NR 224 Exam 1 and 2 study guide PDF

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NR: 224: FUNDAMENTALS: SKILLS EXAM 1

The five component of critical thinking Specific knowledge base- this increase our critical knowledge Experiences- pervious patient care experience Competencies- applying the nursing process in practice Attitude for critical thinking- confident and fairness, creativity, integrity PROFESSIONAL standards – ana scope and standards of nursing practice specially standard of practice. Example, the collaboration aspect and it interprofessional teams. HIPAA:  COULD BE VERBAL, ELECTRONIC, OR WRITTEN FORM ALL PIA  FEDERAL LAW - NOT A STATE LAW Important to know: NUMBER 1 WAY TO PREVENT SPREAD OF INFECTION → HANDWASHING- is the most effective way to break the chain of infection. Infectious process  Incubation period- the appears of the first symptoms( incubation period  Prodromal stage – onset of nonspecific symptoms( fever, fatigue  Illness stage- sign of the disease manifest  Convalescent – recovery stage 7 days to months all acute signs disappears. It can be different for each disease processes. What is expected in these? Localize infection- pain, pus, tenderness, warmth and redness at a wound site. Systemic infection – is when it affects the either body if left Untreated can be fatal PERISTALSIS:  SLOWS DURING PROLONGED PERIODS OF INACTIVITY SUCH AS BED REST PREVENTION OF PNEUMONIA AND PREVENTION OF ATELECTASIS:

 EXPANSION OF LUNG AND DIAPHRAGMATIC MUSCLES AND MOVEMENT OF SECRETIONS ARE VITAL TO PREVENTION OF PNEUMONIA AND ATELECTASIS → PROLONGED BED REST V VITAL SIGN – IMPORATNT TO KNOW FEBRILE – HAVING AN FEVER - INCREASE HEART AND RESPIRATORY RATE AFEBRILE- BROKEN OF THE FEVER CAROTID – IS CHECK DURING CPR APICAL PULSE – USES STETHOSCOPE BRACIAL PULSE- IS WHERE BLOOD PRESSURE ARE ASSESS RADIAL PULSE- IS COUNT FEMORAL – ASSESSMENT AND PROCEDURES POPLITERAL – ASSESSMENT OF BEHIND THE KNEES DORSALIS PEDIS – ASSESSMENT OF ANKLES CHARACTER OF THE PULSE  RATE – THE NUMBER TIMES PER- MINUTES YOU FEEL OR HEAR THE PULSE.  RHYTHM- THE REGULARITY OF IMPLUSES  STRENGTH – REFLECTS THE VOLUME OF BLOOD EJECTED AGAINST THE ARTERIAL WALL WITH EACH HEART CONTRACTION  EQUALITY- PERIPHEAL PULSE IMPULSEES SHOULD BE SYMMETRICAL IN QUALITY AND QUANITY FROM THE RIGHT SIDE OF THE BODY TO THE LEFT. FACTORS AFFECTING BODY TEMPERATURE  AGE  EXERCISE  CIRCADIAN RHYTM  STRESS  ENVIRONMENT  TEMPERATURE ALTERATION VENTILATORY DEPTH- DEEP, NORMAL, SHALLOW OR LABORED VENTILARY RHYTHM- REGUALR /IRREGULAR WHAT IS A NONMODIFIABLE RISK FACTOR FOR BLOOD PRESSURE/ Genetics

