SUPPLEMENTAL BULLETS

FUNDAMENTALS
MEDICAL TERMINOLOGY
Ecchymosis – form of macula that appears as large,
irregularly shaped hemorrhagic area of skin
Bruise – superficial injury in which the skin is discolored but
not broken
Petechia – small purplish, hemorrhagic spot on the skin.
Hematoma - is a localized collection of blood caused by a
break in the blood vessel in an organ tissue or space

Paresis-weakness, plegia – paralysis

Tremors – rhytmic, purposeless body movements.
Spasms are involuntary, sudden movements.
Reflexes are involuntary actions in response to a
stimulus.
Tics are spasmodic contractions of face neck or
shoulder muscles that may be habitual or conditional
reflexes

Ataxia – lack of coordination in performed planned,

purposeful movement, typically resulting from a neurological
deficit.
Apraxia – inability to perform purposeful movementm even
though no neuromuscular deficit exists.
Fasciculations – fine twitching movements
Amnesia – loss of memory
Agnosia – lack of sensory integration
Aphasia – loss or inability to communicatethrough speech ,
written language or signs resulting from brain disease or
trauma
Anomia – lack of memory of items
Akinesia – loss of the ability to move voluntarily
Allen’s test – a test designed to evaluate a client’s collateral
circulation in the arm before an invasiev arterial procedure
such as ABG.the radial and ulnar arteries is occluded while
client clenches his fist causing the hand to blanch.when he
unclenches his fist, the ulnar artery is released.the hand
should become pink, indicating a patent ulnar artery
Battle’s sign – discoloration of the skin behind the ear
following a fracture of the bone in the lower skull

Chvostek’s sign – spasm of the facial muscles elicited by

light taps on the facial nerve. Signals tetany in hypocalcemia
Compartment syndrome – a neurovascular complication
commonly associated with fractures of the the limb;
constrictive or occlusiove dressings, sutures or casts; poor
positioning and any injury causing ischemia, swelling or
bleeding into the tissues that ultimately can lead to
permanent dysfunction and deformity
Kegels exercises – exercises involving alternate contraction
and relaxation performed to strengthen thenperineal
muscles

Kernig’s sign- elicitation of resistance and hamstring muscle

pain when the examiner attempt to extend the knee while
the hip and knee are both flexed 90 degrees
Brudzinski’s sign – passive flexion of the hips and knees in
response to flexion of the neck, signals meningeal irritation
Kussmaul’s respiration – abnormal deep , gasping type of
respirations resulting from air hunger associated with severe
diabetic acidosis and coma
Trousseau’s sign – an assessment technique for evaluating
neuromuscular irritability associated with hypocalcemia.
Positive carpopedal spasms(adducted thumb, flexed wrist ,
metacapophalangeal joint and extended interphalangeal
joints after a bp cuff is applied and infalted to a pressure
above systolic for 1-4 minutes
Lubb closure of Atrioventricular valves
Dubb closure of semilunar valves
Eryth – red , cya – blue , pal/leuk white , ashen – gray,
mela – black
Pulse deficit – PR , pulse pressure – BP
Hyper capnia – elevation of PaCO2 in arterial blood
Hypoxemia – reduced level of oxygen in arterial blood ( less
than 80 nnHg)
Remittent fever – body temperature varies over 24 hours
but remains elevated
Relapsing fever-short febrile periods alternating with
periods of normalk body temp.
Anasarca – generalized edema

It is – inflammation , thrombo – clot , dynia – pain ,

ab , away from
Penia – deficiency
Rhexis – rupture
Narco – stupor
Plasty – repair / formation

Nursing Process
Nursing processp provides continuity of care and patient participation
in health care
Care plans should never be unchangeable and revised prn
NANDA – responsible for formulating taxonomies or classifications
Nursing order should include the date, the specific nursing action,
time / length of time and signature
Provide safety from falls – keep bed in lowest level and locking wheels
The point at which the brachial pulse can no longer be palpated
provides an estimate of the maximum pressure required to measure
systolic blood pressure.
Last Korotkoff sound heard on auscultation with a stethoscope is the
diastolic pressure
The primary reason for bedrest is to decrease metabolic
activity, which reduces the cells need for oxygen.secondary
is to conserve energy and decrease cardiac output
The normal APTT is 16 – 25 seconds and PT is 12 – 15
seconds, these levels must remain within two to two ½ the
normal levels
Negligence – failure to act as an ordinary prudent person
would.
Malpractice – professional misconduct, improper discharge
of professional duties or failure to meet standards of care

Three elements necessary to establish nursing

malpractice – nursing error , injury and proximal
cause
A DNR order means that basic and advanced life
support measures won’t be initiated if respiratory or
cardiac arrest occurs. It does not mean that ordinary
treatment measures or nursing care is stopped

