Term
|
Definition
| disease than be spread through the air, client needs to be in private room with negative air pressure. Wear respirator mask visitor, pt, and nurse |
|
|
Term
| What kind of precaution should you take with TB, Varicella, Rubeola, SARS |
|
Definition
|
|
Term
| what type of prevention is promotion |
|
Definition
|
|
Term
| what type of prevention emphasizes early detection of disease, prompt intervention, and health maintenance. |
|
Definition
|
|
Term
| what type of prevention begins after an illness and helps to rehabilitate individuals or restore them to an optimum level? |
|
Definition
|
|
Term
|
Definition
| Muscle shortening to produce contraction and active movement. Running, jumping, walking, swimming, cycling |
|
|
Term
|
Definition
| Muscle contraction without joint movement. Bed exercise: squeezing a towel or pillow between the knees |
|
|
Term
|
Definition
| Muscle contraction or tension against resistance. Machines used to promote physical condition and build up muscle groups |
|
|
Term
|
Definition
| The cane is held with the hand on the client's strongest side. This provides the client with the ability to support maximum weight and alignment when walking. |
|
|
Term
|
Definition
| COAL (cane on affected leg).Next move the unaffected or stronger leg forward ahead of the cane and weak leg while the weight is borne by the cane and the weak leg. |
|
|
Term
|
Definition
| (Wandering wilma always late ) walker on affected leg |
|
|
Term
|
Definition
| involuntary passing of urine when control should be established @5 yrs of age. can be a problem for school aged children |
|
|
Term
|
Definition
| bed wetting, the involutary passing of uring during sleep |
|
|
Term
|
Definition
| abnormal amounts of urine by the kidneys, polydipsia. can cause excessive fluid loss, leading to intense thirst, dehydration and weight loss. |
|
|
Term
|
Definition
| abnormal large amounts of uring by the kidneys |
|
|
Term
|
Definition
| excessive thirst, may be associated with diseases such as diabetes mellitus, diabetes insipidus and chronic nephritis. |
|
|
Term
|
Definition
| low urine output usually less than 500 mL a day or 30 mL an hour for an adult |
|
|
Term
|
Definition
| abnormal fluid losses or a lack of fluid intake. Indicates impaired blood flow to the kidneys or impending renal failure and should be promptly reported to physician |
|
|
Term
|
Definition
|
|
Term
|
Definition
| technique by which fluids and molecules pass through a semipermeable membrane according to the rules of osmosis |
|
|
Term
|
Definition
| decrease in bladder capacity |
|
|
Term
|
Definition
| voiding two or more times at night. |
|
|
Term
|
Definition
| voiding at frequent intervals, that is, more htan four to six times per day |
|
|
Term
| cause of urinary frequency |
|
Definition
| increased intake of fluid, UTI's, stress, and pregnancy. |
|
|
Term
| cause of nocturnal frequency |
|
Definition
| capacity of bladder and its ability to completely empty at night |
|
|
Term
|
Definition
| retention of residual urine which predisposes the older adult to bladder infections. |
|
|
Term
|
Definition
| sudden strong desire to void. there may not be a great deal of urine in the bladder but person feels the need to void immediately. |
|
|
Term
|
Definition
| voiding that is either painful or difficult. the burning may be described as severe, hot poker or subdued like a sunburn |
|
|
Term
|
Definition
| delay and difficulty in initiating voiding. |
|
|
Term
|
Definition
| involuntary leakage of urine or loss of bladder control |
|
|
Term
|
Definition
| when emtyping of the bladder is impaired, the urine accumulates and the bladder becomes overdistended. Client may eliminate 25-50 mL at frequent intervals |
|
|
Term
|
Definition
| when a client does not perceive bladder fullness and therefore unable to control urine sphincters. |
|
|
Term
| normal output of urine in mL in 24 hours |
|
Definition
|
|
Term
| what is a complete assessment of a client's urinary function? |
|
Definition
| nursing history, physical assessment of the genitourinary system, hydration status and examination of urine, relating data from diagnostic tests and procedures |
|
|
Term
| what does normal urine consist of ? |
|
Definition
| 96% water and 4% solutes organic solutes(urea, ammonia, creatinine, uric acid) inorganic solutes (sodium, chloride, potassium, sulfate, magnesium, and phosphorus) |
|
|
Term
| what does output of urine less than 30mL/hr indicate? |
|
Definition
| decreased blood flow to the kidneys and should be immediately reported |
|
|
Term
| what should the normal color of urine be? |
|
Definition
| normal is clear, straw amber colored and transparent |
|
|
Term
| what does dark amber colored, cloudy, dark orange, red or dark brown mucous plugs, viscid thick urine indicate? |
|
Definition
| red blood cells in urine may be pink , bright red, or rusty(hematuria) White blood cells, bacteria, pus,sperm, vaginal drainage or contaminants may cause cloudiness |
|
|
Term
| what is normal odor characteristic for urine |
|
Definition
|
|
Term
| What is abnormal odor of urine called? |
|
Definition
| offensive, some foods may cause odor or urine specimen that is contaminated by bacteria from perineum |
|
|
Term
| what is the normal specific gravity for urine |
|
Definition
|
|
Term
| what is abnormal specific gravity for urine |
|
Definition
|
|
Term
| what is normal pH of urine |
|
Definition
|
|
Term
| what is abnml pH of urine |
|
Definition
| below 4.5 or over 8 concentrated more specific gravity diluted has lower |
|
|
Term
| is glucose finding normal in urine? |
|
Definition
|
|
Term
| is freshly voided urine acidic or high in alkaline |
|
Definition
|
|
Term
| what can cause low pH (acidic) in urine |
|
Definition
| starvation, diarrhea, diet high in protein foods or cranberries |
|
|
Term
| what does glucose in the urine mean |
|
Definition
| high blood glucose levels (greater than 180mg/dL) indicative of undiagnosed or uncontrolled diabetes mellitus |
|
|
Term
| what does ketones in urine indicate? |
|
Definition
| uncontrolled diabetes mellitus, somebody who is in a state of starvation, or have ingested aexcessive amounts of protein |
|
|
Term
| what does blood in the urine indicate? |
|
Definition
| the presence of a UTI, kidney disease, or bleeding from the urinary tract. |
|
|
Term
|
Definition
| urine remaining in the bladder following voiding normally 50-100 mL |
|
|
Term
| How can you prevent UTI's |
|
Definition
| avoid trauma,drink 8 oz glasses of H20/day, practice frequent voiding q2-4 hrs to flush out bacteria, avoid use of harsh soaps,avoid tight fitting clothes, wipe perineal area from front to back, take showers rather than baths. |
