PNR 205/PNR205 Exam 1 (NEW 2026/2027) Concepts of Leadership & Collaboration | Full Questions & Answers | Verified Correct Solutions | Guaranteed A – Fortis

PNR 205/PNR205 Exam 1 (NEW 2026/2027) Concepts of Leadership & Collaboration | Full Questions & Answers | Verified Correct Solutions | Guaranteed A – Fortis Q. American Nurses Association definition of nursing practice (P,P,O) ANSWER Protection, promotion, and optimization of health and abilities,through diagnosis and treatment. Q. International Council of Nurses definition of nursing practice ANSWER collaboration and autonomous care of individuals, families, groups and communities, sick or well in all settings. Q. Nurses responsibilities of professional nurse ANSWER care giver Change agent Delegator educator Manager advocate Researcher leader Collaborator Q. Development of nursing profession through the ages ANSWER 1.Nightingale founder of nursing (Notes on Nursing journal) 2. Journal was lost then found an started to gain importance 3.Military saw potential and started educating people to be nurses 4.American Red Cross was founded during civil war cement of nursing during WW2 brought about the need more educated nurses Q. ANA standard of practice and performance ensure quality of care and serve as legal criteria for adequate patient care ANSWER 1. Nursing process (direct patient care nurses will always follow these standards) 2.Professional Performance (Cont. education are key factor in enhancing performance) Q. What is a Metaparadigm? ANSWER multiple concepts that I.D. and describe the central basis of something (nurses focus in concepts of, person,enviro., health, and nursing) Q. what is a conceptual model? ANSWER interrelated concepts that provide direction for practice, research, and education Q. What is Nightingales Philosophy? ANSWER patients enviro. plays key role in healing and recovery process. (clean air,water, dressings, housing, etc. and low noise and light setting etc.) Q. Benners model: Socialization into nursing ANSWER 5. Novice= no experience 4.Advanced beginner= limited experience 3.Competent= working 2-3 years learn from these people* 2.Proficient= uses experiences to make decisions 1.Expert= no longer abides by the rules/ guidlines Q. LPN ANSWER (Lowest) Licensed Practical Nurse:12-18 month training, Can only take data and can not diagnose, perform assessment, or initiate patient care Q. RN ANSWER Registered Nurse: 2-4 yr degree program OR 3 yr diploma program (3 types) Associate degree nurse ;ADN Diploma program Bachelor of science in nursing; BSN Q. MSN ANSWER Masters of science nursing: focus in specific area of advanced practice 1.Certified nurse midwife(CNP) 2. Nurse Practitioner (NP) 3.Certified registered nurse anesthetist(CRNA) 4.Clinical nurse leader (CNL) Q. Doctor of Philosophy & Doctor of Nursing Practice ANSWER Leadership role in research, teaching, administration DNP=focus on clinical aspect which include NP, CNS, CNM, CRNA Q. What are future trends that will influence nursing practice? ANSWER 1.Nursing shortage (retiring nurses) 2.Quality and Safety education (cont. edu.) 3.Independent Nursing Practice (renewing license) Q. Formation of of personal beliefs and values ANSWER 1.First-order belief: basic belief in something (hard to change) 2.Higher-order belief:forming stereotypes,generalization, & prejudice Q. What is Values Conflict? ANSWER Doing something you know you shouldn't be doing! when a persons behaviors are inconsistent with their values ie)treating a murderer, you might feel troubled about that Q. What is Values Clarification? ANSWER a process that is used to reflect, clarify, and prioritize personal values to increase self-awareness and decision making. (used with end-of-life care patients) Q. How would you use Values Clarification to solve a Values Conflict? ie)someone cont. to smoke even when they have lung cancer ANSWER 1. inform the patient with facts kindly yet "matter-of-factly" informs the patient of consequences of his/her actions and they have a full understanding of their decisions Q. Autonomy ANSWER making independent decisions for oneself Q. Accountability ANSWER accepting responsibilities for ones own actions Q. Advocacy ANSWER promoting interests of others/ cause greater than ourselves Q. Beneficence ANSWER doing good Q. Confidentiality ANSWER ethical concept that limits sharing private info. Q. Fidelity ANSWER keeping promises/ agreements made with others Q. Justice ANSWER acting fairly and equitably Q. non-maleficence ANSWER do no harm Q. Responsibility ANSWER being dependable/ reliable Q. Veracity ANSWER telling the truth Q. Neumann RISES values ANSWER Reverence (honor dignity of one another) Integrity(acting fairly, honestly, and ethically; accepting responsibilities) Service(work for social transformation) Excellence(doing your hardest and your best to accomplish a task) Stewardship( sharing your resources; care for God's creatures) Q. What was Leininger's nursing care model? ANSWER Cultural Care Model ain patients cultural health practices to said health care practice -pattern/restructure cultural practices as needed Q. What was Watson's nursing care model? ANSWER Holistic Model focuses on values,beliefs,intentions, and caring consciousness "manifestation of universal energy" Q. What are key points for development of compassion and caring beliefs b/w patients? ANSWER 1.Presence 2. Touch stency/Predictability 4.Listening Q. According to AHNA what does it mean to have holistic nursing practice ANSWER healing the patient as a whole person as its goal Q. What is Verbal Communication? ANSWER spoken, written, or electronic communication What is Non-verbal Communication? wordless transmission of info. language 2. Voice inflection What are some types of Verbal Communication? 1. Setting,Context,& Content (Spoken) 2.Written Communication (Documents) 3. Electronic Comm. (e-mails) What is Body Language? Body Language=looking at someone and evaluating their mental and physical status What are ways body language is used? a) posture,stance,& gait= the way someone stands,sits, or ambulates can tell if they are well, sick or upset b)Facial expressions & Eye movement= facial can convey deep seeded emotions & eye movement can make sure someone is paying attention to you or not c)Tough, Gestures, & Symbolic expressions= can visually let patient know your/ their feelings What is therapeutic Communication? encouraging communication which helps to establish trust b/w patients and nurse What are some ways a nurse could offer therapeutic comm.? 1. offering self ("i'll sit with you") 2.Calling patient by preferred name 3.Sharing observations ("You seem tense") 4.Giving Info. ("It's time for your bath.") What is SOLER? aspects of good listening S=sit facing pateint O= open your posture L=lean into the conversation E=eye contact R=Relax What is Non-verbal Comm.? (SAT) SAT S=Silence A= Active listening T=Therapeutic tough What is Intra-personal Communication? occuring internally Positive self-talk= giving motivation and words of encouragement Negative self-talk= internal talk that damages potential of oneself Meditation= prayer, and mindful reflection What is Inter-personal Communication? conversation occurring b/w 2+ people (Formal & informal) a) inter-professional= collaborating comm. b/w diff. medical fields What is the goal of Small Group Communication? meeting established goals or needs of group participants What are the components of Professional Communication? 