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24 Cards in this Set

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List the Organs located in the RUQ.
Majority of Liver
1/2 Ascending Colon
1/2 Transverse Colon
Small Intestine
List the Organs located in the RLQ.
1/2 Ascending Colon
Appendix
Small Intestine
Ovaries
Define Hernia
The protrusion of an anatomical structure through the wall that normally contains it.
Define CVA as it relates to the thorax.
The costovertebral angle is the recess made between the 12th thoracic vertebra and the T12 vertebra at the posteroinferior margin of the thoracic cage on each side.
Define SBE or BSE.
Breast Self Examination.
Define I & O
Input and Output
Define Tympany
Tympanic resonance on percussion. A clear hollow note like that of a drum.
Define Dullness.
Diminished Resonance
Define Hyperresonance
Increased resonance.
Describe Flat Percussion Sound
Absence of Resonance
How long do you have to listen to determine bowel sounds are not present in EACH Quadrant. What might then be the total time that one could spend listening to the abdomen for a bowel sound?
Five Minutes in EACH quadrant for a total for 20 minutes.
Describe the components of a Nursing Diagnostic Statement.
Nursing Diagnosis
AEB (As Evidenced By)
Secondary Two
Define NANDA
North American Nursing Diagnosis Association.
Define NANDA Stem
Approved nursing diagnosis statement
Define how Related to is part of the Nursing Diagnosis Statement
What has contributed to or created change in health status/ probable source of health problem. Categories: pathophysiological, treatment related, situational, maturational.
Define AEB in the Nursing Diagnosis.
As Evidenced By
How does AEB affect the Nursing Diagnosis.
Defining characteristics of the diagnosis- S&S, objective/subjective data.
Define how High Risk, Possible, and Acutal are used in the nursing process.
Actual: shows the defining characteristics, etiology present, nurse should monitor S&S and identify interventions.

High Risk: does not show S&S, etiology (risk factors) is present, nurse should perform assessments looking for onset of S&S and identify ways to eliminate contributing factors.

Possible: S&S are unsure, etiology may be present, nurse should gather more information to determine existence of problems or risk factors.
Define a Medical Diagnosis
The medical diagnosis is made by the physician and addresses the medical problem)Is the physician response and the nurse carries out the written order. Each medical diagnosis intervention requires specific nursing responsibilities and technical nursing knowledge. (i.e. when administering medication the nurse needs to know the drug class, physiological action, normal dosage, side effects and nursing interventions related to its action or side effects.)
Define a Nursing Diagnosis
The nursing diagnosis (Potter 334) is the independent response of the nurse to the client’s health care needs. This type of intervention is an autonomous action based on scientific rationale that should benefit the client in a predicted way. (i.e. printed education regarding nutrition, and ADL’s related to hygiene)
Define a Collaborative problem.
Collaborative problems (Potter 335) these therapies require the knowledge, skill and expertise of multiple health care professionals. (i.e. Physical therapy, occupational therapy, speech therapy, and the Dietician) Through collaboration the nurse is able to tap the best resources to individualize the nursing actions.
Define how GOAL is part of the nursing process.
The goal is the Reverse of the NANDA Stem.

Client will....
Define EOC in the Nursing process.
Expected Outcome.

These support the goal. They are small and build toward the goal.
Define the Acryonym MOSTR
Measurable
Observable
Specific
Timebound
Realistic