NSG Fundamentals Final Exam Review Guide1

Stephanie TalbotNSG 126:FINAL EXAM REVIEW GUIDE

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I. The NSG process is a systematic way of planning and providing client care. It consists of 5 phases: assessment, diagnosis, planning, implementation, and evaluation.

II. 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 other2.Client centered---ns organizes plan of care according to client problems3.Focus on problem solving and decision making4.Interpersonal and collaborative5.Universally applicable6.Employs critical thinking to carry out the nsg process7.Systematic8.Provides for the individualization of care9.Systematic and rational uses research to make decisions for implementation

III. 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 datac. Validate datad. 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 inconsistenciesb. Determine client strengths, risks,, problems and diagnosisc. Formulate nsg diagnosis and collaborative problem statementsd. 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 clientb. Write goal/desired outcomesc. Select nsg intervention


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d. Consult with other HCPe. Write interventions and care planf. Communicate the plan to relevant HCP

V. IMPLEMENTATION: the process of carrying out and documenting the planned nsg interventions: PURPOSE:

1.To assist the client to meet desired goals/outcomes2.Promote wellness3.Prevent illness and dx4.Restore health5.Facilitate coping with altered fxn

1. ACTIVITIES:a. Reassess client to update databaseb. Determine ns need for assistancec. Perform planned nsg interventionsd. Communicate what nsg actions were implementede. Document care and client response to caref. Give verbal reports as necessary

VI. 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 outcomesb. compares that data to the desired outcomes in order to judge

whether the goals/outcomes have been achievedc. relates nsg activities to the clients outcomesd. draws conclusions about the problems statuse. critiques each step of the nsg processf. decides whether to modify, continue, or terminate the care plang. documents achievements of outcomes and makes modifications


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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 sugarb. Fructose – fruit and honey sugarc. Galactose-

2. 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 sugarb. Maltose- glucose + glucose – not found in foodsc. Lactose- milk sugar, glucose and galactose

ii. Complex Carbohydrates:1. Are polysaccharides. Consists of:

a. Starch- stored in plantsb. 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 weightb. The Functions of Carbohydrates:

i. Glucose metabolism- which provides energy for the body cellsii. Brain totally dependent on glucose for energy

iii. Carbs provide 4 cal/giv. 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 cellsv. 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 beansi. Natural and added sugars, Starch, Fibre


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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 bodyiii. 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.

Thrombinvii. 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).

III. 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.

IV. 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.V. 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.VI. SOURCES OF PROTEINS:

a. Meatb. Fishc. Poultry and eggsd. Milk and dairy products


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e. soyf. 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 lifec. 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 lightii. Vitamin. D- maintains serum calcium by stimulating GI absorption, release Ca2+

from bonesiii. Vitamin. E- stimulates Ca2= re-absorption from kidneysiv. Vitamin. K- synthesis of blood clotting proteins and a bone protein that

regulates blood calciume. Water Soluble Vitamins - Need to be eaten everyday: all are coenzymes in energy

metabolismi. Thiamine (Vit. B1)- promotes normal appetite and nervous system fxn

ii. Riboflavin (vit B2)- aids conversion of tryptophan into niaciniii. Niacin (vit B3)- promotes normal nervous system fxniv. 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 characteristicsvi. Vit. B12- coenzyme synthesis new cells, activates folate, maintains nerve cells,

helps metabolize some fatty acids and a.avii. Pantothenic acid- part of co-enzyme A....used in energy metabolism

viii. Biotin- fatty acid synthesis, a.a metabolism, glycogen formationix. Vitamin C-collagen synthesis, antioxidant, promotes iron absorption, involved in

the metabolism of certain a.a, thyroxin synthesis and immune system fxnx. Vitamin supplements are not necessary in healthy people who eat a variety of

nutritious foodsA. WATER:

a. Fxns of water: Provide shape and structure to cellsRegulate body temperatureAids in the digestion and absorption of nutrientsTransports nutrients and O2 to cellsServes as a solvent for vitamins, minerals, glucose and a.a.