|
|
Term
| how can you reduce or eliminate urinary continence? |
|
Definition
| perform kegels, perform bladder/habit training, maintain skin integrity,apply condom or external catheter |
|
|
Term
| What types of food acidify urine? |
|
Definition
| eggs, cheese, meat, poultry, whole grains, cranberries, plums,prunes, tomatoes. |
|
|
Term
| what types of food result in alkaline urine? |
|
Definition
| most fruits and vegetables, legumes, milk and milk products. |
|
|
Term
| how much water should a client with a retention cather drink per day? |
|
Definition
| 3,000 mL large amounts ensure large urine output which keeps the bladder flushed out and decreases liklihood of urinary stasis and infection |
|
|
Term
|
Definition
| surgical rerouting of urine from the kidneys to a site other than the bladder two kinds: incontinent and continent |
|
|
Term
|
Definition
| diverts urine from the kidney to a stoma |
|
|
Term
|
Definition
| may be formed when the bladder is left intact but voiding through a urethra is not possible. ureters remain connected to the bladder and the wall is surgically attached to an opening in the skin below the navel |
|
|
Term
|
Definition
| one or both of the ureters may be brought directly to the side of the abdomen to form small stomas |
|
|
Term
| when can you delegate a procedure to a UAP? |
|
Definition
| when sterile technique is not required, irrigation, or when detailed knowledge of anatomy needs to be known. |
|
|
Term
| How often does a client need to be checked when wearing a condom catheter? |
|
Definition
| Every 30 minutes following catheter application and every 4 hours afterwords check for swelling and discoloration. Make sure it is working properly |
|
|
Term
|
Definition
| method used to collect a culture for urine you instruct pt to urinate small amount and collect the urine afterwards. |
|
|
Term
| What is ADH and what does it do |
|
Definition
| antidiuretic hormone , high levels increase water absorption and urine concentration, low levels decrease water absorption and dilute urine. |
|
|
Term
| external sphincter voluntary/involuntary? |
|
Definition
| voluntary allows the individual to choose when urine is eliminated |
|
|
Term
| internal sphincter voluntary/involuntary? |
|
Definition
| Involuntary, provides the active tension designed to close the urethral lumen. |
|
|
Term
| bladder training (continence training) |
|
Definition
| requires the client to postpone voiding, resist or inhibit the sensation of urgency, void according to a time table rather than according to urge to void. Voiding should be encouraged every 2-3 hours during day but during sleep every 4-6 hours |
|
|
Term
| habit training (continence training) |
|
Definition
| timed voiding or scheduled toileting. Keeps clients dry by having them void at regular intervals. |
|
|
Term
| prompted voiding (continence training) |
|
Definition
| encouraging the client to try to use the toilet (prompting) and reminding the client when to void |
|
|
Term
|
Definition
| pouches that form in the large intestine when the longitudinal muscles are shorter than the colon |
|
|
Term
|
Definition
| largely air and by-products of the digestion of carbohydrates |
|
|
Term
|
Definition
| wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls. |
|
|
Term
| is clay or white feces normal? |
|
Definition
| abnl absence of bile pigment (bile obstruction) |
|
|
Term
| What does black or tarry feces indicate? |
|
Definition
| drug (iron) bleeding from the upper gastrointestinal tract (stomach, small intestine) diet high in red meat and dark green vegetables (spinach) |
|
|
Term
| what does red feces indicate ? |
|
Definition
| bleeding from lower g.i. tract (rectum) some foods (beets) |
|
|
Term
| what do pale feces indicate? |
|
Definition
| malabsorption of fats; diet high in milk and milk products and low in meat. |
|
|
Term
| what do orange or green feces indicate? |
|
Definition
|
|
Term
| should the consistency of normal feces be formed, soft, and moist? |
|
Definition
| yes it is normal.Abnormal hard dry feces indicates dehydration; decreased intestinal motility resulting from lack of fiber in diet, lack of exercise, emotinal upset, laxative abuse. |
|
|
Term
| if the shape of feces is narrow, pencil, shaped or stringlike what does it indicate? |
|
Definition
| obstructive condition of the rectum. Normal should be cylindrical (contour of the rectum) about 2.5(1in) in diameter in adults |
|
|
Term
| what is the normal amount of feces per day? |
|
Definition
| varies with diet (about 100-400 g/day) |
|
|
Term
| what should the normal odor of feces be? |
|
Definition
| aromatic: affected by ingested food and person's own bacterial flora. Pungent means there is infection or blood present. |
|
|
Term
| what are abnormal constituents in feces? |
|
Definition
| pus (bacterial infections), mucus (inflammatory condition), parasites, blood (GI bleeding), foreign objects (accidental ingestion) |
|
|
Term
| what are normal constituents in feces? |
|
Definition
| small amounts of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile, pigments, inorganic matter) |
|
|
Term
| what are some of the factors that affect defecation? |
|
Definition
| development, diet, activity, psychological factors, defecation habits, medications, diagnostic procedures, anesthesia and surgery, pathologic conditions, pain. |
|
|
Term
| What are some fecal elimination problems? |
|
Definition
| Constipation, diarrhea, bowel incontinece, flatulence. |
|
|
Term
| factors that cause constipation |
|
Definition
| insufficient: fiber intake, fluid intake, activity/mobility, irregular defecation habits,** change in daily routine, lack of privacy, chronic use of laxatives or enemas, IBS, pelvic floor dysfunction or muscle damage, poor motility or slow transit, neurologic condition, stroke, or paralysis. |
|
|
Term
|
Definition
| mass or collection of hardened feces in the folds of the rectum. results from prolonged retention and accumulation of fecal matter. |
|
|
Term
| what is liquid fecal seepage? |
|
Definition
| diarrhea, and no normal stool in a client who has fecal impaction. a liquid portion of the feces seeps out around the impacted mass. |
|
|
Term
| How do you control diarrhea? |
|
Definition
| encourage oral intake of fluids and bland foods avoid highly spicy foods and high fiber foods. |
|
|
Term
|
Definition
| incomplete digestion of food or fluid, they induce defecation |
|
|
Term
|
Definition
| loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter. |
|
|
Term
|
Definition
| inability to control flatus or prevent minor soiling |
|
|
Term
| what are major causes of diarrhea? |
|
Definition
