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358 Cards in this Set

  • Front
  • Back
ADVANCING TECHNOLOGY CAN COMPROMISE CARING
FORGET ABOUT THE PATIENT
LACK COMPASSIONATE CARE
HEALTH CARE TODAY IS HECTIC
APPEARS INDIFFERENT
CARING IS PRIMARY
NURSES LEARN TO LISTEN TO CLIENT’S STORIES ABOUT ILLNESSES SO UNDERSTANDING OF THE MEANING OF THE ILLNESS CAN BE OBTAINED
LEININGER
CONCEPT OF CARE DISTINGUISHES NURSING FROM OTHER HEALTH DISCIPLINES – IS VITAL TO RECOVERY

• ESSENTIAL TO HUMAN NEED
• ORIENTED TO ASSIST PERSON TO IMPROVE
• PROTECTS, DEVELOPS, NURTURES, PROVIDES SURVIVAL
JEAN WATSON
TRANSPERSONAL CARING
HOLISTIC MODEL

• CONSCIOUS INTENTION TO CARING POTENTIATES HEALING AND WHOLENESS
• REJECTS DISEASE ORIENTATION TO HEALTH CARE FOR CARING BEFORE CURING
• TRANSFORMATIVE-THE CLIENT AND NURSE ARE INFLUENCED BY THE RELATIONSHIP
KRISTEN SWANSENS
THEORY OF CARING
NURTURING WAY OF RELATING TO A VALUED OTHER PERSON
• HELPS TO DEVELOP PERSONAL STRATEGIES
• REDUCE DEPRESSION & ANGER
• 5 PROCESSES
o CARING PROCESS-UNDERSTAND OTHERS
o BEING WITH-EMOTIONALLY PRESENT
o DOING FOR-WHAT THEY WOULD DO IF THEY COULD
o ENABLING-FACILITATION THROUGH LIFE PASSAGE
o MAINTAINING BELIEF-SUSTAINING FAITH
COMMON THEMES IN NURSING
• CARING IS RELATIONAL-MUTUAL GIVE & TAKE
• EMPATHY & COMPASSION IS PART OF EVERY ENCOUNTER
• CLIENTS KNOW WHEN YOU DON’T RELATE
• UNDERSTAND THE CONTEXT OF THE PERSON’S LIFE
HOW DO CLIENTS KNOW WHEN THEY ARE CARED FOR?
• WHEN WE LISTEN AND RESPOND TO THEIR UNIQUENESS
• BEING PHYSICALLY PRESENT
• BEING SUPPORTIVE
• MAKE THE CLIENT RELAXED & SECURE
• ATTENDING TO COMFORT NEEDS
• USE KIND AND PLEASANT VOICE
• SHOW CONCERN
• USE TOUCH AS FORM OF RELATING
• USE FAMILY AS RESOURCE
SPIRITUAL CARE
OFFERS
• BALANCE BETWEEN LIFE GOALS AND BELIEF SYSTEMS
• ESTABLISH A CARING RELATIONSHIP
• SPIRITUALITY OFFERS CONNECTEDNESS
• MOBILIZE HOPE
• FIND MEANING TO ILLNESS
• ASSISTS CLIENT TO USE EMOTIONAL OR SPIRITUAL RESOURCES
FAMILY INVOLVEMENT
IN CARING
• BE HONEST
• GIVE CLEAR INFORMATION
• MAKE CLIENT COMFORTABLE
• SHOW INTEREST IN ANSWERING QUESTIONS
• PROVIDE NECESSARY EMERGENCY CARE
• GIVE ASSURANCE THAT SERVICE WILL BE AVAILABLE
• BE OPEN, HONEST, WILLING TO ANSWER FAMILY’S QUESTIONS
• TEACH FAMILY TO KEEP PATIENT COMFORTABLE
DEVELOPING A CARE PLAN
• INCLUDE INTERVENTIONS FOR EACH DX
• EVALUATE THE INTERVENTIONS FOR CHANGE
NURSING PROCESS
• COLLECT DATA
• ANALYZE DATA
• USING CRITICAL THINKING & JUDGMENTS, TAKE ACTIONS BASED ON REASON
• USED TO IDENTIFY, DX & TREAT HUMAN RESPONSES TO HEALTH & ILLNESS (ANA)
ASSESSMENT
• DELIBERATE AND SYSTEMATIC COLLECTION OF DATA TO DETERMINE A CLIENT’S CURRENT AND PAST HEALTH AND CURRENT & FUNCTIONAL STATUS PRESENTLY
• ANALYSIS OF DATABASE TO ESTABLISH CLIENT’S NEEDS, PROBLEMS, RESPONSES.
