NUR 112: Nursing process
Alfaro's rule
Assess; PT before performing actions Re-assess; to determine their response Revise; your approach Record; PT response and changes to care plan
Testing sequence to ensure accurate diagnosis
FOBT, barium studies (think contrast for radiography), endoscopic examination
Fecal occult blood test
FOBT; test to detect occult (cant see with the naked eye) blood in feces
When administering a cleansing enema-the client should lie in the ________ position
Sims; left side lying
SMART
Specific; target area Measurable; indicator of progress Attainable; who will do it Realistic; what can be achieved Timely; when can be achieved
Symptoms
Subjective characteristics of disease felt only by the patient
The use of the clarifying question or comment
allows the nurse to gain an understanding of a patient's comment
Medication that cause diarrhea as a SE
amoxicillin clavulanate (antibiotics), metformin, or over-the-counter antacids
Holistic medicine
an approach to health care that emphasizes prevention of illness and takes into account a person's entire physical and social environment
Time-lapsed assessment
an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier
Empathy
an objective understanding of the way in which a patient sees his or her situation, identifying with the way another person feels, putting yourself in another person's circumstances, and imagining what it would be like to share that person's feelings
A white discoloration or speckling in the stool
antacids may cause
Inhibit peristalsis
anti-diarrheal medications
May cause a green-gray color related to impaired digestion
antibiotics
May cause the stool to appear pink to red to black
any drug with the potential to cause gastrointestinal bleeding (e.g., anticoagulants, aspirin products)
Cognitive skills
application of critical thinking in the nursing process
Collaborative problems
approach to treatment involves multiple disciplines; nurses manage using physician prescribed, and nurse, interventions; uses team work
E-mail and text messages
are efficient means to communicate with staff members and, in some cases, patients. The risk for violating patient privacy and confidentiality exists any time a message is sent electronically. Health care agencies usually have security measures in place to safeguard e-mail and text communications.
Yogurt and buttermilk
are natural deodorizers
Antidiarrheal drugs
are used to soothe irritation to the intestinal wall, block GI muscle activity to decrease movement, or affect CNS activity to cause GI spasm and stop movement,
Nursing diagnoses
are within the nursing scope of practice to develop and are client-focused
Normal urine is
aromatic
AEB
as evidenced by, "the defining characteristics"
Nurses ...
assess and educate
The purpose of implementation is to:
assist the patient in achieving valued health outcomes: -promote health -prevent disease and illness -restore health -facilitate coping with altered functioning.
Touch is the most highly developed
at birth
Routine UA
at least 15mL; stability: refrigerated
The patient should be instructed to retain the enema solution for
at least 30 minutes
Point of care
at or near the site or time of patient care
Disconnect the NG tube before
auscultating for bowel sounds
Innervates the muscles of the colon
autonomic nervous system
Maslow's heirarchy
basic needs must be met before a person can focus on higher ones, PT needs may be prioritized according to the following: 1. physiologic 2. safety 3. love and belonging 4. self-esteem 5. self-actualization
Reflection
begins with the description fo events at the most basic level
The nerve fibers innervating the internal and external anal sphincters become fully developed
between the ages of 18 and 24 months; at which point voluntary control of defecation becomes possible
Epitaxis
bleeding from the nose
______ may take longer than ______
boys, girls (urinary continence)
The working phase
is usually the longest phase of the helping relationship; the nurse works together with the patient to meet the patient's physical and psychosocial needs, the nursing roles of teacher and counselor are performed primarily during this phase
Primary organ of bowel elimination
large intestine 'colon' extends from the ileocecal valve to the anus
Cathartic drugs
laxatives
Medications that can promote peristalsis
laxatives
Never use when lying down
leg bag
Normal urine
light yellow and clear
Nursing Interventions Classification (NIC)
list of research-based nursing intervention labels that provides standardization of expected nursing interventions.