5parts RAACD RAACD 1)Respect 2)Advocacy 3)Assertiveness 4)Collaboration 5)Delegation What are the components of Holistic Communication? CLEAR C=center (center yourself) L= Listen (wholeheartedly) E= Empathetic (feeling for the person and their emotions) A=Attentiveness (being attentive to someone) R=Respect (respect the whole person) What are the 5 parts of small group dynamics? (ALL THE 'INGs) Forming= forming what it is that needs to be accomplished Storming= working out any problems w/in the group Norming= problems w/in the group have been overcome and ppl start working together Performing= problem solving and creation of answer emerged Adjourning= group dismisses What is the QSEN definition of Teamwork &Collaboration? "Allows the team to function effectively by maintaining open communication,mutual respect, and shared decision-making." What are characteristics of teamwork? 1.Competence & Accountability 2.Common Purpose 3.Effective communication & competence 4.Trust & Respect 5. Valuing diverse knowledge and skills 6. Humor Nurses Boundary Violations a)self-disclosure of personal info. b)keeping secrets w/ patients from Dr.'s, family, etc. c)spending excessive amount of time w/ 1 patient d) acting as if the patient as close personal relationship e)inappropriate sexual involvement w/ a nurse What are the responsibilities of a Student Nurse? "Promote the highest level of moral & ethical principles" 1.Students must be committed to excellence, compassion, and integrity 2.Disciplined in their studies and clinical practices 5 RULES that make a normal sinus rhythm 1. HR = 60-100 2. Rhythm = regular 3. P wave = identical and before each QRS 4. PR interval = 0.12 - 0.20 seconds 5. QRS = less than 0.12 seconds conducting rate of SA node, AV node, and purkinje fibers SA node= 60-100 AV node= 40-60 Purkinje fibers= 15-30 what is a normal PR interval and QRS interval PR= 0.12 - 0.20 (3 to 5 small boxes) QRS= 0.12 (less than 3 small boxes) 1 small box on an EKG = ? seconds 0.04 where is th PR interval measured from the beginning of the P wave to the beginning of the Q wave what is the problem with 1st and 3rd degree heart block 1st degree = PR CONSTANTLY greater than 0.20 seconds (electrical signals that pass from the atria to the ventricles of the heart are delayed) 3rd degree = conduction disassociated from each other (electrical signals from the atria (upper chambers of the heart) completely fail to reach the ventricles (lower chambers), causing the atria and ventricles to beat independently, resulting in a very slow heart rate and potentially inadequate blood flow throughout the body) treatment for 1st and 3rd degree heart block 1st = monitor 3rd = pacemaker what does 3rd degree heart block look like heart block poem for 1st and 3rd degree HB 1st: if the R is far from the P, then you have a FIRST degree 3rd: if Ps and Qs don't agree, then you have a THIRD degree what does 1st degree heart block look like difference between depolarization and repolarization depolarization = systole repolarization = diastole what to do when there is artifact on an EKG correct electrodes and reassess how to determine HR off an EKG strip (Regular and Irregular) Regular: 1500/ # of tiny boxes between the R peaks Irregular: count the number of R waves in a 6 second strip and x10 causes of sinus bradycardia (CA$$H BAK) Ca+ channel blockers Athlete Stimulation of vagus nerve Sleep Hypothyroidism Beta blockers Amiodarone K+ low initial steps in treating bradycardia/ tachycardia -maintain patent airway/ assist with breathing if necessary -oxygen (if hypoxic) -cardiac monitor to identify rhythm/ monitor blood pressure and oxygenation -IV access -12 lead EKG, don't delay -consider possible hypoxic and toxicologic causes S/S of persistent bradycardia (AHA [i know what that] IS) (HR less than 50!) Acute altered mental status Hypotension Acute heart failure Ischemic chest discomfort Signs of shock treatment for symptomatic bradycardia (BEAT DOPE) Bradycardia... Epinephrine Atropine Transcutaneous pacing DOPamine what meds to give for symptomatic bradycardia (in order and how much) 1. ATROPINE -first dose: 1 mg bolus -repeat every 3-5 minutes -maximum: 3 mg (next is whichever you have most readily available:) 2. Transcutaneous pacing 3. Dopamine (Infusion) -usual infusion rate is 5-20 mcg/kg/min -titrate to pt response -taper off slowly 4. Epinephrine (Infusion) - infusion of 2-10 mcg/min -titrate to pt response causes of sinus tachycardia -stress (psychological or physiological) -pain -anxiety -anemia -hyper/hypo volemia -heart failure -exercise S/S of persistent tachycardia (AHA [i know what that] IS) (HR more or equal to 150!) Acute altered mental status Hypotension Acute heart failure Ischemic chest discomfort Signs of shock meds for tachycardia with a pulse Adenosine -PUSH FAST, FLUSH FAST!!! -First dose: 6 mg IV push -Second dose: 12 mg IV push (if patient returns to same tachycardia or worse) Amiodarone -First dose: 150 mg over 10 minutes -repeat as needed if tachycardia recurs -follow by maintenance infusion of 1 mg/ min for first 6 hours when to use meds vs cardioversion for tachycardia with a pulse meds- when vitals are okay/ pt is hemodynamically stable cardioversion- VS are NOT okay ONLY rhythms that should be defibrillated (unsynchronized cardioversion) -pulseless V Tach -V Fib causes of PACs -caffeine -alcohol (ETOH) -nicotine -hypervolemia -anxiety -hypokalemia atrial flutter -atrial rate is faster than ventricular rate -MANY P's and less QRS complexes -EKG looks like "saw tooth" pattern atrial fibrillation -erratic quivering of atria/ impulses = squiggly baseline with QRS complexes -irregular R to R intervals -P waves are "burried" junctional arrhythmias -originate from the AV node -AV node becomes the pacemaker of the heart instead of the SA node -P wave is inverted and heart beat looks like "J" on EKG PVCs (premature ventricular contractions) -d/t ischemia, Low K+... -come earlier than expected (premature) -wide/ bizarre QRS complexes -QRS interval = or 0.12 seconds (greater than 3 small boxes) -Q deflection and T wave are in opposite directions -compensatory PAUSE present - line forms "V" shape PVC frequency bigeminy trigeminy quadrigeminy unifocal vs multifocal PVCs unifocal= all PVC pointing in one direction (all up or all down) multifocal= pointing different directions (one up and one down) ventricular tachycardia -GHOSTS HOLDING HANDS -wide bizarre complexes with rapid rate -initiate CPR if prolonged Ventricular fibrillation -the rapid, irregular, and useless contractions of the ventricles -CPR STAT causes of asystole H's & T's Hypovolemia; hypoxia; hydrogen ions (acidosis); Hypo/Hyperkalemia; Hypothermia; Hypoglycemia Tension pneumo; tamponade; toxins; thrombosis (pulmonary or coronary); Trauma; Tablets (drug OD) meds for VF/ pVT (pulseless Vtach)/ Asystole/ PEA Epinephrine IV/IO -1 mg every 3 to 5 mins Amiodarone IV/IO -first dose: 300 mg bolus -second dose: 150 mg Lidocaine IV/IO -first dose: 1-1.5 mg/kg -second dose: 0.5-0.75 mg/kg cardioversion vs defibrillation cardioversion: -elective procedure -may use whit conscious sedation -use 25 to 400 watt/seconds -SYNCHRONIZED with QRS defibrillation: -not synchronized -used in emergencies -treats VFib or pulseless VTach -needs conducting gel and 20 to 25 lbs of pressure on paddles -"ALL CLEAR" when discharging shock -continue CPR in between demand (synchronous) vs fixed (asynchronous) pacemakers demand- set rate, works when heart does not fixed- rarely used, constant rate regardless of heart different kinds of pacemakers (AV, temporary, permanent) AV- stim. both, more like usual pathway conduction Temporary- inserted like multilumen central line to