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Nursing Fundamentals > Exam #2 > Flashcards

Exam #2 Flashcards

(85 cards)

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1
Q

Stereotyping

A

One assumes that all members of a culture, ethnic group or race act alike.

Includes:
-ageism
-racism
-sexism

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2
Q

Cultural imposition

A

Belief that someone should conform to your own belief system

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3
Q

Cultural blindness

A

When one ignores differences and proceeds as though they do not exist

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4
Q

Cultural Conflict

A

People become aware of cultural differences, feel threatened and respond by ridiculing the beliefs and traditions of others

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5
Q

Cultural assimilation

A

When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different

They take on the values of the dominant culture.

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6
Q

Culture shock

A

When a person is placed in a different culture that he or she perceives as strange

Result in:
-psychological discomfort

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7
Q

Ethnocentrism

A

The belief that the ideas beliefs and practices of one’s own culture are superior to those of anothers’

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8
Q

Physiologic variations

A

Certain racial and ethnic groups are more prone to certain diseases and conditions

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9
Q

Reactions to pain

A

May be culturally influenced
(Pain is weakness)
(Some cultures encourage open expressions of pain)

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10
Q

Mental Health

A

Many ethnic groups have their own norms and accepable patterns of behavior for psychological well-being

Different normal psychological reaction to certain situations

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11
Q

biological sex roles

A

Man is dominant in most cultures, knowing who is dominant in the family is important!

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12
Q

Health disparities

A

Health differences or gap between groups of people

They can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death

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13
Q

Interpreters

A

-use facility approved interpreters

DO NOT ALLOW FAMILY/FRIENDS TO INTERPRET

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14
Q

Nonverbal

A

Use nonverbal communication with cation because it may have a different meaning to the client depending on their culture

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15
Q

Apologize

A

Apologize if cultural traditions or beliefs are violated

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16
Q

Family patterns & Gender roles

A

Communicate with and include the person who has the authority to make decisions in the family

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17
Q

Clinical reasoning

A

Refer to ways of thinking about patient care issues

-determining
-preventing & managing patient problems

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18
Q

Clinical Judgement

A

Refers to the result (outcome) of critical thinking or clinical reasoning

-conclusion
-decision
-opinion
That you made

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19
Q

Nursing process

A

-assess
-diagnose
-plan
-implement
-evaluate

** A.D.P.I.E. **

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20
Q

(Systemic) Characteristics of the nursing process

A

Each nursing activity is part of an ordered sequences of activities
-each activity depends on the accuracy of the activity that precedes it and influences the actions that follow.

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21
Q

(Dynamic) Characteristics of the nursing process

A

The nursing process is presented as an orderly progression of steps

Great interaction and overlapping among the 5 steps

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22
Q

(Intrapersonal) Characteristics of the nursing process

A

The nursing process insures that nurses are person centered rather than task oriented

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23
Q

(Outcome oriented) Characteristics of the nursing process

A

Nurses and patients work together to identify specific outcomes related to health, to determine which outcomes are most important to the patient and match them with appropriate nursing actions

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24
Q

Universally applicable in nursing situations

A

Mastering the nursing process gives you a valuable tool you can use with ease in any nursing situation

