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189 Cards in this Set

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NURSING PROCESS
A SYSTEMATIC PROCESS THAT IS RATIONAL, CONTINUOUS, CYCLICAL AND DYNAMIC, GOAL-ORIENTED, CLIENT CENTERED AND INTERPERSONAL, COLLABORATIVE AND UNIVERSALLY APPLICABLE
FIVE STEPS OF THE NURSING PROCESS
ASSESSMENT, DIAGNOSIS OR ANALYSIS, PLAN, IMPLEMENT AND EVALUATE
ASSESSMENT PURPOSE
TO ESTABLISH A DATABASE ABOUT THE CLIENTS RESPONSE TO HEALTH CONCERNS OR ILLNESS AND THE ABILITY TO MANAGE HEALTH CARE NEEDS
HOW TO ESTABLISH A DATABASE
OBTAIN A NURSING HEALTH HISTORY CONDUCT A PHYSICAL ASSESSMENT REVIEW CLIENT RECORDS REVIEW NURSING LITERATURE CONSULT SUPPORT PERSONS
CONSULT HEALTH PROFESSIONALS
-UPDATE DATA AS NEEDED
-VALIDATE DATA
-COMMUNICATE/DOCUMENT DATA
PURPOSE OF DIAGNOSING
TO IDENTIFY CLIENT STRENGTH AND HEALTH PROBLEMS THAT CAN BE PREVENTED OR RESOLVED BY COLLABORATIVE AND INDEPENDENT NURSING INTERVENTIONS. TO DEVELOP A LIST OF NURSING DIAGNOSIS AND COLLABORATIVE PROBLEMS. INTERPRET AND ANALYZE DATA
STEPS TO INTERPRET AND ANALYZE DATA FOR DIAGNOSING
COMPARE DATA AGAINST STANDARDS
CLUSTER OR GROUP DATA (GENERATE TENTATIVE HYPOTHESIS)
IDENTIFY GAPS OR INCONSISTENCIES
DETERMINE CLIENTS STRENGTHS, RISKS, AND PROBLEMS
FORMULATE NURSING DIAGNOSIS AND COLLABORATIVE PROBLEM STATEMENTS
PURPOSE OF PLANNING
TO DEV ELOPE AN INDIVIDUALIZED CARE PLAN THAT SPECIFIES CLIENT GOALS/DESIRED OUTCOMES AND RELATED NURSING INTERVENTIONS
SET PRIORITIES AND GOAL/ OUTCOMES IN COLLABORATION WITH THE CLIENT
STEPS OF PLANNING
WRITE GOALS/ DESIRED OUTCOMES
SELECT NURSING STRATEGIES/ INTERVENTIONS
CONSULT OTHER HEALTH PROFESSIONALS
WRITE NURSING ORDERS AND NURSING CARE PLAN
COMMUNICATE CARE PLAN TO RELEVANT HEALTH CARE PROVIDERS
PURPOSE OF IMPLEMENTING
TO ASSIST THE CLIENT TO MEET DESIRED GOALS/OUTCOMES; PROMOTE WELLNESS; PREVENT ILLNESS AND DISEASE; RESTORE HEALTH; AND FACILITATE COPING WITH ALTERED FUNCTIONING
REASSESS THE CLIENT TO UPDATE DATABASE
STEPS OF IMPLEMENTING
DETERMINE NEED FOR NURSING ASSISTANCE
PERFORM OR DELEGATE PLANNED NURSING INTERVENTION
COMMUNICATE WHAT NURSING ACTIONS WERE IMPLEMENTED
DOCUMENT CARE AND CLIENT RESPONSE TO CARE
GIVE VERBAL REPORTS AS NECESSARY
PURPOSE OF EVALUATING
TO DETERMINE WHETHER TO CONTINUE, MODIFY, OR TERMINATE THE PLAN OF CARE
COLLABORATE WITH CLIENT AND COLLECT DATA RELATED TO DESIRED OUTCOMES
STEPS TO EVALUATING
JUDGE WHETHER GOALS/ OUTCOMES HAVE BEEN ACHIEVED
RELATE NURSING ACTIONS TO CLIENT OUTCOMES
MAKE DECISIONS ABOUT PROBLEM STATUS
REVIEW AND MODIFY THE CARE PLAN AS INDICATED OR TERMINATE NURSING CARE
STANDARDS OF CARE
AUTHORITATIVE STATEMENTS THAT DESCRIBE A COMMON OR ACCEPTABLE LEVEL OF CLIENT CARE OF PERFORMANCE. STANDARDS OF CARE DEFINE PROFESSIONAL PRACTICE.
