Fundamentals
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Fundamentals

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Fundamentals Fundamentals Presentation Transcript

  • 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 FamilyEnvironmental 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 ofData, 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 levelof potential pt. involvement, time limit and what?
  • When planning, a nurse should consider the levelof 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, Providecare 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 incollaboration with another professional.
  • Interventions that the nurses carry out incollaboration with another professional. Interdependent Intervention
  • True or False. The NCP is modified as the Ptsstate of Hx changes and as needs for care changes.
  • True or False. The NCP is modified as the Ptsstate 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 ResearchQuality 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 pts. 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 apronNever 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 nonbiodegradableRed 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 useDuration & release from it
  • Assessment of pts response & further need of useHalf 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 minutesRemoved @ 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
  • T.B.
  • 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 CirculationDefibrilation 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 shouldhave the paddles placed 1-rib higher than the usual because?
  • Unconscious pregnant needing defibrilation shouldhave 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 & anurse 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 & anurse 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 unifiedbiopsychosocial system in constant interaction with changing environment.
  • Adaptation model. Each person is a unifiedbiopsychosocial 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 patients recovery.
  • Focused on manipulating the environment for the patients 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 areunitary beings in whom disease is a manifestation of the pattern of health.
  • Health as expanding consciousness. Humans areunitary 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 individuals response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature.
  • Health care system model. Nursing is concerned with all the variables affecting an individuals response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature. Betty Neuman
  • Human becoming. Emphasized free choice ofpersonal meaning in relating value priorities.
  • Human becoming. Emphasized free choice ofpersonal 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
  • Nurses individual philosophy lends credence to nursing care.
  • Nurses 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 isthe psychic reservoir of psychic energy, id, ego, & superego).
  • Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido isthe 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).
  • 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. Humanbeings are more than and different from the sum of their parts.
  • The science of unitary human beings. Humanbeings 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 andscientific mode of helping a client through specific cultural caring process.
  • Transcultural nursing. Nursing is a humanistic andscientific mode of helping a client through specific cultural caring process. Madeleine Leininger
  • Pulsating abdominal mass
  • Pulsating abdominal massAbdominal Aortic Aneurism
  • Painful board-like abdomen
  • Painful board-like abdomen Abruptio Placenta
  • Uremic frost on skin
  • Uremic frost on skinAcute Renal Failure
  • Bronze pigmentation of skin
  • Bronze pigmentation of skin Addisons Disease
  • Outburst laughter or cry fasciculations
  • Outburst laughter or cry fasciculationsAmyotrophic Lateral Sclerosis (ALS)
  • Pain upon exertion
  • Pain upon exertion Angina Pectoris
  • Mc Burneys sign
  • Mc Burneys sign Appendicitis
  • Boutonnier deformity, swan neck deformity, ulnar drift, Bouchards nodes
  • Boutonnier deformity, swan neck deformity, ulnar drift, Bouchards 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
  • Raccoons eye
  • Raccoons eyeBasilar Fracture
  • Meconium staining
  • Meconium staining Breech Birth
  • Russels sign, binge eating
  • Russels sign, binge eating Bulimia Nervosa
  • Cherry pink flushed face
  • Cherry pink flushed faceCarbon Monoxide Poisoning
  • Jack hammer syndrome
  • Jack hammer syndromeCarpal 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 Cushings 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 Ps: polydipsia, polyphagia, polyuria
  • 3 Ps: 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, Brushfields spots (Trisonomy 21)
  • Saddle nose, Brushfields spots (Trisonomy 21) Down Syndrome
  • Ortolanis sign, Galeazzis sign, asymmetry of gluteal, popliteal & thigh folds