Bearing down to defecate, temporarily __________ cardiac output
lowers causing decreased blood flow to the atria and ventricles
Mineral oil
lubricant laxative
Cottonseed oil
lubricates and softens stool
Ethical Skills
making the right decisions, choosing right from wrong
Aromatic
meaning fragrant
BUN (blood urea nitrogen)
measurement of urea (nitrogen waste) levels in blood
Stool collection
medical aseptic technique is imperative
Diuretics
medications administered to increase urine secretion in order to rid the body of excess water and NA+
Expected outcomes
more SPECIFIC to the patient, measurable criteria used to evaluate whether the patient goal has been met
Breastfed babies have ________ stools
more frequent
Gas escapes through the
mouth (belching) and anus (flatus)
Medications that cause constipation
narcotics (opiates) and diuretics
Avoid the following common clichés because they tend to impede effective communication:
"Everything will be all right." "Don't worry. You will be just fine in another day or two." "Your doctor knows best." "Cheer up. Tomorrow is another day."
Any e-mails sent to a patient must be
duplicated and become part of the medical record for that patient.
Any e-mails sent to a patient must be:
duplicated and become part of the medical record for that patient.
E-mail and text messages are:
efficient means to communicate with staff members and, in some cases, patients
Loop diuretics
ex. furosemide, bumetanide, torsemide; most commonly used for hypertension, edema; act at the loop of hene in the kidney
Hyperkalemia
excessive K+ in the blood
Nocturia
excessive urination at night
Patient outcome
expected CONCLUSION to a patient health problem, or in the event of a wellness diagnosis, an expected CONCLUSION to a patient's health expectation
Complex critical thinking
expresses autonomy by analyzing and examining data to determine best alternatives
Urinary meatus
external opening of the urethra
The most expressive part of the body is the
face
Noise
factors that distort the quality of a message and interfere with the communication process
UA is best collected
first thing in the morning
Condom catheter
flexible sheath that is rolled around the penis
Valsalva maneuver
forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure; "bearing down" contraindicated for persons with cardiovascular problems and other illnesses
People who chronically worry and those with certain personality types who tend to hold onto problems and negative feelings may experience....
frequent constipation
Diarrhea
frequent passage of loose, watery stools
Polyuria
frequent urination
Foods with laxative effect
fruits, veggies, bran, chocolate, alcohol, coffee
Nephrons
functional unit; regulate and maintain fluid balance
Alimentary tract or canal
gastrointestinal tract
Physical assessment
gathers objective data observed by the nurse, such as: -vital signs -height -weight.
Open-ended questions
give the client an opportunity to express what the client understands and prevent the client from answering with just 'yes or no'
Glycosuria
glucose in the urine
Constipation
hard, slow stools that are difficult to eliminate; often a result of too little fiber in the diet
Carminative enema
help expel flatus from the rectum
FOBT detects
heme, a type of iron compound in blood in the stool
Diarrhea accompanies periods of ...
high anxiety
Creatinine
nitrogenous waste ('metabolic waste'; cannot be used by the body), excreted in the urine
Infants have____________ control over bowel elimination
no voluntary the stools are yellow to golden and loose, and usually have little odor
The way a person holds the body carries
nonverbal messages
During the implementing step of the nursing process...
nursing actions planned in the previous step are carried out
Intestinal obstruction
occurs when blockage prevents the normal flow of intestinal contents through the intestinal tract
The termination phase
occurs when the conclusion of the initial agreement is acknowledged; discharge planning coordinates with this phase
The rectal receptors in __________ have a ____________ response to stretching
older adults, decreased which can lead to a decreased urge to move the bowels despite a large amount of stool in the rectum
Normal bowel elimination
once every 1-3 days without discomfort
Stool
once excreted, feces are called
Two centers govern the reflex to defecate:
one in the medulla and a subsidiary one in the spinal cord
Indwelling catheter
one that remains inside the body for a prolonged time
Gas producing foods
onions, cabbage, beans, cauliflower, bananas, apples, broccoli
When obtaining nursing hx, use
open ended questions
Medical Model
organizes data collection by body system
Gordon's functional health patterns
organizes info and makes assessments identifying functional and dysfunctional patterns; there are 11 -i.e. sleep and rest dysfunction
The five-step process combines
outcome identification and planning into one step
Cathartic dependence
overuse of laxatives that can lead to the need for strong stimuli to initiate movement in the intestines; local reflexes become resistant to normal stimuli after prolonged use of harsher stimulants, leading to further laxative use
Dysuria
painful urination
Chyme
partially digested food
Lactose intolerance
people who lack the enzyme lactase, which helps to break down the simple sugar lactose found in milk and milk products, cannot digest milk;
Example of an independent nurse-initiated intervention:
performing a focused assessment
Fecal incontinence is a result of
physiologic and lifestyle changes
Discharge comprehensive planning
preparing the PT to leave the health care facility
Actual
present at the time of the nursing assessment; presence of the major defining symptoms, signs and characteristics, would benefit from nursing care.
