Post on 12-Jul-2015
What are the techniques in interviewing process.
Problem Seeking & Problem Solving, Direct &
Open-Ended Questioning
Basic components of the nursing health history.
Bio. Info.
Reasons for seeking hxcare
Pt. expectations
Past Hx
Nursing diagnostic involves four elements.
Analysis & Interpretation of data, Clustering of
Data, Identification of Pt. Problems, Formulation
of Nsg. Dx.
A hx care problem that is currently perceived by
the pt. or assessed by the nurse.
Actual Hx Care Problem
When planning, a nurse should consider the level
of potential pt. involvement, time limit and what?
Available Hx care system resources
In implementation of the NCP, what actions are
taken.
Assist Pt. on ADL, Counsel & support Pt. &
family, Guide Pt., Teach Pt. & Family, Provide
care to achieve NCP, Provide Environment that is
Interventions based on instructions or written
directives given by another professional.
Dependent Intervention
Interventions that the nurses carry out in
collaboration with another professional.
Interdependent Intervention
True or False. The NCP is modified as the Pt's
state of Hx changes and as needs for care changes.
True
In evaluation of NCP, outcomes of nursing
interventions maybe used for.
Malpractice suits
Staff Evaluations
Reviews
What are the enrivonmental fire safety
precautions?
Mark fire exits
Dont use elevator
Turn off O2 machines
What are environmental radiation safety
precautions?
Label radioactive materials
Limit time spent
Distance yourself from the source
What are environmental precautions for disposing
infectious wastes?
Needles should not be recapped, bent or broken
Yellow for infectious
Assessment of pt's response & further need of use
Half bow or safety knot & secured to the bedframe
or chair
Neurovascular, circulatory & skin integrity is
assessed in using restraints when?
Then removed at least every?
Neurovascular, circulatory & skin integrity is
assessed in using restraints when?
Then removed at least every?
Every 30 minutes
Removed @ least q 2 hrs. to promote circulation
In older adults, poisoning & overdose of
prescribed medz. will yield?
Diminished eyesight
Impaired memory
If lye, grease, petroleum or household cleaner is
ingested, a nurse should?
Never induce vomit especially to an unconscious
person
If vomit occurs, bring vomitus to CDC
Nosocomial infections can be transmitted by a
healthcare personnel by?
Improper handwashing
Unchanged gloves between clients
Diseases under transmission based precautions
are?
Measles
Chickenpox (varicella)
Disseminated varicella zoster
Droplet precautions diseases are?
Adenovirus, Influenza
Sepsis, Scarlet Fever
Epiglottitis, Mumps
Meningitis
Barrier protection for transmission based droplet
precautions is?
Placing client in private room or cohort client
Mask
Transmission based contact precautions diseases
are?
Clostridium Difficle
INFxN with multidrug resistant org.
Wound infections
Smallpox is a droplet type with S&S of fever, back
pain, vomiting, malaise, headache & papules that
turn into?
Smallpox is a droplet type with S&S of fever, back
pain, vomiting, malaise, headache & papules that
turn into?
Pustular vessicles in the face & extremities
Head tilt-chin lift is used in B.L.S. but if pt. has a
neck injury, what do you use?
Jaw thrust maneuver
In assessing for a pulse to an
infant < 1 yr old?
a child > 1 yr old?
Brachial (<1yr)
Carotid (>1yr)
For infants on B.L.S., chest compression is 1/2 - 1
inch deep @ least 100 times/min using?
2-3 fingers
Child 1-1.5 inches deep
For unconscious pregnant, a pillow or rolled
blanket is placed on the right side to?
Displace uterus to the left of the abdomen
Unconscious pregnant needing defibrilation should
have the paddles placed 1-rib higher than the usual
because?
Unconscious pregnant needing defibrilation should
have the paddles placed 1-rib higher than the usual
because?
Heart is displaced during pregnancy
This is used to convert ventricular fibrilation into a
perfusing rhythm?
Automated External Defibrillator
A surgeon is responsible for getting consent & a
nurse can be a witness provided the pt. understood
the procedures explained by the doctor. What is
the next step?
A surgeon is responsible for getting consent & a
nurse can be a witness provided the pt. understood
the procedures explained by the doctor. What is
the next step?
Document the witnessing of consent signing
In general anesthesia, solid & liquid foods are
withheld for?
6-8 hrs. prior
Local anesthesia - 3 hrs. prior
If client has a Foley catheter before surgery, it
should be emptied & document the?
Amount & characteristics of the urine
3 levels of moral development (premoral or
preconventional level, conventional level,
postconventional level).
3 levels of moral development (premoral or
preconventional level, conventional level,
postconventional level).
Lawrence Kohlberg
4 conservation principles (conservation of energy,
structural integrity, personal integrity, and social
integrity).
4 conservation principles (conservation of energy,
structural integrity, personal integrity, and social
integrity).
Myra Levine
5 hierarchy of needs (physiological, safety &
security, love & belonging, self esteem, self
actualization).
5 hierarchy of needs (physiological, safety &
security, love & belonging, self esteem, self
actualization).
Abraham Maslow
Adaptation model. Each person is a unified
biopsychosocial system in constant interaction
with changing environment.
Adaptation model. Each person is a unified
biopsychosocial system in constant interaction
with changing environment.
