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NURS313 Fundamentals > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

nosocomial infection

A

hospital acquired infection

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2
Q

components of infection cycle with nursing interventions

A
  1. infectious agents
    hand hygiene, sterilization, antibiotics and antimicrobials
  2. reservoir
    transmission based precautions, sterilization or use of disposable supplies
  3. portal of exit
    dry intact dressing, hand hygiene, gloves
  4. means of transmission
    hand hygiene, pesticide eliminate vectors, adequate refridgeration
  5. portal of entry
    hand hygiene, gloves, masks, dispose needles/sharps
  6. susceptible host
    immunizations/screen healthcare staff
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3
Q

bacteria

A

the most significant infection-causing agents in healthcare.

categorized by shape, gram stain reaction, and need for oxygen

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4
Q

virus

A

smallest infectious agent of all micoorganisms

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5
Q

fungi

A

plantlike organisms present in air, soil, and water

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6
Q

cocci

A

spherical bacteria

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7
Q

bacilli

A

rod shaped bacteria

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8
Q

spirochetes

A

corkscrew shaped bacteria

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9
Q

Factors affecting an organisms potential to produce disease

A 
# of organisms
virulence
host susceptibility
ability of organism to live in the host
length and intimacy of contact between person and microorganism
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10
Q

stages of infection

A

incubation period0mo is growing and multiplying
prodromal stage-most infectious, vague and nonspecific signs of disease
full stage of illness-presence of specific signs and symptoms
convalescent period-recovery from the infection

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11
Q

patients at risk for developing infection

A

invasive medical devices

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12
Q

Nursing Process

A 
ADPIE
Assessing
Diagnosis
Planning and Outcome Identification
Implementation
Evaluation
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13
Q

nursing assessment

A

focus on the patient’s responses to health problems while a medical assessment focuses on targeting data pointing to pathological conditions

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14
Q

initial assessment

A

shortly after admission
patient history-refernce for future assessments, est priorities of care
baseline data

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15
Q

focused assessment

A

data concerning a specific patient health problem

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16
Q

emergency assessment

A

performed when a physiologic or psychological crisis presents to identify life threatening problems

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17
Q

time-lapsed assessment

A

compares patient’s current status to baseline data obtained earlier

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18
Q

Nursing diagnosis

A

clinical judgement about the client’s responses to actual or potential health problems/life processes as opposed to a medical diagnosis which identifies diseases.

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19
Q

collaborative problem

A

certain physiologic complications that nurses monitor to detect onset or changes in status

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20
Q

4 steps to Data Interpretation and Analysis

A
  1. recognize significant data
  2. recognize patterns or clusters
  3. identify strengths and problems
  4. identify potential complications
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21
Q

5 types of nursing diagnosis

A
  1. actual nursing diagnosis
  2. risk nursing diagnosis
  3. possible nursing diagnosis
  4. wellness diagnosis
  5. syndrome nursing diagnosis
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22
Q

nursing diagnosis statement components (3)

A
  1. problem (impaired skin integrity)
  2. etiology (related to prolonged immobility)
  3. defining characteristics (as evidenced by a 2 cm open lesion on back)
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23
Q

purpose of outcome identification and planning

A

design a plan of care for and with the patient that results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient’s health expectations as identified in the patient outcomes
to establish priorities
to id and document expected patient outcomes
to communicate the plan of care

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24
Q

3 elements of comprehensive planning

A
  1. initial planning
  2. ongoing planning
  3. discharge planning
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25
Q

initial planning

A

developed by the nurse who performs the nursing history and physical assessment
addresses each problem listed in the prioritized nursing diagnosis
identifies appropriate patient goals and related nursing care

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26
Q

ongoing planning

A

carried out by any nurse who interacts with the patient
keeps the plan up to date
states nursing diagnoses more clearly
develops new diagnoses
makes outcome more realistic and develops new outcomes as needed
id nursing interventions to accomplish patient goals

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27
Q

discharge planning

A

carried out by the nurse who worked most closely with the patient
begins when the patient is admitted for treatment
uses teaching and counseling skills effectively to ensure home care behaviors are performed competently

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28
Q

prioritizing nursing diagnoses

A

high priority-greatest threat to pt well being
medium priority-non-threatening diagnoses
low priority-diagnoses not specifically related to current health problem

