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NR224 FUNDAMENTALS FINAL EXAM STUDY GUIDE Nr224 Funds final exam prep Nursing Process < Assessment (data, health history, labs, etc.) < Diagnosis (NANDA) < Outcomes identification (SMART goal set) < Planning (nurse and pt. determine steps to reach goal) < Implementation (nurse and pt. take proper steps to reach the goal) < Evaluation (did it work?) < Infection Prevention and Control Clean technique: < Reduces risk of contamination, surfaces free of any dirt, dust, etc. < Clean gloves applied. < NG tube, ulcer wound care, etc. Principles of Sterile Field 1. A sterile object remains sterile only when touched by another sterile object. 2. Only sterile objects may be placed on a sterile field. 3. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. 4. A sterile object or field becomes contaminated by prolonged air exposure. 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. 6. Fluid flows in direction of gravity 7. The edges of sterile field or container are considered to be contaminated Protective Precautions: < PPE * Protective equipment- gown, gloves, scrubs Isolations: Barrier precautions (PPE) Standard Precautions (blood/mucus membrane) 1
NR224 FUNDAMENTALS FINAL EXAM STUDY GUIDE Isolation Precautions Airborne Droplet Contact < Equipped room with negative air flow referred to as an airborne infection < Tuberculosis, measles, chickenpox < Surgical mask when within 3 feet of the patient < Proper hand hygiene < Dedicated-care equipment < Pneumonia, measles, chickenpox < Gown and gloves < MRSA, VRE, diarrheal illnesses, open wounds, RSV Normal Vital Signs Vital Signs Normal Blood pressure 120/80 bpm 2 step method, manual, using cuff and stethoscope Pulse 60-100 bpm 30 seconds x2, apical 1 full minute Respirations 12-20 Count 30 x2, if abnormal count 1 full minute Temperature 98.6-100.4 2
NR224 FUNDAMENTALS FINAL EXAM STUDY GUIDE IMMOBILITY Activity and Exercise < Cane: cane on good side < Crutches: * Up the stairs: good foot first, crutch, then injured foot * Down the stairs: crutch first, then good foot * Sitting in chair: up with the good, down with the bad < Walker: grip upper bars, step, pick walker up to move forward, next step. Complications of Immobility 3 Metabolic Endocrine, calcium absorption, and GI function Respiratory Atelectasis and hypostatic pneumonia Cardiovascular Orthostatic hypotension Thrombus Musculoskeletal changes Loss of endurance and muscle mass and decreased stability and balance Muscle effects Loss of muscle mass Muscle atrophy Skeletal effects Impaired calcium absorption Joint abnormalities Urinary elimination Urinary stasis Renal calculi Integumentary Pressure ulcer Ischemia
NR224 FUNDAMENTALS FINAL EXAM STUDY GUIDE Prevent complication of immobility: < Educate patient, give exercise appropriate for patient, reposition patient, determine risk of patient falls, deep breathing technique IMMOBILITY ASSESSMENT Nursing Diagnoses < Patient assessment mobility focuses on ROM, gait, exercise, activity tolerance, and body alignment <

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