ventricle or transthoracic Permanent- surgically inserted, implanted under skin, set rate nursing responsibilities for temporary and permanent pacemakers Temporary: -check function -monitor for infection -cover electrical parts -grouded electrical equipment -pt education Permanent: -know rate -metal detectors -microwaves (OK) -MRI -pt. education what is failure to capture a pacemaker malfunction that occurs when a pacemaker's electrical impulse doesn't result in a cardiac response what is an AICD automatic implantable cardioverter-defibrillator a small device that's surgically implanted in the chest to monitor and correct irregular heart rhythms. ICDs are used to treat life-threatening arrhythmias that can lead to cardiac arrest what is the difference between a pacemaker and an ICD A pacemaker helps regulate a slow heartbeat, while an implantable cardioverter-defibrillator (ICD) can treat dangerous heart rhythms by delivering an electric shock. Both devices are implanted under the skin and send electrical signals to the heart. stable angina vs unstable angina stable: -chest pain or discomfort that typically occurs with activity or stress unstable -symptoms occur in unexpected or unpredictable times, such as at rest and may be a precursor for a heart attack. medical attention should be sought immediately -ECG/ cardiac biomarkers show no evidence of acute MI STEMI vs NSTEMI NSTEMI -↑ TROPS, no definitive ECG changes STEMI -↑ TROPS with definitive ECG changes in two or more leads (most damaging) modifiable risk factors for coronary atherosclerosis ("DD we want to CHOP THEM") Drugs (cocaine) Diabetes mellitus Cigarettes Hyperlipidemia Obesity Physical inactivity Tobacco use Hypertension ETOH (alcohol abuse) Metabolic syndrome non modifiable risk factors for coronary atheroscleosis -age -gender -family Hx of heart disease -race potential complications for femoral access for a cardiac cath. -coronary artery dissection, spasms, abrupt closure -hematoma -bleeding at insertion site -retroperitoneal bleed -reinfarction assessment/ management for a cardiac cath -check access site -pt would have to lay flat from 3 to 6 hours if femoral artery was accessed -ECG in regards to increased risk or heart disease because of family Hx... Family history includes first degree blood relatives (mother, father, sister, brother) who have been diagnosed with cardiovascular disease at age LESS than __?__ for male relatives or LESS than __?__ for female relatives age less than 55 for male relatives age less than 65 for female relatives levels of ED care Level I - Trauma center w/ all specialties on site ATC Level II - Physician and major specialties on site ATC; other specialties "on call" but available Level III - On call physicians triage in the ED • "to sort" • Process of initial evaluation of all patients presenting for care so that care is prioritized according to needs • Occurs at a triage station or w/ those coming in by ambulance • *Different than disaster triage* true or false? The philosophy of emergency management is that only patients with urgent and critical needs will be treated in the emergency department. False they have to see everyone! categories of triage Emergent (1) -life or limb threatening -needs immediate interventions -(with ESI, subdivided into 1-3) -traumas and injuries to head/neck/spinal cord are automatic emergent Urgent (2) -non life or limb threatening -interventions within 1 to 2 hours -will become emergent if not treated within time frame Non-urgent (3) -can safely wait more than 2 hours for treatment (up to 24 hrs) -(most ERs use 1-5 ESI system) Primary survey (ABCDE) -Quick. done within SECONDS Airway/ C-spine precautions -suction, oral airway, jaw thrust, c collar application Breathing -rate, rhythm, breath sounds, O2 Circulation -pulse, skin T, bleeding, cap refill, CPR, IVs = 2 LG bore w/ NS or LR Disability -alert, verbal, pain, unresponsive, check pupils, glascow coma scale: EVM Expose -remove clothes secondary survey (FGHI) Farenheit -keep warm: blankets, lights -maintain thermoregulation -hypo hs hyper thermia Get vitals -T, P, R, BP, pulse ox Hx/ Head to toe (shift) assessment -AMPLE: Allergies, Medications, Past medical hx, Last meal, Events surrounding injury -pregnant? -bullet direction -PQRST Inspect back surface/ Initiate Interventions -tetanus considerations for airway in ABCs -immediate actions needed -basic CPR steps FIRST! -airway/ devices as indicated: prepare to intubate/ trach/ O2 considerations for bleeding/ circulation in ABCs -fluid replacement with ISOTONIC solutions -hemorrhage/ internal bleeds: blood products, volume expanders, STOP THE BLEED -shock (hemorrhagic or hypovolemic): failure to rescue, BE ALERT goal= maintain BP and blood volume wound management considerations -cleansing -primary closure vs secondary closure -flush wound/ leave wound open -status of clean vs infected wound trauma considerations -unintentional or intentional wound/ injury -4th leading cause of death -collection of forensic evidence ・care with charting, clothing ・looking for criminal activity/ causes re: suicide/ homicide... -injury prevention: education, legislation, automatic protection (airbags, ...) priorities for the trauma patient with multiple traumas -team approach -determine extent of injuries -establish priorities (ABC, head/ neck, SCI, peripheral) -always assume cervical spine injury until ruled out!!! -injuries interfering with vital physiologic function have the highest priority -treat everything as if it will end up in front of a judge -main focus should be OBJECTIVE documentation management of patients with intra-abdominal injuries -ABC -immobilize -continually monitor the pt -document all wounds -dehiscence vs evisceration -hold oral fluids/ NPO -NG tube -tetanus and antibiotics -rapid transport to surgery if indicated dehiscence vs evisceration Dehiscence: Closed wound opens Evisceration: organs protrude through wound crush injury considerations -check compressed "parts", 5 Ps, skin, kidneys in addition to ABCs -fasciotomy if circulation is compromised -hyperbaric chamber to increase O2 to damaged tissues -must maintain perfusion -watch for RHABDOMYOLYSIS (any extreme muscle breakdown) 5 Ps for neurovascular assessment Pain Pulse Pallor Paresthesia (numbness/ tingling) Paralysis considerations for fractures -ABCs then 5 Ps -stabilize -teaching: walkers, assistive devices, limited mobility, nutrition, hygiene environmental emergencies/ heat stroke considerations • A failure of heat regulating mechanisms • Types - Exertional: occurs in healthy individuals during exertion in extreme heat and humidity - Non-exertional: inadequate heat loss, malignant hyperthermia, neuroleptic malignant syndrome • Risks: Elderly, pediatric, ill or debilitated, meds • Can cause death • Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhidrosis, tachypnea, hypotension, and tachycardia more heat stroke considerations • Most serious heat condition • sweating eventually stops (anhidrosis) w/ temp over 105 ° F - hallucinations, combative, HA, N,V, dec. BP,coma • Tx: 100% O2, NS IV cool down to get Temp. down to 102 ° F or below -must cool down IMMEDIATELY lightning injury considerations -exit and injury points -complications: cardiac arrest/ death -nursing management: EKG, defibrillation, wound care/ burn tx frostbite considerations superficial -skin and subQ tissues: fingers, toes, nose... -pale skin, crunchy, swollen, "burning" feeling deep frostbite -amputation may be required Tx -remove jewelry/ clothing -warm soaks, blisters may form -may be painful -do NOT use hot water