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Participates in metabolic rxsEliminates watsIs 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).VIII. 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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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.

IX. 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.

X. CULTURE & NUTRITION:a. Different cultures have different views on what body types are attractiveb. 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.XI. OBESITY:

a. Normal weight---is that whish is statistically correlated to good healthb. 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 resistanceii. Type II diabetes

iii. HTNiv. Dyslipidemiav. Cardiovascular dx

vi. Strokevii. Gallstones and cholecystitis

viii. Sleep apneaix. Respiratory dysfxnx. 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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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.

XII. 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 formd. 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

XIII. 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:


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i. Attain and maintain optimal metabolic controls- glucose, blood lipids levels and BP

ii. Prevent, delay or treat complicationsiii. 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 amountsiv. 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 caloriesvii. Monounsaturated fat- use more monounsaturated fat and less carbs—levels

should be based on weight and lipid levels. Trans fat-keep lowviii. Cholesterol- limit to <300mg/dL

ix. Alcohol- limit to 2 drinks /day and consume with food to avoid hypoglycaemiax. Vit. and mineral supplementation is not recommended unless deficient.

XIV. 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.

XV. MEAN’S HEALTH ISSUES:a. Have shorter life span—partially due to greater risk takingb. Generally drink and smoke more than women, less physically active, do not need

medical care as oftenc. Leading causes death: heart dx, CA, unintentional injuries, stroke, chronic resp. Dx,

diabetes, influenza and pneumonia, suicide, kidney failure and chronic liver dx.XVI. 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

XVII. NANDA: (and many more)a. Imbalanced nutrition: Less/More than body requirementsb. Readiness for enhanced nutritionc. Risk for imbalanced nutrition: Less/more than body requirements

XVIII. COMMON FECAL ELIMINATION PROBLEMS: a. Constipation- less than three bowel movements a week


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i. What contributes to this? 1. Insufficient fibre and fluid intake2. Insufficient activity or immobility3. Irregular defecation habits4. Change daily routine5. Lack of privacy6. Chronic use laxative/enemas7. Emotional disturbances8. 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 defecate2. Rectal pain3. Liquid feces seepage4. Malaise, nausea or vomiting5. Anorexia6. Distended abdomen

XIX. Digital removal fecal impaction:--use an oil retention enema first and hold 30minc. Obtain assistance if indicatedd. Ask client assume left sided position with knees flexede. Place bedpan under buttock and a bedpan nearbyf. Drape clientg. Put on CLEAN glovesh. Gently insert index finger moving along length rectumi. Loosen stool by gently massaging around it...work the finger into the hard massj. Work stool downward, periodically take vitalsk. Following disimpaction, assist client get cleaned up and then put them on a bedpan

or commodeXX. 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 defecation2.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 peristalsis2. When client has urge defecate, assist to commode (note time between

insertion suppository and urge defecate)3. Give privacy and time limit- 30-40min4. Teach client lean forward, apply pressure to abdomen, and bear down

4.Give positive feedback5.Offer encouragement.

XXI. DATA COLLECTION:c. Database- all the information about a client


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d. Subjective data- a.k.a symptoms or covert data, are apparent only to the person affectede. Objective data-a.k.a signs or overt data, are apparent by an observer. They can be

measured or tested against accepted standardsf. Interview- a planned communication or conversation with a purpose

XXII. 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 therapy1. 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

XXIII. 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 sourced. Family and support personse. Healthcare team membersf. Medical recordsg. Other records ex. Laboratory recordsh. Literature review-ex. Nsg, medical, pharmacological about the clients illnessi. 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 datac. Personal passwords, not leaving computer unattended or with clients info displayed

when visitors presentd. 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


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c. Trade(brand) name- name given by the manufacturer of the drug and ownerd. Official name- name listed in the U.S Pharmacopeia-NF

XXVI. ACTIONS OF DRUGS ON THE BODY:XXVII. There are three general principles of drug action:

1. Drugs only modify the bodies existing functions2. Drugs have multiple actions rather than a single action3. A drug response is the result of a physiochemical interaction

between the drug and molecules in the body

XXVIII. 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 ½.

XXIX. 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 absorptionDrug half-life- time required for drug to be metabolized to ½ concentrationPlateau- a maintained concentration of a drug in the plasma during a series

of scheduled doses.XXX. PHARMACODYNAMICS ( How drugs work on the body):

Drug effects on the body. 3 types of interactions:Drug-receptorDrug-enzymeNonspecific drug interaction.

XXXI. PHARMACOKINETICS: (Drug movement through the body):a. It is the study of the absorption, distribution biotransformation and

excretion of drugsAbsorption- 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 actionBiotransformation (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

XXXII. 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)


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B. Mucus Membrane:i. Sublingual- should not be swallowed

ii. Buccal- can have local or systemic effectC. Parenteral: other than by alimentary tract

i. Subcutaneous (SQ)- into sub-q tissue below skinii. Intramuscular (IM)- into a muscle

iii. Intradermal (ID)-under the epidermisiv. Intravenous(IV)-into a veinv. Topical: applied to circumscribed area of body ex. Dermatologic

preparations, irrigations and instillations, as well as inhalations.XXXIII. ADMINISTERING MEDICATIONS SAFETLY:

A. Guidelines administering meds:1. Nurses who administer meds are responsible for own actions,

question all incorrect or illegible orders2. Be knowledgeable about meds3. Keep narcotics and barbiturates locked up4. Use only meds clearly marked5. Do not use liquid meds that are cloudy6. Calculate drug dosage accurately, always double check7. Administer only meds personally prepare8. Before administration I.D client9. 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 meds12. When a med is omitted, document the reason why13. When a med error is made, report it immediately to the charge

nurse or PCPB. Administering meds:

1. I.D client and inform client of med about to take2. 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 indicated4. Record the drug administered5. Evaluate the client’s response to the drug

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

Ten Rights:

Right med Right dose Right time Right route Right client Right education-explain med to

client


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XXXIV. INJECTIONS SITES: Intradermal, Subcutaneous, Intramuscular, Intravenous1) 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 angle2) 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 angle4) Always administer injections with the bevel up.5)

XXXV. Drugs given sub-q=vaccines, insulin and heparinI. 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

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

Ten Rights:

Right med Right dose Right time Right route Right client Right education-explain med to

client


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XXXVII.

XXXVIII.


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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 urine2. To determine disorders of glucose metabolism ex. Diabetes

mellitus3. 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 dipsticki. 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 urined. 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 fluidsb. Acidify urine eating eggs, cheeses, meat, whole grains, tomatoes etcc. Do routine perineal cared. only change catheter if sediment presente. 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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II.

III.


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IV.

V.


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VI.

I. Nsg dx related to urinary elimination: Impaired urinary elimination.

The inside of the glove may be touched with the bare hand

Grasp the first glove at the top edge of the folded-down 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


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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 artery2. Tympanic3. Oral4. Axillary5. 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. Age2. Stress3. Exercise4. Medications5. Diurnal patterns6. Environment7. Fever8. Positional changes9. Pathology

D. When assessing Pulse: use the palpatory method1. Rate-regular or irregular2. Rhythm-the pattern of beats and intervals between beats3. Volume- the strength of beat.4. Arterial wall elasticity- are they flat or do they feel twisted


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E. Procedure:1. Palpate the radial artery of one limb for 1 minute2. 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:


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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 diastolic-

pressure exerted when ventricles are at rest.C. Normal: S<120mmHG, D<80mmHgD. Hypertension is a BP greater than normalE. Hypotension is a BP less than normal.F. What determines BP?

