110 Unit 1

Front 1

Temperature

Back 1

Realative measure of sensible heat and cold.

Front 2

Normal Temp range

Back 2

97-99.6

Front 3

normal temperature average

Back 3

98.6

Front 4

Hypothalamus

Back 4

Helps maintain temperature * Heat loss/Heat gain

Front 5

Core Temp

Back 5

Deep internal Temp. *Remains constant

Front 6

Surface Temp

Back 6

Temp of skin *changes with the envirnoment

Front 7

Constant

Back 7

Remains elevated

Front 8

Intermittent

Back 8

Rise and fall temp returning back to normal

Front 9

Remittent

Back 9

Rise and fall temp, but does not return to normal

Front 10

Hypothermia

Back 10

Below normal (below 97) *Heat Loss

Front 11

Hyperthermia

Back 11

Above normal (above 99.6) *Fever

Front 12

Rectal Temp

Back 12

1 higher than oral

Front 13

Axillary Temp

Back 13

1 lower than oral.

Front 14

Rise in in temp of 1 .

Back 14

will increase pulse by 4 beats

Front 15

High Temp

Back 15

Increases respirations and blood pressure.

Front 16

Hemorage

Back 16

BP and respirations increase and temp decreases.

Front 17

Pulse

Back 17

Is the regular recurrent expansion and contraction of an artery *Wave of blood*

Front 18

Normal Pulse Rate

Back 18

( normal 60-100)

Front 19

Tracycardia

Back 19

Faster than 100 beats (Higher than normal)

Front 20

Dysrhythmia

Back 20

Abnormal rhythm of heart. *Dysfunctional Rhythm

Front 21

Radial and carotid

Back 21

Easiest palpated

Front 22

Radial and Apical

Back 22

most commonly used

Front 23

Apical pulse

Back 23

Actual beating of the heart *s1 & *s2

Front 24

Pulse deficit

Back 24

(difference in radial and apical pause)

Front 25

Respirations

Back 25

Taking in oxygen and giving off carbon dioxide (normal 12-20)

Front 26

Internal Respirations

Back 26

Exchanging of O2 and CO2/ gas exchange

Front 27

Kussmoul Respirations

Back 27

Accelerated and Deep

Front 28

External Respirations

Back 28

can be observed by the nurse (inspiration & expiration) *Getting air in and out*

Front 29

Bradypena

Back 29

slow breathing(below 12)

Front 30

Dyspnea

Back 30

Breathing with difficulty.

Front 31

Apnea

Back 31

*Absence of breathing* Lack of spontaneous respirations. (pause in breathing longer than 15 seconds)

Front 32

cheyna-stokes

Back 32

alternating periods of apnea and deep breathing

Front 33

Blood pressure

Back 33

pressure exercited by circulating volume of blood on artery walls.

Front 34

systolic

Back 34

Ventricle contracting (Higher/top #)

Front 35

Distolic

Back 35

heart is relaxed and refilling with blood. (lower/bottom #)

Front 36

Hypertension

Back 36

Bp above 140/90 (high BP)

Front 37

Hypotension

Back 37

BP below 100/60 (low BP)

Front 38

orthostatic Hypotension

Back 38

Drop in systolic pressure by 25 and drop in diastolic pressure by 10 when moving from lying to sitting.

Front 39

korotko sounds

Back 39

fist and last sound heard

Front 40

signs

Back 40

what can be observed (rash)

Front 41

symptoms

Back 41

not observed, must be described by patient ( burning sensation)

Front 42

Disease

Back 42

Disturbance of a structure. (changes from homeostasis)

Front 43

Etiology

Back 43

Orgin of disease. (how problems develop.)

Front 44

Chronic

Back 44

Develops slowly (lifetime disease) *NOW*

Front 45

Acute

Back 45

Develops fast with intensity of severe signs. (short term illness) *6 MONTHS OR LONGER)

Front 46

Remission

Back 46

partial or complete absence of signs or disease.

Front 47

organic disease

Back 47

change in organ structure that interferes with function.

Front 48

Functional Disease

Back 48

no change in organ structure

Front 49

Infection

Back 49

Invasion of microorganisms (virus)

Front 50

Inflammation

Back 50

Protection response (irritations) *antibodies

Front 51

neoplastic

Back 51

abnormal growth of tissues (tumors) *cancer

Front 52

congenital

Back 52

appears shortly after birth but not hereditary *YOU WERE BORN WITH IT*

Front 53

erythema

Back 53

Zoom

Redness, swelling (burns)

Front 54

edema

Back 54

swelling (excessive fluid)

Front 55

purulent

Back 55

containing pus

Front 56

nursing health system

Back 56

purpose to identify patters of health and illness.

Front 57

family history

Back 57

obtain data about immediate and blood realatives (family history of health conditions)

Front 58

nursing assessment is to?

Back 58

- collect subjective and objective data to look at and determine the overall function of a patient (determine wellness and illness

Front 59

Purpose of Patient Records

Back 59

1 communication

2 accountability

3 record of care

4 teaching

5 research and data collection

Front 60

Diagnosis-Related Group (DRG)

Back 60

A system to determine Medicare reimbursement for a hospital stay on basis of the patients' diagnosis (age, diagnosis, surgical procedure)

Front 61

Auditors

Back 61

people appointed to examine patients charts and health record to assess quality of care.

Front 62

narrative charting

Back 62

Record of patient care in descriptive form. (subjective, objective, or both) (SOAPIER)

Front 63

SOAPIER

Back 63

S: Subjective- information obtained from what the client says
O: Objective-information that is measured or observed
A: Assessment- the interperation or conclusion drawn about the subjective and objective data
P: Plan-plan of care designed to resolve the stated problme
I: Intervention- refer to the specific interventions that have actually been performed by the caregiver
E: Evaluation- includes client responses to nursing interventions and medical treaments. This is primarily reassessment data
R: Revision- reflects care plan modifications suggested by the evaluation

Front 64

Focus Charting

Back 64

Highlights the client's concerns, problems, or strengths Occurs in 3 columns
1- time and date
2- focus or problem being addressed
3. charting in a DARE format: DATA, ACTION, RESPONSE, EDUCATION.

Front 65

Acuity charting

Back 65

consolidation of nursing records into a system that accomadates a 24 hour period.

Front 66

Nursing Documentation

Back 66

written record noting assessment findings, care given and the patients responses

Front 67

problem oriented medical record

Back 67

* SOAPIER

Front 68

Kardex

Back 68

Profile of all current physician's orders for a patient

Front 69

Incident report

Back 69

form that's filled out with any event not consistent with the routine care of a ptused when pt care was not consistent with facility or national standards of expected gave

*give only objective, observed information
don't admit liability or give unnecessary details
don't mention report in nurse's notes

Front 70

Discharge Summary Forms

Back 70

Ideally, discharge begins at admission. Identifies involvement of the client and family members after discharge of institution with expected outcomes and goals.

Front 71

Clinical pathways

Back 71

Provide expected path of client needs, care, teaching, and progress for specific diagnosis.

Front 72

Home health care documentation

Back 72

home bound status- assessment highlighting changes in client condition
- interventions performed(wound care, teaching)
- clients response to intervention
- any interactions or touching that you conducted with caregiver
- any interaction with clients physician

Front 73

Long term health care documentation

Back 73

Omnibus Budget Reconciliation Act (OBRA) 1987 Regulated standards for resident assessment, individualized care plans, and qualifications for health care providers.

Front 74

record ownership and access

Back 74

Original record or chart is the property of the institution or physician.

Front 75

confidentiality

Back 75

respecting privileged information (nurse should not read a record unless there is a clinical reason)

Front 76

Example of a nursing diagnosis

Back 76

Risk for hypothermia

Front 77

what does skin turgor mean

Back 77

Hydration/ skin tenting

Front 78

Where can you check the skin turgor

Back 78

Hands, feet, clavical

Front 79

If the skin stays tented what does that mean

Back 79

Dehydration

Front 80

what is the first thing you assess

Back 80

mental state

Front 81

what is cyanotic

Back 81

blush pale color to the skin

Front 82

perfuse sweating

Back 82

Diaphoresis

Front 83

how would you assess cyonatocis in African American

Back 83

mucous in mouth turns from pink to white

Front 84

Symptom of Anemia

Back 84

- not enough O2- dyspnea/short breath

- fatigue/weak

- loss of appetite

- blurred vision

Front 85

anemia signs

Back 85

spoon nails, fatigue, apathy, irritability, pale skin, weakness, loss of appetite, depression, behavioral problems, learning difficult

Front 86

critical thinking

Back 86

Critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness; fundamental blueprint for how to care for patients

Front 87

What are the steps in the nursing process?

Back 87

A D P I E

1 Assessment

2 Diagnosis

3- Outcomes identifications

4 Planning

5 Implementation

6 Evaluation

Front 88

5 types of Nursing Diagnosis

Back 88

1. ACTUAL - a problem exists

2. RISK - indicates problem doesn't exist but risk factors exist for a problem

3. WELLNESS - indicates the patient's desire to attain a higher level of wellness in some area. ex - readiness for enhanced self help r/t smoking cessation

4. SYNDROME - cluster of diagnoses related to a single event (Rape Trauma Syndrome) *ARWS*

Front 89

Assessment

Back 89

The nurse collects data pertinent to patients health or situation

Front 90

Diagnosis

Back 90

The RN analyzes the assessment data to determine the diagnoses or issues

Front 91

Outcomes identifications

Back 91

The RN identifies expected outcomes for a plan individualized to the patient or situation

Front 92

Planning

Back 92

The RN develops a plan the prescribes strategies and alternatives to attain a expected outcome

Front 93

Implementation

Back 93

The RN implements the identified plan

Front 94

Evaluation

Back 94

The RN evaluates the patients progress toward attainment outcomes

Front 95

Bradycardia

Back 95

Slower than 60 beats