Nursing Review Flashcards

Flashcards based on the lecture notes

Nursing Process

A systematic, rational method of planning and providing individualized nursing care.

Purposes of the Nursing Process

To identify a client’s health care status, to establish plans to meet needs, and to deliver specific nursing interventions.

Nursing

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities and populations.

Subjective Data

Data that can be elicited and verified only by the client; includes sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information.

Primary Source Data

Subjective data acquired directly from the patient.

Secondary Source Data

Data acquired from another individual (such as a family member).

Purposes of a Health Interview

To get information, to identify problems, to evaluate change, to teach, to provide support, and to provide counselling or therapy.

Directive Interview

A highly structured interview that elicits specific information, controlled by the nurse.

Non-Directive Interview

An interview where the client controls the purpose, subject matter, and pacing; used for rapport-building.

Closed Question

Restrictive questions that generally require only “yes” or “no” or short factual answers.

Open-ended Question

Questions that invite clients to elaborate, clarify, or illustrate their thoughts or feelings.

Neutral Question

A question the client can answer without direction or pressure from the nurse; open-ended.

Leading Question

A question that directs the client’s answer and may result in inaccurate data.

Stages of an Interview Opening or introduction

The stage of interview that establishes rapport and orients the interviewee.

Stages of an Interview Body or development

The stage of interview where the client communicates what he or she thinks, feels, knows, and perceives in response to questions from the nurse.

Stages of an Interview Closing

The stage of interview that terminates the interview when the needed information has been obtained

Gordon’s functional health pattern framework

A framework utilized to organize client data

Hand hygiene

A general term that applies to techniques like handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis

Objective Data

Information about the client that the nurse directly observes, including vital signs and data from physical assessment.

Vital Signs

Measurable signs of cardiopulmonary and thermoregulatory health status; includes temperature, pulse rate, respiratory rate, blood pressure, pain, and SP02.

Thermoregulation

The process controlled by the hypothalamus to maintain a stable internal body temperature.

Afebrile

Temperature is normal or without fever

Febrile

Temperature is above normal or the patient has fever

Pyrexia/Hyperthermia

Body temperature above the usual range; 37.5⁰C to 38.3⁰C

Hypothermia

Temperature below 36⁰C

Pulse

Wave of blood created by contraction of the Left Ventricle of the heart.

Peripheral pulse

A pulse located away from the heart (e.g. foot or wrist)

Apical pulse

A central pulse found at the apex of the heart; also referred to as the point of maximal impulse (PMI).

Bradycardia

Pulse rate of less than 60 beats/min.

Tachycardia

Pulse rate of more than 100 beats/min.

Respiration

The act of breathing involving inhalation and exhalation.

Tidal Volume

Amount of air a person takes in during normal inspiration and expiration

Blood Pressure

A measure of the pressure exerted by the blood as it flows through the arteries.

Hypertension

blood pressure that is persistently above normal.

Hypotension

blood pressure that is below normal.

Orthostatic hypotension

A blood pressure that falls when the client sits or stands.

SP02

A non-invasive technique that measures the oxygen saturation (SpO2) of arterial blood.

Pain

Whatever the experiencing person says it is; existing whenever he or she says it does

Acute Pain

Recent onset, self-limiting, reversible, or controllable

Chronic Pain

Non-cancer or Cancer Pain

Inspection

Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner.

Palpation

Examination of the body using the sense of touch.

Percussion

Striking of the body surface with short, sharp strokes in order to elicit palpable vibrations and characteristic sound.

Auscultation

Listening to sounds produced within the body.

Skin Turgor

Indicative of status of hydration of the body; Done by pinching skin