Fundamentals

What are the techniques in interviewing process.

What are the techniques in interviewing process.

Problem Seeking & Problem Solving, Direct &

Open-Ended Questioning

What are the three phases of a basic interview.

What are the three phases of a basic interview.

Orientation, Working, and Termination Phase

What is the first step in nursing assessment.

What is the first step in nursing assessment.

Nursing Health History

Basic components of the nursing health history.

Basic components of the nursing health history.

Bio. Info.

Reasons for seeking hxcare

Pt. expectations

Past Hx

Hospitalization

Treatment

Outcomes

Family

Environmental

Psychosocial

Present Hx State & R.O.S.

What is the focus of nursing history.

What is the focus of nursing history.

Effect of CHANGE in Hx state in meeting basic

human needs.

A statement of potential or actual patient problems.

A statement of potential or actual patient problems.

Nursing Diagnosis

Nursing diagnostic involves four elements.

Nursing diagnostic involves four elements.

Analysis & Interpretation of data, Clustering of

Data, Identification of Pt. Problems, Formulation

of Nsg. Dx.

It requires validation and clustering of data.

It requires validation and clustering of data.

Interpretation of data

Determining whether data gathered is complete

and accurate.

Determining whether data gathered is complete

and accurate.

Validation of data

Grouping related data, usually sx & sy, indicating

a general problem.

Grouping related data, usually sx & sy, indicating

a general problem.

Clustering of data

A hx care problem that is currently perceived by

the pt. or assessed by the nurse.

A hx care problem that is currently perceived by

the pt. or assessed by the nurse.

Actual Hx Care Problem

A hx care problem in which the patient is at risk.

A hx care problem in which the patient is at risk.

Potential Hx Care Problem

When planning, a nurse should consider the level

of potential pt. involvement, time limit and what?

When planning, a nurse should consider the level

of potential pt. involvement, time limit and what?

Available Hx care system resources

In implementation of the NCP, what actions are

taken.

In implementation of the NCP, what actions are

taken.

Assist Pt. on ADL, Counsel & support Pt. &

family, Guide Pt., Teach Pt. & Family, Provide

care to achieve NCP, Provide Environment that is

conducive.

Interventions based on instructions or written

directives given by another professional.

Interventions based on instructions or written

directives given by another professional.

Dependent Intervention

Aspects of care encompassed by licensure and law.

Aspects of care encompassed by licensure and law.

Independent Intervention

Interventions that the nurses carry out in

collaboration with another professional.

Interventions that the nurses carry out in

collaboration with another professional.

Interdependent Intervention

True or False. The NCP is modified as the Pt's

state of Hx changes and as needs for care changes.

True or False. The NCP is modified as the Pt's

state of Hx changes and as needs for care changes.

True

In evaluation of NCP, outcomes of nursing

interventions maybe used for.

In evaluation of NCP, outcomes of nursing

interventions maybe used for.

Malpractice suits

Staff Evaluations

Reviews

Promotions

Nursing Research

Quality Improvement

What are the enrivonmental fire safety

precautions?

What are the enrivonmental fire safety

precautions?

Mark fire exits

Dont use elevator

Turn off O2 machines

Move pt's. by bed, stretcher, or wheelchair

What are environmental radiation safety

precautions?

What are environmental radiation safety

precautions?

Label radioactive materials

Limit time spent

Distance yourself from the source

Use lead apron

Never touch dislodged implants

What are environmental precautions for disposing

infectious wastes?

What are environmental precautions for disposing

infectious wastes?

Needles should not be recapped, bent or broken

Yellow for infectious

Green for biodegradable

Black for nonbiodegradable

Red for blood, sharp items, contaminated

It is to restrict client movement through the

application of a device?

It is to restrict client movement through the

application of a device?

Physical restraints

Medications given to inhibit specific behavior?

Medications given to inhibit specific behavior?

Chemical restraints

Restraints should have?

Restraints should have?

Reason & method

Date & time of use

Duration & release from it

Assessment of pt's response & further need of use

Half bow or safety knot & secured to the bedframe

or chair

Restraints should not be?

Restraints should not be?

P.R.N. & without consent from the pt. & family

Neurovascular, circulatory & skin integrity is

assessed in using restraints when?

Then removed at least every?

Neurovascular, circulatory & skin integrity is

assessed in using restraints when?

Then removed at least every?

Every 30 minutes

Removed @ least q 2 hrs. to promote circulation

Who are those prone to accidental poisoning?

Who are those prone to accidental poisoning?

Toddlers

Preschoolers

Young school age

In older adults, poisoning & overdose of

prescribed medz. will yield?

In older adults, poisoning & overdose of

prescribed medz. will yield?

Diminished eyesight

Impaired memory

If lye, grease, petroleum or household cleaner is

ingested, a nurse should?

If lye, grease, petroleum or household cleaner is

ingested, a nurse should?

Never induce vomit especially to an unconscious

person

If vomit occurs, bring vomitus to CDC

Nosocomial infections can be transmitted by a

healthcare personnel by?

Nosocomial infections can be transmitted by a

healthcare personnel by?

Improper handwashing

Unchanged gloves between clients

Standard precautions apply to?

Standard precautions apply to?

Blood

Non-intact skin

Mucous membrance

All body fluids except sweat

Diseases under transmission based precautions

are?

Diseases under transmission based precautions

are?

Measles

Chickenpox (varicella)

Disseminated varicella zoster

Droplet precautions diseases are?

Droplet precautions diseases are?

Adenovirus, Influenza

Sepsis, Scarlet Fever

Epiglottitis, Mumps

Meningitis

Barrier protection for transmission based droplet

precautions is?

Barrier protection for transmission based droplet

precautions is?

Placing client in private room or cohort client

Mask

Transmission based contact precautions diseases

are?

Transmission based contact precautions diseases

are?

Clostridium Difficle

INFxN with multidrug resistant org.

Wound infections

Cutaneous diptheria

Herpes simplex

Impetigo

Pediculosis

Scabies

Staphylococcus

Varicella Zoster

Conjunctivitis

Smallpox is a droplet type with S&S of fever, back

pain, vomiting, malaise, headache & papules that

turn into?

Smallpox is a droplet type with S&S of fever, back

pain, vomiting, malaise, headache & papules that

turn into?

Pustular vessicles in the face & extremities

In case of fire, a nurse should

R-

A-

C-

E-

In case of fire, a nurse should

R-rescue

A-alarm

C-confine

E-extinguish

Head tilt-chin lift is used in B.L.S. but if pt. has a

neck injury, what do you use?

Head tilt-chin lift is used in B.L.S. but if pt. has a

neck injury, what do you use?

Jaw thrust maneuver

A.B.C.D.'s of B.L.S. are:

A.B.C.D.'s of B.L.S. are:

Airway

Breathing

Circulation

Defibrilation or Definitive Treatment

Each step begins with ASSESSMENT always

Apical & radial pulse will always yield?

Apical & radial pulse will always yield?

Identical result

In assessing for a pulse to an

infant < 1 yr old?

a child > 1 yr old?

In assessing for a pulse to an

infant < 1 yr old?

a child > 1 yr old?

Brachial (<1yr)

Carotid (>1yr)

For infants on B.L.S., chest compression is 1/2 - 1

inch deep @ least 100 times/min using?

For infants on B.L.S., chest compression is 1/2 - 1

inch deep @ least 100 times/min using?

2-3 fingers

Child 1-1.5 inches deep

When performing a Heimlich Maneuver to an

obese or pregnant, what do you do?

When performing a Heimlich Maneuver to an

obese or pregnant, what do you do?

Chest thrusts

For unconscious adult (B.L.S.), you do a?

For unconscious adult (B.L.S.), you do a?

Tongue jaw lift

Fingersweep object

For unconscious pregnant, a pillow or rolled

blanket is placed on the right side to?

For unconscious pregnant, a pillow or rolled

blanket is placed on the right side to?

Displace uterus to the left of the abdomen

Unconscious pregnant needing defibrilation should

have the paddles placed 1-rib higher than the usual

because?

Unconscious pregnant needing defibrilation should

have the paddles placed 1-rib higher than the usual

because?

Heart is displaced during pregnancy

This is used to convert ventricular fibrilation into a

perfusing rhythm?

This is used to convert ventricular fibrilation into a

perfusing rhythm?

Automated External Defibrillator

Automated External Defibrilator is C/I to?

Automated External Defibrilator is C/I to?

< 8 yrs old

Child weighing < 25 kgs.

A surgeon is responsible for getting consent & a

nurse can be a witness provided the pt. understood

the procedures explained by the doctor. What is

the next step?

A surgeon is responsible for getting consent & a

nurse can be a witness provided the pt. understood

the procedures explained by the doctor. What is

the next step?

Document the witnessing of consent signing

In general anesthesia, solid & liquid foods are

withheld for?

In general anesthesia, solid & liquid foods are

withheld for?

6-8 hrs. prior

Local anesthesia - 3 hrs. prior

When is enema or laxative performed in clients for

surgery?

When is enema or laxative performed in clients for

surgery?

The night prior surgery

If client has a Foley catheter before surgery, it

should be emptied & document the?

If client has a Foley catheter before surgery, it

should be emptied & document the?

Amount & characteristics of the urine

3 levels of moral development (premoral or

preconventional level, conventional level,

postconventional level).

