FON 100 final

Discipline

"A unique perspective, a distinct way of viewing all phenomena, which ultimately defines the limits and nature of its inquiry" (theoretical and practical boundaries)

exacerbation

"flare up" occurs when symptoms intensify

Battle-Ax

- Emerged as science & philosophy grew popular during 17th century, religious orders became less common - Nurse Ratched = battle-ax or torturer, treating patients w/ cruelty and disdain

Nurse as Professional

- Florence Nightingale - Before Nightingale, most military men died from infections they acquired afterwards, not their injuries - Used research to come to conclusions & make changes

Purposes of Nursing

- Health promotion - Illness prevention - Health restoration - End-of-life care

Why define nursing?

- Helps the public understand the value of nursing - Helps differentiate activities of nursing from those of medicine - Helps students understand what is expected of them

Angel of Mercy

- Image grew out of influence of religion - Serene and content, with halo or other religious symbol

5 Key characteristics of Therapeutic Communication

1. empathy-under and be sensitive 2. respect- value the client 3. genuiness - respond honestly 4. concreteness - specific terms 5. confrontation

Interventions for undernutrition

1. encourage client to seek counseling for eating disorders 2. devise strategies to improve client appetite (avoid odor) 3. enteral nutrition (through G.I.) 4. parenteral nutrition (IV)

3 branches of goverment

1. executive 2. legislative 3. judicial

Family Health Risk Factors: Families with older adults

Falls and trauma risks Risk for social isolation, depression, and malnutrition (due to retirement) -memory and problem solving abilities changes with age

HIPPA

Health Insurance Portability and Accountability Act was by Congress in 1966 - protect health insurance benefits for workers who lose or change their jobs - protect coverage to person with preexisting medical conditions - establish standards to protect the privacy of personal health information

Complimentary and alternative medicine

Healthcare treatments or services outside the traditional healthcare system

Reflecting Critically About Evaluation: Thinking About Your Thinking

Inquiring Noticing content Analyzing assumptions Reflecting skeptically *RAIN

Evidence-based Practice

Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare.

Sigma Theta Tau International (STTI)

International honor society for nursing to foster nursing scholarship, leadership, service, and research to improve health worldwide.

What are immigrants

New members of a group or country; assume the characteristic of the new culture through learning called acculturation

Pulse oximetry

Noninvasive method of monitoring respiratory status Uses an external device that measures oxygen saturation

NANDA

North American Nursing Diagnosis Association

NANDA-I

North American Nursing Diagnosis Association International

Patricia Benner

Novice to Expert -caring theorist

Responsibility and Delegation

Nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of vital signs, vital sign trends, and decisions based on abnormal vital sign findings. As a student nurse, you are responsible for functioning within your scope of knowledge.

What does it mean to communicate care and concern?

Settling In Attuning (maximally attentive is another key factor in facilitating communication) Acceptance Respecting Enjoying

Kortokoff's Sounds: Fifth Sound

Silence, corresponding with diastole (diastolic BP)

SBAR

Situation Background Assessment Recommendation

SBAR Model

Situation Background Assessment Recommendation *effective for team communication and collaboration

Bradycardia

Slow heart-rate (HR less than 60bpm)

The nurse notes that the client's grandmother is looked to for input whenever questions arise about the client's care choices. Which cultural specific will guide the nurse's plan of care?

Social organization

Pender's Health Promotion Model

These three groups affect health care: 1. individual characteristics and experiences 2. behavior specific cognitions and afect 3. behavioral outcomes

Nursing is about?

Thinking doing caring

4 main concepts of full-spectrum nursing

Thinking, doing, caring, patient situation

Glasgow scale

This is an assessment tool used to determine consciousness in clients. (coma scale)

Direct method

This is done only in in-client setting. A catheter is threaded into an artery under sterile conditions. It is attached to tubing that is connected to an electronic monitoring system. Pressure is constantly displayed as a waveform on the monitor screen.

Sandwich family

Three generation household, where parents care for their parents and their children.

Discharge Summary

Time of departure and method of transportation Name and relationship of person(s) accompanying client at discharge Condition of client at discharge Teaching conducted and handouts/informational matter provided to client Discharge instructions (including medications, treatments, or activity) Follow-up appointments or referrals given

Actual Diagnosis

To detect change in status (improvement or increasing "exacerbation" of problem)

Actual Diagnosis

To detect change in status (improvement, exacerbation of problem)

Collaborative Problem

To detect onset of a complication for early provider notification

Potential Dianosis

To detect progression to an actual problem or an increase or decrease in risk factors Potential=progressuon

Conduction

Transfer of heat from a warm to a cool surface by direct contact ex. patient laying on a cool metal examination table

Convection

Transfer of heat through currents of air or water ex. warm bath or fan

What About Delegation and Supervision?

Transferring responsibility while retaining accountability Includes supervision

Implementation phase

action phase of the nursing process. Emphasizes DOING. Doing, delegating, and documenting *perform or delegate planned interventions

Implementation phase

action phase of the nursing process. The DOING phase! Doing, delegating, and documenting. You can either perform or delegate planned interventions

intentional torts

action taken by one person with the intent to harm another person - criminal law ex. assault, battery, false imprisonment, invasion of privacy

anxiety

anticipation of danger, person worries, feels nervous, uneasy and fearful

Meds affecting color of urine

anticoagulant- red diuretic- pale pyridium- orange (stains) elavil-green/blue Levodopa- brown or black

somatization

anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often and depression

Psychological Responses to Stress

anxiety and fear ego defense mechanisms anger depression feelings, thoughts and behaviors

health problems

any condition that requires intervention to promote wellness or to prevent or treat disease or illness

stress

any disturbance in a persona's normal balanced state

outcomes

any patient response, positive or negative, to interventions, more specific *required on the care plan!

structural abnormalities

anything that restricts or limits the free movement of the chest wall

Illness

appearance of sign and symptoms characteristic of the disease

bioethics

application of ethical principles to healthcare

servant leadership

applies more to supervisors and admin. believes ppl have value as people, not just workers. attitude is employee first manager is there to remove barriers, make the work easier, and provide employees with whatever they need to provide the best pt care.

wisdom

appropriate use of knowledge

Archetypes

are something recurrent, based on facts

Evaluation

are the desired outcomes achieved

Culture specifics

are values, beliefs, and practices that are special or unique to a culture

Culture universals

are values, beliefs, and practices that people from all cultures share

domain

area of activity, study, or interest

psychological stress

arise from life events ex. work pressure, family arguments

validation theory

arises from social work and provides for a way to communicate with older people with dementia

Systemic and pulmonary blood

arteries arterioles: small branches of arteries capillaries veins and venules heart blood vessels red blood cells hemoglobin (carries oxygen) coronary arteries

AEB

as evidenced by

AMB

as manifested by

phenomena

aspects of reality you can observe and experience

P wave

atrial activation

outcome label

broadly stated, neutral label to allow for positive, negative or no change in patient health status

nutrients

building blocks for cells and tissues -supply energy -help manufacturer, repair, and maintain cells found in food

evidence based practice

clinical decision-making that integrates the best available research with clinical expertise and patient characteristics and preferences

therapeutic communication has 5 key characteristics

empathy respect genuineness concreteness confrontation

pulmonary embolus

obstruction of pulmonary arterial circulation by a foreign substance (blood clot, air, fat)

respondeat superior

employer must answer for the negligent acts or omissions of its employees, who are functioning with the scope of their employment

crisis

exists when 1. event in a person's life drastically changes the person's routine and he perceives it as a threat to self 2. person's usual coping methods are ineffective, resulting in high levels of anxiety and inability to function adequately

definition

explains the meaning of the label and distinguishes it from similar nursing diagnosis

other communications

facial expression posture and gait personal appearance gestures touch

Nonverbal messages

facial expressions posture and gait personal appearance distance gestures touch

negligence

failure to use ordinary or reasonable care or the failure to act in a reasonable prudent manner

fidelty

faithfulness, duty to keep promises

fraud

false representation of significant facts by words or by conduct

Dual-earner families

families in which both husband and wife have jobs

Traditional nuclear family

father, mother, and at least one child dad works, mom stays at home

ketones

fats converted into alternative fuel - raise acidity of the blood

satiety

feeling of fullness

Attitudes

feelings and traits of mind. Your attitudes determine whether you will use your thinking skills fairly and with an open mind.

Prodromal stage

first appearance of vague symptoms

family assessment

health behaviors and beliefs from family interactions

Maladaptive coping

ineffective unhealthy style, temporary fix ex. substance abuse, overeating

Minerals

inorganic elements found in nature - occur in food either naturally or as additives

sterile specimen

inserting a catheter into the bladder or by withdrawing a sample from catheter

integrating the change

last step. after the change has been made, its important to make sure everyone has moved into a new comfort zone

complaint

legal document outlining how the plaintiff has been harmed by another person

Factors that influence pulmonary function

life span and development environment lifestyle medications smoking

high priority problems

life threatening or that could have a destructive effect on the client ex. ineffective airway clearance, substance abuse

Local

limited area of the body

Neuromuscular abnormalites

limited movement of the muscles that interfere with the regulation of breathing (trauma, stroke, meds)

pyuria

pus in the urine

How to communicate assertively

question care decisions openly and honestly use I statements focus on the issue, not on participants use effective nonverbal language don't invite negative response use "fogging" use negative inquiry strive for a workable compromise

situational stress

random, unpredictable, affect everyone equally ex. hurricane, accident

analysis/diagnosis

readiness for enhanced communication impaired verbal communication impaired communication

Self Knowledge

realize that your beliefs, values and experiences affect your thinking and can be misleading 1. what biases and stereotypes may have influenced my interpretation of data? 2. did i rely too much on past experiences? 3. did I rely too much on the client's medical diagnosis, the setting, or what others say about the client instead of on the data?

deductive reasoning

reasoning in which a conclusion is reached by stating a general principle and then applying that principle to a specific case

erythema

redness of skin (vasodilation/inflammation)

What is discrimination

refers efers to the behaviors manifestation of that prejustice

distributive justice

requires fair distribution of both benefits and burdens

Mandatory Reporting Laws

requires healthcare workers to report communicable diseases, physical, sexual and emotional abuse or neglect of vulnerable individuals whether you suspect it or have actual evident of it. - protect people who can't protect themselves

Kussmaul's respirations

respirations that are regular but abnormally deep and increaseed in rate

Local Adaption Syndrome

response to stress involving specific body part, tissue, or organ - short term attempt to restore homeostasis -localized 1. Reflex pain response 2. inflammatory response

dehiscence

rupture/separation of one or more layers of a wound

repair

scar tissue replaces the original tissue

BP is recorded as

systolic/diastolic

THINK

talk with an attorney have concrete evidence institute a survival plan note the nature know your reporting options

preceptor

teach about job

transactional leadership

telling style reward and punishment change of command

content

the actual subject matter, words, gestures, and substance of the message

who created the nurse practice acts for each state?

the legislative body created a board of nursing to enforce NPA

Campinha-Bacote

the nurse must see themselves as becoming culturally competent rather than being culturally competent

liability

the person is financially or legally responsible for something

endotracheal tubes

tube inserted through mouth into trachea to establish airway (INDIRECT IN TRACHEA MOUTH FIRST)

Peristalsis

under control of Nervous system contractions occur every 3-12 minutes mass peristalis sweeps occur 1 to 4 times each 24 hour period 1/3 to 1/2 of food waste is excreted in stool within 24 hours

public speaking

unique form of group communication

validate

verify or double check

Family as context

view the family as either a resource or a stressor in your patient (focus on ill individual)

credentialing

voluntary form of self regulation

coping response

voluntary or involuntary, response aimed at restoring equilibrium

value neutrality

we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become nonjudgemental when providing care to clients.

Theories of aging

wearing and tear: more you use it, joints, cease function genetic : preprogrammed, finite # of cell division cellular malfunction: cells break down autoimmune: cells change with age

Always ask

what brought you in today?

value system

your value set ranked from the most important value to the least important value

What is cultural competence

• Having the knowledge, abilities and skills deliver care congruent with clients cultural beliefs o Unconsciously incompetent; consciously incompetent; consciously competent; unconsciously competent

What is racism

• Is a form of prejudice and discrimination based on the belief • Race is the principal determining factor of human traits and capacities • The racial differences produce an inherent superior

How can I become culturally competent

• LIVE and LEARN • Like; Inquire; Visit; Experience; • Listen; Evaluate; Acknowledge; Recommend; negotiate

What is culture competent: QSEN

• Provide patient centered care with sensitivity and respect for the diversity of human experience • Seeks learning opportunities with patients who represent all aspects of human diversity • Recognize personal held attitude about working with patients from different ethnic cultural and social background

Handmaiden

- Male physician in dominant role, w/ female nurse assisting doctor or at bedside of patient - Initially, roles of nurses were to bathe, feed, & support patient

ANA has recognized these organization for describing nursing diagnosis

- NANDA-I - Clinical Care Classification - Omaha System - Perioperative Nursing Data Set - International Classification for Nursing Practice

Naughty Nurse

- Sexy, risqué, mindless, irrelevant

How can nursing improve its recognition as a profession?

- Standardizing educational requirements - Uniform continuing education requirements - Increased participation of nurses in professional organizations - Educating the public about the true nature of nursing practice

Benner's Model Stage 2: Advanced Beginner

- Usually a new graduate - Focuses more on aspects of clinical situation, use more facts, make more sophisticated use of rules, recognize similarities in situations - Can distinguish abnormal findings, but can't understand significance

Thing a nurse can NOT do:

- legally diagnose or treat medical problems

Etiology suggests interventions

- the aim of the nursing interventions is to remove or alter factors contributing to the problem

defamation of character

- was false - was made to another person/persons - caused the defamed person to experience shame and ridicule and had a negative impact on the persona's reputation - was made as a statement of fact rather than as an opinion

Vital Signs

-A means of assessing vital or critical physiological functions -Variations reflect a person's state of health and/or functional ability of the body systems -One of the most frequent assessments you will make as a nurse -The importance of accurate assessments, interpretation, and documentation of VS cannot be overemphasized. **temp, pulse, respiration, BP, oxygen saturation, pain, *Independent- do NOT require an order

What classification systems are commonly used in nursing?

-APA -Manual of the International Classification of Disease and Related Health Problems -Current Procedural Terminology

Health

1. Ideal state of physical wellness and mental well-being 2. A positive concept emphasizing social and personal resources, as well as physical capacities 3. Power of the soul to cope with varying conditions of the body

Why do nurses need teaching skills?

-Teaching clients is part of independent nursing practice. -ANA standard related to promoting health demands skill in teaching clients. -Clients/families need information for decision making. -Shorter hospital stays increase need for teaching about home-care needs. -Teaching facilitates compliance and shortens hospital stays -Teaching empowers clients and families.

4 parts of NANDA-I taxonomy

1. label 2. definition 3. defining characteristics 4. risk factors *Diagnoses define likely risks!

Critiques of NANDA

1. labels are hard to use or not useful 2. diagnoses have not been researched 3. its dehumanizing and stereotypes the patient

Lab test that indicate nutritional status

1. Blood glucose 2. serum protein level (albumin,prealbumin, transferrin) 3. lymphocyte count (WBC) 4. hemoglobin

BP Regulation is influenced by 3 factors

1. Cardiac function (increase CO = increase BP) 2. Peripheral vascular resistance (resistance due to frictions in vessel walls) 3. Blood volume (5 liters)

Health Promotion Programs

1. Change lifestyle and behavior 2. protect the environment 3. Disseminate info 4. acesses wellness and appraise health risk

Documents included in care plans

1. Client Profile and Basic Needs 2. Preprinted, Standarized plans

Factors that Affect Nutrition

1. Developmental Stage (infants to elders, pregnancy) 2. Educational Level 3. Knowledge of Nutrition (concepts of access) 4. Lifestyle choices 5. Ethnic, Cultural, and Religious Practices 6. Disease Processs 7. Functional Limitations

Five stages of illness behavior

1. Experiencing symptoms 2. Sick role behavior 3. Seeking professional care 4. Dependence on other 5. Recovery *ESS DR.

what makes a population vulnerable?

1. limited economic and social resources 2. age 3. chronic disease 4. history of abuse or trauma 5. not having access to health care

How to draw a conclusion about a health status?

1. make inferences 2. identify problem etiologies

Critical thinking

1. making interdisciplinary connections 2. predicting 3. generalizing 4. explaining 5. therapeutic judgement

5 element of communication process

1. message 2. sender 3. channel 4. receiver 5. feedback

Age related physical changes

1. musculoskeletal 2. cardiovascular 3. respiratory 4. gastrointestinal 5. integumentary 6. genitourinary 7. neurological 8. endocrine 9. sensory 10. cognitive 11. personality

Conclusions about health status:

1. nursing diagnosis 2. Medical diagnosis 3. collaborative problems 4. patient strength 5. no problem

Purpose of teaching

1. perform self care 2. make informed decisions about their health care options 3. promote wellness 4. prevent or limit illness 5. facilitate coping with stress

4 basic concepts of Nursing Theory (Metaparadigm)

1. person 2. environment 3. health 4. nursing

what 2 things does a diagnostic statement consists of?

