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170 Cards in this Set
- Front
- Back
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Polyuria |
Large amounts of urine output |
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Oliguria |
Low amounts of urine output Less than 500 ML per day |
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Nocturia |
Frequent nighttime urination |
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Anuria |
Non passage of urine. Less than 50ML of urine a day |
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800 -2000 ML of urine a day is normal |
Urination |
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Fat soluble vitamins |
Vitamin A,D, E, K. ( Adek ) |
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Which vitamin is only found in animal foods? |
Vitamin B12 |
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What is a complete protein? |
Red meat, poultry, fish, eggs, milk, cheese, yogurt, soy beans and quinoa |
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TPN- Total Parenteral Nutrition |
Administered in vein for clients who can not take oral foods Bypasses digestive system and goes right into a vein |
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Stress incontinence |
Happens when stress is put on your bladder such as coughing, sneezing, running, lifting. Puts pressure on your bladder |
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Olfactory - 1 Sensory |
Smell Hold each nostril while smelling alcohol |
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Optic -2 Sensory |
Vision. Test for acuity (sharpness) Eye exam test. Visual fields- fingers test coming towards patient on the side |
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Oculomotor- 3- Motor |
Pupil construction. Raise eyelids Open and close eyes and pupils reacting to light |
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Trochlear- 4 Motor/ proprioceptor |
Eyes- turns eyes downward and inward movement Ask patients to look down and to the sides |
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Trigeminal- 5 Motor |
Jaw movements. Chewing, Face and mouth. Touch and pain Ask patients to open and clench jaw while you palpate the jaw muscles |
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Abducens- 6 Motor |
Turns eyes laterally. Test ocular movement in all directions 6 fields of gaze |
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Facial- 7 Motor |
Facial expressions, tears, saliva and taste Ask patients to raise eyebrows, smile, show teeth and puff out cheeks |
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Vestibulocochlear-8 Sensory |
Hearing Test hearing- whisper have them repeat |
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Glossopharyngeal-9 Motor |
Pharyngeal ( throat )movement and swallowing and Taste Ask patients to say "Ah" do gag response. Note ability to swallow. Ask them to yawn and observe the palate
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Vagus-10 Motor/ Sensory |
(Swallowing and speaking) Ask patients to swallow and speak note hoarseness |
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Accessory- 11 |
(Movement of shoulder muscles) Ask patients to shrug shoulders against your resistance |
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Hypoglossal- 12 Motor |
Movement of the tongue, strength of the tongue Ask patients to stick out tongue and push tongue against cheek |
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Nerve 3, 4 and 6 at same time Eyes |
Oculomotor, Trochlear and Abducens 1. 6 cardinal gaze, 2. Pupil reacting to light Constricting to pen light 3. Hold pen light and bring into nose |
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Crohn's Disease |
Inflammation in the digestive tract ( intestine ) |
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Ulcerative Colitis |
Inflammation and ulceration of the colon and rectum |
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Overflow incontinence |
Overflow of the bladder |
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Functional incontinence |
Urine loss caused by inability to reach the toilet by environment barriers, loss of memory, or physical limitations |
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Total incontinence |
Unpredictable urine loss caused by surgery, trauma or physical malformation |
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Reflex incontinence |
Emptying bladder without sensation to void |
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Things your accountable for |
1. Stability of patients condition 2. Complexity of task delegated 3. Potential of harm4. Predicting outcome 5. Overall needs of the patient |
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A womans urethra is? |
2-3in |
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A man's urethra is |
6-8in |
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Pyuria? |
Pus in the urine |
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Glycosuria? |
Sugar in urine |
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Dysuria? |
Painful or difficulty urinating |
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Orthostatic blood pressure? |
For dehydration Patient sits, than lays then stands If drops 20mmHg lower is positive Then you would look at urine Positive orthostatic specific gravity 0.010-0.030 ( weight of urine ) |
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30mL per hr for urinating |
Yay |
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24 hr urine test |
1st urine get wasted |
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Incontinence |
Peeing and not controlling it |
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Interoperability |
The ability of computer systems to exchange information |
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Informatics Framework |
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Who can receive patient information? |
Those DIRECTLY involved in the patients care |
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What purpose does an audit serve? |
Quality assurance and reimbursement |
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What do parents need to do to view children's records? |
Parents need to put requests in writing to view children's records |
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Informatics nurses should ensure which actions are done before beginning implementation |
• Testing • End-user education • support services availability |
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What is Patient portal? |
Access personal information |
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Naturalness in informatics |
Feels familiar |
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System development lifecycle in informatics |
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Where do you file a fall incident? |
Fill out separate incidence report |
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Naloxone |
Is Narcan- make sure it's on the unit when patients are on opioids Can block the effects of opioids especially decreased breathing in overdose |
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Breakthrough pain? |
Severe pain that erupts while a patient is medicated with a long acting painkiller |
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When should you ask about pain |
When taking vital signs |
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Neuropathic pain |
Shooting or burning pain normally chronic ( lasting long ) Can go with phantom pain *Allodynia* feature of neuropathic |
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Somatic pain? |
Diffused or scattered and originates in tendons, ligaments, bones, blood vessels and nerves *Somatic pain is more localized * |
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Cutaneous pain? |