ASSESSMENT
SYSTEMIC COLLECTION VERIFICATION, ORGANIZATION, INTERPRETATION AND DOCUMENTATION OF DATA TO ESTABLISH A DATABASE
TYPES OF ASSESSMENT
FOCUSED
ONGOING
COMPREHENSIVE
TYPES OF DATA
PRIMARY
SECONDARY
SUBJECTIVE
OBJECTIVE
HEALTH HISTORY
DIAGNOSIS OR ANALYSIS
ANALYSIS OR SYNTHESIS OF DATA TO IDENTIFY THE PT'S ACTUAL OR POTENTIAL NURSING DIAGNOSIS
DATA IS ANALYZED AND NURSING DX. IS IDENTIFIED
DIAGNOSTIC STATEMENTS ARE WRITTEN
NURSING DIAGNOSIS
FIRST ACTUAL NURSING DX. IS THE PROBLEM STATEMENT OR DIAGNOSING LABEL
THREE CATEGORIES OF NURSING DIAGNOSIS
ACTUAL
RISK
WELLNESS
PRIORITIES ACCORDING TO MASLOW'S HIERARCHY OF NEEDS
1. PHYSIOLOGICAL
2. SAFETY AND SECURITY
3. LOVE AND BELONGING
4. SELF ESTEEM
5. SELF ACTUALIZATION
COMPONENTS OF NURSING DX.
1. ACTUAL NURSING DX. OR PROBLEM STATEMENT
2. ETIOLOGY THAT IS R/T THE CAUSE OR CONTRIBUTOR
3. DEFINING CHARECTERISTICS OR S/S SUBJECTIVE DATA OR CLINICAL MANIFESTATION - DX. IS VALIDATED
PLANNING OR OUTCOME IDENTIFICATION INCLUDES:
1. GUIDELINES TO ESTABLISH A COURSE FOR NURSING ACTION TO RESOLVE NURSING DX
2. DEVELOPMENT OF A PLAN OF CARE
PURPOSE OF PLANNING
1. PRIORITIZE PROBLEMS OF DIAGNOSIS
2. ESTABLISH GOALS AND EXPECTED OUTCOMES
3. TO DEVELOP PLAN OF CARE THROUGH GOALS ACHIEVED FROM NURSING INTERVENTIONS
4. TO ESTABLISH OUTCOME CRITERIA USED TO EVALUATE IF GOALS ARE MET
5. TO DELEGATE NURSING ACTIVITIES TO APPROPRIATE HEALTH CARE TEAM MEMBERS
THREE PHASES OF NURSING CARE
1. INITIAL PLANNING
2. ONGOING PLANNING
3. DISCHARGE PLANNING
INITIAL PLANNING
DEVELOPMENT OF PRELIMINARY PLAN OF CARE
ONGOING PLANNING
CONTINUOUS UPDATING OF THE PLAN OF CARE
DISCHARGE PLANNING
PLANNING OF PT'S NEEDS AFTER DISCHARGE
WHERE DOES OUTCOME IDENTIFICATION COME FROM
GOALS AND EXPECTED OUTCOMES FOR EACH NURSING DIAGNOSIS
GOALS
BROAD STATEMENTS THAT DESCRIBE THE INTENDED OR DESIRED CHANGE IN THE CLIENTS CONDITION
EXPECTED OUTCOMES
IDENTIFIED AFTER GOALS ESTABLISHED
MORE SPECIFIC THAN GOALS
REALISTIC AND MEASURABLE
WHEN CAN NURSING INTERVENTIONS BE FORMULATED
AFTER GOALS AND EXPECTED OUTCOMES ARE ESTABLISHED
TYPES OF NURSING INTERVENTIONS
INDEPENDENT
INTERDEPENDENT
DEPENDENT
INDEPENDENT NURSING INTERVENTION
ACTIONS THAT NURSE INITIATES
INTERDEPENDENT NURSING INTERVENTIONS
ACTIONS THAT ARE IMPLEMENTED IN COLLABORATION WITH OTHER HEALTH CARE PROFESSIONALS
DEPENDENT NURSING INTERVENTIONS
ACTIONS THAT REQUIRE AND ORDER BY A PHYSICIAN OR ANOTHER HEALTH CARE PROFESSIONAL.
