Basic Care and Comfort Midterm

health

a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity

illness

a condition of poor health perceived or felt by an individual

wellness

an overall state of well-being or total health

acute disease

symptoms develop rapidly but the disease lasts only a short time

chronic disease

an ongoing condition or illness

3 levels of prevention

1. Primary

2. Secondary

3. Tertiary

primary prevention

Efforts to prevent an injury or illness from ever occurring.

secondary prevention

Efforts to limit the effects of an injury or illness that you cannot completely prevent.

teritary prevention

people who already have the disorder (prevents worsening or rolls back symptoms)

infection control

The methods used to eliminate or reduce the transmission of infectious organisms.

medical asepsis

practices designed to reduce the number and transfer of pathogens; synonym for clean technique

Standard Precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.

-hand hygiene and add ppe when necessary

airbone precautions

N95 mask for TB

-mask or respiratory protection device

-negative airflow

(measles, chicken pox, herpes, rubela)

droplet precautions

Must be followed for a patient known or suspected to be infected with pathogens transmitted by large-particle droplets expelled during coughing, sneezing, talking, or laughing.

-sugical mask and hand hygiene

-private room

-(Influenza, rubella, mumps)

contact precautions

practices used to prevent spread of disease by direct or indirect contact

-gown

-gloves

-private room

-(VRE and MRSA, C. diff, and scabies)

Protective precautions

barrier protection designed to prevent infection in clients who are severely compromised and highly susceptible to infection; also known as reverse isolation. low WBC's

-mask, gown, gloves

-positive airflow with >12 air exchanges, HEPA, filtration for incoming air

asepsis

absence of pathogenic microorganisms

communicable disease

a disease that is spread from one host to another

Hand Hygiene

washing hands with either plain or antiseptic soap and water and using alcohol-based hand rubs

Healthcare-associated infection (HAI)

an infection acquired within a healthcare setting during the delivery of medical care

afebrile

without fever

Antipyretics

Drugs that reduce fever

bradycardia

slow heart rate (less than 60 bpm)

tachycardia

fast heart rate

diaphoresis

excessive sweating

Dysrthymia

irregular or abnormal heart rate

fever/febrile

Increases the cellular metabolic rate & body temp.

100.4?

hypotension

abnormally low blood pressure

Hypertension

high blood pressure

-systolic under 90 mmhg

Hypothermia

abnormally low body temperature below 35 C and 95 F

orthostatic hypotension

Drop in blood pressure upon standing.

-drop in diastolic pressure by 10 mmhg within 2-5 mins of standing

oxygen saturation

a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood

pulse pressure

difference between systolic and diastolic pressure

pyrexia

raised body temperature; fever.

sphygmonanometer

instrument to measure blood pressure

hypoxemia

Low oxygen levels in the blood.

physical assessment

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems

General Survey

physical appearance, body structure, mobility, behavior

ausculatation

listening to sounds within the body

palpation

an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts

inspection

the act of examining or reviewing

percussion

tapping on a surface to determine the difference in the density of the underlying structure

adventitious breath sounds

Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.

Alopecia

hair loss

aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).

point of maximal impulse

The point on the chest wall over the heart at which the contraction of the heart is best seen or felt; normally at the fifth intercostal space in the left midclavicular line in adults

bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

cerumen

a waxy substance secreted by glands located throughout the external canal

-ear wax

clubbing

bulbous enlargement of distal phalanges of fingers and toes that occurs with chronic cyanotic heart and lung conditions

-lack of oxygen

distension

swelling

excoriation

Skin sore or abrasion produced by scratching or scraping

indurated

pertaining to an area of hardened tissue

jaundice

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood

murmurs

sounds created by abnormal, turbulent flow of blood in the heart

peristalsis

Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.

PERRLA

pupils equal, round, reactive to light and accommodation

petechiae

a small red or purple spot caused by bleeding into the skin.

stenosis

narrowing, stricture

thrill

palpable, vibratory sensation felt through the skin over the heart or a blood vessel

turgor

Elasticity of the skin

gallop

abnormal heart sound that mimics the gait of a horse; related to abnormal ventricular contraction

pallor

an extreme or unnatural paleness

Clinical Decision Making

Problem-solving approach that nurses use to define patient problems and select appropriate treatment.

critical thinking

thinking that does not blindly accept arguments and conclusions. Rather, it examines assumptions, discerns hidden values, evaluates evidence, and assesses conclusions.

the nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

nursing process vs clinical judgement model

The nursing process is a general framework for organizing patient care, while the Clinical Judgment Model focuses on how nurses think critically and make decisions about patient needs

nursing health history

Data collected about a patient's present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

objective data

information that is seen, heard, felt, or smelled by an observer; signs

chief complaint

the main reason for the patient's visit

review of symptoms

description of individual body systems in order to discover any symptoms not directly related to the main problem

complete bed bath

bath in which the entire body of a patient is washed in bed

partial bed bath

bath in which only certain body parts are bathed or in which the health care provider bathes those parts of the body that the patient is unable to bathe

perineal care

bathing genitals and surrounding area

oral care

care of the mouth, teeth, and gums.

stage 1 pressure ulcer

intact skin with nonblanchable redness

stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both

stage 3 pressure ulcer

full thickness tissue loss with visible fat

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

unstageable pressure ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

puncture wound

a deep hole made by a sharp object such as a nail

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

Evisceration

The displacement of organs outside of the body.

induration

abnormal hard spots

Nonblanchable erythema

Visible skin redness that persists with the application of pressure

abrasion

Scrape of the skin due to something abrasive

exudate

fluid, such as pus, that leaks out of an infected wound

laceration

a cut, tear

wound vac

A medical device that applies negative pressure to a wound to promote healing and prevent infections.

negative pressure wound therapy

activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid

deep tissue pressure injury

persistent non-blanchable deep red, maroon, or purple discoloration

Acidosis

pH below 7.35

blood is too acidic

alkalosis

pH above 7.45

blood is too basic

how does the body compensate for acidosis

- lungs remove CO2 --> hyperventilation (over venting) --> causes equation to shift to the left, making H+ levels decrease, meaning an increase in pH = back to normal

How does the body compensate for alkalosis?

- lungs retain CO2 --> hypoventilation (under venting) --> causes equation to shift to the right, making H+ levels increase, meaning a decrease in pH = back to normal

buffers

weak acids or bases that can react with strong acids or bases to prevent sharp, sudden changes in pH

colloids

substances such as large protein molecules that do not readily dissolve into true solutions

Crystalloids

salts that dissolve readily into true solutions

extracellular fluid (ECF)

fluid outside the cells; includes intravascular and interstitial fluids

extracellular fluid deficit

loss of body water through vomiting, diarrhea, excessive sweating. Dehydration