123 unit 2

Card Set Information

Author:
callmelauren122001@yahoo.com
ID:
179673
Filename:
123 unit 2
Updated:
2012-10-25 20:51:54
Tags:
123 unit
Folders:

Description:
Fundamentals unit 2
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user callmelauren122001@yahoo.com on FreezingBlue Flashcards. What would you like to do?


  1. Five steps to nursing porcess
    • Assesments
    • Nursing Dx
    • Planning 
    • Implamenting 
    • Evaluation
  2. Nursing Care Plan
    • Nursing process
    • Guidline for clinical care
  3. Nursing Diagnosis
    Term given to PT on whats goin on
  4. Step 2 of care plan
    • Interput and anylaze clustered data
    • Identify PT problem and strengths
    • Formulate nursing dx-statement of how pt is responding to actual problems 
  5. Nursing Dx vs Medical Dx
    • Nursing Dx within nursing practice 
    • identfies pt responce to illness/problem
    • can change from day to day
    • Medical Dx within medical practice 
    • Focus on curing illness
    • Stays the same 
  6. Formation of Nursing Dx
    PES format-Problem-Etiology-S&S
  7. P of PES format 
    Problem statement-pt responce to problem (NANDA)
  8. E of PES format
    Etiology-what causes/contributed to PT problem

    etiology must cause problem
  9. S of PES format
    • Signs and symtoms-evidence of problem
    • state "as evidence by" AEB
  10. Actual Nursing Dx Type
    • Has all three parts PES
    • ex: Imbalanced nutrition: less than body requires related chonic diarrhea, nasuea and pain.  As evidence by height 5'5" weight 105
  11. Risk Nursing Dx Type
    • has just the PE part of PES
    • ex: risk for falls related to altered gait, generalized weakness
  12. Wellness Nursin Dx Type 
    Family coping: potential for growth related to unexpected birth of twins 
  13. Step 3 of care plan-Planning
    • Maslows order of priority
    • organize care plan based on nursing dx
    • nurse and pt formulate goals and out comes 
    • Interventions or tx based on critical judgement-including action, frequency, quantity, method and person to preform them
  14. Patient Goal/Outcome
    • ALWAYS starts with "Pt will..."
    • goal-broad statement-one per Dx
    • outcome-measurable criteria to meet goal(timeframe)
  15. Goals are SMART
    • Specific
    • Measurable
    • Attainable
    • Relavant
    • Time bound
  16. Types of goals
    • Short term
    • Long term
    • Acute care
    • Physiologic goal
    • Cognative goal
    • Psychomotor goal
    • Affective goal
  17. Step 4 Implemenation
    • The doin step, providing care, carrying out interventions
    • ALWAYS teaching pt
    • use verbs, monitor, teach, further asses, observe, administer
    • must have time frame
  18. Intervention rules 
    • Must be evidence based with rationals 
    • Be aware of errors/inappropriate orders
    • RN are legally responsible for complications
  19. Nurse initiated intervention
    Any independent action the nurse can initiate without direct supervision 
  20. Physician initiated intervention
    Dependent nusring action requiring MD orders
  21. Collaborative intervention
    nursing actions performed jointy with other health care teams members
  22. Step 5 Evaluation
    • determines the effectiveness of nursing care plan
    • done throughout patient care 
    • comparision of pt behavior and response 
    • meets goal from step 3
  23. Purpose of documentation
    Supports nursing dx, indicates clients condition, primary communication tool, legal protection, quality assurance, education, decision analysis
  24. Confidentiality
    • Nurses are legaly obligated to keep clients information confidential
    • HIPPA
    • Pt has right to read chart
  25. Documentation guidelines 
    • Record is permanent
    • Sign full name 
    • Do not write error for mistake
  26. Joint Commission requirments 
    • Every pt must have assessment 
    • Physical, psychological, environmental, self-care, client education, discharge planning 
  27. Federal State regulations
    standards of care, set nursing documentation standards 
  28. Multidisciplinary Communication
    • Communication with whole care team
    • records or chart
    • reports
    • consultations
    • referrals
  29. Types of Documenation
    • Progress/Nurses note
    • Flow sheets
    • Graphics
    • Nusring care plan
  30. Methods of Documentation
    • Traditional-Source oriented
    • Problem Oriented medical-SOAP,PIE,Focus DAR
    • Charting by exception
    • Flow sheets
  31. Methods of Recording
    • Progress Notes
    •    SOAP-sub,obj,assess,plan
    •    SOAPIE-sub.obj,asses,plan,intervention,eval
    •    PIE-problem,intervention,evaluation
    •    Focus Charting (DAR)-data,action,response
  32. Guildlines for Quality Documentation
    • Factual
    • Accurate
    • Complete
    • Current
    • Organized
  33. Method of Reporting
    • Source records-seperate section for each discipline
    • Charting by exception CBE-focuses on documenting deviations
    • Case management plan-incorporates a multidisiplinary approch to care 
  34. ABC's of charting
    • Accuracy
    • Brevity
    • Completeness
  35. Pharmacology
    the study of chemical/drugs and their effects on living orgamisms 
  36. Drug effect
    • chemical effect with a specific effect
    • alter physiological function of body, do not creat a new function
  37. Parmacotherapeutics
    • use of grugs to prevent disease 
    • preventative
    • palliative
    • restorative
    • why a drug is prescribed
    • "why is drug prescribed"
  38. Parmacokinetics
    • drug movement
    • absorption
    • distibution
    • biotransformation (metabloism)
    • excretion
    • "how does it move through body"
  39. Movement of drug from site to blood stream
    Absorption
  40. The transport of drug in blood to site of action
    Distribution
  41. Process by which the body degrades the chemical structure of a drug
    Metabolism

