- vital: necessary for life 

- assessment of critical physiological funciton 

- pain as 5th vital sign* (can't be ignored; subjective)

-have to be accurate

- evaluate in context of condition* 

- temperature

-pulse

-respiratory rate

-blood pressure

-oxygen saturation 

- on admission to facility 

-beginning of shift

-visit to clinic/office

- before, during or after procedure/blood transfusion 

-monitor med effects

-whenever the patient condition changes**

- nursing intervention (don't need doctor's order)

- range is 36-38C (98.8-100.4F) 

-fever: oral >37.8 or 100, rectal >38 or 100.4

-hypothermia: <35/95

-hyperthermia:> 40/104

- decreasing: sweat (diaphresis)

-increase: shiver, increase BMR

- read patient cues/ behavioral: removing clothes, fanning, etc. 

- neural/ vascular control

-BMR (thyroid)

-skeletal muscle movement

-nonshivering thermogenesis: neonates can't shiver 

- radiation

-convection: through air and water

-evaporation: sweat 

-conduction: ice pack 

- developmental level (neonates need heat, elderly have trouble producing fever during infection)

-environment

-hormone level (menstural cycle)

-exercise

-emotions and stress

-circadian rhythm (lower in the morning)

- bacteria/foreign substance--> phagocytes secrete pyrogens (interleukin 1)--> prostaglandins--> hypothalamus--> fever 

phases: initial phase> rising temp> second phase> max point> third phase> defercescence

- febrile/afebrile

-pyrexia: bad fever, hallucinations, etc

-hyperthermia: body can no longer regulate temp 

-heatstroke: can't replace loss of fluid

-heat exhaustion: puking 

- hypothermia

-less than 95

- shivering

- syanosis: blue tipped fingers/toes/extremities

-can deliberately induce after stroke to decrease BMR to cause patient cells to rest

-frostbite: can be effect, can lose tips of skin 

- which is the best site to use?

-which is the best device to use?

- heat produced- heat lost= body temperature 

-core temp: tympanic, rectal (critical care: pulmonary artery, urinary bladder, esophageal)

-surface temp: oral, axillary, skin, temporal artery 

- mercury in glass thermometer: not used.

mouth: 7 min, rectum: 3 min , axilla: 10 min 

-electronic: red probe for rectal, blue for oral/axillary, most common in hospitals 

-disposable: surface, not as accurate 

- measurement affected by hot or cold dirnks, cold ambient air, rapid respiratory rate 

-delayed by cigaratte smoking (less blood flow in oral mucosa), oxygen flow

-must be able to follow directions 

- accurate core measurement 

-clients unable to follow directions 

-risk for injury to mucosa 

-contraindicated for those with impaired rectal mucosa. (hemeroids, etc)

- fast, 2-5 seconds 

- uncooperative clients

-cerumen impaction lowers accuracy 

- contraindicated with ear infection, ear surgery 

- armpit

-safe, easy 

-uncooperative clients 

-contraindicated in diaphoretic patients (sweating)

- selecting the approprate route and device 

-taking appropriate precaustions and positioning especially when taking rectal temperatures 

-consider specific client related factors that could raise or lower temperature 

-obtain temperature measurement as ordered/ needed 

- help determine cause of temp

-monitor temp and VS

- observe for other signs and symptoms

- treat cause/ blood cultures

- give fluids/nutrition 

-cooling blankets

-antipyretics

-keep bed linens dry 

-emergency cooling if heat stroke 

-hypothermia 

- normal BPM: 60-100

- systole: left heart ventricle contracts> blood is forced out into arteries, wave pulses through arteries, hear the pulse 

-diastole: left ventricle relaxes, arteries constrict 

CO: cardiac output 5-8L/min; the volume of blood pumped by the heart in one minute 

HR: heart rate 60-100 BPM; number of times the heart pumps in one minute 

SV: stroke volume 50-100mL/beat; the volume of blood pumped from one ventricle of the heart with each beat 

CO= HR x SV

- developmental: newborns have higher rate 

-exercise: conditioning decreases heart rate 

-emotion: fight/flight increase heart rate

-temperature: fever- for every degree raised the HR usually raises 10 beats 

-disease

-hemorrhage/blood loss: drop CO, HR raises to compensate 

-postural changes: lower laying down.. sit to stand up HR increases, BP drops 

-medications/food 

- palpation: radial/carotid 

-auscultation via stethoscope: apical 

- temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis 

- radial most common in adults 

-brachial in infants 

-femoral- good central pulse 

- rate-count number of beats NL 60-100 

-<60: bradycardia

>100 tachycardia 

pulse deficit: pulse taken in two areas, how they match up

-rhythm- regular or irregular 

-dysrthymia: irregular, palpate

regulalary irregular? irregularly irregular?

0: absent (amputated limb) 

+1: diminished or barely palpable 

+2: normal and expected

+3: full or strong 

+4: bounding 

equality: compare sets, except carotid(patient will pass out)

- based on related factors 

-tailored to patient condition 

-interpret high HP/ low HR 

- exchnage of O2 and Co2

- ventilation-movement of air in and out (breathing)

-airway pressure drops below atmospheric pressure, air moves in to lungs (inspiration)

-expulsion of air (expiration)

-diffusion: exchange of o2 and co2 by RBCs and alveoli

-perfusion: RBCs to and from pulmonary capillaries 

- regulated by respiratory center in brain stem 

- uses levels of co2, o2, and hydrogen ion concentration (pH) of the arterial blood to regulate ventilation 

-patients with chronic lung disease are sensitive to low levels of O2 

-inspiration is an active process/ expiration is a passive process 

-trigger to breathe is co2 accumulation except with patients with chronic lung disease then they use O2, normally high levels of co2, must be careful when giving oxygen because low level of o2 is trigger to breathe 