1. problem 2. etiology *should describe the client's health status as specifically as possible

3 components of ANA standards or practice

1. professional standards of care 2. professional performance standards 3. practice guidelines

Responsibility of IRB (Institutional Review Board)

1. protect the research participants from harm 2. ensure that the research is of value

Challenges to being an effective leader

1. resources are scarce 2. resources have alternative uses 3. individuals want different things or have different preferences

Research Process

1. select and define problem 2. select a research design 3. collect data 4. analyze data 5, use research finding

Body Composition Assessment

1. skinfold measuremtns 2. circumferences- girth 3. Body mass index 4. underwater weighing 5. imaging techniques

Make inferences

inferences are only your reasoned judgement about a patient's health status -don't think as right or wrong, but as more accurate or less accurate - no such thing as a perfect diagnoses

nurture

influence of the environment on the individual

nursing informatics

informatics applied to nursing practice, education, and research

4 examination techniques in order for oxygenation

inspect palpate percuss auscultate

Physical assessment of the abdomen

inspection (observe contour, any masses, scars) auscultation (listen for bowel sounds in all quadrants) percussion (expect resonant sound or tympany) palpation(muscular resistance, tenderness, enlargement of organs, masses)

assessment

language barrier cognitive skills sensory perceptual alterations physiological barriers

Client Factors Affecting Effective Therapeutic Communication (LISP)

language barrier impaired cognitive skills sensory-perceptual alterations physiological barriers

24 hour specimen

large container to preserve all voided in a 24 hour period

macrosomia

large-bodied baby commonly seen in diabetic pregnancies

humor

laughter can create physiological changes that contribute to well-being and provide an emotional release in a tense situation, thus positively influencing the patients attitude and healing -be cautious

statute

law passed by Congress or by a state legislative body - benefit of the society as a whole

administrative law

laws that govern activities of administrative agencies by federal level by Congress and at state level by its legislative bodies

Medical Malpractice

lawsuit brought against a healthcare provider for damages when there has been death of, injury to, or other loss to the person being treated

Qualities of an effective manager

leadership, clinical expertise, business sense

palpation

light touch, progressing deeper touch, using the pads of the fingers

oils

lipids that are liquid at room temperature

fats

lipids that are solid at room temperature ex. butter, even when melted Types: monounsatured, polysaturated, saturated, trans fat, dietary cholesterol

value set

list of your values

Enhancing Therapeutic Commmunication

listen actively establish trust be assertive restate, clarify and validate message interpret body language share your observations to clarify use open ending questions use silence summarize the conversation

direct auscultation

listening with the unaided ear for sounds made by the client

indirect auscultation

listening with the use of a stethoscope

denotation

literal meaning of a word (dictionary)

inflammatory response

local reaction to cell injury, either by pathogens or by physical, chemical, or other agents. Pain, heat, swelling, redness,loss of function vascular: constriction, histamine, dilation, hyperemia cellular: phagocytes

Wound assessment

location size appearance draining redness swelling

implementing the change

magnitude of the change complexity of the change pace of the change stress level of those involved

older adults

may need supplements of calcium, vitamin D, and B12 adult failure to thrive can occur

diabetic foot care

may not expirience pain with a foot injury, so treatment may be delayed. If untreated, a minor foot lesion can lead to gangrene/amputation. Refer to cindy bergs story about her mother and page 588 in the book

knowledgde

meaningful info created by grouping and compiling info - previously known or new

Criteria

measurable characteristics, properties, attributes, or qualities that describe the the specific skills, knowledge, behavior and attitudes are desired or expected

inflammation

mechanism for eliminating invading pathogens -stimulated by trauma as well as by pathogens *DO NOT confuse inflammation with infection

Stool Collection

medical aseptic technique is imperative -wear gloves wash hands before and after glove use do NOT contaminate outside of container with stool obtain stool and package, label, and transport according to agency policy

channel

medium used to send the message - pamphlets, telephone, text message, face to face

channel

medium used to send the message (face to face) touch (nonverbal)

orientation phase

meet the client and introduce yourself and your role in the relationship

Orientation Phase

meeting the client, introductions, establishing rapport and trust

attitudes

mental dispositions or feelings toward a person, object, or idea

concepts

mental image of a phenomenon - formed by generalizing an abstract idea from your experiences and observations

conceptual model

model expressed in language (symbols or words)

body system (medical ) framework

model is useful for identifying medical problems, but it needs to be combined with other models to provide the holistic data you need to identify both nursing and medical problems

Finances

money does buy access to healthcare and healthcare choices and thus nourishes wellness. Health Insurance is often tied to employment or income level, and health insurance indicates which providers you have access to and what services are available to you.

transpersonal caring moments

moral ideal rather than task oriented - actual caring occasion or relationship exisits

utilitarianism

most familiar consequentialist theory -asserts that the value of an action is determined by its usefulness - act must result in the greatest good for the greatest number of people

Scientific Management

motivate employees with pay by the piece "fastest way is the best way"

health protection

motivated by a desire to avoid illness

upper G.I.

mouth (mastication) pharynx (epiglottis) esophagus (peristalsis toward stomach) stomach (chyme)

Oral hygiene

mouth care removes food particles and secretions promotes a better appetite reduces incidence of pneumonia in older adults

Ventilation

movement of air into and out of the lungs

chest physiotherapy

moves secretions to the large central airways for expectoration/suctioning

adolescents

muscles growth body appearance pressures

Respiratory Effort

nasal flaring retractions use of accesory muscles grunting body positioning paroxysmal nocturnal dyspnea conversational dyspnea stridor wheezing

micronutrients

needed only in small amounts -regulate body functions 1. vitamins 2. mineral *provide no energy

hearing aids

never go in water electronic devices that are worn to correct a hearing loss.

nocturia

night urination

Exogenous

nonsocomial-in hospital Produced outside the body

Endogenous

norma flora multiply and cause infection Produced within the body

Eupnea

normal respirations

informal planning

not written, occurs while you are performing other nursing process steps

Environmental factors

nourish wellness environ. pollutants are a common cause of illness

NPA

nurse practice acts are statutory laws passed by each state's legislative body that defines the practice of nursing - regulate nursing practice to protect the health, safety, and welfare of general public - define the scope of nursing practice - approve programs providing prelicensure nursing education to students - define nursing and boundaries

respect of dignity

nurse's respect for the intrinsic worth of each person, without respect to age, race, religion, medical condition, or any other factors

Scope of Practice

nurses must be familiar with the definition of nursing at their level to plan and implement care that is consistent with their scope

Leninger

nurses provide culturally congruent care

nursing home

nursing care facilities skilled and unskilled nursing care for older adults and adults with disabilities

ethics of care

nursing philosophy directs attention to the specific situation of individual patients, viewed within the context of their life narrative

Lifestyle

nutrition, exercise, substance abuse, occupational hazards, pregnanzy

justice

obligation to be fair

Ethical knowledge

obligations, right and wrong.

indicators

observable behaviors and stats you can use to evaluate patient status

inspection

observation and visual exam of client, as well as use of equipment such as an otoscope

reciever

observer, listener, interpreter(decoding) determines meaning of what the sender is saying

directive interviewing

obtain factual, easily categorized info, or in an emergency situation - mostly closed ended questions -nurse controls topic

secondary data

obtained "second hand" ex. medical record, report from another nurse

enuresis

occassional wetting

interpersonal communication

occurs between 2 or more people - face to face most common

Secondary enuresis

occurs in children who have had at least 6 months of nighttime dryness

assault

occurs when a nurse intentionally place a patient in immediate fear of personal violence or offensive contact

impaired nursing practice

occurs when the nurses ability to perform the essential functions of nursing is diminished by chemical dependence on drugs or alcohol or by mental illness

assault and battery

occurs when there is the intent to cause a person fear combined with an offensive or harmful contact

Independent interventions

one that registered nurses are licensed to prescribe, perform, or delegate based on their knowledge and skills *does NOT require a provider's order ex. turn a patient, educating,

Classification of Wounds

open/closed acute/chronic clean/contaminated superficial/partial/ full thickness penetrating (stab, gunshot, injection)

secondary infection

opportunistic infection after a primary (predisposing) infection

Vitamins

organic substance that are necessary for metabolism or preventing a particular deficiency disease Fat soluble: A, D, E, K Water soluble: B, C

Lipids

organic substances that are insoluble in water "FAT" *key components of lipidproteins 1.back up energy source 2. organ insulation/protection 3. flavor and satiety LDL- bad cholesterol HDL- good cholesterol *9 kcal/g

nursing theory

organized set of related ideas and concepts that 1. assist us in finding meaning 2. organize our thinking around an idea 3. develop new ideas and insight

Using artifical airways

oropharyngeal nasopharyngeal endotracheal tubes tracheostomy tube

Planning

outcomes/interventions

to diagnose hypertension the pressure needs to be

over 150 on two or more separate occasions

overflow incontinence

overdistention and overflow of bladder

Etiologies for overnutrition

overeating lack of exercise endocrine problems

SA node

pacemaker

insulin

pancreatic hormone that promotes the movement of glucose into the cells for use

Democratic leadership

participative leadership shares the planning, decision making, and responsibility for outcomes with members of the group

school age children

peers and advertisers influence the child's food choices

centenarians

people aged 100 years and older

Personal factors that influence outcome of stress:

perception health status support stytem hardiness age life experiences

ongoing assessment

performed as needed, at any time after the initial database is completed - make observations at every contact with client - used to identify new problems or follow up on previous ones

Intermittent evaluation

performed at specified times to judge progress toward goal or modify care plan.

Ongoing evaluation

preformed while implementing, immediately after intervention, and at each patient contact - to judge progress toward goal or modify care plan

living will

prepared by an alert and oriented individual that gives directions to others about the person's wishes regarding life prolonging treatments if the person becomes unable to make those decisions

Managing urinary incontinence

prevent skin breakdown (maceration) encourage/teach lifestyle modifications (schedule) implement bladder training (every 2 hours) encourage client to perform Kegel exercises use anti-incontinent devices as needed strategies to promote independent urination pharmacological interventions surgical interventions parental teaching for enuresis

Nursing care for catheterization

prevent urinary tract infection prevent backflow of urine encourage fluids ensure perineal hygiene

Interventions for Pressure Ulcers

prevention meticulous skin care and moisture control adequate nutrition frequent reposition therapeutic mattresses client/family teaching

morals

private, personal or group standards that consider in a broad, general manner what is good or bad, right or wrong

medium priority

problems that do not pose a direct threat to life, but that may cause destructive physical or emotional changes ex. ineffective denial, unilateral neglect

Low priority

problems that require minimal supportive nursing interventions ex. risk for delayed development, mild anxiety, interrupted breastfeeding

Scientific method

process in which the researcher, through senses, systematically collects observable, verifiable data to describe, explain and predict events 1. objectivity or self correction (keep beliefs separate) 2. use of empirical data (senses)

development

process of adapting to one's body and environment over time, which is enabled by increasing complexity of function and skill progression

metabolism

process of changing and using nutrients in body 1. anabolism (formation of larger molecules from smaller) 2. catabolism (breakdown of larger molecules into smaller)

Delegation

process of directing another person to perform a task or activity- transfer authority or responsibility but obtain accountability! You cannot delegate any intervention that requires independent, specialized nursing knowledge, skill, or judgment

defecation

process of elimination of waste

discharge planning

process of planning for self care and continuity of care after the patient leaves a healthcare setting *discharge planning begins at assessment!

encoding

process of selecting the words, gestures, tone of voice, signs and symbols used to transmit the message

Mechanical ventilator

produces a controlled flow of gas into the patients airways, volume cycled deliver a predetermined volume of air, pressure cycled works off of pressure (machine that assists a patient to breathe)

physical assessment

produces primarily objective data - inspection -palpation -percussion -auscultation *PIPA

Stress Reduction Interventions

promote adequate nutrition help client establish routine with exercise teach client about getting 7-8 hours of sleep encourage participation in leisure activities help manage time, balance responsibilities advice not to maladaptive behaviors

nondirective interviewing

promote communication, build rapport or help the patient to express feelings - patient controls subject matter -open ended questions

ADLS/self-care ability/facilitating hygiene has one goal and that is it

promote self care

Administering respiratory medications

promote ventilation and oxygenation by their effects on the respiratory system itself (bronchodialators, antiinflammatory agents)

Promoting Normal Urination

provide privacy assist with positioning facilitate toileting routines

Promoting regular defecation

provide privacy correct position timing - often occurs after meals - some clients may not assistance encourage fluids exercise proper diet

community assessment

provides info about demographics, resources, health concerns, points of referral, environmental risks, norms and values

spiritual health assessment

provides insight into how a client interprets life events and health, more than just religious preference

Empowerment

psychological state, a feeling of competence, control, and entitlement that a person experiences - self determination -meaning -competence - impact *feeling

Pulmonary circulation abnormalities

pulmonary embolus pulmonary hypertension

nursing interview

purposeful, structured communication in which you question patient together subjective data for the nursing database -after initial, interviews are informal, brief and narrowly focused

data

raw, unprocessed numbers, symbols or words that have no meaning by themselves

human responses

reactions - can be biological, emotional, interpersonal, social or spiritual

CO2

regulates brain to breathe

Nurse Practice Acts

regulates the practice of the nurse in individual states and specifies which portions of the assessment can legally be completed by individuals with different credentials

communicating

reinforces constructive behavior discourages unproductive behavior provides recognition

(r/t)

related to connect the problem and etiology, believing this phrase due to implies a direct causal relationship

Stress management techniques

relaxation exercise meditation visualization or imagery acupuncture chiropractice adjustments touch therapies massage reflexology

traditional model of healthcare decision making

relies on each practitioner's personal experience and judgement

Artificial Eye care

remove daily to clean w/ mild detergent and water -wear gloves -raise upper lid/ depress lower lid -release suction

regeneration

replacement of the damaged cell with identical or similar cells

healing

replacement of tissue by regeneration or repair

false imprisonment

restraining a person without proper legal authorization

venous system

returns the deoxygenated blood to the heart and lungs veins and venules: thin, muscular but inelestic walls that collapse easily

consequentialist

rightness or wrongness of an action depends on the consequences of the act rather than on the act itself

NANDA diagnosis for Development

risk for disproportional growth adult failure to thrive delayed growth and development risk for delayed development age specific problems

Cardiac Cycle

sequence of mechanical events that occurs during a single heartbeat - simultaneous contraction of the 2 atria, followed a fraction of a second later by the simultaneous contraction of the ventricle

Types of Wound Drainage

serous exudate: straw colored sanguineous:bloody, red, thick serosanguineous mix: bloody and straw colored, pink, thinner purulent: yellow, contains pus

conceptual framework

set of concepts related to form a whole aka, theoretical framework

personal value system

set of values that you have reflected on and chosen that will help you lead a good life

marasmus

severe undernourishment causing an infant's or child's weight to be significantly low for their age (e.g., below 60 percent of normal).

objective data

signs, gathered through a physical assessment or from laboratory or diagnosis tests ex. vital signs, skin color, urine output

hypertension is a

silent killer

policies and procedures

similar to rules and regulations - created due to a situation that occurs frequently

ethical dilemma

situation in which a choice must be made between two equally undesirable actions -there is no clearly right or wrong option

SBAR

situation, background, assessment, recommendation

Maceration

skin breakdown when skin is damp

SPICES

sleep disorder problems eating/feeding Incontinence Confusion Evidence of falls Skin break down

Sleep & Rest

sleep nourishes health allows mind to slow down and rejuvenate

Enculturation

socializing in one's culture

maceration

softening of skin

mentor

someone more experienced who provides career development assistance -provide guidance

mentor

someone with more experience who provides career development assistance. role model to novices

preceptor

someone with more experience who provides practical teaching and guidance for a student or new employee

belief

something that one accepts as true - not always based on fact

Kardex

special kind of paper form or folding cold that briefly summarizes a patient's status and plan of care -demographic data - medical diagnoses -allergies -diet/activity orders -safety precautions -IV therapy orders -ordered treatments summary of medication ordered -special instructions such as preferred intensity of care or isolation orders

open ended questions

specify a topic to be explored, but phrase it broadly to encourage the patient to elaborate - to obtain subjective data

Verbal communication

spoken and written words to send a message

slander

spoken or verbal form of defamation of character

informational responsibilities

spokesperson, monitoring, public relations

systemic

spread by blood/lymph

critical pathways

standardized plans of care for frequently occurring conditions for which similar outcomes and interventions are appropriate for all patients who have the condition

Managing a bowel diversion

stoma assessment and care -pay attention to skin care/peristomal skin assessment -monitor the amount and type of effluent be attentive to client's psychosocial neds -be profesional, show acceptance -attend to odor control - address client participation in ostomy care client teaching for home care

Types of urinary incontience

stress urge mixed overflow functional reflex total

Environment

stress, allergies, air quality, temp/humidity

Purnell and Paulanka

stresses teamwork in providing culturally sensitive and competent care

percussion

striking a body surface with the tip of a finger, which produces vibrations and sounds, depending on what is under the area that is tapped (air, fluid, solid)

anger

strong, uncomfortable feeling of animosity, hostility, extreme indignation, or displeasure

Pulmonary system abnormalities

structure airway inflammation/obstruction alveolar-capillary membrane disorder atelectasis

Carol Gilligan

studied moral development in women 1. Caring for oneself 2. caring for others 3. caring for self and others

nutrition

study of food: how it affects the human body and influences health and metabolism

class

subdivision of a domain ex. health awareness is a class under health promotion ex. digestion is a class under nutrition

primary data

subjective and objective data obtained from the client

teratogens

substances that interfere with normal growth and development

vicarious

substituted liability - law will assign liability to a person or entity that did not directly cause the injury but with who you have a special kind of relationship

Incubation

successful invasion of the pathogen into the body and the first appearence of symptoms

Decline

successfully reducing the number of pathogeniz microbes signs/symptoms begin to fade

Artificial airway patency

suctioning (removes secretions to maintain patency)

sudden infant death syndrome (SIDS)

sudden, unexplained death of an infant

glycosuria

sugar in the urine

colostomy

surgical procedure that brings a portion of the colon through a surgical opening in the abdomen

urinary diversion/urostomy

surgically created opening for elimination of urine

edematous

swollen

model

symbolic representation of a framework or concepts

remission

symptoms are minimal to none

mixed incontinence

symptoms of urge and stress incontinence present

subjective data

symptoms, information communicated to the nurse by the client, family or community -perspective, thoughts, feelings, beliefs, and sensations of the person giving the data

taxonomy

system for classifying ideas or objects based on characteristics they have in common

constitution

system of fundamental laws and principles that prescribes the nature, functions and limits of a government - gives each the power to govern itself and to pass laws to promote health, etc.

assessment

systematic gathering of information related to physical, mental, spiritual, socioeconomic, and cultural status of an individual

ethics

systematic study of right and wrong conduct formal process for making consistent moral decisions

Nursing research

systematic, objective process of anlayzing phenomena of importance in nursing - clinical practice arenas, nursing education, nursing administration

mind-mapping

technique for showing relationships among ideas and concepts in a graphical or pictorial way - stimulates whole brain and critical thinking

dorsum of the hand

temperature

Peak flow monitoring

test that measures the rate of air flow, or how fast air is able to pass through the airways (amount of air exhaled with forcible effort)

older adulthood

the cognitive, psychosocial, and moral progression from 65 years of age and older *fastest growing age group -begins at 65 - most health problems are chronic - frail and fragile

pharmacogenomics

the discipline that blends pharmacology with genomic capabilities

Collaborative (Interdependent) Interventions

the essence of all teams, working together as a team -carried out in collaboration with other healthcare team members. Nurses care for the whole person, their responsibilities often overlap with those of other team members

Collaborative (Interdependent) Interventions

the essence of all teams, working together as a team -carried out in collaboration with other healthcare team members. Nurses care for the whole person, their responsibilities often overlap with those of other team members can be risky because there are more chances at error

Bill of rights

the first 10 amendments to the US Constitution

The longer patient is in the hospital

the greater chance of infection

Wellness diagnosis

to assess a client's wellness practices. (A health promotion)

how is nursing process used to promote health?

to develop an individualized plan of care in collaboration with patients, based on mutual goals and respect

What is the main reason for research?

to establish EVIDENT BASED PRACTICE

Upper Respiratory Infections

toddlers infectious disease of the upper respiratory tract involving the nasal passages, pharynx, and bronchi.

