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153 Cards in this Set

  • Front
  • Back
Name the objectives of Healthy People 2020
Physical Activity, Nutrition, Tobacco Use, Alcohol and Substance Abuse, Sexual and Reproductive Health, Mental Health, Injury and Violence Prevention, Occupational Safety and Health, Enviromental Health, Oral Health, Emerging Issues, Preventive Services
Define Health
A state of complete Physical, Mental, and Social well being
A systemic method of collecting data about a client for the purpose of determining the clients health, predicting risks, and identifying health-promoting activities
Health Assessment
This enables a nurse to clarify points, and obtain missing info while still watching for verbal and nonverbal cues.
Focused Interview
Information that the client experiences and communicates to the nurse. Includes perceptions of nausea, dizziness, or itching sensations
Subjective data
A legal document used to plan care or to communicate information between and among health care providers
Client Record
What does SOAP stand for
S-Subjective data
O-Objective data
A-Assessment
P-Planning
What does APIE
A-Assessment
P-Problem
I-Intervention
E-Evaluation
Refers to the exchange of information, feelings, or ideas
Communication
Considering more than just the physiological health of a patient and incorporating all aspects of the patient
Holism
A hands on Examination of the client that includes a general survey and examination of body systems
Physical Assessment
Data that can be measured by the professional nurse. This data can be known as overt data or signs
Objective Data
What are the different forms of Documentation
1. Narrative Notes
2.Problem Oriented Charting
3.Flow Sheets
4.Focus Documentation
5.Charting by Exception
6.Computer Documentation
How does The Developmental Level of patient affect the approach to care?
Different levels of intellectual ability decide how well a patient can give the appropriate information. This varies with age. In children parents are the primary information source.
What is the Nursing Process
The Nursing Process is a systematic, rational, and dynamic approach used to plan and provide care for a client
What are the stages of the Nursing Process
1.Assessment
2.Diagnosis
3.Planning
4.Implementation
5.Evaluation
True or False.

The Nursing Process is a ongoing and every evolving process of care for a client.
True.

Refer to page 12 in D'Amico to see figure
1st step of the nursing process where data is collected and organized. The data is both subjective and objective. This step begins the second a patient comes into contact with a client
Assessment
After data is collected, using knowledge both scientific and belonging to other disciplines a nurse formulates a judgement based on clustered and like information
Diagonsis
Priorities are set and client goals are stated. Interventions and strategies are dealt in order to provide the best health status for the patient
Planning
Implementation?
Step 4 of the Nursing Process where the plan designed in step 3 is put into action and a ongoing assessment continues to observe the client
What is Evaluation
The nurse compares the present client status to what achievement of the stated goals or outcomes. If necessary steps can be taken to re initiate the process if goals are not met.
Teaching used to explain a question or a procedure. Can be used to reduce anxiety.
Informal Teaching
These responses are designed to a need of a individual, group, or community
Formal Teaching
A state of life that personally satisfying and balanced
Wellness
What are the 3 Levels of prevention
Primary
Secondary
Tertiary
What is Primary Prevention?
Health promoting strategies that imply a high level of health should already exist

EX:Health education or immunizations
What is Secondary Prevention?
secondary prevention emphasises on resolving health issues and preventing serious consequences.

Ex: Health Screenings, Treatment of illness, and examinations across the lifespan
What is Tertiary Prevention?
Aimed at restoring the individual to the highest level of health

