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198 Cards in this Set

  • Front
  • Back
Intimate distance
6 - 18 in
Personal distance
1.5 - 4 ft
Social distance
4 - 12 ft
Public distance
more than 12 ft
Techniques for encouraging conversation
Using broad opening statements

Using general leads

Reflecting or repeating

Giving recognition

Restating or paraphrasing
Techniques to help express thoughts or feelings
Shared observations

Acknowledging the client's feelings

Selective reflecting

Use of silence

Giving information

Placing an event in time or sequence

Encouraging a formulation of a plan of action
Insuring mutual understanding

Verbalizing implied thoughts or feelings

sit squarely facing the client
observe an open posture
lean forward toward client
establish eye contact
Non-therapeutic communication techniques
Asking personal questions

Giving opinions or advice

Changing subject

Automatic responses

False reassurance


Asking for explanations

Approval or disapproval

Defensive responses

Passive or aggressive responses



Probing and challenging






The nursing process




Nursing diagnosis
statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat
Goals (NOC)
indicate anticipated client behavior or responses from nursing care
Expected outcomes (NOC)
step by step objectives that help accomplish the goal and the resolution of the etiology for the nursing diagnosis
Writing expected outcomes

What actions?

Under what circumstances?

How well?

Nursing interventions (NIC)
autonomous actions based on scientific rationale that is expected to benefit the client in a predicted way related to the nursing diagnosis and client-centered goals
measures the client's response to nursing actions and the client's progress toward achieving goals
Correcting documentation mistakes
Draw a single line through it



Normal temperature
98.6 F or 36 C
Temperature after eating or drinking
take 15 minutes after drinking hot/iced drinks

take 2 minutes after smoking
Rectal temperature
1 degree higher than oral temp
Axillary temperature
1 degree lower than oral temp
Normal pulse range
60 - 100 bpm
Taking pulses
Start count with 0

30 seconds if pulse is regular

60 seconds if pulse is irregular

***Compare sides***
Normal respiration range
12 - 20 bpm
Nomal BP
< 120/80
120 - 139/80 - 89
Stage 1 hypertension
140 - 159/90 - 99
Stage 2 hypertension
> 160/100
BP sounds
first and fifth Korotkoff sounds
4+ pulse
strong, bounding, cannot be obliterated
3+ pulse
full pulse, increased
2+ pulse
easily palpable, normal
1+ pulse
pulse diminished, barely palpable
0 pulse
absent, not palpable
Apical pulse location
Angle of Louis

5th intercostal space, midclavicular
always comes first
Follows inspection

Fingertips - fine sensations

Palm and sides of hand - vibrations

Back of hand - temperature
Follows palpation
Loud, high-pitched, moderate duration, drum-like quality

Air filled, intestinal, stomach
Moderate to loud, low-pitched, long duration, hollow quality

Very loud, very low-pitched, longer than resonance, booming quality

Normal in kids, not in adults

Emphysematous lung
Soft to moderate, high-pitched, moderate length, thudlike quality

Liver, masses, spleen
Soft, high-pitched, short length, flat quality

Muscle, bone, tumor
follows palpation
Lethargic or somber
tired, slow
difficult to arouse
Stupor, semi-coma
can respond to pain
cannot be aroused by painful stimuli
Oral fluids for I & Os
anything that can become liquid at room temp
1 mL
1 cc
1 oz
30 mL
1 tsp
5 mL
1 tablespoon
15 ml
1 pint
500 mL
1 quart
1000 mL
1 L
1000 mL
1 cup
8 oz or 240 mL
Insensible fluid loss
fluid loss that is not measureable (i.e. respirations or sweating)
Bathing procedure
Distal to proximal

Long, firm strokes
Bathing sequence
Eyes, face, ears, neck, arms, chest, abdomen, legs, feet, genitals, back of neck, butt, anus
To maintain balance when lifting, bending, or moving
Spine should be kept in vertical alignment

Feet positioned for a broad base of support

Body weight close to the center of gravity
When lifting, bending, or moving we should
Assess the weight of the object to be lifted

Face the direction of movement

Use major muscles of thighs and arms (strongest and longest muscles)

