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198 Cards in this Set
- Front
- Back
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Intimate distance
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6 - 18 in
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Personal distance
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1.5 - 4 ft
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Social distance
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4 - 12 ft
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Public distance
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more than 12 ft
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Techniques for encouraging conversation
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Using broad opening statements
Using general leads Reflecting or repeating Giving recognition Restating or paraphrasing |
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Techniques to help express thoughts or feelings
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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 |
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Insuring mutual understanding
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Clarifying
Verbalizing implied thoughts or feelings Validating |
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Soler
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sit squarely facing the client
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sOler
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observe an open posture
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soLer
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lean forward toward client
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solEr
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establish eye contact
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soleR
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relax
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Non-therapeutic communication techniques
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Asking personal questions
Giving opinions or advice Changing subject Automatic responses False reassurance Sympathy Asking for explanations Approval or disapproval Defensive responses Passive or aggressive responses Arguing Stereotyping Probing and challenging Socializing Intellectualizing Blaming Overlooking Minimizing Patronizing |
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The nursing process
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Assessment
Diagnosis Planning Implementation/intervention Evaluation |
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Nursing diagnosis
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statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat
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Goals (NOC)
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indicate anticipated client behavior or responses from nursing care
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Expected outcomes (NOC)
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step by step objectives that help accomplish the goal and the resolution of the etiology for the nursing diagnosis
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Writing expected outcomes
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Who?
What actions? Under what circumstances? How well? When? |
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Nursing interventions (NIC)
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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
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Evaluation
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measures the client's response to nursing actions and the client's progress toward achieving goals
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Correcting documentation mistakes
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Draw a single line through it
Initials Date Error |
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Normal temperature
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98.6 F or 36 C
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Temperature after eating or drinking
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take 15 minutes after drinking hot/iced drinks
take 2 minutes after smoking |
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Rectal temperature
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1 degree higher than oral temp
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Axillary temperature
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1 degree lower than oral temp
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Normal pulse range
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60 - 100 bpm
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Taking pulses
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Start count with 0
30 seconds if pulse is regular 60 seconds if pulse is irregular ***Compare sides*** |
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Normal respiration range
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12 - 20 bpm
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Nomal BP
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< 120/80
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Pre-hypertension
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120 - 139/80 - 89
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Stage 1 hypertension
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140 - 159/90 - 99
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Stage 2 hypertension
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> 160/100
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BP sounds
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first and fifth Korotkoff sounds
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4+ pulse
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strong, bounding, cannot be obliterated
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3+ pulse
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full pulse, increased
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2+ pulse
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easily palpable, normal
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1+ pulse
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pulse diminished, barely palpable
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0 pulse
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absent, not palpable
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Apical pulse location
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Angle of Louis
5th intercostal space, midclavicular |
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Inspection
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always comes first
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Palpation
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Follows inspection
Fingertips - fine sensations Palm and sides of hand - vibrations Back of hand - temperature |
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Percussion
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Follows palpation
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Tympany
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Loud, high-pitched, moderate duration, drum-like quality
Air filled, intestinal, stomach |
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Resonance
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Moderate to loud, low-pitched, long duration, hollow quality
Lungs |
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Hyperresonance
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Very loud, very low-pitched, longer than resonance, booming quality
Normal in kids, not in adults Emphysematous lung |
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Dullness
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Soft to moderate, high-pitched, moderate length, thudlike quality
Liver, masses, spleen |
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Flatness
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Soft, high-pitched, short length, flat quality
Muscle, bone, tumor |
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Auscultate
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follows palpation
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Alert
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awake
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Lethargic or somber
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tired, slow
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Obtunded
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difficult to arouse
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Stupor, semi-coma
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can respond to pain
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Coma
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cannot be aroused by painful stimuli
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Oral fluids for I & Os
