What are the techniques in interviewing process.
What are the techniques in interviewing process.Problem Seeking & Problem Solving, Direct &         Open-Ended Questioning
What are the three phases of a basic interview.
What are the three phases of a basic interview.Orientation, Working, and Termination Phase
What is the first step in nursing assessment.
What is the first step in nursing assessment.          Nursing Health History
Basic components of the nursing health history.
Basic components of the nursing health history.                  Bio. Info.         Reasons for seeking hxcare            ...
Hospitalization  Treatment  Outcomes   FamilyEnvironmental Psychosocial
Present Hx State & R.O.S.
What is the focus of nursing history.
What is the focus of nursing history.Effect of CHANGE in Hx state in meeting basic              human needs.
A statement of potential or actual patient problems.
A statement of potential or actual patient problems.                Nursing Diagnosis
Nursing diagnostic involves four elements.
Nursing diagnostic involves four elements.Analysis & Interpretation of data, Clustering ofData, Identification of Pt. Prob...
It requires validation and clustering of data.
It requires validation and clustering of data.           Interpretation of data
Determining whether data gathered is complete               and accurate.
Determining whether data gathered is complete               and accurate.             Validation of data
Grouping related data, usually sx & sy, indicating               a general problem.
Grouping related data, usually sx & sy, indicating               a general problem.                Clustering of data
A hx care problem that is currently perceived by        the pt. or assessed by the nurse.
A hx care problem that is currently perceived by        the pt. or assessed by the nurse.           Actual Hx Care Problem
A hx care problem in which the patient is at risk.
A hx care problem in which the patient is at risk.           Potential Hx Care Problem
When planning, a nurse should consider the levelof potential pt. involvement, time limit and what?
When planning, a nurse should consider the levelof potential pt. involvement, time limit and what?      Available Hx care ...
In implementation of the NCP, what actions are                    taken.
In implementation of the NCP, what actions are                     taken.   Assist Pt. on ADL, Counsel & support Pt. & fam...
conducive.
Interventions based on instructions or written  directives given by another professional.
Interventions based on instructions or written  directives given by another professional.          Dependent Intervention
Aspects of care encompassed by licensure and law.
Aspects of care encompassed by licensure and law.            Independent Intervention
Interventions that the nurses carry out incollaboration with another professional.
Interventions that the nurses carry out incollaboration with another professional.      Interdependent Intervention
True or False. The NCP is modified as the Ptsstate of Hx changes and as needs for care changes.
True or False. The NCP is modified as the Ptsstate of Hx changes and as needs for care changes.                      True
In evaluation of NCP, outcomes of nursing       interventions maybe used for.
In evaluation of NCP, outcomes of nursing       interventions maybe used for.            Malpractice suits            Staf...
Promotions Nursing ResearchQuality Improvement
What are the enrivonmental fire safety            precautions?
What are the enrivonmental fire safety            precautions?           Mark fire exits          Dont use elevator       ...
Move pts. by bed, stretcher, or wheelchair
What are environmental radiation safety             precautions?
What are environmental radiation safety             precautions?      Label radioactive materials           Limit time spe...
Use lead apronNever touch dislodged implants
What are environmental precautions for disposing               infectious wastes?
What are environmental precautions for disposing               infectious wastes? Needles should not be recapped, bent or ...
Green for biodegradable      Black for nonbiodegradableRed for blood, sharp items, contaminated
It is to restrict client movement through the            application of a device?
It is to restrict client movement through the            application of a device?             Physical restraints
Medications given to inhibit specific behavior?
Medications given to inhibit specific behavior?             Chemical restraints
Restraints should have?
Restraints should have?   Reason & method   Date & time of useDuration & release from it
Assessment of pts response & further need of useHalf bow or safety knot & secured to the bedframe                     or c...
Restraints should not be?
Restraints should not be?P.R.N. & without consent from the pt. & family
Neurovascular, circulatory & skin integrity is     assessed in using restraints when?       Then removed at least every?
Neurovascular, circulatory & skin integrity is      assessed in using restraints when?        Then removed at least every?...
Who are those prone to accidental poisoning?
Who are those prone to accidental poisoning?                 Toddlers               Preschoolers             Young school ...
In older adults, poisoning & overdose of      prescribed medz. will yield?
In older adults, poisoning & overdose of      prescribed medz. will yield?         Diminished eyesight          Impaired m...
If lye, grease, petroleum or household cleaner is             ingested, a nurse should?
If lye, grease, petroleum or household cleaner is             ingested, a nurse should?Never induce vomit especially to an...
Nosocomial infections can be transmitted by a        healthcare personnel by?
Nosocomial infections can be transmitted by a        healthcare personnel by?         Improper handwashing     Unchanged g...
Standard precautions apply to?
Standard precautions apply to?            Blood       Non-intact skin     Mucous membrance All body fluids except sweat
Diseases under transmission based precautions                    are?
Diseases under transmission based precautions                    are?                 Measles           Chickenpox (varice...
T.B.
Droplet precautions diseases are?
Droplet precautions diseases are?     Adenovirus, Influenza     Sepsis, Scarlet Fever      Epiglottitis, Mumps          Me...
Barrier protection for transmission based droplet                 precautions is?
Barrier protection for transmission based droplet                 precautions is? Placing client in private room or cohort...
Transmission based contact precautions diseases                     are?
Transmission based contact precautions diseases                     are?            Clostridium Difficle      INFxN with m...
Cutaneous diptheria Herpes simplex     Impetigo    Pediculosis      Scabies Staphylococcus
Varicella Zoster Conjunctivitis
Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that                    tur...
Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that                    tur...
In case of fire, a nurse should               R-               A-               C-               E-
In case of fire, a nurse should           R-rescue           A-alarm          C-confine         E-extinguish
Head tilt-chin lift is used in B.L.S. but if pt. has a          neck injury, what do you use?
Head tilt-chin lift is used in B.L.S. but if pt. has a          neck injury, what do you use?               Jaw thrust man...
A.B.C.D.s of B.L.S. are:
A.B.C.D.s of B.L.S. are:                Airway              Breathing              CirculationDefibrilation or Definitive ...
Each step begins with ASSESSMENT always
Apical & radial pulse will always yield?
Apical & radial pulse will always yield?            Identical result
In assessing for a pulse to an      infant < 1 yr old?     a child > 1 yr old?
In assessing for a pulse to an      infant < 1 yr old?     a child > 1 yr old?      Brachial (<1yr)      Carotid (>1yr)
For infants on B.L.S., chest compression is 1/2 - 1     inch deep @ least 100 times/min using?
For infants on B.L.S., chest compression is 1/2 - 1     inch deep @ least 100 times/min using?                   2-3 finge...
When performing a Heimlich Maneuver to an   obese or pregnant, what do you do?
When performing a Heimlich Maneuver to an   obese or pregnant, what do you do?              Chest thrusts
For unconscious adult (B.L.S.), you do a?
For unconscious adult (B.L.S.), you do a?            Tongue jaw lift          Fingersweep object
For unconscious pregnant, a pillow or rolled   blanket is placed on the right side to?
For unconscious pregnant, a pillow or rolled   blanket is placed on the right side to? Displace uterus to the left of the ...
Unconscious pregnant needing defibrilation shouldhave the paddles placed 1-rib higher than the usual                     b...
Unconscious pregnant needing defibrilation shouldhave the paddles placed 1-rib higher than the usual                     b...
This is used to convert ventricular fibrilation into a                 perfusing rhythm?
This is used to convert ventricular fibrilation into a                 perfusing rhythm?         Automated External Defibr...
Automated External Defibrilator is C/I to?
Automated External Defibrilator is C/I to?               < 8 yrs old        Child weighing < 25 kgs.
A surgeon is responsible for getting consent & anurse can be a witness provided the pt. understood the procedures explaine...
A surgeon is responsible for getting consent & anurse can be a witness provided the pt. understood the procedures explaine...
In general anesthesia, solid & liquid foods are                withheld for?
In general anesthesia, solid & liquid foods are                withheld for?                6-8 hrs. prior        Local an...
When is enema or laxative performed in clients for                    surgery?
When is enema or laxative performed in clients for                    surgery?             The night prior surgery
If client has a Foley catheter before surgery, it      should be emptied & document the?
If client has a Foley catheter before surgery, it      should be emptied & document the?    Amount & characteristics of th...
3 levels of moral development (premoral or preconventional level, conventional level,          postconventional level).
3 levels of moral development (premoral or preconventional level, conventional level,          postconventional level).   ...
4 conservation principles (conservation of energy, structural integrity, personal integrity, and social                   ...
4 conservation principles (conservation of energy, structural integrity, personal integrity, and social                   ...
4 types of personality (sanguine, melancholic,            phlegmatic, choleric).
4 types of personality (sanguine, melancholic,            phlegmatic, choleric).                   Galen
5 hierarchy of needs (physiological, safety &security, love & belonging, self esteem, self               actualization).
5 hierarchy of needs (physiological, safety &security, love & belonging, self esteem, self               actualization).  ...
Adaptation model. Each person is a unifiedbiopsychosocial system in constant interaction        with changing environment.
Adaptation model. Each person is a unifiedbiopsychosocial system in constant interaction        with changing environment....
All behavior is learned.
All behavior is learned.     B.F. Skinner
Believed that nurse helps patients meet a perceived  need that the patient cannot meet themselves.
Believed that nurse helps patients meet a perceived  need that the patient cannot meet themselves.                Ida Jean...
Birth trauma.
Birth trauma. Otto Rank
Care, Core, Cure.
Care, Core, Cure.  Lydia Hall
Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal                 operations).
Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal                 operations).   ...
Conceptualized the behavioral system model. Each  person is composed of 7 subsystem (ingestive, eliminative, affiliative, ...
Conceptualized the behavioral system model. Each  person is composed of 7 subsystem (ingestive, eliminative, affiliative, ...
Developed self-care and self-care deficit theory.
Developed self-care and self-care deficit theory.                Dorothea Orem
Developmental task.
Developmental task.Robert Havighurst
Focused on manipulating the environment for the             patients recovery.
Focused on manipulating the environment for the             patients recovery.             Florence Nithingale
Founded psychobiology. Believes in totality of          man/holistic approach.
Founded psychobiology. Believes in totality of          man/holistic approach.                Adolf Meyer
Goal attainment theory. Nursing as a helping                profession.
Goal attainment theory. Nursing as a helping                profession.              Imogene King
Health as expanding consciousness. Humans areunitary beings in whom disease is a manifestation             of the pattern ...
