NUR 155 FINAL EXAM STUDY GUIDE
Health Promotion- promoting good health. Patient isn’t sick. It’s a way of thinking and it a positive approach to wellness
Health protection- patient is already sick. Point is to stop potential health occurrence or insults to health
Maslow’s hierarchy o...
NUR 155 FINAL EXAM STUDY GUIDE
Health Promotion- promoting good health. Patient isn’t sick. It’s a way of thinking and it a
positive approach to wellness
Health protection- patient is already sick. Point is to stop potential health occurrence or insults
to health
Maslow’s hierarchy of needs- used to prioritize nursing diagnosis. ABCs most important is
physiological needs.
levels of prevention:
Primary prevention-focus on health promotion, protection against disease, precedes disease,
applied to generally healthy individual or groups (immunization, nutrition, stress management,
exercise, poison control, injury prevention)
,NUR 155 FINAL EXAM STUDY GUIDE
Secondary prevention-early detection of disease, intervention and health maintenance.
(screening, dental checkups, self examinations, nursing assessments and care provided)
Tertiary prevention- begins after illness, when defect or disability is fixed, or stabilized.
Restore to optimum level of functioning (support groups, teaching to identify or prevent
complications, physical or occupational therapy)
Infection control safety precautions:
- Standard Precautions- all patients, hand hygiene, gloves (mask, eye, and gown if
splash or spray), needles in sharps, handle soiled linens, equipment that is soiled
- Contact precautions- step up plus mask and private room (c-diff, MRSA,
shingles, hepatitis)
- Droplet- major difference, wear mask limit movement of patient, private room,
mask patient if moved- pneumonia, flu
- Airborne- N95 respiratory and AAIR room, TB
- Mixed precautions – private room
Nosocomial infections- Are classified as infections that originate in hospital. Develop during
stay or manifest after discharge. (HAIs) subgroup health-care associated infections. (CLBSI-
central line blood stream infection and CAUTI- catheter associated urinary tract infection)
- Inadequate hand hygiene, improper dressing change, contamination of drainage
system, improper catheterization, improper IV, tubing, site care and suctioning.
Vital signs
Body temperature, pulse, respiration and blood pressure, 5th one pain.
How often we assess vital signs, chiefly nursing judgments, depending on patient’s health
status or primary health care provider specific order.
• Body Temperature (98.6-99.5 normal adults)- reflects balance between heat
produced and heat lost from body. Core temperature- deep tissue. Surface
Temperature- skin or subcutaneous.
• Factors affect heat production: Basal metabolic rate, muscle activity, thyroxin
output increase), Epinephrine and sympathetic stress response(increase)Fever
(increase).
1. Age- infants are greatly influenced must be protected from extreme change. Older
adults 75 and up high risk of hypothermia (loss of fat, lack of activity, inadequate diet)
2. Circadian Rhythms- Diurnal. Lowest point is during sleep 4am-6am and highest
4pm- 6pm
3. Exercise- increase body temperature
4. Hormones- women usually fluctuate more than men because of progesterone.
5. Stress- sympathetic nervous system production of epinephrine or
norepinephrine increase metabolic and heat production
6. Environment- outside temperature or room
temperature. Regulation of body Temperature-
1. Shivering increases heat production
2. Sweating is inhibited to decrease heat loss
, NUR 155 FINAL EXAM STUDY GUIDE
3. Vasoconstriction decreases heat
loss Pyrexia- body above usual range
• Pyrexia, hyperthermia in lay terms means Fever.
• Febrile has fever, Afebrile one with out fever.
Intervention: Monitor vitals, assess skin color and temp, monitor white blood count,
dehydration, remove excess blankets, nutrition, fluids, measure input/output, dry clothing,
tepid sponge bath, oral hygiene to keep mucous moist, reduce physical activity, administer
antipyretics (meds that reduce level of fever).
Sites used for body Temperature:
• Oral- never after oral surgery, inaccurate if client just drank, ate or smoked
• Rectal- Core, very accurate, never after rectal surgery or diarrhea, hemorrhoids,
immune suppressed, clotting disorder. No longer used on in infants.
• Axillary- leave longer
• Tympanic- Core, fast right and left can differ presence of cerumen can affect reading
• Temporal- electronic variation in technique if
perspiration Types of fever:
• Intermittent- regular intervals between fever
• Remittent- stays high
• Relapsing- short febrile and days between
• Constant- not much variation
• Fever spike- really high then gone
fast Hypothermia- heat lost, below normal
limits
*Can be delegated to UAP but monitored by Nurse
Pulse- output of blood that enter the arteries with each ventricular contraction
• Compliance- arteries ability to contract and expand
• Cardiac output- stroke volume multiplied by heart rate.
• Peripheral pulse- located away from heart
• Apical Pulse- located on apex of hear 5th intercostal space mitral,
PMI Factors affecting Pulse
• Age- decreases with age (newborn is high)
• Sex- males lower
• Exercise- increase with activity, rate of professional athlete is less then average
person, greater cardiac strength
• Fever- increase/ response to lowered blood pressure from vasodilation
associated elevated body temp, increased metabolic rate
• Medication- some decrease and other increase
• Hypovolemia/dehydration-loss of blood or fluid
• Stress-sympathetic nervous system
• Position- standing or sitting increase
• Pathology- certain disease, impaired oxygenation, heart conditions
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