NURSING CARE PLAN
ORGANIZED FORMAL STATEMENTS OF STRATEGIES THAT WILL BE IMPLEMENTED AND IS WRITTEN IN A PLAN
PROTOCOL
A SERIES OF STANDING ORDERS OR PROCEDURES THAT SHOULD BE FOLLOWED UNDER CERTAIN CONDITIONS
NURSING PRACTICE ACT
A STATUTE THAT IS ENACTED BY THE LEGISLATURE OF A STATE AND OUTLINES THE SCOPE OF NURSING PRACTICE IN THAT STATE
AMERICAN NURSES ASSOCIATION (ANA)
HAS ESTABLISHED STANDARDS FOR NURSING PRACTICE AND EDUCATION TO IMPROVE THE QUALITY OF CARE
STANDARDS OF PRACTICE
MAY BE OUTLINED IN POLICY AND PROCEDURE MANUALS OF A FACILITY
IMPLEMENTING OR INTERVENING
INVOLVES THE EXECUTION OF THE NURSING CARE PLAN
REQUIREMENTS FOR IMPLEMENTATION
1. CONSTANT REASSESSMENT OF INTERVENTIONS TO SEE IF THEY ARE STILL NEEDED
2. ASSESSMENT OF CLIENT'S CONDITION BEFORE, AFTER, AND DURING Q INTERVENTION
3. DOCUMENT INTERVENTIONS AND RESPONSE
4. PROMOTE CONTINUITY OF CARE
DELEGATION
PROCESS OF TRANSFERRING SELECTED NURSING TASKS TO LICENSED PERSONNEL WHO ARE COMPETENT
EVALUATION
INVOLVES DETERMINING WHETHER THE CLIENT GOALS HAVE BEEN MET, PARTIALLY MET OR NOT MET
VARIABLES AFFECTING OUTCOMES
REASONS GOALS AREN'T MET
1. INITIAL ASSESSMENT INCOMPLETE
2. GOALS WEREN'T REALISTIC
3. TIME FRAME WAS INAPPROPRIATE
4. GOALS OR INTERVENTIONS WEREN'T APPROPRIATE
WHO DEFINITION OF HEALTH
A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL BEING, NOT MERELY THE ABSENCE DISEASE OR INFIRMITY
HEALTH/WELLNESS CONTINUUM
THE RELATIONSHIP THAT DEPICTS HEALTH AND ILLNESS AS EXTREME ELEMENTS AT THE OPPOSITE STATUS POINTS ON THE LINE
HIGH LEVEL WELLNESS (PER HL DUNN)
CONCEPT THAT IS RELATED TO FAMILY, COMMUNITY, ENVIRONMENT AND SOCIETY
FAMILY WELLNESS ENHANCES __________
INDIVIDUAL WELLNESS
COMMUNITY WELLNESS ENHANCES _________
FAMILY ENVIROMENT
SOCIETY WELLNESS ENHANCES _____________
COMMUNITY
HEALTH BELIEF MODEL (ROSENSTOCK AND MODIFIED BY BECKER)
ASSUMED THAT GOOD HEALTH IS AN OBJECTIVE COMMON TO ALL PEOPLE AND IS ACHIEVED ON PERCEPTIONS OF SUSCEPTIBILITY, SERIOUSNESS, AND THREAT
AGENT - HOST ENVIRONMENT MODEL (ECOLOGIC MODEL) -LEVELL AND CLARK
PREDICTING ILLNESS BASED ON RISK FACTORS THAT RESULT FROM THE INTERACTIONS OF AGENT, HOST AND ENVIRONMENT. THESE FACTORS INTERACT IF IN BALANCE THEN HEALTH IS MAINTAINED IF NOT DISEASE OCCURS
AGENT
ANY ENVIRONMENT FACTOR OR STRESSOR THAT BY ITS PRESENCE OR ABSENCE CAN LEAD TO DISEASE
HOST
PERSON WHO MAY OR MAY NOT BE AT RISK FOR ACQUIRING DISEASE
ENVIRONMENT
IS ALL FACTORS EXTERNAL TO THE HOST THAT MAY PREDISPOSE THE PERSON TO DISEASE
STRESS
STIMULUS BASED
DESCRIBE STRESS AS A DISRUPTION IN THE ENVIRONMENT OR WITHIN THE BODY
STRESS
LIFE CHANGE THEORY (HOLMES AND RAHE)
STRESS OF LIFE IS DEFINED BY TERMS OF UNITS OF LIFE CHANGE
STRESS
DAILY HASSLES THEORY (LAZARUS)
IS A TOOL TO MEASURE STRESS IN TERMS OF DAILY HASSLES RATHER THAN MAJOR LIFE EVENTS
STRESS
RESPONSE BASED (HANS SELYE)
DEFINED STRESS AS A NONSPECIFIC RESPONSE TO ANY DEMAND MADE ON THE BODY. THESE DEMANDS ARE LABELED STRESSORS: THEY CAN BE EXTERNAL OR INTERNAL.
THE PERCEPTION OF THE STRESSOR IS WHAT DETERMINES ________________________
THE EFFECT IS POSITIVE OR NEGATIVE
GENERAL ADAPTION SYNDROME (GAS)
BODY ATTEMPTS TO MAINTAIN HOMEOSTASIS OF STRUCTURAL AND CHEMICAL CHANGES IN RESPONSE TO STRESSORS.
3 STAGES OF GENERAL ADAPTATION SYNDROME
1. CRISIS OR ALARM STAGE
2. RESISTANCE OR ADAPTION STAGE
3. EXHAUSTION STAGE
CRISIS OR ALARM STAGE
CNS IS AROUSED AND PHYSIOLOGIC DEFENSE IS MOBILIZED- THE FIGHT OR FLIGHT RESPONSE
RESISTANCE OR ADAPTATION STAGE
THE FIGHT OR FLIGHT RESPONSE IS CARRIED OUT
EXHAUSTION STAGE
WHEN ATTEMPTS TO ADAPT ARE UNSUCCESSFUL. THE INDIVIDUALS ABILITY IS EXHAUSTED. DEATH MAY RESULT
STRESS
TRANSACTION BASED (LAZARUS AND FOLKMAN)
ACTIVATION OF THE STRESS RESPONSE DEPENDS UPON THE MEANING OF THE ENVIRONMENTAL CHANGES TAKING PLACE
3 STRESS CHARACTERISTICS
PHYSICAL
PSYCHOLOGICAL
SOCIAL
PHYSICAL STRESSORS
TRAUMA, SURGERY, OXYGEN DEPRIVATION, FATIGUE, INFECTIOUS PROCESS, PAIN, SLEEP DEPRIVATION
PSYCHOLOGICAL STRESSORS
ANTICIPATING SURGERY, PAIN, HELPLESSNESS, POWERLESSNESS, LONELINESS, REJECTION, JOB LOSS
SOCIAL STRESSORS
POLLUTANTS, URBANIZATION, RELOCATION, POVERTY, LOSS OF PRIVACY, FAMILY PROBLEMS, CHILD REARING
STRESS
PHYSICAL SX.