  • Ortolanis sign, Galeazzis sign, asymmetry of gluteal, popliteal & thigh folds Dysplasia of Hip
  • Cullens sign
  • Cullens signEctopic 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 gazeFailure 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
  • ExopthalmiaGraves Disease
  • Hemarthrosis
  • HemarthrosisHemophilia
  • Asterixis
  • AsterixisHepatic Disease
  • Ribbon-like, foul smelling stool
  • Ribbon-like, foul smelling stoolHirschprungs Disease (megacolon)
  • Grapelike growth, large abdomen
  • Grapelike growth, large abdomen H-mole
  • Bossings sign, setting sun eyes
  • Bossings sign, setting sun eyes Hydrocephalus
  • Trousseaus sign
  • Trousseaus signHypocalcemia
  • High pitch cry
  • High pitch cryIncreased Intracranial Pressure (ICP)
  • Dolls eye
  • Dolls eyeIncreased 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 intoleranceIron Deficiency Anemia (IDA)
  • Strawberry tongue
  • Strawberry tongue Kawasaki
  • Red gelatinous sputum
  • Red gelatinous sputumKleibsella Pneumonia
  • XXY in males
  • XXY in malesKlinefelters 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 Menieres Disease
  • Kernigs sign, Brudzinkis sign
  • Kernigs sign, Brudzinkis sign Meningitis
  • White "cheesy" discharge
  • White "cheesy" discharge Moniliasis
  • Gowers sign
  • Gowers signMuscular Dystrophy
  • Charcots triad: intention tremor, nystagmus, scanning speech (clipped)
  • Charcots triad: intention tremor, nystagmus, scanning speech (clipped) Multiple Sclerosis
  • Nasal smile
  • Nasal smileMyasthenia 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
  • KyphosisOsteoporosis
  • Ringing or buzzing
  • Ringing or buzzing Otosclerosis
  • Steatorrhea
  • SteatorrheaPancreatitis
  • 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 rollingParkinsons Disease
  • Abdominal muscle rigidity with rebound tenderness
  • Abdominal muscle rigidity with rebound tenderness Peritonitis
  • Beefy red tongue
  • Beefy red tonguePernicious Anemia
  • Paroxysmal cough ending with a whoop
  • Paroxysmal cough ending with a whoop Pertussis
  • Nikolsky sign
  • Nikolsky signPhemphigus 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 theintravascular, 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 cant a Colloid fluid do?
  • What cant 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 insolutes 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 andinterstitial 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 forconcentration of glucose, must use pump, dont 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, dont 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 processsystematic, rational method of nursing care
  • Decision making process
  • Decision making processidentify purpose, set criteria, weigh criteria, seek alternatives, examine alternatives, project, implement, evaluate
  • Assessing
  • Assessingcollect, organize, validate,document data
  • Diagnosing
  • Diagnosinganalyze data, identify risks & strengths, formulate diagnostic statements
  • Planning
  • PlanningPrioritize,formulate goals and outcomes,select interventions, write orders
  • Implementing
  • Implementing reassess,implementinterventions,delegate,document
  • Evaluating
  • Evaluatingcompare data to outcomes, draw conclusions, modify care plan
  • subjective data
  • subjective datasymptoms only the pt. can verify
  • objective data
  • objective datasigns detectable to observer
  • directive interview
  • directive interviewhighly structured, elicits specific info
  • Non directive interview
  • Non directive interviewrapport building interview
  • Cephalo caudal approach
  • Cephalo caudal approach head to toe approach
  • Maslows Theory
  • Maslows Theoryhierarchy of needs
  • validation
  • validationdouble checking data to confirm accuracy
  • cues
  • cueswhat pt. says or nurse sees
  • inferences
  • inferencesnurses interpretation
  • diagnosis
  • diagnosisstatement regarding the nature of problem
  • risk factors diagnosis
  • risk factors diagnosisindicates a problem that could develop
  • wellness diagnosis
  • wellness diagnosisreadiness for enhancement of wellness
  • possible diagnosis
  • possible diagnosisevidence is incomplete
  • syndrome diagnosis
  • syndrome diagnosisassociated with a cluster of other diagnoses
  • diagnostic 3 part statement
  • diagnostic 3 part statement PES
  • Problem
  • Problemstatement of clients response
  • Etiology
  • Etiologyfactors contributing to probable cause of response
  • Signs and Symptoms
  • Signs and Symptomsdefining characteristics manifested by pt.
  • nursing intervention
  • nursing interventionany treatment based on clinical judgment that a nurse performs
  • formal care plan
  • formal care planwritten or computerized guide
  • informal care plan
  • informal care planstrategy that exists in the nurses mind
  • standardized care plan
  • standardized care planformal plan for all individuals with same etiology
  • individualized care plan
  • individualized care plantailored 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 SilenceAccepting pauses or silences that may last severalseconds or minutes without any verbal response.
  • Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts andfments or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and feelings into words
  • Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts andfments 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 leadsUsing 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..." ; "wouldit help to discuss your feelings?"; "and then...."; "I know what you are saying"
  • "Perhaps you would like to talk about..." ; "wouldit help to discuss your feelings?"; "and then...."; "I know what you are saying" Providing General leads (example)
  • Using specific and tentative
  • Using specific and tentativemaking statements that are specific rather than general, tentative rather than absolute
  • "You scratched my arm" instead of "you areclumsy as an ox" OR "you seem concerned about mary" rather than "you dont care about mary"
  • "You scratched my arm" instead of "you areclumsy as an ox" OR "you seem concerned about mary" rather than "you dont 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. Clients answers are longer than 1 or 2 words
  • "Id like to hear more about that"; "What brought you to the hospital today?"; "you said you werefrightened yesterday, how are you feeling today?"
  • "Id like to hear more about that"; "What brought you to the hospital today?"; "you said you werefrightened yesterday, how are you feeling today?" Open-ended question (example)
  • Using Touch
  • Using TouchProviding appropriate forms of touch to reinforce caring feelings.
  • Putting arm over clients shoulder OR placing hand over clients hand
  • Putting arm over clients shoulder OR placing hand over clients hand Using touch (example)
  • Restating
  • Restatingusing the same words as the client
  • Client: "I couldnt manage to eat any dinner lastnight- not even dessert" Nursing- "you couldnt manage to eat any dinner last night- not even dessert?"
  • Client: "I couldnt manage to eat any dinner lastnight- not even dessert" Nursing- "you couldnt manage to eat any dinner last night- not even dessert?" Restating (example)
  • Paraphrasing
  • ParaphrasingRestating in different form with implied feeling or observation
  • Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you dont know"
  • Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you dont 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 orgarbled. To clarify, the RN may restate the msg or
  • confess confusion & ask PT to repeat
  • Nurse: "Im puzzled" Nurse: "Im not sure whatyou mean by ___ Would you please repeat that again?"
  • Nurse: "Im puzzled" Nurse: "Im not sure whatyou mean by ___ Would you please repeat that again?" Seeking Clarification (example)
  • Perception Checking/ Consensual Validation
  • Perception Checking/ Consensual Validation A method similar to clarifying that verifies themeaning of specific words rather than the overall message
  • C: "it just wont stop" N: "Im not sure what youmean - it wont stop" OR C: "my husband nevergives me presents" N: "He never gives you gifts for your birthday or christmas?"
  • C: "it just wont stop" N: "Im not sure what youmean - it wont stop" OR C: "my husband nevergives me presents" N: "He never gives you gifts for your birthday or christmas?"
  • Perception Checking/ Consensual Validation (example)
  • Offering Self
  • Offering Self Suggesting ones presence, interest, or wish tounderstand the client without making any depandsor attaching conditions that the client must comply with to receive nurses attention
  • "Ill stay with you till your daughter arrives"; "we can sit here quietly for awhile, we dont need to talk unless you would like to"
  • "Ill stay with you till your daughter arrives"; "we can sit here quietly for awhile, we dont 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 notrequest. 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"; Idont know the answer to that, but Ill find out from the unit manager, when she comes in"
  • "Your surgery is scheduled for 11am tomorrow"; Idont know the answer to that, but Ill find out from the unit manager, when she comes in" Giving information (example)
  • Acknowledging
  • AcknowledgingGiving 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 sequenceHelping 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 ofpeople, usually his followers to attain a desired objective.
  • It is a style or process of persuading a group ofpeople, usually his followers to attain a desired objective. Leadership
  • A leader that is chosen by the administration or agroup which are given the official capacity to act.
  • A leader that is chosen by the administration or agroup which are given the official capacity to act. Formal / appointed / elected / designated
  • A leader that does not have official appointmentsor designations but is usually chosen by the group itself.
  • A leader that does not have official appointmentsor designations but is usually chosen by the group itself. Informal
  • It states that leaders are born and not developedbecause some people are born with characteristics to be great.
  • It states that leaders are born and not developedbecause some people are born with characteristics to be great. Great Man Theory
  • A person can be an effective leader if he has all theintellectual, emotional, physical and other personal traits of an effective leader.
  • A person can be an effective leader if he has all theintellectual, 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 therelationship 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 therelationship 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 littletrust to his members. His aim is to develop Self. Uses trial & error and a critic.
