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64 Cards in this Set
- Front
- Back
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Lymphocytes |
Recognizes foreign antigens, produces antibodies and creates memory cells |
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Suppression |
Choosing not to think about unpleasant feelings |
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Sublimation |
Rechanneling unacceptable impulses into socially acceptable activities |
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Displacement |
Transferring emotional energy away from an actual source of stress to an unrelated person or object. |
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Rationalization |
Denying true motives for an action by identifying a more socially acceptable explanation |
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Elements of communication (6) |
1. Referent (event or thought initiating the communication) 2. Sender (person who initiates and encodes the communication) 3. Receiver (person who received and decodes the communication) 4. Message (information that is communicated) 5. Channel (method of communication) 6. Feedback (response of the receiver) |
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Tuckman's Model of group performance |
Forming Storming Norming Performing Adjourning |
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SBAR |
Situation - happening right now Background - what led to current situation? Assessment - identified problem, concern or need Recommendation - action or interventions should be initiated to alleviate the problem |
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Phases of Nurse-Patient helping relationshil |
Orientation/Introductory Working Termination |
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1st line of defense |
Normal flora on skin, mucous membranes, GI tract, nose |
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2nd line of defense |
Inflammatory response - phagocytes, natural killer T lymphocytes, granule yes, macrophages providing innate, nonspecific immunity |
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3rd line of defense |
Immune response - signs of fever, chills, malaise and altered mental status |
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Types of immunity |
Acquired - exposed to germ and body builds up antibodies Humoral - B lymphocytes Passive - get from a different source and is temporary Cellular - T lymphocytes (HIV - affects CD4 cells which means it can get to the T cells and destroy person's immune system) |
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Hgb A1C |
Blood test that tells the average amount of glucose in pt's blood for past 3 months 4.5-6.5% |
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LDH (Lactate Dehydrogenase) |
Enzyme found in heart, liver, muscles and erthrocytes. Levels are elevated after damage to myocardium and erythrocytes |
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Random blood sugar |
Test blood glucose level to see how their levels are at different times of day. |
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ESR (Erythrocyte Sedimentation Rate) |
Non-specific test to see Inflammation. Used in cancer, infections and autoimmune disorders |
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Albumin |
Protein level in plasma (3.5-5) |
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Cholesterol |
Produced in the liver and increases risk for stroke and heart attacks. LDL is bad and clogs arteries. HDL is good and helps carry cholesterol to liver where it is removed. |
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Platelet count |
Stick together and causes clotting/prevent bleeding (150,000-350,000) |
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Bilirubin |
One of the components of bike, synthesized in the liver, spleen and bond marrow. Bilirubin is also a byproduct of hemolysis. 0.3-1 |
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Uric acid |
Tests part of the pH (foods that create purine break down to uric acid - build up of uric acid can be high in the disease of gout) |
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Partial Thromboplastin Time |
Commonly used while patient is on IV heparin or to detect bleeding disorders caused by abnormalities of the intrinsic clotting system |
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Liver function tests |
ALP and ALT |
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Endoscopy |
Exam of the interior of an organ by means of fiber optic scope. Often used to identify tumors and to remove tissue samples for biopsy. If upper GI tract, pt is NPO |
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MRI |
Most common diagnostic examination for brain pathology and joint visualization. Cross-sectional image of the body (similar to CT scan) but without radiation exposure. Visualize blood vessels and signs of hemorrhage within hours of event. |
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Abdominal ultrasound |
Visualization of soft tissue organs by recording and measuring reflection ultrasonic waves. |
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PET scan (Positive Emission Tomography) |
Nuclear study performed after injection of a radionuclide into a vein. Used commonly in patients |
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Needle aspiration |
May be joint or a cyst Fluid or tissue is tested |
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Paracentesis |
Peritoneal area Cirrhosis Congestive Heart failure Nephrotic syndrome Malignancy Peritonitis Pancreatitis |
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Thoracentesis |
Pleural cavity Infection Malignancy Metastasis Chest trauma Hemothorax |
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Flexible sigmoidoscopy |
Looks at the bottom portion of the colon (not as invasive as a colonoscopy) |
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Interventions for flexible sigmoidoscopy |