3 levels of moral development (premoral or

preconventional level, conventional level,

postconventional level).

Lawrence Kohlberg

4 conservation principles (conservation of energy,

structural integrity, personal integrity, and social

integrity).

4 conservation principles (conservation of energy,

structural integrity, personal integrity, and social

integrity).

Myra Levine

4 types of personality (sanguine, melancholic,

phlegmatic, choleric).

4 types of personality (sanguine, melancholic,

phlegmatic, choleric).

Galen

5 hierarchy of needs (physiological, safety &

security, love & belonging, self esteem, self

actualization).

5 hierarchy of needs (physiological, safety &

security, love & belonging, self esteem, self

actualization).

Abraham Maslow

Adaptation model. Each person is a unified

biopsychosocial system in constant interaction

with changing environment.

Adaptation model. Each person is a unified

biopsychosocial system in constant interaction

with changing environment.

Sister Calista Roy

All behavior is learned.

All behavior is learned.

B.F. Skinner

Believed that nurse helps patients meet a perceived

need that the patient cannot meet themselves.

Believed that nurse helps patients meet a perceived

need that the patient cannot meet themselves.

Ida Jean Orlando

Birth trauma.

Birth trauma.

Otto Rank

Care, Core, Cure.

Care, Core, Cure.

Lydia Hall

Cognitive development (sensorimotor, peri-

operational thought, concrete operations, formal

operations).

Cognitive development (sensorimotor, peri-

operational thought, concrete operations, formal

operations).

Jean Piaget

Conceptualized the behavioral system model. Each

person is composed of 7 subsystem (ingestive,

eliminative, affiliative, aggressive, dependence,

achievement and sexual).

Conceptualized the behavioral system model. Each

person is composed of 7 subsystem (ingestive,

eliminative, affiliative, aggressive, dependence,

achievement and sexual).

Dorothy Johnson

Developed self-care and self-care deficit theory.

Developed self-care and self-care deficit theory.

Dorothea Orem

Developmental task.

Developmental task.

Robert Havighurst

Focused on manipulating the environment for the

patient's recovery.

Focused on manipulating the environment for the

patient's recovery.

Florence Nithingale

Founded psychobiology. Believes in totality of

man/holistic approach.

Founded psychobiology. Believes in totality of

man/holistic approach.

Adolf Meyer

Goal attainment theory. Nursing as a helping

profession.

Goal attainment theory. Nursing as a helping

profession.

Imogene King

Health as expanding consciousness. Humans are

unitary beings in whom disease is a manifestation

of the pattern of health.

Health as expanding consciousness. Humans are

unitary beings in whom disease is a manifestation

of the pattern of health.

Margaret Newman

Health care system model. Nursing is concerned

with all the variables affecting an individual's

response to stress, which are interpersonal,

intrapersonal, and extrapersonal in nature.

Health care system model. Nursing is concerned

with all the variables affecting an individual's

response to stress, which are interpersonal,

intrapersonal, and extrapersonal in nature.

Betty Neuman

Human becoming. Emphasized free choice of

personal meaning in relating value priorities.

Human becoming. Emphasized free choice of

personal meaning in relating value priorities.

Rosemarie Rizzo Parse

Human caring model. Nursing is the application of

the art and human science through transpersonal

caring.

Human caring model. Nursing is the application of

the art and human science through transpersonal

caring.

Jean Watson

Humanistic nursing practice theory. Nursing is an

existential experience.

Humanistic nursing practice theory. Nursing is an

existential experience.

Josephine Paterson & Loreta Zderad

Identified 14 basic needs. Nurse functions to assist

client in performing activities contributing to

health, recovery, or peaceful death.

Identified 14 basic needs. Nurse functions to assist

client in performing activities contributing to

health, recovery, or peaceful death.

Virginia Henderson

Identified 21 nursing problems. Defined nursing as

service to individuals and families, therefore,

society.

Identified 21 nursing problems. Defined nursing as

service to individuals and families, therefore,

society.

Faye Abdellah

Interpersonal model. Nursing is an interpersonal

process of the therapeutic interactions between

sick and nurse.

Interpersonal model. Nursing is an interpersonal

process of the therapeutic interactions between

sick and nurse.

Hildegard Peplau

Interpersonal theory (anxiety occurs due to poor

interpersonal relationship).

Interpersonal theory (anxiety occurs due to poor

interpersonal relationship).

Harry Stack Sullivan

Introversion and extroversion - persona/anima

Introversion and extroversion - persona/anima

Carl Jung

Modeling and role-modeling theory.

Modeling and role-modeling theory.

Helen Erickson, Evelyn Tomlin & Mary Ann

Swain

Nurse's individual philosophy lends credence to

nursing care.

Nurse's individual philosophy lends credence to

nursing care.

Ernestine Weidenbach

Presented grand theory of nursing. All persons are

caring and nursing is a response to unique social

call.

Presented grand theory of nursing. All persons are

caring and nursing is a response to unique social

call.

Anne Boykin & Savina Schoenhofer

Psychosexual theory (oral, anal, phallic, latent,

genital stage). Psychoanalytical theory (Libido is

the psychic reservoir of psychic energy, id, ego, &

superego).

Psychosexual theory (oral, anal, phallic, latent,

genital stage). Psychoanalytical theory (Libido is

the psychic reservoir of psychic energy, id, ego, &

superego).

Sigmund Freud

Psychosocial development (trust vs. mistrust,

autonomy vs. shame/doubt, initiative vs. guilt,

industry vs. inferiority, identity vs. role confusion,

intimacy vs. isolation, generativity vs. stagnation,

integrity vs. despair).

Erik Erickson

Superinferiority and inferiority complex / birth

order.

Superinferiority and inferiority complex / birth

order.

Alfred Adler

The science of unitary human beings. Human

beings are more than and different from the sum of

their parts.

The science of unitary human beings. Human

beings are more than and different from the sum of

their parts.

Martha Rogers

Theory based on bodily characteristics

(endomorphic, mesomorphic, ectomorphic).

Theory based on bodily characteristics

(endomorphic, mesomorphic, ectomorphic).

William Sheldon

Transcultural nursing. Nursing is a humanistic and

scientific mode of helping a client through specific

cultural caring process.

Transcultural nursing. Nursing is a humanistic and

scientific mode of helping a client through specific

cultural caring process.

Madeleine Leininger

Pulsating abdominal mass

Pulsating abdominal mass

Abdominal Aortic Aneurism

Painful board-like abdomen

Painful board-like abdomen

Abruptio Placenta

Uremic frost on skin

Uremic frost on skin

Acute Renal Failure

Bronze pigmentation of skin

Bronze pigmentation of skin

Addison's Disease

Outburst laughter or cry fasciculations

Outburst laughter or cry fasciculations

Amyotrophic Lateral Sclerosis (ALS)

Pain upon exertion

Pain upon exertion

Angina Pectoris

Mc Burney's sign

Mc Burney's sign

Appendicitis

Boutonnier deformity, swan neck deformity, ulnar

drift, Bouchard's nodes

Boutonnier deformity, swan neck deformity, ulnar

drift, Bouchard's nodes

Arthritis

Murmur heard high on chest

Murmur heard high on chest

Atrial Septal Defect

Rocking, spinning, routines

Rocking, spinning, routines

Autism

Grayish white discharge, malodorous

Grayish white discharge, malodorous

Bacterial Vaginosis

Raccoon's eye

Raccoon's eye

Basilar Fracture

Meconium staining

Meconium staining

Breech Birth

Russel's sign, binge eating

Russel's sign, binge eating

Bulimia Nervosa

Cherry pink flushed face

Cherry pink flushed face

Carbon Monoxide Poisoning

Jack hammer syndrome

Jack hammer syndrome

Carpal Tunnel Syndrome

Cloudy vision

Cloudy vision

Cataract

Gluten sensitivity, water, pale, foul smelling stool

Gluten sensitivity, water, pale, foul smelling stool

Celiac Disease

Maculopapulovesiculo rash

Maculopapulovesiculo rash

Chicken Pox

Rice water stools

Rice water stools

Cholera

Pulling up of arms & legs, red-face crying

Pulling up of arms & legs, red-face crying

Colic

Barrel chest, clubbing of fingers

Barrel chest, clubbing of fingers

C.O.P.D.

Moon face, buffalo hump

Moon face, buffalo hump

Cushing's Syndrome

Homonymous hemianopsia

Homonymous hemianopsia

CVA

Feeling of fullness at vagina

Feeling of fullness at vagina

Cystocele & Rectocele

Recent and past memory defect

Recent and past memory defect

Delirium

Recall or learning memory impairment

Recall or learning memory impairment

Dementia

Flashes of light, vein in line of sight

Flashes of light, vein in line of sight

Detached Retina

3 P's: polydipsia, polyphagia, polyuria

3 P's: polydipsia, polyphagia, polyuria

Diabetes Mellitus

Pseudomembrane

Pseudomembrane

Diptheria

Cramping, colicky pain in left lower abdominal

quadrant

Cramping, colicky pain in left lower abdominal

quadrant

Diverticular Disease

Saddle nose, Brushfield's spot's (Trisonomy 21)

Saddle nose, Brushfield's spot's (Trisonomy 21)

Down Syndrome

Ortolani's sign, Galeazzi's sign, asymmetry of

gluteal, popliteal & thigh folds

Ortolani's sign, Galeazzi's sign, asymmetry of

gluteal, popliteal & thigh folds

Dysplasia of Hip

Cullen's sign

Cullen's sign

Ectopic Pregnancy

Premenstrual pain decreasing as menstrual flow

decreases

Premenstrual pain decreasing as menstrual flow

decreases

Endometriosis

Exposed bladder, appears to be turned inside out

Exposed bladder, appears to be turned inside out

Exstrophy of Bladder

Radar gaze

Radar gaze

Failure to Thrive (FTT)

Barret esophagus

Barret esophagus

G.E.R.D.