INCREASE PULSE AND B/P, RAPID SHALLOW BREATHING, DIZZINESS, HEADACHES, DILATED PUPILS, NAUSEA, ALTERED APPETITE, DIARRHEA OR CONSTIPATION, POLYURIA, TENSION AND TWITCHING
STRESS
PSYCHOLOGICAL SX.
ANXIETY, FEAR, ANGER, AGGRESSION,DEFENSIVE BEHAVIOR WITH IRRITABILITY, SADNESS, DEPRESSION, INCREASED SENSITIVITY
STRESS
COGNITIVE SX.
IMPAIRED MEMORY, CONFUSION, POOR DECISION MAKING, DELAYED RESPONSE TIME, ALTERED PERCEPTIONS, INABILITY TO CONCENTRATE
STRESS
BEHAVIOR SX.
PACING, SWEATY PALMS, RAPID SPEECH, INSOMNIA, W/D AND EXAGGERATED STARTLE REFLEX
STRESS
SPIRITUAL SX.
ALIENATION, SOCIAL ISOLATION, FEELINGS OF EMPTINESS
STRESS
ADAPTATION
CONTINUOUS PROCESS IN WHICH INDIVIDUALS USE VARIOUS RESPONSES TO ADJUST TO STRESS
STRESS
PHYSIOLOGICAL
BODY RESPONDS TO STRESS AFFECTING ITS FUNCTIONING.
MORE BLOOD CELLS INCREASED AIR TO LUNGS
STRESS
PSYCHOLOGICAL
USES DEFENSE SYSTEMS TO MENTALLY ACCEPT NEW SITUATIONS
THESES DEFENSE MECHANISMS MAY PROTECT INDIVIDUALS FOR A LIMITED PERIOD OF TIME BUT CAN BLOCK CHANGE AND GROWTH.
FOR HEALTH RESOLUTION OF STRESS THESE DEFENSE MECHANISMS NEED TO BE REPLACED BY EFFECTIVE COPING STRATEGIES
STRESS
REPRESSION
PREVENTING STRESSFUL THOUGHTS AND FEELINGS FROM ENTERING THE THE CONSCIOUS
STRESS
REACTION FORMATION
EXPRESSION OF A FEELING THAT IS THE OPPOSITE OF ONE'S REAL FEELING
STRESS
SUPPRESSION
AN ATTEMPT TO KEEP UNPLEASANT MATERIAL OUT OF CONSCIOUSNESS
STRESS
SUBLIMINATION
DISPLACEMENT OF ENERGY ASSOCIATED WITH MORE AGGRESSIVE DRIVES INTO SOCIALLY ACCEPTABLE ACTIVITIES
STRESS
DENIAL
AVOIDING THE THREAT OF A STRESSOR BY REINTERPRETING THE EVENT AS SOMETHING LESS THREATENING
STRESS
DISPLACEMENT
THE TRANSFERRING OR DISCHARGING OF EMOTIONAL REACTIONS FROM ONE OBJECT OR PERSON TO ANOTHER OBJECT OR PERSON
STRESS
REGRESSION
REVERTING TO LESS MATURE BEHAVIOR
STRESS
RATIONALIZATION
INTELLECTUAL EXPLANATION OR JUSTIFICATION OF IDEAS FEELINGS OR BEHAVIOR
STRESS
PROJECTION
ATTRIBUTION OF ONE'S OWN THOUGHTS, FEELINGS OT IMPULSES OF OTHERS
STRESS
UNDOING
AN ACTION OR WORDS DESIGNED TO CANCEL SOME DISAPPROVED THOUGHTS IMPULSES OR ACTS IN WHICH THE PERSON RELIEVES GUILT BY MAKING REPARATION
COPING WITH STRESS
COPING STRATEGY IS AN INNATE OR ACQUIRED WAY OF RESPONDING TO A CHANGING ENVIRONMENT OR SPECIFIC PROBLEM OR SITUATION
LAZARUS AND FOLKMAN DEFINE COPING AS
INDIVIDUALS ATTEMPTS TO MASTER CONDITIONS OF HARM THREAT OR CHALLENGE WHEN AN AUTOMATIC RESPONSE IS NOT IMMEDIATELY AVAILABLE
MODES OF COPING
EMOTION FOCUSED
PROBLEM FOCUSED
EMOTION-FOCUSED COPING
INCLUDES THOUGHTS AND AND ACTIONS THAT RELIEVE EMOTIONAL DISTRESS. DOESN'T IMPROVE THE SITUATION BUT THE PERSON FEELS BETTER
PROBLEM- FOCUSED COPING
EFFORTS TO IMPROVE A SITUATION BY MAKING CHANGES OR TAKING SOME ACTION.