Describing a patient by using a room number or diagnosis rather than a name is...
still considered a breach of confidentiality and a violation of patient privacy.
Bisacodyl (Dulcolax)
stimulant laxative; overage may cause lazy bowel syndrome, leading to constipation
Bismuth subsalicylate
stimulant laxative; treats/prevents travelers diarrhea; prevents straining, mild stimulation, can cause black stools; i.e. Pepto-Bismol
Cholinergic medication
stimulate contraction of detrusor muscle, producing urination
Parasympathetic nervous system...
stimulates movement
Transient incontinence
temporary or occasional incontinence that is reversed when the cause is treated
Paralytic ileus
temporary stoppage of peristalsis normally lasts 3 to 5 days
Stool culture
test to identify microorganisms or parasites present in feces that are causing a gastrointestinal infection
Quality asssurance
the aim is to provide healthy care to patients, this involves on going evaluation of all systems used in the care of patients.
Health history tool
the client's profile, which consists of: -name -age -sex -genetic background -marital status -religion -occupation -education
Defining characteristics
the clinical criteria or assessment findings that support an actual nursing diagnosis; signal the existent of problem; "AEB"
Ileocecal, or ileocolic, valve
the connection between the ileum of the small intestine and the large intestine this valve normally prevents contents from entering the large intestine prematurely and prevents waste products from returning to the small intestine.
Hyperplasia
the enlargement of an organ or tissue because of an abnormal increase in the number of cells in the tissues
Interpersonal communication
the exchange of thoughts, feelings, and beliefs between two or more people
Stress incontinence
the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing
Ineffective Health Maintenance
the inability to identify, manage, and/or seek out help to maintain health
Control the discharge of feces and flatus (intestinal gas)
the internal sphincter in the anal canal and the external sphincter at the anus
Reflex incontinence
the loss of urine at predictable intervals when the bladder is full
Discharge planning begins
the moment a patient is admitted to a health care facility
Stress causes
the muscles to become tense so that the relaxation of the perineal muscles does not occur, and voiding is inhibited
Critical thinking
the objective analysis and evaluation of an issue in order to form a judgment.
The etiology identifies
the physiological, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor
Hemodialysis
the process by which waste products are filtered directly from the patient's blood
Proxemics
the study of distance zones between people during communication
The orientation phase
the tone and guidelines for the relationship are established
Delegation
the transfer of responsibility for the performance of an activity to another person while retaining accountability for the outcome.
PED
three part nursing DX statement; patients problem, its cause (etiology: R/T), and defining characteristics (AEB)
Micturate
to urinate or void
Kinesthetic
touch
Direct nursing interventions
treatment that is performed through interaction with the pt; "lying on of the hands", involves physiological and psychosocial
Indirect nursing interventions
treatments performed away from the patient but on behalf of the pt or group of patients; may not be hands on
PE
two part nursing DX statement; patients problem, and its cause (etiology: R/T)
Neoplastic diseases
uncontrolled cell growth (tumors)
UGI
upper gastrointestinal series; fluoroscopic examination of the esophagus, stomach, and small intestine after injection of barium sulfate
Territoriality
urge to maintain an exclusive right to certain space
Ideal conduit
urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall
Functional incontinence
urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation
Auscultating for bowel sounds
use the diaphragm of the stethoscope
When an administering an enema, the clients _________ may be stimulated
vagus nerve
Sigmoidoscopy
visual examination of the distal sigmoid colon, rectum, and anal canal through a flexible rigid sigmoidoscope
Esophagogastroduodenoscopy
visual examination of the esophagus, stomach, and upper duodenum through an optic scope
Endoscopy
visual examination within a hollow organ
Colonoscopy
visualizes the rectum, colon, and bowel using a lighted scope
Bacterial action produces:
vitamin K and some of the B-complex vitamins
Social media
web-based technologies that allow users to create, share, and participate in dialogue in virtual communities and network
Best indicator of fluid status
weight
Health promotion nursing dx
wellness; clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential
Signal of preparedness to toilet
when the child is dry for at least 2 hours
A diet lacking in glucose and water
will cause dehydration and (may) cause constipation
Commitment critical thinking
Independent thinking with responsibility
Causes of nonmechanical obstruction include
diseases that weaken or paralyze the intestinal walls such as muscular dystrophy, diabetes mellitus, and Parkinson's disease
Dispositional trait
a characteristic or customary way of behaving
A HEALTH PROMOTION nursing diagnosis contains
a diagnostic label one part statement
A bouncy, purposeful walk usually carries
a message of well-being
Joint Commission
a not-for-profit organization that evaluates and accredits different types of healthcare facilities quality assurance is their focus
Care plan
a plan developed for each pt to achieve certain goals; it outlines the steps and tasks that the care team must perform
Risk
a problem the pt is uniquely at risk for developing
When a patient reports stool has become narrower or ribbon-like...
a tumor may be obstructing normal stool passage through the colon.
Dehydration - urine
dark amber, strong aromatic
Hypovolemia
decreased blood volume
Oliguria
decreased production of urine
Wellness
describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement
Problem
describes state of health are clearly as possible, part of the nursing dx statement; "what is unhealthy about the pt"
Anthelmintic enema
destroy intestinal parasites
Peritoneal dialysis
dialysis in which the lining of the peritoneal cavity acts as the filter to remove waste from the blood
Hyperactive bowel sounds are commonly caused by
diarrhea
Personal zone
distance when interacting with close friends (18 in - 4 ft)
Midstream
"clean catch"
Three phases of the helping relationship
(1) the orientation phase (2) the working phase (3) the termination phase
Decreased or absent bowel sounds indicate
(evidenced only after listening for 5 minutes)-signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility.
Communication process includes
- a stimulus - a source - a message - a channel of communication - a receiver - feedback
Guidelines for ranking diagnose
- high, diagnoses that poses the greatest threat to PT health and well-being - medium, not life threatening - low, not specifically related to the current level of health and well-being
Nursing interventions should include
- subject, the patient - verb, the action the patient will perform - descriptive phrase: how, when, where, how often, how long, or how much
The helping relationship
-(nurse-patient relationship) -does not occur spontaneously- it occurs for a specific purpose with a specific person. -characterized by an unequal sharing of information. The patient shares information related to personal health problems, whereas the nurse shares information in terms of a professional role. -is built on the patient's needs, not on those of the helping person.
Medications that affect the color of urine
-Anticoagulants (i.e. Heparin) : red urine -Diuretics (i.e. Lasix): pale yellow urine -Pyridium (i.e. AZO): orange to orange-red urine -amitriptyline or B complex vitamins (antidepressant): green or blue-green urine -Levodopa (i.e. CNS stimulant; precursor to Dopamine): brown or black urine
Slowing of GI motility nursing strategies
-Encourage small, frequent meals. -Discourage heavy activity after eating. -Encourage a high-fiber, low-fat diet. -Encourage adequate fluid intake. -Discourage regular use of laxatives. -Develop a daily routine to move bowels. (The optimal time is usually 2 hours after awakening and after breakfast.) -Evaluate medication regimen for possible adverse effects.
