Supplemental Bullets Foundations

SUPPLEMENTAL BULLETS FUNDAMENTALS

MEDICAL TERMINOLOGY

Ecchymosis – form of macula that appears as large, irregularly shaped hemorrhagic area of skin Bruise – superficial injury in which the skin is discolored but not broken Petechia – small purplish, hemorrhagic spot on the skin. Hematoma - is a localized collection of blood caused by a break in the blood vessel in an organ tissue or space

Paresis-weakness, plegia – paralysis Tremors – rhytmic, purposeless body movements. Spasms are involuntary, sudden movements. Reflexes are involuntary actions in response to a stimulus. Tics are spasmodic contractions of face neck or shoulder muscles that may be habitual or conditional reflexes Ataxia – lack of coordination in performed planned, purposeful movement, typically resulting from a neurological deficit. Apraxia – inability to perform purposeful movementm even though no neuromuscular deficit exists. Fasciculations – fine twitching movements Amnesia – loss of memory Agnosia – lack of sensory integration Aphasia – loss or inability to communicatethrough speech , written language or signs resulting from brain disease or trauma Anomia – lack of memory of items Akinesia – loss of the ability to move voluntarily

Allen’s test – a test designed to evaluate a client’s collateral circulation in the arm before an invasiev arterial procedure such as ABG.the radial and ulnar arteries is occluded while client clenches his fist causing the hand to blanch.when he unclenches his fist, the ulnar artery is released.the hand should become pink, indicating a patent ulnar artery Battle’s sign – discoloration of the skin behind the ear following a fracture of the bone in the lower skull

Chvostek’s sign – spasm of the facial muscles elicited by light taps on the facial nerve. Signals tetany in hypocalcemia Compartment syndrome – a neurovascular complication commonly associated with fractures of the the limb; constrictive or occlusiove dressings, sutures or casts; poor positioning and any injury causing ischemia, swelling or bleeding into the tissues that ultimately can lead to permanent dysfunction and deformity Kegels exercises – exercises involving alternate contraction and relaxation performed to strengthen thenperineal muscles

Kernig’s sign- elicitation of resistance and hamstring muscle pain when the examiner attempt to extend the knee while the hip and knee are both flexed 90 degrees Brudzinski’s sign – passive flexion of the hips and knees in response to flexion of the neck, signals meningeal irritation Kussmaul’s respiration – abnormal deep , gasping type of respirations resulting from air hunger associated with severe diabetic acidosis and coma Trousseau’s sign – an assessment technique for evaluating neuromuscular irritability associated with hypocalcemia. Positive carpopedal spasms(adducted thumb, flexed wrist , metacapophalangeal joint and extended interphalangeal joints after a bp cuff is applied and infalted to a pressure above systolic for 1-4 minutes

Lubb closure of Atrioventricular valves Dubb closure of semilunar valves Eryth – red , cya – blue , pal/leuk white , ashen – gray, mela – black Pulse deficit – PR , pulse pressure – BP Hyper capnia – elevation of PaCO2 in arterial blood Hypoxemia – reduced level of oxygen in arterial blood ( less than 80 nnHg) Remittent fever – body temperature varies over 24 hours but remains elevated Relapsing fever-short febrile periods alternating with periods of normalk body temp. Anasarca – generalized edema

It is – inflammation , thrombo – clot , dynia – pain , ab , away from Penia – deficiency Rhexis – rupture Narco – stupor Plasty – repair / formation

Nursing Process

Nursing processp provides continuity of care and patient participation in health care Care plans should never be unchangeable and revised prn NANDA – responsible for formulating taxonomies or classifications Nursing order should include the date, the specific nursing action, time / length of time and signature Provide safety from falls – keep bed in lowest level and locking wheels The point at which the brachial pulse can no longer be palpated provides an estimate of the maximum pressure required to measure systolic blood pressure. Last Korotkoff sound heard on auscultation with a stethoscope is the diastolic pressure

The primary reason for bedrest is to decrease metabolic activity, which reduces the cells need for oxygen.secondary is to conserve energy and decrease cardiac output The normal APTT is 16 – 25 seconds and PT is 12 – 15 seconds, these levels must remain within two to two ½ the normal levels Negligence – failure to act as an ordinary prudent person would. Malpractice – professional misconduct, improper discharge of professional duties or failure to meet standards of care

Three elements necessary to establish nursing malpractice – nursing error , injury and proximal cause A DNR order means that basic and advanced life support measures won’t be initiated if respiratory or cardiac arrest occurs. It does not mean that ordinary treatment measures or nursing care is stopped