Sister Calista Roy
Believed that nurse helps patients meet a perceived
need that the patient cannot meet themselves.
Ida Jean Orlando
Cognitive development (sensorimotor, peri-
operational thought, concrete operations, formal
operations).
Cognitive development (sensorimotor, peri-
operational thought, concrete operations, formal
operations).
Jean Piaget
Conceptualized the behavioral system model. Each
person is composed of 7 subsystem (ingestive,
eliminative, affiliative, aggressive, dependence,
achievement and sexual).
Conceptualized the behavioral system model. Each
person is composed of 7 subsystem (ingestive,
eliminative, affiliative, aggressive, dependence,
achievement and sexual).
Dorothy Johnson
Health as expanding consciousness. Humans are
unitary beings in whom disease is a manifestation
of the pattern of health.
Health as expanding consciousness. Humans are
unitary beings in whom disease is a manifestation
of the pattern of health.
Margaret Newman
Health care system model. Nursing is concerned
with all the variables affecting an individual's
response to stress, which are interpersonal,
intrapersonal, and extrapersonal in nature.
Health care system model. Nursing is concerned
with all the variables affecting an individual's
response to stress, which are interpersonal,
intrapersonal, and extrapersonal in nature.
Betty Neuman
Human becoming. Emphasized free choice of
personal meaning in relating value priorities.
Rosemarie Rizzo Parse
Human caring model. Nursing is the application of
the art and human science through transpersonal
caring.
Human caring model. Nursing is the application of
the art and human science through transpersonal
caring.
Jean Watson
Humanistic nursing practice theory. Nursing is an
existential experience.
Josephine Paterson & Loreta Zderad
Identified 14 basic needs. Nurse functions to assist
client in performing activities contributing to
health, recovery, or peaceful death.
Identified 14 basic needs. Nurse functions to assist
client in performing activities contributing to
health, recovery, or peaceful death.
Virginia Henderson
Identified 21 nursing problems. Defined nursing as
service to individuals and families, therefore,
society.
Identified 21 nursing problems. Defined nursing as
service to individuals and families, therefore,
society.
Faye Abdellah
Interpersonal model. Nursing is an interpersonal
process of the therapeutic interactions between
sick and nurse.
Interpersonal model. Nursing is an interpersonal
process of the therapeutic interactions between
sick and nurse.
Hildegard Peplau
Presented grand theory of nursing. All persons are
caring and nursing is a response to unique social
call.
Presented grand theory of nursing. All persons are
caring and nursing is a response to unique social
call.
Anne Boykin & Savina Schoenhofer
Psychosexual theory (oral, anal, phallic, latent,
genital stage). Psychoanalytical theory (Libido is
the psychic reservoir of psychic energy, id, ego, &
superego).
Psychosexual theory (oral, anal, phallic, latent,
genital stage). Psychoanalytical theory (Libido is
the psychic reservoir of psychic energy, id, ego, &
superego).
Sigmund Freud
Psychosocial development (trust vs. mistrust,
autonomy vs. shame/doubt, initiative vs. guilt,
industry vs. inferiority, identity vs. role confusion,
intimacy vs. isolation, generativity vs. stagnation,
integrity vs. despair).
Psychosocial development (trust vs. mistrust,
autonomy vs. shame/doubt, initiative vs. guilt,
industry vs. inferiority, identity vs. role confusion,
intimacy vs. isolation, generativity vs. stagnation,
integrity vs. despair).
The science of unitary human beings. Human
beings are more than and different from the sum of
their parts.
The science of unitary human beings. Human
beings are more than and different from the sum of
their parts.
Martha Rogers
Transcultural nursing. Nursing is a humanistic and
scientific mode of helping a client through specific
cultural caring process.
Transcultural nursing. Nursing is a humanistic and
scientific mode of helping a client through specific
cultural caring process.
Madeleine Leininger
Machinery-type murmur throughout the heartbeat
in the left 2nd or 3rd interspace
Patent Ductus Arteriosus
What is the purpose of IV fluid therapy?
Maintenance, to replace or correct deficits, to
restore ongoing loss, for meds, nutrition,
phlebotomy, transfusions or blood product therapy.
What is the problem with using hypertonic fluids?
If done too fast will draw too much fluid into the
intravascular, dehydrating intracellular, especially
the brain?
What happens if you expand the intra Cellular
compartment too fast?
Deplete the intravascular, decreasing BP and
causing edema.
Why are crystalloid fluids called true solutions?
Because they can pass through semipermeable
membranes.
What three things can an LVN NOT do?
cannot hang, flush or change bags on a central line
even if certified.
What can an RN NOT do with a central line.
Cannot assign to LVN or supervise LVN with
anything to do with a central line.
How do you determine whether it is a central line
or a peripheral line?
Ask the doctor for an x ray order to determine.
Why do you need to be careful with LR and
dehydration?
It is hard for the renal system to process the
electrolytes.
What does the liver do to lactate? (LR)
It metabolizes the lactate to bi-carbonate which
buffers acidosis
What are two common uses for Normal Saline
(NS)?
To treat hyponatremia and intravascular
dehydration.
What is a problem with Hypotonic solutions?
Use too long and it will lower BP. It is low in
solutes so fluid will move out of the vascular
space.
What makes Hyper tonic fluids different than the
others?
It has more dissolved particles than body fluid.
What does a hypertonic fluid do?
