Stephanie Talbot 1 NSG 126:FINAL EXAM REVIEW GUIDE I. II.

The NSG process is a systematic way of planning and providing client care. It consists of 5 phases: assessment, diagnosis, planning, implementation, and evaluation. CHARACTERISTICS OF THE NSG PROCESS: i. The nsg process is a rational and systematic way of planning and providing client care. characteristics: 1. Cyclical and dynamic---each phase feeds into the other 2. Client centered---ns organizes plan of care according to client problems 3. Focus on problem solving and decision making 4. Interpersonal and collaborative 5. Universally applicable 6. Employs critical thinking to carry out the nsg process 7. Systematic 8. Provides for the individualization of care 9. Systematic and rational uses research to make decisions for implementation STEPS TO THE NURSING PROCESS AND ACTIVITIES: II. ASSESSMENT: the systematic collection, organization, validation and documentation of data. Purpose: 1. To establish a database about the clients response to health concerns or illness. 1. ACTIVITIES: a. Establish a database: obtain nsg health hx, physical assessment, rev client records, rev. Nsg literature, consult appropriate support persons, consult other HCP b. Organize data c. Validate data d. Document data III. DIAGNOSIS: the process of analyzing data, identifying health problems, risks and strengths as well as formulating diagnostic statements. Purpose: 1. To i.d client strengths and health problems that can be prevented or resolved 2. to develop a list of nsg and collaborative problems. 1. ACTIVITIES: a. Interpret and analyze data: compare data against standards, cluster/group data, i.d gaps and inconsistencies b. Determine client strengths, risks,, problems and diagnosis c. Formulate nsg diagnosis and collaborative problem statements d. Document nsg diagnosis in care plan IV. PLANNING: the process of prioritizing problems/diagnosis, formulating goals/desired outcomes, selecting nsg interventions as well as writing nsg interventions. PURPOSE: 1. To develop an individualized care plan that specifies client goals/desired outcomes as well as and relate nsg interventions. 1. ACTIVITIES: a. Set priorities and goals/outcomes in collaboration with client b. Write goal/desired outcomes c. Select nsg intervention

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Stephanie Talbot 2 NSG 126:FINAL EXAM REVIEW GUIDE d. Consult with other HCP e. Write interventions and care plan f. Communicate the plan to relevant HCP IMPLEMENTATION: the process of carrying out and documenting the planned nsg interventions: PURPOSE: 1. To assist the client to meet desired goals/outcomes 2. Promote wellness 3. Prevent illness and dx 4. Restore health 5. Facilitate coping with altered fxn 1. ACTIVITIES: a. Reassess client to update database b. Determine ns need for assistance c. Perform planned nsg interventions d. Communicate what nsg actions were implemented e. Document care and client response to care f. Give verbal reports as necessary EVALUATION: measuring the degree to which the goals/outcomes have been achieved and identify factors that +ivlely/-ivley influence goal achievement. PURPOSE: 1. To determine whether to continue, modify or terminate the plan of care. 1. ACTIVITIES: a. collects data related to the desired outcomes b. compares that data to the desired outcomes in order to judge whether the goals/outcomes have been achieved c. relates nsg activities to the clients outcomes d. draws conclusions about the problems status e. critiques each step of the nsg process f. decides whether to modify, continue, or terminate the care plan g. documents achievements of outcomes and makes modifications

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Stephanie Talbot 3 NSG 126:FINAL EXAM REVIEW GUIDE VII. CLASSIFICATION OF CARBOHYDRATES: a. Carbohydrates are classified as SIMPLE or COMPLEX: i. Simple Carbohydrates consist of: 1. Monosaccharides- simplest sugars containing only one sugar molecule. They are absorbed as is. The three types: a. Glucose(dextrose)- the body s fuel sugar b. Fructose fruit and honey sugar c. Galactose2. Disaccharides- composed of 2 monosaccharide s, with one being glucose. They are split into their components before being absorbed by the body. There are three types: a. Sucrose- glucose + fructose a.k.a table sugar b. Maltose- glucose + glucose not found in foods c. Lactose- milk sugar, glucose and galactose ii. Complex Carbohydrates: 1. Are polysaccharides. Consists of: a. Starch- stored in plants b. Glycogen- animal version of starch- it is stored carbohydrates available for energy. Humans store glycogen in the liver and muscles (but only in small amts) c. Fibre- mix of non-digestible polysaccharides that are part of the plant cell wall. Can be soluble ex. Gums, pectin s and mucilage s like apples, barley, dried beans & peas, fruits, vegetables, oatmeal, oat bran etc; or it can be insoluble ex. Cellulose, hemicelluloses and ligans like wheat bran, whole grains, dried beans & peas and vegetables etc. i. Fxn fibre= increase stool weight b. The Functions of Carbohydrates: i. Glucose metabolism- which provides energy for the body cells ii. Brain totally dependent on glucose for energy iii. Carbs provide 4 cal/g iv. Help protein sparing by using carbs instead of protein for energy, thus allowing it to be used for other functions: 1. Protein sparing protein supply s 4cal/g. FXN= replenish enzymes, hormones, antibodies and blood cells v. Use of carbs for energy prevents ketosis because glucose fragments are needed in order for fat to be burned completely for energy. Need minimum of 50-100g of carbohydrates daily to prevent ketosis vi. Carbs assist in the making of amino acids, specific body compounds and are also converted to fat for storage. c. Sources of carbohydrates: grains, vegetables, fruits, milk, meat and beans i. Natural and added sugars, Starch, Fibre

