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NURS 100 FINAL REVIEW
Infection:
•

Stages of infection:
o Incubation: interval between pathogen entering body and first s/s
o Prodromal: interval from onset of general s/s to more distinct ones (pathogen is
multiplying)
o Illness: symptoms specific to infection
o Convalescence: interval when acute symptoms disappear
...
Acquired within 72 hours of
hospital admission
...
surgical asepsis:
o Medical = clean (NG management, personal hygiene)
o Surgical-sterile = removal of all microorganisms

•

Infection process:
Causative agent (bacteria virus, fungus) à reservoir (human animal water) à portal of exit
from host (respiratory tract, GI, GU, Skin, body fluids) à Mode of transportation (contact—
direct or indirect, droplet, airborne, vector) à portal of entry to host à susceptible host
(immunocompormised, children, older adults, post-op)

•

Immune defense: body restricts entry to foreign organisms (antigens)
...

o Specific adaptive immunity allows body to make antibodies in response to antigens
...
Produces specific antibodies to protect against
specific antigens
...

o Requires N95 mask and negative air pressure room
...

o Think SSPIDERMMAN! Sepsis Scarlet fever, Strep, Pneumonia, Pertussis,
Influenza, Diphtheria, Epiglottitis, Rubella, Mumps, Meningitis, ANenovirus)

•

Contact Precautions
o Requires Private room, Gloves and Gown

o Think MRS
...
difficile), Eye infection
(conjunctivitis))
Skin/Pressure Ulcers/Wounds:
•

Causes of skin breakdown: pressure, moisture, diabetic, neuropathy, edema, elderly and very
young (thin skin)

•

Pressure Ulcer: unrelieved pressureà ischemiaàdamage to underlying tissue
...
Edema, partially
infected, pain
o Stage 3: full thickness tissue loss with damage or necrosis to subQ tissue
...
Drainage
...

o The proliferative stage: replaces lost tissue with CT or granulated tissue,
contracts the wound’s edges and resurfaces new epithelial cells
...

o Wound healing: is affected by age, skin turgor and fragility, decrease
circulation and oxygenation, decreased nutrients or collagen, impaired
immune system, medications, nutrition, tissue perfusion, obesity, chronic
diseases or stress, smoking
•

Assess drainage and amount: purulent (yellow, pus, slough, infected), black (eschar,
necrotic), serous (watery/clear), sanguinous (red/RBC), serosanguinous (serum and
blood)

•
•

Dehiscence: partial or total rupture/separation of sutured wound
Evisceration: is a dehiscence that involves protrusion of visceral organs through a
wound opening=Emergency!

•

Wound prevention: adequate fluid/nutrition, repositioning every 2 hours, inspection
frequently, clean dry skin, bathe with tepid water, barrier cream, relieve pressure
(pillows/positioning), lift don’t pull, raise heels, ambulate, active and passive
exercise, hydration, if patient has edema give diuretic or Albumin: pulls fluid from

interstitial space to vascular space (used for edema) or raise extremities
...

Physical Assessment:
•
•

Inspectàauscultateàpalpateàpercuss
Vitals: (TPRBOP=Temp, Pulse, Respirations, Blood pressure, O2 saturation, Pain): establish
baseline to be able to assess treatment
o Temp: neuro+cardio regulate body temp
...
36-38 deg C/ 96
...
4 deg F
...

o Slow = bradycardia, fast = tachycardia
...

o Rate the strength: (amplitude) between 0 (absent), 1(diminished/weak), 2+
(brisk/expected), 3+ (increased/strong), 4+ (full volume/bounding)
...

o Ventilation: exchange of O2 and CO2 in lungs
o Diffusion: exchange of O and CO2 between alveoli and RBCs
o Perfusion: flow of blood to and from pulmonary capillaries

•

Pulse Ox:
SaO2: 95-100%
...
Systolic is max pressure exerted on arteries and diastolic is
minimum (when ventricles are relaxed)
...

Communication:
•

Verbal, nonverbal, provides collaborative care, used on pts and families and coworkers,
provides info

•

Therapeutic communication:
o Referent: incentive/motivation for communication to occur
o Use to elicit thoughts, obtain info, express empathy evaluate
...
Be honest, attentive (active listening), eye contact

(culturally sensitive), caring, establish trust, empathetic, nonjudgmental and use
silence, open ended questions, clarifying techniques, offer leads, show acceptance,
focusing, giving info, summarize, be realistic, offer self and use touch
...