Children and urine

toilet training requires - mature neuromuscular system - adequate communicate skills *usually around 18-36 months problems include enuresis and nocturnal enuresis

intonation

tone of voice

Undernourished

too few calories/nutrients

Obesity

too many calories

evisceration

total separation of the layers of the wound with internal viscera protruding through the incision

Smoking

toxic to the lungs cause cancer most common cause of COPDr's

trait theory

traits distinguish a leader. what leader is. usually have excellent interpersonal skills, high self-esteem, creativity, willingness to take risks, and ability to tolerate consequences from risks

format variation

1. specify 2. secondary to (pathophysiology or disease process) 3. 2 part NANDA- I label 4. adding words to the NANDA-I labels 5. unknown etiology 6. complex etiology

Components of a goal statement

1. subject 2. action verb 3. performance criteria 4. target time 5. special conditions *SPATS your goal out!

inductive reasoning

A type of logic in which generalizations are based on a large number of specific observations.

Hardiness

A very strong positive force to live and enjoying the ride

Factors that may influence a persons response to health and illness

Age, personal bias, personality, previous experience.

heritage group

Are also made up of individuals who share race, religion or ethnic heritage

subculture

Are groups within a larger culture or social system, that have characteristic that are different from those of the dominant cultures

Kortocoffs Sounds: First sound

As you deflate the BP cuff, a sound that occurs during systole (systolic BP)

Korotkoff's Sounds: Second Sound

As you further deflate the cuff, a soft swishing sound caused by blood turbulence

Nursing Process

Assesment Diasgnosis Planing outcomes/interventions Implementation Evaluation ADPIE

Nursing process

Assessment Diagnosis planning outcomes planning interventions implementation evaluation *ADPIE

Primary or essential hypertension

Diagnosed when there is no known cause for the increase Accounts for at least 90% of all cases of hypertension

Dyspnea

Difficult or labored breathing

Arterial blood gases (ABGs)

Directly measures the partial pressures of oxygen, carbon dioxide, and blood pH

Ethnicity

Ethnicity refers to a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics.

Risk factors

Event, circumstances, or conditions that increase the vulnerability of a person or group to a health problem - environmental, physiologial, psychosocial, genetic, or chemical *similar to etiologies (of potential problems)

Chemical Respiration

Exchange of oxygen and carbon dioxide PERFUSION Transport of oxygen and carbon dioxide throughout the body Exchange of gases between capillaries and tissues Chemical- Capalliaries

Resistance Stage

Goal: maintenance of homeostasis involves using coping mechanisms - psychological -physical *failure to adapt leads to 3rd phase

Examples of Teaching Strategies

Group discussion Demonstration/return One-to-one instruction and mentoring Audiovisual materials Printed materials Role-modeling Online sources of information lecture

What is ethnic group

Have some characteristic in common

Wheeze

High-pitched continuous musical sounds, usually heard on expiration

Focus Charting®

Highlights the client's concerns, problems, or strengths in three columns: Column 1: Time and date Column 2: Focus or problem being addressed Column 3: Charting in a DAR format: Data, Action, Response *acute care

Home Healthcare Documentation

Homebound status and in need of skilled care -Assessment highlighting changes in the client's condition -Interventions performed (wound care, teaching, etc.) -Client's response to interventions -Any interaction or teaching that you conducted with caregivers -Any interaction with the client's physician

Vulnerable Populations as Subcultures

Homeless Poor Mentally ill People with physical disabilities Young Elderly Some ethnic and racial minority groups

Facility Standards for Monitoring

Hospital: every 4 to 8 hr Home health setting: each visit Clinic: each visit Skilled nursing facilities (SNFs): weekly to monthly

Nursing settings

Hospitals, clinics, long-term care, home health care, hospice, surgery centers, physician's offices, nursing education, community-based centers

Center or one the left side of chest

How can you differentiate cardiac pain from other chest pain? (location)

Stereognosis

Identify an object without sight

Diagnosis

Identify clients health needs based on review of assessment data

Family Health Assessment

Identifying data Family composition Family history and developmental stage Environmental data Family structure Family functions Health beliefs, values, and behaviors Family stressors and coping Abuse and violence within family Family communication patterns Caregiver role strain Social isolation

wheel of wellness

If one spoke of the wheel is weak, then the whole wheel is week 1. emotion 2. intellectual 3. physical 4. spiritual 5. social/family 6. occupational

Orthopnea

Inability to breathe when horizontal

What is biological variation

Includes way in which people are different genetically and physiology

Stages of infection

Incubation Prodromal stage Illness Decline Convalescence

What is the culture of healthcare

Indigenous healthcare system, professional healthcare system, nursing and other subculture, traditional and alternative healing,

Health and illness

Individual experiences, emerging from each person unique responses - influenced by the client's attitude and lifestyle choices

Respiratory distress syndrome (RDS)

Infants The condition resulting from inadequate production of surfactant and the resultant collapse of alveoli

Phases of Healing

Inflammatory phase- cleansing - hemostatis - inflammation Proliferative-Granulation - regeneration/healing Maturation: Epithelialization - remodeling

Culture

Influences health decisions, behaviors, perceptions, and view self as well or ill Influences responses to illness

Theoretical knowledge

Information, facts, principles, EBT

Course of Fever

Initial—Febrile episode (temp is rising) Second—Course (temp has reached maximum/ set pt.) Third—Defervescence or crisis- temp returns to normal

Personal value

Is a principle or standard that has meaning or with of an individual

Practice

Is a set of behaviors that one follows

Cultural archetype

Is a similar model which you learned about

Cultural stereotype

Is a widely held but oversimplified and unstained beliefs that all people of a certain respects

what is communication

Is an exchange of information, ideas, and feelings; verbal and non-verbal

What is male chauvinism

Is common in many cultures and in healthcare setting

What is folk medicine

Is defined as the belief and practices that the members of a cultural group follow when they are ill

What is alternative medicine

Is defined as therapies used instead of conventional medicine

What is bias

Is one sidedness; tendency to lean a certain way and pack of impartiality

What is the professional healthcare system

Is run by professional healthcare providers who has been formally educated and trained for their appropriate role and responsibilities

What is ethnicity

Is similar to culture in that it refers to groups where members share a common social and cultural heritage that is passed down from generation

What is sexism

Is the assumption that members of one sex are superior to those of the other sex

domain culture

Is the group that has the most authority or power to control value and reward with punish

What is socialization

Is the process if learning to become a member of a society or group

Reflecting Critically About Nursing Orders

Is the set of orders complete? Is each order technically complete? Are the orders clear, specific, and precise? Is the order individualized for this particular client? Are the orders concise? Which orders have priority?

Ethnocentrism

Is the tendency to think that your own group (cultural, professional, ethnic or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong

What is cultural stereotype

Is the unsustained belief that all people of a certain racial or ethnic groups

What is commentary medicine

Is the use of rigously tested therapies to complement those of conventional medicine

Spiritual Development Theory

James Fowler - faith as a universal human concern and as a process of growing in trust

Managing Nutritional Imbalances: Planning

Key point: Must identity the etiology of the imbalance - ask patient if its correct is it mechanical, financial, dislike??? *Promotes healthy and reduction of chronic disease associated with diet and weight

Practical knowledge

Knowing what to do and how to do it., processes (The decision process and nursing process) procedures(how to give an injection)

Barriers to Culturally Competent Care

Lack of knowledge Emotional responses Ethnocentrism Cultural stereotypes-which are not always negative Prejudice Discrimination Racism Sexism Language barrier Street talk, slang, jargon

Indirect or noninvasive

Most common Accurate estimate of arterial BP obtained by external measuring devices

Factors That Affect Client Learning

Motivation Readiness to learn Physical condition Emotions Timing Active involvement Feedback given Repetition Learning environment Scheduling of the session Amount and complexity of content Teacher/learner communication Belonging to a special population Developmental stage Culture Health literacy

MRM

Mutual Recognition Model - allow nurses whose primary state of residency is in a compact state to practice in other compact states without obtaining a new license

what two nursing organization have been responsible for making diagnosis part of the professional nursing role?

NANDA-I American Nursing Association

Family Nursing Diagnosis

NANDA-I family diagnoses describe the health status of the family as a whole.

Nursing Interventions Classification

NIC -Consists of a label, a definition, and a list of specific activities -NIC interventions are linked to NANDA diagnoses and NOC outcome labels -NIC includes interventions applicable to all settings *ONLY INTERVENTIONS

Nursing Interventions Classification

NIC -Consists of a label, a definition, and a list of specific activities -NIC interventions are linked to NANDA diagnoses and NOC outcome labels -NIC includes interventions applicable to all settings ONLY INTERVENTIONS

Nursing Interventions Classification

NIC -consists of a label, definition, and a list of specific activities -linked to NANDA diagnoses and NOC outcome labels -includes interventions applicable to ALL settings *ONLY INTERVENTIONS!

Incontinence

NOT a party of aging involuntary loss of urine

Collective bargaining

Negotiating that allows nurses to seek better wages and working conditions as a group rather than individually

Health

Nurses understand health and illness as individual experiences, emerging from each patient's unique responses.

Who Do Nurses Teach?

Nursing assistive personnel (NAP) Nursing students New employees Single client Families, caregivers Groups of clients Peers

Approaches to Family Nursing

Nursing care holistically directed toward the whole family as well as to individual members 1. as context 2. as unit of care 3. as system

Clinical Judgment

Observing, comparing, contrasting, and evaluating the client's condition to determine whether change has occurred

Acute illness

Occur suddenly and last for a limited amount of time

Remission

Occurs when symptoms are minimal to none

Cultural assimilation

Occurs when the new member gradually learn and take on the essential value beliefs and behavior of the dominant culture

time management

Organizing and using your time in a way that allows you to meet your daily needs as well as your short and long-term goals with as little stress as possible.

Post traumatic stress disorder

PTSD specific response to a violent, traumatizing event or to physical or emotional abuse, such as rape, torture or war

dysuria

Painful urination

Pallor

Paleness of skin when compared with another part of the body

Secondary defenses

Pathogens that dodge the primary defenses and gain entry into the body region release wastes and secretions and to cause the breakdown of cells and tissues - the presence of such chemicals activates a set of...

Illness

Pathology affecting an organ or body system -how it makes a person feel - a disruption of health

PCP

Patient Care Partnership what patients should expect: quality of care clean and safe environment involvement in care protection of privacy help with leaving the hospital help with billing claims *not legally binding

PSDA

Patient Self Determination Act recognized the patient's right to make decisions regarding his own healthcare, based on the information provided to him by the healthcare provider, regarding the medical or surgical treatment options available, the benefits, risks, and alternatives

PACE

Patient/Problem Assessment/Action Continuing care/Changes Evaluation

PICOT

Patient/Problem Intervention Comparison Outcomes Times

Systolic pressure

Peak pressure exerted against arterial walls asthe ventricles contract and eject blood

Factors that disrupt health

Physical disease injury mental illness loss Impending death Pain competing demands the unknown Imbalance isolation

Assessing Oxygen Status

Physical examination -breathing pattern -respiratory efforts -pulse oximetry -using insepction, palpation, percussion, auscultation

Cognitive development theory

Piaget - ability to think, reason and use language 1. sensorimotor 2. preoperational though 3. concrete operations 4. formal operations

tracheostomy tube

Plastic tube placed within the tracheostomy site (stoma). (DIRECTLY IN TRACHEA)

Dunn's health grid

Plots a person's status on the health illness continuum against environmental conditions - nurses use this to predict the likelihood that a client will experience a change in health status

What is environmental control

Refers to a person perception of his ability to plan activities that control nature or direct environment factors

What is space

Refers to an individual personal space or how a person relates to a space around them

What is prejudice

Refers to negative attitude towards other people based on faculty and rigid stenotype about race, gender, sexual orientation, and so on

What is religion

Refers to ordered system of beliefs regarding the cause nature and purpose of the universe

What is race

Refers to the grouping of people based on biological similarities such skin color

Wound healing processs

Regeneration Primary Intention Secondary Intention Tertiary Intention

Evaluating and Revising the Care Plan

Relate outcome to interventions Draw conclusions about problem status Revise the care plan (problems, goals, interventions)

Expiration

Relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs

National Student Nurses Association (NSNA)

Represents nursing students in the U.S.

Checklist for Evaluating the Care Plan

Review assessment Review diagnosis Review planning outcomes Review planning interventions Review implementation *Review entire nursing process!

Vital signs

Temperature Pulse Respirations BP O2 PAIN Provide an indication of a person's state of health and functioning of the body systems.

Evaluating Learning

Tests and written exercises Oral questions Interviews Questionnaires Checklists Direct observation of performance Client report Client records

Core Temp

The "old standby" normal range: 97°F to 100.8°F(36.1°C to 38.2°C) with some variation Typically 1°F to 2°F (0.6°C to 1.2°C) higher than skin temperature

Pulse

The "wave" that begins when the left ventricle contracts and ends when the ventricle relaxes. Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system. influenced by developmental level, gender, exercise, food, disease, position, medications

Documentation

The act of recording client assessments and care in written or electronic form Creating a record of client assessments and care - clear, complete, concise, comprehensive and correct

BP Regulation

The body constantly regulates and adjusts arterial pressure in order to supply blood to body tissues via perfusion of the capillary beds.

Related factors

The cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem (label) - can be pathophysiological, psychological, social, treatment related, situational, maturational *similar to signs and symptoms (of actual problems)

Pulse Pressure

The difference between the systolic and diastolic pressures

Respiration

The exchange of oxygen and carbon dioxide in the body Mechanical Chemical

Documentation

The final step of implementation Records the nursing activities and the client's response

What is Ayurveda

The traditional healthcare system of India

Evaporation

Water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (through the breath) - causing cooling

Health promotion interventions used for

Wellness diagnoses

Questioning an Order

Written illegibly Contact the provider Uncomfortable following an order Follow the chain of command

empowerment

a psychological state, a feeling of competence, control, and entitlement that a person experiences

developmental task

a skill that must be completed during a stage of development Robert Havighurst

acute illness

a sudden illness from which a person is expected to recover

adolescence

ages 12 to 18 puberty ability to think abstractly establishes own identity make decisions that affect the furture goal:driving safety

signs that indicate the need for suctioning

aggitation gurgling sounds during respiration restlessness labored respirations decreased SaO2 increased HR and RR

Pulmonary system

airways and lungs

significant data

aka cues -data that influences your conclusion about the clients health status -should alert you to look for other cues that might be related to it

diagnosis process

aka diagnostic reasoning represents the thinking aspect of nursing diagnosis

comprehensive assessment

aka global assessment, patient database or nursing database - provides holistic info about the client's overall health status -subjective and objective data, functional abilities, emotional status, spiritual healthy and psychosocial - identify problems and clients strengths - enhances your sensitivities to client

Collaborative interventions

aka interdependent one that is carried out in collaboration with other healthcare team members (dietitians, physicians, nurses, therapists)

adaptations

changes that take place as a result of stress and coping -ongoing effort to maintain external and internal homeostasis

pain assessment

check for pain at initial assessment and in ongoing assessments

vernix caseosa

cheeselike protective covering for the skin

Cohabiting adults

choose to live together and not marry or live together as a "trial run" prior to marriage

Primary intention

clean surgical incision/edges approximated minimal scarring -CLOSED

clean catch

cleanse the genitalia before voiding and collect the sample midstream

Intervention for Wound Care

cleansing/irrigating caring for drainage device debriding a wound applying negative pressure wound therapy dressing a wound supporting/immobilizing applying heat and cold

therapeutic communication

client centered communication directed at achieving client goals - client centered -goal directed - strengthens therapeutic relationships

therapeutic communication

client-centered communication directed at achieving client goals

what does assessment include?

collecting data categorizing data recording data using a systematic and ongoing process *Assessment needs a Cru Co.

large intestinge

colon larger in diameter but shorter in length 7 segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus

community oriented nursing

combines components of community and public health - more comprehensive approach - use info from individuals to change health on the community level

battery

committed when an offensive or harmful physical contact is made to the patient without his consent or there is unauthorized touching of a person's body by another person

careful assessment of the feet allows for early detection of

common foot problems

advocacy

communication and defense of the rights and interests of another

OMAHA

community health standardized language

Patient teaching for colostomies

community resources initially encourage patient to avoid foods high in fiber avoid foods that cause diarrhea or flatus drink 2 quarts of water daily teach about meds teach about odor control resume normal activity

DPOA

durable power of attorney for healthcare identifies a person who will make healthcare decision in the even the patient is unable to do so

beneficence

duty to do or promote good "benefit"

veracity

duty to tell the truth "verdad"

communication

dynamic, two way process of sending and receiving messages between two or more people - verbal or nonverbal -helps build relationships - helps meet needs -basic human function

cerumen

ear wax

caput succedaneum

edema of the sculp

AV node

electrical activity passes through AV node into the left and right bundles of HIS and into Purkinje fibers to the ventricles

Electrical conduction

electrical activity that initiates contraction of the myocardium

pulmonary hypertension

elevated pressure within the pulmonary arterial system

Verbal Orders

emergencies

fear

emotion or feeling of apprehension/dread from an identified danger, threat, or pain - real or imagined

pain disorders

emotional pain that manifests physically

manager

employee of an organization who has the power, authority, and responsibility for enforcing decisions and directing the work of others. not all leaders should be managers but all managers should be leaders

manager

employee of an organization who has the power, authority, and responsibility for enforcing decisions and for planning, organizing, coordinating and directing the work of others

reflex incontinence

emptying of the bladder without sensation of need to void

nursing research

encompasses both research to improve the care of people in the clinical setting and to study people and the nursing profession, including education, policy development, ethics, and nursing history

termination phase

end of nurses shift or on the client's discharge from the unit, facility, or service

what factors affect communication?

environment developmental variations gender personal space territoriality sociocultural factors roles and relationships

Factors that affect communication in general

environment (noise) life span variations (toddler verse adults) gender personal space territoriality sociocultural factors roles and relationships

Planning Outcomes

envision acceptable outcomes set small, realistic goals

Structure of Skin

epidermis- outer portion dermis- middle layer subcutaneous tissue-

health promotion

equipping people to have control over, and to improve physical, emotional and social health *motivated by the desire to increase well being

pre-interaction phase

establishing communication by gathering information about the client, but the nurse and client do not have direct communication

enhancing therapeutic communcation

establishing trust being assertive restating, clarifying, validating messages interpreting body language & sharing observations exploring issues using silence summarizing the conversation process recordings

nursing ethics

ethical questions that arise out of nursing practice

Interventions are based on?