• MUST BE RELEVANT
• SKILL DEVELOPED BY EXPERIENCE
• PART OF NURSES COLLABORATIVE ROLE
DATA RELEVANT TO ASSESSMENT DATABASE
• SUBJECTIVE-
o PRIMARY SOURCE-PROVIDED BY CLIENT
o SECONDARY SOURCE-PROVIDED BY OTHER
• OBJECTIVE
• USE CUES FROM 5 SENSES
• PRIOR SKILLS CONTRIBUTE TO ASSESSMENT
• RELEVANT TO PARTICULAR HEALTH PROBLEM
• CRITICAL THINKING DICTATES TYPES OF QUESTIONS TO ASK
• COMPARES DATA TO BASELINE NORMAL
COLLECTING DATA
• FOCUS ON PRESENTING PROBLEM –PROBLEM ORIENTED
• DESCRIPTIVE, CONCISE, COMPLETE
• NURSE & CLIENT ARE AFFECTED BY EACH OTHER’S BEHAVIOR
THEORETICAL / PRACTICE STANDARD ASSESSMENT
• PROVIDES CATEGORIES OF INFORMATION FOR THE NURSE TO ASSESS.

• STANDARDS PROVIDE FOR COMPREHENSIVE ASSESSMENT OF HEALTHCARE PROBLEMS
COMPREHENSIVE ASSESSMENT
PROBLEM ORIENTED APPROACH BASED ON NATURE OF ILLNESS
SOURCE OF DATA
• CLIENT
• FAMILY/SIGNIFICANT OTHERS
• HEALTH CARE TEAM
• MEDICAL/OTHER RECORDS
• LITERATURE REVIEW
• EXPERIENCE
PHASES OF INTERVIEW
• ORIENTATION-INTRODUCTION: NAME, POSITION, EXPLANATION OF PURPOSE OF INTERVIEW
• WORKING-GATHER DATABASE, USE LISTENING/COMMUNICATION SKILLS
• TERMINATION-SUMMARY & CONFIRMATION OF IMPORTANT POINTS
TOUCH AS FORM

OF COMMUNICATION
• COMFORTS PATIENT
• CARING TOUCH-MAKING CONNECTION WITH /SHOWING ACCEPTANCE OF
• PROTECTIVE TOUCH- AVOID ACCIDENT/ HOLDING HAND TO AVOID FALL
• TASK ORIENTED
o GENTLE PERFORMANCE OF NURSING PROCEDURE
• NONVERBAL COMMUNICATION
• FORM OF RELATING
o SKIN TO SKIN / EYE CONTACT
THE NURSING PROCESS
• COMPETENCY WHEN DELIVERING CLIENT CARE
• ADPIE
• ALLOWS NURSES TO HELP CLIENTS MEET AGREED UPON COUTCOMES FOR BETTER HEALTH
• PROVIDES SYSTEMATIC APPROACH FOR GATHERING DATA
• RESPONSIVE TO CONTINUALLY CHANGING NEEDS
• PROVIDES ORGANIZED, CREATIVE STRUCTURE FOR DELIVERY OF NURSING CARE
INTERVIEW
• ORGANIZED CONERSATION W/CLIENT TO OBTAIN HEALTH HISTORY & INFORMATION ABOUT CURRENT ILLNESS
• BUILDS PROFESSIONAL INTERPERSONAL RELATIONSHIP & AIDS IN INVESTIGATION
• ORIENTATION
• WORKING
• TERMINATION
ORIENTATION PHASE OF INTERVIEW
ESTABLISES TRUST / CONFIDENCE
ESTABLISHES THE NURSE/CLIENT RELATIONSHIP
• INTRODUCTION
o NAME, POSITION, PURPOSE OF INTERVIEW
WORKING PHASE OF
INTERVIEW
• GATHERS COMPREHENSIVE AND COMPLETE INFORMATION ABOUT CLIENT’S HEALTH STATUS
• CRITICAL THINKING GUIDES INTERVIEW & QUESTIONS ASKED
TERMINATION PHASE
OF INTERVIEW
• SUMMARY OF IMPORTANT POINTS AND CLARIFICATION FOR ACCURACY
