Fundamentals of Nursing Study Guide

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Assessment:
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collecting vital signs, pain levels, other signs/ symptoms
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Diagnosis:
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nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis
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Planning:
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nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks)
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Implementing:
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following through with plan that was developed for the patient
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Evaluation:
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goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient
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Normal range for temperature
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96.8-100.4
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Normal range for pulse
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60-100
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Normal range for respirations
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12-20
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Normal range for BP
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100/60-140-90
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Normal range for pulse ox.
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>95%
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SOLER
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sit close, observe, lean forward, eye contact, relax
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Types of pain
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acute, chronic, cancer, by inferred pathology, idiopathic
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Pain threshold
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level of stimulus needed to produce the perception of pain
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Pain tolerance
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amount of pain a patient endures without its interference of ADLs
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Factors influencing pain
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age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors
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Behavioral responses to pain
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clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction
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Pharmacological pain relief
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analgesics (NSAIDS & non-opioids, opioids, adjuvants)
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NSAIDS & non-opiates
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has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction, possible liver failure
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Opioids
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pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status
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Naloxone (Narcan)
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opiate antagonist, reverses opioid induced resiratory depression
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Patient Controlled Analgesia (PCA)
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client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses
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Anesthetics
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depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local
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Basal metabolic rate (BMR)
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energy needed to maintain life
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Carbohydrates
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main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey
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Proteins
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essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance
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Fats
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triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential
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Water
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comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids
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Vitamins
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essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight
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Minerals
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inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport
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Free Radical Theory
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presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products
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Erikson’s 8 stages of development
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trust vs mistrust autonomy vs shame and doubt initiative vs guilt industry vs inferiority identity vs identity confusion intimacy vs isolation generativity vs stagnation integrity vs despair
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Pharmacokinetics
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the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions
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Medication absorption
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the passage of medication molecules into the blood from the site of administration
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factors that affect med absorption
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route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication
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meds are excreted through:
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kidney, liver, bowel, lungs, exocrine glands
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medication interactions
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when one med modifies the action of another
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Obese
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increased weight for height by 10% or more
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Morbid Obesity
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100% over weight for height
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Measurements for obesity
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waist size, BMI, ideal weight for height
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causes of obesity
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corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone
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management of obesity
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decreased food intake, increased physical activity
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definition of nursing
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an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems
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evidence based practice
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interventions nurses do that are based on evidence
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roles of nurse
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caregiver, advocate, educator, communicator, manager, autonomy and accountability
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definition of health
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state of complete physical, mental, and social well being not merely the absence of disease or infirmity
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communication-
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process by which people affect one another; exchange of info, ideas, feelings; basic component of human relationships; fundamental element of nurse-client relationship
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intrapersonal communication
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occurs within, self verbalization, self awareness, self talk, guided imagery
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interpersonal communication
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one on one interaction; most frequently used; exchange of idea, problem solving, decision making
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transpersonal communication
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persons spiritual domain; higher power; prayer, meditation, guided reflexion
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small group communication
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small number of people meet; committees; group meetings
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public communication
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with an audience; speaking at conferences; leading class
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elements of communication
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referent sender; message, receiver, channels, feedback, interpersonal
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forms of communication
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verbal, non-verbal
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factors influencing communication process
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developmental level, gender, values/ perception, personal space, territoriality, roles/ relationships, environment, congruence
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teaching
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interactive process that promotes learning
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purpose of teaching
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gaining new knowledge, change attitudes, adopt new behaviors, preform new skills,
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learning
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purposeful acquisition of new knowledge, attitudes, behavior, or skills
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need for nurse to teach client