It moves fluid out of the intracellular and
interstitial compartments into the intravascular.
What type IV line do you use with Hypertonic
dextrose saline?
10% solutions can go peripheral but all others 20%
and above must use a central line?
Why must most hypertonic dextrose saline
solutions be used with a central line?
Because the fluids are very irritating to veins.
Name some indications for TPN.
Non-function GI, Bowel obstruct., acute inflam,
colitis, Crohns, malabsorption, chemo, burns,
sepsis, ooncology, pancreatitis.
What is the consideration with IVs and glucose?
Must use the appropriate IV access for
concentration of glucose, must use pump, don't
play catch up, taper TPN, accu-checks, used
micron filters
Why do you monitor liver and renal function with
TPN?
To make sure that they are excreting electrolytes.
What are some potential complications with TPN?
Fluid imbalances, metabolic acidosis, liver
dysfunction, hyperglycemia and infection.
Decision making process
identify purpose, set criteria, weigh criteria, seek
alternatives, examine alternatives, project,
implement, evaluate
Nursing Care Classification (NOC) standardized
nursing language indicator
concrete observable state of behavior
Using Silence
Accepting pauses or silences that may last several
seconds or minutes without any verbal response.
Sitting quietly (or walking with PT) and waiting
attentively until client is able to put thoughts and
fments or questions that (a) encourage the client to
verbalize, (b) choose a topic of conversation, and
feelings into words
Sitting quietly (or walking with PT) and waiting
attentively until client is able to put thoughts and
fments or questions that (a) encourage the client to
verbalize, (b) choose a topic of conversation, and
feelings into words
Providing general leads
Using statements or questions that (a) encourage
the client to verbalize, (b) choose a topic of
conversation, and facilitate continued
verbalization.
"Perhaps you would like to talk about..." ; "would
it help to discuss your feelings?"; "and then...."; "I
know what you are saying"
"Perhaps you would like to talk about..." ; "would
it help to discuss your feelings?"; "and then...."; "I
know what you are saying"
Providing General leads (example)
Using specific and tentative
making statements that are specific rather than
general, tentative rather than absolute
"You scratched my arm" instead of "you are
clumsy as an ox" OR "you seem concerned about
mary" rather than "you don't care about mary"
"You scratched my arm" instead of "you are
clumsy as an ox" OR "you seem concerned about
mary" rather than "you don't care about mary"
Specific & Tentative (examples)
Open-ended question
ASKING BROAD QUESTIONS that lead or
invite the client to explore, elaborate, clarify,
define, and describe thoughts or feelings. Client's
answers are longer than 1 or 2 words
"I'd like to hear more about that"; "What brought
you to the hospital today?"; "you said you were
frightened yesterday, how are you feeling today?"
"I'd like to hear more about that"; "What brought
you to the hospital today?"; "you said you were
frightened yesterday, how are you feeling today?"
Open-ended question (example)
Client: "I couldn't manage to eat any dinner last
night- not even dessert" Nursing- "you couldn't
manage to eat any dinner last night- not even
dessert?"
Client: "I couldn't manage to eat any dinner last
night- not even dessert" Nursing- "you couldn't
manage to eat any dinner last night- not even
dessert?"
Restating (example)
Client: " I have trouble talking to strangers" Nurse
"You find it difficult talking to people you don't
know"
Client: " I have trouble talking to strangers" Nurse
"You find it difficult talking to people you don't
know"
Paraphrasing (example)
Seeking clarification
Making the clients overall meaning of the msg
understandable. It is used when paraphrasing is
difficult or when communication is rambling or
garbled. To clarify, the RN may restate the msg or
Nurse: "I'm puzzled" Nurse: "I'm not sure what
you mean by ___ Would you please repeat that
again?"
Seeking Clarification (example)
Perception Checking/ Consensual Validation
A method similar to clarifying that verifies the
meaning of specific words rather than the overall
message
C: "it just won't stop" N: "I'm not sure what you
mean - it won't stop" OR C: "my husband never
gives me presents" N: "He never gives you gifts
for your birthday or christmas?"
C: "it just won't stop" N: "I'm not sure what you
mean - it won't stop" OR C: "my husband never
gives me presents" N: "He never gives you gifts
for your birthday or christmas?"
Offering Self
Suggesting ones' presence, interest, or wish to
understand the client without making any depands
or attaching conditions that the client must comply
with to receive nurse's attention
"I'll stay with you till your daughter arrives"; "we
can sit here quietly for awhile, we don't need to
talk unless you would like to"
"I'll stay with you till your daughter arrives"; "we
can sit here quietly for awhile, we don't need to
talk unless you would like to"
Offering Self (example)
Giving Information
Providing, in simple and direct manner, specific
factual information the client may or may not
request. When information is not known, the nurse
states this and indicates how the nurse will obtain
"Your surgery is scheduled for 11am tomorrow"; I
don't know the answer to that, but I'll find out from
the unit manager, when she comes in"
"Your surgery is scheduled for 11am tomorrow"; I
don't know the answer to that, but I'll find out from
the unit manager, when she comes in"
Giving information (example)
"You trimmed your beard and mustache" OR "you
walked twice as far today with your walker"
Acknowledging (example)
Clarifying time or sequence
Helping the client clarify and event, situation, or
happening in relationship to time
It is a style or process of persuading a group of
people, usually his followers to attain a desired
objective.