Health as expanding consciousness. Humans areunitary beings in whom disease is a manifestation             of the pattern ...
Health care system model. Nursing is concerned with all the variables affecting an individuals  response to stress, which ...
Health care system model. Nursing is concerned with all the variables affecting an individuals  response to stress, which ...
Human becoming. Emphasized free choice ofpersonal meaning in relating value priorities.
Human becoming. Emphasized free choice ofpersonal meaning in relating value priorities.           Rosemarie Rizzo Parse
Human caring model. Nursing is the application of the art and human science through transpersonal                     cari...
Human caring model. Nursing is the application of the art and human science through transpersonal                     cari...
Humanistic nursing practice theory. Nursing is an            existential experience.
Humanistic nursing practice theory. Nursing is an            existential experience.      Josephine Paterson & Loreta Zderad
Identified 14 basic needs. Nurse functions to assist   client in performing activities contributing to        health, reco...
Identified 14 basic needs. Nurse functions to assist   client in performing activities contributing to        health, reco...
Identified 21 nursing problems. Defined nursing as   service to individuals and families, therefore,                      ...
Identified 21 nursing problems. Defined nursing as   service to individuals and families, therefore,                      ...
Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between                 sick and ...
Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between                 sick and ...
Interpersonal theory (anxiety occurs due to poor          interpersonal relationship).
Interpersonal theory (anxiety occurs due to poor          interpersonal relationship).             Harry Stack Sullivan
Introversion and extroversion - persona/anima
Introversion and extroversion - persona/anima                 Carl Jung
Modeling and role-modeling theory.
Modeling and role-modeling theory.Helen Erickson, Evelyn Tomlin & Mary Ann                  Swain
Nurses individual philosophy lends credence to                 nursing care.
Nurses individual philosophy lends credence to                 nursing care.            Ernestine Weidenbach
Presented grand theory of nursing. All persons are caring and nursing is a response to unique social                      ...
Presented grand theory of nursing. All persons are caring and nursing is a response to unique social                      ...
Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido isthe psychic reservoir ...
Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido isthe psychic reservoir ...
Psychosocial development (trust vs. mistrust,   autonomy vs. shame/doubt, initiative vs. guilt,industry vs. inferiority, i...
Psychosocial development (trust vs. mistrust,   autonomy vs. shame/doubt, initiative vs. guilt,industry vs. inferiority, i...
Erik Erickson
Superinferiority and inferiority complex / birth                    order.
Superinferiority and inferiority complex / birth                    order.                 Alfred Adler
The science of unitary human beings. Humanbeings are more than and different from the sum of                    their parts.
The science of unitary human beings. Humanbeings are more than and different from the sum of                    their part...
Theory based on bodily characteristics(endomorphic, mesomorphic, ectomorphic).
Theory based on bodily characteristics(endomorphic, mesomorphic, ectomorphic).            William Sheldon
Transcultural nursing. Nursing is a humanistic andscientific mode of helping a client through specific             cultura...
Transcultural nursing. Nursing is a humanistic andscientific mode of helping a client through specific             cultura...
Pulsating abdominal mass
Pulsating abdominal massAbdominal Aortic Aneurism
Painful board-like abdomen
Painful board-like abdomen    Abruptio Placenta
Uremic frost on skin
Uremic frost on skinAcute Renal Failure
Bronze pigmentation of skin
Bronze pigmentation of skin    Addisons Disease
Outburst laughter or cry fasciculations
Outburst laughter or cry fasciculationsAmyotrophic Lateral Sclerosis (ALS)
Pain upon exertion
Pain upon exertion Angina Pectoris
Mc Burneys sign
Mc Burneys sign  Appendicitis
Boutonnier deformity, swan neck deformity, ulnar            drift, Bouchards nodes
Boutonnier deformity, swan neck deformity, ulnar            drift, Bouchards nodes                   Arthritis
Murmur heard high on chest
Murmur heard high on chest   Atrial Septal Defect
Rocking, spinning, routines
Rocking, spinning, routines         Autism
Grayish white discharge, malodorous
Grayish white discharge, malodorous        Bacterial Vaginosis
Raccoons eye
Raccoons eyeBasilar Fracture
Meconium staining
Meconium staining  Breech Birth
Russels sign, binge eating
Russels sign, binge eating    Bulimia Nervosa
Cherry pink flushed face
Cherry pink flushed faceCarbon Monoxide Poisoning
Jack hammer syndrome
Jack hammer syndromeCarpal Tunnel Syndrome
Cloudy vision
Cloudy vision  Cataract
Gluten sensitivity, water, pale, foul smelling stool
Gluten sensitivity, water, pale, foul smelling stool                  Celiac Disease
Maculopapulovesiculo rash
Maculopapulovesiculo rash      Chicken Pox
Rice water stools
Rice water stools    Cholera
Pulling up of arms & legs, red-face crying
Pulling up of arms & legs, red-face crying                  Colic
Barrel chest, clubbing of fingers
Barrel chest, clubbing of fingers           C.O.P.D.
Moon face, buffalo hump
Moon face, buffalo hump  Cushings Syndrome
Homonymous hemianopsia
Homonymous hemianopsia        CVA
Feeling of fullness at vagina
Feeling of fullness at vagina  Cystocele & Rectocele
Recent and past memory defect
Recent and past memory defect          Delirium
Recall or learning memory impairment
Recall or learning memory impairment             Dementia
Flashes of light, vein in line of sight
Flashes of light, vein in line of sight          Detached Retina
3 Ps: polydipsia, polyphagia, polyuria
3 Ps: polydipsia, polyphagia, polyuria          Diabetes Mellitus
Pseudomembrane
Pseudomembrane   Diptheria
Cramping, colicky pain in left lower abdominal                  quadrant
Cramping, colicky pain in left lower abdominal                  quadrant            Diverticular Disease
Saddle nose, Brushfields spots (Trisonomy 21)
Saddle nose, Brushfields spots (Trisonomy 21)               Down Syndrome
Ortolanis sign, Galeazzis sign, asymmetry of       gluteal, popliteal & thigh folds
Ortolanis sign, Galeazzis sign, asymmetry of       gluteal, popliteal & thigh folds              Dysplasia of Hip
Cullens sign
Cullens signEctopic Pregnancy
Premenstrual pain decreasing as menstrual flow                  decreases
Premenstrual pain decreasing as menstrual flow                  decreases               Endometriosis
Exposed bladder, appears to be turned inside out
Exposed bladder, appears to be turned inside out             Exstrophy of Bladder
Radar gaze
Radar gazeFailure to Thrive (FTT)
Barret esophagus
Barret esophagus   G.E.R.D.
Halos around light
Halos around light   Glaucoma
Dysuria, genital discharge
Dysuria, genital discharge       Gonorrhea
Exopthalmia
ExopthalmiaGraves Disease
Hemarthrosis
HemarthrosisHemophilia
Asterixis
AsterixisHepatic Disease
Ribbon-like, foul smelling stool
Ribbon-like, foul smelling stoolHirschprungs Disease (megacolon)
Grapelike growth, large abdomen
Grapelike growth, large abdomen           H-mole
Bossings sign, setting sun eyes
Bossings sign, setting sun eyes        Hydrocephalus
Trousseaus sign
Trousseaus signHypocalcemia
High pitch cry
High pitch cryIncreased Intracranial Pressure (ICP)
Dolls eye
Dolls eyeIncreased Intraoccular Pressure
No passage of meconium
No passage of meconium Intestinal Obstruction
Dance sign, currant jelly-like stool, sausage like
Dance sign, currant jelly-like stool, sausage like                Intussesception
Activity intolerance
Activity intoleranceIron Deficiency Anemia (IDA)
Strawberry tongue
Strawberry tongue   Kawasaki
Red gelatinous sputum
Red gelatinous sputumKleibsella Pneumonia
XXY in males
XXY in malesKlinefelters Syndrome
Pulmonary manifestations (i.e. orthopnea, crackles,                cyanosis, etc.)
Pulmonary manifestations (i.e. orthopnea, crackles,                cyanosis, etc.)          Left Ventricular Heart Failure
Less than 2.5 kgs or 5 1/2 lbs
Less than 2.5 kgs or 5 1/2 lbs     Low Birth Weight
Red-ringed circular rash (erythema chronicum                  migrans)
Red-ringed circular rash (erythema chronicum                  migrans)              Lyme Disease
Blackwater fever
Blackwater fever    Malaria
Whirling, vertigo, tinnitus
Whirling, vertigo, tinnitus    Menieres Disease
Kernigs sign, Brudzinkis sign
Kernigs sign, Brudzinkis sign          Meningitis
White "cheesy" discharge
White "cheesy" discharge       Moniliasis
Gowers sign
Gowers signMuscular Dystrophy
Charcots triad: intention tremor, nystagmus,         scanning speech (clipped)
Charcots triad: intention tremor, nystagmus,         scanning speech (clipped)            Multiple Sclerosis
Nasal smile
Nasal smileMyasthenia Gravis
Nonproductive that progresses to mucoid sputum
Nonproductive that progresses to mucoid sputum           Mycoplasmal Pneumonia
Viselike or crushing pain radiating to shoulder,               arms, jaw or back
Viselike or crushing pain radiating to shoulder,               arms, jaw or back            Myocardial Infarction
Purulent conjunctivitis (N. Gonorrhea)
Purulent conjunctivitis (N. Gonorrhea)       Opthalmia Neonatorum
White patches on tongue (Candida Albicans)
White patches on tongue (Candida Albicans)               Oral Thrush
Kyphosis
KyphosisOsteoporosis
Ringing or buzzing
Ringing or buzzing   Otosclerosis
Steatorrhea
SteatorrheaPancreatitis
Machinery-type murmur throughout the heartbeat       in the left 2nd or 3rd interspace
Machinery-type murmur throughout the heartbeat       in the left 2nd or 3rd interspace           Patent Ductus Arteriosus
Pill rolling
Pill rollingParkinsons Disease
Abdominal muscle rigidity with rebound            tenderness
Abdominal muscle rigidity with rebound            tenderness             Peritonitis
Beefy red tongue
Beefy red tonguePernicious Anemia
Paroxysmal cough ending with a whoop
Paroxysmal cough ending with a whoop              Pertussis
Nikolsky sign
Nikolsky signPhemphigus Vulgaris
Fever, vaginal discharge, lower abdominal                cramping
Fever, vaginal discharge, lower abdominal                cramping   Pelvic Inflammatory Disease (PID)
What is the purpose of IV fluid therapy?