Halos around light

Halos around light

Glaucoma

Dysuria, genital discharge

Dysuria, genital discharge

Gonorrhea

Exopthalmia

Exopthalmia

Grave's Disease

Hemarthrosis

Hemarthrosis

Hemophilia

Asterixis

Asterixis

Hepatic Disease

Ribbon-like, foul smelling stool

Ribbon-like, foul smelling stool

Hirschprung's Disease (megacolon)

Grapelike growth, large abdomen

Grapelike growth, large abdomen

H-mole

Bossing's sign, setting sun eyes

Bossing's sign, setting sun eyes

Hydrocephalus

Trousseau's sign

Trousseau's sign

Hypocalcemia

High pitch cry

High pitch cry

Increased Intracranial Pressure (ICP)

Doll's eye

Doll's eye

Increased Intraoccular Pressure

No passage of meconium

No passage of meconium

Intestinal Obstruction

Dance sign, currant jelly-like stool, sausage like

Dance sign, currant jelly-like stool, sausage like

Intussesception

Activity intolerance

Activity intolerance

Iron Deficiency Anemia (IDA)

Strawberry tongue

Strawberry tongue

Kawasaki

Red gelatinous sputum

Red gelatinous sputum

Kleibsella Pneumonia

XXY in males

XXY in males

Klinefelter's Syndrome

Pulmonary manifestations (i.e. orthopnea, crackles,

cyanosis, etc.)

Pulmonary manifestations (i.e. orthopnea, crackles,

cyanosis, etc.)

Left Ventricular Heart Failure

Less than 2.5 kgs or 5 1/2 lbs

Less than 2.5 kgs or 5 1/2 lbs

Low Birth Weight

Red-ringed circular rash (erythema chronicum

migrans)

Red-ringed circular rash (erythema chronicum

migrans)

Lyme Disease

Blackwater fever

Blackwater fever

Malaria

Whirling, vertigo, tinnitus

Whirling, vertigo, tinnitus

Meniere's Disease

Kernig's sign, Brudzinki's sign

Kernig's sign, Brudzinki's sign

Meningitis

White "cheesy" discharge

White "cheesy" discharge

Moniliasis

Gower's sign

Gower's sign

Muscular Dystrophy

Charcot's triad: intention tremor, nystagmus,

scanning speech (clipped)

Charcot's triad: intention tremor, nystagmus,

scanning speech (clipped)

Multiple Sclerosis

Nasal smile

Nasal smile

Myasthenia Gravis

Nonproductive that progresses to mucoid sputum

Nonproductive that progresses to mucoid sputum

Mycoplasmal Pneumonia

Viselike or crushing pain radiating to shoulder,

arms, jaw or back

Viselike or crushing pain radiating to shoulder,

arms, jaw or back

Myocardial Infarction

Purulent conjunctivitis (N. Gonorrhea)

Purulent conjunctivitis (N. Gonorrhea)

Opthalmia Neonatorum

White patches on tongue (Candida Albicans)

White patches on tongue (Candida Albicans)

Oral Thrush

Kyphosis

Kyphosis

Osteoporosis

Ringing or buzzing

Ringing or buzzing

Otosclerosis

Steatorrhea

Steatorrhea

Pancreatitis

Machinery-type murmur throughout the heartbeat

in the left 2nd or 3rd interspace

Machinery-type murmur throughout the heartbeat

in the left 2nd or 3rd interspace

Patent Ductus Arteriosus

Pill rolling

Pill rolling

Parkinson's Disease

Abdominal muscle rigidity with rebound

tenderness

Abdominal muscle rigidity with rebound

tenderness

Peritonitis

Beefy red tongue

Beefy red tongue

Pernicious Anemia

Paroxysmal cough ending with a whoop

Paroxysmal cough ending with a whoop

Pertussis

Nikolsky sign

Nikolsky sign

Phemphigus Vulgaris

Fever, vaginal discharge, lower abdominal

cramping

Fever, vaginal discharge, lower abdominal

cramping

Pelvic Inflammatory Disease (PID)

What is the purpose of IV fluid therapy?

What is the purpose of IV fluid therapy?

Maintenance, to replace or correct deficits, to

restore ongoing loss, for meds, nutrition,

phlebotomy, transfusions or blood product therapy.

What is oncotic pressure?

What is oncotic pressure?

Colloids, plasma proteins, albumin

What is hydrostatic pressure?

What is hydrostatic pressure?

Blood pressure

What is normal serum osmo?

What is normal serum osmo?

280 - 295 or approx. twice that of the serum Na

level.

What can expand the intravascular compartment?

What can expand the intravascular compartment?

Hypertonic fluids.

What is the problem with using hypertonic fluids?

What is the problem with using hypertonic fluids?

If done too fast will draw too much fluid into the

intravascular, dehydrating intracellular, especially

the brain?

What is a S/sx of fluids administered too fast?

What is a S/sx of fluids administered too fast?

decreased LOC / Confusion.

What happens if you expand the intra Cellular

compartment too fast?

What happens if you expand the intra Cellular

compartment too fast?

Deplete the intravascular, decreasing BP and

causing edema.

What are the two basic types of parenteral fluids?

What are the two basic types of parenteral fluids?

Crystalloid and Colloid

What is a crystalloid fluid?

What is a crystalloid fluid?

An Electrolyte containing solution.

What are the three basic types of crystalloid fluids?

What are the three basic types of crystalloid fluids?

Isotonic, Hypotonic and Hypertonic

Why are crystalloid fluids called true solutions?

Why are crystalloid fluids called true solutions?

Because they can pass through semipermeable

membranes.

What is a Colloid fluid?

What is a Colloid fluid?

Contains proteins and starches.

What can't a Colloid fluid do?

What can't a Colloid fluid do?

Pass between compartments. They draw the fluid

to them.

Name three problems with IV fluid therapy.

Name three problems with IV fluid therapy.

Phlebitis, extravasation and incompatabilities.

What three things can an LVN NOT do?

What three things can an LVN NOT do?

cannot hang, flush or change bags on a central line

even if certified.

What can an RN NOT do with a central line.

What can an RN NOT do with a central line.

Cannot assign to LVN or supervise LVN with

anything to do with a central line.

How do you determine whether it is a central line

or a peripheral line?

How do you determine whether it is a central line

or a peripheral line?

Ask the doctor for an x ray order to determine.

Name some isotonic fluids

Name some isotonic fluids

D5W, LR and NS

Why do you need to be careful with LR and

dehydration?

Why do you need to be careful with LR and

dehydration?

It is hard for the renal system to process the

electrolytes.

What does the liver do to lactate? (LR)

What does the liver do to lactate? (LR)

It metabolizes the lactate to bi-carbonate which

buffers acidosis

What are two common uses for Normal Saline

(NS)?

What are two common uses for Normal Saline

(NS)?

To treat hyponatremia and intravascular

dehydration.

Name a Hypotonic solution?

Name a Hypotonic solution?

0.45 NS ( 1/2 NS)

What is a problem with Hypotonic solutions?

What is a problem with Hypotonic solutions?

Use too long and it will lower BP. It is low in

solutes so fluid will move out of the vascular

space.

What makes Hyper tonic fluids different than the

others?

What makes Hyper tonic fluids different than the

others?

It has more dissolved particles than body fluid.

What does a hypertonic fluid do?

What does a hypertonic fluid do?

It moves fluid out of the intracellular and

interstitial compartments into the intravascular.

What are hypertonic fluids used for?

What are hypertonic fluids used for?

Hydration and nutrition

What is dangerous about hypertonic dextrose

saline solutions?

What is dangerous about hypertonic dextrose

saline solutions?

they can move fluids very quickly.

What is a hypertonic dextrose saline fluid solution

used for?

What is a hypertonic dextrose saline fluid solution

used for?

TPN and PPN. Nutrition.

What type IV line do you use with Hypertonic

dextrose saline?

What type IV line do you use with Hypertonic

dextrose saline?

10% solutions can go peripheral but all others 20%

and above must use a central line?

Why must most hypertonic dextrose saline

solutions be used with a central line?

Why must most hypertonic dextrose saline

solutions be used with a central line?

Because the fluids are very irritating to veins.

How do you infuse hypertonic dextrose saline

solutions?

How do you infuse hypertonic dextrose saline

solutions?

You must use an infusion pump.

Plasma expanders are not considered what?

Plasma expanders are not considered what?

Blood products.

What do you NOT have to do with plasma

expanders?

What do you NOT have to do with plasma

expanders?

Type and cross match.

Which of the two main categories of fluids do

plasma expanders fall into?

