Term
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Definition
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Term
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Definition
| Data that can be observed |
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Term
| What is the order when assessing the abdomen |
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Definition
Look, Listen, Feel
When listening always start at the right lower quad and then right upper, left upper, and left lower....Always in that order |
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Term
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Definition
| Collecting, organizing, validating, and recording data about a pt's health status |
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Term
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Definition
| Sorting, clustering, and analyzing data obtained to form a diagnostic statement |
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Term
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Definition
| Setting priorities, identifying expected outcomes, and developing specific nursing interventions to resolve or minimize the identified problems |
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Term
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Definition
| Putting the nursing care plan into action |
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Term
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Definition
| Assessing the pt's response to the nursing interventions and comparing the response to the expected out come |
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Term
| Where is Apical pulse located |
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Definition
| Over the heart at the 5th intercostal space |
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Term
| Definition of Labored breathing |
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Definition
| Means pt is using accessory muscles to breath |
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Term
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Definition
| Color, Odor, Consistency, Amount |
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Term
| Describe bronchial breath sounds |
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Definition
Loud, "harsh", high pitched sounds
Are created by air moving through the trachea and are heard over the trachea |
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Term
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Definition
Moderate intensity "blowing" sounds heard as air moves through the larger airways
They are normally heard between the scapula |
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Term
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Definition
| Soft intensity "gentle sighing" sounds heard over the lung periphery as air moves through the smaller airways |
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Term
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Definition
| Abnormal sounds result from air passing through moisture, mucus, or narrowed airways |
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Term
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Definition
| Fine, short crackling sounds created as air passes through fluid or mucus in any air passage....Most common in bases of loser lobes |
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Term
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Definition
| Continuous, low pitched gurgling, harsh sounds created as air passes through airways narrowed by secretions, swelling or tumors. These sounds predominate over trachea and bronchi |
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Term
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Definition
| Continuous, high pitched, squeaky musical sounds that can be heard over all lung fields as air passes through a constricted bronchi |
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Term
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Definition
| Superficial grating or creaking sounds created by pleural surfaces rubbing together, They are heard most often over lower anterior and lateral chest (area's of greatest expansion) |
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Term
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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
| One every three seconds and are loud and rushing sounds |
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Term
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Definition
| After listening for 3-5 min per quadrant and no sounds are heard |
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Term
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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
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Term
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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
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Term
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Definition
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Term
| What percent of the body is water |
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Definition
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Term
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Definition
| It is what the pt says it is at the level they say it is and for the duration they state |
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Term
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Definition
| Discomfort of any kind and it is subjective |
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Term
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Definition
| Pain that has a rapid onset and goes away in a short amount of time (Broken bone, Kidney stone, etc.) |
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Term
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Definition
| Pain that is constant and lasts more than six months (Arthritis, Cancer, etc.) |
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Term
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Definition
| Resistant to cure or relief |
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Term
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Definition
| Perceived from part no longer present (amputee) |
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Term
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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
| Abdominal cavity or thorax |
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Term
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Definition
| perceived in area other than location |
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Term
| Effects of untreated pain |
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Definition
| Can lead to sleep deprivation, fatigue, chronic pain, depression, analgesics become less effective in sleep deprived patients |
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Term
| Two compartments where there is body fluid |
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Definition
| ICF (Intracellular Fluid, Inside the cell) and ECF (Extracellular Fluid, Outside the cell) |
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Term
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Definition
| Sometimes fluid is not lost from the body but is unavailable for use by either the ICF or ECF. Loss of ECF into a space that does not contribute to equilibrium between the ICF and the ECF is referred to as a third-space fluid shift, or "third spacing" for short |
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Term
| Third spacing sings and symptoms |
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Definition
| Increased heart rate, decreased blood pressure, decreased central venous pressure, edema, increased body weight, and imbalances in fluid intake and output |
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Term
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Definition
| Hypocalcemia, Decreased iron intake, severe liver disease, alcoholism, hypothyroidism, malabsorption, immobility, burns, cancer |
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Term
| Fluid Volume Deficit (FVD)signs and symptoms (Hypovolemia) |
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Definition
| Postural hypotension, acute weight loss, dry mucous membranes, decreased skin turgor, lassitude, flattened neck veins, delayed capillary refill, decreased CVP, Weak, rapid pulse, Sunken eyeballs, oliguria, concentrated urine, pale, cool, clammy skin, increased temperature, cramps |
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Term
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Definition
| Elevated BUN, Elevated BUN/Cr ratio, Elevated hematocrit due to decreased plasma volume, Serum electrolytes, increased urine specific gravity |
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Term
| FVE, Fluid Volume Excess (Hypervolemia) |
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Definition
| Abnormal retention of water or Sodium (Na)(Na levels not always elevated) |
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Term
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Definition
| Fluid retention leading to weight gain, gallops in the heart, crackles in the lungs, ascites (abdominal distention due to fluid build up), Tachycardia, increased BP, Increased CVP, SOB, Wheezing, increased urine output |
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Term
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Definition
| Decreased BUN, Decreased Hematocrit level from decreased plasma dilution, CXR may revel pulmonary congestion |
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Term
| Diuretic use for Hypervolemia (FVE) |
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Definition
| Thiazide diuretics are prescribed for mild to moderate hypervolemia and loop diuretics for severe hypervolemia |
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