Final Flashcards
Afebrile
A condition in which the body temperature is not elevated.
Febrile
A condition in which the body temperature is elevated.
5 Step Nursing Process
ADPIE
- Assess
- Diagnose
- Plan
- Implement
- Evaluate
Acute Pain
Episode of pain that lasts from seconds to less than 6 months
Chronic Pain
Episode of pain that last for 6 months or longer; may be intermittent or continuous.
Refered Pain
Pain in an area removed from that in which stimulation has its origin.
Cutaneous Pain
Superficial pain usually involving the skin or subcutaneous tissue
Neuropathic Pain
Pain that results as a direct consequence of a lesion or disease affecting abnormal functioning of the peripheral nervous system (PNS) or central nervous system (CNS)
Somatic Pain
Pain originating in structures in the body’s external wall.
Visceral Pain
Pain originating in the internal organs in the thorax, cranium, or abdomen.
Psychogenic Pain
Pain for which no physical cause can be identified.
Phantom Pain
sensation of pain without demonstrable physiologic or pathologic substance; commonly observed after the amputation of a limb.
Nociceptive Pain
Pain from a normal process that results in noxious stimuli (stimulus that can cause tissue damage) being perceived as painful.
Breakthrough pain
Temporary flare-up of moderate to severe pain that occurs even when the patient is taking around the clock medication for persistent pain.
Malpractice
Act of negligence as applied to a professional person such as a physician, nurse, or dentist.
Assult
Threat or an attempt to make bodily contact with another person without that person’s permission.
Battery
An assault that is carried out.
Abandonment
accepting the client assignment and disengaging the nurse and client relationship without giving notice to a qualified person.
Florence Nightingale
- Defined nursing as both an art and a science
- Differentiated nursing from medicine
- created freestanding nursing education
- published books about nursing and health care
- founder of modern nursing
Clara Barton
Volunteered to care for wounds and feed Union soldiers during the Civil War; served as the supervisor of nurses for the Army of the James, organizing hospitals and nurses; established the Red Cross in the United States in 1882
Linda Richards
Graduated in 1873 from the New England Hospital for Women and Children in Boston, Massachusetts, as the first trained nurse in the United States; became the night superintendent of Bellevue Hospital in 1874 and began the practice of keeping records and writing orders
Mary Elizabeth Mahoney
Graduated in 1873 from the New England Hospital for Women and Children in Boston, Massachusetts, as the first trained nurse in the United States; became the night superintendent of Bellevue Hospital in 1874 and began the practice of keeping records and writing orders
Maslow’s Hierarchy of basic human needs (pyramid)
5 total Listed form Highest to Lowest Priority
- Physiologic (Bottom of the pyramid)
- Safety and Security
- Love and Belonging
- Self-Esteem
- Self-Actualization (Top of the pyramid)
3 Levels of Health Promotion and Preventative Care
- Primary ( Prevention): Directed toward promoting health and preventing the development of disease processes or injury.
ex. immunization clinics, family planning services, poison control info, and accident prevention education. - Secondary (Screening): Focus on screening for early detection of disease with prompt diagnosis and treatment of any found.
ex. Assessing children for normal growth. Medical, dental and vision examinations. - Tertiary (Coping if they have it): begins after the illness is diagnosed and treated, with goal of reducing disability and helping rehabilitate patients to max level of functioning
ex. physical therapy, teaching patients with diabetes about complications, support groups.
Illness
Abnormal process in which any aspect of the person’s functioning is altered (in comparison to the previous condition of health)
Standard Precautions
CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions.
Brachial Pulse
by feeling the bicep tendon in the area of the antecubital fossa.
Radial Carotid Pulse
- between your wrist bone and the tendon on the thumb side of your wrist.
Temporal Pulse
on the temple directly in front of the ear with the index finger.
Femoral Pulse
- along the crease midway between the pubic bone and the anterior iliac crest.
Popliteal Pulse
- on the back of your knee over the popliteal artery
Dorsalis Pedis Pulse
on the dorsum of the foot in the first intermetatarsal space just lateral to the extensor tendon of the great toe.
Posterior Tibial Pulse
in the groove between the medial malleolus and Achilles tendon. (ankle)
Skill 36-2 Steps for Intermittent tube feedings
- Gather equipment. Check amount, concentration, type, and frequency of tube feeding in the patient’s medical record. Check formula expiration date.
- Perform hand hygiene and put on PPE, if indicated.
- Identify the patient.
- Explain the procedure to the patient. Answer any questions, as needed.
- Assemble equipment on overbed table or other surface within reach.
- Close the patient’s bedside curtain or door. Raise the bed to a comfortable working position, usually elbow height of the caregiver (VHACEOSH, 2016). Perform abdominal assessments as described above.
- Position the patient with HOB elevated at least 30 to 45 degrees or as near normal position for eating as possible.
- Confrm placement of the nasogastric tube in the patient’s stomach using at least two methods. The frst method utilized should be measurement of the exposed length of tube.
- Put on gloves. Unsecure the tube from the patient’s gown. Verify the position of the marking on the tube at the nostril. Measure length of exposed tube and compare with the documented length.
- Check the pH of and visualize aspirated contents, checking for color and consistency.
- If it is not possible to aspirate contents; assessments to check placement are inconclusive; the exposed tube length has changed; or there are any other indications that the tube is not in place, check placement by radiograph (x-ray) of placement of tube, based on facility policy (and ordered by the primary health care provider).
