[healing by] primary intention
wound tends to heal quickly and results in minimal scar formation. involves use of sutures or other wound closures to approximate the edges of an incision or a clean laceration.
[healing by] secondary intention
new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue. occurs slower than primary intention.
[healing by] tertiary intention
occurs with ulcers and wounds, results in scar formation.
absorption
movement of the smaller elements through the walls of the digestive tract and into the blood.
acute
temporary, resolves when underlying injury heals.
acute wound
wound that heals in a rapid, uncomplicated manner.
adaptive immunity
acquired/specific immunity. provides long-term immunity when the body is exposed to an antigen. (two types of adaptive immunity: humoral [antibody-mediated] & cellular [cell-mediated]).
afebrile
a person who maintains normal body temperature (97.6 - 99.6 degrees F).
afterload
resistance that has to be exceeded to eject the blood during systole.
albinism
congenital loss of pigmentation characterized by a generalized lack of melanin pigment in eyes, skin, and hair.
allergies
life-threatening. the immune system produces antibodies to fight an ingredient of the food.
allodynia
pain for non-injury stimuli.
amino acids
organic compounds that make up proteins.
anabolism
the use of energy to change simple materials into complex body substances and tissue.
analgesic (drug)
pain reliever/painkiller.
anorexia
loss of appetite from illness, medication, allergies, treatments, etc. that comes back after resolution of underlying condition.
anorexia nervosa
life-threatening eating disorder characterized by strict dietary intake regulations and distorted body image.
anosmia
the complete loss of smell.
antibodies
immunoglobulin molecules that recognize foreign invaders.
antigen
any substance that provokes an adaptive immune response.
antioxidants
substances that may protect body cells against effects of free radicals. (beta carotene, selenium, vitamin C, & vitamin E).
anuria
the failure of the kidneys to produce or excrete urine (results from any process that limits blood flow through the kidney). failure to excrete 50 to 100 mL of urine in 24 hours.
apical pulse
can be auscultated over apex of the heart at the point of maximum impulse (PMI). this is located at the mitral valve.
apnea
absence of breathing. (brain damage occurs 4-6 minutes into apnea).
approximated
brought together (in terms of edges of a wound).
asepsis
freedom from and prevention of disease-causing contamination.
assault
threat of bodily harm or violence.
axillary temperature
temperature taken from the center of the axilla (armpit).
basal metabolic rate (BMR)
the minimum amount of energy required to maintain body functions in the resting, awake state.
battery
actual physical harm caused to a person.
belief
a mental representation of a reality or a person’s perceptions about what is correct/true/real, or what a person expects to happen in a situation.
Biot breathing
respirations abnormally shallow for two or three breaths, followed by irregular period of apnea. symptom of meningitis or severe brain injury.
bradycardia
slow heart rate (less than 60 BPM in adults).
bradypnea
a decrease in respiratory rate to less than 10 BPM (in adults).
bulimia nervosa
eating disorder characterized by bingeing (eating excessive amounts of food) and purging (vomiting) with the idea to avoid weight gain from the excess food.
burns
tissue injuries to the skin caused by heat, electricity, chemicals, radiation, extreme cold, or friction.
capillary closing pressure/critical closing pressure
the minimum pressure required to collapse a capillary.
carbohydrates
chemical substances composed of carbon, hydrogen, and oxygen molecules.
cardiac output
heart rate (BPM) x stroke volume (L/beat).
caring
having concern or regard for another.
case law (common law)
judicial decisions from individual court cases.
catabolism
the breaking down of substances from complex to simple, resulting in a release of energy.
cataract
clouding of the lens of the eye.
cathartics
shortens transit time of stool; strong laxative.
cellular immunity
involves defense by WBCs against any microorganisms that the body does not recognize as its own.
cerebrovascular accident (CVA)
a stroke. occurs when an area of the brain is deprived of blood flow.
chain of infection
infectious agents —> source of infection —> portal of exit —> mode of transmission —> portal of entry —> susceptible host.
Cheyne-Stokes respirations
shallow to deep (potential apnea) randomized respirations. symptom of renal failure.
cholecystectomy
removal of gallbladder.
chronic
ongoing for a long period of time.
chronic wound
wound that fails to progress in a timely manner, often remaining open for an extended period of time.
chyme
semiliquid mass that travels through the intestines.
clean contaminated wound
similar to a clean wound, but if surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater.
clean wound
wound with no infection, and low risk for developing an infection.
clinical pathways
multidisciplinary resources designed to guide patient care. developed through EBP research.
closed wound
wound where the skin is still intact (i.e. bruising).
cognition
knowing, influenced by awareness and judgment.
collaborative interventions
collaboration among healthcare professionals and UAP. (i.e. physical therapy, home health care, personal care, spiritual counseling, hospice care).
colonized wound
one or more organisms are present on the surface of the wound when a swab culture is obtained, but there is no overt sign of an infection in the tissue below the surface. (common in chronic wounds, may delay wound healing).
compassion fatigue
physical and emotional exhaustion and an extreme inability to empathize.
consensual
reflex response of an organ to the reflex action of another (usually paired) organ.
conceptual framework/model
a collection of interrelated concepts that provides direction for nursing practice, research, and education.
conduction
the transfer of and reaction to heat through direct contact.
constipation
infrequent or difficult bowl movements, as well as having fewer than 3 bowel movements per week.
constitutional law
law derived from the constitution of the U.S.
contaminated wound
results from a break in sterile technique during surgery; perforation of an organ (i.e. colon, small bowel, appendix) before surgery, which allows for spillage of bacteria-laden material into the wound; or from certain types of trauma or accidents, such as penetrating trauma or a fall.
convection
the transfer of heat by movement or circulation of warm matter such as air or water.
coudé catheter
double-lumen, indwelling catheter. used for patients with an enlarged prostate.
cue
indication/hint of a potential disease process or disorder.
cyanosis
bluish discoloration of the skin and mucous membranes.
data clustering
involves organizing patient assessment data into grouping with similar underlying causes.
defamation of character
false public statements about a person. [LIBEL: written defamation; SLANDER: oral defamation].
dehiscence
partial/complete separation of the tissue layers during the healing process.
delirium
reversible state of acute confusion.
dementia
permanent decline in mental function.
dependent nursing interventions
interventions that originate from health care provider orders. (i.e. orders for oxygen administration, dietary requirements, medications, and diagnostic tests).
depression
mood disorder, characterized by a sense of hopelessness/persistent unhappiness.
diabetes
failure of the pancreas to produce adequate insulin.
diabetic retinopathy
complication of diabetes mellitus in which blood vessels of the retina become damaged.
dialysis
a technique by which fluids and molecules pass through an artificial semipermeable membrane and are filtered through means of osmosis.
diarrhea
intestinal disorder characterized by an abnormal frequency and fluidity of bowel movements.
digestion
the breaking down of food into smaller particles of nutrients.
diplopia
seeing double.
direct care
interventions that are carried out by having personal contact with patients (i.e. cleaning an incision, ambulating with a patient…). can be carried out by RN, LPN, or UAP.
discipline
a specific field of study or branch of instruction or learning.
distress
negative stress (hard to cope with).
dorsal recumbent position
lay on back, legs bent, & feet pointed outwards.
dysesthesia
unpleasant, abnormal sensation.
dysphagia
difficulty in swallowing.
dyspnea
shortness of breath (rapid, shallow pattern).
dysrhythmia/arrythmia
irregular rhythm in pulse (early/late/missed heart beat).
dysuria
painful urination. (many causes, i.e. UTI, STI, kidney/bladder stones, irritation, etc).
elevated systolic BP
120-129 mmHg.
erythema
redness of the skin.
eupnea
normal respiration rate and depth for a person’s age (12-20 RR in adults).
eustress
positive/motivational stress.
evaluation
focuses on the patient’s response to nursing interventions and outcome/goal attainment.
evaporation
the process by which a liquid is changed to a vapor through heat.
evisceration
total separation of the tissue layers, allowing the protrusion of visceral organs through the incision.
external female catheters
wicking material placed between labia and gluteal folds, with continuous suction tubing.
external male catheters
(most common) are condom catheters that apply over the tip and shaft of the penis, or some only attach to the head of the penis (helpful for uncircumcised/retracted penises).
faith
a belief beyond self that is based on trust and life experience rather than scientific data.
false imprisonment
unauthorized restraint/detention of a person.
fat-soluble vitamins
vitamin A, D, E, K. excess fat-soluble vitamins are stored in the liver and fat tissue. NOT excreted by the kidneys. because of this, if excessive amounts are taken, it may result in toxicity.
fats
composed of carbon, hydrogen, oxygen.
febrile
a person with a fever/pyrexia.
fiber
complex carbohydrate classified as soluble or insoluble.
fistula
abnormal connection between an internal organ and another part of the body.
flatulence
the production of a mixture of gases in the intestine, by-products of the digestive process. normal bodily function.
foley catheter
double-lumen, indwelling catheter.
forced expiratory flow (FEF)
maximal flow rate attained during middle of FVC maneuver.
forced expiratory volume in 1 second (FEV1)
volume of air expelled in the first 1 second of FVC (FEV1 is around 75% to 85% of FVC).
forces vital capacity (FVC)
amount of air that can be forcefully exhaled after lungs are maximally inflated (FVC is around 4L in adults).
fowler position
back of bed inclined, sitting 45-60 degrees.
free radicals
molecules produced when the body breaks down food or is subjected to environmental exposures to potential toxins, such as tobacco smoke or radiation.
friction
the rubbing together of two surfaces (i.e. skin and bed).
full-thickness wound
involves the epidermis, dermis, subcutaneous layer, and may even extend farther to the muscle, bone, etc.
functional residual capacity (FRC)
the volume of air left in lungs after normal expiration (FRC is around 2.3L in adults).
gender identity
each person’s deeply felt internal and individual experience of gender (may or may not correspond with the sex assigned at birth).
glaucoma
serious medical condition of the eye.
grief
the emotional response to a loss.
healing ridge
1cm wide ridge palpated next to incision line. indicates new collagen being laid down in the wound.
hematuria
abnormal presence of red blood cells in the urine. bleeding may originate anywhere along the urinary tract.
hemodialysis
patient’s blood flows continuously from the body through vascular catheters to the dialysis machine (which filters the toxins out), and back to the body.
hemoptysis
presence of blood in the sputum.
holistic
physical, mental, emotional, spiritual, & social.
homeostasis
the body’s regulation of systems to maintain a steady state.
hope
confident expectation of a positive outcome in the face of challenging circumstances.
humoral immunity
involves WBCs (B lymphocytes) that produce antibodies in response to antigens or pathogens circulating in the lymph and blood. enables production of inflammatory molecules.
hyperalgesia
excessive sensitivity.
hypercapnia
abnormally high levels of carbon dioxide in blood (greater than 45mmHg in arterial blood).
hyperpathia
greatly exaggerated pain reaction to stimuli.
hypertension
elevated blood pressure.
hypertension stage 1
systolic 130-139, diastolic 80-89.
hypertension stage 2
systolic 140+, diastolic 90+.
hyperthermia
high body temperature (greater than or equal to 102 degrees F).
hypertonicity
increased muscle tone.
hyperventilation
deep, rapid respirations.
hypervolemia
fluid overload.
hypotension
systolic less than 90mmHg, diastolic less than or equal to 60mmHg.
hypothermia
low body temperature (less than or equal to 93.6 degrees F).
hypotonicity
decrease in muscle tone.
hypoventilation
shallow respirations.
ileostomy
a type of ostomy. bypasses the entire large intestine and may not result in an actual stoma (attaches to the anus). stools are frequent, liquid, and can not be regulated.
IM
intramuscular.
ID
intradermal.
immune response
3rd line of defense. inflammation activates the immune response, which is the body’s attempt to protect itself from foreign and harmful substances. the immune response is initiated by recognition of antigens.
immunologic memory
passive immunity. occurs when a person receives an antibody produces in another body. provides immediate but short-term protection against antigens. infants acquire passive immunity naturally in utero or via breast milk. passive immunity can be acquired artificially when antibodies are transferred from one person to another by injection of antibody-rich serum.
implementation
consists of performing a task (i.e. repositioning, administering meds…) and documentation of each intervention.
incontinence
loss of voluntary control of fecal/gaseous discharges through the anus.
independent nursing interventions
nurses initiate these interventions independently as they see necessary (i.e. giving patient an ice pack for swelling).
infected wound
shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not contain pus, and has a bacterial count in the tissue of at least 10^5 per gram of tissue sampled when cultured.
infection
the establishment of a pathogen in a susceptible host.
infertility
a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.
inflammatory response
2nd line of defense. a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. redness, heat, pain, and swelling. leukocytes release a chemical that increases temperature in the area.
innate immunity
nonspecific immunity. gain this immunity from birth. provides immediate defense against foreign antigens. barrier to infectious agents, produces chemical mediators to fight infection, removes foreign substances, and activates the adaptive immune system.
international unit
a unit of potency used to measure things such as vitamins and chemicals.
intolerance
uncomfortable, but not life-threatening. irritation of the digestive tract; inability to break down the food.
invasion of privacy
public disclosure of private information (intrusion into a person’s place of solitude, using someone’s name, accessing unnecessary medical records…). HIPAA violations.
IV
intravenous.
IVPB
intravenous piggyback.
jaundice
a yellow hue to the skin, mucous membranes, or eyes.