Ex: Rehabilitation services
Behavior that is motivated by the desire to increase well-being and actualize human potential
Health Promotion
Being mentally, emotionally, socially, and spiritually well
Psychosocial Health
What are the Internal Factors of psychosocial health
Genetics, Physical Health, and Physical Fitness
What are Genetics?
Genes that are passed down through parents to offspring. They affect can possibly affect the likelihood of a person inheriting a certain condition
What are the external factors of psychosocial health
Family, Culture, Geography, and Economic status
How do external factors effect psychosocial health?
These factors influence the morals and values a person has growing up and can for better or worse greatly affect a persons psychosocial well being
What is Self-Concept
The beliefs and feelings one holds about oneself.
An individuals capacity to identify and fulfill the social expectations related to the variety of roles assumed in a lifetime
Role Development
Relations in which the individual establishes bonds with others based on trust. They show mutual reliance and support among individuals
Interdependent Relationships
What are the physical signs of Stress?
Increased HR
Decreased Blood Clot Time
Increased RR and Depth
Dilated Pupils
Elevated glucose levels
Dilated Blood Vessels
Elevated BP
Increased BV
What is H.O.P.E
H-What helps during hard times
O-Organized Religion
P-Personal Spirituality
E-Effects on Care
Skill of observing the client in a deliberate and systematic manner. Begins when nurse meets the client
Inspection
Skill of assessing the client through the sense of touch to determine specific characteristics
Palpation
Vibratory tremors felt through the chest wall. Can be vocal, when client speaks, or during coughing. Best perceived using the base of the fingers.
Fremitus
Temperature is best felt on this part of the hand
Dorsal surface also known as the back of the hand
What are the 3 forms of palpation
Light
Moderate
Deep
What is Light Palpation
Use of finger pads of dominant hand. Used to assess skin texture, pulse, or tender inflamed areas near skin surface. Depth of only 1cm is reached in the formation of circles
What is Moderate Palpation
Used to assess structures. Moderate pressure using palmar surface of fingers on dominant hand downward 1 to 2 cm rotating in circular motion
What is Deep Palpation
Used to palpate organs deep in cavity. Uses palmar surface of dominant hand while pushing down on dominant hands dorsal surface with palmar surface of non dominant hand to a level of 2 to 4cm
The striking or tapping of body producing a wave of sound
Precussion
What are the different forms of percussion
Direct
Blunt
Indirect
What is Direct Percussion
Tapping of the body with finger tips of dominant hand. Used to examine the thorax of infants and the sinuses of an adult.
What is Blunt percussion
The placing of the palm of non dominant hand flat against the body and striking non dominant dorsal surface with dominant hand in a closed fist.
What is Indirect Percussion
The most used form. The hyper extended middle finger of non dominant hand is placed over the area examined. Using dominant index finger to strike the top of the middle finger to cause a sound to be produced
What do the sounds made by percussion sound like
1.Typany- Loud/High pitched
2.Resonance- Loud/Low pitched
3.Hyperresonance- Loud/low long duration
4.Dullness-High pitched/short
5.Flatness- High/soft/very short
Where are the sounds normally heard when percussing
1.Tympany-Found over air filled organ
2. Resonance-Normal over lungs
3.Hyperresonance- Air trapped in lungs
4.Dullness- Heard over solid organs
5. Flatness- Solid tissue such as muscle or bone.
The skill of listening to the sounds of body. Done using a stethoscope
Auscultation
What is the normal Equipment used by a nurse and for what?
1.Stethoscope-Auscultation
2.Doppler-Auscultation when stethoscope is not enough
3.Opthalmoscope- Inspection of Inner eye
4.Otoscope- Used to inspect external ear
Information that hint to the possibility of a health problems
Cues
What are the major components of the General Survey
Physical Appearance, Mental Status, and Mobility
What are considered Vital Signs
Temperature
Pulse
Respiratory
Blood Pressure
Pain
What is normal Temperature
98.6 F or 37 C
What factors influence body temperature and how?
1.Age- Infants are higher. Core temp stabilizes with age
2.Diurnal Variations- Temp highest at 8 pm and lowest between 4-6AM
3.Exercise
4.Hormones
5.Stress
6.Illness
What are the routes for measuring temperature and where are they taken
1.Oral- Sublingual Pocket
2.Tympanic-Exernal ear canal
3.Rectal-anus towards umbilicus and 1cm in infants and 1.5 cm otherwise
4.Axillary-Central Axila
5. Temporal-Scan across forehead ending at temple
What are the different pulse points
1.Temple
2.Carotid
3.Brachial
4.Radial
5.Femoral
6.Popiteal
7.Posterior Tibial
8.Dorsalis Pedis
What factors effect pulse
1.Age-Infants and children higher till 16.
2.Gender- Males are slower
3.Exercise-Increase
4.Stress-Increases
5.Fever-Increases
6.Blood loss- Increases
7.Meds- Increase or Decrease
8.Position Changes-Decrease
The pressure of the blood as the ventricle contracts
Systolic Pressure
Pressure between ventricle contractions when heart is at rest
Diastolic Pressure
The saturation of oxygen on hemoglobin the body.
Oxygen saturation
This history includes a collection of data that tells the intensity, quality, pattern, and precipitating factors
Pain History
Observation and gathering of data while the client is performing common place or routine activities
Functional Assessment
What are some factors that influence pain
1.Age
2.Gender
3.Culture
4.Previous Experiences
What is the name for the pain receptors
Nociceptors
What is Transduction in the pain process
Stimuli trigger release of biochemical mediators. Ions cross cell membranes. Medications work to block the release of these mediators
What is Transmission in the pain process
Impulses from stimuli travel to the peripheral never fibers in the spine. The impulse travels up the spinothalamatic tract to the brain and thalamus. The signal then goes from the thalamus to the SSC where pain is processed
What is Perception in the pain process
Patient becomes conscious of the pain.
What is Modulation in the Pain Process
Brain sends a signal back down to the dorsal horn of the spinal cord. The fibers release various substances that reduce pain.
Acute pain
Pain that lasts less than 6 months and usually last only as long as the healing process takes
Chronic Pain
Pain that lasts longer than 6 months and interferes with daily functioning.
Cutaneous pain
Pain that originates from within the subcutaneous tissue
Deep Somatic Pain
Pain that arises from ligaments, bones, blood vessels, and nerves
Visceral Pain
Pain that results from the stimulation of pain reception in the abdominal cavity, cranium, and thorax. Appears as aching or feeling of pressure
Radiating Pain
Pain perceived as the source of pain that extends to nearby tissues.
