Fundamental Nursing Principles and Clinical Practice

Flashcards covering the fundamental nursing definitions, legal acts, patient rights, clinical procedures, vital signs, and physiological models from the lecture notes.

Nutrix

The Latin origin of the word Nurse, which means to nourish.

Nursing (Florence Nightingale's definition)

The act of utilizing the ENVIRONMENT of the patient to assist him in his recovery.

Profession

A calling that requires special knowledge, skill, preparation, and an extended education with a basic liberal foundation, growing out of society’s needs.

Caring

The most unique core characteristic of the nursing profession.

Change Agent

A professional nursing role that involves initiating changes or assisting clients to make modifications in themselves or in the system of care.

Nurse Practitioner

An expanded nursing role certified to make nursing assessments, perform physical examinations, and treat minor/self-limiting illnesses.

Philippine Nursing Act of 2002 (RA 9173)

The law responsible for the protection and improvement of the nursing profession through relevant education and humane working conditions.

Data Privacy Act of 2012 (RA 10173)

The law that protects the fundamental human right to privacy of communication and secures personal information in government and private sector systems.

Nursing Metaparadigm

The four major concepts that every nursing theory focuses on: 1. Person, 2. Environment, 3. Health, and 4. Nursing.

Prescriptive Theories (Situation-Producing)

Theories that deal with nursing actions and test the validity or certainty of specific nursing interventions.

Informed Consent Exceptions

Conditions under which written consent is not required: emergency cases with imminent risk, mass health programs for epidemics, or when compulsory by law.

Incompetency Priority List

The legal priority order for third-party signature: I. Spouse \rightarrow II. Child of legal age \rightarrow III. Either parent \rightarrow IV. Sibling of legal age \rightarrow V. Guardian.

Mistaken Entry Protocol

The procedure to correct a documentation error: draw a single line through the entry and write the words “mistaken entry” with initials; never use correction fluid.

Telephone Order (TO) Protocol

Strict legal protocol requiring only Registered Nurses (RNs) receive orders, dual verification by another RN, and countersigning by the physician within $24$ hours.

Nursing Process (ADPIE)

A cyclical and dynamic framework consisting of five phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Emergency Assessment

Assessment performed during acute crises focusing on the ABC framework: Airway, Breathing, and Circulation.

PES Format

A 3-part diagnostic statement structure consisting of Problem + Etiology + Signs/Symptoms.

CSMART Goals

The model for setting client goals: Client-centered, Specific, Measurable, Attainable, Realistic, and Time-bound.

Primary Prevention

Focuses on health promotion and protection in a prepathologic state (e.g., immunizations, quitting smoking, and regular exercise).

Tertiary Prevention

Occurs after disease manifestations to provide rehabilitation and halt further damage (e.g., physical therapy after a stroke).

General Adaptation Syndrome (GAS)

Hans Selye's model of systemic responses to stress involving the Stage of Alarm, Stage of Resistance, and Stage of Exhaustion.

Chemotaxis

The phase in the inflammatory process where injured tissues release chemical substances to attract phagocytes to the injury site.

First Intention (Primary Union)

Wound healing in clean-cut surgical incisions where edges are approximated, resulting in minimal scar tissue.

Medical Asepsis (Clean Technique)

Practices intended to confine a specific organism to a specific area and limit their number and growth.

Bacteremia

The simple presence of bacteria in the blood.

Nosocomial Infections

Healthcare-Associated Infections (HAIs) acquired in a hospital that were not present or incubating at the time of admission.

Airborne Precautions

Used for droplets smaller than $5$ microns (e.g., TB, Measles); requires negative air pressure, a closed door, and an N95 respirator.

PPE Doffing (Removing) Sequence

The correct order to take off equipment: 1. Gloves, 2. Protective Eyewear, 3. Gown, 4. Mask.

Epiglottis

A tissue flap at the entrance of the trachea that seals shut during swallowing to prevent aspiration.

Boyle's Law

The physics principle stating that the volume of a gas is inversely proportional to its pressure.

Hypoxemia

Reduced oxygen levels specifically within the blood.

PVD Treatment Order

The standard sequence for Chest Physiotherapy: Postural Drainage \rightarrow Percussion \rightarrow Vibration \rightarrow Removal of secretions.