- developmental level: infants have higher rate

- exervise: higher

- pain/axiety: shallow breathing 

-stress: increase

-smoking: lung compliance, may have to breathe more at rest

-fever: increase

-hemoglobin- lose RBCs, increase 

- neurologic injury: lower 

caffine: higher 

position: slumping: decreased 

- rate: 12-20 RR per min 

-apnea: not condusive with life, gulping breath every few seconds 

-bradypnea: not as low as apnea but less than 12

- tachypnea: higher than 20 

-depth/volume

-rhythm: regular or irregular/ should be effortless

-breath sounds 

-chest and abdomen movement 

-should be done without patient knowing, after pulse 

- pulse oximeter probe is placed on finger or earlobe

-measures the O2 of arterial blood by bouncing light off of HgB and reading its O2 concentrations 

-less than 88- real problem 

- nail polish/artificial nails could interfere 

-patient has cold fingers could affect reading 

-ambient light: can put towel over 

- pressure exerted by curculating blood upon the walls of blood vessles during cardiac contraction 

- systolic pressure-peak pressure as ventricles contract and eject blood 

- diastolic pressure: min pressure when ventricles are at rest 

physiology of blood pressure 

-cardiac output

-peripheral resistance: how well vessels are constricted/dilated 

-blood volume

-viscosity: thickness 

-elasticity

-developmental stage

-gender: men have slightly higher BP 

-ethnicity 

-smoking: higher BP

-laying flat: lower 

-stress: higher

-activity and weight: higher with obesity 

- diurnal variations: lower in mornings and higher in eveings

-medications 

- normal: systolic (<120), diastolic (<80) 

-prehypertension: stysolic (120-139), diastolic (80-89)- dietary 

-stage I HTN: systolic (140-159), diastolic (90-99)- medication 

-stage II HTN: systolic >160, diastolic >100- urgent 

- systolic BP is below 90 mmHg

- abnormal finding when associated with an illness

-orthostatic hypotension occurs when the BV is decreased resulting in a drop in BP when changing positions from lying to sitting or standing (10 mmHg drop )

- width: 40% of upper arm circumfrence 

-length: 80% of upper arm (cuff covers 2/3 of the extremity) 

phase 1: a sharp thump 

phase 2: a blowing or whooshing sound

phase 3: a crisp intense tapping

phase 4: sofer, blowing sound that fades

phase 5: silence 

- locate pulse 

- inflate to 70-80 

-palpate pulse while continuing to inflate until you no longer feel pulse 

-you can then take the BP, inflating 20-30 above the level you identified

- temp: 36-38c, 98.8-100.4 f (average oral 37/98.6, rectal 37.5/99.5, axillary 36.5/97.7)

-pulse: 60-100 BPM

-respirations: 12-20 per min 

-BP: <120/80

- temperature: don't usually have fevers

-pulse rate lower

-BP higher

-respirations normal 

- basic human need

- institute of medicine report 

- ANA: american nursing association 

-QSEN: quality and safety education for nurses

- JC: Joint comission= decide whether or not hospitals are safe to send insurers too; let hospitals stay open, national patient safety goald 

-medicare: "never" events: falls, burns, etc. won't pay 

- basic needs!

- oxygen, nutrition, temperature

- ABC: airway, breathing, circulation 

- physical hazards: MVAs, poison, falls, fire, disasters

- transmission of pathogens 

-pollution 

-infant, toddler, preschool: MVAs and drowning 

-school age child: bike accidents and MVAs

-adolescent: substane abuse and MVAs

-adult: MVAs and poisoning 

-elderly: falls 

- medical errors: 8th leading cause of death 

- patient-inherent accidents (seizures, falls)

-procedure related accidents: radiation and fires 

- equipment related accidents: electrical hazards 

- RACE: rescue, activate, contain, extinguish 

- restrict patient's freedom, with or without permission 

- may be physical or chemical 

- may be medical-surgical or behavioral 

- medical surgical restraint: underlying medical condition that makes them unable to follow commands & are at risk of harming themselves or others (ex- high amonia levels due to liver so they're confused do to med prob./coming out of anethesia confusion)- check every 2 hrs, reevaluate every 24. 

- behavioral restraint: pt is being uncoorperative/ combative. usually psychiatric condition. document every 15 minutes. 

-need doctor's order 

- reduce risk of falls 

- prevent interruption of therapy 

- prevent confused or combative patients from removing life-support equipment 

- reduce the risk of injury to others by the patient 

- orient clients & families to environment; explain all procedures & treatments 

- provide companionship & supervision; use trained sitter or adjust staffing 

- offer diversionary activities, such as music or something to hold; enlist support & input from family 

- assign confused or disoriented clients to rooms near the nurse's station; observe these clients frequenty 

- use calm, simple statements and physical cues PRN 

-use de-escalation, timeout, & other verbal intervention techniques when managing aggressive behaviors 

- provide appropriate visual & auditory stimuli (fam pics, clock, radio)

- remove cues that promote leaving (elevators, stairs, street clothes)

- promote relaxation techniques & normal sleep patterns 

- institute exercise & ambulation schedules as allowed by the client's condition; consult physical therapist for mobility & exersize programs 

- increase likelihood of injury 

- disadvantages: nerve damage, circulatory impairment, suffocation, pressure ulcers

- avoid restraints if at all possible!