hypothermia considerations -systemic: d/t cold, near drowning, water immersion -temp less than 95 degrees -mild = 90-95 deg F -moderate = 87-90 deg F -profound = 87 deg F ("appears dead") Tx: rewarm at 1 deg C per Hr, watch for arrhythmias (V Fib) drowning and near drowning considerations -drowning= dead -near drowning= alive -most get pulmonary edema (lungs respond with swelling. Reduced by intubating/ treating with diuretics) -tx: ABC, acid/base fluid imbalances bites and bee sting considerations -may cause local or systemic reaction -use scraping motion to remove stinger -mild rx: elevate, cold compress, antihistamines -remove rings/ watches... -Epi, diphenhydramine, steroids for anaphylaxis -gold standard for anaphylactic shock = Epi -always send to ER if Epi is used due to increased HR/BP spider bite considerations -local or systemic reaction -tx: similar to bee stings, may need tetanus -brown recluse may need plastic surgery and antibiotics (due to recurring ulcers that form) -all bites= watch for CELLULITIS tick bite considerations -bite= release of neurotoxin -remove tick: tweezers as close to skin as possible, and without tick diggin in deeper or "vomiting its stomach contents" back into host skin -tx: s/sx, type, abx, lyme disease snake bite considerations -local and systemic reactions -remove restrictive items -NO ice/ TQ -tx: tylenol, NSAIDs, antivenom therapy even more bites considerations (cats/ dogs/ humans) Cat -10% of cases = septic arthritis/ osteomyelitis Dog -forceful bite = plastic surgeon Human -more germs: staph, strep, antibiotics, tetanus rabies vaccine for treatment after bites considerations for allergic reactions/ anaphylactic reactions • ABC's • Epinephrine • Diphenhydramine • Methylprednisolone (steroid) • Tx: other s/sx poisoning considerations -accidental, occupational, recreational, intentional -ingested, inhaled, injected, absorbed ... -severity depends on toxin -Tx: emesis, gastric lavage, eye irrigation, skin cleansing, activated charcoal -acids/ alkalis: milk, H2O dilution, NO VOMITING management/ assessment of pts with ingested poisoning • ABCs • Monitor VS, LOC, ECG,UO • Laboratory specimens • Determine what, when, and how much substance was ingested • Signs and symptoms of poisoning and tissue damage • Health history • Age and weight Management of carbon monoxide poisoning -inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin -carboxyhemoglobin does not transport O2 manifestations -CNS symptoms are predominant -skin color is not a reliable sign and pulse oximetry is not valid -looks/ acts as if they are drunk -decreased O2 sats Tx -get to fresh air IMMEDIATELY -CPR as necessary -administer O2, 100% oxygen under hyperbaric pressure -monitor continuously management of pts with food poisoning • A sudden illness due to the ingestion of contaminated food or drink • ABCs and supportive measures Note: Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death • Determination of food poisoning • Treat fluid and electrolyte imbalances • Control nausea and vomiting • Clear liquid diet and progression of diet after nausea and vomiting subside *common antidote therapy for drug OD* -~pam/lam = flumazenil -opioid = naloxone -acetaminophen = acetylcysteine -warfarin = vitamin K -heparin = protamine sulfate management of pts with substance abuse • Acute alcohol intoxication—a multisystem toxin - Alcohol poisoning may result in death - Maintain airway and observe for CNS depression and hypotension - Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated - Use nonjudgmental, calm manner - May need sedation if noisy or belligerent - Examine for withdrawal delirium, injuries, and evidence of other disorders -give other CNS depressant to mimic effect of alcohol until VS stable (benzodiazepine!) S/S of alcohol withdrawal 48 - 72 hrs = all VS ↑ -BP ↑ -HR ↑ -Resp ↑ -Temp ↑ -DTs (delirium tremens) can result in death if left untreated! sexual assault considerations -SANE = sexual assault nurse examiner -rape trauma syndrome/ PTSD management -exam, specimens, STD testing, follow up human trafficking considerations • May present to ED withinjury, accompanied by boyfriend or travel partner • Hx of chronic runaway,homelessness, self-mutilation • Common behaviors:cowering, frightened,agitated, deferring to the person accompanying them • Common complaints:injuries, poor healing, abd pain, dizziness, headaches,rashes or sores • May demonstrate behaviors: addiction, panic attacks, impulse control,hostility, suicide ideations nurses role in human trafficking • Offer opportunity for patient to speak alone, without companion • Use targeted, appropriate questions: - Are you in control of your own money? - Are you able to come and go as you please? - Who is the person(s) accompanying you? • May decline assistance • Resource: The National Human Trafficking Hotline risk factors for PE -Prolonged immobilization (biggest risk factor) -Surgery -Obesity -Advancing age -Hypercoagulability -History of thromboembolism -Smoking -Pregnancy, estrogen therapy, birth control -Diseases/trauma -All hospitalized clients clinical manifestations of PE • Respiratory 1. Dyspnea, tachypnea, tachycardia 2. Pleuritic chest pain, crackles 3. Hemoptysis 4. ABGs = hypoxemia (review ABG results) treatment for PE • Reduce risk factors in all hospitalized and immobile clients • Oxygen • Monitoring • Heparin/ Warfarin • Newer medications (~xaban) • Embolectomy • Psychosocial • get up and get moving!!! clinical manifestations of ARDS - dyspnea, dense infiltrates "whiteout" - refractory hypoxemia - pulm. edema - ↓ lung compliance treatment for ARDS • Ventilator • Fluids to maintain C.O. • TPN • 4 phases: 1: dyspnea 2: inc. infiltrates 3: up to day 10 = refract. hypoxemia 4: after day 10 = pulm. fibrosis (scar tissue) -intubate to force adequate oxygenation while treating cause of "white out" (very small window of time) -"white out of lungs" = fluid in lungs types of blades for intubation macintosh= C curved blade miller= straight types of ventilators usually positive pressure used... -pressure cycled: RT or PACU use -time cycled: Peds/ NICU -volume cycled: til volume met -non invasive positive pressure cycled (CPAP) ventilator modes controlled -least used, set settings for paralyzed pts (pts do not come off vent) assist/ control -most common, similar to "demand pacemaker" -responds to pts inspiratory effort but with set TV -used with pts they want to eventually get off the vent. Machine settings will let us know when pt starts trying to breathe on their own synchronized interm. mand. vent (SIMV) -also used for weaning -pt can also spontaneously in between ventilator settings • Collaborative with RT, Physician • Rate: usu. 10-16 • FIO2: 21-100% • *Tidal Volume:Kg of body weight X 7* (MUST KNOW) • Sigh: 6-10/hr • PIP: peak inspiratory pressurev ent. needs to deliver set TV,deps. on lung compliance preventing trauma and infection considerations -Infection control measures -Tube care -Cuff management -Oral care -Elevation of HOB (reduces risk of aspiration) causes of altered LOC • Head injury • Stroke • Trauma • Hepatic failure • Renal failure • Alcohol or Drug OD • Diabetic ketoacidosis (DKA) glasgow coma scale highest possible score is 15! patho behind increased intracranial pressure • Decreases cerebral perfusion • Stimulates further swelling and edema • Decreased area within skull • May shift brain tissue • Herniation • Death clinical manifestations of ICP • Change in LOC • Slow speech • Delayed response • Restlessness • Confusion • Increased drowsiness • Stuporous • Posturing manifestations of early