Stephanie Talbot 4 NSG 126:FINAL EXAM REVIEW GUIDE II. PROTEINS: a. Are the large molecules composed of one or more long amino acid chains. The a.a is the building block of proteins. b. FXNS of PROTEINS: i. Body structure and framework- 50% of protein is in skeletal muscle and 15% is in the skin and blood. ii. Enzymes- are proteins facilitate chemical rxs in the body iii. Other body secretions and fluids- ex. Hormones (insulin, thyroxine etc), neurotransmitters (ex. Serotonin, acetylcholine), and antibodies are made of proteins iv. Acid-base balance- proteins can act as acids or base depending of the pH of the surroundings v. Transport molecules- globular proteins transport substances through the blood. vi. Other compounds- a.a are components of numerous body compounds ex. Thrombin vii. Fuelling the body- provides for 4cal/g c. Amino acids are organic compounds mad of carbon, hydrogen, oxygen and a nitrogen component. d. There are 20 amino acids in the body, 9 are essential (our bodies cant make them so we must ingest them) and 11 are nonessential (we do not need to ingest these because our body produces them). NITROGEN BALANCE: a. Nitrogen balance occurs when protein synthesis and protein breakdown occur at the same rate. b. The state of nitrogen balance is determined by comparing the rate of protein synthesis to protein breakdown., c. Health adult has a neutral nitrogen balance, +ive nitrogen balance= protein synthesis is greater than protein breakdown, -ive nitrogen balance=protein synthesis is less than protein breakdown. COMPLETE PROTEIN: a. Provides all 9 essential a.a for the growth and maintenance of body cells and organs. b. All animal sources of protein are complete proteins (ex. Meat, fish, poultry, eggs, milk, and dairy products). Soy protein is the only complete plant proteins. INCOMPLETE PROTEIN: a. Protein that has one or more limiting a.a rendering it incapable of meeting the body s needs for normal protein synthesis (but does provide all essential a.a) ex. All plant proteins. b. RDA healthy adult= 0.8g/kg ~10% recommended daily allowance. SOURCES OF PROTEINS: a. Meat b. Fish c. Poultry and eggs d. Milk and dairy products

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Stephanie Talbot 5 NSG 126:FINAL EXAM REVIEW GUIDE e. soy f. other plants (but incomplete) VII. VITAMINS: a. Are organic compounds made of carbon, hydrogen, oxygen, and sometimes nitrogen. b. Fxn=facilitate biochemical rxs. Within cells to help regulate body processes so that they are essential to life c. They can be antioxidants substances that donate electrons to free radicals (oxidize body cells and DNA, result=damage to cells) to prevent oxidation. Fxns: 1. Protect cells from being oxidized by free radicals ex. Vitamin C (works within cells), Vitamin E (fxns within fat cells) and beta-carotene. d. Fat Soluble Vitamins-do not need to be eaten everyday: i. Vitamin A- allows eye to adapt to dim light ii. Vitamin. D- maintains serum calcium by stimulating GI absorption, release Ca2+ from bones iii. Vitamin. E- stimulates Ca2= re-absorption from kidneys iv. Vitamin. K- synthesis of blood clotting proteins and a bone protein that regulates blood calcium e. Water Soluble Vitamins- Need to be eaten everyday: all are coenzymes in energy metabolism i. Thiamine (Vit. B1)- promotes normal appetite and nervous system fxn ii. Riboflavin (vit B2)- aids conversion of tryptophan into niacin iii. Niacin (vit B3)- promotes normal nervous system fxn iv. Vit B6- coenzyme in a.a and fatty acid metabolism, helps convert tryptophan to niacin and helps produce insulin, hemoglobin, myelin sheath and antibodies. v. Folate- coenzyme in DNA synthesis. It is vital to new cell synthesis and transmission of inherited characteristics vi. Vit. B12- coenzyme synthesis new cells, activates folate, maintains nerve cells, helps metabolize some fatty acids and a.a vii. Pantothenic acid- part of co-enzyme A....used in energy metabolism viii. Biotin- fatty acid synthesis, a.a metabolism, glycogen formation ix. Vitamin C-collagen synthesis, antioxidant, promotes iron absorption, involved in the metabolism of certain a.a, thyroxin synthesis and immune system fxn x. Vitamin supplements are not necessary in healthy people who eat a variety of nutritious foods A. WATER: a. Fxns of water: Provide shape and structure to cells Regulate body temperature Aids in the digestion and absorption of nutrients Transports nutrients and O2 to cells Serves as a solvent for vitamins, minerals, glucose and a.a.

Stephanie Talbot 6 NSG 126:FINAL EXAM REVIEW GUIDE Participates in metabolic rxs Eliminates wats Is a major component of mucus and other lubricating fluids. b. Major mineral: calcium (Ca2+), phosphorus (P), magnesium (Mg), sulphur (S), potassium (k), chloride (Cl)--present in body in more than 5g. c. Trace minerals are: iron (Fe), iodine, zinc (Zn), selenium (Se), copper (Cu), manganese (Mn), fluoride (Fl), chromium (Cr) and molybdenum (Mo)----present in body in less than 5g. d. Major electrolytes are sodium (Na), potassium (k), Chlorine (Cl). FAT (LIPIDS): a. Lipids are a group of water-soluble compounds composed of carbon, hydrogen and oxygen. include: i. triglycerides (fats and oils) ii. Phospholipids (lecithin) iii. Sterols (ex. Cholesterol) b. Unsaturated fats (good fats) are fatty acids that contain one or more double bonds between carbon atoms. They are liquid /soft at room temperature ex. Canola oil, olive oil and peanut oils. Polyunsaturated fats like omega 3 &6 is found in fish oils, and some plant oils like canola, flaxseed, walnuts and hazelnuts. Trans fats are unsaturated fatty acids that have @ least one double bond whose H atoms are on the opposite sides of the double bond. c. LDL-cholesterol (bad cholesterol) is lowered by ingesting unsaturated fats because they carry cholesterol from the liver to the tissues d. Saturated fats (bad fats) increase LDL. Major cause coronary heart dx. They are solid @ room temperature and have no double bonds. e. Hydrogenated fats are made by manufacturers---they hydrogenate oils to make them solid @ rm temperature- that is they remove their double bonds and add hydrogen atoms---usually done to corn, soybean, cottonseed, and safflower or canola oil. Hydrogenated fats are the largest contributors to transfats in the typical American diet. May lower HDL---good cholesterol. f. FXNS Lipids: i. Provide energy 9 cal/g provide 55% bodies calorie needs @ rest. Stored fat is largest and most efficient energy reserve. ii. Cushions body s organs iii. Helps regulates body temperature (insulator) iv. Facilitates absorption of fatsoluble vitamins A, D, E & K. v. Cell membranes composed of phospholipids and cholesterol. g. Catabolism is the breakdown of molecules into smaller units to be used for energy. Fat catabolism occurs during starvation or uncontrolled diabetes (Body increases catabolism fatty acids during this time).

