Powerpoint Definitions Flashcards
Cognitive skills
Using critical thinking; a systematic way to form and shape one’s thinking
interpersonal skills
Promoting the dignity and respect of patients and establishing caring relationships
Ethical/legal skills
Establishing a personal moral code and professional role responsibilities
Systematic
Part of an ordered sequence of activities
Dynamic
Great interaction and overlapping among the 5 steps
Interpersonal
Human being is always at the heart of nursing
Outcome oriented
Nurses and patients work together to identify outcomes
Universally applicable
A framework for all nursing activities
Objective data
what is observed, factual lab results, or vitals, medical record; check for errors, observer bias
Subjective data
What they tell you; verbal reports, use quotes when applicable
Complete Health Assessment
initial, comprehensive
Episodic health assessment
problem oriented
Interval or follow-up health assessment
changes from baseline; focused-digging deeper into ac actual, potential or possible problem
emergency health assessment
ABC (airway, breathing, circulation)
Primary Objective
Gather information to determine another’s concerns and needs regarding health care
Directive Interviewing
Use to obtain factual, easily categorized information or in an emergency situation; closed questions
Non-directive Interviewing
Use to build rapport, promote communication or help the patient express feelings; open ended questions
Open ended questions
specify topic to be explored but patient must elaborate
Facilitation
encourage to say more
silence
provides patient with time to think and organize thoughts
reflection
repeating part of what the person just said and can help expressing feeling behind a person’s words
Empathy
recognize a feeling and put it into words; helps the patient to feel accepted and deal with the feeling openly
Clarification
use when the patient’s word choice is ambiguous or confusing
Confrontation
you have observed a certain action, feeling or statement and you focus the person’s attention to it; give honest feedback
Interpretation
based on your inference or conclusion. Helps the person understand his/her own feelings in relation to the verbal message
Explanation
inform, sharing factual and objective information
Summary
final review of what you understand the patient has said; condenses facts and presents your perception of the health problem or need
HPI
history of present illness
COLDSPA
C- character of quality (describe your ___)
O- onset (when did it begin?)
L- location (location)
D- duration (how ling has it been going on?)
S- severity of symptoms (Scale of 1-10)
P- pattern (What makes it better? What makes it worse?)
A- associated factors/how it affects the client (Does it affect ADL)
Rx
Prescribed
OTC
Over the Counter
Gravida
How many times pregnant
Para
How many live births
Review of systems
Looking at the past health of the body system. Subjective data. It is giving us their medical history
BSI
blood stream infection
CAUTI
catheter-associated urinary tract infection
CDC
Center for disease control and prevention
CLABSI
central line-associated blood stream infection
HAI
healthcare-associated infection
ICU
intensive care unit
SSI
surgical site infeciton
VAP
ventilator-associated pneumonia
AHRQ
Agency for healthcare research and quality
HHA
U.S. Department of health and human services
Incubation
from time of infection until manifestations of symptoms; can infect others
Prodromal
appearance of vague symptoms; not all diseases have this stage
Illness
signs and symptoms present
Decline
number of pathogens decline
Convalescence
tissue repair, return to health
Factors that Increase Infection Risk
Developmental Stage, Breaks in skin, Illness/injury, smoking, substance abuse, multiple sex partners, medication that decrease immune response, medical procedures
Factors that support Host Defenses
Adequate nutrition, balanced hygiene (enough but not too much), rest/exercise, reducing stress, immunization
Local infection
Occurs in a limited region in the body
Systemic infection
spread via blood or lymph, affects amny regions
Acute infection
rapid onset of short duration (common cold)
Chronic infection
slow development, long duration (osteomyelitis- Bone didn’t heal correctly)
Latent infection
infection present with no discernible symptoms (HIV)
Malaise
Feeling of discomfort, illness, or lack of well-being
purulent
puffy
MRSA
survives on skin, clothes, surfaces, and equipment; everyone could have it, depends if you are ill or not
(methicillin resistant Staphylococcus aureus)
VRE
spread of this infection is a result of failure of infection control procedures
(Vancomycin resistant Enterococcus faecium)
C diff
this bacteria is a spore which can survive on surfaces for 5 months and can only be inactivated by bleach
(Clostridium difficile)
KPC
Klebsiella pneumoniae Carbapenemase
MDRO
Multiple drug resistant organisms; need to use drugs that have a lot of side-effects. This happens when people overuse medications or antibiotics and destroy their immune system
Endogenous
Organism that is harmless in one place and causes infection in another (ex: e-coli);
Normal flora multiply and cause infection as a result of a treatment
Exogenous or cross-infection
Organism transferred from another source (ex: nurse to patient)
Pathogen acquired from health care environment
Medical Asepsis
A state of cleanliness that decreases the potential for the spread of infection
Contact Isolation
Used when pathogen is transmitted by: Direct contact Indirect contact Contact with the patient environment (ex: MRSA, C diff)
Droplet Precautions
Used when pathogen is transmitted by:
Close respiratory or mucus membrane contact with large respiratory DROPLETS (propell 3ft., do not remain suspended in the air)
Airborne Precautions
Used when pathogen is transmitted by:
Small droplets stay suspended in the air
Small droplets dispersed long distances
Suspended droplets are inhaled
Transmission can occur via ventilation systems, shaking sheets, sweeping
Private room required (neg. pressure room)
Vital Signs
Assessment of vital or critical physiological functions
Variation could indicate different things
“Stable vital signs indicate physiological well-being, they do not guarantee it.”
