Term
| Normal Temperature Range (F) |
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Definition
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|
Term
| Normal Temperature Range (C) |
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Definition
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Term
| Acceptable Adult Pulse Range |
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Definition
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Term
| Acceptable Adult Respiration Rate |
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Definition
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Term
| Normal Adult Blood Pressure |
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Definition
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Term
| Normal Adult Pulse Pressure |
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Definition
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Term
|
Definition
| temperature of the deep tissues |
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Term
|
Definition
| between the cerebral hemispheres |
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Term
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Definition
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Term
| Heat conservation and production controlled by: |
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Definition
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Term
| Basal Metabolic Rate (BMR) |
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Definition
accounts for the heat produced by the body at absolute rest. Depends on body surface area |
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Term
| Testosterone increases or decreases the BMR? |
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Definition
| Testosterone INCREASES bmr |
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Term
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Definition
| involuntary response to temp differences in the body |
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Term
| nonshivering thermogenesis |
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Definition
occurs in neonates because they cannot shiver. Vascular brown tissue is metabolized for heat production |
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Term
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Definition
| heat transfer with NO direct contact |
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Term
|
Definition
| heat transfer with direct contact |
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Term
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Definition
| heat transfer by air movement |
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Term
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Definition
| transfer of heat energy when a liquid is changed to a gas |
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Term
| Newborn temperature range (when protected from environmental extremes) |
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Definition
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Term
| Newborn temperature range (when protected from environmental extremes) |
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Definition
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Term
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Definition
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Term
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Definition
| elevate body temperature by acting as antigens, triggering immune system responses |
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Term
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Definition
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Term
|
Definition
| etiology of fever cannot be determined |
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Term
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Definition
| elevated body temperature related to the body's inability to promote heat loss or reduce heat production |
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Term
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Definition
| hereditary condition of uncontrolled heat production, occurring when susceptible persons receive anesthetic drugs |
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Term
| sustained pattern of fever |
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Definition
| constant body temp continuously above 38 C (100.4 F) that has little fluctuation |
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Term
| intermittent pattern of fever |
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Definition
| fever spikes interspersed with usual temperature levels. Temperature returns to acceptable value at least once in 24 hours |
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Term
| remittent pattern of fever |
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Definition
| fever spikes and falls without a return to normal temperature values |
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Term
| relapsing pattern of fever |
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Definition
| periods of febrile episodes and periods with acceptable temp values. Febrile episodes and periods of normothermia are often longer than 24 hours |
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Term
| Range of Mild Hypothermia |
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Definition
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Term
| Range of Moderate Hypothermia |
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Definition
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Term
| Range of Sever Hypothermia |
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Definition
Less than 30 C Less than 86 F |
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Term
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Definition
| heat loss during prolonged exposure to cold, overwhelming the body's ability to produce heat |
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Term
| When to not use axilla for temp measurement |
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Definition
| if lesions are present- they alter local temperature and areas are painful to the touch |
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Term
| Class of drugs that are used to reduce fever |
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Definition
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Term
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Definition
| volume of blood pumped by the heart during 1 minute, usually around 5 L/min |
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Term
| 5 major parts of the stethoscope |
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Definition
| Earpieces, binaurals, tubing, bell, and diaphragm |
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Term
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Definition
| Temporal, Carotid, Apical, Brachial, Radial, Ulnar, Femoral, Popliteal |
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Term
| Location of the Point of Maximal Impulse (PMI) |
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Definition
