Exam 2 Flashcards
(112 cards)
1
Q
nursing diag. format
A
problem, “related to”, etiology/cause, “as evidenced by”, defining characteristics
2
Q
risk for nursing diag format
A
“risk for”, problem, “related to”, etiology/cause
*no as evidenced by
3
Q
skin functions
A
protection body core temp regulation sensation vitamin d production immunological absorption elimination psychosocial
4
Q
layers of the skin-deep to superficial
A
dermis, epidermis
5
Q
skin integrity factors
A
circulation, hydration
age or medications ex. steroids
6
Q
skin developmental factors-infant and elderly
A
inc chance for injury
skin thins and becomes less elastic and resilient w/ age
7
Q
wound characteristics- intentional v unintentional
A
planned/purposeful or on accident
8
Q
wound characteristics- open or closed
A
is the dermis visible?
ex. closed= hematoma (bleeding underneath skin)
9
Q
wound characteristics- acute v chronic
A
chronic wounds take longer to heal
10
Q
wound definition
A
integrity of skin or mucous mem. is broken/ no longer intact
11
Q
skin in immunologic defense
A
first line
12
Q
asepsis used for wound care
A
clean/ medical and surgical (sterile)
13
Q
tissue trauma results in what changes
A
local and systemic
= change in vital signs
14
Q
nutrients needed for wound healing
A
protein and adeq. blood supply
15
Q
roll of exudate in wound healing
A
needs to be removed along w/ o/ fluid or foreign material
16
Q
wound healing- first phase
A
hemostasis constriction followed by dilation immediately after tissue/skin injury platelets attract o/ cells exudate is formed= pain and swelling
17
Q
wound healing- second phase
A
inflammatory
lasts 4-6 days
macrophages present, ingest debris and attract fibroblasts
acute inflammatory response = pain, heat, erythema and edema
fatigue is common*
18
Q
wound healing- third phase
A
proliferation starts w/in 2-3 days of injury capillaries grow across wound thing layer epith cells forms new tissue growth (granulation) and scar formation
19
Q
wound healing- fourth phase
A
maturation
begins 3-6 weeks after injury
collegen tissue dev.
wound remodeling
20
Q
wound site factors that affect healing
A
pressure (interferes w/ blood supply)
desiccation (too dry)
Maceration (too moist)- inc bac. growth
edema (disrupts normal o2 and blood flow to wound)
infection (energy is diverted to immune response, not wound healing)
necrosis (tissue slough and eschar)
* dictate the difference btw a chronic and acute wound
21
Q
general factors that affect healing
A
circulation and oxygenation
nutritional status- presence of protein, hydration
addit. chronic illnesses- alter immunes response
wound chara- baseline condition
immunosuppression- ex. aids, or autoimmune reaction
22
Q
wound assessment- inspection
A
inspection
edges, location, size, depth, surr. tissue, drainage, type of closure
23
Q
wound assessment- exudate types
A
type
serous- watery
sanguineous- bloody
serosanguineous- watery and bloody
24
Q
wound assessment- signs of complications
A
odor, pus (purulent), excessive heat, pain w/ palpation
25
wound assessment- tunneling
feel around wound edges
26
wound complications- infection
```
edema, surr. color hot and painful
erythema
drainage inc (maybe purulent)
wound edges could be seperated w/ dehiscence
inc WBC count
febrile temperature 100.5> 101
```
27
wound complications- hemorrhage
excessive bleeding at wound site
28
wound complications- dehiscence
skin pulls apart at suture line
29
wound complications- evisceration
tissue layer seperation
30
wound complications- fistula
opening created by infection
31
pressure ulcer factors
```
immobility
chronic illnesses
aging skin
malnutrition
fecal, urinary incontin
altered lvl consciousness
```
32
pressure ulcer - stage 1
red and non-blanchable
33
pressure ulcer - stage 2
missing top layer of skin
34
pressure ulcer - stage 3
subcutaneous tissue visible
35
pressure ulcer - stage 4
bone and tendon visible
36
pressure ulcer - "unstageable"
ulcer w/ slough or eschar
37
pressure ulcer - "deep"
closed w/ skin intact
| dark purple color
38
braden scale categories
```
23 points possible
less than 16 = at risk
sensory perception
moisture
activity
mobility
nutrition
friction and shearing
```
39
wound dressings- purpose
```
remove necrotic tissue and exudate
prevent and control infection
maintain moist environment
protect surrounding skin + wound from further injury
provide physical comfort
```
40
penrose drain
passive, no reservoir
41
JP, hemovac or wound vac drain
active
| used neg pressure to pull out exudate
42
cold application effects
15 min at time
vasoconstriction
reduces spasms
43
heat application effects
vasodilation
inc cap perm
red. muscle tension
relieves pain
44
nursing v medical diagnosis
nursing- analyzes pat. response "risk for"
| medical- actual pathophysiology
45
nursing diagnosis- pat response
how indivi responds to pot. health
cause or etiology of problem
resources for help
46
diagnosis purpose-
rule out similar problems
determine risk factors
list suspected problems/ symptom patterns
identify resources for health promotion
47
nursing responsibilites
```
rec safety risks and address imm.
