NURS 202 Final Flashcards
(126 cards)
1
Q
Nursing Process
A
Assessment
Diagnosis (nursing)
Planning
Implementation
Evaluation
2
Q
Assessment
A
- Data clustering
- Validate
- Document
3
Q
Nursing Diagnosis
A
Problem r/t reason
CARE vs cure
1. Problem-focused dx - existing process
2. Risk dx - potential problem
3. Health Promotion dx - maintain health
4. Syndrome dx - signs and symptoms that occur together
4
Q
Planning
A
- Initial - 1st time you see them
- Ongoing - while delivering care
- Discharge - going home/long-term
5
Q
High Priority
A
ABC’s - Airway, Breathing, Circulation and Safety
6
Q
Intermediate Priority
A
non-emergent
7
Q
Low Priority
A
Affects future well-being of patient
8
Q
SMART goals
A
Specific
Measurable
Attainable
Realistic
Timing
9
Q
Independent Goals
A
decisions made by the nurse
10
Q
Dependent Goals
A
NP or Doctor make specific orders
11
Q
Collaborative Goals
A
Health care teams work together
12
Q
Implementation
A
Initiate appropriate nursing interventions
13
Q
Evaluation
A
Determine if goals were
Met
Partially Met
Not Met
14
Q
Electronic Health Record (EHR)
A
Advanced charting using electronics
15
Q
Source-Oriented Record
A
Most traditional “chart”
16
Q
Problem-Oriented Record
A
Only based on patient problems
17
Q
Narrative Charting
A
Tells a story, very detailed
18
Q
SOAP/IE
A
Subjective
Objective
Assessment
Plan
Intervention
Evaluation
19
Q
PIE Charting
A
Problem
Intervention
Evaluation
20
Q
Focus Charting
A
Uses DAR
Data
Action
Response
21
Q
Charting by Exception (CBE)
A
Document deviations from the normal
22
Q
Case Management (Interdisciplinary)
A
Care Maps
May include charting by exception
23
Q
Type of Forms
A
Admission Database
Standardized Care Plan
Kardex
Flowsheets = graphic record
Progress notes - specific to nurses
Discharge Summary - given to patient
LTC/Home care
Incident Reports/Unusual Occurrences
24
Q
Word Roots
A
Foundation
Gives Meaning
Body Structure, organ or system
ex. body structure: arthro - (joint)
ex. organ: cardi - (heart)
ex. system: neuro - (nervous system)
25
Suffixes
REQUIRED in every medical term
ends the medical term
adds more info
ex. surgical procedure: -ectomy (to cut out)
ex. condition: -itis (inflammation)
ex. diseases: -pathy (disease)
ex. diagnostic procedure: -gram (record/picture)
ex. -ac (pertaining to)
26
Prefixes
NOT required
adds information
ex. abnormal conditions: dys- (painful)
ex. numbers : quadri- (four)
ex. positions: hypo- (below/underneath)
ex. times: pre- (before)
27
Combining Vowel
Usually an “o”
NO meaning
Only on a suffix that begins with a consonant
28
Developmental Considerations for Infants/Toddlers/Preschoolers
Injuries, educating parents
29
Developmental considerations for School-Aged Children
Increased activities, bullying, HELMETS
30
Developmental considerations for adolescents
sense of identity, peers, risk-taking
31
Developmental considerations for young adults
lifestyle habits, stress
32
Developmental considerations for middle-aged adults
responsibilities, accidents
33
Developmental considerations older adults
physiological changes, chronic conditions
34
Health Care environment risks
Chemicals (cleaning, medications)
Microorganisms (HAI)
Equipment (brakes, oxygen and suction)
Perceptions of Safety (teaching patients)
Risks for medical/procedural errors (incident reports)
Falls (account for 90% of injuries within hospitals)
Delerium
Limited Mobility
35
How to maintain safety in health-care environments
Check patients frequently
Use brakes
Shoes/Rubberized slippers
Keep necessary items within reach
LAST RESORT - restraints (check often, need doctors order)
36
Types of Restraints
1. Physical
- side rails (4 = restraints)
- hold limbs down
2. Chemical
- sedation
3. Environmental
- lock door
37
Infection Control: Chain of Infection
1. Infectious Agent
2. Reservoir
3. Portal of Exit
4. Mode of Transmission
5. Portal of Entry
6. Host
38
Microorganisms
Cause of infection
- number - fewer = less likelihood of infection
- virulence - strength to overcome host
- entry and survival
- susceptibility of host - healthy vs immunocompromised
39
Reservoir
Where pathogens are stored
Requirements:
- Food
- Oxygen (if aerobic)
- Water
- Temperature (heat kills infection)
- pH (optimal = 5-8)
- Light (dark is optimal)
40
Portal of Entry/Exit
Body openings (mouth, rectum, urethra, etc.)
Breaks in skin or mucous membranes (IV, wounds)
Requires fluid to leave - mucus, puss
41
Modes of Transmission
Contact, direct, indirect, droplet
- air (small)
- vehicles (ex. water systems)
- vectors (animals)
42
Ways to break the chain of infection
Hand hygiene
Don’t share equipment
Soiled items should not touch clothing
PPE
43
Host
Body defences (skin, tears, cilia, urine, stomach acid)
- normal flora (saliva, vagina, skin)
- inflammation (protective vascular reaction)
- Vascular/Cellular - increased blood flow
- Exudate (serous = clear, sanguineous = bloody, purulent = thick/colored)
- tissue repair - scar tissue
Signs and Symptoms - redness, pain, heat and swelling
Immune System
Lymphatics (filter blood)
44
Asepsis
“Without spreading infection”
limit exposure to : blood, body fluids, non intact skin, mucous membrane
45
Fowlers position
45-60 degrees
46
Low fowlers
30 degrees
47
High fowlers
90 degrees (=orthopneic)
48
Supine
dorsal recumbant (back-lying)
49
Prone
Front-laying
50
Lateral
Side-laying, support arm and leg joints in proper alignment, support shoulder
51
Sims
semi prone
52
Types of Pain
Acute: warning for seeking healthcare - set off sympathetic response
Chronic/non-Malignant - persists longer than 6 months
Cancer - deep visceral level
53
Sources of Pain
Referred Pain
Nociception (physiological experience of pain)
1. transduction
2. transmission
3. perception
4. modulation
54
Pain Assessment
Onset
Provocative
Quality
Region/Radiation
Severity
Timing/Treatment
Understanding
Value
55
Developmental considerations of pain
Infants: facial expression, leg movement, activity, crying
Older Adults: breathing, facial expression, body language, negative vocalizations
56
General Survey - Physical Appearance
- age
- sex
- LOC
- skin color
- facial features
57
General Survey - Body Structure
- stature
- nutrition
- symmetry
- posture
- body build/contour
58
General Survey - Mobility
- gait
- ROM
59
General Survey - Behaviour
- facial expression
- mood and affect
- speech
- dress
- personal hygiene`
60
Temperature
Normal Range: 36-38 degrees
Regulated by hypothalamus
Influenced by: diurnal/circadian cycle, menstruation/menopause, exercise, age, environment and stress
- oral = most common
- rectal = -0.5 degrees
- axilla = +0.5 degrees
- tympanic = not common
Wait 2min after smoking, 5min after chewing gum, 20min after ingesting hot/cold liquids
61
Pulse
Normal Range: 60-100BPM
influenced by: age, exercise, temp, emotions, pain, medications, body position, hypovolumia
wait 5-10min after exercise
ASSESS:
- Rate = BPM
- Rhythm = regular/irregular
- Force/Strength = bounding (3+), strong/normal (2+), weak/thready (1+), absent (0)
Tachycardia = rapid pulse (> 100 BPM)
Bradycardia = slow pulse (< 60 BPM)
62
Respirations
Normal Range: 12-20 RPM
Influenced by: exercise, temp, pain, anxiety, smoking, body position, medications, brain injury, hemoglobin
Chest rise + chest fall = 1 respiration
ASSESS:
- Resp rate = RPM
- Pattern/Rhythm = regular? laboured?