HYPOTENSION – SYSTOLIC IS LESS THAN 90 MM/HG DILATION OF ARTERIES THREE WAYS TO ASSESS A PERSON WITH ORTHOSTATIC HYPOTENSION/ POSTUAL BLOOD PRESSURE. IS WHEN PATIENT HAS A CHANGE IN DISYSTOLIC PRESSURE WITHIN 2 MINUTES TO A 20MM/HG DROP. WHEN THIS HAPPEN, THE PATIENT IS AT RISK FOR FALLING PATIENTS AT RISK FOR DEVELOPING ORTHOSTATIC HYPOTENSION:  PATIENTS WHO ARE DEHYDRATED  PATIENTS WHO ARE IMMOBILE  PATIENT WHO HAVE HAD SIGNIFICANT BLOOD LOSS ORTHOSTATIC HYPOTENSION SHOULD BE TAKEN WHEN PATIENT ARE LAYING FLAT, SITTING UP AND STANDING PROPER WAY TO TAKE BLOOD PRESSURE IS WHEN THE PATIENT LEGS ARE UNCROSS. IF THE BP PRESSURE IS INACCURATE THE FIRST TIME RETAKE AT 30-60 SECOND. IMPORTANT TO KNOW -PAPLATE THE POPLITEAL. THE SYSTOLIC PRESSURE IN THE LEGS ARE 10 -40MM /HG HIGHER. DISYSTOLIC REMAIN THE SAME. MAKE SURE THE CUFF IS WIDE AND LONG AND PATIENT IS IN PRONE POSITION IF CAN’T BE IN THIS POSTION THEN FLEX KNEES. RADIAL PULSE IS IRREGULAR:xy  CHECK THE APICAL PULSE FOR A FULL MINUTE IN ORDER TO ASSESS PULSE DEFICIT:  TAKE APICAL PULSE AND RADIAL PULSE AND SUBTRACT FACTORS THAT AFFECT BODY TEMPERATURE  SALA  AGE  EXERCISE OR ACTIVITY  CIRCADIAN RHYTHM  ENVIRONMENTAL TEMPERATURE

MOBITY POSTURE AND BODY ALIGNMENT MAY BE USED INTERCHANGEABLE TO DENOTE POSITION OF BODY  BODY BALANCE- ACHIEVEED BY LOW CENTRE OF GRAVIT, ENHANCED BY POSTURE.  FRICTION – OCCURE WHEN MOVING THE PATIENT IN BED, NEED TWO PERSONS TO DO, CAUSES BREAKDOWN OF THE SKIN. PROPER BODY ALIGNMENTS – OCCURS WHEN A PERSON IS PROEPRLY ALIGNED WITH RELATIVELY LOW CENTRE OF GAVITY BALANCED OVER WIDE STABLE BASE SUPPORT. STEP TO ACHIEVED BALANCED AND ALIGNMENT.  WIDEN YOUR BASE OF SUPPORT BY SEPARATING THE FEET TO A COMFORTABLE DISTANCE.  BRING THE CENTRED OF GAVITY CLOSER TO YOUR BASE OF SUPPORT TO INCREASE BALANCE  BEND YOUR KNEES AND FLEX THE HIPS UNTIL SQUATTING AND MAINTAINING PROPER BACK ALIGNEMENT TO KEEP TRUNK ERECT. PRINCIPLE OF SAFE PATIENT TRANSFER AND POSITIONING  USE MECHANICAL LIFTS AND LIFT TEAMS WHEN PATIENT ARE UNABLE TO ASSIST  THE WIDER THE BASE OF SUPPORT, THE GREATER THE STABILITY OF THE NURSE  THE LOWER THE CENTRE OF GAVITY, THE GREATER THE STABILITY OF THE NURSE  THE EQULIBRIUM OF AN OBJECT IS MAINTAINED AS LONG AS THE LINE OF GAVITY PASSES THROUGH ITS BAS OF SUPPORT  FACING THE DIRECTION OF MOVEMENT PREVENTS ABNORMAL TWISTING OF THE SPINE.  DIVIDING BALANCED ACTIVITY BETWEEN ARMS AND LEGS REDUCES THE RISK OF BACK INJURY  LEVERAGE, ROLLING TURNING OR PIVOTING REQUIRES LESS WORK THAN LIFTING