- always attach to bed frame not rail (rails move)

- use quick release knot that you can easily unhook 

- most common, two fingers fit so there's good circulation 

- good for patient trying to get out of bed or at fall risk

- can accidently move to neck and suffocate themselves 

- can't grab anything and can still move freely 

- not considered restraint if not hooked to bed

- if attached to bed then it becomes a restraint 

- adult sized crib, doesn't allow patient to do much 

attached to bed frame, goes up close to neck and can accidently suffocate 

- back injury

- needlestick injury

- radiation injury 

- violence 

- protect patient from health care related infections 

- meet professional standards/guidelines

- protect yourself and your loved ones from disease

- help lower cost of healthcare

- HAIs: healthcare associated infections: hospitals, home care, long-term care, ambulatory setting

- nosocomial infections: hospital-acquired

- entry and multiplication of organism results in disease

- colonization occurs when a microorganism invades the host but doesn't cause infection 

- communicable disease is the infectious process transmitted from one person to another 

- infectious agent or pathogen: normal, transient, and resident flora; virulence

- resevoir or source for pathogen growth: where do bugs like to grow?---> moist areas of body 

- portal of entry: enter body through nose, eyes, mouth, sexually

- susceptible host: who is at risk for infection? immunocompromised, young children, elderly 

- portal of exit: bugs like to travel, spread infection

- mode of transmission: contact, droplet, airborne

-

- local or systemic 

- primary or secondary (primary first infection, secondary knocks out resident flora)

- Iatrongenic: hospital gave it to them 

- exogenous infection: outside source 

- endogenous infection: body suseptable, grows within 

- *Multi drug resistant organism 

- risk factors: 

- severe illness

- previous exposure to antibiotics

- chronic diseases

- invasive procedures/ devices 

- repeat contact with hospitals 

- advanced age 

-ex: MRSA: methicillin resistant staphylococcus aureus, VRE: vancomycin resistant enterococci, C-Diff: clostridium difficile 

- spores only killed by hand-washing, not alcohol gels 

- developmental stage

- breaks in line of defence (wounds/lasserations)

- illness or injury 

- tobacco/substance abuse

- multiple sexual partners

- environmental factors 

- chronic disease

- medications 

- nursing/medical procedures 

Subjective: recent cuts/lacerations? illnesses or diseases? recent diagnostic tests? do you feel like you have or had a fever? pain or burning during urination? what meds are you taking? major lifestyle change? 

Objective: clinical appearance, lab data 

- hand hygiene

- handwashing

- alcohol based hand rub

- **number one way to prevent/ control infection is HAND HYGIENE 

-asepsis: preventing/reducing amount of organisms on the body 

CONSIDER: 

- what type of contact will i have with patient?

- what type of contact will i have with contaminated equipment?

- what is the patient's infection status?

- CDC/WHO & TJC patient safety goal 

- wash hands when hands are visibly dirty, before eating, after using toilet

- *wash hands if C-Diff 

- if not soiled, antiseptic agaent before, after, and between direct patient contact, after contact with body fluids/excretions 

-when moving from contaminated to clean body site 

- after contact with inanimate surfaces/objects

- before caring for patients with immune supression 

- before putting on sterile gloves/inserting devices

- after removing gloves 

- time: 15 seconds 

- soap: 60% alcohol based rub for routine hand cleansing, antimicrobial soap and water when hands are dirty

- friction 

-drying

- natural nail tips should be kept to 1/4 inch in length 

- artificial nails should not be worn when having direct contact with patients 

-1st: standard precautions: hand hygiene, gloves, gown, mask, eye protection or face shield during expected exposure 

- 2nd tier: transmission-based precautions (isolation precautions):

     - contact precautions: hand hygiene, gloves, gown 

     - droplet precautions: hand hygiene, gloves, gown,            face mask 

     - airborne precautions: hand hygiene, gloves, gown,          N95 mask 

- wear gloves when contact with blood or other potentially infectious materials is possible

- remove gloves after caring for a patient 

- do not wear the same pair of gloves for the care of more than one patient 

- do not wash gloves 

- personal protective equipment 

order to put on: 

1) hand hygiene 

2) gown 

3) mask/goggles

4) gloves over sleeves 

- wear a gown for contact isolation, any exposure to bodily fluids/drainages 

to take off:

1) gloves

2)eyewear

3) gown

4) mask 

- describes the activities involved in maintaining personal cleanliness and grooming

- contributes to physical and psychological well being

- ADL's: activities of daily living: bathing/showering, washing hair, brushing teeth/flossing 

- factors influence a client's personal hygiene 

- hygiene care is never routine

- during hygiene assess: physical limitations, health promotion practices and needs, emotional needs 

factors influencing hygiene 

- personal preferences 

- culture & religion/ spirituality 

- economic status or living environment 

- developmental level 

- knowledge and cognitive level 

- pain

- limited mobility 

- sensory deficit (vision, touch-burns 

- cognitive impairment 

- emotional or other mental health disturbances 

- obtain a health history 

- assess cognitive/physical/sensory functioning

- assess other factors 

- determine preferences/practices 

- readiness for enhanced self care

- bathing/hygiene self-care deficit 

- dressing/grooming self-care deficit 

- toileting self-care deficit 

- self neglect 

- types of hygiene care (inpatient):

- hourly rounding (comfort rounds)

- early morning care: brush teeth, wash face, care before breakfast 

- AM care: after breakfast, bath/full care

- PM care: afternoon, before visitors come, see if they want to freshen up 

- HS care: night/ Hour of Sleep care, brush teeth, re do linens, fresh gown, etc

- bathing and skin care (dry skin common in hospitals, moisterize)

- back rub (therapeutic touch help patients thrive)

- foot and nail care

- oral hygiene: brushing and flossing 

- hair and scalp care

- care of the eyes, ears, and nose 

- inspection of client's skin, nails, oral cavity, and sense organs

- determine if client's comfort level improves

- ask the client to demonstrate hygiene self care skills 

- ask the client if expectations are being met 

- functions include: protection, secretion, excretion, temperature regulation, vitamin D formation, sensation 

- three layers: epidermis: shields underlying tissue, dermis: contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles, subcutaneous: contains blood vessels, nerves, lympth, and loose connective tissue filled with fat cells 

- health status: dampness, dehydration, nutritional status, insufficient circulation, skin disease, jaundice (liver not filtering old RBCs), lifestyle & pesonal choices (piercings, tattoos)

