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Stack #48852

What are the alzheimer's sign & symptom? 1114 lost of memory, diff. concentration, diff. w/language, diff. w/ object recognition, diff. w/ judgement, urinary and fecal incontinent.inability to self care, and inability to comunicate.
Subjective/objective dt. 82-3 subj.= what pt says. obj. = Sign that cen be measure and can be observe.
Define assessment 82 The process of making an evaluation or appraisal of pt condition.
Complete assessment 82 Involves a review and physical of all the body system.(Musculoskeletal, respiratory, gastrotestinal etc.).
Focussed assessment. 82 Gathers information about specific health problem.
NREM Non rapid eye movement. consist of 4 stages, lightest level of sleep, sound sleep, deep sleep, and deepest stage of sleep.
how to position after Liver biopsy ? 495 keep pt bed rest for 24 hrs.Keep pt on right side for 1 to 2 hrs.(decreasing risk for hemorrhage or bile leak.
Change of shift report ?1267 the purpose is to provide the next shift w/ pertinent info about the pt. it can be orally in person or recorded or round from pt to pt.
What is initial action when pt falls? 362 Ease pt into a sitting position in a chair or on the floor, and alert the nurse.
Correct positioning for CVA? In ambulation always walk on the weak side and apply gait belt.
What happen in REM 416 Deep sleep
external disaster disaster originated from outside the health care facility and resluted in an influx of casualties brought to the facility.
Good samaritan law 744 Legal stipulation for protection of those who give first aid in an emegency situation.
Negligence 22 The commission( doing) and the omission ( not doing) that the prudence person would have done in a similar situation that lead to harm another person.
confidentiality 25 A duty of an LVN to safe guard and protect information received.
Obtaining urine from foley catheter 573 Clamp the tube just underf neath the port and wait for 30 minutes then aspirate about 5 to 10 ml.
Stool specimen for occult blood 509 Make sure the stool is free from urine mixed.
Urinary retention after surgery. It is a by product of anestesia and it could last from 1 hr to 1 week
Define culture 124 A set of learn values, beliefs customs and practices that are shared by a group people and are passed fr one gen to another.
Transcultural nursing 125 Transcultural nursing is the care provided to a many cultural and subcultural.
Body system assessment. 64 review system.
Log rolling 390 Keep body align when turn.
Development of pressure ulcer. When there is sufficient pressure on the skin to cause the blood vessel in area to collapse.
Nursing responsibility in wound infection 329 Irrigate and change the dressing.
Evisceretion 329 Protrusion of internal organ trough a wound or surgical incission.
Dehiscence 329 Separation of surgical incission or rupture of a wound closure.
the sign of Wound infection 756 A wound is type of physical trauma wherein the skin is torn, cut or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound).Infection occured when it contaminated or when it contains purulent drainage.
How to avoid pressure ulcers 1095 turn q 2 hrs.
Wet to dry dressing 324 Mechanically debride the wound.
BP on obese pt. Get the right size
Head to toe assessment 68/67 Assessment begin c neuro, skin, hair, head, neck, eyes, ears, nose, mouth, chest, back arms, abd, peri, legs and feet.
Femoral Pulse 248/9 Pulase in the femoral artery which is a continuation of the external iliac artery, which comes from the abdominal aorta.
Popliteal Pulse 250 Pulse in the popliteal artery which is the extension of the femoral artery after passing through the adductor canal and adductor hiatus above the knee.
Posterior tibial 250 Behind and below malleolus( ankle bone)at the the posterior tibial artery.
Dorsalis pedis pulse 250 Between great and first toes
Children respiratory pattern 960/1010 new born rate is 40 to 50 breaths /minute and decreases after 36 hours age to 25/32/minutre
Obsessive compulsive disorder 1143 is a psychiatric disorder, more specifically, an anxiety disorder. OCD is manifested in a variety of forms, but is most commonly characterized by a subject's obsessive (repetitive, distressing, intrusive) thoughts and related compulsions (tasks or rituals
Nursing responsibility on overdose drugs 703 1st check the pt and 2nd. report to MD/supervisor immediately.
Drinking due to pain Coping response
Adaptation 1132 Individuals ability to adjust to changing life situation using various strategies.
Anorexia nervosa 640 eating disorder characterized by self imposed starvation.
Low residue diet 636 is a dietary fibre whcich is normally given to a person having gi tract, Low in fibre such as meat fish poultry eggs milk grain fruit and veggie.
Baby sleeping with botle Must be avoided related to SID and can damage dntures and ear.
Wrist restrain 354/5 is designed to immobilize one or more extremities.Secure to the bed that movable portion of the bed NOT to the side rails.
Fainting pt while ambulating n383 Ease the pt.sliding to the floor tyrough your leg to to slide to the floor and call for assisstance.
Nursing response when fire 365 RACE
24- hr specimen 505 void the beg and few minutes before 24 hr end.
Contrast media 486 Check for allergy to iodine.
Bronchoscopy 489 Is a procedure that allows your doctor to look at your airway through a thin viewing instrument. NPO 4 to 8 hrs after midnight.
Changing dressing 322 Remove the dressing away from you. Clean the wound and surrounding area w/ antiseptic swap starting from incission outward, one stroke perswab and discard.
Isolation precaution for tb pt. 292 b must be in a single pt room designed as neg airflow and at least 6 exchange /hr and room air must be vented to the outside. The door must be closed to maintain negative pressure.Health worker must wear N95 particulate respirator mask or HEPA resp and gow
Informed consent who needs one 25 A person agreement to allow ba particular treatment based on full disclosure of the facts needed to make an intelligent (informed) decision. MD team need one.
How to avoid a lawsuit 28 1. Make an open and honest communication 2. Proper documentation 3. Free from error acts.
scope of practice /standard of care 23 Act that is permitted to performed.
Pericare for a weak/terminally ill. Care given trough genitalia with providing comfort.
Traumatic brain injury(TBI) for children 1223 Classified as mild, moderate , severe and catastrophy.
Penetrating head injury for or closed head injury.(area of brain defected) 1223 In penetrating injuries an object destrying the nerve cells.In the closed head injury, the brain collides with an inner surface of the skull.
Postural hypotension 256/1220 Is common in quadriplegic <=90/60 to lessen raise the head of the bed for 15 to 20 minutes before pt is placed in the wheel chair.
Autonomic dysreflexia 1220 spinal cord lesion above T5 may experience sudden and extreem elevation in bp caused by a reflex action of the autonomic nervous system.Find the source of irritation and remove it .Raise the pt. into sitting position immediately.
Hearing impaired (nursing reponse) 46 1. Visual contacts 2. Face the pt. when talking. 3. Speak slowly and articulate clearly.
Open ended question 40 can not be answered by yes or no. x. How do you feel about surgery tomorrow?.
Reflection 40 assiss pt. to reflect on inner feeling and thoughts . x. sometimes I feel my family falling apart.all we do fight and argue.
Clarifying 40 SAeek to understan d pt. message by asking for more q. x. how are you getting along w/ the new bp. med?
Assertive 40 interaction that taken into accnt. the feelings and need of the pt. yet honour the nurse's right as an individual.
Aggressive communication overpowering and forcefull manner to meet one own needs on the expense of others.
Silence communication Extreemly teraupetic technique yet it is quite under used.
advance directives 203 signed and witness docs. providing special instruction for health care treatment in the event pt. cannot make decision personally at the time needed. can be a. living wills or b. durable power of attorney for health care.
post mostem care 209 Death cert. from MD in the MR. Time and action taken in MR.Know the state law and institution policies.
Pediatric death 201 Nurse should be aware how children view or understand death both forthemselves and for others.
Acceptance 39 wilingness to listen and respond to what a pt. is saying without passing a judgement on the pt.
Herniorraphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting hernia.
POMR based on the scientific problem solving system
DARE 105 Data action response/evaluation, education.This is a focus charting. Instead of problem list a modified nursing diagnoses is used.
SOAP Subjective Objective Assessment plan. and soapier-intervention evaluation and revision - .All health care team chart on the same progress notes.
Electrolite670 minerals ie. na+, K+, Ca++, Mg++ and anions: Cl-, HCO3, SO4-, HPO4-
Fctn of sodium to regulate water balance
Extracellular 666 Fluids out side the cells 34% ie. Interstitial 27% and Intravascular 7%
Amt of urine in 1 hr(normal) 1500 ml/24 hr or 62.5/hr.
How to det. accurate weight 639 Based on Height and healthy weight.
Diffusion 669 movement of particle H-L concentration.x. movement of sodium ions into nerve cells
Osmosis Movement of particle from L-H concentration. x. Movement of water in to or out of the cells to correct imbalance of water concentration.
Filtration 669 movement of water and small solute particle from H-L pressure. x. water moves from blood vessel to kidney.
When bathing pt. which are do you bathe first and which one is the last? 444 Eyes area first and pericare is the last.
Hair care for pt For bedfast pt.and helpless, shampoo performed in bed.If hair is matted w/ blood cleans w/ hydrogen peroxite.
Foot care for pt w/ impaired sensation. Foot care is important to prevent from odor and infection. Examin all skin surface prior to care.Pt. w/ DM or peripheral vascular should be observe for adequate circulation to the feet.
Mouth care for unconscious pt. Helps maintain a healthy state of the mouth teeth, gum and lips. It trigger the appetite too.
Pt refuses treatment. Based on bill of rights.
Living will 203 Wriiten doc. that direct treatment in accordance w/pt. wishes in the event of terminal illness or condition.
Pt bill of right 15 Right 12
Chain of infection 271 Micro (infectious agent)--Infected person--exit--Trans--entrance--Host--micro.(infectious agent)
Surgical asepsis Steril
Destroying pathogen and spores Surgical asepsis.
Tool for assessing physical dev. of school age child and over. 158 (blank)
Trust vs mistrust?(infancy) 1- 6 mo W incr. 1.5 lb/mo and H or L incr. 1 inch/mo 4 - 6 mo double birth W. 12 mo Birth W tripple. L+/- 30 Inch. ( 75 cm)
Intimacy vs Isolation? 158 Young adult.
Fear of todler? 158 (blank)
Recognizing a goal (blank)
Actual nursing diagnosis Nanda
Prior to planning? Assessment.
paresis 1220 slight paralysis incomplete loss of muscular power or weakness of the limb.
one of the most teraupetic technique in communication? Listening.yet it is the most difficult skills to acquire.
Schizophrenia is a psychtic disorders characterized by gross dirtortion of reality, language disturbance, withdrawal from social interaction, and siorganization and fragmentationof toughught,perceptionand emotional rection.
Created by: Marianib