithe Ilungs, Idislodge Iand Imobilize Istagnant Isecretions,Iand Iclear Ithe Ilungs _o fluid Iintake I1100-1400 ImL I(non-caffeinated)
- assessing Ipulse: I(palpate)_ o rate, Irhythm, Ipulse Istrength, Iequality _o apical: Irate Iand Irhythm Ionly
- infection: IWBC I(5000 I- I10,000) Iand Ialbumin I(3.4 I- I5.4 Ig/ IdL)
- protective Iisolation: Iprotecting Ipt Ifrom Ius I(bone Imarrow, IHIV)
- PCA_ o can: Ivitals, Icleaning, IHH, Ipositioning, Ifeeding, Ireporting
o cannot: Iassessment, Ievaluate, Imeds
- vitals: Ipain, Igrimacing, Iguarded, Iincreased IHR, Iincreased IBP, Iseating, _Iagitated,Irestless
- primary Iintention: Isurgical Iincision, Iminimal Iscarring_ o red: Ihealing o yellow: Islough _o black/brown: Ieschar
- secondary: Itrauma, Iburns
- hand Ihygiene_ 1. wet Ihands 2. soap 3. 15 Iseconds 4. paper Itowels 5. close Ifaucet - wet Ihands Ican Ibring Ion Ibacteria _- do INOT Iuse Ilotion
- stroke Ipt_ o impaired Iswallowing I(DYSPHAGIA); Icoughing Iwhen Iswallowing o follow Iup: Ithicken Iliquids I= Iconsult Iwith Ispeech Itherapist o suspect Iaspirating: Ipossibly Ihas Ipneumonia Iassess Ilung IsoundsI(should Ihear Icrackles) o vital Isigns: Idecreased IO2 Isat, Itemp, Igive Ioxygen I(do Inot _IneedIorder) Iof I2L
- check Ipulse IOx Ibefore ING ITube Iif Icontinuous Ichoking I(short Itime)
- walking Iwith Icrutches:_
- For ING Itube I- Imake Isure Ipatient Iis Iin Ihigh Ifowler's Iif Ithey Ican Itolerate Ibut INOILESS Ithan I 30 Idegrees Ifor Isure
- semi Ifowler Iis: I30-45 Idegrees
- fowlers I45-
- high Ifowlers I 90 Idegrees
- aspirate I5-10 ImL Ito Itest Ithe IPH Iand Itest IPH Ibefore Ievery Ifeeding I(4-6 Ihours)
- residual Ivolume: Iso Iif Iyou Isee I 250 Ion Ifirst Itime Iits Iokay, Isecond Itime Imore Ithan I 250 ISTOP IFEEDING I- Ibut Iif Iyou Isee Imore Ithan I250/500 ISTOP IFEEDING IandInotify Ithe Idoctor
- make Isure Iyou Iput Ithe Iaspirate Iback Iinto Ithe Istomach Ibecause Ithey Ican Ihave IanIelectrolyte Iimbalance Iif Inot
- if Ithe Itube Iis Iin Iand Ipatient Iis Ivomiting Imake Ithem ISIT IUP Ib/c Irisk Iof Iaspiration I- Ithen Icheck IVITALS Iand Icall IDR
- continuous Ifeeding I 24 Ihours Ithen Ithrow IOUT
- to Icheck Iresidual Ipull Iback I 30 ImL
- TO IPUT IMEDS IIN ITUBE: Ione Iat Ia Itime, Iflush Iw/ I10mL, Icrush, Iflush, IcrushI(document IALL Iflushing)
- if Ino Iresidual I- Ithey Iare Idigesting Iand Ithey Ishould Ihave Ia Ibowel Imovement
- auscultate Ifor Ilung/bowel Isounds I(before Iputting Iin Itube)
Diabetics
- low Icarbs, Imonitor Ifruits Ibecause Iit Iis
Icarbs=sugarsIHypertension
IsodiumIDiarrhea
- avoid Idehydration Iso Imake Isure Ithey Iare Ihaving Ia Ilot Iof Ifluids Iand ImonitorIelectrolytes Ibecause Iwhen Iyou Ihave Idiarrhea Iyou Ilose Ielectrolytes
- after Isurgery: Iliquids, Isoft Ifoods, I and Iregular Idiet
- BRAT: Ibananas, Irice, Iapplesauce, Itoast
- fiber: Ibarley, Igrains, Ioatmeal I(increase Ithese Ifoods)
- calcium: Isupplement Ivit ID, Idairy, Igreen Ileafy
IveggiesIANGLES Iof Iinjections:
- PPD I(tuberculosis) I- ICAUSES IAIWHEALI(bleb) I5-
- subcutaneous I(insulin) I- I 45 Idegrees Ibut Iif Ipatient Iis Iobese Ithen I 90 Idegrees I- IPINCH ISKIN
- IM I- I 90 Idegrees Iand Iuse I 25 ImL Isyringe I 1 Iinch I- IVENTROGLUTEAL Iis Ibest IsiteIif Iit's Iover I2mL Ibut Iif Iit’s Iless Ithan- use Ideltoid
- intradermal: I5-15 Idegrees---TB Itest
- Med-Cal o I 1000 ImL I= I1L ▪ infuse Iat I 200 ImL/ Ihour Iin I 18 Ihrs. Ihow Imany ImL ▪ 3600 ImL o 800 ImL/ I 5 Ihr ▪ 160 ImL/ I 1 Ihr o 750 Img: IIf Iyou Ihave I 250 Img Itablets. IHow Imany Itablets Iwould Iyou Igive ▪ 3 o 1 Icup I= I 240 ImL o 1 Itbs I= I 15 ImL o 1 Itsp I= I 5 ImL o Tylenol I(brand) ▪ acetaminophen I (generic) ▪ 325 Img I(dose) ▪ 325 Img I/ I 100 ImL ▪ 200 ImL I= I 650 Img
QUIZLET: I https://quizlet.com/145786911/fundamentals- final-exam-practice-review- Iflash-cards/
some Imore Iinformation Ithat II Ithink Iwill Ibe Ihelpful:
WHATICAN INAP IDO?
- position Iand Imove Ipatients
- apply Ielastic Istockings
- help Ipatients Iuse Ithe Iincentive Ispirometer
- apply Inasal Icannula
- Assess Iskin Ievery Ihour Iin Iimmobilized Ipatients
- Convection: Itransfer Iof Iheat Iaway Ifrom Ibody Iby Iair Iex: Ifan
- conduction: Itransfer Iof Iheat Ifrom Ione Ipart Iof Ithe Ibody Ito Ianother Iwith IdirectIcontact Iex: Isponge Ibath Iand Icool Icompress
- Radiation: Itransfer Iof Iair Iwithout Idirection Icontact
- evaporation: Iliquid Ito Igas
- hypoxia: Itissues
- hypoxemia: Ilow Ilevel Iof Ioxygen Ito Ithe Iblood
- inspiration: Istimulated Iby Ichemical Ireceptors Iin Ithe Iaorta I(ACTIVE IPROCESS)
- expiration: Ideals Iwith Ithe Ielastic Irecoil Iof Ithe Ilungs I(PASSIVE IPROCESS)
- left Isided Iheart Ifailure: I pulmonary Icongestion Ilike Icrackles, I and IparoxysmalInocturnal Idyspnea
- right Isided Iheart Ifailure Iis ISYSTEMIC: Iedema, Iweight Igain Iand Idistended IneckIveins
- MI Ihappens Ibecause Ithere Iis Ia Ilack Iof Iblood Iflow Idue Ito Ian Iobstruction Iof ItheIcoronary Iartery Iand Ithat Iis Iwhat Isupplies Ithe Iheart Iwith Iblood
- Afterload: Iresistance Ito Ileft Iventricular Iejection
- Preload: Iamount Iof Iblood Iin Ithe Ileft Iventricle Iat Ithe Iend Iof Idiastole I(end IdiastolicIvolume)
- remember Iclosed Isuctioning Iwith Imechanical Iventilation
**** ISomewhere Ion Ithe Ireview II Ican’t I remembe r Iwhere Iit Isays Iwhen Iyou Iare Iinspecting Ithe Iskin Iof Ia Idarkly Ipigmented Ipatient Iuse Ia IHALOGEN Ilight INOTIfluorescent Ilight I(fluorescent Iis Ia Imistake!)**