Nursing Fundamentals Final Exam Study Topics Types of Loss Actual loss: can be recognized by others Perceived loss: is felt by person but intangible to others (a woman after having a double mastectomy states “I no longer feel like a woman”.) Physical loss versus psychological loss (loss of arm) Maturational loss: experienced as a result of natural developmental process Situational loss: experienced as a result of an unpredictable event (a patient who lost everything during a hurricane, a mother who lost a son due to gun violence) Anticipatory loss: loss has not yet taken place Kübler-Ross’s Five Stages of Grief Denial and isolation (“I don’t think this disease is a serious a the doctor thinks it is”) Anger Bargaining (“If I can just stay alive to make it to my daughters wedding”) Depression Acceptance Medications Intramuscular 90 Muscle Subcutaneous 90 or 45 Subcutaneous tissue Intradermal 5-15 Skin Eye – do not put directly into eye, pull lid down Ear- pull down and back for babies Pull up and back for adults Objective- things we can physically, touch, see, and hear from the patient Subjective- what the patient tells us Urinary Incontinence = involuntary or uncontrolled loss of urine from the bladder. Medications Affecting Color of Urine Anticoagulants: red urine Diurectics: pale yellow urine Pyridium: orange to orange-red urine The antidepressant amitriptyline or B-complex vitamins: green or blue-green urine Levodopa: brown or black urine (Parkinson’s) Specific Gravity- measure of the density of urine compared with the density of water. Specific gravity increases when dehydrated Patients at Risk for UTIs -Sexually active women (during intercourse bacteria migrate) -Women who use diaphragms for contraception (spermicide decreases the amount of normal protective vaginal flora) -Postmenopausal women (decreased estrogen contributes to loss of protective vaginal flora) -Individuals with indwelling urinary catheter -Individuals with diabetes mellitus (change in the bodys defense mechanisms lead to increased risk for UTI) -Older adults (physiologic changes add to increased risk for UTI-discussed earlier Types of Urinary Incontinence Transient: appears suddenly and lasts 6 months or less Mixed: urine loss with features of two or more types of incontinence Overflow: overdistention and overflow of bladder Functional: caused by factors outside the urinary tract Reflex: emptying of the bladder without sensation of need to void Total: continuous, unpredictable loss of urine Stress: involuntary loss of urine related to an increase in intra-abdominal pressure Developmental Considerations (YOUNG) Children o Voluntary control of urethral sphincters occurs between 18 and 24 months of age. o Toilet training 2 to 3 years old o Continued incontinence of urine past the age of toilet training is termed enuresis. o Nocturnal enuresis- (night time bed wetting) usually subsides by 6 years of age. Developmental Considerations (OLD) Effects of aging o Diminished ability of kidneys to concentrate urine (nocturia) o Decreased bladder muscle tone (frequency) o Decreased bladder contractility (retention and UTI’s) o Neuromuscular issues (DJD, Alzheimer’s, Weakness) can interfere with voluntary control and the ability to reach the toilet in time Lung Sounds Bronchial breath sounds heard over the larynx and trachea are high-pitched, harsh “blowing” sounds, with sound on expiration being longer than inspiration. Bronchovesicular breath sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds are soft, low-pitched, whispering sounds, heard over most of the lung fields, with sound on inspiration being longer than expiration. Adventitious breath sounds (added, abnormal sounds) are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways. Pulses Brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial, apical, and carotid Vital Sign Parameters for Adults Temp: 97.6 to 99.6 (not considered abnormal until after 100.4) 96.8-100 Respirations: 12-20 breaths/min Pulse: 60-100 (80 average) Blood Pressure: 120/80 Types of Wounds Intentional/Unintentional Wounds Intentional wound- the result of a planned invasive therapy or treatment. -Purposefully created for therapeutic purposes. (surgery, IV, lumbar puncture) sterile Unintentional Wound- accidental, unexpected trauma -Stabbing, gunshot, burns-unsterile Open & Closed Wounds Open Wound: occurs from intentional or unintentional trauma. The skin surface is BROKEN. Closed Wound: results from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash. The skin surface Is NOT BROKEN. Acute or Chronic Wounds Acute wounds- heal within days to weeks. o Edges well approximated o Risk of infection is low Chronic wounds- healing process is impeded. o Wound edges often not approximated o Healing cycle delayed (>30 days) o Risk of infection is increased Partial Thickness, Full Thickness & Complex -Partial Thickness – A partial thickness wound is confined to the skin layers ; damage does not penetrate below the dermis and may be limited to the epidermal layers only. -Full-Thickness – A full-thickness wound indicates that damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone, tendons, etc.). -Complex Wound- A complex wound is