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203 Cards in this Set
- Front
- Back
Compliance
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The ability of the arteries to contract and expand
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Cardiac Output
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Stroke Volume x Heart rate
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Tidal Volume
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During normal inspiration and expiration, an adult takes in about 500 mls of air
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External resps
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interchange of O2 and CO2 between alveoli and pulmonary blood
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internal resps
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happens throughout body
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Resp controlled by
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A. medulla oblongata, and pons in brain
B. by chemoreceptors located centerally in medulla nad periph in the carotid and aortic bodies. |
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Ideal Body Weight Female
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Rule of 5's Female (105lbs for 5 ft of height +6lbs for each inch over, 10% for body frame size
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Ideal Body weight Male
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Rule of 6's Male (106 lbs for 5 ft of height +6lbs for each inch over 5ft, 10% for body frame size.
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BMI- Body mass index
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BMI= Weight in kilograms
____________________ 2 (Height in meters) |
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Embryionic phase
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Pd during which the fertilized ovum dev into organism with most features.
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Embryo tissue's three layers
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Ectoderm(outer layer)
Mesoderm (middle layer) Endo or Ectoderm (inner layer) |
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Puberty
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Girls- 10-14 yrs
Boys- 12-16yrs |
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psysiologic indicators of stress
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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
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Fire, Class A, B, and C... What is each class?
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Class A: Paper,upolstery,rags
Class B:Flammable liq and gas Class C: Electrical |
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What to do in case of fire
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1.Protect and evacuate
2. Report 3Contain 4.Extinguish or RACE rescue, alarm, contain, extingu |
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Water Pumps -extinguisher
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Class A
Do not use on electrical or flammable liq. fires d/t splash |
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Carbon Dioxide CO2 -extinguisher
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Class B and C
Limited range, must be used close to the flames- small surfaces only |
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Dry Chemicals -extinguisher
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Class B and C
causes grease to splatter, small fires only |
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Multi purpose- extinguisher
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Good anywhere in the home because they put out most types of fires
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Foam
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Class B
For home use this type of extinguisher could be placed in garage or basement |
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Special dry powders
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Class D
only for use with designated metals |
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Water Pumps -extinguisher
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Class A
Do not use on electrical or flammable liq. fires d/t splash |
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Carbon Dioxide CO2 -extinguisher
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Class B and C
Limited range, must be used close to the flames- small surfaces only |
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Dry Chemicals -extinguisher
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Class B and C
causes grease to splatter, small fires only |
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Multi purpose- extinguisher
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Good anywhere in the home because they put out most types of fires
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Foam
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Class B
For home use this type of extinguisher could be placed in garage or basement |
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Special dry powders
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Class D
only for use with designated metals |
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Bacteriocins
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some microorganisms found in intestines produces these substances, which are lethal to related strains of bacteria
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Virulence
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The microorg ability to produce dz
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Iatrogenic infections
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As direct result of dx or therapeutic procedures
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What are the basic characteristics of the nursing process?
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A) universally applied in a variety of settings
B) Cyclical and dynamic C) patient centered D) Interpersonal and collaborative |
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What is the required competencies of the nurse in order to apply the Nursing process effectively?
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1) cognitive
2) Technical 3) Inerpersonal |
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What are the 5 parts tot he nursing process?
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1) Assessment
2) Analysis 3) Planning 4) implementation 5) Evaluation |
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What are the parts of assessment?
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* establish a database (patient history)
* Continually update the database (adding lab\\xray) *document in retrievable form ( chart data pertinent to nursing diagnosis) |
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What are the parts of analysis?
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* 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....) |
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What are the 4 parts of the planning phase?
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* 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 . |
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What are the 3 parts of the evaluation process
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* 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. |
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Nursing definition
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according to the American Nurses Assoc. nursing is the diagnosis and treatment of human responses to actual or potential health problems
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Nursing process
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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
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assessment
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process by which nurse collects and analyzes data about the client
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Implementation
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may include any of these activities, intervening, delegating, and coordinating
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Evaluation
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the process of determining both the clients progress toward the attaining of expected outcomes and the effectiveness of nursing care
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Standard of clincial nursing practice
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established by American Nurses Assoc. divided into two subsets standars of care adn standards of professional performance
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standards of care
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1. assessment, 2.diagnosis, 3. outcome ID 4. planning, 5. implementation, 6. evaluation
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Standards of professional performance
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1. quality of care, 2. performance appraisal, 3. education 4. collegiality, 5. ethics 6. collaboration 7. research, 8. Resource Utilization
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focused health assesment
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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
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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
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referrs to the data collection process that occurs in a life threatening situation
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Time lapsed nursing assessment
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repeated assessment obtained to compare data collected at one or more points in time with baseline data
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primary data
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nurse derives directly from the patient, can be subjective or objective
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secondary data
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data derived from all other sources. the sum of all primary and secondary data is the patients database
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Baseline data
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data taken at the time of the first encounter
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objective data
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data capable of being verified
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secondary data
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sources include the patients family and friends, other nurses and professionals
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Gordon's typology of Functional Health patterns
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method to organize data
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valid data
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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.
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nursing diagnosis
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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
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components of a nursing dx
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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.
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defining characteristics
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part of each nursing dx. defining characteristics are like manifestations of the diagnosis or signs or symptoms
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related factors
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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
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risk factors
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refer to those variables that increase a patients vulnerability to developing an actual nursing dx
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types of nursing dx
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actual, risk and wellness
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actual diagnosis
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refers to a human response to a health condition or life process that is happening now at the present time
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risk diagnosis
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refers to a diagnosis that is likely to occure in a vulnerable person
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wellness diagnoses
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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
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formulating nursing diagnoses
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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
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prioritizing nursing diagnosis
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1. physiological needs 2. safety needs 3. social needs 4. esteem needs 5. self actualization needs
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ANA standard of care on Diagnosis
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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 |
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Nursing dx outcomes
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must be time measurable, and attainable.
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Nursing dx goals
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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
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outcomes
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statements of reportable observable, or measurable results expected to occur as a reslt of nursing interventions
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Discharge planning
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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
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handwritten care plans
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handwritten onto kardex which includes patients id and background info, listing of patients dx's and listing of problem specific interventions
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Standardized care plans
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handwritten onto kardex which includes patients id and background info, listing of patients dx's and listing of problem specific interventions
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Standardized care plans
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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
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policies
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written instructions designed to address a commonly occurring problm in an institutionally approved manner
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protocols
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are institutionally approved `preprinted detailed instructions on how to perform specific clinical tasks
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standing orders
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are institutionally and departmentally approved instructions granting the nurse the authority to act in the bsence of a physician
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independent nursing intervention
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include repositioning a patient in bed who is at risk of impaired skin integrity.
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dependent nursing intervention
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ordered by a Dr. or carried out under a physicians supervision for the treatment of a medical dx.
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Terminal evaluation
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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.
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Quality of nursing care evaluation
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looks at structure, process and outcomes
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structure
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the setting or the environment in which the care is given
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process
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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
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outcome evaluation
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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
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audit
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a record or chart review
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concurrent audit
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uses interview, obersravtion and a chart reviwe to evaluate ongoing practice.
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peer review
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is an audit perfomred by one's colleagues, using standards of practice or other standardized criteria to evaluate performance
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planning
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first step is to identify expected outcomes for each of the actual diagnoses and frame them in terms of patient goals
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to observe is to ?
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gather data by using senses
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2 aspects of observation?
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noticing the data / selecting, organizing and interpreting the data
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an interview is?`
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a planned communication or a conversation with a purpose
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physical contact is used only if?
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it has a therapeutic purpose
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during the assessment phase the nurse would?
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validate data
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analysis?
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the seperation of parts
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synthesis
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putting parts together
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what is PES format?
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three part nursing diagnosis statement:
Problem/Etiology/S&S |
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base diagnosis on?
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patterns / on behavior over time-rather than isolated incidence
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etiology of hypothermia
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malnutrition
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planning?
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delibrate/systemic phase that involves decision making`
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parts of Planning ?
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prioritze problems/
formulategoals/desired outcomes/select nursing interventions/write nursing orders |
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for q nsg dx, rn must write at least one?
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desired outcome; when achieved directly demonstrates resolution of the problem clause
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implementing consists of ?
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doing and documenting
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Implementing?
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reassessing the client
determine rn need for help implement rn interventions supervise delgated care document rn activites |
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1st 3 nursing phase, aseesing, diagnosing, planning provide?
