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Terms for Quiz 1
| Question | Answer |
|---|---|
| an/o | anal |
| appendic/o | append, appendix |
| arteri/o | artery |
| arthr/o | joint |
| bronch/o | bronchus |
| cardi/o | heart |
| cerebr/o | cerebrum |
| cholecyst/o | gallbladder |
| col/o | colon |
| crani/o | cranium |
| cyst/o | bladder |
| derm/o | skin |
| gastr/o | stomach |
| hepa, hepat/o | liver |
| hyster/o | uterus |
| mast | breast |
| my/o | muscle |
| neur/o | nerve |
| nephr/o | kidney |
| rhin/o | nose |
| thyr/o | thyroid |
| trache/o | trachea |
| theory | Systematic view of phenomenon, made up of concepts, definitions, relationships, and assumptions |
| nursing theory | Provides nurses with a perspective to view client situations, a way to organize data, and a method to analyze/interpret information-nursing knowlegde used to guide care |
| Major Concepts of any nursing theory | 1. Patient2. environment3. health4. nursing |
| self care | one's own contributions to one's health and well being (practices to maintain life, health and wellbeing) |
| 8 Universal Self Care Requisites | air; water; food; elimination/hygiene/sanitary environment; balance activity and rest, balance solitude and social interaction; prevention of hazards; promotion of normalcy, human dev, integrity of body&mind |
| self care defecits | person not able to meet their own needs. determines when and why nursing is needed. |
| nursing system | method used to assist pt in meeting self care needs; adresses both nurse and pt |
| Health Deviation Self Care requisites | occur when one becomes ill: 1. secure appropriate medical assistance 2.awareness of effects/results of illness 3. carry out prescribed tx 4. awarness of discomfort effects of medical care 5. modify self concept 6. learn to live w/ effects of tx (cont dev) |
| Developmental Self Care Requisites | specific needs that develop through out life, associated with developmental stages (ex: puberty, menopause, pregnancy) |
| orem's concept of "nursing agency" | the agent of care-scientific base, technical skills, critical thinking skills, willingness to care |
| levels of intervention | -wholly compensatory (WC)-everything done for patient-partially compen (PC)-pt assists-educative supportive (ES)-pt can do but may not have knowledge/skill |
| ways of assisting patients | 1. doing for (WC or PC)2. teaching (PC or ES)3. providing dev. environ (ES)4.guiding/counseling (PC or ES)5. supportive, ex: being with pt (PC or ES) |
| Nightengale's theory | descriptive theory-link clients health status with environmental factors (fresh air, light, warmth, cleanliness, quiet, nutrition) |
| Roy's Theory | Adaptative theory-help pt adapt to changes in physiological needs, self concept, role functions, social roles,and interdependent relationships during health and illness. |
| impediments to development | educational deprivation, lack of support system, loss of possessions/residence, loss of occupational security, environ factors (poor housing, substandard sanitation, bad water, inadequate diet), abrupt change in residence to unfamiliar place |
| how self care theory relates to nursing process | 1.asses: pt for deficits b/w self care demands&ability 2 provide care 2.diagnosis- outline actual/pot deficits. 3.planning- determine levels of intervention&ways 2 assist. 4.implementation-carry out plan 5.eval-observe 2 determine if self care req are met |
| purpose of conceptual frame work | -define role of nursing-describe charact of people and environ that req analyzing/management via the nursing process-provide framework for organizing curriculum, and direct research |
| infection | occurs when pathogen enters body and multiplies |
| IgM | very large, first to appear after initial exposure |
| IgG | most common antibody, equally divided between blood and interstitial fluid |
| IgA | large amount in breast milk, saliva, and GI secretion |
| IgD | found on surface of B cells |
| IgE | protect host against invading parasites. responsible for allergic response or hypersensitivity reaction |
| acquired immunity | results from exposure to an antigen, can be active (body dev immunity in response to exposure-illness, vaccine) or passive (breast milk or injection of immune globulins) |
| natural immunity | born with, genetically determined in specific populations or families (some pathogens cannot infect certain species, ex: measles cannot infect dogs) |
| immune globulin | short acting passive immunity (injection), made from pooled serum containing antibodies against usual infections; needed after exposure that disease you have no immunity to (ex: rubella, rabies) |
| Hep B Vaccine | active immunity-made by recombinant DNA, series of 3 injections. protects 5-7 years, followed by booster after 5yrs. req by all health care workers |
| HBIG (hep B immune globulin) | made from serum of people who had hep b, given after exposure. short acting, passive immunity |
| influenza vaccine | active immunity-chosen by CDC in spring, given in fall. req for all health care workers |
| MMR (measles, mumps, rubella) | active immunity-req for all health care workers and pregnant women |
| DPT (diptheria, pertusis, tetanus) | active immunity for adults |
| hepatitis A | new immunization. hep a from liver/GI "elementary tract." requires 2 doses, 6-18 months apart. not given to children under 1. offers 20 years protection, possibly lifelong |
| hep c | no vaccine for hep c |
| varicella vaccine | different dosage size for different ages,mainly 2 doses req or can be offered in a MMRV combo for healthy children 1-12yrs (not approved after 13) |
| nosocomial infection | infection acquired during hospital stay. affects 5% of hospitalized pt, 2 million annually-$5billion added to US Health Care cost/yr |
| contamination | unsterile/unclean object. an object that comes in contact with infectious or potentially infectious material |
| sterilization | complete elimination/destruction of microbes, including spores. (ex: steam under pressure-autoclave) |
| disinfection | elimination of pathogenic bacteria, but not bacterial spores (ex: lysol, alcohol, hydrogen peroxide) |
| standard precautions | applied to prevent contact with blood, mucous, feces, saliva, drainage, urine, non intake skin (bodily fluids except sweat) |
| antiseptic | inhibits growth and reproduction of microbes (ex: neosporin, hand sanitizer, mouth wash) |
| aseptic technique | practices used to prevent the spread of microbes/infection |
| chain of infection | 1. infectious agent 2. resevoir (moisture, dark, warm) 3. portal of exit 4. mode of transmission 5. susceptible host |
| medical asepsis | medical-clean technique, procedures to reduce or inhibit the spread of microbes (includes hand hygiene, clean/utility gloves, clean environ, mask |
| surgical asepsis | sterile technique: used to eliminate all mirobes and spores used when skin integrity is broken (IV insertion, foley catheters, central lines, sterile dressing changes, suctioning a tracheostomy) common in operating room and labor and delivery |
| priciples of surgical asepsis | 1. ster touch sterile=sterile 2. only sterile objects placed on sterile field 3.out of vision/below waist-contaminated 4. ster object/field contam by long exposure to air. 5. ster on wet surface-contam by capillary action |
| principles of surg asepsis (cont) | 6. sterile obj contam if gravity causes contaminated liquid to flow over object's surface 7. 1 inch (2.5cm) edge of sterile field is contaminated |
| bradycardia | slow heart rate, less than 60 BPM |
| tachycardia | fast heart rate, more than 100 BPM |
| rhythm | the rhythm of a beating heart (sinus rhytm-normal beating of a heart) |
| dysrhythmia, arrhythmia | abnormal heart rhythm, lack of a normal heart rhythm |
| apnea | cessation of breathing for 20 seconds or longer; periodic, irregular breathing pattern |
| dyspnea vs eupnea | eupnea-normal breathing; dyspnea-shortness of breath or breathlessness |
| orthopnea | dyspnea (SOB) that is releived in the upright position |
| systolic vs diastolic pressure | systolic-contraction period of heart, esp in ventricles-blood forced into aorta&pulmonary artery. diastolic-relaxation phase between contractions-ventricles are dilated &filling with blood (pressure in aorta decreases,no blood flowing in, still flows out) |
| pulse pressure | the beat of the heart as felt through the walls of peripheral arteries |
| hypotension vs hypertension | hypo-low blood pressure; hyper-high blood pressure |
| tachypnea | rapid respiration, often seen in fever as body tries to rid excess heat-breathing increases at a rate of 8 breaths/min for every degree C above normal. |
| bradypnea | slow breathing (breathing is regular in rhythm but slower than normal in rate). normal during sleep, otherwise associated with brain's resp control center via opiates, narcotics, alcohol, tumor, metabolic disorder or respiratory decompensation mechanism) |
| stertorous respirations | harsh, noisy breathing usually heard on comatous patient |
| Cheyne-Stokes respirations | cyclic pattern of apnea and hyperventillation (neurological pattern, may be a sign of impending death) |
| normal temp range vs fever/death | 96.5-99.5FFever=100.5F/38.5CDeath=95F |
| most and least accurate methods to measure temp | anal-most accurate; axillary-least accurate |
| normal oral, rectal/aural, axillary/skin ranges | oral-98.6F/37Crectal/aural-one degree higher-99.6/37.7Cax/skin-one degree lower than oral-97.6F/36.3C |
| factors effecting body temp | 1. age (kids run high, elderly no fever when sick) 2. exercise-inc temp 3. hormones (ovulate inc .2-.4) 4. circadian rhythm (lowest AM, highest PM) 5. stress 6. environ 7. temp alterations in brain |
| oral temp site limitations | -delayed measurement 4 pt who recently had hot/cold fluids, smoked or received O2 -not 4 pt w/ oral surgery, trauma, -not 4 infants, small children, confused, unconscious or uncoop Pt-risk of body fluid exposure |
| anal temp site limitations | -diarrhea, rectal surgery, rectal disorders, bleeding tendencies-req positioning, pt embarrassment/anxiety-risk of body fluid exposure-not 4 routine VS in newborns-impacted stool influences reading |
| normal pulse | 60-100BPM, AVERAGE-70 |
| factors that increase pulse | 1. short term exercise 2. fever and heat 3. acute pain & anxiety 4. positive chronotropic drugs (epinephrine) 5. standing/sitting 6. diseases causing poor O2 (asthma, COPD) |
| factors that decrease pulse | 1. long term exercise2. cold-hypothermia3. unrelieved severe pain, relaxation4. negative chronotropic drugs (digitalis) 5. laying down |
| use apical pulse when: | -radial pulse rate/rhythm is abnormal or inaccessible -pt on meds that affect HR-infants and young children b/c peripheral pulses are deep and difficult to palpate |
| normal respiration | 12-20/min, 16=average |
| normal BP | 120/80-used to be normal, now considered prehypertensive. hypertensive=140/90 Range=90/60-140/90 |
| kortokoff sounds | 1. clear rhythmic tapping-systolic2. blowing or swishing3. crisper, more intense tapping4. muffled, low pitch-diastolic in children and infants5. disappearance of sound-diastolic in adolescents and adults. |
| BP affected by | stress, race (african americans higher), gender (men higher), and medication.not affected by age, rather lifestyle! |
| BP not measured on a particular arm when | -pt has had a mastectomy-will cause lymphatic problems; pt has AV shunts used for dialysis. also cannot be measured on arms with cast, dressing, IVs, arteriovenous fistulas, or on tramatized extremities |
| improper cuff size causes | inaccurate readings.-too small, cuff comes loose, inaccurate high reading-too large-false low reading |
| pain | the 5th VS to be assessed. location, intensity, quality, and behavioral manifestation. |
| health deviations re: tube feeding | cancer-GI, head, neck; critical ill/trauma; neuro/muscular disorders-brain neoplasm, CVA (stroke), dementia, myopathy, parkinson’s; GI disorder; resp. failure w/ prolonged intubation; inad. oral intake-anorexia, diff chew/swallow, severe depression |
| location of NG tube, G tube, and J tube; type of feeding | Nasogastric tube-in nares, down to stomach-bolus or continuousgastrostomy tube (GT) goes in stomach surgically or endoscopically-bolus or continuous -jejunostomy tube (JT) goes in jejunum surgically or endoscopically-continuous feeding only. |
| equipment needed for both bolus and continuous feeding | -clean gloves-towel/chux-stethoscope-formula -water for irrigation-emesis basis-syringe |
| difference in equipment needed for bolus vs cont feeding | -clean gloves-towel/chux-stethoscope-formula -water for irrigation-emesis basis-syringe |
| types of formulas and orders | Different Formulas: ensure, jevity, osmolite, glucerna (for diabetics): all orders include formula, route, amount, and frequency. |
| free water | Pt may have 200 CC/8 hr shift—or 700CC in 24 hours-must give free water or Na count will rise-water is given for irrigation, and helps keep patency (otherwise formula would get thick and clog the tubing) |
| how to asses adequate fluid intake | a) measure intake and outputb) check residual for absorptionc) skin tugor (tenting)d) urine volume and colore) mucous membrane (eyes, mouth, nose)f) weight |
| fecal elimination problems | a) diarrhea (caused by hyperosmolar formula-formula drawing water out of skin/organs, meds, contam, malabsorption)b) constipation (lack of fiber, lack of free water, inactivity)c) abdominal distention (means pt not absorbing) |
| expected outcomes of tube feeding | a) no signs of respiratory distressb) adequate nutrition c) weight gain or stabilizationd) serum albumin (albumin formed in liver, keeps osmotic fluid in vascular space to prevent edema)e) healing woundsf) no s/s of dehydration |
| risks associated with tube feeding | -aspiration (check for placement-in throat, will go in lungs- pt gets pneumonia)-abd distention (check residuals)-osmolarity (check rate, dilution, &change formula)-microbes (change equip q 24 h; date/time on bag & left overs in fridge) |
| restraints needed when: | a) Pt confused, weak, or dizzyb) Pt poses a threat to self or others-disruptive/agitated behaviorc) To prevent interruption of therapy (IV, NG tube, catheter, life support)d) Pt resisting care (AMA)e) Pt at risk for injury-falls, wandering |
| legal implications | -follow facilities policies-try alternatives first-try least restrictive restraint first-must have Dr order based on face to face assesment-order must include: type of restraint, location, pt behaviors to restrain, and limited time frame for use |
| types of restraints | -belt: prevent fall-extremity: prevent fall or removal of therapeutic device-mitten: prevent removal/scratching-elbow: prevent flexion w/ IV in place-mummy: infants, dx head/neck injuries, restrict torso/extremities-enclosed bed; meds, 4rails up |
| when to change/reasses restraints | restraints only used for 2 hours max-release for 30 minutes every 2 hours, but only release one restraint at a time. -schedule what to do during these times: bath, feed, elimination-visual check every hr, some req more freq checks (5 point-q 15min) |
| complications of restraints | a) pressure ulcersb) constipation from lack of activityc) pneumoniad) incontinencee) urinary retentionf) nerve damageg) circulatory impairmenth) loss of self esteem, humiliation, fear, anger |
| some examples of alternative to restraints | a) bed alarms/ambularmb) family/sitterc) frequent observd) room close 2 nursing statione) orient pt to his surroundingsf) provide scheduled activ-toilet, bath, feed, exerciseg) relax techniquesh) explain why important to stay in bed |
| critical elements when applying restraints | -maintain position without extreme flexion/extension -pad extremity and secure knots w/out impeding circulation -secure restraint to frame, not side rails (and out of clients reach) -remove and exercise joint every 2 hours |
| range of motion | maximum amount of movement available in a joint in it’s available plane (saggital, frontal, or transverse) |
| health deviations req ROM | a) immobilityb) surgery req pt to remain on bedrestc) stroked) surgery or cast affecting limb/jointe) trauma/pt on breathing machine/comaf) obeseg) diabetes with poor circulation |
| active vs passive ROM | active ROM: pt moves all joints, unassisted-passive ROM: nurse moves each joint for the pt**pt may fall somewhere in between** |
| critical elements when performing ROM | 1) movement smooth/rhythmic to point of resistance2) support weight of extremity at joint during ROM |
| good body mechanics | maintain stable center of gravity-grav low, back straight, bend @ knees; maint a wide, stable base of support-feet apart, 1 foot infront of other, flex knees, turn w/ feet; maint line of gravity-back strt, object close;maint proper alignment/posture |