Flatulence causing foods
-cucumber -lentils -onions -cabbage
A POTENTIAL nursing diagnosis contains
-diagnostic label -unknown related factors
A RISK nursing diagnosis contains
-diagnostic label -risk factors PE; two part statement
An ACTUAL nursing diagnosis contains
-diagnostic label (i.e. acute pain), -related factors (i.e. instillation of peritoneal dialysate) -defining characteristics (i.e. wincing, grimacing during procedure, stabbing sensation) PED; 3 part statement
3 muscle layers of bladder
-inner: longitudinal layer -middle: circular layer -outer: longitudinal layer
Assertive behavior
-is the ability to stand up for yourself and others using open, honest, and direct communication. -The focus is on the issue and not the person. -Assertive behaviors, which are one hallmark of professional nursing relationships, are very different from aggressive behaviors.
Factors influencing communication include
-level of development -biological sex -sociocultural differences -roles and responsibilities -space and territoriality -physical, mental, and emotional state -environment
Factors influencing communication include:
-level of development -biological sex -sociocultural differences -roles and responsibilities -space and territoriality -physical, mental, and emotional state -environment
Affect bowel elimination
-mobility -fluid intake -medication -sensory impairments
The challenges of using social media to communicate include:
-protecting patient privacy and confidentiality -preventing unintended consequences for the nurse and the employer
The nursing process is the:
-protection, promotion, and optimization of health and abilities -prevention of illness and injury -alleviation of suffering through the diagnosis -treatment of human response -advocacy in the care of individuals, families, communities, and population
Risk for UTI
-sexually active women -women who use diaphragms for contraception -postmenopausal women -individuals with a indwelling urinary catheter in place -individuals with diabetes mellitus, elderly people
Conversation and listening skills
-silence (most effective; least used) -touch -humor (appropriately)
Functions of the large intestine include:
-the absorption of water -the formation of feces -the expulsion of feces from the body
The small intestine is made up of three parts:
-the first is the duodenum -the middle section is the jejunum -the ileum is the distal section that connects with the large intestine
Common causes of mechanical obstruction are
-tumors of the colon or rectum -diverticulum -adhesions from scar tissue -stenosis -strictures -hernia and volvulus (twisting of a part of the colon).
The stools of formula-fed infants:
-vary from yellow to brown -are paste-like in consistency -have a stronger odor because of the decomposition of protein
Peristomal care
-wash with a mild cleanser and water -pat dry -apply barrier substances such as karats
Foods high in fiber
-whole grains -bran -beans -fresh fruit -vegetables
The six standards of practice
1. assessment 2. diagnosis 3. outcome identification 4. planning 5. implementation 6. evaluation critical thinking model of the nursing process
Aims to be met by health care systems with regard to the quality of care
1. safe: avoiding injury 2. effective: avoiding overuse and underuse 3. patient: responding to PT preferences, needs, values 4. timely: reducing waits and delays 5. efficient: avoiding waste 6. equitable: providing care that does not vary in quality to all recipients
Normal SG of urine
1.015-1.025
Assessment
1st step of the nursing process; gathers information to determine the need for care
Anuria
24 hour period of an output of less than 50mL; common with renal and kidney failure
Diagnosis
2nd step in the nursing process; analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
Children usually achieve daytime urinary continence by
3 years old
Planning
3rd step in the nursing process; identifying expected outcomes and plan care
Nighttime continence may not occur until
4-5 years old
Normal pH of urine
4.5-8.0
Implementing
4th step of nursing process; carrying out plans, initiation of nursing interventions
Evaluation
5th step of the nursing process; evaluates the results of a nursing action
Colonoscopy screening
>50, and continue every 10yrs
Types of nursing dx
Actual- present Risk- does not exist yet Wellness- able to transer to a higher level of wellness
Levels of critical thinking
Basic Complex Commitment
Clostridium difficile
C. diff; bacterial infection causing diarrhea and serious colon inflammation; common after antibiotic use; body system: digestive infection type: bacterial organism: Clostridium difficile tx: antibiotic (change from the first)
Evidence based practice
EVP; is a conscientious, problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences, and a clinician's expertise in making decisions about a patient's care.
Gastroesophageal reflux disease
GERD; long-term condition where acid from the stomach comes up into the esophagus
HIPAA
Health Insurance Portability and Accountability Act; which protects the privacy of individually identifiable health information
HCAHPS
Hospital Consumer Assessment of Healthcare Providers and Systems patient experience of care survey, patient satisfaction
Irritable bowel syndrome
IBS; is a common (chronic) disorder that affects the large intestine. S/S include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both.