    Kindey and Liver 
  42. Process where drugs are removed from body
    Excretion
  43. Pharmacodynamics
    The stuy of the mechanism od drug action on living tissue at the cellular lever

    "what the drug does to the body"
  44. Nurse and Med resposibility
    • Current knowledge 
    • refer to resources (pharmacy)
    • ? any order that is unclear
    • refuse to give drug if harmful
    • perform asses. & correct technique
    • monitor pt responcse 
    • document effects
    • educate pt and family
  45. Check what when giving BP meds
    Blood pressure 
  46. Controled Substance Levels 
    • Schedule 1: highest potential for abuse-heroin
    •     ''          2: morphine dilaudin
    •     "          3: vicodin meperidine
    •     "          4: valium xanax
    •     "          5: cough suppresent w/codeine
  47. Rx
    Presciption-must have written order for pt to recieve 
  48. OTC
    Over the counter-pt treats self no written order
  49. Prescription requirments!!  TRAMPD
    • Written legibly 
    • Pt name 
    • drug name 
    • dose 
    • route 
    • frequency
    • date 
    • signature
  50. TRAMPD
    all need to be on scritp!!
  51. Pt refusal of drug
    • MOST first call doc
    • and document 
  52. Standing or Routine
    administer until order is changed 
  53. Single or one-time
    given only once 
  54. Now
    Give when needed but not stat
  55. PRN
    give as needed or asked for 
  56. STAT
    give immediatly emergency
  57. Prescritions 
    • Daily, b.i.d.-twice a day, t.i.d-three times a day 
    • HS-hours of sleep
  58. Drug classification
    • Therapeutic-organized by disease it treats
    • Pharmacologic-organized by their mechanism of action
    • Controlled substance schedule
    • Pregnancy schedule- A mom can have X mom cant have 
  59. NSAID
    • pharmacologic
    • non steroidal anti-inflammatory agents
    • Advil, motrin, ibeprophine
  60. Beta blockers
    • pharmacologic
    • slows BP HR increases contraction of heart
  61. Generic name
    pharmaceutical name given by US adopted name council
  62. Trade/Brand or Proprietary name
    • copyright name 
    • popular name suppied by manufacture
  63. ?'s to ask befor giving meds
    • Any allergies
    • taking any other meds
    • can you swallow 
    • fluid restiriction
    • religious influences 
    • vital signs 
    • lab values r u pregnant
  64. Untoward effects
    • symptoms of a dose to high 
    • Adverse drug event ADE
  65. Interactions with other drugs
    can potentiate or inhibit drug action
  66. interaction with food
    may delay absorption
  67. Contraindictions
    what conditions are adversly affected by this drug
  68. Blood Glucose levels
    60-100
  69. Potassium
    3.5-5.0
  70. Albumin
    3.5-5.0
  71. WBC
    5000-10000
  72. BUN
    Blood Urine Nitrogen
    10-20
  73. Creatinine
    0.5-1.2
  74. Albumin producer
    The liver 
  75. BUN
    • If it goes up w/out creatinine its dehydration
    • If both go up its kidney issue
  76. 1 Killogram = ? pounds 
    2.2 lb
  77. 1 Ounce = ? millerliters
    30mL
  78. 1 Teaspoon = ? millerliters
    5mL
  79. Solid tablet absorption
    Must be disntegrated
  80. Dissolution
    process where tablet goes into solution 
  81. Solution
    All drugs must be in sloution to cross biologic membranes 
  82. Pharmacokinetics
    • what the body does to drug 
    • Movement of drug by kidney and liver
    • Absorption
    • Distibution
    • Metabolism
    • Excretion
  83. Absorption methods
    • Plasma membrans
    •     diffusion(lipid soluble)
    •     active transport(proteint bound soluble molecule)
    •    
  84. First pass
    the first pass through liver takes part of drug-mostly oral meds
  85. Enteral
    Gut to ass-pill and supository
  86. Parenteral
    Any area outside gut-IV, topical
  87. Absorption fast to slow
    Liquids--powders--capsules--tablets--coated tablets--enteric coated
  88. Enteral Routes
    • Mouth 
    •    Buccal--Sublingual-avoids first pass
    • Oral
    •    Stomach--first pass to liver-low pH
    • Small Intest
    •    Most importatn for absorption-high pH
  89. Pulmonary absorption
    • Gases or aerosols 
    • Rapid absorption
    • Local effects
  90. Topical absorption
    • edidermis low on lipid and water so good for absorption
    • local effects 
  91. Transdermal 
    diskc or patch contains a day or week of meds-steady rate of absorption
  92. Parenteral absorption
    • All pass first pass effect-100% of drug is absorbed by body
    • Intravenous 
    • Subcutaneous 
    • Intramuscular
    • Intradermal
  93. Protein binder for meds
    Albumin--plasma protein produced by liver