Which of the two main categories of fluids do

plasma expanders fall into?

Colloid.

What are Colloids used for?

What are Colloids used for?

Maintenance of blood volume, hypovolemic

shock, dialysis.

In which patients do you need to use colloid

product with cautiously?

In which patients do you need to use colloid

product with cautiously?

renal insufficiency and CHF

PPN is used in what type of line?

PPN is used in what type of line?

Peripheral

TPN is used in what type of line?

TPN is used in what type of line?

Central

What are the components of TPN?

What are the components of TPN?

H2O, PRO, CHO, fat, vitamins, trace minerals.

TPN usually come in a _____hour supply.

TPN usually come in a _____hour supply.

24 hour supply

Name some indications for TPN.

Name some indications for TPN.

Non-function GI, Bowel obstruct., acute inflam,

colitis, Crohns, malabsorption, chemo, burns,

sepsis, ooncology, pancreatitis.

How do you know TPN is working?

How do you know TPN is working?

By weighing daily.

What is the consideration with IVs and glucose?

What is the consideration with IVs and glucose?

Must use the appropriate IV access for

concentration of glucose, must use pump, don't

play catch up, taper TPN, accu-checks, used

micron filters

What should you monitor with TPN?

What should you monitor with TPN?

I & O, weight, liver and renal function and

electrolytes.

Why do you monitor liver and renal function with

TPN?

Why do you monitor liver and renal function with

TPN?

To make sure that they are excreting electrolytes.

Why do you use a micron filter with TPN?

Why do you use a micron filter with TPN?

to filter out bacterial growth.

Why do you taper TPN?

Why do you taper TPN?

To avoid hypoglycemic shock from cutting of the

sugar.

Can you run other things in the TPN IV tubing?

Can you run other things in the TPN IV tubing?

No, don't mix with anything else.

What is an important consideration with albumin?

What is an important consideration with albumin?

May cause anaphylaxis

What are some potential complications with TPN?

What are some potential complications with TPN?

Fluid imbalances, metabolic acidosis, liver

dysfunction, hyperglycemia and infection.

Nursing process

Nursing process

systematic, rational method of nursing care

Decision making process

Decision making process

identify purpose, set criteria, weigh criteria, seek

alternatives, examine alternatives, project,

implement, evaluate

Assessing

Assessing

collect, organize, validate,document data

Diagnosing

Diagnosing

analyze data, identify risks & strengths, formulate

diagnostic statements

Planning

Planning

Prioritize,formulate goals and outcomes,select

interventions, write orders

Implementing

Implementing

reassess,implement

interventions,delegate,document

Evaluating

Evaluating

compare data to outcomes, draw conclusions,

modify care plan

subjective data

subjective data

symptoms only the pt. can verify

objective data

objective data

signs detectable to observer

directive interview

directive interview

highly structured, elicits specific info

Non directive interview

Non directive interview

rapport building interview

Cephalo caudal approach

Cephalo caudal approach

head to toe approach

Maslow's Theory

Maslow's Theory

hierarchy of needs

validation

validation

double checking data to confirm accuracy

cues

what pt. says or nurse sees

inferences

inferences

nurses interpretation

diagnosis

diagnosis

statement regarding the nature of problem

risk factors diagnosis

risk factors diagnosis

indicates a problem that could develop

wellness diagnosis

wellness diagnosis

readiness for enhancement of wellness

possible diagnosis

possible diagnosis

evidence is incomplete

syndrome diagnosis

syndrome diagnosis

associated with a cluster of other diagnoses

diagnostic 3 part statement

diagnostic 3 part statement

PES

Problem

Problem

statement of clients response

Etiology

Etiology

factors contributing to probable cause of response

Signs and Symptoms

Signs and Symptoms

defining characteristics manifested by pt.

nursing intervention

nursing intervention

any treatment based on clinical judgment that a

nurse performs

formal care plan

formal care plan

written or computerized guide

informal care plan

informal care plan

strategy that exists in the nurses mind

standardized care plan

standardized care plan

formal plan for all individuals with same etiology

individualized care plan

individualized care plan

tailored for specific pt.

Nursing Care Classification (NOC) standardized

nursing language indicator

Nursing Care Classification (NOC) standardized

nursing language indicator

concrete observable state of behavior

Using Silence

Using Silence

Accepting pauses or silences that may last several

seconds or minutes without any verbal response.

Sitting quietly (or walking with PT) and waiting

attentively until client is able to put thoughts and

fments or questions that (a) encourage the client to

verbalize, (b) choose a topic of conversation, and

feelings into words

Using Silence (example)

Providing general leads

Providing general leads

Using statements or questions that (a) encourage

the client to verbalize, (b) choose a topic of

conversation, and facilitate continued

verbalization.

"Perhaps you would like to talk about..." ; "would

it help to discuss your feelings?"; "and then...."; "I

know what you are saying"

"Perhaps you would like to talk about..." ; "would

it help to discuss your feelings?"; "and then...."; "I

know what you are saying"

Providing General leads (example)

Using specific and tentative

Using specific and tentative

making statements that are specific rather than

general, tentative rather than absolute

"You scratched my arm" instead of "you are

clumsy as an ox" OR "you seem concerned about

mary" rather than "you don't care about mary"

"You scratched my arm" instead of "you are

clumsy as an ox" OR "you seem concerned about

mary" rather than "you don't care about mary"

Specific & Tentative (examples)

Open-ended question

Open-ended question

ASKING BROAD QUESTIONS that lead or

invite the client to explore, elaborate, clarify,

define, and describe thoughts or feelings. Client's

answers are longer than 1 or 2 words

"I'd like to hear more about that"; "What brought

you to the hospital today?"; "you said you were

frightened yesterday, how are you feeling today?"

"I'd like to hear more about that"; "What brought

you to the hospital today?"; "you said you were

frightened yesterday, how are you feeling today?"

Open-ended question (example)

Using Touch

Using Touch

Providing appropriate forms of touch to reinforce

caring feelings.

Putting arm over client's shoulder OR placing hand

over client's hand

Putting arm over client's shoulder OR placing hand

over client's hand

Using touch (example)

Restating

Restating

using the same words as the client

Client: "I couldn't manage to eat any dinner last

night- not even dessert" Nursing- "you couldn't

manage to eat any dinner last night- not even

dessert?"

Client: "I couldn't manage to eat any dinner last

night- not even dessert" Nursing- "you couldn't

manage to eat any dinner last night- not even

dessert?"

Restating (example)

Paraphrasing

Paraphrasing

Restating in different form with implied feeling or

observation

Client: " I have trouble talking to strangers" Nurse

"You find it difficult talking to people you don't

know"

Client: " I have trouble talking to strangers" Nurse

"You find it difficult talking to people you don't

know"

Paraphrasing (example)

Seeking clarification

Seeking clarification

Making the clients overall meaning of the msg

understandable. It is used when paraphrasing is

difficult or when communication is rambling or

garbled. To clarify, the RN may restate the msg or

confess confusion & ask PT to repeat

Nurse: "I'm puzzled" Nurse: "I'm not sure what

you mean by ___ Would you please repeat that

again?"

Nurse: "I'm puzzled" Nurse: "I'm not sure what

you mean by ___ Would you please repeat that

again?"

Seeking Clarification (example)

Perception Checking/ Consensual Validation


A method similar to clarifying that verifies the

meaning of specific words rather than the overall

message

C: "it just won't stop" N: "I'm not sure what you

mean - it won't stop" OR C: "my husband never

gives me presents" N: "He never gives you gifts

for your birthday or christmas?"


(example)

Offering Self

Offering Self

Suggesting ones' presence, interest, or wish to

understand the client without making any depands

or attaching conditions that the client must comply

with to receive nurse's attention

"I'll stay with you till your daughter arrives"; "we

can sit here quietly for awhile, we don't need to

talk unless you would like to"

"I'll stay with you till your daughter arrives"; "we

can sit here quietly for awhile, we don't need to

talk unless you would like to"

Offering Self (example)

Giving Information

Giving Information

Providing, in simple and direct manner, specific

factual information the client may or may not

request. When information is not known, the nurse

states this and indicates how the nurse will obtain

the information.

"Your surgery is scheduled for 11am tomorrow"; I

don't know the answer to that, but I'll find out from

the unit manager, when she comes in"

"Your surgery is scheduled for 11am tomorrow"; I

don't know the answer to that, but I'll find out from

the unit manager, when she comes in"

Giving information (example)

Acknowledging

Acknowledging

Giving recognition, in non judgmental way, of

change in behavior.

"You trimmed your beard and mustache" OR "you

walked twice as far today with your walker"

"You trimmed your beard and mustache" OR "you

walked twice as far today with your walker"

Acknowledging (example)

Clarifying time or sequence

Clarifying time or sequence

Helping the client clarify and event, situation, or

happening in relationship to time

C: "I puked this morning" N: "before or after

breakfast?"

C: "I puked this morning" N: "before or after

breakfast?"

Clarifying time or sequence(example)

It is a style or process of persuading a group of

people, usually his followers to attain a desired

objective.

It is a style or process of persuading a group of

people, usually his followers to attain a desired

objective.

Leadership

A leader that is chosen by the administration or a

group which are given the official capacity to act.

