everything
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| What are the techniques in interviewing process. | What are the techniques in interviewing process.
Problem Seeking & Problem Solving, Direct & Open-Ended Questioning
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| What are the three phases of a basic interview. | What are the three phases of a basic interview.
Orientation, Working, and Termination Phase
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| What is the first step in nursing assessment. | What is the first step in nursing assessment.
Nursing Health History
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| Basic components of the nursing health history. | Basic components of the nursing health history.
Bio. Info.
Reasons for seeking hxcare
Pt. expectations
Past Hx
Hospitalization
Treatment
Outcomes
Family
Environmental
Psychosocial
Present Hx State & R.O.S.
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| What is the focus of nursing history. | What is the focus of nursing history.
Effect of CHANGE in Hx state in meeting basic human needs.
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| A statement of potential or actual patient problems. | A statement of potential or actual patient problems.
Nursing Diagnosis
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| Nursing diagnostic involves four elements. | Nursing diagnostic involves four elements.
Analysis & Interpretation of data, Clustering of Data, Identification of Pt. Problems, Formulation of Nsg. Dx.
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| It requires validation and clustering of data. | It requires validation and clustering of data.
Interpretation of data
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| Determining whether data gathered is complete and accurate. | Determining whether data gathered is complete and accurate.
Validation of data
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| Grouping related data, usually sx & sy, indicating a general problem. | Grouping related data, usually sx & sy, indicating a general problem.
Clustering of data
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| A hx care problem that is currently perceived by the pt. or assessed by the nurse. | A hx care problem that is currently perceived by the pt. or assessed by the nurse.
Actual Hx Care Problem
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| A hx care problem in which the patient is at risk. | A hx care problem in which the patient is at risk.
Potential Hx Care Problem
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| When planning, a nurse should consider the level of potential pt. involvement, time limit and what? | When planning, a nurse should consider the level of potential pt. involvement, time limit and what?
Available Hx care system resources
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| In implementation of the NCP, what actions are taken. | In implementation of the NCP, what actions are taken.
Assist Pt. on ADL, Counsel & support Pt. & family, Guide Pt., Teach Pt. & Family, Provide care to achieve NCP, Provide Environment that is conducive.
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| Interventions based on instructions or written directives given by another professional. | Interventions based on instructions or written directives given by another professional.
Dependent Intervention
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| Aspects of care encompassed by licensure and law. | Aspects of care encompassed by licensure and law.
Independent Intervention
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| Interventions that the nurses carry out in collaboration with another professional. | Interventions that the nurses carry out in collaboration with another professional.
Interdependent Intervention
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| True or False. The NCP is modified as the Pt's state of Hx changes and as needs for care changes. | True or False. The NCP is modified as the Pt's state of Hx changes and as needs for care changes.
True
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| In evaluation of NCP, outcomes of nursing interventions maybe used for. | In evaluation of NCP, outcomes of nursing interventions maybe used for.
Malpractice suits
Staff Evaluations
Reviews
Promotions
Nursing Research
Quality Improvement
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| What are the enrivonmental fire safety precautions? | What are the enrivonmental fire safety precautions?
Mark fire exits
Dont use elevator
Turn off O2 machines
Move pt's. by bed, stretcher, or wheelchair
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| What are environmental radiation safety precautions? | What are environmental radiation safety precautions?
Label radioactive materials
Limit time spent
Distance yourself from the source
Use lead apron
Never touch dislodged implants
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| What are environmental precautions for disposing infectious wastes? | What are environmental precautions for disposing infectious wastes?
Needles should not be recapped, bent or broken
Yellow for infectious
Green for biodegradable
Black for nonbiodegradable
Red for blood, sharp items, contaminated
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| It is to restrict client movement through the application of a device? | It is to restrict client movement through the application of a device?
Physical restraints
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| Medications given to inhibit specific behavior? | Medications given to inhibit specific behavior?
Chemical restraints
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| Restraints should have? | Restraints should have?
Reason & method
Date & time of use
Duration & release from it
Assessment of pt's response & further need of use
Half bow or safety knot & secured to the bedframe or chair
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| Restraints should not be? | Restraints should not be?
P.R.N. & without consent from the pt. & family
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| Neurovascular, circulatory & skin integrity is assessed in using restraints when? Then removed at least every? | Neurovascular, circulatory & skin integrity is assessed in using restraints when?
Then removed at least every?
Every 30 minutes
Removed @ least q 2 hrs. to promote circulation
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| Who are those prone to accidental poisoning? | Who are those prone to accidental poisoning?
Toddlers
Preschoolers
Young school age
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| In older adults, poisoning & overdose of prescribed medz. will yield? | In older adults, poisoning & overdose of prescribed medz. will yield?
Diminished eyesight
Impaired memory
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| If lye, grease, petroleum or household cleaner is ingested, a nurse should? | If lye, grease, petroleum or household cleaner is ingested, a nurse should?
Never induce vomit especially to an unconscious person
If vomit occurs, bring vomitus to CDC
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| Nosocomial infections can be transmitted by a healthcare personnel by? | Nosocomial infections can be transmitted by a healthcare personnel by?
Improper handwashing
Unchanged gloves between clients
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| Standard precautions apply to? | Standard precautions apply to?
Blood
Non-intact skin
Mucous membrance
All body fluids except sweat
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| Diseases under transmission based precautions are? | Diseases under transmission based precautions are?
Measles
Chickenpox (varicella)
Disseminated varicella zoster
T.B.
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| Droplet precautions diseases are? | Droplet precautions diseases are?
Adenovirus, Influenza
Sepsis, Scarlet Fever
Epiglottitis, Mumps
Meningitis
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| Barrier protection for transmission based droplet precautions is? | Barrier protection for transmission based droplet precautions is?
Placing client in private room or cohort client
Mask
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| Transmission based contact precautions diseases are? | Transmission based contact precautions diseases are?
Clostridium Difficle
INFxN with multidrug resistant org.
Wound infections
Cutaneous diptheria
Herpes simplex
Impetigo
Pediculosis
Scabies
Staphylococcus
Varicella Zoster
Conjunctivitis
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| Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that turn into? | Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that turn into?
Pustular vessicles in the face & extremities
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| In case of fire, a nurse should R- A- C- E- | In case of fire, a nurse should
R-rescue
A-alarm
C-confine
E-extinguish
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| Head tilt-chin lift is used in B.L.S. but if pt. has a neck injury, what do you use? | Head tilt-chin lift is used in B.L.S. but if pt. has a neck injury, what do you use?
Jaw thrust maneuver
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| A.B.C.D.'s of B.L.S. are: | A.B.C.D.'s of B.L.S. are:
Airway
Breathing
Circulation
Defibrilation or Definitive Treatment
Each step begins with ASSESSMENT always
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| Apical & radial pulse will always yield? | Apical & radial pulse will always yield?
Identical result
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| In assessing for a pulse to an infant < 1 yr old? a child > 1 yr old? | In assessing for a pulse to an
infant < 1 yr old?
a child > 1 yr old?
Brachial (<1yr)
Carotid (>1yr)
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| For infants on B.L.S., chest compression is 1/2 - 1 inch deep @ least 100 times/min using? | For infants on B.L.S., chest compression is 1/2 - 1 inch deep @ least 100 times/min using?
2-3 fingers
Child 1-1.5 inches deep
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| When performing a Heimlich Maneuver to an obese or pregnant, what do you do? | When performing a Heimlich Maneuver to an obese or pregnant, what do you do?
Chest thrusts
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| For unconscious adult (B.L.S.), you do a? | For unconscious adult (B.L.S.), you do a?
Tongue jaw lift
Fingersweep object
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| For unconscious pregnant, a pillow or rolled blanket is placed on the right side to? | For unconscious pregnant, a pillow or rolled blanket is placed on the right side to?
Displace uterus to the left of the abdomen
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| Unconscious pregnant needing defibrilation should have the paddles placed 1-rib higher than the usual because? | Unconscious pregnant needing defibrilation should have the paddles placed 1-rib higher than the usual because?
Heart is displaced during pregnancy
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| This is used to convert ventricular fibrilation into a perfusing rhythm? | This is used to convert ventricular fibrilation into a perfusing rhythm?
Automated External Defibrillator
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| Automated External Defibrilator is C/I to? | Automated External Defibrilator is C/I to?
< 8 yrs old
Child weighing < 25 kgs.
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| A surgeon is responsible for getting consent & a nurse can be a witness provided the pt. understood the procedures explained by the doctor. What is the next step? | A surgeon is responsible for getting consent & a nurse can be a witness provided the pt. understood the procedures explained by the doctor. What is the next step?
Document the witnessing of consent signing
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| In general anesthesia, solid & liquid foods are withheld for? | In general anesthesia, solid & liquid foods are withheld for?
6-8 hrs. prior
Local anesthesia - 3 hrs. prior
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| When is enema or laxative performed in clients for surgery? | When is enema or laxative performed in clients for surgery?
The night prior surgery
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| If client has a Foley catheter before surgery, it should be emptied & document the? | If client has a Foley catheter before surgery, it should be emptied & document the?
Amount & characteristics of the urine
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| 3 levels of moral development (premoral or preconventional level, conventional level, postconventional level). Â | 3 levels of moral development (premoral or preconventional level, conventional level, postconventional level).
Lawrence Kohlberg Â
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| 4 conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity). Â | 4 conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity).
Myra Levine Â
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| 4 types of personality (sanguine, melancholic, phlegmatic, choleric). Â | 4 types of personality (sanguine, melancholic, phlegmatic, choleric).
Galen Â
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| 5 hierarchy of needs (physiological, safety & security, love & belonging, self esteem, self actualization). Â | 5 hierarchy of needs (physiological, safety & security, love & belonging, self esteem, self actualization).
Abraham Maslow Â
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| Adaptation model. Each person is a unified biopsychosocial system in constant interaction with changing environment. Â | Adaptation model. Each person is a unified biopsychosocial system in constant interaction with changing environment.
Sister Calista Roy Â
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| All behavior is learned. Â | All behavior is learned.
B.F. Skinner Â
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| Believed that nurse helps patients meet a perceived need that the patient cannot meet themselves. Â | Believed that nurse helps patients meet a perceived need that the patient cannot meet themselves.
Ida Jean Orlando Â
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| Birth trauma. Â | Birth trauma.
Otto Rank Â
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| Care, Core, Cure. | Care, Core, Cure.
Lydia Hall Â
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| Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal operations). Â | Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal operations).
Jean Piaget Â
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| Conceptualized the behavioral system model. Each person is composed of 7 subsystem (ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual). Â | Conceptualized the behavioral system model. Each person is composed of 7 subsystem (ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual).
Dorothy Johnson Â
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| Developed self-care and self-care deficit theory. Â | Developed self-care and self-care deficit theory.
Dorothea Orem Â
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| Developmental task. Â | Developmental task.
Robert Havighurst Â
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| Focused on manipulating the environment for the patient's recovery. Â | Focused on manipulating the environment for the patient's recovery.
Florence Nithingale Â
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| Founded psychobiology. Believes in totality of man/holistic approach. Â | Founded psychobiology. Believes in totality of man/holistic approach.
Adolf Meyer Â
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| Goal attainment theory. Nursing as a helping profession. Â | Goal attainment theory. Nursing as a helping profession.
Imogene King Â
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| Health as expanding consciousness. Humans are unitary beings in whom disease is a manifestation of the pattern of health. Â | Health as expanding consciousness. Humans are unitary beings in whom disease is a manifestation of the pattern of health.
Margaret Newman Â
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| Health care system model. Nursing is concerned with all the variables affecting an individual's response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature. Â | Health care system model. Nursing is concerned with all the variables affecting an individual's response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature.
Betty Neuman Â
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| Human becoming. Emphasized free choice of personal meaning in relating value priorities. Â | Human becoming. Emphasized free choice of personal meaning in relating value priorities.
Rosemarie Rizzo Parse Â
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| Human caring model. Nursing is the application of the art and human science through transpersonal caring. Â | Human caring model. Nursing is the application of the art and human science through transpersonal caring.
Jean Watson Â
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| Humanistic nursing practice theory. Nursing is an existential experience. Â | Humanistic nursing practice theory. Nursing is an existential experience.
Josephine Paterson & Loreta Zderad Â
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| Identified 14 basic needs. Nurse functions to assist client in performing activities contributing to health, recovery, or peaceful death. Â | Identified 14 basic needs. Nurse functions to assist client in performing activities contributing to health, recovery, or peaceful death.
Virginia Henderson Â
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| Identified 21 nursing problems. Defined nursing as service to individuals and families, therefore, society. Â | Identified 21 nursing problems. Defined nursing as service to individuals and families, therefore, society.
Faye Abdellah Â
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| Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between sick and nurse. Â | Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between sick and nurse.
Hildegard Peplau Â
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| Interpersonal theory (anxiety occurs due to poor interpersonal relationship). Â | Interpersonal theory (anxiety occurs due to poor interpersonal relationship).
Harry Stack Sullivan Â
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| Introversion and extroversion - persona/anima  | Introversion and extroversion - persona/anima
Carl Jung Â
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| Modeling and role-modeling theory. Â | Modeling and role-modeling theory.
Helen Erickson, Evelyn Tomlin & Mary Ann Swain Â
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| Nurse's individual philosophy lends credence to nursing care. Â | Nurse's individual philosophy lends credence to nursing care.
Ernestine Weidenbach Â
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| Presented grand theory of nursing. All persons are caring and nursing is a response to unique social call. Â | Presented grand theory of nursing. All persons are caring and nursing is a response to unique social call.
Anne Boykin & Savina Schoenhofer Â
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| Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido is the psychic reservoir of psychic energy, id, ego, & superego). Â | Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido is the psychic reservoir of psychic energy, id, ego, & superego).
Sigmund Freud Â
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| Psychosocial development (trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, integrity vs. despair). Â | Psychosocial development (trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, integrity vs. despair).
Erik Erickson Â
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| Superinferiority and inferiority complex / birth order. Â | Superinferiority and inferiority complex / birth order.
Alfred Adler Â
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| The science of unitary human beings. Human beings are more than and different from the sum of their parts. Â | The science of unitary human beings. Human beings are more than and different from the sum of their parts.
Martha Rogers Â
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| Theory based on bodily characteristics (endomorphic, mesomorphic, ectomorphic). Â | Theory based on bodily characteristics (endomorphic, mesomorphic, ectomorphic).
William Sheldon Â
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| Transcultural nursing. Nursing is a humanistic and scientific mode of helping a client through specific cultural caring process. Â | Transcultural nursing. Nursing is a humanistic and scientific mode of helping a client through specific cultural caring process.
Madeleine Leininger Â
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| Pulsating abdominal mass | Pulsating abdominal mass
Abdominal Aortic Aneurism Â
🗑
|
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| Painful board-like abdomen | Painful board-like abdomen
Abruptio Placenta Â
🗑
|
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| Uremic frost on skin  | Uremic frost on skin
Acute Renal Failure Â
🗑
|
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| Bronze pigmentation of skin  | Bronze pigmentation of skin
Addison's Disease Â
🗑
|
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| Outburst laughter or cry fasciculations  | Outburst laughter or cry fasciculations
Amyotrophic Lateral Sclerosis (ALS) Â
🗑
|
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| Pain upon exertion  | Pain upon exertion
Angina Pectoris Â
🗑
|
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| Mc Burney's sign  | Mc Burney's sign
Appendicitis Â
🗑
|
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| Boutonnier deformity, swan neck deformity, ulnar drift, Bouchard's nodes  | Boutonnier deformity, swan neck deformity, ulnar drift, Bouchard's nodes
Arthritis Â
🗑
|
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| Murmur heard high on chest  | Murmur heard high on chest
Atrial Septal Defect Â
🗑
|
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| Rocking, spinning, routines  | Rocking, spinning, routines
Autism Â
🗑
|
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| Grayish white discharge, malodorous  | Grayish white discharge, malodorous
Bacterial Vaginosis Â
🗑
|
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| Raccoon's eye  | Raccoon's eye
Basilar Fracture Â
🗑
|
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| Meconium staining  | Meconium staining
Breech Birth Â
🗑
|
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| Russel's sign, binge eating  | Russel's sign, binge eating
Bulimia Nervosa Â
🗑
|
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| Cherry pink flushed face  | Cherry pink flushed face
Carbon Monoxide Poisoning Â
🗑
|
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| Jack hammer syndrome  | Jack hammer syndrome
Carpal Tunnel Syndrome Â
🗑
|
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| Cloudy vision  | Cloudy vision
Cataract Â
🗑
|
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| Gluten sensitivity, water, pale, foul smelling stool  | Gluten sensitivity, water, pale, foul smelling stool
Celiac Disease Â
🗑
|
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| Maculopapulovesiculo rash  | Maculopapulovesiculo rash
Chicken Pox Â
🗑
|
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| Rice water stools  | Rice water stools
Cholera Â
🗑
|
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| Pulling up of arms & legs, red-face crying  | Pulling up of arms & legs, red-face crying
Colic Â
🗑
|
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| Barrel chest, clubbing of fingers  | Barrel chest, clubbing of fingers
C.O.P.D. Â
🗑
|
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| Moon face, buffalo hump  | Moon face, buffalo hump
Cushing's Syndrome Â
🗑
|
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| Homonymous hemianopsia  | Homonymous hemianopsia
CVA Â
🗑
|
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| Feeling of fullness at vagina  | Feeling of fullness at vagina
Cystocele & Rectocele Â
🗑
|
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| Recent and past memory defect  | Recent and past memory defect
Delirium Â
🗑
|
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| Recall or learning memory impairment  | Recall or learning memory impairment
Dementia Â
🗑
|
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| Flashes of light, vein in line of sight | Flashes of light, vein in line of sight
Detached Retina Â
🗑
|
||||
| 3 P's: polydipsia, polyphagia, polyuria  | 3 P's: polydipsia, polyphagia, polyuria
Diabetes Mellitus Â
🗑
|
||||
| Pseudomembrane  | Pseudomembrane
Diptheria Â
🗑
|
||||
| Cramping, colicky pain in left lower abdominal quadrant  | Cramping, colicky pain in left lower abdominal quadrant
Diverticular Disease Â
🗑
|
||||
| Saddle nose, Brushfield's spot's (Trisonomy 21) Â | Saddle nose, Brushfield's spot's (Trisonomy 21)
Down Syndrome Â
🗑
|
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| Ortolani's sign, Galeazzi's sign, asymmetry of gluteal, popliteal & thigh folds  | Ortolani's sign, Galeazzi's sign, asymmetry of gluteal, popliteal & thigh folds
Dysplasia of Hip Â
🗑
|
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| Cullen's sign  | Cullen's sign
Ectopic Pregnancy Â
🗑
|
||||
| Premenstrual pain decreasing as menstrual flow decreases  | Premenstrual pain decreasing as menstrual flow decreases
Endometriosis Â
🗑
|
||||
| Exposed bladder, appears to be turned inside out  | Exposed bladder, appears to be turned inside out
Exstrophy of Bladder Â
🗑
|
||||
| Radar gaze  | Radar gaze
Failure to Thrive (FTT) Â
🗑
|
||||
| Barret esophagus  | Barret esophagus
G.E.R.D. Â
🗑
|
||||
| Halos around light | Halos around light
Glaucoma Â
🗑
|
||||
| Dysuria, genital discharge  | Dysuria, genital discharge
Gonorrhea Â
🗑
|
||||
| Exopthalmia  | Exopthalmia
Grave's Disease Â
🗑
|
||||
| Hemarthrosis  | Hemarthrosis
Hemophilia Â
🗑
|
||||
| Asterixis  | Asterixis
Hepatic Disease Â
🗑
|
||||
| Ribbon-like, foul smelling stool  | Ribbon-like, foul smelling stool
Hirschprung's Disease (megacolon) Â
🗑
|
||||
| Grapelike growth, large abdomen  | Grapelike growth, large abdomen
H-mole Â
🗑
|
||||
| Bossing's sign, setting sun eyes  | Bossing's sign, setting sun eyes
Hydrocephalus Â
🗑
|
||||
| Trousseau's sign  | Trousseau's sign
Hypocalcemia Â
🗑
|
||||
| High pitch cry  | High pitch cry
Increased Intracranial Pressure (ICP) Â
🗑
|
||||
| Doll's eye  | Doll's eye
Increased Intraoccular Pressure Â
🗑
|
||||
| No passage of meconium  | No passage of meconium
Intestinal Obstruction Â
🗑
|
||||
| Dance sign, currant jelly-like stool, sausage like  | Dance sign, currant jelly-like stool, sausage like
Intussesception Â
🗑
|
||||
| Activity intolerance  | Activity intolerance
Iron Deficiency Anemia (IDA) Â
🗑
|
||||
| Strawberry tongue  | Strawberry tongue
Kawasaki Â
🗑
|
||||
| Red gelatinous sputum  | Red gelatinous sputum
Kleibsella Pneumonia Â
🗑
|
||||
| XXY in males  | XXY in males
Klinefelter's Syndrome Â
🗑
|
||||
| Pulmonary manifestations (i.e. orthopnea, crackles, cyanosis, etc.) Â | Pulmonary manifestations (i.e. orthopnea, crackles, cyanosis, etc.)
Left Ventricular Heart Failure Â
🗑
|
||||
| Less than 2.5 kgs or 5 1/2 lbs  | Less than 2.5 kgs or 5 1/2 lbs
Low Birth Weight Â
🗑
|
||||
| Red-ringed circular rash (erythema chronicum migrans) Â | Red-ringed circular rash (erythema chronicum migrans)
Lyme Disease Â
🗑
|
||||
| Blackwater fever  | Blackwater fever
Malaria Â
🗑
|
||||
| Whirling, vertigo, tinnitus  | Whirling, vertigo, tinnitus
Meniere's Disease Â
🗑
|
||||
| Kernig's sign, Brudzinki's sign  | Kernig's sign, Brudzinki's sign
Meningitis Â
🗑
|
||||
| White "cheesy" discharge  | White "cheesy" discharge
Moniliasis Â
🗑
|
||||
| Gower's sign  | Gower's sign
Muscular Dystrophy Â
🗑
|
||||
| Charcot's triad: intention tremor, nystagmus, scanning speech (clipped) Â | Charcot's triad: intention tremor, nystagmus, scanning speech (clipped)
Multiple Sclerosis Â
🗑
|
||||
| Nasal smile | Nasal smile
Myasthenia Gravis Â
🗑
|
||||
| Nonproductive that progresses to mucoid sputum  | Nonproductive that progresses to mucoid sputum
Mycoplasmal Pneumonia Â
🗑
|
||||
| Viselike or crushing pain radiating to shoulder, arms, jaw or back  | Viselike or crushing pain radiating to shoulder, arms, jaw or back
Myocardial Infarction Â
🗑
|
||||
| Purulent conjunctivitis (N. Gonorrhea) Â | Purulent conjunctivitis (N. Gonorrhea)
Opthalmia Neonatorum Â
🗑
|
||||
| White patches on tongue (Candida Albicans) Â | White patches on tongue (Candida Albicans)
Oral Thrush Â
🗑
|
||||
| Kyphosis  | Kyphosis
Osteoporosis Â
🗑
|
||||
| Ringing or buzzing  | Ringing or buzzing
Otosclerosis Â
🗑
|
||||
| Steatorrhea  | Steatorrhea
Pancreatitis Â
🗑
|
||||
| Machinery-type murmur throughout the heartbeat in the left 2nd or 3rd interspace  | Machinery-type murmur throughout the heartbeat in the left 2nd or 3rd interspace
Patent Ductus Arteriosus Â
🗑
|
||||
| Pill rolling | Pill rolling
Parkinson's Disease Â
🗑
|
||||
| Abdominal muscle rigidity with rebound tenderness  | Abdominal muscle rigidity with rebound tenderness
Peritonitis Â
🗑
|
||||
| Beefy red tongue  | Beefy red tongue
Pernicious Anemia Â
🗑
|
||||
| Paroxysmal cough ending with a whoop  | Paroxysmal cough ending with a whoop
Pertussis Â
🗑
|
||||
| Nikolsky sign  | Nikolsky sign
Phemphigus Vulgaris Â
🗑
|
||||
| Fever, vaginal discharge, lower abdominal cramping  | Fever, vaginal discharge, lower abdominal cramping
Pelvic Inflammatory Disease (PID) Â
🗑
|
||||
| What is the purpose of IV fluid therapy? Â | What is the purpose of IV fluid therapy?
Maintenance, to replace or correct deficits, to restore ongoing loss, for meds, nutrition, phlebotomy, transfusions or blood product therapy. Â
🗑
|
||||
| What is oncotic pressure? Â | What is oncotic pressure?
Colloids, plasma proteins, albumin Â
🗑
|
||||
| What is hydrostatic pressure? | What is hydrostatic pressure?
Blood pressure Â
🗑
|
||||
| What is normal serum osmo? Â | What is normal serum osmo?
280 - 295 or approx. twice that of the serum Na level. Â
🗑
|
||||
| What can expand the intravascular compartment? Â | What can expand the intravascular compartment?
Hypertonic fluids. Â
🗑
|
||||
| What is the problem with using hypertonic fluids? Â | What is the problem with using hypertonic fluids?
If done too fast will draw too much fluid into the intravascular, dehydrating intracellular, especially the brain? Â
🗑
|
||||
| What is a S/sx of fluids administered too fast? Â | What is a S/sx of fluids administered too fast?
decreased LOC / Confusion. Â
🗑
|
||||
| What happens if you expand the intra Cellular compartment too fast? Â | What happens if you expand the intra Cellular compartment too fast?
Deplete the intravascular, decreasing BP and causing edema. Â
🗑
|
||||
| What are the two basic types of parenteral fluids? Â | What are the two basic types of parenteral fluids?
Crystalloid and Colloid Â
🗑
|
||||
| What is a crystalloid fluid? Â | What is a crystalloid fluid?
An Electrolyte containing solution. Â
🗑
|
||||
| What are the three basic types of crystalloid fluids? Â | What are the three basic types of crystalloid fluids?
Isotonic, Hypotonic and Hypertonic Â
🗑
|
||||
| Why are crystalloid fluids called true solutions? Â | Why are crystalloid fluids called true solutions?
Because they can pass through semipermeable membranes. Â
🗑
|
||||
| What is a Colloid fluid? Â | What is a Colloid fluid?
Contains proteins and starches. Â
🗑
|
||||
| What can't a Colloid fluid do? Â | What can't a Colloid fluid do?
Pass between compartments. They draw the fluid to them. Â
🗑
|
||||
| Name three problems with IV fluid therapy. Â | Name three problems with IV fluid therapy.
Phlebitis, extravasation and incompatabilities. Â
🗑
|
||||
| What three things can an LVN NOT do? Â | What three things can an LVN NOT do?
cannot hang, flush or change bags on a central line even if certified. Â
🗑
|
||||
| What can an RN NOT do with a central line. Â | What can an RN NOT do with a central line.
Cannot assign to LVN or supervise LVN with anything to do with a central line. Â
🗑
|
||||
| How do you determine whether it is a central line or a peripheral line? Â | How do you determine whether it is a central line or a peripheral line?
Ask the doctor for an x ray order to determine. Â
🗑
|
||||
| Name some isotonic fluids  | Name some isotonic fluids
D5W, LR and NS Â
🗑
|
||||
| Why do you need to be careful with LR and dehydration? Â | Why do you need to be careful with LR and dehydration?
It is hard for the renal system to process the electrolytes. Â
🗑
|
||||
| What does the liver do to lactate? (LR) Â | What does the liver do to lactate? (LR)
It metabolizes the lactate to bi-carbonate which buffers acidosis Â
🗑
|
||||
| What are two common uses for Normal Saline (NS)? Â | What are two common uses for Normal Saline (NS)?
To treat hyponatremia and intravascular dehydration. Â
🗑
|
||||
| Name a Hypotonic solution? Â | Name a Hypotonic solution?
0.45 NS ( 1/2 NS) Â
🗑
|
||||
| What is a problem with Hypotonic solutions? Â | What is a problem with Hypotonic solutions?
Use too long and it will lower BP. It is low in solutes so fluid will move out of the vascular space. Â
🗑
|
||||
| What makes Hyper tonic fluids different than the others? Â | What makes Hyper tonic fluids different than the others?
It has more dissolved particles than body fluid. Â
🗑
|
||||
| What does a hypertonic fluid do? Â | What does a hypertonic fluid do?
It moves fluid out of the intracellular and interstitial compartments into the intravascular. Â
🗑
|
||||
| What are hypertonic fluids used for? Â | What are hypertonic fluids used for?
Hydration and nutrition Â
🗑
|
||||
| What is dangerous about hypertonic dextrose saline solutions? Â | What is dangerous about hypertonic dextrose saline solutions?
they can move fluids very quickly. Â
🗑
|
||||
| What is a hypertonic dextrose saline fluid solution used for? Â | What is a hypertonic dextrose saline fluid solution used for?
TPN and PPN. Nutrition. Â
🗑
|
||||
| What type IV line do you use with Hypertonic dextrose saline? Â | What type IV line do you use with Hypertonic dextrose saline?
10% solutions can go peripheral but all others 20% and above must use a central line? Â
🗑
|
||||
| Why must most hypertonic dextrose saline solutions be used with a central line? Â | Why must most hypertonic dextrose saline solutions be used with a central line?
Because the fluids are very irritating to veins. Â
🗑
|
||||
| How do you infuse hypertonic dextrose saline solutions? Â | How do you infuse hypertonic dextrose saline solutions?
You must use an infusion pump. Â
🗑
|
||||
| Plasma expanders are not considered what? Â | Plasma expanders are not considered what?
Blood products. Â
🗑
|
||||
| What do you NOT have to do with plasma expanders? Â | What do you NOT have to do with plasma expanders?
Type and cross match. Â
🗑
|
||||
| Which of the two main categories of fluids do plasma expanders fall into? Â | Which of the two main categories of fluids do plasma expanders fall into?
Colloid. Â
🗑
|
||||
| What are Colloids used for? Â | What are Colloids used for?
Maintenance of blood volume, hypovolemic shock, dialysis. Â
🗑
|
||||
| In which patients do you need to use colloid product with cautiously? Â | In which patients do you need to use colloid product with cautiously?
renal insufficiency and CHF Â
🗑
|
||||
| PPN is used in what type of line? Â | PPN is used in what type of line?
Peripheral Â
🗑
|
||||
| TPN is used in what type of line? Â | TPN is used in what type of line?
Central Â
🗑
|
||||
| What are the components of TPN? Â | What are the components of TPN?
H2O, PRO, CHO, fat, vitamins, trace minerals. Â
🗑
|
||||
| TPN usually come in a _____hour supply. Â | TPN usually come in a _____hour supply.
24 hour supply Â
🗑
|
||||
| Name some indications for TPN. Â | Name some indications for TPN.
Non-function GI, Bowel obstruct., acute inflam, colitis, Crohns, malabsorption, chemo, burns, sepsis, ooncology, pancreatitis. Â
🗑
|
||||
| How do you know TPN is working? | How do you know TPN is working?
By weighing daily. Â
🗑
|
||||
| What is the consideration with IVs and glucose? Â | What is the consideration with IVs and glucose?
Must use the appropriate IV access for concentration of glucose, must use pump, don't play catch up, taper TPN, accu-checks, used micron filters Â
🗑
|
||||
| What should you monitor with TPN? Â | What should you monitor with TPN?
I & O, weight, liver and renal function and electrolytes. Â
🗑
|
||||
| Why do you monitor liver and renal function with TPN? Â | Why do you monitor liver and renal function with TPN?
To make sure that they are excreting electrolytes. Â
🗑
|
||||
| Why do you use a micron filter with TPN? Â | Why do you use a micron filter with TPN?
to filter out bacterial growth. Â
🗑
|
||||
| Why do you taper TPN? Â | Why do you taper TPN?
To avoid hypoglycemic shock from cutting of the sugar. Â
🗑
|
||||
| Can you run other things in the TPN IV tubing? Â | Can you run other things in the TPN IV tubing?
No, don't mix with anything else. Â
🗑
|
||||
| What is an important consideration with albumin? | What is an important consideration with albumin?
May cause anaphylaxis Â
🗑
|
||||
| What are some potential complications with TPN? Â |
What are some potential complications with TPN?
Fluid imbalances, metabolic acidosis, liver dysfunction, hyperglycemia and infection. Â
🗑
|
||||
| Nursing process  | Nursing process
systematic, rational method of nursing care Â
🗑
|
||||
| Decision making process  | Decision making process
identify purpose, set criteria, weigh criteria, seek alternatives, examine alternatives, project, implement, evaluate Â
🗑
|
||||
| Assessing  | Assessing
collect, organize, validate,document data Â
🗑
|
||||
| Diagnosing  | Diagnosing
analyze data, identify risks & strengths, formulate diagnostic statements Â
🗑
|
||||
| Planning  | Planning
Prioritize,formulate goals and outcomes,select interventions, write orders Â
🗑
|
||||
| Implementing  | Implementing
reassess,implement interventions,delegate,document Â
🗑
|
||||
| Evaluating  | Evaluating
compare data to outcomes, draw conclusions, modify care plan Â
🗑
|
||||
| subjective data  | subjective data
symptoms only the pt. can verify Â
🗑
|
||||
| objective data  | objective data
signs detectable to observer Â
🗑
|
||||
| directive interview  | directive interview
highly structured, elicits specific info Â
🗑
|
||||
| Non directive interview  | Non directive interview
rapport building interview Â
🗑
|
||||
| Cephalo caudal approach  | Cephalo caudal approach
head to toe approach Â
🗑
|
||||
| Maslow's Theory  | Maslow's Theory
hierarchy of needs Â
🗑
|
||||
| validation  | validation
double checking data to confirm accuracy Â
🗑
|
||||
| cues  | cues
what pt. says or nurse sees Â
🗑
|
||||
| inferences  | inferences
nurses interpretation Â
🗑
|
||||
| diagnosis  | diagnosis
statement regarding the nature of problem Â
🗑
|
||||
| risk factors diagnosis  | risk factors diagnosis
indicates a problem that could develop Â
🗑
|
||||
| wellness diagnosis  | wellness diagnosis
readiness for enhancement of wellness Â
🗑
|
||||
| possible diagnosis  | possible diagnosis
evidence is incomplete Â
🗑
|
||||
| syndrome diagnosis  | syndrome diagnosis
associated with a cluster of other diagnoses Â
🗑
|
||||
| diagnostic 3 part statement | diagnostic 3 part statement
PES Â
🗑
|
||||
| Problem  | Problem
statement of clients response Â
🗑
|
||||
| Etiology  | Etiology
factors contributing to probable cause of response Â
🗑
|
||||
| Signs and Symptoms  | Signs and Symptoms
defining characteristics manifested by pt. Â
🗑
|
||||
| nursing intervention  | nursing intervention
any treatment based on clinical judgment that a nurse performs Â
🗑
|
||||
| formal care plan  | formal care plan
written or computerized guide Â
🗑
|
||||
| informal care plan  | informal care plan
strategy that exists in the nurses mind Â
🗑
|
||||
| standardized care plan  | standardized care plan
formal plan for all individuals with same etiology Â
🗑
|
||||
| individualized care plan  | individualized care plan
tailored for specific pt. Â
🗑
|
||||
| Nursing Care Classification (NOC) standardized nursing language indicator  | Nursing Care Classification (NOC) standardized nursing language indicator
concrete observable state of behavior Â
🗑
|
||||
| Using Silence  | Using Silence
Accepting pauses or silences that may last several seconds or minutes without any verbal response. Â
🗑
|
||||
| Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts and fments or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and feelings into words  | Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts and fments or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and feelings into words
Using Silence (example)
🗑
|
||||
| Providing general leads  | Providing general leads
Using statements or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and facilitate continued verbalization. Â
🗑
|
||||
| "Perhaps you would like to talk about..." ; "would it help to discuss your feelings?"; "and then...."; "I know what you are saying" Â | "Perhaps you would like to talk about..." ; "would it help to discuss your feelings?"; "and then...."; "I know what you are saying"
Providing General leads (example) Â
🗑
|
||||
| Using specific and tentative  | Using specific and tentative
making statements that are specific rather than general, tentative rather than absolute Â
🗑
|
||||
| "You scratched my arm" instead of "you are clumsy as an ox" OR "you seem concerned about mary" rather than "you don't care about mary" Â | "You scratched my arm" instead of "you are clumsy as an ox" OR "you seem concerned about mary" rather than "you don't care about mary"
Specific & Tentative (examples) Â
🗑
|
||||
| Open-ended question  | Open-ended question
ASKING BROAD QUESTIONS that lead or invite the client to explore, elaborate, clarify, define, and describe thoughts or feelings. Client's answers are longer than 1 or 2 words Â
🗑
|
||||
| "I'd like to hear more about that"; "What brought you to the hospital today?"; "you said you were frightened yesterday, how are you feeling today?" Â | "I'd like to hear more about that"; "What brought you to the hospital today?"; "you said you were frightened yesterday, how are you feeling today?"
Open-ended question (example) Â
🗑
|
||||
| Using Touch  | Using Touch
Providing appropriate forms of touch to reinforce caring feelings. Â
🗑
|
||||
| Putting arm over client's shoulder OR placing hand over client's hand  | Putting arm over client's shoulder OR placing hand over client's hand
Using touch (example) Â
🗑
|
||||
| Restating  | Restating
using the same words as the client Â
🗑
|
||||
| Client: "I couldn't manage to eat any dinner last night- not even dessert" Nursing- "you couldn't manage to eat any dinner last night- not even dessert?" Â | Client: "I couldn't manage to eat any dinner last night- not even dessert" Nursing- "you couldn't manage to eat any dinner last night- not even dessert?"
Restating (example) Â
🗑
|
||||
| Paraphrasing  | Paraphrasing
Restating in different form with implied feeling or observation Â
🗑
|
||||
| Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you don't know" Â | Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you don't know"
Paraphrasing (example) Â
🗑
|
||||
| Seeking clarification  | Seeking clarification
Making the clients overall meaning of the msg understandable. It is used when paraphrasing is difficult or when communication is rambling or garbled. To clarify, the RN may restate the msg or confess confusion & ask PT to repeat
🗑
|
||||
| Nurse: "I'm puzzled" Nurse: "I'm not sure what you mean by ___ Would you please repeat that again?" Â | Nurse: "I'm puzzled" Nurse: "I'm not sure what you mean by ___ Would you please repeat that again?"
Seeking Clarification (example) Â
🗑
|
||||
| Perception Checking/ Consensual Validation  | Perception Checking/ Consensual Validation
A method similar to clarifying that verifies the meaning of specific words rather than the overall message Â
🗑
|
||||
| C: "it just won't stop" N: "I'm not sure what you mean - it won't stop" OR C: "my husband never gives me presents" N: "He never gives you gifts for your birthday or christmas?" |
C: "it just won't stop" N: "I'm not sure what you mean - it won't stop" OR C: "my husband never gives me presents" N: "He never gives you gifts for your birthday or christmas?"
Perception Checking/ Consensual Validation (example) Â
🗑
|
||||
| Offering Self  | Offering Self
Suggesting ones' presence, interest, or wish to understand the client without making any depands or attaching conditions that the client must comply with to receive nurse's attention Â
🗑
|
||||
| "I'll stay with you till your daughter arrives"; "we can sit here quietly for awhile, we don't need to talk unless you would like to" Â | "I'll stay with you till your daughter arrives"; "we can sit here quietly for awhile, we don't need to talk unless you would like to"
Offering Self (example) Â
🗑
|
||||
| Giving Information  | Giving Information
Providing, in simple and direct manner, specific factual information the client may or may not request. When information is not known, the nurse states this and indicates how the nurse will obtain the information. Â
🗑
|
||||
| "Your surgery is scheduled for 11am tomorrow"; I don't know the answer to that, but I'll find out from the unit manager, when she comes in" Â | "Your surgery is scheduled for 11am tomorrow"; I don't know the answer to that, but I'll find out from the unit manager, when she comes in"
Giving information (example) Â
🗑
|
||||
| Acknowledging  | Acknowledging
Giving recognition, in non judgmental way, of change in behavior. Â
🗑
|
||||
| "You trimmed your beard and mustache" OR "you walked twice as far today with your walker" Â | "You trimmed your beard and mustache" OR "you walked twice as far today with your walker"
Acknowledging (example) Â
🗑
|
||||
| Clarifying time or sequence  | Clarifying time or sequence
Helping the client clarify and event, situation, or happening in relationship to time Â
🗑
|
||||
| C: "I puked this morning" N: "before or after breakfast?" Â | C: "I puked this morning" N: "before or after breakfast?"
Clarifying time or sequence(example) Â
🗑
|
||||
| It is a style or process of persuading a group of people, usually his followers to attain a desired objective. Â | It is a style or process of persuading a group of people, usually his followers to attain a desired objective.
Leadership Â
🗑
|
||||
| A leader that is chosen by the administration or a group which are given the official capacity to act. Â | A leader that is chosen by the administration or a group which are given the official capacity to act.
Formal / appointed / elected / designated Â
🗑
|
||||
| A leader that does not have official appointments or designations but is usually chosen by the group itself. Â | A leader that does not have official appointments or designations but is usually chosen by the group itself.
Informal Â
🗑
|
||||
| It states that leaders are born and not developed because some people are born with characteristics to be great. Â | It states that leaders are born and not developed because some people are born with characteristics to be great.
Great Man Theory Â
🗑
|
||||
| A person can be an effective leader if he has all the intellectual, emotional, physical and other personal traits of an effective leader. Â | A person can be an effective leader if he has all the intellectual, emotional, physical and other personal traits of an effective leader.
Trait Theory Â
🗑
|
||||
| He is a leader who makes other people feel better in his/her presence which is an inspirational quality that the leader possessed. Â | He is a leader who makes other people feel better in his/her presence which is an inspirational quality that the leader possessed.
Charismatic Theory Â
🗑
|
||||
| It states that there is no personality, traits to be a good leader, but rather leadership is the relationship that exists among people in a social situation. Â | It states that there is no personality, traits to be a good leader, but rather leadership is the relationship that exists among people in a social situation.
Situational Theory Â
🗑
|
||||
| A leader that can immediately resolve a sudden crisis, emergency or critical situation. Â | A leader that can immediately resolve a sudden crisis, emergency or critical situation.
Contingency Theory Â
🗑
|
||||
| A leader that knows how to determine the maturity of his followers. Â | A leader that knows how to determine the maturity of his followers.
Life-Cycle Theory Â
🗑
|
||||
| A leader who uses a support system method. Â | A leader who uses a support system method.
Path Goal Theory Â
🗑
|
||||
| A style where the leader makes all the decisions and disallows his members to influence him. Followers dislike this leader and leader has little trust to his members. His aim is to develop Self. Uses trial & error and a critic. Â | A style where the leader makes all the decisions and disallows his members to influence him. Followers dislike this leader and leader has little trust to his members. His aim is to develop Self. Uses trial & error and a critic.
Authoritarian Â
🗑
|
||||
| A leadership style where it is loose and permissive. His approach is "Do your own thing". His reference is "You" and has the desire to develop only "Friendship". Â | A leadership style where it is loose and permissive. His approach is "Do your own thing". His reference is "You" and has the desire to develop only "Friendship".
Laissez-Faire Â
🗑
|
||||
| A leader whose authority is from the group. Gives importance to participation, involvement and development of the group. He is a helper and uses "We" as his reference of leadership. Â | A leader whose authority is from the group. Gives importance to participation, involvement and development of the group. He is a helper and uses "We" as his reference of leadership.
Democratic Â
🗑
|
||||
| A leadership style that uses repetition and tries to develop the system as his objective. His reference is "they" and acts as a ruler and a regulator type of leader. Â | A leadership style that uses repetition and tries to develop the system as his objective. His reference is "they" and acts as a ruler and a regulator type of leader.
Bureaucratic Â
🗑
|
||||
| A power whereby the leader has the official capacity to exercise rights and demand obligations from subordinates. Â | A power whereby the leader has the official capacity to exercise rights and demand obligations from subordinates.
Legitimate Powers Â
🗑
|
||||
| I - olfactory (sensory) | I - olfactory (sensory)
sense of smell Â
🗑
|
||||
| II - optic  (sensory) | II - optic (sensory)
visual acuity Â
🗑
|
||||
| III - oculomotor  (motor) | III - oculomotor (motor)
extraocular eye movement, pupil
constriction and dilation Â
🗑
|
||||
| IV - trochlear  (motor) | IV - trochlear (motor)
upward/downward movement of eyeball Â
🗑
|
||||
| V - trigeminal  (sensory/motor) | V - trigeminal (sensory/motor)
sensory nerve to skin of face, motor
nerve to muscles of jaw Â
🗑
|
||||
| VI - abducens (motor) | VI - abducens (motor)
lateral movement of eyeballs Â
🗑
|
||||
| VII - facial  (sensory/motor) | VII - facial (sensory/motor)
facial expression, taste Â
🗑
|
||||
| VIII - auditory  (sensory) | VIII - auditory (sensory)
hearing Â
🗑
|
||||
| IX - glossopharyngeal  (sensory/motor) | IX - glossopharyngeal (sensory/motor)
taste, swallowing Â
🗑
|
||||
| X - vagus  (sensory/motor) | X - vagus (sensory/motor)
sensation of pharynx, movement of vocal
cords
🗑
|
||||
| XI - spinal accessory  (motor) | XI - spinal accessory (motor)
movement of head and shoulders Â
🗑
|
||||
| XII - hypoglossal  (motor) | XII - hypoglossal (motor)
position of tongue Â
🗑
|
||||
| Trust vs. Mistrust  | Trust vs. Mistrust
Infancy (0-18 mos) Â
🗑
|
||||
| Autonomy vs. Shame & Doubt  | Autonomy vs. Shame & Doubt
Early Childhood (18mos-3yrs) Â
🗑
|
||||
| Initiative vs. Guilt  | Initiative vs. Guilt
Preschool (3-6yrs) Â
🗑
|
||||
| Industry vs. Inferiority  | Industry vs. Inferiority
School-age (6-12yrs) Â
🗑
|
||||
| Identity vs. Role Confusion  | Identity vs. Role Confusion
Adolescence (12-18yrs) Â
🗑
|
||||
| Intimacy vs. Isolation  | Intimacy vs. Isolation
Young Adult (18-25yrs) Â
🗑
|
||||
| Generativity vs. Stagnation  | Generativity vs. Stagnation
Adulthood (25-45yrs) Â
🗑
|
||||
| Integrity vs. Despair  | Integrity vs. Despair
Late Adulthood (45-death) Â
🗑
|
||||
| Teaching that is Dependent on environment Needs security  | Teaching that is Dependent on environment Needs security
Infant (0-18mos) Â
🗑
|
||||
| Teaching focused on Separation anxiety Self exploration Environment  | Teaching focused on Separation anxiety Self exploration Environment
Infant (0-18mos)
🗑
|
||||
| Teaching focused on Natural curiosity Separation Intrusive procedure  | Teaching focused on Natural curiosity Separation Intrusive procedure
Toddler (18mos-3yrs) Â
🗑
|
||||
| Teaching focused on Ego Body mutilation (pain) believes illness is self caused & punitive  | Teaching focused on Ego Body mutilation (pain) believes illness is self caused & punitive
Preschooler (3-6yrs) Â
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|
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| Teaching focused on Limited time Active imagination (animistic thinking, fearful) Â | Teaching focused on Limited time Active imagination (animistic thinking, fearful)
Preschool (3-6yrs) Â
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|
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| Teaching focused on Reality Objectivity Separation anxiety (tries to appear brave) Â | Teaching focused on Reality Objectivity Separation anxiety (tries to appear brave)
School Age (6-12yrs) Â
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|
||||
| Teaching focused on Cause & effect Concrete Information (passive coping strategy) Â | Teaching focused on Cause & effect Concrete Information (passive coping strategy)
School Age (6-12yrs) Â
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|
||||
| Teaching focused on Abstract hypothetical thinking Logic & scientific principles  | Teaching focused on Abstract hypothetical thinking Logic & scientific principles
Adolescence (12-18yrs) Â
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|
||||
| Teaching focused on Body image Self esteem & identity (feel invincible) Â | Teaching focused on Body image Self esteem & identity (feel invincible)
Adolescence (12-18yrs) Â
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|
||||
| Teaching focused on Autonomy Self direction Critical thinking  | Teaching focused on Autonomy Self direction Critical thinking
Young adult (18-25yrs) Â
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|
||||
| Teaching focused on Competency based learner (can make decision personally & socially) Â | Teaching focused on Competency based learner (can make decision personally & socially)
Young Adult (18-25yrs) Â
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|
||||
| Teaching focused on Physical changes Alternative lifestyle Sense of well developed (questions achievements & contributions to family & society, confident) Â | Teaching focused on Physical changes Alternative lifestyle Sense of well developed (questions achievements & contributions to family & society, confident)
Middle Adult (25-45yrs) Â
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|
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| Teaching focused on Cognitive & physical changes No formal learning (decreased S.T.M., risk taking, easily fatigue) Â | Teaching focused on Cognitive & physical changes No formal learning (decreased S.T.M., risk taking, easily fatigue)
Older Adult (45-death) Â
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|
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| For a hospitalized Child, focus on  | For a hospitalized Child, focus on
Separation Â
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|
||||
| For a hospitalized Toddler, focus on  | For a hospitalized Toddler, focus on
Separation & Intrusive procedure Â
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|
||||
| For a hospitalized Preschooler, focus on  | For a hospitalized Preschooler, focus on
Body mutilation & Pain Â
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|
||||
| For a hospitalized School-age, focus on  | For a hospitalized School-age, focus on
Loss of control Â
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|
||||
| For a hospitalized Adolescent, focus on  | For a hospitalized Adolescent, focus on
Body image Â
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|
||||
| PRE-OPERATIVE CARE, a parent or a legal may sign the consent of a MINOR, while the OLDER client may need whom? |
Legal Guardian
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|
||||
| PRE-OPERATIVE CARE, a nurse can be a witness in consent signing & document the same only if the client understood surgeon's explanations and the client? |
Acknowledges understanding of the procedure
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|
||||
| PRE-OPERATIVE CARE, NPO is 6-8 hrs. before Gen. Anesthesia, while for Local Anesthesia is? |
3 hours before surgery
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|
||||
| PRE-OPERATIVE CARE, prepare ___ administration for malnourished, with protein or metabolic deficiencies or cannot ingest food client. |
Total Parenteral Nutrition
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|
||||
| PRE-OPERATIVE CARE, if client has a Foley Catheter, drain before the surgery and note the? |
Amount of urine & characteristics
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|
||||
| PRE-OPERATIVE CARE, what do you use to clean the surgical site? |
Mild Antiseptic Soap
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|
||||
| PRE-OPERATIVE CARE (client teaching), inform the client what to expect POST-OP like pain & discomfort, and that he/she can request what? |
Narcotic Drugs as pain reliever, note it will not make the client an addict to such
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|
||||
| PRE-OPERATIVE CARE (client teaching), demonstrate what to the client? |
Patient Controlled Analgesic (PCA)
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|
||||
| PRE-OPERATIVE CARE (client teaching), instruct not to what? 24 hours before the surgery. |
Smoke
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|
||||
| PRE-OPERATIVE CARE (client teaching), instruct to do Deep Breathing & Coughing Exercises, use of Incentive Spirometry for the prevention of? |
Pneumonia & Atelactasis
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|
||||
| PRE-OPERATIVE CARE (client teaching), instruction of let & foot exercises will prevent what? Facilitate what? |
Venous Stasis / Venous blood return
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|
||||
| PRE-OPERATIVE CARE (client teaching), instruct the client on how to splint an incision by? |
Placing a pillow, or one hand with the other hand on top, over the incisional area.
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|
||||
| PRE-OPERATIVE CARE (checklist), ensure the client is wearing identification bracelet and assess for what? |
Allergies for latex
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|
||||
| PRE-OPERATIVE CARE (checklist), ensure that informed consent forms were signed for the operative procedure and for what other reasons? | PRE-OPERATIVE CARE (checklist), ensure that informed consent forms were signed for the operative procedure and for what other reasons?
Blood transfusions, disposal of a limb, or for surgical sterilization procedures.
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|
||||
| PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, chest radiography are documented & recorded plus? | PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, chest radiography are documented & recorded plus?
Blood type, screened & cross matching is performed.
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|
||||
| PRE-OPERATIVE CARE (checklist), after removing everything unnecessary, documented it, kept or given to family members, the nurse must document the? | PRE-OPERATIVE CARE (checklist), after removing everything unnecessary, documented it, kept or given to family members, the nurse must document the?
Last time client ate or drank, voided before surgery, medications given prior surgery then monitor V.S.
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|
||||
| PRE-OPERATIVE CARE (medications), instruct client about the desired effects and then what? | PRE-OPERATIVE CARE (medications), instruct client about the desired effects and then what?
Keep client in bed with side rails up.
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|
||||
| PRE-OPERATIVE CARE (medications), after administering medications, next to the client, place what? | PRE-OPERATIVE CARE (medications), after administering medications, next to the client, place what?
Call bell, instruct client not to get out of bed and call for assistance if needed
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|
||||
| PRE-OPERATIVE CARE (inside O.R.), after verifying identification bracelet & verbal response, the nurse will review chart and then confirm what? | PRE-OPERATIVE CARE (inside O.R.), after verifying identification bracelet & verbal response, the nurse will review chart and then confirm what?
Operative procedure & site
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|
||||
| PRE-OPERATIVE CARE (inside O.R.), the clients chart will be reviewed for completeness and taking a note about what? | PRE-OPERATIVE CARE (inside O.R.), the clients chart will be reviewed for completeness and taking a note about what?
Allergic reactions information
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|
||||
| POST-OPERATIVE CARE (immediate), what is the period of this stage? | POST-OPERATIVE CARE (immediate), what is the period of this stage?
1-4 hours after surgery
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|
||||
| POST-OPERATIVE CARE (immediate), monitor airway patency & adequate ventilation because prolonged mechanical ventilation during anesthesia may affect what? | POST-OPERATIVE CARE (immediate), monitor airway patency & adequate ventilation because prolonged mechanical ventilation during anesthesia may affect what?
Postoperative Lung function, extubated patients may not be able to maintain airway
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|
||||
| POST-OPERATIVE CARE (immediate), the client maybe unable to clear his/her airway, that is why it is important to monitor what? | POST-OPERATIVE CARE (immediate), the client maybe unable to clear his/her airway, that is why it is important to monitor what?
Secretions
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|
||||
| POST-OPERATIVE CARE (immediate), encourage Deep Breathing & Coughing exercises, monitor pulse oximetry, O2 administration and then observer for? | POST-OPERATIVE CARE (immediate), encourage Deep Breathing & Coughing exercises, monitor pulse oximetry, O2 administration and then observer for?
Chest movements for symmetry and use of accessory muscles.
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|
||||
| POST-OPERATIVE CARE (immediate), note rate, depth & quality of respirations, RR should be? | POST-OPERATIVE CARE (immediate), note rate, depth & quality of respirations, RR should be?
>10 and not <30 BPM
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|
||||
| POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates what? | POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates what?
Partial obstruction, bronchospasm, laryngospasm
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|
||||
| POST-OPERATIVE CARE (immediate), a breath sound of crackles or ronchi may indicate? | POST-OPERATIVE CARE (immediate), a breath sound of crackles or ronchi may indicate?
Pulmonary Edema, monitor signs of Atelectasis or Pulmonary embolism
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|
||||
| POST-OPERATIVE CARE (immediate), check capillary refill, assess the skin, peripheral pulses & edema and monitor for bleeding. A bounding pulse may indicate what? | POST-OPERATIVE CARE (immediate), check capillary refill, assess the skin, peripheral pulses & edema and monitor for bleeding. A bounding pulse may indicate what?
Hypertension, Fluid overload, or excitement.
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|
||||
| POST-OPERATIVE CARE (immediate), unless contraindicated, client is placed on Fowler's position after surgery to increase? | POST-OPERATIVE CARE (immediate), unless contraindicated, client is placed on Fowler's position after surgery to increase?
Size of the thorax for lung expansion
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|
||||
| POST-OPERATIVE CARE (immediate), what type of positioning is avoided if the pharyngeal reflexes have not yet returned? | POST-OPERATIVE CARE (immediate), what type of positioning is avoided if the pharyngeal reflexes have not yet returned?
Supine
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|
||||
| POST-OPERATIVE CARE (immediate), if comatose or semicomatose, what type of positioning? | POST-OPERATIVE CARE (immediate), if comatose or semicomatose, what type of positioning?
Side lying & keep an oral airway in place.
🗑
|
||||
| POST-OPERATIVE CARE (immediate), assess L.O.C., wake client periodically until awaken and if awaken? | POST-OPERATIVE CARE (immediate), assess L.O.C., wake client periodically until awaken and if awaken?
Orient client to the environment in a soft tone
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|
||||
| POST-OPERATIVE CARE (immediate), main body temperature and prevent heat loss by? | POST-OPERATIVE CARE (immediate), main body temperature and prevent heat loss by?
Blanketing & raise room temperature
🗑
|
||||
| POST-OPERATIVE CARE (immediate), an exposed skin, cool OR, or maybe from anesthesia may result to? | POST-OPERATIVE CARE (immediate), an exposed skin, cool OR, or maybe from anesthesia may result to?
Hypothermia, keep blanket on & continue O2 if shivering
🗑
|
||||
| POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for? | POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for?
Redness, abrasions or breakdown
🗑
|
||||
| POST-OPERATIVE CARE (immediate), record I&O, monitor for Fluid & Electrolyte imbalance, N&V, NGT patency, abdominal distention and the return of what? | POST-OPERATIVE CARE (immediate), record I&O, monitor for Fluid & Electrolyte imbalance, N&V, NGT patency, abdominal distention and the return of what?
Bowel sounds
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|
||||
| POST-OPERATIVE CARE (immediate), how many hours is it that the client is expected to void urine after the surgery? | POST-OPERATIVE CARE (immediate), how many hours is it that the client is expected to void urine after the surgery?
6-8 hours, note color, quantity & quality
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|
||||
| POST-OPERATIVE CARE (immediate), assess for pain, PRE-OP & POST-OP medz, then inquire about the type & location of pain by asking the client to? | POST-OPERATIVE CARE (immediate), assess for pain, PRE-OP & POST-OP medz, then inquire about the type & location of pain by asking the client to?
Rate the pain from 1-10, note facial expression, body gestures, increase PR, BP & RR.
🗑
|
||||
| POST-OPERATIVE CARE (immediate), inquire effectiveness of last medication, if on a Narcotic drug, assess every 30 minutes for? | POST-OPERATIVE CARE (immediate), inquire effectiveness of last medication, if on a Narcotic drug, assess every 30 minutes for?
RR & pain relief
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), how many hours is this stage after surgery? | POST-OPERATIVE CARE (intermediate), how many hours is this stage after surgery?
4-24 hours
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|
||||
| POST-OPERATIVE CARE (intermediate), monitor airway patency, encourage Deep Breathing & Coughing exercises, monitor circulatory status encourage the use of what? | POST-OPERATIVE CARE (intermediate), monitor airway patency, encourage Deep Breathing & Coughing exercises, monitor circulatory status encourage the use of what?
Antiembolism stockings if not C/I
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), assess for mobility on all extremities & encourage early ambulation by first sitting on the edge of the bed with feet supported. But if client is unable to move, what do you do next? | POST-OPERATIVE CARE (intermediate), assess for mobility on all extremities & encourage early ambulation by first sitting on the edge of the bed with feet supported. But if client is unable to move, what do you do next?
Turn the client every 1-2 hours.
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), reinforce wound with sterile dressing if necessary and always keep it? | POST-OPERATIVE CARE (intermediate), reinforce wound with sterile dressing if necessary and always keep it?
Dry & intact, notify physician if bleeding occurs
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), monitor I&O, N&V and if vomiting, have a suctioning equipment available and ready to use. NPO status is observed until? | POST-OPERATIVE CARE (intermediate), monitor I&O, N&V and if vomiting, have a suctioning equipment available and ready to use. NPO status is observed until?
Gag reflex & peristalsis returns
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), when oral fluids are permitted, start with? | POST-OPERATIVE CARE (intermediate), when oral fluids are permitted, start with?
Ice chips & water, then advance to Clear Liquids up to Regular Diet as prescribed
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), after NPO order is lifted, what do you assess for? | POST-OPERATIVE CARE (intermediate), after NPO order is lifted, what do you assess for?
Bowel sounds on all four quadrants
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), how many mL per hour should a client void? | POST-OPERATIVE CARE (intermediate), how many mL per hour should a client void?
Should be > 30 mL/hr
🗑
|
||||
| POST-OPERATIVE CARE (intermediate), if with Foley Catheter, client is expected to void within 6-8 hours. Ensure that the amount is at least? | POST-OPERATIVE CARE (intermediate), if with Foley Catheter, client is expected to void within 6-8 hours. Ensure that the amount is at least?
200mL
🗑
|
||||
| POST-OPERATIVE CARE (extended), what is the period of this stage? | POST-OPERATIVE CARE (extended), what is the period of this stage?
1-4 hours after surgery
🗑
|
||||
| POST-OPERATIVE CARE (extended), on this stage, you monitor for signs of infection such as? | POST-OPERATIVE CARE (extended), on this stage, you monitor for signs of infection such as?
Redness, swelling, & tenderness at the surgical site, fever & leukocytes
🗑
|
||||
| POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours and encourage ambulation to promote? | POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours and encourage ambulation to promote?
Peristalsis & passage of flatus
🗑
|
||||
| POST-OPERATIVE CARE (extended), the client is encouraged to perform A.D.L. & eat foods that will promote wound healing. What are the foods? | POST-OPERATIVE CARE (extended), the client is encouraged to perform A.D.L. & eat foods that will promote wound healing. What are the foods?
Protein & Vitamin C
🗑
|
||||
| Inflammation of the alveoli caused by an infectious process that may develop as a result of infection, aspiration or immobility? | Inflammation of the alveoli caused by an infectious process that may develop as a result of infection, aspiration or immobility?
Pneumonia, usually around 3-5 days postoperatively
🗑
|
||||
| Collapse of the alveoli with retained mucous secretions and is the most common postoperative complication? | Collapse of the alveoli with retained mucous secretions and is the most common postoperative complication?
Atelectasis, usually around 1-2 days postoperatively
🗑
|
||||
| POST-OPERATIVE CARE (Pneumonia & Atelectasis) Assessment / increase risk for dyspnea/ elevated temperature/ productive cough/ and what more? | POST-OPERATIVE CARE (Pneumonia & Atelectasis) Assessment / increase risk for dyspnea/ elevated temperature/ productive cough/ and what more?
Increased R.R. & chest pain
🗑
|
||||
| POST-OPERATIVE CARE (Pneumonia & Atelectasis) Nsg Inter / assess for lung & breath sounds/ reposition client every 1-2 hour/ inc O.F.I. / early ambulation and what more? | POST-OPERATIVE CARE (Pneumonia & Atelectasis) Nsg Inter. / assess for lung & breath sounds/ reposition client every 1-2 hour/ inc O.F.I. / early ambulation and?
Deep breathing & coughing exercises/ incentive spirometer/ chest physio/ postural drainage
🗑
|
||||
| An inadequate concentration of oxygen in arterial blood? | An inadequate concentration of oxygen in arterial blood?
Hypoxia
🗑
|
||||
| POST-OPERATIVE CARE (Hypoxia) Assessment / cyanosis/ dyspnea/ hypertension/ tachycardia and what else? | POST-OPERATIVE CARE (Hypoxia) Assessment / cyanosis/ dyspnea/ hypertension/ tachycardia and what else?
Restlessness & Diaphoresis
🗑
|
||||
| POST-OPERATIVE CARE (Hypoxia) Nursing Intervention, monitor signs of hypoxia/ eliminate cause/ monitor lung sounds/ administer oxygen/ D.B. & C. E. and what more? | POST-OPERATIVE CARE (Hypoxia) Nursing Intervention, monitor signs of hypoxia/ eliminate cause/ monitor lung sounds/ administer oxygen/ D.B. & C. E. and what more?
Monitor pulse oximetry & reposition client
🗑
|
||||
| It blocks the pulmonary artery and disrupts blood flow to one or more lobes of the lung? | It blocks the pulmonary artery and disrupts blood flow to one or more lobes of the lung?
Pulmonary Embolism
🗑
|
||||
| POST-OPERATIVE CARE (Pulmonary Embolism) Assessment / dyspnea/ cyanosis/ tachycardia and what more else? | POST-OPERATIVE CARE (Pulmonary Embolism) Assessment / dyspnea/ cyanosis/ tachycardia and what more else?
Decreased blood pressure & sudden chest or upper abdominal pain
🗑
|
||||
| POST-OPERATIVE CARE (Pulmonary Embolism) Nursing Intervention / what is the first thing that you should do? | POST-OPERATIVE CARE (Pulmonary Embolism) Nursing Intervention / what is the first thing that you should do?
1)Notify the physician 2)Monitor V.S. 3)Administer O2 & medications
🗑
|
||||
| Loss of large amount of blood externally or internally in a short time? | Loss of large amount of blood externally or internally in a short time?
Hemorrhage
🗑
|
||||
| POST-OPERATIVE CARE (Hemorrhage) Assessment / restlessness/ hypotension/ cool, clammy skin and what other else? | POST-OPERATIVE CARE (Hemorrhage) Assessment / restlessness/ hypotension/ cool, clammy skin and what other else?
Weak rapid pulse & reduced urine output
🗑
|
||||
| POST-OPERATIVE CARE (Hemorrhage) Nursing Intervention / provide pressure to the site of bleeding immediately and then what? | POST-OPERATIVE CARE (Hemorrhage) Nursing Intervention / provide pressure to the site of bleeding immediately and then what?
Notify the physician, administer O2, IV fluids & blood as prescribed & lastly prepare client for surgery if needed
🗑
|
||||
| Loss of circulatory fluid volume, which usually is caused by hemorrhage? | Loss of circulatory fluid volume, which usually is caused by hemorrhage?
Shock
🗑
|
||||
| POST-OPERATIVE CARE (Shock) Assessment / / restlessness/ hypotension/ cool, clammy skin and what other else? | POST-OPERATIVE CARE (Shock) Assessment / / restlessness/ hypotension/ cool, clammy skin and what other else?
Weak rapid pulse & reduced urine output
🗑
|
||||
| POST-OPERATIVE CARE (Shock) Nursing Intervention / elevate legs only if the client did not have Spinal Anesthesia/ determine & treat cause of shock/ administer O2/ monitor V.S., L.O.C./ monitor I & O. and what if the client had Spinal Anesthesia? | POST-OPERATIVE CARE (Shock) Nsg Inter / elevate legs (w/o Spinal Anes.)/ treat cause of shock/ adm. O2/ monitor V.S., L.O.C./ monitor I&O. & if client had Spinal Anes.?
Elevate legs not higher than pillow/ assess skin turgor, moisture and mucous membra
🗑
|
||||
| Inflammation of a vein, leg veins commonly affected, often accompanied by clot formation? | Inflammation of a vein, leg veins commonly affected, often accompanied by clot formation?
Thrombophlebitis
🗑
|
||||
| POST-OPERATIVE CARE (Thrombophlebitis) Assessment / vein inflammation/ aching or cramping pain/ elevated temperature and what? | POST-OPERATIVE CARE (Thrombophlebitis) Assessment / vein inflammation/ aching or cramping pain/ elevated temperature and what?
(+) Homan's Sign
🗑
|
||||
| POST-OPERATIVE CARE (Thrombophlebitis) Nursing Intervention / monitor leg/ encourage antiembolism stockings – removed 2x/day for washing & inspection of leg/ give heparin sodium or warfarin (coumadin)/ the leg is elevated by 30 degrees & do not? | Apply pressure on popliteal area. No leg dangling & sitting on one position for long periods
🗑
|
||||
| Involuntary accumulation of urine in the bladder as a result of loss of muscle tone? | Involuntary accumulation of urine in the bladder as a result of loss of muscle tone?
Urinary Retention
🗑
|
||||
| POST-OPERATIVE CARE (Urinary Retention) Assessment / inability to void/ restlessness & diaphoresis/ lower abdominal pain/ distended bladder and what else? | POST-OPERATIVE CARE (Urinary Retention) Assessment / inability to void/ restlessness & diaphoresis/ lower abdominal pain/ distended bladder and what else?
Hypertension & Drumlike sound upon bladder percussion
🗑
|
||||
| POST-OPERATIVE CARE (Thrombophlebitis) Nursing Intervention / monitor voiding/ assess distended bladder/ encourage inc. O.F.I./ provide privacy and what? | Pour warm water on the perinium, allow pt to hear running water then CATHETERIZE if all non invasive attempts fail
🗑
|
||||
| Failure of appropriate forward movement of bowel contents and maybe due to anesthetic medications or manipulation of the bowel during the surgical procedure? | Failure of appropriate forward movement of bowel contents and maybe due to anesthetic medications or manipulation of the bowel during the surgical procedure?
Paralytic Ileus
🗑
|
||||
| POST-OPERATIVE CARE (Paralytic Ileus) Assessment / abdominal distention/ absence of bowel sounds, bowel movement or flatus, what is the first indication of this condition? | POST-OPERATIVE CARE (Paralytic Ileus) Assessment / abdominal distention/ absence of bowel sounds, bowel movement or flatus, what is the first indication of this condition?
Nausea & Vomiting immeidately postoperatively
🗑
|
||||
| POST-OPERATIVE CARE (Paralytic Ileus) Nursing Intervention / monitor I & O/ maintain NPO until bowel sounds return/ patency of NGT/ early ambulation/ administer IVF or TPN, medications and what is the noninvasive action? | NGT insertion and connected to intermittent or constant suction for bowel decompression
🗑
|
||||
| Caused by poor aseptic technique or a contaminated wound before surgical exploration? | Caused by poor aseptic technique or a contaminated wound before surgical exploration?
Wound Infection
🗑
|
||||
| POST-OPERATIVE CARE (Wound Infection) Assessment / fever & chills/ edematous skin at incision site & tight skin sutures/ increased WBC and what is the order of the inflamed incision site? | POST-OPERATIVE CARE (Wound Infection) Assessment / fever & chills/ edematous skin at incision site & tight skin sutures/ increased WBC and what is the order of the inflamed incision site?
1)Warm, 2)Tender, 3)Painful
🗑
|
||||
| POST-OPERATIVE CARE (Wound Infection) Nursing Intervention / monitor temperature/ maintain patency of drains & note amount, color, consistency/ change dressing/ give antibiotics and what are the signs of infection? | REEDA- Redness, Erythema, Ecchynosis, Drainage, Approximation for wound edges
🗑
|
||||
| Separation of the wound edges at the suture line? | Separation of the wound edges at the suture line?
Wound Dehiscence, usually occurs 6-8 days after
🗑
|
||||
| POST-OPERATIVE CARE (Wound Dehiscence) Assessment / increased drainage/ opened wound edges and? | Appearance of underlying tissues through the wound
🗑
|
||||
| POST-OPERATIVE CARE (Wound Dehiscence) Nursing Intervention / low Fowler's position to avoid abdominal tension/ cover with NSS dressing and then immediately? | Notify physician & prevent wound infection, antiemetics is given to avoid abdominal tension as well, splint incision when coughing
🗑
|
||||
| Protrusion of internal organs through an incision. Common on obese, with past abd. surgery or who have poor wound healing. | Protrusion of internal organs through an incision. Common on obese, with past abd. surgery or who have poor wound healing.
Wound Evisceration, usually occurs 6-8 days after. It is an Emergency
🗑
|
||||
| POST-OPERATIVE CARE (Wound Evisceration) Assessment / serosanguinous discharge from dry wound/ with loops of bowel or other abdominal contents through the wound and the client is reporting? | POST-OPERATIVE CARE (Wound Evisceration) Assessment / serosanguinous discharge from dry wound/ with loops of bowel or other abdominal contents through the wound and the client is reporting?
A feeling of popping after coughing or turning
🗑
|
||||
| POST-OPERATIVE CARE (Wound Evisceration) Nursing Intervention / Fowler's position/ cover wound with sterile NSS and ? | POST-OPERATIVE CARE (Wound Evisceration) Nursing Intervention / Fowler's position/ cover wound with sterile NSS and ?
Notify DR & prevent wound infection, antiemetics is given to avoid abdominal tension as well, splint incision when coughing
🗑
|
||||
| In ambulatory surgery, the criteria for client discharge are the following, he/she is alert and oriented/ has voided/ not in respiratory distress/ vomiting & in minimal pain and also the client is able to? | In ambulatory surgery, the criteria for client discharge are the following, he/she is alert and oriented/ has voided/ not in respiratory distress/ vomiting & in minimal pain and also the client is able to?
Ambulate, swallow & cough
🗑
|
||||
| POST-OPERATIVE CARE (Discharging) assess pt's readiness to learn, educ. level, & desire modify lifestyle/ demo incision care/ written guide to pt & family &? | POST-OPERATIVE CARE (Discharging) assess pt's readiness to learn, educ. level, & desire modify lifestyle/ demo incision care/ written guide to pt & family &?
Instruct PT to cover incision with plastic when showering & give a 48 hour of dressing suppl
🗑
|
||||
| Formula for IV Calculations | Formula for IV Calculations
CC's per hour X Drop Factor / 60
🗑
|
||||
| Ordered 1000 cc 5% D/ 0.45 NS at 100cc/hr. Drop factor is 60 | Ordered 1000 cc 5% D/ 0.45 NS at 100cc/hr. Drop factor is 60
100
🗑
|
||||
| Ordered: 1500 ML0.9% NS to infuse 90 cc/hr. Drop Factor: 20 gtt/ml | Ordered: 1500 ML0.9% NS to infuse 90 cc/hr. Drop Factor: 20 gtt/ml
30
🗑
|
||||
| ORDERED: Ampicillin 500 mg in 50 cc 0.9% NS to infuse 1hour. Drop Factor: 10 gtts/ml | ORDERED: Ampicillin 500 mg in 50 cc 0.9% NS to infuse 1hour. Drop Factor: 10 gtts/ml
8
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| Ordered 1250 cc 2.5 % D/W to infuse from 12 noon to 6 pm. The Drop Factor is 15 gtts/ml. | Ordered 1250 cc 2.5 % D/W to infuse from 12 noon to 6 pm. The Drop Factor is 15 gtts/ml.
52
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|
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| ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS and 1000 cc 0.9% NS to infuse over 24 hours. DROP FACTOR: 12 gtt/ml | ORDERED: 1000 cc RLS adn 1000 cc 5% D/LRS and 1000 cc 0.9% NS to infuse over 24 hours. DROP FACTOR: 12 gtt/ml
25
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|
||||
| ORDERED: 1000 cc 5%D/0.45% NS with 40 mEq of KCL to infuse in 8 hours. DROP FACTOR: 12 gtts / ml | ORDERED: 1000 cc 5%D/0.45% NS with 40 mEq of KCL to infuse in 8 hours. DROP FACTOR: 12 gtts / ml
25
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|
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| ORDERED: An infant weighs 18 # has an IV of 500 cc 10% D/W to infuse over 24 hours. DROP FACTOR: 60 gtts/ml | ORDERED: An infant weighs 18 # has an IV of 500 cc 10% D/W to infuse over 24 hours. DROP FACTOR: 60 gtts/ml
20-21
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| ___% of the average adult's weight is fluid | ___% of the average adult's weight is fluid
60%
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|
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| Intracellular fluids (ICF) | Intracellular fluids (ICF)
all fluid w/in body cells
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|
||||
| What % of body weight is ICF? | What % of body weight is ICF?
40%
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|
||||
| Extracellular fluid (ECF) | Extracellular fluid (ECF)
fluid outside of a cell; divided into 3 parts, Interstitial fluid, intravascular fluid, and transcellular fluids
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|
||||
| What % of ECF makes up body weight? | What % of ECF makes up body weight?
20%
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|
||||
| What is interstitial fluid? | What is interstitial fluid?
contains lymph, fluid between cells and outside blood vessels
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|
||||
| What is Intravascular fluid? | What is Intravascular fluid?
blood plasma
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|
||||
| Electrolytes | Electrolytes
minerals or salts; when melted or dissolved in water it separates into ions and is able to carry an electrical current
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|
||||
| Cation | Cation
+ charged electrolytes EX: Na+ K+ Ca+
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|
||||
| Anion | Anion
- charged electrolytes EX: Cl- HCO3- SO4-
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|
||||
| Solute | Solute
dissolvable in water
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|
||||
| Solvent | Solvent
dissolvable in plasma
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|
||||
| Osmosis | Osmosis
movement of a pure solvent, through a semipermeable membrane, from an area of lesser solute concentration to an area of greater solute concentration to try to equalize concentrations on both sides of a membrane
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|
||||
| Osmotic pressure is: | Osmotic pressure is:
the drawing power for water & depends on the number of molecules in solution
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|
||||
| A solution with the same osmolarity as blood plasma is called: | A solution with the same osmolarity as blood plasma is called:
isotonic
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|
||||
| Movement of a solute in a solution across a semipermeable membrane from an area of higher concentration to an area of lower concentration is: | Movement of a solute in a solution across a semipermeable membrane from an area of higher concentration to an area of lower concentration is:
diffusion
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|
||||
| Filtration | Filtration
water and diffusable substances move together in response to fluid pressure, moving from an area of higher pressure to an area of lower pressure
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|
||||
| Hydrostatic pressure | Hydrostatic pressure
movement of water from interstitial space into the intravascular space by filtration
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|
||||
| Increased hydrostatic pressure causes what? | Increased hydrostatic pressure causes what?
edema, as with CHF
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|
||||
| Active transport | Active transport
movement of materials across cell membranes requiring metabolic activity
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|
||||
| Homeostasis | Homeostasis
physiological balance
🗑
|
||||
| Osmoreceptors | Osmoreceptors
continually monitor the serum osmotic pressure, when osmolality increases, hypothalamus is stimulated
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|
||||
| ADH | ADH
Antidiuretic hormone; stored in pituitary gland; works directly on kidney tubules and collecting ducts making them more permeable which returns water to systemic circulation
🗑
|
||||
| Aldosterone | Aldosterone
released by adrenal cortex in response to increased K+ levels; it increases the reabsorption of Na+ and secretion of K+
🗑
|
||||
| Insensible water loss | Insensible water loss
continuous and not perceived by person
🗑
|
||||
| Sensible water loss | Sensible water loss
through excessive perspiration
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|
||||
| The lungs expire____ml of water a day | The lungs expire____ml of water a day
400ml
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|
||||
| What are the major cations? | What are the major cations?
Na+ K+ Ca+ Ions
🗑
|
||||
| What are the major anions? | What are the major anions?
chloride, bicarbonate, phosphate
🗑
|
||||
| __% of sodium is in the ECF? Function of Na+? | __% of sodium is in the ECF? Function of Na+?
90%, maintain water balance
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|
||||
| __% of K+ in ECF. What's it's function? | __% of K+ in ECF. What's it's function?
2%; regulates metabolic activity
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|
||||
| 1% of Ca+ is in blood, 99% in bone; what is the function? | 1% of Ca+ is in blood, 99% in bone; what is the function?
blood clotting, bone/teeth formation
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|
||||
| Magnesium is essential for: | Magnesium is essential for:
enzyme activities, neurochemical activities, cardiac and skeletal excitability
🗑
|
||||
| __% of magnesium in ECF. Na plasma concentration is: | __% of magnesium in ECF. Na plasma concentration is:
1%; 1.5-2.5 mEq/L
🗑
|
||||
| Bicarbonate, a chemical base buffer, is regulated by: | Bicarbonate, a chemical base buffer, is regulated by:
the kidneys
🗑
|
||||
| Buffer | Buffer
a substance or group of substances that can absorb or release H+ to correct an acid-base balance
🗑
|
||||
| What is the largest chemical buffer in ECF? | What is the largest chemical buffer in ECF?
carbonic acid and bicarbonate buffer system; reacts to change in pH of ECF within seconds
🗑
|
||||
| Biological regulation | Biological regulation
occurs when H= ions are absorbed and released by cells, occurs only after chemical buffering and takes 2-4 hrs
🗑
|
||||
| Fluid volume deficit (FVD) | Fluid volume deficit (FVD)
water & electrolytes lost in equal or isotonic proportions
🗑
|
||||
| Fluid volume excess (FVE) | Fluid volume excess (FVE)
water and sodium retained in isotonic proportions
🗑
|
||||
| Hyperosmolar imbalance | Hyperosmolar imbalance
dehydration
🗑
|
||||
| Hypoosmolar imbalance | Hypoosmolar imbalance
water excess
🗑
|
||||
| TPN or total parenteral nutrition | TPN or total parenteral nutrition
nutritionally adequate hypertonic solution of glucose, electrolytes, and other nutrients given through an indwelling or central IV
🗑
|
||||
| IV fluid and electrolyte therapy | IV fluid and electrolyte therapy
crystalloids
🗑
|
||||
| Colloids | Colloids
blood and blood component
🗑
|
||||
| Vascular access devices include: | Vascular access devices include:
catheters, cannulas, infusion ports,
🗑
|
||||
| the breakdown of RBC's is called: | the breakdown of RBC's is called:
hemolysis
🗑
|
||||
| Autologous transfusion collection of clients own blood (pre-op) | Autologous transfusion collection of clients own blood (pre-op)
Safest and done before surgery
🗑
|
||||
| One of the most common electrolyte imbalances is: | One of the most common electrolyte imbalances is:
hypokalemia
🗑
|
||||
| The client most at risk for FVD's is: | The client most at risk for FVD's is:
an infant
🗑
|
||||
| One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances is they: | One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances is they:
have a decreased thirst sensation
🗑
|
||||
| Output recorded on an I & O record includes: | Output recorded on an I & O record includes:
urine, diarrhea, vomitus, gastric suction, and drainage from wounds and tubes
🗑
|
||||
| Health promotion activities in the area of fluid and electrolyte imbalances focuses primarily on: | Health promotion activities in the area of fluid and electrolyte imbalances focuses primarily on:
client teaching
🗑
|
||||
| TPN is delivered by: | TPN is delivered by:
indwelling or central IV catheter
🗑
|
||||
| As a safety alert the RN is aware the following med is never given directly through IV: | As a safety alert the RN is aware the following med is never given directly through IV:
Potassium chloride, it will burn the vein
🗑
|
||||
| Indications of IV fluid infiltration include: | Indications of IV fluid infiltration include:
pallor and coolness
🗑
|
||||
| CDC recommends replacing peripheral venous catheters and rotating sites should occur at least every: | CDC recommends replacing peripheral venous catheters and rotating sites should occur at least every:
72-96 hours
🗑
|
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