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also called Adult Health Nursing |
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_____ ____ nursing cares for adults 18-100 |
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____ ____ must have a broad knowledge base to meet the needs of patients in a variety of health care settings across the continuum. |
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Biological Psychological Cultural Spiritual |
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The primary concern of medical-surgical nursing care is to meet the ________, ___________, _________, and ________needs of the adult patient in a mutually trusting, respectful, and caring relationship. |
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RRT (Rapid Response Team) |
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__________ Provides care to patient before a respiratory or cardiac arrest occurs. |
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RRT (Rapid Response Team) |
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_________ is called by the nurse or family member (according to agency guidelines) when clinical changes in condition occur, for example… hypotension, tachycardia, & mental status changes. |
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Swanson's ________ :avoiding assumptions, centering on the one care-for, assessing thoroughly, engaging the self of both |
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Swanson's ___________: being there conveying ability, sharing feeling, not-burdening |
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Swanson's _______: comforting, anticipating, performing competently/skillfully, protecting, preserving dignity |
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Swanson's _________: informing/explaining, supporting/allowing, focusing, generating alterations/thinking it through, validity/giving feedback |
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Swanson's _______: believing in/holding in esteem, maintaining a hop-filled attitude, offering realistic optimism, “going the distance” |
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_______ is the deliberate use of current best evidence to make decisions about patient care. Considers the pt preferences and values, as well as one’s own clinical expertise. |
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______________ is purposeful, outcome-directed thinking that is used to make clinical judgments based on scientific evidence, rather than on tradition or conjecture (guesswork) |
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Change the stressful person–environment situations (when possible) Reduce the stress response Develop positive coping skills
These are goals for _______ stress. |
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Selye's Gen Adaption _____________:physical or mental trauma triggers immediate biological responses designed to counter stress, responses depress the immune system, resistance lowers, person is more susceptible to infection and disease. If stress is short-lived, the person recovers rapidly. |
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Selye's Gen. Adaptation _____________:body starts to adapt to prolonged stress, immune system increases to meet the demands, but the perception of threat lingers, body remains under stress, person may become complacent and not take measures to relieve stress. |
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Selye's Gen Adaptation _________:with chronic stress, adaptive mechanisms eventually wear down, body can no longer meet its increased demands, immunity and resistance decline, illness is likely to set in. |
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Fight or Flight is a __________ nervous system response to stres. |
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These are _________ stress responses: Negative emotions Positive emotions Borderline emotions Non-emotions |
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Def. Mechanism: weakness overcome by excelling in another area |
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Def. Mechanism: ignores or denies situation |
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Def. Mechanism: transfers emotions to another source |
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Def. Mechanism: learns from and incorporates info in own life |
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Def. Mechanism: person attributes own thoughts to someone else |
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Def. Mechanism: behavior justification |
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Def. Mechanism: conscious attitudes are opposite real feelings |
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Def. Mechanism: returns to earlier method of behaving |
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Def. Mechanism: voluntarily forgets an anxiety-producing event |
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Def. Mechanism: socially acceptable goal is substituted for unacceptable one |
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Def. Mechanism: act used to negate a previous unacceptable act |
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Local Adaptation Responses (LAS) |
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The 2 most common ___________ responses are the: Reflex pain |
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response of the CNS to pain. Occurs rapidly and automatically as a protective mechanism to prevent injury. |
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local response to an injury or infection. Localizes and prevents spread of infection and promotes wound healing. |
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“normal processing of pain” |
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skin/musculoskeletal origin |
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pain with nerve origin that may be: burning, shooting, stabbing, “pins & needles” |
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cause of pain cannot be identified |
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CHARACTERISTICS: Short duration Usually a well-defined cause Decreases with healing Is reversible Mild to severe Anxiety/restless may accompany it Examples: post-op, trauma, procedural, obstetric, any ischemia… |
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CHARACTERISTICS: lasts > 3 months may not have well defined cause begins gradually and persists exhausting mild to severe depression, fatigue, decreased functional ability may accompany |
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Gate Control Theory of Pain |
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Idea that Relationship between pain and emotions: thalmus and cerebral cortex regulate thoughts/emotions/beliefs/values and can alter the actual pain perception. |
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are genetic, morphine-like substances that CLOSE the gate pathway to the brain and thereby stop the sensation of pain. |
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Types of _____________ ____________ tools: McGill-Melzack pain questionnaire Iggie, pg. 42
Pain scale: 1-10 or Wong-Baker FACES
McCaggery method
WILDA pain measurement scale |
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Patitent Controlled Analgesics (PCA) |
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route of opioid admin. where pt. has control |
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are non-steroidal anti-inflammatory drugs which include aspirin, Advil, Aleve, Motrin, etc. |
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Side Effects: Can cause GI disturbances, such as GI ulcers and GI bleeding. COX-2 inhibitors are for long-term use |
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Med that: Available in liquid form; can be taken on empty stomach Preferable for patients for whom GI bleeding is likely Side Effects: Can cause liver or renal toxicity if used long-term. |
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is the term used to describe the state of slight contraction—the usual state of skeletal muscles. If bed rest is prolonged, there is danger of developing contractures if the patient does not have exercise and if good posture is not maintained. |
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permanent contraction of a muscle |
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there are: long, short, flat and irregular |