GOALS AND EXPECTED OUTCOMES
• PROVIDE DIRECTION FOR USE OF NURSING INTERVENTIONS
• PROVIDE FOCUS FOR EVALUATION OF NURSING INTERVENTIONS
GOALS OF NURSING CARE
• CLIENT-CENTERED GOAL –MEASURES CLIENT’S HIGHEST POSSIBLE LEVEL OF WELLNESS
• CONTAINS SINGULAR BEHAVIORS OR RESPONSES
• CRITERIA FOR SUCCESS IS WRITTEN IN OUTCOME STMT
• MUST BE TIME LIMITED
• INCLUDES CLIENT AND FAMILY TO PRIORTIZE AND DEVELOP PLAN OF CARE
• REALISTIC/BASED ON CLIENT NEEDS AND RESOURCES
• SHORT TERM –LESS THAN WEEK
• LONG TERM-OVER WEEKS OR MONTHS
EXPECTED OUTCOMES
• SPECIFIC MEASURABLE CHANGE AS RESPONSE TO NURSING CARE
• DEFINITION OF EFFECTIVENESS & EFFICIENCY OF INTERVENTION
• PROVIDE FOCUS FOR CARE
• SEVERAL OUTCOMES FOR EACH NURSING Dx
• MUST BE MEASURABLE WITH TIME FRAME
• OBSERVABLE
• REALISTIC /ACHIEVABLE CONSIDERING CLIENT’S RESOURCES
EMPATHY
• ABILITY TO UNDERSTAND AND ACCEPT ANOTHER PERSON’S REALITY, PERCEIVE FEELINGS, COMMUNICATE UNDERSTANDING
• UNDERSTAND THE IMPORTANCE OF WHAT THE CLIENT HAS SAID
• REQUIRES SENSITIVITY & IMAGINATION
• NEUTRAL & NONJUDGMENTAL
Client’s Motivation of Learning
• Behavior-attention span, concentration
• Health belief and perception of the severity of health problem (benefits/barriers to treatment)
• Perceived ability to complete a required health behavior
• Desire to learn
• Attitudes about health care providers
• Prior knowledge of information being taught
• Physical symptoms that may interfere with the ability to hold attention and participate
• Sociocultural background
• Learning style preference
Client’s Ability to Learn
• Factors impair clients ability to learn: body temp., electrolyte level, O2 saturation, blood glucose
• Physical strength, the extent to which client can perform skills
• Sensory deficits may affect ability to understand
• Reading level
• Developmental level, influences approach chosen
• Cognitive function, memory, knowledge, association, judgment
ABG  
arterial blood gases  
a.c.  
before meals  
ACLS  
advanced cardiac life support  
ADL  
activities of daily living  
AIDS  
acquired immune deficiency syndrome  
ANS  
autonomic nervous system  
ARC  
AIDS-related complex  
ARD  
acute respiratory disease  
AROM  
active range of motion  
ASCVD  
arteriosclerotic cardiovascular disease  
Ba  
barium  
BBB  
bundle branch block (L for left, R for right)  
BE  
barium enema  
b.i.d.  