- developmental state: very young and old have fragile skin 

-subjective: allergies, preferences, PMH, other factors 

-objective: pallor, erythema, jaundice, cyanosis, pruritus, dry skin, maceration (pruney), excoriation, abrasion (friction), pressure ulcers, acne, burns 

-have to move patient every 2 hours to prevent pressure ulcers 

- risk for impaired skin integrity 

- impaired skin integrity 

- assist: when patient can do some stuff but RN is there to help, reach hard places, etc, but mostly supervise 

- partial: only washing certain area (bowel movement cleanup)

-bed bath: patient can't get out of bed (maybe can turn)

- towel bath: dry towel/ wet towel and cleaning agent 

- bag bath: goes into microwave, can't use in perineal area b/c too sensitive

- tub bath: sometimes still in burn unit, scrub dead tissue

- perineal care: always after the face and last thing 

- special concerns: patients with dementia (bag bath), morbidly obese (clean in skin folds), elderly (high risk for skin breakdown, assess while you clean)

- risk factors for oral problems: 

-PMH (past medical history)

- lack of access to dental care

-pregnancy

- poor nutrition

- medications/treatments (dry mouth, radiation can kill salivary glands)

- dry mouth 

- PMH

- inspect lips, oral mucosa, gums, tongue

- should be pink and moist, look for loose/decaying teeth 

- risk for infection related to mouth lesions 

- impaired dentition 

- impaired oral mucous membrane 

- deficient knowledge 

- oral care for critically ill patients: don't put hands in mouth of unconscious/dementia-bite down) 

- denture care: cleaned with toothpaste and stored in water so they don't crack/dry out, label appropriately 

- growth, distribution, and pattern indicate general health staus 

- hormonal changes, emotional stress, physical stress, aging, infection, and other illnesses can affect the hair 

- course hair can be endocrine imbalance 

- emotional status: pulling/loosing hair 

- chemotherapy hair loss 

- hair care for african americans: don't undo braids/ cornrows, use heated shower cap, rub cap around and remove, removes oils and cleans hair 

- never cut anyones hair without written consent 

- bearch/mustache/shaving: if patient has bleeding tendencies use electric razor or clip the hair, have to be careful with patients on blood thinners 

- eye care for unconscious patients 

- eyeglasses and contact lenses

- artifical eyes 

- ears: cerumen buildup, care of hearing aids (do not break/lose!!) 

- nose: secretions, NG tube site- can cause ulcer, need to clean around the tube so it doesn't rub 

- optimize comfort/safety

- room temperature

- siderails up (most important when moving)

- bed in low position 

- bed wheels locked 

- call ight within reach 

- uncluttered walking space

- unpleasant odors 

- flat

- semi fowler's position (30 degree angle)- drink 

- fowler's position (45 degree angle)

- trendelenburg's position (feet up, head flat) 

- reverse trendelenburg's position (head up, feet flat)- good for spinal cord injury, need orders 

- sitting position (special wound care beds, also adjust to standing position)

- high fowler's good for patient at risk of choking/having trouble breathing 

- bed can change pressure points 

- kidneys 

- ureters

- bladder

- urethra 

- known as voiding, micturation 

- process: filling of bladder (200-450 mL of urine)-> acitivation of stretch receptors in bladder wall->signaling to the voiding reflex center->contraction of detrusor muscle->conscious relaxation of external urethral sphincter

- voluntary voiding problem for stroke victims, sprinal injuries, etc

-1500 mL normal urine output/ 24 hrs (60 mL per hour)

- if patient drops urine output less than 30 mL per hour, nephrons not getting enough fluid or patient not making urine correctly= medical emergency

- might need urinary catheter or give fluid ^ need order

- oliguria: urine output less than 400-500 ML in 24 hrs

-anuria: less than 100mL/24 hrs, basically no functional urine output 

- bladder scanning being used now before folley insertion 

- older adults: kidney function decreases, urgency and frequency common, loss of bladder elasticity and muscle tone leads to nocturia (night peeing) & incomplete emptying (higher risk for retention/ infection)

- decrease in GFR with age, clearance of urine, somewhat normal with elderly, urgency and frequency common bc of slowing of signals 

- diseases (of kidney, scarring of urethra from bladder cancer, etc)

- sociocultural (very personal, UTI if hold it in) 

-psychological 

-environmental 

- growth and development 

- muscle tone 

- fluid balance (bladder can important to see if fluid is even in the bladder to urinate)

- diagnostics

- medications (can slow down or increase urine output 

 - surgey and anesthesia (can interfere with signals, automatically need folley catheter)

-pathological conditions: UTI, urinary retention, urinary incontinence, urinary diversions 

- urinary tract infections 

     -risk factos: sexually active females, use of spermicidal contraceptive gel, older women, pregnant women, englarged prostate, indwelling catheter (80%.. needs to be sterile; number one cause of nosocomial infections)

    -CMS "never" event! 

- urinary retention- inability to empty bladder: obstruction (stone, enlarged prostate), inflammation and swelling, neurological problem, medications, anxiety

- urinary incontinence: involuntary leakage- urge (large amt), stress (small amts, childbirth), overactive/hyperactive bladder  

- history 

- physical assessment: swollen? holding in fluid

- assessing urine: I&O, oliguria/anuria, urine samples 

- urinalysis 

- blood studies: BUN: products of muscle breakdown, creatinin: filtration of kidneys (mimicks GFR)

- diagnostic procedures: risk for trauma/bloody urine

speciments:

- freshly voided specimen

- clean catch: clean outside of urethra, have patient urinate a little and stop, then have second clean catch that should be bacteria free 

- sterile specimen: after insertion of sterile catheter, attach seringe and get sterile specimen 

- 24 hour urine: best way*** to evaluate kidney status is doing 24 hour sample: put inverted bed pan in toilet, 6am-6am, urine collected and put into jug, can put on ice to get rid of smell.. concentration of urine and waste products in urine examined 