1. The pumping action of the heart2. Blood volume3. Blood viscosity4. Vascular resistance

G. Factors influencing BP:1. Age2. Race3. Gender4. Obesity5. Stress6. Medications7. Dx processes8. Exercise9. Diurnal variation

H. Korotkoff’s sounds: 5 phases1. Phase1: initial tapping phase heard on auscultation=systolic pressure2. Phase 2: muffled sounds, gentle whooshing3. Phase 3: sounds become clearer and crisper4. Phase 4: sounds muffled again5. Phase5: level at which no sound is heard=diastole

I. Common mistakes taking BP:1. Cuff to large/small2. Bp retaken to soon3. Cuff to loose/tight4. Arm not level with the heart/supported5. Haste on part of hcp and unconscious bias6. Deflating cuff to quickly/slowly7. Failure I.D ausculatory gap8. 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


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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 occurrenceC. ABCDE of Pain:

a. A- ask often if in painb. B- believe the patientc. C-chose a pain control methodd. D-deliver interventions in a timely mannere. E-empower the patient and enable them to control

D. Phases of pain:a. Acute- temporary but sudden onsetb. Chronic- last longer than 6mnths and unresponsive to txc. Anticipatory- related to invasive procedures, influence

anxietyE. Should be assessed every time take vitalsF. Characteristics of pain to assess:

a. Onset and duration b. Locationc. Severity on a scale of 1-10d. Quality (what does it feel like)e. Pain patternf. What relieves the pain and what makes it worse


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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

painb. Developmental- infants, children and women often

undertreatedc. Environment and support people- with increase in outpt

.services, families increasingly responsible for pain management

d. Past pain experiences alters a persons sensitivity to paine. 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 communityB. Demonstrate safety practices.C. Experience a decrease in the frequency or severity of injuryD. Describe methods to prevent specific hazardsE. Report use of home safety measuresF. Alter home physical environment to reduce risk of injuryG. Describe emergency procedure for poisoning and fireH. Describe age specific risks, work safety risks, or community safety risksI. Demonstrate correct administration of CPR

Interventions:A. Educate the adult and elderly about safety hazards

a. Encourage elderly to get regular vision checksb. Ensure adequate lighting at nightc. Employ use smoke detectorsd. Remove all unsafe objectse. Encourage elderly home hazard appraisalf. Encourage elderly to remain as active as possible


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Relate the Following to Application of Restraints:

A. Alternatives to restraints:1. Work in pairs, one nurse to watch when other leaves the unit2. Place unstable clients near nurses station for close observation3. Prepare clients before any moves4. Stay with client using bedside commode or bathroom5. Monitor all meds and attempt to lower or eliminate sedatives or

psychotropic’s6. Position bed at lowest level7. Use ¾ length side rails8. Wedge pillows or pads against sides of wheelchairs to keep upright9. Use environmental restraints like furniture and plants to keep them

from wandering where you don’t want them to goB. 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

temporaryb. Ensure primary care giver gives order within 24hrsc. Apply restraint in such a way that client can still move freelyd. Secure restraint, but not tight enough to impede blood flowe. Do not tie to side railsf. Use a knot to tie but not a double knot, knot must be able to release

quicklyg. Assess restraint and skin integrity regularly, and proved ROMS q2hrsh. Assess and assist with basic needs: nutrition, hydration, hygiene,

eliminationi. When restraint is removed temporarily, do not leave client unattendedj. 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 periodc. Restraints should be used only after all other means of ensuring safety

have been unsuccessfuld. Documente. Provide ROM exercises


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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. Dependent edema

J. 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


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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 client’s 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 client’s 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 diagnosisb. 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:


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D. PLANNING PROCESS:1. Set Priorities - life threatening problems have top priority ex. Loss resp/cardiac fxn

are high priorityi. 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=client2. 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 dxb. 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, domains2. Level 2, classes3. 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)


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c. Terms:i. Cognitive skills- include problem-solving, decision making, critical

thinking and creativityii. 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 shear2. Immobility3. Inadequate nutrition4. 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.


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Documents

NSG Fundamentals Final Exam Review Guide1