Term
| Four broad goals within nursing |
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Definition
1. To promote health
2. To prevent illness
3. To treat human responses to health or illness
4. To advocate for individuals, families, communitites, and populations |
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Term
| Nurses advocate for patients in many ways: |
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Definition
| keeping them safe, communicating their needs, identifying side effects of treatment and finding better options, and helping patients to understand their diseases and treatments so that they can optimize self-care |
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| Nursing value 1: Altruism |
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Definition
| a true concern for the welfare of others; reflected in the desire to understand patient's perspective and health beliefs |
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| Nursing value 2: Human dignity |
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Definition
| when nurses show respect for patients, such as by ensuring privacy and confidentiality |
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| Nursing value 3: Autonomy |
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Definition
| pateints' right to make decisions about their health care |
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| Nursing value 4: Integrity |
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Definition
| providing honest information to patients, documenting care accurately and reporting errors |
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| Nursing value 5: social justice |
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Definition
| when nurses work to ensure equal treatment and access to quality health care |
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Definition
| gathering information about the health status of the patient, analyzing and synthesizing those ata, making judgements about nursing interventions based on the findings and evaluating patient care outcomes; includes both health history and physical assessment |
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Definition
| involves strategies aimed at preventing problems (immunizations, health teaching, safety precautions, and nutrition counseling) |
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Definition
| includes the early diagnosis of health problems and prompt treatment to prevent complications. (vision screening, pap smears, bp screening, hearing testing, scoliosis screening, and tb skin test) |
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Definition
| focuses on preventing complications of an existing disease and promoting health to the highest level (diet teaching for patients with diabetes, inhaler teaching for patients with lung disease, and exercise programs for those who have had MI) |
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Definition
| Assessing the patient, analyzing data and making diagnoses, determining patient outcomes or planning care, intervening, and then evaluating the patient's status to determine if interventions were effective |
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Definition
| includes gathering and clustering data to draw inferences and propose diagnoses; 7 step process |
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Definition
| involves a life-threatening or unstable situation, such as a patient in an ED who has experienced a traumatic injury; Airway, Breathing, Circulation, Disability |
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Definition
| includes a complete health history and physical assessment; done annually on an outpatient basis, following admission to a hospital, or every 8 hours for patients in ICU |
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Term
| Critical interventions in life-threatening situations |
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Definition
| open the patient's airway, assists the patient's breathing, perform CPR, protect the cervical spine if patient is injured, ensure that the disoriented or suicidal patient is safe, provide pain management and sedation |
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Definition
| based upon the patient's issues; can occur in all settings; usually involves one or two body systems and smaller than comprehensive |
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Term
| Guidelines for prioritizing |
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Definition
| 1. Life-threatening situations (ABC), an issue that needs immediate attention, a concern that is very important to a patient, or something on which the nurse is spending a lot of time |
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Definition
| take into account cultural background and practices of patient before planning nursing care |
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Definition
| what the patient tells you; based on patient experiences and perceptions |
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Term
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Definition
| Measurable data; Information gathered from physical assessment |
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Definition
| How you communicate with doctor about patient; Situation, Background, Assessment, Recommendation |
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Term
| Frameworks for health assessment |
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Definition
1. Functional Assessment (focuses on the functional patterns that all humans share)
2. Head-to-toe assessment (most organized)
3. Body systems (promotes critical thinking and allows nurses to analyze findings as they cluster similar data) |
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Term
| Evidence-based Critical Thinking |
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Definition
4 steps:
1. Clearly identify issue or problem based on an accurate analysis of current nursing knowledge and practice
2. Search literature for relevant research
3. Evaluate the research evidence using established criteria regarding scientific merit
4. Choose interventions and justify the selection with the most valid evidence |
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Term
| Levels of evidence triangle |
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Definition
1. Systematic Reviews (best)
2. Randomized Clinical Trial
3. Cohort studies
4. Case control studies
5. Case reports
6. Editorials, expert opinions (lowest) |
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Term
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Definition
| Exchanging information so that we understand each other |
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Term
| Phases of interview process |
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Definition
| Preinteraction phase (collecting data from medical record), beginning phase (introductions and purpose), working phase (collecting data by asking questions), closing phase (ends interview by summarizing and stating most important patterns or problems might be) |
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Term
| Primary data source vs secondary data source |
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Definition
| Patient is primary source. Family member or other is secondary source |
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Term
| Characteristics of symptom to note |
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Definition
| location, duration, intensity, quality/description, aggravating/alleviating factors, pain goal, functional goal, quantity or severity |
