Term
|
Definition
| energy needed to maintain life sustaining activities for a specific period of time at rest. Affected by age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level and thyroid function. |
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Term
REE
resting energy expenditure or resting metabolic rate |
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Definition
| amount of energy an individual needs to consume over a 24 hour period for the body to maintain all its internal working activities while at rest. Affected by illness, pregnancy, lactation and energy level. |
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Term
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Definition
| used by hospitals and providers to measure energy requirements by measuring oxygen consumption, carbon dioxide production and nitrogen excretion |
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Term
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Definition
| unit of energy of 1,000 calories (equal to one large calorie)Too many than energy demands and gain weight, too little and lose weight. |
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Term
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Definition
| elements necessary for body processes and functions. Carbs, proteins, fats, water, vitamins and minerals. |
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Term
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Definition
| the proportion of essential nutrients to the number of kcals |
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Term
| high nutrient density foods |
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Definition
| fruits and vegetables, provide large number of nutrients in relationship to kcals |
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Term
| low nutrient density foods |
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Definition
| alcohol and sugar, high in kcals but are poor in nutrients |
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Term
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Definition
| main source of energy, provides glucose (fuel) for the brain, skeletal muscles, erythrocyte and leukocyte production and cell function of the renal medulla. Mainly from plant sources or lactose |
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Term
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Definition
| Mainly polysaccharides that humans cannot break down because they are lacking the enzymes. Can prevent diarrhea in tube fed clients |
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Term
|
Definition
| cellulose, hemicellulose and lignin |
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Term
|
Definition
| pectin, guar gum and mucilage |
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Term
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Definition
| source of energy and needed for synthesis of body tissue in growth, maintenance and repair. Make up collage, hormones, enzymes, immune cells, DNA, RNA. Needed for blood clotting, fluid regulation and acid base balance. Transport nutrients and drugs in the body |
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Term
| indispensable amino acids |
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Definition
| body cannot synthesize so they need to be provided in diet. Includ histidine, lysine, phenylalanine |
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Term
|
Definition
| synthesized in the body and include, alanine, asparagine, and glutamic acid |
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Term
| complete protein or high quality protein |
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Definition
| contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. includes fish, chicken, soybeans, turkey and cheese. |
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Term
| What occurs when the intake of nitrogen is greater than the output? |
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Definition
| The body is in positive nitrogen balance. This is important for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing |
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Term
| What occurs when the body loses more nitrogen than the body gains? |
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Definition
| Negative nitrogen balance. Occurs with infection, sepsis, burns, fever, starvation, head injury and trauma. Happens because there is a body tissue destruction and loss of nitrogen containing body fluids. |
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Term
| Importance of nutrition during healing and nitrogen balance |
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Definition
| Patient needs to be in positive nitrogen balance during healing. Need an adequate balance of kcals from nonprotein sources so that the protein can be used for growth, maintenance and repair. Carbohydrates need to be included to meet the energy needs of the body so that protein can be used for healing |
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Term
|
Definition
| most calorie dense nutrient |
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Term
|
Definition
| beta carotene, vitamins A, C and E |
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Term
|
Definition
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Term
|
Definition
| C, B complex (8 different) Body cannot store so they need to be provided in diet. |
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Term
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Definition
| inorganic elements essential to the body as catalysts in biochemical reactions. macro=100mg or more is needed and trace elements or micro=less than 100mg is needed daily |
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Term
| What is the primary absorption site for nutrients? |
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Definition
|
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Term
|
Definition
|
|
Term
| RDI's reference daily intakes |
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Definition
| protein, vitamins and minerals based on the RDA's |
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Term
| DRV's daily reference values |
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Definition
| nutrients such as total fat, saturated fat, cholesterol, fiber, sodium and potassium |
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Term
| choose my plate and food guide pyramid |
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Definition
| USDA. Changes recently include adding exercise and decreasing amounts of sugar |
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Term
| DRI's dietary reference intakes |
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Definition
| acceptable ranges of vitamins and minerals to avoid deficiencies or toxicities |
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Term
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Definition
| recommended amount of a nutrient that maintains a specific body function for 50% of the population |
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Term
|
Definition
| average needs of a nutrient for 98% of the population |
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Term
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Definition
| adequate intake suggested for an individual |
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Term
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Definition
| highest level that likely poses no risk of adverse health events |
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Term
| Protein intake during pregancy |
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Definition
| throughout pregnancy, important to increaseto 60g daily |
|
|
Term
| calcium intake during pregnancy |
|
Definition
| third trimester is important when fetal bones are mineralized |
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Term
| Iron needs during pregnancy |
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Definition
| Needs to be supplemented to provide for increased maternal blood volume and fetal blood storage and for blood loss during delivery |
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Term
| folic acid during pregnancy |
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Definition
| Needed for DNA synthesis and growth of red blood cells. Inadequate intake can lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. Women of childbearing age should consume 400 mcg of folic acid daily and 600mcg during pregnancy |
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Term
|
Definition
| measurement system of the size and makeup of the body. Height and weight are obtained from each client upon admission |
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Term
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Definition
| estimate of what a person should weigh. Fluctuations in weight can be attributed to water retention or loss. |
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Term
|
Definition
Divide the patients weight in kg by height in meters squared.
weight kg/height meters(squared) |
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Term
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Definition
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Term
|
Definition
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Term
|
Definition
| broth, coffee, tea, carbonated beverages, clear fruit juices, gelatin, popscicles |
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Term
|
Definition
| clear liquid, plus ice cream, custard, refined cooked cereals, vegetable juice, fruit juice |
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Term
|
Definition
| Clear liquid, soft liquid, scrambled eggs, pureed meats, vegetables, mashed potatoes and gravy |
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Term
|
Definition
| clear and full liquid, pureed, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter |
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Term
|
Definition
| addition of low fiber, easily digested foods such as pasta, casseroles, moist tender meats, canned fruits and vegetables, desserts, cakes and cookies without nuts or coconut |
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Term
|
Definition
| addition of uncooked fruits, steamed vegetables, bran, oatmeal and dried fruits |
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Term
|
Definition
| can vary from no added salt to sever sodium restriction which requires selective food purchases. |
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Term
|
Definition
|
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Term
|
Definition
| 1800 calories, needs to include balance of carbs, fats, proteins. |
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Term
|
Definition
| given in the GI tract, clients GI tract needs to be functioning. Nasogastric, jejunal or gastric |
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Term
|
Definition
| low risk for gastric reflux |
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Term
|
Definition
| risk of gastric reflux, can lead to aspiration |
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Term
|
Definition
| 1-2 kcal per mL milk based, can include commercially produced whole nutrient formulas if digestion is ok to absorb whole nutrients |
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Term
|
Definition
| 3.8-4 kcal per mL single macronutrients, not nutritionally complete, used for specific nutrition needs |
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Term
|
Definition
| 1-3 kcal per mL, predigested nutrients |
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Term
|
Definition
| 1-2 kcal per mL specific to certain nutritional needs during illness |
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Term
|
Definition
| nutrients are provided intravenously. used on clients who are unable to digest or absorb enteral nutrition. Burns, sepsis, head injury. |
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|
Term
| Who is at risk for pressure ulcers? |
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Definition
| Decreased mobility, decreased sensory perception, fecal or urinary incontinence, and poor nutrition |
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|
Term
| Three pressure related factors that contribute to ulcer development |
|
Definition
| pressure intensity, pressure duration and tissue tolerance |
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Term
|
Definition
| active, organized cognitive process used to carefully examine ones thinking and thinking of others. Involves recognizing that an issue exists, analyzing information about the issue and evaluating information and making conclusions |
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Term
|
Definition
| learner trusts that experts have the right answer. Thinking is concrete and based on a set of rules or principles. ie: using procedure manual to perform a task, going step by step and not changing any thing to meet the clients unique needs. Something is either right or wrong |
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Term
| complex critical thinking |
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Definition
| begin to separate themselves from authorities. Analyze and examine choices more independently. Learns alternatives and perhaps conflicting solutions do exist. |
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Term
|
Definition
| Person anticipates the need to make choices without assistance from others. Accepts accountability. |
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Term
|
Definition
| determining a client's health status after you assign meaning to the behaviors, physical signs and symptoms presented. Begins when you enter into an interaction with a client or when you make physical or behavioral observations. |
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Term
|
Definition
| drawing conclusions from related pieces of evidence. Involves forming patterns of information from data before making a diagnosis. |
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Term
|
Definition
| requires careful reasoning so tha tyou can choose the options for the best client outcomes on the basis of the clients condition and the priority of problems |
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Term
|
Definition
| judgement about the likely course of events and outcome of the diagnosed problem, considering any health risks the clients has |
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Term
|
Definition
| assessment, diagnosis, planning, implementation and evaluation |
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Term
|
Definition
| two steps: collect and verify data from primary and secondary sources (client and family) analyze all data to develop nursing diagnosis, identifying problems, and develop individualized plan |
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Term
|
Definition
| information that you obtain through use of senses |
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Term
|
Definition
| judgement based on interpretation of clues |
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|
Term
| orientation phase of assessment |
|
Definition
| get to know client, explain purpose of interview, assure it will be confidentiall |
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Term
|
Definition
| gather information about health status, use a variety of different communication strategies. Obtain current illness, health history and expectations of care. |
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Term
|
Definition
| give client cue interview is coming to an end. |
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Term
|
Definition
| active listening prompts such as "go on" "uh huh", etc |
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Term
|
Definition
| Includes biographical data, reason for seeking care, client expectations, present illness or health concerns, health history, family history, environmental history, psychosocial history, spiritual health, review of systems, documentation of history findings, physical examination, observe client behavior, lab data |
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Term
|
Definition
| comparison of data with another source to determine accuracy |
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Term
|
Definition
| recognizing patters or trends in the clustered data, comparing them to standards and then coming to a reasoned conclusion |
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Term
|
Definition
| actual or potential physiological complication that nurses monitor to detect the onset of changes in a clients status |
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Term
|
Definition
| clinical criteria or assessment findings that support an actual nursing diagnosis |
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Term
|
Definition
| objective or subjective signs and symptoms, clusters of signs and symptoms or risk factors that lead to a diagnostic conclusion |
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Term
|
Definition
| describes human responses to health conditions or life processes that exist in an individual, family or community. |
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Term
|
Definition
| describes human responses to health conditions, life processes that will possibly develop in a vulnerable individual, family or community |
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Term
| health promotion nursing diagnosis |
|
Definition
| clinical judgement of a person, family or community's motivation and desire to increase well being and actualize human health potentials.. such as nutrition and exercise |
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Term
| wellness nursing diagnosis |
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Definition
| describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement |
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Term
|
Definition
| nursing diagnosis approved by NANDA, includes descriptors such as "impaired" |
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Term
|
Definition
| condition or etiology identified from assessment data. Associated with actual or potential response to the health problem and can change by using nursing interventions |
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Term
| etiology of nursing diagnosis |
|
Definition
| always within the domain of nursing practice and a condition that responds to nursing interventions. |
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Term
|
Definition
| sets client centered goals and expected outcomes and plans nursing interventions |
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Term
|
Definition
| measurable criteria to evaluate goal achievement |
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Term
| nursing sensitive client outcome |
|
Definition
| individual, family or community state, behavior or perception that is measurable along a continuum in response to a nursing intervention |
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Term
| Guidelines for writing goals or expected outcomes |
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Definition
| Client centered, singular goal or outcome, observable, measurable, time limited, mutual factors (client nurse agree), realistic |
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Term
| independent nursing interventions |
|
Definition
| actions nurse initiates, do not require direction or an order from another health care professional |
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Term
| dependent nursing interventions |
|
Definition
| actions that require an order from a physician or another health care professional |
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Term
| When choosing interventions consider... |
|
Definition
| characteristics of nursing diagnosis, goals and expected outcomes, evidence base for interventions, feasibility of the intervention, acceptability to the client, own competency |
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Term
|
Definition
| aim, intent, end. Broad general statement that describes a desired change in a clients condition or behaviour. |
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Term
|
Definition
| multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition |
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Term
|
Definition
| formally begins after the nurse develops the plan of care |
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Term
|
Definition
| any treatment, based upon clinical judgement or knowledge that a nurse performs to enhance client outcomes. |
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Term
|
Definition
| protocol or document that guides decision and interventions for specific health care problems or conditions |
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Term
|
Definition
| walking, eating, bathing, dressing, brushing teeth, grooming |
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Term
|
Definition
| shopping, preparing meals, writing checks, and taking medications. |
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Term
|
Definition
| impaired skin integrity related to unrelieved, prolonged pressure. Localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and or friction |
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|
Term
| Whose at risk for pressure ulcers? |
|
Definition
| Client experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and or poor nutrition |
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|
Term
| What three major elements contribute to pressure ulcers? |
|
Definition
| Pressure intensity, pressure duration and tissue tolerance |
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Term
|
Definition
| If the pressure applied over a capillary exceeds normal capillary pressure, causes vessel occlusion and tissue ischemia. Client can have reduced sensation and cant respond to discomfort. |
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Term
|
Definition
| if press finger over the affected area and it blanches and erythema returns when finger is removed, the hyperemia is transient and may be able to overcome the ischemia |
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Term
|
Definition
| area does not blanch when finger is pressed onto affected area. Deep tissue damage is probable |
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Term
|
Definition
| low pressure over a long period of time or high pressure over a short period of time can both cause tissue damage |
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Term
|
Definition
| ability of tissue to endure pressure depends upon the integrity of skin and supporting structures. |
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Term
|
Definition
| force exerted parallel to skin resulting from both gravity pushing down on the body and resistance between the client and the surface. ie: sliding of the skeleton starts but the skin is fixed because of friction of the bed |
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Term
|
Definition
| force of two surfaces moving across one another. ie: skin is dragged across a coarse surface such as linens. |
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Term
|
Definition
| intact skin with nonblanchable redness of a localized area, usually over bony prominence. Dark pigmented=color may differ from surrounding area |
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Term
|
Definition
| Partial thickness skin loss involving epidermis, dermis or both. Ulcer is superficial and presents as a abrasion, blister or shallow crater. |
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Term
|
Definition
| Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining or tunneling |
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Term
|
Definition
| Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling |
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Term
|
Definition
| red moist tissue composed of new blood vessels, the presence of which indicates progression towards healing |
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Term
|
Definition
| soft yellow or white tissue (stringy substance attached to wound bed. needs to be removed before wound is able to heal |
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Term
|
Definition
| black or brown necrotic tissue, needs to be removed for healing to proceed |
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Term
|
Definition
| proceeds through an orderly and timely reparative process that results in sustained resoration of anatomical and functional integrity (trauma or surgical incision) |
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Term
|
Definition
| wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity (chronic inflammation or repetitive insults to the tissue |
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Term
|
Definition
| wound that is closed. surgical incision, wound that is sutured or stapled. risk of infection is low, heals quickly with minimal scar formation |
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Term
|
Definition
| wound edges are not approximated. Pressure ulcers, surgical wounds that have tissue loss. filled by scar tissue, takes longer to heal, greater risk of infection |
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Term
|
Definition
| wound left open for several days, then wound edges are approximated (wounds that are contaminated and require observation for signs of inflammation |
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Term
|
Definition
| shallow wounds involving loss of epidermis and possibly partial loss of dermis. heal by regeneration. |
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Term
|
Definition
| extends into dermis, heals by scar formation because deeper structures do not regenerate |
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|
Term
| partial thickness wound repair |
|
Definition
| inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers |
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|
Term
| full thickness wound repair |
|
Definition
| inflammatory, proleferative and remodeling |
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Term
|
Definition
| occurs within 30 minutes of injury and lasts about 3 days. hemostasis occurs, clots form fibrin. Histamine is secreted causing vasodilation, exudation of serum and white blood cells. Redness, warmth and throbbing. No value in cooling area, inflammation is beneficial |
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|
Term
|
Definition
| lasts 3-24 days. Filling of wound with granulation tissue, contraction of wound and resurfacing of the wound by epitheliazation |
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Term
|
Definition
| maturation, takes place for more than a year sometimes. |
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Term
|
Definition
| yellow, green or brown drainage |
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Term
|
Definition
| partial or total separation of wound layers, normally when wound fails to heal properly. can occur with coughing, vomiting |
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|
Term
|
Definition
|
|
Term
|
Definition
| pale, red, water. Mixture of clear and red fluid |
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Term
|
Definition
| bright red, indicates active bleeding |
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Term
|
Definition
| protrusion of visceral organs through a wound healing |
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|
Term
| low risk body fluids for skin breakdown |
|
Definition
| saliva, serosanguineous drainage |
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|
Term
| moderate risk body fluids for skin breakdown |
|
Definition
| bile, stool, urine, ascitic fluid, purulent exudate, |
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|
Term
| high risk body fluids for skin breakdown |
|
Definition
| gastric drainage and pancreatic drainage |
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Term
|
Definition
| abnormal passage between two organs or between an organ and the outside of the body |
|
|
Term
| Norton Scale for pressure ulcer risk |
|
Definition
| Scores five risk factors: physical condition, mental condition, activity, mobility and incontinence |
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|
Term
| Braden scale for pressure ulcer risk |
|
Definition
| Six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear |
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|
Term
| Nutrition and wound healing |
|
Definition
| normal healing requires proper nutrition. Deficiencies in nutrients can result in impaired or delayed healing. Needs proteins, Vitamin A and C, traces of zinc and copper |
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|
Term
| Protein and wound healing |
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Definition
| collagen is a protein formed from amino acids and needed by fibroblasts, acquired from protein ingested in food. Wound remodeling, immune function |
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|
Term
| Vitamin C and wound healing |
|
Definition
| necessary for the synthesis of collagen, capillary wall integrity, fibroblast function, immunologic function, antioxidant |
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|
Term
| Vitamin A and wound healing |
|
Definition
| reduces the negative side effects of steroids on wound healing. Epitheliazation, wound closure, inflammatory responses, angiogenesis, collagen formation |
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|
Term
|
Definition
| collagen formation, protein synthesis, cell membrane and host defenses |
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|
Term
| Nutrition and risk of pressure ulcers |
|
Definition
| malnutrition is a major risk factor for pressure ulcer development |
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Term
|
Definition
| lies under a dressing, at the time of placement a pin or clip is placed through the drain to prevent it from slipping further into the drain |
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|
Term
| jackson pratt or hemovac drain |
|
Definition
| exerts a constant low pressure as long as the suction device is fully compressed |
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|
Term
| staple/ suture closure care |
|
Definition
| provides more strength than nylon or silk sutures and causes less irritation. Assess for irritation around staples and not whether or not closures are intact. First 2-3 days skin is edematous. |
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Term
|
Definition
| Never from old drainage. Clean wound first with normal saline. Aerobic grow in superficial wounds and anaerobic grow within body. Gold standard is tissue biopsy |
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|
Term
| low air loss mattress for wound prevention |
|
Definition
| provides flow of air to assist in managing the heat and humidity of the skin, pressure redistribution |
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|
Term
| air fluidized beds for pressure ulcer prevention |
|
Definition
| redistributes pressure via fluid filled medium created by forcing air through beads |
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|
Term
| lateral rotation for pressure ulcer prevention |
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Definition
| provides rotation about a longitudinal axis as characterized by degree of client turn, duration and frequency |
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|
Term
|
Definition
| wet when placed and dries, works to debride the wound |
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Term
|
Definition
| removed before dry to keep wound moist |
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Term
|
Definition
|
|
Term
|
Definition
| impulse travel time through the AV node, bundle of His and to the Purkinje fibers 0.12-.2 seconds normally. |
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Term
|
Definition
| indicates the electrical impulse traveled through the ventricles. Usually 0.12-.42 seconds |
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Term
|
Definition
| time needed for ventricular depolarization and repolarization. 0.12-.42 seconds |
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Term
|
Definition
| amount of air exhaled in a normal breath |
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Term
|
Definition
| exchange of respiratory gases in the alveoli and capillaries |
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|
Term
| neural regulation of oxygenation |
|
Definition
| maintains rhythm and depth of respiration and balance between inspiration and expiration |
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|
Term
| cerebral cortex and oxygenation |
|
Definition
| voluntary control of respiration, accommodates speaking eating and swimming |
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|
Term
| medulla oblongata and oxygenation |
|
Definition
| automatic control of respiration occurs continuously |
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|
Term
| chemical regulation of oxygenation |
|
Definition
| maintains appropriate rate and depths of respirations based on changes in the bloods CO2 and O2 and H+ concentration |
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|
Term
| Cervical trauma at C3-C5 and oxygenation |
|
Definition
| paralysis of phrenic nerve |
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|
Term
| Trauma to spinal cord below C5 and oxygenation |
|
Definition
| damages nerves that innervate intercostal muscles, prevents anteroposterior chest expansion |
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Term
|
Definition
| left ventrical decreased functioning, decreased amount of blood ejected and results in decreased cardiac output. Fatigue, breathlessness, dizziness, confusion, pulmonary congestion |
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|
Term
| right sided heart failure |
|
Definition
| decreased function of right ventricle. pulmonary disease or long term left sided failure. Elevated pulmonary vascular resistance, increased oxygen demand of heart, blood backs up in systemic circulation. |
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Term
|
Definition
| eliminates CO2. also caused by anxiety, drugs, infections, acid base imbalance |
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Term
|
Definition
| alveolar ventilation is inadequate, eliminates sufficient CO2. Common in COPD if given excessive oxygen |
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|