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anything that can become liquid at room temp
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1 mL
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1 cc
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1 oz
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30 mL
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1 tsp
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5 mL
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1 tablespoon
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15 ml
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1 pint
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500 mL
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1 quart
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1000 mL
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1 L
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1000 mL
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1 cup
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8 oz or 240 mL
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Insensible fluid loss
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fluid loss that is not measureable (i.e. respirations or sweating)
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Bathing procedure
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Distal to proximal
Long, firm strokes |
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Bathing sequence
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Eyes, face, ears, neck, arms, chest, abdomen, legs, feet, genitals, back of neck, butt, anus
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To maintain balance when lifting, bending, or moving
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Spine should be kept in vertical alignment
Feet positioned for a broad base of support Body weight close to the center of gravity |
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When lifting, bending, or moving we should
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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 |
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Principles of syncopal episodes
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Wide base of support
Center of gravity midline Strongest and longest muscles Reduce force or work |
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Bed to chair transfers
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Sit patient up and wait 2 minutes (in case of dizziness or nausea)
Knee and feet alignment Rocking Pivoting and support Ease client into chair |
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Inspection and palpation of the musculoskeletal system
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Size and contour of joints
Skin and tissues over joints ROM Muscle strength Gait |
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5 grade muscle strength
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full ROM against gravity, full resistance
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4 grade muscle strength
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full ROM against gravity, some resistance
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3 grade muscle strength
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full ROM with gravity
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2 grade muscle strength
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full ROM with gravity eliminated
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1 grade muscle strength
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slight contraction
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0 grade muscle strength
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no contraction
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Activity intolerance
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insufficient physiological or psychological energy to endure or complete required or desired daily activities
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Impaired physical mobility
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a limitation in independent purposeful physical movement of the body or of one or more extremities
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ABCD warning
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Asymmetry of shape
Border irregularity Color variation Diameter larger than 6 mm |
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Primary intention
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Skin edges are approximated or closed
Surgical wound |
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Secondary intention
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Loss of tissue, wound is left open until it becomes filled with scar tissue
Burn, pressure ulcer, severe lacteration |
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Serous drainage
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clear, watery plasma
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Purulent drainage
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Thick, yellow, green, tan, or brown
May smell |
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Serosanguineous
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pale, red, watery: mixture of clear and red fluid
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Sanguineous
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bright red: indicates active bleeding
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Pressure ulcer risk assessment
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Sensory perception
Peripheral circulation Motor function or mobility Neurological function Presence of moisture (incontinence) Friction or pressure on the skin Nutritional state Older adulthood |
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Stage 1 wound
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no break in skin, pink or pale, may be boggy or firm
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Stage 2 wound
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looks like a blister or abrasion, may go through epidermis and dermis
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Stage 3 wound
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may go through SQ layer (partial-thickness), will not go through to fascia
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Stage 4 wound
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may all the way through to the bone
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6 rights of medication administration
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Right medication
Right dose Right client Right route Right time Right documentation |
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Topical medications
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ALWAYS use gloves when applying
May have systemic effects |
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Normal head and neck findings in aging adults
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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 |
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Ectropion
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eversion of eyelid exposing conjunctiva
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Entropion
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inversion of eyelid
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Eyes and the aging adult
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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) |
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Ocular fundus inspection
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Right with right, left with left (hand to eye)
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Otalgia
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earaches
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Presbycusis
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hearing loss
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Right light reflex (ear)
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5:00
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Left light reflex (ear)
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7:00
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Straightening of ear canal in adults
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pull pinna up and back
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Straightening of ear canal in children
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pull pinna down and back
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Weber test
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bone conduction - should be heard equally laterally
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Rinne test
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air to bone conduction - AC > BC
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Mouth and nose in the aging adult
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Nose prominence