Role Ambiguity: uncertainty about what is expected when assuming role
Death/Dying:
•
•

Grief: denialàangeràbargainingàdepressionàacceptance
Disenfranchised grief – entails an experienced loss that cannot be publicaly shared or is not
socially acceptable such as suicide SUICIDES ABORTION

•

Palliative care: Prevention, relief, reduction, or soothing of symptoms, care of dying,
achieves best possible quality of life

•

Hospice: comprehensive care delivery system implemented when a client is not expected to
live longer than 6 months
...
Enhance quality of
life and provide peace, support, dignity, and comfort
...
and family
...


•

Dim the lights and minimize noise

Sleep:
•

Sleep Cycle:
o Stage 1 NREM: light sleep, few minutes
o Stage 2: NREM: deeper sleep, 10-20 min, vitals decrease
o Stage 3: NREM: deepest sleep, 15-30 min difficult to awaken
o REM: vivid dreams, 90 min after falling asleep, longer with each cycle
o Help sleep by: decreasing caffeine, exercise, decrease stress/anxiety, meds, establish
bedtime routine, limit fluids, soothing music, medications that promote circadian
rhythm (melatonin, tea)
o In hospital setting: it is hard for patient to get adequate sleep with all the sounds,
lights, pain, fear, and constant checkups

Developmental stages of sleep: neonates need 16 hours of sleep but sleep decreases
throughout lifespan
...
If correct, it reduces strain and without it, there is
risk for injury or falls

•

Immobility: affects
o Integumentary: ischemiaà pressure ulcer
o Respiratory: weakened musclesàatelectasis, pneumonia, decreased cough response
o Cardio: orthostatic hypotension, less volume, stasis of blood in legs, decreased CO,
increased O requirement, risk for thrombus
o Metabolic: decreased metabolism and appetite and protein and urinary output, weight
loss,
o Elimination: urinary stasis, decrease fluid intake, decreased peristalsis
o Musculoskeletal: decreased endurance, strength and mass, atrophy, decreased
stability, osteoporosis, food drop, contractures
...

Pain Tolerance: amount of pain pt can bear
...

Adjuvant analgesics enhance the effects of nonopioids
PCA: Patient Controlled Analgesic
...

Before discharge, wean pt off PCA and begin oral analgesic
...
Be prepared to administer narcan (antidote)

Bowel:
o Mouthàesophagusàstomachàsmall intestineàlarge intestineàanus
o Affected by age (older adults have decreased peristalsis=constipation), diet (fiber),
fluid, physical activity, psychosocial factors (emotional distress), personal habits,
positioning, pain, pregnancy, surgery/anesthesia (paralytic ileus, slowed intestinal
activity), medications (laxatives soften, cathartics promote peristalsis, antidiarrheal,
fiber supplements)
...

o End Stoma: from colorectal cancer or bowel disease

o Loop colostomy: medical emergency, temporary
o Double barrel: 2 stomas (1 proximal, 1 distal)
o Enemas instill solution into rectum to promote defecation and stimulate peristalsis
and soften stool
...

o Polyuria: excessive urine output
o Oliguria: decreased urine output
o Anuria: no urine production
o Dysuria: pain or burning during urination
o Kidneys should put out 30mL/hour
...

o Decrease urine output in normal kidney function may result from BPH (Benign
Prostatic Hypertrophy—prostate occludes urethethra), Third Spacing (fluid moves
from cellular to vascular to contribute to equilibrium), anesthesia (slows all
processes),
o An elevation in BUN but not creatinine means hypovolemia (less fluid=more
concentration)
...

o Full bladder control by 4-5 yrs old
o Assess: intake vs
...

o Pregnancy, enlarged prostate push on bladder, diet (high sodium-less urine, alcohol
and caffeine = more, immobility (incontinence), psychosocial (stress anxiety), pain,
surgery (anesthesia decreases urine output), medications (diuretics prevent
reabsorption of h2O, antihistamines and anticholinergics cause urinary retention,
some meds change color)
o Incontinence:
o Stress: laugh, sneeze, lift=weak pelvic muscles

o Urge: inability to stop urine flow—overactive detrusor muscle
o Reflex: involuntary loss of moderate amount without warning
o Overflow: involuntary loss of urine at intervals without sensation of urge to
void
...
non-meaningful, amount,
social interaction, mental status, environmental & cultural factors
o Hearing impaired: face client, use hearing devices, rephrase don’t repeat, don’t
shout, slow and clear, lower pitch before increasing volume, minimize background
noise
...

