Scott Gardner TCC Nursing Q1F04 Unit Eight
Terms
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- Define Scabies.
- A skin infestation by the itch mite that produces intense itching especially at night.
- Define Alopecia
- Acute hair loss that may be caused by chemotherapy and radiation to the head.
- Define Halitosis.
- Term that refers to bad breath.
- Define Stomatitis.
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Inflammation of the oral cavity.
Inflammation of the mouth (including the lips, tongue, and mucous membranes). - Define periodontal disease.
- A disease of the supporting structures of the teeth, the periodontium, including alveolar bone to which the teeth are anchored.
- Define Dental Caries.
- Tooth decay; progressive decalcification of the enamel and dentin of a tooth.
- What is Hygiene offered outside of the regularly scheduled routine? Clients who are incontinent or who sweat profusely may require frequent linen changes.
- PRN Care
- Identify the care provided before bedtime that helps the clientrelax and sleep. Might include back rub, toileting, and oral care.
- hs Care (hs=hour sleep=bedtime
- Define the hygiene measure offered in the afternoon that may refresh and comfort the client. Examples washing hands, face, assisting with oral care, toileting and evnironmental hygiene.
- pm Care.
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Define the hygiene that is given after the client has had breakfast. Includes toileting, bathing or shower, oral care, foot, nail, and haircare. Giving back rub, skin care.
Assess the client room for safety. Check for call bell availability. - Morning Care
- Define the hygiene that is offered in the early morning after the client awakens. The nurse assists with toileting and then provides comfort measures such as washing the face and hands and providing oral care.
- am Care
- During a patient transfer or lift, who coordinates and "Calls" the activity.
- The person with the heaviest load.
- Describe the body mechanic actions for health care workers.
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Protect the Back.
Bend the Knees
Plant Feet at Shoulder Width
Know what you are lifting and plan according.
Use Available patient assistance.
Get help from colleague. - What are pressure points (danger for pressure ulcers) in lying and sitting positions?
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Mainly Boney Prominences
Scapula
Elbows
Heels
Sacrum
Back of Head
Coccyx - Define the High Fowlers Position
- Sitting at a 90% Angle with the head elevated.
- Define Semi Fowlers
- Head Elevated sitting at a 45% Angle. The legs might need to be Gatched.
- Define Gatch
- Raising the knees when in a fowler position. Also referres to a Gatched Bed.
- Define Side Lying
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Head less than 30 Degrees
Pillow Between Legs
Pillows at back for support
High knee bent - Define Log Rolling
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Three people inline to role an immobilized client.
Key is keeping spine straight with sholders inline with hips. - Define the Sims Position
- Semi Prone
- Define Supine Position
- On Back, Face Up, Head Back
- What is a Hoyer Lift?
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A hydrolic lift used to lift a client. - When does the Nurse use the Call Button?
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When you are placing it in reach of the client.
To call for help from a colleague. - When do you use Side Rails in a Long Term Care facility?
- Only with Orders that are reinstated every 24 hours. This is meant to prevent abuse.
- In an Acute Care Setting, why are side rails used?
- To prevent falls.
- Discuss principles in feeding clients.
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Try for Independence
Offer varied Menu
Place client in High Flowler
Watch for Pocketing (Food in bucal area) which is not planned.
Keep the food separate per client wishes.
Ask for input, pace, liquid needed.
Sight imparement can utalize the clock system. - Define Bedpan
- A pan-shaped device placed under a bedridden patient for collecting fecal and urinary excreta.
- What is a Chux
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A Blue absorbant pad that is placed under an incontinent patient, or when using a bedpan. - Define Catheter.
- A tube passed through the body for evacuating fluids or injecting them into body cavities.
- Define Aspirate
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1. To draw in or out by suction.
2. To make a sound like that of the letter h.
(Tabers Online) - Define Prone
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1. Horizontal with the face downward.
2. Denoting the hand with the palm turned downward.
(Tabers Online) - Define Supine
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1. Lying on the back with the face upward.
