NR226 Exam 1 type shit

Vocabulary-style flashcards covering key nursing concepts, clinical judgement steps, nursing diagnoses, legal/ethical rules, scope of practice, fluid and electrolyte management, IV fluids, and blood transfusion protocols from NR226 Units 1–3.

Clinical Judgement

A systematic decision-making approach nurses use to organize and provide patient care, built upon the foundation of the nursing process.

Recognize Cues

The first step of the Clinical Judgement Measurement Model, defined as noticing relevant data.

Analyze Cues

The second step of the Clinical Judgement Measurement Model, defined as interpreting what the collected data mean.

Prioritize Hypotheses

The third step of the Clinical Judgement Measurement Model, defined as ranking possible patient problems.

Generate Solutions

The fourth step of the Clinical Judgement Measurement Model, defined as planning nursing interventions.

Take Action

The fifth step of the Clinical Judgement Measurement Model, defined as implementing nursing care.

Evaluate Outcomes

The sixth step of the Clinical Judgement Measurement Model, defined as determining whether implemented care was effective.

NANDA-I

North American Nursing Diagnosis Association International; the official organization that maintains the accepted list of nursing diagnoses.

Concept Map

A non-linear visual tool showing relationships between ideas, such as linking a nursing diagnosis to its cause and evidence.

Problem-Focused Nursing Diagnosis

A 3-part diagnostic statement formatted as PES: Diagnostic Label + Related to (cause) + As evidenced by (signs/symptoms).

Risk Nursing Diagnosis

A 2-part diagnostic statement formatted as Diagnostic Label + Related to (etiology only), containing no 'as evidenced by' phrase because no symptoms exist yet.

Health Promotion Nursing Diagnosis

A 2-part diagnostic statement formatted as Label + As Evidenced By, used when a patient demonstrates evidence of enhanced wellness.

SMART Goals

Goal criteria used during the planning phase that are Specific, Measurable, Achievable, Relevant, and Time-bound.

Nurse-Initiated Interventions

Independent actions a nurse can perform without a provider order, such as client education, assisting with ADLs, and health promotion activities.

Healthcare-Provider-Initiated Interventions

Dependent nursing actions that require a provider's prescription or order to treat a medical diagnosis, such as medication administration and NG tube insertion.

Collaborative Interventions

Interdependent nursing actions that require the combined expertise of a multidisciplinary team, such as physical therapy or speech-language pathology referrals.

Direct Care

Hands-on therapeutic actions provided directly with the patient, including medication administration, hygiene, and patient education.

Indirect Care

Behind-the-scenes nursing actions performed on behalf of the patient, including documentation, hand hygiene, consulting other disciplines, and calling shift report.

Total Patient Care

A care delivery model in which one RN provides all aspects of care for a patient during a shift, best suited for patients benefiting from one consistent caregiver.

Patient-Centered Care (PFCC)

A multidisciplinary care model that increases safety by focusing on patient and family preferences, adapting care to cultural and religious practices.

Case Management

A care delivery model that coordinates services across disciplines to lower costs without compromising quality, best for patients with complex or chronic illnesses.

Autonomy

A professional nursing concept referring to independence, self-direction, and the client's right of self-determination (e.g., informed consent, right to refuse care).

Authority

The legal power to act in nursing, originating from education, licensure, state law, and workplace policy.

Accountability

Ownership of one's actions ('I did that') regardless of the outcome.

Beneficence

An ethical principle defined as doing or promoting good and acting in the client's best interest.

Justice

An ethical principle defined as treating all clients fairly and equally, including equitable distribution of time, staffing, and supplies.

Nonmaleficence

An ethical principle defined as avoiding harm, maintaining professional competence, and reporting suspected abuse or impaired colleagues.

Living Will

An advance directive that states a client's preferences for future medical treatment if they become unable to decide for themselves; can be revoked at any time.

Durable Power of Attorney for Healthcare

An advance directive that names a designated proxy or agent to make healthcare decisions if the client becomes incapacitated.