(NEUTRALIZES STRESSOR)
ANXIETY
A STATE OF MENTAL UNEASINESS APPREHENSION DREAD OR FOREBODING, OR A FEELING OF HELPLESSNESS R/TAN IMPENDING OR ANTICIPATED UNIDENTIFIED THREAT TO SELF OR SIGNIFICANT RELATIONSHIPS. IT IS A SUBJECTIVE RESPONSE THAT OCCURS WHEN A PERSON EXPERIENCES A REAL OR PERCEIVED THREAT TO WELL BEING
MILD ANXIETY
INCREASED DEGREE OF ALERTNESS AND VIGILANCE, MOTIVATION, VITAL SIGNS,
OPTIMAL TIME FOR CLIENT TEACHING
MODERATE ANXIETY
SUBJECTIVE DISTRESS OR TENSION, DECREASED PERCEPTION AND ATTENTION
ALERT ONLY TO SPECIFIC INFORMATION
POSSIBLE TENDENCY TO COMPLAIN OR ARGUE
POSSIBLE HEADACHE, DIARRHEA, NAUSEA OR VOMITING
SEVERE ANXIETY
INCREASED SUBJECTIVE DISTRESS, FEELINGS OF IMPENDING DANGER, SELECTIVE ATTENTION, DISTORTED COMMUNICATION, FEELINGS OF FATIGUE
PANIC
MAJOR PERCEPTUAL DISTORTION
IMMOBILIZATION
INABILITY TO FUNCTION
FEELINGS OF TERROR
POSSIBLE HARM TO SELF AND OTHERS
HEALTH PROMOTION AND MAINTENANCE
THE MAINTENANCE OR IMPROVEMENT OF EXISTING SELF CARE BEHAVIORS
PRIMARY HEALTH PROMOTION
GENERALIZED HEALTH PROMOTION AND SPECIFIC PROTECTION AGAINST DISEASE
SECONDARY HEALTH PROMOTION
EARLY IDENTIFICATION OF HEALTH PROBLEMS AND PROMPT INTERVENTION TO ALLEVIATE HEALTH PROBLEMS
TERTIARY HEALTH MAINTENANCE
RESTORATION AND REHABILITATION TO AN OPTIMAL LEVEL OF FUNCTIONING
HEALTH PROMOTION AND ILLNESS PREVENTION
PRIMARY CARE AGENCIES
HEALTH PROMOTION, PREVENTIVE CARE, HEALTH EDUCATION, ENVIRONMENTAL PROTECTION, EARLY DETECTION AND TX.
EX: PUBLIC HEALTH, PHYSICIANS OFFICE, AMBULATORY CARE CENTER
ILLNESS PREVENTION
SECONDARY CARE AGENCIES
DEDICATED TO DX. AND TX OF ILLNESS
EX. HOSPITALS, PHYSICIANS OFFICE, CLINICS
REHABILITATION
TERTIARY CARE
PROCESS OF RESTORING ILL OR INJURED PEOPLE TO OPTIMUM AND FUNCTIONAL LEVELS OF WELLNESS
EMPHASIZE IMPORTANCE OF ASSISTING CLIENTS TO FUNCTION ADEQUATELY IN PHYSICAL, MENTAL, SOCIAL, ECONOMIC, VOCATIONAL AREAS OF THEIR LIVES
EX: LTC, CARE OF THE DYING, REHABILITATION
medical asepsis- clean technique
hand washing, gloving, and gowning, and disinfecting help contain microbial growth and prevent spread of organisms from one place to another
STANDARD PRECAUTIONS
WASH HANDS, WEAR CLEAN GLOVES, MASK, EYE PROTECTION, COVER GOWN
TRANSMISSION BASED PRECAUTIONS
FOR HIGHLY TRANSMISSIBLE
AIRBORNE
MICROORGANISMS THAT CAN BE SUSPENDED IN AIR; NEGATIVE AIRFLOW ROOM
DROPLET
LARGER PARTICLES. WEAR MASK IF WITHIN THREE FEET OF CLIENT
CONTACT
HAND TO SKIN CONTACT
BACTERICIDAL
KILLS MICROORGANISMS
BACTERIOSTATIC
PREVENTS MULTIPLICATION OF BACTERIA
SURGICAL ASEPSIS
STERILE TECHNIQUE
EX: IV INSERTION, CATH, INJECTIONS, DRESSING CHANGES, IRRIGATION OF TUBES THAT ENTER STERILE PARTS OF BODY
FOR IMMUNE CAPABILITY: PRETERM BABY, BURN PT. , TRANSPLANT CLIENT, CHEMO, RADIATION, AIDS
STERILIZATION
STEAM OR AUTOCLAVE
GAS (ETHYLINE OXIDE) USED WHEN STEAM CANT BE BUT IS EXPENSIVE AND TAKES LONGER
STERILE FIELD
AREA FREE OF MICROORGANISMS, ANYTHING OUTSIDE OF VISUAL FIELD SHOULD BE CONSIDERED CONTAMINATED