(Tabers Online) - Define Side Lying Position
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A lateral recumbent position in which the individual rests on the right or left side, usually with the knees slightly flexed.
(Tabers Online) - Define Side Lying Position.
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A lateral recumbent position in which the individual rests on the right or left side, usually with the knees slightly flexed.
(Tabers Online) - Define Commode
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A receptacle suitable for use as a toilet.
(Tabers Online) - Define defecation
- Evacuation of the bowels.
- Define Fracture Pan
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A bedpan specifically designed to be used with clients who are unable to lift the hips to accomodate a normal bedpan. Smaller in shape and size. - Define Perineum
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1. The structures occupying the pelvic outlet and constituting the pelvic floor.
2. The external region between the vulva and anus in a female or between the scrotum and anus in a male. - Define Sims' position:
- A semiprone position with the patient on the left side, right knee and thigh drawn well up, left arm along the patient's back, and chest inclined forward so that the patient rests on it.
- Define Fowlers Position
- Sitting up in bed. The bed is elevated to about 60 Degrees.
- Define Semi Folwers
- The Bed is elevated to about 45 degrees.
- Define lithotomy position
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A position in which the patient lies on the back, thighs flexed on the abdomen, legs on thighs, thighs abducted.
This is used in genital tract operations, vaginal hysterectomy, and the diagnosis and treatment of diseases of the urethra and bladder.
(Tabers Online) - Define Urinal
- 1. A container into which one urinates
- Define Dorsal Recumbent Position
- A position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward.
- Define expectoration:
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1. The act or process of spitting out saliva or coughing up materials from the air passageways leading to the lungs.
2. The expulsion of mucus or phlegm from the throat or lungs. - Define vulva:
- That portion of the female external genitalia lying posterior to the mons veneris, consisting of the labia majora, labia minora, clitoris, vestibule of the vagina, vaginal opening, Bartholin's glands.
- Define void:
- To evacuate the bowels or
- Define urination:
- The release of urine from the body.
- Define regurgitation:
- A backward flowing, as in the return of solids or fluids to the mouth from the stomach or the backflow of blood through a defective heart valve.
- Define footdrop:
- Plantar flexion of the foot due to weakness or paralysis of the anterior muscles of the lower leg.
- Defineanatomical position:
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The position assumed when a person is standing erect with arms at the sides, palms forward. - Define torsion
- 1. The act of twisting or the condition of being twisted.
- Define Trochanter Roll
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trochanter roll- Used to prevent the external rotation of hips when the client is supine. To form: a cotton bath blanket is folded lengthwise to a width that will extend from the greater trochanter of the femur to the lower border of the popliteal space. Blanket is placed under buttocks and then rolled counterclockwise until the thigh is in a neutral or inward rotation. When correct alignment of hips is achieved, the patella face directly upward. (Potter 1456) - Define Toe Pleat
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toe pleat- A fold in linens made toward the foot of the bed to allow for movement of the clientÂ’s feet in order to reduce the risk of pressure sores on the clientÂ’s toes and heels. (Potter 1118) - Define Mitered Corner
- Similiar to a hospitcal corner, but it is not tucked in, but rather remains open.
- Define Dysphagia
- Inability to swallow or difficulty in swallowing.
- Define Anaorexia
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Loss of appetite.
Anorexia is seen in depression, malaise, commencement of fevers and illnesses, disorders of the alimentary tract (esp. the stomach), and alcoholism and drug addiction (esp. cocaine). Many medicines and medical procedures have the undesired side effect of causing the suppression of appetite. - Define Partial Bed Bath
- Consists of bathing only body parts that would cause discomfort or odor if left unbathed, such as hands, face, breasts, perineal area, and axillae. Generally for aging or dependent clients in need of only partial hygiene or self-sufficient bed ridden clients unable to reach all body parts receive partial bed baths.
- Define Backrub
- - A back rub or back message usually follows the client's bath. It promotes relaxation, relieves muscular tension, and stimulates the skin circulation. Analysis showed that the long, slow, gliding strokes (effleurage) of a massage are associated with a reduction in heart and respiration rate. Massage is contraindicated in patients who recently had heart surgery, fractured ribs, and skin.