Superficial on skin or just below |
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Visceral pain? |
Poorly localized and is in body organs |
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FOCUS charting |
Focuses on patient alone |
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PIE charting |
Problem, intervention, evaluation *Does not develop a separate care plan but incorporates the care plan into progress notes |
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Source oriented charting |
Getting information from family Each healthcare group keeps data in it's own separate form |
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Acuity Records |
Level of sickness 1-4 score to put patients in order of priority |
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Flow chart |
Activity of patients |
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ISBAR |
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5 Rights of delegation |
• Right task •Circumstance •Person • Right direction and communication • Right supervision and evaluation |
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What law is Malpractice? |
Common law Judiciary system reconciles controversies. Body of common law |
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Statutory Law |
Enacted by a legislative body |
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Constitutions |
Serve as guide to legislative bodies |
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State Nursing practice act |
Most important law affecting nursing practices |
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Gross negligence |
Did not perform like others would have performed |
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Tort Example- Falsely imprisoning a patient |
Is a wrong committed by a person against another person or property |
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Energy nutrients |
Carbohydrates, Protein and Lipids |
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Nutrients that regulate body processes |
Vitamins, minerals and water |
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Basal Metabolic Rate -BMR |
How many calories your body burns while at rest Men- BMR 1 cal/ kg of body weight per hr Women- 0.9 cal/kg per hr Factors affecting BMR growth, infection, fever Factors decreasing BMR- aging, fasting and sleep |
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Carbohydrates 90% of intake is ingested Converts to glucose |
•Sugars and starches Lactose is only animal source Classifieds as simple or complex |
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Protein Building blocks 10-35% of calorie intake |
Labeled complete or incomplete based on amino acid •Animal protein is complete •Plants are incomplete |
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Fats Incapable of being dissolved in water an blood *Body will use fats last* |
95% of lipids in diet are triglycerides Contain mixture of saturated (raise cholesterol) unsaturated ( lower levels) •Animal products are saturated •Vegetables fats are unsaturated |
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Fats Digestion occurs in small intestine |
Fats 10% or less in diet |
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What is partially hydrogenated liquid oils |
Trans Fat This raises serum cholesterol Cholesterol is only found in animal products |
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Vitamins |
•Your body does not make essential vitamins •Needed by body in small amounts Needed for metabolism of carbohydrates, protein and fats *Important* Most vitamins are active in the form of coenzymes |
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Vitamin A |
Visual acuity, formation of skin and immune function |
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Vitamin D |
Provides calcium and phosphorus metabolism and stimulates calcium absorption |
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Vitamin E |
Antioxidant that protects Vitamin A |
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Vitamin K |
Helps synthesis of certain proteins for blood clotting |
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Minerals |
•Zinc- Immune system •Iron- blood •Manganese-Mn metabolism of cholesterol and carbs. Also with protein and amino acid digestion. Heart and nerves • Chromium- Insulin action and glucose breakdown. Enhance carb and lipid metabolism Magnesium- Mg bones, muscles, heart • Molybdenum-Removes toxins •Selenium- Thyroid and immune function • Iodine- Thyroid hormone •Copper-Iron form and red blood cells |
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Macrominerals |
• Calcium- heart, blood clotting building bones. Muscles contraction • Phosphorus- calcium and phosphorus build bones. Nucleic acids and cell membrane •Chloride- Electrolyes. Balances acids and bases. Moves water in and out of cell |
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Obesity |
When BMI is above 30 |
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Anorexia |
Lack of appetite |
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Normal BMI |
18.5- 25 25-30 overweight |
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Basal Metabolic Panel |
A1C - glucose Normal level 5.7 A1C- Prediabetic 5.7-6.4 Type 2- over 6.5 |
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NG feeding tube Short term |
Small bowel obstruction * Takes pressure off stomach * |
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Enterostomal Tube- (peg tube)Peg is Percutaneous endoscopic gastronomy |
Opening in the stomach to deliver nutrition. Used for long term |
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TPN- Total Parenteral Nutrition Bypasses gastrointestinal tract |
Needs dr orders every 24hrs Contains vitamins, nutrients, insulin Given in Central line- IV |
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Cholinergic medications |
Stimulates contraction of detrusor muscles, producing urine |
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Analgesics and tranquilizers |
Suppress CNS diminishes effectiveness of neural reflex |
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Diuretics |
Prevent reabsorption of water and electrolytes in tubules |
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Color of Urine |
•Anticoagulant- Red urine •Diuretics- pale yellow •Pyridium- orange •Antidepressants or B complex vitamins-green or blue urine •Levodopa ( Parkinson's )- brown or black |
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What is aromatic urine? |
A pleasant smell |
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Transient incontinence |
Appears suddenly and last 6 months or less |
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Mixed incontinence |
Urine loss of two or more types of incontinence |
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Functional incontinence |
Caused by factors outside the urinary tract |
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What controls peristalsis? |
The nervous system |
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What is the main job of the small intestine? |
Absorption of nutrients and minerals |
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What foods have a laxative effect? |
Fruits, vegetables, alcohol and coffee |
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What foods have a constipation effect? |
Cheese, eggs, lean meat, pasta |
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Gas producing foods |
Onions, cabbage, beans, cauliflower |
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Medications effecting stool |
•Aspirin, anticoagulant -Pink to red stool •Iron- black stool • Bismuth sub salicylate can also cause black stool •Antiacids- white discoloration or spackling in stool • Antibiotics- Green- gray color |
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Timed specimen |
