FUNDAMENTALS IN NURSING Flashcards by Andrei Altamarino

Q

environmental theory

A

Florence nightingale

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Q

14 fundamental needs

A

Virginia Henderson

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Q

Patient-Centered Approaches to Nursing Model

Identifies 21 nursing problems

A

Faye Glenn Abdella

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Q

behavior system model

A

Dorothy Johnson

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Q

goal attainment theory

A

Imogene king

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Q

transcultural nursing

A

madeleine Leininger

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Q

four conservation principles

A

Myra estrin Levine

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Q

healthcare system model

A

betty Neuman

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Q

Self-care and Self-care deficit Nursing Theory

A

dorothea orem

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Q

Psychodynamic (interpersonal relations) Model

A

Hildegard Peplau

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Q

Science of Unitary Human Being

A

Martha rogers

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Q

Adaptation Model

A

sister callista roy

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Q

Care, Core and Cure Model

A

Lydia hall

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Q

The Dynamic Nurse-Patient Relationship Model

Nurses provide direct assistance to meet an immediate need

A

Ida Jean Orlando

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Q

Human Caring Theory

A

Jean Watson

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Q

Human Becoming Theory

A

Rosemarie Rizzo Parse

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Q

ROLES AND FUNCTIONS OF A NURSE

Encompasses activities that assist the client physically and psychologically

A

CAREGIVER

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Q

ROLES AND FUNCTIONS OF A NURSE

Communicates the identified problem of the client to other health care team

A

COMMUNICATOR

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Q

ROLES AND FUNCTIONS OF A NURSE

Nurse teaches client about their health and procedures they need to perform to restore their health

A

TEACHER

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Q

ROLES AND FUNCTIONS OF A NURSE

Nurse assist clients in exercising their rights and help them speak for themselves

A

CLIENT ADVOCATE

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Q

ROLES AND FUNCTIONS OF A NURSE

Nurse provides emotional, intellectual and psychological support

A

COUNSELOR

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Q

ROLES AND FUNCTIONS OF A NURSE

Nurse assists clients to make modification in their behavior

A

CHANGE AGENT

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Q

ROLES AND FUNCTIONS OF A NURSE

influences others to work together to accomplish a specific goal

A

LEADER

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Q

ROLES AND FUNCTIONS OF A NURSE

nurse plans, give direction, develop staffs, monitor operations

A

MANAGER

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ROLES AND FUNCTIONS OF A NURSE works with multidisciplinary team to measure the effectiveness of the case

CASE MANAGER

ROLES AND FUNCTIONS OF A NURSE nurse participates in scientific investigation and uses research findings to improve client care

RESEARCHER

ROLES AND FUNCTIONS OF A NURSE Nurse works in combined effort with all those involve in care delivery

COLLABORATOR

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE No experience

STAGE I (Novice)

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE Demonstrates marginally acceptable performance

STAGE II (Advanced Beginner)

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE 2-3 years of experience Demonstrates organizational and planning abilities

STAGE III (Competent)

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE 3-5 years of experience Has holistic understanding of the client, which improves decision making

STAGE IV (Proficient)

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE Performance is fluid, flexible, and highly proficient

STAGE V (Expert)

TYPES OF RECORDS Each person or department makes notations in a separate section/s of client’s chart

Source-Oriented Medical Record (Traditional Client Record/ SOMR)

TYPES OF RECORDS Records integrates all data about the problem, gathered by members of health team

PROBLEM-ORIENTED MEDICAL RECORD

TYPES OF RECORDS A series to flip cards usually kept in portable file

KARDEX

TYPES OF BODY TEMP temp of the deep tissues of the body

core temp

temp of skin, SQ tissue and fat rises and falls in response to environment

surface temp

transfer of heat without contact

radiation

transfer of heat through contact

conduction

dispersion of heat by air currents

convection

vaporization of moisture

evaporation

body temp above usual range

pyrexia/fever/hyperthermia

very high fever 41'C

hyperpyrexia

impaired hypothalamic thermoregulation BBT lower than normal

hypothermia

TYPES OF FEVER alternates at regular intervals between normal and abnormal temp

intermittent fever

TYPES OF FEVER wide range of fluctuations for 24hrs all above normal

remittent fever

TYPES OF FEVER short febrile periods of a few days are scattered with periods of 1-2 days normal temp

relapsing fever

TYPES OF FEVER BBT fluctuates minimally but remains above normal

constant fever

thermometer cleaning stem to bulb

after use

thermometer cleaning bulb to stem

before use

LEAVELL AND CLARK'S THREE LEVEL OF PREVENTION PRIMARY PREVENTION

Health promotion

LEAVELL AND CLARK'S THREE LEVEL OF PREVENTION SECONDARY PREVENTION

Health maintenance

LEAVELL AND CLARK'S THREE LEVEL OF PREVENTION TERTIARY PREVENTION

rehabilitation

ASSESSING BODY TEMPERATURE Considered to be the most convenient and most accessible

oral

ASSESSING BODY TEMPERATURE Considered to be very accurate

rectal

ASSESSING BODY TEMPERATURE Safest and non-invasive

axillary

ASSESSING BODY TEMPERATURE Frequent site for estimating core body temperature

tympanic

When will you start TSB?