| 5th intercostal space and mid-clavicular line |
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Term
| When to measure pulse for 1 minute (instead of 30 s) |
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Definition
| if heart rate is irregular or client is receiving cardiovascular medication |
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Term
| Characteristics of Heart sounds (when taking apical pulse) |
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Definition
S1 is low pitched and dull (lub) S2 is higher pitched and shorter (dub) |
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Term
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Definition
abnormally fast heart rate greater than 100 beats per minute |
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Term
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Definition
abnormally slow heart rate below 60 beats per minute |
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Term
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Definition
| an interval interrupted by and early or late beat of a missed beat that indicates an abnormal rhythm |
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Term
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Definition
more common in children irregular heart beat that speeds up with inspiration and slows down with expiration. Verify that this is a normal finding by having child hold their breath, HR usually becomes regular |
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Term
| 3 Processes involved in Respiration |
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Definition
Ventilation Diffusion Perfusion |
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Term
| Location of respiratory center |
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Definition
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Term
|
Definition
| low levels of arterial O2 |
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Term
|
Definition
normal, good, unlaboured ventilation normal rate and depth |
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Term
|
Definition
rate of breathing is regular but abnormally slow less than 12 breaths per minute |
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Term
|
Definition
rate of breathing is regular but abnormally rapid greater than 20 breaths per minute |
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Term
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Definition
respirations are labored, increased in depth, and increased in rate (greater than 20 breaths per minute) Occurs normally during exercise |
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Term
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Definition
| respirations cease for several seconds |
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Term
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Definition
rate and depth of respirations increase Hypocarbia (Less than the normal level of carbon dioxide in the blood) sometimes occurs |
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Term
|
Definition
| respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia (high CO2 levels) sometimes occurs |
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Term
| Cheyne-Stokes respiration |
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Definition
respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth, the pattern reverses, breathing slows and becomes shallow, climaxing in apnea before respiration resumes |
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Term
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Definition
| respirations are abnormally deep, regular, and increased in rate |
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Term
|
Definition
| respirations are abnormally shallow for two to three breaths followed by irregular period of apnea |
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Term
| machine used to measure arterial oxygen saturation: |
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Definition
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Term
| Normal oxygen saturation percentages |
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Definition
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
|
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Term
| antihypertensive medication categories (6) |
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Definition
diuretics B Blockers Vasodilators Ca channel blockers ACE inhibitors Antiotensin II receptor blockers |
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Term
|
Definition
| systolic BP of 90 mmHg or below |
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Term
| orthostatic (or postural) hypotension |
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Definition
| occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position |
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Term
| blood pressure cuff guidlines |
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Definition
| cuff width 20% more than upper arm diameter or 40% or circumference and 2/3 of arm length |
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Term
| What Korotkoff sounds correspond to systolic and diastolic blood pressures? |
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Definition
1st korotkoff sound = systolic BP 4th korotkoff sound = diastolic BP in infants and children 5th korotkoff sound= diastolic BP in ADULTS |
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Term
|
Definition
| temporary disappearance of sound typically ocurring between first and second korotkoff sounds |
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Term
| what are the vital sign measurements? |
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Definition
| temperature, pulse, blood pressure, respirations, and oxygen saturation (sometimes pain is included) |
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Term
| common errors in BP assessment |
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Definition
bladder or cuff too wide/narrow cuff wrapped too loosely or unevenly deflating cuff too slowly or quickly arm below or above heart level bad stethoscope or impaired examiner hearing stethoscope pressed too firmly against antecubital fossa inflating too slowly inadequate inflation level multiple examiners using diff korotkoff sounds for diastolic readings |
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Term
| client conditions not appropriate for electronic BP measurement: |
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Definition
| irregular HR, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, BP less them 90 systolic |
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Term
| when to measure vital signs |
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Definition
admission to health care facility assessing client during home care visits on a routine schedule according to orders before and after surgery or invasive procedure before, during, and after blood transfusions before, during and after admin. of cardiac drugs when general physical condition changes before and after nursing interventions influencing a vital sign when client reports non-specific symptoms of physical distress (feeling funny or different) |
