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128 Cards in this Set

  • Front
  • Back

scope of practice


range of responsibilities and practice guidelines that determine the boundaries within which a healthcare worker practices

reflection

step in active listening; repeating the main idea of the conversation while also identifying the patients feelings

restatement

step in active listening; paraphrasing or repeating the patients statement

clarification

step in active listening; summarizing or simplifying the patients thoughts and feelings to resolve any confusion in the message

auto immune disease disorder

disturbance in which the body reacts against it's own tissue examples are multiple sclerosis rheumatoid arthritis and sle

parenteral

injection or introduction of substances into the body by any route other then the digestive tracts

chain of infection

infectious agent; reservoir host; portal of exit; mode of transmission; portal of entry; susceptible host

infectious agent

first link to the chain of infection; can be a virus,bacteria,protozoa and helminth,fungi, and rickettsia

reservoir host

second link; May be people,insects,animals,water,food,or contaminated instruments and equipment. pathogens must gain entrance or they will die.

portal of exit

third link; how the pathogen escapes the reservoir host. exits include the mouth,nose,eyes,ears,intestines,urinary tract,reproductive tract and open wounds

mode of transmission

fourth link; can be direct or indirect. direct occurs from contact with an infectious person or discharges from an infectious substance. indirect occurs from air borne droplets; vectors that harbor pathogens

portal of entry

fifth link; how the transmitted pathogen gains entry into a new host. entry could be mouth,nose,eyes,ears,intestines,urinary tract, reproductive tract or open wounds.

susceptible host

sixth link; if a host is susceptible the organism multiplies. factors include the location of entry,dose of organisms,individuals state of health. if conditions are right the organism reaches infectious levels and starts the chain of infection again.

nososcomial

infections that are acquire in a healthcare setting

CDC recommendations

universal precautions; all blood and certain body fluids must be treated as if known to be infectious for blood borne pathogens.

antibiotics

unable to destroy viral invaders that enter a normal cell and multiply within the cell

antigens

foreign substance that causes the production of a specific antibody

soape

patients notes

S:

subjective data

O:

objective data

A:

assessment of the problem

P:

plan of care

E:

evaluation

humoral immunity

the immune system responds by producing antibodies specifically designed to combat the presence of a foreign substance, or antigen; this occurs because of the body's B cells

cell mediated immunity

immune system also reacts at the cellular level with t-cell activity; causing the destruction of pathogenic cells at the site of invasion. ex: phagocytosis

hand washing

friction hot running water

sanitization

Cleansing process that reduces the number of microorganisms to a safe level, as dictated by the public health guidelines

disinfection

process of killing pathogenic organisms or rendering them inactive

sterilization

destruction of all microrganisms can be achieved by moist heat in an autoclave, dry heat, radiation, gas or with chemicals

microbial growth

nutrients,moisture,temperature,oxygen,neutral ph

disease reported to health department

anthrax,measles,polio,tuberculosis

appropriate conditions for handling body fluids

exposure control plan, blood borne pathogens standard

PPE

personal protective equipment; gloves,mask,gown,hairnet,goggles

inflammation

redness,swelling,pain,heat

acute

rapid inset of symptoms but lasts a relatively short time

chronic

persists for a long time sometimes for life

latent

persistent infection in which the symptoms cycle through relapse and remission

opportunistic infection

caused by organisms that are not typically pathogenic but that occur in hosts with an impaired immune system response

viral; virus

inserts infection into host cell to multiply throughout the body; may not cause immediate symptoms

bacterial; bacteria

an infection in the body that can be treated by antibiotics

antibiotic resistance

caused when a bacteria mutates and grows stronger then the antibiotic or when an antibiotic is improperly used.

interview techniques

introduce yourself; initiation


why they are there; body


doctor will be in; closing

objective

signs can be observed and or measured by the provider or medical assistant

subjective

symptoms perceptible only to the patient aka opinion

medical record- EHR

database;chief complaint; past history; family history;social history; systems review

database

record of the patients name; first

chief complaint

purpose of the patients visit; second

past history

patients previous health; third

family history

details about the patients parents siblings and there health; fourth

social history

patients lifestyle; fifth

systems review

guide to the patients general health, helps detect conditions other then the chief complaint; sixth

what EHR record contains the head to toe body review

systems review ROS SR

therapeutic communications

open or closed questions, active listening,silence,establishing guidelines,acknowledgement,restating,reflecting,summarizing

defense mechanisms

denial,suppression,reaction information,projection,rationalization,undoing,regression,sublimation

denial

rejecting information

suppression

aware of the information or feeling but refuses to admit it

reaction information

expresses feelings as the opposite of how they really feel

projection

accusing someone else of having the feelings they do

rationalization

various explanations to justify their response

undoing

reverse a negative feeling by doing something that indicates the opposite feelings

regression

reverse to an old;immature behavior to ventilate feelings

sublimation

redirects negative feelings into a socially productive activity

History of present illness (HPI)

location,quality,severity,duration,timing,context,modifying factors,associates Sxs; signs and symptoms

non verbal gestures

facial expressions,gestures,mannerisms,tone,posture

ac

before eating

BP

blood pressure

CHF

congestive heart failure

CXR

chest x-ray

DVT

deep vein thrombosis

f/u

follow up

HS

at bedtime

Hx

history

NKA

no known allergies

prn

as needed

RBC

red blood cells

Rx

treatment

URI

upper respiratory infection

bid

twice a day

CAD

coronary artery disease

CVA

cerebrovascular disease

dc

discontinue

Dx

diagnosis

fx

fracture

HTN

hypertension

MI

myocardial infarction

NPO

nothing by mouth

pt

patient

R/O

rule out

stat

immediately

VS

vital signs

a

without

adip/o

fat

-algia

pain

brady

slow

cephal/o

head

cyan/o

blue

hem/o

blood

hyper

increase

inter

between

leuk/o

white

-malacia

soft

phleb/o

vein

py/o

pus

-stenosis

tightening

cyt/o

cell

-emia

blood condition

my/o

muscle

supra-

above

thorac/o

chest

aden/o

gland

-algesia

sensitivity to pain

arthro

joint

cardi/o

heart

-clast

to break

gastr/o

stomach

hepat/o

liver

hyster/o

uterus

intra

within

lith/o

stone

-penia

decrease

-pnea

breathing

-sclerosis

hardening

cyst/o

urinary bladder

-ectomy

excision

morph/o

shape

olig/o

scanty

tachy-

fast

viscer/o

internal organs