| psychological stress, medications, antibiotics, iron, cathartics, allergy to food, fluid, or drugs, intolerance of food or fluid, disease of the colon (malabsorption syndrom, Chrohn's disease) |
|
|
Term
| what do antidiarrheal medications do |
|
Definition
| they slow the motility of the intestine or absorb excess fluid in the intestine. |
|
|
Term
| what is a main reason a client would be constipated? |
|
Definition
|
|
Term
| how do you promote regular bowel training? |
|
Definition
| provision of privacy, a client should be encouraged to defecate when the urge is recognized, changing the diet so the client can have regular bowel movements, exercise, and good positionig for defecation. |
|
|
Term
| what is the proper position for giving an enema for an enema? |
|
Definition
|
|
Term
| name the four types of enemas |
|
Definition
| cleaning,carminative, retention, return-flow |
|
|
Term
| what is a carminitive enema used for? |
|
Definition
| to expel flatus (herbal oils known to act as agens that help expel gas from the stomach and intestines.) |
|
|
Term
| what does a retention enema used for? |
|
Definition
| it introduces oil or medication into the rectum and sigmoid colon for a relatively long time(1-3hrs) it softens the feces and lubricates the rectum and anal canal to facilitate passage of feces |
|
|
Term
| what is a return-flow enema? |
|
Definition
| (Harris flush) used to expel flatus alternate 100-200 mL of fluid and out of the rectum and sigmoid colon to stimulate peristalsis, process is repeated five times until flatus is expelled. |
|
|
Term
| how far should you insert an enema on a client? |
|
Definition
|
|
Term
| what is a cleansing enema given for? |
|
Definition
| intended to remove feces given chiefly to Prevent the escape of feces during surgery, prepare the intestine for certain diagnostic tests, remove feces in instances of constipation or impaction. |
|
|
Term
| Factors affecting nutrition |
|
Definition
| development, sex, nutrient req are diff for men than women,ethnicity and culture, beliefs about food, personal preferences, religious practices, lifestyle, economics, medications and therapy, health, alcohol consumption, advertising, psychological factors |
|
|
Term
|
Definition
| difficulty swallowing due to painfully inflamed throat or a stricture of the esophagus. |
|
|
Term
| Do older adults require more nutrition than younger adults? |
|
Definition
| No they require the same nutrition but fewer calories because of lower metabolic rate and decreased physical activity. |
|
|
Term
| what is a complete protein? |
|
Definition
| grains plus legumes or legumes plus nuts or seeds. |
|
|
Term
| what is an example of a legume? |
|
Definition
| beans; black beans,lentils, soybeans, black eyed peas |
|
|
Term
| what is an example of a grain? |
|
Definition
| brown rice, barley, corn meal, whole wheat, oats |
|
|
Term
| what do you use to determine fat stores? |
|
Definition
|
|
Term
| what do you use to determine the measure of fat, muscle, and skeleton? |
|
Definition
| Mid-arm circumference (MAC) |
|
|
Term
| what is the Mid arm Muscle area (MAMA) used to calculate? |
|
Definition
| estimate of lean body mass, or skeletal muscle reserves. |
|
|
Term
| what does a low serum albumin level indicate? |
|
Definition
| prolonged protein depletion |
|
|
Term
| what is the purpose of a a nutritional assessment? |
|
Definition
| to identify cleints at risk for malnutrtiion and those with poor nutritional status. |
|
|
Term
| what is the difference between a vegan diet and a vegetarian diet? |
|
Definition
| A vegan does not eat animal products at all. A vegetarian can eat foods that include milk, eggs, or dairy products. |
|
|
Term
| What vitamins can vegans lack and why? |
|
Definition
| B12,iron,vitamin C, calcium because vegans do not eat animal meat which is rich in B12 |
|
|
Term
| what is nitrogen balance? |
|
Definition
| measure of the degree of protein anabolism and catabolism. when nitrogen intake equals introgen output a state of nitrgen balance exists |
|
|
Term
|
Definition
| building of tissue or protein synthesis |
|
|
Term
|
Definition
| breaking down of tissue or protein degradation |
|
|
Term
| what is the BMI range for an underweight person |
|
Definition
|
|
Term
| what is the BMI range for a normal person |
|
Definition
|
|
Term
| what is the BMI range for an overweight person |
|
Definition
|
|
Term
| what is BMI range for obese person? |
|
Definition
|
|
Term
| what is positive nitrogen balance? |
|
Definition
| intake exceeds nitrogen output |
|
|
Term
| what is a negative nitrogen balance |
|
Definition
| occurs when output exceeds nitrogen intake |
|
|
Term
|
Definition
| chief end product of amino acid metabolism, formed from ammonia detoxified by the liver, circulated in the blood and transported to the kidneys for excretion in the urine. |
|
|
Term
| Describe what a patient looks like when they're aspirating if they have a PEG tube |
|
Definition
| decreased level of consciousness, poor cough or gag reflex (no cough), agitated, restless, color is dusky |
|
|
Term
| what position do you put a patient in if they are aspirating? |
|
Definition
|
|
Term
| what does increase in white blood cell count mean? |
|
Definition
|
|
Term
| when you are wearing ppe which object is the most soiled? |
|
Definition
|
|
Term
|
Definition
| gloves, hand hygiene, eyewear, gown, mask |
|
|
Term
|
Definition
| hand hygiene, gown, mask, eyewear, gloves |
|
|
Term
|
Definition
| infection caused by a diagnostic or therapeutic procedure. |
|
|
Term
|
Definition
| compassion, competence, confidence, conscience, commitment, comportment |
|
|
Term
| When wearing a gown is the inside of the gown contaminated? |
|
Definition
|
|
Term
| Are the neck and waist ties of the gown contaminated? |
|
Definition
|
|
Term
| what are Gordon's Health Patterns? |
|
Definition
| a guide for establishing a comprehensive nursing data base 11 categories |
|
|
Term
| Gordons, what is health perception and health management? |
|
Definition
| data collection that is focused on the person's perceived level of health and well being and on practicies for maintaning health. |
|
|
Term
| Gordon's, nutrition and metabolism assessment |
|
Definition
| focused on pattern of food and fluid consumption relative to metabolic needs. actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as GI system |
|
|
Term
|
Definition
| focused on exceretory patterns such as incontinence, constipation, diarrhea, and urinary retention |
|
|
Term
| Gordon's activity and exercise |
|
Definition
| focused on ADLs requiring energy expenditure, including self-care activities, exercise, and leisure activities. body systems,respiratory, cardiovascular, and musculoskeletal systems evaluated |
|
|
