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