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NURS104 > Lecture 3 > Flashcards

Lecture 3 Flashcards

1
Q

SOAP

A

S- subjective
O- objective
A- assessment
P- plan

acronym for medial record

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2
Q

subjective info

A

problem in patients own words, duration, quality, and what makes better/worse

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3
Q

objective info

A

labs, tests results, and assessment findings

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4
Q

assessment info

A

what provider sees, can include a diagnosis, identificaiton of problem or list of potential diagnoses

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5
Q

plan info

A

course of action and treatment options

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6
Q

know general subjective terms

A

acute v chronic
abrupt
febrile v afebrile
malaise
progressive v exacerbation
symptom
lethargic
genetic or hereditary

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7
Q

general objective terms

seen:

A

alert- can answer questions
oritented- person, place, time

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8
Q

general objective terms

heard:

A

auscultation: to listen
percussion: to tap on something

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9
Q

general objective terms

felt:

A

palpation: to feel

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10
Q

general objective terms

description of observations:

A

marked- its notable (something is abnormal)
unremarkable- normal

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11
Q

Assessment

characteristics of assessments:

A
  • combination of subjective and objective data
  • helps to determine the diagnosis
  • no single cause —> a differential diagnosis is given and a list of most likely causes
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12
Q

general assessment terms

morbidity

A

suffering from a disease or condition

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13
Q

general assessment terms

occult

A

hidden

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14
Q

general assessment terms

lesion

A

abnormal skin condition

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15
Q

general plan terms

palliative

A

treatment (not to cure) of symptoms

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16
Q

general plan terms

discharge

A

leaving after treatment

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17
Q

general plan terms

observation

A

to be watched over a period of time to see if anything happens/tests are done

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18
Q

general plan terms

prophylaxis

A

provide treatment to prevent illness

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19
Q

body planes and oritentation

anatomical position

A

standing straight with palms forward
*always assume patient is in this position unless otherwise noted

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20
Q

body planes and oritentation

proximal

A

closer to center

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21
Q

body planes and oritentation

distal

A

furthest away from the center

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22
Q

body planes and oritentation

cranial/superior

A

toward head

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23
Q

body planes and oritentation

caudal/inferior

A

lower/under head

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24
Q

body planes and oritentation

supine

A

lying on back

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25
Q

body planes and oritentation

prone

A

lying face down

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26
Q

body planes and oritentation

sims

A

left side lying positon

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27
Q

body planes and oritentation

unilateral

A

one side

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28
Q

body planes and oritentation

bilateral

A

two sides

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29
Q

body planes and oritentation

ipsilateral

A

same side of the body (leg and arm)

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30
Q

body planes and oritentation

contralateral

A

opposite side of body (arms and legs)

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31
Q

body planes and oritentation

dorsum

A

top of feet or hands

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32
Q

body planes and oritentation

palmar

A

palm of hand

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33
Q

body planes and oritentation

plantar

A

bottom side of feet

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34
Q

communication process

interpretation

A

-reciever can have a different belief
-can be influenced by context, environment, precipitating events, transmission, and past experiences

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35
Q

communication process

filtered information

A

-loss of valuable information

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36
Q

communication process

response

A

-feedback loop system

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37
Q

communication process

therapeutic communication

A

*develop trust
-clear communication with words they can understand
-keep promises (dont give time limits)
-protect confidentiality/privacy
-avoid negative communication
-be available
-eye contact
-sit down
-express empathy
-open communication with open-ended questions
-clarifying information
-be aware of body language
-use touch

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38
Q

communication process

active listening

A

-paraphrasing
-reflecting
-open questions
-acknowledgement
-summarize
-framing
-reframing

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39
Q

communication process

what is the biggest communication problem?

A

we do not listen to understand, only to reply.

need to understand and not just what your response will be

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40
Q

communication process

nonverbal communication

A

-facial expressions
-eye contact
-posture
-body movement
-how one dresses
-lifestyle
-material possessions

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41
Q

communication process

what can nonverbal communication do?

A

confirm or deny verbal communication

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42
Q

communication process

types of communication

A

-passive
-passive aggressive
-aggressive
-assertive

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43
Q

communication process

passive

A

emotionally dishonest, indirect, inhibited, self-denying, blaming, apologetic

“others rights and needs take precedent over mine”

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44
Q

communication process

passive agressive

A

emotionally dishonest, indirect, self-denying at first, self-enhancing at expense of others later.