A leader that is chosen by the administration or a

group which are given the official capacity to act.

Formal / appointed / elected / designated

A leader that does not have official appointments

or designations but is usually chosen by the group

itself.

A leader that does not have official appointments

or designations but is usually chosen by the group

itself.

Informal

It states that leaders are born and not developed

because some people are born with characteristics

to be great.

It states that leaders are born and not developed

because some people are born with characteristics

to be great.

Great Man Theory

A person can be an effective leader if he has all the

intellectual, emotional, physical and other personal

traits of an effective leader.

A person can be an effective leader if he has all the

intellectual, emotional, physical and other personal

traits of an effective leader.

Trait Theory

He is a leader who makes other people feel better

in his/her presence which is an inspirational

quality that the leader possessed.

He is a leader who makes other people feel better

in his/her presence which is an inspirational

quality that the leader possessed.

Charismatic Theory

It states that there is no personality, traits to be a

good leader, but rather leadership is the

relationship that exists among people in a social

situation.

It states that there is no personality, traits to be a

good leader, but rather leadership is the

relationship that exists among people in a social

situation.

Situational Theory

A leader that can immediately resolve a sudden

crisis, emergency or critical situation.

A leader that can immediately resolve a sudden

crisis, emergency or critical situation.

Contingency Theory

A leader that knows how to determine the maturity

of his followers.

A leader that knows how to determine the maturity

of his followers.

Life-Cycle Theory

A leader who uses a support system method.

A leader who uses a support system method.

Path Goal Theory

A style where the leader makes all the decisions

and disallows his members to influence him.

Followers dislike this leader and leader has little

trust to his members. His aim is to develop Self.

Uses trial & error and a critic.

Authoritarian

A leadership style where it is loose and permissive.

His approach is "Do your own thing". His

reference is "You" and has the desire to develop

only "Friendship".

A leadership style where it is loose and permissive.

His approach is "Do your own thing". His

reference is "You" and has the desire to develop

only "Friendship".

Laissez-Faire

A leader whose authority is from the group. Gives

importance to participation, involvement and

development of the group. He is a helper and uses

"We" as his reference of leadership.

A leader whose authority is from the group. Gives

importance to participation, involvement and

development of the group. He is a helper and uses

"We" as his reference of leadership.

Democratic

A leadership style that uses repetition and tries to

develop the system as his objective. His reference

is "they" and acts as a ruler and a regulator type of

leader.

A leadership style that uses repetition and tries to

develop the system as his objective. His reference

is "they" and acts as a ruler and a regulator type of

leader.

Bureaucratic

A power whereby the leader has the official

capacity to exercise rights and demand obligations

from subordinates.

A power whereby the leader has the official

capacity to exercise rights and demand obligations

from subordinates.

Legitimate Powers

I - olfactory (sensory)

I - olfactory (sensory)

sense of smell

II - optic (sensory)

II - optic (sensory)

visual acuity

III - oculomotor (motor)

III - oculomotor (motor)

extraocular eye movement, pupil

constriction and dilation

IV - trochlear (motor)

IV - trochlear (motor)

upward/downward movement of eyeball

V - trigeminal (sensory/motor)

V - trigeminal (sensory/motor)

sensory nerve to skin of face, motor

nerve to muscles of jaw

VI - abducens (motor)

VI - abducens (motor)

lateral movement of eyeballs

VII - facial (sensory/motor)

VII - facial (sensory/motor)

facial expression, taste

VIII - auditory (sensory)

VIII - auditory (sensory)

hearing

IX - glossopharyngeal (sensory/motor)

IX - glossopharyngeal (sensory/motor)

taste, swallowing

X - vagus (sensory/motor)

X - vagus (sensory/motor)

sensation of pharynx, movement of vocal

cords

XI - spinal accessory (motor)

XI - spinal accessory (motor)

movement of head and shoulders

XII - hypoglossal (motor)

XII - hypoglossal (motor)

position of tongue

Trust vs. Mistrust

Trust vs. Mistrust

Infancy (0-18 mos)

Autonomy vs. Shame & Doubt

Autonomy vs. Shame & Doubt

Early Childhood (18mos-3yrs)

Initiative vs. Guilt

Initiative vs. Guilt

Preschool (3-6yrs)

Industry vs. Inferiority

Industry vs. Inferiority

School-age (6-12yrs)

Identity vs. Role Confusion

Identity vs. Role Confusion

Adolescence (12-18yrs)

Intimacy vs. Isolation

Intimacy vs. Isolation

Young Adult (18-25yrs)

Generativity vs. Stagnation

Generativity vs. Stagnation

Adulthood (25-45yrs)

Integrity vs. Despair

Integrity vs. Despair

Late Adulthood (45-death)

Teaching that is Dependent on environment Needs

security

Teaching that is Dependent on environment Needs

security

Infant (0-18mos)

Teaching focused on Separation anxiety Self

exploration Environment

Teaching focused on Separation anxiety Self

exploration Environment

Infant (0-18mos)

Teaching focused on Natural curiosity Separation

Intrusive procedure

Teaching focused on Natural curiosity Separation

Intrusive procedure

Toddler (18mos-3yrs)

Teaching focused on Ego Body mutilation (pain)

believes illness is self caused & punitive

Teaching focused on Ego Body mutilation (pain)

believes illness is self caused & punitive

Preschooler (3-6yrs)

Teaching focused on Limited time Active

imagination (animistic thinking, fearful)

Teaching focused on Limited time Active

imagination (animistic thinking, fearful)

Preschool (3-6yrs)

Teaching focused on Reality Objectivity

Separation anxiety (tries to appear brave)

Teaching focused on Reality Objectivity

Separation anxiety (tries to appear brave)

School Age (6-12yrs)

Teaching focused on Cause & effect Concrete

Information (passive coping strategy)

Teaching focused on Cause & effect Concrete

Information (passive coping strategy)

School Age (6-12yrs)

Teaching focused on Abstract hypothetical

thinking Logic & scientific principles

Teaching focused on Body image Self esteem &

identity (feel invincible)

Teaching focused on Autonomy Self direction

Critical thinking

Teaching focused on Autonomy Self direction

Critical thinking

Young adult (18-25yrs)

Teaching focused on Competency based learner

(can make decision personally & socially)

Teaching focused on Competency based learner

(can make decision personally & socially)

Young Adult (18-25yrs)

Teaching focused on Physical changes Alternative

lifestyle Sense of well developed (questions

achievements & contributions to family & society,

confident)

Teaching focused on Physical changes Alternative

lifestyle Sense of well developed (questions

achievements & contributions to family & society,

confident)

Middle Adult (25-45yrs)

Teaching focused on Cognitive & physical

changes No formal learning (decreased S.T.M.,

risk taking, easily fatigue)

Teaching focused on Cognitive & physical

changes No formal learning (decreased S.T.M.,

risk taking, easily fatigue)

Older Adult (45-death)

For a hospitalized Child, focus on

For a hospitalized Child, focus on

Separation

For a hospitalized Toddler, focus on

For a hospitalized Toddler, focus on

Separation & Intrusive procedure

For a hospitalized Preschooler, focus on

For a hospitalized Preschooler, focus on

Body mutilation & Pain

For a hospitalized School-age, focus on

For a hospitalized School-age, focus on

Loss of control

For a hospitalized Adolescent, focus on

For a hospitalized Adolescent, focus on

Body image

PRE-OPERATIVE CARE, a parent or a legal may

sign the consent of a MINOR, while the OLDER

client may need whom?

Legal Guardian

PRE-OPERATIVE CARE, a nurse can be a

witness in consent signing & document the same

only if the client understood surgeon's explanations

and the client?

Acknowledges understanding of the procedure

PRE-OPERATIVE CARE, NPO is 6-8 hrs. before

Gen. Anesthesia, while for Local Anesthesia is?

3 hours before surgery

PRE-OPERATIVE CARE, prepare ___

administration for malnourished, with protein or

metabolic deficiencies or cannot ingest food client.

Total Parenteral Nutrition

PRE-OPERATIVE CARE, if client has a Foley

Catheter, drain before the surgery and note the?

Amount of urine & characteristics

PRE-OPERATIVE CARE, what do you use to

clean the surgical site?

Mild Antiseptic Soap

PRE-OPERATIVE CARE (client teaching),

inform the client what to expect POST-OP like

pain & discomfort, and that he/she can request

what?

Narcotic Drugs as pain reliever, note it will not

make the client an addict to such


demonstrate what to the client?

Patient Controlled Analgesic (PCA)


instruct not to what? 24 hours before the surgery.


instruct to do Deep Breathing & Coughing

Exercises, use of Incentive Spirometry for the

prevention of?

Pneumonia & Atelactasis


instruction of let & foot exercises will prevent

what? Facilitate what?

Venous Stasis / Venous blood return


instruct the client on how to splint an incision by?

Placing a pillow, or one hand with the other hand

on top, over the incisional area.

PRE-OPERATIVE CARE (checklist), ensure the

client is wearing identification bracelet and assess

for what?

Allergies for latex

PRE-OPERATIVE CARE (checklist), ensure that

informed consent forms were signed for the

operative procedure and for what other reasons?


informed consent forms were signed for the

operative procedure and for what other reasons?