try to control or prevent risks
id response (problems, signs and sympt)
anticipate pot. problems
prioritize immediate needs
```
48
collaborative problems
use b/ nursing and physician-prescribed interventions
| ex. pain
49
validation
ask pat. more questions if symptoms don't match subjective report
50
data interpretation- 4 steps
rec. sig. data- compare to standards
rec. patterns (ex. pain, swelling, redness, exudate could indicate an infection)
id strengths and potential problems
reach conculsions (point where make final decision)
51
types of nursing diagnosis
problem- focused (3 parts)
risk- (2 parts)
health promotion or "readiness for education"
52
4 diagnosis componets
label
definition
defining charac
related factor
53
validation of diagnosis
have pattern, accurate data, objective data and based on scientific knowledge
need have >50% confidence o/ get same result
54
nursing diag benefits
indiv. pat. care
definition of nursing to legislators
funding evidence
55
nursing diag limitations
pat could be misdiag
| nursing practice could be restricted
56
nursing diag. errors
making legally inadvisable statements
identifying a patient's etiology when it cannot be changed
identifying environmental problems and not patient problems
57
nursing diag. errors continued
revere clause
"imbal. nutr. related to insuf. funds in meal budget"
versus
"deficient knowledge related to alteration in diet"
inc. value judgements ("pat. is lazy")
inc. medical diagnosis in nurse diag. statement
diag. with no evidence or data
faulty data analysis
non-specific or individualized diagnosis
58
outcome id and planning- purpose
design PoC w/ pat.
| to prevent, reduce or resolve problems
59
outcome id and planning- goals
est. priorities
id and write expected pat. outcomes
use evidence-based interventions
communicate the PoC
60
outcome id and planning- legal standards
the law
national practice standards
speciality professional organizations
accrediting bodies (the joint commission)
AHRQ- agency for healthcare research and quality
employer standards
61
plan of care- allows nurse to
```
indivi care maximizes outcome achievement
set priorities
comm w/ colleagues/ healthcare providers
promote continuity high-quality + cost effective care
coordinate care
evaluate response to care
create record for reimbursement
promote own professional dev
```
62
outcome id and planning- clinical reasoning
know standards for care plan, interventions, and pat outcomes
keep big picture in mind (discharge goals) (how effects interventions and choices)
respect intuition
recg. personal bias
make sure research supports plan before id outcomes
63
goal of patient care
keep pat and pat interests / preferences in mind
| not going to do something they hate
64
comprehensive planning- parts
initial
ongoing
discharge
65
comprehensive planning- initial
dev. by nurse who records history
id e/ problem in prioritized nursing diag
id pat goals
66
comprehensive planning- ongoing
```
done by nurse who has contact w pat
manages risk factors and keeps plan up to date
states diag more clearly
dev new diag
makes outcomes more realistic
id nursing inteventions
```
67
comprehensive planning- discharge
done by nurse w/ closest relationship
begins upon admission
uses teaching skills make sure pat is successful at home
(can incl family educ)
68
nursing diag- problem statement- purpose
suggests pat goals/ outcomes
69
nursing diag- etiology- purpose
suggests nursing interventions
70
high priority interventions
impaired gas exchange
risk for powerlessness
act. intolerance (if not related to condition)
71
medium priority interventions
nonthreatening
72
low priority interventions
not related to specific health problem
73
maslows hierarchy of human needs
physiologic needs-
| safety, love + belonging, self esteem, self actualization
74
categories of outcomes- cognitive
inc pat knowledge/ intellec beh
| "why infection prevention is important"
75
categories of outcomes- psychomotor
pat achieves new skills
76
categories of outcomes- affective
changes values, beliefs and attitudes of pat
77
categories of outcomes- clinical
desc expected status of health issues after treatment complete
78
categories of outcomes- functions
ability compared to desired ADL's
79
categories of outcomes- quality of life
factors affecting enjoyment + goal achievement
80
IOM's 6 aims for quality of care
```
safe- avoid injury
effective- avoid under and overuse
patient centered- respect values
timely
efficient- avoid waste
equitable- treat w/out bias
```
81
errors writing outcomes
includ more than 1 manifestation in short-term outcomes
vagueness
use verbs that are non-measurable
82
outcome parts- measureable
```
subject- patient
verb
conditions
performance criteria
target time
smart goals (specific, measurable, achiev, relevant, timely)
```
83
implementing-purpose
4th step of process
| help pat achieve goals, prevent dis, and restore health
84
alfaro's rule
assess, reassess, revise and record
85
types nursing interventions
direct v indirect
indivi v family v community
nurse initiated v provider initiated
86
nurse initiated inteventions
```
not need provider order
monitor health status
redu. risks
resolve and manage problem
assist w/ ADL
promote emotional and physical well-being
```
87
physician initiated interventions
physician response to med diag.
| care carried out by nurse under doc. orders
88
collab. interventions
initiated by provider, carried out by nurse
89
intervention dev- considerations
pat willingness to coop
dev age and psycho background
response to PoC and goal achievement progress
90
implementation- components
carry out plan
cont. data collection (modify as needed)
document care
91
implementation- process
```
id pat need for assistance
promote self care and teaching
assist pat achieve goals
reassess/review
interventions need by evidence based
intervent. consist w/ all policies and procedures
actions are safe for pat and desirable
clarify questionable orders
organize resources
anticip unexpec outcomes
prevent of errors
```
92
clinical checklist for care
```
pat profile
family needs
priorit for care and schedule
pat main complaint
assist needed for ADL
current health status
```
93
patient var. influence pat goals
dev. stage
| psychosocial backgrnd
94
nurse var. influence pat goals
resources
curr standards of care
research findings
ethical and legal guides to practice
95
reasons for noncompl w/ interventions
```
lack family supp
low value for outcomes
lack understanding abt beliefs
emotion/phys effects of trtmnt
inabil afford trtmnt
limited access trtmnt
```
96
implementation- care/experience
supp family and pat
reasses pat to see if action is necessary
approach w/ care and compentency
modify interventions accord to need
dev. experience (more interve= greater poss for success)
97
delegation-considerations
state laws
make sure person understands, is competent, has training
know what pat is at risk for
take reports from CNA and family for changing condition
98
evaluating
purpose- allow pat achiev direct future intervention
| final step nursing process
99
evaluating- allows nurse to
measure pat achievem outcome
directs nurse intervent
id factors for achiev
modify plan if necess
100
termination
when outcomes are achiev
101
modification
if diff achiev outcomes
102
continuation
if more time needed for outcome achiev
103
eval- elements (5)
```
id- eval criteria and standards
collect data- determ if standards are met
interpret findings
docum judgement
termin, continuing or modifiying plan
```
104
eval- criteria
measurable qualit. that specify skills, or health status
| ex. performance accept. lvl for state
105
eval- standards
lvl perform expected by nurse
| est. by auth
106
var affecting outc. achiev
patient (ex refusal)
nurse
health care system (understaffing)
107
statement eval- met
term PoC
108
statement eval- partially met
continue w/ modification
| make more realistic
109
statement eval- not met
start over
110
PoC revisions-
change interventions
adjust time
make more realisitic
111
IOM's 10 rules improve care
```
care based on healthy relationship
customiz based on pat needs
pat controls care
pat education
evidence-based decisions
high safety
high transparency
anticip pat needs
coop w/ provider
```
112
improving performance (4)
step 1- id problem
plan strategy
implement change
if outcomes not met, assess achievement