“I subtly make clear that my rights and needs prevail”

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45
Q

communication process

aggressive

A

inappropiately honest, direct, expressive, attacking, blaming, controlling, self-enhancing at expense of others

“I boldy insist that my rights and needs prevail”

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46
Q

communication process

Assertive

A

appropiately honest, direct, self-enhancing, expressive, self-confident, empathetic to emotions of all involved.

“I clearly express that we both have rights and needs.”

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47
Q

conflict resolution pg 354

A

avoidance, accommodation,

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48
Q

communication process

what percentage of medical errors are due to miscommunication?

A

80%

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49
Q

communication process

what is the prefferred type of communication in the hospital; especially emergency?

A

closed loop

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50
Q

communication process

SBAR

A

situation, background, assessment, and recommendation

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51
Q

medical terminology:integumentary

adip/o

A

fat

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52
Q

medical terminology:integumentary

lip/o

A

fat

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53
Q

medical terminology:integumentary

steat/o

A

fat

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54
Q

medical terminology:integumentary

cutane/o

A

skin

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55
Q

medical terminology:integumentary

derm/o

A

skin

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56
Q

medical terminology:integumentary

dermat/o

A

skin

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57
Q

medical terminology:integumentary

hidr/o

A

sweat

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58
Q

medical terminology:integumentary

seb/o

A

oil

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59
Q

medical terminology:integumentary

sebace/o

A

oil

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60
Q

medical terminology:integumentary

pil/o

A

hair

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61
Q

medical terminology:integumentary

trich/o

A

hair

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62
Q

medical terminology:integumentary

karato

A

hard

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63
Q

medical terminology:integumentary

xero

A

dryness

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64
Q

medical terminology:integumentary

crypto

A

hidden

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65
Q

medical terminology:integumentary

leuko

A

white

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66
Q

medical terminology:integumentary

erythro

A

red

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67
Q

medical terminology:integumentary

xantho

A

yellow

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68
Q

medical terminology:integumentary

melano

A

black

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69
Q

medical terminology:integumentary

cyan/o

A

blue

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70
Q

medical terminology:integumentary

dermatalgia/dermatodynia

A

RASH

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71
Q

medical terminology:integumentary

Pruritus

A

an itch

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72
Q

medical terminology:integumentary

urticaria

A

hives

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73
Q

medical terminology:integumentary

diaphoresis

A

sweating

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74
Q

medical terminology:integumentary

depigmentation

A

loss of pigmentation

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75
Q

medical terminology:integumentary

vitiligo

A

disease causes loss of skin color

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76
Q

medical terminology:integumentary

hypermelanosis

A

a darkening area of the skin

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77
Q

medical terminology:integumentary

alopecia

A

hair loss

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78
Q

medical terminology:integumentary

hypertrichosis

A

too much hair

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79
Q

medical terminology:integumentary

comedo

A

white head or black head

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80
Q

medical terminology:integumentary

macerate

A

very wet, soggy to touch

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81
Q

medical terminology:integumentary

urticaria

A

swollen, raised, itchy area

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82
Q

description of a rash should include:

A

-location
-size
-color
-texture
-filling of the rash (pustules)

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83
Q

location of rash

A

-localized or generalized (centrifugal vs centripetal)

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84
Q

presence of bumps and their size

A

papules, nodules, plaques, and tumors

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85
Q

bumps filled with fluid (rashes)

A

vesicles filled with clear fluid, bulla filled with clear fluid, pustules filled with pus, abscesses.

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86
Q

flat spots (rashes)

A

freckles (macules)

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87
Q

what are large macules called?

A

patches

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88
Q

what are burn injuries caused from?

A

heat, radiation, chemicals, electricity, or friction

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89
Q

how are burns categorized?

