NUR 3067

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Intimate distance: 6 - 18 in
Personal distance: 1.5 - 4 ft
Social distance: 4 - 12 ft
Public distance: more than 12 ft
Techniques for encouraging conversation: Using broad opening statements

Using general leads

Reflecting or repeating

Giving recognition

Restating or paraphrasing
Techniques to help express thoughts or feelings: Shared observations

Acknowledging the client's feelings

Selective reflecting

Use of silence

Giving information

Placing an event in time or sequence

Encouraging a formulation of a plan of action
Insuring mutual understanding: Clarifying

Verbalizing implied thoughts or feelings

Validating
Soler: sit squarely facing the client
Non-therapeutic communication techniques: Asking personal questions

Giving opinions or advice

Changing subject

Automatic responses

False reassurance

Sympathy

Asking for explanations

Approval or disapproval

Defensive responses

Passive or aggressive responses

Arguing

Stereotyping

Probing and challenging

Socializing

Intellectualizing

Blaming

Overlooking

Minimizing

Patronizing
The nursing process: Assessment

Diagnosis

Planning

Implementation/intervention

Evaluation
Nursing diagnosis: statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat
Goals (NOC): indicate anticipated client behavior or responses from nursing care
Expected outcomes (NOC): step by step objectives that help accomplish the goal and the resolution of the etiology for the nursing diagnosis
Writing expected outcomes: Who?

What actions?

Under what circumstances?

How well?

When?
Nursing interventions (NIC): autonomous actions based on scientific rationale that is expected to benefit the client in a predicted way related to the nursing diagnosis and client-centered goals
Evaluation: measures the client's response to nursing actions and the client's progress toward achieving goals
Correcting documentation mistakes: Draw a single line through it

Initials

Date

Error
Normal temperature: 98.6 F or 36 C
Temperature after eating or drinking: take 15 minutes after drinking hot/iced drinks

take 2 minutes after smoking
Rectal temperature: 1 degree higher than oral temp
Axillary temperature: 1 degree lower than oral temp
Normal pulse range: 60 - 100 bpm
Taking pulses: Start count with 0

30 seconds if pulse is regular

60 seconds if pulse is irregular

***Compare sides***
Normal respiration range: 12 - 20 bpm
Nomal BP: < 120/80
Pre-hypertension: 120 - 139/80 - 89
Stage 1 hypertension: 140 - 159/90 - 99
Stage 2 hypertension: > 160/100
BP sounds: first and fifth Korotkoff sounds
4+ pulse: strong, bounding, cannot be obliterated
3+ pulse: full pulse, increased
2+ pulse: easily palpable, normal
1+ pulse: pulse diminished, barely palpable
0 pulse: absent, not palpable
Apical pulse location: Angle of Louis

5th intercostal space, midclavicular
Inspection: always comes first
Palpation: Follows inspection

Fingertips - fine sensations

Palm and sides of hand - vibrations

Back of hand - temperature
Percussion: Follows palpation
Tympany: Loud, high-pitched, moderate duration, drum-like quality

Air filled, intestinal, stomach
Resonance: Moderate to loud, low-pitched, long duration, hollow quality

Lungs
Hyperresonance: Very loud, very low-pitched, longer than resonance, booming quality

Normal in kids, not in adults

Emphysematous lung
Dullness: Soft to moderate, high-pitched, moderate length, thudlike quality

Liver, masses, spleen
Flatness: Soft, high-pitched, short length, flat quality

Muscle, bone, tumor
Auscultate: follows palpation
Alert: awake
Lethargic or somber: tired, slow
Obtunded: difficult to arouse
Stupor, semi-coma: can respond to pain
Coma: cannot be aroused by painful stimuli
Oral fluids for I & Os: anything that can become liquid at room temp
1 mL: 1 cc
1 oz: 30 mL
1 tsp: 5 mL
1 tablespoon: 15 ml
1 pint: 500 mL
1 quart: 1000 mL
1 L: 1000 mL
1 cup: 8 oz or 240 mL
Insensible fluid loss: fluid loss that is not measureable (i.e. respirations or sweating)
Bathing procedure: Distal to proximal

Long, firm strokes
Bathing sequence: Eyes, face, ears, neck, arms, chest, abdomen, legs, feet, genitals, back of neck, butt, anus
To maintain balance when lifting, bending, or moving: Spine should be kept in vertical alignment