  • A style where the leader makes all the decisions and disallows his members to influence him.Followers dislike this leader and leader has littletrust 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 anddevelopment 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 anddevelopment of the group. He is a helper and uses "We" as his reference of leadership. Democratic
  • A leadership style that uses repetition and tries todevelop the system as his objective. His referenceis "they" and acts as a ruler and a regulator type of leader.
  • A leadership style that uses repetition and tries todevelop the system as his objective. His referenceis "they" and acts as a ruler and a regulator type of leader. Bureaucratic
  • A power whereby the leader has the officialcapacity to exercise rights and demand obligations from subordinates.
  • A power whereby the leader has the officialcapacity 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. MistrustInfancy (0-18 mos)
  • Autonomy vs. Shame & Doubt
  • Autonomy vs. Shame & DoubtEarly Childhood (18mos-3yrs)
  • Initiative vs. Guilt
  • Initiative vs. GuiltPreschool (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. IsolationYoung Adult (18-25yrs)
  • Generativity vs. Stagnation
  • Generativity vs. Stagnation Adulthood (25-45yrs)
  • Integrity vs. Despair
  • Integrity vs. DespairLate 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 Activeimagination (animistic thinking, fearful)
  • Teaching focused on Limited time Activeimagination (animistic thinking, fearful) Preschool (3-6yrs)
  • Teaching focused on Reality ObjectivitySeparation anxiety (tries to appear brave)
  • Teaching focused on Reality ObjectivitySeparation 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 Abstract hypothetical thinking Logic & scientific principles Adolescence (12-18yrs)
  • Teaching focused on Body image Self esteem & identity (feel invincible)
  • Teaching focused on Body image Self esteem & identity (feel invincible) Adolescence (12-18yrs)
  • 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 (questionsachievements & contributions to family & society, confident)
  • Teaching focused on Physical changes Alternative lifestyle Sense of well developed (questionsachievements & contributions to family & society, confident) Middle Adult (25-45yrs)
  • Teaching focused on Cognitive & physicalchanges No formal learning (decreased S.T.M., risk taking, easily fatigue)
  • Teaching focused on Cognitive & physicalchanges 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 sameonly if the client understood surgeons 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 ormetabolic deficiencies or cannot ingest food client.
  • Total Parenteral Nutrition
  • PRE-OPERATIVE CARE, if client has a FoleyCatheter, 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 likepain & discomfort, and that he/she can request what?
  • Narcotic Drugs as pain reliever, note it will not make the client an addict to such
  • PRE-OPERATIVE CARE (client teaching), demonstrate what to the client?
  • Patient Controlled Analgesic (PCA)
  • PRE-OPERATIVE CARE (client teaching),instruct not to what? 24 hours before the surgery.
  • Smoke
  • PRE-OPERATIVE CARE (client teaching), instruct to do Deep Breathing & CoughingExercises, use of Incentive Spirometry for the prevention of?
  • Pneumonia & Atelactasis
  • PRE-OPERATIVE CARE (client teaching),instruction of let & foot exercises will prevent what? Facilitate what?
  • Venous Stasis / Venous blood return
  • PRE-OPERATIVE CARE (client teaching),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 theclient 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?
  • PRE-OPERATIVE CARE (checklist), ensure that 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.
  • PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, chest radiography are documented & recorded plus?
  • PRE-OPERATIVE CARE (checklist), ensure that 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), afterremoving everything unnecessary, documented it, kept or given to family members, the nurse must document the?
  • PRE-OPERATIVE CARE (checklist), afterremoving 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), afteradministering medications, next to the client, place what?
  • PRE-OPERATIVE CARE (medications), afteradministering 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.), afterverifying identification bracelet & verbal response,the nurse will review chart and then confirm what?
  • PRE-OPERATIVE CARE (inside O.R.), afterverifying identification bracelet & verbal response,the nurse will review chart and then confirm what? Operative procedure & site
  • PRE-OPERATIVE CARE (inside O.R.), theclients chart will be reviewed for completeness and taking a note about what?
  • PRE-OPERATIVE CARE (inside O.R.), theclients 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 the period of this stage? 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), theclient maybe unable to clear his/her airway, that is why it is important to monitor what?
  • POST-OPERATIVE CARE (immediate), theclient 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), noterate, depth & quality of respirations, RR should be?
  • POST-OPERATIVE CARE (immediate), noterate, 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?
  • POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates what?Partial obstruction, bronchospasm, laryngospasm
  • POST-OPERATIVE CARE (immediate), a breath sound of crackles or ronchi may indicate?
