Vital Signs
Another name for fever
Pyrexia
Lateral movement of a body part away from the midline of the body.
Abduction
Function is sense of smell
CNI Olfactory
The first line of defense against microorganisms
Skin
Patient data that is measurable and directly observed
Objective Data
regulatory body having the authority to make and enforce rules and regulations concerning the nursing profession; detemines number of CEU's required for license renewal.
State Board of Nursing
Normal range for pulse in adults
60-100 beats per minute
The state of being in a straight line.
Extension
responsible for pupillary response and accomodation
CN III Oculomotor
(dehydration)- the process of drying up.
Desiccation
Term for fullness or elasticity of the skin
Turgor
Most important law affecting your nursing practice; describes the “who,” “what,” “when,” “where,” “why,” and “how” of nursing practice.
Nurse Practice Act
Most common site to assess peripheral pulse in adults when taking vital signs
radial pulse
Backward bending of the hand or foot.
Dorsiflexion
Responsible for chewing and facial sensation; corneal reflex
CN V Trigeminal
In wound healting- the tissue that often appears as red, bumpy tissue that is described as “cobblestone-like” in appearance; forms the foundation for scar tissue development.
Granulation Tissue
Visual acuity is assessed using this tool
Snellen Chart
The process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area.
Certification
Grade for a normal, brisk pulse amplitude (strength)
+2
involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling.
Isotonic exercise
Tests for visual acuity and visual fields
Type of drainage composed primarily of the clear, watery portion of the blood
Serous
Acronym used for normal eye function
PERRLA
Type of intentional tort in which a threat or an attempt to make bodily contact with another person without that person’s consent.
Assault
Movement of air in and out of the lungs
ventilation
the maximum degree of movement of which a joint is normally capable)
Range of Motion
Sense of hearing
CN VIII Acoustic
known as the repair phase of wound healing
Proliferation phase
Breath sounds heard over the mainstem bronchus
Bronchovesicular
Spoken Defamation of Character
Slander
Normal range for respirations in an adult
12-20
semi-sitting position, calls for the head of the bed to be elevated 30 to 45 degrees.
semi-fowlers
Lateral movement of the eyes; side-to-side
CN VI abducens
Term for dead tissue in wounds; appears as slough—moist, yellow, stringy tissue—and eschar appears as dry, black, leathery tissue.
Necrosis
term for abnormal lung sounds
adventitious
Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property
Fraud
Increased respiratory rate; may occur in response to an increased metabolic rate
Tachypnea
the patient lies flat on the back with the head and shoulders slightly elevated with a pillow unless contraindicated
supine
Tested by raising eyebrows, smile, frown; taste on anterior 2/3 tongue
CN VII Facial
The partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
Dehiscence
Harsh, loud, high pitched sound that indicates obstruction of the airway
stridor
Defined as performing an act that a reasonably prudent person under similar circumstances would not do or, conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do
Negligence
Maximum pressure when left ventricle contracts and pushes blood through aortic valve into the aorta
Systolic Pressure
True or False: The cane is held on the patient’s stronger side and is advanced one small stride ahead
True
Swallow, gag reflex; taste on posterior 1/3 of tongue
CN IX Glossopharyngeal
Pressure injury stage with nonblanchable erythema of intact skin.
Stage I
first and second heart sounds "lub-dub"
S1S2
The four elements that MUST be established to prove that malpractice or negligence has occurred.
Duty, Breach, Causation, Damages
Lowest pressure when the heart rests between beats
Diastolic Pressure
True or False: when going down stairs-Move crutches and unaffected leg first, followed by the affected leg.
False
Downward, inward eye movement
CN IV Trochlear
Type of drainage that consists of large numbers of red blood cells and looks like blood
Sanguineous
Anatomical location of pulmonic valve
2nd ICS, left sternal border
The protection and support of another’s rights
Advocacy
Results from an inadequate physiologic response to position changes
Orthostatic Hypotension
an increased thoracic spinal curve; common in older adults
Kyphosis
Movement of the tongue
CN XII Hypoglossal
When the abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area.
Evisceration
Anatomical location of the mitral valve
5th ICS, midclavicular line
Acting in accordance with an appropriate code of ethics and accepted standards of practice.
Integrity
Factors that affect pulse oximetry reading- Name 3
Temperature of the extremity
Nail polish/artificial nails
Movement
Inflated BP cuff on same extremity
Perfusion
Characterized by the displacement of a bone from a joint with tearing of ligaments, tendons, and capsules.
Dislocation
Swallowing and speaking
CN X Vagus
Pressure injury stage with full-thickness skin and tissue loss that may extend to the muscle, bone, tendon, or joint
Stage IV
Amount of time to auscultate bowel sounds before documenting absent
1 minute per quad, 5 min total
value that is reflected in professional practice when the nurse works to assure equal treatment under the law and equal access to quality health care.
social justice
S/S include headache, fatigue, Skin moist/sweating, increased pulse, temperature elevated but typically 102 or less.
Heat exhaustion
type of exercise that refers to sustained (often rhythmic) muscle movements that increase blood flow, heart rate, and metabolic demand for oxygen over time, promoting cardiovascular conditioning
Aerobic
Movement of shoulder muscles
CN XI Accessory
Type of open drain that does not have a collection device
Penrose drain
Percussion sound heard over normal lung
Resonance (hollow)
Involves the transfer of responsibility for the performance of an activity to another person while retaining accountability for the outcome.
Delegation
S/S include Anxiety, confusion, skin hot and dry, impaired sweating, increased pulse and respirations, hypotension; body temp 105 or greater
Heat stroke
Weight bearing term for ability to remove a sheet of paper from beneath foot at all times
Touch down/Toe Touch
Number of cranial nerves that are both sensory and Motor
Four; CN V, VII,IX,X
Factors that affect pressure injury development/impaired skin integrity- List 4
Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders
Ration for T:AP Diameter
2:1
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision