Fundamentals Flashcards by Maggie Wong

Orientation phase

get to know; trust; rapport

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working phase

explore and develop solutions

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termination phase

evaluate and discharge

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TeamSTEPPS

evidence based framework to optimize team performance and communication
leadership, situation monitor, mutual support, communication

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SBAR

team members communicate information

situation - what is happening
background - clinical
assessment - issue
recommendation

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I PASS the BATON

introduction - self/job

Patient - name, sex etc.
Assessment - CC, VS, symptoms, Dx
Situation - status/circumstance (code status, changes, response to treat)
Safety Concerns - critical lab values, episodes, current meds

Background - comorbidities, previous episode 
Action - rationale
Timing - urgency and prioritize
Ownership - responsible
Next - anticipated

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Nursing Process

tool to treat health issues and assess effectiveness

assessment –> diagnosis –> outcome –> planning –> implementation –> evaluation

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aerobic

CV; ski; run

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anaerobic

resistance; yoga

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isotonic

constant tension with contraction

walk, run

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isometric

constant tension and hold muscle

wall sit, plank

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Ataxic gait

stagger and unsteady

Parkinson’s

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Spastic gait

stiff and drag

stroke

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flaccidity

decrease muscle tone

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spasticity

increase muscle tone –> spasms

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Temor

rhythmic and repetitive

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contractures

shortening of muscle/joint b/c too tight

foot drop (plantar flexion > dorsiflexion)

flexion stronger than extension

orthostatic hypotension

decrease effectiveness of neurovascular reflex

decrease BP when upright

SBP decrease by 20, DBP decrease by 10
HR increase by 10bpm

DVT

deep vein thrombosis

immobility –> venous stasis (dehydrated + poor position) –> increase viscosity –> thrombus formation

heparin to prevent

atelectasis

collapsed alveoli

trochanter roll

prevent external rotation of hips

First sign of deterioration

Radiation

heat transfer without contact

body heat to cold room

Conduction

body to another surface

ice pack, cool cloth

Convection

dispersion by air currents fan, wind

evaporation

water vapor sweat, diaphoresis

Oral temperature caution

no nebulized/O2 mask no within 15-30 min drinking no infant/toddler no seizure disorders

Rectal temperature cautions

trauma to rectal mucosa no infant up to 3 months no surgery on lower body

Tympanic temperature cautions

straighten ear canal child and adult - pull pinna up and back 3 month old - pull ear down and back

Breathing patterns

women - chest men - diaphragm infant/children - irregular

medications that decrease pulse

beta blockers, calcium channel blockers, digoxin

Mastectomy

breast tissue removal

AV Fistula

arteriovenous fistula | abnormal connect between artery and vein so blood from A --> V bypassing capillaries

Nutrients for fuel/energy

carbs, fats, proteins

Nutrients for regulation

minerals, vitamins, water

Cholecystitis

gallbladder inflammation

esophagitis

esophagus inflammation

NPO

rest GI, clera for sx, test, treat N/V/D, let gastric motility return

Clear Liquid

gelatin, clear juice and broth, popsicles

Full Liquid

smooth, cream soup, custard, refined hot cereal, yogurt

Dysphagia

difficulty swallow