A

levels of trauma

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90
Q

levels of trauma from burns

A

first degree, second degree, third degree, and fourth degree

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91
Q

VS

A

vital signs

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92
Q

T

A

temperature

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93
Q

BP

A

blood pressure

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94
Q

HR

A

heart rate

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95
Q

RR

A

respiratory rate

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96
Q

Ht

A

height

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97
Q

Wt

A

weight

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98
Q

I/O

A

intake/output

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99
Q

Dx

A

diagnosis

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100
Q

Tx

A

treatment

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101
Q

H&P

A

History and physical

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102
Q

Hx

A

history

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103
Q

HPI

A

history of present illness

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104
Q

PMHx

A

past medical history

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105
Q

NKDA

A

no known drug allergies

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106
Q

pt

A

patient

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107
Q

PCP

A

primary care provider

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108
Q

f/u

A

follow up

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109
Q

d/t

A

due to

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110
Q

CC

A

cheif complaint

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111
Q

SOB

A

short of breath

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112
Q

HEENT

A

head, eyes, ears, nose throat

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113
Q

PERRLA

A

pupils are equal, round, reactive to light, and accomodation

114
Q

NAD

A

no acute distress

115
Q

CV

A

cardiovascular

116
Q

RRR

A

regular rate and rhythm

117
Q

CTA

A

clear to auscultation

118
Q

WDWN

A

well developed, well nourished

119
Q

A&O x

A

alert and oriented times

120
Q

WNL

A

within normal limits

121
Q

PO

A

per os or by mouth

122
Q

NPO

A

Nil per os or nothing by mouth

123
Q

PR

A

per rectum (anal)

124
Q

IM

A

intramuscular

125
Q

SC

A

subcutaneously

126
Q

IV

A

intravascular

127
Q

CVL

A

central venous line

128
Q

PICC

A

peripherally inserted central catheter

129
Q

PRN

A

as needed

130
Q

BID

A

twice daily

131
Q

TID

A

three times daily

132
Q

Q

A

each

133
Q

QD

A

each day

134
Q

QID

A

four times daily

135
Q

AC/PC

A

before meals/after meals

136
Q

HS

A

hour of sleep

137
Q

AD LIB

A

as desired

138
Q

effective communication

A

important because it is the key component of safe and effective care

139
Q

communication process

A

sender > message> receiver

140
Q

what can happen after a message is sent?

A

it will be interpreted based on the receivers belief and influenced by context, environment, past experiences, etc
it can also look valuable information

141
Q

therapeutic communication

A

 Develop trust
 Clear communication in words they
understand
 Keep promises
 Protect confidentiality/privacy
 Avoid negative communication
 Be available
 Eye contact
 Sit down
 Express empathy
 Open communication with open-ended
questions
 Clarifying information
 Be aware of body language
 Use touch

142
Q

active listening

A

-paraphrase
-reflect
-open ended questions
-summarize
-frame and reframe

143
Q

biggest communication issue

A

we do not listen to understand, only to reply

144
Q

non verbal communication

A

 Facial
expressions
 Eye contact
 Posture
 Body movement
 How one dresses
 Lifestyle
 Material
possessions

145
Q

verbal communication

A

 Talking
 Listening
 Tone of voice
 Inflection
 Attitude

146
Q

professional communication

A

 Empathy
 Equality
 Openness
 Positivity
 Supportiveness
 Respect
 Dignity
Emotional and Social
Intelligence (ESI) are
vital components of
effective communication
and leadership.

147
Q

written communication

A

-accuracy
-attention to detail
-thoroughness
-conciseness
-forms of written communication: documentation, white boards, emails, texts

148
Q

neagtive communication

A

-yes or no questions (closed communication)
-blocking
-fasle assurances/false hope
-conflicting messages

149
Q

types of communication

A

passive, passive agressive, agressive, and assertive

150
Q

passive

A

emotionally dishonest, indirect, inhibited, self-denying, blaming, apologetic

151
Q

passive agressive

A

emotionally dishonest, indirect, self denying at first, self enhancing at expense of others later

152
Q

agressive

A

inappropiately honest, direct, expressive, attacking, blaming, controlling, self enhancing at expense of others

153
Q

assertive

A

appropiately honest, direct, self enhancing, expressive, self confident, empathetic to emotions of all involved

154
Q

closed loop communication

A

-effectively decrease erros
-each verable communication should be adressed to a specific person by name, and the reciever should repeat the message back to sender
-helps avoid confusion

155
Q

what percentage of medical errors are due to miscommunication

A

80%

156
Q

handoff report

A

 Transfer and acceptance
of patient care
 Vital for effective
communication
 Poor handoff reports can
result in medical errors
 Standardized methods
 Use of SBAR

157
Q

SBAR

A

situation, background, assessment, recommendation

158
Q

why is SBAR important?

A

-clear communication about a situation
-allows all members of a healthcare team to provide input on a patient situation
-provide opportunity to discuss and collaborate

159
Q

S why do we need it

A

poor communication = errors

160
Q

B why do we need it

A

communication styles vary, lack of assertiveness, distractions can cause lack of attention to detail

161
Q

A why do we need it

A

We need a communication tool that all members of healthcare can use

162
Q

R why do we need it

A

use SBAR to decrease errors, increase efficiency, improve communication

163
Q

How can SBAR help?

A

 Similar to the SOAP model, it
standardizes the approach to
transfer of information
 Helps sender to be concise,
detailed, and accurate
 Helps receiver to understand the
message
 Creates an environment where
all staff can express their
concerns

164
Q

S in SBAR

A

situation ; briefly describe and give overview
who are you, where are you from, who are you speaking about, why are you calling

165
Q

B in SBAR

A

background; briefly state peritnent history
age,gender, presenting complaint, very brief summary of relevant history

166
Q

A in SBAR

A

assessment; summarize facts
NEWS and key clinical findings, relevant tests and treatments done so far, diagnosis, any specific major concern

167
Q

R in SBAR

A

recommendation; what are you asking for?
can i please ask you to help with…, is there anything i need to do in the meantime?

168
Q

what does the skin do?

A

serve as protection to body, first line of defense from germs and irritants, first point of contact w surrounding, largest organ

169
Q

adip/o, lip/o, steat/o

A

fat

170
Q

cutane/o, derm/o, dermat/o

A

skin

171
Q

hidr/o

A

sweat

172
Q

seb/o, sebace/o

A

oil

173
Q

pil/o, trich/o

A

hair

174
Q

kerato

A

hard

175
Q

xero

A

dryness

176
Q

crypto

A

hidden

177
Q

leuko

A

white

178
Q

erythro

A

red

179
Q

xantho

A

yellow

180
Q

melano

A

black

181
Q

cyan/o

A

blue

182
Q

pruritus

A

an itch

183
Q

urticaria

A

hives

184
Q

diaphoresis

A

sweating

185
Q

hyperhidrosis

A

excess

186
Q

anhidrosis

A

lack of

187
Q

depigmentation

A

loss of pigmentation

188
Q

vitiligo

A

disease causes loss of skin color

189
Q

hypermelanosis

A

a darkening area of the skin

190
Q

alopecia

A

hair loss

191
Q

hypertrichosis

A

too much hair

192
Q

comedo

A

white head or black head

193
Q

macerate

A

very wet, soggy to touch (exposed to moisture, poor wound healing)

194
Q

appearance of rashes

A

location, size, color, texture, filling of the rash

195
Q

papules

A

< 1cm

196
Q

nodules

A

> 1 cm

197
Q

vesicles

A

<1cm and filled with clear fluid

198
Q

bulla

A

> 1cm and filled with clear fluid

199
Q

pustules

A

filled with pus

200
Q

abscesses

A

large pustules

201
Q

freckles

A

macules

202
Q

large macules

A

patches

203
Q

keloid

A

overgrowth of scar tissue

204
Q

biopsy

A

procedure to remove a piece of tissue or a sample of cells from your body

205
Q

excisional v incisional biopsy

A

When the entire tumor is removed, it is called an excisional biopsy. If only a portion of the tumor is removed, it is called an incisional biopsy

206
Q

shave biopsy

A

a tool like a razor is used to scrape the surface of the skin.

207
Q

punch biopsy

A

diagnostic test where a small, tube-shaped piece of skin and some other tissue underneath are removed using a sharp cutting tool.

208
Q

nevus

A

mole

209
Q

verruca

A

wart on foot

210
Q

cicatrix

A

a scar resulting from formation and contraction of fibrous tissue in a wound.

211
Q

decubitus ulcer

A

pressure wound or bed sore

212
Q

antibiotic

A

anti-infection - bacterial

213
Q

antiseptic

A

anti infection - bacterial or viral, usually topical

214
Q

steroid

A

anti-immune

215
Q

antihistamines

A

anti itch or allergy

216
Q

procedures for skin

A

 Chemicals (Chemotherapy, Chemosurgery)
 Vacuums (Liposuction)
 Cold (Cryosurgery)
 Lasers (Dermabrasion)
 Electricity (Electrocauterization)
 Surgery (Incision and drainage – I&D)
 Skin grafting

217
Q

ABCDE

A

asymmetry, border, color, diameter, evolving

218
Q

AK

A

actinic keratosis

219
Q

Bx

A

biopsy

220
Q

C&S

A

culture and sensitivity

221
Q

derm

A

dermatology

222
Q

ID

A

intradermal

223
Q

SQ

A

subcutaeous

224
Q

musculoskeletal system

A

 Supports the body
 Binds body tissues together
 Allows motion
 Provides protection
 Includes: bones, muscles, cartilage,
tendons, ligaments, joints, connective
tissues