vs late ICP Early -changes in LOC -any change in condition (restlessness, confusion, increasing drowsiness, increased resp effort, purposeless movement) -pupil changes and impaired ocular movements -weakness in one extremity or one side -HA: constant or increasing in intensity or aggravated by movement or straining Late -resp and vasomotor changes -cushing's triad: bradycardia, hypertension, bradypnea -projectile vomiting -further deterioration of LOC, stupor to coma -hemiplegia, decortication, decerebration, or flaccidity -resp pattern alterations including cheyne stokes breathing or resp arrest -loss of brainstem reflexes = pupil/ gag/ corneal/ swallowing ICP medical management • Decrease cerebral edema • Maintain cerebral perfusion • Reduce cerebrospinal fluid and intracranial blood volume • Control fever • Maintain oxygenation and reduce metabolic demands nursing management for ICP • A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care. Protection also includes maintaining the patient's dignity and privacy preoperative care/ nursing management for insertion of foramen of monro for calibration of ICP monitoring system • Obtain baseline neurologic assessment • Assess patient and family understanding of and preparation for surgery. • Provide information, reassurance, and support spinal cord injury considerations • The result of concussion, contusion, laceration or compression of spinal cord. • Primary injury- result of the initial trauma. • Secondary injury- result of ischemia, hypoxia, and hemorrhage that destroys the nerve tissues. -reversible/preventable during the first 4-6 hours after injury. • Treatment is needed to prevent partial injury from developing into more extensive, permanent damage. spinal vs neurogenic shock (acute) •Spinal shock - A sudden depression of reflex activity below the level of spinal injury - Muscular flaccidity, lack of sensation and reflexes - Low BP, Low HR (MAP should be maintained at 85 or higher) Neurogenic shock - Loss of function of the autonomic nervous system - Decrease BP, HR, CO - Venous pooling occurs due to peripheral vasodilation (DVT's) - Paralyzed portions of the body do not perspire (Impaired thermoregulation) -loss of function of the autonomic NS -increased risk for clotting autonomic dysreflexia (lifelong) considerations • Acute emergency! (result of NS sensing that something is wrong and reacts to it accordingly although the body cannot physically feel it) • Occurs after spinal shock has resolved and may occur years after the injury. • Occurs in persons with a SC lesion above T6 .• Autonomic nervous system responses are exaggerated. • S/S: severe pounding headache, sudden increase in blood pressure, profuse diaphoresis,nausea, nasal congestion and bradycardia. • Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (such as constipation), or stimulation of the skin. nursing interventions for autonomic dysreflexia • Place patient in seated position to lower BP • Rapid assessment to identify and eliminate cause - Empty the bladder using a urinary catheter or irrigate/change indwelling catheter - Examine rectum for fecal mass - Examine skin - Examine for any other stimulus • Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV • Label chart or medical record that patient is atrisk for autonomic dysreflexia • Instruct patient in prevention and management care plan for all dependent clients (problem and intervention) Ineffective Airway Clearance -Suction as needed -Chest Physiotherapy -Reposition (Proning) -Mucolytics Impaired Gas Exchange -Oxygen -Monitor patient PO, Vent settings -Bronchodilators, Anticholinergic, Steroids Decreased Cardiac Output -Fluids maintain CO -DVT Prophylaxis -Monitor BP/VS Risk for infection -Monitor for sepsis -Administer Antibiotics Impaired Nutrition -TPN PEG TUBE Impaired Skin Integrity -Reposition -Braden Scale -ORAL care (every1-2 hours) Immobility -PROM -Reposition Q2 hours -Prevent contractures Impaired Urinary Elimination -Monitor Urine output -Catheter with a urometer -Purewick or condom cath Impaired Bowel Elimination -Miralax, Senna, Docusate -Monitor Bowel sounds/ Paralytic ileus Impaired Thermoregulation -Monitor body temperature Impaired Communication/ Social Isolation Failure to Thrive/ Ineffective Coping care plan for spinal cord injury clients (problem and intervention) AD= autonomic dysreflexia NS= neurogenic shock SS= spinal shock Ineffective airway clearance - incentive spirometry Decreased cardiac output -midodrine keeps BP up (NS) -DVT prophylaxis (NS) Impaired skin integrity -no wrinkles (AD) Immobility -steroids to prevent further SCI (SS) Impaired urinary elimination -intermittent straight catheterization (AD) Impaired bowel elimination -digital disimpaction (AD) Impaired thermoregulation -control fever (NS) Impaired communication/ social isolation Failure to thrive/ ineffective coping care plan for increased intracranial pressure clients (problem and intervention) Ineffective airway clearance -CAREFUL suctioning Fluid volume excess -diuretics (mannitol), Furosemide (ototoxic) -ICP monitor -steroids Impaired skin integrity -braden scale Immobility -HOB elevated 30 degrees or higher Impaired bowel elimination -NO straining Impaired thermoregulation -NO shivering (control fever!) Impaired communication/ social isolation -NO thinkin -decrease stress -no noise -quiet environment Factors affecting safety -Developmental considerations -Lifestyle -Mobility -Sensory perception -Knowledge -Ability to communicate -Physical health state -Psychosocial health state what is the focus of safety assessment? the person, the environment, specific risk factors risk factor assessments Falls Fires Poisoning Suffocation and choking Firearm injuries nursing history consists of -assess for history of falls or accidents -note assistive devices -be alert to history of drug or alcohol abuse -obtain knowledge of family support systems and home environment physical assessment of the older adult -assess mobility status -assess ability to communicate -assess level of awareness or orientation -assess sensory perception -identify potential safety hazards -recognize manifestations of domestic violence or neglect factors that contribute to falls -Age 65 -History of falls -Impaired vision or balance -Altered gait or posture, impaired mobility -Medication regimen -Postural hypotension -Slowed reaction time; weakness, frailty -Confusion or disorientation -Unfamiliar environment Fires: RACE r: rescue anyone in immediate danger a: activate the fire alarm c: confine the fire by closing doors and windows e: evacuate patients and other people to safe area patient outcomes for safety -Identify real and potential unsafe environmental situations. -Implement safety measures in the environment. -Use available resources for safety information. -Incorporate accident prevention practices into ADLs. -Remain free of injury. nursing responsibilities in regards to in home safety: education and counseling health teaching in the schools -Monitor the child's use of the Internet. -Get involved in school activities and ask pertinent questions. -Volunteer for safety committees that include staff and parents. -Ensure that the school's emergency preparedness plan is current. safety considerations for neonates -Avoid behaviors that might harm the fetus. -Never leave the infant unattended. -Use crib rails. -Monitor setting for objects that are choking hazards. -Use car seats properly. safety considerations for toddlers and preschoolers -childproof home environment -prevent poisoning -be alert to manifestations of child maltreatment