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358 Cards in this Set
- Front
- Back
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ADVANCING TECHNOLOGY CAN COMPROMISE CARING
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FORGET ABOUT THE PATIENT
LACK COMPASSIONATE CARE HEALTH CARE TODAY IS HECTIC APPEARS INDIFFERENT |
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CARING IS PRIMARY
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NURSES LEARN TO LISTEN TO CLIENT’S STORIES ABOUT ILLNESSES SO UNDERSTANDING OF THE MEANING OF THE ILLNESS CAN BE OBTAINED
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LEININGER
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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 |
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JEAN WATSON
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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 |
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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 |
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COMMON THEMES IN NURSING
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• 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 |
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HOW DO CLIENTS KNOW WHEN THEY ARE CARED FOR?
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• 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 |
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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 |
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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 |
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DEVELOPING A CARE PLAN
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• INCLUDE INTERVENTIONS FOR EACH DX
• EVALUATE THE INTERVENTIONS FOR CHANGE |
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NURSING PROCESS
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• COLLECT DATA
• ANALYZE DATA • USING CRITICAL THINKING & JUDGMENTS, TAKE ACTIONS BASED ON REASON • USED TO IDENTIFY, DX & TREAT HUMAN RESPONSES TO HEALTH & ILLNESS (ANA) |
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ASSESSMENT
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• 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 |
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DATA RELEVANT TO ASSESSMENT DATABASE
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• 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 |
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COLLECTING DATA
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• FOCUS ON PRESENTING PROBLEM –PROBLEM ORIENTED
• DESCRIPTIVE, CONCISE, COMPLETE • NURSE & CLIENT ARE AFFECTED BY EACH OTHER’S BEHAVIOR |
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THEORETICAL / PRACTICE STANDARD ASSESSMENT
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• PROVIDES CATEGORIES OF INFORMATION FOR THE NURSE TO ASSESS.
• STANDARDS PROVIDE FOR COMPREHENSIVE ASSESSMENT OF HEALTHCARE PROBLEMS |
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COMPREHENSIVE ASSESSMENT
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PROBLEM ORIENTED APPROACH BASED ON NATURE OF ILLNESS
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SOURCE OF DATA
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• CLIENT
• FAMILY/SIGNIFICANT OTHERS • HEALTH CARE TEAM • MEDICAL/OTHER RECORDS • LITERATURE REVIEW • EXPERIENCE |
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PHASES OF INTERVIEW
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• ORIENTATION-INTRODUCTION: NAME, POSITION, EXPLANATION OF PURPOSE OF INTERVIEW
• WORKING-GATHER DATABASE, USE LISTENING/COMMUNICATION SKILLS • TERMINATION-SUMMARY & CONFIRMATION OF IMPORTANT POINTS |
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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 |
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THE NURSING PROCESS
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• 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 |
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INTERVIEW
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• ORGANIZED CONERSATION W/CLIENT TO OBTAIN HEALTH HISTORY & INFORMATION ABOUT CURRENT ILLNESS
• BUILDS PROFESSIONAL INTERPERSONAL RELATIONSHIP & AIDS IN INVESTIGATION • ORIENTATION • WORKING • TERMINATION |
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ORIENTATION PHASE OF INTERVIEW
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ESTABLISES TRUST / CONFIDENCE
ESTABLISHES THE NURSE/CLIENT RELATIONSHIP • INTRODUCTION o NAME, POSITION, PURPOSE OF INTERVIEW |
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WORKING PHASE OF
INTERVIEW |
• GATHERS COMPREHENSIVE AND COMPLETE INFORMATION ABOUT CLIENT’S HEALTH STATUS
• CRITICAL THINKING GUIDES INTERVIEW & QUESTIONS ASKED |
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TERMINATION PHASE
OF INTERVIEW |
• SUMMARY OF IMPORTANT POINTS AND CLARIFICATION FOR ACCURACY
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GOALS AND EXPECTED OUTCOMES
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• PROVIDE DIRECTION FOR USE OF NURSING INTERVENTIONS
• PROVIDE FOCUS FOR EVALUATION OF NURSING INTERVENTIONS • |
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GOALS OF NURSING CARE
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• 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 |
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EXPECTED OUTCOMES
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• 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 |
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EMPATHY
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• 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 |
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Client’s Motivation of Learning
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• 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 |
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Client’s Ability to Learn
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• 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 |
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ABG
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arterial blood gases
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a.c.