It is a style or process of persuading a group of
people, usually his followers to attain a desired
objective.
Leadership
A leader that is chosen by the administration or a
group which are given the official capacity to act.
A leader that is chosen by the administration or a
group which are given the official capacity to act.
Formal / appointed / elected / designated
A leader that does not have official appointments
or designations but is usually chosen by the group
itself.
A leader that does not have official appointments
or designations but is usually chosen by the group
itself.
Informal
It states that leaders are born and not developed
because some people are born with characteristics
to be great.
It states that leaders are born and not developed
because some people are born with characteristics
to be great.
Great Man Theory
A person can be an effective leader if he has all the
intellectual, emotional, physical and other personal
traits of an effective leader.
A person can be an effective leader if he has all the
intellectual, emotional, physical and other personal
traits of an effective leader.
Trait Theory
He is a leader who makes other people feel better
in his/her presence which is an inspirational
quality that the leader possessed.
He is a leader who makes other people feel better
in his/her presence which is an inspirational
quality that the leader possessed.
Charismatic Theory
It states that there is no personality, traits to be a
good leader, but rather leadership is the
relationship that exists among people in a social
situation.
It states that there is no personality, traits to be a
good leader, but rather leadership is the
relationship that exists among people in a social
situation.
Situational Theory
A leader that can immediately resolve a sudden
crisis, emergency or critical situation.
Contingency Theory
A style where the leader makes all the decisions
and disallows his members to influence him.
Followers dislike this leader and leader has little
trust to his members. His aim is to develop Self.
Uses trial & error and a critic.
A style where the leader makes all the decisions
and disallows his members to influence him.
Followers dislike this leader and leader has little
trust to his members. His aim is to develop Self.
Uses trial & error and a critic.
A leadership style where it is loose and permissive.
His approach is "Do your own thing". His
reference is "You" and has the desire to develop
only "Friendship".
A leadership style where it is loose and permissive.
His approach is "Do your own thing". His
reference is "You" and has the desire to develop
only "Friendship".
Laissez-Faire
A leader whose authority is from the group. Gives
importance to participation, involvement and
development of the group. He is a helper and uses
"We" as his reference of leadership.
A leader whose authority is from the group. Gives
importance to participation, involvement and
development of the group. He is a helper and uses
"We" as his reference of leadership.
Democratic
A leadership style that uses repetition and tries to
develop the system as his objective. His reference
is "they" and acts as a ruler and a regulator type of
leader.
A leadership style that uses repetition and tries to
develop the system as his objective. His reference
is "they" and acts as a ruler and a regulator type of
leader.
Bureaucratic
A power whereby the leader has the official
capacity to exercise rights and demand obligations
from subordinates.
A power whereby the leader has the official
capacity to exercise rights and demand obligations
from subordinates.
Legitimate Powers
Teaching focused on Ego Body mutilation (pain)
believes illness is self caused & punitive
Preschooler (3-6yrs)
Teaching focused on Limited time Active
imagination (animistic thinking, fearful)
Preschool (3-6yrs)
Teaching focused on Reality Objectivity
Separation anxiety (tries to appear brave)
School Age (6-12yrs)
Teaching focused on Cause & effect Concrete
Information (passive coping strategy)
School Age (6-12yrs)
Teaching focused on Abstract hypothetical
thinking Logic & scientific principles
Adolescence (12-18yrs)
Teaching focused on Competency based learner
(can make decision personally & socially)
Young Adult (18-25yrs)
Teaching focused on Physical changes Alternative
lifestyle Sense of well developed (questions
achievements & contributions to family & society,
confident)
Teaching focused on Physical changes Alternative
lifestyle Sense of well developed (questions
achievements & contributions to family & society,
confident)
Middle Adult (25-45yrs)
Teaching focused on Cognitive & physical
changes No formal learning (decreased S.T.M.,
risk taking, easily fatigue)
Teaching focused on Cognitive & physical
changes No formal learning (decreased S.T.M.,
risk taking, easily fatigue)
Older Adult (45-death)
PRE-OPERATIVE CARE, a parent or a legal may
sign the consent of a MINOR, while the OLDER
client may need whom?
PRE-OPERATIVE CARE, a nurse can be a
witness in consent signing & document the same
only if the client understood surgeon's explanations
and the client?
PRE-OPERATIVE CARE, prepare ___
administration for malnourished, with protein or
metabolic deficiencies or cannot ingest food client.
PRE-OPERATIVE CARE (client teaching),
inform the client what to expect POST-OP like
pain & discomfort, and that he/she can request
what?
PRE-OPERATIVE CARE (client teaching),
instruct to do Deep Breathing & Coughing
Exercises, use of Incentive Spirometry for the
prevention of?
PRE-OPERATIVE CARE (client teaching),
instruction of let & foot exercises will prevent
what? Facilitate what?
PRE-OPERATIVE CARE (checklist), ensure the
client is wearing identification bracelet and assess
for what?
PRE-OPERATIVE CARE (checklist), ensure that
informed consent forms were signed for the
operative procedure and for what other reasons?
PRE-OPERATIVE CARE (checklist), ensure that
informed consent forms were signed for the
operative procedure and for what other reasons?
Blood transfusions, disposal of a limb, or for
surgical sterilization procedures.