etiology (cause)

How can I honor each client's unique health/illness experience?

examines life uncertainties envision wellness for your clients and yourself establish trust at first patient contact

sigmoidoscopy

examines the distal sigmoid colon, rectum and anal canl through a flexible or rigid sigmoidoscope

esophagogastroduadenoscopy

examines the esophagus, stomach, and upper duodenum through an optic scope

special purpose forms

examples are diabetic flow sheet and medication administration form

job of kidneys

filter metabolic wastes, toxins, excess ions, and water from bloodstream and excrete them as urine

barriers to therapeutic communication

fire hosing information changing subject inappropriately failing to probe expressing approval/disapproval offering advice false reassurance stereotyping patronizing language

primary infection

first infection that occurs in patient

menarche

first menstraution

Alarm Stage

flight or fight -involves involuntary body responses shock and countershocks are phases

circulation

flow of blood

exudate

fluid and WBC that move from the circulation to the site of injury

LGI series

fluoroscopic examination of the large intestine after instillation via an enema of barium sulfate

Family as a system

focus is on the family as a system/whole, and the family is viewed as an interacting system in which the whole is more than the sum of its parts; simultaneously focuses on individual members and the family as a whole

Assessment of Skin and Wounds

focused skin assessment braden scale

community healthy nursing

focuses on how the health of individuals, families and groups affects the community as a whole goal: maintain health of population - deliver personal health sevices

therapeutic relationship

focuses on improving the health of the client, whether an individual or community. The client gains information and knowledge and works through issues, concerns, and problems related to health status, treatments, and nursing care.

therapeutic relationship

focuses on improving the health of the client, whether and individual or community

qualitative research

focuses on lived experience of people -share the experience of people "own words".

compensatory justice

focuses on making amends for wrong that have been done to individuals or groups

Tertiary Prevention

focuses on stopping the disease from progressing and returning the individual to the pre-illness phase (rehabilitation) *TREATMENT

public health nursing

focuses on the community as a whole and the eventual effect the community's health status on the health of individuals, families, and groups goal: prevent disease, promote health, protect health of community

Nutritious Foods on a Budget

SNAP Comodity Supplemental Food Program WIC National School Lunch and Breakfast programs

Defining characteristics

The cues, signs and symptoms, that allow you to identify problem or wellness diagnosis

Process of bowel elimintation

1.fecal material reaches rectum 2.stretch receptors initiate contraction of sigmoid colon/rectal muscles 3. internal anal sphincter relaxes 4. sensory impulses cause voluntary bearing down 5. external sphincter relaxes

Infants and urine

15 to 60 mL per kg produce 8 to 10 wet diapers per day no voluntary control

Young adulthood

19 to 40 years old healthiest stage of life leaves home and explore options begins to function as independent person - screen for disease - suicide revention

Recovery

3rd stage, if adaption is successful

Measurement Scale

5 point scale for describing patient status for each indicator 1 is least desirable 5 is more desirable *NOC

Fat Soluble Vitamins

A, D, E, K - stored in liver and adipose tissues

How can you Prioritize a patients needs?

ABC Maslow Problem Urgency Future Consequences patient preferences

What organizations has the Code of Ethics for Nurses?

ANA

Tachypnea

Abnormally fast respirations >24

3 approaches for coping with stress

Alter the stressor Adapt to the stressor Avoid the stressor *Call Triple A when coping with stress

How Are Standards and Criteria Used in Evaluation?

American Nurses Association (ANA) standards include a set of criteria to help describe the standard -Criteria: -Reliable -Valid

ADA

Americans with Disabilities provides protection again discrimination of individuals with disabilities

census tracts

An area delineated by the U.S. Bureau of the Census for which statistics are published; in urbanized areas, census tracts correspond roughly to neighborhoods.

Pulse oximetry

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds. noninvasive estimate of ABG (SaO2) % of hemoglobin molecules carrying O2 normal value is 95-100%

Obtaining a Pulse Rate

Apical is most accurate Use a stethoscope to auscultate the number of heartbeats at the apex of the heart A heartbeat is one series of the LUB and DUB sounds Brachial for Babies Carotid for CPR Radial for routines

Team Nursing

CNA and LPN assigned to a group of patients and work as a team (LPN cannot assess, but can observe, or give medications)

what is social organization

Can be found in all cultures; however the specific vary; Of your clients cultures can provide clues as to how they will act during life events; Kinship and social ties also determine who receive healthcare and in what is priority

Independent Interventions

Can be performed without consulting anyone TEACHING (one that RN's are licensed to prescribe, perform or delegate based on their knowledge and skills) *do NOT need a provider's order ex. turn a patient, educating

Narrative

Can use with source- or problem-oriented system "Story" of care in chronological format Tracks the client's changing status Can be lengthy and disorganized

Admission Database

Chief complaint or reason for admission Physical assessment data Vital signs Allergy information Current medications ADL status and discharge planning information/needs Data about client support system and contact information 1. benchmark and monitor change 2. provide info about client 3. contains critical info

Roles of a community nurse

Client advocate education collaborator counselor case manager

Specialty Organizations

Clinical, group identity, or value-specific

Don't of documenting

DON"T use subjective terms leave blank lines chart that you filled out an occurrence report

Assessment

Data gathering stage (client history)

A nursing order contains

Date Subject (NEVER write NURSE, its a given) Action verb Times and limits Signature

A nursing order contains

Date, Subject, Action verb, Times and limits, Signature

Temperature

Degree of heat maintained by the body Heat produced minus heat lost -decrease temp, vasodilation -increase temp, vasoconstriction influenced by developmental level, gender, exercise, stress

Evidence Based practice

EBP approach that used firm scientific data rather than anecote, tradition, intuition or folklore in making decisions about medical nursing practice

Single-parent families

Families that include one parent and his or her children living in the same household. Usually resulting from divorce, death, or choosing not to marry and live together

Tachycardia

Fast heart rate (HR greater than 100bpm)

International Council of Nursing (ICN)

Federation of national nursing organizations to ensure quality nursing care for all, supports global health policies that advance nursing and improve worldwide health, and strives to improve working conditions for nurses throughout the world.

Hyperpyrexia

Fever >105.8°F (41.0°C) dangerous and requires intervention

Physical Activity

Healthy people are active people ((certain types of exercise have been shown to reduce the risk for specific diseases, such as osteoporosis and heart disease-weight training decreases risk of osteo. walking dec. risk of heart disease))

Why define nursing?

Helps the public understand the value of nursing Helps differentiate activities of nursing from those of medicine Helps students understand what is expected of them

Promoting Family Wellness

Interventions when a family member is ill Interventions for caregiver strain Interventions when there is a death in the family *involve the family in each phase of Nursing process *address both family and individual needs

Pressure Ulcer development

Intrinsic factors: immobility impaired sensation malnourishment aging fever extrinsic factors: friction pressure shearing exposure to moisure ***can't change aging or impaired sensation

parenteral

Introduction of fluids, nutrients, or drugs into the body by an avenue other than the digestive tract (intravenous)

Direct care

Involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medications or care)

Caring has 5 components

Knowing- striving to understand what an event means to the patient. Being with- being emotionally present for the patient. Doing for- Doing what the patient would do for himself if he could Enabling- supporting the patient through coping with life changes, unfamiliar events. Maintaining belief- having faith in the patient ability to get through the change and event and to find fulfillment and meaning

PIC your knowledge

Knowledge: Psychomotor Interpersonal Cognitive

Moral Development Theory

Kohlberg - moral reasoning seems to be age related - based on one's ability to think at progressively higher levels * only studies boys

Stertor

Labored breathing that produces a snoring sound

ischemia

Lack of blood supply

What is territoriality

Means the behavior and attitude that a person exhibits about the area around them that they have claims

Pulse rate

Measured in beats per minute (bpm) Normal range for healthy adults = 60 to 100 bpm Average = 70 to 80 bpm *lower if an athlete or using a Beta Blocker check for rate (regular or irregular), quality (bounding or thready) and rhythem

mm Hg

Measured in millimeters of mercury (mm Hg)

MRSA

Methicillin-Resistant Staphylococcus aureus

Reporting

Method to inform other caregivers about the client condition. -Nurse to nurse; nurse to provider -Communication of vital information related to the client's status/plan of care.

Safety

Minimize risk of harm to patients and providers through both system effectiveness and individual performance.

American Nurses Association (ANA)

Official professional organization for nurses in U.S. focused on establishing standards of nursing to promote high-quality care and work toward licensure as a means of ensuring adherence to the standards.

The most important concept about vulnerable subcultures guiding nursing care is that persons belonging to these groups

Often have limited access to health care

Primary Nursing

One nurse manages all care for a group of patients

Dependent Interventions

One that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse ex. medications, treatments, IV therapy, diet

Dependent Interventions

One that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse examples are medications, treatments, IV therapy, and diet

Occupation

One's regular, principle, or immediate business

Case Method/Total Care Model

One-to-one relationship with patient and provide all nursing care on that shift (i.e., ICU or private duty nursing)

Problem oriented system

Organized around client problems 1. database 2. problem list 3. plan of care 4. progress notes *Promotes greater collaboration

Lifestyle choices

People who consider themselves healthy are usually making healthy lifestyle choices. They are aware of the threats to health created by cigarette smoke, drinking alcohol, drug abuse, unprotected sex, other risky behaviors.

Monitoring Vital Signs

Performed on a regular basis Frequency determined by -Provider's prescription and/or nursing judgment -Client's condition -Facility standards *#'s are a told with what we see and assess

PIE

Planning, Interventions, Evaluation (response by patient)

Reflecting skeptically

Questioning, analyzing, and reflecting on the rationale for your decisions. Ex: What aspects of the situation require the most careful attention? Am i sure of my interpretation of this situation?

Standardized Language

Standardized nursing terminology helps to make nursing care and its effects on patients more visible. NANDA International (NANDA-I) Nursing Interventions Classifications (NIC) Nursing Outcomes Classification (NOC)

Where can you look to find info on delegating tasks?

State nurse practice acts National Council of State Boards of Nursing Agency policies The Joint Commission ANA

SWOT

Stengths Weaknesses Opportunities Threats

Cognitive

Storage and recall of information, ability to analyze, syntehize, apply and evaluate ideas (e.g., facts about a disease, can report names and doses of 3 meds)

Cardiac output

Stroke volume × pulse (heart) rate

Evaluation

The final step of the nursing process -planned, ongoing, systematic activity in which you will make judgments about... -Client's progress toward goals -Effectiveness of nursing care plan -Quality of care in the healthcare setting

Counting Respiratory Rate

The nurse should count the respiratory rate (RR) after taking the radial pulse. The patient can alter the rate and pattern of respirations. RR must be accurate, especially in older adults.

Illness

The person with an illness rarely perceives the experience as a medical diagnosis. Instead, people describe their illness in terms of how it makes them FEEL.

Why learn about culture

The population is diverse; Health disciparties exist among racial and ethic groups; Nursing is challenged to provide culturally competent care

suctioning

The process of removing or sucking up fluid or body secretions

What are nursing interventions?

The purpose of a nursing intervention is to achieve client outcomes. They are also called nursing actions, measures, strategies, or activities. Nursing interventions are based on clinical judgment and nursing knowledge. They can be either direct care or indirect care

Stroke volume:

The quantity of blood pumped out by each contraction of the left ventricle average is 70mL is most healthy adults

Hypoventilation

The rate and depth of respirations are decreased and CO2 is retained. - take deep breaths

polypharmacy

The simultaneous use of multiple medications by a patient as typically seen in elderly people.

etiology

The study of the causes of disease

Alteration in Urinary Elimination

UTI Urinary retention urinary incontinence urinary diversion/urostomy

Manage change

Unfreeze (moving out of comfort zone) overcome resistance implement change integrate change (asking for feedback)

Quality Improvement (QI)

Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safe of HC systems.

Informatics

Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

What is time orientation

Various among people of different cultures; people are rooted in the past or future

Handoff Report

Verbal Walking rounds (patient to patient) Audio-recorded report (not the preferred method) -demographics and diagnosis -medical history -significant assessment finding -treatments -upcoming porcedures -restrictions -plan of care -concerns (going to lunch or at end of shift) WAV

Neuman's continuum

Views health as an expression of living energy available to an individual

leukocytes

WBC

Health promotions are used for?

Wellness diagnosis

Family as unit of care

Wellness of each member is critical to promoting family health. Family is the sum of all individual members and provide assessment and care for all family members. You might direct interventions to individual family members rather than the family as a whole

How do cultural values, beliefs, and practice affect health

What are the culture universal and specific Archetype or stereotype How do culture specific affect health

PROBLEMS

What do nursing diagnosis flow from?

ETIOLOGY

What do nursing interventions flow from?

Calcium

What is the #1 deficiency?

NIC, CCC, OMAHA

What organization include interventions to address health promotion and cultural and spiritual needs?

ANA

What organization includes documentation in many of it standards? document nursing process and communicates effectively

Indirect care

When nurses work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart, ordering unit supplies, arranging unit staffing, or serving on an ethics committee)

What is biomedical healthcare system

Which combines western biomedical beliefs with traditional north American values

Transfer Reports

Your contact information Client demographics, diagnoses, reason for transfer Family contact information Summary of care Current status, including medications, treatments, and tubes in the client—when the next medication is due Presence of wounds or open areas of the skin Special directives, code status, preferred intensity of care, or isolation required Always ask if the receiver has any questions.

Communication

a basic function of life

incentive spirometry

a common postoperative breathing therapy using a specially designed spirometer to encourage the patient to inhale and hold an inspiratory volume to exercise the lungs and prevent pulmonary complications (encourage patients to take deep breaths by reaching a goal-directed volume of air)

Step family/blended family

a family in which one or both spouses bring child(ren) from a previous relationship biological siblings and parents and step sibling and parents

Exacerbation

a flare up, occurs when symptoms intensify

clarity and brevity

a message that is direct and simple, saying precisely what is meant, and using the fewest words necessary

disability

a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having an impairment

Nursing interventions

actions based on clinical judgement and nursing knowledge, that nurses perform to achieve client outcomes aka. nursing actions, nursing measures, strategies, activities 1. direct care interventions 2. indirect care interventions

Working phase

active part client clarifies feelings and concerns through verbal and nonverbal communication

sources of power

authority (position) reward (benefits) expert (knowledge is power) coercion (threat)

reflexes

automatic responses 1. rooting: turns head towards stimulus and sucks 2. sucking: touch the infants lips for sucking 3. swallowing: without gagging or coughing 4. grasp: palmar and plantar, fingers/toes curl 5. tonic neck- fencing: 6. moro- startle: 7. stepping: hold infant and let one foot touch a surface 8. crawling: place on abdomen 9. babinski: stroke the lateral aspect of the sole

BRAT diet

bananas rice applesauce toast

deontology

based on rules and principles and uses the languages of rights and duties - considers actions to be right or wrong regardless of its consequences

nephron

basic structural and functional unit of the kidney

PES format

basic three part statement: problem, etiology, symptoms - adds the patients signs and symptoms that led you to make the diagnosis

Holistic Nursing Care

basis of modern nursing, examine the entire person and the person's world when making healthcare decision

enuresis

bed wetting

nocturanal enuresis

bed wetting

Primary nocturnal enuresis

bedwetting in a child who has not achieved consistent dryness at night

puberty

beginning of reproductive abilities - physical, cognitive, and pyschological changes

sender

begins conversation to deliver a message to another person. The sender, also called the source or the encoder, uses verbal and nonverbal methods to trasmit a message

initial planning

begins with the first patient contact, development of the initial comprehensive care plan- written ASAP after initial assessment

value

belief about the worth of something, it serves as a principle or a standard that influences decision making - ideals, beliefs, customs, modes of conduct, qualities, goals -idea, person, a way of doing, even an object

Osteoporosis

calcium deficiency marked by porous bones

honoring personhood

calling a patient by their name

distress

can threaten health

burnout

can't cope effectively with the physical and emotional demands of the workplace

Oxygen therapy

cannula mask transtracheal catheter

Indigenous health

care system-folk medicine and traditional healing methods

Professional health

care system-received formal education

Biomedical health

care system-scientific method

Functional incontinence

caused by factors outside the urinary tract

Diagnostic testing is important in determining

causes of impaired O2 (sputum samples, Tb testing, pulse oximetry, spirometry, capnography)

population

certain geographic region

NANDA's definition of nursing diagosis

clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Atelectasis

collapse of alveoli (RDS is characterized by a widespread of atelectasis)

freshly voided

collect urine like in same manner as input/output label container with name, date and time moisture proof speciman handling bag take to lab

Overweight/obesity

consuming nutrients - in excess of metabolic demands - more than needed for activity, gender, height, and weight overweight BMI >25 but <29.9 obesity BMI >30 *affects 2/3 of adult population

Stressed Induced organic responses

continual stress repeated CNS stimulation elevation of certain hormones results in long term changes in body systems

total incontinence

continuous, unpredictable loss of urine

Adaptive coping

coping strategy - healthy choices - directly reduce negative effects of stress ex. change in life style, problem solving

protocols

cover specific actions usually required for a clinical problem unique to a subgroup of patients

felonies

crimes punishable by more than 1 year in jail - murder, assisted suicide, rape, stealing drugs

Statement of Health Status

critical thinking + knowledge + Data

strabismus

crossed eyes

Madeleine Leininger

cultural competence

Factors that affect skin

dampness dehydration nutritional status insufficient circulation skin disease jaundice lifestyle/personal choices

psychosocial assessment

data about lifestyle, usual coping patterns, understanding of the current illness, personality style, previous psychiatric disorders, recent stressors, major issues related to illness and mental status

How does assessment relate to planning outcomes?

data about patient's motivation, family, and available resources help your formulate REALISTIC GOALS

wellness assessment

data about spiritual health, social support, nutrition, physical fitness, health beliefs, and lifestyle, as well as a life stress review

Nursing orders include:

date subject (never write the word NURSE, its a given) action verb times and limits signature

encopresis

daytime wetting or soiling

tort law

deals with wrong done to one person by another person that do not involve contracts 1. quasi- intentional tort 2. intentional tort 3. unintentional tort

criminal law

deals with wrongs or offenses against society - state or federal government brings charges against a person

external stress

death of a family member exccesive heat in a room

unit standard of care

describes the care that nurses are expected to provide for all patients in defined situations 1. apply to every patient in a defined situation, rather than a subgroup 2. do not become part of the patients care plan but are kept on file on the unit 3. do not usually include specific medical orders *minimum level of care the nurses are expected to achieve