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25
Assessment
Gather data that you will use to draw conclusions about the clients health status
26
Diagnosis
(Analysis) Identify the clients health needs (usually stated in the form of a problem) based on careful review of your assessment data -analyze all your data -synthesize/cluster info -hypothesize about you clients health status
27
Planning outcomes
Making decisions about goals for your care, the client outcomes you want to achieve through your nursing activities Outcomes will drive your choice of interventions
28
Planning Interventions
Developing a list of all possible interventions based on our nursing knowledge and then choosing the most likely to help the client achieve the stated goals.
29
Implementation
Plan in action
30
evaluation
Determine if the goals were met, partially met, or not met.
31
Initial assessment
Performed shortly after patient admitted. Establish a complete database for problem identification and care planning. -The nurse collects data concerning all aspects of the patient’s health, establishing priorities for ongoing focused assessment and creating a reference baseline for future comparison
32
Focused assessment
Data gathered about a specific problem that has already been identified. Routinely part of ongoing data collection
33
Emergency Assessment
When a person presents with a psychological or physiologic crisis IDENTIFY LIFE THREATENING PROBLEMS
34
Time-Lapsed assessment
Periodic assessments usually in long-term care. To reassess their health status and to make necessary revisions to the care plan.
35
Subjective data
What the patient tells you
36
Objective data
What the nurse sees, hears, measures or observed -physiologic -pychologic -developmental -environmental
37
Primary source of data
Client
38
Gordon’s functional health patterns
-Health perception/health management -nutritional/metabolic -Elimination -Activity/exercise -Cognitive-perceptual -Sleep/rest -Self-perception/Self-concept -role/relationship -Sexulity and reproductive -coping/tress tolerance -value belief
39
Assessment ENTAILS
Collect data Identify cues and make inferences Validating data Clustering related data and identifying patterns Reporting and recording data
40
Diagnosing
Cluster or group data Identify strengths and problem Identify potential complications Reaching conclusions
41
Actual Nursing Diagnosis, Problem-Focused
Problem that has been validated -Has major defining characteristics
42
Risk Nursing Diagnosis
-Client is more vulnerable to develop the problem
43
Health Promotion Diagnosis
-Present status or function is effective -Desire for a higher level of wellness
44
Syndrome Nursing Diagnosis
-Clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions -Chronic pain syndrome is an example
45
Problem (NANDA)
Etiology: cause
46
Etiology: cause
As evidenced by (AEB) or As manifested by
47
Defining Characteristics
Subjective & objective data that provides evidence
48
Criteria for prioritizing
A, B, C Maslow’s Hierarchy of Human Needs Patient Preference Anticipation of Future Problems
49
Individualize
Individualize care that maximizes outcome achievement
50
Set
Set priorities
51
Facilitate
Facilitate communication among nursing personnel and colleagues
52
Promote
Promote continuity of high-quality, cost-effective care
53
Coordinate
Coordinate care
54
Evaluate
Evaluate patient response to nursing care
55
Create
Create a record used for evaluation, research, reimbursement, and legal reasons
56
Promote
Promote nurse’s professional development
57
Initial Planning:
Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized nursing diagnoses/clinical problems Identifies appropriate patient goals and related nursing care
58
Ongoing Planning:
Carried out by any nurse who interacts with patient Keeps the plan up to date, manages risk factors, promotes function States nursing diagnoses/clinical problems more clearly Develops new diagnoses/clinical problems Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals
59
Discharge Planning:
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 that home care behaviors are performed competently
60
Cognitive outcome
Cognitive outcome describes an increase in patient knowledge or intellectual behaviors. This can be asking the client to repeat information or to apply knowledge.
61
Psychomotor outcomes
Psychomotor outcomes describe the patient’s achievement of new skills. This can be asking a client to demonstrate the new skill.
62
Affective outcomes
Affective outcomes describe changes in patient values, beliefs and attitudes. Affective outcomes are more complex, must observe client behavior and conversation.
63
Physiologic outcome
Physiologic outcome measuring the change, assess for skin changes, ect.
64
S.M.A.R.T. Outcomes
S – specific, individualized to the patient M – measurable A – attainable R – realistic T – time-bound
65
Nurse-Initiated (nursing intervention)
Actions performed by a nurse without MD order.
66
Physician-Initiated Interventions
Actions initiated by the physician in response to a medical dx but carried out by a nurse under doctor’s orders.
67
Collaborative Interventions
Treatments initiated by other providers and carried out by a nurse.
68
Characteristics of nursing interventions
-action statement that starts with an action verb. -answer who, what, how, when, where, how often, how much, and how long. -assist the client in meeting specific outcomes and be individualized to the client. -always be well documented in the care plan and signed by the RN. With any intervention that we do, it should be evidence-based.
69
Implementation
Carry out nursing interventions
70
Documentation
Document all nursing actions/assessments Document patient responses
71
5 Rights of delegation
1. Right Task 2. Right Circumstances 3. Right Person 4. Right Directions and Communication 5. Right Supervision and Evaluation
72
Evaluation
Did your client meet his or her goals? Why or why not? What modifications (if any) need to be done? ​
73
The five classic elements of evaluation are:​
Identifying evaluative criteria and standards (what you are looking for when you evaluate – i.e. expected patient outcomes)​ Collecting data to determine whether these criteria and standards are met​ Interpreting and summarizing findings​ Documenting your judgment​ Terminating, continuing or modifying the plan​
74
Evaluative Statements
When evaluating the patient’s care plan, you need to determine how well the outcome was met. Was it met, partially met or not met. Include the patient data or behaviors that support your decision.
75
Revisions in the Care Plan
-delete or modify the nursing diagnosis/clinical problem -make the outcome statement more realistic -increase the complexity of the outcome statement -adjust time criteria in the outcome statement -change nursing interventions
76
Micturition/Voiding
is the process of emptying the bladder, also known as urination or voiding.
77
Process of emptying/voiding/urinating
Detrusor muscle contracts Internal sphincter relaxes Urine enters posterior urethra Painless
78
Frequency
Usually, every 3-4 hours Kidneys concentrate urine during sleep *** Urinary output should be >30ml/hr. 8 hour shift =min. 240ml urine output ***
79
Factors that Affect Urinary Elimination
Developmental -Infant’s urine is typically light in color and odorless. Infants are born with little ability to concentrate urine. Toilet Training Readiness -Voluntary control of urethral sphincters~18-24m (Training at 2-3yrs old) -Hold urine for 2 hours -Recognize feeling of bladder fullness -Communicate need to void -Desire to use toilet -Cultural approaches vary
80
Aging
-Bladder perineal muscles – inability to hold urine or inability to empty bladder -Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of UTI. -Getting to the toilet is affected by neuromuscular problems, Degenerative Joint Disease, thought changes, weakness -The bladder also has a decreased ability to concentrate urine which results in nocturia.
81
Physiological Factors Affecting Urinary Elimination
Neurological integrity Fluid intake volume Food intake Fluid loss from other routes Intra-abdominal pressure Activity (immobility) Decreased bladder & sphincter tone
82
Psychological Factors Affecting Urinary Elimination
Anxiety and stress Pain
83
Renal Problems
Congenital abnormalities of urinary tract Polycystic kidney disease, UTI, renal calculi (kidney stones) Hypertension, Diabetes Mellitus Gout, Connective Tissue Disorders
84
Other conditions affecting urinary elimination
Arthritis – DJD, Parkinson’s Disease Cognitive deficits & some psychiatric problems Fever & diaphoresis, Congestive Heart Failure
85
Medications Affecting Urinary Elimination
Nephrotoxic drugs – cause kidney damage Diuretics & cholinergic medications Analgesics & tranquilizers Some drugs can change urine color

Nursing Fundamentals (8 decks)

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