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Final Exam Study Guide

Module #1: Intro to nursing  Nursing is an art and a science which integrates and assimilates knowledge and skills derived from biological, physical, social, and behavioral sciences. o Science is the knowledge base. Nurses are concerned with the human response to the medical diagnosis. Characteristics of professional nursing: caring, commitment, accountability. Patricia Benner-Novice to Expert o Novice beginner with no experience  taught general rules to help perform tasks o Advanced Beginner Demonstrates acceptable performance  Has gained prior experience in actual situations to recognize recurring meaningful components.  Principles, based on experiences, begin to be formulated to guide actions. o Competent Typically a nurse with 2-3 years’ experience on the job in the same area or in similar day-to-day situations  More aware of long-term goals  Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization o Proficient Perceives and understand situations as whole parts  More holistic understanding, improves decision making  Learns from experience what to expect in certain situations and how to modify plans o Expert No longer relies on principles, rules, or guidelines to connect situations and determine actions  Much more background of experience  Has intuitive grasp of clinical situations  Performance is now fluid, flexible, and highly-proficient

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Module #2: Health Care Systems

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4 Components: People, Settings, Regulatory Agencies, Health Care financing Mechanisms Peopleo Participants in the health care system  RN’s, LPN’s, Medical doctors, pharmacists, dentists, dietitians, physical, respiratory, and occupational therapists, assistive personnel. Settingso Where health care is provided  Hospitals, homes, skilled nursing facilities, assisted living, community/health departments, adult day care centers, schools, hospices, provider’s offices, ambulatory care clinics, occupational health clinics. Regulatory Agencieso Where regulations for practice are enforced  US Department of health and human services  US food and drug administration  State and local public health agencies  State licensing boards  To ensure that health care providers and agencies comply with state regulations  The Joint Commission  To set quality standards for accreditation of health care facilities  Professional Standards Review Organizations  Utilization Review Committees  To monitor for appropriate diagnosis and treatment of hospitalized clients. Health Care Financing Mechanisms o Federally funded programs:  Medicare-65+ or permanent disabilities.  Insurance program-Reimburses providers based on DRG’s.  Managed care organizations (MCO’s)-Enrolled clients receive comprehensive care overseen by a primary care provider.  Medicaid-clients with low incomes.  Federally funded. State regulated. o Private plans:  Traditional insurance reimburses for services on a fee-for-service basis.  Managed Care Organizations-Comprehensive care is overseen by a primary care provider and focuses on prevention and health promotion.

Using non-contracted providers increases the clients out of pocket costs. A nurse has volunteered to give influenza injections at a local clinic. Exclusive provider organizations-The client chooses from a list of providers within a contracted organization. air bags.   Preferred provider organizations-The client chooses from a list of contracted providers. Long-term care insurance-This provides for long-term care expenses not covered by Medicare. What level of care is he demonstrating? Primary . bike helmets) Secondary Care (problem trying to solve) o Emergency care o Acute medical-surgical care o Radiological procedures Tertiary Care (specialized facility) o Intensive care o Subacute care Restorative Care (bring back to what might have been) o Cardiovascular and pulmonary rehabilitation o Sports medicine o Spinal cord injury programs o Home care Continuing Care o Assisted living o Psychiatric and older adult day care EX.      Primary Care (Health Promotion) o Prenatal care o Well-baby care o Nutrition counseling o Family planning o Exercise classes  Preventive Care  Blood pressure and cancer screening  Immunizations  Poison control information  Mental health counseling and crisis prevention  Community legislation (seat belts.

HIPAA o State Regulation/Licensure: DHHS. DHSR o Utilization Review Committees-monitor appropriate diagnosis and treatment of hospitalized clients    Sentinel evento an unexpected occurrence (or risk of) involving death or a serious psychological injury o called sentinel because they signal the need for immediate investigation and response o purpose: monitor trends Role of nurse in quality improvement: o Communication o Safety-keeping current o Reporting any errors or sentinel events . QIO.Module #3 & 4: Health Care Policy & Quality Improvement  Health Care Economics: How healthcare is financed o Payment Sources o Commercial Insurance Plans o Prospective payment systems Healthcare regulation: Used to promote and improve the quality of healthcare o Accreditation: Joint Commission o Federal Regulation/Licensure: OSHA. CMS.