Communication Skills

Nursing theory – one that generates knowledge in nursing

Conceptual model – group of general ideas that serves as
framework upon which nursing theories can be developed
and tested.
In 1960, Nursing schools adopted theories from the
biological and psychosocial sciences to serve as conceptual
frameworks
Four concepts – person, environment – health and
nursing(actions)

Martha Rogers – life process model – evolving

creature interacting with the environment in an
open, adaptive manner-achieve maximum health in
his environment
Dorothea Orem – persons need to achieve self care.
Goal of nursing is to help patient develop self- care
activities to maintain maximum wellness
High level wellness - OLOF

Maslow – a need as a satisfaction whose absence can cause

illness
Safest way to identify patient is checking identification band
on his wrist
Diagnosis and Tx of human responses to actual or potential
health problems
Profession – requires specialized knowledge with long and
intensive academic preparation
Student nurses do not provide services, they are solely on
the unit to learn
Patient safety is a major concern in all situations
The goal of listening- identify problems and needs and a
supportive act.

Delegating responsibility shows respect for the staff

members abilities to solve problems on their own
The nurse managers function is to guide , direct and
coordinate patient care, not to provide it.
Primary nursing – comprehensive form of nursing in which
one nurse is responsible for comprehensive care of a given
patient
Evaluation of staff members must be based on performance
criteria as established by professional standards and the job
description.
Poor performance stems from poor morale
Communicating
Trust is the foundation of positive nurse patient
relationship
Therapeutic communication – two way , deliberative
interaction between the patient and nurse in which
they establish mutually acceptable, achievable goals
---fundamental component at all phases of the
nursing process

Problem orientedmedical record- information is recorded as

prob.,observations and plan
Narrative chart – decriptive storylike record
A positive change in the patient’s behavior is the best way
to identify learning
Teacher should always try to involve the learner
Asking questions shows that the patient is interested in
learning
Maintaining independence, a need common to patients of
all age-groups, fosters the elderly person’s feelings of self
worth
NURSING ASSESSMENT
Too much Yin causes digestive disorders and nervousness and too
much yang causes dehydration , fever and irritability.
Correct sequence in abdl. Assessment is RLQ, RUQ, LUQ and LLQ
Guaiac – hemoccult test
Rectal examination – sims , genupectoral and dorsal recumbent
Romberg test – test for sensory or cerebellar ataxia
Narrowed pulse pressure less than 30 – hypovolemia
Oral temp.-36.1- 37.8’C (axillary 1‘deg.lower) (rectal -1’higher)
BP cuff small – false high readings

Rectal temp – 3 to 5 mins. And axillary 10 mins.

Rinne hearing tests compare sound conduction
through air and bone.air conduction greater than
bone conduction normal hearing or sensorineural
hearing loss. Vice versa conductive hearing loss
Weber’s – determine if patient hears better in one
ear or to differentiate sensorineural hearing loss
from conductive hearing loss

Level of consciousness is the most important element in

assessing the patient’s mental status
Letargic patient sleep’s on and off but will respond to verbal
or tactile stimuli. Stupor – needs constant stimulation
Brain highly sensitive to inadequate oxygenation ( mental
changes – hypoxia – first sign)
Body’s response to elevated temperature – tachycardia and
peripheral vasodilation(inc. metabolism) - hypotension
Crisis – turning point in the course of a disease usually
indicated by a rapid decrease in temperature
Lysis – gradual improvement in condition

MOBILITY
INCREASED ADRENALIN PRODUCTIONIN IMMOBILE PATIENTS –
DECREASED PERISTALSIS
Anorexia – depleted protein stores
Anatomic alignment prevents ctrain on body parts, amintains balance
and promotes physiologic functioning
Drawsheet is the best device to use when moving a patient up in bed
Virchow’s triad, collectively predispose a ptient to thrombophlebitis ,
impaired venous return to the heart , blood hypercoagubility and injury
to to blood vessel wall.

