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95 Cards in this Set
- Front
- Back
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Acid base balance |
The maintenance of arterial blood pH between 7.35 and 7.45 through control of hydrogen ion production, and elimination |
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Cellular regulation |
The genetic & physiologic processes that controls cellular growth, replication, differentiation, and function to maintain homeostasis |
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Clotting |
A complex multi step process by which blood forms a protein-based structure (clot) in an appropriate area of tissue injury to prevent excessive bleeding while maintaining whole body blood flow |
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Cognition |
The complex integration of mental processes and intellectual function for the purpose of reasoning, learning, memory, and personality |
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Comfort |
A state of physical well-being, pleasure, and absence of pain or stress. Has physical and emotional dimensions. |
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Constipation |
Hard, dry stool, that is difficult to pass through the rectum |
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Delirium |
Acute fluctuating mental confusion |
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Dementia |
Chronic mental confusion |
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Diarrhea |
Watery stool without solid form |
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Elimination |
The excretion of waste from the body by the G.I. tract (as feces) and buy the renal/urinary system (as urine) |
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Exemplar |
Selected health problem or issue that represents priority concepts |
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Fluid and electrolyte balance |
The regulation of body fluid volume, osmolality, and composition. The regulation of electrolytes by the processes of filtration, diffusion, osmosis, and selective excretion. |
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Gas exchange |
The process of oxygen transport to the cells and carbon dioxide transport away from the cells through ventilation and diffusion |
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Glucose regulation |
The process of maintaining optimal blood glucose levels |
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Immunity |
Protection from illness or disease that is maintained by the body’s physiologic defense mechanisms |
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Infection |
The invasion of pathogens into the body, that multiply and causes disease or illness |
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Inflammation |
A syndrome of normal responses to cellular injury, allergy, or invasion by pathogens |
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Mobility |
The ability of an individual to perform purposeful physical movement of the body |
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Nutrition |
The process of ingesting and using food and fluids to grow, repair, and maintain optimal body functions |
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Pain |
An unpleasant sensory and emotional experience, that may be acute or persistent (chronic) |
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Perfusion |
Adequate arterial blood flow through the peripheral tissues, (peripheral perfusion) and blood that is pumped by the heart to oxygenate major body organs, (central perfusion) |
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Sepsis |
A life threatening response of the body to infection and widespread inflammation that can cause multiple organ dysfunction syndrome (MODS) |
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Sensory perception |
The ability to perceive and interpret sensory input into one or more meaningful responses |
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Sexuality |
A complex integration of physiologic, emotional, and social aspects of well-being related to intimacy, self-concept, and role relationships |
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Tissue integrity |
The intactness of the structure and function of the integument (skin and subcutaneous tissue) and mucous membranes |
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Common risk factors for acid base balance |
•Poisoning, such as excessive salicylate ingestion • medical conditions, such as COPD, uncontrolled, diabetes mellitus, and chronic kidney disease • Excessive emesis (vomiting) • Prolonged, diarrhea • hyperventilation • electrolyte, imbalances, especially potassium |
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Assessment of cellular regulation |
Patient history, family history, psychosocial history, physical, examination, diagnostic test, colonoscopy, laboratory tests |
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Health promotion strategies to maintain cellular regulation, and prevent impaired cellular regulation |
•Protect expose skin with sunscreen at least 30 SPF •Minimize exposure to sunlight and ultraviolet light to prevent skin cancers •Stop smoking •Consume diet low in saturated fat in high in fiber •Increase physical activity and regular exercise •Avoid exposure to environmental hazards |
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Common risk factors for impaired clotting |
Mobility or decreased mobility, health problems such as polycythemia, and smoking |
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Interventions to lower client’s risk for injury of fall |
Light and clear pathway, proper footwear, assisted devices near, and use of grab bars |
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In Maslow’s Hierarchy of Needs, what do all people need? |
Basic human needs- air, food, drink, shelter, clothing, warmth, sex, and sleep. If not satisfied the body cannot function properly |
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What would be priority for a client transferring to ensure safety? |
Safety lock wheelchair and place wheelchair parallel to bed |
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What would be priority for a client transferring to ensure safety? |
Safety lock wheelchair and place wheelchair parallel to bed |
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A client is coughing in the dining room what is priority? |
Promote coughing |
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Tripping hazards |
Throw rugs— remove throw rugs bc they are tripping hazards. Clear pathways and lighted area. |
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Tripping hazards |
Throw rugs— remove throw rugs bc they are tripping hazards. Clear pathways and lighted area. |
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A client is admitted to the facility/room, what is the priority intervention? |
Orientate client to the room |
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Maslow’s Hierarchy of needs to prioritize |
The client w/ a temp of 101F -ABC (airway, breathing, circulation) (diarrhea vs hip fracture - you would see the client w/ diarrhea bc of fluid loss and imbalance) Priority assessment ABC - use Maslow’s Hierarchy of needs •Homeless man •A client w/ a temperature of 101 •The client who is depressed |
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True or False— Side rails have been linked to injuries |
Side rails have been linked to cause injury especially for clients who have cognitive repair |
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True or False— Side rails have been linked to injuries |
Side rails have been linked to cause injury especially for clients who have cognitive repair |
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Who is the most reliable source of pain? |
The client. Pain is subjective |
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What level of Maslow’s Hierarchy of Needs does food belong to? |
Physiological |
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What is an example of alternative therapy? |
Using garlic to manage clotting disorder |
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How do you prevent poisoning in children? |