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clarify info given by doc or other health care providers; has to be complete, accurate, and relevant; should be based on patient’s needs and learning ability
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cognitive learning
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includes all intelectual behavior/ requires thinking
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affective learning
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expression of feelings and acceptance of attitude, opinion, values
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psychomotor learning
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acquiring skills that require the integration of mental / muscular activity
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motivation to learn
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person’s desire/ willingness to learn
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ability to learn
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developmental / physical ability
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learning environment
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privacy, room temperature, lighting, noise, furniture, ventilation
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infection
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invasion of a susceptible host by pathogens or microorganisms. resulting in disease
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colonization
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occurs when a microorganism invades the host but doesn’t cause infection
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communicable disease
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the infectious process transmitted from one person to another
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symptomatic infection
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when the infection has signs and symptoms like fever, cough, etc
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asymptomatic infection
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when the infection does not cause any signs or symptoms, making the diagnosis difficult
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hand hygiene
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the most important technique used in preventing and controlling transmission of infection
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chain of infection
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infectious agent/ pathogen > reservoir/ source for pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host
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4 stages of infection
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incubation period, prodromal stage, illness stage, convalescence
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Latrogenic HAI
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from a procedure in a hospital
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Exogenous HAI
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from microorganisms outside the individual ( Salmonella)
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Endogenous HAI
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when patient’s normal flora becomes altered (C.diff)
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factors influenceing infection
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age, stress, disease process, treatment/ condition that compromise the immune system
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disinfection
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eliminates many or all microorganisms with exception of spores from inaminate objects
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sterilization
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complete elimination or destruction of all microorganisms including spores
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social patterns affecting hygiene
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ethnic, social, and family influences on hygiene patterns
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personal preferences affecting hygiene
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dictates personal hygiene practices for individual patients
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body image affecting hygiene
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a person’s subjective concept of his/her body appearance
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socioeconomic status affecting hygiene
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influences type and extent of hygiene practice used
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health beliefs and motivation
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motivation is the key factor in hygiene
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cultural variables in hygiene
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people from diverse cultures practice different hygiene rituals
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developmental stage in hygiene
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affects the patient’s ability to preform hygiene care
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physical condition in hygiene
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may lack physical energy / dexterity to preform self-care
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safety guidelines in hygiene
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communicate with team members; incorporate patient’s priorities; move from cleanest to less clean areas; use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood; test tempo of water or solutions; use principles of body mechanics and safe patient handling; be sensitive to invasion of privacy
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autonomy
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commitment to include clients in decisions
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beneficence
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taking positive actions to help others
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non-maleficence
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avoidance of harm/ hurt
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justice
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being fair
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fidelity
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agreement to keep promises
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professional nursing code of ethics
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a set of guiding principles that all members of a profession accept; helps professional groups settle questions about practice or behavior; includes responsibility, accountability, and confidentiality
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Values
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personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior
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deontology
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defines actions as right or wrong
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utilitarianism
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proposes that the value of something is determined by its usefulness
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feminine ethics
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focuses on the inequality between people
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ethic of care
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emphasizes the importance of understanding relationships, especially as they are revealed in narratives
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JCAHO’s ethical standards
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mandate that health care institutions provide multidisciplinary ethics committees or similar structures to write guidelines and policies, provides education, counselling, and support for staff on ethical issues
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how to process an ethical dilemma
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1. ask if this is an ethical dilemma 2. gather all relevant info 3. clarify values 4. verbalize problem 5. identify possible courses of action 6. negotiate a plan 7. evaluate plan
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quality of life
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central to discussions about futile care, cancer therapy, physician assisted suicide, DNR
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futile care
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interventions unlikely to produce benefit for the client
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allocating scares resources
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a key issue in discussions about access to care
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the nursing shortage
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produces difficult working conditions and affects client outcomes
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source of laws
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legal guidelines that come from statutory, regulatory, and common law
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standards of care
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legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care
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consent
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a signed form required for all routine treatment, hazardous procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language clients
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what does mobility mean?
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allows ability to move freely about; musculoskeletal and nervous systems working together to make movement; decreases risk for injury
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labs for obesity
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electrolyte/sodium/potassium, blood glucose, triglycerides, hemoglobin, serum albumin
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bariatrics-
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lap band reduction; gastric bypass
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lap band reduction
