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