Final review for N142
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| Surgical Asepsis? | “sterile technique” the complete elimination of microorganisms
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| Asepsis | the absence of pathogenic microorganisms
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| Aseptic techniques | practices that keep a client as free from pathogens as possible by preventing the spread of infection from one person to another
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| Medical Asepsis: | clean technique” prevents the spread of microorganisms, as clean as possible.
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| Standard Precautions | health protecting measures which keep clients and health care works safe, apply to blood, mucous membranes, secretions, body fluids, and non-intact skin
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| Cleaning | physical removal of foreign material from objects and surfaces
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| Disinfection | elimination of all pathogens except for bacterial spores
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| Sterilization? | destruction of all microorganisms including spores
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| Body Alignment? | refers to the relationship of one body part to another along a horizontal or vertical line, correct alignment reduces the strain on muscular-skeletal structures
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| Body balance? | achieved when a relatively low center of gravity is balanced over a wide, stable base of support, enhance by proper posture
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| STABLE? | S: maintain the natural curves of the spine
T: avoid trunk twisting
A: keep your arms in close
B: use a wide base of support
L: use your legs
E: evaluate the load, environment, and yourself
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| Verbal communication? | words you speak, vocalizations, and tone of voice
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| Non-verbal communication? | body language (posture, gestures, facial expressions etc), under less conscious control
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| Unconditional Positive Regard? | having a general optimistic view of people, an assumption of strengths and acceptance of their weaknesses, patient must feel accepted unconditionally
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| Empathy? | viewing the world from the others inner frame of reference while remained yourself, understanding how he or she views their own world. putting yourself into the patients shoes while remaining yourself
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| Active listening | completely listening to what the person is saying and how they are saying it, you are not distracted and are solely concerned with the persons needs not your own
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| Facilitation? | encourage the patient to say more ie: maintaing eye contact, nodding
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| Silence? | communicates that the person has time to think
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| reflection? | echoing the patients words
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| Clarification | use when the persons word choice is confusing
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| Confrontation | focusing the persons attention on an observed situation
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| Interpretation | links events, makes associations or implies cause
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| Explanation | inform the person using factual and objecting information
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| Summary | final review of what you understand the person has said, condenses facts
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| Subjective Data | information based on what the persons says about himself or herself
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| Objective Data | information gathered from the physical assessment ie: pulse, blood pressure
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| What are PQRSTU? | P: Provocative or Palliative * What brings it on?
Q: Quality or Quantity * How does it feel, look or sound?
R: Region or Radiation*
S: Severity Scale* How bad is it?
T: Timing * Onset, Duration
U: Understanding patients perception
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| Nursing Process: based on scientific method, involves? | Assessment: collect data
Diagnosis: interpret data
Outcome Identification: identify expected outcome Planning: establish priorities.
Implementation: schedule and coordinate plan of care
Evaluation: review plan of care, take corrective action
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| Critical thinking? | means by which we learn to assess and modify before acting, encompasses theoretical, experiential knowledge and intellectual and manual skills
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| Nursing Diagnosis? | clinical judgments about the persons response to an actual or potential health state. * symptoms
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| Inspection | : “concentrated watching”, careful scrutiny of the individual as a whole
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| Palpation | using touch to assess texture, temperature, moisture, organ location, and size.
* palpate sensitive areas last, intermittent pressure
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| Percussion | tapping the persons skins with short, sharp strokes to assess underlying structures through vibrations
* direct or indirect
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| Ascultation | listening to sounds produced by the body, using a stethoscope
* listen before palpating in abdominal cases
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| Body temperture | the difference between the amount of heat produced by the body processes and the amount of heat lost to the external environment
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| thermoregulation | the balance between heat lost and heat produced, controlled by the hypothalamus
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| Shivering | an involuntary response to temperature differences in the body, increases heat production
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| non- shervering thermogenesis? | occurs primarily in newborns, they cannot shiver so they rely on vasoconstriction through an increase in norepinepherine
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| Fever (Pyrexia)? | occurs when heat loss mechanisms are unable to keep pace with the excess heat production resulting in a rise of body temp to an abnormal level.
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| Febrile | Fever
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| Afebrile | : no fever/fever breaks
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| Hypothermia | above normal body temp due to bodies inability to promote heat loss or reduce heat production
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| Malignant Hypothermia | increased temp developed as a response to general anesthetic
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| Heat Stroke | prolonged exposure to the sun or high environmental temperatures depresses the hypothalamic function and overwhelms heat loss mechanisms
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| Heat Exhaustion | profuse diaphoresis that results in excess water and electrolyte balance
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| Frostbite | occurs when the body is exposed to subnormal temps, injured area becomes white, waxy and firm to touch
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| Pulse | bounding of blood flow that is palpable at various points of the body
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| Pulse rate | number of pulsing sensations that occur in one minute
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| Cardiac output | the volume of blood pumped by the heart during one minute (product of heart rate and ventricular stroke volume)
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| Tachcardia | abnormally rapid pulse, more than 100bpm
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| bradycardia | abnormally slow pulse, less than 60 bpm
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| Respiration | the mechanism the body uses to exchange gases between the atmosphere and the blood and the blood to the cells
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| Ventilation | movement of gases in/out of lungs
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| Diffusion | the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
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| Perfusion | the distribution of red blood cells to and from the pulmonary capillaries
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| Tidal volume | amount of inhaled air during normal, relaxed breathing (approx 500 ml)
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| Eupnea | normal rate/depth of respiration
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| Hypercarbia | increased ventilatory effort, removes excess carbon dioxide by increasing exhalation
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| Hypoxemia | low levels of arterial oxygen
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| Bradypnea | abnormally slow breathing rate, below 12 bpm
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| Tachypnea | abnormally fast breathing rate, above 20 bpm
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| Hyperpnea | difficulty breathing, respirations are labored with increased depth & rate
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| Apnea | temporary inability to breath
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| Orthopnea | shortness of breath (dysapnea) when lying flat
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| Synscope | light headedness, fainting
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| Hyperventilation | rate/depth of ventilations increase
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| Hypoventilation | rate/depth of ventilation decrease
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| Cheyne-stokes respiration | rate/depth of ventilations are irregular with alternating periods of apnea and hyperventilation
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| Kussmauls respiration | respirations are abnormally deep, regular and increase in rate
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| Biots respirtaion | respirations are shallow for 2-3 breaths followed by irregular period of
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| Blood pressure | measurement of force against the arterial walls
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| Sphygmomanometer? | device used to measure BP
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| Systolic pressure | maximum amount of pressure felt when ventricles contract
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| Diastolic pressure | maximum amount of pressure felt when ventricles relax
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| Pulse pressure | difference between the systolic and diastolic, reflects the stroke volume (60-70ml)
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| Mean Arterial | pressure forcing blood into the tissues, averaged over the cardiac
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| Ausculatory Gap? | period where Korotkoffs sounds disappear during auscultation
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| Hypotension | abnormally low BP
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| Orthostatic Hypotension | occurs when a person with normal BP develops symtoms of low BP when rising to an upright position
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| Hypertension | abnormally high BP
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| White Coat Hypertension | BP is elevated during a visit with a health care professional
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| Masked Hypertension | BP is normal while the client is with a health care professional but becomes elevated at home
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| Neuropathic pain | pain initiated or caused by a primary lesion or dysfunction of the nervous system, pain can be severe and difficult to manage * burning, soothing, or lancinating
Referred Pain: pain that is felt in a particular site but originated from another
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| Nocioceptive | due to tissue injury, resolves as healing takes place. *aching or throbbing
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| Somatic pain | superficial or deep ( skin vs joints/tendons)
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| Visceral pain | originates from larger interior organs
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| Acute pain | short term and self-limiting, ends after injury heals
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| Persistent Chronic pain | pain that has been present for 6 months or longer than the time of expected tissue healing, can be categorized as malignant (cancer related) or non-malignant
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| Documentation | anything written or electronically generated that describes the status of a client or the care or service given to that client. Must be: factual, accurate, complete, current, organized and compliant with standards.
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| SOAPIE(R) |
Subjective, Objective, Assessment, Plan, Implementation, Evaluation, (Revision)
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| PIE |
Problem, Intervention, Evaluation
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| Mental illness | biological condition of the brain that causes alterations in thinking, mood, or behaviour and is associated with significant distress and impaired functioning
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| mental consciousness | being aware of ones own existence, feelings, thoughts, and environment.
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| Epidermis | thin but tough, stratified outer layer of skin. sheds every 4-6 weeks.
Dermis: inner supportive layer consisting mostly of connective tissue and collagen (enables skin to resist tearing)
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| Hypo-pigmentation | the loss of pigmentation
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| Hyper-pigmentation | increase in color
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| Seborrhea | oily skin
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| Xerosis | dry skin
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| Pruritus | ichiness
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| Alopecia | hair loss
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| Hirsutism | shaggy or excessive hair
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| Vitiligo | the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices. can occurs in all people.
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| Erythema | intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries, expected with fever, inflammation or with emotional reactions such as blushing
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| Cyanosis | bluish, mottled discoloration that signifies decreased perfusion. indicates hypoxemia.
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| Jaundice | yellow pigmentation to the skin, indicates rising amounts of bilirubin in the blood
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| Diaphoresis | profuse perspiration
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| Hypothyroidism | skin feels rough, dry, flaky
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| Edema | fluid accumulating in the intercellular spaces, normally not present
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| Turgor | ability for pinched skin to return to place promptly when released, poor turgor is evident in extreme dehydration or weight loss, increases with age. (pinched skin recedes slowly or tents)
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| Scleroderma | “hard skin” chronic connective tissue disorder associated with decreased mobility
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| Range of motion | the maximum amount of movement available at a joint
Active: performed by the client unassisted,
Passive: the client is unable to move all joints independently, nurse moves each joint
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| Gait | style or manner of walking
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| Prone Position | client lying chest down
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| Supine position | client lying on their back
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| Side laying (lateral) position | Side-Lying (Lateral) Position: client resting on their side with the major portion of the body weight on the dependent hip and shoulder
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| sims position | similar to lateral position however weight distribution is placed more on the ilium, humerus and clavicle
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| Myalgia |
muscle pain, cramping or aching
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| Hemiplegia | one-sided paralysis
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| Hemiparesis | one-sided weakness
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| Dislocation | one or more bones in a joint being out of position
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| Subluxation | partial dislocation of a joint
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| Contracture | shortening of a muscle leading to limited ROM of joint
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| Ankylosis | stiffness or fixation of a joint
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| Crepitation | an audible and palpable crunching or grating that accompanies movement
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| Dyshezia | pain may be due to a local condition or constipation
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| Melena | black/tarry stools due to occult blood in the stool
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| Steartorrhea | excessive fat in the stool
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| Encopresis | persistent passing of stools into clothing in a child older than 4yrs
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| Constipation | *symptom, infrequent bowel movements, difficult evacuation of feces, inability to defecate at will, and hard feces
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| Impaction | results from unrelieved constipation
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| Diarrhea | increase in number of stools (several bowel movements per day) and the passage of liquid, unformed feces
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| urgency | feeling as if you can’t wait to urinate
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| Nocturia | the need to get up in the night to urinate
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| Dysuria | pain or burning while urinating
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| Hesitancy | straining, trouble starting to urinate, loss of force, terminal dribbling
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| Hematuria | presence of red blood cells in the urine
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| True incontinence | loss of urine without warning
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| urgency incontinence | sudden loss, as with acute cystitis
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| stress incontinence | : loss of urine with physical strain due to weakness of sphincters
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| Nocturnal enuresis | involuntary passing of urine after an age at which continence is expected
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| Phimosis | unable to retract the foreskin
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| Paraphimosis | unable to return foreskin to original position
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| cryptorchidism | undescended testes, common in premature infants
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| Menopause | cessation of menstruation
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| Osteoporosis | decrease in skeletal bone mass, occurring when rate of bone resorption is greater than bone formation
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| Rheumatoid Arthritis | chronic, systemic inflammatory disease of joints and surrounding connective tissue
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| Oseoarthritis | noninflammatory, localized, progressive disorder involving deterioration of articular cartilages and subchondral bone and formation of new bone
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| Scoliosis | abnormal curing of the spine
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| Pigeon toed | when you tend to walk on the lateral side of the foot and the longitudinal arch looks higher than normal
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| Striae | jagged linear “stretch marks” of silver to pink colour, may not fade
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| Linea Nigra | brownish black line down the midline
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