Medical Definitions & Procedures PDF

Definitions: 1. Affect: The visible expression of emotion or feeling. 2. Denotation: The literal or primary meaning of a word. 3. Intonation: The variation in pitch when speaking; can convey different meanings or emotions. 4. Pneumonia: Infection that inflames air sacs in one or b...

Definitions: 1. Affect: The visible expression of emotion or feeling. 2. Denotation: The literal or primary meaning of a word. 3. Intonation: The variation in pitch when speaking; can convey different meanings or emotions. 4. Pneumonia: Infection that inflames air sacs in one or both lungs, causing cough, fever, and difficulty breathing. 5. Angina: Chest pain due to reduced blood flow to the heart. 6. Aphasia: A disorder affecting a person's ability to communicate, typically caused by brain damage. 7. Peristalsis: The wave-like muscle contractions that move food through the digestive tract. 8. Decubitus ulcer: Also known as a pressure ulcer, it is a wound caused by prolonged pressure on the skin, often seen in immobile patients. Nurse-Patient Relationship Components: Acceptance: Acknowledging and respecting patient choices and feelings. Caring: Showing empathy, concern, and compassion. Mutuality: Collaborating with the patient in the care plan. Authenticity: Being genuine in communication and interactions. Zones of Personal Space: Intimate (0-18 inches): Used for physical assessments or personal care. Personal (18 inches to 4 feet): For taking a patient history or conducting an interview. Social (4-12 feet): During formal communication, such as a group setting or education session. Public (12+ feet): Used in public speaking or when addressing larger groups. Verbal vs. Non-verbal Communication: Verbal: Use of words, language, and speech to convey messages. Precise and clear. Non-verbal: Body language, facial expressions, gestures, posture, and eye contact. Can reinforce or contradict verbal communication. Phases of a Helping Relationship: 1. Pre-interaction Phase: Planning and gathering information before meeting the patient. 2. Orientation Phase: Establishing trust and rapport.  3. Working Phase: Collaborating to meet patient goals. 4. Termination Phase: Ending the relationship after goals are met or the patient is discharged. SBAR (Situation, Background, Assessment, Recommendation): Situation: What is happening at the current time? Background: Background information relevant to the situation. Assessment: Your clinical assessment or observations. Recommendation: Your recommendation for what should happen next. SBAR is considered a best practice in healthcare communication because it provides a structured framework for conveying critical information between healthcare providers, ensuring that communication is clear, concise, and focused on important details. This method helps prevent misunderstandings and improves patient safety. Example: ○ S: The patient is experiencing chest pain. ○ B: The patient has a history of angina. ○ A: Chest pain rated 8/10, blood pressure elevated. ○ R: Recommend starting oxygen and getting an ECG. Best Practice for Non-English Speaking Patients: Use professional medical interpreters. Avoid using family members for translation. Use simple language, and visual aids, and repeat information as needed. Compare OT, PT, and ST: OT (Occupational Therapy): Focuses on helping patients with daily living activities (e.g., bathing, dressing). PT (Physical Therapy): Focuses on improving mobility, strength, and function (e.g., walking, balance). ST (Speech Therapy): Focuses on communication and swallowing disorders. Communication with Sensory Deficits: Visual deficits: Use large print materials, and ensure proper lighting. Auditory deficits: Face the patient while speaking, reduce background noise, and use visual aids. Verbal deficits: Use writing tools, gestures, or picture boards. HIPAA Principles:  Protect patient privacy and confidential information. Share information only with those involved in the patient's care. Do not disclose information without patient consent. Best Practice for Shift Change Information: Bedside report: Ensures accurate and timely exchange of information and patient involvement. Include medication administration, current patient status, and any changes in condition. Key Components of Documentation: Accuracy: Ensure all information is correct. Timeliness: Document as soon as possible after providing care. Completeness: Include all relevant details, such as assessments, interventions, and patient responses. Medication Toxicity Signs: Renal toxicity: Decreased urine output. Hepatic toxicity: Jaundice, elevated liver enzymes. Cardiotoxicity: Irregular heart rhythms. Legal