What is the purpose of IV fluid therapy?   Maintenance, to replace or correct deficits, to     restore ongoing loss, for m...
What is oncotic pressure?
What is oncotic pressure?Colloids, plasma proteins, albumin
What is hydrostatic pressure?
What is hydrostatic pressure?      Blood pressure
What is normal serum osmo?
What is normal serum osmo?280 - 295 or approx. twice that of the serum Na                    level.
What can expand the intravascular compartment?
What can expand the intravascular compartment?              Hypertonic fluids.
What is the problem with using hypertonic fluids?
What is the problem with using hypertonic fluids? If done too fast will draw too much fluid into theintravascular, dehydra...
What is a S/sx of fluids administered too fast?
What is a S/sx of fluids administered too fast?        decreased LOC / Confusion.
What happens if you expand the intra Cellular          compartment too fast?
What happens if you expand the intra Cellular          compartment too fast?Deplete the intravascular, decreasing BP and  ...
What are the two basic types of parenteral fluids?
What are the two basic types of parenteral fluids?             Crystalloid and Colloid
What is a crystalloid fluid?
What is a crystalloid fluid?An Electrolyte containing solution.
What are the three basic types of crystalloid fluids?
What are the three basic types of crystalloid fluids?       Isotonic, Hypotonic and Hypertonic
Why are crystalloid fluids called true solutions?
Why are crystalloid fluids called true solutions? Because they can pass through semipermeable                 membranes.
What is a Colloid fluid?
What is a Colloid fluid?Contains proteins and starches.
What cant a Colloid fluid do?
What cant a Colloid fluid do?Pass between compartments. They draw the fluid                  to them.
Name three problems with IV fluid therapy.
Name three problems with IV fluid therapy.Phlebitis, extravasation and incompatabilities.
What three things can an LVN NOT do?
What three things can an LVN NOT do?cannot hang, flush or change bags on a central line                 even if certified.
What can an RN NOT do with a central line.
What can an RN NOT do with a central line.Cannot assign to LVN or supervise LVN with    anything to do with a central line.
How do you determine whether it is a central line            or a peripheral line?
How do you determine whether it is a central line            or a peripheral line? Ask the doctor for an x ray order to de...
Name some isotonic fluids
Name some isotonic fluids    D5W, LR and NS
Why do you need to be careful with LR and             dehydration?
Why do you need to be careful with LR and             dehydration?It is hard for the renal system to process the          ...
What does the liver do to lactate? (LR)
What does the liver do to lactate? (LR)It metabolizes the lactate to bi-carbonate which                buffers acidosis
What are two common uses for Normal Saline                 (NS)?
What are two common uses for Normal Saline                 (NS)?  To treat hyponatremia and intravascular               de...
Name a Hypotonic solution?
Name a Hypotonic solution?    0.45 NS ( 1/2 NS)
What is a problem with Hypotonic solutions?
What is a problem with Hypotonic solutions?Use too long and it will lower BP. It is low insolutes so fluid will move out o...
What makes Hyper tonic fluids different than the                  others?
What makes Hyper tonic fluids different than the                  others?It has more dissolved particles than body fluid.
What does a hypertonic fluid do?
What does a hypertonic fluid do?    It moves fluid out of the intracellular andinterstitial compartments into the intravas...
What are hypertonic fluids used for?
What are hypertonic fluids used for?      Hydration and nutrition
What is dangerous about hypertonic dextrose             saline solutions?
What is dangerous about hypertonic dextrose             saline solutions?    they can move fluids very quickly.
What is a hypertonic dextrose saline fluid solution                    used for?
What is a hypertonic dextrose saline fluid solution                    used for?            TPN and PPN. Nutrition.
What type IV line do you use with Hypertonic              dextrose saline?
What type IV line do you use with Hypertonic                dextrose saline?10% solutions can go peripheral but all others...
Why must most hypertonic dextrose saline solutions be used with a central line?
Why must most hypertonic dextrose saline  solutions be used with a central line?Because the fluids are very irritating to ...
How do you infuse hypertonic dextrose saline                solutions?
How do you infuse hypertonic dextrose saline                solutions?      You must use an infusion pump.
Plasma expanders are not considered what?
Plasma expanders are not considered what?            Blood products.
What do you NOT have to do with plasma             expanders?
What do you NOT have to do with plasma             expanders?        Type and cross match.
Which of the two main categories of fluids do        plasma expanders fall into?
Which of the two main categories of fluids do        plasma expanders fall into?                  Colloid.
What are Colloids used for?
What are Colloids used for?Maintenance of blood volume, hypovolemic             shock, dialysis.
In which patients do you need to use colloid         product with cautiously?
In which patients do you need to use colloid         product with cautiously?       renal insufficiency and CHF
PPN is used in what type of line?
PPN is used in what type of line?           Peripheral
TPN is used in what type of line?
TPN is used in what type of line?            Central
What are the components of TPN?
What are the components of TPN?H2O, PRO, CHO, fat, vitamins, trace minerals.
TPN usually come in a _____hour supply.
TPN usually come in a _____hour supply.            24 hour supply
Name some indications for TPN.
Name some indications for TPN.Non-function GI, Bowel obstruct., acute inflam, colitis, Crohns, malabsorption, chemo, burns...
How do you know TPN is working?
How do you know TPN is working?       By weighing daily.
What is the consideration with IVs and glucose?
What is the consideration with IVs and glucose?    Must use the appropriate IV access forconcentration of glucose, must us...
What should you monitor with TPN?
What should you monitor with TPN?I & O, weight, liver and renal function and               electrolytes.
Why do you monitor liver and renal function with                   TPN?
Why do you monitor liver and renal function with                   TPN?To make sure that they are excreting electrolytes.
Why do you use a micron filter with TPN?
Why do you use a micron filter with TPN?      to filter out bacterial growth.
Why do you taper TPN?
Why do you taper TPN?To avoid hypoglycemic shock from cutting of the                   sugar.
Can you run other things in the TPN IV tubing?
Can you run other things in the TPN IV tubing?      No, dont mix with anything else.
What is an important consideration with albumin?
What is an important consideration with albumin?            May cause anaphylaxis
What are some potential complications with TPN?
What are some potential complications with TPN?   Fluid imbalances, metabolic acidosis, liver   dysfunction, hyperglycemia...
Nursing process
Nursing processsystematic, rational method of nursing care
Decision making process
Decision making processidentify purpose, set criteria, weigh criteria, seek   alternatives, examine alternatives, project,...
Assessing
Assessingcollect, organize, validate,document data
Diagnosing
Diagnosinganalyze data, identify risks & strengths, formulate              diagnostic statements
Planning
PlanningPrioritize,formulate goals and outcomes,select           interventions, write orders
Implementing
Implementing       reassess,implementinterventions,delegate,document
Evaluating
Evaluatingcompare data to outcomes, draw conclusions,             modify care plan
subjective data
subjective datasymptoms only the pt. can verify
objective data
objective datasigns detectable to observer
directive interview
directive interviewhighly structured, elicits specific info
Non directive interview
Non directive interviewrapport building interview
Cephalo caudal approach
Cephalo caudal approach  head to toe approach
Maslows Theory
Maslows Theoryhierarchy of needs
validation
validationdouble checking data to confirm accuracy
cues
cueswhat pt. says or nurse sees
inferences
inferencesnurses interpretation
diagnosis
diagnosisstatement regarding the nature of problem
risk factors diagnosis
risk factors diagnosisindicates a problem that could develop
wellness diagnosis
wellness diagnosisreadiness for enhancement of wellness
possible diagnosis
possible diagnosisevidence is incomplete
syndrome diagnosis
syndrome diagnosisassociated with a cluster of other diagnoses
diagnostic 3 part statement
diagnostic 3 part statement           PES
Problem
Problemstatement of clients response
Etiology
Etiologyfactors contributing to probable cause of response
Signs and Symptoms
Signs and Symptomsdefining characteristics manifested by pt.
nursing intervention
nursing interventionany treatment based on clinical judgment that a               nurse performs
formal care plan
formal care planwritten or computerized guide
informal care plan
informal care planstrategy that exists in the nurses mind
standardized care plan
standardized care planformal plan for all individuals with same etiology
individualized care plan
individualized care plantailored for specific pt.
Nursing Care Classification (NOC) standardized         nursing language indicator
Nursing Care Classification (NOC) standardized         nursing language indicator     concrete observable state of behavior
Using Silence
Using SilenceAccepting pauses or silences that may last severalseconds or minutes without any verbal response.
Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts andfments or questions t...
Sitting quietly (or walking with PT) and waiting attentively until client is able to put thoughts andfments or questions t...
Using Silence (example)
Providing general leads
Providing general leadsUsing statements or questions that (a) encourage  the client to verbalize, (b) choose a topic of   ...
"Perhaps you would like to talk about..." ; "wouldit help to discuss your feelings?"; "and then...."; "I             know ...
"Perhaps you would like to talk about..." ; "wouldit help to discuss your feelings?"; "and then...."; "I             know ...
Using specific and tentative
Using specific and tentativemaking statements that are specific rather than   general, tentative rather than absolute
"You scratched my arm" instead of "you areclumsy as an ox" OR "you seem concerned about mary" rather than "you dont care a...
"You scratched my arm" instead of "you areclumsy as an ox" OR "you seem concerned about mary" rather than "you dont care a...
Open-ended question
Open-ended question  ASKING BROAD QUESTIONS that lead or  invite the client to explore, elaborate, clarify,define, and des...
"Id like to hear more about that"; "What brought  you to the hospital today?"; "you said you werefrightened yesterday, how...
"Id like to hear more about that"; "What brought  you to the hospital today?"; "you said you werefrightened yesterday, how...
Using Touch
Using TouchProviding appropriate forms of touch to reinforce               caring feelings.
Putting arm over clients shoulder OR placing hand                over clients hand
Putting arm over clients shoulder OR placing hand                over clients hand             Using touch (example)
Restating
Restatingusing the same words as the client
Client: "I couldnt manage to eat any dinner lastnight- not even dessert" Nursing- "you couldnt manage to eat any dinner la...
Client: "I couldnt manage to eat any dinner lastnight- not even dessert" Nursing- "you couldnt manage to eat any dinner la...
Paraphrasing
ParaphrasingRestating in different form with implied feeling or                    observation
Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you dont                    ...
Client: " I have trouble talking to strangers" Nurse "You find it difficult talking to people you dont                    ...