Term
| Gordon's cognition and perception |
|
Definition
| ability to comprehend and use information and on sensory functions.sensory experiences such as pain and altered sensory input may be identified and evaluated |
|
|
Term
|
Definition
| person's sleep, rest, and relaxation practices. dysfunctional sleep patters, fatigue and responses to sleep deprivations identified |
|
|
Term
| Gordon's self-perception and self concept |
|
Definition
| focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. level of self esteem and response to threats to his or herself concept may be identified. |
|
|
Term
| Gordon's roles and relationships |
|
Definition
| focused on the person's roles in the world and relationships with others. satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated |
|
|
Term
| Gordon's sexuality and reproduction |
|
Definition
| focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may be identified |
|
|
Term
| Gordon's coping and stress tolerance |
|
Definition
| focused on the person's percepion of stress and on his or her coping strategies, support systems are evaluated, and symptoms of stress are noted. |
|
|
Term
| Gordon's values and beliefs |
|
Definition
| focused on the person's values and beliefs (including spiritual belief) or on the goalds tha guide his/her decisions |
|
|
Term
|
Definition
| difference between the systolic and diastolic blood pressure |
|
|
Term
|
Definition
| defects in or loss of the power to express onself by speech, writing, or signs, or to comprehend spoken or written language |
|
|
Term
|
Definition
| loss of power to express oneself by writing, making signs, or speaking |
|
|
Term
| sensory/receptive aphasia |
|
Definition
| loss of the ability to comprehend written or spoken words two types auditory and visual aphasia |
|
|
Term
| purpose of health promotion |
|
Definition
| enhance the quality of life |
|
|
Term
| what scale is used to test mental/neurological status and what does it test? |
|
Definition
| Glascow Coma Scale tests eye response, motor response, and verbal response. |
|
|
Term
|
Definition
| enduring beliefs or attitudes about the worth of a person, object, idea, or action. Not all values are moral values. learned through observation and experience. |
|
|
Term
|
Definition
| they influence decisions and actions including nurses' ethical decision making |
|
|
Term
|
Definition
| opinions or interpretations that ppl accept as true. do not necessarily involve values based more on faith than facts judged as correct or incorrect |
|
|
Term
|
Definition
| private personal standards of what is right and wrong in conduct, character, and attitude. awareness of feelings such as guilt, hope, or shame. |
|
|
Term
|
Definition
| ethical issues that occur in nursing practice. |
|
|
Term
|
Definition
| ethics as applied to human life or health. |
|
|
Term
|
Definition
| process of leaning to tell the difference between right and wrong and of learning what out and what ought not to be done |
|
|
Term
|
Definition
| mental positions or feelings toward a person, object, or idea (acceptance, compassion, openness), judged as bad or good |
|
|
Term
|
Definition
| values derived from society and their individual subgroups |
|
|
Term
|
Definition
| acquired during socialization into nursing from codes of ethics, nursing experience, teachers and peers. |
|
|
Term
| what are the five values essential for the professional nurse? |
|
Definition
| altruism, autonomy, human dignity, integrity, and social justice |
|
|
Term
| example of behaviours that may help clients clarify their values |
|
Definition
| list alternatives, examine possible consequences of choices, choose freely, feeling about the choice, affirm the choice, act with a pattern |
|
|
Term
|
Definition
| a method of inquiry that helps people to understand the morality of human behavior, the practices or belifs of a certain group, the expected standards or moral behavior |
|
|
Term
| what is the difference between morality and law? |
|
Definition
| laws reflect the moral values of a society, they offer guidance in determining what is moral, the action can be legal but not moral. |
|
|
Term
|
Definition
| constitutional, statutes (legislation) administrative, and common law |
|
|
Term
| fuctions of the law in nursing |
|
Definition
| provides a framework for establishing which nursing action in the care of the clients are legal, differentiates the nurse's responsibilities from those of other health professionals, hleps establish boundaries of independent nursing action, assists in maintaining a std of nursing practice by making nurses accountable under the law. |
|
|
Term
| which law or regulation passes statutes that define and regulate nursing and nursing practice acts? |
|
Definition
| Legislation (statutory law) |
|
|
Term
| what is the purpose of the Nursing Practice Act? |
|
Definition
| differs from state to state, protects the public bylegally defining and describing the scope of nursing practice also legally control nursing practice through licencing requirements. |
|
|
Term
|
Definition
| process of determing and maintaining competence in nursing practice.One way in which the ursing profession maintains stds of practice and accountability for the educational preparation of its members |
|
|
Term
| what is a mutual recognition model? |
|
Definition
| allows for multistate licensure which helps facilitate a nurse to practice in person or electronically across state lines with just one license |
|
|
Term
|
Definition
| voluntary practice of validating that an individual nurse has met mininum stds of nursing competence in specialty areas such as maternal-child health, pediatrics,mental health, gerontology, and school nursing. |
|
|
Term
| do states require approval/accreditation by the state board of nursing? |
|
Definition
| yes some states require that nursing programs be both state approved/accredited and accredited by a national accrediting agency such as NLNAC(national league for nusing acrredting commission) or CCNE (commision on collegiate nursing education) |
|
|
Term
| what is the purpose of standards of care? |
|
Definition
| skills & learning commonly possessed by members of a profession.used to evaluate the quality of care nurses provide nad therefore become legal guidelines for nursing practice. |
|
|
Term
|
Definition
| the nurse's job description, education, and expertise as well as individual institutional policies and procedures. |
|
|
Term
|
Definition
| nx practice acts, professional organizations, nx speciality-practice organizations(emergency nurses assoc., oncology nx society), federal organizations and federal guidelines (joint commission and medicare) |
|
|
Term
| what should a lawful contract require |
|
Definition
| promise or agreement between 2 or more persons for the performance or an action or restraint from certain actions,mutual understanding of the terms and meaning of the contract by all, a lawful purpose, compensation in the form of something of value-most cases monetary |
|
|
Term
|
Definition
| agreement between two or more competent persons on sufficient consdieration to do or not to do some lawful act,may be written or oral (equally binding as a written contract) |
|
|
Term
|
Definition
| quality or state of being legally responsible for one's obligations and actions fnd for making financial restitution for wrongful acts. |
|
|
Term
| what are the legal roles of nurses |
|
Definition
| provider of service, employee or contract for service, and citizen |
|
|
Term
| what is contractual obligation |
|
Definition
| nurse's duty of care,that is dury to render care, established by the presence of an expressed or implied contract |
|
|
Term
| what are the three major elements of informed consent |
|
Definition
| the consent must be given voluntarily, must be given by a client or individual with the capacity and competence to understand, the client or individual must be given enough information to be the ultimate decision maker. |
|
|
Term
|
Definition
| may take the form of either an oral or written agreement usually the more invasive a procedureand/or the greater the potential for risk the greater the need for written permission |
|
|
Term
|
Definition
| individual's nonverbal behavior indicates agreement, obtaining informed consent for specific medical and surgical tx is responsibility of the person who is going to perform the procedure |
|
|
Term
| name three groups of people who cannot provide consent |
|
Definition
| minors (an adult who has the mental capacity of a child and has appointed guardian) person who is unconscious or injured who are unable to give consent, and people with mental illness who have been judged as incompetent. |
|
|
Term
| when obtaining a consent form, what does the nurse's signature confirm? 3 things |
|
Definition
| the client gave consent voluntarily, the signature is authentic, and the client appears competent to give consent |
|
|
Term
| can a patient change refuse or cancel a procedure after signing a consent? |
|
Definition
| yes they can do it at any time, the right to refuse continues even after signing a consent form. |
|
|
Term
|
Definition
| transfer of responsibility for hte performance of an activity from one person to another while retaining accountability for the outcome |
|
|
Term
| what is the American's with Disabilities Act? |
|
Definition
| prohibits discrimination on the basis of disability in employment, public services, and public accomodations. |
|
|
Term
| what is the purpose of the ADA? |
|
Definition
| provide clear and comprehensive national mandate for eliminating discrimination against individuals with disabilities, provide clear, strong, consistent, enforceable stds addressing discrimination against indiv. with disabilities, ensure the fed gvt. plays a central role in enforcing stds established under the act |
|
|
Term
| advanced health care directives |
|
Definition
| variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should the become unable to make or communicate their preferences |
|
|
Term
| What does the Patient Self-Determination Act implement for facilities receiving Medicare and Medicaid? |
|
Definition
| recognize advance directives, ask clients whether they have advance directives and provide educational materials advising cleints of their rights to declare their personal wishes regarding tx decisions including right to refuse medical tx |
|
|
Term
|
Definition
| provides specific instructions about what medical tx the client chooses to omit or refuse (ventilatory support) in the event that the client is unable to make those decisions |
|
|
Term
| what is a health care proxy |
|
Definition
| durable power of attorney for health care, is notarized or witnessed statement appointing someone else (relative or trusted friend) to manage health care tx decisions when the client is unable to do so |
|
|
Term
| is an autopsy always performed after a pt dies? |
|
Definition
| no, only in certain cases. the laws describe under what circumstances an autopsy must be performed such as when a death is sudden or when death occurs within 48 hrs of admission to a hospital. |
|
|
Term
| is consent needed to order an autopsy? |
|
Definition
| yes it is the responsibility of the pcp or a person designated in the hospital, must be given by the decendent (before death) or by the next of kin. |
|
|
Term
| who has authority to pronouce a person dead? |
|
Definition
| primary care provider, a coroner, or a nurse in some states. |
|
|
Term
|
Definition
| do not resuscitate order, for clients who are in a stage of terminal, irreversibe illness or expected death.The order indicates that the goal of tx is comfortable, dignignified death, and that further life-sustaining measures are not indicated. |
|
|
Term
| is euthanasia legal in the United States? |
|
Definition
| it is legally wrong and can lead to criminal charges of homicide or to a civil lawsuit for whithholding tx or providing an unnacceptable standard of care. |
|
|
Term
| what is the only state that has a "right to die" or physician assisted suicide law in the US? |
|
Definition
| Oregon, called the Death with Dignity Act provides pcps to prescribe lethal doses of medications. |
|
|
Term
| Nursing liability is usually involved with what kind of law? |
|
Definition
| Tort law, civil wrong committed against a person or persons property.almost always based on fault which is something that was done incorrectly. |
|
|
Term
| what are unintentional torts? |
|
Definition
| negligence misconduct or practice that is below the stds expected of an ordinary reasonable and prudent person.Malpractice is negligence that occured while the person was performing as a professional. |
|
|
Term
| 6 elements that must be present for a case of nursing malpractice to be proven |
|
Definition
| duty,breach of duty,foreseeability,causation, harm or injury, damages |
|
|
Term
| categories of negligence that result in malpractice lawsuits |
|
Definition
| 1. failure to follow stds of care 2. failure to use equipment in a responsible manner 3.failure to communicate 4.failure to document 5.failure to assess and monitor 6. failure to act as a client advocate. |
|
|
Term
| what are intentional torts and give examples |
|
Definition
| the defendant executed the act on purpose or with intent examples: assault/battery, false imprisonment, invasion of privacy, and defamation |
|
|
Term