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Stephanie Talbot 7 NSG 126:FINAL EXAM REVIEW GUIDE h. Metabolism- the building of molecules occurs when ingests excess calories. Body makes triglycerides for storage. i. Sources of fats: i. Avocado, coconut, olives, most nuts, meats, beans and oils. My PYRAMID: a. A new symbol has vertical groups and 3D shape depicting physical activity at the side. b. Represents 12 customized pyramids of food intake patterns from the Dietary Guidelines for Americans each one represents a calorie level total calories range form 1000-3200 cal. c. Additional themes incorporated, are proportionality, gradual improvement, personalization and physical activity. d. When visit MyPryamid.org, enter age, gender, usual activity level to see your estimated caloric needs. CULTURE & NUTRITION: a. Different cultures have different views on what body types are attractive b. Culture defines what is edible, how food is handled, prepared and consumed, what foods are appropriate for particular groups with the culture, and the meaning of food and health. c. Different cultures have different diets. OBESITY: a. Normal weight---is that whish is statistically correlated to good health b. BMI- index of weight in relation to height N=18.5-24.9. Limitation BMI it can be elevated for numerous reasons from excessive fat to increase muscle mass edema, thus arbitrary in that the relationship between increase in weight and risk of dx is con t. c. Obese is considered a BMI greater than or equal to 30. d. 31% Americans between 20-74, are obese and women of lower economic status in all races tend to be more obese. e. Complications obesity: i. Insulin resistance ii. Type II diabetes iii. HTN iv. Dyslipidemia v. Cardiovascular dx vi. Stroke vii. Gallstones and cholecystitis viii. Sleep apnea ix. Respiratory dysfxn x. Increase incidence certain cancers f. Goals weight management: i. Moderate loss of 5-10% initial body weight or drop of 1-2 BMI units. More realistic than weight falling to healthy BMI by losing 1-2lbs/wk for 1st 6mnths

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Stephanie Talbot 8 NSG 126:FINAL EXAM REVIEW GUIDE ii. Strategies for weight loss is to ingest less calories than expend over a period of time through nutritional therapy, increasing physical activity, behaviour therapy ex, self monitoring, stress management, social support, pharmacotherapy, surgery ex. Gastric bypass. TYPES OF DIETS IN HOSPITAL: a. Clear liquid- short-term, highly restrictive, composed only clear fluids or foods that become fluid @ body temperature ex. Gelatine. Offers inadequate calories and nutrients except vit. C b. Full liquid diet- composed of foods that are liquid or liquefy @ body temp. Can approximate nutrient value of regular diet, may be inadequate for folic acid, iron, VitB6 and fibre c. Blenderized (pureed diet)- composed of liquids and foods blended in liquid form d. Soft diet (bland or low fibre diet)- an adequate diet low in fibre and lightly seasoned. Potentially gas forming foods usually excluded. e. Mechanical diet0 a regular diet modified in texture only excludes most raw fruits and vegetables, and foods with seeds, nuts and dried fruits. f. Therapeutic lifestyle change (TLC) diet a.k.a cardiovascular diet diet low in saturated fat and cholesterol, increase physical activity and weight loss, increase fibre and decrease total fat. g. DASH DIET (dietary approach to stop HTN)- low in saturated fat and cholesterol and high in fibre. Total fat is low and protein is slightly high. Encourages more fruit, vegetables, and low-fat dairy products---has separate food group entitled nuts, seeds, dried peas and beans recommends 4-5 servings/wk h. Renal diet: Diet alterations are made in terms of response to symptoms and lab values. goal: i. decrease renal workload to delay/prevent further damage ii. restore/maintain optimal nutritional status iii. control accumulation of uremic toxins ex. Urea, phosphorus, sodium, and potassium DIABETES: a. Type I- glycemia related to a relative or absolute deficiency of insulin. Characterized by an absence of insulin. b. Type II- a progressive dx that begins as insulin resistance- decrease cellular response to insulin impaired glucose tolerance inability to maintain normal glucose levels without excessive amounts of insulin hyperinsulinemia elevated blood levels of insulin. c. Long term complications diabetes increases in morbidity and mortality. Ex heart dx, blindness, neuropathy (can cause gastro paresis-delayed gastric emptying), impaired peripheral circulation and impotence in men as well as impaired wound healing. d. Goal medical therapy and general nutrition recommendations: i. Attain and maintain optimal metabolic controls- glucose, blood lipids levels and BP