Reduce friction

Reduce force of work
Principles of syncopal episodes
Wide base of support

Center of gravity midline

Strongest and longest muscles

Reduce force or work
Bed to chair transfers
Sit patient up and wait 2 minutes (in case of dizziness or nausea)

Knee and feet alignment


Pivoting and support

Ease client into chair
Inspection and palpation of the musculoskeletal system
Size and contour of joints

Skin and tissues over joints


Muscle strength

5 grade muscle strength
full ROM against gravity, full resistance
4 grade muscle strength
full ROM against gravity, some resistance
3 grade muscle strength
full ROM with gravity
2 grade muscle strength
full ROM with gravity eliminated
1 grade muscle strength
slight contraction
0 grade muscle strength
no contraction
Activity intolerance
insufficient physiological or psychological energy to endure or complete required or desired daily activities
Impaired physical mobility
a limitation in independent purposeful physical movement of the body or of one or more extremities
ABCD warning
Asymmetry of shape

Border irregularity

Color variation

Diameter larger than 6 mm
Primary intention
Skin edges are approximated or closed

Surgical wound
Secondary intention
Loss of tissue, wound is left open until it becomes filled with scar tissue

Burn, pressure ulcer, severe lacteration
Serous drainage
clear, watery plasma
Purulent drainage
Thick, yellow, green, tan, or brown

May smell
pale, red, watery: mixture of clear and red fluid
bright red: indicates active bleeding
Pressure ulcer risk assessment
Sensory perception

Peripheral circulation

Motor function or mobility

Neurological function

Presence of moisture (incontinence)

Friction or pressure on the skin

Nutritional state

Older adulthood
Stage 1 wound
no break in skin, pink or pale, may be boggy or firm
Stage 2 wound
looks like a blister or abrasion, may go through epidermis and dermis
Stage 3 wound
may go through SQ layer (partial-thickness), will not go through to fascia
Stage 4 wound
may all the way through to the bone
6 rights of medication administration
Right medication

Right dose

Right client

Right route

Right time

Right documentation
Topical medications
ALWAYS use gloves when applying

May have systemic effects
Normal head and neck findings in aging adults
Facial bones and orbit are more prominent

Facial skin is thin, less fat and turgor

Temporal arteries are more prominent

Senile tremors may be present

Neck has less fat

Submandibular glands are more prominent and prolapsed
eversion of eyelid exposing conjunctiva
inversion of eyelid
Eyes and the aging adult
Involution of lacrimal glands

Lipid material may infiltrate the limbus

Pupil size decreases

Lenses lose elasticity

Visual functioning decrease - presbyopia (inability to see close-up)
Ocular fundus inspection
Right with right, left with left (hand to eye)
hearing loss
Right light reflex (ear)
Left light reflex (ear)
Straightening of ear canal in adults
pull pinna up and back
Straightening of ear canal in children
pull pinna down and back
Weber test
bone conduction - should be heard equally laterally
Rinne test
air to bone conduction - AC > BC
Mouth and nose in the aging adult
Nose prominence

Teeth color changes

Gum margins recede

Buccal mucosa thinning
Abbreviation: D
Abbreviation: S
Abbreviation: U
Medication orders must contain
Name of the patient

Date when order is written

Medication name, dose, route, and time and frequency of administration

Signature of the prescriber
Opthalamic medication
Dominant hand on forehead

Drop medication into the conjunctiva
Opthalamic medication: systemic effects
when administering medications that cause systemic effects, apply pressure to the lacrimal duct for 30 - 60 seconds
Procedure for insulin mixture
Inject air into the long-acting (cloudy) insulin

Inject air into the rapid-acting (clear) insulin

Withdraw the clear insulin

Withdraw the cloudy insulin
Intradermal injections
15 degree angle

Tuberculin syringe
SQ injections
0.5 - 1 mL

3/8 - 5/8 inch needle

25 - 27 gauge needle

45 degree angle
IM injections
2 - 3 mL

1 - 1.5 inch needle

16 - 19 gauge needle

90 degree angle
Dorsogluteal landmarks
Post. superior iliac spine, greater trochanter
Ventrogluteal landmarks
Anterosuperior iliac crest, greater trochanter
Deltoid landmarks
Acromion process, deltoid muscle (3 fingerbreadths below the acromion process)
Vastus lateralis landmarks
Lateral femoral condyle (1 handbreadth above), greater trochanter (1 handbreadth below)
Mixing ampule and vial injections
withdraw from the vial first, the ampule second
Nail clubbing
Angle is > 160 degrees