  • POST-OPERATIVE CARE (immediate), a breath sound of crackles or ronchi may indicate?Pulmonary Edema, monitor signs of Atelectasis or Pulmonary embolism
  • POST-OPERATIVE CARE (immediate), checkcapillary refill, assess the skin, peripheral pulses &edema and monitor for bleeding. A bounding pulse may indicate what?
  • POST-OPERATIVE CARE (immediate), checkcapillary 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 Fowlers position after surgery to increase?
  • POST-OPERATIVE CARE (immediate), unless contraindicated, client is placed on Fowlers position after surgery to increase? Size of the thorax for lung expansion
  • POST-OPERATIVE CARE (immediate), whattype of positioning is avoided if the pharyngeal reflexes have not yet returned?
  • POST-OPERATIVE CARE (immediate), whattype 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), assessL.O.C., wake client periodically until awaken and if awaken?
  • POST-OPERATIVE CARE (immediate), assessL.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), anexposed skin, cool OR, or maybe from anesthesia may result to?
  • POST-OPERATIVE CARE (immediate), anexposed skin, cool OR, or maybe from anesthesia may result to?Hypothermia, keep blanket on & continue O2 if shivering
  • POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for?
  • POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for? Redness, abrasions or breakdown
  • POST-OPERATIVE CARE (immediate), recordI&O, monitor for Fluid & Electrolyte imbalance,N&V, NGT patency, abdominal distention and the return of what?
  • POST-OPERATIVE CARE (immediate), recordI&O, monitor for Fluid & Electrolyte imbalance,N&V, NGT patency, abdominal distention and the return of what? Bowel sounds
  • POST-OPERATIVE CARE (immediate), howmany hours is it that the client is expected to void urine after the surgery?
  • POST-OPERATIVE CARE (immediate), howmany hours is it that the client is expected to void urine after the surgery? 6-8 hours, note color, quantity & quality
  • POST-OPERATIVE CARE (immediate), assessfor pain, PRE-OP & POST-OP medz, then inquire about the type & location of pain by asking the client to?
  • POST-OPERATIVE CARE (immediate), assessfor 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), inquireeffectiveness of last medication, if on a Narcotic drug, assess every 30 minutes for?
  • POST-OPERATIVE CARE (immediate), inquireeffectiveness 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?
  • POST-OPERATIVE CARE (intermediate), how many hours is this stage after surgery? 4-24 hours
  • POST-OPERATIVE CARE (intermediate), monitor airway patency, encourage Deep Breathing & Coughing exercises, monitorcirculatory status encourage the use of what?
  • POST-OPERATIVE CARE (intermediate), monitor airway patency, encourage Deep Breathing & Coughing exercises, monitorcirculatory status encourage the use of what? Antiembolism stockings if not C/I
  • POST-OPERATIVE CARE (intermediate), assessfor 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?
  • POST-OPERATIVE CARE (intermediate), assessfor 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.
  • POST-OPERATIVE CARE (intermediate),reinforce wound with sterile dressing if necessary and always keep it?
  • POST-OPERATIVE CARE (intermediate),reinforce wound with sterile dressing if necessary and always keep it?Dry & intact, notify physician if bleeding occurs
  • POST-OPERATIVE CARE (intermediate), monitor I&O, N&V and if vomiting, have asuctioning equipment available and ready to use. NPO status is observed until?
  • POST-OPERATIVE CARE (intermediate), monitor I&O, N&V and if vomiting, have asuctioning 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
  • POST-OPERATIVE CARE (intermediate), how many mL per hour should a client void?
  • POST-OPERATIVE CARE (intermediate), how many mL per hour should a client void? Should be > 30 mL/hr
  • POST-OPERATIVE CARE (intermediate), if withFoley Catheter, client is expected to void within 6- 8 hours. Ensure that the amount is at least?
  • POST-OPERATIVE CARE (intermediate), if withFoley Catheter, client is expected to void within 6- 8 hours. Ensure that the amount is at least? 200mL
  • POST-OPERATIVE CARE (extended), what is the period of this stage?
  • POST-OPERATIVE CARE (extended), what is the period of this stage? 1-4 hours after surgery
  • POST-OPERATIVE CARE (extended), on thisstage, you monitor for signs of infection such as?
  • POST-OPERATIVE CARE (extended), on thisstage, 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?
  • POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours and encourage ambulation to promote? Peristalsis & passage of flatus
  • POST-OPERATIVE CARE (extended), the clientis encouraged to perform A.D.L. & eat foods thatwill promote wound healing. What are the foods?
  • POST-OPERATIVE CARE (extended), the clientis encouraged to perform A.D.L. & eat foods thatwill promote wound healing. What are the foods? Protein & Vitamin C
  • Inflammation of the alveoli caused by aninfectious process that may develop as a result of infection, aspiration or immobility?
  • Inflammation of the alveoli caused by aninfectious 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 mucoussecretions and is the most common postoperative complication?
  • Collapse of the alveoli with retained mucoussecretions and is the most common postoperative complication? Atelectasis, usually around 1-2 days postoperatively
  • POST-OPERATIVE CARE (Pneumonia & Atelectasis) Assessment / increase risk fordyspnea/ elevated temperature/ productive cough/ and what more?
  • POST-OPERATIVE CARE (Pneumonia & Atelectasis) Assessment / increase risk fordyspnea/ elevated temperature/ productive cough/ and what more? Increased R.R. & chest pain
  • POST-OPERATIVE CARE (Pneumonia & Atelectasis) Nsg Inter / assess for lung & breathsounds/ reposition client every 1-2 hour/ inc O.F.I. / early ambulation and what more?
  • POST-OPERATIVE CARE (Pneumonia & Atelectasis) Nsg Inter. / assess for lung & breathsounds/ 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) NursingIntervention, monitor signs of hypoxia/ eliminate cause/ monitor lung sounds/ administer oxygen/ D.B. & C. E. and what more?
  • POST-OPERATIVE CARE (Hypoxia) NursingIntervention, 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 (PulmonaryEmbolism) Assessment / dyspnea/ cyanosis/ tachycardia and what more else?
  • POST-OPERATIVE CARE (Pulmonary Embolism) Assessment / dyspnea/ cyanosis/ tachycardia and what more else?Decreased blood pressure & sudden chest or upper abdominal pain
  • POST-OPERATIVE CARE (PulmonaryEmbolism) Nursing Intervention / what is the first thing that you should do?
  • POST-OPERATIVE CARE (PulmonaryEmbolism) 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?
  • POST-OPERATIVE CARE (Hemorrhage)Assessment / restlessness/ hypotension/ cool, clammy skin and what other else? Weak rapid pulse & reduced urine output
  • POST-OPERATIVE CARE (Hemorrhage)Nursing Intervention / provide pressure to the site of bleeding immediately and then what?
  • POST-OPERATIVE CARE (Hemorrhage)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) NursingIntervention / elevate legs only if the client did nothave 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 ofshock/ 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 commonlyaffected, often accompanied by clot formation?
  • Inflammation of a vein, leg veins commonlyaffected, often accompanied by clot formation? Thrombophlebitis
  • POST-OPERATIVE CARE (Thrombophlebitis) Assessment / vein inflammation/ aching orcramping pain/ elevated temperature and what?
  • POST-OPERATIVE CARE (Thrombophlebitis) Assessment / vein inflammation/ aching orcramping pain/ elevated temperature and what? (+) Homans Sign
  • POST-OPERATIVE CARE (Thrombophlebitis) Nursing Intervention / monitor leg/ encourage antiembolism stockings – removed 2x/day forwashing & inspection of leg/ give heparin sodiumor 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
  • POST-OPERATIVE CARE (Thrombophlebitis) Nursing Intervention / monitor voiding/ assessdistended 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 bowelcontents and maybe due to anesthetic medications or manipulation of the bowel during the surgical procedure?
  • Failure of appropriate forward movement of bowelcontents 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 ofbowel sounds, bowel movement or flatus, what is the first indication of this condition?
  • POST-OPERATIVE CARE (Paralytic Ileus) Assessment / abdominal distention/ absence ofbowel sounds, bowel movement or flatus, what is the first indication of this condition?Nausea & Vomiting immeidately postoperatively
  • POST-OPERATIVE CARE (Paralytic Ileus) Nursing Intervention / monitor I & O/ maintainNPO 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 acontaminated wound before surgical exploration?
  • Caused by poor aseptic technique or acontaminated wound before surgical exploration? Wound Infection
  • POST-OPERATIVE CARE (Wound Infection) Assessment / fever & chills/ edematous skin at incision site & tight skin sutures/ increased WBCand what is the order of the inflamed incision site?