Ramifications of Documentation: Be factual, clear, and concise. Do not document opinions or guesses. Avoid alterations or backdating entries. Types of Documentation: Progress notes: Record the patient’s daily care and response to treatments. Patient care summaries: Overview of the patient's plan of care, medications, and treatment. Flow sheets: Used for routine assessments (e.g., vital signs, intake/output). Safe Patient Discharge Considerations: Provide clear instructions/education for medication management. Arrange follow-up appointments. Assess the home environment for safety. Make sure the patient understands any necessary lifestyle changes, while also addressing any potential barriers such as mobility or transportation.  Coordinating with community resources, and arranging home health services if needed can help set the patient up for success at home and in the community. Telephone and Verbal Orders: Repeat orders back to the provider to confirm. Document the order, including the provider's name, time, and date. Z-track Method: A technique for IM injections to prevent medication from leaking back into subcutaneous tissue. Used for medications that can irritate the skin. Considerations with the Older Adult and Medication Administration/Absorption: Slower metabolism: Medications are metabolized and excreted more slowly. Increased sensitivity to medications: Older adults may have increased sensitivity to certain drugs, especially those affecting the central nervous system. Polypharmacy: Older adults often take multiple medications, increasing the risk of drug interactions. Decreased renal and hepatic function: Impacts the metabolism and excretion of medications. Changes in body composition: Increased fat-to-muscle ratio can affect drug distribution. Difficulty swallowing: May require liquid forms or crushed medications. The Rights of Medication Administration: 1. Right patient: Verify patient identity using two identifiers. 2. Right medication: Ensure the correct drug is given. 3. Right dose: Confirm the correct dosage. 4. Right route: Verify the correct route of administration. 5. Right time: Administer at the prescribed time. 6. Right documentation: Document the medication immediately after administration. 7. Right reason: Ensure the medication is appropriate for the patient’s condition. 8. Right response: Monitor the patient for the intended therapeutic response. 9. Right to refuse: Respect the patient's right to refuse medication. What Happens if a Medication Error Occurs: Responsibility: The nurse is responsible for reporting and addressing the error. Actions:  ○ Assess the patient for adverse effects. ○ Notify the healthcare provider immediately. ○ Document the error in the patient's chart and according to facility policy. ○ Complete an incident report (without placing blame). Routes of Medication Administration (Fastest to Slowest Absorption): Fastest: Intravenous (IV). Intermediate: Intramuscular (IM), subcutaneous (SC), and sublingual. Slowest: Oral and topical routes. Medications Requiring a “Waste”: Narcotics or controlled substances often require a second nurse to witness and document any medication that is "wasted" (unused or discarded) due to partial doses or returned meds. Patient’s Right to Refuse Medication or Intervention: Patients have the legal right to refuse any treatment, including medication. Nurse's Action: Educate the patient on the consequences of refusal, document the refusal, and notify the healthcare provider. Interventions for Suspected IV Complication: Infiltration: Stop infusion, remove IV, elevate the limb, and apply a cold compress. Phlebitis: Stop infusion, remove IV, and apply a warm compress. Air embolism: Clamp the IV, place the patient in the Trendelenburg position, administer oxygen, and notify the provider. Considering Patient Preferences for Medications: Whenever possible, patient preferences (e.g., timing of medication, route) should be considered and respected if safe and clinically appropriate. Tool for Assessing Pain: Numeric Rating Scale (NRS) or Visual Analog Scale (VAS): Common tools for verbal pain assessment. Best resource: The patient is always the best source for assessing their pain. Ways to Assess and Monitor Pain:  Verbal: Ask the patient to rate their pain on a scale. Behavioral: Observe for non-verbal signs like grimacing, restlessness, or guarding. Best Practice When Assessing Pain: Non-judgmental: Believe in the patient’s report of pain, regardless of whether it aligns with objective findings. Frequent assessment: Monitor pain regularly and reassess after interventions. General Adaptation Syndrome (G.A.S.): A three-stage response to stress: 1. Alarm: Immediate stress reaction. 2. Resistance: The body tries to cope with the stress. 3. Exhaustion: If stress persists, the body’s resources are depleted. Pharmacologic vs. Non-Pharmacologic Pain Management: Pharmacologic: Includes medications like opioids, NSAIDs, and muscle relaxants. Non-pharmacologic: Includes therapies like heat/cold application, massage, relaxation techniques, and acupuncture. Opioids and Their Routes of Administration: An opioid is a class of potent pain-relieving medications that act on the nervous system to reduce pain, often used for managing moderate to severe pain, such as post-surgical or cancer-related pain. Opioids can be administered in various forms, including PO (oral) for chronic pain IM (intramuscular) for faster relief IV (intravenous) for acute pain in hospital settings Dermal (transdermal patches) for continuous, long-term pain management. PCA Pump: Function: Allows patients to self-administer pain medication (usually opioids) within prescribed limits. Effectiveness: Monitored by pain relief and patient use. Side effects: Respiratory depression, sedation, nausea. Monitor closely. Common Side Effects of Opioids: Constipation: Educate patients to increase fluid and fiber intake as opioids may cause constipation.  Sedation: Encourage regular activity and avoid driving when taking an opioid. Nausea: May need antiemetic treatment. Diabetes Mellitus (DM) Complications: Common complications: Neuropathy, retinopathy, and nephropathy. Preventative measures: Blood glucose monitoring, foot care, regular eye exams, regular exercise, a healthy diet, education on signs of hyperglycemia, and use of devices like continuous glucose monitors. NSAID Primary Function: Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation, pain, and fever. Priorities in Medication Administration: Safety: Ensure correct patient, medication, dose, route, and time. Assessment: Always assess the patient's condition before administering medication. Administering Pain Medication for Acute Pain: Nursing Process: Always assess pain and document findings before administering medication. UAP (Unlicensed Assistive Personnel): Scope of Practice: Can perform non-invasive, routine tasks (e.g., bathing, vital signs). Appropriate delegation: Measuring vital signs, and assisting with ADLs. Inappropriate delegation: Administering medications, and performing assessments. Basic Structures of the GI System: Mouth: Breaks down food. Esophagus: Transports food. Stomach: Breaks down food with acids. Small intestine: Absorbs nutrients. Large intestine: Absorbs water, and forms stool. Nutritional Considerations for Healthy Bowel Function: Fiber: Encourages healthy bowel movements. Fluids: Prevents constipation. Best Position for Bowel or Bladder Elimination: Sitting upright or squatting (e.g., on a toilet or bedpan). MRI Considerations: An MRI (Magnetic Resonance Imaging) is a medical test that uses strong magnets and radio waves to take detailed pictures of the inside of your body, such as your organs and tissues. It helps doctors see what's happening inside without using X-rays or surgery. Safety precautions: Check for metal implants, pacemakers, or claustrophobia. Complications of Incontinence: Skin breakdown: Use barrier creams and frequent changing of pads. Psychosocial effects: Provide emotional support and maintain dignity. C. Diff: C. diff (Clostridioides difficile) is a type of bacteria that can cause severe diarrhea and inflammation of the colon, often after taking antibiotics. It spreads easily in healthcare settings and requires strict infection control measures like wearing personal protective equipment (PPE) and thorough handwashing to prevent transmission. Requires contact precautions (gown and gloves). Prevention: Hand hygiene with soap and water, proper cleaning of surfaces. What is a colostomy and how do we assess it? Colostomy: A surgical procedure where part of the colon is brought through the abdominal wall to create an opening (stoma) for feces to exit the body. Assessment: ○ Healthy stoma: Should appear moist, round, and red/pink in color (resembling the inside of the mouth). ○ Unhealthy stoma: Pale, blue, or black discoloration can indicate ischemia or necrosis. What is a pressure injury and how do we prevent and treat them? What are the considerations for patients at high risk for developing this? Pressure injury: Localized damage to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure or shear. Prevention: ○ Frequent repositioning (at least every two hours).  ○ Use of pressure-relieving devices (e.g., specialty mattresses, cushions). ○ Proper nutrition and hydration. ○ Maintaining skin hygiene. Treatment: Includes relieving pressure, wound care, debridement if necessary, and appropriate dressings. High-risk considerations: ○ Immobility, incontinence, poor nutrition, decreased sensation, and advanced age increase the risk. Environmental Considerations for Performing Accurate Skin Assessments: Ensure good lighting to observe color changes, wounds, and moisture. Privacy and comfort are key, especially for sensitive areas. Room temperature: A comfortable room temperature helps the patient relax during the assessment. What are the stages of healing? 1. Hemostasis: Immediate response post-injury, clot formation. 2. Inflammatory phase: Lasts up to a few days; redness, swelling, and warmth occur as the immune system clears debris. 3. Proliferative phase: Granulation tissue forms, collagen is laid down, and the wound contracts. 4. Maturation (remodeling): This can last months to years, where scar tissue strengthens and reorganizes. Compare and contrast: eschar, slough, granulation, purulence Eschar: Dry, dark, necrotic tissue (black or brown) that needs debridement for wound healing to progress. Slough: Moist, yellow, white, or green dead tissue; it is softer and typically adheres to the wound bed, requiring removal. Granulation tissue: Red or pink, healthy tissue that indicates wound healing, appearing as small, bumpy nodules. Purulence: Thick, yellow, green, or brown drainage, indicating infection. Signs of Healthy Wound Healing vs. Signs of Complications: Healthy signs: Pink or red granulation tissue, no foul odor, minimal or clear drainage, and wound edges approximating (closing). Signs of complications: Increased redness, swelling, pus, foul odor, increased pain, or wound dehiscence (separation of wound edges). Important Objective Assessments for Wound Healing (Affected Limb and CSMs): CSMs: Assess circulation, sensation, and movement in the affected limb. ○ Check capillary refill, distal pulses, temperature, color, and movement. ○ Ensure sensation is intact and no numbness or tingling is present. Priority Steps in Caring for a Patient with Acute “Open” Injuries (e.g., Lacerations): 1. Control bleeding by applying pressure. 2. Clean the wound with normal saline or an antiseptic. 3. Protect the wound with a sterile dressing. 4. Assess for signs of infection. 5. Monitor for further complications (e.g., infection, worsening pain). Compare and Contrast JP Drain vs. Hemovac Drain: JP Drain (Jackson-Pratt): A small, bulb-shaped device that uses low suction to collect fluid. ○ Use: Typically for smaller surgical sites or wounds with moderate drainage. Hemovac Drain: A larger, accordion-like device that provides more negative pressure to collect fluid. ○ Use: Often used for larger surgical sites or wounds that produce more fluid. Important Intervention Prior to Painful Procedures or Therapy: Pain management: Administer prescribed analgesics before procedures or physical therapy to ensure patient comfort and reduce anxiety. Anticipated Interventions for a Patient with Eschar on Wounds: Debridement: Removal of necrotic tissue (mechanical, surgical, enzymatic). Wound care: Apply appropriate dressings to maintain moisture balance and promote healing. Monitor for signs of infection: Increased redness, warmth, or purulent drainage. Appropriate Delegation in Multidisciplinary Teams (e.g., UAP, PT, OT, ST, RT): UAP (Unlicensed Assistive Personnel): Can assist with bathing, vital signs, repositioning, and feeding, but cannot assess or administer medications. PT (Physical Therapist): Focuses on mobility, strength, and functional movement. OT (Occupational Therapist): Works on daily living activities (e.g., dressing, bathing).  ST (Speech Therapist): Helps with speech, swallowing, and communication issues. RT (Respiratory Therapist): Manages respiratory care, including breathing treatments. High-Risk Patient Groups for Communication Challenges: Pediatrics: May not fully understand medical procedures; require simple, age-appropriate explanations. Elderly: May have hearing or cognitive impairments that affect communication. Non-English speakers: May need an interpreter or communication aids. Patients with disabilities: Those with sensory, cognitive, or verbal impairments may need alternative methods of communication. Important Components to Consider When Assessing a Patient at High Risk for Skin Breakdown: Mobility status: Patients who are bedbound or have limited mobility are at higher risk. Incontinence: Urinary or fecal incontinence can lead to skin maceration and breakdown. Nutritional status: Poor nutrition, particularly protein deficiency, affects skin integrity and wound healing. Circulatory issues: Impaired blood flow, such as in patients with diabetes or vascular disease, increases the risk.