CHAIN OF INFECTION
INFECTIOUS AGENT
RESERVOIR
PORTAL OF EXIT
TRANSMISSION
PORTAL OF ENTRY
SUSCEPTIBLE HOST
INFECTIOUS AGENT
BACTERIA, VIRUS, FUNGUS OR PARASITE
RESERVOIR
SOURCE OF ORGANISMS
PORTAL OF EXIT
MEANS BY WHICH THE MICROORGANISM LEAVES THE SOURCE
EX: SPUTUM, EMESIS, BLOOD, STOOL, URINE, WOUND DRAINAGE, GENITALIA SECRETIONS
MODES OF TRANSMISSION
AIRBORNE
CONTACT- MOST FREQUENT
DIRECT- ONE BODY SURFACE TO ANOTHER
INDIRECT- CONTAMINATED OBJECT (FOMITE)
VEHICLE TRANSMISSION- TRANSFER. OF INFECTION BY WAY OF CONTAMINATE ITEMS
DROPLET
MUCOUS MEMBRANES ARE EXPOSED TO COUGH, SNEEZE OR TALKING
VECTOR
ANIMAL OR INSECT THAT SERVES AS A INTERMEDIATE MEANS OF TRANSPORTING INFECTION
PORTAL OF ENTRY
MEANS BY WHICH THE MICROORGANISMS ENTER THE SOURCE
SUSCEPTIBLE HOST
ANY PERSON AT RISK FOR INFECTION
3 STAGES OF INFLAMMATORY RESPONSE
1. VASCULAR AND CELLULAR RESPONSE
2. EXUDATE PRODUCTION
3. REPARATIVE PHASE
5 STAGES OF INFLAMMATION
1. INITIAL INJURY-CAUSES RELEASE OF HISTAMINE, BRADYKININ, SEROTONIN, PROSTOGLANDINS, AND LYMPHOKINES. THEY ALL ACTIVATE THE INFLAMMATION PROCESS
2. INCREASED BLOOD FLOW TO THE INFLAMED AREA- ERETHMA CAUSES REDNESS AND WARMTH
3. INCREASED CAPILLARY PERMEABILITY- LEAKAGE OF PLASMA CAUSING FIBROGEN CLOTS TO BLOCK LYMPHATICS AND RESULTS INTO NON PITTING EDEMA
4. DAMAGED TISSUE IS ENGULFED BY LEUKOCYTES. THEY DIE AND CAUSE PUS
5. DESTROYED TISSUE IS REPLACED BY SIMILAR TISSUE TO PROMOTE HEALING OR SCAR TISSUE FORMS
SIGNS OF INFLAMMATION OR INFECTION
1. ERYTHEMA OR REDNESS FROM INCREASED BLOOD FLOW 2. HEAT FROM INCREASED BLOOD FLOW AND METABOLISM 3. PAIN FROM ^ PRESSURE ON PAIN SENSORS 4. EDEMA FROM ^ FLUID AND LEUKOCYTES 5. LOSS OF FUNCTION FROM PAIN AND EDEMA 6. PUS FROM WBC,DEAD CELLS, BACTERIA AND OTHER DEBRIS
SIGNS OF SYSTEMIC INFLAMMATION OR INFECTION
1. GENERAL MALAISE 2. FEVER COMMON BUT NOT ALWAYS PRESENT 3. MYALGIA AND ARTHRALGIA 4. NONSPECIFIC GI SX. 5. INCREASED WBC 6. CHILLS OR SWEATS
ANTIGENS
SUBSTANCE CAPABLE OF INDUCING FORMATION OF ANTIBODIES- FOREIGN PROTEINS IN THE BODY
ANTIBODIES
IMMUGLOBULIN
A PROTECTIVE PROTEIN SUBSTANCE PRODUCED IN THE BODY TO COUNTERACT ANTIGENS
IMMUNITY
SPECIFIC RESISTANCE OF THE BODY TO INFECTION
2 TYPES OF IMMUNITY
ACTIVE AND PASSIVE
ACTIVE IMMUNITY
HOST PRODUCES IT'S OWN ANTIBODIES IN RESPONSE TO NATURAL ANTIGENS (INFECTION) OR ARTIFICIAL INFECTIONS (VACCINES)
PASSIVE IMMUNITY
THE HOST RECEIVES NATURAL (NURSING MOTHER) OR ARTIFICIAL (INJECTION OF IMMUNE SERUM) ANTIBODIES PRODUCED BY ANOTHER SOURCE
ANTIBODY - MEDIATED DEFENSES
HUMORAL (CIRCULATING) IMMUNITY
RESIDES IN B LYMPHOCYTES AND MEDIATED BY ANTIBODIES PRODUCED BY B LYMPHOCYTES
STEPS OF MEDIATED DEFENSES
1. B CELLS ARE ACTIVATED AND RECOGNIZE A FOREIGN INVADER OR ANTIGEN
2. THEY THEN DIFFERENTIATE INTO PLASMA CELLS WHICH SECRETE ANTIBODIES
3. THE ANTIBODIES INITIATE A VARIETY OF ELIMINATION PROCESSES
4. Ig M, G, A , D, E
IgM SHOWS A CURRENT INFECTION
IgG INDICATES A PAST INFECTION
CELL MEDIATED DEFENSES
CELLULAR IMMUNITY THROUGH THE T CELL SYSTEM
STEPS OF CELL MEDIATED DEFENSES
1. WHEN EXPOSED THE LYMPHS RELEASE A LARGE # OF T CELLS BECAUSE OF THE RELEASE OF LYMPHOKINES THAT ATTRACT OTHER PHAGOCYTES AND LYMPHOCYTES
T CELLS ALSO STIMULATE THE PRODUCTION OF B CELLS
3 TYPES OF T CELLS
1. T HELPER CELL- HELP IN FUNCTION OF IMMUNE SYSTEM
2. CYTOTOXIC T CELLS- SUPPRESS THE HELPER AND CYTOTOXIC CELLS
3. T CELLS ALSO STIMULATE THE PRODUCTION OF B CELLS
STAGES OF INFECTIOUS PROCESS
1. INCUBATION PERIOD
2. PRODROMAL STAGE
3. ILLNESS
4. CONVALESCENT
INCUBATION PERIOD
INTERVAL OF TIME BETWEEN ENTRY OF AN INFECTIOUS AGENT INTO THE BODY AND ONSET OF SYMPTOMS
PRODROMAL STAGE
PERIOD OF TIME FROM ONSET OF NONSPECIFIC SX UNTIL SPECIFIC SYMPTOMS MANIFEST
ILLNESS
PERIOD OF TIME WHEN THE CLIENT IS MANIFESTING SPECIFIC S/S
CONVALESCENT
PERIOD OF TIME FROM THE BEGINNING OF DISAPPEARANCE OF ACUTE SX UNTIL THE CLIENT RETURNS TO THE PREVIOUS STATE OF HEALTH
WOUND HEALING PHASES
1.INFLAMMATION-LASTS APPROX 3 DAYS
2.REGENERATION-AFTER INFLAMMATION PHASE DAY 4-21
3.MATURATION-FROM 3 WEEKS TO 2 YEARS
WOUND HEALING TYPES
1. PRIMARY INTENTION
2. SECONDARY INTENTION
3. TERTIARY INTENTION
PRIMARY INTENTION
OCCURS IN MINIMAL TISSUE LOSS, GRANULATION TISSUE IS NOT VISIBLE AND SCARRING IS MINIMAL, RISK FOR INFECTION IS LOW
EX: CLEAN SURGICAL EXCISION EDGES APPROXIMATED OR LIGHTLY PULLED TOGETHER
SECONDARY INTENTION
OCCURS IN FULL THICKNESS TISSUE LOSS, OPEN WOUND GRADUALLY FILLS IN WITH GRANULATION TISSUE, SCARRING IS MORE PREVALENT
EX: BURNS DEEP LACERATIONS, EDGES ARE NOT APPROXIMATED
TERTIARY INTENTION
THERE IS A DELAY B/T THE INJURY AND WOUND CLOSURE OR DELAYED PRIMARY CLOSURE, WOUND IS PURPOSELY LEFT OPEN, DEEPER WIDER SCAR IS COMMON
EX: BAD TRAUMA OR INFECTIONS FROM SURGERY GANGRENOUS
PUSTULE
ELEVATED LESION CONTAINING PURULENT MATERIAL (ACNE)
VESICLE
ELEVATED SHARPLY DEFINED LESION CONTAINING SEROUS MATERIAL (BLISTER)
SEROUS
CLEAR AND WATERY DRAINAGE
SAGUIENEOUS
RED AND WATERY DRAINAGE
PURULENT
PUS THICK YELLOW, TAN , GREEN OR BROWN
DEHISCENCE
TOTAL OR PARTIAL DISRUPTION IN WOUND EDGES (WOUND SEPARATION)
EVISCERATION
PROTRUSION OF VISCERA THROUGH AN ABDOMINAL WOUND FISTULA
COMMUNICATION
NURSE MUST APPRECIATE HER OWN BACKGROUND AND AT THE SAME TIME ACKNOWLEDGE THE DIFFERENT PERSPECTIVE HELD BY THE CLIENT
METHODS OF COMMUNICATION
VERBAL AND NONVERBAL
VERBAL COMMUNICATION
SPEAKING/ LISTENING AND WRITING/ READING
NONVERBAL COMMUNICATION
BODY LANGUAGE, GESTURES, FACIAL EXPRESSIONS, POSTURE AND GAIT, TONE OF VOICE, EYE CONTACT, TOUCH, BODY POSITION
SIMPLICITY
USE OF WORDS COMMONLY UNDERSTOOD
BREVITY
ASPECT OF SIMPLICITY USING SHORT SENTENCES AND AVOIDING UNNECESSARY MATERIAL
CLARITY
SAYING EXACTLY WHAT IS MEANT
TIMING OF COMMUNICATION
MUST BE APPROPRIATE TO ENSURE WORDS ARE HEARD
RELEVANCE OF COMMUNICATION
MAKING SURE THE MESSAGES RELATE TO THE CLIENT
INTONATION OF THE VOICE
CAN EXPRESS HOW THE PERSON IS FEELING
ASPECTS OF THERAPEUTIC COMMUNICATION
OBTAIN OR PROVIDE INFO.