Blood transfusions, disposal of a limb, or for

surgical sterilization procedures.


history, P.E., consultation requests, prescribed

laboratory results, EKG, chest radiography are

documented & recorded plus?


history, P.E., consultation requests, prescribed

laboratory results, EKG, chest radiography are

documented & recorded plus?

Blood type, screened & cross matching is

performed.

PRE-OPERATIVE CARE (checklist), after

removing everything unnecessary, documented it,

kept or given to family members, the nurse must

document the?

PRE-OPERATIVE CARE (checklist), after

removing everything unnecessary, documented it,

kept or given to family members, the nurse must

document the?

Last time client ate or drank, voided before

surgery, medications given prior surgery then

monitor V.S.

PRE-OPERATIVE CARE (medications), instruct

client about the desired effects and then what?

PRE-OPERATIVE CARE (medications), instruct

client about the desired effects and then what?

Keep client in bed with side rails up.

PRE-OPERATIVE CARE (medications), after

administering medications, next to the client, place

what?

PRE-OPERATIVE CARE (medications), after

administering medications, next to the client, place

what?

Call bell, instruct client not to get out of bed and

call for assistance if needed

PRE-OPERATIVE CARE (inside O.R.), after

verifying identification bracelet & verbal response,

the nurse will review chart and then confirm what?

PRE-OPERATIVE CARE (inside O.R.), after

verifying identification bracelet & verbal response,

the nurse will review chart and then confirm what?

Operative procedure & site

PRE-OPERATIVE CARE (inside O.R.), the

clients chart will be reviewed for completeness and

taking a note about what?

PRE-OPERATIVE CARE (inside O.R.), the

clients chart will be reviewed for completeness and

taking a note about what?

Allergic reactions information

POST-OPERATIVE CARE (immediate), what is

the period of this stage?

POST-OPERATIVE CARE (immediate), what is


1-4 hours after surgery

POST-OPERATIVE CARE (immediate), monitor

airway patency & adequate ventilation because

prolonged mechanical ventilation during

anesthesia may affect what?

POST-OPERATIVE CARE (immediate), monitor

airway patency & adequate ventilation because

prolonged mechanical ventilation during

anesthesia may affect what?

Postoperative Lung function, extubated patients

may not be able to maintain airway

POST-OPERATIVE CARE (immediate), the

client maybe unable to clear his/her airway, that is

why it is important to monitor what?

POST-OPERATIVE CARE (immediate), the

client maybe unable to clear his/her airway, that is

why it is important to monitor what?

Secretions

POST-OPERATIVE CARE (immediate),

encourage Deep Breathing & Coughing exercises,

monitor pulse oximetry, O2 administration and

then observer for?

POST-OPERATIVE CARE (immediate),

encourage Deep Breathing & Coughing exercises,

monitor pulse oximetry, O2 administration and

then observer for?

Chest movements for symmetry and use of

accessory muscles.

POST-OPERATIVE CARE (immediate), note

rate, depth & quality of respirations, RR should

be?

POST-OPERATIVE CARE (immediate), note

rate, depth & quality of respirations, RR should

be?

>10 and not <30 BPM

POST-OPERATIVE CARE (immediate), a breath

sound of stridor, wheezing or crowing indicates

what?


sound of stridor, wheezing or crowing indicates

what?

Partial obstruction, bronchospasm, laryngospasm


sound of crackles or ronchi may indicate?


sound of crackles or ronchi may indicate?

Pulmonary Edema, monitor signs of Atelectasis or

Pulmonary embolism

POST-OPERATIVE CARE (immediate), check

capillary refill, assess the skin, peripheral pulses &

edema and monitor for bleeding. A bounding pulse

may indicate what?

POST-OPERATIVE CARE (immediate), check

capillary refill, assess the skin, peripheral pulses &

edema and monitor for bleeding. A bounding pulse

may indicate what?

Hypertension, Fluid overload, or excitement.

POST-OPERATIVE CARE (immediate), unless

contraindicated, client is placed on Fowler's

position after surgery to increase?

POST-OPERATIVE CARE (immediate), unless

contraindicated, client is placed on Fowler's

position after surgery to increase?

Size of the thorax for lung expansion

POST-OPERATIVE CARE (immediate), what

type of positioning is avoided if the pharyngeal

reflexes have not yet returned?

POST-OPERATIVE CARE (immediate), what

type of positioning is avoided if the pharyngeal

reflexes have not yet returned?

Supine

POST-OPERATIVE CARE (immediate), if

comatose or semicomatose, what type of

positioning?

POST-OPERATIVE CARE (immediate), if

comatose or semicomatose, what type of

positioning?

Side lying & keep an oral airway in place.

POST-OPERATIVE CARE (immediate), assess

L.O.C., wake client periodically until awaken and

if awaken?


L.O.C., wake client periodically until awaken and

if awaken?

Orient client to the environment in a soft tone

POST-OPERATIVE CARE (immediate), main

body temperature and prevent heat loss by?

POST-OPERATIVE CARE (immediate), main

body temperature and prevent heat loss by?

Blanketing & raise room temperature

POST-OPERATIVE CARE (immediate), an

exposed skin, cool OR, or maybe from anesthesia

may result to?

POST-OPERATIVE CARE (immediate), an

exposed skin, cool OR, or maybe from anesthesia

may result to?

Hypothermia, keep blanket on & continue O2 if

shivering


surgical site, drains & wound dressings for?


surgical site, drains & wound dressings for?

Redness, abrasions or breakdown

POST-OPERATIVE CARE (immediate), record

I&O, monitor for Fluid & Electrolyte imbalance,

N&V, NGT patency, abdominal distention and the

return of what?

POST-OPERATIVE CARE (immediate), record

I&O, monitor for Fluid & Electrolyte imbalance,

N&V, NGT patency, abdominal distention and the

return of what?

Bowel sounds

POST-OPERATIVE CARE (immediate), how

many hours is it that the client is expected to void

urine after the surgery?

POST-OPERATIVE CARE (immediate), how

many hours is it that the client is expected to void

urine after the surgery?

6-8 hours, note color, quantity & quality


for pain, PRE-OP & POST-OP medz, then inquire

about the type & location of pain by asking the

client to?


for pain, PRE-OP & POST-OP medz, then inquire

about the type & location of pain by asking the

client to?

Rate the pain from 1-10, note facial expression,

body gestures, increase PR, BP & RR.

POST-OPERATIVE CARE (immediate), inquire

effectiveness of last medication, if on a Narcotic

drug, assess every 30 minutes for?

POST-OPERATIVE CARE (immediate), inquire

effectiveness of last medication, if on a Narcotic

drug, assess every 30 minutes for?

RR & pain relief

POST-OPERATIVE CARE (intermediate), how

many hours is this stage after surgery?


many hours is this stage after surgery?

4-24 hours

POST-OPERATIVE CARE (intermediate),

monitor airway patency, encourage Deep

Breathing & Coughing exercises, monitor

circulatory status encourage the use of what?


monitor airway patency, encourage Deep

Breathing & Coughing exercises, monitor

circulatory status encourage the use of what?

Antiembolism stockings if not C/I

POST-OPERATIVE CARE (intermediate), assess

for mobility on all extremities & encourage early

ambulation by first sitting on the edge of the bed

with feet supported. But if client is unable to

move, what do you do next?

Turn the client every 1-2 hours.


reinforce wound with sterile dressing if necessary

and always keep it?


reinforce wound with sterile dressing if necessary

and always keep it?

Dry & intact, notify physician if bleeding occurs


monitor I&O, N&V and if vomiting, have a

suctioning equipment available and ready to use.

NPO status is observed until?


monitor I&O, N&V and if vomiting, have a

suctioning equipment available and ready to use.

NPO status is observed until?

Gag reflex & peristalsis returns

POST-OPERATIVE CARE (intermediate), when

oral fluids are permitted, start with?

POST-OPERATIVE CARE (intermediate), when

oral fluids are permitted, start with?

Ice chips & water, then advance to Clear Liquids

up to Regular Diet as prescribed

POST-OPERATIVE CARE (intermediate), after

NPO order is lifted, what do you assess for?

POST-OPERATIVE CARE (intermediate), after

NPO order is lifted, what do you assess for?

Bowel sounds on all four quadrants


many mL per hour should a client void?


many mL per hour should a client void?

Should be > 30 mL/hr

POST-OPERATIVE CARE (intermediate), if with

Foley Catheter, client is expected to void within 6-

8 hours. Ensure that the amount is at least?

POST-OPERATIVE CARE (intermediate), if with

Foley Catheter, client is expected to void within 6-

8 hours. Ensure that the amount is at least?

200mL

POST-OPERATIVE CARE (extended), what is


POST-OPERATIVE CARE (extended), what is


1-4 hours after surgery

POST-OPERATIVE CARE (extended), on this

stage, you monitor for signs of infection such as?

POST-OPERATIVE CARE (extended), on this

stage, you monitor for signs of infection such as?

Redness, swelling, & tenderness at the surgical

site, fever & leukocytes

POST-OPERATIVE CARE (extended), the client

is advised to do R.O.M. exercises every 2 hours

and encourage ambulation to promote?


is advised to do R.O.M. exercises every 2 hours

and encourage ambulation to promote?

