Exam 2 Intro

wash hands with soap
highly contagious

fecal impaction
water can seep around the impaction

manual extraction WITH GLOVES
need orders to do it

liquidy

liquid to pasty

full formed bowel movement

right before colon so it will be liquid and less formed

blood

painful urination

small, tiny amount
infrequent

kidney -> ureter -> bladder -> urethra

bladder scan = validating the patient

no, not comparable with two different patients

pain DOES NOT decrease with age

ear lobe

no you always need your own
including nursing students

nursing students must be held to the same standards of practice as a RN

dr or surgeon

obesity
cigarette smoking
heavy alcohol consumption
high sodium intake
sedentary lifestyle

lightest level of sleep, lasting a few minutes
decrease physiological activity begins with gradual fall in vital signs and metabolism
easily arouse sleeper
person feels as though daydreaming has occurred if awakened

sound sleep during which relaxation preogresses
arousal is still relatively easy
brain and muscle activity continue to slow

called slow-wave sleep
deepest stage of sleep
sleepr is difficult to arouse and rarely moves
brain and muscle activity are significantly decreased
vital signs are lower than during making hours

rapid eye movement
vivid, full-color dreaming occurs
usually begins about 90 minutes after sleep has begun
autonomic response of rapidly moveing eyes, fluctuating heart and respiratory rates and icnreased or fluctuating BP
loss of skeletal muscle tone
gastric secretions increase
very difficult to arouse sleeper
sleep increases with each cycle and average 20 minutes

measuring CO2 in the body
normal range is 35-45%
55 is too high = too much CO2 in body

rubbing an injured area can reduce pain
small-diameter fibers activated by noxious stimuli open the gate to pain transmission and large-diameter fibers have inhibitory effects to shut the gate
rubbing the injured area promotes propioceptive large-diameter fiber input and there inhibits further transmission of pain signals from small-diameter nerves to the brain

normal stimulation of special peripheral nerve endings called nociceptors; usually responsive to nonopioids and/or opioids

comes from bone, joint, muscle, skin, or connective tissue
usually aching or throbbing in quality and well localized

arise from visceral orans such as gastro tract and pancreas
tumor involvement of organ capsule that causes aching and fairly well-localized pain
obstruction of hollow viscus, which causes intermittent cramping and poorly localized pain

94%

difference between systolic and diastolic - subtract
120/80 120-80 = 40 pulse pressure

wait 30 minutes to retake it
may have drank something hot

transfer of heat from the surface of one object to another without direct contact
pt open in surgery heat loss of environment

transfer of heat away by direct contact

liquid is changes to gas
sweat

visible percipitation on forehead and upper thorax

pyrexia
occurs because heat-loss mechanisms are unable to keep pace with excessive heat productions
results in abnormal rise in body temperatue
100.4 F

body temperature of 104 or more accompanied by hot, dry skin adn cneteral nervous system abnormalities such as delirium, convulsion or coma

caused by environmental heat exposure and peresents with profuse diaphoresis that results in excess water and electrolyte loss

heat loss during prolonged exposure to cold overwhelms body ability to produce heat
classified as core temperature measurements

hypothalamus

body temperature

mechanical movemnt of gases into and out of lungs

movement of oxygen and carbon dioxide between alveoli and RBCS

distribution of RBC to and from the pulmonary capillaries

ability to do things on your own
pt decides about meds

what to do the best for your patient

do no harm to your patient
avoid harming

fairness
treating all pt the same

keep your promise
come back in 15 min

right and wrong action s
follows rules regardless
looks before act happens

outcome or consequences of actions
looks at an effect from the action
does the ends justify the means

dealing with vulnerable populations
doing what's best to vulnerable population

can cahnge
fear and anxiety

relaxation and guided imagery
distraction
music
cutaneous stimulation
herbals
reducing pain perception and reception
help pt manage their pain

diet = high intake of red meat and processed meats such as lunch meats or hot dogs
warning signs = changes in bowel habits, rectal bleeding or blood in stool, sensation of incomplete evacuation, unexplained abdominal or back pain
over 50 higher risk

Interrupting sleep can be harmful
It restores us mentally, physically, and emotionally

limit liability and offers legal immunity of the nruse at scene of accident
don't give trachotomy to pt bc out of scope of practice
ONLY DO WHAT KNOW HOW TO DO

carotid

temperature drops

if a patient asks to change you can say yes you can and they will send case management or a social worker

folding towels
distractions

age
sleep
circadian rhythm
stress
hormone level
exercise
temp alterations = rectal and axillary

drugs and susbtances = need to ask about melatonin
lifestyle = schedules, daily routine
unusal sleep patterns = keep sleep patters for waking
emotional stress = can amke stay awake or more sleepy
environment = need the environment the way you need it to fall asleep
excersie and fatigue = 2 or more hours before bedtime allows the body to cool down and maintain state of fatigure to promote relaxation
food and claoric intake = eat well before bedtime

written bad things about people

spoken bad thing about people

must only practice within the knowledge that you know

standard of proof is what a reasonable, prudent nurse would do in similar circumstances with same skill level as you

abortion
refuses life saving blood transfusion and health care team knows it is vital

how many hours of sleep are you getting
it is subjective

important to use objective forms of communication when describing an incident
only document want you see
use objective and factual report

gun you shoot at forehead

goes in the mouth

promote safety
promote comfort
promote activity

radial and apical pulse
assess at the same time

no caffiene at bed time
interrupting your sleep routine
dinner normally at 5pm but you eat at 8pm
antacid decrease acid in stomach = sleepingbeg
cigs before bed decreases sleep

must suction when doing oral mouth

life threatening blood stream infection from upper UTI infection

the amoutn of urine lef tin the bladder after voiding
measured with ultrasynogrophy or sraight cath

bacteria in the urine
does not always mean a UTI

the inability to empty the baldder partially or completely

can't hold it and can't control

brain triggers the bladder to empty
urination

when protein is in the urine

when blood is in the urine

irritation of the bladder
urgency, frequency, incontinence

rectal 0.5-1.0 degree higher
axillary 0.5-1.0 degree lower
temporal and tympanic no variation

temperature