Term
|
Definition
| Transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. |
|
|
Term
|
Definition
| An elevated body temp r/t the inability of the body to promote heat loss or reduce heat production. |
|
|
Term
|
Definition
Heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat.
|
|
|
Term
| Location of mitral heart sound (PMI) |
|
Definition
| Left 5th intercostal space, just medial of the midclavicular line. |
|
|
Term
| Location of the tricuspid sounds |
|
Definition
| Left 4th intercostal space |
|
|
Term
|
Definition
| Left 3rd intercostal space |
|
|
Term
| Location of the pulmonary heart sounds |
|
Definition
| Left 2nd intercostal space |
|
|
Term
| Location of aortic heart sounds |
|
Definition
| Right 2nd intercostal space |
|
|
Term
|
Definition
| Describes the concept of care as the essence and cetral, unifying, and dominant domain that distinguishes nursing from other health disciplines |
|
|
Term
|
Definition
| Directed at increasing the patient's well-being. Defines health as a positive, dynamic state, not merely the absence of disease. Results in improved health, enhanced functional ability and beter quality of life at all stages of development. |
|
|
Term
|
Definition
| Attempts to creat conditions that promote optimal health. Healing process. Nurses recognize the natural healing abilities of the body and incoporate complimentary and alternative interventions. Music therapy, reminiscence, relaxation therapy, therapeutic touch and guided imagery. |
|
|
Term
|
Definition
| Helps you understand factors influencing patient's perceptions, beliefs, and behavior to plan care that will most effectively assist patients in maintaining or restoring health and preventing illness. |
|
|
Term
| From where does the primary source of information come during assessment? |
|
Definition
Primary source: the patient.
Secondary sources: family members, health professionals, and medical records. |
|
|
Term
| Normal ranges for temperature. |
|
Definition
|
|
Term
| Normal blood pressure ranges. |
|
Definition
120/80
Prehypertensive: 103-139 / 81-89
Stage 1: 140-159 / 90-99
Stage 2: 160 & up / 100 & up |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| 12 - 20 breaths per minute |
|
|
Term
|
Definition
| Pertaining to or characterized by and elevated body temp. |
|
|
Term
|
Definition
|
|
Term
| Use of accessory muscles. |
|
Definition
| Muscles in the thoracic cage that assist with respriations. |
|
|
Term
|
Definition
| Thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. |
|
|
Term
|
Definition
| Shared identity r/t social and cultural heritage such as values, language, geographical space, and racial characteristics. |
|
|
Term
|
Definition
| Insider/Native perspective |
|
|
Term
|
Definition
|
|
Term
|
Definition
| a comparative study of cultures to understand similarities (culture universal) and differences (cultural specific) across human groups |
|
|
Term
| culturally congruent care |
|
Definition
| care that fits the person's life patterns, values, and a set of meanings |
|
|
Term
|
Definition
| the process of aquiring specific knowledge, skills, and attitudes to ensure delivery of cultural congruent care |
|
|
Term
| What do you do if client does not speak English? |
|
Definition
| use a hospital employed translator |
|
|
Term
clarifying
(therapeutic tech.) |
|
Definition
| To check whether understanding is accurate, restate an unclear or ambiguous message to clarify the sender's meaning. |
|
|
Term
using silence
(therapeutic tech.) |
|
Definition
| Particularly useful when people are confronted with decisions that require much thought. Useful during times of profound sadness or grief. |
|
|
Term
|
Definition
| Prompts patients to describe a situation in more than one or two words. Patients are able to actively describe their health status. |
|
|
Term
|
Definition
- Intake and output
- all liquids in mL
- food in percentage
- IV fluids |
|
|
Term
|
Definition
-pinch injection site
-45 degree angle for thin patients
-90 degree angle for obese patients
-R & L side abdomen @ least 2 inches from umbilicus
-upper ventral or dorsal gluteal areas
-deltoid |
|
|
Term
|
Definition
-ventro gluteal
-vastus lateralis
-deltoid
-tolerates 2-5mL (only in larger muscles)
-90 degree angle
**NOT dorsal gluteal** |
|
|
Term
|
Definition
| used to minimize local skin irritation by sealing the medication in the muscle |
|
|
Term
|
Definition
| Outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. |
|
|
Term
| What is a narrative report? |
|
Definition
- traditional method
- story-like format to document informations specific to patient's conditions and nursing care |
|
|
Term
|
Definition
Subjective Data Subjective
Objective Action Objective
Assessment Response Assessment
Plan Plan
Intervention
Problem Evaluation
Intervention
Evaluation |
|
|
Term
| What do you do if you make a mistake in documentation? |
|
Definition
| Draw a line through & initial. |
|
|
Term
|
Definition
1. denial
2. anger
3. bargaining
4. depression
5. acceptance |
|
|
Term
|
Definition
1. numbing
2. yearning and searching
3. disorganization and despair
4. reorganization |
|
|
Term
|
Definition
|
|
Term
| Rando's "R" process model |
|
Definition
- recognizing loss
- reacting to the pain of separation
- reminicing
- relinquishing old attachments
- readjusting to life after loss |
|
|
Term
|
Definition
| Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms. (difficulty sleeping, loss of appetite) |
|
|
Term
|
Definition
Avoiding emotional conflicts by refusing to consiously acknowledge anything that causes intolerable emotional pain.
(a person refuses to acknowledge personal loss) |
|
|
Term
|
Definition
Making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset.
(a person with poor communication skills relies on organizational skills) |
|
|
Term
| primary care health promotion |
|
Definition
-prenatal
-nutrition counseling
-family planning
-exercise classes
-health education
-maternal/child health care
-immunizations
-control of diseases |
|
|
Term
|
Definition
-emergency care
-acute med-surg care
-radiological procedures for acute problems (x-rays, CT scans) |
|
|
Term
|
Definition
-intensive care
-subacute care |
|
|
Term
|
Definition
-lymph nodes, carotid arteries, thyroid gland & trachea
-head: inspect & palpate
-eyes: visual acuity
-extraoccular movements, eyebrows, eyelids, position alignment, conjunctiva, lacrimal apparatus, corneas, pupils, irises (PERRLA), internal eye structure
-ears, hearing
-nose, sinuses, mouth/pharynx |
|
|
Term
|
Definition
- neck muscles, lymph nodes of head and neck, carotid arteries, jugular veins, thyroid gland, and trachea
- inspect and palpate |
|
|
Term
| assessment of thorax and lungs |
|
Definition
- ventilatory and respiratory function of lungs
- nipples, angle of Louis, suprasternal notch, costal angle, clavicles, and vertebraes
- location of ribs
- vocal or tactile fremitus
- adventitious sounds |
|
|
Term
|
Definition
- usually in bases
- high-pitched, fine, short
- heard in CHF patients |
|
|
Term
|
Definition
- heard over trachea and bronchi
- sonorous wheeze
- loud, low-pitched, rumbling course sounds are heard either during inspiration or expiration |
|
|
Term
|
Definition
- heard over all lung fields
- high-pitched
- squeak heard continuously during inspiration or expiration
- usually louder on expiration |
|
|
Term
|
Definition
- heard over anterior lung field
- dry, rubbing, or grating quality is heard during inspiration and expiration |
|
|
Term
|
Definition
| sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase |
|
|
Term
| assessment of the abdomen |
|
Definition
- skin, umbilicus, contour, and symmetry, enlarged organs or massess, movements or pulsations
- auscultation: bowel mobility, vascular sounds, kidney tenderness
- palpation: light palpation and deep palpation - aortic pulsations |
|
|
Term
|
Definition
| a clinical judgement about individual, family, or community responses to actual potential health threat |
|
|
Term
|
Definition
- patient centered goal: reflects a patient's highest possible level of wellness and independence in function
- broad statement
- may be short term or long term |
|
|
Term
|
Definition
| a measurable criterion to evaluate goal achievement |
|
|
Term
| independent nursing interventions |
|
Definition
| actions that the nurse initiates |
|
|
Term
| dependent nursing interventions |
|
Definition
| actions that require an order from a physician or another health care professional |
|
|
Term
| collaberative interventions |
|
Definition
| therapies that require the combined knowledge, skill, and expertise of multiple health care professionals |
|
|
Term
| When choosing nursing interventions... |
|
Definition
- characteristics of the nursing dx
- expected outcomes
- research base
- feasability
- acceptability to the patient
- capability of the nurse |
|
|
Term
|
Definition
| You evaluate by knowing what to look for as described in the criterion-based standards included in a patient's goals and expected outcomes. |
|
|
Term
|
Definition
| information provided by the patient |
|
|
Term
|
Definition
| information that comes from the nurse's assessment findings |
|
|
Term
|
Definition
| scraping or rubbing away of epithelial tissue that results in localized bleeding and later weeping or serous fluid |
|
|
Term
|
Definition
| flaky, rough texture on exposed areas such as hands, arms, legs, or face |
|
|
Term
|
Definition
| inflammatory, papulopostular skin eruption, usually involving bacteria breakdown of sebum; appears on face, neck, shoulders and back |
|
|
Term
|
Definition
| skin eruptions that result from over exposure to sun or moisture or from allergic reaction (flat or raised, localized or systemic, pruritic or nonpruritic) |
|
|
Term
|
Definition
| inflammaiton of skin characterized by abrupt onset with erythema; pruritus; pain; and appearance of scaly, oozing lesions (seen on face, neck, hands, forearms, and genetalia) |
|
|
Term
|
Definition
| hospital acquired infections |
|
|
Term
|
Definition
- working to breathe
- increased respirations |
|
|
Term
| How do we prevent nosocomial infections? |
|
Definition
- wash your hands
- staff education
- recommend appropriate isolation procedures
- screening patients |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Where do you NOT give IM injections? |
|
Definition
|
|
Term
|
Definition
- palpate the lower edge of the acromion process which forms a triangle line with the midpoint of the lateral aspect of the upper arm
- injection site is in the middle of the triangle
- 3 fingers below the acromion process |
|
|
Term
|
Definition
- gluteus medius
- position patient in supine or lateral position
- palm of hand over greater trochantor
- R hand for L hip
- a V-shape with anterosuperior iliac spine |
|
|
Term
|
Definition
|
|
Term
|
Definition
| inadequate cellular oxygenation that may result from a deficiency in the delivery of use of oxygen at the cellular level |
|
|
Term
|
Definition
| arterial blood oxygen level less than 60 mm Hg; low levels in the blood |
|
|
Term
|
Definition
| sensation of shortness of breath |
|
|
Term
|
Definition
| Bluish discoloration of the skin and mucous membranes caused by an excess of deoxygenated hemoglobin in the blood or structural defect in the hemoglobin molecule. |
|
|
Term
|
Definition
| Clear liquid, with addition of smooth-textured dairy products (ice cream), strained or blended cream soups, custard, refined cooked cereals, veg. juice, preed veggies, all fruit juices, sherbets, pudding, frozen yogurt. |
|
|
Term
|
Definition
| 4g (no added salt), 2g, 1g, or 500mg sodium diets; vary from no added salt to severe sodium restriction (500mg sodium diet), which requires selective food purchases |
|
|
Term
|
Definition
- expect slight swaying of body
- used in neurological examinations |
|
|
Term
| proper suctioning of trachea |
|
Definition
- recommendation is about half the internal diameter of the ET tube
- maintain suctioning between 120 & 150 mm Hg as you withdraw
- rotating the catheter enhances removal of secretions that have adhered to the sides fo the ET tube |
|
|
Term
|
Definition
| Involves using a reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions. |
|
|
Term
|
Definition
| A catheter inserted through the thorax to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapleural and intrapulmonic pressures. |
|
|
Term
|
Definition
- collection of air in the pleural space
- causes a collapsed lung |
|
|
Term
|
Definition
- An accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma
- TB, pneumonia, full chest expansion |
|
|
Term
|
Definition
| collection of air or gas in the pleural space |
|
|
Term
| What is the worst thing skin can be exposed to for a prolonged amount of time? |
|
Definition
|
|
Term
| **Never give more than 15 units of regular insulin via IV unless physician is present.** |
|
Definition
|
|
Term
|
Definition
Has valve between bag and mask to prevent exhaled air from returning in bag.
- 60% - 80% O2
- Min. 10 L/min |
|
|
Term
What is a nasal cannula?
How many liters can be administered? |
|
Definition
- simple, comfortable device used for precise oxygen delivery
- up to 6 L/min
- 24% to 40% O2 |
|
|
Term
|
Definition
-occurs when profuse diaphoresis results in excess H2O and electrolyte loss
- caused by heat exposure, patient exhibits signs and symptoms of fluid volume deficit |
|
|
Term
|
Definition
- body temp above 40* C
- very high mortality rate
- S/S: giddiness, nausea, muscle cramps, visual disturbances, and even incontinence
- do not sweat |
|
|
Term
| Why do we take vital signs with pain meds? |
|
Definition
- certain meds need to have BP assessed or pulse assessment before med is given
- creates a baseline |
|
|
Term
| What are the pain rating scales? |
|
Definition
- Numerical
- Verbal description
- Visual analogue
- Oucher pain scale (1-10)
- Wong-Baker FACES pain-rating scale (1-5) |
|
|
Term
|
Definition
- onset and duration
- location
- intensity
- quality
- pain pattern
- relief measures
- contributing symptoms
- effects of pain on patient (bahavioral & ADLs) |
|
|
Term
| vital signs for peds (infants) |
|
Definition
Temp: 36* - 38*
Pulse: 120-160 bpm
Resp: 30-50
BP: 85/54 |
|
|
Term
|
Definition
Temp: 36*-38*
Pulse: 90-140 bpm
Resp: 25-32
BP: 95/65 |
|
|
Term
| Preschooler normal Vital Signs |
|
Definition
Temp: 36*-38*
Pulse: 80-110 bpm
Resp: 20-30
BP: 105/65 |
|
|
Term
| School-age child vital signs |
|
Definition
Temp: 36*-38*
Pulse: 75-100 bpm
Resp: 20-30
BP: 110/65 |
|
|
Term
|
Definition
Temp: 36*-38*
Pulse: 60-90
Resp: 16-20
BP: 119/75 |
|
|
Term
| What do you expect to see with vascular disease? |
|
Definition
- leg cramps
-numbness & tingling in extremities
- sensation of cold hands & feet
- pain in the legs
- swelling
- cyanosis of feet, ankles or hands
- smoking, nutritional problems, exercise
- HTN, varicose veins, diabetes, heart diesease, phlebitis |
|
|
Term
CN #1?
How do you test it? |
|
Definition
- Olfactory
- sensory
- sense of smell
- ask patient to smell something with a common odor |
|
|
Term
CN #2?
How do you test it? |
|
Definition
- Optic
- sensory
- visual acuity
- Snellen chart, read printed material |
|
|
Term
CN #3?
How do you test it? |
|
Definition
- Oculomotor
- motor
- extraocular eye movement - inward, up and inward, up and outward, down and outward
- pupil constriction and dilation, opening of the eye
- assess using PERRLA |
|
|
Term
CN #4?
How do you test it?
|
|
Definition
- Trochlear
- motor
- downward, inward eye movements
- assess six directions of gaze |
|
|
Term
CN #5?
How do you test it? |
|
Definition
- Trigeminal
- sensory and motor
- sensory nerve to skin of face
- jaw
- use cotton ball and use light touch against face |
|
|
Term
CN #6?
How do you test it? |
|
Definition
- Abducens
- motor
- lateral eye movement
- assess six directions of gaze |
|
|
Term
CN #7?
How do we test it? |
|
Definition
- Facial
- sensory and motor
- facial expressions
- taste
- assess facial expressions and sweet or salty taste |
|
|
Term
CN #8?
How do we test it? |
|
Definition
- Auditory
- sensory
- hearing
- assess ability to hear spoken word |
|
|
Term
CN #9?
How do we test it? |
|
Definition
- Glossopharyngeal
- sensory and motor
- taste
- ability to taste sweet and salty |
|
|
Term
CN #10?
How do we test it?
|
|
Definition
- Vagus
- sensory and motor
- sensation of pharynx/vocal chords
- ask patient to "ah" and observe movement of palate and pharynx
- assess speach hoarsness |
|
|
Term
CN #11?
How do we test it? |
|
Definition
- Spinal Accessory
- motor
- movement of head and shoulders
- shrug shoulders and turn head |
|
|
Term
CN #12?
How do we test it? |
|
Definition
- Hypoglossal
- motor
- position of the tongue
- stick out tongue/move side to side |
|
|
Term
| What does the nurse do during preop? |
|
Definition
- patient teaching
- baseline vital signs
- informed consent
- administer preop analgesics
- hygeine, hair, cosmetics, removal of prostheses, safeguarding valuables, preparing the bowel & bladder, VS, documentation
- eliminate wrong site and wrong procedure |
|
|
Term
|
Definition
| clear liquid, advance as tolerated |
|
|
Term
| How long do we expect peristalsis to be absent post-abd surgery? |
|
Definition
|
|
Term
| What do you feed post-abd surgery patients? |
|
Definition
| ice first, then clear liquids |
|
|
Term
| What are non bulk forming foods? |
|
Definition
- fiberous foods
- BRAN, legumes, leafy green veggies, apples, avocado |
|
|
Term
| Proper suctioning technique of NG tube...? |
|
Definition
- intermittent
- lasts no longer than 15 seconds
- p. 858 |
|
|
Term
| How do you obtain a 24 hour urine collection? |
|
Definition
- dump first specimen
- keep on ice
- ends at time of 24 hour period |
|
|
Term
| Different types of urinary diversions? |
|
Definition
- continent urinary resevoir that is created from a distal portion of the ileum and proximal portion of the colon
- continent urinary diversion: orthotopic neo bladder uses an ileal pouch to replace bladder
- drainage from both kidneys pools in renal pelvis nephrostomy |
|
|
Term
| Catheterization of a male? |
|
Definition
- supine or sitting
- 7-9 inches or until urine flows, then 1-2 more inches
- Coude catheter used for enlarged prostate |
|
|
Term
| Catheterization of a female? |
|
Definition
- dorsal recumbant
- 2-3 inches until urine appears, then 1-2 more inches |
|
|
Term
|
Definition
| 60-120 day glucose diagnostic testing |
|
|
Term
| What are acceptable VS ranges for postop patient? |
|
Definition
- decreased temp
- expect VS to return to baseline; if not, notify provider |
|
|
Term
What does the nurse do during intra op?
(scrub and circulating) |
|
Definition
Scrub: remains sterile, counts gauze
Circulating: is not sterile; verifies gauze count |
|
|
Term
| What most commonly treats Fluid Volume Excess? |
|
Definition
|
|
Term
| Potential nursing diagnosis for Alzheimer's? |
|
Definition
| Self-care deficit r/t impaired cognitive motor function |
|
|
Term
| Potential nursing diagnosis for CVA (stroke)? |
|
Definition
| Sensory-perceptual alterations: visual, auditory, kinesthetic, and tactile as related to tissue injury |
|
|
Term
| acute inflammatory response |
|
Definition
| response trauma to specific area of the body |
|
|
Term
| What is the Chovestek sign? |
|
Definition
-An abnormal spasm of the facial muscles elicited by light taps on teh cheek to stimulate the facial nerve in patients who are hypocalcemic.
-Sign of tetany
-Post thyroid/parathyroid surgery |
|
|
Term
|
Definition
| Increase rate of formation and excretion of urine. |
|
|
Term
|
Definition
Results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial O2 demands.
Angina pectoris and MI |
|
|
Term
Diabetic care...?
(patient teaching) |
|
Definition
- foot care
- diet
- frequent glucose testing
- exercise
- insulin |
|
|
Term
|
Definition
Prothrombin Time International Normalized Ratio
- tests patient's clotting factor |
|
|
Term
|
Definition
| Collapse of alveoli, preventing the normal respiratory exchange of O2 and CO2 |
|
|
Term
| What are the risks for patients on prolonged bedrest? |
|
Definition
- sepsis
- decreased skin integrity
- decreased physical mobility
- risk for pneumonia |
|
|
Term
| How do we assess skin integrity? |
|
Definition
- level of sensation
- movement
- continence
- Braden scale (pressure ulcer risk)
- Norton scale
- visual and tactile inspection, esp. bony prominences
- palpate (observe for blanching) |
|
|
Term
| What is a 'wet to dry' dressing? |
|
Definition
- used for debridement
- not continuously wet dressing
- used for necrotic tissue
- wet dressing is placed inside wound, when dry it debrides dead tissue from wound |
|
|
Term
|
Definition
- intact, redness in an area
- hydrocolloid dressing, transparent, or none |
|
|
Term
|
Definition
- partial-thickness loss or blister
- red/pink without slough
- composite film dressing, hydrocolloid, and hydrogel |
|
|
Term
|
Definition
- full thickness (fat visible)
- slough, maybe tunneling
- hydrocolloid dressing, hydrogel foam cover, gauze, NS
- bone, tendon, and muscle NOT exposed |
|
|
Term
|
Definition
- full thickness
- exposed bone, muscle, tendon
- slough and eschar, includes undermining and tunneling
- wet to dry dressing, hydrogel |
|
|
Term
| What are finger sticks used for? |
|
Definition
| frequent blood glucose testing |
|
|
Term
| How do you mix and draw up insulin? |
|
Definition
- aspirate air into NPH first, then regular
- draw up regular first, then NPH |
|
|
Term
|
Definition
- decrease serum glucose levels
- need for sweets
- sweats profusely |
|
|
Term
|
Definition
- elevated serum glucose levels
- exercise |
|
|
Term
| Pt teaching for patients with diuretics? |
|
Definition
- Don't take right before bed
- eat potassium rich foods |
|
|
Term
|
Definition
|
|
Term
| Hearing impaired patient? |
|
Definition
- sit in front of them and speak slowly
- use picture books |
|
|
Term
|
Definition
- clock for food
- clear areas of fall hazards
- keep things within reach
- place things in the same area at all times |
|
|
Term
Trough levels
(med administration) |
|
Definition
- lowest concentration
- measured 30 min before med is given |
|
|
Term
|
Definition
| highest level of concentration in body |
|
|
Term
| Nusing diagnosis r/t cardiovascular disease? |
|
Definition
- excess fluid volume
- decrease cardiac output
- ineffective tissue perfusion |
|
|
Term
|
Definition
- myocardial infarction
- necrosis of a portion of cardiac muscles caused by obstruction in a coronary artery |
|
|
Term
| Right sided heart failure? |
|
Definition
- edema
- too weak to pump into lungs, backs up systemically |
|
|
Term
|
Definition
- hearing (auditory)
- touch (tactile)
- smell (olfactory)
- taste |
|
|
Term
| What does the nurse do during post op? |
|
Definition
| VS, respiratory adequacy, postop cardiac status, neurological status, peripheral circulation, LOC, orientation, IV patency, pain level, motor abilities, skin integrity, positioning, surgical wound assessment, N/V |
|
|
Term
| What kind of foods do patients with colonoscopies eat? |
|
Definition
- low fiber bread, noodles, rice, cream cheese, eggs (not fried), strained fruit juice
- drink 10-12 glasses of water daily
- avoid foods that cause gas |
|
|
Term
What are colostomies?
Different types? |
|
Definition
- loop: medical emergencies - temporary stoma
- double barrel: transsected colon
- end colostomy: terminalend of descending or sigmoid colon |
|
|
Term
| What is thrombocytopenia? |
|
Definition
| relative decrease in platelets in blood |
|
|
