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198 terms

Fundamentals Exam 1

STUDY
PLAY
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
c
with
CA
cancer
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
et
and
F
Fahrenheit
FBS
fasting blood sugar
FUO
fever of unknown origin
fl. oz.
fluid ounce
GB
gallbladder
GI
gastrointestinal
GU
genitourinary
g
gram
gr
grain
gtt
drop
hr
hour
hgb
hemoglobin
hct
hematocrit
h.s.
hour of sleep, bedtime
IM
intramuscularly
I & O
intake & output
IV
intravenously
IVP
intravenous pyelogram
l
liter
lb
pound
m
minim
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
per
by
oz.
ounce
p.o.
by mouth (os)
p.r.n.
whenever or as often as necessary
PT
physical therapy
q
every
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
s
without
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
Small Group
interactions with a small number of people
Public
interaction with an audience
Verbal Communication
includes vocabulary, denotative & connotative meaning, pacing, intonation, clarity & brevity, timing & relevance
Nonverbal Communication
includes personal appearance, posture & gait, facial expressions, eye contact, gestures, sounds, territoriality & personal space
Professional Nursing Relationships
Nurse/client, nurse/family, nurse/health team, and nurse/community
4 Phases of Nurse/Client Relationship
preinteraction, orientation, working, and termination
Communication with Assessment
physical & emotional factors, developmental factors, sociocultural factors, and gender
Communication with Diagnosis
clients may experience difficulty with communication
Communication with Planning
goals & outcomes (specific and measurable), setting of priorities, and continuity of care (collaboration with other health care providers
Communication with Implentation
therapeutic, nontherapeutic, and adapting communication techniques
Communication with Evaluation
nurses & clients need to determine whether the plan of care has been successful; interventions are evaluated to determine which strategies or interventions were effective
Safety in Health Care Settings
reduces the incidence of illness and injury; prevents extended length of treament/stay; improves or maintains functional status; increases client's sense of well-being
Safe Environment
includes meeting client's needs, reduces transmissions of pathogens, and maintains sanitation & reduces pollution
Nursing Knowledge Base
includes knowledge of developmental levels; mobility, sensory, & cognitive status; lifestyle choices ; special risks found in health care settings
Urinalysis
important indicator of urolgic functions
1.025-1.030
specific gravity of urine
6
normal pH of urine
0
normal protein in urine
0
normal glucose in urine
0
normal ketones in urine
CBC
consists of platelets, WBCs, hematocrit, hemoglobin, & RBCs
normal RBCs
men: 4.7-6.1 and women 4.2-5.4
normal hemoglobin
men: 14-18 and women: 12-16
normal hematocrit
men: 42-52 and women 37-47
5,000-10,000
normal WBCs
55-70%
normal neutrophil
20-40%
normal lymphocyte
2-8%
normal monocyte
1-4%
normal eosinophil
0.5-1%
normal basophil
normal platelets
150-400/mL3
BMP
includes sodium, potassium, chloride, calcium, magnesium, BUN, creatinine, protein, glucose, lipids (cholesterol)
135-145
normal sodium
3.5-5
normal potassium
95-105
normal chloride
normal calcium
8.5-10.5 mg/dl or 4.5-5.5 meg/l
1.5-2.5
normal magnesium
60-120
normal glucose
10-20
normal BUN
0.5-1.2
normal creatinine
less than 200
normal cholesterol
25-115
normal amylase
normal ESR
men: 0-15 and women: 0-20
normal hemoglobin A1C
4-8%
normal CK
10-70u/ml
normal CKMB
0-10
normal PT clot time
11-12.5 seconds
normal INR
2 and 3
normal PTT
30-40