Module #5: Safety  Patient Safety Goals:    Patient-Inherent Accidents. o Administer medications appropriately. improper applications Equipment-Related Accidents-Cords. o Delegate Responsibly o Know and follow facility policies and procedures.To ensure safe and competent care. 7 legal tips for safe nursing practice: o Communicate effectively o Document in an accurate. o Use equipment properly.seizures. malfunction. Risks to safety related to developmental age. Infants-oral. misuse Patient Practice Act. choking. drowning. toddlers-falls. disrepair. poisoning)  . o Monitor for and report deterioration.Medication errors. preschoolers-drowning. infiltrations. burns Procedure-Related Accidents. (Ex. timely manner.

Barriers to effective collaborationo Lack of communication o Lack of understanding roles o Lack of trust and respect for or in others o Lack of confidence o Bad listener o Controlling o Time Management Chain of command-report to manager o EX. Who would you report to when you notice a nurse is not performing her assessments but charting them as complete?  Manager    .Module #6: Collaboration  Definitionso Cooperative effort that focuses on a win-win strategy o Working together for the common good o Working as a group utilizing individual skills and talents to reach the highest of patient care standards Factors encouraging effective collaborationo Communication o Understanding roles of interdisciplinary team o Effective problem solving skills.

risks. o Nurse is responsible for obtaining and witnessing the patient’s signature and act as a patient advocate if s/he does not understand or has questions Legal requirements o person signing must be A&O x 3 (not under the influence of sedatives/narcotics) o must be18 years old or an emancipated minor. and consequences of refusal. complications. It is required for surgery. other treatment options. an X must be witnessed by 2 people o patients cannot be coerced. o Functions:  To regulate the practice of nursing  To license registered nurses and licensed practical nurses. manipulated or forced to give consent o physicians can assume responsibility in emergency situations without a signed consent form o date and time of signing must be identified      .  To issue interpretations of the Nursing Practice Act  To maintain a registry of nurse aide  To investigate complaints against nurses Document Meticulously: o Factual Accurate Complete Current Organized Informed consento A person’s agreement to allow something to happen based on a full disclosure of facts needed to make an intelligent decision. parents sign the form for children under 18 o telephone or faxed consent is acceptable o if patient is unable to write a signature. Must include information about procedure/treatment and why it is needed. certain diagnostic and medical treatments and research involving clients. through licensing. consequences if procedure or treatment not done. alternative treatment options. etc. nature of the procedure or treatment. and accreditation The whole point of licensure: o To protect public from harm NC Board of Nursing: o To protect the public by ensuring the provision of safe nursing care to the people of North Carolina through the regulation of nursing practice.  To approve educational programs leading to licensure. benefits. o Physician is responsible for explaining the need for the procedure.Module #7: Legal Issues  Key points: o Nurses are legally responsible for the care they deliver o Knowledge of the law helps maintain standards of practice and protect the nurse from liability o Nursing practice is regulated primarily at the state level. risks involved. legislation (nurse practice act).

not prescribing a medical treatment regimen or making a medical diagnosis.  Teaching. assisting. delivering. and communities.o o o o o  no medical abbreviations can be used no blank spaces can be left on form physician’s full name must be legible (No initials) patient’s signature or legal guardian and relationship must be obtained witnesses’ signature (usually nurse)(student nurses do not witness)  HIPAAo Health Insurance Privacy Accountability act o Maintains privacy Nurse Practice Acto ‘Nursing’ is a dynamic discipline which includes the assessing.  Reporting and recording the plan for care. vigilant.  Providing for the maintenance of safe and effective nursing care. caring.  Collaborating with other health care providers in determining the appropriate health care for a patient but. teaching.  Supervising.2. teaching. initiating. teaching.  Planning. 90-18. supervising patients during convalescence and rehabilitation. disability or the achievement of a dignified death. and sustained.  Implementing the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe the regimen. except under supervision of a licensed physician. prevention and management of illness. injury. o The “practice of nursing by a registered nurse” consists of the following ten components:  Assessing the patient's physical and mental health including the patient's reaction to illnesses and treatment regimens. whether rendered directly or indirectly. It is ministering to. and the patient's response to that care. counseling. assigning. referring and implementing of prescribed treatment in the maintenance of health. and evaluating appropriate nursing acts.S. . and the administration of nursing programs and nursing services. delegating to or supervising other personnel in implementing the treatment regimen.  Providing teaching and counseling about the patient's health. nursing care given. and continuous care of those acutely or chronically ill. subject to the provisions of G. groups. the supervision. and evaluating those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services. the supportive and restorative care given to maintain the optimum health level of individuals.  Recording and reporting the results of the nursing assessment. and evaluation of those who perform or are preparing to perform these functions.