| what types of invasions should a client be protected against? |
|
Definition
| use of the client's name or likeness for profit, without consent, unreasonable intrusion, public disclosure of private facts, putting a person in a false light |
|
|
Term
|
Definition
| defamation by means of print, writing or pictures |
|
|
Term
|
Definition
| defamation by the spoken word stating unpriviledged (not legally protected) or false words by which a reputation is damaged. |
|
|
Term
| how many pounds in a kilogram? |
|
Definition
|
|
Term
| how many grams in a kilogram |
|
Definition
|
|
Term
| how many grains in a gram |
|
Definition
|
|
Term
| how many milligrams in a gram |
|
Definition
|
|
Term
| how many milligrams in a grain |
|
Definition
|
|
Term
| how many micrograms in a mg |
|
Definition
|
|
Term
| how many milligrams in 1/4 gram |
|
Definition
|
|
Term
| how many milligrams in 1/2gr |
|
Definition
|
|
Term
| how many milligrams in 3/4 gr |
|
Definition
|
|
Term
| what is a Braden scale used for? |
|
Definition
| scale for predicting pressure sores highest 23 lowest is 6. 18 or less is considered at risk for developing pressure ulcers |
|
|
Term
| how many milliliters in 8 oz? |
|
Definition
|
|
Term
| how many mL in a teaspoon |
|
Definition
|
|
Term
| how many mL in a tablespoon |
|
Definition
|
|
Term
|
Definition
|
|
Term
| what is normal temperature range |
|
Definition
|
|
Term
|
Definition
| core body temperature below normal |
|
|
Term
|
Definition
| fever, body temperature above normal |
|
|
Term
| what is considered a fever? |
|
Definition
|
|
Term
| what is normal pulse rate range? |
|
Definition
|
|
Term
| what is rate for bradycardia? |
|
Definition
| less than 60bpm low pulse |
|
|
Term
| what is rate for tachycardia? |
|
Definition
|
|
Term
| what is dysrhythmia (arrythmia) |
|
Definition
|
|
Term
| how do you characterize pulse volume( pulse strenght, amplitude)? |
|
Definition
| 3+full (bounding) 2+ normal, 1+ weak, 0 may be absent or not palbable |
|
|
Term
| how long do you check radial pulse when doing vital signs? |
|
Definition
|
|
Term
|
Definition
| strength of heart's stroke volume |
|
|
Term
|
Definition
| normal rate and depth 12-20 bpm |
|
|
Term
| what is tachypnea and rate? |
|
Definition
| rapid shallow breathing less than 20 breaths per minute |
|
|
Term
| what is bradypnea and rate? |
|
Definition
| decreased but regular rate less than 12 breaths per minute |
|
|
Term
| how do you characterize depth in respirations? |
|
Definition
|
|
Term
| what is the character of effort of respirations |
|
Definition
|
|
Term
| what is average blood pressure rate in a healthy adult? |
|
Definition
|
|
Term
| what is prehypertension and rate |
|
Definition
|
|
Term
| what is stage 1 hypertension rate? |
|
Definition
| systolic 140-159 diastolic 90-99 mmHg |
|
|
Term
| what is stage 2 hypertension rate? |
|
Definition
| systolic > 160 or diastolic >100mmHg |
|
|
Term
| What is hypotension and rate? |
|
Definition
| blood pressure that is consistently below 85-100 mmHG in a person whose normal BP is higher |
|
|
Term
| what is systolic pressure? |
|
Definition
| the first sharp tapping sound (Korotkoff phase I) |
|
|
Term
| What is diastolic pressure? |
|
Definition
| the last sound heard (Korotkoff phase 5) |
|
|
Term
|
Definition
| deep, rapid breathing, usually from hypoxia,anxiety, or exercise |
|
|
Term
|
Definition
| shallow slow breathing can be related to sedation |
|
|
Term
|
Definition
| difficulty breathing unless sitting or standing |
|
|
Term
| Cheyne stokes respiration |
|
Definition
| rythmic waxing and waning of respirations from very deep breathing to very shallow breathing |
|
|
Term
|
Definition
|
|
Term
|
Definition
| shallow breathing with period of apnea |
|
|
Term
|
Definition
|
|
Term
| pulse oximetry rate for healthy person |
|
Definition
|
|
Term
| what rate in pulse oximetry is considered life threatening? |
|
Definition
|
|
Term
| what is the difference between fear and anxiety? |
|
Definition
| source of anxiety may not be identifiable; source of fear is, anxiety is related to the future, that is to an anticipated event, fear is related to the past present and future; anxiety is vague where as fear is definite, anxiety is the result of psychological or emotional conflict; fear is the result of a specific physical or psychoogical entity |
|
|
Term
|
Definition
| difference between the apical pulse and radial pulse |
|
|
Term
| what are your pulse sites? |
|
Definition
| temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal (dorsalis pedis) |
|
|
Term
| what are factors that affect the pulse |
|
Definition
| age, sex, exercise, fever, medications, hypovolemia/dehydration, stress, position, pathology |
|
|
Term
| what is another name for apical pulse? |
|
Definition
| point of maximal impulse (PMI) |
|
|
Term
| what is inductive reasoning? |
|
Definition
| generalizations formed from a set of facts or observations. |
|
|
Term
| is the nursing process inductive or deductive? |
|
Definition
| inductive because you form a generalization from signs and symptoms you are presented with. |
|
|
Term
| what is intimate distance? |
|
Definition
|
|
Term
| what is personal distance |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| diminutive- terms of endearment, honey, sweetie, innapropriate plural pronouns, tag questions, shortened sentences |
|
|
Term
| what are some barriers of communication? |
|
Definition
| stereotyping, agreeing and disagreeing, being offensive, challenging, probing, testing, rejecting, changing topics and subjects, unwarranted reassurance, passing judgement, giving common advice |
|
|
Term
|
Definition
| nurse reviews pertinent assessment data and knowledge considers potential areas of concern, and develops plans for interaction |
|
|
Term
|
Definition
| opens the relationship, clarifies the problem, structuring and formulating the contract |
|
|
Term
|
Definition
| exploring and understanding thoughts and feelings, facilitating and taking action |
|
|
Term
|
Definition
| nurse and client accept feelings of loss, client accepts the end of the relationship without feelings of anxiety or independence. |
|
|
Term
| example of a closed question |
|
Definition
| it is a directive requires yes or no or short factual answers they begin with when, where, who, what. used when information is needed quicklyex:what medication did you take today? are you having pain now? |
|
|
Term
| example of open ended question |
|
Definition
| nondirective interview,let the interviewee do that alking, longer answers example; What brought you to the hospital? what would you like to talk about today? would you describe more about how you feel in that situation? |
|
|
Term