PRE-OPERATIVE CARE (checklist), ensure that
history, P.E., consultation requests, prescribed
laboratory results, EKG, chest radiography are
documented & recorded plus?
PRE-OPERATIVE CARE (checklist), ensure that
history, P.E., consultation requests, prescribed
laboratory results, EKG, chest radiography are
documented & recorded plus?
Blood type, screened & cross matching is
PRE-OPERATIVE CARE (checklist), after
removing everything unnecessary, documented it,
kept or given to family members, the nurse must
document the?
PRE-OPERATIVE CARE (checklist), after
removing everything unnecessary, documented it,
kept or given to family members, the nurse must
document the?
Last time client ate or drank, voided before
PRE-OPERATIVE CARE (medications), instruct
client about the desired effects and then what?
Keep client in bed with side rails up.
PRE-OPERATIVE CARE (medications), after
administering medications, next to the client, place
what?
Call bell, instruct client not to get out of bed and
call for assistance if needed
PRE-OPERATIVE CARE (inside O.R.), after
verifying identification bracelet & verbal response,
the nurse will review chart and then confirm what?
PRE-OPERATIVE CARE (inside O.R.), after
verifying identification bracelet & verbal response,
the nurse will review chart and then confirm what?
Operative procedure & site
PRE-OPERATIVE CARE (inside O.R.), the
clients chart will be reviewed for completeness and
taking a note about what?
PRE-OPERATIVE CARE (inside O.R.), the
clients chart will be reviewed for completeness and
taking a note about what?
Allergic reactions information
POST-OPERATIVE CARE (immediate), monitor
airway patency & adequate ventilation because
prolonged mechanical ventilation during
anesthesia may affect what?
POST-OPERATIVE CARE (immediate), monitor
airway patency & adequate ventilation because
prolonged mechanical ventilation during
anesthesia may affect what?
Postoperative Lung function, extubated patients
POST-OPERATIVE CARE (immediate), the
client maybe unable to clear his/her airway, that is
why it is important to monitor what?
POST-OPERATIVE CARE (immediate), the
client maybe unable to clear his/her airway, that is
why it is important to monitor what?
Secretions
POST-OPERATIVE CARE (immediate),
encourage Deep Breathing & Coughing exercises,
monitor pulse oximetry, O2 administration and
then observer for?
POST-OPERATIVE CARE (immediate),
encourage Deep Breathing & Coughing exercises,
monitor pulse oximetry, O2 administration and
then observer for?
Chest movements for symmetry and use of
POST-OPERATIVE CARE (immediate), note
rate, depth & quality of respirations, RR should
be?
>10 and not <30 BPM
POST-OPERATIVE CARE (immediate), a breath
sound of stridor, wheezing or crowing indicates
what?
Partial obstruction, bronchospasm, laryngospasm
POST-OPERATIVE CARE (immediate), a breath
sound of crackles or ronchi may indicate?
Pulmonary Edema, monitor signs of Atelectasis or
Pulmonary embolism
POST-OPERATIVE CARE (immediate), check
capillary refill, assess the skin, peripheral pulses &
edema and monitor for bleeding. A bounding pulse
may indicate what?
POST-OPERATIVE CARE (immediate), check
capillary refill, assess the skin, peripheral pulses &
edema and monitor for bleeding. A bounding pulse
may indicate what?
Hypertension, Fluid overload, or excitement.
POST-OPERATIVE CARE (immediate), unless
contraindicated, client is placed on Fowler's
position after surgery to increase?
POST-OPERATIVE CARE (immediate), unless
contraindicated, client is placed on Fowler's
position after surgery to increase?
Size of the thorax for lung expansion
POST-OPERATIVE CARE (immediate), what
type of positioning is avoided if the pharyngeal
reflexes have not yet returned?
POST-OPERATIVE CARE (immediate), what
type of positioning is avoided if the pharyngeal
reflexes have not yet returned?
Supine
POST-OPERATIVE CARE (immediate), if
comatose or semicomatose, what type of
positioning?
Side lying & keep an oral airway in place.
POST-OPERATIVE CARE (immediate), assess
L.O.C., wake client periodically until awaken and
if awaken?
POST-OPERATIVE CARE (immediate), assess
L.O.C., wake client periodically until awaken and
if awaken?
Orient client to the environment in a soft tone
POST-OPERATIVE CARE (immediate), main
body temperature and prevent heat loss by?
Blanketing & raise room temperature
POST-OPERATIVE CARE (immediate), an
exposed skin, cool OR, or maybe from anesthesia
may result to?
Hypothermia, keep blanket on & continue O2 if
shivering
POST-OPERATIVE CARE (immediate), assess
surgical site, drains & wound dressings for?
Redness, abrasions or breakdown
POST-OPERATIVE CARE (immediate), record
I&O, monitor for Fluid & Electrolyte imbalance,
N&V, NGT patency, abdominal distention and the
return of what?
POST-OPERATIVE CARE (immediate), record
I&O, monitor for Fluid & Electrolyte imbalance,
N&V, NGT patency, abdominal distention and the
return of what?
Bowel sounds
POST-OPERATIVE CARE (immediate), how
many hours is it that the client is expected to void
urine after the surgery?
POST-OPERATIVE CARE (immediate), how
many hours is it that the client is expected to void
urine after the surgery?