Thermoregulation Center

The area regulated by the hypothalamus to maintain core temperature within $36.0^{\circ}C$ ($97^{\circ}F$) to $37.5^{\circ}C$ ($99.5^{\circ}F$).

Celsius to Fahrenheit Formula

$^{\circ}F = ( ^{\circ}C \times 9/5 ) + 32$.

Pulse Pressure

The mathematical difference between Systolic and Diastolic pressure (e.g., $120 - 80 = 40$).

Tachycardia

A heart rate above $100$ beats per minute.

Intracellular Fluid (ICF)

Fluid contained inside the cells, making up roughly $\frac{2}{3}$ of total body water.

Hyponatremia

Low sodium concentration in the Extracellular Fluid (ECF).

Macronutrient Energy Yields

Carbohydrates: $4\,kcal/g$; Proteins: $4\,kcal/g$; Fats/Lipids: $9\,kcal/g$.

Clear Liquid Diet

Contains fluids transparent at room temperature with minimal residue (e.g., clear broth, black coffee, gelatin).

Anuria

Complete absence of urine production, clinically defined as less than $50\,mL$ of output in $24$ hours.

Stress Incontinence

Involuntary escape of urine triggered by sudden increases in intra-abdominal pressure (e.g., coughing, sneezing).

Valsalva Maneuver

Voluntarily contracting abdominal muscles and fixing the diaphragm while closing the glottis; contraindicated in cardiac patients.

Paralytic Ileus

A condition where peristalsis is temporarily paralyzed after abdominal surgery or anesthesia, typically resolving in $24$ to $48$ hours.

Center of Gravity (Human)

Located in the center of the pelvis, approximately at the level of the second sacral vertebra ($S_2$).

Virchow's Triad

Three factors leading to deep vein thrombosis (DVT): 1. Venous Stasis, 2. Hypercoagulability, 3. Endothelial Injury.

Isometric (Static) Exercise

Muscle contraction without shortening the muscle or moving the joint (e.g., quad sets).

Bed Cradle

A frame placed over the bed to keep the weight of top linens off the patient's feet, useful for burn patients.

Sims' (Semi-Prone) Position

The standard position for administering enemas or inserting rectal suppositories, with the patient on the left side.

Gate Control Theory

Suggests a mechanism in the spinal cord's dorsal horn where non-painful sensory fibers (touch) can block pain impulses.

NREM Stage 4 (Delta Sleep)

The deepest sleep stage where growth hormone is released for tissue repair; the stage where bedwetting and sleepwalking occur.

Narcolepsy

A neurological condition marked by sudden attacks of REM sleep during waking hours, accompanied by cataplexy.

PLISSIT Model

A framework for addressing sexual health: Permission, Limited Information, Specific Suggestions, and Intensive Treatment.

Anticipatory Loss

A loss experienced psychologically and emotionally before the actual event takes place.

Disenfranchised Grief

Grief that occurs when a loss cannot be openly acknowledged or disclosed to society (e.g., suicide, abortion).

Rigor Mortis

The temporary stiffening of the body resulting from a lack of Adenosine Triphosphate (ATP) that begins $2$ to $4$ hours after death.

Algor Mortis

The gradual decrease of body temperature after death at a rate of approximately $1^{\circ}C$ ($1.8^{\circ}F$) per hour.

Pharmacodynamics

The study of the biochemical and physical effects of drugs on the body and their mechanisms of action.

Z-track Method

The specific technique required for all Intramuscular (IM) injections.

Bleb

A visible wheal on the skin surface that MUST form during a correct Intradermal (ID) injection.

Infiltration

IV complication where fluid leaks into tissue, characterized by site pain, swelling, coolness, and lack of blood return.

Stage 3 Pressure Injury

Full-thickness skin loss where adipose (fat) tissue and granulation tissue are visible, but bone/muscle are not.

Braden Scale

Standardized tool for pressure sore risk with six subscales; a score of $18$ or below indicates risk.

Harris Flush

A return flow enema used to expel flatus involving an alternating flow of $100$ to $200\,mL$ of fluid.

Rectal Tube Sizing (Adult)

A Fr. $22$ to $32$ tube inserted $3$ to $4$ inches into the anal canal.