Nursing Process

Includes 6 phases:

assesment, diagnosis, outcome identification, planning, implementation and evaluation.

Evidence Based Practice

A systematic approach to practice that emphasizes the use of the best evidence in combination with the clinician's experience, as well as the patient's preferences and values, to make decisions about care and treatment.

Complete Database

Complete health history and full physical exam. Used most often in a primary care setting.

Focused/Problem-centered database

It concerns mainly one problem, smaller in scope and more targeted than a complete database. Used in all settings.

Follow-up Database

The status of any identified problem should be evaluated at appropriate intervals.

Emergency Database

Rapid collection of data, often compiled concurrently with lifesaving measures.

LEP

Limited English Proficiency

Cultural Competence

Must have knowledge about:

1) own personal heritage

2)heritage of the nursing profession

3)heritage of the health care system

4) heritage of the patient

Biomedical theory of illness causation

Assumption that all events in life have a cause and effect, and that all of reality can be observed and measured.

yin/yang theory

Health is believed to exist when all aspects of a person are in balance.

hot/cold theory

An explanatory model with origins in Greek humoral theory. The four humors of the body, blood, phlegm, black bile and yellow bile, regulate basic bodily functions and are described in terms of temperatures, dryness and moisture.

Magicoreligious

The world is seen as an arena where supernatural forces dominate

Culture-bound Syndrome

A condition that is culturally defined, may or may not have a biomedical basis.

Equal-status seating

Both you and the patient should be comfortably seated at eye level.

Open-ended question

Asks for narrative information

Closed or Direct Question

One or two word answer required: usually "yes" or "no"

10 Traps of Interviewing

1) Providing False assurance 2) Giving unwanted advice

3) Using authority 4) Using avoidance language (i.e. euphemism) 5) Engaging in distancing 6) Using professional jargon 7) Using leading or biased questions

8) Talking too much 9) Interrupting 10) Using "why" questions.

Telegraphic Speech

Used by 2 year old children. Consists of simple two word combinations which is usually a noun and a verb. (i.e. "all gone", "me up," etc.)

Symptom

Subjective sensation that the person feels from the disorder

Sign

Objective abnormality that you as the examiner could detect on physical examination or in laboratory reports.

PQRSTU

P = Provocative or Palliative

Q = Quality or Quantity

R=Region or Radiation

S=Severity Scale

T= Timing

U=Understand Patient's Perception

Genogram

A graphic family tree that uses symbols to depict the gender, relationship and age of immediate blood relatives in at least three generations.

Review of Systems

The purpose of this is to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the Present Illness section and to evaluate health promotion practices.

HEEADSSS

Psychosocial review of symptoms for use with adolescents.

Home Environment

Education and Employment

Eating

Peer-related Activities

Drugs

Sexuality

Suicide/depression

Safety from injury and violence

Mental Disorder

Is apparent when a person's response is much greater than the expected reaction to a traumatic life event.

Organic Disorders

Mental disorder that is due to a brain disease of known specific organic cause (i.e. dementia, alcohol or drug impairment, etc.)

Psychiatric Mental Illness

Organic etiology has not yet been established (i.e anxiety disorder or schizophrenia)

ABCT

Four main headings of mental status assesment:

A: Appearance

B: Behavior

C: Cognition

T: Thought Processes

Obtunded

Confused

Dysphonia

Abnormal volume or pitch when speaking

Dysarthria

Distorted speech, misuses words;omits letters, syllables or words; transposes words, occurs with aphasia.

Aphasia

Disorder of language comprehension and production secondary to brain damage (3 types)

Global Aphasia

The most common and severe form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds.

Broca's Aphasia

Expressive aphasia. The person can understand language, but cannot express him/herself using language.

Wernicke's Aphasia

Receptive Aphasia. The linguistic opposite of Broca's aphasia. The person can hear sounds and words but cannot relate them to previous experiences.

Denver II Screening Test

Designed to detect developmental delays in infants and preschoolers within four functions: gross motor, language, fine motor-adaptive, personal social skills.