o Presbyopia: inability to focus on close objects
o Cataract: opaque lens
o Glaucoma: loss of peripheral vision
o Macular degeneration: loss of central vision
o Aphasia: greet by name, speak clear and slow, no shouting, pause between
statements, check for understanding, simple answers, nonverbal communication

•

Pharmacokinetics: how meds travel through the body
o Absorption: transmission of meds from location of administration into bloodstream
...
Influenced by
circulation, permeability of cell membrane, and plasma protein binding
o Metabolism/biotransformation: changes meds into less active forms by action of
enzymes (happens in liver, kidneys, lungs, bowel and blood)
...
Physical exam to provide baseline
o 7 Rights of medication administration:
o Right Patient: ID badge, 2 identifiers (Name & DOB), family, check
belongings (ID
o Right Drug: check MAR (Medication Administration Report), description on
package
...

Double check for children or elderly—dosed by weight! Calculate
o Right Documentation: everything you give, you do, time, lot number,
location, patient response
...
Pt refusal
...
orders
...
Do Not crush coated tablets
or non-scored tablet if pt can’t swallow
o Right time: depends upon last dose, ask pt or check chart, re-assess pt for pain
first and check order to see how many times per day
...

o Arterial insufficiency: tingling, poor oxygenation to extremities (pale), numb, no
capillary refill, pulseless, bad hair growth
o Venous insufficiency: edema/pooling, warmth
o Normal Sinus Rhythm: PQRST in EKG (P = atrial contraction, QRS = contraction
of ventricle, T = relaxation and filling of ventricle)
o COPD patients: start them at 2 L of oxygen
o Begin O therapy at lowest level, assess hypercarbia (increased CO2), oral hygiene,
turn and cough, deep breath, IS, suctioning
o Nasal Cannula: 24-44% at flow rate of 1-6 L/min
...

o Positive cations (Mg, K, Na, Ca)
o Negative Anions (Phosphate, Sulfate, chloride and bicarbonate) in water
...

o ADH: regulates water excretion from kidneys (acts on renal tubules)
o PTH: regulates calcium and phosphate balance by influencing bone re-absorption
...
60% of body weight
o Third spacing: tissue flows into tissues (edema, abdomen distention)
...

o Malnourished children have distended abdomen because they lack protein to keep
fluid in their cells so it escapes into the tissues = Ascites
o Isotonic: same solute concentration as our plasma (0
...
NS injected in vein stays in the vascular space since it
is the same concentration as our plasma—it is used to help hypOvolemia or
dehydration and increase volume
...
9% (D5W, D10W = 10% dextrose in water, D5 ½
NS = 5% dextrose in water and one half saline, TPN)
...
Fluid shifts OUT of cell
INTO vascular system
...
9% = 0
...
225% = ¼ NS) when
delivered into vein will cause fluid to move into cell
...
has water loss but still have fluid so you want to give them fluid but
no sodium)
...
(cell swells)
...
hypOtonic solution)
o <0
...
45% NS)
o 0
...
9% = HypERtonic: fluid moves INTO bloodstream, cells shrink (3%
saline, D5NS)
o HypERvolemia: too much fluid: retention of water and Na
...
Marked by edema, SOB, high blood
pressure, fluid in lungs/adventitious lung sounds, distended neck vein (JVD = Jugular
Vein Distension), weight gain (1lb=500ml fluid), skin turgor, I&O measurement
(should be even), tachycardic, polyuria (if kidney is functioning), wide pulse pressure
(difference between systolic and diastolic is >40 mmHg), bounding pulse
o Interventions: check Na and K and then give diuretic, restrict fluids and
sodium, sit them up to semi-fowlers, give incentive spirometer to clear lungs,
suction to remove lung secretions, if they have renal failure give dialysis,
check albumin—if it is low then fluid is seeping out of cells and into
interstitial space,
o Compensatory mechanism: increased release of natriuretic peptides resulting
in increased excretion of Na and H2O and decreased release of aldosterone
...
Tachycardia, hypotension,
tachypnea, hypoxia, syncope, weak, oliguria, diaphoresis, increased specific gravity,
weak thready pulse, weight loss, skin turgor is slow to rebound, dry mucous
membrane, increased temperature, dizzy/lethargic, output decrease
...

Can lead to hypovolemic shock
o Sodium Imbalance: found in ECF: expected value =135-145mEq/L
o HypOnatremia: less than 135, gain of water, loss of Na, water moves from
ECF à ICF causing cell SWELLING
...
Hyperthermia, tachycardia, hypotension, twitching, weakness,
thirst, edema, warm flushed skin, oliguria,
o Potassium Imbalance: major cation of ICF
...
Expected Value =
3
...
5
...