Peristalsis & passage of flatus


is encouraged to perform A.D.L. & eat foods that

will promote wound healing. What are the foods?


is encouraged to perform A.D.L. & eat foods that

will promote wound healing. What are the foods?

Protein & Vitamin C

Inflammation of the alveoli caused by an

infectious process that may develop as a result of

infection, aspiration or immobility?

Inflammation of the alveoli caused by an

infectious process that may develop as a result of

infection, aspiration or immobility?

Pneumonia, usually around 3-5 days

postoperatively

Collapse of the alveoli with retained mucous

secretions and is the most common postoperative

complication?

Collapse of the alveoli with retained mucous

secretions and is the most common postoperative

complication?

Atelectasis, usually around 1-2 days

postoperatively

POST-OPERATIVE CARE (Pneumonia &

Atelectasis) Assessment / increase risk for

dyspnea/ elevated temperature/ productive cough/

and what more?


Atelectasis) Assessment / increase risk for

dyspnea/ elevated temperature/ productive cough/

and what more?

Increased R.R. & chest pain


Atelectasis) Nsg Inter / assess for lung & breath

sounds/ reposition client every 1-2 hour/ inc O.F.I.

/ early ambulation and what more?


Atelectasis) Nsg Inter. / assess for lung & breath

sounds/ reposition client every 1-2 hour/ inc O.F.I.

/ early ambulation and?

Deep breathing & coughing exercises/ incentive

spirometer/ chest physio/ postural drainage

An inadequate concentration of oxygen in arterial

blood?

An inadequate concentration of oxygen in arterial

blood?

Hypoxia

POST-OPERATIVE CARE (Hypoxia)

Assessment / cyanosis/ dyspnea/ hypertension/

tachycardia and what else?

POST-OPERATIVE CARE (Hypoxia)

Assessment / cyanosis/ dyspnea/ hypertension/

tachycardia and what else?

Restlessness & Diaphoresis

POST-OPERATIVE CARE (Hypoxia) Nursing

Intervention, monitor signs of hypoxia/ eliminate

cause/ monitor lung sounds/ administer oxygen/

D.B. & C. E. and what more?

POST-OPERATIVE CARE (Hypoxia) Nursing

Intervention, monitor signs of hypoxia/ eliminate

cause/ monitor lung sounds/ administer oxygen/

D.B. & C. E. and what more?

Monitor pulse oximetry & reposition client

It blocks the pulmonary artery and disrupts blood

flow to one or more lobes of the lung?

It blocks the pulmonary artery and disrupts blood

flow to one or more lobes of the lung?

Pulmonary Embolism

POST-OPERATIVE CARE (Pulmonary

Embolism) Assessment / dyspnea/ cyanosis/

tachycardia and what more else?


Embolism) Assessment / dyspnea/ cyanosis/

tachycardia and what more else?

Decreased blood pressure & sudden chest or upper

abdominal pain


Embolism) Nursing Intervention / what is the first

thing that you should do?


Embolism) Nursing Intervention / what is the first

thing that you should do?

1)Notify the physician 2)Monitor V.S.

3)Administer O2 & medications

Loss of large amount of blood externally or

internally in a short time?

Loss of large amount of blood externally or

internally in a short time?

Hemorrhage

POST-OPERATIVE CARE (Hemorrhage)

Assessment / restlessness/ hypotension/ cool,

clammy skin and what other else?


Assessment / restlessness/ hypotension/ cool,

clammy skin and what other else?

Weak rapid pulse & reduced urine output


Nursing Intervention / provide pressure to the site

of bleeding immediately and then what?


Nursing Intervention / provide pressure to the site

of bleeding immediately and then what?

Notify the physician, administer O2, IV fluids &

blood as prescribed & lastly prepare client for

surgery if needed

Loss of circulatory fluid volume, which usually is

caused by hemorrhage?

Loss of circulatory fluid volume, which usually is

caused by hemorrhage?

Shock

POST-OPERATIVE CARE (Shock) Assessment /

/ restlessness/ hypotension/ cool, clammy skin and

what other else?

POST-OPERATIVE CARE (Shock) Assessment /

/ restlessness/ hypotension/ cool, clammy skin and

what other else?

Weak rapid pulse & reduced urine output

POST-OPERATIVE CARE (Shock) Nursing

Intervention / elevate legs only if the client did not

have Spinal Anesthesia/ determine & treat cause of

shock/ administer O2/ monitor V.S., L.O.C./

monitor I & O. and what if the client had Spinal

Anesthesia?

POST-OPERATIVE CARE (Shock) Nsg Inter /

elevate legs (w/o Spinal Anes.)/ treat cause of

shock/ adm. O2/ monitor V.S., L.O.C./ monitor

I&O. & if client had Spinal Anes.?

Elevate legs not higher than pillow/ assess skin

turgor, moisture and mucous membra

Inflammation of a vein, leg veins commonly

affected, often accompanied by clot formation?

Inflammation of a vein, leg veins commonly

affected, often accompanied by clot formation?

Thrombophlebitis

POST-OPERATIVE CARE (Thrombophlebitis)

Assessment / vein inflammation/ aching or

cramping pain/ elevated temperature and what?


Assessment / vein inflammation/ aching or

cramping pain/ elevated temperature and what?

(+) Homan's Sign


Nursing Intervention / monitor leg/ encourage

antiembolism stockings – removed 2x/day for

washing & inspection of leg/ give heparin sodium

or warfarin (coumadin)/ the leg is elevated by 30

degrees & do not?

Apply pressure on popliteal area. No leg dangling

& sitting on one position for long periods

Involuntary accumulation of urine in the bladder as

a result of loss of muscle tone?

Involuntary accumulation of urine in the bladder as

a result of loss of muscle tone?

Urinary Retention

POST-OPERATIVE CARE (Urinary Retention)

Assessment / inability to void/ restlessness &

diaphoresis/ lower abdominal pain/ distended

bladder and what else?

POST-OPERATIVE CARE (Urinary Retention)

Assessment / inability to void/ restlessness &

diaphoresis/ lower abdominal pain/ distended

bladder and what else?

Hypertension & Drumlike sound upon bladder

percussion


Nursing Intervention / monitor voiding/ assess

distended bladder/ encourage inc. O.F.I./ provide

privacy and what?

Pour warm water on the perinium, allow pt to hear

running water then CATHETERIZE if all non

invasive attempts fail

Failure of appropriate forward movement of bowel

contents and maybe due to anesthetic medications

or manipulation of the bowel during the surgical

procedure?

Failure of appropriate forward movement of bowel

contents and maybe due to anesthetic medications

or manipulation of the bowel during the surgical

procedure?

Paralytic Ileus

POST-OPERATIVE CARE (Paralytic Ileus)

Assessment / abdominal distention/ absence of

bowel sounds, bowel movement or flatus, what is

the first indication of this condition?


Assessment / abdominal distention/ absence of

bowel sounds, bowel movement or flatus, what is

the first indication of this condition?

Nausea & Vomiting immeidately postoperatively


Nursing Intervention / monitor I & O/ maintain

NPO until bowel sounds return/ patency of NGT/

early ambulation/ administer IVF or TPN,

medications and what is the noninvasive action?

NGT insertion and connected to intermittent or

constant suction for bowel decompression

Caused by poor aseptic technique or a

contaminated wound before surgical exploration?

Caused by poor aseptic technique or a

contaminated wound before surgical exploration?

Wound Infection

POST-OPERATIVE CARE (Wound Infection)

Assessment / fever & chills/ edematous skin at

incision site & tight skin sutures/ increased WBC

and what is the order of the inflamed incision site?


Assessment / fever & chills/ edematous skin at

incision site & tight skin sutures/ increased WBC

and what is the order of the inflamed incision site?

1)Warm, 2)Tender, 3)Painful


Nursing Intervention / monitor temperature/

maintain patency of drains & note amount, color,

consistency/ change dressing/ give antibiotics and

what are the signs of infection?

REEDA- Redness, Erythema, Ecchynosis,

Drainage, Approximation for wound edges

Separation of the wound edges at the suture line?

Separation of the wound edges at the suture line?

Wound Dehiscence, usually occurs 6-8 days after

POST-OPERATIVE CARE (Wound Dehiscence)

Assessment / increased drainage/ opened wound

edges and?

Appearance of underlying tissues through the

wound

POST-OPERATIVE CARE (Wound Dehiscence)

Nursing Intervention / low Fowler's position to

avoid abdominal tension/ cover with NSS dressing

and then immediately?

Notify physician & prevent wound infection,

antiemetics is given to avoid abdominal tension as

well, splint incision when coughing

Protrusion of internal organs through an incision.

Common on obese, with past abd. surgery or who

have poor wound healing.

Protrusion of internal organs through an incision.

Common on obese, with past abd. surgery or who

have poor wound healing.

Wound Evisceration, usually occurs 6-8 days after.

It is an Emergency

POST-OPERATIVE CARE (Wound Evisceration)

Assessment / serosanguinous discharge from dry

wound/ with loops of bowel or other abdominal

contents through the wound and the client is

reporting?

A feeling of popping after coughing or turning


Nursing Intervention / Fowler's position/ cover

wound with sterile NSS and ?


Nursing Intervention / Fowler's position/ cover

wound with sterile NSS and ?