or abuse -use car seats properly safety considerations for school-aged children -Help to avoid activities that are potentially dangerous. -Provide interventions for safety at home, school, and neighborhood. -Teach bicycle safety. -Teach about child abduction. -Wear seatbelts. physical indications of a concussion headache, vomiting, problems with balance, fatigue, dazed or stunned appearance cognitive indications of a concussion mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities emotional indications of a concussion irritability, nervousness, very emotional behavior how is sleep affected after a concussion? drowsiness, difficulty falling asleep, sleeping more or less than usual safety considerations for adolescents -Teach safe driving skills. -Teach avoidance of tobacco and alcohol. -Teach risk of infection with body piercing. -Teach about guns and violence. -Discuss dangers associated with the Internet. safety considerations for adults -Remind them of effects of stress on lifestyle and health. -Counsel about unsafe health habits (reliance on drugs and alcohol). -Counsel about domestic violence. Safety Plan for Victims of Domestic Abuse -A place to stay -An escape route -A person you can call in a crisis -A signal to a neighbor to call for help -Keys for the house and car -Secure copies of important papers -A packed bag -Additional addresses and phone numbers Safety devices to prevent falls -hand rails in the bath -increased lighting -update glasses prescriptions Ambularm Device DAME Acronym to Assess Risk for Falls in Older Adults D: drug and alcohol use A: age-related physiologic status M: medical problems E: environment Safety Considerations for Older Adults -Prevent accidents. -Orient person to surroundings (avoid falls). -Maintain vehicle in working order, schedule eye exams, and keep noise at a minimum. -Promote safe environment at home (avoid fires). -Use medication trays (avoid poisoning). Physiologic hazards associated with restraints -Increased possibility of serious injury due to fall -Skin breakdown -Contractures -Incontinence -Depression -Delirium -Anxiety -Aspiration and respiratory difficulties -Death wrist restraint a physical restraint that limits arm movement elbow restraint A type of restraint that is used in the care of infants or small children to prevent flexing an arm to scratch or touch skin on the face or head, primarily during surgery mummy restraint A blanket wrapped in a special way to enclose a child's body to prevent movement during a procedure. true or false: a side rail is considered a restraint if the patient asks for it to be raised to assist in getting into and out of bed false; as long as the patient is aware and assessed the necessary use of the side rail to get into and out of bed procedure-related accidents/ possible errors -Administering medications or intravenous solutions -Transferring a patient -Changing a dressing -Applying external heat to a patient's extremity safety event report documentation describing any injury or potential for injury suffered by a patient in a health care agency -details the patient's response to the examination and treatment of the patient after the incident -completed by the nurse immediately after the incident -is not part of the medical record and should not be mentioned in the documentation sentinel event an accident or incident that results in grave physical or psychological injury or death Maintaining Emergency Preparedness -Addressing biological threats -Addressing chemical threats -Addressing radiation threats -Addressing cyber terror -Preparing for mass trauma terrorism -Identifying disaster resources -Addressing psychological aspects of disasters Chemicals Used for Mass Destruction Choking/lung/pulmonary agents Blood agents Vesicants/blister agents Nerve agents Incapacitating agents factors affecting personal hygiene -Culture -Socioeconomic class -Spiritual practices -Developmental level -Health state -Personal preferences assessing hygiene -interview patient about their daily hygiene routine -physically assess the patient to gather data about patient's hygiene status -assisting with hygiene allows nurse to view skin, hair, nails, eyes, ears, mouth and identify problems patient may have while performing hygiene interview questions for skin alterations how long have you had this problem? does it bother you? how does it bother you? (itching) have you found anything helpful in relieving these symptoms? factors to consider when examining the skin cleanliness, color, temp, turgor, moisture, sensation, vascularity, evidence of lesions guidelines for assessing the skin -Proceed systematically in head-to-toe sequence. -Use a good source of light, preferably daylight. -Compare bilateral parts for symmetry. -Use standard terminology to report and record findings. -Allow data obtained to direct skin assessment. -Identify variables known to causes skin problems. purposes of bathing -Cleanses the skin -Acts as a skin conditioner -Helps to relax a person -Promotes circulation -Serves as musculoskeletal exercise -Stimulates the rate and depth of respirations -Promotes comfort through muscle relaxation and skin stimulation -Provides person with sensory input -Helps improve self-image -Strengthens nurse-patient relationship CHG bath Chlorhexidine gluconate used to reduce the spread of infections in hospitals. CHG baths are especially helpful in intensive care units (ICUs). Used for post op patients, patients with PICC lines, etc. patients at risk for skin breakdown -very young -geriatric patients -certain disease states: diabetes, PVD, cancer, S/P stroke, neuro diseases -obese patients -immobile patients -immuno-compromised patients Administering Oral Hygiene -Moistening the mouth -Cleaning the mouth -Caring for dentures -Toothbrushing and flossing -Using mouthwashes glossitis inflammation of the tongue stomatitis inflammation of the mucosa of the mouth dental caries decay in the teeth; cavities gingivitis red, swollen gum margins that bleed easily plaque soft, whitish debris on teeth periodontitis inflammation of the gums that also involves a degeneration of dental tissue and bone cheilosis oral problem that involves an ulceration of the lips usually caused by vitamin B complex deficiencies care of the eyes Clean from inner to outer canthus with wet, warm cloth, cotton ball, or compress. -Use artificial tear solution or normal saline every 4 hours if blink reflex is absent. -Care for eyeglasses, contact lens, or artificial eye if indicated. ear and nose care -Wash external ear with washcloth-covered finger; do not use cotton-tipped swabs. -Perform hearing aid teaching and care if indicated. -Clean nose by having patient blow it if both nares are patent. -Remove crusted secretions around nose by applying warm, moist compress. Providing Hair Care -Identify patient's usual hair and scalp care practices and styling preferences. -Note any history of hair or scalp problems such as dandruff, hair loss, or baldness. -Treat any infestations, such as pediculosis and ticks. -Groom and shampoo hair. -Care for beards and mustaches. -Assist with unwanted hair removal. pediculosis infestation with lice true or false: Pediculosis (lice) can be spread directly by contact with the infested areas or indirectly through contact with clothing, bed linen, brushes, or combs. true Nail and Foot Care -Assess nails for color and shape, intactness and cleanness, and tenderness. -Check for history of nail or foot problems. -Wash nails and feet and assist with cleaning and trimming nails. -Massage the feet to promote relaxation and