cystoscopy - pt teaching
- direct visualization of urethra & bladder
2. burning, frequency, dysuria, blood in urine after exam
hemorrhoids - assessment & interventions
when veins become distended, apply repeated pressure
take Hx, PE, feces inspection, assess for pain
factors affecting a pt’s elimination needs
- poor fluid intake
- medication
- feeding tube
- laxative
- no fiber
- cognitive impairment
- immobility
pt teaching R/T promotion of proper elimination
- maintain proper food and fluid intake
- promote regular exercise
- promote regular bowel habits
- facilitate normal defecation
- promote comfort (skin care, hemorrhoids, ostomy)
- maintain skin integrity
professional boundaries - nsg actions to avoid crossing boundaries
- effectiveness & to safety
2. stay in the middle of the continuum between too involved and negligent
most important legal document for a nurse & why
State Nurse Practice Act
single most important piece of legislation for nursing
affects all facets of nursing practice
it is the law with in the state
scope of nursing practice (what we can and cannot do)
-regulated by State Board of Nursing
definition of subjective data
“S”
-stated
what the pt tells you
SYMPTOMS
definition of objective data
“O”
-observed
everything else
SIGNS
Nursing Process steps
- assessment
- diagnosis/analysis
- planning
- implementation
- evaluation
Ns Process: assessment
collection and verification of data
-establishing a database
bedside assessment, hx, records, obtain temp & vital signs, PE
Ns Process: diagnosis/analysis
ID pt strengths & problems
ID problem R/T cause 2º med dx
Ns Process: planning
developing POC
individualized or routine?
- goals
- orders
- actions taken
Nsg orders
Ns Process: Implementation
performs activities necessary for achieving pt’s health goals
-bathing and other actions
Ns Process: Evaluation
judging the quality, value, or worth by comparing to previous desired outcomes
-modify or terminate?
look at coccygeal area, conclude goal not met, change Dx and order, 2 days later
goal evaluation format
Specific Measurable Action-oriented Realistic Timely
effectiveness:
- goal met
- partially met
- not met
How to phrase Nsg Dx
related to: R/T
problem R/T etiology 2º med Dx
definitions of NANDA labels: O2 needs
- ineffective airway clearance
- ineffective breathing pattern
- impaired gas exchange
- activity intolerance
definitions of NANDA labels: comfort/pains
acute pain: signs of discomfort and change in vital signs <6mo
chronic pain: >6mo impaired comfort
readiness for enhanced comfort
definitions of NANDA labels: self-care
- self-care, readiness for enhanced
- self-care deficit, bathing
- self-care deficit, dressing
- self-care deficit, feeding
- self-care deficit, toileting
definitions of NANDA labels: mobility
- mobility, impaired bed
- mobility, impaired physical
- mobility, impaired wheelchair
Critique of nursing interventions
are they
- clear?
- specific?
- have a time frame?
- begin with a verb?
physiological manifestations of stress in pts
- increased V/S
- behavior
- appetite
- activity
- thought processes
- feelings of hopelessness
- continual frustration/worry
- cold hands/feet
- neck/shoulder tension
- clenched jaw
- constant fatigue
- nervous laughter
stages of GAS
General Adaptation Syndrome (Seyle)
- alarm reaction: SNS
- resistance: PNS
- stage of exhaustion
GAS: alarm reaction
- stressor perceived (fight or flight)
- increased HR, BP, RR
- decreased nonessential functions
- dilated pupils
- death if prolonged or severe
- can last from 1 min-24 hours