Temp., pulse, respiration, BP, Pain assessment
Body Temperature
The degree of heat maintained by the body; the difference between heat produced by the body & heat lost to the environment
Basal Metabolic Rate
(BMR) drops about 5% every decade
Radiation
Diffusion or dissemination of heat by electromagnetic waves; body gives off heat from an uncovered surface
Conduction
Dissemination of heat by motion between areas of unequal density; use a fan on patient with fever
Exaporation
Conversion of a liquid to a vapor; body fluid in the form of perspiration (insensible loss) is vaporized from skin
Convection
Transfer of heat to another object through contact; Body transfers heat to an ice pack causing the ice to melt
Tympanic membrane Temp.
Fast, simple, convenient
Core temp
Do not use if pt. has had recent ear surgery
Ear wax alters readings
Oral Temp
Surface temp
Simple/convenient
Bradypnea can cause false temp elevation
Anal/rectal temp
Most accurate core temp Doesn't reflect change as easily as oral Stool can cause inaccurate reading Potential rectal injury Stimulates vagal nerve (will make temp drop)
Axillary Temp
Surface temp
Least accurate
Sweating affects the reading
Temporal-arterial temp
Core temp
Fast, safe
Any covering falsely increases reading
Pulse
The rhythmic expansion of an artery produced as blood travels away from the heart
Stroke Volume
Quantity of blood forced out of the left ventricle with each contraction; Averages 70ml; Pulse rate increases to compensate if there is loss of volume
Cardiac Output
Total quality of blood pumped/min;
CO=SV+PR (cardiac output=stroke volume+pulse rate)
Bradycardia
Heart rate below 60 bpm
Tachycardia
Heart rate above 100 bpm
Pulse Rhythm
Interval between heartbeats
Can be irregular or regular
Regular Pulse Rhythm
Evenly spaced beats, may vary slightly with respiration
Regularly Irregular Pulse Rhythm
regular pattern overall with “skipped” beats
Irregularly Irregular
chaotic, no real pattern, very difficult to measure rate accurately
Types of Quality with Pulse
Equal bilateral volume Three point scale 3+ Full, bounding 2+ Normal 1+ Weak, thready 0 Absent
Pulse deficit
the difference between the two pulse rates
Mechanical respiration
Physically breathing
Pulmonary ventilation
movement of air in and out of lungs
Inhilation
breathing in
Exhalation
Breathing out
Chemical respiration
Exchange of O2 and CO2 between the alveoli and pulmonary blood supply
Tachypnea
more than 20 respirations/min
Bradypnea
less than 12 respirations/min
Blood Pressure
The force of the blood against arterial walls; measured in mmHg; rises as ventricles contracts and falls as heart relaxes
Systolic
Peak pressure exerted against the arterial walls as the ventricles contract & eject blood; top number
Diastolic
Minimum pressure exerted against arterial walls between cardiac contractions
Pulse Pressure
The difference between the systolic and diastolic and reflects the stroke volume; bottom number
Mean Arterial Pressure
(MAP) Pressure forcing blood into the tissues
Ausculatory Gap
a loss and later return of the korotkoff sound while taking a blood pressure; occurs in patients with hypertension
Orthostatic vital signs
Serial measurements of pulse and blood pressure taken when:
– Volume depletion is suspected
–Pt. is hypertensive or is taking antihypertensive meds
–pt. reports fainting or syncope
–Assess in 3 positions: lying, sitting, standing
Present when a drop of >20mmHg is SBP or pulse increases by >20bpm
Pain Threshold
The point at which patients experience pain
This differs person to person
Pain Tolerance
Amount of pain a person is willing to endure
This differs person to person
Acute pain
Rapid in onset, varies in intensity and duration
Protective in nautre
Chronic Pain
may be limited, intermittent, or persistent
Lasts beyond the normal healing period
Periods of remission or exacerbation are common
Intractable Pain
Chronic
Resistant to relief
Frustrating for both patient and healthcare provider
Must be approached with multiple methods to provide relief
Environment
includes the physical and psychosocial factors that contribute to each person’s life and well being
Factors affecting Safety
Age/Development Lifestyle Environmental factors Mobility/heath status Cognitive awareness Emotional State Ability to communicate Safety awareness
Theory Assumption
Believed that the environment could be maintained in a fashion that allowed nature to promote health/healing in the patient
Nightingale’s ____ Canons of Nursing
13
Flat bed position
Used for sleeping, maintaining proper spine alignment, and bed making
Fowlers or High Fowlers Position
Sitting at a 45-60 angle, knees are flexed to decrease the risk of shearing
Used for: feeding/eating, easing dyspnea, and watching TB
Semi-Fowlers Position
HOB 15-30 angle, knees are flexed
Used for decreasing the risk of aspiration in patients receiving tube feedings
Trendelenburg Position
HOB down and FOB up,
Used for increasing circulation to vital organs, patient in shock, promoting postural drainage from basal lobes of lung
Reverse Trendelenburg
HOB up FOB down
Used for promoting stomach emptying (hernia- out pouching around the stomach), can also help with orthostatic hypotension before standing
The 4 Sources of Laws
The constitution, Statutes, Administrative bodies, and the courts
The constitution
Superior law of the land, gives power to the states
Statutes
Nurse Practice Act
Administrative bodies
State Boards of Nursing
The Couts
Case of law
Assault
a threat or an attempt to make bodily contact with another person without that person’s consent
Battery
an assault that is carried out and includes willful, angry, and violent or negligent touching of another person’s body or clothes or anything attached or held by that person
Defamation of Character
an intentional tort in which one party makes derogatory remarks about another that diminishes the other party’s reputation
Slander
oral defamation of character
Libel
written defamation of character
HIPAA
Health Insurance Portability and Accountability Act,
Protect the privacy of personal health information
Patient’s Rights under HIPAA
see and copy their health record, update their health record, list of the disclosures, request a restriction on certain uses or disclosures, choose how to receive health information
Emergency Medical Treatment and Active Labor Act
(EMTALA) provide emergency medical treatment regardless of their ability to pay
Americans with Disabilities Act
(ADA) provides protection against discrimination of people with disabilities, must be provided reasonable accommodations
Patient Self Determination Act
(PSDA) Advanced Directives, living will, patient gives direction about their wishes, Power of Attorney
Ethics
the study of how we behave or how we should determine the right thing to do in our interactions with others
Bioethics
Autonomy (respect for person)
Non-maleficence (Do no harm)
Benevolence (Doing good)
Justice (fair distribution of burden and benefit)
Value
a belief about the worth of something, about what matters
Altruism
concern for the welfare and well-being of others
Autonomy
the right to self-determination
Human Dignity
respect for the inherent worth and uniqueness of individuals and populations
Integrity
acting in accordance with an appropriate code of ethics and accepted standards of practice
qSocial Justice
upholding moral, legal, and humanistic principles
Ethical dilemma
occurs when 2 or more clear moral principles apply but support mutually inconsistent courses of action
Ethical distress
occurs when the nurse knows the right thing to do but wither personal or institutional factors make it difficult to follow the correct course of action
Advocacy
the protection and support of another’s rights
Patient Medical Record
accurate and prompt recording of observations, relevant information about the patient, patient progress, results of treatments, tests, surgical procedures, physical assessment, etc
Informatics
the managing and processing of information necessary to make decisions
Nursing Informatics
informatics applied to nursing practice, education, and research
Data
discrete entities that are described objectively without interpretation
Information
groupings of data put into meaningful structure
Knowledge
formed when group data (information) is added to other structured information
Wisdom
appropriate use of knowledge in managing or solving human problems
Kardex
A summary worksheet reference of basic information that traditionally is not part of the record. It usually contains: client data, medical diagnoses, allergies, medical orders, and activities permitted
Osteomyelitis
Bone didn’t heal correctly
Osteomyelitis
Bone didn’t heal correctly
