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