Feet positioned for a broad base of support

Body weight close to the center of gravity
When lifting, bending, or moving we should: Assess the weight of the object to be lifted

Face the direction of movement

Use major muscles of thighs and arms (strongest and longest muscles)

Reduce friction

Reduce force of work
Principles of syncopal episodes: Wide base of support

Center of gravity midline

Strongest and longest muscles

Reduce force or work
Bed to chair transfers: Sit patient up and wait 2 minutes (in case of dizziness or nausea)

Knee and feet alignment

Rocking

Pivoting and support

Ease client into chair
Inspection and palpation of the musculoskeletal system: Size and contour of joints

Skin and tissues over joints

ROM

Muscle strength

Gait
5 grade muscle strength: full ROM against gravity, full resistance
4 grade muscle strength: full ROM against gravity, some resistance
3 grade muscle strength: full ROM with gravity
2 grade muscle strength: full ROM with gravity eliminated
1 grade muscle strength: slight contraction
0 grade muscle strength: no contraction
Activity intolerance: insufficient physiological or psychological energy to endure or complete required or desired daily activities
Impaired physical mobility: a limitation in independent purposeful physical movement of the body or of one or more extremities
ABCD warning: Asymmetry of shape

Border irregularity

Color variation

Diameter larger than 6 mm
Primary intention: Skin edges are approximated or closed

Surgical wound
Secondary intention: Loss of tissue, wound is left open until it becomes filled with scar tissue

Burn, pressure ulcer, severe lacteration
Serous drainage: clear, watery plasma
Purulent drainage: Thick, yellow, green, tan, or brown

May smell
Serosanguineous: pale, red, watery: mixture of clear and red fluid
Sanguineous: bright red: indicates active bleeding
Pressure ulcer risk assessment: Sensory perception

Peripheral circulation

Motor function or mobility

Neurological function

Presence of moisture (incontinence)

Friction or pressure on the skin

Nutritional state

Older adulthood
Stage 1 wound: no break in skin, pink or pale, may be boggy or firm
Stage 2 wound: looks like a blister or abrasion, may go through epidermis and dermis
Stage 3 wound: may go through SQ layer (partial-thickness), will not go through to fascia
Stage 4 wound: may all the way through to the bone
6 rights of medication administration: Right medication

Right dose

Right client

Right route

Right time

Right documentation
Topical medications: ALWAYS use gloves when applying

May have systemic effects
Normal head and neck findings in aging adults: Facial bones and orbit are more prominent

Facial skin is thin, less fat and turgor

Temporal arteries are more prominent

Senile tremors may be present

Neck has less fat

Submandibular glands are more prominent and prolapsed
Ectropion: eversion of eyelid exposing conjunctiva
Entropion: inversion of eyelid
Eyes and the aging adult: Involution of lacrimal glands

Lipid material may infiltrate the limbus

Pupil size decreases

Lenses lose elasticity

Visual functioning decrease - presbyopia (inability to see close-up)
Ocular fundus inspection: Right with right, left with left (hand to eye)
Otalgia: earaches
Presbycusis: hearing loss
Right light reflex (ear): 5:00
Left light reflex (ear): 7:00
Straightening of ear canal in adults: pull pinna up and back
Straightening of ear canal in children: pull pinna down and back
Weber test: bone conduction - should be heard equally laterally
Rinne test: air to bone conduction - AC > BC
Mouth and nose in the aging adult: Nose prominence

Teeth color changes

Gum margins recede

Buccal mucosa thinning
Abbreviation: D: right
Abbreviation: S: left
Abbreviation: U: both
Medication orders must contain: Name of the patient

Date when order is written

Medication name, dose, route, and time and frequency of administration

Signature of the prescriber
Opthalamic medication: Dominant hand on forehead

Drop medication into the conjunctiva
Opthalamic medication: systemic effects: when administering medications that cause systemic effects, apply pressure to the lacrimal duct for 30 - 60 seconds
Procedure for insulin mixture: Inject air into the long-acting (cloudy) insulin

