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126 Cards in this Set

  • Front
  • Back
nurse practice act
A statute enacted by the state legislature or appropriate officers that delineates the legal scope of the practice of nursing within the geographic boundaries of the jurisdiction.
standards of care
Guidelines developed for the practice of nursing.
summary sheet
Portion of the patient's chart that lists the patient's general information, such as name, address, insurance carrier, etc.
consent form
Grants permission to the health care facility and physician to provide treatment to the patient
physician's order form
Form used by the physician to order procedures and treatments for a patient.
history and physical examination form
Form used by the health care provider to record findings from the patient interview and physical examination.
progress notes
Frequent observations of the patient's health status made by the physician and other health care professionals.
critical pathways
Comprehensive individualized plan of care that describes a multidisciplinary plan to track a patient's progress toward expected outcomes within a specified period. Also known as integrated care plans, care or clinical maps, and clinical trajectories.
nurses' notes
Section of the patient's chart where the nurse documents observations and actions taken, such as routine care given, abnormal findings, and client or family problems. There are many formats used.
nursing history
Data collected about a patient's level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.
nursing care plan
The written or computer-generated document that evolves from planning
laboratory tests record
Section of a patient's chart that lists all laboratory test results.
graphic record
Section of a patient's chart that lists all laboratory test results.
flow sheets
Condensed form for recording information for quick comparison of patient data
consultation reports
Section of the patient record where specialists' summary of findings, diagnoses, and recommendations for treatment are recorded.
other diagnostic reports
Section of the patient's chart that contains reports of surgery, EEG, ECG, pulmonary function tests, radiography, etc.
medication administration record (MAR) or medication profile
Section of the patient's chart listing all medications to be administered
PRN
Latin for pro re nata, meaning "as circumstances require."
unscheduled medication orders
Separate sheet in a patient's medication administration record that lists PRN medications.
case management
The coordination of patient care provided to individuals, their families, and significant others on a continuum, providing efficient transitions to services that may be needed after discharge.
patient education record
Documentation of the health teaching provided to the patient, family, or significant others, including statements regarding the learner's mastery of the content presented.
Kardex
A large index-type card usually kept in a flip-file or a separate holder; it contains pertinent information such as the patient's name, diagnosis, allergies, schedules of current medications with stop dates, treatments, and the nursing care plan.
floor or ward stock system
Medication delivery system where all but the most dangerous or rarely used medications are stocked at the nursing station in stock containers.
individual prescription order system
medications are dispensed from the pharmacy upon receipt of a prescription or drug order for an individual patient. The pharmacist usually sends a 3- to 5-day supply of medication in a bottle labeled for a specific patient. Once received at the nurse's station, medications are placed in the medication cabinet in accordance with institutional practices. Generally, the medication containers are arranged alphabetically by the patient's name, but they may be arranged numerically by the patient's room or bed number. This system provides greater patient safety due to the review of prescription orders by both the pharmacist and the nurse before administration, less danger of drug deterioration, easier inventory control, smaller total inventories, and reduced revenue loss due to improved charging systems and less pilferage.
computer-controlled dispensing system
Is supplied by the pharmacy daily, stocked with single- unit packages of medicines.
computer-controlled dispensing system
supplied by the pharmacy daily, stocked with single-unit packages of medicines. When a drug order is received in the pharmacy for a patient, it is entered into the computerized system. The nurse, using a security code and password, and for newer systems, a thumb print, accesses the system and selects the patient's name, medication profile, and drugs due for administration. The drug order appears on the screen, and a specific section of the cart automatically opens so the nurse can take the single dose of medicine out of the cart. This process continues until all drugs ordered for a specific time of administration are retrieved. During the actual administration process at the bedside, the nurse uses a handheld scanner that reads the barcodes on the nurse's identification badge, the patient's wristband, and the unit-dose medication packet, linking this information with the patient database. If there is an error such as the wrong dose, wrong time of administration, or wrong patient, an alarm sounds to stop the administration process. If the process is correct and the medicine is administered, there is automatic documentation in the patient's MAR of the administration.
unit dose drug distribution system
Use of single-unit packages of drugs, dispensed to fill each dose requirement as it is ordered.