Seeking clarification
Seeking clarification  Making the clients overall meaning of the msg understandable. It is used when paraphrasing is diffi...
confess confusion & ask PT to repeat
Nurse: "Im puzzled" Nurse: "Im not sure whatyou mean by ___ Would you please repeat that                   again?"
Nurse: "Im puzzled" Nurse: "Im not sure whatyou mean by ___ Would you please repeat that                   again?"       S...
Perception Checking/ Consensual Validation
Perception Checking/ Consensual Validation A method similar to clarifying that verifies themeaning of specific words rathe...
C: "it just wont stop" N: "Im not sure what youmean - it wont stop" OR C: "my husband nevergives me presents" N: "He never...
C: "it just wont stop" N: "Im not sure what youmean - it wont stop" OR C: "my husband nevergives me presents" N: "He never...
Perception Checking/ Consensual Validation                (example)
Offering Self
Offering Self  Suggesting ones presence, interest, or wish tounderstand the client without making any depandsor attaching ...
"Ill stay with you till your daughter arrives"; "we can sit here quietly for awhile, we dont need to           talk unless...
"Ill stay with you till your daughter arrives"; "we can sit here quietly for awhile, we dont need to           talk unless...
Giving Information
Giving Information  Providing, in simple and direct manner, specific   factual information the client may or may notreques...
the information.
"Your surgery is scheduled for 11am tomorrow"; Idont know the answer to that, but Ill find out from       the unit manager...
"Your surgery is scheduled for 11am tomorrow"; Idont know the answer to that, but Ill find out from       the unit manager...
Acknowledging
AcknowledgingGiving recognition, in non judgmental way, of            change in behavior.
"You trimmed your beard and mustache" OR "you  walked twice as far today with your walker"
"You trimmed your beard and mustache" OR "you  walked twice as far today with your walker"          Acknowledging (example)
Clarifying time or sequence
Clarifying time or sequenceHelping the client clarify and event, situation, or      happening in relationship to time
C: "I puked this morning" N: "before or after                 breakfast?"
C: "I puked this morning" N: "before or after                 breakfast?"   Clarifying time or sequence(example)
It is a style or process of persuading a group ofpeople, usually his followers to attain a desired                     obj...
It is a style or process of persuading a group ofpeople, usually his followers to attain a desired                     obj...
A leader that is chosen by the administration or agroup which are given the official capacity to act.
A leader that is chosen by the administration or agroup which are given the official capacity to act.    Formal / appointe...
A leader that does not have official appointmentsor designations but is usually chosen by the group                       ...
A leader that does not have official appointmentsor designations but is usually chosen by the group                       ...
It states that leaders are born and not developedbecause some people are born with characteristics                     to ...
It states that leaders are born and not developedbecause some people are born with characteristics                     to ...
A person can be an effective leader if he has all theintellectual, emotional, physical and other personal             trai...
A person can be an effective leader if he has all theintellectual, emotional, physical and other personal             trai...
He is a leader who makes other people feel better  in his/her presence which is an inspirational         quality that the ...
He is a leader who makes other people feel better  in his/her presence which is an inspirational         quality that the ...
It states that there is no personality, traits to be a      good leader, but rather leadership is therelationship that exi...
It states that there is no personality, traits to be a      good leader, but rather leadership is therelationship that exi...
A leader that can immediately resolve a sudden    crisis, emergency or critical situation.
A leader that can immediately resolve a sudden    crisis, emergency or critical situation.            Contingency Theory
A leader that knows how to determine the maturity                 of his followers.
A leader that knows how to determine the maturity                 of his followers.               Life-Cycle Theory
A leader who uses a support system method.
A leader who uses a support system method.            Path Goal Theory
A style where the leader makes all the decisions  and disallows his members to influence him.Followers dislike this leader...
A style where the leader makes all the decisions  and disallows his members to influence him.Followers dislike this leader...
Authoritarian
A leadership style where it is loose and permissive.    His approach is "Do your own thing". His reference is "You" and ha...
A leadership style where it is loose and permissive.    His approach is "Do your own thing". His reference is "You" and ha...
A leader whose authority is from the group. Gives  importance to participation, involvement anddevelopment of the group. H...
A leader whose authority is from the group. Gives  importance to participation, involvement anddevelopment of the group. H...
A leadership style that uses repetition and tries todevelop the system as his objective. His referenceis "they" and acts a...
A leadership style that uses repetition and tries todevelop the system as his objective. His referenceis "they" and acts a...
A power whereby the leader has the officialcapacity to exercise rights and demand obligations                from subordin...
A power whereby the leader has the officialcapacity to exercise rights and demand obligations                from subordin...
I - olfactory (sensory)
I - olfactory (sensory)   sense of smell
II - optic (sensory)
II - optic (sensory)   visual acuity
III - oculomotor (motor)
III - oculomotor (motor)extraocular eye movement, pupil    constriction and dilation
IV - trochlear (motor)
IV - trochlear (motor)upward/downward movement of eyeball
V - trigeminal (sensory/motor)
V - trigeminal (sensory/motor)sensory nerve to skin of face, motor     nerve to muscles of jaw
VI - abducens (motor)
VI - abducens (motor)lateral movement of eyeballs
VII - facial (sensory/motor)
VII - facial (sensory/motor)  facial expression, taste
VIII - auditory (sensory)
VIII - auditory (sensory)        hearing
IX - glossopharyngeal (sensory/motor)
IX - glossopharyngeal (sensory/motor)          taste, swallowing
X - vagus (sensory/motor)
X - vagus (sensory/motor)sensation of pharynx, movement of vocal                  cords
XI - spinal accessory (motor)
XI - spinal accessory (motor)movement of head and shoulders
XII - hypoglossal (motor)
XII - hypoglossal (motor)   position of tongue
Trust vs. Mistrust
Trust vs. MistrustInfancy (0-18 mos)
Autonomy vs. Shame & Doubt
Autonomy vs. Shame & DoubtEarly Childhood (18mos-3yrs)
Initiative vs. Guilt
Initiative vs. GuiltPreschool (3-6yrs)
Industry vs. Inferiority
Industry vs. Inferiority School-age (6-12yrs)
Identity vs. Role Confusion
Identity vs. Role Confusion  Adolescence (12-18yrs)
Intimacy vs. Isolation
Intimacy vs. IsolationYoung Adult (18-25yrs)
Generativity vs. Stagnation
Generativity vs. Stagnation  Adulthood (25-45yrs)
Integrity vs. Despair
Integrity vs. DespairLate Adulthood (45-death)
Teaching that is Dependent on environment Needs                    security
Teaching that is Dependent on environment Needs                      security                 Infant (0-18mos)
Teaching focused on Separation anxiety Self        exploration Environment
Teaching focused on Separation anxiety Self         exploration Environment             Infant (0-18mos)
Teaching focused on Natural curiosity Separation             Intrusive procedure
Teaching focused on Natural curiosity Separation              Intrusive procedure            Toddler (18mos-3yrs)
Teaching focused on Ego Body mutilation (pain)   believes illness is self caused & punitive
Teaching focused on Ego Body mutilation (pain)   believes illness is self caused & punitive             Preschooler (3-6yrs)
Teaching focused on Limited time Activeimagination (animistic thinking, fearful)
Teaching focused on Limited time Activeimagination (animistic thinking, fearful)          Preschool (3-6yrs)
Teaching focused on Reality ObjectivitySeparation anxiety (tries to appear brave)
Teaching focused on Reality ObjectivitySeparation anxiety (tries to appear brave)         School Age (6-12yrs)
Teaching focused on Cause & effect Concrete   Information (passive coping strategy)
Teaching focused on Cause & effect Concrete   Information (passive coping strategy)           School Age (6-12yrs)
Teaching focused on Abstract hypothetical  thinking Logic & scientific principles
Teaching focused on Abstract hypothetical  thinking Logic & scientific principles         Adolescence (12-18yrs)
Teaching focused on Body image Self esteem &           identity (feel invincible)
Teaching focused on Body image Self esteem &           identity (feel invincible)           Adolescence (12-18yrs)
Teaching focused on Autonomy Self direction             Critical thinking
Teaching focused on Autonomy Self direction              Critical thinking          Young adult (18-25yrs)
Teaching focused on Competency based learner  (can make decision personally & socially)
Teaching focused on Competency based learner  (can make decision personally & socially)           Young Adult (18-25yrs)
Teaching focused on Physical changes Alternative   lifestyle Sense of well developed (questionsachievements & contribution...
Teaching focused on Physical changes Alternative   lifestyle Sense of well developed (questionsachievements & contribution...
Teaching focused on Cognitive & physicalchanges No formal learning (decreased S.T.M.,         risk taking, easily fatigue)
Teaching focused on Cognitive & physicalchanges No formal learning (decreased S.T.M.,         risk taking, easily fatigue)...
For a hospitalized Child, focus on
For a hospitalized Child, focus on           Separation
For a hospitalized Toddler, focus on
For a hospitalized Toddler, focus on Separation & Intrusive procedure
For a hospitalized Preschooler, focus on
For a hospitalized Preschooler, focus on        Body mutilation & Pain
For a hospitalized School-age, focus on
For a hospitalized School-age, focus on            Loss of control
For a hospitalized Adolescent, focus on
For a hospitalized Adolescent, focus on             Body image
PRE-OPERATIVE CARE, a parent or a legal may sign the consent of a MINOR, while the OLDER              client may need whom?
Legal Guardian
PRE-OPERATIVE CARE, a nurse can be a witness in consent signing & document the sameonly if the client understood surgeons ...
Acknowledges understanding of the procedure
PRE-OPERATIVE CARE, NPO is 6-8 hrs. before Gen. Anesthesia, while for Local Anesthesia is?
3 hours before surgery
PRE-OPERATIVE CARE, prepare ___ administration for malnourished, with protein ormetabolic deficiencies or cannot ingest fo...
Total Parenteral Nutrition
PRE-OPERATIVE CARE, if client has a FoleyCatheter, drain before the surgery and note the?
Amount of urine & characteristics
PRE-OPERATIVE CARE, what do you use to        clean the surgical site?
Mild Antiseptic Soap
PRE-OPERATIVE CARE (client teaching),inform the client what to expect POST-OP likepain & discomfort, and that he/she can r...
Narcotic Drugs as pain reliever, note it will not       make the client an addict to such
PRE-OPERATIVE CARE (client teaching),     demonstrate what to the client?
Patient Controlled Analgesic (PCA)
PRE-OPERATIVE CARE (client teaching),instruct not to what? 24 hours before the surgery.