twice a day  
BM  
bowel movement  
BMR  
basal metabolic rate  
BP  
blood pressure  
BPH  
benign prostatic hypertrophy  
Broncho  
bronchoscopy  
BS  
breath sounds, bowel sounds, blood sugar  
BUN  
blood urea nitrogen  
BX,bx  
biopsy  
C1, C2, etc...  
first cervical vertebra, second cervical vertebra  
Ca  
cancer  
CABG  
coronary artery bypass graft  
CAD  
coronary artery disease  
CAT, CT  
computerized axial tomography  
cath  
catheterization  
CBC  
complete blood count  
CCU  
coronary care unit, cardiac care unit  
chemo  
chemotherapy  
ENT  
ears, nose, and throat  
ET  
endotracheal  
FBS  
fasting blood sugar  
FHR  
fetal heart rate  
FHT  
fetal heart tone  
5-FU  
5-fluorouracil chemo  
FX, fx  
fracture  
GB  
gallbladder  
GI  
gastrointestinal  
grav1  
first pregnancy  
GSW  
gunshot wound  
GU  
genitourinary  
gyn, gyne  
gynecology  
HBV  
hepatitis B virus  
HCG  
human chorionic gonadotropin  
HCT, Hct, crit  
hematocrit  
HCV  
hepatitis C virus  
Hgb, Hb, Hgh  
hemoglobin  
HIV  
human immunodeficiency virus (causes AIDS)  
H2O  
water  
h.s.  
at bedtime  
HTN  
hypertension  
ICU  
intensive care unit  
I&D  
incision and drainage  
IDDM  
insulin dependent diabetes mellitus  
IM  
intramuscular  
I&O  
intake and output  
IUD  
intrauterine device  
IV  
intravenous  
K  
potassium  
KUB  
kidneys, ureters, bladder  
LAT, lat  
lateral  
LB  
large bowel  
PERLA (Pearl)  
pupils equal, react to light and accomodation  
PFT  
pulmonary function test  
pH  
acidity or alkalinity of urine  
PKU  
phenylketonuria  
PMS  
premenstrual syndrome  
P.O.  
per os (by mouth)  
PP  
postprandial (after meals)  
PPD  
purified protein derivative  
prn  
as required; as needed  
PROM  
passive range of motion  
PSA  
prostate specific antigen  
PT  
prothrombin time  
PVC  
premature ventricular contraction  
q.d.  
daily  
q.i.d.  
four times daily  
RBC  
red blood cells  
REM  
rapid eye movement  
RLL  
right lower lobe  
RLQ  
right lower quadrant  
ROM  
range of motion  
RUL  
right upper lobe  
RUQ  
right upper quadrant  
S1  
first heart sound  
S2  
second heart sound  
SIDS  
sudden infant death syndrome  
SOB  
shortness of breath  
stat  
immediately  
STD  
skin test done; sexually transmitted disease  
Subcu  
subcutaneous  
SVT  
supraventricular tachycardia  
T&A  
tonsillectomy and adenoidectomy  
NPO  
nothing by mouth  
TSI  
Transient Ischemic Attack  
MVA  
motor vehicle accident  
q.2h  
every 2 hours  
cc.  
cubic centimeter  
PMC  
Post Mortem Care  
q.o.d.  
every other day  
q.am.  
every morning  
TB  
Tuberculosis  
VS  
Vital Signs  
w/c  
wheelchair  
tx  
treatment  
TWE  
Tap Water Enema  
S.S.E.  
Soap suds enema  
t.i.d.  
three times a day  
MI  
Myocardial Infarction  
NIDDM  
Non insulin dependent diabetes mellitus  
hypo  
low  
hyper  
high  
Tx  
treatment  
Hx  
history  
BRP  
bathroom privileges  
HOB  
head of bead  
HOH  
hard of hearing  
NKA  
no known allergies  
H&P  
history and physical  
PID  
pelvic inflammatory disease  
DNR  
do not resusitate  
BKA  
below knee amputation  
AKA  
above knee amputation  
ID  
intradermal  
N&V;N/V  
nausea and vomiting  
N/V/D  
nausea, vomiting and diarrhea  
Q12H  
every twelve hours  
Quiz #2
1 dram
4 mL.