Fine: discontinous, soft, high-pitched, brief

Coarse: loud, low-pitched, bubbling and gurgling
High-pitched: connected, musical squeaking, multiple notes

Low-pitched: single note, muscical snoring, moaning
Pleural friction rub
coarse, low-pitched, grating quality
high-pitched, inspiratory, louder in neck
Nursing interventions for altered respiratory functioning
Deep breathing and coughing

Pursed-lip breathing

Diaphragmatic breathing
Nursing interventions for maintenance/promotion of lung expansion
Positioning: semi-Fowler's

Chest tube placement
Incentive spirometer
increases inspiratory reserve volume
Nasal cannula
Lowest concentration of oxygen

Skin breakdown may occur
Simple face mask
highest concentration of oxygen
Venturi face mask
second highest concentration of oxygen
Bronchial/tracheal sounds
Heard over the trachea and larynx...only anteriorly

High-pitched, loud, inspiration < expiration, harsh, hollow tubular quality
Bronchovesicular sounds
Anteriorly heard around the sternum in the 1st and 2nd intercostal spaces, posteriorly heard between the scapulae

Moderate pitch and amplitude, inspiration = expiration, mixed quality
Vesicular sounds
Heard over the lung periphery

Low-pitched, soft, inspiration > expiration, rustling quality (like the sound of the wind in the trees)
Breast self-exam
performed each month at the end of the menstrual cycle
American Cancer Society BSE recommendations
Pads of three middle fingers with dime-sized circular motions of the finger pads

3 levels of pressure

Vertical strip pattern

Move from underarm to the middle of the sternum

Lying down
specimen of pleural fluid is taken
visual examination of the bronchio/tracheal tube
Mitral and tricuspid valve closure

Beginning of systole

Heard strongest at the apex
Pulmonic and aortic valve closure

End of systole

Heard strongest at the base
Preadolescent breast development (stage 1)
only a small elevated nipple
Breast bud stage (stage 2)
a small mound of breast and nipple develops; the areola widens
Stage 3 breast development
the breast and areola enlarge; the nipple is flush with the breast surface
Stage 4 breast development
the areola and nipple form a secondary mound over the breast
Mature breast (stage 5)
only the nipple protrudes; the areola is flush with the breast contour
Lungs in the aging adult
The lung is a more rigid structure that is harder to inflate

Decreased vital capacity

Increased residual capacity

Gradual loss of intraalveolar septa and decresed number of alveoli result in less surface area for gas exchange to occur
Ventricular filling vibrations

Immediately following S2

Heard best at the apex and left lower sternal border

Use bell

Normal in kids and adults older than 40 years
Aging and the CV system
Increase in BP

Left ventricular wall thickness increases

Ability of the heart to increase cardiac output with exercise decreases

Presence of arrhythmias
Carotid pulse
auscultate before palpating
At 45 degrees jugular veins should not be visible

2 -3 cm from the sternal angle is normal
Biggest concern with blood clots
injury to the vessel wall
big concern in patients with peripheral vascular disease
4+ edema
very deep pitting, indentation lasts a long time, leg is very swollen
3+ edema
deep pitting, indentation lasts a short time, leg looks swollen
2+ edema
moderate pitting, indentation subsides rapidly
1+ edema
mild pitting, slight indentation, no perceptible swelling of the leg
Signs of venous insufficiency
Normal or cyanotic color

Normal temperature

Normal pulse

Often marked edema

Brown pigmentation around ankles
Signs of arterial insufficiency
Pale, worsened with elevation, dusky red when lowered

Cool temperature

Decreased of absent pulse

Absent or mild edema

Thin, shiny skin; decreased hair growth; thickened nails
Restraint selection
Restrict movement as little as possible

