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203 Cards in this Set

  • Front
  • Back
Compliance
The ability of the arteries to contract and expand
Cardiac Output
Stroke Volume x Heart rate
Tidal Volume
During normal inspiration and expiration, an adult takes in about 500 mls of air
External resps
interchange of O2 and CO2 between alveoli and pulmonary blood
internal resps
happens throughout body
Resp controlled by
A. medulla oblongata, and pons in brain
B. by chemoreceptors located centerally in medulla nad periph in the carotid and aortic bodies.
Ideal Body Weight Female
Rule of 5's Female (105lbs for 5 ft of height +6lbs for each inch over, 10% for body frame size
Ideal Body weight Male
Rule of 6's Male (106 lbs for 5 ft of height +6lbs for each inch over 5ft, 10% for body frame size.
BMI- Body mass index
BMI= Weight in kilograms
____________________
2
(Height in meters)
Embryionic phase
Pd during which the fertilized ovum dev into organism with most features.
Embryo tissue's three layers
Ectoderm(outer layer)
Mesoderm (middle layer)
Endo or Ectoderm (inner layer)
Puberty
Girls- 10-14 yrs
Boys- 12-16yrs
psysiologic indicators of stress
Pupils dilate, sweat production, heart rate and output increase, H2O and sodium retention, urinary output decreases, rate and depth of resp increase, dialation of bronchials, skin is paile d/t constriction of periph bl veswsels, peristalsis decreases, bl. sugar increases, mouth dries, mental awareness increases
Fire, Class A, B, and C... What is each class?
Class A: Paper,upolstery,rags
Class B:Flammable liq and gas
Class C: Electrical
What to do in case of fire
1.Protect and evacuate
2. Report
3Contain
4.Extinguish
or RACE rescue, alarm, contain, extingu
Water Pumps -extinguisher
Class A
Do not use on electrical or flammable liq. fires d/t splash
Carbon Dioxide CO2 -extinguisher
Class B and C
Limited range, must be used close to the flames- small surfaces only
Dry Chemicals -extinguisher
Class B and C
causes grease to splatter, small fires only
Multi purpose- extinguisher
Good anywhere in the home because they put out most types of fires
Foam
Class B
For home use this type of extinguisher could be placed in garage or basement
Special dry powders
Class D
only for use with designated metals
Water Pumps -extinguisher
Class A
Do not use on electrical or flammable liq. fires d/t splash
Carbon Dioxide CO2 -extinguisher
Class B and C
Limited range, must be used close to the flames- small surfaces only
Dry Chemicals -extinguisher
Class B and C
causes grease to splatter, small fires only
Multi purpose- extinguisher
Good anywhere in the home because they put out most types of fires
Foam
Class B
For home use this type of extinguisher could be placed in garage or basement
Special dry powders
Class D
only for use with designated metals
Bacteriocins
some microorganisms found in intestines produces these substances, which are lethal to related strains of bacteria
Virulence
The microorg ability to produce dz
Iatrogenic infections
As direct result of dx or therapeutic procedures
What are the basic characteristics of the nursing process?
A) universally applied in a variety of settings
B) Cyclical and dynamic
C) patient centered
D) Interpersonal and collaborative
What is the required competencies of the nurse in order to apply the Nursing process effectively?
1) cognitive
2) Technical
3) Inerpersonal
What are the 5 parts tot he nursing process?
1) Assessment
2) Analysis
3) Planning
4) implementation
5) Evaluation
What are the parts of assessment?
* establish a database (patient history)
* Continually update the database (adding lab\\xray)
*document in retrievable form ( chart data pertinent to nursing diagnosis)
What are the parts of analysis?
* Set priorities based on the patients development level. Based on maslows hierarchy of needs, based on optimal resources.
*Determine clinical problems that require collaboration with other health care professionals
* Establish expected outcomes for care related to health promotion, health maintenance and health restoration.
* incorporate factors influencing the patients health status (age, sex....)
What are the 4 parts of the planning phase?
* use nursing measures appropriate to the patients identified health problems
* Provide information and instruction related to the patients identified health problem
* Use nursing measures to promote continuity of care.
* Record and report the patients response to nursing actions .
What are the 3 parts of the evaluation process
* Reassess and revise the patients plan of care as necessary.
* Determine the patients response to care provided by other members of the health care team.
Nursing definition
according to the American Nurses Assoc. nursing is the diagnosis and treatment of human responses to actual or potential health problems
Nursing process
systematic method of assessing, diagnosing, planning, implementing and evaluating the care required by any patient in any setting. nursing process is a clinical framework and themeans by which the majority of the Nurse Practyice Acts in the US define practice of nursing
assessment
process by which nurse collects and analyzes data about the client
Implementation
may include any of these activities, intervening, delegating, and coordinating
Evaluation
the process of determining both the clients progress toward the attaining of expected outcomes and the effectiveness of nursing care
Standard of clincial nursing practice
established by American Nurses Assoc. divided into two subsets standars of care adn standards of professional performance
standards of care
1. assessment, 2.diagnosis, 3. outcome ID 4. planning, 5. implementation, 6. evaluation
Standards of professional performance
1. quality of care, 2. performance appraisal, 3. education 4. collegiality, 5. ethics 6. collaboration 7. research, 8. Resource Utilization
focused health assesment
performing selected portions of the history and examination. - primary tool by which nurses nurture and sustain life and contribute to the success of the health care team
performing selected portions of the history and examination. - primary tool by which nurses nurture and sustain life and contribute to the success of the health care team
referrs to the data collection process that occurs in a life threatening situation
Time lapsed nursing assessment
repeated assessment obtained to compare data collected at one or more points in time with baseline data
primary data
nurse derives directly from the patient, can be subjective or objective
secondary data
data derived from all other sources. the sum of all primary and secondary data is the patients database
Baseline data
data taken at the time of the first encounter
objective data
data capable of being verified
secondary data
sources include the patients family and friends, other nurses and professionals
Gordon's typology of Functional Health patterns
method to organize data
valid data
only valid data is documented, to be valid data must be accurate, complete, and factual. ie recording slept well is an assumtion that may or may not be factual.
nursing diagnosis
are derived from assessment. are also called conclusions. the subject of the dx may be a patient, family or community. may be health or life problem. nursing dx directs the planning of patient goals and the selection of appropriate nursing interventions
components of a nursing dx
consists of a dx label, the defenition of the dx and its defining characteristics, related factors and risk factors. the dx label is the name of the diagnosis, each dx has its own defenition.
defining characteristics
part of each nursing dx. defining characteristics are like manifestations of the diagnosis or signs or symptoms
related factors
part of each nursing dx. show some sort of pattern in relationship to the dx. factors may be causative, antecedent to the dx, are associated with a dx are contributing to the dx or are abetting a dx
risk factors
refer to those variables that increase a patients vulnerability to developing an actual nursing dx
types of nursing dx
actual, risk and wellness
actual diagnosis
refers to a human response to a health condition or life process that is happening now at the present time
risk diagnosis
refers to a diagnosis that is likely to occure in a vulnerable person
wellness diagnoses
refer to human responses to achieve even greater levels of welleness. the dx name or label includes the words potential for enhanced or readiness for enhanced
formulating nursing diagnoses
dx may be documented in one of 3 ways, 1. using the dx name or label alone 2. along with its related factors 3. using the name related factor and defining characteristics
prioritizing nursing diagnosis
1. physiological needs 2. safety needs 3. social needs 4. esteem needs 5. self actualization needs
ANA standard of care on Diagnosis
Anurse analyzes the assessment data in determining diagnoses
dx are validated with the patient, family etc. dx are documented in a menner that facilitates the determination of expected outcomes and plan of care
Nursing dx outcomes
must be time measurable, and attainable.
Nursing dx goals
patient centered future oriented and action / direction oriented. always expressed in terms of patients goals to be achieved. most often use the very will do not refer to a nurses to do list, not statements of what tx are to be performed
outcomes
statements of reportable observable, or measurable results expected to occur as a reslt of nursing interventions
Discharge planning
begins at the time the patient is admitted. involves active participation from the pt. family etc. is faciliated by an interdisciplinary team approach and requires teaching so that the patient or family is capable of managing post discharge care
handwritten care plans
handwritten onto kardex which includes patients id and background info, listing of patients dx's and listing of problem specific interventions
Standardized care plans
handwritten onto kardex which includes patients id and background info, listing of patients dx's and listing of problem specific interventions
Standardized care plans
Joint Commission for the Accrediation of Healthcare Organizations supports the use of standardized plans. they are specific for dx, allow for addl or deletion to accomodate agency policies, sprovide space to tailor, are included in the patients chart
policies
written instructions designed to address a commonly occurring problm in an institutionally approved manner
protocols
are institutionally approved `preprinted detailed instructions on how to perform specific clinical tasks
standing orders
are institutionally and departmentally approved instructions granting the nurse the authority to act in the bsence of a physician
independent nursing intervention
include repositioning a patient in bed who is at risk of impaired skin integrity.
dependent nursing intervention
ordered by a Dr. or carried out under a physicians supervision for the treatment of a medical dx.
Terminal evaluation
evaluation of outcomes which occurs prior to the discharge of a patient from the hospital or prior to a case being closed in a community setting.
Quality of nursing care evaluation
looks at structure, process and outcomes
structure
the setting or the environment in which the care is given
process
the appropriateness of the care given and wheterh policies and procedures were followed to maximize patient safety, minimize medication error, minimize infections , and insure patients and families feel welcome
outcome evaluation
examines such quality indicators as number of patient falls, number of new pressure ulcers formed, number of postoperative wound infections and number of tube fed patients developing aspiration pneumonia
audit
a record or chart review
concurrent audit
uses interview, obersravtion and a chart reviwe to evaluate ongoing practice.
peer review
is an audit perfomred by one's colleagues, using standards of practice or other standardized criteria to evaluate performance
planning
first step is to identify expected outcomes for each of the actual diagnoses and frame them in terms of patient goals
to observe is to ?
gather data by using senses
2 aspects of observation?
noticing the data / selecting, organizing and interpreting the data
an interview is?`
a planned communication or a conversation with a purpose
physical contact is used only if?
it has a therapeutic purpose
during the assessment phase the nurse would?
validate data
analysis?
the seperation of parts
synthesis
putting parts together
what is PES format?
three part nursing diagnosis statement:
Problem/Etiology/S&S
base diagnosis on?
patterns / on behavior over time-rather than isolated incidence
etiology of hypothermia
malnutrition
planning?
delibrate/systemic phase that involves decision making`
parts of Planning ?
prioritze problems/
formulategoals/desired outcomes/select nursing interventions/write nursing orders
for q nsg dx, rn must write at least one?
desired outcome; when achieved directly demonstrates resolution of the problem clause
implementing consists of ?
doing and documenting
Implementing?
reassessing the client
determine rn need for help
implement rn interventions
supervise delgated care
document rn activites
1st 3 nursing phase, aseesing, diagnosing, planning provide?
the basis for the rn actions performed during implementation
cognitive skills
include problem solving, decision making, critical thinking and creativity
interpersonal skills
are all the activities, verbal and nonverbal when interacting with one another
Nutrition
sum of all interactions between an organism & the food it consumes
Nutrients
organic & inorganic substances found in foods & are required for body functioning
energy-providing nutrients
Carbs, fats, proteins
Carbs are composed of the elements
carbon(C), hydrogen(H), oxygen(O)
Carbs are two basic kinds
simple (sugars)
complex (starches & fiber)
Sugars
simplest of all carbs
-water soluble
-produced naturally by plants & animals
sugars may be:
monosaccharides (single molecule)
disaccharides (double molecule)
3 monosaccharides:
-glucose (most abbundant)
-fructose
-galctose
Starches:
insoluble, nonsweet forms of carbs
-polysaccharide(branch chains of dozens of glucose molecules)
Fiber:
-complex carb derived from plants
-cannot be digested by humans
-present in outer layer of grains, bran, pulp of many fruits and vegs
Major enzymes of carb digestion:
ptyalin (salivary amylase)
-pancreatic amylase
the disaccharides: maltase, sucrase & lactase
Enzymes
biologic catalysts that speed up chemical reations
Carbs are stored as:
glycogen
-fat
Glycogen
large polymer of glucose
glycogenesis
glycogen formation
Protein
organic substance composed of amino acids
contains (C), (H), (O) and (N)
Essential amino acids
cannot be manufactured by the body
Nine essential amino acids
threonine, leucine, isoeucine, valine, methionine, phenylalanine, tryptophan, histidine
Arginine
appears to have role in immune system
Nonessential amino acids
body can manufacture
Ten nonessential amino acids
glycine, alanine, aspartic acid, glutamic acid, proline, hydroxyproline, cystine, tyrosine, serine
Complete proteins
contain all essential amino acids include:
most animal-meats, poultry, fish, diary products & eggs
Incomplete proteins
lack one or more essential amino acis ( most commonly lysine, methionine or tryptophan)
Complementary proteins
combination of two of more vegetables make complete protein
Protein metabolism include thre activities
-anabolism(building tissue)
-catabolism(breking down tissue)
-nitrogen balance
Lipids
organic substances that are greasy & insoluble in water but soluble in alcohol or ether
Fats
lipids solid at room temp
Oils
lipids liquid at room temp
Fatty acids
made up of carbon chains & hydrogen and are basic structure unit of most lipids
Saturated fatty acids
carbon atoms are filled to capacity with hydrogen
Monosaturated fatty acids
fatty acid with one double bond of carbon
Polyunsaturated fatty acid
more than one carbon double bond( or many carbons not bonded to a hydrogen atom)
Lipids are clssified as
simple and compound
Triglyceride
has 3 fatty acids, account for more than 90% of the lipids in food and in the body
Cholesterol
fatlike substance produced by both the body and found in foods of animal origin
Cholesterol is needed for
create bile acids and to synthesize steriod hormones
Lipoproteins
made up of various lipids and proteins
Vitamin
organic compound that cannot be manufactured by the body & is needed in small quanities to catalyze metabolic processes
Water-soluble vitamins
C,B-complex vitamins:B1(thiamine),B2(riboflavin), B3(Niacin), B6(pyridoxine, B9(floic acid, B12(cobalamin, pantothenic acid & biotin
Fat-soluble vitamins
A,D,E & K
Minerals
found in organic compound, as inorganic compounds, and as free ions
Calcium and phophorus make up
80% of all mineral elements in the body
Macrominerals-amount
those required daily by people in amounts over 100mg
Macrominerals
calcium, phosphorus, sodium, potassium, magnesium, chloride, sulfur
Microminerals-amount
less than 100mg
Microminerals
iron, zinc, manganese, iodine, fluoride, copper, cobalt, chromium, selenium
Caloric value
amount of energy that nutrients or food supply to the body
Large calorie
amount of heat required to raise the temp of 1 gram of water 15 to 16 degrees Celsius
Energy liberated from metabolism
Carb- 4 cal
Protein- 4 cal
Fat- 9 cal
Alcohol- 7 cal
Metabolism
refers to all biochemical & physiologic processes by which the body grows and maintians itself
Basal metabolic rate (BMR)
rate at which the body metabolizes food to maintian energy requirements of a person awake and at rest
Resting Energy Expenditure (REE)
amount of energy required to maintain basic body functions
Gallstones
can block flow of bile, common cause of lipid digestion
Diseases of the Pancreas
can affect glucose metabolism or fat digestion
Lactose intolerance
30 to 50 million Americans
75% of African Americans & American Indians
90% of Asian Americans
date and sign the plan
essential for evaluation, review, and future planning. nse's signature demonstrates accountability
catagory headings
"nursing dx","goals or desired outcomes", nursing interventions", "evaluation".
Use standardized medical or English symbols rather than complete sentences
for example Turn and repositon q2h instead of turn and reposition every two hours.
Be specific
shifts can be 8 hours or 12 hours. witing orderes needs to have specific times and not q shift
refer to procedure book or other sources
for steps of care such as trach care, write see procedure book instead of writting out all steps
tailor plan to unique characteristics of the client by ensuring client choices such as time preferences, and methods are included
reinforces clients individuality and sence of control
ensure careplan incorporate preventative and health maintenence aspects as well as restorative
for example, active range of motion to affected limbs q2h. prevents contractures and maintains muscle strength
ensure care plan has interventions for ongoing assessment
for example, inspect incision q8h
include collaborative and coordination activies
for example, PT OT ST or nutritionist consult
include plans for client discharge and home care needs
often necessary to consult and make arrangements with community health nurse, social worker,and specific agencies that supplythat supply client info and eqipment. add teaching and discharge planning as an addendaif are lengthy and complex.
The Planning Process- processs of developing client care plans
1 set priorities
2 establish desired goals and patient outcomes
3 selecting nursing interventions
4 writing nsg orders
components of a goal
subject, verb, conditions or modifiers,criterion for desired performance
components of a nsg order
date, action verb, content area, time element, signature
cognitive skills
intellectual skills
interpersonal skills
all activities, verbal and nonverbal, people use when interacting directly with one another.
technical skills
hands on skills
evaluation is...
continuous
evaluation statements
consists of conclusion and supporting data. statement that goal was met, partially met or not met.
inflammation and local infection
pain, swelling, redness, heat and impaired function
systemic infection
fever, elevated pulse,elevated respirations, malaise, loss of energy, anorexia, n&v, enlarged and/or tender lymph nodes. leucocytes > 11,000, elevated ESR.
wound healing
absence of bleeding or clots binding the edges, inflammation at wound edges at first then decrese in inflammation as clot deminishes, scar formation, diminished scar over peiod of months to years.
The Helping Relationship
interpersonal relationships or interpersonal relationships
Preinteraction phase
similar to planning phase prior to an interview. nurse has some limited information
introductory phase
orientation phase or prehelping. sets tone for the rest of the relationship. client may display some resistive behaviors
working phase
nse helps client explore thoughts, feelings, actions and helps the client plan a programor action tomeet preestablished goals
skin integrity
normal is prescence of normal skin and skin layers uniterrupted by wounds. skin integrity is first line of defense against infection.
parts of med orders.
clients full name, date and time order was written, name of drug to be administered,dosage of med route of admin, signature of Dr or nurse making drug request.
sterile field
micro-organism free area
all objects in a sterile field must be sterile
all articles are sterile with the field,always check package for intactness, check expiration date, storage areas needs to be clean, dry, off the floor and away from sinks.
sterile objects become unsterile when touched by unsterile objects
handle sterile objects that will touch open wounds or enter body cavities only with sterile forcepts or sterile gloves
sterile items that are out of site or below the waist level of the nurse are considered unsterile
once left unattended field in unsterile, do not turn back to sterile field, only front part of sterile gown from waist to shoulders and 2in above the elbowsto the cuff of the sleeve is condiered sterile, keep sterile gloves above waist and in sight and only touch sterile things, once a sterile field becomes unsterile, it must be set up again before proceeding.
sterile objects can become unsterile by prolonged exposure to airborne micro-organisms
moving air can carry dust particles and microorganisms, keep doors closed and traffic to a minimum, keep areas clean by damp cleaning with a germicide, keep hair clean and contained to keep it from falling into a sterile field, wear surical caps in OR, no sneezing or coughing over sterile field, nse with URI needs to refrain from doing procedures, keep talking to a minimum over a sterile field, do not reach over a sterile field
fluids flow in the direction of gravity
always hold forceps with the tips below the handles, after surgical hand washing, hold hands higher than the elbows.
moisture that passes through a sterile field draws microorganisms from unsterile surfaces to sterile surfaces by capillary action
sterile moisture proof barriers are used beneath sterile objects, keep sterile covers on sterile containers dry, replace sterile field when they become moist
the edges of a sterile field are considered unsterile
a 1 inch margin at each edge of an open drape is considered unsterile because the edges are in contact with unsterile surfaces
Skin is unsterile and cannot be sterilized
use sterile gloves or sterile forceps to handle sterile items, wash hands to reduce number of microrganisms
Conscientous, alertness, and honesty are essential qualities in maintaining surgical asepsis
when an object becomes unsterile it does not necessarily change in appearance, person who sees an object become unsterile must correct or report situation do not set up a sterile field ahead of time or future use
application of heat to a wound
increases capillary permeability, increases cellualr metabolim increases inflammation sedative effect, vasodilation. softens exudateincreases blood flow to specific area bringing oxygen, nutrients, antibodies an leukocytes.
drug half life
time required for the elimination process to reduce the concentration of a drug to one- half what ot was at initial administration
use of fire extinguishers
PASS- Pull pin, Aim, Squeeze, Sweep
fluid volume deficit
occurs when the body loses both water and electrolytes.goals include maintain or restore fluis balance, maintain or restore normal balance of electrolytes in the intracellular and extracellular compartments, maintain or restore pulmonary ventilation and oxygenation, prevent associated resks ( tissue breakdown, decreased cardiac output, confusion, other neurolgic signs).
sensory overload
occurs when a person is unable to process or manage the amount or intensity of sensory stimuli. imterventions can include minimizing unnecessary distraction, control pain, introduce self by name and address client by name, provide orientation cues, provide a private room, limit visitors, plan care to allow for uninterrupted periods of sleep and rest speak in a low tone and in a unhurried mannor, provide new info gradually, describe procedure and tests before hand. reduce noxious odors, take time to duscuss clients problems, assist client with stress reducing techniques