Nursing diagnosis should include
NANDA-I nursing diagnosis problem statement and the etiology of the problem; PE: two part statement
NANDA
North American Nursing Diagnosis Association purpose is to define and refine terminology that accurately reflects nurses clinical judgements
Signs
Objective changes that a clinician can observe and measure
The small intestine is responsible for:
digestion of food and absorption of nutrients into the bloodstream
Technical skills are
ability to work with things
Hemmorhoids
abnormally distended rectal veins
Anuria
absence of urine production
Excess loss of colonic fluid can result in
acid-base imbalances of fluid/electrolyte imbalances
Mannitol (osmotic diuretic)
acts everywhere in the nephron. Administered in large enough doses to significantly increase the osmolality of plasma and tubular fluid, expanding ECF volume, decreasing blood viscosity, and inhibiting renin release. Does not affect Na+ excretion. Must be given IV. Used to increase urine flow in patients with acute renal failure, reduce increased intracranial pressure and treat cerebral edema, and promote excretion of toxic substances. Adverse - extracellular water expansion leading to hyponatremia, and tissue dehydration. Contraindicated in patients with active cranial bleeding.
Antispasmodic
agent that prevents muscle spasms
Fresh urine sample
discard the first void of the day
3 aspects of critical thinking
basic complex commitment
Creative intuitive thinking
can be useful supplements to more "in the box" thinking off problem solving
Mineral oil enemas
can interfere with absorption of fat soluble vitamins
Infrequent urination; stagnation of urine
can lead to UTI due to growth of bacteria
The essence of nursing
caring for, caring with, and caring about people
Ongoing comprehensive planning
carried out by any nurse who interacts with the PT; keeps an up-to-date plan; facilitates the resolution of health problems
Etiology
cause or contributing factor to the problem-linking concepts; identifies factors that are maintaining the unhealthy state
Bulk stimulants
cause the fecal matter to increase in bulk
Structure of the large intestine
cecum
Constipating foods
cheese, lean meat, eggs, pasta
Secondary sources of information
client's spouse, friends, and test results
Problem focused nursing diagnosis
clinical judgement concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community has four components: 1. label 2. definition 3. defining characteristics 4. related factors
Risk nursing diagnosis
clinical judgement concerting the vulnerability of an individual for developing an undesirable response to a health condition
Infection - urine
cloudy, foul smelling
Indwelling catheter specimen collection
collect from the catheter itself using the special port for specimens
Timed specimen
collected over a predetermined time period to obtain more specific information
Fecal impaction
collection in the rectum of hardened feces that cannot be passed
Facebook, Twitter, and LinkedIn
common websites used by nurses
Small-group communication
communication occurring within small groups of two or more people
Public zone
communication when speaking to an audience or small groups (12-15 ft)
Initial comprehensive assessment
completed at admission, nursing HX and the physical assessment
Interpersonal skills
concerning or involving relationships between people
External catheter
condom or Texas catheter
Describing a patient by using a room number or diagnosis rather than a name
considered a breach of confidentiality and a violation of patient privacy
Depression can cause
constipation
Iron supplements cause
constipation
Total incontinence
continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation
Overflow incontinence
continuous leaking from the bladder either because it is full or because it does not empty completely
Pyloric sphincter
controls passage of food from stomach to small intestine
2-3 days before FOB testing
costume less than 250mg of Vitamin C
Collaborative pathways and
critical pathways or care maps
A parent's report that a child's stools are frequent, bulky, greasy, and foul smelling suggests...
cystic fibrosis
Changes in stool characteristics or frequency may be one of the first clinical manifestations of a...