Delirium

 Acute confusional change of loss of consciousness and perceptual disturbance. May accompany acute illness, and is usually resolved when the underlying cause is treated.

Dementia

Gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake and is non-reversible.

Mini-cog

Newly developed, reliable, quick and easily available instrument to screen for cognitive impairment in otherwise healthy adults.

3 item recall test and clock drawing.

Levels of Consciousness

1) Alert

2) Lethargic

3) Obtunded

4) Stupor/ Semi-coma

5) Coma

Alcohol

Most used and abused psychoactive drug, thus many patients will have alcohol related disorders.

Marijuana

Most commonly used illicit drug.

Prescription Drugs

Fastest growing drug problem in the United States.

CAGE

For use in assesing alcohol disorders

Cutdown

Annoyed

Guilty

Eye-opener

TWEAK

For use in screening women for alcohol disorders:

Tolerance

Worry

Eye-opener

Amnesia

Kut down

Gamma glutamyl transferase (GGT)

Most commonly used biochemical marker of alcohol drinking. Occasional use will not raise this marker, but chronic heavy drinking will.

Risk Factors for Child maltreatment

1) Disabilities or mental retardation

2) Social isolation of families

3) Parents' lack of understanding of child development

4) Parents' history of domestic abuse

5)Poverty and unemployment

6) Family disorganization or dissolution

7) Substance abuse

8) Parental stress and distress, including mental illness

9) Community violence

Abuse Assesment Screen (AAS)

Used in many healthcare settings, has strong support for reliability and validity. Never copyrighted so that nurses can amend it to be adaptable to their health care setting.

Reporting of Elder Abuse

Do not need proof that abuse is ocurring, only reasonable cause to suspect it may be occuring to report.

Ecchymoses

A hemmorhagic spot or blotch in the skin or mucous membrane, forming a nonelevated, rounded or regular, purplish blue patch.

Not directly related to blunt-force trauma. Related to purpura.

Risk of Homicide

Women in the U.S. are more often killed by a boyfriend, husband or ex-husband than by anyone else, and 75% had been abused by the man who subsequently killed them.

Nutritional Status

Refers to the degree of balance between nutrient intake and nutrient requirement.

Nutrition Screening

First step in assesing nutrition status, required in all health care settings within 24 hours of admission.

24-hour recall

Patient is interviewed or fills out a questionairre about all food consumed within the last 24 hours.

BMI

Body Mass Index

Weight in Pounds/Height in Inches x 703

Adults

<18.5 =underweight

18.5 - 24.9 = Normal weight

25.0 - 29.9 = Overweight

30-39.9 = Obese

>40 = Morbidly obese

Serum Albumin

Common measure of visceral protein status.

Obesity

Due to caloric excess. Refers to body weight more than 20% above ideal body weight. Causes are complex and multifactorial.

Marasmus

Protein-calorie malnutrition. Due to inadequate intake of protein and calories or prolonged starvation. Measured by weight loss and subcutaneous fat and muscle wasting. Visceral protein levels may remain within normal levels.

Kwashiorkor

Due to a diet high in calories but contains little or no protein. Decreased visceral protein levels, but adequate anthropometric measurements. They will appear well nourished or even obese.

Marasmus/Kwashiorkor Mix

Prolonged inadequate intake of protein and calories. Severe starvation. Muscle, fat and visceral protein wasting. Highest risk for morbidity and mortality.

Pellagra

Pigmented keratotic scaling lesions resulting from a deficiency of niacin.

Follicular Hyperkeratosis

Dry, bumpy skin associated with Vitamin A and/or lineolic acid deficiency.

Scorbutic Gums

Deficiency of Vitamin C.

Magenta Tongue

A sign of riboflavin deficiency. Pale tongue indicates iron deficiency.

Rickets

Sign of Vitamin D and Calcium deficiencies in children (disorders of cartilage cell growth, enlargement of epiphyseal growth plates)

Bitot's Spots

Foamy plaques of the cornea that are a sign of vitamin A deficiency.