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tough fibrous bands of connective tissue that bind joints, bones and cartilage. (bone to bone) |
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strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue that attach muscle to bone. |
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hard, nonvascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx. Cartilage in joints functions as a shock absorber and as a bearing surface that reduces friction between the moving parts of the joint. Fat may also provide padding at joints. |
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Lateral movement of a body part away from the midline of the body. |
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Lateral movement of a body part toward the midline of the body. |
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Movement of the distal part of the limb to trace a complete circle while the proximal end of the bone remains fixed. |
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The state of being in a straight line. |
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The state of exaggerated extension. It often results in an angle greater than 180 degrees. Example: A person's cervical spine is hyperextended when looking overhead, toward the ceiling. |
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____ _____ are staged from I to IV |
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Type 1 herpes simplex virus (HSV-1)— |
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classic recurring cold sore |
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Type 2 herpes simplex virus (HSV-2)— |
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form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with herpes simplex viral secretions |
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superficial infection involving only the upper portion of the follicle |
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much deeper infection in the follicle |
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generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue |
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such as body temperature, blood electrolytes, blood pH, and blood volume need to be kept within a narrow range of normal for the human body to work its best. Water makes up 55-60% of body wt in healthy young adults, and 50-55% in healthy older adults. |
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is maintained when hydrostatic pressure between 2 spaces remains in equilibrium. The human body constantly seeks equilibrium |
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controls and regulates volume of body fluids |
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chief regulator of cellular enzyme activity and water content |
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nerve impulse, blood clotting, muscle contraction, B12 absorption |
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metabolism of carbohydrates and proteins, vital actions involving enzymes |
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maintains osmotic pressure in blood, produces hydrochloric acid |
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body’s primary buffer system |
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involved in important chemical reactions in body, cell division, and hereditary traits |
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refers to a sodium deficit in ECF caused by a loss of sodium or gain of water. |
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refers to a surplus of sodium in ECF. |
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refers to a potassium deficit in ECF. |
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refers to an excess of potassium in ECF. |
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secreted by adrenal cortex in response to low sodium levels; acts on the kidney nephrons to reabsorb sodium and water from the urine back into the blood, increasing blood osmolarity and volume. _________ prevents excessive kidney excretion of sodium & helps prevent blood potassium levels from becoming too high. |
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Antidiuretic Horomone (ADH) |
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________ or vasopressin-produced in the brain/stored in the posterior pituitary gland. _______ release from posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Acts directly on kidney tubules and collecting ducts, making them more permeable to water, so more water is reabsorbed by these tubules and returned to the blood, decreasing blood osmolarity by making it more dilute. |
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BNP brain ______________ increase in response to increased blood volume and blood pressure. Opposite effect of Aldosterone…promotes water & sodium loss. (____ elevates in CHF) |
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Fluid intake is less than what is needed to meet the body’s fluid needs, resulting in a fluid volume deficit. |
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These are some common causes of __________________: Hemorrhage, Vomiting, Diarrhea, Profuse salivation, Fistulas, Ileostomy, Profuse diaphoresis, Burns, Severe wounds, Long-term nothing-by-mouth (NPO) status, Diuretic therapy, GI suction, Hyperventilation, Renal failure (early phase), Diabetes insipidus, Difficulty swallowing, Impaired thirst, Unconsciousness, Fever, Impaired motor function |
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_____________ dehydration is the most common type of fluid volume deficit. |
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Lab Assessments for _____________: Elevated hemoglobin Elevated hematocrit Elevated serum osmolarity Elevated glucose Elevated protein Elevated BUN Elevated electrolytes Elevations due to Hemoconcentration – plasma osmolarity is increased due to water loss. |
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measures the concentration of hydrogen ions or H+. |
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ECF in the body is slightly _________. |
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Normal pH of ARTERIAL BLOOD |
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Normal pH of VENOUS BLOOD |
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Gas exchange, the intake of oxygen and the release of carbon dioxide, is _________ ___________. |
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1. Inspiration 2. Alveoli 3. Expiration |
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Oxygen is taken in by _______, gas exchange occurs in the ________, then CO2 is exchanged via _________. |
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Lungs: bases are at the __________, and apexes are above the first ______. |
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The right lung has ___ lobes, the left lung has __. |
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where o2 and co2 exchange occurs |
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a detergent-like phospholipid which reduces the surface tension between the moist membranes of the alveoli, preventing their collapse. When __________ production is reduced, the lung becomes stiff and the alveoli collapse; |
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Pleura Visceral Pleura Parietal Pleura |
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1- serous membrane lining; _____2_____ covers the lungs, and the ______3_____ lines the thoracic cavity. These two membranes are continuous with each other and form a closed sac. |
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on inspiration, intermittent sounds occurring when air moves through airways that contain fluid. Often heard in pneumonia or bronchitis. Classified as fine, medium, or coarse |
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continuous sounds heard on inspiration or expiration as air passes through airways constricted by swelling, secretions, or tumors. Classified as sibilant (whistling) or sonorous(snoring). Often heard in asthma or COPD. |
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procedure to drain excess pleural fluid, blood, or for diagnostic reasons. |
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low levels of oxygen in the blood |
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decreased tissue oxygenation |
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DO NOT increase O2 above _____ L/min for chronic lung patients unless it is ordered. |
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