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before meals
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ACLS
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advanced cardiac life support
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ADL
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activities of daily living
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AIDS
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acquired immune deficiency syndrome
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ANS
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autonomic nervous system
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ARC
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AIDS-related complex
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ARD
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acute respiratory disease
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AROM
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active range of motion
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ASCVD
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arteriosclerotic cardiovascular disease
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Ba
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barium
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BBB
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bundle branch block (L for left, R for right)
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BE
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barium enema
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b.i.d.
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twice a day
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BM
|
bowel movement
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BMR
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basal metabolic rate
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BP
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blood pressure
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BPH
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benign prostatic hypertrophy
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Broncho
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bronchoscopy
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BS
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breath sounds, bowel sounds, blood sugar
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BUN
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blood urea nitrogen
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BX,bx
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biopsy
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C1, C2, etc...
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first cervical vertebra, second cervical vertebra
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Ca
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cancer
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CABG
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coronary artery bypass graft
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CAD
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coronary artery disease
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CAT, CT
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computerized axial tomography
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cath
|
catheterization
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CBC
|
complete blood count
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CCU
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coronary care unit, cardiac care unit
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chemo
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chemotherapy
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ENT
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ears, nose, and throat
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ET
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endotracheal
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FBS
|
fasting blood sugar
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FHR
|
fetal heart rate
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FHT
|
fetal heart tone
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5-FU
|
5-fluorouracil chemo
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FX, fx
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fracture
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GB
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gallbladder
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GI
|
gastrointestinal
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grav1
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first pregnancy
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GSW
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gunshot wound
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GU
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genitourinary
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gyn, gyne
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gynecology
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HBV
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hepatitis B virus
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HCG
|
human chorionic gonadotropin
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HCT, Hct, crit
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hematocrit
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HCV
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hepatitis C virus
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Hgb, Hb, Hgh
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hemoglobin
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HIV
|
human immunodeficiency virus (causes AIDS)
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H2O
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water
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h.s.
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at bedtime
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HTN
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hypertension
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ICU
|
intensive care unit
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I&D
|
incision and drainage
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IDDM
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insulin dependent diabetes mellitus
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IM
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intramuscular
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I&O
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intake and output
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IUD
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intrauterine device
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IV
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intravenous
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K
|
potassium
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KUB
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kidneys, ureters, bladder
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LAT, lat
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lateral
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LB
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large bowel
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PERLA (Pearl)
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pupils equal, react to light and accomodation
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PFT
|
pulmonary function test
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pH
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acidity or alkalinity of urine
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PKU
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phenylketonuria
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PMS
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premenstrual syndrome
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P.O.
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per os (by mouth)
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PP
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postprandial (after meals)
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PPD
|
purified protein derivative
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prn
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as required; as needed
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PROM
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passive range of motion
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PSA
|
prostate specific antigen
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PT
|
prothrombin time
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PVC
|
premature ventricular contraction
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q.d.
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daily
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q.i.d.
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four times daily
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RBC
|
red blood cells
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REM
|
rapid eye movement
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RLL
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right lower lobe
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RLQ
|
right lower quadrant
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ROM
|
range of motion
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RUL
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right upper lobe
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RUQ
|
right upper quadrant
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S1
|
first heart sound
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S2
|
second heart sound
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SIDS
|
sudden infant death syndrome
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SOB
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shortness of breath
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stat
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immediately
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STD
|
skin test done; sexually transmitted disease
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Subcu
|
subcutaneous
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SVT
|
supraventricular tachycardia
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T&A
|
tonsillectomy and adenoidectomy
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NPO
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nothing by mouth
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TSI
|
Transient Ischemic Attack
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MVA
|
motor vehicle accident
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q.2h
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every 2 hours
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cc.
|
cubic centimeter
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PMC
|
Post Mortem Care
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q.o.d.
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every other day
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q.am.
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every morning
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TB
|
Tuberculosis
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VS
|
Vital Signs
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w/c
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wheelchair
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tx
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treatment
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TWE
|
Tap Water Enema
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S.S.E.
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Soap suds enema
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t.i.d.
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three times a day
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MI
|
Myocardial Infarction
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NIDDM
|
Non insulin dependent diabetes mellitus
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hypo
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low
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hyper
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high
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Tx
|
treatment
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Hx
|
history
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BRP
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bathroom privileges
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HOB
|
head of bead
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HOH
|
hard of hearing
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NKA
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no known allergies
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H&P
|
history and physical
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PID
|
pelvic inflammatory disease
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DNR
|
do not resusitate
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BKA
|
below knee amputation
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AKA
|
above knee amputation
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ID
|
intradermal
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N&V;N/V
|
nausea and vomiting
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N/V/D
|
nausea, vomiting and diarrhea
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Q12H
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every twelve hours
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Quiz #2
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1 dram
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4 mL.
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1 minium
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1 gtt.
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1 tbs.
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15 mL.
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1 tsp
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1 minum = 5 mL.
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3 tsp
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1 tbs. = 15 mL.
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a
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before meals
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Abx
|
antiobiotics
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ad
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to; up to
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ad lib
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freely
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b.i.w.
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twice a week
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c, C
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cup
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c.
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with
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C.
|
centigrade
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cap.
|
capsule
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cm.
|
centimeter
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DS
|
double strength
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EC
|
enteric coated
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EEG
|
electroencephalogram
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EKG
|
electrocardiogram
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elix.
|
elixir; drugs dissolved in syrup containing alcohol
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f.
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Fahernheit
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fl, fld.
|
fluid
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G.A.D.
|
glucose, acetone and diacetic acid urine test
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Gm.
|
gram
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Gm./100ml.
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grams per 100 milliliters
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gr.
|
grain
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gt, GT
|
gastrostomy tube
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gtt.
|
drops
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H.S.
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at bedtime (hour of sleep)
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h/o
|
history of
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Kg.
|
kilogram
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L.
|
liter
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L./in
|
liters per minute
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lb.
|
pound
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LP
|
lumbar puncture / spinal tap
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MAR
|
Medication Administration Record
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Medi/Medi
|
person who has both Medicare and Medicaid
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mg.
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milliliter
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N.P.O.
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nothing by mouth
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NGT, ng
|
nasogastric tube
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NS, N/S
|
normal saline
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O
|
a pint
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oz.
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ounce
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P.C.
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after meals
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p.o.
|
postoperative
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P.O.
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by mouth
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P.R.
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by rectum
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Per
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through or by
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post-op
|
after an operation
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pre-op
|
before operation
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pt
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patient
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PT
|
physical therapy
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q. 2 (3,4)h
|
every 2 (3,4) hours
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Q.D.
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every day
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q.H or q.1H
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every hour
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Q.I.D. or 4 i.d
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four times a day
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q.s.
|
a sufficient quantity
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qt.
|
quart
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Rx
|
prescription
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s
|
without
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S.O.S. or s.o.s.
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if necessary
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sig
|
label
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sol
|
solution
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Susp
|
suspension
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Sx
|
symptoms
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T
|
one
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tab
|
tablet
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tbsp.
|
tablespoon
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tsp.
|
teaspoon
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U.R.I.
|
upper respiratory infection
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ung
|
ointment
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vag, v
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vaginally
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Doctor/Specialist Abbreviations
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GP
|
general practioner
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NS
|
neurosurgoen
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Neur
|
neurologist
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OS
|
orthopedic surgeon
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Ortho
|
orthopedic
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PM
|
pain management doctor
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PCP
|
parimary care physician
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Rheumy
|
rheumatologist
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Illness Abbreviations
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ACM
|
arnold chairi malformation
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AS
|
aspergers syndrome
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BP
|
bipolar
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CFS
|
chronic fatigue syndrome
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CMP
|
chronic myofascial pain
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CRPS
|
complex regional pain syndrome
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CTD
|
connective tissue disease
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DDD
|
degenerative disc disease
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FMS
|
fibromyalgia
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GS
|
gluten sensitivity
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IBS
|
irritable bowel syndrome
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MS
|
multiple sclerosis
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OA
|
osteoarthritis
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PN
|
peripheral neuropathy
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RA
|
rheumatoid arthritis
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RSD
|
reflex sympathetic dystrophy
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RSI
|
repetative strain injury
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SLE
|
lupus
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TMJ
|
temporomandibular joint disorder
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TOS
|
thoracic outlet syndrome, Terms of Service
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URI
|
upper respiratory infection
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UTI
|
urinary tract infection
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Medication Abbreviations
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AD
|
antidepressant
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AED
|
antiepileptic drug
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APAP
|
acetaminophen/tylenol
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BID
|
twice a day
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BT
|
breakthrough medication
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CR
|
controlled released
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ER
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extended release
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IR
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immediate release
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LA
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long acting
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p.c., PP
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after meals, post prandial
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p.o.
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orally
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QID
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four times a day
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SA
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short acting
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SR
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sustained release
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TID
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three times a day
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DOE
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dyspnea on exertion
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DVT
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deep venous thrombosis
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ETOH
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alcohol
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GOMER
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get out of my emergency room
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gtt
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drops
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H&H
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hemoglobin and hematocrit
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H/O, h/o
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history of
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HA
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headache
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IMP
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impression
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in vitro
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in the laboratory
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in vivo
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in the body
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IU
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international units
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JT
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joint
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KCL
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potassium chloride
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LBP
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low back pain
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lytes
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electrolytes (potassium, sodium, ..)
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MCL
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medial collateral ligament
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mg
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Milligrams
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ml
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Milliters
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MVP
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mitral valve prolapse
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Na
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Sodium-electrolyte frequently monitored regularly
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O&P
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ova and parasites
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O.D.
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right eye
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O.S.
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left eye
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O.U.
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both eyes
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ORIF
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open reduction and internal fixation
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OTC
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over the counter
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P
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pulse
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PCL
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posterior cruciate ligament
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Plt
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Platelets
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PMI
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point of maximum impulse of the heart
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qhs
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at each bedtime
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qPM
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each evening
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R/O
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rule out
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REB
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rebound
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ROS
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review of systems
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s/p
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status post
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SQ
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subcutaneous
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T
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temperature
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TAH
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total abdominal hysterectomy
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THR
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total hip replacement
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TKR
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total knee replacement
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UA, u/a
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urinalysis
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URI
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upper respiratory infection
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VSS
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vital signs are stable
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Wt
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weight
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ecchymosis
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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.
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malaise
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A vague feeling of discomfort, one that cannot be pinned down but is often sensed as "just not right."
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abscission
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To remove tissue by cutting it away, as in surgery.
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ADL's
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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.
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adipose
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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."
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agonist
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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.
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Akinesia
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Impaired body movement; without movement (or without much movement). a term used in neurology to denote the absence (or poverty) of movement.
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Alopecia
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Baldness. There are many types of alopecia, each with a different cause.
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Bradycardia
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A slow heart rate, usually defined as less than 60 beats per minute.
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Bruxism
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Grinding and gnashing the teeth.
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Hydrocele
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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.
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Hypervolemia
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An abnormal increase in blood volume or, strictly speaking, an abnormal increase in the volume of blood plasma. From hyper- + volume + emia (blood).
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Hypotonic solution
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A solution with a lower salt concentration than in normal cells of the body and the blood.
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Stenosis
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A narrowing
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Aortic stenosis
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narrowing of the aortic valve of the heart
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Pulmonary stenosis
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narrowing of the pulmonary valve of the heart
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Pyloric stenosis
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narrowing of the outlet of the stomach
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Spinal stenosis
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narrowing of the vertebral canal
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Syncope
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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:
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Systemic
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Affecting the entire body. A -- disease such as diabetes can affect the whole body.
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Lateral
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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.
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Whipple Procedure
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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.
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Generic Drug
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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.
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Lysis
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Destruction. Hemolysis is the destruction of red blood cells with the release of hemoglobin; bacteriolysis is the destruction of bacteria; etc.
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overactive neurological reflexes
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