Valsalva maneuver – forced expiratory effort against

a closed glottis
Oxygen improves respiratory function only if he has
symptoms of hypoxia
Cold skin and impalpable pulse in the leg – refer
asap (embolus)
Pulse rate – most reliable indicator of activity
tolerance
Complication of immobility – foot drop
HUMAN NEEDS
BODY IMAGE – PERCEPTION OF HIS APPEARANCE ,
FUNCTION IN COMPARISON TO OTHERS
PERCEPTIONS TO BODY IMAGE BEGIN AT A YOUNG AGE
AND CONTINUE TO EVOLVE THROUGHOUT LIFE.
SELF – CONCEPT – PERCEPTIONS OF ONE’S BODY IMAGE,
SELF-ESTEEM AND PERSONAL IDENTITY
STRESSOR-ANY FACTOR THAT CAUSES PHYSICAL OR
MENTAL WEAR AND TEAR ON THE BODY THAT ALTERS
EQUILIBRIUM

WEIGHING FOR M.I.O. – 1 g = 1 ml

Average urine output – 1,500 – 2,00 ml.
Caffeine – diuretic effect
Urine pH – 6.0
Activity and elimination – one of man’s physiologic
need(rest , sleep , food , clothing , shelter and air , water
and temp. maintenance)
TPN CONSIDERATION:GENERAL COND;- LOSS OF 7%
OF USUAL BODY WEIGHT OVER 2 MONTHS, LACK OF ORAL
NUTRITION FOR 5 DAYS, PRE-OP. PREPARATION OF
SEVERELY MALNOURISHED PATIENTS, Ca in the GIT and IBD

Soft diet – no fried foods , organ or red meats, whole grain

breads and seasoning
Bland – no gastric irritants and seasonings, fruit juice OK
Venturi mask – precise o2 concentration.
Humidification of o2 – distilled H2O
Vomiting of fluids for 3 days – loss of fluids
Lungs and kidneys - body’s homeostatic regulator’s
Hypertonic solution enema-120 ml left in place for 7 – 10
minutes
Cleansing enema – 1000 ml.

Comfort and safety measures

Lotions containing lanolin – preferred for backrub
Sleep deprivation causes behavior and personality changes. Adequate
sleep maintains coordination and perception and decreases
restlessness
REM –deep sleep, depressed muscle tone and possibly irregular heart
and respiratory rates
Non-REM sleep is a deep restful sleep without dreaming
Delta stage or slow wave sleep – non REM satge III and IV –quiet
sleep
Napping in the afternoon – not conducive to nightime sleeping
Pain is whatever the patient says it is , exists whenever she says it
does
Preventing pain is always easier than releiving it
Bedrail only a reminder not to leave bed
SPECIAL NEEDS
AGING DECREASED ELASTICITY OF BLOOD VESSELS, INCREASED
PERIPHERAL RESISTANCE AND DECREASED BLOOD FLOW
HIP FRACTURE FROM OSTEOPOROSIS
ALZHEIMER’S – LOSS OF SHORT TERM MEMORY
SENSORY DEPRIVATION- INVOLUNTARY LOSS OF PHYSICAL
AWARENESS CAUSED BY DETACHMENT FROM EXTERNAL SENSORY
STIMULI – ISOLATION
SPEAK DIRECTLY IN FRONT AND ENUNCIATE WELL- HEARING
IMPAIRED
“DEVOID OF FEELINGS” – ACCEPTANCE IN THE GRIEVING PROCESS
NURSE CAN HELP ENSURE A PEACEFUL DEATH BY PROVIDING
DIGNIFIED SUPPORT
HIGH PROTEIN DIET – ACIIDC URINE , VEGETARIAN DIET –
ALKALINE URINE

MAINTAINING ASEPSIS
ORGANISMS MODE OF TRANSMISSION DETERMINES ISOLATION PRECAUTIONS
BARRIER USED TO BRAEK THE CAHIN OF INFECTION BETWEEN MODE OF
TRANSMISSION AND SUSCEPTIBLE HOST
STERILE ITEMS CAN BE ONLY STORED FOR 1 -2 MONTHS
HANDWASHING NOT LESS THAN 30 SECONDS
AUTOCLAVE – KILLS ALL MICORBES INCLUDING SPORES –PENETRATE THICK LINEN
PATIENT IN ISOLATION – NEED SENSORY STIMULATION
SOAPS AND DETRGENTS – REMOVE BACTERIA – LOWER SURFACE TENSION OF
WATER AND ACT AS EMULSIFYING AGENTS
ANTISEPTIC – INHIBIT GROWTH
BACTERICIDES AND DISINFECTANTS – DETSROY PATHOGENS
EXUDATE – CLEAR PROTEIN RICH FLUID
GOOD NUTRITION CRUCIAL IN THE HEALING OF PRESSURE ULCERS

THERAPIES AND TREATMENTS

PHLEBITIS – WARMTH AND BURNING SENSATION
Z – TRACK PREVENT SKIN STAINING And IRRITATION
Mid – deltoid can accommodate only 1 ml. of medication
Insulin injection- validate dose accuracy
Insulin injection – G25 , 5/8 “ needle
G20 – IM oil based
22G 1 ½”– IM meds.
G26 – intradermal
Length of tubing should make no influence in how the infusion flows