comfort. -Provide diabetic foot care if indicated. perineal and vaginal care -Assess for perineal or vaginal problems and related treatments. -Perform a physical assessment of male and female genitalia. -Perform perineal care in matter-of-fact and dignified manner according to procedure. -Cleanse vaginal area with plain soap and water. bed pan condom catheter Foley catheter measuring intake and output -instruct patient and family of need to record I&O -post in room on white boards -measure both intake and output, include patient's food tray -document each time your patient has input or output -computer will add and document 24 hour total -measure all food that is liquid at room temperature for intake (jello, popsicle, ice cream) -remember to include liquids used to give meds -all IV fluids (not IVPD PowerChart puts this in when you scan to give the med) -flushes for tubes, IVs, drains, tube feeds Anti-embolism stockings (TED hose) 1. Should apply while resident is in bed or with feet elevated 2. Hold foot and heel of stocking and gather up stocking - turning the stocking inside out down to the heel, aids in application 3. Smooth up and over leg so hose is even, snug and not twisted or wrinkled 4. Heel and toe in proper location 5. If there is a hole at the foot portion of the hose, it makes no difference if it is on top of the foot or the bottom. (The hole was put there by the different manufacturers, to check circulation of the toes) Focus of Self-Care Deficit Diagnoses Feeding Bathing and hygiene Dressing and grooming Toileting Role of Skeletal System in Movement Supports the soft tissues of the body Protects crucial components of the body Furnishes surfaces for the attachment of muscles, tendons, and ligaments Provides storage areas for minerals and fat Produces blood cells Relationship of skeletal muscles to bones. - Muscles are attached to bones by tendons known as the origins and insertions. - Skeletal muscles produce movements by pulling on bones. - Bones serve as levers, and joints act as fulcrums for the levers. - Muscles that move a body part often do not cover the moving part. Bones are classified by shape types of joints ball-and-socket, condyloid, gliding, hinge, pivot, saddle Joint Movements Abduction Adduction Circumduction Flexion Extension Hyperextension Dorsiflexion Plantar flexion Rotation Internal rotation External rotation Supination Pronation Inversion Eversion Three types of muscle tissue skeletal, cardiac, smooth or visceral functions of muscles produce movement, maintain posture, stabilize joints, generate heat skeletal muscle a muscle that is connected to the skeleton to form part of the mechanical system that moves the limbs and other parts of the body. cardiac muscle Involuntary muscle tissue found only in the heart. smooth or visceral muscle involuntary muscle; around organs, GI tract, blood vessels Effect of Nervous System on Muscle Contraction -The afferent nervous system conveys information to the CNS. -Neurons conduct impulses from one part of the body to another. Information is processed by the CNS. -The efferent system conveys a response from the CNS to skeletal muscles via the somatic nervous system. afferent sensory efferent motor postural reflexes reflexes that help us maintain body position and equilibrium at rest or during movement labyrinthine sense the sensory organs in the inner ear provide this sense of position, orientation, and movement Proprioceptor or kinesthetic sense informs the brain of the location of a limb or body part as a result of joint movements stimulating special nerve endings in muscles, tendons, and fascia visual or optic reflexes visual impressions contribute to posture by alerting the person to spatial relationships with the environment Extensor or stretch reflexes when extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture factors influencing mobility -Developmental considerations -Physical health -Mental health -Lifestyle -Attitude and values -Fatigue and stress -External factors physical assessment for mobility -General ease of movement and gait -Alignment -Joint structure and function -Muscle mass, tone, and strength -Endurance mobility and immobility a person's ability to inability to move can be represented on a continuum with many degrees of partial immobility effects of immobility MUSCOSKELETAL: Disuse osteoporosis: without weight bearing the bone demineralize and become spongy Disuse atrophy: decrease in size looses normal function Contractures: permanent shortening of the muscle Stiffness and pain in the joints- ankylosis CARDIOVASCULAR: Diminished cardiac reserve Increased use of Vasalva maneuver Orthostatic (postural) hypo tension Venous vasodilation and stasis Dependent edema Thrombus formation Thrombophlebitis (impaired venous return, hypercoagulability, injury to a blood vessel) Thrombus (clot) Embolus RESPIRATORY: Decreased respiratory movement Shallow respirations and decreased vital capacity Pooling of secretions Hypostatic pneumonia Atelectasis METABOLIC: Decreased metabolic rate Basal metabolic rate Negative nitrogen balance Anabolism/catabolism Anorexia Negative calcium balance URINARY: Urinary stasis: lack of gravity Renal calculi: Increase calcium salt Urine become alkaline Urinary retention accumulation of urine Urinary incontinence: involuntary urine Urinary infections: static in the urine is a source for bacterial growth Escherichia Coli Urinary reflux EXERCISE: Improves the appetite Increases GI tract tone Facilitates peristalsis IMMOBILITY: constipation PSYCHONEUROLOGIC: Apathetic Withdrawn Regression Anger Aggressive Problem solving, decision making complications of immobility generalized weakness, orthostatic intolerance, telecasts, pneumonia, pulmonary emboli, thrombophlebitis, muscle atrophy, osteoporosis, urinary retention, constipation, impaired sensory perception SCDs (sequential compression devices) NANDA North American Nursing Diagnosis Association, purpose is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. disuse syndrome Loss in the ability to perform ADL functions as a result of a sedentary lifestyle disability contractures permanently contracted state of a muscle foot drop weakness of muscles in the feet and ankles that causes difficulty with the ability to flex the ankles and walk normally activity the quality or process of exerting energy exercise a type of physical activity that is planned, structured and repetitive bodily movement done to improve or maintain physical fitness isotonic exercise activity that combines muscle contraction with repeated movement isometric exercise an exercise in which muscles contract but very little body movement takes place isokinetic exercise exercise involving muscle contractions with resistance varying at a constant rate benefits of exercise on the cardiovascular system Increased efficiency of the heart Decreased heart rate and blood pressure Increased blood flow to all body parts Improved venous return Increased circulating fibrinolysin (substance that breaks up small clots) benefits of exercise on the respiratory system Improved alveolar ventilation Decreased work of breathing Improved diaphragmatic excursion benefits of exercise on the musculoskeletal system increased muscle efficiency and flexibility increased coordination reduced bone loss increased efficiency of nerve impulse transmission fowler's position a semi-sitting position; the head of the bed is raised between 45 and 60 degrees protective supine position Prevent exaggerated curvature of the spine and flexion of the hips by providing a firm, supportive mattress