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removable, premanent life cange; can cause dehydration, electrolyte problem, backup into esophagus, blockage
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gastric bypass
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malabsorption surgery; can cause dehydration and electrolyte problems; overeating can cause dumping syndrome-food deposits into small intestines too quickly
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kidney/ renal disease
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not enough RBCs; anemia; metabolizes calcium and Vitamin D; ADL intolerance; risk for hyper/hypotension, anemia, soft bones, and fractures; caused by diabetes; patient has to out out at least 30mls per hour
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labs for kidney/ renal disease
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BUN, creatinine, GRF, Rennin, EPO
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oliguria
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patient has some form of renal failure; not producing as much urine as regular patient; strict I&Os
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anuria
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irreversible renal disease; need kidney transplant or dialysis; not producing urine; increased phosphorus in system
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polyuria
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excessive urine; sign of diabetes or hormone issue
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hematuria
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blood in urine; not a good sign
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nocturia
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voiding at night; early sign of hypertension; pressure on bladder during pregnancy
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peritoneal dialysis
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shunt placed in peritoneum; diasolate poured in peritoneum, about 1hr later diasolate, nitrogenous waste, fluid, electrolytes removed
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hemodialysis
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3 days out of week, 3-4 hr long process; blood circulated through the machine and nitrogenous waste, fluid, electrolytes removed; BP before and after treatment; weight before and after; can be used for drug overdose
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UTI causes
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E. coli, young and old women at risk; uncircumcised men (smegma); frequent sexual intercourse/ unprotected/ multiple partners; poor hygiene; HAI; med/surg related
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UTI s/s
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frequency/ urgency; burning pain when voiding; hematuria; fever; chills; nausea; vomiting; pyelonenephritis; malaise
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UTI treatment
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antibiotic- Siproflaxin; cranberry juice for prevention
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functional incontinence
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can’t make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule
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stress incontinence
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usually in women who didn’t do kegels during labor
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reflex incontinence
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on urge to go; it just comes out
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ESRD
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irreversible damage to kidney tissue
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uremic syndrome
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increase in nitrogenous wastes in the blood
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urinary incontinence
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can be temporary; affects everyone especially elderly
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causes of urinary incontinence
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urethral obstruction, surgical trauma, alterations in sensory/ motor innervation, medication side effects, anxiety
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dysuris
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pain or burning on urination
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nephrostomy
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urinary diversion; bypasses the ureters, bladder, urethra; used in patient with kidney stones, cancer, ureter problem, any GU problem
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urinalysis
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pH; protein; glucose; ketones; blood; specific gravity; WBCs; bacteria
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factors affecting bowel elimination
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age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics
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constipation
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stool gets lodged in the intestines; a symptom not a disease
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impaction
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result of unrelieved constipation; leaky drainage
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diarrhea
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liquid stool; associated with disorders affecting digestion, absorption, and secretion in GI tract
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incontinence
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inability to control passage of feces or gas through rectum
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loose stool
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chunks of stool
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pressure ulcers
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tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis
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stage 1 ulcer
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intact skin; red/irritation; unblanchable
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stage 2 ulcer
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broken skin; partial thickness; blister epidermis and dermis; can ooze
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stage 3 ulcer
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epidermis, dermis, and subQ tissue; oozing, signs of infection; full thickness loss
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stage 4 ulcer
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full thickness loss; can see organs/ bones; very painful
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granulation tissue
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healing tissue; looks beefy
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slough
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dead tissue; yellowish, brownish; makes wound unstageable; has to be debritied
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eschar
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necrotic/black; surgically removed
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xerosis
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dry skin; becomes reddish; low humidity; frequent washing
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pruritis
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chemical, allergic, physical agent; drugs, food, sweat-act on nerve fibers, releases histamine and affects itch receptors; insect bites, scabies, medication (opioid) , systemic effect
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uriticaria
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reddish, whitish, plaques edematous; usually show up on torso; usually caused by drugs, histamine, bed linen detergent
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health care delivery system
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complex, dynamic, constantly changing; past 10-15 yrs managed care, primary care provider; services provided by a wide variety of licensed/ non-licensed staff
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new philosophy of health care
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manage health; wellness and prevention
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old philosophy of health care
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manage illness; disease management
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school health
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support educational success by enhancing health
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occupational health
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health promotion, accident or illness prevention
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MD, APRN office
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annual PE and screening/ preventative education
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clinics
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screening to comprehensive care
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nursing centers
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focus on health promotion/ health education, disease prevention, chronic disease management, support for self-care and caregivers
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block and parish nursing
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services based on need vs availability of reimbursement; religous involvement
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primary care in community
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health professionals, community members, govt
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hospital and med centers
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inpatient services, diagnostic and treatment services
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psych facilities
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focus on clients with emotional / behavioral problems
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ICU
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close monitoring; 1:2 staffing; equipped with most advanced technology; staff educated in critical care principles/ techniques
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sleep
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purpose unclear; physiological and psychological restoration; maintenance of biological function; regulated by reticular activating system > regulates sleep cycle in hypothalamus
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dreams
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occur in NREM and REM; REM in color; important for learning, memory, and adopting to stress
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stage 1 of sleep
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4-5%; light sleep; muscle activity slows
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stage 2 of sleep
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45-55%; breathing and heart rate slow
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stage 3 of sleep
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4-6%; deep sleep
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stage 4 of sleep
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12-15%; very deep sleep; rhythmic breathing
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stage 5 of sleep
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20-25%; REM; brainwaves speed up and dreaming occurs; increased heart rate; rapid and shallow breathing
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changes in pattern affecting sleep
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illness (cardiac, resp, pain), RLS; food before bed; change in daily pattern
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insomnia
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more than 45 min to fall asleep/ trouble staying asleep
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narcolepsy
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falling asleep at inappropriate times
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sleep deprivation causes
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irritability, cognitive impairment, memory lapses/loss, severe yawning, s/s like ADHA, impaired immune system, risk of type 2 diabetes, increased heart rate variability, decreased reaction time and accuracy, tremors, aches, growth suppression, decreased temp, risk of obesity, hallucinations
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parasomnias
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night terrors, sleep walking/talking/eating/driving, bed wetting
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sleep apnea
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lack of airflow through mouth/nose >10sec during sleep; airway collapses, blocking airflow to lungs
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left sided failure
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blood backing up into lungs; shortness of breath; impaired gas exchange; hypertrophied left ventricle wall; coughing up blood; orthopnea; exertional dyspnea; cyanosis of extremities; paroxymal nocturnal dyspnea
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right sided failure
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lower extremity edema; dependent edema; HTN; daily weights; increased peripheral venous pressure; distended jugular veins; cyanosis of extremities; asites, GI distress
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treating CHF
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upright position, high semi fowlers; nitrates- vasodilate coronary arteries and myocardium (dizzy feeling, hypotension); Lasix- diuretic/ urine output; oxygen- when pulse ox. under 95%; ACE inhibitors- Vasotech, Nosinopro (check BP before admin, low potassium or under 60 bpm hold); Digoxin- slows heart rate; apical pulse before admin; nausea and vomiting; toxic if stays in blood for too long; cardiac glycocide- increases contraction, slows heart rate, increases CO and oxygen in blood; decrease fluids to 1500ml; decrease salt to 2000-3000mg; test dig level, ABGs, potassium
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myocardial ischemia
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chest pain, aching, associated with activity, pain leaves when patient rests
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stable angina
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predictable
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unstable angina
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spontaneous pain
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varient angina/ prinz metals
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occurs at rest (sort of constant)
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myocardial infarction
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pain (sudden onset, substernal, crushing/ tightness/severe; affects back, neck, jaw, arm, shoulder), dyspnea, syncope with low BP, shortness of breath, nausea, vomiting, sweating, increased heart rate, DENIAL
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treatment for MI
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stent angioplasty or balloon; thrombolytic therapy- breaks clot apart; M-morphine, O-oxygen, N-nitrates, A-aspirin
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hyperventillation (kussmaul)
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>40 RR; over-breathing, decreased CO2 leads to alkaline; panic attack, stress/anxiety, fever/infection, intense exercise
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treatment for hyperventillation
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have patient hold one nostril; try to reduce patient;s stress/panic; purse-lipped breathing
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hypoventillation
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decreased ability to remove CO2 from body; pH below 7.35; RR below 12; emphysema/ CVA; hypoxic
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treatment for hypoventillation
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if narcotic based, reduce/ discontinue; stroke- high fowlers/ oxygen; other meds to increase breathing
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hypoxia
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decreased tissue oxygenation; restlessness, anxiety, confusion, increased heart rate and RR
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chenye-strokes
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irregular breathing; altering rapid/apnea episodes; near death breathing pattern
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cardiac panel
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sodium, LDL/HDL, potassium, ABG, CKMB, triponin, C-Reactive, protein
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tamaflu
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stops flu virus multiplication; increases risk for self injury; take within 48 hr of onset
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avian flu
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H5N1; bird to human trough droppings, saliva, blood; stayed in Asia
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swine flu
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H1N1; person to person transmission; touching infected surfaces; nose/throat culture; vaccine
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laryngitits
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inflammation/ swelling of larynx; occurs as single problem or with resp infection; risk/irritant-smoking; dry coughing; voice changes; throat cultures to check for strep; comfort care
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arteriosclerosis
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hardening of arteries
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atherosclerosis
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affects intima of arteries; plaque froms and narrows lumen of arteries; pain when tissues don’t get oxygen
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causes of atherosclerosis
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lifestyle; HTN; smoking; diabetes; genetic
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lab work for atherosclerosis
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cholesterol; LDL/HDL, homocystine; C-Reactive protein
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treatment for atherosclerosis
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decreased cholesterol intake; smoking cessation; blood work; exercise
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peripheral artery disease
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caused by atherosclerosis; usually lower extremities; deprives lower extremities of oxygen; cramps and muscle pain with activity
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stage 1 PAD
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asymptomatic; Bruit may be present; toes cool to touch; slow capillary bed refill
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stage 2 PAD
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claudication; muscle pain/ cramping
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stage 3 PAD
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rest pain
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stage 4 PAD
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necrosis/ gangrene; loss of oxygen to toes > toes fall off/ need to be removed
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treatment for PAD
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Statins- help metabolize cholesterol; Crestor, Lipitor- muscle pain, leg pain, cramping, diarrhea
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deep vein thrombosis
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clots in the veins; usually in the extremities
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Virchow’s triad
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stasis-immobility, bed ridden, car/plane/ train travel vessel wall injury, fracture, trauma hypercoagulability- altered coagulation (birth control, hormone therapy, smokers, dehydration)
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s/s of PAD
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red, inflammed, shortness of breath, coughing, increased heart rate, sweating, anxious feeling
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pulmonary emboli
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complication of DVT
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treatment for pulmonary emboli
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prevention- anticoagulant therapy; thrombolytic therapy; surgery to remove thrombus

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