an acute or chronic injury to human skin tissues that does not respond to conventional treatments in a timely manner. Complex wounds often cause extensive damage to both the epidermal, and dermal layers of the skin as well as the underlying subcutaneous tissues. Donning PPE Put on: Gown Mask Goggles Gloves Take off: Gloves Goggles Gown Mask direct contact: way for organisms to enter the body that involves proximity between the susceptible host and an infected person or a carrier, such as through touching, kissing, or sexual intercourse indirect contact: personal contact with either a vector, a living creature that transmits an infectious agent to a human, usually an insect; or an inanimate object, called a fomite, such as equipment or countertops vector: nonhuman carriers—such as mosquitoes, ticks, and lice—that transmit organisms from one host to another an inanimate object, called a fomite, such as equipment or countertops C. Diff Must use PPE (gloves, gowns mask and protective eye Gear) Standard Precautions Used in the care of ALL hospitalized patients regardless of their diagnosis or possible infection status Apply to blood, all body fluids, secretions, and excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes New additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures Stages of Pressure injuries Stage 1: nonblanchable erythema of intact skin Stage 2: partial-thickness skin loss with exposed dermis Stage 3: full-thickness skin loss; not involving underlying fascia Stage 4: full-thickness skin and tissue loss Unstageable: obscured (by slough or eschar) fullthickness skin and tissue loss Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration Nursing Practice Acts: most important law that each state established to protect the public as we serve as nurses. Deines our scope of pracice and what our limits are. Also, list the violations that can result in disciplinary action. Standards: Voluntary and implemented by the profession itself American Nurses Association (ANA) standards of practice professional standards for the accreditation of education programs and service organizations standards for the certification of individual nurses in general and specialty area of practice assault: threat or an attempt to make bodily contact with another person without that person’s permission negligence: performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do Administering an Enema -Have the client take slow, deep breaths to relax and ease discomfort. -If a patient c/o cramping clamp the tube for 30 seconds to reduce intestinal spasms. -Lower the level of the enema fluid container if patient c/o abdominal cramping. -Would you tell the patient “cramping is common”? Does this help the patient in this situation? Or would you manipulate your procedure? Lower infusion; clamp tube -WARM the enema solution as COLD fluid can cause abdominal cramping, and HOT fluid can injure the intestinal mucosa. -Position the patient on their left side with the right leg flexed forward. -Lubricate the rectal tube or nozzle. -Insert the rectal tube 2 in for a child and 3-4 for an adult. -The MAXIMUM recommended height to hang the fluid container is 46 cm (18 in). -Muslims do not eat PORK…NO Bacon, sausage, ham! -Middle Eastern patients ASSURE you respect their privacy and modesty and cover body parts! -Asians are more susceptible Thalassemia An inherited blood disorder that causes your body to have less hemoglobin than normal. Hemoglobin enables red blood cells to carry oxygen. Thalassemia can cause anemia, leaving you fatigued. Cultural assimilation (acculturation) -When a minority group lives with in a dominant group and lose the characteristics that made them different. - Values replaced by those of dominant culture - (i.e., a wife who married someone of a different culture who adopts the practices of his culture= CULTURAL ASSIMILATION) Culture shock -A person may experience this when placed in a different culture -May result in psychological discomfort or disturbances. Cultural imposition is the belief that everyone should conform to the majority belief system. Cultural Blindness - A nurse ignores differences and proceeds as though they don’t exist. Culture Conflict -Becoming aware of cultural differences and feeling threatened and responding by ridiculing the beliefs and traditions. Stereotyping -The assumption that all members of a culture or ethnic group act alike -May be positive or negative -Negative includes racism, ageism, and sexism Ladder Day Saints and Muslims are modest Urinary retention difficulty urinating and completely emptying the bladder Petechiae CBC -A contusion is caused by a blunt instrument and may result in bruising or hematoma. -An abrasion is the rubbing or scraping of epidermal layers of skin. -A laceration is the tearing of skin and tissue with a blunt or irregular instrument. -Avulsion is the tearing of a structure from normal anatomic position. The goal of palliative care is to give patients with life-threatening illness aggressive treatment of symptoms the best quality of life. COPD chronic obstructive pulmonary disease Patients who have COPD require a high-protein/high-calorie diet to counter malnutrition.
