foundations hesi

no; not

a/an

self

aut

complete through

dia

bad, painful, difficult, abnormal

dys

within

endo

above, upon, on

epi

outside

expo

excessive, more than normal, too much

hyper

below, less than normal, under

hypo

all

pan

surrounding

pen

before, forward

pro

back

re

behind

retro

below, under

sub

across, through

trans

digestive

organ that bring food into the body and break it down to enter the bloodstream or eliminate it through the rectum and anus

endocrine

organs that produce (secrete hormones)

nervous

organs that transmit electrical impulses throughout the body

skin

outer covering that protects the body

laparosopy

visual examination of the abdomen, small incisions are made near the navel, and an instrument (endoscope or laparoscope) is inserted to view abdominal pains

laparotomy

incision of the abdomen, the surgeon makes a large incision to examine and operate on its organs

laminectomy

removal of a piece of backbone (lamina) to relive pressure on nerves from a herniating disc

laparoscope

an instrument to visually examine the abdomen, the endoscope is inserted through a small incision in the abdominal wall

pharygneal

pertaining to the pharynx (throat)

laryngeal

pertaining to the larynx (voice box)

diaphragmatic

of involving or resembling a diaphragm

pleural

pertaining to the pleura

cervical

neck region

thoracic

chest region

lumbar

loin or waist region

coccygeal

coccyx or tailbone region

superior

above

posterior

back side

distal

far

medial

middle

dsyuria

painful or difficult urination

oliguria

when kidneys have a reduced capacity to make urine

urinary incontinence

compliant of any involuntary loss of urine (coughing or sneezing)

stress urinary incontinence

involuntary leakage of small volume of urine associated with increased inter-abdominal pressure

urinary tract infection

fifth most common health care associated infection

urine specimen results

color, clarity, odor, volume

indwelling catheters

a closed drainage system that comes in many different sizes, and is attached to a urinary drainage bag to collect the continuous flow of urine

ostomy

a surgical opening outside of the small intestine that contains your fecal matter

diagnostic errors

occurs during data collection, analysis of data cluster or patterns, and interpretation of choosing a nursing diagnostic statement

prioritization of nursing diagnosis

is a product of patient’s basic needs, making generalization on what seems more important, and relying on the patients and other caregivers to support a priority

nursing diagnosis statements

problem-focused, risk diagnosis, and health promotion

problem focused nursing diagnosis statement

or negative identify an undesirable human response to existing problems or concerns of a patient

risk diagnosis nursing statement

when there is an increased potential or vulnerability for a patient to develop a problem or complication

health promotion nursing diagnosis statement

and positive diagnosis identify the desire or motivation to improve health status through a positive behavioral change

nursing process steps (ADPIE)

assessment, diagnosis, planning, implementation, evaluation

assessment

involves as much information you can get from the patient, family, community

recognize cues

diagnosis

analyze cue, what is the problem?

planning

come up with a solution to fix or resolve the problem

implementation

take action and go through with the planning

evaluation

determine if the outcomes have been achieved

objective data

what the nurse or other healthcare profession observes or finds, from patient behavior or clinical setting,

subjective data

the patients words, signs & symptoms, perception

problem focused assessment

collected during rounding or while you administer patient care include quick screening to rule out or follow up on patient problems

ABC approach to see what the problem is

nursing diagnosis

a clinical judgement made by a registered nurse to describe a patients response or vulnerability to health conditions or life events that the nurse is licensed and component to treat

bladder distension

a condition to when the bladder becomes enlarged or inflamed

pelvic floor exercises

instructing a patient to tighten or relax a muscle group

comprehensive database

provides information on the overall status of a client’s health in addition to providing data about each individual body system

cultural considerations

obtaining a nursing health history requires cultural competence, involves self-awareness, reflective practice, and knowledge of a patient’s core cultural knowledge

digital removal of stool

Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.

2. Perform hand hygiene, pull curtains around bed, obtain patient’s baseline vital signs and assess level of comfort, auscultate bowel sounds, and palpate for abdominal distention before the procedure.

3. Explain the procedure and help patient lie on left side with knees flexed and back toward you.

4. Drape trunk and lower extremities with a bath blanket, and place a waterproof pad under buttocks. Keep a bedpan next to patient.

5. Perform hand hygiene and apply clean gloves; lubricate index finger of dominant hand with water-soluble lubricant.

6. Instruct patient to take slow, deep breaths. Gradually and gently insert index finger into the rectum and advance the finger slowly along the rectal wall.