- Describe Daily Care with an Occupied Bed
- This can be difficult and should only be done when totally necessary. The nurse must get all of the bedding together. Then the nurse would double glove and then basically roll patient to one side of the bed and roll up the linen. Clean up the patient and remove gloves. Put on clean linen on half of bed. Roll the client to other side and to the same thing.
- Define Shaving
- Shaving facial hair can be done after the bath or shampoo. Women may prefer to shave their legs or axilae while bathing. When assisting a client the nurse should take care to avoid cutting the client with a razor blade. Clients prone to bleeding should use an electric razor. Electric razors should only be used on one client to avoid cross contamination. Soften skin by placing a warm washcloth on the face, then put shaving cream on. The nurse should pull the skin taut and use short, firm strokes in the direction the hair grows.
- Describe Daily Care of an Unoccupied Bed
- Bed is folded closed meaning it is tucked in at the top and bottom and generally used for new patients. It can also be folded so that the top is "open" so a client can get in and out easily.
- Describe Daily Care of a Surgical Bed
- Make your basic unoccupied bed but fold the two corners of one side toward the middle like the start of a paper air plane. Then fold in three sections.
- Define circadian rhythm:
- Diverse yet predictable changes in physiological variables, including sleep, appetite, temperature, and hormone secretion, over a 24-hour period.
- Define Biological Clock
- An internal system in organisms that influences behavior in a rhythmic manner.
- Define NREM
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Sleep during which non–rapid eye movements occur.
In NREM stage 1, the transition from wakefulness to sleep occurs. Eye movements are slow, and an electroencephalogram (EEG) shows low brain wave activity. In stage 2, EEG activity is increased, with the appearance of spikes called K complexes. Eye movement ceases in stage 3; wave frequency is reduced and amplitude increased. In stage 4, the EEG is dominated by large spikes, or delta activity. Stages 3 and 4 are considered deep sleep. - Define REM
- Sleep during which rapid eye movements occur. In REM sleep, which follows stage 4 of non–rapid eye movement (NREM) sleep, electroencephalographic activity is similar to that of NREM stage 1, and muscle paralysis occurs
- Define Ethnocentrism
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Belief in the superiority of one's own ethnic group.
Overriding concern with race. - Define Acculturation
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The modification of the culture of a group or individual as a result of contact with a different culture.
The process by which the culture of a particular society is instilled in a human from infancy onward - Define Rest
- REST is the state of mental, physical, and spiritual activity that leaves one feeling refreshed
- Define Sleep
- SLEEP is a cyclical physiological process that alternates with longer periods of wakefulness. The sleep wake cycle influences and regulates physiological function and behavioral responses.
- Describe the Total Sleep Cycle
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Total Sleep Cycle = Nrem 1, Nrem 2, Nrem 3, Nrem 4 THEN Nrem 3, Nrem 2 thenÂ…REM.
With each cycle stage 3&4 shorten and REM lengthens.
*Remember/ 1-2-3-4-3-2-REM-2-3-4-3-2-REM-2-3-4-3-2-REMÂ…cont. (see pg 1253) - Define Assimiliation
- The process whereby a minority group gradually adopts the customs and attitudes of the prevailing culture.
- Define Ethnicity
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Ethnic character, background, or affiliation.
An ethnic group.
Its Genetic. - Define Culture
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The totality of socially transmitted behavior patterns, arts, beliefs, institutions, and all other products of human work and thought.
These patterns, traits, and products considered as the expression of a particular period, class, community, or population: Edwardian culture; Japanese culture; the culture of poverty.
These patterns, traits, and products considered with respect to a particular category, such as a field, subject, or mode of expression: religious culture in the Middle Ages; musical culture; oral culture.
The predominating attitudes and behavior that characterize the functioning of a group or organization.
Its not Genetic. - Define Nitrogen Balance
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nitrogen balance - the difference between the amount of nitrogen taken in and the amount excreted or lost.