 WHEN FRICTION IS REDUCED BETWEEN THE OBJECT TO BE MOVED AND THE SURFACE ON WHICH IT IS MOVED, LESS FORCEMIS REQUIRED TO MOVED. SAFETY IS A BIG PRIPORIT. GAIT IS A TERM WHICH DESCRIBES MANNER OF WALKING EXAMPLE: STEADY/UNSTEADY GAIT IMPORTANT TO KNOW ASSISTING A PATINET TO SITTING POSITION- DANGLING REFERS TO SITTING ON THE SIDE OF THE BED WITH THE FEET HANGING DOWNTHIS PREVENT ORTHOSTATIC HYPOTENSION FOR THE PATIENT. TO PREVENT DIZZINESS IF PATIENT HAS BEEN ON BEDREST FOR SEVERAL DAYS OR POST OP:  PATIENT CAN DEVELOP ORTHOSTATIC HYPOTENSION  FLUID SHIFT IN BODY → BLOOD PRESSURE DROPS  TO PREVENT THIS: HAVE PATIENT RISE SLOWLY AND DANGLE OVER SIDE OF THE BED  FLUIDS CAN STABILIZE AND CAN PREVENT ORTHOSTATIC HYPOTENSION IMMOBILITY – INCAPABLE OF MOVEMENT  MAY INVOLVE A SPECIFIC PART OF THE BODY DUE TO INJURY  PARAPLEGIA- MAY INVOLVE LOWER PART OF THE BODY  HEMIPLEGIA- MAY INVOLVE ONE SIDE OF BODY  QUADRIPLEGIA- MAY INVOLE ENITRE BODY FROM THE NECK DOWN HEMIPLEGIA RELATED TO STROKE:  PARALYSIS OF HALF THE BODY  UNAFFECTED LEG SHOULD BE ADVANCED FIRST BECAUSE WEIGHT OF THE BODY IS LIFTED TO NEXT STEP ON THE LEG WITH THE GREATEST STRENGTH DEEP VEIN THROMBOSIS- PAIN IN THE LOWER LEG, MAY OCCUR WITHOUT SYMPTOMS AND CAN TRAVEL TO THE BRAIN AND HEART SIGN INCLUDES :

REDNESS, PAIN, EDMA, WARMTH, DISCOLOR IN THE LEG, TRAVELING HISTORY CAN BE A RISK FACTOR AND SMOKING, OBSITY, IMMOBILTY,PREGNACY. RENAL CALCULI RISK FACTOR FOR IMMOBILITY  ANOTHER NAME FOR KIDNEY STONES 2. DUE TO EXCESSIVE CALCIUM IN BLOOD KNOWN AS HYPERCALCEMIA PATIENT WHO IS IMMOBILIZED SIGN AND SYMPTOMS/ EDUCATION :  ALWAYS ENCOURAGE COUGH  DEEP BREATHING TO PREVENT DISEASE  COUGH AND DEEP BREATHING EVERY 1-2 HOURS PREVENT RESPIRATORY PROBLEMS  PROVIDES CHEST PHYSIOTHERAPY o HIGH PROTEIN OR FIBRE DIET IS RECOMMENDED FOR PATIENT WHO IMMOBILITY. VITAMIN B AND C TED STOCKINGS- PREVENTS DVT FROM OCCURING  ANTI-EMBOLISM STOCKINGS TO PROMOTE VENOUS RETURN  AIDS IN PREVENTION OF BLOOD CLOT DEVELOPMENT PASSIVE RANG OF MOTION PREVENT DVT/ CLOTS FROM RETURNING IMPORTANT TO KNOW POSTION THE PATIENT 1-2 HOURS IN THE BED AND IN THE CHAIR IS EVERY 1 HOURS AND PROVIDE SKIN CARE TO PREVENT SKIN BREAK DOWN. Trochanter Roll– Helps legs stay in position so they will be upright, prevents hips and ankles from rotating outward

HAND ROLL - IS WHEN THE PATIENT IS NOT MOVING AND THEIR HAND CLOSE TOGETHER- PREVENT CONTRACTION POSITIONING TECHNIQUES SUPPORT FOWLER – HEAD OF THE BED IS ELEVATED 45-60 DEGREE AND THE PATIENT KNEES ARE ELVATED SUPINE – PATIENT IS ON THEIR BACK PRONE -LIES FACE DOWN TO CHEST SIDE LYING – LATERAL ON ONE SIDE- LYING SIM – RECTUAL POSITION

DORAL RECUBERLENT – IS WHEN ABDOMINAL ASSESSMENT LAYING ON BACK KNEES FLEX . ASSISTIVE DEVICES  WALKER- PLACE HAND ON WALKER AND THEN TAKE A STEP THEN PUSH WALKER FORWARD AND THEN TAKE ANOTHER STEP. IT SHOULD BE LIKE 6 CM, WHEN MEASURING FOR A WALKER ELBOW SHOULD BE FLEX 15- 30 DEGRESS WHEN STANDING INSIDE THE WALKER  CANE- THE CAN ALWAYS SHOULD BE ON THE STRONGER SIDE OF THE BODY. THE CAN SHOULD BE PLACED FORWARD 6 TO 10 INCHES, KEEPING BODY WEIGHT ON BOTH LEGS AND THE MOVE WEAKER LEG FORWARDS NEXT TO THE CAN AND THE STRONGER LEG GO FORWARD IN FRONT THE CANE AFTER, DIVIDE WEIGHT BETWEEN CANE AND WEAKER LEGS. DO NOT REMOVE RUBBER TIPS  CRUTCHES- MOST COMMON IS THE AXILLARY CRUTCHESWHEN MEASURING FOR CRUTCHES - MAKE SURE THAT YOU COULD SLIP 2-3 FIGURE WIDTH IN BETWE FROM THE AXILLARY TO THE CRUTH PADS TO DETERMINE THE HEIGHT OF THE CRUTCH. THE ELBOW SHOULD BE SLIGHTLY FLEX AT 20-25 DEGREES FOR THE ELBOW FLEXION. SUPPORT THE WEIGHT ON THE HAND GRIPS. -TRIPOD POSITON – WHEN THE CRUTCHES ARE PLACE 15 CM IN FRONT AND 15 CM TO THE SIDE OF EACH FOOT OR 6 INCHES  THE 3 POINT GAIT – REQUIRE THE PATIENT TO BARE ALL THE WEIGHT ON THE UNAFFEECTED LEG. ALL WEIGHT GOES TO THE UNAFFECTED LEG. THE GOOD FOOT TOUCHES THE FLOOR ONLY. THE AFFECTED LEG NEVER TOUCHES THE GROUND.  THE 2 POINT GAIT - IT REQUIRE PARTIAL WEIGHT OF BOTH LEG, THE PATIENT WILL MOVE THE CRUTCH AT THE SAME TIME OPOSING LEG AND THEN SWITCH.  THE 4 POINT GAIT - WEIGHT BARING ON BOTH LEGS EACH LEGS TOUCHES THE FLOOR AND ALTERNATING WHEN MOVING UP AND DOWN STAIR THE 3 POINT GAIT IS USEGO UP THE STAIRS THE PATIENT WILL TRANSFER BODY WEIGHT TO CRUTCHES AND THEN TO THE STRANGER SIDE DOING IT OVER. NO PRESSURE GOES ON THE AFFECTED LEGS . FROM CRUTCHES TO CHAIR

 MAKES SURE THE PATIENT HOLD BOTH THE CRUTCHES ON THERE GOOD SIDE AND USE THE OTHER HAND TO HAOLD ON THE CHAIR RAIL GAIT BELT WHILE WALKING  STAND WITH FEET APART TO PRIVDE A BROAD BASE OF SUPPORT  EXTEND ON LEG AND LET PATIENT SLIDE AGAINST IT TO THE FLOOR  BEND KNEES TO LOWER BODY AS PATIENT SLIDE TO THE FLOOR DO NOT PUT DIRTY ON THE FLOOR AND ALSO KEEP AWAY FROM BODY PRIMARY INTENSION- THESE ARE WOUND WITH CLEAN SURGICAL INCISION / CLOSE EDGES- THEY ARE CLOSE WITH SURGICAL STICHES WHICH RESULT IN FINE SCAR, THIS LIMIT INFECTION SECONDARY INTENTION- THIS IS A WOUND FROM BURN OR INJURY NORMALLY FILL WITH SCAR TISSUE, WHICH TAKES LONGER TO HEAL, THE CHANCES OF INFECTION IS GREATER ULCERS  STAGE 1 – SKIN IS INTACT WITH NONBLANCHABLE REDNESS  STAGE 2- PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS, OR BOTH  STAGE 3- FULL THICKNESS TISSUE LOSS WITH VISBLE FAT IS WHEN ESCHAR PRESENT BUT WONT COVER ALL  STAGE 4 – FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, MUSCLES OR TENDONS/ CAN HAVE NECROSIS AND ESCHAR ARE PRESENT  UNSTAGEABLE PRESSURE INJURY- IS WHE ESCHAR BLOCKS THE VISION  SUSPECTED DEEP TISSUE INJURY- INJURY IS DEEP IN THE TISSUE SHOWING A REDDISH PURPLE OUTER LAYER COULD BE PAINFUL, NOT SURE HOW DEEP THE INJURY IS. COMPLICATION OF WOUND HEEALING HEMORRHAGE- PATIENT ARE AT A GREATER RISK 24-48 HOURS AFTER SURGERY. CHECK FOR SWELLING, PATIENT MIGHT GO INTO