Communication Skills Nursing theory – one that generates knowledge in nursing Conceptual model – group of general ideas that serves as framework upon which nursing theories can be developed and tested. In 1960, Nursing schools adopted theories from the biological and psychosocial sciences to serve as conceptual frameworks Four concepts – person, environment – health and nursing(actions)

Martha Rogers – life process model – evolving creature interacting with the environment in an

open, adaptive manner-achieve maximum health in his environment Dorothea Orem – persons need to achieve self care. Goal of nursing is to help patient develop self- care activities to maintain maximum wellness High level wellness - OLOF Maslow – a need as a satisfaction whose absence can cause illness Safest way to identify patient is checking identification band on his wrist Diagnosis and Tx of human responses to actual or potential health problems Profession – requires specialized knowledge with long and intensive academic preparation Student nurses do not provide services, they are solely on the unit to learn Patient safety is a major concern in all situations The goal of listening- identify problems and needs and a supportive act.

Delegating responsibility shows respect for the staff members abilities to solve problems on their own The nurse managers function is to guide , direct and coordinate patient care, not to provide it. Primary nursing – comprehensive form of nursing in which one nurse is responsible for comprehensive care of a given patient Evaluation of staff members must be based on performance criteria as established by professional standards and the job description. Poor performance stems from poor morale

Communicating

Trust is the foundation of positive nurse patient relationship Therapeutic communication – two way , deliberative interaction between the patient and nurse in which they establish mutually acceptable, achievable goals ---fundamental component at all phases of the nursing process Problem orientedmedical record- information is recorded as prob.,observations and plan Narrative chart – decriptive storylike record A positive change in the patient’s behavior is the best way to identify learning Teacher should always try to involve the learner Asking questions shows that the patient is interested in learning Maintaining independence, a need common to patients of all age-groups, fosters the elderly person’s feelings of self worth

NURSING ASSESSMENT

Too much Yin causes digestive disorders and nervousness and too much yang causes dehydration , fever and irritability. Correct sequence in abdl. Assessment is RLQ, RUQ, LUQ and LLQ Guaiac – hemoccult test Rectal examination – sims , genupectoral and dorsal recumbent Romberg test – test for sensory or cerebellar ataxia Narrowed pulse pressure less than 30 – hypovolemia Oral temp.-36.1- 37.8’C (axillary 1‘deg.lower) (rectal -1’higher) BP cuff small – false high readings

Rectal temp – 3 to 5 mins. And axillary 10 mins. Rinne hearing tests compare sound conduction through air and bone.air conduction greater than bone conduction normal hearing or sensorineural hearing loss. Vice versa conductive hearing loss

Weber’s – determine if patient hears better in one ear or to differentiate sensorineural hearing loss from conductive hearing loss

Level of consciousness is the most important element in assessing the patient’s mental status Letargic patient sleep’s on and off but will respond to verbal or tactile stimuli. Stupor – needs constant stimulation Brain highly sensitive to inadequate oxygenation ( mental changes – hypoxia – first sign) Body’s response to elevated temperature – tachycardia and peripheral vasodilation(inc. metabolism) - hypotension Crisis – turning point in the course of a disease usually indicated by a rapid decrease in temperature Lysis – gradual improvement in condition

MOBILITY

INCREASED ADRENALIN PRODUCTIONIN IMMOBILE PATIENTS – DECREASED PERISTALSIS Anorexia – depleted protein stores Anatomic alignment prevents ctrain on body parts, amintains balance and promotes physiologic functioning Drawsheet is the best device to use when moving a patient up in bed Virchow’s triad, collectively predispose a ptient to thrombophlebitis , impaired venous return to the heart , blood hypercoagubility and injury to to blood vessel wall.