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Stephanie Talbot 9 NSG 126:FINAL EXAM REVIEW GUIDE ii. Prevent, delay or treat complications iii. Improve overall health through optimal nutrition and physical activity e. Nutritional recommendations: i. Same nutritional requirements as general population ii. Carb 60-70% total cal, avoid foods sweetened with fructose, but natural sources fructose o.k iii. Fibre ingestion within normal amounts iv. Protein- may need to increase higher than RDA (15-20%calories) v. Saturated fats- limit to <10% total calories vi. Polyunsaturated fat- should be up to 10% total calories vii. Monounsaturated fat- use more monounsaturated fat and less carbs levels should be based on weight and lipid levels. Trans fat-keep low viii. Cholesterol- limit to <300mg/dL ix. Alcohol- limit to 2 drinks /day and consume with food to avoid hypoglycaemia x. Vit. and mineral supplementation is not recommended unless deficient. WOMEN s HEALTH ISSUES: a. Women tend to have more health problems than yet live 7yrs longer. b. WHI refers to those that are unique to women ex. Menstruation, pregnancy, and reproductive dx. c. Women more likely to develop osteoporosis, autoimmune dx, eating disorders, breast CA, certain gastrointestinal dx, and psychiatric conditions. d. Certain dx like heart dx and AIDS is manifested differently in women than men. MEAN S HEALTH ISSUES: a. Have shorter life span partially due to greater risk taking b. Generally drink and smoke more than women, less physically active, do not need medical care as often c. Leading causes death: heart dx, CA, unintentional injuries, stroke, chronic resp. Dx, diabetes, influenza and pneumonia, suicide, kidney failure and chronic liver dx. AGING: changes in body systems have a potential impact on diet and nutritional status of the older adult. They tend to have decrease lean muscle mass and increase/decrease in fat tissue, decreased metabolic rate et. Often need lower calories due to the decrease in BMR and loss of muscle mass. May need to increase protein---but this is not an official recommendation yet. Fluid needs remain the same but should increase fluid needs with heat, fever, vomiting, diarrhea, and drug induced fluid loss. Recommended vitamins and minerals do not change NANDA: (and many more) a. Imbalanced nutrition: Less/More than body requirements b. Readiness for enhanced nutrition c. Risk for imbalanced nutrition: Less/more than body requirements COMMON FECAL ELIMINATION PROBLEMS: a. Constipation- less than three bowel movements a week i. What contributes to this? 1. Insufficient fibre and fluid intake

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Stephanie Talbot 10 NSG 126:FINAL EXAM REVIEW GUIDE 2. Insufficient activity or immobility 3. Irregular defecation habits 4. Change daily routine 5. Lack of privacy 6. Chronic use laxative/enemas 7. Emotional disturbances 8. Medications b. Fecal impaction- collection hardened feces in folds in rectum. Results from prolonged retention and accumulation of feces. i. Why? 1. Due to prolonged retention and accumulation of fecal material ii. Signs and symptoms: 1. Non-productive desire to defecate 2. Rectal pain 3. Liquid feces seepage 4. Malaise, nausea or vomiting 5. Anorexia 6. Distended abdomen Digital removal fecal impaction:--use an oil retention enema first and hold 30min c. Obtain assistance if indicated d. Ask client assume left sided position with knees flexed e. Place bedpan under buttock and a bedpan nearby f. Drape client g. Put on CLEAN gloves h. Gently insert index finger moving along length rectum i. Loosen stool by gently massaging around it...work the finger into the hard mass j. Work stool downward, periodically take vitals k. Following disimpaction, assist client get cleaned up and then put them on a bedpan or commode BOWEL TRAINING PROGRAMS: a. For those with chronic constipation, frequent impactions, or fecal incontinence. b. Purpose: help client establish normal defecation. Phases: 1. Det. Usual bowel habits and factors help/hinder normal defecation 2. Design plan includes: 1. 2500-3000mL fluid intake, increase fibre, intake hot drinks- especially just before usual defecation, increase exercise 3. Maintain daily routine 2-3wks: 1. Administer cathartic suppository 30min before clients defecation time to stimulate peristalsis 2. When client has urge defecate, assist to commode (note time between insertion suppository and urge defecate) 3. Give privacy and time limit- 30-40min 4. Teach client lean forward, apply pressure to abdomen, and bear down 4. Give positive feedback 5. Offer encouragement. DATA COLLECTION: c. Database- all the information about a client d. Subjective data- a.k.a symptoms or covert data, are apparent only to the person affected

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Stephanie Talbot 11 NSG 126:FINAL EXAM REVIEW GUIDE e. Objective data-a.k.a signs or overt data, are apparent by an observer. They can be measured or tested against accepted standards f. Interview- a planned communication or conversation with a purpose PRINCIPLE METHODS USED TO COLLECT DATA: a. Initial comprehensive assessment. Includes: i. Nsg hx- pts hx, biographical data, hx illness, present fxning, expectations, emotional status, strengths and coping ii. Physical exam- review of body systems, vital signs, muscle strengths, and observation (inspection, palpation, percussion, auscultation) b. Ongoing assessment: includes: i. Interview- to i.d problems of mutual concern, evaluate changes, teach, provide support and counselling or therapy 1. APPROACHES TO INTERVIEWS: a. Two types: i. Directive interview- nurse controls the purpose, subject matter and asks questions in order to obtain specific information ex. In an emergency rm ii. Nondirective interview- nurse allows patient to control the purpose, subject matter and pacing. Nurse clarifies, summarizes and uses open-ended questions and comments to encourage communication iii. Examination

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SOURCES OF DATA: c. Client- primary source statements made by client and includes those objective data that can be directly obtained ex. Gender,; everyone else is a secondary source d. Family and support persons e. Healthcare team members f. Medical records g. Other records ex. Laboratory records h. Literature review-ex. Nsg, medical, pharmacological about the clients illness i. Nurses experience XXIV. IMPORTANCE OFCONFIDENTIALITY: a. All patients have the right to privacy and confidentiality. b. Due to increased use of computers, need guidelines to protect patient sensitive data c. Personal passwords, not leaving computer unattended or with clients info displayed when visitors present d. Only staff directly involved with client has legitimate access to records XXV. DRUGS: A. Drugs can have 4 types of names: a. Chemical name- given by the chemist, the exact description of its constituents. b. Generic name- given by the developer of the drug and before the drug gets approved c. Trade(brand) name- name given by the manufacturer of the drug and owner

Stephanie Talbot 12 NSG 126:FINAL EXAM REVIEW GUIDE d. Official name- name listed in the U.S Pharmacopeia-NF ACTIONS OF DRUGS ON THE BODY: There are three general principles of drug action: 1. Drugs only modify the bodies existing functions 2. Drugs have multiple actions rather than a single action 3. A drug response is the result of a physiochemical interaction between the drug and molecules in the body Actions of drugs is described in terms of HALF-LIFE that is the amount of time it takes the body to metabolize the drug to . Key terms: Onset of action- time it takes the drug to produce its effects that is when the body first responds to the drug. Peak plasma level- highest plasma level achieved by a single dose. Occurs when rate elimination=rate absorption Drug half-life- time required for drug to be metabolized to concentration Plateau- a maintained concentration of a drug in the plasma during a series of scheduled doses. PHARMACODYNAMICS ( How drugs work on the body): Drug effects on the body. 3 types of interactions: Drug-receptor Drug-enzyme Nonspecific drug interaction.

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PHARMACOKINETICS: (Drug movement through the body): a. It is the study of the absorption, distribution biotransformation and excretion of drugs Absorption- process by which a drug passes into the blood stream. Distribution- the transportation of a drug from its site of absorption to its site of action Biotransformation (detoxification/metabolism)- process by which a drug is converted to a less active form. Usually takes place in liver formation metabolites. Excretion- process by which metabolites and drugs are eliminated from the body. Done by the kidneys in urine ROUTES OF ADMINISTRATION: A. Oral: i. Advantage- most common, cheapest , most convenient. ii. Disadvantage- unpleasant taste, irritation gastric mucosa, irregular absorption, slow absorption and harm to clients teeth (some drugs) B. Mucus Membrane: i. Sublingual- should not be swallowed

Stephanie Talbot 13 NSG 126:FINAL EXAM REVIEW GUIDE ii. Buccal- can have local or systemic effect C. Parenteral: other than by alimentary tract i. Subcutaneous (SQ)- into sub-q tissue below skin ii. Intramuscular (IM)- into a muscle iii. Intradermal (ID)-under the epidermis iv. Intravenous(IV)-into a vein v. Topical: applied to circumscribed area of body ex. Dermatologic preparations, irrigations and instillations, as well as inhalations. ADMINISTERING MEDICATIONS SAFETLY: A. Guidelines administering meds: 1. Nurses who administer meds are responsible for own actions, question all incorrect or illegible orders 2. Be knowledgeable about meds 3. Keep narcotics and barbiturates locked up 4. Use only meds clearly marked 5. Do not use liquid meds that are cloudy 6. Calculate drug dosage accurately, always double check 7. Administer only meds personally prepare 8. Before administration I.D client 9. DO NOT LEAVE MEDS AT THE BEDSIDE!!!!!! 10. If client vomits after a liquid med, report this to charge nurse, PCP, 11. Have another nurse double check dosages of insulin, anticoagulants and certain IV meds 12. When a med is omitted, document the reason why 13. When a med error is made, report it immediately to the charge nurse or PCP B. Administering meds: 1. I.D client and inform client of med about to take 2. Administer the drug-read the MAR (medication administration record) carefully and perform 3 checks with the labelled medication then administer. Provide for the 5 rights to medication administration 3. Provide adjunctive interventions as indicated 4. Record the drug administered 5. Evaluate the client s response to the drug Ten Rights:         Right med Right dose Right time Right route Right client Right education-explain med to client right documentation right to refuse

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Check 3 times for safety: First check:  Rd MAR and remove meds from clients drawer, verify clients name and rm number match MAR Compare label of med against MAR If dosage doesn t match MAR, determine if you need to do a math calculation Check expiration date

 

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XXXIV. INJECTIONS SITES: Intradermal, Subcutaneous, Intramuscular, Intravenous 1) For adults: SQ- use needle #24-26gauge and 3/8-5/8 inch long *obese persons may require 1 inch needle at a 45-90 degree angle 2) For adult IM- use needle #20-22gauge and 1-1.5 inch long needle, at a 90 degree angle. 3) Intradermal injections use either a tuberculin needle or insulin syringe at a 10-15degree angle 4) Always administer injections with the bevel up. 5) XXXV. Drugs given sub-q=vaccines, insulin and heparin I. Must rotate sites to decrease tissue damage, aid absorption, and avoid discomfort II. Insulin is absorbed most quickly from the abdomen and most slowly from the thighs and buttocks XXXVI. For insulin administration and heparin, you no longer need to aspirate before administration

Stephanie Talbot 15 NSG 126:FINAL EXAM REVIEW GUIDE

Intradermal Injections

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Administering Intradermal Injections- Skill 35-5

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Stephanie Talbot 16 NSG 126:FINAL EXAM REVIEW GUIDE

Subcutaneous Injections

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Administering a Subcutaneous Injection - Skill 35-6

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Stephanie Talbot 17 NSG 126:FINAL EXAM REVIEW GUIDE

Injections (Intramuscular) Video

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Intramuscular Injections
Ventrogluteal Vastus lateralis Dorsogluteal Deltoid Rectus femoris

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Stephanie Talbot 18 NSG 126:FINAL EXAM REVIEW GUIDE

Ventrogluteal Site

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Vastus Lateralis Site

infant adult
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Stephanie Talbot 19 NSG 126:FINAL EXAM REVIEW GUIDE

orsogluteal Site

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eltoid Site

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Stephanie Talbot 20 NSG 126:FINAL EXAM REVIEW GUIDE

