Fundamentals of Nursing Study Guide. 1005% Coverage & Mastery. Rated A+

Assessment: - ✔✔collecting vital signs, pain levels, other signs/ symptoms Diagnosis: - ✔✔nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis Planning: - ✔✔nurse comes up with cl ...

Assessment: - ✔✔collecting vital signs, pain levels, other signs/ symptoms Diagnosis: - ✔✔nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis Planning: - ✔✔nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks) Implementing: - ✔✔following through with plan that was developed for the patient Evaluation: - ✔✔goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient Normal range for temperature - ✔✔96.8-100.4 Normal range for pulse - ✔✔60-100 Normal range for respirations - ✔✔12-20 Normal range for BP - ✔✔100/60-140-90 Normal range for pulse ox. - ✔✔>95% SOLER - ✔✔sit close, observe, lean forward, eye contact, relax Types of pain - ✔✔acute, chronic, cancer, by inferred pathology, idiopathic Pain threshold - ✔✔level of stimulus needed to produce the perception of pain Pain tolerance - ✔✔amount of pain a patient endures without its interference of ADLs Factors influencing pain - ✔✔age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors Behavioral responses to pain - ✔✔clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction Pharmacological pain relief - ✔✔analgesics (NSAIDS & non-opioids, opioids, adjuvants) NSAIDS & non-opiates - ✔✔has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction, possible liver failure Opioids - ✔✔pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status Naloxone (Narcan) - ✔✔opiate antagonist, reverses opioid induced resiratory depression Patient Controlled Analgesia (PCA) - ✔✔client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses Anesthetics - ✔✔depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local Basal metabolic rate (BMR) - ✔✔energy needed to maintain life Carbohydrates - ✔✔main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey Proteins - ✔✔essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance Fats - ✔✔triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential Water - ✔✔comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids Vitamins - ✔✔essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight Minerals - ✔✔inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport Free Radical Theory - ✔✔presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products Erikson's 8 stages of development - ✔✔trust vs mistrust autonomy vs shame and doubt initiative vs guilt industry vs inferiority identity vs identity confusion intimacy vs isolation generativity vs stagnation integrity vs despair Pharmacokinetics - ✔✔the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions Medication absorption - ✔✔the passage of medication molecules into the blood from the site of administration factors that affect med absorption - ✔✔route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication meds are excreted through: - ✔✔kidney, liver, bowel, lungs, exocrine glands medication interactions - ✔✔when one med modifies the action of another Obese - ✔✔increased weight for height by 10% or more Morbid Obesity - ✔✔100% over weight for height Measurements for obesity - ✔✔waist size, BMI, ideal weight for height causes of obesity - ✔✔corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone management of obesity - ✔✔decreased food intake, increased physical activity definition of nursing - ✔✔an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems evidence based practice - ✔✔interventions nurses do that are based on evidence