Unlicensed Assistive Personnel (UAP) Scope

Assistance with basic hygiene, grooming, ADLs, measuring I&O, reporting concerns, and taking vital signs on STABLE clients; restricted to non-invasive tasks without sterile technique.

Licensed Practical Nurse (LPN) Scope

Care for stable/chronic patients with expected outcomes, reinforcing teaching, discussing findings with the RN, and administering meds within scope; CANNOT give IV push (IVP) meds or chemotherapy.

High Priority

A priority setting level involving immediate threats to survival or safety, such as emergent or life-threatening conditions.

Intermediate Priority

Non-emergent, non life threatening but needs prompt intervention to prevent deterioration (acute urinary elimination problems, abnormal labs, infection risk, mental status changes)

Low Priority

May or may not relate directly to the illness, important but addressed after high level concerns; long-term interventions.

Malpractice

A type of unintentional tort (negligence) defined as injury to a client resulting from a nurse's failure to provide the expected level of care.

Negligence (Unintentional)

Failure to take proper care in doing something, leading to injury or damage. In nursing, it involves a breach of duty to uphold standards of care, resulting in harm to a patient.

Assault

An intentional threat or attempt to cause unwanted physical contact or harm, no physical contact.

Battery

An intentional tort involving physically harming or touching a client without consent (e.g., inserting an NG tube without consent).

False imprisonment

Unlawfully restricting or preventing a patient from leaving or moving freely without legal justification/proper authorization.

Invasion of Privacy

A quasi-intentional tort defined as exposing a client or failing to maintain confidentiality (e.g., leaving a door open during hygiene care).

Defamation

A false statement communicated to another person that damages someone’s reputation

Slander

Verbal defamation

Libel

Written defamation

Hypovolemia

Not enough fluid, concentration/osmolality is normal.

Treatment: Isotonic Fluids

Hypervolemia

Too much fluid, concentration/osmolality is normal.

Treatment: Diuretics, dialysis in severe cases.

High Osmolality

Blood too concentrated.

Treatment: Needs hypotonic fluid

Low Osmolality

Blood too dilute

Treatment: Needs hypertonic fluid

Blood osmolality normal range

280-300 mmol/kg

Urine specific gravity normal range

1.005-1.030

Hemoglobin normal adult range

13.8-17.2 g/dl

Normal Hematocrit

41-50%

Sodium osmolality range

Where sodium goes, fluid follows.

High NA = High osmolality.

Hydrostatic Pressure

Force pressing outward against a surface (push)

Osmotic Pressure

An inward pulling pressure directed toward a higher concentration of solutes.

Diffusion

Passive movement of particles

Active Transport

Uses energy to move electrolytes across cell membranes.

Fluid volume assessment: Hypervolemia

Crackles in lungs

JVD in hyper/hypovolemia

Hyper - JVD present/disintended neck veins

Hypo - Flat or poorly visible neck veins

Isotonic IV Fluids

Solutions with equal osmolality to blood.

0.9% Normal Saline

Lactated Ringers (LR)

D5W* iso but becomes hypo in body

Hypotonic IV Fluids

Solutions with lower osmolality than blood

0.25 % NaCl

0.45% NaCl

2.5% Dextrose

5% Dextrose

Hypertonic IV Fluids

Solutions with higher osmolality than blood.

D5 0.9% NaCl

D5 Lactated Ringers (D5LR)

D5 0.45% NaCl

Normal Sodium Range

135-145 mEq/L

Normal Potassium Range

3.5-5 mEq/L

Normal Magnesium Range

1.3-2.1 mEq/L

Normal Calcium Range

9-10.5 mg/dL

What volume should Potassium be diuluted in

In a large volume with at least 250-500 mL.

Undiluted K+ causes venous discomofrt/phlebitis

ALSO NEVER BOLUS OR IV PUSH POTASSIUM

Peripheral IV (PIV)

Standard short term access. site/size chosen based on fluid type, rate, patient age, duration, location.

PICC (Peripherally Inserted Central Catheter)

Placed at beside by RN or INR. Tip ends near the heart. 1-3 lumens.

Flush with >10 ml saline every shift

If Migrates out, do not push it back in

Central Line (subclavian, internal jugular, femoral)

Ends in superior vena cava, sterile insertion & dressing changes; requires consent;

risk for infection & DVT /blood clots

Port-A-Cath

Implanted device lasting months to years; client may swim/shower

Accessed/deaccessed monthly with heparin flush; lower infection risk than central

Central Venous Access

Indicated for difficult IV access, long-term infusions (chemo, antibiotics), caustic/vesicant meds, hemodynamic monitoring.

Confirm placement with CHEST X RAY.

Change dressing q3-7 days, flush with 10 mL saline every 24 hrs

Phlebitis

Chemical, mechanical, or bacterial inflammation of a vein.

Signs: redness, warmth, and pain along the vein site.

Infiltration

Leakage of non-vesicant IV fluid into subcutaneous tissue,

Signs: coolness, paleness, and swelling at the insertion site.

Extravasation

Leakage of IV fluid containing vesicants or additives into subcutaneous tissue.

Signs. coolness, swelling, and local tissue damage or sloughing.

Vesicant fluid: Fluids that cause blistering severe tissue injury if it leaks outside the vein

Autologous Transfusion

Patient receives their own-pre donated blood. Useful for planned surgery, Jehova’’s witness or rare blood types

Fresh Frozen Plasma

Replaces clotting factors - for bleeding risk from anticoagulants, liver disease, DIC

Blood storage

Refrigerated at 1-6 C, shelf life around 42 days

Transfusion Administration Essentials

Baseline vitals

Prime tubing with 0.9% normal saline only

START SLOWLY STAY WITH PATIENT FOR FIRST 15 MINS.

Documentation

TACO (Transfusion-Associated Circulatory Overload)

A transfusion reaction caused by fluid volume excess.

Signs: tachycardia, crackles, JVD, hypertension, edema, dyspnea, orthopnea, and hypoxia.

Treatment: Stop IVF, anticipate chest x ray, give diuretic, consider O2.

Prevention: Infuse slowly

Febrile Non-Hemolytic Reaction

The most common blood transfusion reaction, caused by recipient antibodies attacking donor WBCs.

Signs: fever, chills/rigors, headache, anxiety, and muscle pain.

Treatment: Stop infusion, assess, page provider, give acetaminophen, resume slowly with provider approval.

Acute Intravascular Hemolytic Reaction

A severe transfusion reaction caused by antibodies attacking donor RBCs.

Signs: fever, chills, low back pain, flushing, hypotension, hematuria, and oliguria.

Treatment: STOP INFUSION IMMEDIATELY AND DISCONNECT TUBING. Hang new NS line, notify provider

Anaphylactic reaction

Recipient anti-IgA antibodies attack donor plasma.

Signs: Hives, SOB, wheezing, cyanosis, hypotension, shock, death.

Treatment: STOP IMMEDIATELY, DISCONNECT, TREAT AS EMERGENCY

Mild Allergic

Antibodies attack donor plasma proteins

Signs: Flushing, itching, hives

Treatment: Stop transfusion, notify provider, resume slowly if mild & approved

Transfusion Reaction Universal Priority Step

Immediately STOP the blood product, disconnect the IV tubing, and hang a new line with $0.9\%$ normal saline before assessing the patient and calling the provider.

Informed Consent

Requires: Decision making capacity, understanding of risks vs benefits, purpose, procedure, details and alternatives.

Lack of Capacity

Impaired/disturbed mental status (schizo, dementia, intoxication) → cannot consent

AMA (Against Medical Advice)

Nurse must access capacity, educate on risks, document thoroughly if a patient chooses to leave.

Five Rights of Delegation

Assess the knowledge

Match tasks to the person’s skills

Communicate clearly: task, expected outcome, time frame

Listen attentively

Provide feedback.