Jean Watson

developed the nursing theory: Science of Human Caring -caring theorist

Outcomes evaluation

focuses on observable or measureable changes in the patient's health status that result from the care given -evaluates quality of care in an organization too (need %) *most important aspect is improvement in patient health status ex. Patient will walk, assisted, to end of hallway by postoperative day 5 ex. Post-catherization urinary tract infection does no occur: Expected compliance 100%

incomplete proteins

foods do not provide all the essential amino acids - vegetables, legumes, nuts

community based care

health care or rehabilitative services performed in clinics, offices, mobile care units and other facilities in the community- rather than in acute care settings, such as hospitals 1.community health nursing: 2.public health nursing: 3.community oriented nursing:

Nutrition

health requires nourishment (FOOD)

Structures of cardiovascular system

heart systemic and pulmonary blood vessels coronary arteries

IPOCs

integrated plans of care are standardized plans that function as both care plan and documentations form. - different form for each day of care DO not... organize care according to diagnosis nor describe the minimal standards of care, nor specify a timeline for interventions/outcomes

group communication

interaction that occurs among several people - staff meetings, educational groups, self help groups

Anemia

iron deficiency *most common problem worldwide

Nurse's role

maintain patient safety maintain confidentiality and privacy provide education and counseling delegate according to guidelines accept assignment for which you are qualified participate in continuing education observe professional boundaries observe mandatory reporting regulations *POOP MAD

Use of chest tube drainage systems

make room for lungs to full expand removes air/fluid from pleural space

Caring for the hair

make sure bristles aren't sharp enough to injure patients scalp encourage autonomy

laissez faire leader

makes little or no attempt to move the group permissive or nondirective

kwashiorkor

malnutrition caused by a deficiency of protein in a diet, that is primary starches

Cardiac Planning and Intervention

manage anxiety promote ciruclation prevent clot formation administer medicatin perform CPR

informatics

managing and processing necessary to make decesions

valid

measures what it was intended to measure

UTI

microorganisms enter the urethra and begin to multiply overwhelming the normal flora Risk factors: sexual active women women who use spermicidal contraceptive gel pregnant women older women men with an enlarged prostate people with kidney stones indwelling catheter diabetes mellitus immunocompromised patients

misdemeanor

minor charge, less than a year in jail - assault, battery, theft

Interventions for Optimal Oxygenation

mobilizing secretions oxygen therapy

critical pathways

often used in managed care systems, outcome based, interdisciplinary plans that sequence patient outcomes and broad interventions for each day, or in some situations, for each hour required to meet the recommended length of stay for patients with a particular condition or diagnosis-related group - do NOT provide a way to judge nursing effectivness

Cardiac insufficency

older adults difficulty expelling mucus/foreign material diminished ability to increase ventilation decline immune response

1 part statements

omit the etiology from certain kinds of diagnostic statements: 1. syndrome diagnoses 2. wellness diagnoses 3. very specific labels

Feedback

once the reciever has recieved and interpreted the message he may be stimulated to respond -validated that the receiever got the message

standardized language

one in which the terms are carefully defined and mean the same thing to all who use them

addendum

one or more discharge or teaching plans

malpractice

one source of legal liability - professional person has failed to act in a reasonable and prudent manner

Dependent interventions

one that is prescribed by a physician or advanced practice nurse but is carried out by the bedside nurse ex. medications, treatments, IV therapy, diet,

informed consent

permission of any and all types of care given by the patient with full knowledge of the risks, benefits, costs, and alternatives 1. completeness 2. clarity and comprehension 3. voluntariness 4. competence

Assimilation

person adopts a new culture

plaintiff

person bringing the lawsuit

Managing Fecal Impaction

prevention is the best treatment determine presence- digital examine enemas - oil retention to soften - tap water or fleet enemals to remove and cleanse manual /digital removal: disim establish bowel program to prevent recurrence

borrowed servant doctrine

primary employer of liability for the actions or omision of its employees when the employee was borrowed by another person

Carbohydrates

primary energy source for body simple carbs: sugars 1. supply energy for muscles an dorgan function - glycogen 2. spare protein (ketones) 3. other phsyiological functions (insulin) 4 kcal/g

alzheimer's disease

primary form of dementia and is considered progressive - increasing age is the greatest known risk - doubles every 5 years after 65

accreditation

seek from the Joint Commission -ensures a minimum standard quality of care is provided - educational requirements for nursing programs and continuing education courses

Encoding

selecting the words, gestures, tone of voice, signs and symbols used to transmit the message

Self knowledge

self-understanding, being aware of your beliefs values and cultural and religious biases. Helps you find errors in YOUR thinking and to help "tune in" to your patient

feces

semisolid mass of fiber, undigested, food, inorganic material

5 elements (communication)

sender, message, receiver, feedback, channel

dyspnea

short of breath

American Nurses Association Code of Ethics

standards of professional responsibility for nurses and provides insight into ethical and acceptable behavior - these are not laws - patient 's right to dignity, privacy and safety - nurse will be accountable, use informed judgement, quality patient care, protect the client, collaborate with other healthcare

health

state of complete physical, mental, and social well-being - not just absence of disease

rationales

state the scientific principles or research that supports nursing interventions

thromus

stationary clot

stressor

stimulus that the person pereceives as a challenge or threat; it disturbs the person's equilibrium by initiating a physical or emotional resposne

Glycogen

stored glucose in liver and skeletal muscles

SOAR analysis

strengths opportunities, aspirations results

Hildegard Peplau

theory of interpersonal relations: the relationship the nurse has with a patient

human relations-based mangement

theory x theory y

Diagnostic reasoning

thinking process that enables you to make sense of it 1. data anaylsis 2. drawing inferences and interpretation of data 3. critiquing the diagnostic statement (problem + etiology) 4. verifying the diagnosis 5. Prioritizing

nursing sensitive outcomes

those that can be influenced by nursing interventions

milia

tiny white spots on baby's face

Convalescence

tissue repair and return to health as the remaining number of microorganisms approaches 0

Wellness diagnosis

to assess a client's wellness practices health promotion

Psychmotor

"Hands-on" skill, imitation and performance of skills Requires thinking and doing (e.g., self-administration of insulin)

Nursing (ANA definition)

"The protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations."

primary defense

"soldiers" prevent organisms from entering the body

Latent

(HIV/AIDS) infection present but no symptoms

Verbal Orders

(V.O.) Spoken to you; often during a client emergency Should be made for critical change in patient conditions

Inquiry

(based on credible sources) Applying standards of good reasoning to your thinking when analyzing a situation and evaluating your actions. ex: How do i go about getting the info i need? do i have enough knowledge to decide? if not, what do i need to know?

Contextual awareness

(deciding what to observe and consider) An awareness of whats happening in the total situation, including values, interpersonal relationships, and environmental influences. ex: What is going on in the situation that may influence the outcome? what about the situation have i seen before? what is different?

decisional activities

(employee evaluation, resource allocation, personnel action, planning for future changes, job analysis and redesign, unit-based decisions)

Religion & Spirituality

(kind of like culture) religious beliefs and practices can influence healthcare choices

HELP

*help you observe systematically as you enter a patient's room HELP ENVIRONMENT LOOK PEOPLE

Benner's Model Stage 4: Proficient

- Able to quickly take in all aspects of situation and immediately give meaning to cluster of assessment data - Serves as a resource for less experienced nurses - Can see "big picture" and coordinate services and forecast needs

Benner's Model Stage 3: Competence

- Achieved after 2-3 years of nursing practice in same area - Complex concerns - Able to hand patient load and prioritize - More involved in care-giving role and emotionally involved in clinical choices made - Do not fully grasp overall scope and most important aspects

Military Battlefield Caregiver

- B.C. to present - Provided care to the sick, wounded, and dying soldiers

Benner's Model Stage 1: Novice

- Begins with onset of education - Little nursing experience, acquiring nursing knowledge - Task-oriented and focus narrowly on "learning the rules"

Benner's Model Stage 5: Expert

- Can see needs to be achieved and how to do it - Trust in/use their intuition while operating with a deep understanding of situation, often recognizing problem in absence of signs and symptoms - Expert skills - Often consulted when others need advice/assistance

Respiration

-Exchange of o2/co2 -alveolar capillary/capillary cell membrane

Family Health Risk Factors: Families with young children

-Experience financial difficulties. -finding child care -Illness and injuries create risks to family health. -marital issues

Differences between medical and nursing diagnosis

-MD can be associated with any number of nursing diagnoses associated with it -clients can have same medical diagnoses but different nursing diagnoses

State Laws

-Mandatory reporting laws - Good Samaritan laws - nurse practice acts - medical malpractice statutes

Teaching

-Process that involves a teacher and a learner -Interactive -Involves planning and implementing instructional activities -Requires good communication skills (convey info, assess nonverbal/verbal feedback, accomodate various learners) -Includes providing activities that allow clients to learn -Goal of teaching activities: to meet learner outcomes

What Is a Family?

-Two or more people related by birth, marriage, or adoption residing in the same household -Two or more individuals who provide physical, emotional, economic, or spiritual support while maintaining involvement in each other's lives May or may not be blood relatives Concept of nontraditional families

timing and relevance

-consider presence of others -both parties value interaction and find the discussion relevant -interaction must allow time for response

Stages of Illness Behvaior

-experiencing symptoms -sick role behavior -seeking professional care -dependence on others -recovery

conflict resolution

-identify problem -generate possible solutions -evaluate suggested solutions -choose the best solution -implement the solution chosen -evaluate is the problem solved?

Infants

-maximum brain growth, need more optimal nutrients -higher metabolic rate and water loss should not receive cows milk or honey before a year old

Client's responses to illness

-physical responses -understanding of illness -how it affects their lives and ability to care for themselves -emotional responses and concerns *U HAPE?

What to use to choose nursing interventions:

-professional standards: ANA - Theories - nursing research - evidence based guidelines

nursing diagnosis

-reasoning process used in interpreting assessment data -formal diagnostic statements of the client's health status, containing both problem and etiology - assessment data must be COMPLETE and accurate *human responses to disease, injury or other stressors, and it can be either a problem or a strenght

Types of research based support

-single studies - critical pathways - protocols - clinical practice guidelines - systematic review of literature

Patient outcome for Normal B.E.

-soft formed bowel movement every 1 to 3 days without discomfort - relationship btw bowel elimination and diet, fluid, and exercise is explained -patient should seek medical evaulatuion if changes in stool color or consistency persist

Process Used for Generating and Selecting Interventions

1 Review the nursing diagnosis 2 Review the desired client outcomes 3 Identify several interventions/actions 4 Choose the best interventions for this client 5 Individualize the standardized interventions

Process Used for Generating and Selecting Interventions

1 Review the nursing diagnosis 2 Review the desired client outcomes 3 Identify several interventions/actions 4 Choose the best interventions for this client 5 Individualize the standardized interventions RRICI (said Ricky) selects interventions

infancy

1 month to 1 year learns by doing * development of trust -depended on care giver

toddlerhood

1 year to 3 year * goal is SAFETY temper tantums, desire to gain autonomy -rapid language development -explores environment - growth rate is slower

Kortokoffs sounds

1) a sound that occurs during systole. tapping - pulse 2) swishing sounds caused by blood turbulence 3) sharp rhythmic tapping sound 4) like 3rd but softer and fading 5) silence

How do I know which label to use?

1. Identify the broad topic, or domain, that seems to fit the cue cluster 2. Narrow your search, to the class or most likely label 3. Using a nursing diagnosis handbook, compare definition defining characteristics of the diagnostic labels to your cue cluster

Maslow's Hierarchy of Basic Human Needs

1. Physiological: 2. Safety and Security 3. Love and Belonging 4. Self Esteem 5. Cognitive 6. Aesthetic 7. Self actualization 8. Transcendence *Pink scarves look so cool at school too!

4 Phases of Therapeutic Communication

1. Pre-interaction phase 2. Orientation Phase 3. Working Phase 4. Termination Phase

Process for generating or selecting interventiosn

1. Review the nursing diagnosis 2. review the desired client outcomes 3. identify several interventions/actions 4. choose the best interventions for client 5. individualize the standardized interventions RRICI (said RICKY)

Recognizing cues:

1. a deviation from population norms 2. changes in usual health patterns not explained by developmental or situational changes 3. indications of delayed growth and development 4. changes in usual behavior in roles or relationships 5. nonproductive or dysfunctional behavior *CHAIN of recognizing cues

What do nursing interventions include?

1. activities for observation/assessment 2. prevention 3. treatment 4. health promotion: used for wellness diagnoses

5 types of nursing diagnosis

1. actual nursing diagnosis 2. risk (potential) nursing diagnosis 3. Possible Nursing diagnosis 4. syndrome nursing diagnosis 5. wellness nursing diagnosis *WRAPS

3 core competencies of Cognitive Development

1. adaptation (adjust to and interact with environment 2. assimilation (integration of old with new) 3. accommodation (change due to process of new info)

Factors that affect skin integrity

1. age (turgor, drier, reduced collagen, more prone to injury) 2. mobility status ( increased pressure, shearing) 3. nutrition/hydration (protein, C, zinc, copper) 4. sensation level (diminished) 5. impaired circulation 6. medications 7. moisture 8. fever 9. infection 10. lifestyle

3 stages of GAS

1. alarm stage 2. resistance (adaptation) 3. Recovery or Exahustion

Disease Processes and Functional Limitations Affecting Nutrition

1. alcoholism 2. cognitve function 3. ability to obtain and prepare food 4. chewing and swallowing 5. stomach functions 6. peristalsis 7. intestinal surface area 8. enzyme secretion 9. bariatric surgery 10. medications

characteristic of collaborative problems

1. all patients who have a certain disease or medical treatment are at risk for developing the same complications 2.always a potential problem 3. if you can prevent the complication with independent nursing intervention alone, it is NOT a collaborative problem

Analyzing Research

1. analytical reading 2. research appraisal

Goal of crisis intervention

1. assess the situation 2. ensure the patient's safety 3. defuse the situation 4. decrease the person's anxiety 5. determine the problem 6. decide on the type of help needed 7. return the person to precrisis level of functioning

Interventions for obesity

1. assist with calorie calculations and meal planning 2. encourage exercise/lifestyle changes 3. weigh weekly, NOT daily 4. food diary

4 group goals

1. attain high quality longer lives 2. achieve health equity, 3. create social and physical environment that promote good health for all 4. promote quality of life, healthy development A CAP on good health!

What makes a healthy community?

1. attain high quality longer lives free of preventable disease, disability, injury and premature death 2. achieve health equity, elimnate health disparities and improve the health of all groups 3. create social and physical environments that promote good healthy for all 4. promote quality of life, healthy development and healthy behaviors across all life stages

care plans include:

1. basic needs 2. medical/multidisciplinary treatment 3. nursing diagnoses and collaborative problems 4. special discharge needs or teaching needs 5. ADL's *B MANS

10 components of health history

1. biological data 2. chief complaint 3. history of present illness 4. clients perception of health status/expectations 5. past health history 6. family healthy history 7. social history 8. medication history/device use 9. CAM 10. review of body systems and functional abilities

Factors that affect BMR

1. body composition 2. growth periods 3. body temp 4. environmental temp 5. disease process 6. prolonged physical exertion

3 classes of nutrients

1. carbohydrates 2. proteins 3. lipids

informal negotiation

1. clarify the situation in your own mind 2. set the stage 3. conduct the negotiation 4. continue with offers and counteroffers 5. agree on the resolution of the conflict

Managing Nutritional Imbalances: Interventions

1. client/family teaching related to - vitamin (fat or water soluble) & mineral supplements - obtaining nutritious foods on a limited budget 2. supports special clients nutritional needs -clients who are NPO -older adults 3. assisting clients with meals - inpatient: delegating feedings - home care: refer to agency for help obtaining food ex. meals on wheels

3 components of attitudes

1. cognitive- thinking 2. affective- feeling 3. behavioral- doing CAB the attitude

Preprinted Standarized Plans

1. contain nursing or multidisciplinary interventions 2. prescribe care for one or more nursing diagnoses or a disease or medical condition ex. policies and procedures protocols unit standards of care

Model of Change

1. contemplation 2. determination 3. action 4. maintenance

Life Style Choices

1. dietary patterns 2. work environments 3. cooking methods 4. oral contraceptive use 5. using food to relieve stress 6. smoking 7. alcohol 8. caffeine 9. vegetarianism 10. health and athletic perfomances 11. dieting for weight loss

Common diagnostic tests

1. direct visualization -colonoscopy - sigmoidoscopy 2. radiographic views - flat plate of the abdomen

Guidelines for Recording Assessment Data

1. document ASAP after you perform the assessment 2. write legibly in black in or electronically 3. acronyms sparingly 4. write the patients own words when possible 5. record only the most important patients words 6. use concrete, specific info 7. record cues, no inferences

To win a lawsuit, 4 elements must be proven

1. duty 2. breach of duty 3. causation 4. damages (money)

Importance of care plan

1. ensures the care is complete 2. provides continuity of care 3. promotes efficient use of nursing efforts 4. provides a guide for assessments and charting 5. meets the requirement of accrediting agencies

How to identify a clinical nursing problem

1. experience 2. social issues 3. theories 4. ideas from others 5. nursing literature

How to identify a clinical nursing problem

1. experience 2. social issues 3. theories 4. ideas from others 5. nursing literature * N SITE

most common malpractice claims

1. failure to assess and diagnose 2. failure to plan 3. failure to implement 4. failure to evaulate *usually failure of Nursing Process!!!!

Scheduling diagnostic Tests

1. fecal occult blood test 2. barium studies (should precede UGI) 3. endoscopic examinations -noninvasive procedures take precedence over invasive procedures

5 steps of Assertive Communication

1. get the person's attention 2. express your concern 3. state the problem 4. propose an action 5. reach a decision

Problem suggests a goal

1. goal or outcome is the opposite of the unhealthy response 2. goals suggest assessments 3. if the problem is not an accurate statement of healthy status, then your goals and resulting assessment will be wrong

Leading causes of death

1. heart disease 2. cancer 3. chronic lower respiratory disease 4. stroke 5. alzheimer diease 6. diabetes mellitus 7. influenza and pneumonia 8. nephritis 9. accidents 10. septicemia

Theoretical Knowledge

1. helps to recognize cues and patterns 2. associate patterns with the correct problem 3. gain confidence in your ability to reason 4. keep from relying too much on authority figures

Health assessment

1. history of physical exam 2. physical fitness exam 3. lifestyle and risk appraisal 4. life stress review 5. health beliefs 6. nutrition 7. healthy screening

Watson's Caring Theory

1. holistic care 2. honoring personhood 3. transpersonal caring moments 4. personal presence 5. comfort 6. listening 7. spirital care 8. caring for the family 9. cultural competence

Watson's Caring Theory

1. holistic care 2. honoring personhood 3. transpersonal caring moments 4. personal presence 5. comfort 6. listening 7. spirital care 8. caring for the family 9. cultural competence *Tall, happy, hairy people like serving crunchy canned carrots!