Smoke
PRE-OPERATIVE CARE (client teaching),  instruct to do Deep Breathing & CoughingExercises, use of Incentive Spirometry for ...
Pneumonia & Atelactasis
PRE-OPERATIVE CARE (client teaching),instruction of let & foot exercises will prevent            what? Facilitate what?
Venous Stasis / Venous blood return
PRE-OPERATIVE CARE (client teaching),instruct the client on how to splint an incision by?
Placing a pillow, or one hand with the other hand         on top, over the incisional area.
PRE-OPERATIVE CARE (checklist), ensure theclient is wearing identification bracelet and assess                     for what?
Allergies for latex
PRE-OPERATIVE CARE (checklist), ensure that   informed consent forms were signed for the operative procedure and for what ...
PRE-OPERATIVE CARE (checklist), ensure that   informed consent forms were signed for the operative procedure and for what ...
PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, ches...
PRE-OPERATIVE CARE (checklist), ensure that history, P.E., consultation requests, prescribed laboratory results, EKG, ches...
performed.
PRE-OPERATIVE CARE (checklist), afterremoving everything unnecessary, documented it, kept or given to family members, the ...
PRE-OPERATIVE CARE (checklist), afterremoving everything unnecessary, documented it, kept or given to family members, the ...
surgery, medications given prior surgery then               monitor V.S.
PRE-OPERATIVE CARE (medications), instruct client about the desired effects and then what?
PRE-OPERATIVE CARE (medications), instruct client about the desired effects and then what?      Keep client in bed with si...
PRE-OPERATIVE CARE (medications), afteradministering medications, next to the client, place                     what?
PRE-OPERATIVE CARE (medications), afteradministering medications, next to the client, place                     what? Call...
PRE-OPERATIVE CARE (inside O.R.), afterverifying identification bracelet & verbal response,the nurse will review chart and...
PRE-OPERATIVE CARE (inside O.R.), afterverifying identification bracelet & verbal response,the nurse will review chart and...
PRE-OPERATIVE CARE (inside O.R.), theclients chart will be reviewed for completeness and              taking a note about ...
PRE-OPERATIVE CARE (inside O.R.), theclients chart will be reviewed for completeness and              taking a note about ...
POST-OPERATIVE CARE (immediate), what is         the period of this stage?
POST-OPERATIVE CARE (immediate), what is         the period of this stage?          1-4 hours after surgery
POST-OPERATIVE CARE (immediate), monitor airway patency & adequate ventilation because    prolonged mechanical ventilation...
POST-OPERATIVE CARE (immediate), monitor airway patency & adequate ventilation because    prolonged mechanical ventilation...
may not be able to maintain airway
POST-OPERATIVE CARE (immediate), theclient maybe unable to clear his/her airway, that is       why it is important to moni...
POST-OPERATIVE CARE (immediate), theclient maybe unable to clear his/her airway, that is       why it is important to moni...
POST-OPERATIVE CARE (immediate),encourage Deep Breathing & Coughing exercises, monitor pulse oximetry, O2 administration a...
POST-OPERATIVE CARE (immediate),encourage Deep Breathing & Coughing exercises, monitor pulse oximetry, O2 administration a...
accessory muscles.
POST-OPERATIVE CARE (immediate), noterate, depth & quality of respirations, RR should                       be?
POST-OPERATIVE CARE (immediate), noterate, depth & quality of respirations, RR should                       be?           ...
POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates                      what?
POST-OPERATIVE CARE (immediate), a breath sound of stridor, wheezing or crowing indicates                      what?Partia...
POST-OPERATIVE CARE (immediate), a breath   sound of crackles or ronchi may indicate?
POST-OPERATIVE CARE (immediate), a breath   sound of crackles or ronchi may indicate?Pulmonary Edema, monitor signs of Ate...
POST-OPERATIVE CARE (immediate), checkcapillary refill, assess the skin, peripheral pulses &edema and monitor for bleeding...
POST-OPERATIVE CARE (immediate), checkcapillary refill, assess the skin, peripheral pulses &edema and monitor for bleeding...
POST-OPERATIVE CARE (immediate), unless  contraindicated, client is placed on Fowlers       position after surgery to incr...
POST-OPERATIVE CARE (immediate), unless  contraindicated, client is placed on Fowlers       position after surgery to incr...
POST-OPERATIVE CARE (immediate), whattype of positioning is avoided if the pharyngeal        reflexes have not yet returned?
POST-OPERATIVE CARE (immediate), whattype of positioning is avoided if the pharyngeal        reflexes have not yet returne...
POST-OPERATIVE CARE (immediate), if comatose or semicomatose, what type of              positioning?
POST-OPERATIVE CARE (immediate), if comatose or semicomatose, what type of              positioning?Side lying & keep an o...
POST-OPERATIVE CARE (immediate), assessL.O.C., wake client periodically until awaken and                   if awaken?
POST-OPERATIVE CARE (immediate), assessL.O.C., wake client periodically until awaken and                   if awaken?  Ori...
POST-OPERATIVE CARE (immediate), main body temperature and prevent heat loss by?
POST-OPERATIVE CARE (immediate), main body temperature and prevent heat loss by?    Blanketing & raise room temperature
POST-OPERATIVE CARE (immediate), anexposed skin, cool OR, or maybe from anesthesia                 may result to?
POST-OPERATIVE CARE (immediate), anexposed skin, cool OR, or maybe from anesthesia                 may result to?Hypotherm...
POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for?
POST-OPERATIVE CARE (immediate), assess surgical site, drains & wound dressings for?      Redness, abrasions or breakdown
POST-OPERATIVE CARE (immediate), recordI&O, monitor for Fluid & Electrolyte imbalance,N&V, NGT patency, abdominal distenti...
POST-OPERATIVE CARE (immediate), recordI&O, monitor for Fluid & Electrolyte imbalance,N&V, NGT patency, abdominal distenti...
POST-OPERATIVE CARE (immediate), howmany hours is it that the client is expected to void            urine after the surgery?
POST-OPERATIVE CARE (immediate), howmany hours is it that the client is expected to void            urine after the surger...
POST-OPERATIVE CARE (immediate), assessfor pain, PRE-OP & POST-OP medz, then inquire  about the type & location of pain by...
POST-OPERATIVE CARE (immediate), assessfor pain, PRE-OP & POST-OP medz, then inquire  about the type & location of pain by...
body gestures, increase PR, BP & RR.
POST-OPERATIVE CARE (immediate), inquireeffectiveness of last medication, if on a Narcotic        drug, assess every 30 mi...
POST-OPERATIVE CARE (immediate), inquireeffectiveness of last medication, if on a Narcotic        drug, assess every 30 mi...
POST-OPERATIVE CARE (intermediate), how   many hours is this stage after surgery?
POST-OPERATIVE CARE (intermediate), how   many hours is this stage after surgery?                4-24 hours
POST-OPERATIVE CARE (intermediate),  monitor airway patency, encourage Deep  Breathing & Coughing exercises, monitorcircul...
POST-OPERATIVE CARE (intermediate),  monitor airway patency, encourage Deep  Breathing & Coughing exercises, monitorcircul...
POST-OPERATIVE CARE (intermediate), assessfor mobility on all extremities & encourage early ambulation by first sitting on...
POST-OPERATIVE CARE (intermediate), assessfor mobility on all extremities & encourage early ambulation by first sitting on...
Turn the client every 1-2 hours.
POST-OPERATIVE CARE (intermediate),reinforce wound with sterile dressing if necessary              and always keep it?
POST-OPERATIVE CARE (intermediate),reinforce wound with sterile dressing if necessary              and always keep it?Dry ...
POST-OPERATIVE CARE (intermediate),  monitor I&O, N&V and if vomiting, have asuctioning equipment available and ready to u...
POST-OPERATIVE CARE (intermediate),  monitor I&O, N&V and if vomiting, have asuctioning equipment available and ready to u...
POST-OPERATIVE CARE (intermediate), when     oral fluids are permitted, start with?
POST-OPERATIVE CARE (intermediate), when     oral fluids are permitted, start with?Ice chips & water, then advance to Clea...
POST-OPERATIVE CARE (intermediate), after  NPO order is lifted, what do you assess for?
POST-OPERATIVE CARE (intermediate), after  NPO order is lifted, what do you assess for?      Bowel sounds on all four quad...
POST-OPERATIVE CARE (intermediate), how   many mL per hour should a client void?
POST-OPERATIVE CARE (intermediate), how   many mL per hour should a client void?           Should be > 30 mL/hr
POST-OPERATIVE CARE (intermediate), if withFoley Catheter, client is expected to void within 6-   8 hours. Ensure that the...
POST-OPERATIVE CARE (intermediate), if withFoley Catheter, client is expected to void within 6-   8 hours. Ensure that the...
POST-OPERATIVE CARE (extended), what is        the period of this stage?
POST-OPERATIVE CARE (extended), what is        the period of this stage?          1-4 hours after surgery
POST-OPERATIVE CARE (extended), on thisstage, you monitor for signs of infection such as?
POST-OPERATIVE CARE (extended), on thisstage, you monitor for signs of infection such as? Redness, swelling, & tenderness ...
POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours      and encourage ambulation t...
POST-OPERATIVE CARE (extended), the client is advised to do R.O.M. exercises every 2 hours      and encourage ambulation t...
POST-OPERATIVE CARE (extended), the clientis encouraged to perform A.D.L. & eat foods thatwill promote wound healing. What...
POST-OPERATIVE CARE (extended), the clientis encouraged to perform A.D.L. & eat foods thatwill promote wound healing. What...
Inflammation of the alveoli caused by aninfectious process that may develop as a result of       infection, aspiration or ...
Inflammation of the alveoli caused by aninfectious process that may develop as a result of       infection, aspiration or ...
Collapse of the alveoli with retained mucoussecretions and is the most common postoperative                   complication?
Collapse of the alveoli with retained mucoussecretions and is the most common postoperative                   complication...
POST-OPERATIVE CARE (Pneumonia &   Atelectasis) Assessment / increase risk fordyspnea/ elevated temperature/ productive co...
POST-OPERATIVE CARE (Pneumonia &   Atelectasis) Assessment / increase risk fordyspnea/ elevated temperature/ productive co...
POST-OPERATIVE CARE (Pneumonia &  Atelectasis) Nsg Inter / assess for lung & breathsounds/ reposition client every 1-2 hou...
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Fundamentals

  1. 1. What are the techniques in interviewing process.
  2. 2. What are the techniques in interviewing process.Problem Seeking & Problem Solving, Direct & Open-Ended Questioning
  3. 3. What are the three phases of a basic interview.
  4. 4. What are the three phases of a basic interview.Orientation, Working, and Termination Phase
  5. 5. What is the first step in nursing assessment.
  6. 6. What is the first step in nursing assessment. Nursing Health History
  7. 7. Basic components of the nursing health history.
  8. 8. Basic components of the nursing health history. Bio. Info. Reasons for seeking hxcare Pt. expectations Past Hx
  9. 9. Hospitalization Treatment Outcomes FamilyEnvironmental Psychosocial
  10. 10. Present Hx State & R.O.S.
  11. 11. What is the focus of nursing history.
  12. 12. What is the focus of nursing history.Effect of CHANGE in Hx state in meeting basic human needs.
  13. 13. A statement of potential or actual patient problems.
  14. 14. A statement of potential or actual patient problems. Nursing Diagnosis
  15. 15. Nursing diagnostic involves four elements.
  16. 16. Nursing diagnostic involves four elements.Analysis & Interpretation of data, Clustering ofData, Identification of Pt. Problems, Formulation of Nsg. Dx.
  17. 17. It requires validation and clustering of data.
  18. 18. It requires validation and clustering of data. Interpretation of data
  19. 19. Determining whether data gathered is complete and accurate.
  20. 20. Determining whether data gathered is complete and accurate. Validation of data
  21. 21. Grouping related data, usually sx & sy, indicating a general problem.
  22. 22. Grouping related data, usually sx & sy, indicating a general problem. Clustering of data
  23. 23. A hx care problem that is currently perceived by the pt. or assessed by the nurse.
  24. 24. A hx care problem that is currently perceived by the pt. or assessed by the nurse. Actual Hx Care Problem
  25. 25. A hx care problem in which the patient is at risk.
  26. 26. A hx care problem in which the patient is at risk. Potential Hx Care Problem
  27. 27. When planning, a nurse should consider the levelof potential pt. involvement, time limit and what?
  28. 28. When planning, a nurse should consider the levelof potential pt. involvement, time limit and what? Available Hx care system resources
  29. 29. In implementation of the NCP, what actions are taken.
  30. 30. In implementation of the NCP, what actions are taken. Assist Pt. on ADL, Counsel & support Pt. & family, Guide Pt., Teach Pt. & Family, Providecare to achieve NCP, Provide Environment that is
  31. 31. conducive.
  32. 32. Interventions based on instructions or written directives given by another professional.
  33. 33. Interventions based on instructions or written directives given by another professional. Dependent Intervention
  34. 34. Aspects of care encompassed by licensure and law.
  35. 35. Aspects of care encompassed by licensure and law. Independent Intervention
  36. 36. Interventions that the nurses carry out incollaboration with another professional.
  37. 37. Interventions that the nurses carry out incollaboration with another professional. Interdependent Intervention
  38. 38. True or False. The NCP is modified as the Ptsstate of Hx changes and as needs for care changes.
  39. 39. True or False. The NCP is modified as the Ptsstate of Hx changes and as needs for care changes. True
  40. 40. In evaluation of NCP, outcomes of nursing interventions maybe used for.
  41. 41. In evaluation of NCP, outcomes of nursing interventions maybe used for. Malpractice suits Staff Evaluations Reviews
  42. 42. Promotions Nursing ResearchQuality Improvement
  43. 43. What are the enrivonmental fire safety precautions?
  44. 44. What are the enrivonmental fire safety precautions? Mark fire exits Dont use elevator Turn off O2 machines
  45. 45. Move pts. by bed, stretcher, or wheelchair
  46. 46. What are environmental radiation safety precautions?
  47. 47. What are environmental radiation safety precautions? Label radioactive materials Limit time spent Distance yourself from the source
  48. 48. Use lead apronNever touch dislodged implants
  49. 49. What are environmental precautions for disposing infectious wastes?
  50. 50. What are environmental precautions for disposing infectious wastes? Needles should not be recapped, bent or broken Yellow for infectious
  51. 51. Green for biodegradable Black for nonbiodegradableRed for blood, sharp items, contaminated
  52. 52. It is to restrict client movement through the application of a device?
  53. 53. It is to restrict client movement through the application of a device? Physical restraints
  54. 54. Medications given to inhibit specific behavior?
  55. 55. Medications given to inhibit specific behavior? Chemical restraints
  56. 56. Restraints should have?
  57. 57. Restraints should have? Reason & method Date & time of useDuration & release from it
  58. 58. Assessment of pts response & further need of useHalf bow or safety knot & secured to the bedframe or chair
  59. 59. Restraints should not be?
  60. 60. Restraints should not be?P.R.N. & without consent from the pt. & family
  61. 61. Neurovascular, circulatory & skin integrity is assessed in using restraints when? Then removed at least every?
  62. 62. Neurovascular, circulatory & skin integrity is assessed in using restraints when? Then removed at least every? Every 30 minutesRemoved @ least q 2 hrs. to promote circulation
  63. 63. Who are those prone to accidental poisoning?
  64. 64. Who are those prone to accidental poisoning? Toddlers Preschoolers Young school age
  65. 65. In older adults, poisoning & overdose of prescribed medz. will yield?
  66. 66. In older adults, poisoning & overdose of prescribed medz. will yield? Diminished eyesight Impaired memory
  67. 67. If lye, grease, petroleum or household cleaner is ingested, a nurse should?
  68. 68. If lye, grease, petroleum or household cleaner is ingested, a nurse should?Never induce vomit especially to an unconscious person If vomit occurs, bring vomitus to CDC
  69. 69. Nosocomial infections can be transmitted by a healthcare personnel by?
  70. 70. Nosocomial infections can be transmitted by a healthcare personnel by? Improper handwashing Unchanged gloves between clients
  71. 71. Standard precautions apply to?
  72. 72. Standard precautions apply to? Blood Non-intact skin Mucous membrance All body fluids except sweat
  73. 73. Diseases under transmission based precautions are?
  74. 74. Diseases under transmission based precautions are? Measles Chickenpox (varicella) Disseminated varicella zoster
  75. 75. T.B.
  76. 76. Droplet precautions diseases are?
  77. 77. Droplet precautions diseases are? Adenovirus, Influenza Sepsis, Scarlet Fever Epiglottitis, Mumps Meningitis
  78. 78. Barrier protection for transmission based droplet precautions is?
  79. 79. Barrier protection for transmission based droplet precautions is? Placing client in private room or cohort client Mask
  80. 80. Transmission based contact precautions diseases are?
  81. 81. Transmission based contact precautions diseases are? Clostridium Difficle INFxN with multidrug resistant org. Wound infections
  82. 82. Cutaneous diptheria Herpes simplex Impetigo Pediculosis Scabies Staphylococcus
  83. 83. Varicella Zoster Conjunctivitis
  84. 84. Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that turn into?
  85. 85. Smallpox is a droplet type with S&S of fever, back pain, vomiting, malaise, headache & papules that turn into? Pustular vessicles in the face & extremities
  86. 86. In case of fire, a nurse should R- A- C- E-
  87. 87. In case of fire, a nurse should R-rescue A-alarm C-confine E-extinguish
  88. 88. Head tilt-chin lift is used in B.L.S. but if pt. has a neck injury, what do you use?
  89. 89. Head tilt-chin lift is used in B.L.S. but if pt. has a neck injury, what do you use? Jaw thrust maneuver
  90. 90. A.B.C.D.s of B.L.S. are:
  91. 91. A.B.C.D.s of B.L.S. are: Airway Breathing CirculationDefibrilation or Definitive Treatment
  92. 92. Each step begins with ASSESSMENT always
  93. 93. Apical & radial pulse will always yield?
  94. 94. Apical & radial pulse will always yield? Identical result
  95. 95. In assessing for a pulse to an infant < 1 yr old? a child > 1 yr old?
  96. 96. In assessing for a pulse to an infant < 1 yr old? a child > 1 yr old? Brachial (<1yr) Carotid (>1yr)
  97. 97. For infants on B.L.S., chest compression is 1/2 - 1 inch deep @ least 100 times/min using?
  98. 98. For infants on B.L.S., chest compression is 1/2 - 1 inch deep @ least 100 times/min using? 2-3 fingers Child 1-1.5 inches deep
  99. 99. When performing a Heimlich Maneuver to an obese or pregnant, what do you do?
  100. 100. When performing a Heimlich Maneuver to an obese or pregnant, what do you do? Chest thrusts
  101. 101. For unconscious adult (B.L.S.), you do a?
  102. 102. For unconscious adult (B.L.S.), you do a? Tongue jaw lift Fingersweep object
  103. 103. For unconscious pregnant, a pillow or rolled blanket is placed on the right side to?
  104. 104. For unconscious pregnant, a pillow or rolled blanket is placed on the right side to? Displace uterus to the left of the abdomen
  105. 105. Unconscious pregnant needing defibrilation shouldhave the paddles placed 1-rib higher than the usual because?
  106. 106. Unconscious pregnant needing defibrilation shouldhave the paddles placed 1-rib higher than the usual because? Heart is displaced during pregnancy
  107. 107. This is used to convert ventricular fibrilation into a perfusing rhythm?
  108. 108. This is used to convert ventricular fibrilation into a perfusing rhythm? Automated External Defibrillator
  109. 109. Automated External Defibrilator is C/I to?
  110. 110. Automated External Defibrilator is C/I to? < 8 yrs old Child weighing < 25 kgs.
  111. 111. A surgeon is responsible for getting consent & anurse can be a witness provided the pt. understood the procedures explained by the doctor. What is the next step?
  112. 112. A surgeon is responsible for getting consent & anurse can be a witness provided the pt. understood the procedures explained by the doctor. What is the next step? Document the witnessing of consent signing
  113. 113. In general anesthesia, solid & liquid foods are withheld for?
  114. 114. In general anesthesia, solid & liquid foods are withheld for? 6-8 hrs. prior Local anesthesia - 3 hrs. prior
  115. 115. When is enema or laxative performed in clients for surgery?
  116. 116. When is enema or laxative performed in clients for surgery? The night prior surgery
  117. 117. If client has a Foley catheter before surgery, it should be emptied & document the?
  118. 118. If client has a Foley catheter before surgery, it should be emptied & document the? Amount & characteristics of the urine
  119. 119. 3 levels of moral development (premoral or preconventional level, conventional level, postconventional level).
  120. 120. 3 levels of moral development (premoral or preconventional level, conventional level, postconventional level). Lawrence Kohlberg
  121. 121. 4 conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity).