long-term care unit dose system
Medication delivery cart designed with individual drawers to hold one patient's medication containers for 1 week.
stat order
A drug that is used on an emergency basis, to be administered as soon as possible, but only once.
single order
A drug administered at a certain time, but only one time.
standing order
A medication that is to be given for a specified number of doses. Also may indicate that a drug is to be administered until discontinued at a later date.
renewal order
Medication order that must be written and signed by the physician before the nurse can continue to administer the medication
PRN order
Administer if needed. This order allows a nurse to judge when a medication should be administered, based on the patient's need and when it can be safely administered.
adverse drug events (ADEs)
Serious complications resulting from pharmacological treatment.
computerized prescriber order entry (CPOE)
Ordering system used for medications and laboratory studies; this technology checks for potential drug interactions and appropriateness of drug dosages ordered, as well as for lab studies.
clinical decision-making support systems (CDSS)
Interactive computer programs that directly assist physicians and other health professionals with decision-making tasks.
verification
The practice of checking a medication order to make sure the type of drug, therapeutic intent, dose, and mathematical and physical preparation of the dose are all acceptable to give to the patient.
transcription
The practice of transferring a physician's order from the physician's order sheet onto the Kardex or MAR
creams
semisolid emulsions containing medicinal agents for external application.
lotions
Usually aqueous (water-based) preparations that contain suspended materials. Commonly used as soothing agents to protect the skin and relieve rashes and itching.
ointments
Semisolid preparations of medicinal substances in an oily base such as lanolin or petrolatum.
dressings
Material used to treat and cover wounds.
patch testing
A method used to identify a patient's sensitivity to contact materials (e.g., soaps, pollens, dyes)
allergens
Antigenic substances that can produce an immediate hypersensitivity in the body.
antigens
Any substance that will lead to the formation of antibodies.
transdermal disk
A disk or patch that provides controlled release of a prescribed medication (e.g., nitroglycerin, clonidine, Ortho-Evra) through a semipermeable membrane for several hours to 3 weeks when applied to intact skin.
buccal
Pertaining to the cheek. In drug administration, the buccal pouch is composed of the mucous-membrane side of the inner cheek and the posterior, lower gums.
opthalmic
Pertaining to the eye.
otic
Pertaining to the ear.
nebulae
Very small droplets of water or oil, usually sprayed from an atomizer
aerosols
Medication that is inhaled through a flow of air or oxygen under pressure to disperse the drug throughout the respiratory tract.
metered-dose inhaler
A device used to administer small amounts of aerosolized medicine by inhalation.
dry powder inhaler
A device used to administer small amounts of powdered medicine by inhalation.
capsules
Small, cylindrical gelatin containers that hold dry powder or liquid medicinal agents.
lozengers
Flat disks containing a medicinal agent in a suitably flavored base.
tablets
Dried, powdered drugs that have been compressed into small disks. In addition to the drug, tablets also contain one or more of the following ingredients: binders (adhesive substances that allow the tablet to stick together), disintegrators (substances that encourage dissolution in body fluids), lubricants (required for efficient manufacturing), and fillers (inert ingredients to make the tablet size convenient).
elixirs
Clear liquids made up of drugs dissolved in alcohol and water. Elixirs are primarily used when the drug will not dissolve in water alone.
emulsions
Dispersions of small droplets of water in oil or oil in water; used to mask bitter tastes or provide better solubility to certain drugs.
suspensions
Liquid dose forms that contain solid, insoluble drug particles dispersed in a liquid base.
syrups
Preparation that contains medicinal agents dissolved in a concentrated solution of sugar, usually sucrose. Particularly effective for masking the bitter taste of a drug.
unit dose packaging
A single dose of medication in one package, ready for dispensing.
bar code
Code on most unit dose package labels used for electronic charting of medication administration and inventory control.
soufflé cup
A small paper or plastic cup that may be used to transport solid medication forms such as a tablet or capsule to the patient to prevent contamination by handling.
medicine cup
Glass or plastic container that has three scales (apothecary, metric, and household) for the measurement of liquid medications.
medicine dropper
Device used to administer eye drops, ear drops, and occasionally, pediatric medications.
oral syringe
Plastic device used to measure liquid medications accurately.
