Lecture 3 Flashcards

(281 cards)

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
# body planes and oritentation prone
lying face down
26
# body planes and oritentation sims
left side lying positon
27
# body planes and oritentation unilateral
one side
28
# body planes and oritentation bilateral
two sides
29
# body planes and oritentation ipsilateral
same side of the body (leg and arm)
30
# body planes and oritentation contralateral
opposite side of body (arms and legs)
31
# body planes and oritentation dorsum
top of feet or hands
32
# body planes and oritentation palmar
palm of hand
33
# body planes and oritentation plantar
bottom side of feet
34
# communication process interpretation
-reciever can have a different belief -can be influenced by context, environment, precipitating events, transmission, and past experiences
35
# communication process filtered information
-loss of valuable information
36
# communication process response
-feedback loop system
37
# communication process therapeutic communication
*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
38
# communication process active listening
-paraphrasing -reflecting -open questions -acknowledgement -summarize -framing -reframing
39
# communication process what is the biggest communication problem?
we do not listen to understand, only to reply. | need to understand and not just what your response will be
40
# communication process nonverbal communication
-facial expressions -eye contact -posture -body movement -how one dresses -lifestyle -material possessions
41
# communication process what can nonverbal communication do?
confirm or deny verbal communication
42
# communication process types of communication
-passive -passive aggressive -aggressive -assertive
43
# communication process passive
emotionally dishonest, indirect, inhibited, self-denying, blaming, apologetic | "others rights and needs take precedent over mine"
44
# communication process passive agressive
emotionally dishonest, indirect, self-denying at first, self-enhancing at expense of others later. | "I subtly make clear that my rights and needs prevail"
45
# communication process aggressive
inappropiately honest, direct, expressive, attacking, blaming, controlling, self-enhancing at expense of others | "I boldy insist that my rights and needs prevail"
46
# communication process Assertive
appropiately honest, direct, self-enhancing, expressive, self-confident, empathetic to emotions of all involved. | "I clearly express that we both have rights and needs."
47
conflict resolution pg 354
avoidance, accommodation,
48
# communication process what percentage of medical errors are due to miscommunication?
80%
49
# communication process what is the prefferred type of communication in the hospital; especially emergency?
closed loop
50
# communication process SBAR
situation, background, assessment, and recommendation
51
# medical terminology:integumentary adip/o
fat
52
# medical terminology:integumentary lip/o
fat
53
# medical terminology:integumentary steat/o
fat
54
# medical terminology:integumentary cutane/o
skin
55
# medical terminology:integumentary derm/o
skin
56
# medical terminology:integumentary dermat/o
skin
57
# medical terminology:integumentary hidr/o
sweat
58
# medical terminology:integumentary seb/o
oil
59
# medical terminology:integumentary sebace/o
oil
60
# medical terminology:integumentary pil/o
hair
61
# medical terminology:integumentary trich/o
hair
62
# medical terminology:integumentary karato
hard
63
# medical terminology:integumentary xero
dryness
64
# medical terminology:integumentary crypto
hidden
65
# medical terminology:integumentary leuko
white
66
# medical terminology:integumentary erythro
red
67
# medical terminology:integumentary xantho
yellow
68
# medical terminology:integumentary melano
black
69
# medical terminology:integumentary cyan/o
blue
70
# medical terminology:integumentary dermatalgia/dermatodynia
RASH
71
# medical terminology:integumentary Pruritus
an itch
72
# medical terminology:integumentary urticaria
hives
73
# medical terminology:integumentary diaphoresis
sweating
74
# medical terminology:integumentary depigmentation
loss of pigmentation
75
# medical terminology:integumentary vitiligo
disease causes loss of skin color
76
# medical terminology:integumentary hypermelanosis
a darkening area of the skin
77
# medical terminology:integumentary alopecia
hair loss
78
# medical terminology:integumentary hypertrichosis
too much hair
79
# medical terminology:integumentary comedo
white head or black head
80
# medical terminology:integumentary macerate
very wet, soggy to touch
81
# medical terminology:integumentary urticaria
swollen, raised, itchy area
82
description of a rash should include:
-location -size -color -texture -filling of the rash (pustules)
83
location of rash
-localized or generalized (centrifugal vs centripetal)
84
presence of bumps and their size
papules, nodules, plaques, and tumors
85
bumps filled with fluid (rashes)
vesicles filled with clear fluid, bulla filled with clear fluid, pustules filled with pus, abscesses.
86
flat spots (rashes)
freckles (macules)
87
what are large macules called?
patches
88
what are burn injuries caused from?
heat, radiation, chemicals, electricity, or friction
89
how are burns categorized?
levels of trauma
90
levels of trauma from burns
first degree, second degree, third degree, and fourth degree
91
VS
vital signs
92
T
temperature
93
BP
blood pressure
94
HR
heart rate
95
RR
respiratory rate
96
Ht
height
97
Wt
weight
98
I/O
intake/output
99
Dx
diagnosis
100
Tx
treatment
101
H&P
History and physical
102
Hx
history
103
HPI
history of present illness
104
PMHx
past medical history
105
NKDA
no known drug allergies
106
pt
patient
107
PCP
primary care provider
108
f/u
follow up
109
d/t
due to
110
CC
cheif complaint
111
SOB
short of breath
112
HEENT
head, eyes, ears, nose throat
113
PERRLA
pupils are equal, round, reactive to light, and accomodation
114
NAD
no acute distress
115
CV
cardiovascular
116
RRR
regular rate and rhythm
117
CTA
clear to auscultation
118
WDWN
well developed, well nourished
119
A&O x
alert and oriented times
120
WNL
within normal limits
121
PO
per os or by mouth
122
NPO
Nil per os or nothing by mouth
123
PR
per rectum (anal)
124
IM
intramuscular
125
SC
subcutaneously
126
IV
intravascular
127
CVL
central venous line
128
PICC
peripherally inserted central catheter
129
PRN
as needed
130
BID
twice daily
131
TID
three times daily
132
Q
each
133
QD
each day
134
QID
four times daily
135
AC/PC
before meals/after meals
136
HS
hour of sleep
137
AD LIB
as desired
138
effective communication
important because it is the key component of safe and effective care
139
communication process
sender > message> receiver
140
what can happen after a message is sent?
it will be interpreted based on the receivers belief and influenced by context, environment, past experiences, etc it can also look valuable information
141
therapeutic communication
 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
active listening
-paraphrase -reflect -open ended questions -summarize -frame and reframe
143
biggest communication issue
we do not listen to understand, only to reply
144
non verbal communication
 Facial expressions  Eye contact  Posture  Body movement  How one dresses  Lifestyle  Material possessions
145
verbal communication
 Talking  Listening  Tone of voice  Inflection  Attitude
146
professional communication
 Empathy  Equality  Openness  Positivity  Supportiveness  Respect  Dignity Emotional and Social Intelligence (ESI) are vital components of effective communication and leadership.
147
written communication
-accuracy -attention to detail -thoroughness -conciseness -forms of written communication: documentation, white boards, emails, texts
148
neagtive communication
-yes or no questions (closed communication) -blocking -fasle assurances/false hope -conflicting messages
149
types of communication
passive, passive agressive, agressive, and assertive
150
passive
emotionally dishonest, indirect, inhibited, self-denying, blaming, apologetic
151
passive agressive
emotionally dishonest, indirect, self denying at first, self enhancing at expense of others later
152
agressive
inappropiately honest, direct, expressive, attacking, blaming, controlling, self enhancing at expense of others
153
assertive
appropiately honest, direct, self enhancing, expressive, self confident, empathetic to emotions of all involved
154
closed loop communication
-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
what percentage of medical errors are due to miscommunication
80%
156
handoff report
 Transfer and acceptance of patient care  Vital for effective communication  Poor handoff reports can result in medical errors  Standardized methods  Use of SBAR
157
SBAR
situation, background, assessment, recommendation
158
why is SBAR important?
-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
S why do we need it
poor communication = errors
160
B why do we need it
communication styles vary, lack of assertiveness, distractions can cause lack of attention to detail
161
A why do we need it
We need a communication tool that all members of healthcare can use
162
R why do we need it
use SBAR to decrease errors, increase efficiency, improve communication
163
How can SBAR help?
 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
S in SBAR
situation ; briefly describe and give overview who are you, where are you from, who are you speaking about, why are you calling
165
B in SBAR
background; briefly state peritnent history age,gender, presenting complaint, very brief summary of relevant history
166
A in SBAR
assessment; summarize facts NEWS and key clinical findings, relevant tests and treatments done so far, diagnosis, any specific major concern
167
R in SBAR
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
what does the skin do?
serve as protection to body, first line of defense from germs and irritants, first point of contact w surrounding, largest organ
169
adip/o, lip/o, steat/o
fat
170
cutane/o, derm/o, dermat/o
skin
171
hidr/o
sweat
172
seb/o, sebace/o
oil
173
pil/o, trich/o
hair
174
kerato
hard
175
xero
dryness
176
crypto
hidden
177
leuko
white
178
erythro
red
179
xantho
yellow
180
melano
black
181
cyan/o
blue
182
pruritus
an itch
183
urticaria
hives
184
diaphoresis
sweating
185
hyperhidrosis
excess
186
anhidrosis
lack of
187
depigmentation
loss of pigmentation
188
vitiligo
disease causes loss of skin color
189
hypermelanosis
a darkening area of the skin
190
alopecia
hair loss
191
hypertrichosis
too much hair
192
comedo
white head or black head
193
macerate
very wet, soggy to touch (exposed to moisture, poor wound healing)
194
appearance of rashes
location, size, color, texture, filling of the rash
195
papules
< 1cm
196
nodules
> 1 cm
197
vesicles
<1cm and filled with clear fluid
198
bulla
> 1cm and filled with clear fluid
199
pustules
filled with pus
200
abscesses
large pustules
201
freckles
macules
202
large macules
patches
203
keloid
overgrowth of scar tissue
204
biopsy
procedure to remove a piece of tissue or a sample of cells from your body
205
excisional v incisional biopsy
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
shave biopsy
a tool like a razor is used to scrape the surface of the skin.