    if no binding then toxicity levels will rise
  94. Blood Brain Barrier Drugs
    • Highly lipid solube
    • Not all can cross BBB
    • caffeine, nicotine, antidepressants
    • Less effective in older people 
  95. Metabolite
    • Chemical structure of a drug broken down to another form
    • Water soluble easily excreted by LIVER 
  96. Cytochromes 
    metabolize lipid soluble drugs in liver 
  97. Excretion Organ
    • Kidney
    • drugs removed from body 
  98. Biliary
    Excretion of bile and feces 
  99. Half life
    • How long it takes to metabolize half of the drug
    • Concentration of drug in blood to drop below 50%
  100. Analgesic
    Pain reducer, pain killer 
  101. Antidysrhythmic
    Used to correct cardiac function
  102. Diuretic
    removes excess water from body
  103. Antiemetic
    prevent vomiting 
  104. NSAID
    • non-steroidal anti-inflammatory drugs
    • aspirin
  105. Cathartic
    Laxative
  106. Antipyretic
    fever reducers
  107. Antitussive
    cough medicine
  108. Onset
    how long it takes to get response from drug
  109. Peak
    time it takes to reach maximum response 
  110. Duration
    • how long it lasts 
    • time a concentration is sufficient to maintain response 
  111. Digoxin
    • increases HR
    • Highly specific-less side effects
    • Less specific-more side effects
  112. Agonists
    • produces a desired therapeutic effect when bound to the receptor
    • has same effect as body would 
  113. Antagonists
    • Produce no receptor response 
    • Blocks the reaction of receptor
  114. Enzyme interaction
    Bind to enzyme and block their action on cells 
  115. Non specific interactions 
    • no enzyme action
    • drug gets into cell and causes cell death
  116. Peak and Trough levels
    blood taken after drug given and just before next dose 
  117. Trough level
    lowest concentration of drug in blood
  118. Therapeutic range 
    concentration between minimum and toxic level
  119. Loading doses
    higher amout of drug given to achieve maximum effectiveness dose quickly
  120. Maintenance dose
    intermittent doses given to maintain levels 
  121. Teratogenic effects
    drug induced birth defects from drugs given to mom
  122. Additive effects 
    two or more drugs given to egual same responce 
  123. Synergism
    two or more drug combined to get response greater than either drug 
  124. Neuropothy
    Diabetics less sensation in limbs 
  125. RAS reticular activating system
    • responsible for stimulus arousal
    • monitors imcoming stimuli
  126. Opioids effects
    CNS despessant
  127. Sensory Overload symtoms
    unrealistic perception, bewilldered, disoriented, difficulty concentrating, scattered attention ect,
  128. Sensory overload interventions
    • reduce stimuli
    • establish routine of care 
    • speak calmly
  129. Sensory deprivation
    • isolation
    • impaired ability to receive and send stimuli
    • inability to cognitively process stimuli
  130. NREM sleep
    • non-rapid eye movement
    • has 4 stages 
    • 75-80% of sleep 
  131. REM sleep
    • rapid eye movement 
    • 20-25% of sleep
    • dreaming
  132. "Pain"
    What ever the pt says is pain
  133. Acute pain
    • sudden onset 
    • short duration
    • can ID cause 
  134. Chronic pain
    • gradual onset
    • duration 3 month 
    • dont know what causes it 
  135. Nocioceptive pain
    Cutaneous-superfical-stimuli of nerve fibers in skin

    Somatic-deep-tendons, bone ligaments 

    Visceral-arise from internal organs
  136. Neuropathic pain
    Referred-pain in different part of body than actual trama

    Psychogenic-pain from a mental event not physical

    Neuropathic-damaged nervous system
  137. Phantom pain
    sensation perceived when body limb is missing 
  138. Intractable pain
    Pain highly resistant to relief
  139. Radiating pain
    Perceived at the source ans extends to nearby tissue
  140. Idiopathic pain
    Chronic pain in the absence of any indentifiable cause 
  141. Pain Process
    • Transduction-biochemical release excite nocioceptors
    • Transmission-impulse travel along neurons to spinal cord
    • Perception-stimulus recieved by thalamus
    • Modulation-body releases pain blockers
  142. Gate Control
    relieve pain by brain and emotion
  143. Physiologic pain response
    • Involuntary
    • sympathetic response increased BP, HR
  144. Behavioral pain response 
    • Voluntary
    • guarding, rubbing, moaning
  145. Affective pain response
    anxeity, fear, fatigue
  146. ABCDE of pain assesment
    • A-ask about pain
    • B-believe the pt
    • C-choose pain control
    • D-deliver intervention
    • E-empower pt and fam
  147. SLINDA fifth vital sign
    • S-sevarity 0-10
    • L-location
    • I-intensity
    • D-duration
    • A-what asserbates pain
  148. Nonopioids 
    acetaminophen, NSAID's ibuprofen
  149. Opioids
    • narcotics
    • morphine, codeine
  150. Adjuvant
    drug developed to enhance opioids effects
  151. Opioids sife effects
    • constipations
    • reduced respiration
    • orthostatic hypertension
    • urine retention 
    • vomiting 

What would you like to do?

Home > Flashcards > Print Preview