| what are the stages of an interview |
|
Definition
| the opening (most important part establishes rapport), the body(client communicates what he or she thinks, feels knows), and the closing ( nurse terminates the interview when needed info is obtained) |
|
|
Term
| what are Maslow's Heirarchy Needs in order? |
|
Definition
| physiological needs (survival needs ex food water), safety and security needs, love and belonging needs, self-esteem needs, self-actualization needs) |
|
|
Term
| what are the phases of the nursing process in order |
|
Definition
| assessing, diagnosing, planning, implementing, and evaluating |
|
|
Term
| in the diagnostic process what does analyzing involve? |
|
Definition
| comparing the data against standards, cluster the cues, and identify gaps in inconsistencies. |
|
|
Term
| what does a basic two part statement consist of? |
|
Definition
| problem (P) statement of the client's response and Etiology (E) factors contributing to or probably causes of the responses. |
|
|
Term
| what are qualifiers in nx dx |
|
Definition
| words that have been added to some NANDA labels to give additional meaning to the dx stmt |
|
|
Term
| what does deficient mean in a dx statement |
|
Definition
| inadequate in amount, quality, or degree; not sufficient |
|
|
Term
| what does impaired mean in a dx |
|
Definition
| made worse,weakened, damaged,reduced, deteriorated |
|
|
Term
| what does decreased me in dx |
|
Definition
| lesser in size,amount, or degree |
|
|
Term
| what does ineffective mean in dx |
|
Definition
| not producing the desired effect |
|
|
Term
| what does compromised mean in dx |
|
Definition
| to make vulnerable to threat |
|
|
Term
| differentiate nx dx according to status |
|
Definition
| actual, health promotion, risk nursing dx, wellness dx, syndrome dx |
|
|
Term
| compare nursing diagnoses, medical dianoses, and collaborative problems |
|
Definition
| nursing dx is "human response" to disease process or health problems (independent interventions) medical dx describes disease and pathology, not human responses, collaborative dx is independent and physician prescribed interventions |
|
|
Term
| identify basic steps in the dx process |
|
Definition
analyze data-compare against stds
identify health problems- risks and strengths
formulate dx statement |
|
|
Term
|
Definition
| not disease oriented, motivated by personal positive approach to wellness seeks to expand positive |
|
|
Term
|
Definition
| illness or injury specific motivated by avoidance of illness, seeks to stop the potential for health occurence of insults to health and well-being |
|
|
Term
| example of primary prevention |
|
Definition
| immunizations, risk assessments for specific disease, family planning services |
|
|
Term
| example of secondary prevention |
|
Definition
| screening surveys, encouranging regular medical dental checkups, teaching self breast examinations |
|
|
Term
| example of tertiary prevention |
|
Definition
| refer a client who had a colostomy to a support group, referring a client to a rehabilition center. |
|
|
Term
| what are the stages of health behavior change |
|
Definition
| precontemplation stage, contemplation, preparation, action,maintenance,termination |
|
|
Term
| in life change index what does a score of 300+ mean? |
|
Definition
| the higher your life change score, the higher the possibility of illness means 300+ about 80% chance of likelihood for illness in the future |
|
|
Term
|
Definition
| chronic obstructive pulmonary disease |
|
|
Term
| what are adventitious breath sounds |
|
Definition
| abnormal breath sounds when air passes thorugh narrowed airways or airways filled with fluid or mucus |
|
|
Term
|
Definition
| rales, fine short interrupeted crackling best heard on inspiration air but also on expiration, air passing through fluid or mucus in any air passage |
|
|
Term
|
Definition
| rhonchi, continuos low pitched, coarse gurgling, harsh, louder sounds with moaning or snoring quality heard over the trachea and bronchi |
|
|
Term
|
Definition
| continuous high pitched squeaky musical sounds heard over all lung fields air passing through constricting bronchus |
|
|
Term
|
Definition
period when ventricles relax, s2, aortic, pulmonic valves close
starts with s2 and ends with s1 |
|
|
Term
|
Definition
| period in which the ventricles contract s1 mitral, tricuspid valves close. |
|
|
Term
| what does s3 and s4 indicate in an older |
|
Definition
| heart failure (but s3 is normal in children and young adults) S4 may be a sign of hypertension |
|
|
Term
| the S4 sounds is also called what? |
|
Definition
| ventricular gallup occurs near the very end of diastole just before S1 and creates the sound dee-lub-dub (S4, S1, S2) |
|
|
Term
| what are abnl heart sounds called |
|
Definition
| clicks, rubs and murmurs caused by valve disorders or impaired blood flow |
|
|
Term
|
Definition
| blowing or swishing sound created by turbulence of blood flow due to either narrowed arterial lumen or anemia if bruit is found then you need to palpate for a thrill |
|
|
Term
| Mumps Pneumonia,pertussis streptococcal pharyngitis scarlet fever rubella diptheria and adenovirus are need what kind of precaution? |
|
Definition
|
|
Term
| Tuberculosis vanilla rubeola and SARS require what type of precaution precaution? |
|
Definition
|
|
Term
| C. Diff ,shigella , hepatitis A require what type of precaution ? |
|
Definition
|
|
Term
|
Definition
| Assets pupil for size,equality,roundness,reactivity, to light and accommodation. |
|
|
Term
| What are techniques used during physical exam? (not the abdomen) |
|
Definition
| Inspection , palpation,percussion,auscultation |
|
|
Term
| What are techniques are used to assess the abdomen abdomen? |
|
Definition
| Inspection auscultation palpation percussion |
|
|
Term
| increased heart rate, respiratory rate and depth, shivering, pallid, cold skin, complaints of feeling cold gooseflesh appearance, cessation of sweating is what phase of a fever? |
|
Definition
| Onset (cold or chill phase) |
|
|
Term
| absence of chills, skin that feels warm,photosensitivity, glassy eyed,increased puls and resp. rate increased thirst,mild to severe dehydration,drowsiness,restlessness,delirium convulsions,herpetic lesions,loss off appetite, malaise what what phase of fever |
|
Definition
|
|
Term
| skin that appears flushed and feels warm, sweating, decreased shivering, possible dehydration is what phase of fever? |
|
Definition
| defervescense (fever abatement/flush phase |
|
|
Term
| factors that affect body temperature |
|
Definition
| age, diurnal variations (circadian rhythm), exercise, hormones,stress, environment |
|
|
Term
| what is an auscultory gap? |
|
Definition
