Medical/Surgical Nursing: Lecture 1 Handout

I. Introduction Medical Surgical Nursing A. Care of ______during ______B. Goals: Promote & maintain ______Alleviate ______C. Nurses: “Focus on the clients ______to actual or ______disruption in health” II. 5 Core competencies A. Provide ______care A.1. ______A.2. ______A.3. ______& ______A.4. Relieve ______B. Working in ______teams B.1. C______B.2. C______B.3. Collaborate C. Using ______practices C.1. Clinical ______D. Appling ______improvement principles D.1. ______D.2. ______D.3. Quality A______E. Using information ______III. Nursing Process A. Introduction A.1. A ______method of providing ______to clients A.2. Allows nurses to ______plans and activities A.2.a. ______A.2.b. Other ______care providers A.2.c. ______A.3. Encourages ______thought, analysis, planning A.4. Purpose: to provide client care that is: A.4.a. ______A.4.b. ______A.4.c. ______A.4.d. ______A.5. Consists of ______steps A.5.a. ______on each other; not ______006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 1 A.6. Used throughout the ______spans in ______care setting IV. Small Group Questions A.1. Describe the steps of the nursing process? A.2. What is the purpose of the nursing process? A.3. In what clinical setting is the nursing process used? B. Assessment: Step # ____ B.1. Involves B.1.a. ______, ______, ______, ______, ______data B.2. Purpose of assessment is ______collection B.3. Types of assessments B.3.a. ______B.3.a.a. Base______B.3.a.b. ______& psychosocial B.3.b. ______B.3.b.a. ______in scope B.3.b.b. Screening for a ______problem B.3.b.c. ______stay B.3.c. ______B.3.c.a. Follow - ______B.3.c.b. Monitoring and observing ______B.4. Types of data B.4.a. ______B.4.a.a. Data from the ______viewpoint: ______B.4.b. ______B.4.b.a. Observable & ______B.4.b.a.i. ______B.4.b.a.ii. ______B.4.b.a.iii. ______tests C. Diagnosis: Step # _____ C.1. “A clinical ______about individual, family or community responses to actual or ______health problems/ life processes.” C.2. The bases for selection of nursing ______to achieve outcomes for which the nurse is______. Medical Diagnosis Nursing Diagnosis Identifies conditions the ______is Identifies situation the ______is licensed and licensed and qualified to treat qualified to treat Focuses of ______, injury or disease Focuses on the clients ______to actual 006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 2 processes or potential health / life problems Remains ______until a cure is effected ______as the clients responses and or the health problem changes

D. Planning & Outcome identification: Step # ______D.1. Types of planning D.1.a. ______, ongoing, ______D.2. Identifying outcomes: ______D.2.a. Short term goals: ______D.2.b. Long term goals: ______D.3. Developing specific nursing interventions D.3.a. ______dependent Nursing interventions:______D.3.b. ______dependent Nursing interventions:______D.3.c. ______dependent Nursing interventions:______D.4. Prioritizing the nursing diagnosis D.4.a. ______hierarchy of needs D.4.a.a. ______: breathing, food, water, sleep, homeostasis, excretion D.4.a.b. ______: security of body, employment, recourses, morality, family, health, property D.4.a.c. ______: Friendship, family, sexual intimacy D.4.a.d. ______: Self-esteem, confidence, achievement, respect D.4.a.e. ______: Morality, creative, spontaneous E. Implementation: Step #______E.1. ______of the care plan E.1.a. ______perform the plan, assist, ______, delegate, ______, monitor F. Evaluation: Step # ______F.1. Have the client’s ______have been met, partially met, or not met V. Role of the LVN A. Use the nursing ______B. ______to the diagnosis C. The ______has ultimate responsibility

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 3 D. RN’s can work ______LVN’s work In ______with RN’s E. Provide ______& ______F. Multiple Roles F.1. ______F.1.a. Provide ______, individual assistance F.2. ______/ Leader F.2.a. ______care F.2.b. Manage ______, ______, environment F.2.c. ______F.3. ______F.3.a. “One who ______for another” F.3.b. Protect the client’s ______F.3.b.a. ______F.3.b.b. ______F.3.b.c. ______F.3.b.d. ______F.4. ______F.4.a. Who? ______F.4.b. What? ______promotion, ______prevention F.4.c. Why? ______of care F.4.d. How? ______VI. Critical Thinking A. “A goal-directed thinking in which a person attempts to use cognitive ______and ______to determine the best overall result or choose the best ______, given the particular circumstances.” VII. Nurse-Patient Relationship A. Professional ______“The ______maintained between a person who is vulnerable ______& the person with power______” VIII. Communication A. Convey A.1. ______, ______, Caring, & ______B. Establish the ______C. ______communication D. Interviewing techniques D.1. ______D.2. ______006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 4 D.3. ______- ended questions D.4. ______D.5. Clarification IX. Health-Illness continuum: The individuals stat of health is one of continual ______X. Culture/ race/ ethnic groups/ prejudice A. Culture B. Ethnic group C. Ethnocentrism D. Prejudice E. Race E.1. ______“A group of people who share and are unified by experiences and background based on such factors as socioeconomic status, religion, education and residence.” E.2. ______“Belief that their own cultural group’s beliefs and values are the only acceptable ones” E.3. ______“Is the learned behavior, values, beliefs, norms, and practices shared by a particular group of people that guide their thinking, decisions and actions” E.4. ______“The act or state of holding unreasonable preconceived judgments or convictions.” E.5. ______“To identify differences in physical characteristics, such as skin color, eye shape and bone structure.” F. Cultural Respect: Nurses must be F.1. ______, ______, ______G. 6 Cultural Characteristic G.1. ______G.2. ______G.3. ______orientation G.4. ______G.5. Environmental ______G.6. ______variations XI. Religious Care Considerations A. Islam: A.1. ______, washing, privacy A.2. Caregivers of the same ______A.3. Food: Do not eat ______A.4. Fasting: ______B. Judaism B.1. Sabbath: ______006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 5 B.2. Food: ______, do not eat ______C. Hinduism C.1. Food: ______do not eat ______D. Catholic: D.1. No ______on Fridays D.2. Icons: D.3. Anointing for ______and ______E. The Church of Jesus Christ of Latter-day Saints/ Mormon E.1. Food: Do not eat______E.2. Wear special ______F. Methodist/ Lutherans F.1. Anointing G. Assemblies of God G.1. Pray & Laying on of ______for healing H. Jehovah’s Witness H.1. NO ______transfusions H.2. Do not ______holidays I. 7th day Adventist I.1. Food: Do not eat: ______, ______, ______I.1.a. Vegetarians I.2. Sabbath: ______J. Christian Science: J.1. Do not ______traditional medical treatment J.2. Avoid ______XII. Inflammation A. “Non-______response to injury A.1. ______harmful agents A.2. Limits ______A.3. Begins to ______B. Body’s first line of Defense:______& ______membranes XIII. Pathophysiology of Inflammation A. 3 step process A.1. ______response A.1.a. Vessels ______ release of chemical mediators A.1.a.a. ______, bradykinin, prostaglandins A.1.b. ______blood flow  A.1.b.a. ______& ______

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 6 A.1.c. ______hydrostatic pressure  A.1.d. Capillaries ______fluids into surrounding tissue  ______A.2. ______response A.2.a. ______blood flow  ______WBC A.2.a.a. Neutrophils: Blood ______ Injured tissue A.2.a.a.i. “ Diapedesis” A.2.a.b. Monocytes  ______A.2.a.b.i. ______harmful bacteria & Dead tissue A.2.a.b.ii. “PHAGOCYTOSIS” A.2.a.c. Neutrophils A.2.a.d. Dead bacteria ______formation A.2.a.e. Tissue debris A.2.a.e.i. ______drainage A.2.a.e.i.1.Staphylococcus, Streptococci, neisseria A.3. ______and tissue repair A.3.a. Minor injury: ______process heals A.3.b. Major injury: A.3.b.a. ______cells are produced  ______tissue XIV. S&S of Inflammation A. 5 cardinal S&S A.1. ______AKA: ______A.2. Heat A.3. ______AKA: ______A.4. Pain A.5. Loss of ______XV. Geriatric consideration of Inflammation A. Conditions A.1. ______skin A.2. ______blood flow A.3. ______macrophages A.4. ______phagocytic activity A.5. ______can interfere with inflammation & healing B. Results: B.1. ______risk of injury B.2. ______wound healing B.3. ______resistance C. Diminished S&S

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 7 C.1. ______C.2. ______C.3. ______XVI. Acute vs Chronic A. Acute inflammation A.1. ______term reaction: Duration: ______B. Chronic inflammation B.1. ______onset: Duration: ______C. Delayed healing  C.1. Cellulites C.1.a. Inflammation that ______to the surrounding ______tissue C.2. Abscesses C.2.a. ______pockets C.3. Fistula C.3.a. Abnormal ______from one area to another D. Diabetes mellitus and inflammation D.1. ______risk of poor wound healing & ______D.2. High blood ______levels  D.2.a. ______phagocytic function D.2.b. ______capillaries E. Systemic manifestations of inflammation E.1. Enlarged ______LYMPHADENPATHY E.2. ______appetite E.3. ______E.4. ______heart rate: ______E.5. ______respiratory rate: ______E.6. ______WBC: LEUKOCYTOSIS E.7. Fever E.7.a. ______ chemicals “endogenous pyrogens”  E.7.b. ______- E.7.c. ______temperature set point E.7.d. Fever E.7.d.a. inhibits microorganism ______E.7.d.b. ______tissue repair E.8. Geriatric considerations of FEVER

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 8 E.8.a. Best indicator of systemic infection in the elderly: ______or change in ______function XVII. Diagnostic tests for inflammation A. WBC with differential A.1. ______leukocytes A.2. ______of WBC made up by each type A.3. Normal Total WBC: ______- ______mm3 A.4. > 10,000 mm3 = ______A.5. < 4,500 mm3 = ______(______infection) B. Erythrocyte sedimentation rate (ESR) B.1. Detects ______inflammation B.2. ______= inflammation C. C-Reactive Protein (CRP) C.1. Produced by the ______ bloodstream, during inflammation C.2. ______result = inflammation D. Cultures D.1. Culture blood or body fluids to determine if inflammation is due to infection XVIII. Medications for inflammation A. Antibiotics A.1. ______infection caused by ______A.2. ______infection: Prophylactic A.3. C&S done ______A.4. Teach client to ______B. Acetaminophen AKA: ______B.1. Not an ______inflammatory B.2. Analgesic: ______B.3. Antipyretic: ______C. Anti-inflammatory Agents C.1. Salicylates: C.1.a. e.g. ______Acetylsalicylic Acid (ASA) C.1.b. WARNING: Do not give to ______with ______or influenza  REYE’S syndrome C.2. (Other)Non-steroidal Anti-inflammatory Drugs C.2.a. e.g. : ______C.2.b. Action: C.2.b.a. Anti-______C.2.b.b. Anti-______C.2.b.c. ______

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 9 C.2.c. S/E C.2.c.a. ______irritation C.2.c.b. ______C.3. Corticosteroids C.3.a. Action: C.3.a.a. Anti-______C.3.a.b. Anti-______C.3.a.c. Anti-______C.3.b. Indications: C.3.b.a. Acute ______reactions C.3.b.b. ______inflammatory disease C.3.c. S/E C.3.c.a. ______wound healing C.3.c.b. ______& ______retention C.3.d. WARNING: C.3.d.a. ______effective dose C.3.d.b. Never stop ______: ______the dose XIX. Fluids & Diet with inflammation A. Healing requires A.1. Adequate ______A.2. Adequate ______A.3. Adequate ______B. Catabolism: ______C. Anabolism: ______D. Foods/nutrients that promote healing D.1. ______D.2. ______D.3. Vitamins & Minerals D.3.a. Vitamin ______: Capillary formation & tissue growth D.3.b. ______-complex: Wound healing D.3.c. Vitamin ______: collagen synthesis D.3.d. Vitamin ______: Blood clotting D.3.e. ______: immune health XX. Nursing process for inflammation A. ______A.1. Subjective / Objective data A.1.a. Vital Signs

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 10 A.1.a.a. P______A.1.a.b. T______A.1.a.c. BP ______A.1.a.d. R ______A.1.b. Circulation A.1.c. Skin check A.1.d. Edema A.1.e. Lymph nodes B. ______B.1. Pain B.1.a. Assess B.1.b. ______B.1.c. Encourage ______B.1.d. Apply: ______or ______B.1.e. Administer meds: ______B.2. Impaired tissue integrity B.2.a. Protect B.2.b. Clean B.2.c. Rest B.2.d. Movement B.2.e. Diet B.3. Risk for infection B.3.a. Monitor ______B.3.b. Culture B.3.c. Enc. Fluids B.3.d. Infection control measures XXI. Chain of Infection A. ______: A.1. Pathogen A.2. Virulence A.3. Invasiveness B. ______: Where the pathogen ______& ______C. A ______of exit from the reservoir D. Mode of ______D.1. ______contact D.1.a. ______–to – person D.2. ______contact D.2.a. Infected person to - ______- to – Person

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 11 D.2.b. ______transmission D.2.b.a. Large, ______droplets D.2.c. ______borne D.2.c.a. Small, ______particles carried by air- currents D.2.d. Vectors D.2.d.a. ______or animals that act and intermediate hosts E. ______or entry F. Susceptible ______F.1. ______F.2. ______F.3. Natural ______mechanisms XXII. Stages of infectious process A. Initial stage A.1. ______period. Pathogen is ______but no ______B. ______stage B.1. ______begin to appear: vague B.1.a. General malaise, Fever, Fatigue, Muscle ache C. ______stage C.1. Pathogens continue to ______& ______C.2. Obvious S&S: D. ______stage D.1. Infection is ______D.2. Tissue ______D.3. Symptoms ______E. Resolution E.1. Infection is ______from host E.2. ______S&S XXIII. Health associated infections : AKA ______infections A. High risk clients: B. Common sites B.1. #1: ______B.2. ______infections / wounds B.3. ______B.4. Bloodstream C. Common pathogens

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 12 C.1. Escherichia coli C.2. Staphylococcus aureus C.3. Group A streptococci C.4. Enterococcus XXIV. Resistant pathogens A. Causes A.1. Inappropriate use of ______B. Results B.1. Resistance & ______C. Methicillin-Resistant Staphylococcus Aureus (MRSA) C.1. Reservoir: ______membranes & ______tract C.2. Isolation: ______precaution D. Vancomycin-Resistant Enterococcus (VRE) D.1. Reservoir: ______& ______genital tract D.2. Isolation: ______precautions XXV. Diagnostic Tests for Infection A. WBC – differential B. Culture & Sensitivity B.1. Culture B.1.a. ______technique collect sample  Immediately take to lab B.1.b. Duration: ______B.2. Sensitivity B.2.a. Determine which ______are most effective against the identified pathogen B.2.b. Duration: ______C. Antibiotic peak and trough levels C.1. Monitors blood level of medication: ______range (Amount of drug needed to effectively ______pathogens while producing few ______effects) C.2. Peak : When medication is at its ______level in the blood stream C.2.a. IM______C.2.b. Oral______C.2.c. I.V. ______C.3. Trough: When medication is at its ______level in the blood C.3.a. right ______next dose XXVI. Medications to treat infection

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 13 A. Antimicrobials: Drugs able to ______or ______pathogens B. Types B.1. Antibiotics, Antifungal, Antiviral, Antiparasitic C. Antibiotics C.1. ______-spectrum antibiotics: Act against limited number of pathogens C.2. ______-spectrum antibiotics: Inhibit a wide variety of pathogens D. Prophylactic E. Super-infection XXVII. Infection Control & Prevention A. #1 ______B. Personal ______C. ______D. Standard precaution: D.1. Do not touch D.1.a. ______D.1.b. Body ______(except sweat) D.1.c. Non-intact ______D.1.d. ______membranes D.2. Hand washing D.3. Gloves / Gown / Mask D.4. Equipment D.5. Linen D.6. Needles / sharps D.7. Client resuscitation D.8. Respiratory hygiene E. Airborne precaution E.1. ______room & bath E.2. ______pressure room E.3. Keep door ______E.4. ______client during transportation F. Droplet Precaution F.1. ______room & bath F.2. Wear ______when within 3 feet of patient F.3. ______client if being transported G. Contact Precaution G.1. ______room & bath G.2. ______when entering the room

006f276c85e526dd3cbb949d903fe7c0.docx 4/8/2018 14 G.3. ______& gloves when giving direct care or touching surfaces G.4. Leave ______in the room G.5. Wash hands immediately after ______gloves

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