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Term
| nursing interventions for clients with a fever |
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Definition
obtain blood cultures if ordered minimize heat production- limit physical activity, allow rest maximize heat loss- reduce external coverings, keep linens/clothing dry satisfy req. for increased metabolic rate- admin. O2, stimulate appetite, provide fluids (3L/d at least), promote client comfort ID onset and duration of febrile episode phases initiate health teaching control environmental temp to 70-80 F (21-27C) |
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Term
| what to do if BP is above acceptable range |
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Definition
repeat BP measurements on other arm, verify correct positioning of cuff ask nurse or colleague to repeat measurement in 1-2 minutes report elevated BP to nurse in charge or health care provider administer antihypertensive medications as ordered |
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Term
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Definition
| infectious agent (presence does NOT necessarily mean infection will occur) |
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Term
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Definition
| microorganism is present or invades a host, grows and/or multiplies but does not cause an infection |
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Term
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Definition
| may not pose a risk for transmission, some examples include viral meningitis or pneumonia |
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Term
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Definition
| if the infectious disease can be transmitted directly from one person to another |
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Term
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Definition
| if the pathogens multiply and cause clinical signs and symptoms |
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Term
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Definition
| if clinical signs and symptoms are not present (common example is hepatitis C) |
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Term
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Definition
| infectious agent--> resevoir--> portal of exit-->mode of transmission-->portal of entry-->host |
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Term
| potential for microorganisms to cause disease depends upon: |
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Definition
dose-sufficient # of organisms virulence- ability to survive in host or outside body ability to enter and survive in host susceptibility of the host (host resistance) |
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Term
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Definition
| persons who show no symptoms of illness buy who have pathogens in their bodies that can be transferred to others |
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Term
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Definition
require oxygen for survival cause more infections in humans than anaerobic bacteria |
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Term
| course of infection by stage |
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Definition
incubation period- entrance of pathogen to appearance of symptoms prodromal stage- interval from onset of nonspecific s/sx to more specific symptoms illness stage-client manifests s/sx specific to type of infection convalescence- acute symptoms disappear, recovery |
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Term
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Definition
| caused by use of broad-spectrum antibiotics to treat an infection |
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Term
| inflammatory response includes: |
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Definition
vascular and cellular responses formation of inflammatory exhudates tissue repair |
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Term
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Definition
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Term
|
Definition
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Term
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Definition
| containing WBCs and bacteria |
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Term
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Definition
| type of health care associated infection from a diagnostic or therapeutic procedure |
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Term
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Definition
| from an organism that is present outside the client |
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Term
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Definition
| can occur when part of the client's flora becomes altered and an overgrowth results |
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Term
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Definition
5,000-10,000 cells/mm^3 level will be increased in in acute infection, decreased in certain viral or overwhelming infections |
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Term
| erythrocyte sedimentation rate |
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Definition
up to 15 mm/hr for men and 20 mm/hr for women will be elevated in presence of inflammatory responses |
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Term
|
Definition
60-90 g/L decreased in chronic infection |
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Term
| cultures of urine and blood |
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Definition
normally sterile, w/o microorganism grown presence of microorganism may indicate infection |
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Term
| cultures and gram stain of wound, sputum, and throat |
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Definition
Normal finding- no WBCs on gram stain, possibly normal flora abnormal finding- presence of infectious microorganism and WBCs on gram stain |
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Term
| normal neutrophil % of total WBCs |
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Definition
55-70% increased in acute suppurative (pus forming) infection decreased in overwhelming bacterial infection (older adult) |
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Term
| normal lymphocyte % of total WBCs |
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Definition
20-40% increased in chronic bacterial and viral infection, decreased in sepsis |
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Term
| normal monocyte % of total WBCs |
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Definition
5-10% increased in protozoan, rickettsial (gram negative cocci,susceptible to tetracyclines), and tuberculosis infections |
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Term
| normal eosinophil % of total WBCs |
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Definition
1-4% increased in parasitic infection |
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Term
| normal basophil % of total WBCs |
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Definition
0.5-1.5% normal during infection! |
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Term
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Definition
| the kind and amount of activity or exercise that the person is able to perform |
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Term
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Definition
| muscle contraction with a change in muscle length |
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Term
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Definition
| tightening or tensing of muscles without moving body parts |
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Term
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Definition
| fit closely together and are fixed, permitting little, if any, movement such as the syndesmosis between the tibia and fibula |
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Term
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Definition
| have little movement but are elastic and use cartilage to unite separate body surfaces such as the synchondrosis that attaches the ribs to the costal cartilage |
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Term
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Definition
true joints are freely movable and are the most mobile, numerous, and anatomically complex of the body's joints. Ex: hinge joint at the elbow |
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Term
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Definition
| white shiny flexible bands of fibrous and elastic that bind joints. Connect bones and cartilage |
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Term
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Definition
| white, glistening, fibrous bands of tissue that connect muscle to bone |
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Term
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Definition
| non-vascular, supporting connective tissue with the flexibility of a firm, plastic material. Can sustain weight and serve as a shock absorber between articulating bones |
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Term
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Definition
| awareness of the position of the body and its parts |
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Term
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Definition
| uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bone. mineral calcification and deposition do not occur. replaced bone consists of soft material rather than rigid bone |
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Term
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Definition
| lateral position with all but one pillow and all positioning supports removed from the bed, vertebrae are in straight alignment without observable curves |
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Term
| how to calculate maximum heart rate |
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Definition
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Term
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Definition
| 60-90% of maximum heart rate, depending on health care provider's recommendation |
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Term
| what needs to be included in an exercise program no matter what? |
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Definition
warm up and cool down about 5-10 minutes each |
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Term
| recommended frequency of aerobic exercise |
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Definition
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Term
|
Definition
laundry making the bed ironing washing dishes |
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Term
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Definition
sweep kitchen or sidewalk wash windows folding clothes vacuuming |
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Term
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Definition
moving furniture carrying boxes or heavier items up and down stairs |
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Term
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Definition
congenital is a condition causing extremely fragile bones. All people with OI have weak bones, which makes them susceptible to fractures. |
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Term
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Definition
assessment diagnosis planning implementation evaluation |
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Term
| Hinduism : Religious Dietary Regulations |
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Definition
| Some sects are vegetarians. The belief is to no kill ANY living creature |
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Term
| Buddhism : Religious Dietary Regulations |
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Definition
| Some are vegetarians and will not use alcohol. Many will fast on Holy Days |
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Term
| Islam : Religious Dietary Regulations |
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Definition
| Prohibits consumption of pork and alcohol. Fasts during the month of Ramadan. |
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Term
| Judaism : Dietary Religious Regulations |
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Definition
| Some observe the kosher dietary restrictions (e.g., avoid pork and shellfish, do not prepare and eat milk at meat at the same time) |
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Term
| Christianity : Religious Dietary Regulations |
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Definition
| Some Baptists, Evangelicals, and Pentecostals discourage the use of alcohol and caffeine. Roman Catholics fast on Ash Wednesday, Good Friday, and 1 hour before receiving Communion; do not eat meat on Fridays during Lent. |
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Term
| Jehovah's Witnesses : Religious Dietary Regulations |
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Definition
| Members avoid food prepared with or containing blood |
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Term
| Mormonism : Religious Dietary Regulations |
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Definition
| Members abstain from alcohol and caffeine |
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Term
| Russian Orthodox Church : Religious Dietary Regulations |
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Definition
| Followers observe fast days as well as a no meat rule on Wednesdays and Fridays. During Lent all animal products, including dairy products and butter, are forbidden. |
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Term
| Native Americans : Religious Dietary Regulations |
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Definition
| Individual tribal beliefs influence food practices |
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Term
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Definition
lightest level of sleep lasts a few minutes decreased physiological activity begins with gradual fall in vital signs and metabolism sensory stimuli (noise) easily awakes the person awakened, person feels as though day dreaming has occurred |
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Term
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Definition
period of sound sleep relaxation progresses arousal remains relatively easy stage lasts 10-20 minutes body functions continue to slow |
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Term
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Definition
involves initial stages of deep sleep sleeper is difficult to arouse and rarely moves muscles are completely relaxed vital signs decline but remain regular stage lasts 15-30 minutes |
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Term
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Definition
deepest stage of sleep very difficult to arouse sleeper if sleep loss occurred- sleeper will spend most of night in this stage vital signs are significantly lower than during day stage lasts approximately 15-30 minutes sleepwalking and enuresis (bedwetting) sometimes occur |
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Term
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Definition
vivid, full color dreaming occurs less vivid dreaming occurs in other stages stage usually begins 90 min. after sleep has begun typified by autonomic response of rapidly moving eyes, fluctuating HR and RR, and increased or fluctuating BP loss of skeletal muscle tone gastric secretions increase very difficult to arouse sleeper duration of REM sleep increases with each cycle and averages 20 min |
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Term
| Stages and order of adult sleep cycle |
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Definition
| sleepiness -- stage1-- stage2 -- stage3 -- stage4 -- stage3 -- stage 2 -- REM -- stage2 -- repeat!! |
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Term
| how many sleep cycles does a person pass through in the course of 1 night? |
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Definition
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Term
| most common type of sleep disorder |
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Definition
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Term
|
Definition
spore forming gram+ bacillus infected by skin contact, ingestion, or inhalation Respiratory: flulike symptoms, brief improvement, then abrupt onset of respiratory failure, shock, hemodynamic collapse, and death within 24-36 hours Cutaneous: head, forearms, hands, localized itching followed by lesion that gets worse GI: ab pain, N&V, fever, bloody diarrhea, symptoms begin 1-8 days depending on route of exposure and dose |
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Term
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Definition
neurotoxin Food-borne is most common, airborne possible Foodborne s/sx= ab cramping, diarrhea, GI symptoms, no fever, drooping eyelids, weakened jaw clench, dysphagia, dysarthria, blurred & double vision, paralysis Neuro symptoms start 12-36 hr after ingestion and 24-72 hr after inhalation non transmittable |
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Term
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Definition
| bioterrorism outbreak may be airborne fever, cough, chest pain, hemoptysis w/in 24 hr of symptom onset. Mucopurulent of watery sputum with gram negative rods in a gram stain test. Xray film shows bronchopneumonia. person to person transmission is possible via large aerosol droplets. symptoms appear within 1-3 days |
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Term
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Definition
potential to cause sever morbidity in a non-immune population, airborne A single case is a public health emergency flulike symptoms, skin lesions appear quickly, macules-->papules-->vesicles 2-4 days of fever and myalgia, rash most prominent on face and extremities, rash scabs over in 1-2 weeks symptoms begin after an ave of 12 days |
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Term
|
Definition
overweight, high BP, rapid resting pulse rate, pulse and BP increase substantially after minimal physical exertion breathing rate increases after just a little bit of activity |
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Term
| 4 phases of bioterrorism attack management |
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Definition
Mitigation-determine hazard vulnerability for the hospitals service area. ID types of situations that are most likely to occur Preparedness- improve ability to manage attack, have supplies and staff who can use them, have backup communication, and conduct drills response- steps taken in the event of an attack, report to predetermined areas, issue alerts, and decontaminate recovery- restore essential services and resume normal operations asap |
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Term
| when to use mechanical lift |
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Definition
| use with full body sling to transfer uncooperative client who can bear partial weight or client who cannot bear weight and is either uncooperative or does not have upper body strength into chair |
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Term
|
Definition
protection sensation temperature regulation excretion and secretion |
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Term
|
Definition
0-18 inches zone of personal space |
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Term
|
Definition
18in-4ft zone of personal space |
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Term
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Definition
4-12 feet zone of personal space |
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Term
|
Definition
12+ feet zone of personal space |
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Term
|
Definition
hands, arms, shoulders, back permission not needed |
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Term
|
Definition
mouth, wrists, feet permission needed |
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Term
|
Definition
face, neck, front of body special care needed |
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Term
|
Definition
genitalia, rectum great sensitivity needed |
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|
Term
| phases of the helping relationship |
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Definition
preinteraction orientation working termination |
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Term
| therapeutic communication techniques |
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Definition
| active listening, sharing observations, sharing empathy,sharing hope, sharing humor, sharing feelings, using touch, using silence, providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self-disclosure, confrontation |
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Term
|
Definition
|
|
Term
| nasogastric tube insertion |
|
Definition
does not require sterile technique uncomfortable procedure for the client, irritate the nasal mucosas. maintain patency |
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Term
| type of patients at risk for negative nitrogen balance |
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Definition
| weak, immobile, muscle atrophy, nutritional intake due to anorexia and/or restrictions |
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Term
|
Definition
| client is as risk for injury from wandering, falls, and disruptive or agitated behavior |
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Term
| alternatives to restraints |
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Definition
| orient clients/family to envirnoment, provide companionship and supervision, ofer music or distracting activities, put disoriented clients near nurses station, use calm, simple statements, use time out, de-escalation,promote relaxation, camouflage IV lines with clothing, ensure effective pain management |
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Term
| Hypnotics effect on sleep |
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Definition
| interfere with reaching deeper sleep stages, only temporary benefits, cause hangover during day, worsens sleep apnea |
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|
Term
antidepressants and stimulants: effects on sleep |
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Definition
suppress REM sleep decrease total sleep time |
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Term
|
Definition
speeds onset of sleep reduces REM sleep awakens person during night and difficult to return to sleep |
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Term
|
Definition
prevents person from sleeping causes person to awaken during night interferes with REM sleep |
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|
Term
Diuretics: effect on sleep |
|
Definition
| nighttime awakenings caused by nocturia |
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|
Term
|
Definition
| nightmares, insomnia, awakenings |
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|
Term
benzodiazepines: effect on sleep |
|
Definition
alter REM sleep increase sleep time increase daytime sleepiness |
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|
Term
narcotics: effects on sleep |
|
Definition
suppress REM sleep cause increased daytime drowsiness |
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|
Term
anticonvulsants: effects on sleep |
|
Definition
decrease REM time daytime drowsiness |
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|
Term
| sleep promotion in elderly |
|
Definition
maintain regular schedule no naps warm bath minimal noise keep path to bathroom free and illuminated use meds only as a last resort limit alcohol, caffeine, and nicotine in late afternoon and evening elevate head of bed pain relief 30 minutes before bedtime |
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Term
|
Definition
| sudden muscle weakness during intense emotions such as anger, sadness, or laughter |
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Term
|
Definition
| a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day |
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Term
|
Definition
| thought to be related to apnea, hypoxia, and cardiac arrhythmias caused by abnormalities in the autonomic nervous system that are manifested during sleep |
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|
Term
| Babies double their birth weight by: |
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Definition
|
|
Term
| babies triple their birth weight by: |
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Definition
|
|
Term
| Benefits of breastfeeding |
|
Definition
| reduced food allergies and intolerances, fewer infant infections, easier digestion, convenient, always the correct temp, fresh, economical |
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|
Term
| breastmilk provides sufficient nutrition for how long? |
|
Definition
| the first 4-6 months of life |
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|
Term
| high nutrient density foods provide: |
|
Definition
a large number of nutrients in relationship to kilocalories ex: fruits and vegetables |
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|
Term
| when introducing solid foods to infant, wait how long in between each new food? |
|
Definition
| 4-7 days to identify allergies |
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|
Term
| what is typically the first solid food to be introduced |
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Definition
|
|
Term
| most important non milk source of protein for infants 4-11 months |
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Definition
|
|
Term
| problem with giving toddlers too much cow's milk: |
|
Definition
| milk anemia because milk is a poor source of iron. Toddlers need to drink whole milk until the age of 2 to ensure adequate intake of fatty acids necessary for brain and neurological development |
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Term
|
Definition
| measurement system of the size and makeup of the body |
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Term
|
Definition
myogenic neurogenic obstructive other- surgery, vagotomy, CT disorders |
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Term
| 4 types of enteral formulas |
|
Definition
polymeric- milk based blenderized foods, commercially prepared whole nutrient formulas Modular formulas- single macronutrient (not complete nutrition) elemental formulas- predigested nutrients for dysfunctional GI tracts specialty formulas- meet specific nutritional needs in certain illnesses |
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|
Term
| enteral vs parenteral benefits |
|
Definition
| enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, maintains intestinal structure and function |
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|
Term
| serious complication of enteral feedings |
|
Definition
| aspiration of formula into the tracheobronchial tree. results in reduced blood supply to affected pulmonary tissue |
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|
Term
| recommended daily intake of grains |
|
Definition
|
|
Term
| recommended daily intake of vegetables |
|
Definition
|
|
Term
| recommended daily intake of fruits |
|
Definition
|
|
Term
| recommended daily intake of milk |
|
Definition
|
|
Term
| recommended daily intake of meat/beans |
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Definition
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Term
| adolescence leading cause of death |
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Definition
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Term
| leading cause of death and injury in school aged period |
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Definition
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Term
| leading cause of death in young adults |
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Definition
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Term
| leading cause of death in older adults |
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Definition
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