Rectus Femoris Site

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Stephanie Talbot 21 NSG 126:FINAL EXAM REVIEW GUIDE XXXIX. URINARY ELIMINATION: I. Urine specimens: UAP may collect for routine specimens a. Collect via: i. Clean void- used routine urinalysis and need at least 10mL ii. Clean catch or midstream- collected to I.D microorganisms causing urinary tract infection iii. A timely urine collection is produced and voided over a specific period of time ranging from 1-24hrs. Ex. BUN and creatine clearance Purpose: 1. Assess ability of kidney to concentrate and dilute urine 2. To determine disorders of glucose metabolism ex. Diabetes mellitus 3. Determine levels of specific constituent s ex. Albumin, amylase, creatin, urobilinogen, and certain hormones. II. Urine tests: usually done by nurse from a kit which can contain the required equipment, a reagent (can be a tablet or fluid), or paper test strip or dipstick i. Specific gravity- indicator of urine concentration or amt solutes present in urine ex. Metabolic wastes and electrolytes N=1.010-1.025.The more concentrated the urine, the greater the specific gravity ii. High specific gravity may indicate fluid deficit or dehydration, or excess solutes like glucose in the urine b. Urinary pH is measured to determine the acidity or alkalinity of urine. N=6. Good indicator if kidneys responding approp. To acid-base imbalance. c. Glucose, ketones protein and blood not normally seen in urine d. Osmolality- is a measure of the solute concentration. it is more exact measurement of urine concentration that specific gravity. Used to monitor fluid and electrolyte balance. Normal=500-800Osm/kg. increased levels indicate a fluid volume deficiency, and decrease reflects fluid volume excess III. INTERVENTIONS INDWELLING CATHERS: a. Drink 2000-3000mL fluids b. Acidify urine eating eggs, cheeses, meat, whole grains, tomatoes etc c. Do routine perineal care d. only change catheter if sediment present e. Prevent contamination of the catheter with feces in the incontinent patient. I. The use of sterile technique is used when inserting catheters. Sterile technique a.k.a surgical asepsis refers to those practices that keep an area or object free of all microorganisms. it includes practices that destroy all microorganisms and spores.

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Surgical Asepsis
AKA: St ril t c iq  r ctic s t t destr all micr r anisms & t eir s res  Used in s ecialized areas & skills


are of s r ical wounds  at eter insertion  Invasive procedures  Sur er



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Sterile Technique
Procedures t at keep an object or area free from living organisms  Sterile vs. contaminated areas  Articles must remain away from and in front of t e body and above t e waist


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Sterile Technique
Never reac across t e sterile field  Never turn your back to t e sterile field  Two inc es around border is considered contaminated  Sterile field must be kept dry


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Sterile Gloving
Only touc t e outside of t e package wit bare hands.  The inside of the package, in which the gloves are placed, is considered sterile.  The wrapper, when opened provides a sterile field.  Grasp only the outside edge of the wrapper.


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Stephanie Talbot 24 NSG 126:FINAL EXAM REVIEW GUIDE VI.

   

The inside of the glove may be touched with the bare hand Grasp the first glove at the top edge of the foldeddown cuff and slip in hand Slip gloved fingers into cuff of second glove and slip in second hand without contaminating The outer aspect of the glove must remain sterile
   

Includes wrist area Keep hands above level of waist Sterile to sterile only If contamination occurs, start again with new pair of gloves

Techniques to Remove Articles from Sterile Wraps



Drop technique
 

For gauze pads, dressings, small items Wrapper is partially opened , held upside down over sterile field, dropped onto sterile field For bowls, drapes, linen Using the wrap as a mitten, sterile supplies can be placed on a sterile field For cotton balls, small items, or articles Sterile gloves or transfer forceps are used to transfer objects to sterile field

Mitten technique
 

Transfer forceps
 

I.

Nsg dx related to urinary elimination: Impaired urinary elimination.

Stephanie Talbot 25 NSG 126:FINAL EXAM REVIEW GUIDE II. Difference in evaluation and assessment documentation: f. Assessment: data is recorded in a factual manner and not interpreted by the nurse ex. coffee 240mL, juice 120mL etc as well as client stated l feel tired g. Evaluation: made in terms of the clients goals/outcomes: ex. Goal=decrease in reports of fear and anxiety...evaluative statement=MET. Stated I know I can get enough air, but it still hurts to breathe . Evaluation data is collected concerning the client goals/outcomes.

Discuss Temperature. Include: normal range, body temperature regulation, temperature alterations, assessment sites, type of thermometers, and procedures: A. The normal body temperature is 96.8-98.6F (35-37C). B. Body temperature is regulated by the hypothalamus in the brain, sensors in the skin and an effector system that adjusts the production and loss of heat. C. An increased body temperature above normal is termed hyperthermia or pyrexia. D. A decreased body temperature below normal is termed hypothermia. E. Temperature can be assessed at the following sites: 1. Temporal artery 2. Tympanic 3. Oral 4. Axillary 5. Rectal-most accurate Discuss pulse. Include: normal range, factors influencing, assessment-rate, rhythm, strength, sites and procedure: A. Pulse is the palpable force of blood flowing through the arteries. B. Normal pulse is 60-100bpm. C. Factors influencing Pulse: 1. Age 2. Stress 3. Exercise 4. Medications 5. Diurnal patterns 6. Environment 7. Fever 8. Positional changes 9. Pathology D. When assessing Pulse: use the palpatory method 1. Rate-regular or irregular 2. Rhythm-the pattern of beats and intervals between beats 3. Volume- the strength of beat. 4. Arterial wall elasticity- are they flat or do they feel twisted

Stephanie Talbot 26 NSG 126:FINAL EXAM REVIEW GUIDE E. Procedure: 1. Palpate the radial artery of one limb for 1 minute 2. Then palpate the radial artery of the other limb. 3. When you get a difference in pulses, and then take an apical pulse. Sites to Assess Pulse:

Stephanie Talbot 27 NSG 126:FINAL EXAM REVIEW GUIDE Discuss blood pressure. Include normal range, physiology, factors influencing BP, assessment Korotkoff s sounds, procedure, common mistakes in BP assessment: A. Blood pressure is the force exerted on the arteries with every heart beat. B. Consists of systolic- pressure exerted when ventricles contract and diastolicpressure exerted when ventricles are at rest. C. Normal: S<120mmHG, D<80mmHg D. Hypertension is a BP greater than normal E. Hypotension is a BP less than normal. F. What determines BP? 1. The pumping action of the heart 2. Blood volume 3. Blood viscosity 4. Vascular resistance G. Factors influencing BP: 1. Age 2. Race 3. Gender 4. Obesity 5. Stress 6. Medications 7. Dx processes 8. Exercise 9. Diurnal variation H. Korotkoff s sounds: 5 phases 1. Phase1: initial tapping phase heard on auscultation=systolic pressure 2. Phase 2: muffled sounds, gentle whooshing 3. Phase 3: sounds become clearer and crisper 4. Phase 4: sounds muffled again 5. Phase5: level at which no sound is heard=diastole I. Common mistakes taking BP: 1. Cuff to large/small 2. Bp retaken to soon 3. Cuff to loose/tight 4. Arm not level with the heart/supported 5. Haste on part of hcp and unconscious bias 6. Deflating cuff to quickly/slowly 7. Failure I.D ausculatory gap 8. Assessing immediately after a meal (elevated) Discuss Respirations. Include normal range, rate, depth, rhythm, procedure: A. Respiration is the act of breathing. Two types of breathing: costal and diaphragmatic. When you breathe diaphragm flattens pulling lungs down, while ribs move up and out expanding the lungs. Two types of respiration: internal (between blood and cells) and external (between air and muscles) B. Ventilation is the rate at which gas moves in and out of the lungs. C. Normal is 12-20 breaths/minute. D. Assess: rate, rhythm and depth and count for 1 minute

Stephanie Talbot 28 NSG 126:FINAL EXAM REVIEW GUIDE Describe the relationship between temperature, pulse and respiration: A. Temperature variation has the ability to affect both pulse and respirations, either increasing or decreasing them depending on whether the temperature has increased or decreased. B. RR and HR have no impact on temperature though. You can have an increased HR and RR with no fluctuation in temperature. C. On the other hand pain can cause temperature, RR, and HR to increase.

Discuss Pain as the 5th Vital Sign: A. Pain is considered by JCAHO & AHCPR as a national problem and is the 5th vital sign. B. Pain is subjective occurrence C. ABCDE of Pain: a. A- ask often if in pain b. B- believe the patient c. C-chose a pain control method d. D-deliver interventions in a timely manner e. E-empower the patient and enable them to control D. Phases of pain: a. Acute- temporary but sudden onset b. Chronic- last longer than 6mnths and unresponsive to tx c. Anticipatory- related to invasive procedures, influence anxiety E. Should be assessed every time take vitals F. Characteristics of pain to assess: a. Onset and duration b. Location c. Severity on a scale of 1-10 d. Quality (what does it feel like) e. Pain pattern f. What relieves the pain and what makes it worse

Stephanie Talbot 29 NSG 126:FINAL EXAM REVIEW GUIDE Describe BPSCDE/conditioning factors that influence the pain experience: A. BPSCDE stands for biological, psychological, social, cultural, developmental and environmental. B. Many factors affect a person s response and perception to pain: a. Cultural- influence a person reaction and expression of pain b. Developmental- infants, children and women often undertreated c. Environment and support people- with increase in outpt .services, families increasingly responsible for pain management d. Past pain experiences alters a persons sensitivity to pain e. Meaning of pain- can be a source of spiritual distress or strength and enlightenment.

Describe Therapeutic Nursing Interventions Used to Decrease Common Safety Risks Associated with the Adult and Older Adult: Goals/Outcomes: A. Identify environmental hazards in home and community B. Demonstrate safety practices. C. Experience a decrease in the frequency or severity of injury D. Describe methods to prevent specific hazards E. Report use of home safety measures F. Alter home physical environment to reduce risk of injury G. Describe emergency procedure for poisoning and fire H. Describe age specific risks, work safety risks, or community safety risks I. Demonstrate correct administration of CPR Interventions: A. Educate the adult and elderly about safety hazards a. Encourage elderly to get regular vision checks b. Ensure adequate lighting at night c. Employ use smoke detectors d. Remove all unsafe objects e. Encourage elderly home hazard appraisal f. Encourage elderly to remain as active as possible

Stephanie Talbot 30 NSG 126:FINAL EXAM REVIEW GUIDE Relate the Following to Application of Restraints: A. Alternatives to restraints: 1. Work in pairs, one nurse to watch when other leaves the unit 2. Place unstable clients near nurses station for close observation 3. Prepare clients before any moves 4. Stay with client using bedside commode or bathroom 5. Monitor all meds and attempt to lower or eliminate sedatives or psychotropic s 6. Position bed at lowest level 7. Use length side rails 8. Wedge pillows or pads against sides of wheelchairs to keep upright 9. Use environmental restraints like furniture and plants to keep them from wandering where you don t want them to go B. Clinical Objectives for the Use of Restraints: a. Behaviour management- when a client is a danger to themselves or others b. Acute medical and surgical care- temporary immobilization of client is required to perform a procedure C. Safety Precautions and Nursing care Necessary for clients with restraints: a. Obtain consent client and family members, ensuring it is only temporary b. Ensure primary care giver gives order within 24hrs c. Apply restraint in such a way that client can still move freely d. Secure restraint, but not tight enough to impede blood flow e. Do not tie to side rails f. Use a knot to tie but not a double knot, knot must be able to release quickly g. Assess restraint and skin integrity regularly, and proved ROMS q2hrs h. Assess and assist with basic needs: nutrition, hydration, hygiene, elimination i. When restraint is removed temporarily, do not leave client unattended j. Provide emotional support to client and family D. Common policies and procedures related to application and continued use of restraints: a. Must have a written restraint order, following an evaluation, and it is only valid for 4hrs b. Order must state the reason and time period c. Restraints should be used only after all other means of ensuring safety have been unsuccessful d. Document e. Provide ROM exercises

Stephanie Talbot 31 NSG 126:FINAL EXAM REVIEW GUIDE

E. Legal Implications restraints: a. Restraints restrict individual freedom so nurse must know the institutional policy regarding restraints. b. Prn orders are illegal F. Side rails...how do they relate: a. If all side rails are up, considered a restraint...clients often try to climb over them causing injury

III.