Notify DR & prevent wound infection, antiemetics

is given to avoid abdominal tension as well, splint

incision when coughing

In ambulatory surgery, the criteria for client

discharge are the following, he/she is alert and

oriented/ has voided/ not in respiratory distress/

vomiting & in minimal pain and also the client is

able to?

Ambulate, swallow & cough

POST-OPERATIVE CARE (Discharging) assess

pt's readiness to learn, educ. level, & desire modify

lifestyle/ demo incision care/ written guide to pt &

family &?

POST-OPERATIVE CARE (Discharging) assess

pt's readiness to learn, educ. level, & desire modify

lifestyle/ demo incision care/ written guide to pt &

family &?

Instruct PT to cover incision with plastic when

showering & give a 48 hour of dressing suppl

Formula for IV Calculations

Formula for IV Calculations

CC's per hour X Drop Factor / 60

Ordered 1000 cc 5% D/ 0.45 NS at 100cc/hr. Drop

factor is 60

Ordered 1000 cc 5% D/ 0.45 NS at 100cc/hr. Drop

factor is 60

100

Ordered: 1500 ML0.9% NS to infuse 90 cc/hr.

Drop Factor: 20 gtt/ml

Ordered: 1500 ML0.9% NS to infuse 90 cc/hr.

Drop Factor: 20 gtt/ml

30

ORDERED: Ampicillin 500 mg in 50 cc 0.9% NS

to infuse 1hour. Drop Factor: 10 gtts/ml

ORDERED: Ampicillin 500 mg in 50 cc 0.9% NS

to infuse 1hour. Drop Factor: 10 gtts/ml

8

Ordered 1250 cc 2.5 % D/W to infuse from 12

noon to 6 pm. The Drop Factor is 15 gtts/ml.

Ordered 1250 cc 2.5 % D/W to infuse from 12

noon to 6 pm. The Drop Factor is 15 gtts/ml.

52

ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS

and 1000 cc 0.9% NS to infuse over 24 hours.

DROP FACTOR: 12 gtt/ml

ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS

and 1000 cc 0.9% NS to infuse over 24 hours.

DROP FACTOR: 12 gtt/ml

25

ORDERED: 1000 cc 5%D/0.45% NS with 40 mEq

of KCL to infuse in 8 hours. DROP FACTOR: 12

gtts / ml

ORDERED: 1000 cc 5%D/0.45% NS with 40 mEq

of KCL to infuse in 8 hours. DROP FACTOR: 12

gtts / ml

25

ORDERED: An infant weighs 18 # has an IV of

500 cc 10% D/W to infuse over 24 hours. DROP

FACTOR: 60 gtts/ml

ORDERED: An infant weighs 18 # has an IV of

500 cc 10% D/W to infuse over 24 hours. DROP

FACTOR: 60 gtts/ml

20-21

___% of the average adult's weight is fluid

___% of the average adult's weight is fluid

60%

Intracellular fluids (ICF)

Intracellular fluids (ICF)

all fluid w/in body cells

What % of body weight is ICF?

What % of body weight is ICF?

40%

Extracellular fluid (ECF)

Extracellular fluid (ECF)

fluid outside of a cell; divided into 3 parts,

Interstitial fluid, intravascular fluid, and

transcellular fluids

What % of ECF makes up body weight?

What % of ECF makes up body weight?

20%

What is interstitial fluid?

What is interstitial fluid?

contains lymph, fluid between cells and outside

blood vessels

What is Intravascular fluid?

What is Intravascular fluid?

blood plasma

Electrolytes

Electrolytes

minerals or salts; when melted or dissolved in

water it separates into ions and is able to carry an

electrical current

Cation

Cation

+ charged electrolytes EX: Na+ K+ Ca+

Anion

- charged electrolytes EX: Cl- HCO3- SO4-

Solute

Solute

dissolvable in water

Solvent

Solvent

dissolvable in plasma

Osmosis

Osmosis

movement of a pure solvent, through a

semipermeable membrane, from an area of lesser

solute concentration to an area of greater solute

concentration to try to equalize concentrations on

both sides of a membrane

Osmotic pressure is:

Osmotic pressure is:

the drawing power for water & depends on the

number of molecules in solution

A solution with the same osmolarity as blood

plasma is called:

A solution with the same osmolarity as blood

plasma is called:

isotonic

Movement of a solute in a solution across a

semipermeable membrane from an area of higher

concentration to an area of lower concentration is:

Movement of a solute in a solution across a

semipermeable membrane from an area of higher

concentration to an area of lower concentration is:

diffusion

Filtration

Filtration

water and diffusable substances move together in

response to fluid pressure, moving from an area of

higher pressure to an area of lower pressure

Hydrostatic pressure

Hydrostatic pressure

movement of water from interstitial space into the

intravascular space by filtration

Increased hydrostatic pressure causes what?

Increased hydrostatic pressure causes what?

edema, as with CHF

Active transport

Active transport

movement of materials across cell membranes

requiring metabolic activity

Homeostasis

Homeostasis

physiological balance

Osmoreceptors

Osmoreceptors

continually monitor the serum osmotic pressure,

when osmolality increases, hypothalamus is

stimulated

ADH

Antidiuretic hormone; stored in pituitary gland;

works directly on kidney tubules and collecting

ducts making them more permeable which returns

water to systemic circulation

Aldosterone

Aldosterone

released by adrenal cortex in response to increased

K+ levels; it increases the reabsorption of Na+ and

secretion of K+

Insensible water loss

Insensible water loss

continuous and not perceived by person

Sensible water loss

Sensible water loss

through excessive perspiration

The lungs expire____ml of water a day

The lungs expire____ml of water a day

400ml

What are the major cations?

What are the major cations?

Na+ K+ Ca+ Ions

What are the major anions?

What are the major anions?

chloride, bicarbonate, phosphate

__% of sodium is in the ECF? Function of Na+?

__% of sodium is in the ECF? Function of Na+?

90%, maintain water balance

__% of K+ in ECF. What's it's function?

__% of K+ in ECF. What's it's function?

2%; regulates metabolic activity

1% of Ca+ is in blood, 99% in bone; what is the

function?

1% of Ca+ is in blood, 99% in bone; what is the

function?

blood clotting, bone/teeth formation

Magnesium is essential for:

Magnesium is essential for:

enzyme activities, neurochemical activities,

cardiac and skeletal excitability

__% of magnesium in ECF. Na plasma

concentration is:

__% of magnesium in ECF. Na plasma

concentration is:

1%; 1.5-2.5 mEq/L

Bicarbonate, a chemical base buffer, is regulated

by:

Bicarbonate, a chemical base buffer, is regulated

by:

the kidneys

Buffer

Buffer

a substance or group of substances that can absorb

or release H+ to correct an acid-base balance

What is the largest chemical buffer in ECF?

What is the largest chemical buffer in ECF?

carbonic acid and bicarbonate buffer system; reacts

to change in pH of ECF within seconds

Biological regulation

Biological regulation

occurs when H= ions are absorbed and released by

cells, occurs only after chemical buffering and

takes 2-4 hrs

Fluid volume deficit (FVD)

Fluid volume deficit (FVD)

water & electrolytes lost in equal or isotonic

proportions

Fluid volume excess (FVE)

Fluid volume excess (FVE)

water and sodium retained in isotonic proportions

Hyperosmolar imbalance

Hyperosmolar imbalance

dehydration

Hypoosmolar imbalance

Hypoosmolar imbalance

water excess

TPN or total parenteral nutrition

TPN or total parenteral nutrition

nutritionally adequate hypertonic solution of

glucose, electrolytes, and other nutrients given

through an indwelling or central IV

IV fluid and electrolyte therapy

IV fluid and electrolyte therapy

crystalloids

Colloids

Colloids

blood and blood component

Vascular access devices include:

Vascular access devices include:

catheters, cannulas, infusion ports,

the breakdown of RBC's is called:

the breakdown of RBC's is called:

hemolysis

Autologous transfusion collection of clients own

blood (pre-op)

Autologous transfusion collection of clients own

blood (pre-op)

Safest and done before surgery

One of the most common electrolyte imbalances

is:

One of the most common electrolyte imbalances

is:

hypokalemia

The client most at risk for FVD's is:

The client most at risk for FVD's is:

an infant

One reason older adults experience fluid and

electrolyte imbalance and acid-base imbalances is

they:

One reason older adults experience fluid and

electrolyte imbalance and acid-base imbalances is

they:

have a decreased thirst sensation

Output recorded on an I & O record includes:

Output recorded on an I & O record includes:

urine, diarrhea, vomitus, gastric suction, and

drainage from wounds and tubes

Health promotion activities in the area of fluid and

electrolyte imbalances focuses primarily on:

Health promotion activities in the area of fluid and

electrolyte imbalances focuses primarily on:

client teaching

TPN is delivered by:

TPN is delivered by:

indwelling or central IV catheter

As a safety alert the RN is aware the following

med is never given directly through IV:

As a safety alert the RN is aware the following

med is never given directly through IV:

Potassium chloride, it will burn the vein

Indications of IV fluid infiltration include:

Indications of IV fluid infiltration include:

pallor and coolness

CDC recommends replacing peripheral venous

catheters and rotating sites should occur at least

every:

CDC recommends replacing peripheral venous

catheters and rotating sites should occur at least

every:

72-96 hours

Fundamentals

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