  • POST-OPERATIVE CARE (Wound Infection) Assessment / fever & chills/ edematous skin at incision site & tight skin sutures/ increased WBCand what is the order of the inflamed incision site? 1)Warm, 2)Tender, 3)Painful
  • POST-OPERATIVE CARE (Wound Infection) 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 Fowlers position toavoid 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?
  • 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
  • POST-OPERATIVE CARE (Wound Evisceration) Nursing Intervention / Fowlers position/ cover wound with sterile NSS and ?
  • POST-OPERATIVE CARE (Wound Evisceration) Nursing Intervention / Fowlers position/ cover wound with sterile NSS and ?Notify DR & prevent wound infection, antiemeticsis 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?
  • 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) assesspts readiness to learn, educ. level, & desire modifylifestyle/ demo incision care/ written guide to pt & family &?
  • POST-OPERATIVE CARE (Discharging) assesspts readiness to learn, educ. level, & desire modifylifestyle/ 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 CalculationsCCs 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 12noon to 6 pm. The Drop Factor is 15 gtts/ml.
  • Ordered 1250 cc 2.5 % D/W to infuse from 12noon 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 mEqof KCL to infuse in 8 hours. DROP FACTOR: 12 gtts / ml
  • ORDERED: 1000 cc 5%D/0.45% NS with 40 mEqof KCL to infuse in 8 hours. DROP FACTOR: 12 gtts / ml 25
  • ORDERED: An infant weighs 18 # has an IV of500 cc 10% D/W to infuse over 24 hours. DROP FACTOR: 60 gtts/ml
  • ORDERED: An infant weighs 18 # has an IV of500 cc 10% D/W to infuse over 24 hours. DROP FACTOR: 60 gtts/ml 20-21
  • ___% of the average adults weight is fluid
  • ___% of the average adults 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 inwater it separates into ions and is able to carry an electrical current
  • Cation
  • Cation+ charged electrolytes EX: Na+ K+ Ca+
  • Anion
  • Anion- charged electrolytes EX: Cl- HCO3- SO4-
  • Solute
  • Solutedissolvable in water
  • Solvent
  • Solventdissolvable in plasma
  • Osmosis
  • Osmosis movement of a pure solvent, through asemipermeable membrane, from an area of lesser solute concentration to an area of greater soluteconcentration 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 asemipermeable membrane from an area of higherconcentration to an area of lower concentration is:
  • Movement of a solute in a solution across asemipermeable membrane from an area of higherconcentration to an area of lower concentration is: diffusion
  • Filtration
  • Filtration water and diffusable substances move together inresponse to fluid pressure, moving from an area of higher pressure to an area of lower pressure
  • Hydrostatic pressure
  • Hydrostatic pressuremovement 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 transportmovement of materials across cell membranes requiring metabolic activity
  • Homeostasis
  • Homeostasisphysiological balance
  • Osmoreceptors
  • Osmoreceptorscontinually monitor the serum osmotic pressure, when osmolality increases, hypothalamus is stimulated
  • ADH
  • ADH Antidiuretic hormone; stored in pituitary gland; works directly on kidney tubules and collectingducts making them more permeable which returns water to systemic circulation
  • Aldosterone
  • Aldosteronereleased by adrenal cortex in response to increasedK+ levels; it increases the reabsorption of Na+ and secretion of K+
  • Insensible water loss
  • Insensible water losscontinuous and not perceived by person
  • Sensible water loss
  • Sensible water lossthrough 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. Whats its function?
  • __% of K+ in ECF. Whats its 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
  • Buffera 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 regulationoccurs 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 ofglucose, electrolytes, and other nutrients given through an indwelling or central IV
  • IV fluid and electrolyte therapy
  • IV fluid and electrolyte therapy crystalloids
  • Colloids
  • Colloidsblood and blood component
  • Vascular access devices include:
  • Vascular access devices include:catheters, cannulas, infusion ports,
  • the breakdown of RBCs is called:
  • the breakdown of RBCs 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 FVDs is:
  • The client most at risk for FVDs is: an infant
  • One reason older adults experience fluid andelectrolyte imbalance and acid-base imbalances is they:
  • One reason older adults experience fluid andelectrolyte 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 venouscatheters and rotating sites should occur at least every:
  • CDC recommends replacing peripheral venouscatheters and rotating sites should occur at least every: 72-96 hours