basis for all healthcare o Nonmaleficence-to avoid doing harm. the public. o Beneficence-doing or promoting good. Be honest with patients. families. Ethical Principles: o Autonomy-people have the right to make decisions. prevent harm or remove from harm o Justice-involves fair treatment of all individuals with equal allocation of resources o Fidelity-keep promises and don’t make promises you can’t keep o Veracity-tell the truth. The students responsibility in the clinical environment is: o To take responsibility for assignments assigned by CI’s. the profession.  Ex. employer.  A self-directed and ongoing process carried out by the individual nurse for the purpose of licensure renewal  Based on a reflective model (Benner: Novice to expert) How is it done? Assess practice Based on standards Collect feedback Develop a learning plan . Continued competence in nursing in NC is:  An evaluative process carried out by the nurse. They have the right to refuse.  Student nurses as well as licensed nurses are accountable for their actions. the institution. and peers o Accountability-take responsibility for your own actions o Confidentiality-keep information private Ethical Dilemmas: o A problem that is unable to be solves solely through a review of scientific data.Module 8 & 9: Ethics & Accountability   Definition: o The practices or beliefs of a certain group.  Frequently occurring ethical dilemmas:  End of life care  Non-response by a physician  Unsafe nurse-patient ratio  Refusal of treatment  Fertility Issues  Stem-cell research  Use of scarce resources  Incompetent health care providers  Accountability  The responsibility that nurses assume for their nursing practice and the obligation to report and account for their actions to: themselves. and BON.  Students must always function within the scope of the student nurse role.

It is the nurse’s responsibility to ensure the patient has access to health care services that meet health needs. giving them full. mentally or emotionally disabled or challenged  Children or elderly  Dying. even if the nurse believes the decision to be wrong. or unconscious  Institutionalized or incarcerated  Pregnant women and fetuses Nurses are advocates when they:  Inform patients of their rights  Provide patients with the information they need to make informed decisions  Support patients to get additional info from others  Support patient decisions. . The advocate must be careful to be objective and not convey approval or disapproval of the patient’s choices.Module #10 Advocacy:    Advocacy requires accepting and respecting the patient’s right to decide. sedated. Vulnerable populations that may need advocating for:  Physically. or at least mutual responsibility in decision making when they are capable of it.

o EX. and for establishing and evaluating standards. discharge. Leadership: o Autocratic. power.group is involved in decision making o Lassez-Faire-non-directive.leader makes all the decisions o Democratic.  Primary Nurse aide I & II tasks. and directing the work of others. o Nurse manager strives to meet goals and objectives. coordinating. . ____ nursing is when all care is by a registered nurse. etc. and responsibility for planning. permissive leader. testing.Module # 11: Managing Care     The nurse as a manager: o Someone who is given authority. Nursing care delivery modelso Functional Nursing  Task focused not patient focused o Team nursing  Staff assigned to group of patients organized by geographical location  RN is team leader o Modular nursing or care partners  Form of team nursing  RN cares for patient assisted by CAN o Total patient care  RN responsible for all aspects of care  Shift-based focused  Critical care setting o Primary nursing  RN autonomous-responsible for caseload of patients  Develops a 24 hr nursing care plan  Ensures quality of care o Case management  Coordinates care for patients  Does not give direct care  Facilitates referrals. organizing.

 Functions of automated patient record: o Communications pertinent pt.Module # 12 & 16 Health team communication: Informatics The nurse understands: o Patients have the right to read their record. costing. quality assurance. and/or accounting purposes o Provides a retrievable database for administrative queries. Not a part of patient’s permanent record.  . Pts. and research o Supports data exchange with internal and external systems. first.  Purposes: o Legal documentation o Communication o Financial Billing o Education o Research o Auditing or monitoring standards of care  Acuity records: o Determine the staffing to patient ratio  Incident/variance report: o Sentinel events are not charted.  Telephone reports: o Always repeat information back  Situation  Background  Assessment  Recommendation  Repeat Ex. Forearm is red what would you do first. Assess pt. information o Provides the legal record of care o Support clinical decision making o Captures costs for billing.

Module # 13: Evidence Based Practice   Evidence based practice is essential to provide competent.communicate your results . safe nursing care. Five steps: o o o o o o Ask the clinical question Collect the best evidence Critique the evidence Integrate the evidence Evaluate the practice decision or change 6th step.

” High level wellness  The awareness and ability to apply wellness habits Levels of prevention  Primary-Preventive screening.Module # 14: Health. possible relapses  Termination-Previous behavior no longer pleasurable Health People  > 5 fruits and vegetables a day  Exercise > 12 times/month  Maintain healthy weight  Moderate alcohol consumption  No Smoking . Illness “Just because you aren’t sick doesn’t mean you are health. Wellness.Not intending to change anytime soon  Contemplation-Considering Change  Preparation-making small changes for action plan  Action-Actively engaged in plan  Maintenance-Sustained change. optimal management of chronic conditions and functions 8 ways to stay healthy• Maintain a healthy weight • Exercise regularly • Don’t smoke (Cut down if you do. immunizations  Secondary-Diagnosis and treatment  Tertiary-Rehabilitation.) • Eat a healthy diet • Drink alcohol only in moderation • Protect yourself from the sun • Protect yourself from sexually transmitted diseases • Get screening tests Stages of health behavior change  Precontemplation.

Learner identifies learning needs and takes responsibility for meeting them  Learning Domains   Cognitiveo Includes all intellectual behaviors and requires thinking Psychomotoro Requires the integration of mental and muscular activity. Client is providing ostomy care without contaminating hands is an example of which learning domain? Psychomotor Factors that inhibit learning     Emotions Physiological Psychomotor ability Language barriers Cultural barriers Factors that facilitate learning      Motivation of learner Readiness of learner Active involvement of learner Relevance of the content to the learner Feedback that is meaningful to the learner Nonjudgmental support     Simple to complex Repetition Timing Environment . psychomotor. (Thinking and doing) Affectiveo Deals with expression of feelings/acceptance of attitudes. Three areas of domain:  Cognitive. Ex. and values. affective Humanismo Learning focuses on self-development/achieving full potential. opinions.Module # 15: Teaching-Learning Learning theories  Behaviorismo Learning that occurs in response to environmental stimuli Cognitiveo Learning is a mental or thinking process in which the learner structures/processes information.

in planning Seize the teachable moment Use vocabulary the pt. Of a patient showing readiness to learn: o Teaching must be: o o o o o Sequencing:      Start with something pt. values .Ex. is concerned about Review what the patient knows. understands Do not overwhelm with information Communicate clearly and concisely Use agency materials if available Allow ample practice for psychomotor learning Relate learning to something the pt. then proceed to new material Address early any area that is creating anxiety Teach the basics first before teaching variations or adjustments (Simple-complex) Schedule time for review and questions Purposeful Interactive Goal oriented Individual or group Planned or spontaneous “I’m not sure I’ll be able to do this at home” Suggestions for effective teaching            Assess for readiness to learn Be trustworthy and consistent Respect patient Involve pt.

inferiority (6-12 years) Identity vs. cousins) in addition to nuclear family Single-Parent family Formed when one parent leaves the family unit  Single person decides to adopt or have a child Blended family Formed when parents bring unrelated children from prior or foster parenting relationships into a new. despair (late 60-death) Nuclear family Husband. joint living situation . role confusion (12-20 years) Intimacy vs. guilt (3-6 years) Industry vs. wife.mid 40 years) Generativitiy vs.Module # 17 & 18: Self & Family Self-concept  An individual’s conceptualization or “image” about himself or herself. Ex. children Extended family Relatives (grandparents. Empty nest syndrome may alter self-concept. self-absorption (mid 40. attitudes. mistrust (0-1 year) Autonomy vs. Erikson’s Psychosocial Theory of Development Trust vs. shame (1-3 years) Initiative vs. isolation (mid 20. and perceptions.mid 60) Ego integrity vs. aunts. It is a subjective sense of the self and a complex mixture of unconscious and conscious thoughts.

or dread from a real or perceived threat.” EgoMediates demands of the environment and the demands for instinctual satisfaction Ego functions: o Perception of reality o Perception of others o Judgment o Control of thoughts. Displacement . behavioral. which involves mobilization of the body’s defenses.* Ex. uneasiness. A nurse is reprimanded by her manager and tells the NA to do her job. Fight or flight response. If adaptation does not occur the person moves to exhaustion. Vital signs and hormone levels return to normal. Mechanisms of defenseConcepts: IDPrimitive instinctual drives Seeks gratification “I want what I want when I want it. It is a feeling of apprehension. May be manifested by physiological.  Exhaustion o Illness or death may occur. feelings and actions o Thinking and cognition SuperegoStrives for perfection and morality Know defense mechanisms. or psychological symptoms.Module # 19: Stress and Coping Distress-harmful to individuals health Eustress-positive stress General Adaptation Syndrome Alarm o The body’s first response. Anxiety A universal human experience.  Resistance o The body stabilizes. It is assess on a continuum from mild to panic level. uncertainty.

toward whom one feels a personal sense of commitment and responsibility.           Knowing Being with Doing for Enabling Maintaining belief Touch o Provides Comfort o Creates a connection Contact toucho Hand shake Noncontact touch o Eye contact Protective touch o Used to protect nurse and/or client to prevent an accident Task-oriented touch o Any time going into room to do something to patient .Module 23 Caring Interventions SwansonDefines caring as a nurturing way of relating to a valued other.

problem solving. interpreting. Cognitive processing supports reasoning. stores. retrieves. except with trauma or illness  Older adults o Decline in the ability to:  Perform information processing  Divide attention between tasks  Switch attention rapidly from one auditory input to the other  Maintain sustained attention or perform vigilance tasks  Filter out irrelevant information  Perform word finding  Perform abstraction tasks  Maintain mental flexibility .Module 25: Cognition Definition A complicated process by which an individual learns. remembering. and uses information. and communicating Paiget’s stages of cognitive development  Sensorimotor phase: Birth-2 years o Peek a boo  Pre-operational phase: 2-7 years o Thinks a tall skinny glass holds more than a short wider glass  Concrete operational phase: 7-11 years  Formal Operational phase: 11 years to adult o A stitch in time saves nine Cognitive development across the lifespan:  Newborn o Require sensory stimulation  Infant o Learn by experiencing and manipulating the environment  Toddler o Increased ability to remember events and put thoughts into words  Pre-schooler o Aware of cause and effect relationships  School-age Children o Begin to use logical thought processes  Adolescents o Make decisions through logical operations  Young adults o General life experiences and occupational opportunities dramatically increase cognitive skills  Middle adults o Cognitive changes are rare.

7 steps to a positive approach  Come from front  Go slow  Side  Low  Hand  Use preferred name  Wait for response Delirium Acute. reversible Dementia Chronic. degenerative Somatic delusion Belief that one’s body is changing in an unusual way . confused.

confusion. drowsiness. perception or both of one or more senses . crying. Pt shouts and nods and smiles-hearing deficit Sensory deprivation-lack of meaningful stimuli  Excessive yawning. decreased attention. overwhelmed. not in control. difficulty concentrating. depression. somatic complaints Sensory overload-Unable to process or manage amount of intensity stimuli  Unable to selectively ignore stimuli. smoking.impaired reception.Module # 26: Sensory/perception Interventions for hearing loss:  Get attention  Face client  Clean glasses  Speak slowly  Normal tone  Rephrase rather than repeat  Visible expressions  Talk towards best ear  Use written info  Avoid eating. while speaking  Avoid walking away/speaking from another room Ex. restlessness. chewing. cognitive overload Sensory deficit. fatigue.

despite harm and craving Pseudoaddiction. cramping. delirium. compulsive use.mild-moderate pain Do not give to pt. convulsions When to assess pain 5th vital  Each report of pain  Before and after an intervention  Unexpected intense pain  Noted changes in pt. first thing to do is: assess pain. Anticoagulants would contraindicate an epidural catheter for pain management.Module # 27: Comfort Addiction. Pain is whatever the patient says it is. When going into pts. should know you believe them about their pain.characterized by impaired control over drug use. behavior Ex. staff suspect’s addiction Distinguished from true addiction in behaviors resolve when pain is effectively treated Tolerance. Room to give meds -you DON’T take vitals every time or look up side effects every time.  Provocative/palliative factors  Quality  Region/radiation  Severity  Timing  How pain is affecting you Acetaminophen60-75mg/kg for children < 50kg 4gm for adults Is 200mg every 4-6 hours a safe dose for a child that weighs 10kg? NO! NSAIDS. Encourage the patient to press the button when she feels discomfort. can push. continued use. Pt. . with a peptic ulcer! Give pt. oxycodone for less side effects. profuse perspiration. muscle twitching.iatrogenic syndrome created by undertreatment of pain.state of adaptation in which exposure to drug results in a decrease in one or more drug effects over time Physical dependence.Withdrawal syndrome. PCA pump-only pt. can’t function without it Withdrawal syndrome-N&V. Pt reports pain.

obesity/diet. Right sided heart failure=rest of body. DVT.7-6.2-5. sedentary lifestyle. gender. this disturbs blood flow causing a blowing or swishing sound. allergies. makes “whooshing” sound mitral murmurs best heard at the apex of the heart Bruit (pronounced “brew-ee”) – when the lumen of a blood vessel is narrowed. Edema – alterations in cardiac function (congestive heart failure or hypertension) pts. 14-18g/dL males Hematocrit: 37-47% females. 4. alternative medicine.1 Male. 42-52% males RBC: 4. often have pedal or lower extremity edema • • Left sided heart failure=crackles in lungs. home environment.Module # 28 & 29: Oxygenation & Perfusion • Murmur – valvular dysfunction causes backflow or regurgitation of blood through the incompetent valve. ethnic background. family history Hemoglobin: 12-16g/dL females. • • • Non modifiable risk factors: age. dust or fumes • Prescription & OTC drugs.4 Female White Blood Cell Count: 5000. family history of heart disease Modifiable risk factors: smoking history.000 Neutrophils: 55-70 Lymphocytes: 20-40 .nurse anticipates anticoagulation therapy. psychological variables Diabetes significantly increases risk of death from stroke & heart disease Hypoxia.s/s Oxygenation history• Workplace. pollution. nutrition.10. past illnesses • Smoking history in Pack Years • Travel.

20 Creatinine: 0. 0.45 Pco2: 35 .5 – 5.5 .6-1.145 Potassium: 3.45 Po2: 80 – 100 HCO3: 21-28 O2 Saturation: 95%-100% Medications that promote oxygenation-bronchodilaters Medications that promote perfusion-anticoagulants Coumadin (warfarin)-antidote Vitamin K .1.0 BUN: 10 .2 mg/dL Male Glucose: 70-110 Chloride: 98-106 pH: 7.Sodium: 136 .1 mg/dL Female.35 -7.

o Hyperthermia  Pyrexia. Tachypnea  Malaise  Anorexia. Exudate production 3. tissue integrity. .  Primary intention  Clearly incised & re-approximated  Healing occurs without complications  Secondary intention  Healing occurs in open wounds  Wound edges are not approximated and it heals with formation of granulation tissue. Tissue repair-damaged cells replaced with new Serous-clear fluid Sanguineous-bloody Seroussanguineous-pinkish Purulent-yellow. Vascular and cellular responses 2. cancer. etc. Infection.4F or < 96.000  Tachycardia.Module # 30-33: Inflammation.8F  Leukocytosis > 12. fever  Body temperature above normal range  Illness: viral or bacterial infections. contraction and eventual spontaneous migration of epithelial cells  Tertiary intention – delayed primary  Occurs when a wound is allowed to heal open for a few days and the is closed as if primary Pre-albumin is the most important protein when it comes to wound healing. indicates puss-infection  Local  Edema  Erythema  Warmth  Pain or tenderness  Loss of function to affected body part Systemic  Local plus:  T >100. N/V  Enlarged lymph nodes  Organ failure  Appropriate interventions for contact dermatitis: Teach the importance of not itching it so it will not spread.. thermoregulation Stages of inflammation 1.

Know stages of pressure ulcers. Indications of dvt-swollen leg Pt. has a broken arm: priority assessment is neurosensory/circulation assessment.o  Heat exhaustion or stroke  Impaired hypothalamic thermoregulation Hypothermia  Core body temperature falls below 35C (95F)  Excessive heat loss  Inadequate heat production to counteract heat loss  Impaired hypothalamic thermoregulation To prevent shearing: turn patient on side. . To see if pressure ulcer is tunneling: probe with sterile cotton swabs.