Describe risk associated with immobility: A. Disuse osteoporosis B. Disuse atrophy C. Contractures D. Stiffness in the joints E. Diminished cardiac reserve F. Increased valsalva manoeuvre G. Orthostatic hypotension H. Venous vasodilation and stasis I. J. Dependent edema Thrombus formation

K. Decreased respiratory movement L. Pooling of respiratory secretions M. Atelectasis N. Hypostatic pneumonia O. Decreased metabolic rate P. Negative nitrogen balance Q. Anorexia R. Negative calcium balance S. Urinary stasis T. Renal calculi U. Urinary retention V. Urinary infection W. Constipation X. Reduced skin turgor

Stephanie Talbot 32 NSG 126:FINAL EXAM REVIEW GUIDE Y. Skin breakdown Z. Negative mood effects ex. Decreased self-esteem, apathetic, with drawl, aggressiveness

A. There are 5 types of NSG diagnosis: 1. Actual NSG diagnosis- this describes the client problem when the nurse does the initial NSG assessment. Ex. Impaired tissue integrity. 2. Potential NSG diagnosis- the client does not have a problems (signs or symptoms) at this time but has RISK FACTORS which could lead to a problem if no NSG intervention is taken. Ex. Risk for infection. 3. Possible NSG diagnosis- this is one in which there is incomplete evidence that a problem exists or there is uncertainty that a problem exists. Ex. Possible social isolation of unknown etiology 4. Wellness NSG diagnosis-are the human response to levels of wellness in families, individuals and communities. Characterized by a readiness for enhancement ex. Ready for enhanced spiritual well-being 5. Syndrome NSG diagnosis- this occurs when you have multiple diagnosis associated with the client problem. Ex. Risk for disuse syndrome: has more than one sub-diagnosis B. Differentiate between a nursing diagnosis, medical diagnosis, and a collaborative diagnosis: 1. Nursing diagnosis- is a clinical judgement of the human response to a clients health problems or potential health problems. It is a statement of what nurses are educated, experienced and legally allowed to treat. 2. Medical diagnosis- is a judgement of a clients actual problem and is what physicians are legally trained to treat. 3. Collaborative diagnosis consists of nursing diagnosis- problems nurses treat independently and physician diagnosis which nurses are obligated to treat and carry out as a dependant function. (Denoted by PC: Potential Complication). A. There are three ways to write a NSG diagnostic statement: a. One part: used in wellness and syndrome diagnosis b. Two parts: consists of a problem and an etiology (PE)-uses r/t to link the (P) and (E). c. Three part: consists of a problem statement, etiology and defining characteristics (PES)-uses r/t to link (P) and (E) and aeb to link (PE) to the defining characteristics (the signs and symptoms). This is very useful for the beginning nursing student C. In each of these methods you want to list the symptoms, group them according to their similarities, look in your NANDA guide for possible diagnosis, narrow it down making sure the cause and effects match, and then choosing your diagnosisfy methods to formulate diagnostic statements:

Stephanie Talbot 33 NSG 126:FINAL EXAM REVIEW GUIDE D. PLANNING PROCESS: 1. Set Priorities- life threatening problems have top priority ex. Loss resp/cardiac fxn are high priority i. Use Maslow s hierarchy of needs. 2. Establish Goal/Outcomes- derived from nsg dx, should I.D human responses, define behaviours that demonstrate the problem has been decreased, prevented or reduced. 1. They are broadly stated and are made specific by i.ding indicators that apply to your client. 2. MUST INCLUDE CLIENT BEHAVIOUR, TARGET TIME, CONDITIONS/MODIFIERS and PERFORMANCE CRITERIA i. Write label, indicator that applies, and location on the measuring Goals are derived from the diagnostic label and stated as opposites of the problem ii. Components goal/desired outcomes statements: 1. Subject- noun=client 2. Verb- action the client is to perform (behaviour) 3. Condition/modifiers- added to verb to explain what, where, when and how the behaviour is to be performed (behaviour) 4. Criterion of desired performance- indicates standard by which a performance is evaluated or the level at which the client will perform the specific behaviour- how long, well, how fare and what is the expected standard. iii. Goals should be SMART- Specific, Measurable, Appropriate, Realistic, Timely. II. Selecting NSG Interventions: a. Nsg should focus on decreasing or eliminating the ETIOLOGY of nsg dx b. Types: i. Independent interventions- those activities nurses licensed to initiate ii. Dependent interventions- those carried out under the physicians orders or according to specified routine iii. Collaborative interventions- carried out in collaboration with other health care members c. Ns should consider alternative and consequences before choosing and intervention d. Ns writes interventions for observation, preventative, tx, and health promotion i. NIC taxonomy levels: 1. Level 1, domains 2. Level 2, classes 3. Level 3, interventions III. IMPLEMENTATION: a. Consists of doing and documenting activities that are the specific nsg actions needed to carry our interventions. b. ADP- provides basis for nsg actions and implementing provides actual activities and client responses that are examined in final phase (EVALUATION)

Stephanie Talbot 34 NSG 126:FINAL EXAM REVIEW GUIDE c. Terms: i. Cognitive skills- include problem-solving, decision making, critical thinking and creativity ii. Technical skills- hands on skills a.k.a tasks iii. Interpersonal skills- all of the verbal and nonverbal skills PRESSURE ULCERS: A. A.k.a debicutus ulcers, pressure sores or bedsores- are any lesions caused by unrelieved pressure, which results in damage to the underlying tissue. B. ETIOLOGY: 1. Are due to ischemia a deficiency in blood supply to the tissue due to compression of vessels between two surfaces (>32mmHg of pressure). Cells deprived of oxygen and nutrients, the waste products of metabolism accumulate in cells, and tissues and dies. IV. After skin compressed appears pale, and once pressure relieved turns bright red=REACTIVE HYPEREMIA. This flush is due to VASODILATION C. RISK FACTORS: 1. Friction and shear 2. Immobility 3. Inadequate nutrition 4. Advanced age skin changes as we age, this makes prone to impaired skin integrity. Changes include: Chronic medical conditions ex. Diabetes and cardiovascular dx delays healing 5. Other risk factors ex. Poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices.