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Nursing Fundamentals

Nursing Fundamentals for Finals Mod A

TermDefinition
American Nurses Association (ANA) the protection, promotion, and optimization of health and abilities
Florence NIghtingale developed the first organized training program for nurses
Clara Barton founder of the American Red Cross
Harriet Tubman underground railroad
Licensed Practical Nurse (LPN) a nurse who completes a practical nursing program and passes a licensure exam. Practices under the supervision of an RN or other licensed person.
Registered Nurse (RN) completion of an associates degree, diploma/baccalaureate degree program in nursing
In-service education programs that are instructed/training by a healthcare agency or institution designed to increase knowledge, skills, and competencies of nurses and other HCP's
Code of Ethics formal statement that delineates a profession's guidelines for ethical behavior; sets standards or expectations for the professional to achieve
3 essential nursing components 1. Cure 2. Cure 3. Coordination
Nurse Practice Act (NPA) regulates the scope of nursing practice for the state and protects public health, safety, and welfare
Caregiver helps patients maintain and regain health, manage disease & symptoms and maintain a maximal level of function and independence through the healing process
Patient Advocate protect your patient's human and legal rights and will provide assistance in asserting these rights if the need arises (acting on behalf of your patient)
Advanced Practice Registered Nurse (APRN) independently functioning nurse
Clinical Nurse Specialist (CNS) APRN who is an expert clinician in a specialized area of practice
Nurse Practitioner (NP) APRN who provides healthcare to a group of patients , usually in an outpatient, ambulatory care, or community-based setting
Certified Nurse-Midwife (CNM) APRN who is educated in midwifery
Certified Registered Nurse Anesthetist (CRNA) APRN with advanced education in anesthesia accredited program
Nurse Educator works in schools of nursing; staff development departments of health care agencies, and patient education departments
Nurse Administrator manages patient care and the delivery of specific nursing services within a facility
Nurse Researcher investigates problems to improve nursing care and further define and expand the scope of nursing practice
Professional Organization deals with issues of concern to those practicing in the profession
National League for Nursing (NLN) advances excellence in nursing education to prepare nurses to meet the needs of a diverse population in a changing health care environment
American Nurse Association (ANA) the protection, promotion, and optimization of health and abilities
International Council of Nurses (ICN) promoting national associations of nurses, improving standards of nursing practice, seeking a higher status for nurses, and providing an international power base for nurses
Genomics the study of all the genes in a person and interactions of the genes with on another and with at person's environment
Health a state of being that people define in relation to their own values, personality, and lifestyle
Health beliefs a peron's ideas, convictions, and attitudes about health and illness
Health Belief Model addresses the relationship between a person's beliefs/behaviors
Health Promotion Model describes the multidimensional nature of people as they interact within their environment to pursue health
Maslow's Hierarchy of Needs a model developed by Abram Maslow; used to explain human motivation (basic needs)
Holistic Model comprehensive view of a person as a biopsychosocial/spiritual being. Health maintenance
Passive strategies of health promotion individuals gain from the activities of others w/out acting themselves
Active strategies of health promotion individuals adopt specific health programs
Health Promotion activities such as routine exercise and good nutrition; motivate to act positively
Wellness Education teaches people how to care for themselves in a healthy way
Illness Prevention activities such as immunization programs protect pt's from actual or potential threats to health
3 Levels of Health Prevention 1. Primary Prevention (meds, change in diet) 2. Secondary Prevention (going for check-ups) 3. Tertiary Prevention (preventative care)
Risk Factor any situation, habit, environmental condition, physiological condition, or other variable that increases an individual/group vulnerability to an illness/accident
Illness a state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished/impaired
Acute illness short term and severe
Chronic illness longer than 6 months and sometimes life threatening
Illness behaviors cognitive, affective and behavioral reactions; how a person interprets their symptoms, take remedial action and use health care system
Internal Variables perception of symptoms and nature (acute or chronic) way a patient behaves when ill
External Variables visibility of symptoms, social group, cultural background, etc
Professional Standards Review Organizations (PSRO) review the quantity, quality, and cost of health care services provided through Medicare/Medicaid
Utilization Review Committees (UR) review admissions, diagnostic testing and treatments provided by HCP's
Prospective Payment System (PPS) eliminated cost-based reimbursements
Diagnostic-Related Groups (DRGs) fixed reimbursement amount w/ adjustments for cost severity (set dollar amount)
Capitation payment mechanism in which provider's receive a fix amount per month per patient or enrollee of a health care plan
Managed Care systems in which a payer has control over primary health care srvs.
Integrated Deliver Networks (IDNs) a set of providers and services organized to deliver a coordinated continuum of care to the population of patients in a specific market or geographic area
6 Levels of Care 1. Preventive 2. Primary 3. Secondary 4. Tertiary 5. Restorative 6. Continuing Care
Acute Care patient's who have signs and symptoms of disease are diagnosed and treated
Restorative Care settings and services in which pt's who are recovering from illness or disability receive rehab and supportive care
Primary Care -prenatal, well-baby, nutrition counseling, family planning, exercise
Secondary Care -emergency care, acute med-surg., radiological procedures
Tertiary Care -intensive care, psychiatric
Restorative Care -cardiovascular/pulmonary, sports medicine, home care
Continuing Care -assisted living, psychiatric /older-adult day care
Discharge Planning centralized, coordinated, multidisciplinary process that ensures that a pt. has a plan for care after leaving hospital
REMEMBER!!! When does discharge begin????? The moment a patient is admitted!!!!!
Intensive Care ICU/CCU unstable/critically ill close monitoring most expensive
Mental Health Facilities pt's w/ emotional/behavioral problems voluntary/involuntary Inpatient/Outpatient services
Rural Hospitals CAH hospital in rural area 24 E.R. care 25 patient's or less stabilization before transfer
Restorative Care pt's recoving from acute/chronic illness or disabilities
Home Care provision of medically related professional services/equipment to patients and families in their home
Rehabilitation P.T./O.T./S.T., psychological, social services; use of multiple therapies
Extended Care Facilities intermediate care, skilled care, long-term care, assisted living
The Omnibus Budget Reconciliation Act of 1987 nursing home reform act
Minimum Data Set (MDS) required by omnibus; uniform data set established by Dept. of Health (DHS), framework for any state-specified assessment instruments used to develop a written/comprehensive plan of care
Respite Care short-term relief for people providing home care
Adult Day Care health/social services to specific patient populations who live alone or w/ family
Hospice family-centered care that allows patients to live and remain at home w/ comfort and dignity caused by terminal illness
Patient-Centered Care concept to improve/work efficiently by changing the way patient care is delivered
Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice
Case Manager makes an appropriate plan of care based on assessment
Epidemiologist a person who studies in the branch of medicine and deals with the incidence, distribution, and possible control of diseases
Common Law judicial decisions or case law precedent
Statutory law rules codified by legislative bodies of government
Nurse Practice Acts (NPA) define the scope of nursing practice and expanded nursing care
Due Process required State Board to notify nurse of charges, conduct hearing, offer defense with or without legal counsel
Criminal Laws federal/state laws; crime certain actions that inflict/threaten substantial harm to individuals
Tort wrongful act/acts against a person/persons property that are compensated by awarding monetary damages to the individual violated
Intentional Tort deliberate act of wrongful conduct (assault/battery)
Assault intentional threat toward another person that places that person in harmful, imminent , or unwelcome contact
Battery intentional offensive touching w/o consent
Negligence failure to use degree of care
Malpractice failure to use the degree of care that a reasonable nurse would use under the same circumstances
Standards of Care legal guidelines for minimally safe and adequate nursing practice
Risk Management identifying possible risks, analyzing them, acting to reduce them and evaluating the measures taken to reduce them (occurrence report)
Never Events preventable errors (falls, UTI's) that should never happen in a hospital setting
Good Samaritan Laws laws that limit liability and offer legal immunity if a nurse helps at a scene of an accident
Consent signed consent by a patient for admission to a health care facility
Informed Consent patient's agreement to allow something such as surgery to happen based on full disclosure
Restraint manual method, physical, or mechanical device/material/equipment that immobilizes
2 standards to determine death 1. Cardio-pulmonary- lack of circulatory/respiratory function 2. irreversible failure of all functions of the entire brain/stem
Advanced Directives written statement of a person's wishes regarding medical treatment, living will
Living Will instructing a provider to withhold/withdraw life-sustaining procedures
Durable Power of Attorney/Health Care Proxy designates an individual to give consent when a patient is no longer able
Confidentiality HIPAA, patients rights to consent to use and disclose protected health information
Ethics standards of conduct, right/wrong behavior
Morals the judgement about behavior
Value a personal belief about the worth of a person
Bioethics the study of ethics
Autonomy person's independence; (nurse makes decision to give treatment w/o order due to pt's symptoms)
Justice fairness; fair treatment
Fidelity agreement to keep promises
Beneficence promotes taking "positive/good" steps to help others
Non-maleficence to do harm
Accountability ability to answer for you own actions
Deontology right/wrong based on "right making characteristics" such as truth and justice
Ethics of Care health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by the promoting of fundamental act of caring
Evidence-Based Practice (EBP) a problem-solving approach to clinical practice that combines the conscientious use of best evidence w/ clinicians exptertise; making decisions about patient care
PICO (PICOT) P = patient of interest I = intervention of interest C = comparison of interest O = outcome (achieve) T = Time (how long)
Sentinel Event unexpected occurrence involving death/serious physical/psychological injury of a patient
Critical Thinking continuous process characterized by open-mindedness, willing to look at each unique patient situation and determine which identified assumptions are true/relevant
3 Levels of Critical Thinking 1. Basic 2. Complex 3. Commitment
Scientific Method a way to solve problems using reasoning
Problem-Solving information obtained and applying it together with what you already know
Intrapersonal Communication "self-talk", powerful form of communication within a person
Interpersonal Communication interaction that occurs between two people/small group
Denotative Meaning individuals that use a common language
Connotative Meaning shade/interpretation of the meaning of a word
Pacing talking rapidly
Therapeutic Communication verbal/nonverbal exchanges between the nurse and the patient
SBAR (sit back and assess the recommendation) standard communication between health care providers S = situation B = background A = assessment R = recommendation
Language assess the patient's understanding of ALL communication
Empathy ability to understand and accept another person's perspective
Clarifying validates whether the person interpreted the message correctly
Focusing directs conversation to a specific topic/issue when a discussion becomes unclear
Paraphrasing restating a sender's msg. in your own words
Summarizing concise review of main ideas from a discussion
Self-disclosure personal statements intentionally revealed to the other person
Instilling Hope "sense of possibility"
Overusing Medical Vocabulary can cause confusion/anxiety
Sympathy concern, sorrow
Health People 2020 key intervention strategy to improve health behaviors
Teaching practice that results in an individuals learning knowledge, new behaviors or skills
Learning purposeful acquisition of new knowledge
Referent idea that initiates reason for communication
Domains of Learning -cognitive - what a person knows -affective - person's feelings -psychomotor - person can do physically
Attention Set the mental state that allows a learning to focus on and understand the material
Participating you and the patient set objectives; participate in the learning process together
Entrusting patient accepts responsibility and correctly performs a task while you observe
Reinforcement using a stimulus that increases the probability of a response
Demonstration showing patient what he/she needs to do
Return Demonstration permits patient to perform skill as nurse observes
Analogies two similar things
Caring universal phenomenon influencing the way we think, feel and behave in relation to one another
5 steps of the nursing process 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation
Cue information obtains through the senses (see)
Inference your judgement/interpretation of cues
Gordon's 11 functional health patters provides a holistic framework for assessment of a patients health history, from which you derive a broad range of nursing diagnosis
Subjective Data patient's verbal description (what they tell you)
Objective Data observations of a patients health status (what you see)
Open-ended questions describes situation in more than 1 or 2 words; leads to discussion
Back-channeling using words as "all right" "go on" or "uh huh"
Closed-ended questions limit patients answers to 1 or 2 words such as "yes" or "no"
Validation comparison of data with another source to confirm accuracy
Critical Thinking involves logically analyzing and interpreting assessment data about a patient to form a clinical judgement
NANDA International (NANDA-I) model for organizing nursing diagnosis for documentation, auditing, and communication process
Etiology condition that responds to nursing intervention
PES Format -Problem (problem) - Etiology (cause) -Symptoms (characteristics)
Patient-centered goal broad statement that describes a desired change in a patients condition/behavior
3 steps in choosing a nursing intervention 1. know scientific rationale (reason) 2. possessing psychomotor/interpersonal skills 3. function within particular setting; using available resources
Independent Nursing does not require a doctors order; take upon self
Dependent Nursing requires a doctors order
Standard of Care the minimum level of care accepted to ensure high quality of care to patients
RBC (red blood cells circulating) Men: 4.7 - 6.1 Women: 4.2 - 5.4
Hgb (hemoglobin) the 14 yr. old goblin goes trick/treating while transporting candy) red protein responsible for transporting O2 in the blood Men: 14 - 18 Women: 12 - 16
Hct (hematocrit) men (42) minus 5 for women (37) volume of red blood cells : total blood volume Men: 42 - 52 Women: 37 - 47
ESR non specific marker for inflammation
Cultures blood, wound, urine, etc (collection of)
urinalysis (UA) looks for presence of WBC's, bacteria, etc in urine
WBC (white blood count) measures the % of each type of leukocyte present 5,000 - 10,000
WBC 4,000 and below bone marrow failure, radiation, overwhelming infection, etc.
Granulocyte WBC containing bacteria combating granules
Agranulocyte WBC = no granules
Never Let Moneys / Eat Bananas Granulocyte Agranulocyte Neutrophils Lymphocytes Monocytes / Eosinphils Basophils Granulocyte Agranulocyte
Neutrophils (granulocyte) 55 - 70 % -form in 7 - 14 days stay for only 6 hours -kill bacteria -produced by acute infection/trauma -bands form (infection
Lymphocytes (granulocyte) 20 - 40% -fight bacteria and acute vial infections
Monocytes (granulocyte) 2 - 8% -are phagocytic, fight bacteria, remove necrotic debris and microorganisms from the blood -produce rapidly
Basophils (Agranulocyte) 0.5 - 1% -involved in allergic reactions -basos contain heparin, histamine, & serotonin, inflammatory response to allergic reaction increases -do not respond to bacterial/viral infection
Eosinophils (Agranulocyte) 1 - 4% -as the allergic response increases so the number of eosinophils -do not respond to bacteria
ILIA/OSIS high, up
PENIA (pick the penia off the ground) low, down
Adult blood pressure 120/80
Adult pulse 60 - 100
Adult respirations 12 - 20
Normal Body Temperature 96.8 - 100.4 F
5 parts of an examination Inspect Palpation Percussion Auscultation Smell
Resolving an Ethical Dilemma step 1: ASK step 2: GATHER step 3: CLARIFY step 4: VERBALIZE step 5: IDENTIFY step 6: NEGOTIATE PLAN step 7: EVAULATE
Crackles fine bubbling sounds in the lungs
Atrophy wasted or reduced size of tissue
Adventitious Lung Sounds Abnormal lung sounds
Turgor normal resiliency of the skin
Melena dark stool
Phlebitis inflammation of a vein
Petichiae tiny red/purple spots; minute hemorrhages
Pallor paleness/lack of color in the skin
Orthopnea abnormal condition in which a person must sit up or stand to breathe confortably
Cerumen yellowish waxy substance found in the ear canal
Jaundice yellowish discoloration of the skin; caused by greater amounts of bilirubin in the blood
Erythema Redness
Edema abnormal accumulation of fluid in the interstitial spaces
Dyspnea difficulty breathing
Dorsal back
Cyanosis bluish color of the skin
Indurated skin hardening
OTO- ear
Arthro- joint
Pre- before
-ology science/study of
Post- after
tachy- fast
eryth- red
-ostomy to form an opening
adeno- glandular
bi- double, two, twice
nephron- kidney
Broncho bronchi
derma- skin
-megaly enlargement
cardio- heart
neuro- nerve
chole- gall/bile
-ectomy surgical removal of
-lysis disintegration
-osis disease/condition
costo- rib
-plasty repair/reconstruction
vaso- a vessel
-algia pain
cysto- bladder
-lithiasis presence of stones
mal- bad/poor
dorso- back
entero- pertaining to intestines
glosso- tongue
pan- all
pneumo- air
brachio- arm
brady- slow
ambi- on both sides
hyper- above, beyond, increased
gastro- stomach
-rhage hemorrage
ileo- intestine
cholesysto- gallbladder
- it is inflammation of
-lith stone/calculus
neo- new
-genesis origin/beginning
-rhea excessive discharge
a- / an- not/without
hemi- half
-cele tumor/swelling
auto- self
hemo- blood
gyneco- female
extra- outside of/in addition to
dys- difficult/abnormal
ad- to/toward
leuko- white
hepato- liver
-cide kill/destroy
hemato- blood
-emia blood
osteo- bone
histo- tissue
Heat Loss normal heat loss through radiation, conduction, convection, and evaporation
Diaphoresis excessive sweating
Pyrexia FEVER
Febrile elevated body temperature FEVER
Afebrile without fever
Sustained Fever constant body temperature
Intermittent Fever Fever spikes; returns to acceptable level in 24 hours
Remittent Fever Fever spikes; falls w/o returning to normal temperature
Relapsing Fever Fever mixed w/ normal temperature lasting longer than 24 hours
Antipyretics medication that reduce fever
Hyperthermia elevated body temperature due to inability to promote heat loss
Heat Stroke prolonged exposure to the sun or high temperatures
Hypothermia heat loss during prolonged exposure to cold
Oral Temp. easy accessible; no patient position change
Tympanic Temp. easy accessible; minimal patient repositioning/not waking pt.
Rectal Temp. Gold standard for core temp.; more reliable than oral; difficult/ impossible to obtain
Axilla safe/inexpensive; used on newborns, children, or unconscious
Skin Temp. inexpensive; continuous reading; safe/nonevasive
Temporal Artery easy access; no position change; rapid measurement; no risk/injury
5 major parts of a stethescope earpiece binaurals tubing bell chest piece diaphragm chest piece
Temporal Pulse over temporal bone of head; above lateral eye
Carotid Pulse along medial edge of sternocleidomastoid in neck
Apical Pulse 5th intercostal space at left mid-clavicular line
Brachial Pulse groove between biceps/triceps muscles at antecubital fossa
Radial Pulse radial/thumb side of forearm at the wrist
Ulnar Pulse ulnar side of forearm at wrist
Femoral Pulse below inguinal ligament; midway between symphysis pubis and anterior superior iliac spine
Popliteal Pulse behind the knee
Posterior Tibial Pulse inner side of ankle; below medial malleolus
Dorsalis Pedis Paulse along top of the foot; between tendons of great and first toe
Pulse rate speed of the heartbeat measured by the number of contractions of the heart per minute (bpm)
Tachycardia elevated heart rate; more than 100 beats/min.
Bradycardia slow heart rate; less than 60 beats/min.