6-8 hours, note color, quantity & quality
POST-OPERATIVE CARE (immediate), assess
for pain, PRE-OP & POST-OP medz, then inquire
about the type & location of pain by asking the
client to?
POST-OPERATIVE CARE (immediate), assess
for pain, PRE-OP & POST-OP medz, then inquire
about the type & location of pain by asking the
client to?
Rate the pain from 1-10, note facial expression,
POST-OPERATIVE CARE (immediate), inquire
effectiveness of last medication, if on a Narcotic
drug, assess every 30 minutes for?
POST-OPERATIVE CARE (immediate), inquire
effectiveness of last medication, if on a Narcotic
drug, assess every 30 minutes for?
RR & pain relief
POST-OPERATIVE CARE (intermediate),
monitor airway patency, encourage Deep
Breathing & Coughing exercises, monitor
circulatory status encourage the use of what?
POST-OPERATIVE CARE (intermediate),
monitor airway patency, encourage Deep
Breathing & Coughing exercises, monitor
circulatory status encourage the use of what?
Antiembolism stockings if not C/I
POST-OPERATIVE CARE (intermediate), assess
for mobility on all extremities & encourage early
ambulation by first sitting on the edge of the bed
with feet supported. But if client is unable to
move, what do you do next?
POST-OPERATIVE CARE (intermediate), assess
for mobility on all extremities & encourage early
ambulation by first sitting on the edge of the bed
with feet supported. But if client is unable to
move, what do you do next?
POST-OPERATIVE CARE (intermediate),
reinforce wound with sterile dressing if necessary
and always keep it?
POST-OPERATIVE CARE (intermediate),
reinforce wound with sterile dressing if necessary
and always keep it?
Dry & intact, notify physician if bleeding occurs
POST-OPERATIVE CARE (intermediate),
monitor I&O, N&V and if vomiting, have a
suctioning equipment available and ready to use.
NPO status is observed until?
POST-OPERATIVE CARE (intermediate),
monitor I&O, N&V and if vomiting, have a
suctioning equipment available and ready to use.
NPO status is observed until?
Gag reflex & peristalsis returns
POST-OPERATIVE CARE (intermediate), when
oral fluids are permitted, start with?
Ice chips & water, then advance to Clear Liquids
up to Regular Diet as prescribed
POST-OPERATIVE CARE (intermediate), after
NPO order is lifted, what do you assess for?
Bowel sounds on all four quadrants
POST-OPERATIVE CARE (intermediate), if with
Foley Catheter, client is expected to void within 6-
8 hours. Ensure that the amount is at least?
POST-OPERATIVE CARE (intermediate), if with
Foley Catheter, client is expected to void within 6-
8 hours. Ensure that the amount is at least?
200mL
POST-OPERATIVE CARE (extended), on this
stage, you monitor for signs of infection such as?
Redness, swelling, & tenderness at the surgical
site, fever & leukocytes
POST-OPERATIVE CARE (extended), the client
is advised to do R.O.M. exercises every 2 hours
and encourage ambulation to promote?
POST-OPERATIVE CARE (extended), the client
is advised to do R.O.M. exercises every 2 hours
and encourage ambulation to promote?
Peristalsis & passage of flatus
POST-OPERATIVE CARE (extended), the client
is encouraged to perform A.D.L. & eat foods that
will promote wound healing. What are the foods?
POST-OPERATIVE CARE (extended), the client
is encouraged to perform A.D.L. & eat foods that
will promote wound healing. What are the foods?
Protein & Vitamin C
Inflammation of the alveoli caused by an
infectious process that may develop as a result of
infection, aspiration or immobility?
Inflammation of the alveoli caused by an
infectious process that may develop as a result of
infection, aspiration or immobility?
Pneumonia, usually around 3-5 days
postoperatively
Collapse of the alveoli with retained mucous
secretions and is the most common postoperative
complication?
Collapse of the alveoli with retained mucous
secretions and is the most common postoperative
complication?
Atelectasis, usually around 1-2 days
postoperatively
POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Assessment / increase risk for
dyspnea/ elevated temperature/ productive cough/
and what more?
POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Assessment / increase risk for
dyspnea/ elevated temperature/ productive cough/
and what more?
Increased R.R. & chest pain
POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Nsg Inter / assess for lung & breath
sounds/ reposition client every 1-2 hour/ inc O.F.I.
/ early ambulation and what more?
POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Nsg Inter. / assess for lung & breath
sounds/ reposition client every 1-2 hour/ inc O.F.I.
/ early ambulation and?
Deep breathing & coughing exercises/ incentive
POST-OPERATIVE CARE (Hypoxia)
Assessment / cyanosis/ dyspnea/ hypertension/
tachycardia and what else?
POST-OPERATIVE CARE (Hypoxia)
Assessment / cyanosis/ dyspnea/ hypertension/
tachycardia and what else?
Restlessness & Diaphoresis
POST-OPERATIVE CARE (Hypoxia) Nursing
Intervention, monitor signs of hypoxia/ eliminate
cause/ monitor lung sounds/ administer oxygen/
D.B. & C. E. and what more?
POST-OPERATIVE CARE (Hypoxia) Nursing
Intervention, monitor signs of hypoxia/ eliminate
cause/ monitor lung sounds/ administer oxygen/
D.B. & C. E. and what more?
Monitor pulse oximetry & reposition client
It blocks the pulmonary artery and disrupts blood
flow to one or more lobes of the lung?
Pulmonary Embolism
POST-OPERATIVE CARE (Pulmonary
Embolism) Assessment / dyspnea/ cyanosis/
tachycardia and what more else?
POST-OPERATIVE CARE (Pulmonary
Embolism) Assessment / dyspnea/ cyanosis/
tachycardia and what more else?
Decreased blood pressure & sudden chest or upper
abdominal pain
POST-OPERATIVE CARE (Pulmonary
Embolism) Nursing Intervention / what is the first
thing that you should do?
POST-OPERATIVE CARE (Pulmonary
Embolism) Nursing Intervention / what is the first
thing that you should do?
1)Notify the physician 2)Monitor V.S.
3)Administer O2 & medications
POST-OPERATIVE CARE (Hemorrhage)
Assessment / restlessness/ hypotension/ cool,
clammy skin and what other else?
POST-OPERATIVE CARE (Hemorrhage)
Assessment / restlessness/ hypotension/ cool,
clammy skin and what other else?
Weak rapid pulse & reduced urine output
POST-OPERATIVE CARE (Hemorrhage)
Nursing Intervention / provide pressure to the site
of bleeding immediately and then what?
POST-OPERATIVE CARE (Hemorrhage)
Nursing Intervention / provide pressure to the site
of bleeding immediately and then what?
Notify the physician, administer O2, IV fluids &
blood as prescribed & lastly prepare client for
POST-OPERATIVE CARE (Shock) Assessment /
/ restlessness/ hypotension/ cool, clammy skin and
what other else?
POST-OPERATIVE CARE (Shock) Assessment /
/ restlessness/ hypotension/ cool, clammy skin and
what other else?
Weak rapid pulse & reduced urine output
POST-OPERATIVE CARE (Shock) Nursing
Intervention / elevate legs only if the client did not
have Spinal Anesthesia/ determine & treat cause of
shock/ administer O2/ monitor V.S., L.O.C./
monitor I & O. and what if the client had Spinal
Anesthesia?
POST-OPERATIVE CARE (Shock) Nsg Inter /
elevate legs (w/o Spinal Anes.)/ treat cause of
shock/ adm. O2/ monitor V.S., L.O.C./ monitor
I&O. & if client had Spinal Anes.?
Elevate legs not higher than pillow/ assess skin
Inflammation of a vein, leg veins commonly
affected, often accompanied by clot formation?
Thrombophlebitis
POST-OPERATIVE CARE (Thrombophlebitis)
Assessment / vein inflammation/ aching or
cramping pain/ elevated temperature and what?
POST-OPERATIVE CARE (Thrombophlebitis)
Assessment / vein inflammation/ aching or
cramping pain/ elevated temperature and what?
(+) Homan's Sign
POST-OPERATIVE CARE (Thrombophlebitis)
Nursing Intervention / monitor leg/ encourage
antiembolism stockings – removed 2x/day for
washing & inspection of leg/ give heparin sodium
or warfarin (coumadin)/ the leg is elevated by 30
degrees & do not?
Involuntary accumulation of urine in the bladder as
a result of loss of muscle tone?
Urinary Retention
POST-OPERATIVE CARE (Urinary Retention)
Assessment / inability to void/ restlessness &
diaphoresis/ lower abdominal pain/ distended
bladder and what else?
POST-OPERATIVE CARE (Urinary Retention)
Assessment / inability to void/ restlessness &
diaphoresis/ lower abdominal pain/ distended
bladder and what else?
Hypertension & Drumlike sound upon bladder
POST-OPERATIVE CARE (Thrombophlebitis)
Nursing Intervention / monitor voiding/ assess
distended bladder/ encourage inc. O.F.I./ provide
privacy and what?
Pour warm water on the perinium, allow pt to hear
running water then CATHETERIZE if all non
invasive attempts fail
Failure of appropriate forward movement of bowel
contents and maybe due to anesthetic medications
or manipulation of the bowel during the surgical
procedure?
Failure of appropriate forward movement of bowel
contents and maybe due to anesthetic medications
or manipulation of the bowel during the surgical
procedure?
Paralytic Ileus
POST-OPERATIVE CARE (Paralytic Ileus)
Assessment / abdominal distention/ absence of
bowel sounds, bowel movement or flatus, what is
the first indication of this condition?
POST-OPERATIVE CARE (Paralytic Ileus)
Assessment / abdominal distention/ absence of
bowel sounds, bowel movement or flatus, what is
the first indication of this condition?
Nausea & Vomiting immeidately postoperatively
POST-OPERATIVE CARE (Paralytic Ileus)
Nursing Intervention / monitor I & O/ maintain
NPO until bowel sounds return/ patency of NGT/
early ambulation/ administer IVF or TPN,
medications and what is the noninvasive action?
Caused by poor aseptic technique or a
contaminated wound before surgical exploration?
Wound Infection
POST-OPERATIVE CARE (Wound Infection)
Assessment / fever & chills/ edematous skin at
incision site & tight skin sutures/ increased WBC
and what is the order of the inflamed incision site?
POST-OPERATIVE CARE (Wound Infection)
Assessment / fever & chills/ edematous skin at
incision site & tight skin sutures/ increased WBC
and what is the order of the inflamed incision site?