INFECTION – WOUND INFECTION ARE PRESENT WHEN MICROORGANISM ARE INVADES THE WOUND TISSUE. AN INCREASE AMOUNT OF DRAIAGNE IS PRESENT EVISCERATION- TOTALLY SEPARATION OF WOUND LAYERS PROTRUSION OF VISCERAL ORGAN THROUGH OWUND OPENING. EMERGENCRY SURGERY IS NEE DEHISCENCE- WHEN INCISION FAILS TO HEAL PROPERLY THE LAYERS OF SKIN AND TISSUE SEPARATE, MOSTLY HAPPEN WITH PATIENT WHO ARE DIABETES TYPES OF WOUND DRAINAGE SEROUS- CLEAR, WATERY PLASMA PRULENT- THICK, YELLOW , GREEN, TAN OR BROWN RISK FACTOR FOR PRESSURE ULCERS  IMPAIRED SENSORY PERCEPTION  IMPAIRED MOBILITY  ALTERATION IN LEVEL OF CONSCIOSNESS  SHEAR  FRICTION  MOISTURE TROCHANTER ROLL- PREVENTS EXTERNAL ROTATION OF THE HIPS WHEN A PATIENT IS IN A SUSPINE POSITION. SEROSANGUINEOUS- PALE, PINK, WATERY, MIXTURE OF CLEAR AND RED FLUID SANGUINEOUS- BRIGHT RED INDICATES ACTIVE BLEEDING SEROUS- CLEAR, WATERY NORMAL FINDING PURULENT- THICK, YELLOW, GREEN, TAN OR BROWN COLOR. COCA- COLOR , ORDOR, CONSITENT AND AMOUNT DEBRIDEMENT IS THE REMOVAL OF NONVIABLE NECROTIC TISSUE. IT THE REMOVAL OD NECROTIC TISSUE IS NECESSARY TO RID THE WOUND OF A SOURCE OF INFECTION, CLEAN BASE NECESSARY FOR HEALING. SALINE IS WHAT IS USE FOR NORMAL WOUND CLEANING TRANPARENT DRESSING PROVIDE A MOIST ENVIRONMENT THEY ARE USE FOR STAGE 1 PRESSURE INJURE,PROTECT THE AREA

HYDROCOLLOID DRESSING- ARE DRESSING WITH COMPLEX FORMULATION OF COLLID AND ADHESION STAYS 3-5 DAYS ON THE WOUND. HYDROGEL DRESSING- IS A MOISTURE DRESSING GOOD FOR WOUND HEALING. Four stages of healing- 1. Hemostasis 2. Inflammation 3. Proliferation/ granulation 4. remodeling / maturation. Wound care vac- applies negative pressure which removes fluid and promotes circulation and healing 3-4 days Four stage of healing are. – 1, hemostatsis, 2. Inflammation 3. Proliferation/ granulation 4. Remodeling or maturation Acute wound are- usually traumatic or surgical and should moved periodly Braden scale- is a pressure, ulcer scale- where the higher the number the more light the patient will have a pressure ulcer. Sensory perception, moisture, activity, mobility, nutrition and friction and shear The greater trochanter. Is the lying on the side hips. Transparent film – traps moisture over wound, hydrocolloid- dressing complex adhensive, hydrogel – are grauze sheet dressing impregrated with water glucerin. Alignated dressing for wound that are large amount of exudate with need packing. RIGHT SIDED HEART FAILUR IS BLOOD BACK IN THE IN THE BODY SIGN ARE- LIVER ENLARGEMENT, JUGULAR NECK DISTENTION, PERIPHERAL EDMA, CHUCKLE OBESITY LEFT SIDED HEART FAILURE IS ASSOCIATED WITH PULMONARY PROBLEMS AND LUNG ISSUE, FOR EXAMPLE, SHORTNESS OF BREATHS, CRACLE, DYSPNEA, ATELECTASIS- AIRLESSNESS OR COLLAPSE LUNGS AS A RESULT OF HYPOVENTILATION OR OBSRTRUCTION. PATIENT WILL HAVE A DIMINISHED BREATH SOUNDS....