| Term | Definition |
|---|---|
main function for sodium | fluid balance, nerves, muscles |
main function for potassium | heart and muscle function |
main function for calcium | bones, muscles, nerves |
main function for magnesium is to | muscles, nerves, heart |
main function for chloride | fluid and acid base balance |
main function for phosphorus | bones, energy, cells |
what is intracellular fluid | fluid inside cells |
what is extracellular fluid | fluid outside cells |
examples of fluid balance intake | oral fluids, Iv fluids, tube feedings, foods containing fluids |
examples of fluid output | urine, vomiting, diarrhea, drainage, perspiration. |
what is fluid deficit | too little fluid |
what are some signs of fluid deficit? | dry mouth, poor skin turgor, dark urine, low BP, weight loss |
what is fluid excess | to much fluid |
what are some signs of fluid excess? | edema, weight gain, crackles, increased BP, shortness of breath |
what is a carbohydrate | main source of energy, ex. bread, pasta, rice |
what is protein | builds and repairs tissues, helps with wound healing, ex. meat, eggs, beans |
what is a fat? | concentrated source of energy, helps absorb vitamin A,D,E,K |
what are some fat soluble vitamins? | A,D,E,K |
what are some water soluble vitamins that | b and c |
what are some examples of minerals | calcium, iron, potassium, sodium |
what are some examples of clear liquids | broth, clear juice, tea, water, gelatin |
what are some examples of full liquids | milk, pudding, ice cream, cream soups |
when do we put patients on a low-sodium diet | hypertension, heart failure, fluid retention |
what does normal urine smell and look like | pale yellow, clear, mild odor |
what are some signs of urinary retention? | bladder distention, urgency, small amounts of urine, lower abdominal pain discomfort |
what are some signs of urinary incontinence | leakage when coughing/sneezing, bladder is leaking/full |
what are some things that need to be done when performing catheter care? | keep drainage bag below bladder, perform catheter/perineal care, maintain a closed system, monitor color and odor of urine |
how do you promote bowel function? | fluids, fiber, activity |
what is enema used for | relieve constipation, empty bowels, prepare for procedure |
what does a healthy stoma look like | pink/red, moist,
*if blue, purple, or black stoma report immediately |
what does febrile mean | fever |
what does afebrile mean | no fever |
what is hypothermia | abnormally low temperature |
what is hyperthermia | abnormally high temperature |
where is the apical pulse located | 5th intercostal space, left midclavicular line |
tachycardia is? | greater than 100 bpm |
bradycardia is? | less than 60 bpm |
name all pulse points | carotid, apical, radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis. |
what is tachypnea | fast breathing |
what is bradypnea | low breathing |
what is apnea | no breathing |
what is dyspnea | difficulty breathing |
what is hypertension | persistently elevated BP |
what is hypotension | abnormally low BP |
what is orthostatic hypotension? | blood pressure drops when changing positions |
what does PQRST stand for | Provocation, quality, region, severity, timing |
what is an admission assessment | complete assessment when patient enters care |
what is a focused assessment | looks at a specific problem |
what is an emergency assessment | rapid assessment for life threatening problems |
what is an ongoing assessment | repeated assessments to monitor changes |
sign= | objective |
symptom= | subjective |
what is a normal lung sound | vesicular |
abnormal lung sounds would have | popping, crackling, wheezing, high pitched sounds
*can occur when fluid is in lungs. |
what are the six P's in a neurovascular assessment | pain, pallow, paresthesia, paralysis, pulse, poikilothermia |
what does SBAR mean | Situation, background, assessment, recommendations |
shift report should include | patient identification, diagnosis, current condition, vital signs, pain, medications, treatments, safety concerns, pending test |
why is sleep important? | restores energy, heal tissue, support immune function, improves concentration |
what are some factors that could affect sleep | stress, pain, illness, medications, noise, light |
what stage of sleep is NREM | the physical restoration(body) |
what stage of sleep is REM | dreaming is common, brain activity increases (brain) |
what is biorhythm | a natural biological rhythm that repeats over time |
what is insomnia | difficulty falling/staying asleep |
what is sleep apnea | repeated interruptions in breathing during sleep
*symptoms- snoring, gasping, morning headaches |
what is gerontology | study of aging |
what is geriatrics | healthcare of older adults |
what is ageism | discrimination or stereotyping based on age |
what is polypharmacy | the use of multiple medications
* risks include confusion, falls, side effectts |
immobiliy can cause? | pressure injuries, muscle weakness, contractures, constipation, DVT, bone loss |
what is Active ROM | patient does the movement |
what is passive ROM | nurse/caregiver moves the joint |
what is flexion | bending |
what is extension | straightening |
what is abduction | away from body |
what is adduction | toward body |
what is rotation | turning around an axis |
what is dorsiflexion | toes toward head |
what is plantar flexion | toes pointed downward |
what is pronotion | palms turns downward |
what is supination | palms turns upward |
what is supine | lying on back |
what is prone | lying on stomach |
what is sims' | side lying, semi pron |
what is fowlers | head of bed elevated |
what is high fowlers | 60-90 degrees |
what is fowler's | 30-45 degrees |
what is lithotomy | on back with hips/knees flexed and legs supported |
stage 1 pressure injury | intact skin, redness, does not blanch |
stage 2 pressure injury | partial-thickness skin loss, shallow open area/blister |
stage 3 pressure injury | full-thickness skin loss, fat may be visible |
stage 4 pressure injury | extensive tissue loss, muscle/tendon/bone may be exposed |
what do I asked myself before giving a medications? | vital signs, allergies, labs, kidney function, blood glucose, BP, pulse |
what do I monitor when giving beta blockers | HR and BP, can cause bradycardia/hypotension |
what do I monitor when giving insulin | check blood glucose, watch for hypglycemia |
what do I monitor when giving heparin | bleeding |
what do I monitor when giving furosemide | monitor BP, daily weight and potassium |
what do I monitor when giving nitroglycerin | check BP and headaches/hypotension |
what do I monitor when giving potassium chloride | potassium levels
*never give IV potassium by IV push |
formula for dosage calculations | desired/have*quantity |
when thinking of NCLEX test ?'s, I would think of what first | if there was an answer that involved an airway emergency |
what are the levels of maslows hierarchy | physiological, safety, love, esteem, self actualization |
what is the nursing process(ADPIE) | assessment, diagnosis, planning, implementation, evaluation |
what is the normal temp for an adult | 97-99 degree F |
what is the normal pulse | 60-100 |
what is the normal respirations | 12-20 |
what is the normal SpO2 | 95-100% |
what is the normal BP | generally <120/80 |
Electrolytes Na= | 135-145 |
Electrolytes K= | 3.5-5 |
Electrolytes Ca= | 8.5-10.5 |
Electrolytes Mg= | 1.5-2.5 |
Electrolytes Phosphorus= | 2.5-4.5 |
Electrolytes CI= | 96-106 |
what is circadian | 24-hour rhythm |