1)Warm, 2)Tender, 3)Painful
POST-OPERATIVE CARE (Wound Infection)
Nursing Intervention / monitor temperature/
maintain patency of drains & note amount, color,
consistency/ change dressing/ give antibiotics and
what are the signs of infection?
POST-OPERATIVE CARE (Wound Dehiscence)
Nursing Intervention / low Fowler's position to
avoid abdominal tension/ cover with NSS dressing
and then immediately?
Notify physician & prevent wound infection,
antiemetics is given to avoid abdominal tension as
well, splint incision when coughing
Protrusion of internal organs through an incision.
Common on obese, with past abd. surgery or who
have poor wound healing.
Protrusion of internal organs through an incision.
Common on obese, with past abd. surgery or who
have poor wound healing.
Wound Evisceration, usually occurs 6-8 days after.
It is an Emergency
POST-OPERATIVE CARE (Wound Evisceration)
Assessment / serosanguinous discharge from dry
wound/ with loops of bowel or other abdominal
contents through the wound and the client is
reporting?
POST-OPERATIVE CARE (Wound Evisceration)
Assessment / serosanguinous discharge from dry
wound/ with loops of bowel or other abdominal
contents through the wound and the client is
reporting?
POST-OPERATIVE CARE (Wound Evisceration)
Nursing Intervention / Fowler's position/ cover
wound with sterile NSS and ?
POST-OPERATIVE CARE (Wound Evisceration)
Nursing Intervention / Fowler's position/ cover
wound with sterile NSS and ?
Notify DR & prevent wound infection, antiemetics
is given to avoid abdominal tension as well, splint
In ambulatory surgery, the criteria for client
discharge are the following, he/she is alert and
oriented/ has voided/ not in respiratory distress/
vomiting & in minimal pain and also the client is
able to?
In ambulatory surgery, the criteria for client
discharge are the following, he/she is alert and
oriented/ has voided/ not in respiratory distress/
vomiting & in minimal pain and also the client is
able to?
POST-OPERATIVE CARE (Discharging) assess
pt's readiness to learn, educ. level, & desire modify
lifestyle/ demo incision care/ written guide to pt &
family &?
POST-OPERATIVE CARE (Discharging) assess
pt's readiness to learn, educ. level, & desire modify
lifestyle/ demo incision care/ written guide to pt &
family &?
Instruct PT to cover incision with plastic when
ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS
and 1000 cc 0.9% NS to infuse over 24 hours.
DROP FACTOR: 12 gtt/ml
ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS
and 1000 cc 0.9% NS to infuse over 24 hours.
DROP FACTOR: 12 gtt/ml
25
ORDERED: An infant weighs 18 # has an IV of
500 cc 10% D/W to infuse over 24 hours. DROP
FACTOR: 60 gtts/ml
ORDERED: An infant weighs 18 # has an IV of
500 cc 10% D/W to infuse over 24 hours. DROP
FACTOR: 60 gtts/ml
20-21
Extracellular fluid (ECF)
fluid outside of a cell; divided into 3 parts,
Interstitial fluid, intravascular fluid, and
transcellular fluids
Electrolytes
minerals or salts; when melted or dissolved in
water it separates into ions and is able to carry an
electrical current
Osmosis
movement of a pure solvent, through a
semipermeable membrane, from an area of lesser
solute concentration to an area of greater solute
concentration to try to equalize concentrations on
Movement of a solute in a solution across a
semipermeable membrane from an area of higher
concentration to an area of lower concentration is:
Movement of a solute in a solution across a
semipermeable membrane from an area of higher
concentration to an area of lower concentration is:
diffusion
Filtration
water and diffusable substances move together in
response to fluid pressure, moving from an area of
higher pressure to an area of lower pressure
Hydrostatic pressure
movement of water from interstitial space into the
intravascular space by filtration
Osmoreceptors
continually monitor the serum osmotic pressure,
when osmolality increases, hypothalamus is
stimulated
ADH
Antidiuretic hormone; stored in pituitary gland;
works directly on kidney tubules and collecting
ducts making them more permeable which returns
water to systemic circulation
Aldosterone
released by adrenal cortex in response to increased
K+ levels; it increases the reabsorption of Na+ and
secretion of K+
Magnesium is essential for:
enzyme activities, neurochemical activities,
cardiac and skeletal excitability
Buffer
a substance or group of substances that can absorb
or release H+ to correct an acid-base balance
What is the largest chemical buffer in ECF?
carbonic acid and bicarbonate buffer system; reacts
to change in pH of ECF within seconds
Biological regulation
occurs when H= ions are absorbed and released by
cells, occurs only after chemical buffering and
takes 2-4 hrs
TPN or total parenteral nutrition
nutritionally adequate hypertonic solution of
glucose, electrolytes, and other nutrients given
through an indwelling or central IV
One reason older adults experience fluid and
electrolyte imbalance and acid-base imbalances is
they:
One reason older adults experience fluid and
electrolyte imbalance and acid-base imbalances is
they:
have a decreased thirst sensation
Output recorded on an I & O record includes:
urine, diarrhea, vomitus, gastric suction, and
drainage from wounds and tubes
Health promotion activities in the area of fluid and
electrolyte imbalances focuses primarily on:
client teaching
As a safety alert the RN is aware the following
med is never given directly through IV:
Potassium chloride, it will burn the vein
CDC recommends replacing peripheral venous
catheters and rotating sites should occur at least
every: