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111 Cards in this Set

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What are the 3 phases of nurse-client relationship?
1. Orientation Phase
2. Working Phase
3. Termination Phase
What develops in the Orientation Phase of nurse-client relationship?
Legal contract with patient
What two things are put in place in the contract of the orientation phase in the nurse-client relationship?
1. Set limitations for termination
2. Establish confidentiality
What happens in the Working Phase of the nurse-client relationship?
Nursing process
Name the parts of the nursing process
1. Assessment
2. Diagnosis
3. Planning
4. Intervention
5. Evaluation
What step in the nursing process gathers data?
Assessment
What two types of data are gathered during ASSESSMENT? And where are they from? -2
1. primary data is from the patient
2. secondary data is from their file and kardex
What are the three types of INTERVENTIONS?
independent interventions
dependent interventions
collaborative interventions
What are independent interventions?
nurse can do alone
What are dependent interventions?
nurse does under doctors' orders
What are collaborative interventions?
nurse does with other members of team
What are the five parts to the nursing diagnosis?
Label
Definition
Defining characteristics
Related factors
Risk factors
What is evoked by the "label" part in the nursing diagnosis? examples (no, you don't need to know all of 'em)?
qualifiers: acute vs. chronic, altered, impaired, potential, decreased, deficient, excessive, readiness, involuntary
What is the key phrase that's evoked for the 'defining characteristics' part of the nursing diagnosis?
...as evidenced by...
Evidence in the 'defining characteristics' part of the nursing diagnosis needs to be what?
measurable
What is the key phrase evoked from the 'related factors' part of the nursing diagnosis?
...related to the medical diagnosis of...
What are 'risk factors' in regard to the nursing diagnosis?
things that increase the chance of a problem occurring
What two things should a patient expect due to CLINICAL PATHWAYS?
guidelines for what a patient should expect in time and procedures with a certain diagnosis.
Who dictates the guidelines for infection control?
CDC
What are the six elements to the chain of infection?
1. Infectious agent
2. Reservoir (source
3. Portal of exit (from reservoir)
4. Mode of transport
5. Portal of Entry
6. Susceptible host
What are the five phases of infection?
1. Exposure
2. Incubation
3. Prodromal
4. Clinical illness
5. Convalescence
What marks the beginning and end of the INCUBATION phase?
Time of exposure to onset of symptoms
During what phase is the most infectious a person can be?
Incubation phase
When is it best to isolate someone so as not to spread an infection?
During the INCUBATION PHASE of infection
What defines the PRODROMAL PHASE? -3
Similar to INCUBATION PHASE, haven't developed peak of symptoms, but feeling sick
What defines the CLINICAL ILLNESS phase of infection?
Full manifestation of all symptoms
What marks the beginning and end to CONVALESCENCE? How does it feel?
From the peak of clinical illness to the time all symptoms have abated.
Still feel pretty run down
During the INFLAMMATORY RESPONSE, what three things does the body do to protect and heal itself?
1. remove invasive substance
2. localize invasion
3. repair damage
Three classic signs of INFLAMMATORY RESPONSE
erythema, warmth, edema
What two things do capillaries do during the local response before healing?
dilate & leak
What five (general) things are drawn to the infection in the inflammatory response?
nonspecific building components (blood plasma), phagocytes, interferon, RBCs, WBCs
What do phagoctyes do?
Lyse
What is an interferon?
What's it do?
protein to fight viral infection
Why does a cut get red?
RBCs have rushed to it
What are the 5 WBC types?
...in order
Neutrophils, Lymphocytes, Eosinophils, Basophils, Monocytes
What does it mean when Lymphocytes increase?
Infection definitely present
Which Lymphocyte is antigen specific?
B cell
What are the three types of T cells?
helper, memory and killer
What is the Humoral Response also called?
Antigen-Antibody Response
What is an antibody?
protein from B cell
What does the antibody do?
recognizes antigen
About how long does it take for immunoglobulins to be stimulated?
~3 days
What are the 5 IMMUNOGLOBULINS?
IgM, IgG, IgA, IgD, IgE
Which IMMUNOGLOBULIN is the first to rise?
IgM
What does presence if IgG mean?
previous exposure
What does CELLULAR IMMUNITY form?
B & T cells
What percent of Lymphocytes are T Cells?
70%
How do immunizations become effective?
Cellular immunity response
What are the four PRIMARY DEFENSES against infection?
Skin, mucous membranes, GI system, mucocillary pathway in lungs
What are the two SECONDARY DEFENSES against infection?
Immune system, supportive therapy (nutrition, rest)
What technique is MEDICAL ASEPSIS?
clean technique
What technique is SURGICAL ASEPSIS?
sterile technique
What is the threshold (in number) for something to be considered an infection?