Valsalva maneuver – forced expiratory effort against a closed glottis Oxygen improves respiratory function only if he has symptoms of hypoxia Cold skin and impalpable pulse in the leg – refer asap (embolus)

Pulse rate – most reliable indicator of activity tolerance Complication of immobility – foot drop

HUMAN NEEDS

BODY IMAGE – PERCEPTION OF HIS APPEARANCE , FUNCTION IN COMPARISON TO OTHERS PERCEPTIONS TO BODY IMAGE BEGIN AT A YOUNG AGE AND CONTINUE TO EVOLVE THROUGHOUT LIFE. SELF – CONCEPT – PERCEPTIONS OF ONE’S BODY IMAGE, SELF-ESTEEM AND PERSONAL IDENTITY STRESSOR-ANY FACTOR THAT CAUSES PHYSICAL OR MENTAL WEAR AND TEAR ON THE BODY THAT ALTERS EQUILIBRIUM WEIGHING FOR M.I.O. – 1 g = 1 ml Average urine output – 1,500 – 2,00 ml. Caffeine – diuretic effect Urine pH – 6.0 Activity and elimination – one of man’s physiologic need(rest , sleep , food , clothing , shelter and air , water and temp. maintenance) TPN CONSIDERATION:GENERAL COND;LOSS OF 7% OF USUAL BODY WEIGHT OVER 2 MONTHS, LACK OF ORAL NUTRITION FOR 5 DAYS, PRE-OP. PREPARATION OF SEVERELY MALNOURISHED PATIENTS, Ca in the GIT and IBD Soft diet – no fried foods , organ or red meats, whole grain breads and seasoning Bland – no gastric irritants and seasonings, fruit juice OK Venturi mask – precise o2 concentration. Humidification of o2 – distilled H2O Vomiting of fluids for 3 days – loss of fluids Lungs and kidneys - body’s homeostatic regulator’s Hypertonic solution enema-120 ml left in place for 7 – 10 minutes

Cleansing enema – 1000 ml.

Comfort and safety measures

Lotions containing lanolin – preferred for backrub Sleep deprivation causes behavior and personality changes. Adequate sleep maintains coordination and perception and decreases restlessness REM –deep sleep, depressed muscle tone and possibly irregular heart and respiratory rates Non-REM sleep is a deep restful sleep without dreaming Delta stage or slow wave sleep – non REM satge III and IV –quiet sleep Napping in the afternoon – not conducive to nightime sleeping Pain is whatever the patient says it is , exists whenever she says it does Preventing pain is always easier than releiving it Bedrail only a reminder not to leave bed

SPECIAL NEEDS

AGING DECREASED ELASTICITY OF BLOOD VESSELS, INCREASED PERIPHERAL RESISTANCE AND DECREASED BLOOD FLOW HIP FRACTURE FROM OSTEOPOROSIS ALZHEIMER’S – LOSS OF SHORT TERM MEMORY SENSORY DEPRIVATION- INVOLUNTARY LOSS OF PHYSICAL AWARENESS CAUSED BY DETACHMENT FROM EXTERNAL SENSORY STIMULI – ISOLATION SPEAK DIRECTLY IN FRONT AND ENUNCIATE WELL- HEARING IMPAIRED “DEVOID OF FEELINGS” – ACCEPTANCE IN THE GRIEVING PROCESS NURSE CAN HELP ENSURE A PEACEFUL DEATH BY PROVIDING DIGNIFIED SUPPORT HIGH PROTEIN DIET – ACIIDC URINE , VEGETARIAN DIET – ALKALINE URINE

MAINTAINING ASEPSIS

ORGANISMS MODE OF TRANSMISSION DETERMINES ISOLATION PRECAUTIONS BARRIER USED TO BRAEK THE CAHIN OF INFECTION BETWEEN MODE OF TRANSMISSION AND SUSCEPTIBLE HOST STERILE ITEMS CAN BE ONLY STORED FOR 1 -2 MONTHS HANDWASHING NOT LESS THAN 30 SECONDS AUTOCLAVE – KILLS ALL MICORBES INCLUDING SPORES –PENETRATE THICK LINEN

PATIENT IN ISOLATION – NEED SENSORY STIMULATION SOAPS AND DETRGENTS – REMOVE BACTERIA – LOWER SURFACE TENSION OF WATER AND ACT AS EMULSIFYING AGENTS ANTISEPTIC – INHIBIT GROWTH BACTERICIDES AND DISINFECTANTS – DETSROY PATHOGENS EXUDATE – CLEAR PROTEIN RICH FLUID GOOD NUTRITION CRUCIAL IN THE HEALING OF PRESSURE ULCERS

THERAPIES AND TREATMENTS

PHLEBITIS – WARMTH AND BURNING SENSATION Z – TRACK PREVENT SKIN STAINING And IRRITATION Mid – deltoid can accommodate only 1 ml. of medication Insulin injection- validate dose accuracy Insulin injection – G25 , 5/8 “ needle G20 – IM oil based 22G 1 ½”– IM meds. G26 – intradermal Length of tubing should make no influence in how the infusion flows