- After multiple steps have been taken to ensure that the feeding tube is located in the stomach or small intestine, aspirate all gastric contents with the syringe and measure to check for gastric residual—the amount of feeding remaining in the stomach. Return the residual based on facility policy. Proceed with feeding if amount of residual does not exceed facility policy or the limit indicated in the medical record.
- Flush tube with 30 to 50 mL of water for irrigation. Disconnect syringe from tubing and cap end of tubing while preparing the formula feeding equipment. Remove gloves. 14. Put on gloves before preparing, assembling, and handling any part of the feeding system.
- Administer feeding.
Pain Severity Scale:
Mild:1-4
Moderate:5-7
Severe: 8-10
Levels of care:
Preventive- education and prevention (health history, wellness visits)
Restorative- Intermediate follow-up care (surgical postoperative routine care, routine medical care), Rehabilitation, Home Care.
Secondary- Emergency treatment, and Critical care (intense and elaborate diagnosis and treatment)
What is included in sleep diary?
pg. 1214
- Time patient retires
- Time patient tries to fall asleep
- Approximate time patient falls asleep
- Time of any awakenings during the night and when sleep was resumed
- Time of awakening in the morning
- Presence of any stressors patient believes are affecting his or her sleep
- A record of any food, drink, or medication patient believes has positively or negatively influenced his or her sleep (include time of ingestion)
- Record of physical activities—type, duration, and time
- Record of mental activities—type, duration, and time
- Record of activities performed 2 to 3 hours before bedtime, bedtime rituals, changes in sleep environment
- Presence of any worries or anxieties patient believes are affecting his or her sleep
Nursing interventions to assist patient with sleep
pg. 1219
- Maintaining a brighter room environment during daylight hours and dim lights in the evening
- Decreasing the volume on alarms, telephones, overhead paging, and staff conversations
- Closing doors to patient rooms
- Scheduling procedures together so as not to awaken patients multiple times for vital signs, blood draws, bathing, or medication administration that can safely be postponed for a short time
- Medicating for pain if needed
- Keeping the room cool and providing earplugs and eye masks if requested and as appropriate
Steps for performing a glucose finger stick
SKILL 36-4
- Check the patient’s health record or nursing care plan for monitoring schedule. You may decide that additional testing is indicated based on nursing judgment and the patient’s condition.
- Gather equipment. Check expiration date on blood test strips.
- Perform hand hygiene and put on PPE, if indicated.
- Identify the patient. Explain the procedure to the patient and instruct the patient about the need for monitoring blood glucose.
- Close curtains around the bed and close the door to the room, if possible.
- Turn on the monitor.
- Enter the patient’s identifcation number or scan his or her identifcation bracelet, if required, according to facility policy.
- Put on nonsterile gloves.
- Prepare lancet using aseptic technique.
- Remove test strip from the vial. Recap container immediately. Test strips also come individually wrapped. Check that the code number for the strip matches the code number on the monitor screen.
- Insert the strip into the meter according to directions for that specifc device. Alternately, strip may be placed in meter after collection of sample on test strip, depending on meter in use.
- Have the patient wash hands with skin cleanser and warm water and dry thoroughly. Alternately, cleanse the skin with an alcohol swab. Allow skin to dry completely.
- Choose a skin site that is intact, warm and free of calluses and edema
- Hold lancet perpendicular to skin and pierce skin with lancet.
- Encourage bleeding by lowering the hand, making use of gravity. Lightly stroke the fnger, if necessary, until a suffcient amount of blood has formed to cover the sample area on the strip, based on monitor requirements (check instructions for monitor). Take care not to squeeze the fnger, not to squeeze at puncture site, or not to touch puncture site or blood.
- Gently touch a drop of blood to the test strip without smearing it. Depending on meter in use, insert strip into meter after collection of sample on test strip.
- Apply pressure to puncture site with a cotton ball or dry gauze. Do not use alcohol wipe.
- Read blood glucose results and document the results in EHR or other designated location, based on facility policy. Inform patient of test result.
- Turn off meter, remove test strip, and dispose of supplies appropriately. Place lancet in sharps container.
- Remove gloves and any other PPE, if used. Perform hand hygiene
Cholesterol
: a molecule made with types of lipid molecules. Naturally produces in the liver
What vitamin aids in absorption of iron?
Vitamin C.
Sedation scores:
S = sleep, easy to arouse: no action necessary 1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone
Modifiable risk factors
smoking, alcohol use, stress, obesity, physical inactivity, psychological factors
What does a Clear Liquid diet consist of?
consists of clear liquids — such as water, broth and plain gelatin — that are easily digested and leave no undigested residue in your intestinal tract.
BMI level
pg. 1282
Underweight: below 18.5 normal weight: 18.5 – 24.9 Overweight: 25 – 29.9 Obese: 30 or more Extreme obesity: 40 or more
Anorexia
eating disorder characterized by:
- inability to maintain a minimally healthy body weight
- An intense fear of gaining weight
- Relentless dietary habits that prevent weight gain
- Severe body image distortions.
Route of TPN: total parental nutrition
TPN is administered into a vein, generally through a PICC (peripherally inserted central catheter) line, but can also be administered through a central line or port-a-cath.
What increases BMR: basal metabolic rate?
pg. 1282
growth, infections, fever, emotional tension, extreme environmental temps, elevated levels of certain hormones, especially epinephrine and thyroid hormones