Manage Conflict

1. identify the problem 2. generate possible solutions 3. evaluate suggested solutions 4. choose the best solution 5. implement the solution chosen 6. evaluate- is the problem resolved

Ability to adapt depends on

1. intensity of the stressor 2. effectiveness of coping skills 3. personal factors *I need PIE to adapt!

Final judgements about data

1. is it complete? 2. how do I know the data is accurate? 3. have I recorded data rather than conclusions? 4. did i validate any data that do not make sense? 5. Did i record data in specific terms? 6. Have i followed up with in depth special needs when appropriate? 7. Have I included only relevant data? 8. Assessment interview 9. physical assessment 10. memory

when do you validate data?

1. subjective and objective data do not agree 2. patients statements differ at different times in interview 3. data falls out of normal range 4. factors are present that interfere with accurate measurements

Better Communicator as a Nurse

1. take time to communicate 2. Identify the Patient's main concern 3. develop your observation skills

Laws are derived from 4 sources

1. the Constitution 2. statutes 3. administrative bodies 4. the courts

Ways to Gain Knowledge

1. trial and error plus common sense 2. authority and tradition (ask an expert) 3. intuition and inspiration (have a feeling) 4. logical reasoning (inductive and deductive) 5. scientific method

Geopolitical Community Assessment

1. windshield survey 2. data base utilization 3. client perceptions

Special Diets

1.Regular diet 2.NPO 3Modified by Consistency (clear liquids, full liquids, mechanical soft, pureed) 4. Modified for Disease (calorie restricted, diabetic, renal diet)

Guidelines for Judging the Quality of Diagnostic Statements

1.do not rely on label definition alone 2. include both problem and etiology,with cause and effect stated correctly 3. be sure that etiology does not merely restate the problem 4.avoid using medical diagnoses and treatments as etiological factos 5. write the statement clearly 6. write the statement concisely 7. be sure the statement is descriptive and specific 8. state the problem as a patient response 9. use nonjudgemental language 10. avoid legally questionable language

Middle adulthood

40 to 64 years of age menopause and andropause balances aspirations with reality needs of children diminishes needs of aging parents increase

Water

55-65% in men 50-55% in women Functions: 1. solvent 2. transport 3. form for tissues 4. maintain body temperature

chronic illness

6 months- lifetime requires life changes

School age children

6 years to 12 years lower center of gravity uses thought process to experience actions and events able to develop relationships outside the home goal: safety (seatbelts, helmets)

young-old

65-74 years adaptation to retirement

middle old

75-84 increasing solitary, sedentary lifestyle

oldest old

85 and above sensory impairments, oral health, inadequate nutritional intake, and functional limitations

Cyanosis

A bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood

Integrated Plans of Care (IPOCs)

A combined charting and care plan form Maps out on a daily basis, from admission to discharge -Client outcomes, interventions, and treatments for a specific diagnosis or condition - Laboratory work, diagnostic testing, medications, and therapies included in the pathway

statute of limitation

A federal or state statute setting the maximum time period during which a certain action can be brought or certain rights enforced.

How do people experience health and illness? BIOLOGICAL FACTORS

A healthy genetic makeup and freedom from debilitating age-related changes are certainly desired states, and they tip the scale toward the wellness end of the health-illness continuum

Stridor

A piercing, high-pitched sound heard primarily during inspiration

Critical Thinking

A reflective thinking process that involves collecting information, analyzing adequacy and accuracy of information, and carefully considering options for action

Model

A set of interrelated concepts that represent a particular way of thinking about something.

transtracheal catheter

A small tube surgically placed in back of neck into trachea to deliver oxygen. Must be cleansed 2/3 times a day to prevent mucous obstruction.

Nursing process

A systematic problem solving process that guides all nursing actions. (Assessment, diagnoses, planning outcome, planning intervention, implementation, and evaluation)

Do's of documenting

ABC's adhere to the reimbursement requirements provide detail about client's response legibly and ASAP attempt to contact PCP chart use of restraints chart refusal of meds and what you did about it black ink

who makes the delegation policy for nurses?

ANA (American Nursing Association)

What do groups have standards for documentation?

ANA and the Joint Commission

What is culturally competent care

ANA, QSEN, campinha- bacote, Parnell and paulanka, leininger

regulating cardiovascular function

ANS- sympathetic and parasympathetic fibers - heart: regulate HR and contractility - vascular system: maintain vascular tone Brain Stem centers: regulate cardiac function and BP - Baroreceptors- sensitive to pressure changes - Vascular system- sensitive to blood pH, oxygen levels, and CO2

Fever (pyrexia)

Abnormally high body temperature (>100°F or37.8°C) Occurs in response to pyrogens (e.g., bacteria) Pyrogens (fever producing substances) induce secretion of substances (prostaglandins) that reset the hypothalamic thermostat at a higher temperature *febrile- with fever afebrile- without a fever

Bradypnea

Abnormally slow respiration <10

Apnea

Absence of breathing

Documentations ABC's

Accurate Bias free Complete Detailed Easy to read Factual Grammatical Harmless (legally)

ADL

Activities of daily living

Treatment interventions

Actual nursing diagnoses Collaborative problems

Treatment interventions/prevention intervention

Actual nursing diagnoses Collaborative problems

Observation/assessment interventions used for:

Actual nursing diagnoses Potential nursing diagnoses Possible nursing diagnoses Collaborative problems Wellness diagnoses

Outcome of Stress

Adaptation or Disease

Family Health Risk Factors: Childless and childbearing couples

Adapting to new roles creates stress. This can led to maladaptive coping (wrong ways to cope)

Styles of coping

Adaptive Maladaptive

Common Beliefs Related to Culture

African - thin body denotes poor health Hispanic - plump baby is considered healthy Arab - pregnancy is normal part of life and, therefore, medical care not necessary Hmong - epilepsy means the soul has left the body and the soul must be brought back for healing

Factors that influence illness behavior

Age family patterns culture nature of the illness hardiness Intensity, duration and multiplicity of the disruption *AF CHIN

Nursing Process

Assessment (health status) Diagnosis (health issues) Planning outcomes (realistic and valued by patient and family) Implementation (draw on patient and family strengths to help achieve desired outcomes)

Rhythm

Assessment of the pattern of respirations

Phases of nursing process

Assessment, diagnosis, planning, implementation, evaluation

Research by Degree

Associates: help identify problems, collect data, use EBR Bachelors: critique, identify problems, apply research Master: analyze problems, support, conduct research Doctoral:conduct research, leaders, develop ways

systems theory

Assumption that all living systems are open systems that constantly exchange information with the environment.

Water Soluble Vitamins

B, C -excreted regularly by kidneys

basal metabolic rate

BMR measure of the energy used while at rest in a neutral temperature environment - measured by a calorimeters

Prehypertension

BP reading of 120 to 130 mm Hg systolic or 80 to 89 diastolic mm Hg Obtained with two readings, taken 6 min apart, with the client sitting (JNC 7, 2003)

Healthy Interventions for Health Promotion

Be a role model Couseling Healthy Education Supporting lifestyle changes

Documenting Client Care

Be familiar with facility forms. Chart in the required format. Include all aspects of care. Be accurate, complete, and consistent.

Promote Client Participation

Be sensitive to client's cultural, spiritual, and needs Assess clients support and resources Determine the client's main concerns Help the client set realistic goal Assess the client's knowledge Realize & accept that some attitudes can't be changed Talk openly about adherence/ Teach *BAD HART

Kortocoff's Sounds: Third Sound

Begins midway through the BP and is a sharp, rhythmic tapping sound

Neuman's Continuum

Betty Neuman views health as an expression of living energy available to an individual. The energy is displayed as a continuum with high energy (wellness) at one end and low energy (illness) at the opposite end.

What are concepts related to culture

Bicultural: Describes a person who identifies with two culture and intergrade some values and lifestyles of each into his life; Multicultural: Refers to many cultures and is used to describe groups rather than individual

Dimensions of health

Biological factors nutrition physical activity sleep and rest meaningful work Lifestyle choices personal relationships culture religion and spirituality environmental factors finances

Culture of North AmericanHealth-Care System

Biomedical system Value technology Desire to conquer disease Definition of health as absence or minimization of disease Adherence to a set of ethical standards or minimization of disease

Pathological conditions that affect urination

Bladder/kidney infections kidney stones hypertrophy of prostate, enlarged prostate gland mobility problems decreased blood flw through glomeruli neurological conditions communication problems alteration in cognition

Obtaining a pulse rate:

Brachial for Babies, BB Carotid for CPR, CC Radial for routines, RR

Differentiated Practice

Brings together nurses with various areas of expertise related to the types of patients on their unit to deliver care

Independent Interventions

Can be performed without consulting anyone TEACHING (one that RN's are licensed to prescribe, perform or delegate based on their knowledge and skills) *does NOT need a provider's order examples are turning a patient to prevent bed sores, educating and teaching, or if a patient feels nauseous-move the food tray away from them to reduce the smell

Functional Nursing

Care is provided by different staff members based on their level of skill (i.e., CNA bathes, LPN gives oral medications, RN gives IV medications and performs assessments); economical way to provide care but can be fragmented

Learning

Change in behavior, knowledge, skills, or attitude Learning occurs as a result of planned or spontaneously occurring situations, events, or exposures

Affective

Changing feelings, beliefs, attitudes, and values, responding to new ideas (e.g., changing a belief about diet)

What is meant by culture

Characteristics of culture; Ethnicity, race, religion; Concepts related to culture

Charting by Exception

Chart only significant findings or exceptions to norms. Use this method to streamline charting and save time. Use preprinted forms and checklists. Note that inadvertent omissions are the biggest problem.

Planning for Implementation Phase

Check your knowledge and abilities Organize your work -Establish feedback points - Prepare supplies and equipment Prepare the client *COP

Abnormal Rhythm

Cheyne-Stokes, Biot

Hypertension

Diagnosed when BP is persistently higher than normal. Diagnosed when BP is >140 mm Hg systolic or>90 mm Hg diastolic on two or more separate occasions. *silent killer

The Three Domains of Learning

Cognitive Psychomotor Affective

Skills in critical thinking (definition)

Cognitive processes used in complex thinking operations such as problem solving and decision making.

What to check for with skin? COTTTLE your Skin:

Color Odor Turgor Temp Texture Lesions Edema

Purpose of the Written Record

Communication between providers -Continuity of care Educational tool Legal documentation of care Quality improvement Research Reimbursement Education *not documented, it didn't happen!

How do culture specific affect heath

Communication, space, time orientation, social organization, environmental control, biological variation and other culture specific

Medication Administration Records (MAR)

Comprehensive list of all ordered medications Provides information on client's medication allergies Documents scheduled/routine, PRN, STAT, or omitted doses Additional explanation may be required for nonroutine or omitted medications.

Keep it CUBAN

Confidential Uninterrupted Brief Accurate Named nurse *for hand off report

Problem Solving

Consider an issue and attempt to find a satisfactory solution to achieve the best outcomes

What is ingenious healthcare system

Consist of folk medicine and traditional healing and methods which may also include OTC

Approaches to Family: CUS!

Context for Care Unit System

5 major categories of Critical thinking

Contextual awareness, Inquiry, Considering alternatives, analyzing assumptions, reflecting skeptically

Implementing the Plan

Coordinated Care Use cognitive, interpersonal, and psychomotor skills Promote client participation * CUP

Hypothermia

Core temperature below normal (<95°F or 35°C) Associated with extended exposure to cold (e.g., extreme weather, immersion in cold water, or lack of shelter and clothing)

Stress Induced Psychological Responses

Crisis burnout post traumatic stress disorder

Intellectual humility

Critical thinkers are aware they do not know everything. Not embarrassed to ask for help when they do not know. Not to proud to seek wisdom of mentors with knowledge, skills, and ability.

Independent thinking

Critical thinkers do not believe everything they are told; do not just go along with the crowd. They do not accept or reject a new idea before they understand it.

Intellectual perseverance

Critical thinkers do not jump to conclusions or settle for quick obvious answers.

Intellectual courage

Critical thinkers evaluate their own beliefs and values as well as others. They are willing to rethink as well as reject previously held beliefs that are not well justified.

Intellectual curiosity

Critical thinkers love to learn new things, show an attitude of curiosity . "what if...." or "How could we do this differently?"

Fair Mindedness

Critical thinkers try to make impartial judgement. Treat all viewpoints fairly, realizing that personal biases, customs, and social pressures can influence their thinking.

Intellectual empathy

Critical thinkers try to understand the feelings and perceptions of others. Try to see the situation as the other person sees it.

What are culture universal and specific

Cultural university:Are values, beliefs, and practice, that people from all cultures share; Culture specific: Are those values, beliefs, and practice that are special; or unique to culture

How do I communicate with clients who speaks a different language

Culturally and linguistically appropriate service of standards; Use an interpreter

What are nursing and other professional subcultures

Culture of nursing : As the learned or transmitted of lifeway, value, symbols, patterns, and normative practices; Silent is a suffering as a response to pain; Objective reporting and description of pain but not emotional response; Use of the nursing process; Nursing autonomy; Caring

CINAHL

Cumulative Index to Nursing and Allied Health Literature

Common Documentation Systems: Source-oriented system

Disciplines document in separate sections of the chart Contains a variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) Data scattered; may lead to fragmentation

Crackles

Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds (fine) or low-pitched bubbling sounds (course)

What Do Nurses Teach?

Disease information Information about medications Procedures/psychomotor skills Disease prevention and health promotion Clinical processes

Categories of stress

Distress eustress developmental situational physiological psychological internal and external

Inspiration

Drawing air into the lungs Involves the ribs (move up) and diaphragm (moves down), creating negative pressure and allowing air to flow into the lungs

Importance of standardized nursing teminologies:

EHR research clear, precise, consistent communication among nurses

Importance of standardized nursing terminologies

EHR research clear, precise, consistent communication among nurses

EHR

Electronic Health Record

EMTALA

Emergency Medical Treatment and Active Labor requires health care facilities to provide emergency medical treatment to patients who seek health in the emergency department regardless of their ability to pay, legal status, or citizenship status

Alarm Stage effects on body

Endocrine: CRH, ACTH, ADH Sympathetic nervous system: epinephrine, norepinephrine Cardiovascular: vasoconstriction, elevated BP Respiratory: dilated bronchioles Metabolic: increased availabilty of glucose Urinary: sodium and water retention GI: decreases peristalsis Musculoskeletal: increased blood flow to muscles

Psychosocial development theory

Erikson personality continues to evolve throughout life span as person itnteacts with social world 1.Trust vs. mistrust 2. autonomy verse shame/doubt 3. Initiative verse guilt 4. industry verses inferiority 5. identity verses role confusion 6. intimacy verse isolation 7. Generativity verse stanation 8. ego integrity verse despair *The Artificial Intelligence Is In Identity, Genetics, Ego!

National League for Nursing (NLN)

Establishes and maintains a universal standard of education

Considering Alternatives

Exploring and imagining as many alternatives as you can think of for the situation. EX: what are two main possibilities/ Alternatives? Of the possible actions i am considering, which one is the most reasonable? why are the others not as reasonable?

Common Errors of Evaluation

Failing to evaluate systematically Failing to record results Failing to use reassessment data to reexamine and modify the care plan

Process of urinary elimination

Filling of bladder (200 to 450 mL of urine) Activation of stretch receptors in bladder wall Signaling to the voiding reflex center Contraction of detrusor muscle Conscious relaxation of external urethral sphincter

FACT

Flow Sheets, Assessment, Concise, Timely

essential patient goals

Flow from the problem side of the nursing diagnosis because the problem side describes the unhealthy response you intend to change

FACT Documentation

Flow sheets individualize specific services Assessment with baseline data Concise, integrated progress notes Timely entries

Primary Care

Focuses on health promotion, illness prevention, health educations, screening for early detection of healthcare problems

Tertiary Care

Focuses on promoting a comfortable quality of life until death = end-of-life care (i.e., hospice care)

What are traditional and alternative healing

Folk medicine, complementary and alternative medicine

Occurrence Reports

Formal record of unusual occurrence or accident Not a part of patient's health record Quality improvement *only what you OBSERVE

goal of home healthcare

Foster INDEPENDENCE

Psychoanalytical Theory

Freud - personality consists of id, ego, supego - motivation for human behavior and personality development stages: oral, anal, phallic, latency, genital instinctual drives, libido, survival

Teamwork and Collaboration

Function effectively within nursing and inter professional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

General Adaptation Syndrome

GAS theoretical model of physiological responses to stress -nonspecific bodily responses shared by al -responses to distress as well as eustress

Biological factors that affect health and illness

Genetic makeup gender age and developmental stage

Conscious, Subconscious

Goal-oriented, intended, and deliberate, involving motivation to learn (conscious) Without active participation in the learning process (subconscious) Active process involving more than giving of information

ageism

aged based discrimination

Chronic illness

Last for long period of time usually 6 months or more often for a lifetime

Nurse Practice Acts

Laws that regulate nursing practice - State Boards of nursing - Licensure - Professional standards

what are cultural characteristics

Learned Taught Shared by its members Dynamic and adaptive Complex Is diverse Exists at many levels Has common beliefs and practices Is all-encompassing Provides identity

Components of a Learning Assessment

Learning needs/knowledge level Health beliefs and practices Physical and emotional readiness Ability to learn Literacy level Health literacy Ability to see, feel, hear, grasp Learning style Time constraints Available resources

put a CAP on learning

Learning: Cognitive Affective Psychomotor

Framingham Heart Study

Longitudinal, multidisciplinary research project over 50 years to identify health and healthcare practices -Influenced healthcare practices for diabetes mellitus, breast cancer *importance of mamograms)*, heart disease, osteoarthritis

Radiation

Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air *August- Asphalt

Rhonchi

Low-pitched continuous sounds caused by secretions in the large airways

Surface Temperature

Lower than core temperature Use oral and axillary method

MORAL Model

M- Massage the dilema O- Outline the options R- Resolve the Dilemma A- Act by Applying the chosen option L- Look back and evaluate

Meaningful WOrk

Many people find that work is a healthy way to cope with stressors

Diastolic pressure

Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest

Computerized Care Plan: Potential Interventions

Popular. Individualized plans can be entered into the computer. More commonly, Standardized care plans are used and the individualized to deal with the nursing problem.

