| Term | Definition |
|---|
| Goal of Nursing | To facilitate optimal wellness for client thru retention, attainment, or maintenance of client system stability |
| Goal of Nursing | To facilitate optimal wellness for client thru retention, attainment, or maintenance of client system stability |
| The Nursing Process | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| Caring in Nursing Practice | presence, touch, + listening |
| Normal Body Temp | 36 C - 38 C (96.8 F - 100.4 F) |
| Heat loss | Radiation, Convection, Evaporation, Conduction |
| Febrile | increased body temp |
| Fever | pyrexia |
| S/S of Fever | hot dry skin, flushed face, thirst, loss of appetite, general malaise, headache, delirium (children/elderly with high fevers), dehydration, rapid HR, ↓ urinary output |
| Nursing Interventions for Fever | antipyretics (aspirin/acetaminophen), antibiotic (if bacterial infection), tepid sponge bath, remove blankets, hydration |
| Nursing Interventions for Heatstroke | move to cooler environment, remove excess clothing, cool wet towels over skin, oscillating fans, IV fluids, stomach and lower bowel irrigation with cool solutions |
| Nursing Interventions for Heat Exhaustion | replace fluids and electrolytes, rest |
| Nursing Interventions for Hypothermia | remove wet clothing, apply dry clothing, wrap pt in blankets, if conscious give hot liquids (avoid caffeine and alcohol), keep head covered |
| Tachycardia | 100-180 bpm (adult) |
| Bradycardia | below 60 bpm (adult) |
| Average Infant HR | 100-160 bpm |
| Normal Adult HR | 60-100 bpm |
| Normal Respiration Rate | 12-20 breaths per min (adult at rest), 30-60 breaths per min (infant at rest) |
| Tachypnea | above 20 breaths per min |
| Bradypnea | less than 12 breaths per min |
| Pulse Ox/O2 Sat | % of hemoglobin that is bound w/ oxygen (95-100%) |
| Hypertension | above 140/90 |
| Hypotension | systolic BP below 90 |
| Orthostatic Hypotension | ↓ in BP (+ ↑ in HR) w/ position change (failure of autonomic nervous system to compensate volume shift) |
| S/S of Orthostatic Hypotension | dizziness, weakness, blurred vision |
| Health Perception/Health Management | Client's perceived pattern of health + well-being + how health is managed (1 of Gordon's 11 Functional Health Patterns) |
| Nutritional/Metabolic | Pattern of food + fluid consumption relative to metabolic need + patterns (1 of Gordon's 11 Functional Health Patterns) |
| Elimination | Patterns of excretory function (bowel, bladder, and skin) (1 of Gordon's 11 Functional Health Patterns) |
| Activity/Exercise | Patterns of exercise, activity, leisure, + recreation (1 of Gordon's 11 Functional Health Patterns) |
| Cognitive/Perceptual | Sensory perceptual + cognitive patterns (1 of Gordon's 11 Functional Health Patterns) |
| Sleep/Rest | Patterns of sleep, rest, + relaxation (1 of Gordon's 11 Functional Health Patterns) |
| Self Perception/Self Concept | Client's self-concept pattern + perceptions of self (1 of Gordon's 11 Functional Health Patterns) |
| Role/Relationship | Client's pattern of role engagements + relationships (1 of Gordon's 11 Functional Health Patterns) |
| Sexuality/Reproductive | Patterns of satisfaction/dissatisfaction with sexuality/reproductive pattern (1 of Gordon's 11 Functional Health Patterns) |
| Coping/Stress Tolerance | General coping pattern + effectiveness of pattern in terms of stress tolerance (1 of Gordon's 11 Functional Health Patterns) |
| Value/Belief | Patterns of values, beliefs (including spiritual), + goals that guide client's choices/decisions (1 of Gordon's 11 Functional Health Patterns) |
| Assessment | Collect + organize data |
| Diagnosis | Identify present health status (problems and strengths) |
| Planning | Choose desired patient outcomes + nursing interventions |
| Implementation | Carry out plan of action |
| Evaluation | Determine if plan was effective |
| Nursing Diagnosis | clinical judgment about client in response to actual/potential health problem |
| Medical Diagnosis | identification of disease/condition based on specific evaluation of S/S |
| Collaborative Problem | actual/potential complication that nurses monitor to detect change in client status |
| Diagnostic Label | name of nursing Dx |
| Related Factors | condition/etiology |
| As Manifested By | defining characteristics/symptoms |
| Personal Protective Equipment (PPE) | Gloves, Masks, Gowns, Eyewear |
| S/S of Localized Infection | Redness, Swelling, Warmth, Pain, Drainage |
| S/S of Systemic Infection | Fever, Fatigue, N/V, Malaise |
| Stages of Infection | Incubation, Prodromal Stage, Full stage of illness, Convalescent |
| Factors That Affect a Pt's Risk for Infection | Age, Lifestyle, Occupation, Diagnostic Procedures, Medical history/Therapies, Travel History, Trauma, Nutrition, Stress |
| Medical Asepsis | hand washing |
