Term
| Therapeutic Communication |
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Definition
Offering Self
Open-ended questions
Broad Openings
Offering General Leads
Reflection
Focusing
Seeking Clarification |
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Term
| Therapeutic Communication |
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Definition
Verbalizing the Implied
Placing an Event in Sequence
Encouraging Comparison
Opening Remarks
Silence
Summarizing
Looking at Alternatives |
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Term
| Non-Therapeutic Communication |
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Definition
False Reassurance
Giving Advice
Changing the subject
Being Moralistic
Requesting an Explanation
Closed-ended questions |
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Term
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Definition
Rationalization
Compensation
Displacement
Projection
Repression |
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Term
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Definition
Conversion Reaction
Regression
Identification
Denial
Introjection |
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Term
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Definition
Radiation - loss of heat thru infrared rays.
Conduction - transfer from one object to another.
Convection - loss of heat thru air currents.
Evaporation - loss as water transforms to gas. |
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Term
| Factors affecting body temperature? |
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Definition
Age
Environment
Time of Day
Exercise
Stress
Hormones |
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Term
| Methods for taking temperature? |
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Definition
Oral
Rectal
Tympanic
Axillary
Temporal artery (forehead) |
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Term
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Definition
| Contraction of the left ventricle ejects blood into the aorta causing a pulse wave to travel along the blood vessels. |
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Term
| Factors affecting the pulse? |
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Definition
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Term
| Sites for pulse readings? |
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Definition
Temporal
Carotid
Apical
Brachial
Femoral
Radial
Popliteal
Dorsal |
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Term
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Definition
| Pulse rates above 100 bpm in adults. |
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Term
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Definition
| Pulse rates below 60 bpm in adults. |
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Term
| What is the "quality" of a pulse? |
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Definition
The strength of the pulsations.
0 - no pulse
1+ - thready, weak pulse
2+ - difficult to palpate
3+ - normal pulse
4+ - bounding, hyperactive pulse |
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Term
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Definition
When a ventricular contraction does not perfuse the body adequately, the nurse will see a difference between the apical and radial pulse.
*The radial pulse rate is always lower than the apical pulse rate when pulse deficit is present. |
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Term
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Definition
| Respiration rate above 20 breaths per min. |
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Term
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Definition
| Respiration rate less than 12 breaths per min. |
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Term
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Definition
| Absence of respirations (over a specific period of time). |
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Term
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Definition
| Respirations that require excessice effort. |
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Term
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Definition
| Normal respiratory rhythm and depth. |
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Term
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Definition
| Cyclic breathing pattern characterized by shallow breathing alternating w/ periods of apnea. |
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Term
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Definition
| Cyclic breathing pattern characterized by periods of resp. of increased rate and depth alternating with apnea. |
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Term
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Definition
| Increased rate (+12bpm) and depth of respirations. |
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Term
| What is "blood pressure"? |
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Definition
| The force that blood exerts against the walls of the blood vessels. |
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Term
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Definition
| Contraction of the heart muscles, especially the venticles. |
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Term
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Definition
| After the contraction of the heart muscle...when the chambers are filling back up with blood. |
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Term
| Factors affecting blood pressure? |
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Definition
Age
ANS
Circulatory vol.
Medications
Normal fluctuations |
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Term
| Contraindications to taking BP? |
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Definition
IV lines (use opposite)
Mastectomy
Patient has been active in the last 15 mins (must sit still for 5 mins)
Patient has just eaten, drank caffeine or used nicotine product. |
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Term
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Definition
Phase I - Systolic pressure
Phase V - Diastolic pressure
Auscultatory Gap - Btwn Phase I & II; absence of sounds. |
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Term
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Definition
| Readings between 120/80 - 139/89 mm Hg |
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Term
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Definition
| Chronically elevated BP, +140/90 mm Hg |
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Term
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Definition
| Readings below 100/60 mm Hg |
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Term
| What is oxygen saturation? |
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Definition
The percentage of hemoglobin that combines with oxygen.
Normal = <95% SaO2
Abnormal = >93% |
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Term
| Factors affecting pulse oximetry? |
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Definition
Room lighting
Patient motion
Cigarette smoking
dark nail polish
CO poisoning
Edema |
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Term
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Definition
| When tissue or nerves suffer damage. |
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Term
| Physiologic responses to pain? |
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Definition
| Increased BP, HR, RR, neuroendocrine & metabloic responses ("Stress Response"). |
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Term
| Behavioral responses to pain? |
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Definition
verbal recognition
non-verbal: rubbing, grimacing, immobilization |
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Term
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Definition
Numeric rating scale (NRS)
Verbal descriptor scale
faces pain scale (FPS)
Wong-Baker FACES Pain Rating Scale is useful for assessing children under 8. |
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Term
| Factors influencing communication |
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Definition
Congruent relationships (good fit)
Incongruent relationships (mixed messages)
language - body & verbal
culture & experience |
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Term
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Definition
| Decisions about nursing & healthcare are made collaboratively; informal contractual model. |
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Term
| Elements of Communication |
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Definition
1. Sender
2. Receiver
3. Message
4. Feedback |
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Term
| Phases of the nurse-patient relationship |
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Definition
1. Orientation - intro, establish trust, rapport
2. Working - explore & develop solutions
3. Termination - closure of relationship |
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Term
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Definition
Situation - What is happening?
Background - Previous circumstances?
Assessment - What's the problem?
Recommendation - How to correct problem? |
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Term
| Data for a patient's chart should be... |
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Definition
Accurate
Complete
Concise
Objective
Organized
Timely
Legible
Factual |
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Term
| Patient Care Summary (Kardex) |
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Definition
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Term
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Definition
| Nursing history and physical assessment |
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Term
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Definition
| Tables designed to document routine assessments & procedures (vitals, I/O, etc) |
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Term
| Charting By Exception (CBE) |
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Definition
| Only records findings that fall outside of the standard of care and institutional norms. |
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Term
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Definition
| Reflect a specific problem being addressed or the care provided over a specific period. |
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Term
| 5 elements of an Informal Nurse-Client Contract |
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Definition
1. Nurse & patient know/use each other's names.
2. Roles & responsibilities are clarified.
3. Parameters of the professional relationship are clear.
4. Mutual expectations are agreed on.
5. Circle of confidentiality is respected. |
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Term
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Definition
| Records documentation of relevant patient or nursing activities throughout a shift or during a single visit. |
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Term
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Definition
A progress note that relates only to one health problem.
S - subjective
O - Objective
A - Assessment
P - Plan
I - Intervention
E - Evaluation
R - Revision |
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Term
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Definition
D - Data
A - Action
R - Response |
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Term
| How one pictures and feels about their body |
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Definition
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Term
| How people feel about themselves |
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Definition
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Term
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Definition
| The awareness that one is a distinct individual separate from others. |
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Term
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Definition
| The degree of confidence a person has about their ability to perform specific activities. |
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Term
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Definition
| A person's expected characteristic behavior in a social position. |
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Term
| Factors that affect self-concept |
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Definition
Biological make-up
Culture, values, & beliefs
Coping & stress tolerance
Self-efficacy
Previous experience
Developmental level |
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Term
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Definition
-Role ambiguity: lacks knowledge of role expectations, fostering anxiety & confusion.
-Role strain: perceived as inadequate or unsuited for a role.
-Role conflict: expected to fulfill two roles at one time, expectations differ, role differs from personal values. |
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Term
| Manifestations of altered self-concept |
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Definition
Self-care deficit
Emotional & behavioral changes
Anxiety & depression
Self-destructive behavior
Decreased eye contact
Critical/angry |
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Term
| Erikson's developmental stages affecting adults |
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Definition
Intimacy vs. isolation (stage 6)
Generativity vs. self-absorption (stage 7)
Integrity vs. despair (stage 8) |
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Term
| Comfortable sense of self |
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Definition
1. Awareness of personality, values, etc
2. Awareness of physical characteristics
3. Awareness of multiple roles
4. Ability to self-evaluate
5. Maintain interpersonal boundaries |
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Term
| Methods to enhance patient's self-concept |
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Definition
1. Establish trusting relationship
2. Encourage patient to express freely
3. Show acceptance of feelings
4. Meet physical needs
5. Address psychological needs (respect privacy, treat w/ dignity & respect, encourage independence).
6. ID strengths |
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Term
| Application of Nursing Process in patient's w/ altered self-concept |
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Definition
Normal pattern Identification
- "Are you experiencing changes in your body?"
Risk Identification
-Patient's previous experience, developmental level, etc.
Dysfunction Identification
- Assessment of thoughts & feelings
- Abnormal answers from normal pattern ID |
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Term
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Definition
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Term
| Nursing interventions that enhance sexual well-being |
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Definition
1. Promote open discussions
2. Data collection re: sexual history
3. Managing of sexual needs of resident
-private rooms, private time, sign on door, spouse in same room |
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