nasogastric tube
A tube inserted into the nostril that passes through the nasopharynx, the pharynx, the esophagus, and into the stomach. May be used to administer liquid medicine or food for patients who cannot take any substance by mouth or who cannot swallow.
barrel
The outer portion of a syringe on which the calibration for the measurement of the drug volume are located.
plunger
The inner cylindrical portion of a syringe that fits snugly into the barrel.
tip
The portion of a syringe that holds the needle.
minim scale
A syringe is calibrated in minims and milliliters, but the milliliter scale is more accurate than the minim scale.
milliliter scale
A milliliter (ML) is a measure of volume on a syringe; the milliliter scale represents the units by which medications are routinely ordered.
tuberculin syringe
A 1-ML syringe that was originally designed to administer tuberculin skin tests and now is routinely used to measure small volumes of medication accurately.
insulin syringe
A syringe with a scale specifically calibrated for the measurement of insulin
prefilled syringe
A disposable cartridge-needle unit that holds a premeasured amount of medication
insulin pen
A prefilled insulin-containing syringe that resembles a pen when capped.
needle gauge
The diameter of the hole through the needle.
safety devices
Devices on safety-designed syringes/needles that avoid needle exposure through shielding or retracting mechanisms.
ampules
Glass containers that usually contain a single dose of a medication.
vials
Glass containers that contain one or more doses of a sterile medication.
Mix-O-Vials
Glass containers with two compartments: the lower chamber contains the drug (solute) and the upper chamber contains a sterile diluent (solvent).
intradermal
Within the dermis layer of the skin
erythema
Morbid redness of the skin caused by congestion of the capillaries, comes in many varieties; rose rash.
anergic
Characterized by abnormal inactivity
subcutaneous
The layer of skin between the dermis and muscle fascia; also known as the hypodermis.
intramuscular
Into or within the muscle
vastus lateralis
Muscle located on the anterior lateral thigh away from the nerves and blood vessels.
rectus femoris
The muscle that lies just medial to the vastus lateralis muscle but does not cross the midline of the interior thigh.
ventrogluteal area
An anatomic site often used for intramuscular injection of medicine that is easily accessible when the patient is in a prone, supine, or side-lying position. It is located by placing the palm of the hand on the lateral portion of the greater trochanter, the index finger on the anterior superior iliac spine, and the middle finger extended to the iliac crest
dorsoglutealarea
An injection site identified by drawing an imaginary line from the posterior superior iliac spine to the greater trochanter of the femur. The injection should be given at any point between the imaginary straight line and below the curve of the iliac crest (hip bone.
deltoid muscle
The shoulder muscle often used for intramuscular medication administration because of ease of access in the standing, sitting, or prone position.
Z-track method
A technique of intramuscular administration used to prevent staining of the skin by medicine that may seep out of the injection track.
intravenous
Into or within the vein.
Infusion Nurses Society
A professional organization that publishes the Infusion Nursing Standards of Practice
IV administration sets
The apparatus that connects a large volume parenteral solution with the intravenous access device in the patient's vein.
volumetric IV Controllers
Pumps that apply pressure to the administration set tubing to squeeze the solution through the tubing at a specific rate.
nonvolumetric IV controllers
Electronic control devices that monitor only the gravity infusion rate by counting the drops that drop through the chamber.
syringe pumps
Developed to hold a prefilled syringe to apply positive pressure to the plunger, delivering a specific volume of medicine over a set time.
peripheral devices
Intravenous access devices for short-term veins in the hand or forearm.
midline catheters
Intravenous access devices for use over 2 to 4 weeks, inserted into intermediate-sized veins and advanced into larger vessels.
central devices
Intravenous access device that is inserted into intermediate-sized veins and advanced into central veins for maximal mixing with large volumes of blood.
implantable venous infusion ports
Ports that are surgically placed under the skin and into central veins for long-term therapy
winged, butterfly, or scalp needles
Short, sharp-tipped needles that were originally designed for venipuncture of small veins in infants and geriatric use and are designed to minimize tissue injury during insertion.
over-the-needle catheters
Also known as short peripheral venous catheters. The needles are recommended for routine peripheral infusion therapy; are stainless steel and coated with a Teflonlike plastic catheter. After venipuncture the needle is removed and an IV administration set is attached to the catheter for infusion of fluid.