| Surgical Asepsis | Sterile Technique, Sterile object touching sterile object, any object that enters body/penetrates skin (wound, injections, caths, IVs) must be sterile |
| Factors That Affect Risk of HAIs | # of providers w/ direct contact, type + # of invasive procedures, type of therapy, length of hospitalization, improper hand hygiene |
| Isotonic exercise | muscle contraction and change in muscle length (walking, swimming, cycling), ↑ circul/resp function, ↑ muscle mass + tone + strength, ↑ osteoblastic activity |
| Isometric exercise | tightening/tensing of muscles w/o moving body parts (quad sets), ↑ muscle mass + tone + strength, ↓ potential for muscle wasting, ↑ circulation, ↑ osteoblastic activity |
| Resistive Isometric exercise | contract muscle while pushing against stationary object/resisting movement of object (pushups, pushing against footboard, hip lifting), ↑ muscle strength + endurance, ↑ muscle strength + osteoblastic activity |
| Proprioception | awareness of position of body + its parts (monitored by proprioceptors located on nerve endings in muscles, tendons + joints) |
| Balance | ability to maintain upright posture in sitting, standing, walking or other ADLs (controlled by nervous system: cerebellum + the inner ear) |
| ROM | Flexion, Extension, Hyperextension, Rotation, Abduction, Adduction, Circumduction, Supination, Pronation, Inversion, Eversion |
| Complications of Immobility | ↓ metabolic rate, muscle atrophy, weight ↓, calcium ↓ from bones, ↓ GI functioning, constipation, pseudodiarrhea from fecal impaction, atelectasis, hypostatic pneumonia, orthostatic hypotension, ↓ blood volume, peripheral edema, ↓ autonomic response, ↓ venous return, ↓ BP, thrombi, pulmonary emboli (PE), UTIs, kidney stones, pressure ulcers, depression, anxiety, mood changes, sleep-wake disturbances, sensory alterations, withdrawal, passive/angry behavior |
| Nursing Interventions for Immobility | ↑ protein, ↑ calorie diet, vit B & C, enteral feedings if necessary, cough + deep breathing, changing position, preventing DVTs by leg exercises, ROM, encouraging fluids, position changes, avoiding prolonged pressure, compression stockings |
| Ergonomics | fitting the task to the worker |
| Risk Factors for Injury + Job Tasks | Awkward postures, Lifting heavy loads, Excessive pushing/pulling, Frequent/repeated lifting + moving, Tasks that last a long time (duration), Reaching |
| Risk Factors for Injury + Job Environent | Slip, trip, + fall hazards, uneven work surfaces (stretchers, beds, chairs, toilets at different heights), space limitations (small rooms, lots of equipment) |
| The Nursing Process | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| Caring in Nursing Practice | presence, touch, + listening |
| Normal Body Temp | 36 C - 38 C (96.8 F - 100.4 F) |
| Heat loss | Radiation, Convection, Evaporation, Conduction |
| Febrile | increased body temp |
| Fever | pyrexia |
| S/S of Fever | hot dry skin, flushed face, thirst, loss of appetite, general malaise, headache, delirium (children/elderly with high fevers), dehydration, rapid HR, ↓ urinary output |
| Nursing Interventions for Fever | antipyretics (aspirin/acetaminophen), antibiotic (if bacterial infection), tepid sponge bath, remove blankets, hydration |
| Nursing Interventions for Heatstroke | move to cooler environment, remove excess clothing, cool wet towels over skin, oscillating fans, IV fluids, stomach and lower bowel irrigation with cool solutions |
| Nursing Interventions for Heat Exhaustion | replace fluids and electrolytes, rest |
| Nursing Interventions for Hypothermia | remove wet clothing, apply dry clothing, wrap pt in blankets, if conscious give hot liquids (avoid caffeine and alcohol), keep head covered |
| Tachycardia | 100-180 bpm (adult) |
| Bradycardia | below 60 bpm (adult) |
| Average Infant HR | 100-160 bpm |
| Normal Adult HR | 60-100 bpm |
| Normal Respiration Rate | 12-20 breaths per min (adult at rest), 30-60 breaths per min (infant at rest) |
| Tachypnea | above 20 breaths per min |
| Bradypnea | less than 12 breaths per min |
| Pulse Ox/O2 Sat | % of hemoglobin that is bound w/ oxygen (95-100%) |
| Hypertension | above 140/90 |
| Hypotension | systolic BP below 90 |
| Orthostatic Hypotension | ↓ in BP (+ ↑ in HR) w/ position change (failure of autonomic nervous system to compensate volume shift) |
| S/S of Orthostatic Hypotension | dizziness, weakness, blurred vision |
| Health Perception/Health Management | Client's perceived pattern of health + well-being + how health is managed (1 of Gordon's 11 Functional Health Patterns) |
| Nutritional/Metabolic | Pattern of food + fluid consumption relative to metabolic need + patterns (1 of Gordon's 11 Functional Health Patterns) |
| Elimination | Patterns of excretory function (bowel, bladder, and skin) (1 of Gordon's 11 Functional Health Patterns) |
| Activity/Exercise | Patterns of exercise, activity, leisure, + recreation (1 of Gordon's 11 Functional Health Patterns) |