If there is 1°C to 2°C increase in body temperature

TSB Temperature of water

32°C TSB

Wave of blood created by contraction of the left ventricle of the heart

pulse

Normal Cardiac output per min

5L per min cardiac output

PULSE SITES

T CRAB FPP pulse sites

PULSE SITES used when radial pulse is not accessible

temporal

PULSE SITES used during cardiac arrest

Carotid

PULSE SITES readily accessible

Radial

PULSE SITES routinely used for infants and children up to 3 y/o

Apical

PULSE SITES used to measure BP and used during cardiac arrest in infants

Brachial

PULSE SITES used in cardiac arrest/shock and determine leg circulation

Femoral

PULSE SITES used to determine circulation on the lower leg

Popliteal

PULSE SITES used to determine circulation to the foot

Posterior tibia and Dorsal Pedal

RESPIRATIONS (The Act of Breathing) three processes

ventilation diffusion perfusion

movement of air in and out of the lungs (inhale exhale)

ventilation

exchange of gases from higher pressure to an area of lower pressure

Diffusion

movement of the blood for transport of gases

Perfusion

two types of breathing

costal and diaphragmatic

Respiratory center Medulla Oblongata

primary respiratory center

Respiratory center Pons

contains pneumotaxic center that is responsible for rhythmic quality of breathing

Assessing Respirations observed through the movement of the chest and describe. as normal, deep or shallow

depth (respiration)

Assessing Respirations refers to the regularity of the expirations and inspirations

rhythm (respiration)

Assessing Respirations character refers to respiratory effort and sound of breath

quality (respiration)

very deep to very shallow breathing followed by temporary apnea

Cheyne-Stokes

rapid, deep and labored breathing

Kussmaul's

shrill, harsh sound heard during inspiration

Stridor

snoring

Stertor

high-pitched musical squeak or whistling sound occurring on expiration

Wheeze

Shallow breaths interrupted by apnea

Biot's (cluster) respirations

Pressure exerted by blood as it flows through the arteries

BLOOD PRESSURE (BP)

BP as a result of ventricular contraction

Systolic pressure

BP when ventricles are at rest

Diastolic pressure

difference between systolic and diastolic pressure

Pulse pressure

unpleasant sensory and emotional experience

pain

CHARACTERISTICS OF PAIN (PQRST)

Provoking Factors Quality Radiation Severity/Intensity Time

Modes of Examination

inspection palpation percussion auscultation (IPPA)

Modes of Examination (abdominal)

inspection auscultation percussion palpation (IAPePa)

PERCUSSION SOUNDS AND TONES Flatness

PERCUSSES Muscle and bone

PERCUSSION SOUNDS AND TONES Dullness

PERCUSSES liver and heart

PERCUSSION SOUNDS AND TONES Resonance

PERCUSSES normal lung

PERCUSSION SOUNDS AND TONES Hyper resonance

PERCUSSES emphysematous lung

PERCUSSION SOUNDS AND TONES Tympany

PERCUSSES stomach filled with air

Soft-intensity,low-pitched,"gentle sighing" sounds created by air moving through smaller airways (bronchioles and alveoli) breath sounds

Normal Breath Sounds vesicular

Moderate-intensity and moderate-pitched "blowing" sounds created by air moving through larger airway (bronchi) breath sounds

Normal Breath Sounds broncho-vesicular

High pitched loud, “harsh” sounds created by air moving through the trachea breath sounds

Normal Breath Sounds bronchial

Back lying position with knees flexed and hips externally rotated

Dorsal recumbent

Back lying position with legs extended

Dorsal (supine)

Seated position; back unsupported and leg hanging freely

Sitting

Back lying position with feet supported in stirrups, hips in line with edge of the table

Lithotomy

Side lying

Sim's

Face-lying position

Prone

Classification of Blood Pressure in mmHg Normal BP

<120 and <80

Classification of Blood Pressure in mmHg prehypertension

120-139 and 80-89

Classification of Blood Pressure in mmHg hypertension stage 1

140-159 and 90-99

Classification of Blood Pressure in mmHg hypertension stage 2

>160 and >100

Common Problems of the skin scraped superficial skin, should be kept dry

abrasion

Common Problems of the skin scaly skin, increase OFI and use lotion not alcohol

excessive dryness

Common Problems of the skin inflammation around sebaceous gland due to high fat diet and stress

acne

Common Problems of the skin redness associated with rashes must wash skin and use antiseptic

erythema

Common Problems of the skin increased perspiration

hyperhidrosis

Common Problems of the skin foul smelling perspiration

bromhidrosis

hypopigmentation patches in skin, decrease in melanin

vitiligo

to clean, improve circulation and relaxation while assessing body parts

bed bath

bed bath use warm water _____ celsius assess temperature using _____ of hand or an ______

43-46, celcius dosal part, elbow

bed bath prevent ______ to avoid chilling

air convection (fans and aircon)

bed bath cleanse eyes with _______ unless patient wants _____

water only, soap

lesions from unrelieved pressures

pressure ulcers

stages of sore/ulcer formation stage 1

erythema

stages of sore/ulcer formation stage 2

partial thickness skin loss, epidermis and dermis

stages of sore/ulcer formation stage 3

full thickness skin loss subQ tissue presents deep crater

stages of sore/ulcer formation stage 4

full thickness skin loss, necrosis of mucles, bones and joints

pressure ulcer prevention keep skin ____ and increase ______

dry, OFI

pressure ulcer prevention position every _______ and elevate bed by no more than _______

15mins to 2hrs, 30 degrees

pressure ulcer prevention avoid massaging over ______

bony prominences

pressure ulcer prevention use ______ instead of dragging

lifting device

pressure ulcer treatment use alcohol free cleanser on wound and avoid ______ (kills wound healing factor)

hydrogen peroxide

pressure ulcer treatment use ______ asepsis in cleaning

surgical

pressure ulcer treatment black wounds requires ______

debridement

pressure ulcer treatment (debridement) uses scalpel to separate and remove dead tissues

Sharp debridement

pressure ulcer treatment (debridement) uses moist-to-moist dressing

Mechanical debridement

pressure ulcer treatment (debridement) uses collagenase enzyme agents

Chemical debridement

pressure ulcer treatment (debridement) uses dressings that contains wound moisture

Autolytic debridement