Exam (elaborations)
NURS 100 Nursing Fundamentals | NURS 100 Final Study Guide
- Course
- NURS 100
- Institution
- West Coast University
NURS 100 Nursing Fundamentals | NURS 100 Final Study Guide
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NURS 100 Final Study Guide Hand -washin g · BIGGEST/BEST way to prevent infection, to control. · Moving from 1 room to another, can spread germs. · WASH HANDS BEFORE & AFTER PATIENT. (gel in, gel out) · 15-20 seconds of washingà between fingers & wrists, between nails & cuticles and underneath nails, rinse downward. · Wash hands with soap & water when visibly soiled (any bodily fluid secretions) · After ¾ times gelling, wash hands. · C. Diff fecal (WASH HANDS w/ soap & water) Infection · Nosocomial Infection (caused in hospital)à Infection that you acquire when in hospital · Isolation signs (why they are on isolation contamination) PPE - personal protective equipment ● Contact Precautions Any type of organisms (C. Di ff, MRSA, herpes simplex virus) ● Airborne spread through air (Measles, Varicella, TB) ● Droplet (Hib, Mumps, Rubella, Strep. Pneumonia, Pertussis) ● Universal/standard gloves · Stages of infection 1. Incubation interval between ENTERING body and PRESENTATION of FIRST SYMPTOM. 2. Prodromal interval from ONSET of GENERAL SYMPTOMS to more DISTINCT symptoms. (pathogen multiplying) 3. Illness interval when symptoms SPECIFIC to INFECTION OCCUR. 4. Convalescence interval when ACUTE symptoms DISAPPEAR, TOTAL RECOVERY could take days to months. · Reporting Communicable Diseases ● Ensure appropriate medical treatment of disease ● Monitor common source outbreaks ● Plan & evaluate control & prevention plans ● Identify outbreaks and epidemics ● Determine public health priorities based on trends. Oxygenation ● Hypoxia restlessness, increased respiration, increase BP (tachycardia) ● Cyanosis later stage, turn blue. ● Pneumonia infection that inflames air sacs in or or both lungs which may fill with fluid. ● Pneumothorax air in pleural space ● Factors that influence o2 ○ smoking, genetics, environments, age, elevation, trauma, exercise, obesity, nutrition, substance abuse, medication, stress. ● Assessment ○ listening to lungs (adventitious sounds) when inspecting the chest walls, make sure it's equal, auscultating & palpating. ● Lungs ○ Alveoli when ventilation (gas exchange) is carried out Surfactant chemical that reproduces at 8 months in vitro that maintain surface tension of alveoli to prevent them from collapsing. · Suctioning oral, nasal, tracheotomy, O 2 therapy. · Chest tubes remove air & fluid from pleural space to reestablish pressure. · Chest physiotherapy postural drainage, chest percussion, chest vibration. · Post -op patients TCD (turn, cough, deep breath), breathing exercises, increase fluids & get to ambulate Want to prevent Pneumonia infection that inflames air sacs in or or both lungs which may fill with fluid. · Apnea suspension of breathing · Different Oxygen masks Low Flow Oxygen Delivery Systems Nasal Cannula - lowest concentration of oxygen Delivers 24%-44% at flow rate of 1 to 6 L/min Simple Face Mask Delivers 40% -60% at flow rate of 5-8 L/min Non-rebreather Mask Delivers 60% -100% at flow rate of 10-15 L/min to keep reservoir bag 2/3 f full during inspiration and expiration High Flow Oxygen Delivery Systems Venturi Mask - delivers most precise oxygen concentration Delivers 24%-60% at flow rate of 4012 L/min via different adapters, which allows specific amounts of air to mix with oxygen Mobilit y and Immobility Mobility - freedom and independence in purposeful movement. It refers to adapting and having self-awareness of the environment. Immobility - the inability to move freely and independently at will. It can be ● Temporary such as following knee arthroplasty ● Permanent such as paraplegia ● Sudden onset such as fractured arm and leg following a motor -vehicle crash ● Slow onset such as multiple sclerosis Body mechanics - involves coordination between musculoskeletal and nervous systems, and the use of gait alignment , balance, gravity, and friction. Factors affecting mobility : alteration in muscles, injury to the musculoskeletal system, poor posture, impaired CNS, health status, age Application of heat and cold: Thera peutic effects Heat ● Increases blood flow ● Increases tissue metabolism ● Relaxes muscles ● Eases joint stiffness Cold ● Decreases inflammation ● Prevents swelling ● Reduces bleeding ● Reduces fever ● Diminishes muscle spasm ● Decreases pain by decreasing the velocity of nerve conduction Types of heat application MOIST DRY ○ Hot compress ○ Hot soaks ○ Sitz baths ● Hot pack ● Warming blanket Types of cold application DRY MOIST ● Ice bag, ice collar, ice glove, or a cold pack ● Cooling blanket ● Cold water compresses ● Cold soaks Nursing considerations for patients at risk for injury from heat and cold applications ● Clients who are very young or fair skinned, and older adults have fragile skin ● Immobile clients may not be able to move away from application if it becomes uncomfortable ● Clients with impaired sensory perception may not feel numbness, pain or burning. ● Avoid long applications for either heat or cold because it can result to tissue damage, burns or reflex dilations. Promoting venous return ● Elastic antiembolic stockings or TED’S/ thromboembolic device ○ Help maintain external pressure on the muscle of the lower extremities and promote blood return to the heart. ○ Must be removed every 8 hours to assess for redness warmth or tenderness. ● SCD/ sequential compression devices and IPC/intermittent pneumatic compression (remove every 8 hours for assessment of calves) ● Positioning techniques (to reduce compression of veins) ○ Put pillows behind knees ● ROM exercises hourly while awake ○ Ankle pumps ○ Foot circles ○ Knee flexion COMPLICATIONS Thrombophlebitis, Deep vein thrombosis - are inflammation of a vein in the lower extremities that can result to clot formation. ● Pain, edema and warmth on the site ● Position the client in the bed with leg elevated ● Avoid any pressure to the site of inflammation Pulmonary embolism - is a potentially life threatening occlusion of blood flow to one or more pulmonary arteries by a clot. ● s/s: Shortness of breath, chest pain, hemoptysis, decreased blood pressure, and rapid pulse ● Position client in high fowler’s porition ● Obtain pulse oximetry ● Administer oxygen. ● Monitor vitals. Valsalva maneuver - a maneuver in which a person tried to exhale forcibly with closed glottis so that no air exits through the mouth or nose (E.g lifting a heavy weight). Contracture - shortening of the muscles due to lack of use Raynaud’s phenomenon - periodic ischemic attacks affecting the extremities of the body. Hypervolemia Fluid Overload · Increase blood volume · Signs & symptoms ● Edema, jugular vein distention, pu ffiness, hypertension, bounding pulse, shortness of breath with crackles (lungs building with fluid). **WEIGHT gain is best indicator for this. ● Over -hydration - retention of more water than electrolytes. Expected Findings ● Vital signs ○ Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure ● Neuromusculoskeletal ○ Confusion, muscle weakness ● GI ○ Weight gain, ascites ● RespiratoryThe benefits of buying summaries with Stuvia:
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