-urinalysis

-dipstick test: pH of urine, important to tell if kidneys buff

-specific gravity

- color (hematuria: red particles/bloody appearance), some medications will turn yellow greenish, tea colored= very dehydrated 

-clarity (cloudy= infection or renal/kidney damage)

- odor: dehydrated or kidney problems 

- provide privacy 

- assist with positioning 

- facilitating toileting routines 

- promote adequate fluids and nutrition 

- assist with hygiene 

- perineal skin care 

- behavioral interventions: lifestyle modification, bladder training (every 2-4 hrs), schedule voiding, pelvis floor muscle rehab (kegel)

- supportive interventions 

- anti-incontinence devices: meatus plugs, catheters

- surgery/meds

- prevent skin breakdown

- strategies to promote independent urination 

- parental teaching for enuresis (bedwetting- development issue not behavioral, need to grow out of it can't teach)

- administer cholinergic meds

- crede's maneuver: applying pressure to bladder gently 

- run water, pour warm water over perineum, relaxation, give fluids 

- perform urinary catheterization (after more than 6-8 hr)- prevent UTI, prevent backflow of urine, encourage fluids, perineal hygiene

- introduction of a sterile tube into the bladder 

- straight catheter: one time, does not stay inside bladder; just emptying and removal (single lumen)

- indwelling catheter: folley- cont. urine drainage (double lumen)

- suprapubic catheter 

- insertion of catheter (pliable tube) into the bladder to alow drainage of urine

- sterile urine specimen, drain bladder for surgical/ diagnostic purposes, prevent/treat bladder overdistention, post-void residual volume measurement, protect excoriated skin from contact with urine, reduce need for movement/moribund pt. 

#1 cause of nosocomial infections, lubricate to prevent damage to urethra.

- SCI may use clean technique for intermittent cath. 

- prevent UTI

- maintain free flow of urine

- prevent reansmission of infection 

- promote normal urine production 

- maintain skin and mucosal integrity 

- diverting completely the bladder and urethra 

- goes directly in the absomen straight into the bladder bc of trauma, surgery, tumor, etc 

- not in SCI patient 

- surgical insertion 

- don't need an order 

- only for males 

- condom that goes on outside of penis to hlep drain urine

- good for incontinent patients 

- external collection device 

- diversion/urostomy- surgically created opening for elimination of urine 

- cancer, radiation injury to bladder, trauma, disease of urinary system 

- surgically created 

- use a part of the intestine to drain the urine, completely diverting bladder and urethra 

- illeal conduit- pouch collects urine 

-continent urostomy: same concept, diff pouch placement, usually for take home 

- practical and vocational nurse 

- registered nurse entry education

- diploma programs

- associate degree programs- community college 

- baccalaureate degree programs- direct care, serve community, involved in research, administrative positions

- master's degree: indp role of nurse as practitioner, wider scope of practice, can diagnose and treat, care

- doctoral programs: advanced clinical practice or research practice 

- nurse practice act

- state boards of nursing 

- establishes criteria for RN/LPN/ARNP

-determines scope of practice: acticities and rules 

- nursing: scope and standards of practice 

- foundational for decision making and competent nursing care 

- systematic problem solving approach toward giving individualized nursing care

- process for nurses to use as a PROBLEM SOLVING process in all settings, with clients of all ages, to identify and treat human responses to potential or actual health problems incorporating each client's unique aspects 

- assessment 

- diagnosis 

- planning 

- implementation 

- evaluation 

-critical thinking skills are interwoven- cognitive processes used in complex thinking operations such as problem solving and decision making 

- knowledge: underlying disease process; normal growth and development; normal physiology and psychology; normal assessment findings; health promotion; assessment skills; communication skills 

- standards: ANA scope and standards of nursing; speciality standards of practice' intellectual standards of measurement 

- attitudes: persevereance, fairness, integrity, confidence, creativity

- experience: previous patient care experience, validation of assess,ent findings, observation of assessment techniques

- systematic gathering of info related to physical, mental, spiritual, socioeconomic and cultural status of an individual, group, or community.

- appraisal of pt's current health state, deficits, strengths

-collection of objective/subjective data

- consideration of physical, psychological, emotional, sociocultural, & spiritual

- becomes reference point for all other assessments 

- provides foundation for nursing diagnosis

RN WILL: 

- collect comprehensive data

- include pt, family, and SO as the pt requests 

- identify barriers to appropriate adaptation 

- prioritize data based on real and anticipated events

- use evidence-based tools for data collection 

- synthesize data to identify patterns or variances 

- accurately document the data to share with other HCPs 

- Code of ethics for nurses (ANA)= nurse determine appropriate delegation of tasks 

- CNA, PCT can collect data for the nurse but the nurse must determine what is to be delegated and remains accountable and responsible. 

- can't delegate to unliscenced caregiver

-TCJ: RN must assess pt needs for all nursing care within 24 hrs of inpatient admission, assessment must be written, comprehensive, and used to identify and assign priorities for care, each agency designates timeframes for reassessment 

- subjective info in from client and family 

- objective data- gathered through physical assessment, lab/diagnostic tests 

- primary -subjctive and objective data from client 

- secondary "secondhand" from chart/family member 

- initial: why is client seeking care? collect data

- ongoing: performed as needed, dynamic 

- comprehensive: observation, physical assessment, nursing interview 

- focused: obtain data about an actual, potential or possible prob that has been idenfied/suspected, not on overall health status 

- special needs: in depth focuesed assessment, stemming from specific client needs 

- by other disciplines (collaboration) 

- to plan for nursing care

- to ensure clients receive the proper care by qualified individuals at the time needed 

- health problem is any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness 

- decide how to treat it: independently or collaboratively

-NANDA nursing dianostic: clinical judgement about individual, fam, community responses to actual/potential health probs/life processes. provides basis for selection of nursing interventions 

