Term
| Suspected deep tissue injury |
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Definition
| Discolored but intact skin caused by damage to underlying tissues |
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Term
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Definition
| Intact skin w/area of persisent, non blanchable redness, may feel warm OR cool to touch. Swollen, congested - possible discomfort at site |
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Term
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Definition
| Partial thickness skin loss involving epidermis and dermis. The ulcer is visible and superficial. May appear as abrasion, blister, or shallow crater. |
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Term
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Definition
| Full-thickness tissue loss with damage to or necrosis of subq tissue. May extend down to, but NOT thru underlying fascia. Appears as deep crater without exposure of muscle/bone |
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Term
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Definition
| Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,bone, or supporting structures. There may be sinus tracks, deep pockets of infection, tunneling, undermining, eschar (black-scab like material), slough (tan,yellow, or green scab-like material) |
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Term
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Definition
| Ulcers who stage cannot be determined |
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Term
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Definition
| First 3 days: attempts to control bleeding with clot formation. Deliver oxygen,wbc,and nutrients to area via blood supply |
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Term
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Definition
| 3 - 24 days, effects to wound: replacing lost tissue with CT, contracting wound's edges, resurfacing new epith cells |
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Term
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Definition
| Can take 1 + years. Strengthening of collagen scar and restoration of a more normal appearance. |
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Term
Types of Healing: Primary Intention
--> Characteristics + Wound Type |
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Definition
Characteristics - little/no tissue loss, edges are approximated (surgical incision)
Wound Type - heals rapidly, low risk of infection, no/minimal scarring |
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Term
Types of Healing: Secondary Intention
--> Characteristics + Wound Type |
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Definition
Loss of tissue, wound edges widely separated (pressure ulcers, stab wounds)
Wound Type: Longer healing time, increased risk of infecion, scarring |
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Term
Types of Healing: Tertiary Intention
--> Characteristics + Wound Type |
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Definition
Characteristics: widely separated, deep, spontaneous opening of a previously closed wound, risk of infection
Wound Type - extensive drainage and tissue debris, closed later, long healing time |
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Term
| Factors Affecting Wound Healing: Age (7) |
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Definition
| loss of skin turgor, skin fragility, decreased peripheral circ + oxygenation, slower tissue regeneration, decreased absorption of nutrients, decreased collagen, impaired function of immune system |
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Term
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Definition
| Fatty Tissues lacks blood supply |
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Term
| Color of Open Wounds (red, yellow, black) |
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Definition
Red: healthy regeneration
Yellow: Presence of purulent drainage and slough
Black - presence of eschar that hinders healing and must be removed |
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Term
| Characteristics of drainage distinguished by: |
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Definition
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Term
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Definition
| portion of blood (serum) that is watery and clear or slightly yellow in appearance |
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Term
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Definition
| Contains serum and RBC - thick and appears redish |
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Term
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Definition
| Contains both serum and bllod. Water and appears blood-streaked or blood-tinged |
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Term
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Definition
| Encourage 2,000 - 3,000 mL of fluid/day |
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Term
| Serum Albumin Levels (Wound Care) |
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Definition
| NOTE!!! If low - (below 3.5 g/dL), b/c a lack of protein puts the pt at greater risk for delayed wound healing and infection |
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Term
| Cleansing Wound Direction |
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Definition
From least contaminated to most - so from inside, then out
Also - top to bottom |
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Term
| Preferred Solutions to Cleanse wound |
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Definition
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Term
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Definition
| Dressing that swells in presence of exudate (used to maintain granulating wound bed, may be left in place up to 5 days) |
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Term
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Definition
| partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers. |
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Term
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Definition
| Dehiscence that involes the protrusion of visceral organs through a wound opening. It is usually caused by increased flow of serosanguineous fluit about 3 - 11 days post op |
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Term
| Signs + Symptoms of Dehiscence |
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Definition
1. Sig increase in flow of serosanguineous fluid on wound dressinging
2.Immediate hx of straining (cough, sneeze, vom)
3. Client reporting "pop" in wound area
4. Visualization of viscera |
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Term
| Treatment for evisceration/dehiscense |
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Definition
-Call for help
-stay with client
-cover wound + any protruding organs w/sterile towels or dressings that have been soaked in sterile saline solution. Do not attempt to reinsert
Position:supine w/hips and knees bent
-Observe for signs of shock
-Maintain calm environment |
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Term
| Signs + Symptoms of Infection |
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Definition