- Depth = deep, normal or shallow
O2 Sat normal range: 92-100%
63
Blood Pressure
Normal Range: 120-130/80-85
Systolic = ventricular contraction
Diastolic = resting, filling heart
influenced by: age, ethnocultural background, weight, emotions, gender, diurnal rhythm, exercise, stress, medications
Rest at least 5mins, wait 60mins after caffeine or smoking, 30min after exercise
64
Kortokoff’s Sounds
Phase 1: Systolic P (clear tapping)
Phase 4: Muffling of sounds
Phase 5: Diastolic P (silence)
65
Inspection
“concentrated watching”
66
Palpation
Touch - asses temp, moisture, lumps + bumps, vibration/pulsations, rigidity, crepitation, tenderness/pain
67
Percussion
Vibration (location, size and density)
- resonant = “hollow” (ex. air-filled lungs)
- hyper resonant = louder (ex. child’s lungs)
- tympany = “drum-like” (ex. gas in abdomen)
- dull = “thud” (ex. liver/dense organs)
- flat = shorter, flat sound (ex. bone)
68
Ausculation
Using stethoscope
- diaphragm = high-pitched sounds
- bell = low-pitched sounds (murmurs)
69
Types of Baths
Complete/Total: patient dependent for care
Assisted: assistance needed
Partial: areas prone to odor are washed
Tub: rinse entire body
Bag Bath: disposable package (expensive/not common)
70
Order of Washing
Face/neck - arms (axilla) - hands - chest (under breasts) - abdomen - legs - feet - back (massage) - peri care - front to back
71
Epidermis
Thin, tough outer layer
Avascular
1. Stratum Corneum: exposed, keratinized
2. Stratum Germinativum: inner, melanin and keratin
72
Dermis
contains collagen, elastic fibres, blood vessels, nerves, sensory receptors, lymphatics
73
Subcutaneous layer
hypodermis (adipose) - stabilize skin in relation to underlying tissue, shock absorb and heat storage
74
Function of the skin
- protection
- acts as a barrier
- maintenance of temp
- perception
- identification
- communication
- wound repair by surface cell replacement
- absorption and excretion of metabolic wastes
- production of vitamin D
75
Hair
epidermal appendages
root - shaft - arrector pili
Vellus - thin, covers whole body
Terminal - thick, extra protection
76
Functions of Hair
protects, cushions, insulates and guards entrance
77
Glands
Epidermal appendages
- sebaceous glands: secrete sebum
- sweat glands: excrete waste; cools skin; provides protection
- eccrine = “everywhere” - lose heat
- apocrine = active after puberty (cloudy/stinky)
78
Nails
Nail plate
Nail bed
Protects tips of fingers/toes
Alters with diseases
79
Pallor
white/pale
80
Cyanosis
Blue (lack of O2)
81
Erythema
red (fever, inflammation/heat)
82
Jaundice
yellow (usually has to do with liver)
83
ABCDE
Asymmetry
Border
Color
Diameter
Elevation and Enlargement
84
Effects of Immobility
1. musculoskeletal
- disuse osteoporosis
- decrease in muscle mass
- contractures (shortening of muscles)
- stiffness and pain in the joints
2. Cardiovascular
- increased work of the heart
- postural/orthostatic hypotension
- venous vasodilation (leads to dependent edema) and (stasis - thrombus formation)
3. Respiratory
- decrease in respiratory movement
- pooling of secretions - may lead to atelectasis and/or (hypostatic) pneumonia)
4. Metabolism
- decreased metabolic rate
- anorexia
- constipation
- urinary stasis - can lead to renal calculi
- urinary retention - can lead to incontinence and infection
5. Integument
- reduced skin turgor
- impaired circulation - leads to skin breakdown
- pressure ulcers
6. Psychosocial