Inject air into the rapid-acting (clear) insulin

Withdraw the clear insulin

Withdraw the cloudy insulin
Intradermal injections: 15 degree angle

Tuberculin syringe
SQ injections: 0.5 - 1 mL

3/8 - 5/8 inch needle

25 - 27 gauge needle

45 degree angle
IM injections: 2 - 3 mL

1 - 1.5 inch needle

16 - 19 gauge needle

90 degree angle
Dorsogluteal landmarks: Post. superior iliac spine, greater trochanter
Ventrogluteal landmarks: Anterosuperior iliac crest, greater trochanter
Deltoid landmarks: Acromion process, deltoid muscle (3 fingerbreadths below the acromion process)
Vastus lateralis landmarks: Lateral femoral condyle (1 handbreadth above), greater trochanter (1 handbreadth below)
Mixing ampule and vial injections: withdraw from the vial first, the ampule second
Nail clubbing: Angle is > 160 degrees

COPD
Crackles: Fine: discontinous, soft, high-pitched, brief

Coarse: loud, low-pitched, bubbling and gurgling
Wheezes: High-pitched: connected, musical squeaking, multiple notes

Low-pitched: single note, muscical snoring, moaning
Pleural friction rub: coarse, low-pitched, grating quality
Stridor: high-pitched, inspiratory, louder in neck
Nursing interventions for altered respiratory functioning: Deep breathing and coughing

Pursed-lip breathing

Diaphragmatic breathing
Nursing interventions for maintenance/promotion of lung expansion: Positioning: semi-Fowler's

Chest tube placement
Incentive spirometer: increases inspiratory reserve volume
Nasal cannula: Lowest concentration of oxygen

Skin breakdown may occur
Simple face mask: highest concentration of oxygen
Venturi face mask: second highest concentration of oxygen
Bronchial/tracheal sounds: Heard over the trachea and larynx...only anteriorly

High-pitched, loud, inspiration < expiration, harsh, hollow tubular quality
Bronchovesicular sounds: Anteriorly heard around the sternum in the 1st and 2nd intercostal spaces, posteriorly heard between the scapulae

Moderate pitch and amplitude, inspiration = expiration, mixed quality
Vesicular sounds: Heard over the lung periphery

Low-pitched, soft, inspiration > expiration, rustling quality (like the sound of the wind in the trees)
Breast self-exam: performed each month at the end of the menstrual cycle
American Cancer Society BSE recommendations: Pads of three middle fingers with dime-sized circular motions of the finger pads

3 levels of pressure

Vertical strip pattern

Move from underarm to the middle of the sternum

Lying down
Thoracentesis: specimen of pleural fluid is taken
Bronchoscopy: visual examination of the bronchio/tracheal tube
S1: Mitral and tricuspid valve closure

Beginning of systole

Heard strongest at the apex
S2: Pulmonic and aortic valve closure

End of systole

Heard strongest at the base
Preadolescent breast development (stage 1): only a small elevated nipple
Breast bud stage (stage 2): a small mound of breast and nipple develops; the areola widens
Stage 3 breast development: the breast and areola enlarge; the nipple is flush with the breast surface
Stage 4 breast development: the areola and nipple form a secondary mound over the breast
Mature breast (stage 5): only the nipple protrudes; the areola is flush with the breast contour
Lungs in the aging adult: The lung is a more rigid structure that is harder to inflate

Decreased vital capacity

Increased residual capacity

Gradual loss of intraalveolar septa and decresed number of alveoli result in less surface area for gas exchange to occur
S3: Ventricular filling vibrations

Immediately following S2

Heard best at the apex and left lower sternal border

Use bell

Normal in kids and adults older than 40 years
Aging and the CV system: Increase in BP

Left ventricular wall thickness increases

Ability of the heart to increase cardiac output with exercise decreases

Presence of arrhythmias
Carotid pulse: auscultate before palpating
JVP: At 45 degrees jugular veins should not be visible

2 -3 cm from the sternal angle is normal
Biggest concern with blood clots: injury to the vessel wall
Edema: big concern in patients with peripheral vascular disease
4+ edema: very deep pitting, indentation lasts a long time, leg is very swollen
3+ edema: deep pitting, indentation lasts a short time, leg looks swollen
2+ edema: moderate pitting, indentation subsides rapidly
1+ edema: mild pitting, slight indentation, no perceptible swelling of the leg
Signs of venous insufficiency: Normal or cyanotic color

Normal temperature

Normal pulse

Often marked edema

Brown pigmentation around ankles
Signs of arterial insufficiency: Pale, worsened with elevation, dusky red when lowered

Cool temperature

Decreased of absent pulse

Absent or mild edema

Thin, shiny skin; decreased hair growth; thickened nails
Restraint selection: Restrict movement as little as possible

