Fundamentals Exam 1

198 terms by tslayden

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a.c.

before meals

abd

abdominal

ad lib

as desired

adm

admission

a.m.

morning

amb

ambulatory

amp

ampule

amt

amount

A & P

anterior & posterior/auscultation & percussion

ax

axillary

b.i.d.

twice a day

BM

bowel movement

BMR

basal metabolic rate

B/P

blood pressure

BRP

bathroom privileges

BUN

blood urea nitrogen

cap

capsule

cath

catheterized

CBC

complete blood count

CNS

central nervous system

c/o

complains of

CS

central supply

CVA

cerebrovascular accident

D & C

dilatation & curettage

D.O.A.

dead on arrival

Dr.

doctor

ECG or EKG

electrocardiogram

ER or ED

emergency room or department

F

Fahrenheit

FBS

fasting blood sugar

FUO

fever of unknown origin

fl. oz.

fluid ounce

GB

gallbladder

GI

gastrointestinal

GU

genitourinary

hgb

hemoglobin

hct

hematocrit

h.s.

hour of sleep, bedtime

IM

intramuscularly

I & O

intake & output

IV

intravenously

IVP

intravenous pyelogram

mg

milligram

MI

myocardial infarction

ml

milliliter

MAEs

moves all extremities

neg

negative

NPO

nothing by mouth (cs)

N/S

normal saline

N & V

nausea & vomiting

OB

obstetrical

p.c.

after meals

p.o.

by mouth (os)

p.r.n.

whenever or as often as necessary

PT

physical therapy

qh

every hour

q2h

every 2 hours

q3h

every 3 hours

q4h

every 4 hours

q.i.d.

4 times a day

qs

quantity sufficient

RBC

red blood count

sp. gr.

specific gravity

spec

specimen

stat

at once

SQ or subq

subcutaneous

T & A

tonsillectomy & adenoidectomy

TCDB

turn, cough, deep breath

tid

3 times a day

tinct

tincture

TLC

tender loving care

TPR

temperature, pulse, respirations

VD

venereal disease

WBC

white blood count

w/c

wheelchair

Critical Thinking

essential to safe, competent, skillful nursing practice; answers not always clear-cut in nursing; need to be creative; takes practice

Nursing Process

based on medical order by MD; focused on specific disease rather than person; origin of term by Lydia Hall in 1955

Nursing Process Definition

systematic, rational method of planning and providing nursing care; goal is to identify a client's health status, health care problems, establish plans to meet identified needs, and to deliver specific nursing interventions to meet those needs

Nursing Process

organizes our thinking process and allows critical thinking; method for organizing and delivering nursing care; characterized by purpose, organization, and creativity; series of planned actions or operations directed toward a result

Characterisitcs

planned, client-centered, problem-oriented, and goal-directed

Six Steps

assessing, diagnosing/analyzing, outcomes identification, planning, implementing, and evaluating

Assessment

to establish a client data base

Diagnosis

to identify client's heath care needs

Outcome Identification

to determine priorities of care and goals and expected outcomes

Planning

to create a plan of care

Implementation

to enact the plan

Evaluation

to determine the effectiveness of nursing care in achieving goals

Nursing Process

meets legal standards and provides for nurse accountability; meets professional standards; establishment of consistent and systematic nursing education

Nursing Process

data from each phase provides input into the next phase; client-centered; adaptation of problem solving and systems theory; decision-making is involved in every phase; interpersonal and collaborative; framework for nursing care in all settings; must use a variety of critical-thinking skills

Assessment

process of gathering, validating, organizing, and documenting data about a client; countinuous process carried out during all the steps; includes perceived needs, health problems, related experiences, health practices; provides basis for actions and decisions in entire process; focus is to establish a database about client

Database

nursing history & physical; physician history & physical; labs and other diagnostic studies; material contributed by other health personnel

Objective Data Collection

can be detected by observer; can be measured, verified, or tested; seen heard, felt, smelled; obtained by observation or physical exam; "signs" or overt data

Subjective Data Collection

apparent only to person affected; verified or described by that person only; opinion/feelings; "symptoms" or covert data

Data

must be complete, accurate, factual, and without judgment

Sources of Data

client, support people, client records, health care professionals, and literature

Primary Data Collection

direct source; client provides this data; usually the best source of data (unless client is too ill, young, or confused)

Secondary Data Collection

indirect source; family members, friends, and cargivers provide this data; client records (lab results & diagnostics), health care professionals, and literature

Problems with Data Collection

patient level of consciousness, no family or caregiver available, gaps in data

Data Collection Methods

observation (posture, breathing, communication skills); interviewing (health history); examining (in depth observation)

Implementation

phase where nurse implements nursing interventions; need cognitive, interpersonal & technical skills

Types of Implementation

Collaborative, independent, dependent, and protocols

Collaborative

need help with or working with someone else

Independent

your own decision by yourself

Dependent

need physicians orders to do something

Protocols

guidelines

Implementation Process

Reassessing, determining need for nurse assistance, implementing nursing interventions, supervising delegated care, and documenting

Delegation

the transfer of responsibility and authority for performance of an activity to a competent individual; retains accountability

Evaluation

to judge or appraise; last phase of nursing process; nurse & client determine progress toward achievement of goals; determines if intervention should be terminated, continued, or changed

Steps in Evaluation

Collecting data, comparing data with outcomes, relating nursing activities to outcomes, drawing conclusions about problem, and continuing, modifying, or terminating care plan

Collecting Data

nurse needs these to see if goals have been met; may require interpretation; must be recorded accurately

Comparing Data with Outcomes

Conclusion: goal was met/partiallymet/not met

Drawing Conclusions

Resolved/Prevented; prevented but remains at risk; problem remains although goals are met

Continuing, Modifying, or Terminating

nurse may modify care plan as indicated; patient may need all six steps of nursing process again

Diagnosing

Second phase of nursing process; nurse uses critical thinking to interpret assessment data & identify client's strengths and problems; reflects clinical judgment about responses to actual & potential health problems

Types of Diagnoses

actual, risk, wellness, possible, & syndrome

Components of Nursing Diagnosis

problem statement describes client's health problem; etiology identifies one or more probably causes of a health problem; defining characteristics are signs & symptoms that indicate presence of problem

Analyzing Data

compare data to standards, identify gaps & inconsistencies in data, and nurse & client can together identify problems that support diagnoses

Formulating Diagnoses

Problem, etiology, "related to", signs and symptoms

Problem

statement of the client's response (NANDA label)

Etiology

factors contributing to or probable causes of the responses

Planning

intial (when you first meet patient), ongoing (entire time they are in hospital and are with them), and discharge (when you first meet patient)

Nursing Care Plans

Standardized vs individualized; includes actions nurses must take to address nursing diagnosis & outcomes; protocols, policies & procedures, standing order

Standardized

pre-made care plans for patients with certain diseases

Protocol

physician writes what you do for a certain disease, regardless

Outcome Identification

Prioritizing according to Maslow's hierarchy for diagnosis, outcomes, and goals

Outcome Identification

goals and outcomes

Goal

broad statement; desired outcome or change in client behavior in the direction of health

Outcomes

statements that describe specific, observable, and measureable responses (long-term vs short-term)

Nursing Interventions

derived from the second portion of nursing diagnosis (general statements); nurse should choose those that are most likely to achieve desired outcomes; nursing actions/orders are more specific

Communication

lifelong learning process for nurses; essential attribute of professional nursing practice; builds relationships with clients, families, and multidisciplinary team members

Interpersonal Relationships

to establish helping & healing relationships and the ability to relate to others is important

Communication

developing skills requires both an understanding of process and of one's own experience

Intrapersonal

occurs within an individual

Interpersonal

one-to-one interaction between two people

Transpersonal

interaction within a person's spiritual domain

See More

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