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NUR 3737_ Principles of Personalized Nursing Care
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NUR 3737_ Principles of Personalized Nursing Care
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NUR 3737: Principles of PersonalizedNursing Care
Hyponatremia - electrolyte imbalance - correct answer-deficient sodium in the blood
Causes - Diuretics, GI fluid loss, adrenal insufficiency
Signs/Symptoms - anorexia, nausea, and vomiting, weakness, confusion ,and muscle
cramps
Treatment - Monitor I&O, sodium levels, and IV saline infusion
PRN order - correct answer-As needed order, permits the nurse to give a medication when,
in the nurse's judgment, the client requires it
Dehydration - correct answer-Dehydration is a disorder of water loss with or without loss of
sodium and is frequently observed in critically ill patients. There are three types of
dehydration: (1) isotonic, (2) hypotonic, and (3) hypertonic.
Hypotonic dehydration - correct answer-ELECTROLYTE LOSS exceeds water loss
Results: fluid shifts between compartments causing a decrease in plasma volume and the
cells to SWELL.
Hypertonic dehydration - correct answer-WATER LOSS exceeds electrolyte loss; alteration
in the concentration of specific plasma electrolytes
Results: fluid moved from the intracellular compartment into the plasma and interstitial fluid
spaces causing cellular dehydration and SHRINKAGE
Isotonic dehydration - correct answer-WATER LOSS = ELECTROLYTE LOSS aka
Hypovolemia
Results: decreased circulating blood volume and inadequate tissue perfusion
MOST COMMON TYPE of dehydration!
Steps of the Nursing Process - correct answer-ADPIE:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Subjective Information - correct answer-Information from the patient's point of view.
,"I feel dizzy."
Objective information - correct answer-Factual information collected using the senses of
sight, hearing, smell, and touch; also called signs.
Objective information is often quantitative information such as vital signs and lab results.
Clinical Reasoning - correct answer-A specific term usually referring to ways of thinking
about patient care issues (determining, preventing, and managing patient problems);
A cognitive process that uses formal and informal thinking strategies to gather and analyze
client information, evaluate the significance of this information and determine the value of
alternative actions.
Three part diagnostic statement - correct answer-P (problem) - The nursing diagnosis label:
a concise term or phrase that represents a pattern of related cues.
E (etiology) - "Related to" (r/t) phrase or etiology: related cause or contributor to the problem.
The antecedent to.
S (symptoms) - Symptoms that the nurse identified in the assessment.
Three Types of Nursing Diagnosis - correct answer-(1) Problem (Actual) -Focused Diagnosis
- a clinical judgment concerning an undesirable human response to a health condition/life
process that exists in an individual, family, group or community.
(2) Risk (Potential) Nursing Diagnosis - clinical judgement concerning the susceptibility of an
individual, family, group, or community.
(3) Health Promotion Nursing Diagnosis - a clinical judgment concerning motivation and
desire to increase well-being and to actualized health potential.
Apical Pulse - correct answer-The pulse on the left side of the chest, just below the nipple
(apex of the heart).
Dyspnea - correct answer-Difficulty breathing
AEB or aeb - correct answer-As evidence by
Theoretical Knowledge - correct answer-Knowing why - consists of information, facts,
principles, and evidence-based theories in nursing and related disciplines.
Practical Knowledge - correct answer-Knowing what to do and how to do it. For example:
How to give an injection
,Self-Knowledge - correct answer-To be aware of your beliefs, values, and cultural and
religious biases. This kind of knowledge helps you find errors in your thinking and enables
you to tune in to your patients.
Ethical Knowledge - correct answer-Knowledge of obligation, or right and wrong. Consist of
information about moral principles and processes for making moral decisions. based on
personal past experience.
What is the nursing process? - correct answer-Provides the framework in which nurses use
their knowledge and skills to express human caring.
What are health problems? - correct answer-Any condition that requires intervention to
promote wellness or to prevent or treat disease or illness
After you identify a health problem, you must decide how to treat it: independently or in
collaboration with other health professionals.
Bloodborne Pathogens - correct answer-Pathogenic microorganisms present in blood and
other potentially infectious material (OPIM) that can cause disease in humans
Primary routes of occupational exposure to BBPs? - correct answer-Percutaneous - effected
through skin
Hepatitis - correct answer-Inflammation of the liver, usually caused by a viral infection, that
causes fever, loss of appetite, jaundice, fatigue, and altered liver function.
Hepatitis B Virus (HBV, HepB) - correct answer-HepB is 100 times more infectious than HIV
yet it can be prevented with a safe and effective vaccine.
15-25% of those chronically infected will develop cirrhosis, liver failure or liver cancer
resulting in 2000-4000 deaths/per year in the U.S.
For adults, typical schedule is 3 IM injections given at 0, 1, and 6 months.
Hepatitis C Virus (HCV, HepC) - correct answer-Most common infectious cause of death in
the U.S. - exceeds deaths from HIV, hepatitis B and tuberculosis combined
Produces a mild disease initially, but most individuals develop chronic hepatitis that can lead
to chronic liver disease.
No vaccine available; several new drugs on the market.
HIV - correct answer-Human Immunodeficiency Virus
Risk for HIV transmission after: Percutaneous injury - 0.3%
Hand washing - correct answer-Average person washes their hands for ~10 seconds - CDC
recommends at least 20 seconds
, Medical Diagnosis vs Nursing Diagnosis - correct answer-Medical Diagnosis: is used to
evaluate the cause or etiology of disease. Except for advanced practice nurses, nurses
cannot legally diagnose or treat a medical problem.
Nursing Diagnosis: clinical judgments about a person's response to an actual or potential
health problem.
Nosocomial Infection - correct answer-An infection acquired during hospitalization.
Clostridium difficile - correct answer-C. diff; bacterial infection causing diarrhea and serious
colon inflammation; common after antibiotic use; body system: digestive; infection type:
bacterial; organism: Clostridium difficile; tx: antibiotic (change from the first)
Most commonly reported pathogen in hospitals.
The Joint Commission - correct answer-a not-for-profit oversite organization that evaluates
and accredits different types of healthcare facilities.
Normal Flora - correct answer-Microorganisms that reside in or on the body without causing
disease.
Transient flora - correct answer-Microbes that reside on the skin surface and are easily
removed.
Resident flora - correct answer-Microbes that normally reside below the skin surface or
within the body and cannot usually be removed with routine hand washing.
Pathogens - correct answer-Microbes that cause disease.
The largest group of pathogenic microorganisms are bacteria, viruses, and fungi.
The less common pathogens are protozoa, helminths (worms), and prions.
Most pathogens flourish in a warm, moist, dark environment. This is way the human body is
the most common reservoir for pathogens.
Chain of Infection - correct answer-All six links in the chain of infection must be present for
infection to be transmitted from one person to another:
(1) Infectious agent - A microorganism
(2) Reservoir - a source of infection: a place where pathogens survive and multiply.
(3) Portal of exit - a pathogen must exit the reservoir, the most frequent is through body
fluids.
(4) Mode of transmission - contact, either direct or indirect, is the most frequent mode of
transmission of infection. Other examples are: droplet, airborne, and vector (mosquito).
(5) Portal of entry - pathogens enter the body through various portal of entry such as; eyes,
nose, mouth, urethra, vagina, anus, wounds and abrasions.
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