| Purulent drainage, pain, redness and edema, fever, chills, increase pulse + resp rate, increase WBC count |
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Term
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Definition
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Term
| HOB to prevent pressure ulcers? |
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Definition
| Maintain at 30 degrees or below or flat - unless contraindication, to relieve pressure on scarum, buttocks, and heels |
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Term
| Treatment: Suspected deep tissue injury and Stage 1 |
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Definition
Relieve pressure
Encourage frequent repositioning
Use pressure relieving devices
Implement pressure - reduction surfaces (air mattress, foam mattress)
-Keep client dry, clean, well-nourished, and hydrated |
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Term
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Definition
Maintain moist healing environment
Promote natural healing while preventing formation of scar tissue
Provide nutritional supplements as RX |
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Term
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Definition
Clean and/or debride: prescribed dressing, surgical intervention, proteolytic enzymes
-Provide nutritional supplements as RX
-Admin antimicrobials as RX |
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Term
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Definition
Clean and/or debride: prescribed dressing, surgical intervention, proteolytic enzyme
-perform nonadherent dressing changes every 12 hr
-treatment may include skin gradts
-provide nutritional supplements as prescribed
admin analgesics as RX |
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Term
| Interventions: Unstageable |
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Definition
| Debride as prescribed until ulcer can be staged |
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Term
How do you treat Hypothermia?
(7) |
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Definition
Provide warm environment temp, heated humidified oxygen, a warming blanket, friction to the extremities, and/or warmed oral or IV fluids
Provide continuous cardiac monitoring
Have ER resuscitation equipment on stand by |
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Term
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Definition
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Term
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Definition
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Term
| How to treat Hyperthermia? |
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Definition
-Provide fluids and rest, minimize activity
-Prevent shivering (increases body demand)
-Provide Oral Hygiene and dry clothing and linens
-Keep head covered
-Maintain enviro temp btw 70 - 80 F or 21 and 27 C |
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Term
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Definition
| ability to make personal decisions, even when those decisions may not be in client's best interest |
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Term
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Definition
| Care given is in the best interest of the client, take positive actions to help others |
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Term
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Definition
| Agreement to keep one's promote to pt about care that was offered |
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Term
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Definition
| Fair treatment in matters related to physical and psychosocial care and use of resources |
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Term
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Definition
| Avoidance of harm or pain as much as possible |
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Term
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Definition
Can't be solved by scientific date
involves conflict btw 2 more imperatives
answer will have a profound effect on situation/client |
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Term
| Check on PT with restraints every ___ hr(s)? What should you be checking? |
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Definition
| -Check every 2 hours (neurosensory checks of affected extremities – circulation, sensation, mobility) |
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Term
| Offer what to patient in restraints? |
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Definition
| Offer food and fluid, provided with means for hygiene and elimination, monitor for vital signs, offer range of motion of extremities |
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Term
| Frequency of needs assessed for patient in restraints? |
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Definition
| -Frequency of client assessments in regards to food, fluids, comfort, and safety should be performed and documented every 15 – 30 min |
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Term
| Transcribing Medical Orders |
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Definition
-Have a second RN/LPN listen to telephone order
-Repeat back order given (include med name, dosage, time, and route)
-document that you read back the order and the presence of the second nurse on the telephone |
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Term
| Client Information (sharing) |
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Definition
-Client info CAN’T be disclosed to unauthorized individuals/fam memberswho request it or individuals who call on phone
SOME HOSPITALS = Use code system – info only disclosed to individuals who can provide care
→The nurse should ask the individual inquiring about pt’s status for code for anyone inquiring about pt’s status for the code and disclose info on when the individ can give the code |
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Term
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Definition
-Droplet infections smaller than 5 mcg
-Private room
-Mask/respiratory protection devices for caregivers and visitors
- N95 or high-efficiency particulate air (HEPA) respirator is used if the client is KNOWN or SUSPECTED of tuberculosis
-tuberculosis, varicella, measles
-Negative pressure airflow exchange in the room of at least six exchanges per hour |
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Term
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Definition
-Protect against droplets larger than 5 mcg
Pneumonia, scarlet fever, rubella, pertussis, sepsis, pneumonic plague, mumps, mycoplasma pneumonia, meningococcal pneumonia)
-Private room or room w/ other clients with the same infectious disease
-Masks |
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Term
| Droplet Precautions: diseases |
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Definition
| Pneumonia, scarlet fever, rubella, pertussis, sepsis, pneumonic plague, mumps, mycoplasma pneumonia, meningococcal pneumonia) |
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Term
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Definition
| tuberculosis, varicella, measles |
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Term