Does not interfere with treatment

Readily changeable

Safe for the client

Least obvious to others

Renew order q24 hours
Psychological and spiritual symptoms of nearing death: Fear

Nearing death awareness

Withdrawal

Increased focus on spiritual issues
Physical symptoms of nearing death: Confusion, disorientation, delerium

Weakness and fatigue

Drowsiness, sleeping, decreased responsiveness

Decreased intake, swallowing reflex

Surges of energy

Restlessness/agitation

Fever

Bowel changes

Incontinence
Universal symptoms of death: Decreased urinary output

Cold and mottled extremities

Vital sign changes

Respiratory congestion

Breathing pattern changes
Perioperative nursing: a specialized area of practice that describes the provision of care for the surgical client from the preoperative, intraoperative, and postoperative phases of the surgical experience
Pre-op physical assessment: Physical examination: previous medical history, risk for surgery

Medical clearance: specialist
Pre-op psychological assessment: Level of anxiety: may affect the amount of anethesia required

Coping ability: determine previous coping strategies

Support system: family and friends available
Pre-op spiritual assessment: Determine client's beliefs

Determine client's source of hope and strength

Determine client's religious practices

Determine client's percieved relation between spiritual belief and health
Pre-op teaching: NPO

Discontinuing medications

Deep breathing, incentive spirometer

Exercises, turning, leg exercise

Expectations

Surgical procedure

Pain control

Lifestyle changes
Diagnostic surgery: surgical exploration to assist in making a diagnosis or cause of a disorder
Curative surgery: performed to resolve a health problem by repairing or removing the cause
Restorative surgery: performed to improve a client's functional ability
Palliative surgery: reduces the intensity of the disease, but does not cure
Cosmetic surgery: performed to alter or enhance appearance
Elective surgery: performed on basis of client's choice; is not essential and may not be necessary for health
Urgent surgery: necessary for client's health, may prevent additional problems from developing; not necessarily an emergency
Emergency surgery: must be done immediately to save life or preserve function of body part
Major surgery: Procedure of greater risk

To improve health, restore function, or preserve life
Minor surgery: Procedure without significant risk

Restores function or corrects deformities
Factors that increase risk of surgery: Over 65 y/o

Medications: antihypertensives, trycyclic antidepressants, anticoagulants, NSAIDs
Nurses preoperative checklist: Consents

Allergies

Health and physical

Assessment

Anesthesia interview

Lab results, EKG, chest X-ray

Old chart (for anethesiologist)
Preoperative procedures: Voided or catheter inserted

Shave/prep

Jewelry, hairpins, metal removed

TED hose applied as ordered

Dentures, etc. removed

IV started

Pre-op meds given

Mark site
Actual loss: any loss of a person or object that can no longer be felt, heard, or experienced by the individual
Percieved loss: any loss that is uniquely defined by the grieving client
Maturational loss: any change in the development process that is normally expected during a lifetime
Situational loss: includes any sudden, unpredictable external event (i.e. paralysis)
Grief: the emotional response to a loss
Bereavement: includes grief and mourning
Kubler-Ross's stages of dying: Denial

Anger

Bargaining

Depression

Acceptance
Bowlby's phases of mourning: Numbing

Yearning and searching

Disorganization and despair

Reorganization
Worden's four tasks of mourning: Accepting the reality of loss

Working through the pain of grief

Adjusting to the environment without the deceased

Emotionally relocating the deceased and moving on with life
Anticipatory grief: grief before loss
Normal grief: normal feelings, behaviors, and reactions to loss
Complicated grief: Chronic grief, delayed grief, exaggerated grief (suicide), masked grief
Disenfranchised grief: when loss cannot be openly acknowledged or socially sanctioned or publicly shared
Dysfunctional grief: prolonged emotional instability, withdrawal from usual tasks of activities, lack of progression to successful coping
Stage 1 of grief: Notification and shock

Share acknowledge of the reality of the loss by assessing the loss, recognizing the loss
Stage 2 of grief: Experience the loss emotionally and cognitively

Share in the process of working through the pain by reacting to, expressing, and experiencing the pain of seperation/grief
Stage 3 of grief: Reintegration

Reorganize and restructure family systems and relationships and reinvest in other relationships and life pursuits by adjusting to an environment without the deceased, relinquishing old attachments, forming new identity without deceased, adapting to new role while retaining memories

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Number of cards 194