1 minium
1 gtt.
1 tbs.
15 mL.
1 tsp
1 minum = 5 mL.
3 tsp
1 tbs. = 15 mL.
a
before meals  
Abx
antiobiotics
ad
to; up to
ad lib
freely
b.i.w.
twice a week
c, C
cup
c.
with
C.
centigrade
cap.
capsule
cm.
centimeter
DS
double strength
EC
enteric coated
EEG
electroencephalogram
EKG
electrocardiogram
elix.
elixir; drugs dissolved in syrup containing alcohol
f.
Fahernheit
fl, fld.
fluid
G.A.D.
glucose, acetone and diacetic acid urine test
Gm.
gram
Gm./100ml.
grams per 100 milliliters
gr.
grain
gt, GT
gastrostomy tube
gtt.
drops
H.S.
at bedtime (hour of sleep)
h/o
history of
Kg.
kilogram
L.
liter
L./in
liters per minute
lb.
pound
LP
lumbar puncture / spinal tap
MAR
Medication Administration Record
Medi/Medi
person who has both Medicare and Medicaid
mg.
milliliter
N.P.O.
nothing by mouth  
NGT, ng
nasogastric tube
NS, N/S
normal saline
O
a pint
oz.
ounce
P.C.
after meals
p.o.
postoperative
P.O.  
by mouth
P.R.
by rectum
Per
through or by
post-op
after an operation
pre-op
before operation
pt
patient
PT
physical therapy
q. 2 (3,4)h
every 2 (3,4) hours
Q.D.
every day
q.H or q.1H
every hour
Q.I.D. or 4 i.d
four times a day
q.s.
a sufficient quantity
qt.
quart
Rx
prescription
s
without
S.O.S. or s.o.s.
if necessary
sig
label
sol
solution
Susp
suspension
Sx
symptoms
T
one
tab
tablet
tbsp.
tablespoon
tsp.
teaspoon
U.R.I.
upper respiratory infection
ung
ointment
vag, v
vaginally
Doctor/Specialist Abbreviations
GP
general practioner
NS
neurosurgoen
Neur
neurologist
OS
orthopedic surgeon
Ortho
orthopedic
PM
pain management doctor
PCP
parimary care physician
Rheumy
rheumatologist
Illness Abbreviations
ACM
arnold chairi malformation
AS
aspergers syndrome
BP
bipolar
CFS
chronic fatigue syndrome
CMP
chronic myofascial pain
CRPS
complex regional pain syndrome
CTD
connective tissue disease
DDD
degenerative disc disease
FMS
fibromyalgia
GS
gluten sensitivity
IBS
irritable bowel syndrome
MS
multiple sclerosis
OA
osteoarthritis
PN
peripheral neuropathy
RA
rheumatoid arthritis
RSD
reflex sympathetic dystrophy
RSI
repetative strain injury
SLE
lupus
TMJ
temporomandibular joint disorder
TOS
thoracic outlet syndrome, Terms of Service
URI
upper respiratory infection
UTI
urinary tract infection
Medication Abbreviations
AD
antidepressant
AED
antiepileptic drug
APAP
acetaminophen/tylenol
BID
twice a day
BT
breakthrough medication
CR
controlled released
ER
extended release
IR
immediate release
LA
long acting
p.c., PP
after meals, post prandial
p.o.
orally
QID
four times a day
SA
short acting
SR
sustained release
TID
three times a day
DOE
dyspnea on exertion
DVT
deep venous thrombosis
ETOH
alcohol
GOMER
get out of my emergency room
gtt
drops
H&H
hemoglobin and hematocrit
H/O, h/o
history of
HA
headache
IMP
impression
in vitro
in the laboratory
in vivo
in the body
IU
international units
JT
joint
KCL
potassium chloride
LBP
low back pain
lytes
electrolytes (potassium, sodium, ..)