Computerized Care Plan: Potential Interventions

Popular. Individualized plans can be entered into the computer. More commonly, Standardized care plans are used and the individualized to deal with the nursing problem.

Challenges to Family Health

Poverty and unemployment Infectious diseases Chronic illness and disability Homelessness Family violence and neglect *F CHIP

Blood Pressure

Pressure of the blood as it is forced against arterial walls during cardiac contraction

PIE Charting

Problem Interventions Evaluation Used only in problem-oriented charting Establishes an ongoing plan of care *how patient responded P and P

medical asepsis

Procedures used to reduce and prevent the spread of microorganisms "clean technique"

What is culture competent: ANA

Provide holistic care that address the needs of diverse population

Mechanical Respiration

Pulmonary ventilation; breathing Active movement of air in and out of the respiratory system Mechanical- MOVEMENT

What are nursing interventions?

Purpose: to achieve client outcomes Also called nursing actions, measures, strategies, activities Based on clinical judgment and nursing knowledge 1.direct 2. indirect care

Evaluating Quality of Care in a Healthcare Setting

Quality assurance (QA) goal To evaluate and improve care provided in the healthcare setting QA involves evaluation of Structures, outcomes, and processes.

Read back and verify

RBAV

What are some barriers to culturally competent care

Racism, sexism, language barrier, other barriers, health history, physical assessment, cultural assessment models and tools

Hyperventilation

Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea) - give person a paper bag to breath in Client may complain of feeling light-headed and tingly. *CO2 tells the brain to breath

Telephone orders (T.O.)

Received by phone and transcribed onto the provider order sheet Have an increased risk for errors -date/time -text -to be followed by provider's name -your signature *provider must countersign within 24 hours -RBAV -spell medications -pronounce digits separtely

Patient-centered Care

Recognize the patient or designee as the source of control and [a] full partner [when] providing compassionate and coordinated care based on respect for patient's preferences, values and needs.

Analyzing Assumptions

Recognizing and analyzing assumptions you are making about the situation and examining the beliefs that underlie your choices Ex: What have I or others taken for granted in this situation? what beliefs/values are shaping my assumptions?

Nursing Documentation Forms: Nursing Admission Assessment

Record of baseline data from which to monitor change Helps forecast future needs *Must be done by an RN

Flow Sheets

Record routine aspects of care (hygiene, turning). Document assessments, usually organized according to body systems. Track client response to care (wound care, pain, IV fluids). Use graphic records to record vital signs. Record intake and output.

How Do I Evaluate Client Progress?

Review outcomes Collect reassessment data (focused assessment) Judge goal achievement (achieved, not, partial achieved) Record the evaluative statement Evaluate collaborative problems *R JERC

Five Rights of Delegation

Right task Right circumstance Right person Right direction/communication Right supervision *Supervisor's can delegate tasks & procedures!

Rights of Research participants

Right to... 1. not be harmed 2. full disclosure 3. self determination (say no or leave) 4. privacy and confidentiality *need a informed CONSENT

Family Health Risk Factors: Families with adolescents and young adults

Risk-taking behaviors Dealing with aging grandparents (sandwich family) Life transitions between dependence and independence

What are health belief systems

Scientific- biomedical health system, magio-religious system, holistic belief system

Health - illness continuum

See health and illness as a graduated spectrum that cannot be divided except arbitrarily into parts

Secondary Care

Services to diagnose and treat illness, disease and injury = health restoration

High level of communicating

Settling In (initial approach) Attuning (be attentive) acceptance (attitude of acceptance) respecting Enjoying ( broaden the repertoire) *SAARE

Korokoff's Sounds: Fourth Sound

Similar to the third sound, but softer and fading

Indirect method Equipment

Sphygmomanometer -Consists of a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer Stethoscope -Used to auscultate the systolic and diastolic pressures

Determine Wound Stage

Stage I to IV: classified by tissue involvement Stage III and IV: involve tissue necrosis UNstageable: wound with eschar Suspected deep tissue injury use PUSH tool

Components of a Community

Structure (demographic data- age, gender, ethnicity) Status (biological, emotional, social) -mortality rate, mental health, crime rates Process- over effectiveness level of the community

SOAP Charting

Subjective data Objective data Assessment Plan Some Add IER Intervention Evaluation Revision

SOAP

Subjective, Objective, Assessment, Plan

Hypotension

Systolic blood pressure <100 mm Hg; some clients normally have low BP; ask if client is light-headed or dizzy. Orthostatic or postural hypotension is a sudden drop in BP on moving from a lying to a sitting or standing position. (Wait 15 seconds between movement)

Task- relationship theories

Task: some leaders emphasize tasks (get charting done) Relationship: interpersonal aspect *most effective leader combines the two

Profession

Technical and scientific knowledge; be evaluated by a community of peers; have a service orientation and a code of ethics

Potential Dianosis

To detect progression to an actual problem or an increase or decrease in risk factors Potential diagnosis=progression of problem

Possible Diagnosis

To obtain more data to confirm or rule out a suspected nursing diagnosis *no Interventions!

Possible Diagnosis

To obtain more data to confirm or rule out a suspected nursing diagnosis. Has no Interventions!

interoperability

ability of many different kinds of computers and operating systems to talk with each other through standard languages or formats without losing the meaning of the information

Graphesthesia

ability to "read" a number by having it traced on the skin

Skills of a Leader

ability to communicate ability to delegate ability to manage change ability to manage conflict ability to manage time

leadership

ability to influence other people - enable movement of people toward a common goal 1. set direction 2. build commitment 3. confront challenges

power

ability to influence other people despite resistance from them 1. authority (power granted to an individual) 2. reward (money, goods, services) 3. expert (power from knowledge and skills) 4. coercion (threat of pain or harm physical, economic, psychological)

leadership

ability to influence other people. 1. set direction 2. build commitment 3. confront challlenges

Power

ability to influence others despite their resistance *action

transformational leadership

ability to inspire and motivate followers

Transformational leadership

ability to inspire and motive followers selling style

anuria

absence of urine synonymous with kidney shutdown or renal failure

pus

accumulation of dead white cells, digested bacteria, and other cell debris in the presence of infection

professional values

acquired during socialization into nursing from code of ethics, nursing experiences, teachers, and peers

Process

act of sending, receiving, interpreting, and reacting to a message

process

act of sending, receiving, interpreting, and reacting to a message

Implementation

action phase

working phase

active part of the relationship the patient expresses thoughts and feelings, mutual respect, is maintained, and honest verbal and nonverbal expression occurs

Primary prevention

activities are designed to prevent or slow the onset of disease (eating healthy foods, exercising, wearing sunscreen) *PREVENT

Treatment interventions are used for?

actual collaborative

Prevention interventions are used for?

actual potential collaborative wellness *you can't have a prevention for a possible diagnosis

Prevention interventions are used for?

actual potential collaborative wellness *you can't have a prevention for a possible diagnosis

Observation/assessment interventions are used for?

actual potential possible collaborative wellness

Communcation involves content

actual subject matter, words, gestures, and substance of the message

Situational Theories

adaptability is the key to this approach 1. understand all of the factors that affect a group 2. vary the type of leadership to meet the needs of the situation

Acculturation

adapting to a new culture

What is part of the 1st level of Maslow?

adequate nutrition

Wound closures

adhesive strips sutures surgical staples surgical glue

Discharge starts at

admission

initial assessment

admission - completed when the client first comes to the health care agency -static (demographic occupation, marriage status) ex. why is the person seeking nursing or medical assistance? *comprehensive comes next

Pressure ulcer

affect 15% of patients -caused by unrelieved pressure to an area, resulting in ischemia

physiological stress

affect body: structure/function ex. diseases, mobility problems chemical- tobacco use physical or mechanical- trauma, cold nutritional- vitamin deficiency biological- viruses genetic- metabolism lifestyle- obesity

AMA

against medical advice

naturally occurring retirement community

age in place within a specific area

health record

aka medical record or chat collection of documentation, orders, and other are info for a patient 1. care in chronological order 2. patient's responses to interventions and treatments 3. important facts about client's health history, including pat and present illnesses, examinations, tests, treatments, and outcomes

ethical agency

aka moral agency ability to base their practice on professional standards of ethical conduct and to participate in ethical decision making - nurses are responsible for their actions

ethical framework

aka morel framework systems of thought (theories) that are the basic for the differing perspectives people have in ethical situations

abusive head trauma

aka shaken-baby syndrome - violent shaking of an infant that causes severe brain injury

skin integrity

all layers of skin must be intact

patient database

all the pertinent patient data obtained by nurses and other health professions 1. nursing interview 2. physical assessment

airway inflammation and obstruction

allergic reactions, smoke irritation, choking on a foreign object or bolus of food, swollen epiglottis or tonsils

Group Communication

among several people

Common Pulse Points

apical (apex of heart) carotid (neck)- only for CPR and assessing circulation to head brachial (elbow) radial (writst) femoral (groin) popliteal (knee)

aging in place

as people age, they live in their own residences and receive supportive services for their changing needs, rather than moving

How does assessment relate to implementation?

as you perform nursing actions, you will also gather data by observing the client's responses.. this may lead to identifying new diagnosis

barriers to therapeutic communication

asking too many questions asking why closed ended questions changing the subject abruptly failing to listen offering advice providing false reassurance expressing approval or disapproval stereotyping use patronizing language

Effect of Medication on Stool

aspirin/anticoagulants: pink to red to black stool iron salts- black stool antacids- white discoloration or speckling in stool antibiotics: green gray color

National Council of State Boards of Nursing

asserts that the scope of nursing includes surveillance and comprehensive assessment of the health status of individuals, families, groups, and communities - differentiates between assessmetns by RNs and LPNs/LVNs

delegating

assess and diagnose plan goals and interventions implement evaluate

cultural assessment

assess and honor the diversity among all clients

How does assessment relate to evaluation?

assess the client's responses - reassessment provides the basis for changes in care plan

nutritional assessment

assess when client is undernourished, at risk for Imbalanced Nutrition, or requires nutritional therapy as an intervention

functional ability assessment

assessing ADL's

How does assessment relate to planning interventions?

assessment data help you to choose the interventions most likely to be acceptable to and effective for the client

How does assessment relate to DIAGNOSIS?

assessment provides the data necessary for identifying the client's health problems and strengths

continuing care retirement communities

assisted living, nursing home care, and independent living may all be met in a single residence

developmental stress

associated with life stages (ex. college graduation) -predictable

transactional theory

assumes ppl are motivated by reward and punishment and they work best within a clear chain of command. leaders monitor behaviors closely to point out errors and make corrective criticisms.

Magio-religious

belief in the supernatural

more outrage

belief that others are acting immorally -powerlessness - can not prevent a wrong - whistleblower

theory x

believe most people really do not want to work hard and managers need to make sure that they do work hard. manager needs to be strict and use threat of punishment

theory y

believe that work itself can be motivating and people want to do their jobs well emphasizes guidance rather than control more concerned with keeping staff morale high as possible

law

binding practice, rule or code of contact that guides appropriate actions and defensible decisions of an individual or a group

Neonatal Period

birth to 28 days * stabilize body's major organ systems and adapt to life outside uterus 1. establish respiration 2. independent circulation 3. themoregulation 4. production of urine

eschar

black necrotic tissue

coronary arteries

blood supply to the heart fill during diastole

nonverbal communication

body language

nonverbal communication

body language exchange of messages with out using words -unconscious level)

win-win resolution

both sides feel they have won

proximodistal

center to outward of body ex. of growth: central body is formed first in utero ex. of development: babies learn to use eyes first than crawl

Comprehensive patient care plan

central source of info needed guide holistic, goal oriented care to address each patient's unique needs - document that specifies dependent, interdependent, and independent nursing actions necessary for care of a specific patient

stress and adaptation theory

certain amount of stress is good for epople, its keeps them motivated and alert; however too much causes distress

stress and adaptation theory

certain amount of stress is good for people, its keeps them motivated and alert; however too much causes distress

collaborative problems

certain physiologic complications that nurses monitor to detect onset or changes in status - always a potential problem

menopause

cessation of menstrual periods for at least 12 months

Alveolar-capillary membrane disorder

change in consistency of lung tissue, especially alveolar level. The alveoli become stiff and difficult to ventilate and gas exchange is impaired. (pulmonary edema, acute respiratory distress syndome, pulmonary fibrosis)

managing change

change is a naturally occuring phenomena, a part of everyones life.

long term goals

changes in health status that you wish to achieve over a longer period-perhaps a week, a month or longer -describe optimal level of functioning you expect that patient to achieve "return to normal functioning"

ongoing planning

changes made in the plan as you evaluate the patients responses to care or obtain new data and make new nursing diagnoses

standardized nursing language

comparatively recent attempt to bring such clarity to communication about nursing knowledge and nursing thinking - clear, precise, consistent terminology 1. supports EHR 2. increase visibility and awareness of interventions 3. improve patient care 4. facilitate research to demonstrate the contribution of nurses to health care 5. define, communicate and expand nursing knowledge

common law

compilation of laws made by judges or courts aka case law

Proteins

complex molecules made up of amino acids (20 total) 1. tissue building 2. metabolism 3. immune system function 4. fluid balance 5. acid base balance 6. secondary energy source *needed for healing 4 kcal/g

Gestational period

conception to birth (40 weeks) 1st Trimester- embryonic phase, 8 weeks 2nd trimester- can feel "quickening" 3rd trimester- fetus is full term by 37 weeks *woman's health is goal

termination phase

conclusion of the relationship - end of shift - discharge

diagnostic format

concrete product

Comorbidities

concurrently occurring health problems. ex: an adult patient who had a stroke and recently broke his arm)

malnutrition

condition of impaired development or function caused by a long term deficiency, excess, or imbalance in energy and/or nutrient intake

Somatoform Disorders

conditions characterized by the presence of physical symptoms with no known organic cause hypochondriasis somatization pain disorder malingering

Diseases associated with renal problems

congenital urinary tract abnormalties polycytic kidney disease UTI urinary calculi hypertension diabetes mellitus Gout connective tissue disorders

assisted living facilities

congregated residential settings that provide or coordinate personal services, 24 hours supervision and assistance, activities and healthy related services

formal planning

conscious and deliberate, involves decision making, critical thinking, and creativity - work with patient and family - identify nursing interventions - holistic care plan

malingering

conscious effort to escape unpleasant situations - merely pretends to have the symptoms for personal or tangible gain ex. calling in sick

intrapersonal commnication

conscious internal dialogue self talk

Intrapersonal Communication

conscious internal dialouge, sometimes known as self-talk

moral behavior

consistent with customs or traditions based on the external influence (such as religious beliefs)

Foods that affect B.E.

constipating foods: cheese, lean meat, eggs, pasta foods with laxative effect: fruits and veggies, bran, chocolate, alcohol, coffee gas producing foods: onions, cabbage, beans, cauliflower

exudate

drainage

fecal impaction

dry, hard stools lodged in the rectum that can't be passed

Small intestine

dueodenum jejunum ileum *most digestion and absorption of food occurs here

andropause

decline in testosterone production, lower sperm count, and a need for more time to achieve an erection

Cardiac Diagnosis

decreased cardiac output ineffective tissue perfusion risk for shock

mobilizing secretions

deep breathing and coughing (ventilation/gas exchange) hydration (oral fluids, humidified inhaled air) chest physiotherapy

fissure

deep crack An opening; a groove; a split

Tertiary intention

delayed healing granulating tissue brought together delayed closure of wound edges - less than secondary, more than primary

observation

deliberate use of all of your senses to gather and interpret patient and environmental data - see , hear, feel, or smell

fire-hosing information

deliver an overwhelming amount of information

Medications

depress respirations respiratory depressants depress the CNS control of breathing or by weakening the muscles of breathing

goals

describe the changes in patient health status that you hope to achieve, aka expected outcome - provide a guide -motivate the client - form the criteria you will use in evaluation process

medical diagnosis

describes a disease, illness, or injury -purpose is to identify a pathology so that appropriate medical treatment can be given. - more narrowly focused

perfusion

describes blood flow to a capillary bed to provide nutrients and oxygen to tissues and organs

problem

describes the client's health status (human response to a health problem) and identifies a response that needs to be changed

Terminal evaluation

describes the client's health status and progress toward goals at the time of discharge

Good Samaritan laws

designed to protect from liability those who provide emergency care to someone who is in need of medical services - vary state to state

Standardized patient care plans

detail the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition - more detailed - organized by nursing diagnosis - part of CCP and become permanent record - includes checklist, blank tests, etc.