Hyperthermia, hypotension, muscle weakness, respiratory distress,
bradycardia, hypoactive bowel, polyuria
o HypERkalemia: greater than 5, movement of K OUT of the cell
...
5-10
...
Important for cardio, neuro, and endocrine
functioning and blood clotting
...
5
...
5
...
5-2
...
5 Muscle paralysis, bradycardia,
hypotension
...
5 – 4
...
35 à 7
...
Check pH and determine if it is alkaline or acidic
o 2
...
Check HCO3 (bicarbonate = base): the higher it gets the more basic, the lower =
acidic
o Respiratory
Opposite
saME = MEtabolic
Metabolic
REverse = REspiratory
Equal
EX: pH = 7
...
3, CO2 = 50, HCO3 = 30 (all out of range but go by whichever value
matches the pH (acidic or basic—in this case it’s the CO2)
...

o *If both are out of range, pick the value that matches the pH
...
3, CO2 = 43, HCO3 = 20: Metabolic Acidosis
o EX: pH = 7
...
5, CO2 = 40, HCO3 = 35: Respiratory Alkalosis (with partial
compensation)
o
o
o
o
o

o Respiratory acidosis: hypoventilation (COPD, obstruction, shallow breath)
o Respiratory acidosis: respiratory arrest, intubate the patient if high CO2
o Respiratory Alkalosis: HypERventilation: kidneys will compensate by holding back
bicarbonate to decrease pH
...
Lungs Compensate by breathing quickly to eliminate more acid
(CO2)
Metabolic Acidosis compensation = hyperventilation
Low HCO3 low pH
Decreased level of consciousness, increased respiration
o Metabolic Alkalosis: vomiting, prolong NG suction (pulls out too much acid),
cushing syndrome, diuretics, respiratory compensates by decreasing respirations
...
secretions from airways by coughing or nonproductive coughing

•

Complication: hypoxia, injury to airway, nosocomial infections, cardiac dysrhythmia

R
...
Sided heart failure
•

Decreased functioning of the L
...
ventricle per min

•

Normal: 4-6 litters per min

•

Stroke volume x heart rate = cardiac output

Stroke volume
•

The amount of blood ejected from L
...
Monosaccharides, polysaccharides
§

Protein: made of amino acids, provides energy and essential for synthesis of body tissue
in growth, maintenance, and repair
...
Ex: ground beef, poultry, whole milk
o Fats: lipids, most calorie-dense nutrient: 9 kcal/g
...

o If pt cannot digest any foodà TPN (Total Parenteral Nutrition)
o if pt has NG tube, provide oral care often, verify placement often
...
Check blood glucose and output
...
Use 10x1hr
Common dosage administration abbreviations
•
•
•
•
•
•
•
•

a
...
= before meals
b
...
d = two times a day
h
...
= bedtime
p
...
= after meals
prn = as needed
qd = everyday
q
...
d = 4 times a day
t
...
d = three times a day

•

PO: by mouth

•

PR: per rectum

•

PRN: as needed

•

NPO: not by mouth

•

Q: every

•

NG- crush and flush

•

15-30mL before and after

The nursing process
• Assess – O2 sat of 95%

•
•
•
•

Diagnosis – Fluid overload
Planning – to give oxygen
Implementation – give O2
Evaluation – Goals met

Therapeutic communication
•

Purposeful use of communication to build and maintain helping relationships with clients,
families, and significant others
...


Indwelling catheters
•

Short-term: obstruction to urine outflow, surgical repair of bladder, sutures

•

Long-term: ulcers, severe urinary retention due to UTI

•

Position: Males (supine w/ thighs abducted) Female (dorsal recumbent)

Urinary tract infection and nursing process including teaching
UTI QUESTIONS
•
•

Common cause is e
...