Does not interfere with treatment

Readily changeable

Safe for the client

Least obvious to others

Renew order q24 hours
Psychological and spiritual symptoms of nearing death

Nearing death awareness


Increased focus on spiritual issues
Physical symptoms of nearing death
Confusion, disorientation, delerium

Weakness and fatigue

Drowsiness, sleeping, decreased responsiveness

Decreased intake, swallowing reflex

Surges of energy



Bowel changes

Universal symptoms of death
Decreased urinary output

Cold and mottled extremities

Vital sign changes

Respiratory congestion

Breathing pattern changes
Perioperative nursing
a specialized area of practice that describes the provision of care for the surgical client from the preoperative, intraoperative, and postoperative phases of the surgical experience
Pre-op physical assessment
Physical examination: previous medical history, risk for surgery

Medical clearance: specialist
Pre-op psychological assessment
Level of anxiety: may affect the amount of anethesia required

Coping ability: determine previous coping strategies

Support system: family and friends available
Pre-op spiritual assessment
Determine client's beliefs

Determine client's source of hope and strength

Determine client's religious practices

Determine client's percieved relation between spiritual belief and health
Pre-op teaching

Discontinuing medications

Deep breathing, incentive spirometer

Exercises, turning, leg exercise


Surgical procedure

Pain control

Lifestyle changes
Diagnostic surgery
surgical exploration to assist in making a diagnosis or cause of a disorder
Curative surgery
performed to resolve a health problem by repairing or removing the cause
Restorative surgery
performed to improve a client's functional ability
Palliative surgery
reduces the intensity of the disease, but does not cure
Cosmetic surgery
performed to alter or enhance appearance
Elective surgery
performed on basis of client's choice; is not essential and may not be necessary for health
Urgent surgery
necessary for client's health, may prevent additional problems from developing; not necessarily an emergency
Emergency surgery
must be done immediately to save life or preserve function of body part
Major surgery
Procedure of greater risk

To improve health, restore function, or preserve life
Minor surgery
Procedure without significant risk

Restores function or corrects deformities
Factors that increase risk of surgery
Over 65 y/o

Medications: antihypertensives, trycyclic antidepressants, anticoagulants, NSAIDs
Nurses preoperative checklist


Health and physical


Anesthesia interview

Lab results, EKG, chest X-ray

Old chart (for anethesiologist)
Preoperative procedures
Voided or catheter inserted


Jewelry, hairpins, metal removed

TED hose applied as ordered

Dentures, etc. removed

IV started

Pre-op meds given

Mark site
Actual loss
any loss of a person or object that can no longer be felt, heard, or experienced by the individual
Percieved loss
any loss that is uniquely defined by the grieving client
Maturational loss
any change in the development process that is normally expected during a lifetime
Situational loss
includes any sudden, unpredictable external event (i.e. paralysis)
the emotional response to a loss
includes grief and mourning
Kubler-Ross's stages of dying




Bowlby's phases of mourning

Yearning and searching

Disorganization and despair

Worden's four tasks of mourning
Accepting the reality of loss

Working through the pain of grief

Adjusting to the environment without the deceased

Emotionally relocating the deceased and moving on with life
Anticipatory grief
grief before loss
Normal grief
normal feelings, behaviors, and reactions to loss
Complicated grief
Chronic grief, delayed grief, exaggerated grief (suicide), masked grief
Disenfranchised grief
when loss cannot be openly acknowledged or socially sanctioned or publicly shared
Dysfunctional grief
prolonged emotional instability, withdrawal from usual tasks of activities, lack of progression to successful coping
Stage 1 of grief
Notification and shock

Share acknowledge of the reality of the loss by assessing the loss, recognizing the loss
Stage 2 of grief
Experience the loss emotionally and cognitively

Share in the process of working through the pain by reacting to, expressing, and experiencing the pain of seperation/grief
Stage 3 of grief

Reorganize and restructure family systems and relationships and reinvest in other relationships and life pursuits by adjusting to an environment without the deceased, relinquishing old attachments, forming new identity without deceased, adapting to new role while retaining memories