disease
Medical model
disease centered; set of procedures in which all doctors are trained
Incontinence
inability to control bladder and/or bowels
Retention
inability to empty the bladder
Ineffective Coping
inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
Hypervolemia
increased blood volume
Hyperactive bowel sounds indicate
increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction
Diuresis
increased output of urine
Diverticulitis
inflammation and/or infection of a diverticulum, a small, bulging pouch in the colon
Cystitis
inflammation of the bladder
Subjective data
information perceived only by the affected person verbs: reports states verifies denies
Objective data
information perceptible to the senses; may be verified by another person ex. V/S S/S med dx hx diagnostic testing physical exam
SBAR
information sheet for handoff communication -Situation (situation) -Background (provide objective data) -Assessment, and Recommendations (allow for presentation of subjective information) I-SBAR-R The adapted form includes the initial identification of "yourself and your patient (I)" and the opportunity to ask and respond to questions, or "read back (R)," at the close of the communication.
The sympathetic system...
inhibits movement
Intimate zone
interaction between parents and children or people who desire close personal contact (0-18 in)
Consists of involuntary smooth muscle tissue that is innervated by the autonomic nervous system
internal sphincter
Tympanites
intestinal distention (with gas/air)
Visible waves of peristalsis are commonly seen in
intestinal obstruction
Enuresis
involuntary discharge of urine, "bed wetting"
Fecal incontinence
involuntary or inappropriate passing of stool or flatus
Peristalsis
involuntary waves of muscle; involves contractions of the smooth muscles that push the food toward the stomach (occurs every 3-12 minutes)
Group dynamics
involve how individual group members relate to one another during the process of working toward group goals
Aggressive behavior
involves asserting one's rights in a negative manner that violates the rights of others. Aggression can be verbal or physical.
The reflective question technique
involves repeating what the person has said or describing the person's feelings.
Nurse-initiated intervention
is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes).
Cellulose
is an insoluble fiber that the body can not digest (think corn)
CUS
is another communication tool, recommended for use to assist in effective communication related to patient-safety concerns -I am Concerned -I am Uncomfortable -This is a Safety issue
Colostomy output
is formed stool
Stool produced from an ileostomy
is liquid and contains large amounts of electrolytes
Limiting fluid intake
is not a healthy practice
Confirming a medical diagnosis
is not the responsibility of the nurse
24 hour urine specimen
is required for accurate measurement of the kidneys excretion of substances that the kidney does not excrete at the same rate throughout the day
Primary source of information
is the client; BEST source
Sympathy
is the expression of sorrow for someone's situation, involving compassion and kindness. Sympathy shifts the emphasis from the patient to the nurse as the nurse shares feelings and personal concerns and projects them onto the patient.
Clinical reasoning
is the process for analyzing a situation, making a judgement, deciding a possible alternative reason, and choosing an action to be taken.
Sequencing
is used to place events in a chronologic order or to investigate a possible cause-and-effect relationship between events
Clean catch
is used when a specimen relatively free from microorganisms is required
Random urine specimen
is used when sterile urine is not required
1st task
prioritize
Defecation
process of bowel elimination from the large intestine
Organizational communication
process of communication that involves individuals and groups to achieve established goals
The challenges of using social media
protecting patient privacy and confidentiality and preventing unintended consequences for the nurse and the employer
Proteinuria
protein in the urine
Close-ended questions
provide the receiver with limited choices of possible responses and might often be answered by one go the two words: 'yes or no'
Pyuria
pus in the urine
R/T
related to; can not use medical dx for this
Iron salts
result in a black stool from the oxidation of iron
Basic critical thinking
results from limited knowledge and experience
Incivility
rude, intimidating, and undesirable behavior directed at another person
Intrapersonal communication
self-talk; communication with oneself
Client outcomes
should be SMART; measurable, realistic, time bound, and specific to the client
A family member
should not be used as an interpreter, BUT in some cultures the male is considered the 'head of the family' and makes health care decisions related to medical care
Visual
sight, observations, and perception
Feces
solid waste products that have reached the distal end of the colon and are ready for excretion
Social zone
space when interacting with acquaintances such as in a work or social setting (4-12 ft)
Incongruent communication
speech and non-speech do not match
Laxatives
speed the passage of the intestinal contents through the GI tract.
Auditory
spoken words and cues
With urine specimens use
standard precautions
Indwelling catheter can be used for _________ specimens
sterile