The nurse should consider the first stool passed the start of the collection period |
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Colonoscopy |
Visualizes the rectum, colon and bowel using a lighted scope |
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Sigmoidoscopy |
Examines the distal sigmoid colon, rectum and anal canal through flexible sigmoid scope |
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UGI series |
Involves examination of the esophagus, stomach and small intestine after digestion of barium sulfate *Barium sulfate coats stomach, esophagus and stomach for ct scans and xrays* |
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Antihelmintic enemas |
Destroys intestinal parasites |
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Carminative enema |
Expel gases in the abdomen |
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Nasogastric Tubes |
•Inserted to decompress or drain the stomach or fluid of unwanted stomach contents •Used to allow the gastrointestinal tract to rest after surgery for healing • Inserted to monitor gastrointestinal bleeding |
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Somatic pain |
Deep somatic pain originates in bones, tendons, blood, nerves and vessels |
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Cutaneous pain |
Is skin pain |
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Visceral pain |
Organ pain |
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Transduction pain process |
Activation of pain receptors |
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Transmission |
Conduction along pathways A- delta and C-delta fibers |
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Modulation |
Inhibition or modification of pain |
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Bradykinin Inflammatory mediator |
Powerful vasodilator that increases capillary permeability and constricts smooth muscles |
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Prostaglandin |
At injured sites causes inflammation and sends pain to CNS |
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Substance P |
Neurotransmitter that delivers the signal of pain to the CNS |
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Nociceptors |
Transmit pain |
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Enkephalins |
Reduce pain by inhibiting the release of substance P |
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Endorphins and Dynorphins |
Released when certain measures are used to relieve pain |
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Acute |
Rapid onset of pain |
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Chronic |
Persistent pain lasting a long time |
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Cries pain scale |
Used for neonates 0-6 months |
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FLACC |
Faces, legs, activity, cry, consolibilty |
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Nonpharmacolgic pain relief |
Distraction, humor, music, acupuncture, relaxation |
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Beyer Oucher pain scale |
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Wong- Baker faces |
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Democratic leadership |
Leadership where individuals with unequal power are allowed to have shared power to make decisions |
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Tap-in unlicensed assistive person |
Things they can do •Bathing a patient •Dispose of disconnected IV set • Obtain weight of patients on bed scale |
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Magnet Recognition |
Better patient outcomes |
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Laissez faire leadership |
Policy of letting things take their own course without interfering |
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Autocratic |
Authoritative leadership using power or position |
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Transformational leadership |
Work with teams to identify needed change |
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Enkephalins |
Gonadal function |
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Endorphins |
Diminish perception of pain |
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Efferent |
Damage would lead to loss of motor control |
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Afferent |
Damage would lead to sensory function loss |
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Pupils dialated when in pain |
Yep |
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Neuromodulator released with skin stimulation |
Endorphins |
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Most potent neuromodulators |
Endorphins |
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Chronology of pain |
Development and progression |
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Sedation scale |
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What do you worry about with Opioids |
Respiratory depression |
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When do you assess pain after administering meds? |
30 min after |
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Diffuse pain? |
Widespread. In many areas |
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Monitoring vital signs after epidural analgesic |
Respiratory status, oxygen saturation, pain and sedation level |
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A diet lacking fruits and vegetables causes what? |
Constipation Fruit and vegetables keep your stool regular |
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Food that causes constipation |
Such as whole grains, seeds and nuts |
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Functional unit of the kidneys |
Nephron |
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What postion for emema |
Sims postion |
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Refrain from douching |
In female clients don't touch unless prescribed |
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Polyps for colonoscopy |
Hereditary should discuss screening |
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Tube feeding do not increase survival rates among older Alzheimers patients |
Yep |
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What the most reliable way to verify nasogastric tube placement? |
Radiographic |
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Digital ( fingers) removal of poop? |
Is last resort. May cause parasympathetic stimulation |
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What is flatus |
Gas in stomach or intestines |
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Enema tubes get inserted how many inches |
3-4 |
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Take vital signs every 4 hrs |
Yep |
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Certain vegetables can cause flatus |
Flatus is stomach gas |
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If patient can not vocalize and grasps where is the nasogastric tube |
In airways |
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TPN |
Monitor for complications related to fluid and electrolytes |
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What factor causes primary constipation? |
Inadequate intake of liquids |
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Process of fecal occult blood test |
1. Fecal occult test 2. Barium studies 3. Endoscopic examination |
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Purpose of FOBT |
The test detects heme an iron compound in blood within stool |
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Avoid more than 250 mg of vitamin C |
Before fecal occult blood test |
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Constipation |
If you don't have enough fiber or liquid you get constipation |