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the basis for the rn actions performed during implementation
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cognitive skills
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include problem solving, decision making, critical thinking and creativity
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interpersonal skills
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are all the activities, verbal and nonverbal when interacting with one another
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Nutrition
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sum of all interactions between an organism & the food it consumes
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Nutrients
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organic & inorganic substances found in foods & are required for body functioning
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energy-providing nutrients
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Carbs, fats, proteins
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Carbs are composed of the elements
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carbon(C), hydrogen(H), oxygen(O)
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Carbs are two basic kinds
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simple (sugars)
complex (starches & fiber) |
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Sugars
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simplest of all carbs
-water soluble -produced naturally by plants & animals |
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sugars may be:
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monosaccharides (single molecule)
disaccharides (double molecule) |
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3 monosaccharides:
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-glucose (most abbundant)
-fructose -galctose |
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Starches:
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insoluble, nonsweet forms of carbs
-polysaccharide(branch chains of dozens of glucose molecules) |
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Fiber:
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-complex carb derived from plants
-cannot be digested by humans -present in outer layer of grains, bran, pulp of many fruits and vegs |
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Major enzymes of carb digestion:
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ptyalin (salivary amylase)
-pancreatic amylase the disaccharides: maltase, sucrase & lactase |
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Enzymes
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biologic catalysts that speed up chemical reations
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Carbs are stored as:
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glycogen
-fat |
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Glycogen
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large polymer of glucose
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glycogenesis
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glycogen formation
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Protein
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organic substance composed of amino acids
contains (C), (H), (O) and (N) |
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Essential amino acids
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cannot be manufactured by the body
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Nine essential amino acids
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threonine, leucine, isoeucine, valine, methionine, phenylalanine, tryptophan, histidine
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Arginine
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appears to have role in immune system
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Nonessential amino acids
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body can manufacture
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Ten nonessential amino acids
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glycine, alanine, aspartic acid, glutamic acid, proline, hydroxyproline, cystine, tyrosine, serine
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Complete proteins
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contain all essential amino acids include:
most animal-meats, poultry, fish, diary products & eggs |
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Incomplete proteins
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lack one or more essential amino acis ( most commonly lysine, methionine or tryptophan)
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Complementary proteins
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combination of two of more vegetables make complete protein
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Protein metabolism include thre activities
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-anabolism(building tissue)
-catabolism(breking down tissue) -nitrogen balance |
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Lipids
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organic substances that are greasy & insoluble in water but soluble in alcohol or ether
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Fats
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lipids solid at room temp
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Oils
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lipids liquid at room temp
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Fatty acids
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made up of carbon chains & hydrogen and are basic structure unit of most lipids
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Saturated fatty acids
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carbon atoms are filled to capacity with hydrogen
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Monosaturated fatty acids
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fatty acid with one double bond of carbon
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Polyunsaturated fatty acid
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more than one carbon double bond( or many carbons not bonded to a hydrogen atom)
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Lipids are clssified as
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simple and compound
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Triglyceride
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has 3 fatty acids, account for more than 90% of the lipids in food and in the body
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Cholesterol
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fatlike substance produced by both the body and found in foods of animal origin
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Cholesterol is needed for
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create bile acids and to synthesize steriod hormones
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Lipoproteins
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made up of various lipids and proteins
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Vitamin
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organic compound that cannot be manufactured by the body & is needed in small quanities to catalyze metabolic processes
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Water-soluble vitamins
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C,B-complex vitamins:B1(thiamine),B2(riboflavin), B3(Niacin), B6(pyridoxine, B9(floic acid, B12(cobalamin, pantothenic acid & biotin
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Fat-soluble vitamins
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A,D,E & K
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Minerals
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found in organic compound, as inorganic compounds, and as free ions
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Calcium and phophorus make up
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80% of all mineral elements in the body
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Macrominerals-amount
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those required daily by people in amounts over 100mg
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Macrominerals
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calcium, phosphorus, sodium, potassium, magnesium, chloride, sulfur
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Microminerals-amount
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less than 100mg
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Microminerals
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iron, zinc, manganese, iodine, fluoride, copper, cobalt, chromium, selenium
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Caloric value
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amount of energy that nutrients or food supply to the body
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Large calorie
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amount of heat required to raise the temp of 1 gram of water 15 to 16 degrees Celsius
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Energy liberated from metabolism
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Carb- 4 cal
Protein- 4 cal Fat- 9 cal Alcohol- 7 cal |
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Metabolism
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refers to all biochemical & physiologic processes by which the body grows and maintians itself
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Basal metabolic rate (BMR)
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rate at which the body metabolizes food to maintian energy requirements of a person awake and at rest
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Resting Energy Expenditure (REE)
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amount of energy required to maintain basic body functions
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Gallstones
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can block flow of bile, common cause of lipid digestion
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Diseases of the Pancreas
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can affect glucose metabolism or fat digestion
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Lactose intolerance
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30 to 50 million Americans
75% of African Americans & American Indians 90% of Asian Americans |
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date and sign the plan
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essential for evaluation, review, and future planning. nse's signature demonstrates accountability
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catagory headings
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"nursing dx","goals or desired outcomes", nursing interventions", "evaluation".
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Use standardized medical or English symbols rather than complete sentences
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for example Turn and repositon q2h instead of turn and reposition every two hours.
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Be specific
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shifts can be 8 hours or 12 hours. witing orderes needs to have specific times and not q shift
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refer to procedure book or other sources
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for steps of care such as trach care, write see procedure book instead of writting out all steps
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tailor plan to unique characteristics of the client by ensuring client choices such as time preferences, and methods are included
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reinforces clients individuality and sence of control
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ensure careplan incorporate preventative and health maintenence aspects as well as restorative
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for example, active range of motion to affected limbs q2h. prevents contractures and maintains muscle strength
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ensure care plan has interventions for ongoing assessment
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for example, inspect incision q8h
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include collaborative and coordination activies
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for example, PT OT ST or nutritionist consult
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include plans for client discharge and home care needs
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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.
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The Planning Process- processs of developing client care plans
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1 set priorities
2 establish desired goals and patient outcomes 3 selecting nursing interventions 4 writing nsg orders |
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components of a goal
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subject, verb, conditions or modifiers,criterion for desired performance
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components of a nsg order
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date, action verb, content area, time element, signature
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cognitive skills
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intellectual skills
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interpersonal skills
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all activities, verbal and nonverbal, people use when interacting directly with one another.
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technical skills
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hands on skills
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evaluation is...
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continuous
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evaluation statements
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consists of conclusion and supporting data. statement that goal was met, partially met or not met.
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inflammation and local infection
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pain, swelling, redness, heat and impaired function
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systemic infection
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fever, elevated pulse,elevated respirations, malaise, loss of energy, anorexia, n&v, enlarged and/or tender lymph nodes. leucocytes > 11,000, elevated ESR.
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wound healing
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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.
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The Helping Relationship
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interpersonal relationships or interpersonal relationships
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Preinteraction phase
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similar to planning phase prior to an interview. nurse has some limited information
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introductory phase
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orientation phase or prehelping. sets tone for the rest of the relationship. client may display some resistive behaviors
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working phase
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nse helps client explore thoughts, feelings, actions and helps the client plan a programor action tomeet preestablished goals
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skin integrity
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normal is prescence of normal skin and skin layers uniterrupted by wounds. skin integrity is first line of defense against infection.
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parts of med orders.
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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.
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sterile field
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micro-organism free area
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all objects in a sterile field must be sterile
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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.
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sterile objects become unsterile when touched by unsterile objects
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handle sterile objects that will touch open wounds or enter body cavities only with sterile forcepts or sterile gloves
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sterile items that are out of site or below the waist level of the nurse are considered unsterile
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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.
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sterile objects can become unsterile by prolonged exposure to airborne micro-organisms
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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
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fluids flow in the direction of gravity
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always hold forceps with the tips below the handles, after surgical hand washing, hold hands higher than the elbows.
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moisture that passes through a sterile field draws microorganisms from unsterile surfaces to sterile surfaces by capillary action
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sterile moisture proof barriers are used beneath sterile objects, keep sterile covers on sterile containers dry, replace sterile field when they become moist
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the edges of a sterile field are considered unsterile
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a 1 inch margin at each edge of an open drape is considered unsterile because the edges are in contact with unsterile surfaces
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Skin is unsterile and cannot be sterilized
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use sterile gloves or sterile forceps to handle sterile items, wash hands to reduce number of microrganisms
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Conscientous, alertness, and honesty are essential qualities in maintaining surgical asepsis
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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
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application of heat to a wound
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increases capillary permeability, increases cellualr metabolim increases inflammation sedative effect, vasodilation. softens exudateincreases blood flow to specific area bringing oxygen, nutrients, antibodies an leukocytes.
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drug half life
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time required for the elimination process to reduce the concentration of a drug to one- half what ot was at initial administration
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use of fire extinguishers
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PASS- Pull pin, Aim, Squeeze, Sweep
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fluid volume deficit
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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).
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sensory overload
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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
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