If you excrete more nitrogen than you consume your body will break down muscle tissue to get the nitrogen it needs. (Negative nitrogen state) Muscle loss occurs.
If you consume more nitrogen than you excrete you will be in an anabolic - muscle building - state (positive nitrogen state).
(Potter 1288-1289 & 1273-1274) - Define Stereotype
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A conventional, formulaic, and oversimplified conception, opinion, or image.
One that is regarded as embodying or conforming to a set image or type.
(Potter 120) - Define Oral care
- - Good oral hygiene helps to maintain the healthy state of the mouth, teeth, gums and lips. Brushing cleans the teeth of food particles, plaque, and bacteria. It also massages the gums and relieves discomfort resulting from unpleasant odors and tastes. Flossing further helps remove plaque and tarter from between teeth to reduce gum inflammation and infection. Complete oral hygiene enhances well-being and comfort and stimulates the appetite. Tooth brushing 4 times a day is an effective oral hygiene program. Some clients require special oral hygiene methods because to their level of dependence on the nurse or the presence of oral mucosal problems. Unconscious clients are susceptible to drying of mucous thickened salivary secretions because they are unable to eat or drink, frequently breathe through the mouth and often receive oxygen therapy. The unconscious client also cannot swallow salivary secretions that accumulate in the mouth. These secretions often contain bacteria, which can cause pneumonia. Clients who are unconscious require two people brushing in which one-person brushes while the other suctions. Client should be warned of sensations before beginning. Sponge toothbrushes may be used but do not effectively clean at the gum line.
- Define Perineal care
- - Clients in need of perineal care are those at greatest risk for acquiring an infection (uncircumcised males, clients with indwelling catheters, clients recovering from rectal or genital surgery and childbirth, and women on menstrual period. Clients and nurses may be embarrassed to do perineal care and it is best to have someone of the same sex provide care. Clients most at risk for skin breakdown in the perineal area are those with urinary or fecal incontinence, rectal and perineal surgical dressings, indwelling urinary catheters and morbidly obesity.
- Define Complete bed bath
- - for clients who are totally dependent and require total hygiene care. This activity can be exhausting for a client even if the nurse provides all of the care. The nurse must anticipate and assess whether clients are physically able to tolerate a complete bath. Measuring heart rate before, during and after the bath provides a measure of the client's physical tolerance.
- Define Canthus
- The angle at either end of the slit between the eyelids; the external canthus or commissura palpebrarum lateralis and the internal canthus or commissura palpebrarum medialis. (TaberÂ’s)
- Define Haircare
- A person's appearance and feeling of well-being often depend on the way the hair looks and feels. Illness or disability may prevent a client from maintaining daily hair care. Brushing, combing and shampooing are basic hygiene measures for all clients
- Define Ingestion
- The process of taking material (particularly food) into the gastrointestinal tract (Taber
- Define Aspiration
- draw by suction; remove by aspiration (ie remove body fluids); inhale. Proper position prevents aspiration of foreign material into airways during feeding, drinking and taking of meds. Aspiration is a risk with enteral tube feeding.
- Define Base of Support
- A steady base, with legs planted at shoulder width, knees bent which should be assumed before doing any lifting.
- When is a Fanfold used?
- When making a surgical bed.
- Define a Footboard
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Footboard- the end of the bed, patients may often slide down because of gravity toward the footboard. It keeps the patient from sliding off the bed. It can also be used to allow client to push himself or herself up in the bed. (clinical notes)
Anatomic position - the client would be lying with head forward palms out feet forward, leaves pressure on occipital bone, shoulders, buttocks, and heals - Define NPO
- Nils per ost (Nothing By Mouth)
- Define Reflux
- Reflux - is basically food moving backwards into the throat out of the stomach (Potter1437) this can be prevented by putting the client in upright "sitting postition" Fowlers or semifowlers
- Define Malnutrition
- Any disease-promoting condition resulting from either an inadequate or excessive exposure to nutrients (i.e., undernutrition or overnutrition, respectively).