- low mood/depression
- less social interaction
- isolation
- sleep/wake cycles
- decreased self-esteem/lack of purpose
- passive/dependent
- acceptance/relying on other people
85
Braden scale
predicts risk of pressure ulcer
lower score = higher risk
1. sensory perception
2. moisture
3. activity level
4. mobility
5. nutrition
6. risk for friction
86
Ambulation
cane - standard, tripod or quad
walkers - standard, two or four wheeled
crutches - bear wt in arms (not axillae)
87
Cartilage
dense connective tissue
1. hyaline - most abundant
2. fibrous - dense and strong
3. elastic - pliable and resilient
88
Tendons
Connect bone to muscle
89
Ligaments
Connect bone to bone
90
Bursae
fluid-filled sac to reduce friction
91
Major Muscles
1. Masseter
2. Sternomastoid
3. Trapezius
4. Deltoid
5. Pectoralis
6. Triceps Brachii
7. Biceps Brachii
8. Rectus Abdominus
9. Latissimus Dorsi
10. Gluteus maximus
11. Quadriceps Femoris (4)
12. Biceps Femoris
13. Gastrocnemius
92
Bones
206 in the body
Axial Skeleton - 80 bones
Appendicular - limbs and girdles
1. long (femur)
2. short (carpals)
3. flat (skull)
4. irregular (vertebra)
5. sesamoid (patella)
93
Major Bones
1. Cranium
2. Clavicle
3. Ribs
4. Radius
5. Ulna
6. Metacarpals
7. Carpals
8. Phalanges
9. Scapula
10. Humerus
11. Vertebrae
12. Pelvis
13. Femur
14. Tibia
15. Patella
16. Fibula
17. Tarsals
18. Metatarsals
19. Talus
94
Joints
Non-synovial = immoveable or slightly moveable - surfaces of bones are bound closely
Bone - bone = immoveable
Bone - cartilage - bone = slightly moveable
Synovial = freely moveable (synovial cavity, fluid, cartilage, capsular ligament)
95
Types of Joints
Planar - gliding, a bit of rotation (ex. wrist)
Hinge - flexion/extension (ex. knee)
Pivot - rotation ONLY (ex. c1 and c2)
Condyloid - lots of movement (ex. wrist)
Saddle modified condyloid (ex. thumb)
Ball-and-Socket - most moveable (ex. shoulder and hips)
96
Major Joints
1. TMJ (only moveable joint in skull)
2. Spine (S-Shape)
3. Cervical (7)
4. Thoracic (12)
5. Lumbar (5)
6. Sacral/coccyx (fused, immoveable)
7. Shoulder (most moveable)
8. Acromion (rotator cuff)
9. Elbow
10. Olecranon Process
11. Wrist
12. Carpals
13. Hands/Fingers
14. Phalanges
15. Hip (greater trochanter; ischial tuberosity; acetabulum)
16. Medial/Lateral malleolus
97
Head and Face Functions
- protect, support and stabilize the brain
- houses delicate sense organs
- entrance to digestive and respiratory systems
- cranial and facial bones serve attachment to muscles
98
Lymph Nodes
1. Preauricular
2. Posterior Auricular
3. Occipital
4. Submental
5. Submandibular
6. Jugulodigastric
7. Superficial Cervical
8. Deep Cervical
9. Posterior Cervical
10. Supraclavicular
99
Parts of the Nose
External = bridge, tip, nares, ala, vestibule
Internal = olfactory region, turbinates, meatuses, bony/soft palate
100
Paranasal Sinuses
Frontal, ethmoid, sphenoid, maxillary
101
Function of the Nose
1st part of the respiratory system
Warms, moistens and filters air
Sense of smell
Sinuses - lighten skull, sound and mucusproduction
102
Parts of the Mouth/Throat
Hard/soft palates, uvula, tongue, teeth (32), salivary glands (parotid, submandibular, sublingual)
103
Function of the Mouth
1st part of digestive system
Formation of speech
Sense of Taste
104
Parts of the Throat
PHARYNX - nasopharynx, tonsils, oropharynx
105
Function of Throat
Passage for food, propelled to esophagus
Passage for air
Tonsils - immune response