Dysrhythmia regular interval interrupted by an early/late/missed beat
Blood pressure force EXERTED on the walls of an artery created by pulsing blood under pressure from the HEART
Systolic Pressure PEAK pressure; top number (SBP)
Diastolic Pressure MINIMAL pressure; bottom number (DBP)
Pulse Pressure the difference between systolic/diastolic
Hypertension persistently elevated blood pressure; systolic greater than 140 : diastolic greater than 90 -if measured high like this 2 times
Hypotension low blood pressure; systolic less than 90 : diastolic less than 60
Auscultation listening to sounds produced by the body w/ stethescope
Korotkoff Sound clear, rhythmic tapping series that corresponds to the pulse rate and gradually increases in intensity
Auscultatory Gap temporary disappearance of sound
Respiration mechanism the body uses to exchange gases between the atmosphere, blood, and cells
Ventilation movement of gases INTO and OUT of the lungs
Diffusion movement of oxygen and carbon dioxide between the alveoli and the red blood cells
Perfusion distribution of red blood cells to and from the pulmonary capillaries (e.g. capillary refill)
Eupnea normal rate and depth of ventilation
Respiration rate full inspiration and expiration = 1
Bradypnea respiratory rate less than 12 / min. or lower
Tachypnea respiratory rate more than 20 / minute or higher
Apnea lack of respiratory movement
Pulse Oximetry indirect measurement of oxygen in the blood (5th vital sign)
ETCO2 (end-tidal carbon dioxide) measures the exhaled carbon dioxide
Chief Concern why patient is seeking health care
Inspection the use of vision to distinguish normal from abnormal findings
Percussion tapping the body with the fingertips
Olfaction SMELL
Integument skin, hair, scalp, and nails
Documentation a legal document used for malpractice issues; correct time of events, signing orders and billing
Electronic Health Record (EHR) electronic record of patient health information generated by one or more encounters in any care delivery setting
Meaningful Use level with which I.T. is available and used to support clinic decision to improve quality/safety
Incident/Occurrence Report when an actual/potential injury happens, but is not part of a patient record
Infection the invasion of a susceptible host by potentially harmful microorganisms (bacteria, viruses, fungi, protozoa)
Colonization the presence and growth of microorganisms within a host
Symptomatic pathogens that multiply and cause clinical signs and symptoms are not present
Chain of Infection Agent Reservoir Port of exit/entry mode of transmission susceptible host
Carrier person that hosts a disease, but shows no symptoms
Flora large number of microorganisms residing on the surface and deep layers of the skin, in the saliva, and on the oral mucosa and intestinal walls
Suprainfection secondary infection
Fomites inanimate surfaces (counter/desk)
Inflammation protective vascular reaction that delivers fluid, blood products, and nutrients to interstitial tissues in an area of injury
Necrotic of or pertaining to the death of tissue in response to disease/injury
Antigen foreign material
Health-Care Aquired Infection (HAI) patient develops an infection that was not present at the time of admission
Exogenous-Infection (OUT) comes from microorganisms found OUTSIDE the body
Endogenous-Infection (IN) occurs when part of a patients flora becomes altered INSIDE the body
Aseptic Technique an effort to keep patients as free from exposure to infection-causing pathogens as possible
Asepsis the absence of disease
Medical Asepsis clean techniques includes procedures used to reduce the number and prevent the spread of microorganisms (handwashing/PPE)
Surgical Asepsis sterile technique, includes procedures to eliminate all microorganisms from an area
Standard Precautions good hand hygiene and use of barriers such as gloves/mask
Disinfection eliminates all pathogenic organisms with the EXCEPTION of bacterial spores
Sterilization eliminates/destroys ALL forms of microbial life
3 types of transmission -airborne -droplet -contact precautions
Homeostasis state of relative constancy in the internal environment of the body equilibrium; maintained naturally by physiological adaptive mechanisms
Carbon Monoxide affects a person's oxygenation by binding strong with hemoglobin; reducing supply of oxygen delivered to tissues
Immunization process by which RESISTANCE to an infectious disease is produced or increased
C.U.S. I'm CONCERNED I'm UNCOMFORTABLE SAFE ("this is not safe, you should stop now")
RACE Rescue Activate Confine Extinguish
Auditory hearing
Tactile touch
Gustatory taste
Proprioception body's ability to sense its position and movement in space
Sensory Deficits LOW vision/blindness; problem w/ reception; rely on other senses
Sensory Deprivation INADEQUATE quality/quantity of stimuli; impairs perception
Sensory Overload MULTIPLE sensory stimuli; to much going on
Presbycusis decreased hearing acuity, speech intelligibility, and pitch discrimination
Accommodation reduced depth perception and reduced color discrimination
Ototoxic analgesics, antibiotics affecting hearing acuity
Tinnitus ringing in the ears
Presbyopia gradual decline in ability of the lens to focus
Meniere's Disease cause unknown (vertigo, tinnitus)
Gerontology study of all aspects of the aging process
Geriatrics dealing with physiology/psychology of aging in older adults
Alzheimers form of dementia
Dementia generalized impairment of intellectual functioning that interferes with social and occupational functioning; gradual; progressive
Ischemic Vascular Dementia 2nd form of dementia; reversible; stroke or onset gradual
Created by: Smccunn