Prevent flexion contracture of the neck by placing pillows under the upper shoulders, neck, and head Prevent internal rotation of the shoulders and extension of the elbows(hunch shoulders) by placing pillows or arm supports under the forearms so that upper arms are alongside the body and the forearms are pronated slightly Prevent flexion of lumbar curvature by placing rolled towel or small pillow under lumbar curvature Prevent external rotation of the femurs by placing sandbags or a trochanter roll alongside the hips and the upper half of the thighs Prevent hyperextension of the knees by placing a pillow under the lower legs from below the knees to the ankles Prevent extension of the fingers and abduction of the thumbs(clawhand) with hand-wrist splints Prevent footdrop by supporting the feet in dorsal flexion with foot board; high top sneakers protective side lying or lateral position Prevent lateral flexion of the neck by placing a pillow under the head and the neck Prevent extension of the fingers and abduction of the thumbs(clawhand) with hand-wrist splints Prevent inward rotation of the arm and interference with respiration by placing a pillow under the upper arm; lower arm should be flexed and positioned comfortably Prevent internal rotation and adduction of the femur by using one or two pillows to support the leg from the groin to the foot Prevent twisting of the spine by ensuring that both shoulders are aligned with both hips protective sims position Helps to prevent respiratory complications, pressure ulcers, and contractures r/t complications of immobility. Facilitates oral drainage. Reduces pressure over the sacrum and greater trochanter. modified lateral/oblique position ambulatory aids gait belts, stand assist and repositioning aids, lateral assist device, friction reducing sheets, transfer chairs, power stand assist and repositioning lifts, power lift body lifts COAL Cane Opposite Affected Leg WWAL walker with affected leg Proper body mechanics Ways of standing and moving one's body to make the best use of strength and avoid injury and fatigue. thinking like a nurse Using nurse's clinical judgment to draw conclusions based on patient's needs, concerns, or health problems AND the decision to take action or modify approach as deemed appropriate by the patient's response nursing process was labeled in 1950 how nurses use the nursing process -critically think & make decisions -identify patient problems -determine patient outcomes -prioritize patient care five steps of the nursing process Assessment Diagnosis Planning Implementation Evaluation assessing collecting, validating, and communicating patient data diagnosing analysis of patient data to identify patient strengths and health problems planning specifying patient outcomes and related nursing interventions; prioritizing nursing diagnoses based upon immediate needs implementation carrying out the plan of care; initiation of care plan, performing interventions, assessing effectiveness, documentation evaluation measuring extent to which patient achieves outcomes; measure how well patient achieved outcomes, identify factors that contribute to success or failure open-ended questions questions that allow respondents to answer however they want closed-ended questions questions a person must answer by choosing from a limited, predetermined set of responses PES problem, etiology, symptom -diagnosing portion of the nursing process when writing NANDAs medical diagnosis the identification of a disease or condition by a doctor nursing diagnosis describes a health problem that can be treated by nursing measures; a step in the nursing process etiology identifies the factors that are maintaining the unhealthy state or response -- contributing or causative factors types of nursing diagnosis actual, risk/ potential, wellness Types of Nursing Diagnosis: Actual problem is present at the time of diagnoses; 3 part NANDA statement Types of Nursing Diagnosis: Risk for problem is not present at time of diagnosis -- nurse uses clinical judgment to determine if an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation; 2 part NANDA statement types of nursing diagnosis: wellness diagnosis clinical judgments about an individuals, group or community in transition from a specific level of wellness to a higher level of wellness; 1 part NANDA statement ABCs airway, breathing, circulation Maslow's Hierarchy of Needs physiological, safety, love/belonging, esteem, self-actualization First-level priority problems emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing Second-level priority problems urgent, prompt intervention, prevent further deterioration such as mental status change, acute pain, untreated medical problems Third-level priority problems non-urgent; important to patient's health such as knowledge deficit problems, activity, coping Writing Outcomes SMART Specific (to client) Measurable Achievable Relevant (to the nursing diagnosis and client symptoms) Time-Bound the Nursing Outcomes Classification (NOC) a comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions Nursing Interventions Classification (NIC) Any treatment the nurse performs to enhance patient outcomes based on clinical judgment and knowledge independent intervention nurse-initiated intervention collaborative intervention Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals rationale the scientific reason for carrying out an intervention inspiration the active phase of ventilation -movement of muscles and thorax to move air into the lungs expiration the passive phase of ventilation -air out of the lungs gas exchange the process of obtaining oxygen from the environment and releasing carbon dioxide; combination of respiration, ventilation, and perfusion alveoli tiny sacs of lung tissue specialized for the movement of gases between air and blood perfusion the process by which oxygenated capillary blood passes through body tissues pulmonary ventilation movement of air into and out of the lungs hypoventilation decreased rate or depth of air movement into the lungs hypoxia inadequate amount of oxygen available to the cells hypoxemia decreased O2 concentration in arterial blood dyspnea difficulty breathing apnea cessation of breathing for 20 seconds what two systems work together for adequate ventilation and perfusion? respiratory and cardiovascular system kyphosis excessive outward curvature of the spine, causing hunching of the back. -appearance of leaning forward barrel chest deformity increased anterior posterior - transverse diameter (COPD) retractions Movements in which the skin pulls in around the ribs during inspiration. crackles intermittent sounds occurring when air moves through airways that contain fluid Classified as fine, medium, or coarse wheezes continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors wheezes commonly heard in asthma patients -- constriction of airway crackles heard commonly in pneumonia patients -- fluid in lungs pulmonary function studies (PFT) evaluates overall condition/ functioning of respiratory system ABG's arterial blood gases CBC complete blood count early signs/ symptoms of hypoxia/ hypoxemia tachypnea, dyspnea, tachycardia, restlessness, pallor, elevated BP, accessory muscle use, nasal flaring late signs/ symptoms of hypoxia/ hypoxemia bradypnea, bradycardia, hypotension, confusion, stupor, cyanosis, cardiac dysrhythmias nebulizers disperse fine particles of liquid medication into the deeper passages of the respiratory tract (mask, mouthpiece) nasal cannula A device that delivers low concentrations of oxygen through