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| Activity of Daily Living; include self-care activities (eating, bathing), mobility (walking, grasping small objects, balance) and home maintenance (laundry, cooking, shopping) |
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Definition
| Want to assess for: self-concept/self-esteem, activity/exercise, nutrition and elimination, sleep/rest, interpersonal relationships/resources, spiritual resources, coping and stress management, health perception/management, sexuality/reproductive |
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Definition
| precautions used for every single person; include mask, eye protection, gown; patient care equipment; environmental control; linen; occupational health and blood-borne pathogens; patient placement (Page 46) |
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Term
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Definition
Hyperresonant, resonant, tympanic, dull, flat
Page 60 Table 4.3 |
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Term
| Anthropometric measurements |
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Definition
| vital signs plus height and weight |
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Term
| Pounds to kilogram conversion |
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Definition
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Definition
| Indicators for overall body function, establish a baseline, monitor patient's condition, monitor response to treatment, identify problems/potential problems, monitor risks for health complications |
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Definition
96.7-110.5 F or 35.9-38 C
Fever is higher in afternoon and evening than in morning |
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Term
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Definition
oral, axillary, tympanic, temporal artery, rectal
Route determined by age, equipment, LOC, state of health |
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Term
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Definition
| mouth; easiest and most comfortable for patient; do not use with altered mental status, oral tube, seizure history, oral surgery or trauma, children younger than 6; Use blue tip cover |
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Term
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Definition
| under the arm; use when oral is contraindicated; measures skin surface temp which is lower than oral by 0.5-1 degree F; good for small kids, oxygen therapy patients, confused patients |
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Term
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Definition
| noninvasive, good for small children, technique is difficult to get right; 1 degree lower than core temp; avoid with ear infections, drainage, scarred tym membranes |
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Definition
| quick, noninvasive; 0.7-1 degree F higher than oral; good for confused, unconscious, and children; poor results if done incorrectly; skin temperature (less reliable than membrane) |
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Term
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Definition
| core temperature; most accurate; use red tip cover; used when other routes are contraindicated; 0.7-1 degree higher than oral; CI in newborns, young children, rectal disease, heart patients |
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Term
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Definition
60-100 beats per minute
Bradycardia <60
Tachycardia >100
Asystole = Absent (cardiac arrest) |
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Term
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Definition
0 = absent
+1 = weak/diminshed
+2 = normal
+3 = full, increased
+4 = bounding |
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Term
| 4 things to note when checking pulse |
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Definition
| rate (#), rhythm (regular or irregular), amplitude(0-+4), elasticity (artery feels smooh, straight, resilient) |
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Term
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Definition
| an abnormal heart rate/rhythm caused by abnormal electrical currents in the heart |
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Term
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Definition
| when the heart does not produce enough force to perfuse peripheral body parts. To assess for this, assess the peripheral and apical pulse rates at the same time and compare. PD is difference between apical and radial pulse rates |
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Definition
| when the heart rate speeds with inhalation and slows with exhalation. It's normal in children |
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Definition
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Definition
| absence of breaths for more than 10 seconds |
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Term
| When assessing respirations, check 4 factors |
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Definition
| Rate (#), Rhythm (reg/irregular, labored/nonlabored), Depth (hyperpnea), Quality (dyspnea) |
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Definition
| deeper and more rapid breathing than normal |
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Definition
| difficulty breathing, shortness of breath |
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Definition
| high-pitched crowing sounds |
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Definition
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Definition
Before puberty - genders equal
After puberty - males higher BP
After menopause - females higher than males |
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Definition
| A drop of 15 systolic, drop of 10 diastolic, or increased HR upon position changes |
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Term
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Definition
| noxious stimuli create enough of an energy potential to cause a nerve impulse perceived by nociceptors (free nerve endings) |
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Term
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Definition
| the neuronal signal moves from the periphery to the spinal cord and up to the brain |
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Term
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Definition
| the impulses being transmitted to the higher areas of teh brain are identified as pain |
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Term
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Definition
| inhibitory and facilitating input from the brain modulates or influences the sensory transmission at the level of the spinal cord |
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Term
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Definition
| says that the body responds to a painful stimulus by either opening a neural gate to allow pain to be produced or creating a blocking effect at the synaptic junction to stop the pain |
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Term
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Definition
| pain that lasts beyond the normal healing period of 3-6 months; there may be no identifiable cause |
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Term
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Definition
| pain of a short duration that has an identifiable cause such as trauma, surgery, or injury |
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Term
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Definition
| pain that results from damage to nerves in the peripheral or central nervous system (diabetics) |
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