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51 Cards in this Set
- Front
- Back
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assault
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threatening to harm |
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Battery
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hitting another
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Nurse practice law
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rules and regulations statues a nurse must follow
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nursing process
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patient goal directive - decision making framework used by all nurses. Guidline
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Steps in nursing process
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Assessment- physical Diagnosis - Nanda Planning - Setting goals Implementation - Actual interventions Evaluation - See if interventions are working |
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Critical Thinking
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Skillful reasoning and logical thought
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Documentation
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commutation tool account of care given financial to bill Ins for care done |
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working outside scope
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go in front of board-$250 min fine and can lose license
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Subjective
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Comes from pt or family - what they tell us |
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Objective
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Measurable physical signs
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DAR
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Data Action Response
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Soap and Soapier
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Subjective Objective Assessment Plan I- Implementation E-Evaluation R- Revision |
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Discharge planning
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Social Worker - hospice - home health- Starts at admission
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Focused Assessment
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Specific system - EXP - Nuero
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perrla
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pupils equal - round - reactive to light - and accomodation |
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Cant hear heart beat
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lean forward and to left
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Sterile
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Putting anything inside body do not need sterile supplies at home |
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UA Normal
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Color straw or yellow odor - slightly appearance - clear specific gravity 1.005 - 1.035 PH 4.5-8 Urine is acidic microorganism don't like acid |
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TURP Cath
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3 way = Alcock irrigation - o2 urine
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Purpose of 24 hr urine collection
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Looking at kidney function
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Sentinel Event
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HUGE causes severe harm or death to pt.- Should not happen
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root cause annalysis
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finding fundamental reasoning for error
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After cath removed when should we call dr
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If pt has not voided within 6 - 8 hours |
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pathogens
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microorganisms that cause infection in humans
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bacteria
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one-celled microorganisms found everywhere in body
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viruses
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not individual cells, rather they are tiny parasites that live w in the cell of host and reproduce there
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Protozoa
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are single celled animals that live in water |
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Fungi
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made up of one or more cells. exp - mold on bread - wild mushrooms present in environments they cause illness to humans tru cuts or cracks in skin |
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Hellminths
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parasite worms that can inhibit the digestive tract of humans
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NGT ph
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1-4
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NGT
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Always check placement before feeding - PH test - air bolis 10-20 cc- gastric residual - xray - feeding room temp.
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Clay color stool
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Gallbladder - liver issues
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constipation
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increase activity - fluids and fiber slowly
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vagal response
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dizzy - pallor - remove immediately take VS
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classification of wounds
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abrasion - laceration - puncture- pressure ulcer - penetrating - contusions
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Know decubitus stages
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1-4 - 1 red - 2 - blister broken skin - 3- partial thickest - 4 - full thickness clean from - clean to dirty |
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Infection
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Purulent - slough - red - hot - odor
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drainage of wound
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circle area put time date on it
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IV requires
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strict asepsis
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Intermittent Infusion
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IV used when needed - not constant flow - Hep lock devise used to stop flow |
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heat therapy
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25 - 30 minutes max
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Cold application
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Pain-- burning - mottled skin
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leucopenia
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too little wbc count
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what diagnose for low hemoglobin
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altered tissue perfussion
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therapy used instead of conventional
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alternative
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forms of massage
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Swedish - long stroke - reflexology - foot shiatsu - thumbs -- deep tissue - muscle |
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know former knowledge of disease Nanda
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Knowledge deficient
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Some knowledge Nanda
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Readiness for enhanced knowledge
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ISOTONIC
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- wont change blood cells 5% dextrose in water
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Hypotonic
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half strength saline over 10% thru central line 50%
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hypertonic
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5% dextrose in .45% sodium - sugar and salt
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