Watch for dehydration Rise slowly Not to eat solid foods |
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Nursing interventions after sedation |
Vitals, specifically respiration Level of consciousness Pain level Kidney function Watch IV site |
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24 hour urine test |
Used to measure the glomerular filtration rate 1. Label collection container 2. Prepare basin with ice in bathroom 3. Begin testing in the morning, if possible 4. Patient voids, documents and discard specimen 5. For 24 hour period collect all voided urine |
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Low albumin symptoms |
Weak, eyes are lack luster, won't be engaged in conversation. |
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Potassium levels; s/sx of hypo and hyper kalemia |
3.5-5.3 Hyperkalemia : Anxiety, irritability, confusion Dysrhythmias including bradycardia and heart block Muscle weakness, flaccid paralysis Parathesia Abdominal cramping
Hypokalemia Weak, irregular pulse Fatigue, lethargy Anorexia, nausea, vomiting Muscle weakness, cramping Decreased peristalsis Pats thesis Cardiac Dysrhythmias Increased risk of digitalis toxicity |
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Potassium wasting diuretics |
Lasix and Hydrochlorothiazide Monitor I/O Labs especially K+ Daily weight in morning |
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Overhydration symptoms |
Elevated BP Crackles on lungs Distended jugular vein Respiratory rate and O2 stats are increased Edema
Treat with diuretic, watch vitals, watch electrolytes, lessen fluids |
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Underhydration |
Decreased output Increased heart rate Poor skin turgor IV fluids |
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4 hypertonic fluids |
D5 0.45%NS D5 0.9%NS D5 LR 3% NS |
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IV phlebitis |
Stop IV Clean site with disinfectant Apply warm, moist compresses for 20 minutes 3-4 times per day Use different side of body when inserting new IV |
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Ideal needle gauge size for blood/blood products |
18 gauge |
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Magnesium levels and s/sx of hypo and hypermagnesemia |
1.3-2.1 Hypomagnesemia Irritable nerves and muscles Hyperactive deep tendon reflexes Seizures Dysrhythmias ECG changes Altered LOC Mood swings Delusions, hallucinations Dysphasia, nausea, vomiting Magnesium Sulfate is prescribed
Hypomagnesemia Warm, flushed appearance Nausea, vomiting Drowsiness, lethargy Decreased muscle strength Generalized weakness Decreased deep tendon reflexes Hypotension Dysrhythmias, especially bradycardia Slow, shallow respirations Calcium Gluconate prescribed |
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Calcium levels and s/sx of hypo and hypercalcemia |
8.5-10.5 Hypocalcemia Confusion, anxiety Numbness, tingling of extremities Muscle cramps that progress to tetany Hyperactive reflexes Cardiac Dysrhythmias Positive Chvostek and Trousseau signs
Hypercalcemia Lethargy, stupor, coma Decreased muscle strength and tone Anorexia, nausea, vomiting Constipation Pathologic fractures Dysrhythmias Renal calculi |
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Nursing interventions for decompressed CHF |
Lung assessments Watch IV fluids (slow them down) Fowler position Monitor urinary output Watch level of consciousness |
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Chvostek's signs |
Calcium deficiency!!! Tap angle of jaw and cheek muscle flexes |
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Trousseau's sign |
Calcium deficiency!!! Tetany of upper extremities at the wrists |
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Sodium levels and s/sx of hypo and hypernatremia |
135-145 Hyponatremia Lethargy, confusion, weakness Muscle cramping Seizures Anorexia, nausea, vomiting Serum osmolarity <280
Hypernatremia Thirst, dry sticky membranes Weakness, elevated temp Confusion, irritability Hallucinations and convulsions Serum osmolarity >300 |
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Bacteriastatic |
Puts bacteria in an environment so there is eventual die off |
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Bacteriastatic |
Puts bacteria in an environment so there is eventual die off |
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Bacteriacidal |
Causes the direct kill of the bacteria |
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CBC |
provides information about O2 and CO2 transport capabilities |
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Neutrophils |
First defenders against bacterial and fungal infections, foreign antigens and cell debris |
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Neutrophils |
First defenders against bacterial and fungal infections, foreign antigens and cell debris |
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Monocytes |
Involved in phagocytosis, become macrophages |
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Eosinophil |
Destroys parasites, involved in allergic reactions |
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Eosinophil |
Destroys parasites, involved in allergic reactions |
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Basophil |
Involved in inflammatory response to injury, releases histamine |
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Lymphocytes |
Recognizes foreign antigens, produces antibodies and creates memory cells |
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Basophils and eosinophils together |
Parasitic or protozoal infection |
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Neutrophil and monocytes together |
Means bacterial infection |
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Severe infection symptoms |
Body goes into shook them septic Temperature no longer elevated BP drops Decreased LOC Kidneys shut down |
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Isolation categories |
Contact Droplet Airborne Protective |