225
Q

what do most bones start as

A

cartilage

226
Q

process of cartilage to bone

A

blood enters the cartilage, promoting the change of cartilage to bone, blood vessels cause the middle of the bone to hollow out

227
Q

epiphyseal plate

A

area of cartilage remaining near the ends of the bones
allows bone to continue to grow length wise
turns to bone at end of puberty

228
Q

epiphyses

A

ends of bones

229
Q

diaphysis

A

middle of bone, also called shaft

230
Q

metaphysis

A

neck, connects the diaphysis with the epiohysis

231
Q

axial

A

center

232
Q

appendicular

A

arms and legs

233
Q

parts of axial

A

skull, spine, sternum, ribs

234
Q

parts of appendicular

A

upper and lower extremities

235
Q

upper extremtities

A

arms, wrists, hands

236
Q

lower extremities

A

legs, ankles, feet

237
Q

oste/o

A

bone

238
Q

crani/o

A

head or skull

239
Q

cervic/o

A

neck

240
Q

joints

A

where two bones meet
allows movement between bones
held together by ligaments and tendons
can have supportive strcuture

241
Q

chondr/o

A

cartilage

242
Q

arthr/o

A

joint

243
Q

burs/o

A

bursa

244
Q

ten/o, tend/o, tendin/o

A

tendon

245
Q

muscul/o, my/o, myos/o

A

muscle

246
Q

fasci/o

A

fascia

247
Q

kinesi/o, kinet/o

A

root for movement

248
Q

ton/o

A

pressure or tone

249
Q

tax/o

A

root for arrangement, order, and or coordination

250
Q

knowledge expansion and technology

A

-access to unlimited information
-online learning
-social media
-nursing informatics
-computerized testing

251
Q

practice based competency outcomes

A

-used to set goals
-provides a framework for education
competence is both the target and the purpose of education

252
Q

essential skills for students

A

-problem solving
-integration of concepts, knowledge
-communication
-teaching
-caring
-management
-advocating

253
Q

performance based learning

A

teacher= provides direction
learner= responsibility and accountability

254
Q

simulation

A

develops and improves clinical decision making, confidence, muscle-memory, competence
allows for student learning and interaction in safe, realistic environment
allows faculty to assess skills

255
Q

ADPIE

A

Assess, Diagnose, Plan, Implement, and Evaluate

256
Q

sociodemographics

A

factors that define people in a specific group or population, what they have in common

257
Q

patient centered care

A

partnership between nurse and patient
not just “giving patient care” but “working with the patient”
care must be safe, quality, competent, and preventative

258
Q

nursing ethics

A

must differentiate personal beliefs, values, and preferences from professional practice responsibilities

259
Q

blood

A

provides energy, carries signals, removes wastes

260
Q

lymphatic system

A

repairs injuries, fights infections

261
Q

three types of cells found in blood

A

erythrocytes, leukocytes, and thrombocytes

262
Q

proteins dissolved in blood

A

immunoglobulins

263
Q

coagul/o

A

bloods ability to form clots

264
Q

thromb/o

A

clot

265
Q

hem/o, hemat/o

A

blood

266
Q

cyt/o

A

cell

267
Q

-emia

A

blood condition

268
Q

lymphatic system

A

-collects fluid from body tissues
-collected fluid flows into lymphatic vessels
-empties into veins
-functions; immunity, cleaning
-includes lymphatic vessels, lymph nodes, tonsils, spleen, and thymus

269
Q

immun/o

A

auto immune

270
Q

lymph/o

A

lymph or lymphatic system

271
Q

myel/o

A

marrow

272
Q

too few cells

A

-penia

273
Q

too many cells

A

-cytosis

274
Q

spherocyte

A

sphere

275
Q

elliptocyte

A

oval

276
Q

red blood cell problems

A

fix cause, if severe, do transfusion

277
Q

white blood cell problems

A

chemotherapy, if severe, transfusion

278
Q

platelets

A

prevent clots, break clots, if severe, transfusion

279
Q

drugs to breakdown clots and stop clotting

A

anti-coagulant or thrombolytic

280
Q

drug to stop blood flow

A

hemostatic

281
Q
A

NURS104 (2 decks)

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