106
Types of Diets
1. Regular - variety
2. NPO - nothing by mouth
3. DAT - diet as tolerated
4. Clear Fluids - see through
5. Full Fluids
6. Soft/Low Residue - pureed, mechanical soft
7. Low Sodium - for patients with hypertension
8. Low Cholesterol
9. Diabetic - health, attention to glycemic index
107
How to promote healthy bowel habits
- diet (high fibre) and fluids (water)
- exercise (keep bowel’s moving)
- positioning (sitting, leaning forward)
- timing (AM or PM)
108
Suppository Administration
1. Confirm doctor’s order
2. Wear gloves, lubricate
3. Position on left side
4. Touch sphincter... wait
5. Ask patient to take slow, deep breaths
6. Insert suppository - 10cm
109
Enema Administration
1. Confirm Doctor’s order
2. Be organized
3. Explain procedure
4. Ensure privacy
5. Wear gloves
6. Pay attention to how patient tolerates it
110
Urinary System
Kidneys: regulate blood volume and pressure, excretes waste
Ureters: deliver urine to bladder from kidneys
Bladder: stores urine, connects with urethra
111
Male GU Parts
External: penis (glans, corona, urethra, foreskin) and scrotum (rugae)
Internal: Testes (sperm production), epididymis (sperm matures), vas deferens, spermatic cord, cremaster muscle, inguinal canal (spermatic cord) and femoral canal (femoral artery/vein)
112
Functions of the Male GU
- urinary: urethra expels urine from the body
- reproduction: testes produce sperm and testosterone, sperm maturation and delivery vie epididymis - vas deferens - joints with seminal vesicles - ejaculatory duct - urethra
- cremaster muscle: controls size of scrotum (optimal temp for sperm production)
113
Female GU Parts
External: vulva, mons pubis, labia majora/minora, clitoruis, frenulum, vestibule urethral meatus, skene’s/bartholin’s glands
Internal: Vagina (rugae), Cervix (OS), Uterus, Fallopian tubes, ovaries
114
Function of Female GU
- Urinary: urethra expels urine
- reproduction: ovaries (hormones and oocytes), uterus, menstruation, pregnancy sites
115
Parts of the complete health history
1. Biographical Data
2. Source/Reliability
3. Current health/reason for seeking care
4. Past Health
5. Family history
6. Review of systems
7. Functional Assessment/ADL’s
116
Examples of traps when gathering information
1. providing false assurance
2. giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engage in distancing
6. Using professional jargon
7. using leading/biased questions
8. talking too much
9. interrupting
10. using “why” questions
117
Nonverbal Skills
1. Physical Appearance
2. Posture (open vs closed)
3. Gestures
4. Facial Expressions
5. Eye Contact
6. Voice
7. Silence
8. Touch
118
Mental Status Exam - Appearance
- posture
- body movements
- dress
- grooming and hygiene
119
Mental Status Exam - Behaviour
- LOC
- Facial Expression
- Speech
- Mood and affect
120
Mental Status Exam - Cognitive
- orientation
- attention span
- memory (immediate, recent, remote)
- new learning (4 unrelated words)
- judgement and insight
121
Mental Status Exam - Thought Processes
- Thought processes (way)
- Thought Content (what)
- Perceptions (illusions, hallucinations)
- Suicidal/Homicidal Thoughts
122
Delirium
Acute Confusion
123
Dementia
Chronic Confusion
124
Depression
Prolonged sadness/emptiness
125
Most common type of dementia
Alzheimer’s
126
Responsive behaviours in dementia
- purposeful walking (wandering)
- repeating same question/words or difficulty expressing themselves