Lock cabinets. Adults should be educated to only use one pharmacy and if have multiple doctors to ensure that they all know medication‘s taken. |
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Factors that affect bowel elimination |
Age, diet, fluid intake, mobility |
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Interventions to prevent constipation are |
A high fiber, diet, increase fluid, and get exercise |
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Dangers for toddlers |
Unattended pools |
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Which organization publishes the national patient safety goals? |
The joint commission |
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What type of event is a surgical sponge left in a client incision? |
Never Event |
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Never events are |
That should never happen, and are preventable. |
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Sentinel event |
An event that should never happen, but results and serious injury or death. |
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Needle should always go directly into what? |
The sharps container |
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What are the signs of?: Cyanosis, pallor, coolness, and weak pulses. |
Inadequate perfusion |
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Interventions, to reduce risk of falls |
Keep the stairs well lit, use shower chairs, and raised toilet seats, keep stairs free of clutter, encourage the use of nonslip, socks, or shoes |
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What should the nurse monitor for with clients who have fluid imbalance? |
Intake and output |
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Neuropathic pain |
Pain caused by damaged or disease affecting the nervous system. Clients with diabetes may experience this type of pain also amputees due to damage nerves. |
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Neuropathic pain |
Pain caused by damaged or disease affecting the nervous system. Clients with diabetes may experience this type of pain also amputees due to damage nerves. |
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Amputees will also experience |
Phantom pain. Where the nerve still recognizes the amputated limbs, so clients will experience pain in the missing limb. |
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Natural active immunity |
natural active immunity occurs when an antigen enters the body and the body creates antibodies to fight off the antigen |
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A client has a low platelet count. What is important to teach the client? |
Shave with an electric razor |
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Nonpharmacological interventions for a recent ankle sprain include: |
Rest Ice Compress Elevation |
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Bathing promotes |
Circulation, relaxation, and enhanced healing. Great time to assess the skin also. |
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Sleep patterns are negatively affected by |
A stressful job, a large meal right before bedtime, frequent travel |
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Nonverbal signs of pain |
Increased agitation, decrease focus, grimacing, increased heart rate, and blood pressure. |
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Echinacea |
Enhances immunity |
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Echinacea |
Enhances immunity |
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Ginseng |
Increases physical endurance |
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Aloe |
Promotes wound healing |
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Alternative therapies |
Massage therapy, cupping therapy, utilizing lavender |
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Alternative therapies |
Massage therapy, cupping therapy, utilizing lavender |
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Complementary therapy |
Exercise and medication |
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Float heels |
To prevent pressure ulcers |
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Shearing injury |
Do not drag client up in bed. If needed use a Hoyer lift to pull client up. |
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Narcolepsy safety |
Client should not drive |
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Oral pain medication |
After given reassess after 30-60 minutes. |
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Promote determination and autonomy by |
By allowing the client to do as much as possible for themselves |
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Proper foot care to reduce |
infection. Educate client to inspect feet daily. If they cannot see the bottom of their feet they can use a mirror. |
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Sleep walking occurs in |
Stage 4 NREM sleep |
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Educate female clients to prevent UTIs by |
Wiping front to back and drink plenty of fluids. |
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With pain what increases? |
Blood pressure and heart rate increases |
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What position is best for eating to reduce aspiration? |
High Fowler’s position |
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When performing a bed bath start with: |
The cleanest to dirtiest. Start with the face. |
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Dementia |
Chronic, progressive cognitive decline, develops slowly, duration: months-years cause: unknown possibly familial, chemical |
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Delirium |
Acute, fluctuating confusional state, comes on fast. Duration: hours- less than a month. Cause: multiple, such as surgery, infection, drugs |
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Comfort |
A state of physical well-being, pleasure, and absence of pain or stress. Has physical and emotional dimensions. |
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Risk factors for changes in elimination |
Incontinence, neurological disorders such as stroke, dementia, and multiple sclerosis, excessive use of laxatives, chronic inflammatory bowel diseases, urinary retention, retention of stool/obstipation, lack of exercise, certain medications, spinal cord and brain injuries, renal/urinary problems, urinary tract obstructions, chronic kidney disease |
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Dehydration |
Fluid intake or retention is less than what is needed to meet the body’s fluids needs |
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Fluid overload |
Fluid excess— usually have an increase in Blood Pressure due to increased blood volume. |
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What can alter a person’s fluid and electrolyte balance? |
Hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypermagnesemia, hypomagnesemia |
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List risk factors for changes in immunity: |
Older adults, low socioeconomic groups, non immunized adults, non healthy lifestyle and genetic risk |
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List risk factors for changes in immunity: |
Older adults, low socioeconomic groups, non immunized adults, non healthy lifestyle and genetic risk |
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List the categories of infection |
Bacteria, viruses, fungi, parasites, or protozoa |
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What are common risk factors for infection |
Immunocompromised, COPD, diabetes, advanced age, live in crowded or unsanitary environment, ingest contaminated food/water, impaired tissue integrity, exposed to influenza or tuberculosis, stress |
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Complications of decreased mobility |
Pressure injuries, disuse osteoporosis, constipation, weight loss or gain, muscle atrophy, atelectasis, venous thromboembolism, urinary system calculi |
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How do you manage inflammation? |
RICE Rest, Ice, Compression, Elevation |