Factors that influence Cardiac Function

developemental stage environment stress (allergic reaction, air quality, heat and cold) medication life style (pregnancy, obesity, exercise, smoking)

Hardiness

developing a very strong positive force to live- and enjoying the ride

Factors that influence bowel elimination

developmental considerations daily patterns food and fluid activity and muscle tone lifestyle, psychological variables pathological conditions medications diagnostic studies surgery and anesthesia

Factors that are at risk for infection

developmental stage breaks in the first line defense illness/injury tobacco use substance abuse multiple sex partners environmental factors chronic disease medications invasive nursing/medical procedures

Type 2 diabetes

diabetes mellitus endocrine disorder characterized by insullin resistance

Alteration in defecation

diarrhea constipation fecal impaction bowel diversions

Focused Nutritional Assessment

dietary history 24 hour recall Food frequency questionnaire food record *only as good as the person wants it to be (relies on honesty of patient)

Etiologies for undernutrition

difficult chewing/swallowing alcoholism metabolic disorder

aphasia

difficulty expressing or interpreting messages

Roles of home health nurse

direct care provider client family educator client advocate care coordinator

The charge nurse of a unit tries, as a rule, to admit Hispanic clients to a room at the end of the hall so that "the noise from the family will not disturb others." This nurse is exhibiting

discrimination

internal stress

diseases, anxiety, nervous anticipation

wound

distruption in the normal skin integrity

Effects of meds on Urination

diuretics- prevent reabsorption of water and certain electrolytes in tubules cholinergic- stimulate contraction of detrusor muscle, producing urine angelsics and tranqs- suppress CNS, diminish effectiveness of neural reflex

Process evaluation

focuses on the manner in which care is given (activities performed by nurses): policies and procedures - relevant -appropriate - complete -timely ex. protects patient's privacy when performing procedures, washes hands before each patient contact

Structure evaluation

focuses on the setting in which care is provided (building, staffing, money) ex. at least one RN is present on each unit at all time

pregnant and lactating women

folic acid intake is critical in 1st trimester screen for gestational diabetes additional 500 calories if breastfeeding

Complete proteins

foods that contain all of the essential amino acids necessary for protein synthesis - animal sources

certification

form of credentialing criteria: 1. education preparation 2. clinical experience 3. certification by another agency

litigation

formal process wherein the legal issues, rights, and duties between the parties are heard and decided 1. pleading and pretrial motions 2. discovery 3. alternative dispute resolution 4. trial 5. appeal

professional code of ethics

formal statements of a groups expectations and standards for professionalism behavior generally accepted by members of the profession

Florence Nightingale

founder of nursing healthy environment, clean air, nutritional foods,

Types of specimens

freshly voided clean catch sterile speciman 24 hour urine

Factors to Consider with use of Absorbent Products

functional disability of patient type and severity of incontinence gender availability of caregivers failure with previous treatment programs patient preference

quantitative research

gather enough data from enough subject to be able to GENERALIZE the results to similar populations - numbers

Pre-interaction phase

gather info prior to meeting client

Physical Exam Indication of Nutritional Imbalances

general survery alteration in vital signs poor skin turgor, wound healing concave abdomen/ascites change in muscle mass

nature

genetic endowment

community

gift or fellowship of common relations and feelings -group of like minded people who work together and share a common language, ritual and customes

credibility

give information if certain of facts if a situations makes you uncomfortable, it is better to acknowledge your discomfort than to risk loss of credibility always be open and honest nonverbal communication must match spoken words

scientific management

given a properly designed task and sufficient incentive to get the work done, worker would be more productive

authoritarian leadership

gives orders, makes decisions, for the group as a whole, and bears most of the responsibility for the outcomes

short term goals

goal you expect to achieve within a few hours or days

Preschool

goal: safety proportions of head to trunk are closer able to control bodily functions able to communicate needs through language able to separate from parents develops conscience

eustress

good stress ex. strong passionate kiss

Cheyne-Stokes respirations

gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea

health-illness continuum

graduated spectrum that cannot be divided-except arbitrarily-into parts. A person't position moves back and forth on the continuum with physiological changes, lifestyle choices, and the results of various therapies.

cluster

group of cues that are related to each other in some way *derive a nursing diagnosis from data clusters, rather than just a single cue

aggregate

group of individuals with at least one shared characteristic either personal or environmental

information

grouping of processed data

toddlers and preschoolers

have all deciduous teeth by age 3 lifelong food habits are developed

edentulism

having no natural teeth

cephalocaudal

head to tail (toe) ex. of growth: at birth, head is bigger ex. of development: babies use arms before legs

Cardiovascular abnormalties

heart failure (ineffecient pump) cardiomyopathy ( heart muscle disorder) cardiac ischemia (leads to MI, part of heart dies) coronary artery disease (plaque buildup, clots) heart valve abnormalities (murmur, mitral and aortic) dysrhytmias- decrease cardiac output Peripheral vascular abnormalities (impaired blood flow) oxygen transport (anemia, carbon monoxide)

Screen Assessment

height weight BMI brief dietary history

Comprehensive discharge plan

helps to - maintain functional ability - lengthen the time between rehospitalizations - involve all concerned parties in decision making - involve interagency communication - emphasize client and family invovement *done with, not for, the patient

Arterial Blood Gases

hemoglobin (iron containing pigment of rbcs that carries oxygen in the blood) PO2 (amount of oxygen available to combine with hemoglobin to make oxyhemoglobin) SaO2 (reflects oxygen that is actually bound to hemoglobin) (most accurate for O2 levels, invasive, hypokalemia levels)

Complications of wound healing

hemorrhage infection dehiscence evisceration fistula formation (tunnel connecting 2 body cavities)

Wheeze:

high pitched sound, usually on EXPIRATION (both have "E")

Stridor:

high pitched sound, usually on INPIRATION (both have "I")

CCC

home health standardized language - Clinical Care Classification

CCC

home health standardized language Clinical Care Classification

logical reasoning

how theories are developed - develop an argument or statement based on evidence - inductive or deductive

Oxygenation

how well the cells, tissues, and organs of the body are supplied with oxygen

Tertiary defense

humoral immunity, b cell production of antibodies in response to an antigen, cell mediated immunity, direct destruction of infected cells by t cells

assumptions

ideas we take for granted

American Nurses Association

identifies assessment as a professional responsibility -"the RN collects comprehensive data pertinent to the healthcare consumer's health and/or situation." - guides decisions on who is ultimately responsible and qualified to collect assessment data

The Joint Commission

identifies assessment as an essential element of patient care - assessments are written, comprehensive and used to identify and assign priorities of care - agency policies delegate when each patient is to be reassessed and which disciplines can make which assessment - all patients are assessed for PAIN states who can perform and document assessments

Trait Theory

identify traits, or qualities that distinguish a leader from a nonleader - intelligence and initiative *what leader is?

exhaustion

if adaption mechanism become ineffective/nonexistant decreased BP elevated pulse and respiration usually ends in disease or death

Promoting respiratory functions

immunizations/prevent URIs positioning: maximum lung excursion (frequently) incentive spirometry aspiration precautions

Planning interventions

implementation envision strengths and potential in clients and families who are too overwhelmed to identify their own

connotation

implied or emotional meaning of the word

procedural justice

important in processes that require ranking or ordering

Cardiopulmonary Resuscitation

in hospital arrect- AED hands only CPR

How are diagnosis stated?

in terms of HUMAN RESPONSES

moral distress

inability to carry out a moral decision perceived constraints

urinary retention

inability to empty the bladder completely

stress incontinence

increase in intra abdominal pressure

Manage constipation

increase intake of high fiber foods increase fluid intake increase activity provide privacy help client to a position that faciliates defecation allow uninterrupted time offer laxatives

followers

individuals who take another person as a role model and who act in accordance with, imitate, support and advocate the ideas and opinions of another

Future consequences

ineffective denial may lead to further problems with treatment plan- assign this a top priority

Developmental considerations for Bowel elimination

infant- stool depends on formual or breast milk toddler- physiological maturity is 1st priority for training child/adolescent/adult- defecation patterns vary in quantity, frequency, and rhytmicity older adults- consitpation is often a choronic problem

graphic flow sheet

vital signs

Assessment of Anus and Rectum

inspection and palpation -cracks, nodules, distended veins, masses or polyps, or fecal mass - insert gloved finger into anus to assess sphincter tone and smoothness of mucosal lining - inspect perineal area for skin irritation secondary to diarrhea

nursing orders

instructions that describe how and when nursing interventions are to be implemented -usually written on a patient care plan

Nursing Orders

instructions that describe how and when nursing interventions are to be implemented -usually written on patient care plan

Nursing Orders

instructions that describe how and when nursing interventions are to be implemented-usually written on patient care plan

Underweight/undernutrition

insufficient intake of protein, fat, vitamins and minerals consume less calories than needed according to activity, gender, height and weight

intake and output sheet

intake: oral, intraveous, and tube feeings output: urine, fluid from drainage, would drainage, and bowel movement

Activities of an effective manager

interpersonal activities (networking, conflict negotiation and resolution, employee development, rewards and punishments, coaching)

decoding

interpretation relating the message to your past experiences to determine the sender's meaning

enema

introduction of solution into the rectum to soften feces, distend the colon, and stimulate peristalsis and evacuation of feces

quasi-intentional tort

involve actions that injure a person's reputation - defamation of character

civil law

involves a dispute between individuals or entities 1. contract law 2. tort law

UGI series

involves fluorosopic examination of the esophagus, stomach, and SI after ingestion of barium sulfate

Secondary prevention

involves screening activities and education for detecting illnesses in the early stages (self breast exam, tb test, diabetes screen) *SCREEN

verbal communication

involves speaking or writing words to send a message

contract law

involves written or oral agreement between 2 parties in which one party accept an offer made by the other party to perform (or not perform) certain acts in exchange for something of value

Biot's respirations

irregular respirations of variable depth (usually shallow), alternating with periods of apnea

lavage

irrigation of tissue with fluid

Full spectrum nursing

is a unique blend of thinking, doing, and caring. It is performed by nurses who fully develop and apply nursing knowledge, critical thinking and the nursing process to patient situations for the purpose of effecting good out comes.

Providing a Healing Presence

is most important because patients will never forget how you made them feel. a patient might forget simple things you did (medications, dressing, toileting) but they will never forget how you made them feel. (communication, politeness, healing presence, care)

dementia

is not a normal result of aging - irreversible, progressive decline in mental abilities - both memory impairments and a disturbance in at least one area of cognition

Ethnocentrism

is the cause of bias and prejudice toward other cultures

Systole

is the peak of the wave, or contraction of the heart.

Reflecting critically on Nursing ordes

is the set of orders complete? is each order technically complete? are the orders clear, specific, precise? is the order individualized for this particular client? are the orders concise? which orders have priority?

Diastole

is the trough or resting phase of the heart.

Vocabulary

it is your responsibility to deliver messages that the client can understand; therefore, use medical terms only when you are certain the listener understands them

pruritis

itching

xerosis

itchy, red, dry, scaly, cracked or fissured skin

inferences

judgments and interpretations about what the cues mean

Colostomy Care

keep patient as free of odors as possible, empty appliance frequency inspect the patient's stoma regularly measure the patient's fluid intake/outake explain each aspect of care encourage patient to care for and loo at ostomy

older adults and urine

kidney function decreases urgency and frquency common loss of blader eleasticity and muscle tone - nocturia -incomplete emptying - retention, increases risk for UTI

renal calculi

kidney stones

Indirect-care interventions

performed away from the client but on behalf of a client or group of clients ex. advocacy, managing the environment, consulting with other members of the healthcare team, making referrals

Indirect-care interventions

performed away from the client but on behalf of a client or group of clients examples are advocacy, managing the environment, consulting with other members of the healthcare team, and making referrals

Indirect care interventions

performed away from the client by on behalf of a client or group of clients. ex. advocacy, managing the environment, consulting with other members, making referrals

Direct care interventions

performed through interaction with the clients ex. physical care, emotional support, patient teaching

Direct-care interventions

performed through interaction with the clients ex. physical care, emotional support, patient teaching if a patient feels nauseous-move the food tray away from them

Direct-care interventions

performed through interaction with the clients examples are physical care, emotional support, and patient teaching

focused assessment

performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected. -particular topic, body part, or functional ability (not on overall health)

surrogate decision maker

person given the right to make medical decisions as long as the person is not able to do so for himself

Biculturalism

person identifies with two or more cultures.

hypochondriasis

person is preoccupied with the idea that he is or will become seriously ill

defendant

person who must defend against the lawsuit

whistleblower

person who reveals info about the practices of others that he reasonably believes is corruption, mismanagement, fraud, abuse, illegal, or harmful to the health, safety, and welfare of the general public

autonomy

person's right to choose and ability to act on that choice

Factors that affect urination

personal sociocultural environmental nutrition (asparagus) hydration activity level medications (diuretics, anticholinergic, analgesics, and tranquilizers) surgery and anesthesia

Caring

personal concern for people, events, projects, and things

oropharyngeal

pertaining to the mouth and pharynx

nasopharyngeal

pertaining to the nose and pharynx

Maslow's Hierarchy of needs

physciological safety and security love and belonging self esteem cognitive aesthetic self actualization Transcendence *Pink scarves look so cool at school too

apagar scoring system

physical assessment at birth - based on heart rate, respiratory effort, muscle tone, reflex irritability, and skin color

growth

physical changes that occur over time, such as increase in weight, height, sexual maturation, muscle tone

What factors disrupt health?

physical disease injury mental illness pain loss impending death competing demands the unknown imbalance isolation

Cardiovascular Assessment

physical exam (WILDA, fatigue, dyspnea, peripheal circ.) tests of blood oxygenation (ABG's) lab testing (ECG) cardiac monitoring (supreventricular, junctional )

Captain of the ship

physician is held liable for the negligence of another healthcare provider

Establish a Bowel Training Program

plan program with client increase fiber in diet gradually increase fluid intake to 8 glasses of water per day establish a designated time for defecation privacy treatment plan should be staged treatment may include stool softener plan should be modified based on client results

Dunn's Health Grid

plots a person's status on the health-illness continuum against environmental conditions. Many nurses use this grid to help them predict the likelihood that a client will experience a change in health status.

occurence type insurance

policy covers malpractice claims for any injury or damage that occurred during the time the policy was in force, regardless of when the claim was reported and the law suit occurred.

American Nurses Association nurse's Bill of Rights

policy statement adopted by the ANA to identify the 7 conditions that nurses should expect from their workplace that are necessary for sound professional practice

Adaptation

possible/desired outcome of stress involves adjusting to the stress allows for: 1. normal growth and development 2. effective responses to life's challenges

transmission based precautions

precautions to be takes based on the mode of transmission of the infection (contact, droplet, airborne)

5 Phases of Crisis

precrisis impact crisis adaptive postcrisis

CNS abnormalities

trauma/stroke spinal cord injuries immature breathing patterns/apnea/periodic breathing

embolus

traveling clot

paternalism

treating others like children

democratic leader

tries to move the group toward its goals -aka participative leadership share the planning, decision making and responsibility for outcomes with members

autocratic leader

tries to move the group toward the leader's goals aka authoritarian, directive, controlling - gives orders, makes decisions for the group as a whole

enteral nutrition

tube feeding, delivery of liquids nutrition into the upper intestinal tract via a tube

IntERpersonal Communication

two or more people face to face *most frequent form of communication

nonmaleficence

twofold duty to do not harm and prevent harm "no mal"

special needs assessment

type of focused assessment that provides in depth info about a particular area of client functioning and often involves using a specially designed form

Ego Defense Mechanisms

unconscious mental mechanism that make a stressful situation more tolerable by decreasing the inner tension associated with the stressors

Lived experience

unique to each patient The perspective of an individual who has experienced the phenomenon

Common Urine Studies

urinalysis dipstick testing specific gravity

urinary catheterization

urinary catheterization - introduction of a sterile tube into the bladder straight indwelling or Foley suprapubic

urge incontinence

urine lost during abrupt and strong desire to void

Identify problem etiologies

use theoretical knowledge and the patient data to answer questions: 1. what factors are known to cause this problem? 2. what patient cues are present that may be contributing to this problem? 3. how likely is it that these factors are contributing to the problem? 4. what past experiences do I have that support my judgement? 5. are these cues causing the problem or are they merely symptoms of the problem?

Choosing nursing interventions

use: Professional standards (ANA) Theories Nursing research Evidence-based guidelines

Choosing nursing interventions

use: Professional standards (ANA) Theories Nursing research Evidence-based guidelines *PENT house for nursing interventions

basic 2 part statement

used for actual, risk, and possible diagnoses - problem r/t etiology - NANDA-I label r/t related factors

Individualized Patient Care plans

used to address nursing diagnoses unique to a particular client - best demonstrate the nurse's critical thinking and clinical expertise. -includes goals and nursing orders

ongoing focused assessment

used to evaluate the status of existing problems and goals

initial focused assessment

used to follow up on a client reported symptoms or unusual finding during the first exam

cue

usually an unhealthy response

QRS

ventricular depolarization

T wave

ventricular repolarization, rest

message

verbal and/or nonverbal information the send communicates -content of a speech, conversation, gesture, letter

feedback

verbal, nonverbal or both, response to message

medical paradigm

views a person through a lens that focuses on identifying and treating diseases - person's parts

nursing paradigm

views the person through a leans that focuses more broadly on the entire person and how he responds

nursing paradigm

views the person through a lens that focuses more broadly on the entire person and how he responds

invasion of privacy

violates a persons right to be left alone

crime

violation of a law as defined by a legislative body, specifies punishment 1. misdemeanors 2. felonies

colonoscopy

visualizes the rectum, colon, and bowel using a lighted scope

Factors that affect verbal communication

vocab denotative verses (literal meaning) connotative meaning (implied) pacing intonation (tone, pitch, cadence, volume) clarity and brevity timing relevance of information credibility humor

Patient Stool Collection

void first so that urine is not in stool sample defecate into the container rather than toilet bowl do not place toilet tissue in bedpan notify nurse when specimen is available

Urinary elimination

voiding micturition urination

Magenesium

what decreases the risk of hypertension and coronary artery disease in women?

PROBLEMS

what do nursing diagnosis flow from?

ETIOLOGY

what do nursing interventions flow from?

Prealbumin

what is a better gauge for malnutrition?

Calories

what is energy of carbohydrates, proteins and lipids measured in? the # we consume must = the # we burn, if not weight gain or weight loss results

Virginia Henderson

what is means to be a nurse

Behavioral theories

what leader does. 1.democratic leader- toward its goals 2. autocratic leader- toward leader goal 3. laissez-faire leader- little/no attempt to move group (let it alone)

NIC, CCC, OMAHA

what organizations include interventions to address health promotion and cultural and spiritual needs?

cues

what the client says and what you observe

Behavioral theories

what the leader does 1.democratic 2. autocratic 3. laissez fair

message

what the sender is communicating (verbal or nonverbal)

Personal Relationships

when an illness occurs, some people prefer to be totally independent, priding themselves on never asking for help. But the reality is that during times of disruption, support from others is crucial.

hostility

when anger involves destructive behaviors such as physical or verbal abuse

FACTUAL

when charting, be FACTUAL F- factual A- accurate C- complete T- timely U- unusual occurrences, be diligent A assessment data L- legal record

flatulence

when gas is excessive or leads to complaints of abdominal distention, cramping, or discomfort

Reflex pain response

when you perceive a painful stimulus, especially in your limbs, you immediately and unconsciously withdraw from the source of pain ex. touching a hot stove *involuntary reflex

Registered Nurse

who is responsible for choosing nursing interventions?

followership

willingness to work with others toward accomplishing the group mission

diagnostic label

word or phase that represent a pattern of related cues and describes a problem or wellness response - descriptors of time, age

Human relations-oriented management

work will motivate people considers feelings of staff

paradigm

worldview or ideology

Secondary intention

would edges not approximated tissue loss heals from inner layer to surface *most scarring OPEN

libel

written or published form of defamation of character

jaundice

yellow discoloration of the skin can be caused by accumulation of bile pigments and is a symptom of certain diseases (itchy/dry)

closed questions

yes or no questions

reliable

yields consistent results - same results every time

What are cultural assessment models and tools

• Purnell model for cultural competence • Andrews and boyle transcultural nursing assessment guide • Spectors heritage assessment model • Giger and davidhizar transcultural assessment model

What are other culture specific

• Religion and philosophy • Education • Technology • Politics and law • Economy

How should I respond to a client cultural health practice

• The practice of efficacious • The practice of is neutral \the effects are uncertain • The practice is dysfunctional