  122. 122. 4 conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity). Myra Levine
  123. 123. 4 types of personality (sanguine, melancholic, phlegmatic, choleric).
  124. 124. 4 types of personality (sanguine, melancholic, phlegmatic, choleric). Galen
  125. 125. 5 hierarchy of needs (physiological, safety &security, love & belonging, self esteem, self actualization).
  126. 126. 5 hierarchy of needs (physiological, safety &security, love & belonging, self esteem, self actualization). Abraham Maslow
  127. 127. Adaptation model. Each person is a unifiedbiopsychosocial system in constant interaction with changing environment.
  128. 128. Adaptation model. Each person is a unifiedbiopsychosocial system in constant interaction with changing environment. Sister Calista Roy
  129. 129. All behavior is learned.
  130. 130. All behavior is learned. B.F. Skinner
  131. 131. Believed that nurse helps patients meet a perceived need that the patient cannot meet themselves.
  132. 132. Believed that nurse helps patients meet a perceived need that the patient cannot meet themselves. Ida Jean Orlando
  133. 133. Birth trauma.
  134. 134. Birth trauma. Otto Rank
  135. 135. Care, Core, Cure.
  136. 136. Care, Core, Cure. Lydia Hall
  137. 137. Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal operations).
  138. 138. Cognitive development (sensorimotor, peri-operational thought, concrete operations, formal operations). Jean Piaget
  139. 139. Conceptualized the behavioral system model. Each person is composed of 7 subsystem (ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual).
  140. 140. Conceptualized the behavioral system model. Each person is composed of 7 subsystem (ingestive, eliminative, affiliative, aggressive, dependence, achievement and sexual). Dorothy Johnson
  141. 141. Developed self-care and self-care deficit theory.
  142. 142. Developed self-care and self-care deficit theory. Dorothea Orem
  143. 143. Developmental task.
  144. 144. Developmental task.Robert Havighurst
  145. 145. Focused on manipulating the environment for the patients recovery.
  146. 146. Focused on manipulating the environment for the patients recovery. Florence Nithingale
  147. 147. Founded psychobiology. Believes in totality of man/holistic approach.
  148. 148. Founded psychobiology. Believes in totality of man/holistic approach. Adolf Meyer
  149. 149. Goal attainment theory. Nursing as a helping profession.
  150. 150. Goal attainment theory. Nursing as a helping profession. Imogene King
  151. 151. Health as expanding consciousness. Humans areunitary beings in whom disease is a manifestation of the pattern of health.
  152. 152. Health as expanding consciousness. Humans areunitary beings in whom disease is a manifestation of the pattern of health. Margaret Newman
  153. 153. Health care system model. Nursing is concerned with all the variables affecting an individuals response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature.
  154. 154. Health care system model. Nursing is concerned with all the variables affecting an individuals response to stress, which are interpersonal, intrapersonal, and extrapersonal in nature. Betty Neuman
  155. 155. Human becoming. Emphasized free choice ofpersonal meaning in relating value priorities.
  156. 156. Human becoming. Emphasized free choice ofpersonal meaning in relating value priorities. Rosemarie Rizzo Parse
  157. 157. Human caring model. Nursing is the application of the art and human science through transpersonal caring.
  158. 158. Human caring model. Nursing is the application of the art and human science through transpersonal caring. Jean Watson
  159. 159. Humanistic nursing practice theory. Nursing is an existential experience.
  160. 160. Humanistic nursing practice theory. Nursing is an existential experience. Josephine Paterson & Loreta Zderad
  161. 161. Identified 14 basic needs. Nurse functions to assist client in performing activities contributing to health, recovery, or peaceful death.
  162. 162. Identified 14 basic needs. Nurse functions to assist client in performing activities contributing to health, recovery, or peaceful death. Virginia Henderson
  163. 163. Identified 21 nursing problems. Defined nursing as service to individuals and families, therefore, society.
  164. 164. Identified 21 nursing problems. Defined nursing as service to individuals and families, therefore, society. Faye Abdellah
  165. 165. Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between sick and nurse.
  166. 166. Interpersonal model. Nursing is an interpersonal process of the therapeutic interactions between sick and nurse. Hildegard Peplau
  167. 167. Interpersonal theory (anxiety occurs due to poor interpersonal relationship).
  168. 168. Interpersonal theory (anxiety occurs due to poor interpersonal relationship). Harry Stack Sullivan
  169. 169. Introversion and extroversion - persona/anima
  170. 170. Introversion and extroversion - persona/anima Carl Jung
  171. 171. Modeling and role-modeling theory.
  172. 172. Modeling and role-modeling theory.Helen Erickson, Evelyn Tomlin & Mary Ann Swain
  173. 173. Nurses individual philosophy lends credence to nursing care.
  174. 174. Nurses individual philosophy lends credence to nursing care. Ernestine Weidenbach
  175. 175. Presented grand theory of nursing. All persons are caring and nursing is a response to unique social call.
  176. 176. Presented grand theory of nursing. All persons are caring and nursing is a response to unique social call. Anne Boykin & Savina Schoenhofer
  177. 177. Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido isthe psychic reservoir of psychic energy, id, ego, & superego).
  178. 178. Psychosexual theory (oral, anal, phallic, latent, genital stage). Psychoanalytical theory (Libido isthe psychic reservoir of psychic energy, id, ego, & superego). Sigmund Freud
  179. 179. Psychosocial development (trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt,industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, integrity vs. despair).
  180. 180. Psychosocial development (trust vs. mistrust, autonomy vs. shame/doubt, initiative vs. guilt,industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation, integrity vs. despair).
  181. 181. Erik Erickson
  182. 182. Superinferiority and inferiority complex / birth order.
  183. 183. Superinferiority and inferiority complex / birth order. Alfred Adler
  184. 184. The science of unitary human beings. Humanbeings are more than and different from the sum of their parts.
  185. 185. The science of unitary human beings. Humanbeings are more than and different from the sum of their parts. Martha Rogers
  186. 186. Theory based on bodily characteristics(endomorphic, mesomorphic, ectomorphic).
  187. 187. Theory based on bodily characteristics(endomorphic, mesomorphic, ectomorphic). William Sheldon
  188. 188. Transcultural nursing. Nursing is a humanistic andscientific mode of helping a client through specific cultural caring process.
  189. 189. Transcultural nursing. Nursing is a humanistic andscientific mode of helping a client through specific cultural caring process. Madeleine Leininger
  190. 190. Pulsating abdominal mass
  191. 191. Pulsating abdominal massAbdominal Aortic Aneurism
  192. 192. Painful board-like abdomen
  193. 193. Painful board-like abdomen Abruptio Placenta
  194. 194. Uremic frost on skin
  195. 195. Uremic frost on skinAcute Renal Failure
  196. 196. Bronze pigmentation of skin
  197. 197. Bronze pigmentation of skin Addisons Disease
  198. 198. Outburst laughter or cry fasciculations
  199. 199. Outburst laughter or cry fasciculationsAmyotrophic Lateral Sclerosis (ALS)
  200. 200. Pain upon exertion
  201. 201. Pain upon exertion Angina Pectoris
  202. 202. Mc Burneys sign
  203. 203. Mc Burneys sign Appendicitis
  204. 204. Boutonnier deformity, swan neck deformity, ulnar drift, Bouchards nodes
  205. 205. Boutonnier deformity, swan neck deformity, ulnar drift, Bouchards nodes Arthritis
  206. 206. Murmur heard high on chest
  207. 207. Murmur heard high on chest Atrial Septal Defect
  208. 208. Rocking, spinning, routines
  209. 209. Rocking, spinning, routines Autism
  210. 210. Grayish white discharge, malodorous
  211. 211. Grayish white discharge, malodorous Bacterial Vaginosis
  212. 212. Raccoons eye
  213. 213. Raccoons eyeBasilar Fracture
  214. 214. Meconium staining
  215. 215. Meconium staining Breech Birth
  216. 216. Russels sign, binge eating
  217. 217. Russels sign, binge eating Bulimia Nervosa
  218. 218. Cherry pink flushed face
  219. 219. Cherry pink flushed faceCarbon Monoxide Poisoning
  220. 220. Jack hammer syndrome
  221. 221. Jack hammer syndromeCarpal Tunnel Syndrome
  222. 222. Cloudy vision
  223. 223. Cloudy vision Cataract
  224. 224. Gluten sensitivity, water, pale, foul smelling stool
  225. 225. Gluten sensitivity, water, pale, foul smelling stool Celiac Disease
  226. 226. Maculopapulovesiculo rash
  227. 227. Maculopapulovesiculo rash Chicken Pox
  228. 228. Rice water stools
  229. 229. Rice water stools Cholera
  230. 230. Pulling up of arms & legs, red-face crying
  231. 231. Pulling up of arms & legs, red-face crying Colic
  232. 232. Barrel chest, clubbing of fingers
  233. 233. Barrel chest, clubbing of fingers C.O.P.D.
  234. 234. Moon face, buffalo hump
  235. 235. Moon face, buffalo hump Cushings Syndrome
  236. 236. Homonymous hemianopsia
  237. 237. Homonymous hemianopsia CVA
  238. 238. Feeling of fullness at vagina
  239. 239. Feeling of fullness at vagina Cystocele & Rectocele
  240. 240. Recent and past memory defect
  241. 241. Recent and past memory defect Delirium
  242. 242. Recall or learning memory impairment
  243. 243. Recall or learning memory impairment Dementia
  244. 244. Flashes of light, vein in line of sight
  245. 245. Flashes of light, vein in line of sight Detached Retina
  246. 246. 3 Ps: polydipsia, polyphagia, polyuria
  247. 247. 3 Ps: polydipsia, polyphagia, polyuria Diabetes Mellitus
  248. 248. Pseudomembrane
  249. 249. Pseudomembrane Diptheria
  250. 250. Cramping, colicky pain in left lower abdominal quadrant
  251. 251. Cramping, colicky pain in left lower abdominal quadrant Diverticular Disease
  252. 252. Saddle nose, Brushfields spots (Trisonomy 21)
  253. 253. Saddle nose, Brushfields spots (Trisonomy 21) Down Syndrome
  254. 254. Ortolanis sign, Galeazzis sign, asymmetry of gluteal, popliteal & thigh folds
  255. 255. Ortolanis sign, Galeazzis sign, asymmetry of gluteal, popliteal & thigh folds Dysplasia of Hip
  256. 256. Cullens sign
  257. 257. Cullens signEctopic Pregnancy
  258. 258. Premenstrual pain decreasing as menstrual flow decreases
  259. 259. Premenstrual pain decreasing as menstrual flow decreases Endometriosis
  260. 260. Exposed bladder, appears to be turned inside out
  261. 261. Exposed bladder, appears to be turned inside out Exstrophy of Bladder
  262. 262. Radar gaze
  263. 263. Radar gazeFailure to Thrive (FTT)
  264. 264. Barret esophagus
  265. 265. Barret esophagus G.E.R.D.