Teeth color changes Gum margins recede Buccal mucosa thinning |
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Abbreviation: D
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right
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Abbreviation: S
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left
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Abbreviation: U
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both
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Medication orders must contain
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Name of the patient
Date when order is written Medication name, dose, route, and time and frequency of administration Signature of the prescriber |
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Opthalamic medication
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Dominant hand on forehead
Drop medication into the conjunctiva |
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Opthalamic medication: systemic effects
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when administering medications that cause systemic effects, apply pressure to the lacrimal duct for 30 - 60 seconds
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Procedure for insulin mixture
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Inject air into the long-acting (cloudy) insulin
Inject air into the rapid-acting (clear) insulin Withdraw the clear insulin Withdraw the cloudy insulin |
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Intradermal injections
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15 degree angle
Tuberculin syringe |
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SQ injections
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0.5 - 1 mL
3/8 - 5/8 inch needle 25 - 27 gauge needle 45 degree angle |
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IM injections
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2 - 3 mL
1 - 1.5 inch needle 16 - 19 gauge needle 90 degree angle |
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Dorsogluteal landmarks
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Post. superior iliac spine, greater trochanter
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Ventrogluteal landmarks
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Anterosuperior iliac crest, greater trochanter
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Deltoid landmarks
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Acromion process, deltoid muscle (3 fingerbreadths below the acromion process)
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Vastus lateralis landmarks
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Lateral femoral condyle (1 handbreadth above), greater trochanter (1 handbreadth below)
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Mixing ampule and vial injections
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withdraw from the vial first, the ampule second
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Nail clubbing
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Angle is > 160 degrees
COPD |
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Crackles
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Fine: discontinous, soft, high-pitched, brief
Coarse: loud, low-pitched, bubbling and gurgling |
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Wheezes
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High-pitched: connected, musical squeaking, multiple notes
Low-pitched: single note, muscical snoring, moaning |
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Pleural friction rub
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coarse, low-pitched, grating quality
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Stridor
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high-pitched, inspiratory, louder in neck
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Nursing interventions for altered respiratory functioning
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Deep breathing and coughing
Pursed-lip breathing Diaphragmatic breathing |
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Nursing interventions for maintenance/promotion of lung expansion
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Positioning: semi-Fowler's
Chest tube placement |
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Incentive spirometer
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increases inspiratory reserve volume
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Nasal cannula
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Lowest concentration of oxygen
Skin breakdown may occur |
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Simple face mask
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highest concentration of oxygen
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Venturi face mask
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second highest concentration of oxygen
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Bronchial/tracheal sounds
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Heard over the trachea and larynx...only anteriorly
High-pitched, loud, inspiration < expiration, harsh, hollow tubular quality |
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Bronchovesicular sounds
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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 |
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Vesicular sounds
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Heard over the lung periphery
Low-pitched, soft, inspiration > expiration, rustling quality (like the sound of the wind in the trees) |
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Breast self-exam
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performed each month at the end of the menstrual cycle
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American Cancer Society BSE recommendations
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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 |
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Thoracentesis
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specimen of pleural fluid is taken
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Bronchoscopy
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visual examination of the bronchio/tracheal tube
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S1
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Mitral and tricuspid valve closure
Beginning of systole Heard strongest at the apex |
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S2
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Pulmonic and aortic valve closure
End of systole Heard strongest at the base |
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Preadolescent breast development (stage 1)
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only a small elevated nipple
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Breast bud stage (stage 2)
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a small mound of breast and nipple develops; the areola widens
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Stage 3 breast development
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the breast and areola enlarge; the nipple is flush with the breast surface
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Stage 4 breast development
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the areola and nipple form a secondary mound over the breast
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Mature breast (stage 5)
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only the nipple protrudes; the areola is flush with the breast contour
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Lungs in the aging adult
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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 |
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S3
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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 |
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Aging and the CV system
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Increase in BP
Left ventricular wall thickness increases Ability of the heart to increase cardiac output with exercise decreases Presence of arrhythmias |
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Carotid pulse
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auscultate before palpating
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JVP
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At 45 degrees jugular veins should not be visible
2 -3 cm from the sternal angle is normal |
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Biggest concern with blood clots
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injury to the vessel wall
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Edema
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big concern in patients with peripheral vascular disease
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4+ edema
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very deep pitting, indentation lasts a long time, leg is very swollen