207
punch biopsy
diagnostic test where a small, tube-shaped piece of skin and some other tissue underneath are removed using a sharp cutting tool.
208
nevus
mole
209
verruca
wart on foot
210
cicatrix
a scar resulting from formation and contraction of fibrous tissue in a wound.
211
decubitus ulcer
pressure wound or bed sore
212
antibiotic
anti-infection - bacterial
213
antiseptic
anti infection - bacterial or viral, usually topical
214
steroid
anti-immune
215
antihistamines
anti itch or allergy
216
procedures for skin
 Chemicals (Chemotherapy, Chemosurgery)  Vacuums (Liposuction)  Cold (Cryosurgery)  Lasers (Dermabrasion)  Electricity (Electrocauterization)  Surgery (Incision and drainage – I&D)  Skin grafting
217
ABCDE
asymmetry, border, color, diameter, evolving
218
AK
actinic keratosis
219
Bx
biopsy
220
C&S
culture and sensitivity
221
derm
dermatology
222
ID
intradermal
223
SQ
subcutaeous
224
musculoskeletal system
 Supports the body  Binds body tissues together  Allows motion  Provides protection  Includes: bones, muscles, cartilage, tendons, ligaments, joints, connective tissues
225
what do most bones start as
cartilage
226
process of cartilage to bone
blood enters the cartilage, promoting the change of cartilage to bone, blood vessels cause the middle of the bone to hollow out
227
epiphyseal plate
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
epiphyses
ends of bones
229
diaphysis
middle of bone, also called shaft
230
metaphysis
neck, connects the diaphysis with the epiohysis
231
axial
center
232
appendicular
arms and legs
233
parts of axial
skull, spine, sternum, ribs
234
parts of appendicular
upper and lower extremities
235
upper extremtities
arms, wrists, hands
236
lower extremities
legs, ankles, feet
237
oste/o
bone
238
crani/o
head or skull
239
cervic/o
neck
240
joints
where two bones meet allows movement between bones held together by ligaments and tendons can have supportive strcuture
241
chondr/o
cartilage
242
arthr/o
joint
243
burs/o
bursa
244
ten/o, tend/o, tendin/o
tendon
245
muscul/o, my/o, myos/o
muscle
246
fasci/o
fascia
247
kinesi/o, kinet/o
root for movement
248
ton/o
pressure or tone
249
tax/o
root for arrangement, order, and or coordination
250
knowledge expansion and technology
-access to unlimited information -online learning -social media -nursing informatics -computerized testing
251
practice based competency outcomes
-used to set goals -provides a framework for education **competence is both the target and the purpose of education**
252
essential skills for students
-problem solving -integration of concepts, knowledge -communication -teaching -caring -management -advocating
253
performance based learning
teacher= provides direction learner= responsibility and accountability
254
simulation
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
ADPIE
Assess, Diagnose, Plan, Implement, and Evaluate
256
sociodemographics
factors that define people in a specific group or population, what they have in common
257
patient centered care
partnership between nurse and patient not just "giving patient care" but "working with the patient" care must be safe, quality, competent, and preventative
258
nursing ethics
must differentiate personal beliefs, values, and preferences from professional practice responsibilities
259
blood
provides energy, carries signals, removes wastes
260
lymphatic system
repairs injuries, fights infections
261
three types of cells found in blood
erythrocytes, leukocytes, and thrombocytes
262
proteins dissolved in blood
immunoglobulins
263
coagul/o
bloods ability to form clots
264
thromb/o
clot
265
hem/o, hemat/o
blood
266
cyt/o
cell
267
-emia
blood condition
268
lymphatic system
-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
immun/o
auto immune
270
lymph/o
lymph or lymphatic system
271
myel/o
marrow
272
too few cells
-penia
273
too many cells
-cytosis
274
spherocyte
sphere
275
elliptocyte
oval
276
red blood cell problems
fix cause, if severe, do transfusion
277
white blood cell problems
chemotherapy, if severe, transfusion
278
platelets
prevent clots, break clots, if severe, transfusion
279
drugs to breakdown clots and stop clotting
anti-coagulant or thrombolytic
280
drug to stop blood flow
hemostatic
281