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Definition
-protect visitors and caregivers against direct client/environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multidrug-resistant organisms)
-private room or room w/ other clients with the same infection
-gloves and gowns worn by the caregivers and visitors
-disposal of infectious dressing material into a single, nonporous bag without touching the outside of bag |
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Term
| Contact Precautions Diseases |
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Definition
| (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multidrug-resistant organisms) |
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Term
| Use of medical - nasa/trach |
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Definition
| Surgical asepsis (STERILE gloves of AT LEAST dominant hand) |
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Term
| Use of medical suctioning - oral |
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Definition
| Medical asepsis (use CLEAN gloves) |
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Term
| Pressure for Suctioning never HIGHER than... |
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Definition
| -Never set pressure higher than 120 mmhgs |
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Term
| Nasopharyngeal and Nasotracheal -- while you are preparing equipment you should do what to patient? |
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Definition
| Hyperoxygenate!!! Fi02 100% biatch |
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Term
| Endotracheal Suctioning - what should you do while preparing equipment? |
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Definition
| Hyperoxygenate pt using a bag-valve mask or specialized ventilator fuction w/an Fi02 of 100% |
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Term
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Definition
| glove, goggles, gown, and lastly mask |
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Term
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Definition
| gown, mask, goggles, clean gloves |
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Term
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Definition
| Age 20, every 1 -3 years, beginning at 40 yearly |
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Term
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Definition
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Term
| Blood Pressure (when to have assessed?!) |
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Definition
| Age 20, each routine health care visit, minimum every 2 years |
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Term
| BMI (when to have assessed) |
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Definition
| Age 20, ever routine HC visit |
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Term
| Blood Cholesterol (when to have assessed?!) |
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Definition
| Age 20, minimum every 5 years |
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Term
| Blood Glucose (when to have assessed?!) |
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Definition
| 45, minimum every 3 years |
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Term
Fecal Occult Blood Test – 50, yearly
AND Flexible Sigmoidoscopy
OR colonoscopy
OR double contrast barium enema |
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Definition
Fecal Blood - 50 , yearly
AND Fleixble Sig - every 5 years
OR colonoscopy - every 10 years
OR Double Contrast Barium Enema - every 5 years |
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Term
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Definition
| Starting at age 50, every 1 to 10 years, depending on test used by provider |
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Term
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Definition
| nurses knowledgeable about the cultures prevalent in their area of practice |
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Term
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Definition
| nurses apply knowledge of a client’s culture to their care delivery |
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Term
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Definition
| means that nurses understand and address the entire cultural context of each client within the realm of the care they deliver |
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Term
| Hearing Impairment...what should you do? |
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Definition
-lower pitch before you bring up the volume (don’t shout)
- write down what is not understood
- sign language interpreter if necessary |
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Term
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Definition
| liquids that leave little residue (clear fruit juices, gelatin, broth) |
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Term
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Definition
| clear liquids plus liquid dairy products, all juice, pureed vegetables |
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Term
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Definition
| clear + full liquids plus pureed meats, fruits, and scrambled eggs |
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Term
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Definition
| clear and full liquids + diced/ground foods |
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Term
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Definition
| foods low in fiber/ easy to digest |
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Term
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Definition
| whole grains, raw and dried fruits |
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Term
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Definition
| no added salt or 1 to 2g of sodium |
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Term
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Definition
| no more than 300mg/day of dietary cholesterol |
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Term
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Definition
| balanced intake of protein, fats, and carbs ~1800 calories |
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Term
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Definition
| pureed food and thickened liquid |
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Term
| People who can give informed consent |
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Definition
| emancipated, married underage, legal guardian, parent of minor, court-specified representative, durable power of attorney |
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Term
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Definition
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Term
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Definition
| Assessment, analysis, planning, implementation, evaluation (AAPIE) |
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Term
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Definition
use of precise practices to reduce number, growth, and spread of micro-organisms from an object, person, or area.