saline, heparin, or medlock in-the-needle catheters
When a patient no longer needs IV fluid therapy but venous access is still needed for medicine administration, an extension tube with an injection port is attached to the catheter and the IV fluid discontinued. The intravenous access device is then referred to at different clinical sites as a saline, heparin, or medlock. (See page 178-2nd colum-last paragraph)
peripherally inserted central venouse catheters (PICCs)
Inserted into the superior vena cava or just outside the right atrium by way of the cephalic or basilar veins of the antecubital space, providing an alternative to subclavian or jugular vein catheterization. (See page 179-Column 2-Last paragraph
tunneled central venous catheters
Intravenous catheters that are surgically implanted in an outpatient procedure under local anesthesia.
implantable infusion ports
Central IV access device used when long-term therapy is required and intermittent accessing of the central vein is required for IV fluids, medications, TPN, and blood products.
intravenous (IV) solutions
Solutions consisting of water (the solvent) containing one or more types of dissolved particles (solutes). The solutes most commonly dissolved in intravenous solutions are sodium chloride, dextrose, and potassium chloride.
electrolytes
Solutes that dissolve in water and dissociate into ion particles. These ions give water the ability to conduct electricity. The solutes most commonly dissolved in body fluids are sodium, chloride, potassium, and magnesium.
intravascular compartment
One of the three compartments among which the water is distributed in the body, including the arteries, veins, and capillaries.
isotonic
Having a uniform tension; isotonic solutions are those that have the same osmotic pressure as normal blood. Normal blood serum osmolality is 295 to 310 milliosmoles/liter (m0sm/L). Since intravenous solutions also contain dissolved particles, they also have an osmolality. Intravenous solutions with a similar concentration of dissolved particles as blood are considered to be isotonic solutions (e.g., normal saline=0.9% sodium chloride).
hypotonic
Lower tension; normal blood serum osmolality is 295 to 310 milliosmoles/liter (m0sm/L). Since intravenous solutions also contain dissolved particles, they also have an osmolality. Intravenous solutions with a lower concentration (osmolality) of dissolved particles than blood are considered to be hypotonic solutions.
hypertonic
Excessive tone, tension, or activity; Normal blood serum osmolality is 295 to 310 milliosmoles/liter (m0sm/L). Since intravenous solutions also contain dissolved particles, they aslo have an osmolality. Intravenous solutions with a higher concentration of dissolved particles than blood are considered to be hypertonic solutions.
tendem setup, piggyback (IVPB), or IV rider
Some medicines, such as antibiotics, are administered by intermittent infusion through an apparatus known as a tandem setup, piggyback (IVPB), or IV rider (See page 183-2nd column-last paragraph)
SASH guideline
Guideline used when administering drugs by IV push or bolus. Saline flush first; Administer the prescribed drug; Saline flush following the drug; Heparin flush line, depending on type of line, such as Hickman catheter (check institution policy)
phlebitis
Inflamation of a vein
thrombophlebitis
Inflamation of a vein or veins resulting from an infection or clot
septicemia
A systemic infection that occurs when pathogens associated with a local infection invade the bloodstream and are carried to other parts of the body.
infiltration
Leakage of an intravenous solution into the tissue surrounding the vein
extravasation
Leakage of an irritant chemical (e.g., a medicine being infused intravenously) into the tissue surrounding the vein.
infiltration scale
A scale used to measure signs and symptoms of infiltration.
air embolism
An air bubble in the cardiovascular system that obstructs blood flow.
pulmonary edema
Abnormal, diffuse, extravascular accumulation of fluid in the pulmonary tissues and air spaces as a result of changes in hydrostatic forces in the capillaries or to increased capillary permeability.
pulmonary embolism
Blood clot or foreign material that travels through the circulation and finally lodges in a blood vessel in the lungs.
"speed shock"
occurs as a systemic reaction to a foreign substance given too rapidly into the bloodstream. This can occur when an IV drug is administered too rapidly into the circulation most commonly by IV push. The rapid delivery of the IV drug creates a concentrated plasma level in the patient that may result in shock, syncope, and cardiac arrest. (See page 204-column 2-last paragraph)