Factors that increase risk of UTI
o Close proximity of urethra and anus
o Frequent sexual intercourse
o Uncircumcised males
o Use of indwelling catheters

•

A FEW

Implications
o Cleanse females from front to back
o Cleanse foreskin in male
o Provide catheter care regularly

Types of urinary incontinence and difference between and interventions for
•

Stress – the loss of small amounts of urine when laughing, d/t weak pelvic muscles,
urethra, or surrounding tissues

•

Urge - the inability to stop urine flow long enough to reach bathroom d/t overactive
detrusor muscle with increased bladder pressure

•

Overflow – urinary retention from bladder over distention and frequent loss of small
amounts of urine d/t obstruction of the urinary outlet or impaired detrusor muscle

•

Reflex - involuntary loss of moderate amount of urine usually without warning d/t
hyperreflexia of detrusor muscle

•

Functional – inability to get to bathroom to urinate d/t physical, cognitive, or social
impairment

•

Total – unpredictable, involuntary loss of urine that doesn’t respond to treatment

Pneumothorax
•

Collection of air in the pleural space

•

Causes: chest trauma surgery, insertion of IV line

Hemothorax
•

Accumulation of blood and fluid in the pleural cavity between parietal and visceral
pleura
...

Promotes lung expansion, treats pneumothorax or hemothorax
...
non-traditional
•
•

Western medicine - allopathic therapies
Non-traditional – holistic, naturalistic, herbalistic

MEDS:
•
•
•
•
•
•
•
•

Lioresal & Dantrium: muscle relaxer
Celebrex, aspirin, ibuprofen, Motrin: NSAID
Stadol, Talwin: Opioid agonist
Narcan: opioid antagonist
Deltasone: glucocorticoid
Restoril & ambien: therapy for insomnia
Metamucil: fiber suppleent
Colace, docusate sodium, Senna Peri-Colace: stool softener

•
•
•
•
•
•

Dulcolax: laxative
Lomotil and Imodium: drug therapy for diarrhea
Zofran, Compazine: nausea
Dramamine, Reglan: antihistamine
Ditropan: anticholinergic = therapy for incontinence/over-active bladder
Urecholine: cholinergic = therapy for urinary retention

Post-traumatic stress disorder
•

Person experiences/witnesses or is connected w/ traumatic events and responds w/ fear or
helplessness
...


•

Acculturation: occurs when a client is living in a new dominant culture and adopts those
patterns of behaviors
...


•

Durable power of attorney: designates a health care proxy, who can make health care
decisions for a client who is unable
...


Identity, body image,
•

Identity: internal sense of individuality, wholeness, and consistency of self

•

Body image: physical appearance

Roles
•

Role performance: way in which individual perceives their ability to carry out significant
roles

•

Role overload: more roles than are manageable

•

Role conflict: assuming two or more roles that are inconsistent, contradictory, or
mutually exclusive

•

Role strain: frustration when a person feel inadequate for assuming a role

SBAR, HIPAA, Kardex, Clinical Pathway
•

SBAR: (situation, background, assessment, recommendation) shortened reports

•

HIPAA: health insurance portability & accountability act
...


•

Kardex: filling system that allows quick references to the needs of pt
...
Tools are based on cost and length of stay parameters mandated by prospective
payment systems such as Medicare and insurance companies
...
It may result
from various causes
...
Then
change to sitting or standing, wait 1-3 min and reassess BP and HR
...


•

Originates w/ SA node (pacemaker)àAV nodeàbundle of his/purkinjie fibers

•

P: electrical conduction through both atria
...
12-0
...
06-0
...
ventricle pulmonic valveàlungs
(oxygenated)àL
...


Life-threatening rhythms that require immediate intervention
•

Ventricular tachycardia: caused by decreased cardiac output &7 potential to deteriorate
into ventricular fibrillation or sudden cardiac death

Autonomic nervous system

•

Involuntary

•

Sympathetic: increased rate of impulse (fight or flight)

•

Parasympathetic: decreased rate & innervates atria, ventricles, SA/AV noes (rest &
digest)
Complications of inactivity/bed rest
•

Integumentary: pressure ulcers, decreased circulation leading to ischemia

•

Respiratory: decreased oxygenation & CO2 exchange, stasis of secretions, weakened
resp
...
It measures pulse
saturation (SpO2) via wave of infrared light that measures light absorption by oxygenated
and deoxygenated hemoglobin in arterial blood
...


•
•

Reference range = 95 – 100%
Additional reasons for low readings: hypothermia, poor peripheral blood flow, too much
sun, low hemoglobin levels, movement, edema, nail polish

•

Intervention for readings below 90%
o Confirm probe placement
o Confirm that the oxygen delivery system is functioning and the pt is receiving
prescribed o2 levels

o Place in semi- fowlers to promote chest expansion and maximize ventilation
o Encourage deep breathing
Jugular vein distention
•

When pt
...
w/ heart disease

Right sided heart failure
Idiosyncratic, allergic, adverse vs

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