| temporary disappearance of sounds normally heard over the brachial artery. |
|
|
Term
| when taking a bp which point at which point should systolic and diastolic be recorded? |
|
Definition
| systolic is first tapping Korotkoff sound, diastolic is pt where sounds become inaudible 4 or 5 (phase 5 may be 0) |
|
|
Term
| what are factos afecting oxygen saturation readings? |
|
Definition
| hemoglobin if it is saturated, circulation, activity, carbon monoxide poisoning, something covering the nails like nailpolish or fake nails |
|
|
Term
| what position is used for doing a vaginal check on a patient with back lying and feet supported on stirrups |
|
Definition
|
|
Term
| what position has pt side lying with lowermost arm behind the body and upper most leg flexed at hip and knee, upper arm is flexed at the shoulder to assess the rectum or vagina |
|
Definition
|
|
Term
| what is the back lying position with knees flexed and hips externally rotated, small pillow may be under head soles of feet on the surface to assess female genitals, rectum and female reproductive tract |
|
Definition
|
|
Term
| the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt is called what? |
|
Definition
|
|
Term
| example of locations with flat sound, high pitch, short duration quality of percussion is dull |
|
Definition
|
|
Term
| example of dullness, medium intensity, medium pitch, moderate duration thudlike quality in percussion |
|
Definition
|
|
Term
| example of resonance, loud intensity, low pitch, long duration, hollow quality |
|
Definition
|
|
Term
| example of hyperresonance intensity very loud, very low pitch, very long duration, booming quality percussion |
|
Definition
|
|
Term
| example of tympany sound, loud intensity, high pitch, moderate duration, musical quality percussion |
|
Definition
| stomach filled with gas (air) |
|
|
Term
| a "visible hard deposit" of plaque and dead bacteria that forms at the gumline |
|
Definition
|
|
Term
| invisible soft film that adheres to the enamel surface of teeth consists of bacteria, moleculse of saliva and remnants of epithelial cells and leukocytes |
|
Definition
|
|
Term
| what can alter the size of a the chest cavity in an older adult? |
|
Definition
| kyphosis and osteoporosis |
|
|
Term
| what can cause pidgeon chest |
|
Definition
| caused by rickets (abnl bone formation due to lack of dietary calcium) |
|
|
Term
| what is a funnel chest describe appearance? |
|
Definition
| pectus excavatum is a congenital defect opposite of pigeon chest and the sternum is depressed, narrowing the anteroposterior diameter. pt has abnml pressure on the chest |
|
|
Term
| describe a vesicular breath sound |
|
Definition
| soft intensity, low pitched "gentle sighing" over peripheral lung best heard at base of lungs |
|
|
Term
| describe broncho-vesicular breath sounds |
|
Definition
| moderate intensity "blowing sounds" )bronchi) between scapulae and lateral to sternum at the 1st and 2nd intercostal space |
|
|
Term
| describe bronchial (tubular) breath sounds |
|
Definition
| high pitched loud "harsh" sounds air moving through the trachea anteriorly over trachea |
|
|
Term
| What chambers of the heart do the upper portion of the heart contain? |
|
Definition
|
|
Term
| what chambers of the heart does the lower portion contain? |
|
Definition
| ventricles (apex of heart) |
|
|
Term
| a dull low pitched sound described as a lub is which heart sound? |
|
Definition
|
|
Term
| a higher pitch described as dub and shorter duration is which heart sound? |
|
Definition
|
|
Term
|
Definition
| when the atrioventricular (A-V) valve closes, they close when the ventricles have been sufficiently filled produce the first heart sound (lub) |
|
|
Term
|
Definition
| after ventricles empty the blood in to the aorta and pulmonary arteries, the semilunas valves close to produce the second heart sound (dub) |
|
|
Term
| What position do you put a client in to check for jugular vein distension? |
|
Definition
| fowler's (15-45 degree angle) |
|
|
Term
| what is the reason for palpating peripheral pulses? |
|
Definition
| to instpect the skin and tissues and determine perfusion (blood supply to an area) |
|
|
Term
| what tests can you perform on a pt to test motor function? |
|
Definition
| gross motor and balance tests such as the Romberg, heel to to walking, finger to nose test,finger to nose and to the nurse's finger,finger to thumb |
|
|
Term
| what does a pap smear detect? |
|
Definition
|
|
Term
|
Definition
| includes all practices intended to confine a specific microorganism to a specific area, limiting the number of growth and transmission of microorganism. objects are referred to as clean (absence of almost all microorganisms) or dirty (soiled, contaminated) |
|
|
Term
| what is surgical asepsis and sterile technique |
|
Definition
| practices that keep an area or object free of all microorganisms; includes practices that destroy all microorganisms and spores. |
|
|
Term
| when is surgical asepsis used? |
|
Definition
| for all procedures involving the sterile areas of the body. |
|
|
Term
| what is a local infection |
|
Definition
| limited to a specific part of the body where microorganims remain |
|
|
Term
| what is a systemic infection |
|
Definition
| microorganisms spread and damage to different parts of the body |
|
|
Term
| what is bacterimia referred to as when it is systemic? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| person or animal reservoir or a specific infections agent that usually does not manifest any clinical signs of disease ex: anopheles mosquito |
|
|
Term
| sign of systemic infecstion |
|
Definition
| fever,increased pulse and respiratory rate if fever is high, malaise and loss of energy, anorexia and in some situations nausea and vomiting, enlargement and tenderness of lymph nodes that dreain the area of infection |
|
|
Term
|
Definition
| localized swelling, localized redness, pain or tenderness with palpation or mvmt, palpable heat at the infected area, loss of function of the body part affected, depending on the site and extent of involvement. |
|
|
Term
| General Adaptive System (GAS) |
|
Definition
| a general arousal response of the body to a stressor characterized by certain physiologic events and dominated by the sympathetic nervous system also called stress syndrome |
|
|
Term
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Definition
| pupils dilate, sweat production(diaphoresis), heard rate and cardiac output increase, skin pallid,sodium and h20 retention increase,rate and depth of resp increase, mouth may be dry, urinary output decreases, peristalsis decreases, muscle tension increases, blood sugar increases |
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