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29
Q

prioritization

A

maslow’s hierarchy of human needs
ABC’s
Patient Preference
anticipation of future problems

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30
Q

goals

A

generally longer term “an aim or an end”

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31
Q

Objectives

A

generally shorter term-used to describe what is wanted

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32
Q

outcomes

A

used to describe the results achieved
Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis in the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

33
Q

SMART Outcome statements

A 
Specific
measurable
attainable
realistic
timed
34
Q

Writing Measurable Outcomes

A

Subject: The patient or part of the patient
Verb: indicates the action the patient will perform
Define
Prepare
Demonstrate
Explain
Conditions: Specifies the particular circumstances in or by which the outcome is to be achieved
Performance Criteria: describe in observable, measurable terms the expected patient behavior or other manifestation
Target Time: specifies when the patient is expected to be able to achieve the outcome
Target time may be realistic, actual date, or a statement indicating time such as prior to discharge.

35
Q

developing realistic patient centered outcomes

A

The nurse must be realistic and consider:
Patient’s health state, overall prognosis
Expected length of stay
Growth and development
Patient values & cultural considerations
Other planned patient therapies
Available resources
Risks, benefits, current scientific evidence

36
Q

cognitive outcome

A

describes increases in patient knowledge or intellectual behaviors

37
Q

psychomotor outcome

A

describes patient’s achievement of new skills

38
Q

affective outcomes

A

describes changes in patient values, beliefs, and attitudes

39
Q

common errors in writing patient outcomes

A

Expressing patient outcome as nursing intervention
Using verbs that are not observable or measurable
Including more than one patient behavior or manifestation in short term outcomes
Writing vague outcomes

40
Q

actions performed in nurse initiated interventions

A

monitor health status
reduce risks
resolve, prevent, or manage a problem
facilitate independence or assist with ADL’s
Promote optimum sense of physical, psychological, and spiritual well being

41
Q

physician initiated intervention

A

an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a doctor’s order. ex administering a medication

42
Q

collaborative intervention

A

interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple health care professionals. ex implementing interventions written by an occupational, physcial, or speech therapist

43
Q

Actual Nursing Diagnosis

A

reduce of eliminate contributing factors
promote higher-level of wellness
monitor and evaluate status

44
Q

Risk nursing diagnosis

A

reduce of eliminate risk factors
prevent the problem
monitor and evaluate status

45
Q

Possible Nursing Diagnosis

A

collect additional data to rule out or confirm the diagnosis

46
Q

delegated tasks

A 
taking vitals
measuring and recording intake and output
bathing
feeding
attending to safety
47
Q

tasks that CANNOT be delegated

A 
assessment
interpretation of data
creating a nursing care plan
care of invasive lines
insertion of NG tubes
48
Q

8 implementing guidelines

A
  1. patient involved in care plan
  2. reassess pt before implementing plan to ensure still applicable
  3. Be competent. Know how, why and adverse responses of intervention. have equip and supplies
  4. be caring and genuine
  5. modify intervention based on 1) pt cognition 2) ability/willingness to participate 3) response to previous interventions
  6. is intervention consistent with standards of care, legal, and ethical?
  7. Is the intervention the BEST of all alternatives?
  8. Develop a repertoire of skilled nursing interventions
49
Q

Evaluation

A

purpose is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions. Therefore, evaluation is a team effort between the nurse and the patient.

50
Q

Cognitive Evaluating Outcome

A

ask patient to repeat information or apply new knowledge

51
Q

Psychomotor Evaluation Outcome

A

asking patient to demonstrate new skill

52
Q

Affective Evaluation Outcome

A

observe pt behavior and conversation

53
Q

physiologic evaluation outcome

A

using physical assessment skill to collect and compare data

54
Q

documentation goal

A

complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.