| Cognitive/Perceptual | Sensory perceptual + cognitive patterns (1 of Gordon's 11 Functional Health Patterns) |
| Sleep/Rest | Patterns of sleep, rest, + relaxation (1 of Gordon's 11 Functional Health Patterns) |
| Self Perception/Self Concept | Client's self-concept pattern + perceptions of self (1 of Gordon's 11 Functional Health Patterns) |
| Role/Relationship | Client's pattern of role engagements + relationships (1 of Gordon's 11 Functional Health Patterns) |
| Sexuality/Reproductive | Patterns of satisfaction/dissatisfaction with sexuality/reproductive pattern (1 of Gordon's 11 Functional Health Patterns) |
| Coping/Stress Tolerance | General coping pattern + effectiveness of pattern in terms of stress tolerance (1 of Gordon's 11 Functional Health Patterns) |
| Value/Belief | Patterns of values, beliefs (including spiritual), + goals that guide client's choices/decisions (1 of Gordon's 11 Functional Health Patterns) |
| Assessment | Collect + organize data |
| Diagnosis | Identify present health status (problems and strengths) |
| Planning | Choose desired patient outcomes + nursing interventions |
| Implementation | Carry out plan of action |
| Evaluation | Determine if plan was effective |
| Nursing Diagnosis | clinical judgment about client in response to actual/potential health problem |
| Medical Diagnosis | identification of disease/condition based on specific evaluation of S/S |
| Collaborative Problem | actual/potential complication that nurses monitor to detect change in client status |
| Diagnostic Label | name of nursing Dx |
| Related Factors | condition/etiology |
| As Manifested By | defining characteristics/symptoms |
| Personal Protective Equipment (PPE) | Gloves, Masks, Gowns, Eyewear |
| S/S of Localized Infection | Redness, Swelling, Warmth, Pain, Drainage |
| S/S of Systemic Infection | Fever, Fatigue, N/V, Malaise |
| Stages of Infection | Incubation, Prodromal Stage, Full stage of illness, Convalescent |
| Factors That Affect a Pt's Risk for Infection | Age, Lifestyle, Occupation, Diagnostic Procedures, Medical history/Therapies, Travel History, Trauma, Nutrition, Stress |
| Medical Asepsis | hand washing |
| Surgical Asepsis | Sterile Technique, Sterile object touching sterile object, any object that enters body/penetrates skin (wound, injections, caths, IVs) must be sterile |
| Factors That Affect Risk of HAIs | # of providers w/ direct contact, type + # of invasive procedures, type of therapy, length of hospitalization, improper hand hygiene |
| Isotonic exercise | muscle contraction and change in muscle length (walking, swimming, cycling), ↑ circul/resp function, ↑ muscle mass + tone + strength, ↑ osteoblastic activity |
| Isometric exercise | tightening/tensing of muscles w/o moving body parts (quad sets), ↑ muscle mass + tone + strength, ↓ potential for muscle wasting, ↑ circulation, ↑ osteoblastic activity |
| Resistive Isometric exercise | contract muscle while pushing against stationary object/resisting movement of object (pushups, pushing against footboard, hip lifting), ↑ muscle strength + endurance, ↑ muscle strength + osteoblastic activity |
| Proprioception | awareness of position of body + its parts (monitored by proprioceptors located on nerve endings in muscles, tendons + joints) |
| Balance | ability to maintain upright posture in sitting, standing, walking or other ADLs (controlled by nervous system: cerebellum + the inner ear) |
| ROM | Flexion, Extension, Hyperextension, Rotation, Abduction, Adduction, Circumduction, Supination, Pronation, Inversion, Eversion |
| Complications of Immobility | ↓ metabolic rate, muscle atrophy, weight ↓, calcium ↓ from bones, ↓ GI functioning, constipation, pseudodiarrhea from fecal impaction, atelectasis, hypostatic pneumonia, orthostatic hypotension, ↓ blood volume, peripheral edema, ↓ autonomic response, ↓ venous return, ↓ BP, thrombi, pulmonary emboli (PE), UTIs, kidney stones, pressure ulcers, depression, anxiety, mood changes, sleep-wake disturbances, sensory alterations, withdrawal, passive/angry behavior |
| Nursing Interventions ofr Immobility | ↑ protein, ↑ calorie diet, vit B & C, enteral feedings if necessary, cough + deep breathing, changing position, preventing DVTs by leg exercises, ROM, encouraging fluids, position changes, avoiding prolonged pressure, compression stockings |
| Ergonomics | fitting the task to the worker |
| Risk Factors for Injury + Job Tasks | Awkward postures, Lifting heavy loads, Excessive pushing/pulling, Frequent/repeated lifting + moving, Tasks that last a long time (duration), Reaching |
| Risk Factors for Injury + Job Environent | Slip, trip, + fall hazards, uneven work surfaces (stretchers, beds, chairs, toilets at different heights), space limitations (small rooms, lots of equipment) |
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