| back support and gait belt | back support-worn by nurse- support stomach muscles, paraspinal muscles, reminds RN not to twist body, and 2face forward when lifting-gait belt-worn by pt, for nurse to hold to provide support/stability and to help pt maintain center of gravity. |
| safety guidelines for transferring pt | -side rails up-safety bars around toilet-call bell in reach-wheels locked on gurneys, wheelchairs-all equip in good working order-rubber soled shoes or slippers on pt-remove excess furniture/clutter-intact rubber tips on walking aids |
| health deviations that req pivot trasfer | a) weakb) elderlyc) post op/rehabd) intense paine) diagnostic procedures |
| mechanical life used when | a) weakb) elderlyc) post op/rehabd) intense paindiagnostic procedures |
| roller board | long, stiff, 2 by 6, small conveyer belt with side to side movement (for OR, 2 nurses lift/pull pt, 3rd nurse places roller board under pt and lift sheet)-bridges gap b/w rolling stretcher (gurney) and bed |
| large slider board | stiff plastic, used like rollerboard, powdered for easy movement |
| small slider board | used by pt w/ paraplegia, gap space between bed and wheel chair. Pt uses arms to pull self into chair |
| bath lifts | large bath tubs with special rolling/stretcher lift, on the spot orientation at facility |
| Mechanical "Hover" lift | to move from bed to sitting, net 4 bathing and solid slings available; req 2 nurses-one with hands on pt at all times |
| variables that will effect positioning of pt | -weakness -pain (if above 5, must be medicated prior to repositioning) -COPD/breathing problems-head cannot be all the way down |
| effects of immobility | loss of muscle, dec. endurance/stability/balance; urinary stasis, UTI, kidney stones; constipation; hypostatic pneumonia; skeletal-impair Ca absorp, contractures;metabolic-endocrine, ca absorp/GI func impaired; hyptotension, thrombus; pressure ulcers |
| psychosocial effects of immobility | a) emotional/behavioral-hostility, giddiness, fear, anxietyb) sensory-sleep/wake cycle disturbancesc) changes in coping-depression, sadness, dejection |
| pathological influences on mobility | a) postural abnormalities-pain, impaired alignmentb) impaired muscle development, related to injury or diseasec) CNS damage-ischemia from stroke, head injuryd) Musculoskeletal trauma-direct trauma or fracture, osteoporosis |
| doral recumbent (supine) | pt rests on back; pillows under arms, trochanter roll on hips, hand rolls, pillow under knees, feet rest on hand rolls, pillow or braces/shoes placing foot in flexed position to prevent foot fall |
| modified side laying (30 degree lateral) | majority of body weight on hip and shoulder. Trochanter roll behind hip, pillow behind back. Pillow under arm touching mattress, pillow between legs, hand roll under malleolus of out heel, pillow/braces placing foot in flexed position. |
| prone | pt laying chest/face down, head 2 side. Pillow under head thin-prevent cervical flexion/extension, maintain align of lumbar spine. Pillow under lower legs for flexion of ankles, knees-may benefit pt w/ acute resp distress syndrome & chronic lung injury |
| Sim's (semi prone) | intermediate between lateral and prone. pt wt on anterior ileum, humurus, and clavical. Least tolerated position. Good for drainage of mucous and saliva. |
| Fowler's | HOB 45 degrees elevated, knees slightly elevated, supports need to permit flexion of hips, knees, and proper alignment of normal curves in vertebrae. Food for eating, inserting tubing, suctioning, and promoting lung expansion |
| Semi-Fowler's | HOB 30 degrees elevated, during NG feeding to prevent regurgitation and risk of aspiration, promotes lung expansion, esp with ventilator assisted pt. |
| Trendelenberg | entire bed frame tilted with HOB downward. For postural drainage. Facilitates venous return in pt with poor peripheral perfusion. |
| Reversed Trendelenberg | entire bed frame tiltled with foot of bed downward-used infrequently. Promotes gastric emptying, prevent esophageal reflux. |
| when to reposition pt | every 2 hours. check every 15 min when introducing a new position while pt develops tolerance |
| trochanter roll | places outside of hip, to prevent hip abduction and to take pressure of the trochanter |
Created by:
laurenduranlb
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