Referred Pain
Pain felt in a part of the body that is considerably removed from the tissues causing the pain
Intractable Pain
Pain that is highly resistible to relief. Pain that from advanced malignancy normally
Neuropathic pain
Results from current or past damage to the peripheral or central nervous system. Does not need a stimulus for the pain to start.
The amount of pain stimulation the person requires to feel pain
Pain threshold
An excessive sensitivity to pain
Hyperalgesia
Pain Sensation
Considered to be the same as pain threshold
The ANS and the behavioral responses to pain
Pain Reaction
Pain Tolerance
Maximum amount and duration of pain that an individual is willing to endure.
What is included in a Pain Assessment
1.Onset
2.Duration
3.Characteristics
4.Aggravating Factors
5.Relief
6.Treatment
7.Impact of pain on life
8.Coping
9.Emotional Response
An exchange of information between individuals
Communication
The process of formulating a message for transmission to another person
Encoding
Actions that are used during the encoding/decoding process to obtain and disseminate information, develop relationships, and promoting understanding
Interactional Skills
Listening
Paying undivided attention to what the client says and does.
Attending
Giving full attention to verbal and nonverbal message.
Paraphrasing
Clarification, through the restating of basic messages
Used to encourage open communication. Most effective when starting an interaction or when trying to get the client to discuss specific health concerns
Leading
A very direct way of speaking with clients to obtain subjective data for decision making and planning care
Questioning
Repeating the clients verbal or nonverbal message for the clients benefit
Reflecting
The process of gathering the ideas, feelings, and themes that the client has discussed throughout the interview and restating through several general statements
Summarizing
What are the Barriers to Effective Client Interaction
1.False Reassurance
2.Interrupting or changing the subject
3.Passing Judgement
4.Cross Examination
5.Technical Terms
6.Sensitive Issues
what are the factors of the influence of culture on nurse-client interactions
1.Diversity
2.Body Language
3.Language Differences
Positive Regard
The ability to appreciate and respect another persons worth and dignity with a non judgmental attitude
Empathy
The capacity to respond to another s feelings and experiences as if they were your own
Genuineness
The ability to present oneself honestly and spontaneously. Down to earth and real.
Concreteness
Speaking to the client in specific terms rather than vague generalities
The best source of information for the health history assessment interview
Primary Source
Secondary Source
A person or record that provides additional information about a client
What are the phases of a Health Assessment Interview
1.Perinteraction
2.The Initial Interview
3.The Focused Interview
What happens in the Preinteraction phase of a Health Assessment
A nurse collects data from the medical record, previous health patterns, screening, and other information gained from professionals
What happens in the initial interview phase of a Health Assessment
This is planned meeting in which the nurse gathers information form the client directly. Data is gathered on every facet of the clients life.
What happens in the Focused Interview phase of Health Assessment
The focused interview is used to clarify previously obtained information and to update current information. It is also done to hone in on a specific health issues.
What is OLD CART
O-Onset
L-Location
D-Duration
C-Characteristics
A-Aggravating Factors
R-Relieving Factors
T-Treatment
What is ICE
I-Impact on ADL's
C-Coping Strategies
E-Emotional Response
What are the components of a Health History
1.Biographical Data
2.Present Health or Illness
3.Past History
4.Family History
5.Psychosocial History
6.Review of Body Systems
What does Biographical Data contain
Name, Adress, Age, DOB, Birthplace, Gender, Marital Status, Race, Ethnic Identity, Religion, Occupation, Health Insurance, Source of Information, Reliability
What does Present Health and Illness contain
Reason for care
Health beliefs and practices
Health Patterns
Medications, prescriptions,and OCD
What does Past History contain
Medical, surgical, hospitalization, outpatient care, childhood illnessess, immunizations, mental and emotional health, allergies, substance abuse
What does Family History contain
Immediate family
Extended family
Genogram
What does Psychosocial History contain
Occupational history
Education
Finances
Roles and relationships
Family
Social structure
Self-concept
What does Body Systems contain
Skin, Hair, Nails
Head, Neck, Lymph
Eyes
Ears, Nose, Mouth, Throat
Respiratory, Breasts, Axillary
Cardiovascular
Peripheral Vascular
Abdomen
Urinary
Male/Female Repo
Neuro
Muscloskeletal
What are the 3 phases of decision making
1.Identify the problem
2.Determine the alternatives
3.Select the most appropriate alternative
What are the 11 Functional Health Patterns
Health Perception, Activity, Metabolism, Elimination, Sleep, Cognition, Self-Concept, Role-Relationships, Coping, Sexual Activity, Values/Beleifs
What is the Clinical health Model
Health Model that interprets health as the absence of disease or injury, therefore a person is sick if they have any illness no matter how small
What is the Host-Agent-Environment Model
A model that helps identifying the cause of a illness and depends on the interaction between the host, agent, and the environment these exist in
What is the Health Belief Model
This model show that a relation exists between a person beliefs and their actions. If a person believes they are sick they will be and vice versa.
What is the High-Level Wellness Model
This model recognizes health as an ongoing process towards a persons highest potential of functioning
What is the Holistic Health Model
This model acknowledges the interaction between mind, body, and spirit.
First knowing then caring for oneself
Self-Awareness
What does it mean to make informed choices
This means being an active participant in ones life and actively benefiting ones self-concept
What is disease?
A state of disharmony of the mind, body, and spirit.
A product of the disharmonious interaction among mind, body, emotions, and spirit
Illness
The balance of the body
Homeostatsis
Normal Body Temps for Infant, Children, Adults, and Elderly
Infant-99.4-99.7
Children-98.0-98.6
Adult-97-99
Elderly-95-99
Normal Pulse for Infant, Children, Adults, and Elderly
Infant-80-160
Children75-100
Adult-60-100
Elderly-60-100
Normal RR for Infant, Children, Adults, and Elderly
Infant-30-60
Children-18-30
Adults-12-20
Elderly-12-20
Normal BP for Infant, Children, Adults, and Elderly
Infant-74-100/50-70
Children-84-120/54-80
Adult-90-120/60-80
Elderly-90-120/60-80
The difference between the apical pulse and the peripheral pulses
Pulse Deficit
The amount of air that moves in and out of the lungs every breath
Tidal Volume
A pulse rate above 100