1. physiological: food, air, water, temp regulation, elimination, rest, physical activity 

2. safety and security: protection, emotional, physical safety and security, order, law, stability, shelter 

3. love and belonging: giving and recieving affection, meaningful relationships, belonging to groups 

4. self esteem: pride, sense of accomplishment, recognition by others 

5. cognitive: knowledge, understanding, exploration 

6. aesthetic: symmetry, order, beauty 

7. self actualization: personal growth, reaching potential 

8. transcendence: of self, helping others self actualize 

- analyze your assessment data 

- using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status 

- includes strengths, problems, and factors contributing to the problems

- derive the diagnosis based on assessment 

- validate diagnosis in a manner that facilitates development of expected outcomes and measure 

- identify actual or potential risks to the patient as well as identify potential barriers to health 

- use standardize classification system, when available in naming diagnosis.

- physiological complications of diseases, medical treatments, of diagnostic studies 

- clients with certain diseases or treatments are at risk for developing the same complications 

- always a potential problem 

- treatment of pain- collaborative problem 

- medical diagnosis: describes disease, illness, or injury: RNs can't legally diagnose (ARNP's can & do) 

  - identify appropriate pathology and determine treatment, monitor for improvement or worsening of condition. order appropriate diagnostic testing. (acute myocardia infarction) 

- nursing diagnosis: statement of client health status that nurses can identify, prevent, or treat independently. treat or prevent a problem, relieve symptoms. (ineffective tissue perfusion) 

- actual 

- risk 

- health promotion 

- what beliefs, values and experiences affect your thinking and may be misleading? 

- are there sterotypes or biases that influence your thinking?

- are you relying heavily on past experience? 

- have you relied heavily on medical diagnosis, the care setting, or what others have said about the pt? 

* make sure you're not making judgements 

- non biased reaction to pt... observe for yourself 

- system for classification based on characteristics the items have in common 

- medications classified by groups: DSM-IV for psychiatric conditions, ICD-10 for disease classification 

- NANDA: north american nursing diagnosis association international : description of health problems treated by nurse 

- diagnositc label-NANDA approved, includes descriptors (impaired, decreased, delayed, ineffective): decreased cardiac output 

- definition: inadequate blood pumped by the heart to meet the metabolic demands of the body 

-defining characteristics: S "fatigue, short of breath, palpitations" O "tachycardia, weight gain, clammy skin)

- related factors/risk factors: identified from data, reason for nursing diagnosis (Etiology): decreased venous return, altered contractility 

- nursing interventions stem from etiology 

- problem: describes client's health status or human response to problem and identifies a response that needs to be changed 

- connecting phrase: related to, as evidenced by 

- etiology: contains factors that cause, contribute to, or create risk for the problem. may include label, defining characteristics, related factors, or other factors 

- ex: Mr. Hart: decreased cardiac output related to impaired contractility as evidenced by shortness of breath

- include both problem and etiology with "cause and effect" stated correctly 

- avoid using medical diagnoses and treatments 

- write the statement clearly/ concisely 

- be descriptive and specific 

- state the problem as a patient response 

- use nonjudgemetal llanguage 

- avoid legally questionable language 

- problem r/t etiology 

- etiology: factor that causes or contributes to the problem, avoid medical diagnosis 

- etiology directs the nursing interventions- if you fix the etiology you fix the problem 

- imbalance body nutrition r/t loss of appetite from nausea 

- two part statement use for actual, risk, and possible diagnosis

- ex: risk for deficient fluid volume r/t excessive nausea and vomitting 

- three part diagnosis: PES format (problem, etiology, symptom) problem r/t etiology AEB signs and symptoms 

- what did you see to believe this problem was real?

- constipation r/t inadequate intake of fluids and fiber AEB painful hard stool every 3 days 

- assess patient/ identify problems/ prioritize problems/ identify desired outcomes/ identify interventions for achieving outcomes/ prioritize interventions/ deliver pt care/ evaluate interventions 

-ANA: RN develops a plan that prescribes stategies and alternatives to attain expected outcome 

- plans have to be realistic, measureable, flexible (change and have to be appropriate) 

-may delegate appropraite pieces to their support staff

-formal planning: conscious, deliberate activity involving decision making, critical thinking, creativity

- informal planning: making mental notes or plans 

- intial: begins with first client contact, writeen as soon as possible after initial assessment, devlopment of the initial comprehensive care plan 

- ongoing: changes made in the plan as you evaluate the client's responses to care 

- if pt can help/ contribute to plan let them have a say 

- long term goals: to be achieved over a longer period of time (week, month, or more) 

short term goals: to be achieved within a few hours or days (less than a week) 

- subject-pt centered 

- singular goal or outcome

- observable 

- measureable- use objective language 

- time-limited target: realistic dates or times negotiated with client 

- mutual factors: patient and nurse agree on goals 

- realistic; NANDA linked NOC 

- independent nursing interventions 

- dependent nursing interventions 

- collaborative interventions 

- NANDA linked NIC 

- consultation 

- planning for self care and continuity of care after client leaves health care setting 

- begins with initial assessment 

- all clients need discharge planning 

- requires collaboration 

- standardized nursing care plans: detailed nursing care for a particular nursing diagnosis 

- for all nursing diagnoses that commonly occur with a certain medical condition 

- outcome-based, interdisciplinary plans that sequence client care based on case type 

- make a working problem list

- decide which problems can be managed with standardized care plans or critical pathways 

- individualize the standardized plan as needed

- transcribe medical orders to approprate documents 

- for each nursing diagnostic: is there at least one goal that when met demonstrates problem resolution? are predicted outcomes adequate to completely address the nursing diagnosis? 

- in each ecpected outcome: stated in positive terms? measurable or observable? given specific and concrete performance criteria? 