DEV ELOPE TRUST
SHOW CARING
EXPLORE FEELINGS
TECHNIQUES OF THERAPEUTIC COMMUNICATION
1. ATTENDING OR OFFERING SELF, IS MAKING ONESELF AVAILABLE TO LISTEN TO THE CLIENT
2. FOCUSING IS KEEPING THE COMMUNICATION FOCUSED ON THE TOPIC
3. CLARIFYING AND VALIDATION ARE USED WHEN THE NURSE IS NOT SURE OF THE MEANING OF A MESSAGE
4. REFLECTING IS REPEATING ALL OR PART OF A MESSAGE BACK TO THE SENDER
5. PARAPHRASING IS RESTATING THE MESSAGE IN THE RECEIVERS OWN WORDS
6. OPEN QUESTIONS ENCOURAGE THE CLIENT TO EXPRESS HIS OR HER OWN THOUGHTS AND FEELINGS
7. SUMMARIZING OR HIGHLIGHTING
8. SILENCE CAN BE A VALUABLE THERAPEUTIC TECHNIQUE
BARRIERS TO COMMUNICATION
CLOSED QUESTIONS, STEREOTYPING, FALSE REASSURANCE, GIVING ADVICE, CLICHES, JUDGMENTAL OR MORALISTIC RESPONSES, DEFENDING, A REQUEST FOR A EXPLANATION OF BEHAVIORS CAN BE INTIMIDATING, CHANGING SUBJECT ABRUPTLY
NURSE/CLIENT RELATIONSHIP
INTRODUCTORY OR ORIENTATION PHASE
NURSE INTRODUCES SELF AND SETS TONE FOR REST OF RELATIONSHIP
NURSE/ CLIENT RELATIONSHIP
WORKING PHASE
USED TO ACCOMPLISH GOAL OR OBJECTIVE DEFINED DURING INTRO. PERIOD
NURSE/ CLIENT RELATIONSHIP
TERMINATION PHASE
FINAL PHASE WHICH ENDS THE RELATIONSHIP
CHARACTERISTICS OF NURSE/ CLIENT RELATIONSHIP
RESPECT, GENUINENESS, EMPATHY
THERAPEUTIC COMMUNICATION KEY INGREDIENTS
EMPATHY, POSITIVE REGARD, COMFORTABLE SENSE OF SELF
SCHEDULE I CONTROLLED SUBSTANCE
HIGH ABUSE POTENTIAL
HEROIN, LSD, MARIJUANA
SCHEDULE II CONTROLLED SUBSTANCE
MEDICAL USE WITH HIGH POTENTIAL FOR ABUSE
AMPHETAMINES, CODEINE, MEMPRIDINE, METHADONE
SCHEDULE III CONTROLLED SUBSTANCE
MEDICAL USE WITH ABUSE POTENTIAL LESS THAN II'S
PROPOSYPHEN, SOME CODEINE
SCHEDULE IV CONTROLLED SUBSTANCE
MEDICAL USE WITH LIMITED RISK OF ABUSE
(BEZODIAZEPINES, NON NARCOTICS, PHENOBARBITAL)
SCHEDULE V CONTROLLED SUBSTANCE
MEDICAL USE WITH MINIMAL RISK OF ABUSE
OPIOID DIARRHEALS AND COUGH SYRUPS
NURSING GUIDELINES FOR CONTROLLED SUBSTANCES
1. DOUBLE LOCKED 2. ONGOING RECORD KEPT 3. WASTES COSIGNED 4. COUNTED AT BEGIN AND END OF EACH SHIFT 5. DISCREPANCIES ARE REPORTED 6. SIGNED OUT WITH NAME, DATE, TIME OF ADMINISTRATION
1G = 1,000mg =
1,000,000 mcg
DOSE ON HAND /QUANTITY ONHAND =DESIRED DOSE/QUANITY DESIRED
AMOUNT TO ADMINISTER
IV FLOW RATE FORMULA
VOLUME TO BE INFUSED/TOTAL TIME IN MIN X DROP FACTOR = RATE OF FLOW
DRUG ACTIONS
MECHANISM, THERAPEUTIC SIDE EFFECT, TOXIC EFFECT, ALLERGIC RESPONSE, IDIOSYNCRATIC RESPONSE,
ALLERGIC RESPONSE
SUPPORTIVE CARE AND ADMINISTRATION OF EPI, BRONCHODIALATORS, ANTIHISTAMINES, CORTICOSTEROIDS
IDIOSYNCRATIC RESPONSE
UNEXPLAINED UNPREDICTABLE RESPONSE TO A MED
5 RIGHTS TO MED ADMINISTRATION
DRUG
DOSE
CLIENT
ROUTE
TIME