- Define Transfer Belt
- Transfer belt: is used to lift patients from their beds and chairs. It is used when the nurse needs assistance in lifting a client, the client has severe weakness, impaired balance, hemiparesis, or difficulty cooperating due altered mental status.
- Define Trapeze
- A triangular device that descends from a securely fastened overhead bar that is attached to the bed frame. Device used for proper positioning. It allows the client to pull with the upper extremities to raise the trunk off the bed, to assist in transfers or to perform upper body exercises/strengthing.
- Define bed board:
- A firm board placed beneath a mattress to keep it from sagg
- Define the Normal Sleep Requirement for an Neonate
- Upto 3 Months is 16 Hours
- Define the Sleep Patterns of an infant.
- Several naps and 8-10 hours = 15 hours total each day
- Define Sleep Patterns for a Toddler
- By Age 2 Naps and sleeping through the night averages 12 hours daily.
- Define sleep patterns for a Pre-Schooler.
- By age 5 naps are diminished. Sleeps about 12 hours at night.
- Define sleep patterns for School Age Children
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6 Year Old averages 11-12
11 year old averages 9-10 - Define sleep patterns for adolescents
- Typically about 7.5 hours sleep nightly
- Define sleep patterns for young adults.
- 6-8.5 hours nightly.
- Define sleep pattern for middle adults.
- Total sleeping at night begins to decline. The amount of stage IV begins to decline that continues with age.
- Define sleep patterns for Older adults.
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REM sleep shortens.
80% of adults >65 complain of trouble sleeping. - What are the factors that can affect ability to sleep?
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Drugs and substances
Lifestyle
Usual sleep patterns and excessive daytime sleepiness – EDS
Emotional Stress-
Environment
Food and caloric intake - Define Nursing Interventions to promote sleep
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Health Promotion
Environmental Controls
Promoting Bedtime Routines
Promoting Comfort
Establishing Periods of Rest and Sleep
Stress Reduction
Bedtime Snacks
Medication Approaches - Describe the components of a complete sleep assessment.
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Determine the clients current sleep pattern
Review factors affecting the clientÂ’s sleep
Evaluate the clientÂ’s response to sleep disturbance
Evaluate the clientÂ’s developmental level
Explore the clientÂ’s approaches to improve sleep - How many servings of Bread Rice and Cereal are recommended on the food guide?
- 6-11
- How many servings Vegetabels of are recommended on the food pyramid?
- 3-5
- How many servings of fruit are recommended on the food pyramid?
- 2-4
- How many servings of milk, yoghurt and cheese are recommended on the food pyramid?
- 2-3
- How many servings of Meat Beans, eggs, and nuts are recommended on the food pyramid?
- 2-3
- How many servings of Fats, Oils and Sweets are recommended on the food pyramid?
- Spairingly
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What is the role of protein in the diet?
How many kcal/gr energy does it provide? -
Only source of Nitrogen
4kcal/gr - What are the role of lipids or fats?
- Most caloric dense at 9 kcal/gr
- Describe the role of Carbohydrates in the diet.
- Are the main source of energy in the diet. They provide 4 kcal/gm and serve as the main source of fuel for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. They are obtained primarily from plant foods, except for lactose.
- What are the Fat Soluable vitamins?
- A D E K
- Define the role of Calcium in the diet
- Calcium: Calcium has 4 basic functions in the body: bone and tooth formation, blood clotting, muscle and nerve action and metabolic reactions. Milk and milk products are the most important sources of readily available calcium.
- Define the role of potassium in the diet.
- Partner with sodium. Potassium also has many metabolic functions, like water balance, metabolic reactions, muscle action, insulin release and blood pressure. It is abundant in all natural foods. The richer dietary sources are unprocessed foods.
- Define the role of Sodium in the diet.
- Has an important task in acid-base balance, muscle action and water balance. Common table salt is the main dietary source of salt. There is enough sodium in natural food sources to meet the bodyÂ’s needs.