- does each goal/outcome include all necessary parts?

- is each outcome/goal realistic and achievable? 

- does it not conflict with the medical or other collaborative treatment plan? 

- purpose: to achieve client outcomes 

- also called nursing acitons, measures, strategies, activities

- based on clinical judgment and nursing knowledge 

- reflect direct and indirect care 

- use clinical practice guidelines, standing orders, NIC interventions, standards of practice 

1. review the nursing diagnostic 

2. review the desired client outcomes 

3. identify several interventions/actions 

4. choose the best interventions for this client 

5. individualize the standardized interventions 

- standard 5

- the registered nurse implements the identified plan

- standard 5A- the RN coordinates the care delivery 

-standard 6: the RN utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible 

-reassess patient 

- review and revise care plan 

- organize resources and care delivery 

- equipment, personnel, environment, patient 

-anticipate and prevent complications 

- implementation skills: cognitive, interpersonal, psychomotor 

- transferring responsibility while retaining accountability 

- includes supervision, responsibility, and accountability 

- you cannot delegate: any intervention that requires independent, specialized, nursing knowledge, skill or judgement: assessment

-you may delegate the collection of data 

-explain exactly what task you want done and how

- provide specific times and methods for reporting the event to the RN: when do you want the feedback 

- explain the purpose or objective of task- what outcome are we anticipating and waht potential risks should be cautious of... be specific 

1. right task 

2. right circumstance 

3. right person 

4. right direction/communication 

5. right supervision: monitor, intervene if necessary, obtain and provide feedback, evaluate client outcomes, ensuring proper documentation by all members of the team 

- activities of daily living (ADLs) 

- instrumental activities of daily living (IADLs)

- physical care techniques

- lifesaving measures 

- counseling 

- teaching

- controlling for adverse reactions 

- preventative measures 

- communicating nursing interventions 

- delegating, supervising and evaluating others 

- ex: documentation, infection control, environmental safety, telephone consultations, change of shift report 

- the final step of the nursing process

- evaluate client's progress toward goals, effectiveness of nursing care plan, quality of care in health care setting 

- standard 6: registered nurse evaluates progress towards attainment of outcomes 

- conducts a systematic, ongoing, criterion based evaluation

- collaborates with other members of the health care team 

- documents the care and the outcomes (*if you don't document it didn't happen)

- ANA standards include a set of critera to help describe the standard 

- criteria: measureable characteristics, properties, attributes, or qualities 

- reliable 

- valid 

- structure: the setting, staffing

- process: manner in which care was provided, appropriateness, completeness, timeliness 

- outcomes: how did it effect the patient and the problem?

-ongoing: happening immidiately with contact with pt, within 30 min of delivering pain meds you need to make sure it works and evaluate

-intermittent: at specific times, ex: every 4 hours

-terminal: at the end of relationship with pt, leaving shift or discharge 

- review outcomes 

- collect reassessment data 

- judge goal achievement 

- record the evaluative statement 

- evaluate collaborative problems 

- relate outcome to interventions 

- draw conclusions about problem status 

- revise the care plan 

- checklist: review assessment, review diagnosis, review planning outcomes, review planning interventions, review implementation 

- failing to evaluate systematically 

- failing to record results 

- failing to use reassessment data to reexamine and modify the care plan 

- quality assurance (QA) goal: to evaluate and improve care provided in the health care setting 

- QA involves evaluation of structures, outcomes, and processes 

- IOM recommended 2700 mL for women 

- 3700 mL for men 

- engaging in moderate activity and moderate temps 

- 8-10 glasses per day = 1920- 2400 mL per day 

- 80% of fluid comes from drinking 

- 20% from food 

- thirst is major regulator 

-age

- environment: heat/humidity 

- dietary intake: potassium intake needed 

- lifestyle: substance abusers 

- medications: diuretics, prone to fluid/ectrolyte imbalance

- PMH: surgery, GI output, acute illness or traume, chronic illness 

-physical assessment: skin, mucous membranes, CV system, repiratory system, neurological system 

-VS: temp (high temp sweat), pulse (quality, bounding, threading), RR, BP 

-daily weight is best way to indicate fluid status 

- tracking I&O is nursing interveniton 

- sensible loss: urine, feces, gastric drainage

- insensible loss: not measured, usually be diffusion and evaporation through skin, lungs (usually about 900 mL per day, increases in open wounds, burns, or other breaks in the skin, increases in hypermetabolic states- fever) 

- labs

- CBC: complete blood count: hematocrit/hemaglobin 

- electrolytes

- serum/urine osmolality 

- UA

- ABG's 

- structural changes in kidneys decrease ability to conserve water 

- hormonal changes lead to decrease in ADH and ANP 

- reduced thirst mechanism results in decreased fluid intake 

- nurse must assess for these changes and implement treatment accordingly 

- decreased cardiac output 

- acute confusion 

- risk for electrolyte imbalance 

- deficient fluid volume 

- excess fluid volume- renal pt  

- impaired gas exchange 

- impaired skin integrity 

- ineffective tissue perfusion 

- goal: "the patient will achieve normal hydration status at discharge" 

- outcomes: balanced I/Os 

- serum electrolytes WNL 

- enternal replacement of fluid and electrolytes 

- oral/feeding tube 

- restriction of fluids: NPO except meds, restrict in evening, oral care 

-parenteral replacement of fluid/electrolyte: isotonic, hypotonic, hypertonic 

- purposes

1. maintanance: when oral intake is not adequate 

2. replacement: when losses have occured 

-isotonic: expands only in ECF,

-no net loss/gain from ICF

-hypotension/hypovolemia

-CHF risk.