MCL
medial collateral ligament
mg
Milligrams
ml
Milliters
MVP
mitral valve prolapse
Na
Sodium-electrolyte frequently monitored regularly
O&P
ova and parasites
O.D.
right eye
O.S.
left eye
O.U.
both eyes
ORIF
open reduction and internal fixation
OTC
over the counter
P
pulse
PCL
posterior cruciate ligament
Plt
Platelets
PMI
point of maximum impulse of the heart
qhs
at each bedtime
qPM
each evening
R/O
rule out
REB
rebound
ROS
review of systems
s/p
status post
SQ
subcutaneous
T
temperature
TAH
total abdominal hysterectomy
THR
total hip replacement
TKR
total knee replacement
UA, u/a
urinalysis
URI
upper respiratory infection
VSS
vital signs are stable
Wt
weight
ecchymosis
The skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels. Ecchymoses can similarly occur in mucous membranes as, for example, in the mouth.
malaise
A vague feeling of discomfort, one that cannot be pinned down but is often sensed as "just not right."
abscission
To remove tissue by cutting it away, as in surgery.
ADL's
The things we normally do in daily living including any daily activity we perform for self-care (such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure. The ability or inability to perform ADLs can be used as a very practical measure of ability/disability in many disorders.
adipose
means "fat" but is usually used to refer specifically to tissue made up of mainly fat cells such as the yellow layer of fat beneath the skin.The word "adipose" comes from the Latin "adeps" meaning "fat, particularly lard."
agonist
A drug that binds to a receptor of a cell and triggers a response by the cell. Often mimics the action of a naturally occurring substance.
Akinesia
Impaired body movement; without movement (or without much movement). a term used in neurology to denote the absence (or poverty) of movement.
Alopecia
Baldness. There are many types of alopecia, each with a different cause.
Bradycardia
A slow heart rate, usually defined as less than 60 beats per minute.
Bruxism
Grinding and gnashing the teeth.
Hydrocele
Accumulation of fluid in the coat around the testis. Small -- tend to disappear by a year of age while larger hydroceles may persist and warrant surgery.
Hypervolemia
An abnormal increase in blood volume or, strictly speaking, an abnormal increase in the volume of blood plasma. From hyper- + volume + emia (blood).
Hypotonic solution
A solution with a lower salt concentration than in normal cells of the body and the blood.
Stenosis
A narrowing
Aortic stenosis
narrowing of the aortic valve of the heart
Pulmonary stenosis
narrowing of the pulmonary valve of the heart
Pyloric stenosis
narrowing of the outlet of the stomach
Spinal stenosis
narrowing of the vertebral canal
Syncope
Partial or complete loss of consciousness with interruption of awareness of oneself and ones surroundings. When the loss of consciousness is temporary and there is spontaneous recovery, it is referred to as syncope or, in nonmedical quarters, fainting. Syncope accounts for one in every 30 visits to an emergency room. It is pronounced sin-ko-pea.Syncope is due to a temporary reduction in blood flow and therefore a shortage of oxygen to the brain. This leads to lightheadedness or a "black out" episode, a loss of consciousness. Temporary impairment of the blood supply to the brain can be caused by heart conditions and by conditions that do not directly involve the heart:
Systemic
Affecting the entire body. A -- disease such as diabetes can affect the whole body.
Lateral
In anatomy, the side of the body or a body part that is farther from the middle or center of the body. Typically, lateral refers to the outer side of the body part, but it is also used to refer to the side of a body part. For example, when referring to the knee, lateral refers to the side of the knee farthest from the opposite knee.
Whipple Procedure
A type of surgery used to treat pancreatic cancer. The head of the pancreas, the duodenum, a portion of the stomach, and other nearby tissues are removed.
Generic Drug
Has several meanings as regards drugs 1. The chemical name of a drug; 2. A term referring to the chemical makeup of a drug rather than to the advertised brand name under which the drug is sold; 3. A term referring to any drug marketed under its chemical name without advertising.
Lysis
Destruction. Hemolysis is the destruction of red blood cells with the release of hemoglobin; bacteriolysis is the destruction of bacteria; etc.
overactive neurological reflexes