7. Gently loosen the fecal mass by massaging around it. Work the finger into the hardened mass.

8. Work the feces downward toward the end of the rectum. Remove small pieces one at a time and discard into bedpan.

9. Periodically reassess patient’s pulse and level of comfort and look for signs of fatigue. Stop the procedure if pulse rate drops significantly (check agency policy) or rhythm changes.

10. Continue to clear rectum of feces and allow patient to rest at intervals.

11. After completion, wash and dry buttocks and anal area.

12. Remove bedpan; inspect feces for color and consistency. Dispose of feces. Remove gloves by turning them inside out and then discard.

13. Help patient to toilet or on a bedpan if urge to defecate develops.

14. Perform hand hygiene. Record results of procedure by describing fecal characteristics and amount.

15. Follow procedure with enemas or cathartics as ordered by health care provider.

16. Reassess patient’s vital signs and level of comfort, auscultate bowel sounds, and observe status of abdominal distention.

17. Place nurse call system in an accessible location within patient’s reach.

18. Raise side rails (as appropriate) and lower bed to lowest position.

opioid analgesics

slow peristalsis and contractions causing conspation

antibiotics

decrease intestinal bacterial flora resulting in diarrhea

laxatives or cathertics

promote defection (makes you go poop)

implementation skills

requires cognitive, interpersonal, and psychomotor skills as you direct and indirect nursing interventions

cognitive implementation skills

you apply these skills to ensure that no nursing action is automatic but instead is thought and patient-centered

interpersonal implementation skills

by developing a trusting relationship, expressing caring, and communicating clearly with patients and their families

psychomotor skills

require the integration of cognitive and motor skills

direct care interventions

nurses provide a wide variety of direct care measures, treatments or procedures performed through direct contact with a patient

activities of daily living, physical care techniques, counseling, and teaching

activities of daily living

usually performed during a normal day, toileting, ambulation, eating, dressing, bathing etc.

physical care techquies

involve the safe and competent administration of nursing procedures (turning, positioning, inserting a feeding tube, etc.)

counseling direct care interventions

helps patients use problem solving processes to recognize and manage stress and facilitate interpersonal relationships

teaching direct care interventions

patient education is the key to patient-centered care, a teaching plan is essential for every patient, especially when patients need to manage health care problems they are facing for the first time

writing expected outcomes (goal)

SMART- specific, measurable, attainable, realistic, timed

specific- expected outcomes

outcomes that reflect a specific patient behavior or response

measurable- expected outcomes

you must be able to measure or observe whether a change takes place in a patients status

attainable-expected outcomes

outcomes that are more achievable when you mutually set them with a patient

realistic - expected outcomes

set expected outcomes that are realistic and relevant for patients

timed- expected outcomes

set a time for each outcome to be met

factors influencing bowel elimination

diet

regular daily food intake helps maintain a regular pattern of peristalsis in the colon, fiber in the diet provides bulk in the fecal material

factors influencing bowel elimination

fluid intake

varies on the person but intake for men is 3.7 L per day and women intake is 2.7 L per day

factors influencing bowel elimination

psychological factors

during emotional stress the digestive process is accelerated, and peristalsis is increased, the side effects include diarrhea and gaseous distention

C diff

ranges from mild diarrhea to severe colitis,

most common type of healthcare related infection, removed by hand washing with soap and water

patients with c diff are moved to a prevent room placed in contact/enteric isolation precautions and have their own toilet

outcome (goal) & why is it used

a broad statement in that describes the desired change in a patients condition, perception, or behavior , short term , long term ,

often based on standards of care or clinical guidelines established for minimal state practice

clinical judgement in outcomes identification

prioritizing outcomes, role of health care team in setting outcomes

SMART model

steps for placing in feeding tube

1. Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement.

2. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2021).

3. Review patient’s medication record for orders for enteral feeding, a gastric acid inhibitor (e.g., ranitidine, famotidine, nizatidine), or a proton pump inhibitor (e.g., omeprazole).

4. Review patient’s medical record for history of prior tube displacement.

5. Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation.

6. Identify conditions that increase risk for spontaneous tube migration or dislocation: altered level of consciousness, agitation; retching, vomiting; nasotracheal suction.

7. Perform hand hygiene. Assess bowel sounds and perform abdominal examination.

8. Obtain pulse oximetry reading.

9. Note ease with which previous tube feedings infuse through tubing. Monitor volume of continuous enteral formula administered during shift and compare with ordered amount.