-normal saline .9%

-expands IV volume- preferred fluid for immediate response/risk for fluid overload higher 

- does not change ICF volume 

- blood products 

- compatible with most mediacations 

-lactated ringer's (caution with liver failure pts)

- more similar to plasma than NS: has less NaCl, has K, Ca, phosphate, lactate

- expands ECF

- more water than electrolytes 

- pure water lyses RBCs

- water moves from ECF to ICF by osmosis 

- usually maintenance fluids 

-D5W

- isotonic in bag only, 170 cal/L

- free water moves into ICF

- increases renal solute excretion

- used o replace water losses and treat hyponatremia 

-does not provide electrolytes 

-.45 saline (1/2 NS)

- osmo higherr than serum 

- initially expands and raises the osmolality of ECF

- require frequent monitoring of BP, lung sounds, serum sodium levels 

-D5 NS, D5 .45% NS, D 50% 

- common maintenance fluid 

- KCl added for maintenance or replacement 

- if injected too rapidly will enter brain= intercranial swelling= BAD

- stay in vascular space and increase osmotic pressure 

- colloids (protein solutions)

- packed RBCs 

- albumin 

- plasma 

- treat underlying cause 

- if oral fluids cannot be ingested, IV solution of 5% dextrose in water or hypotonic saline 

- diuretics

- serum sodium levels must be reduced gradually to avoid cerebral edema 

- caused by water excess 

- fluid restriction if needed 

- severe symptoms (seizures)- give small amount of IV hypertonic saline solution (3% NaCl)

- abnormal fluid loss- fluid replacement with sodium containing solution 

- eliminate oral and parenteral K intake 

- increase elimination of K (diuretics, dialysis, kayexalate)

- severe levels: force K from ECF to ICF by IV insulin or sodium bicarbonate, revere membrane effects of elevated ECF potassium by administering clacium gluconate IV 

- KCl supplements orally or IV

- should not exceed 10 to 20 mEq/hr to prevent hyper or cardiac arrest 

- never give potassium too quickly or heart will stop 

hypercalcemia nursing management /

hypocalcemia nursing managemnt 

-excretion of Ca with loop diuretic

- hydration with isotonic saline infusion 

- sythetic calitonin 

- mobilization 

-hypo: treat cause, oral or IV calcium supplements (not IM to avoid local reactions), daily/monthly 

hypermagnesemia nursing management /

hypomagnesemia 

- prevention 

- emergency treatment: IV CaCl or calcium gluconate 

- fluids to promote urinary excretion 

-hypo: oral supplements, increase dietary intake, parenteral IV or IM mg when severe 

(not eating correctly or typically alcoholics)

hyperphosphatemia managment /

hypophosphatemia

- identify and treat underlying cause 

- restrict foods and fluids containing phosphate 

- adequate hydration and correction of hypocalcemic conditions 

- mostly pts with renal disease, not evry common 

-hypo: oral supplementation, ingestion of foods high in phosphate, slow IV administration of sodium or potassium phosphate 

- which one to use?: length of treatment, type of fluid infused, gauge

- over the needle

- inside the needle 

- butterfly needle 

- PIV lock 

- midline peripheral cetheter 

- PICC: can go home with, months at a time, tip has to end in vena cava 
- nontunneled CVC

- tunneled CVC

- implantable ports

- intraosseous  

- advantages: fluid type, monitoring, access, length of use, nutrition 

- disadvantages: training, consent, XRAY verification, risks of complications, training, consent

- IV catheter 

- administration set (infusion kit) 

- solutions 

- IV site choice 

- venipuncture 

- height of solution 

- client position 

- blood pressure

- IV cath diameter

- condition of catheter and tubing 

- gravity flow 

- volume control set 

- infusion pump 

- review steps for changing gown with IV, pg 909 

- for showeing, protect IV site and dressing from getting wet by covering completley in plastic 

- infiltration, extravasation (vesicant substance will burn and breakdown tissue around it.. causing sluffing/necrosis of tissue), phlebitis (inflammation of the vein), lcoal infection, bleeding 

- change IV solutions (every 24 hrs)

- changing administration sets  (tubing every 72 hours)

- changing IV dressings (every 72-96 hrs, includes site)

- converting to PIV 

- D/c IV line 

- indications: O2, blood loss, deficiency in blood component 

- HgB <7 or 8 with active bleed/symtomatic 

- 4 major blood groups determined by the presence or absence of 2 antigens- A and B on the surface of RBCs

- group A: only the A antigen on RBCs (b in plasma)

- group B: has only B antigen on RBCs (A antibody in plasma) 

- group AB: has both A & B antigens on red cells (neither A nor B antibody in the plasma) 

- group O: has neither A nor B antigens on red cells (but both A and B antibody are in the plasma ) 

- Rh factor 

- ABO & Rh tested 

- screening for infection 

- crossmatching 

-autologous transfusion 

- universal recipient is AB

- universal donor is O 

- whole blood 

- red blood cells 

- plasma 

- platelets

- white blood cells 

- plasma derivities 

- verify prescription 

- obtain VS: premedicate

- ID patient 

- site of transfusion, size of catheter (lowest gauge=20)- most common is 18 

- two RN/MD verification 

- VS Q 15 X 2, then 30 min, then 1 hour, then post infusion 

- allergic-allergy to blood: flushing, itching, urticaria, ANAPHYLAXIS

- bacterial-contamination of blood: fever, chills, vomitting, diarrhea 

- febrile-sensitivity to WBCs, plasma proteins: fever, chills, warm flushed skin, aches 

- hemolytic reactions-RBC breakdown due to incompatible blood: fever, chills, dyspnea, chest/back pain, tachycardia, HYPOTENSION

- citculatory overload-too much or too rapid infusion: cough, crackles, HTN, distended neck veins 

- stop transfusion 

- replace with saline infusion

- notify healthcare provider 

- IF HEMOLYTIC: send tubing, blood, sample of blood and urine from pt to lab 

-prepare to call a CODE/CPR/MEDS 

- physical signs and symptoms disappear

- normalization of labs 

- modification of plan as needed