A pulse rate below 60
Tachycardia

Bradycardia
RR above 20

RR below 12
Tachypnea

Bradypnea
The absence of respirations

A normal respiratory rhythm and depth

Difficulty breathing
Apnea

Eupnea

Dyspnea
The mathematical differences between the Systolic and Diastolic pressures
Pulse Pressure
An exaggerated decrease in systolic blood pressure with inspiration
paradoxical blood pressure
Sound made when blood flow returns which can be heard with a stethoscope during the measurement of blood pressure
Korotkoff sounds
The absence of kortokoff sounds between phases 1 and 2.
Auscultatory Gap
A condition which blood pressure is chronically elevated above the normal measurements
Hypertension which is above 140/90
Prehypertension
A blood pressure that is between 120/80 and 139/89 mm HG
A blood pressure that is below 100/60
Hypotension
Inadequate reflex compensation upon position change that cause a imbalance in cerebral perfusion
Orthostatic Hypotension
Lifespan considerations for vitals for Newborn/Infants and Toddlers and preschoolers
Newborn/Infants- RR, BP, and pulse fluctuate rapidly due to immature mechanisms

Toddlers/Preschoolers-Vitals begin to stabilize. Monitoring becomes more of a concern that stabilizing
Life Span Considerations for vitals in School-Age/Adolescent and Adult/Older Adults
School-Age/Adolescent-High variability in vitals as RR,BP, and pulse decrease.

Adult/Older Adult- Stable Vitals, disease prevention becomes more of worry than maintaining proper vitals.