  266. 266. Halos around light
  267. 267. Halos around light Glaucoma
  268. 268. Dysuria, genital discharge
  269. 269. Dysuria, genital discharge Gonorrhea
  270. 270. Exopthalmia
  271. 271. ExopthalmiaGraves Disease
  272. 272. Hemarthrosis
  273. 273. HemarthrosisHemophilia
  274. 274. Asterixis
  275. 275. AsterixisHepatic Disease
  276. 276. Ribbon-like, foul smelling stool
  277. 277. Ribbon-like, foul smelling stoolHirschprungs Disease (megacolon)
  278. 278. Grapelike growth, large abdomen
  279. 279. Grapelike growth, large abdomen H-mole
  280. 280. Bossings sign, setting sun eyes
  281. 281. Bossings sign, setting sun eyes Hydrocephalus
  282. 282. Trousseaus sign
  283. 283. Trousseaus signHypocalcemia
  284. 284. High pitch cry
  285. 285. High pitch cryIncreased Intracranial Pressure (ICP)
  286. 286. Dolls eye
  287. 287. Dolls eyeIncreased Intraoccular Pressure
  288. 288. No passage of meconium
  289. 289. No passage of meconium Intestinal Obstruction
  290. 290. Dance sign, currant jelly-like stool, sausage like
  291. 291. Dance sign, currant jelly-like stool, sausage like Intussesception
  292. 292. Activity intolerance
  293. 293. Activity intoleranceIron Deficiency Anemia (IDA)
  294. 294. Strawberry tongue
  295. 295. Strawberry tongue Kawasaki
  296. 296. Red gelatinous sputum
  297. 297. Red gelatinous sputumKleibsella Pneumonia
  298. 298. XXY in males
  299. 299. XXY in malesKlinefelters Syndrome
  300. 300. Pulmonary manifestations (i.e. orthopnea, crackles, cyanosis, etc.)
  301. 301. Pulmonary manifestations (i.e. orthopnea, crackles, cyanosis, etc.) Left Ventricular Heart Failure
  302. 302. Less than 2.5 kgs or 5 1/2 lbs
  303. 303. Less than 2.5 kgs or 5 1/2 lbs Low Birth Weight
  304. 304. Red-ringed circular rash (erythema chronicum migrans)
  305. 305. Red-ringed circular rash (erythema chronicum migrans) Lyme Disease
  306. 306. Blackwater fever
  307. 307. Blackwater fever Malaria
  308. 308. Whirling, vertigo, tinnitus
  309. 309. Whirling, vertigo, tinnitus Menieres Disease
  310. 310. Kernigs sign, Brudzinkis sign
  311. 311. Kernigs sign, Brudzinkis sign Meningitis
  312. 312. White "cheesy" discharge
  313. 313. White "cheesy" discharge Moniliasis
  314. 314. Gowers sign
  315. 315. Gowers signMuscular Dystrophy
  316. 316. Charcots triad: intention tremor, nystagmus, scanning speech (clipped)
  317. 317. Charcots triad: intention tremor, nystagmus, scanning speech (clipped) Multiple Sclerosis
  318. 318. Nasal smile
  319. 319. Nasal smileMyasthenia Gravis
  320. 320. Nonproductive that progresses to mucoid sputum
  321. 321. Nonproductive that progresses to mucoid sputum Mycoplasmal Pneumonia
  322. 322. Viselike or crushing pain radiating to shoulder, arms, jaw or back
  323. 323. Viselike or crushing pain radiating to shoulder, arms, jaw or back Myocardial Infarction
  324. 324. Purulent conjunctivitis (N. Gonorrhea)
  325. 325. Purulent conjunctivitis (N. Gonorrhea) Opthalmia Neonatorum
  326. 326. White patches on tongue (Candida Albicans)
  327. 327. White patches on tongue (Candida Albicans) Oral Thrush
  328. 328. Kyphosis
  329. 329. KyphosisOsteoporosis
  330. 330. Ringing or buzzing
  331. 331. Ringing or buzzing Otosclerosis
  332. 332. Steatorrhea
  333. 333. SteatorrheaPancreatitis
  334. 334. Machinery-type murmur throughout the heartbeat in the left 2nd or 3rd interspace
  335. 335. Machinery-type murmur throughout the heartbeat in the left 2nd or 3rd interspace Patent Ductus Arteriosus
  336. 336. Pill rolling
  337. 337. Pill rollingParkinsons Disease
  338. 338. Abdominal muscle rigidity with rebound tenderness
  339. 339. Abdominal muscle rigidity with rebound tenderness Peritonitis
  340. 340. Beefy red tongue
  341. 341. Beefy red tonguePernicious Anemia
  342. 342. Paroxysmal cough ending with a whoop
  343. 343. Paroxysmal cough ending with a whoop Pertussis
  344. 344. Nikolsky sign
  345. 345. Nikolsky signPhemphigus Vulgaris
  346. 346. Fever, vaginal discharge, lower abdominal cramping
  347. 347. Fever, vaginal discharge, lower abdominal cramping Pelvic Inflammatory Disease (PID)
  348. 348. What is the purpose of IV fluid therapy?
  349. 349. What is the purpose of IV fluid therapy? Maintenance, to replace or correct deficits, to restore ongoing loss, for meds, nutrition,phlebotomy, transfusions or blood product therapy.
  350. 350. What is oncotic pressure?
  351. 351. What is oncotic pressure?Colloids, plasma proteins, albumin
  352. 352. What is hydrostatic pressure?
  353. 353. What is hydrostatic pressure? Blood pressure
  354. 354. What is normal serum osmo?
  355. 355. What is normal serum osmo?280 - 295 or approx. twice that of the serum Na level.
  356. 356. What can expand the intravascular compartment?
  357. 357. What can expand the intravascular compartment? Hypertonic fluids.
  358. 358. What is the problem with using hypertonic fluids?
  359. 359. What is the problem with using hypertonic fluids? If done too fast will draw too much fluid into theintravascular, dehydrating intracellular, especially the brain?
  360. 360. What is a S/sx of fluids administered too fast?
  361. 361. What is a S/sx of fluids administered too fast? decreased LOC / Confusion.
  362. 362. What happens if you expand the intra Cellular compartment too fast?
  363. 363. What happens if you expand the intra Cellular compartment too fast?Deplete the intravascular, decreasing BP and causing edema.
  364. 364. What are the two basic types of parenteral fluids?
  365. 365. What are the two basic types of parenteral fluids? Crystalloid and Colloid
  366. 366. What is a crystalloid fluid?
  367. 367. What is a crystalloid fluid?An Electrolyte containing solution.
  368. 368. What are the three basic types of crystalloid fluids?
  369. 369. What are the three basic types of crystalloid fluids? Isotonic, Hypotonic and Hypertonic
  370. 370. Why are crystalloid fluids called true solutions?
  371. 371. Why are crystalloid fluids called true solutions? Because they can pass through semipermeable membranes.
  372. 372. What is a Colloid fluid?
  373. 373. What is a Colloid fluid?Contains proteins and starches.
  374. 374. What cant a Colloid fluid do?
  375. 375. What cant a Colloid fluid do?Pass between compartments. They draw the fluid to them.
  376. 376. Name three problems with IV fluid therapy.
  377. 377. Name three problems with IV fluid therapy.Phlebitis, extravasation and incompatabilities.
  378. 378. What three things can an LVN NOT do?
  379. 379. What three things can an LVN NOT do?cannot hang, flush or change bags on a central line even if certified.
  380. 380. What can an RN NOT do with a central line.
  381. 381. What can an RN NOT do with a central line.Cannot assign to LVN or supervise LVN with anything to do with a central line.
  382. 382. How do you determine whether it is a central line or a peripheral line?
  383. 383. How do you determine whether it is a central line or a peripheral line? Ask the doctor for an x ray order to determine.
  384. 384. Name some isotonic fluids
  385. 385. Name some isotonic fluids D5W, LR and NS
  386. 386. Why do you need to be careful with LR and dehydration?
  387. 387. Why do you need to be careful with LR and dehydration?It is hard for the renal system to process the electrolytes.
  388. 388. What does the liver do to lactate? (LR)
  389. 389. What does the liver do to lactate? (LR)It metabolizes the lactate to bi-carbonate which buffers acidosis
  390. 390. What are two common uses for Normal Saline (NS)?
  391. 391. What are two common uses for Normal Saline (NS)? To treat hyponatremia and intravascular dehydration.
  392. 392. Name a Hypotonic solution?
  393. 393. Name a Hypotonic solution? 0.45 NS ( 1/2 NS)
  394. 394. What is a problem with Hypotonic solutions?
  395. 395. What is a problem with Hypotonic solutions?Use too long and it will lower BP. It is low insolutes so fluid will move out of the vascular space.
  396. 396. What makes Hyper tonic fluids different than the others?
  397. 397. What makes Hyper tonic fluids different than the others?It has more dissolved particles than body fluid.
  398. 398. What does a hypertonic fluid do?
  399. 399. What does a hypertonic fluid do? It moves fluid out of the intracellular andinterstitial compartments into the intravascular.
  400. 400. What are hypertonic fluids used for?
  401. 401. What are hypertonic fluids used for? Hydration and nutrition
  402. 402. What is dangerous about hypertonic dextrose saline solutions?
  403. 403. What is dangerous about hypertonic dextrose saline solutions? they can move fluids very quickly.
  404. 404. What is a hypertonic dextrose saline fluid solution used for?
  405. 405. What is a hypertonic dextrose saline fluid solution used for? TPN and PPN. Nutrition.
  406. 406. What type IV line do you use with Hypertonic dextrose saline?
  407. 407. What type IV line do you use with Hypertonic dextrose saline?10% solutions can go peripheral but all others 20% and above must use a central line?
  408. 408. Why must most hypertonic dextrose saline solutions be used with a central line?
  409. 409. Why must most hypertonic dextrose saline solutions be used with a central line?Because the fluids are very irritating to veins.
  410. 410. How do you infuse hypertonic dextrose saline solutions?
  411. 411. How do you infuse hypertonic dextr