One million parts per mL
What are three nonverbal factors in communication?
environmental factors, facial expressions, posture
Five BARRIERS to communication (MEDICAL)
EXPRESSIVE APHASIA, RECEPTIVE APHASIA, GLOBAL APHASIA, DYSARRTHRIA, DYSPHONIA
What is expressive aphasia?
What area is affected?
Inability to express verbally.
Broca's Area
What is receptive aphasia?
What area is affected?
Cannot understand what's said to them.
Frontal Lobe, left side
What area is affected global aphasia?
Frontal area where all 12 Cranial nerves pass through.
What is DYSARRTHRIA?
difficulty articulating
What is DYSPHONIA?
speaking softly
What are the three layers of the SKIN?
1. Epidermis
2. Dermal Layer
3. Subcutaneous Layer
What layer of skin is sensitive to pain and pressure?
Dermal layer
Which is the thinnest layer of skin?
Epidermis
What layer of skin contains sweat glands, hair follicles?
Dermal layer
What are the three skin glands?
Apocrine glands
Eccrine glands
Sebaceous glands
Where do you find apocrine glands? -3
Axilla, under breasts, pubic area
What glands secrete pheromones and odor?
apocrine glands
What are the most prevalent sweat glands?
eccrine glands
What two functions does sweat from eccrine glands perform?
regulate body temperature
secrete waste products
What do sebaceous glands secrete?
Sebum
What are the two functions of sebum?
keep hydrated,
inhibit bacterial growth
What do the sebaceous glands in the ear produce? Also, called what?
Cerumen
aka ear wax
What are the two types of hair?
Villous hair,
terminal hair
What is villous hair?
fine body hair that covers the whole body
What is terminal hair?
Where is it found?
Coarser hair.
Found on head, male face, pubic area.
What does no hair signify?
Hyperthyroidism
What does excessive hair mean?
Hypothyroidism
What are the four stages of wound healing?
1. Initial insult
2. Inflammatory response
3. Proliferation
4. Maturation
What is another name for the INITIAL INSULT stage of wound healing?
Hemostasis
What forms during the initial insult stage?
Scab
What two things form a scab?
platelets and collagen
How long is the INITIAL INSULT stage?
1 to 3 days
How long is the INFLAMMATORY RESPONSE stage?
3 to 4 days
What does fibrin do? During what stage?
Fibrin pulls the edges back together during the INFLAMMATORY RESPONSE stage
What causes redness during INFLAMMATORY RESPONSE? -4
HISTAMINE released by MAST CELLS, area DILATES from INCREASED BLOOD FLOW
What do NEUTROPHILS do during inflammatory response?
Phagocytosis of any debris left in wound
What new skin cell migrates up from subcutaneous toward the wound and lies across it to pull the wound together? (during INFLAMMATORY RESPONSE)
FIBROBLAST
What cell lays down a grid for collagen?
Fibroblast
What tissue causes epithelialization?
Collagen
What process does collagen perform during INFLAMMATORY RESPONSE causing bumps?
Epithelialization
During what stage is tissue replaced with collagen?
PROLIFERATION
During what stage is wound warm to touch?
INFLAMMATORY RESPONSE
During what stage does a scar form?
MATURATION
What are the three types of wound healing?
Primary, secondary and tertiary intention
What kind of wound is PRIMARY INTENTION? -2
scalpel cut with sutures
What kind of wound makes a wider thicker scar?
SECONDARY INTENTION
What kind of wound is TERTIARY INTENTION?
Open wound
What are the two kinds of WOUND COMPLICATIONS?
Dehinscence
Evisceration
What is dehiscence?
When wound edges come apart
What is it when tissue erupts out of a wound?
Evisceration
What are the signs of stage 1 DECUBITUS? -3
reddened, not blanchable for more than 1/2 hour
How deep is stage 2 DECUBITUS?
into dermal layer
How deep is stage 3 DECUBITUS?
thru subcutaneous layer
How deep is stage 4 DECUBITUS?
into muscle layer or even bone
What scale is used to assess DECUBITUS?
Braden scale
What cause does a round pressure ulcer signify?
pressure only
What cause does oval pressure ulcer signify?
friction & shear
What cause does irregular shaped pressure ulcer signify?
moisture
What do pressure ulcers need to be in order to heal? -3
Moist
Protected
Clean
What four things do patients with pressure ulcers need regarding nutrition?
Calories
Protein
Fluid
Carbohydrates
What eight things do we do to describe a bed sore?
Locate, ulcer stage, shape, measure, healing stage, COCA, debris (eschar)