55
Q

source oriented record

A

each healthcare group keeps data on its own separate form
chronological by nurse, dr, x-ray, etc
data is easy to find and chart
fragmented data, difficult to track chronologically problems
utilzed narrative notes

56
Q

narrative notes

A

used within source oriented documentation model
include a description of the status of the problem related nursing interventions, patient responses, and needed revisions to the plan of care

57
Q

problem oriented medical record

A

data is organized around a pt’s problem rather than sources of information.
advantage-collaborative care

58
Q

PIE Charting

Problem, Intervention, Evaluation

A

unique in that it does not develop a separate plan of care
the plan of care is incorp into the progress notes in which problems are identified by number.
a complete pt assessment begins each shift using flow sheets.
patient problems id’d in the assessment are numbered, documented in the progress notes, and worked up using the PIE format and evaluated each shift.
Resolved problems are dropped from daily documentation following the nurse’s review
promotes continuity of care
saves time with no separate plan of care
disadvantage-no formal care plan means nurses have to read all the nurse’s notes to determine problems and planned interventions before initiating care.
nursing origin

59
Q

Focus Charting

A

bring the focus of care back to the patient and the patient’s concerns
focus column
DAR (Data, Action, Response) format for nurse’s notes
holistic emphasis on the patient
ease
DAR categories are artificial and not helpful when documenting care

60
Q

Charting by Exception

A

shorthand documentation method
only significant findings or exceptions are documented in narrative notes
decreased charting time
greater emphasis on significant data
timely bedside charting
standadized assessment
greater interdisciplinary communication, better tracking of important pt responses
lower costs
limited usefulness when trying to prove high-quality safe care in response to a negligence claim

61
Q

case management model

A

promotes collaboration, communication, and teamwork among caregivers
efficient use of time
increases quality by focusing care on carefully developed outcomes
works best for “typical patients” with few individualized needs

62
Q

Collaborative Pathways

A

care maps
used in the case managegement model
specifies the plan of care linked to expected outcomes along a timeline
Charting by exception is also often used

63
Q

computerized records

A

admission assessment
develops plan of care NANDA approved diagnosis
adds to and modifies pt database automatically
receives a work list throughout shift
Documents care immediately using computer at pt bedside

64
Q

3 categories of minimum data sets

A 
nursing care elements (diagnoses and interventions)
Patient Demographics (sex, DOB, Ethnicity)
Service Elements (admission and discharge dates and expected payer for services)
65
Q

Purpose of nursing diagnosis

A

the purpose of nursing diagnosis is to identify:

1) how an individual, group, or community responds to actual or potential health and life processes
2) factors that contribute to or cause health problems (etiologies)
3) Strengths the patient can draw on to prevent or resolve problems

66
Q

Verbs to avoid when writing patient outcomes

A

know, understand, learn, and become aware

67
Q

Maslow’s Hierarchy

A

1) physiologic needs-airway clearance
2) safety needs
3) love and belonging-impaired social interaction
4) self-esteem- body image
5) self-actualization-spiritual distress

68
Q

Quality by Inspection

A

find deficient workers and replace them

69
Q

Quality as opportunity

A

focuses on finding opportunity for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned.

70
Q

Health Insurance Portability Act of 1996

A

patients have a right to

1) to see and copy their health record
2) update their health record
3) to get a list of the disclosures a healthcare institution has made independent of disclosures made for the purpose of treatment, payment, and healthcare operations
4) request a restriction on certain uses or disclosures
5) choose how to receive health information

71
Q

graphic sheet

A

a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

72
Q

flow sheets

A

documentation tools used to record routine aspects of nursing care.

73
Q

SOAP format

A 
Subjective Data
Objective data
Assessment
Plan
used to organize data entries in the progress notes of Problem-oriented medical record.
some believe SOAP is too narrow focus
74
Q

quality assurance

A

specially designed programs that promote excellence in nursing.
2 types
1) Quality by inspection
2) Quality as Opportunity

75
Q

American Nurses Association developed a model quality-assurance program consisting of 7 steps

A

1) identify values
2) identify structure, process, and outcome standards and criteria
3) measure the degree of attainment
4) make interpretations about strengths and weaknesses based on above measurements
5) identify possible courses of action
6) choose a course of action
7) take action

76
Q

quality improvement

A 
CQI-continuous quality improvement
TQM-total quality management
internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than individuals, and has no end points.  Its outcome is improving quality rather than assuring quality.
focus on organizational mission
continuous improvement
customer orientation
leadership commitment
empowerment
collaborative/crossing boundaries
focus on process
focus on data and statistical thinking
77
Q

Three part Nursing diagnosis statement

A

Problem (drives outcomes)
etiology ( drives nursing intervention)
defining characteristics

78
Q

What part of the three part nursing diagnosis statement suggests or drives the selection of interventions?

A

the etiology

79
Q

what part of the three part nursing diagnosis statement suggests or drives the selection of outcomes?

A

the problem

NURS313 Fundamentals (3 decks)

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