**use for: admin of oral meds, manage NG tubes, provide personal hygeine, and other common nursing tasks |
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Term
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Definition
Use of precise practices to eliminate ALL micro-orgs from an object or area "sterile technique"
-->used for parenteral med admin, insertion catheters, surg procedures, sterile dressing changes |
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Term
| Indicates infection - WBC |
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Definition
| Leukocytosis - WBCs > 10,000/uL |
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Term
| Increase in neutrophils is called.. |
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Definition
| Left shift (sign of infection) |
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Term
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Definition
| Prevent legs from turning outward (goes under butt near hips) |
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Term
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Definition
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Term
| Fluids should not hang for.. |
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Definition
| more than 24 hours unless closed system (pressure bags for hemodynamic monitoring) |
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Term
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Definition
| trauma pts, rapid fluid volume |
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Term
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Definition
| surgical pts, rapid blood administration |
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Term
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Definition
| all others (child + adults) |
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Term
| IV: Select Vein by Chosing |
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Definition
- distal veins on nondom hand
- site not painful/bruised, will not interfere w/ activity
- vein resillent w/soft, bouncy feeling when palpitated |
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Term
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Definition
| Flush IV catheters w/ appropriate solution after every medication administration or every 8 - 12 hours when not in use |
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Term
| Monitor site and infusion rate? |
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Definition
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Term
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Definition
palor, local swelling at site, decreased skin temperature around site, damp dressing, slowed infusion
e diffusion or accumulation (in a tissue or cells) of substances not normal to it or in amounts in excess of the normal. |
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Term
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Definition
STOP infusion and remove cath, elevate extremity
encourage active ROM
Apply warm compress 3-4xday
Restart infusion proximal to site or another extremity |
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Term
| Phlebitis/thrombophlebitis: Signs |
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Definition
edema, throbbing, buring, or pain @ site, high skin temp, erythema, red line up arm with palpable band @ vein site, slowed infusion
phleb = inflammation of vein/ thromb - clot in vein |
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Term
| Phlebitis/Thrombophlebitis: Treatment |
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Definition
Discontinue infusion and remove cath
Elevate extremity
Apply warm compress 3-4 X day
Restart infusion proximal to site or in another extremity
culture site and cath if drainage is present |
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Term
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Definition
Ecchmyosis @ site (the escape of blood into the tissues from ruptured blood vessels )
- bruise |
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Term
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Definition
Don't apply alcohol
apply pressure after cath IV removal
use warm compress and increase after bleeding stops |
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Term
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Definition
| pain, warmth, edema, induration(hardening), red streaking, fever, chills, malaise |
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Term
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Definition
Discontinue infusion, remove cath
Elevate, warm compress 3-4x day
obtain specimen for culture/culture cath if drainage present
-admin meds as prescribed |
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Term
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Definition
| distended neck veins, high BP, tachycardia, SOB, crackles in lungs, edema |
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Term
| Fluid Overload: Treatment |
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Definition
stop infusion
raise HOB, assess vitals
adjust rate as prescribed |
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Term
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Definition
| Missing catheter tip when discontinued, severe pain at site w/migration, or NO symptoms if no migration |
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Term
| Catheter Embolus: Treatment |
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Definition
Place turniquette high on extremity and limit venous flow
Prep for removal under x-ray or surgery
save cath after removal to determine cause |
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Term
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Definition
| neonates have immature liver + kidney functions, alkaline gastric juices, and immature B:B barrier |
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Term
Pharm Factors specific to children
gastric production and emptying time? |
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Definition
| Slower gastric production and slower gastric emptying time |
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Term
Pharm Factors specific to children
Topical Meds |
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Definition
| Absorb at higher rate (greater body surface and thinner skin) |
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Term
Pharm Factors specific to children
Blood Pressure |
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Definition
| Lower blood pressure ( more blood flow to lover and brain, less to kids) |
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Term
Pharm Factors specific to children
Water content |
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Definition
| Higher % water content (diluting water soluble meds) |
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Term
| Pharm Factors specific to older adults - gastric |
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Definition
| Higher gastric production (alkaline) |
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Term
Pharm Factors specific to older adults
GI |
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Definition
| Decrease GI motility and gastric emptying |
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Term
Pharm Factors specific to older adults
hepatic enzyme functions |
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Definition
| decreased (basically everything is decreased except body fat which increases) |
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Term
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Definition
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Term
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Definition
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