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3+ edema
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deep pitting, indentation lasts a short time, leg looks swollen
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2+ edema
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moderate pitting, indentation subsides rapidly
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1+ edema
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mild pitting, slight indentation, no perceptible swelling of the leg
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Signs of venous insufficiency
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Normal or cyanotic color
Normal temperature Normal pulse Often marked edema Brown pigmentation around ankles |
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Signs of arterial insufficiency
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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 |
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Restraint selection
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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 |
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Psychological and spiritual symptoms of nearing death
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Fear
Nearing death awareness Withdrawal Increased focus on spiritual issues |
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Physical symptoms of nearing death
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Confusion, disorientation, delerium
Weakness and fatigue Drowsiness, sleeping, decreased responsiveness Decreased intake, swallowing reflex Surges of energy Restlessness/agitation Fever Bowel changes Incontinence |
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Universal symptoms of death
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Decreased urinary output
Cold and mottled extremities Vital sign changes Respiratory congestion Breathing pattern changes |
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Perioperative nursing
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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
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Pre-op physical assessment
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Physical examination: previous medical history, risk for surgery
Medical clearance: specialist |
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Pre-op psychological assessment
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Level of anxiety: may affect the amount of anethesia required
Coping ability: determine previous coping strategies Support system: family and friends available |
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Pre-op spiritual assessment
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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 |
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Pre-op teaching
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NPO
Discontinuing medications Deep breathing, incentive spirometer Exercises, turning, leg exercise Expectations Surgical procedure Pain control Lifestyle changes |
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Diagnostic surgery
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surgical exploration to assist in making a diagnosis or cause of a disorder
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Curative surgery
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performed to resolve a health problem by repairing or removing the cause
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Restorative surgery
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performed to improve a client's functional ability
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Palliative surgery
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reduces the intensity of the disease, but does not cure
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Cosmetic surgery
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performed to alter or enhance appearance
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Elective surgery
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performed on basis of client's choice; is not essential and may not be necessary for health
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Urgent surgery
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necessary for client's health, may prevent additional problems from developing; not necessarily an emergency
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Emergency surgery
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must be done immediately to save life or preserve function of body part
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Major surgery
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Procedure of greater risk
To improve health, restore function, or preserve life |
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Minor surgery
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Procedure without significant risk
Restores function or corrects deformities |
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Factors that increase risk of surgery
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Over 65 y/o
Medications: antihypertensives, trycyclic antidepressants, anticoagulants, NSAIDs |
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Nurses preoperative checklist
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Consents
Allergies Health and physical Assessment Anesthesia interview Lab results, EKG, chest X-ray Old chart (for anethesiologist) |
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Preoperative procedures
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Voided or catheter inserted
Shave/prep Jewelry, hairpins, metal removed TED hose applied as ordered Dentures, etc. removed IV started Pre-op meds given Mark site |
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Actual loss
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any loss of a person or object that can no longer be felt, heard, or experienced by the individual
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Percieved loss
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any loss that is uniquely defined by the grieving client
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Maturational loss
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any change in the development process that is normally expected during a lifetime
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Situational loss
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includes any sudden, unpredictable external event (i.e. paralysis)
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Grief
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the emotional response to a loss
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Bereavement
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includes grief and mourning
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Kubler-Ross's stages of dying
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Denial
Anger Bargaining Depression Acceptance |
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Bowlby's phases of mourning
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Numbing
Yearning and searching Disorganization and despair Reorganization |
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Worden's four tasks of mourning
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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 |
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Anticipatory grief
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grief before loss
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Normal grief
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normal feelings, behaviors, and reactions to loss
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Complicated grief
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Chronic grief, delayed grief, exaggerated grief (suicide), masked grief
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Disenfranchised grief
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when loss cannot be openly acknowledged or socially sanctioned or publicly shared
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Dysfunctional grief
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prolonged emotional instability, withdrawal from usual tasks of activities, lack of progression to successful coping
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Stage 1 of grief
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Notification and shock
Share acknowledge of the reality of the loss by assessing the loss, recognizing the loss |
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Stage 2 of grief
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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 |
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Stage 3 of grief
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Reintegration
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 |