10. Assess patient’s or family caregiver’s knowledge, experience, and health literacy.

11. Perform hand hygiene and apply clean gloves. Be sure pulse oximeter is in place.

12. Verify tube placement.

sensory organs

parts of the body that receive messages from the environment and rely them to the brain so that we see, hear, and feel sensations

clinical decision in nursing diagnosis

When you approach a clinical problem, such as a patient who is less mobile and develops an area of redness over the hip, you make a clinical decision that identifies a patient problem (impaired skin integrity in the form of a pressure injury), and through clinical judgment you choose the best nursing interventions (e.g., skin care, special bed surface, and a turning schedule).

nursing process with nursing critical thinking

requires a nurse to use general and specific critical thinking competencies

critical thinking in evaluation

Look at all situations objectively. Use objective criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior.

critical thinking in real life scenarios

Critical thinkers question, are honest in facing personal biases, and examine information for answers and deeper meanings in order to understand their patients

nursing diagnosis - care plan

is a road map for delivering nursing care and demonstrates your accountability for patient care. By making accurate nursing diagnoses, your subsequent care plan communicates a patient’s health care responses to problems to all health care professionals and ensures high-quality care.

cultural dietary concerns

muslims don’t eat pork, or drink alcohol, and they fast during Ramadan- sunset to sunrise for a month

Christianity- some baptist don’t drink, some meatless days for lent

Hinduism- all meats, fish, shellfish with some exceptions, no alcohol

Judaism - pork, predatory fowl shellfish, (eat only with scales), rare meats blood (blood sausage), mixing of milk or dairy products with meat or meat utensils/dishes, must be kosher food prepared methods, 24 hr fasting for Yom Kippur,

mormons- alcohol, tobacco, caffeine like teas, coffee, soda

seventh day adventist church - pork, shellfish, fish, alcohol, caffeine, vegetarian

assist patient for oral feeding

first assess for aspiration

Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Have the patient flex the head slightly to a chin-down position to help prevent aspiration.

Feed patients with dysphagia slowly, providing smaller-size bites. Allow them to chew thoroughly and swallow the bite before taking another. More frequent chewing and swallowing assessments throughout the meal are necessary. Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patient’s readiness

steps for enteral feeding

1. Perform hand hygiene. Stand on same side of bed as naris chosen for insertion and position patient upright in high-Fowler position (unless contraindicated). If patient is comatose, raise head of bed as tolerated in semi-Fowler position with head tipped forward, using a pillow chin to chest. If necessary, have an AP help with positioning of confused or comatose patients. If patient is forced to lie supine, place in reverse Trendelenburg position.

2. Apply pulse oximeter/capnograph and measure vital signs. Maintain oximetry or capnography continuously.

3. Place bath towel over patient’s chest. Keep facial tissues within reach.

4. Determine length of tube to be inserted and mark location with tape or indelible ink. Some tubes have centimeter markings.

5. Prepare tube for intubation. NOTE: Do not ice tubes.

6. Prepare tube fixation materials (e.g., membrane dressing, tube fixation device, or precut piece of hypoallergenic tape, 10 cm [4 inches] long).

7. Apply clean gloves.

8. Option: Dip tube with surface lubricant into glass of room-temperature water or apply water-soluble lubricant (see manufacturer directions).

9. Offer patient a cup of water with straw (if alert and able to swallow).

10. Tube Insertion. Explain next steps and gently insert tube through nostril to back of throat (posterior nasopharynx). This may cause patient to gag. Aim back and down toward ear (see illustration).

11. Have patient take deep breath, relax, and flex head toward chest after tube has passed through nasopharynx.

12. Encourage patient to swallow small sips of water. Advance tube as patient swallows. Rotate tube gently 180 degrees while inserting.

13. Emphasize need to mouth breathe and swallow during insertion.

14. Do not advance tube during inspiration or coughing because it is more likely to enter respiratory tract. Monitor oximetry and capnography at this time

15. Advance tube each time patient swallows until desired length has been reached (see illustratio

16. Check for position of tube in back of throat using penlight and tongue blade.

17. Temporarily anchor tube to nose with small piece of hypoallergenic tape.

18. Keep tube secure and check its placement by aspirating stomach contents to measure gastric pH (see Box 45.14). Also measure amount, color, and quality of return.

Maslow’s hierarchy of needs

Self actualization, Self-esteem, love & belonging needs, safety & security, Physiological