Exam 2: NR410 Flashcards
(227 cards)
1
Q
What is our job as nurses?
A
- minimize risk or harm
- safe & effective
2
Q
Safety factors for Infants?
A
- can’t recognize danger
- tactile explore envt
- dependent
3
Q
Safety factors for pre-schoolers?
A
- play outdoors
- more adventruous
- proper attire
- helmet safety
4
Q
Safety factors for adolescents
A
- indestructable
- risk taking
- lack adult judgment
- Main cause for injury: drug/alcohol, car accidents. Car accidents are greater risk
5
Q
Safety factor for adults?
A
- workplace injury
- lifestyle
- strength/stamina decline
- joint mobility
- slowing reflexes
- sensory loss
6
Q
Individual factors affecting safety for all
A
- lifestyle
- cognition
- balance, gait, mobility
- communication
- visual acuity
- emotional helath
- safety awareness
7
Q
In meeting the saftey needs of the adolescent client, it would be most important for the nurse to focus teaching on?
A
driver’s education
8
Q
What are concerns for a child?
A
- do not leave unattended
- drowning
- taking meds
9
Q
What are concerns for adult?
A
- lighting
- handrails
- Kitchen safety (turn stove on/off)
- poisoning
- carbon monoxide (detectors)
- burns
- fires
- falls
- firearms
10
Q
Safety factors for school-age
A
- try new activites w/o practice
- stranger danger
- more time outside of home
11
Q
Whats the biggest safety issue in the home and hospital?
A
falls
12
Q
Safety in the Env’t?
A
- vehicles
- bicycles
- community acquired pathogens
- pollution
- sun exposure
- walking/running- headphones
- toxins
13
Q
What are problems with CFL’s (compact fluorescent lamp)?
A
- Mercury exposure - open area on skin
- Fire hazard
14
Q
Organizations working to make healthcare safer?
A
- IHI (institue on health improvement)
- Joint Commission
- HCAHPS & CORE
- America Association of Colleges of Nursing
- ANA
15
Q
How much medical harm occursi annually in the U.S.?
A
- 40-50 incident for every 100 patients/minute
16
Q
How many deather per year for medical errors?
A
98,000
17
Q
What are impacts of death per year?
A
- motor vehicle
- breast cancer
- AIDS
18
Q
How do most hospitals view their quality of care?
A
Above average
19
Q
What do you think are major issues in healthcare setting for safety?
A
- falling
- med errors
- wrong site in surgery
- diagnostic inaccuracy- wrong treatment
- equip failure-iv pump
- transfusion error-wrong blood type
- lab- incorrect labeling
- system failure
- env’t- spills
- communication-documentation important
20
Q
Who is the last line of defense for meds?
A
- The Nurse
21
Q
What percent of falls are accounted for at hosptials
A
25%
22
Q
What percent of falls are accounted for deaths in a hospital?
A
12%
23
Q
What can you do to reduce falls?
A
- Identify fall risk, how high?
- Tag patient w/ wristband
- Family Education
- Move closer to Nurse’s station
- Room is free of clutter
- Non-skid booties
- Document everything you did
24
Q
Who is the highest at risk for falls?
A
- patients who have fallen in the past 6 months
25
What are the procedures when a patient falls?
* Focused Assess
* **L**icensed **I**ndependent **P**ractitioner
* Document what you **saw**
* Interventions
* Occurence/Incident Report
26
What is the acronym for FIre
R.A.C.E
27
Race (R) stands for
rescue, alarm, contain, extinguish, relocate
28
P.A.S.S for fire stands for..
* Pull, Aim, Squeeze, Sweep
29
What do we do immediately after a patient falls?
ASSESS for injury before getting them up
30
What are considered a restraint?
* Side rails
* IV arm boards
31
What facilities do sometimes allow side-rails up?
Long Term Care
32
Why do we restrain a patient?
* violence
* at risk to themselves or others
* last resort
* pulling out IV
33
Is restraint a standard of practice?
No
34
What do you assess for after restraint?
* neurosensory, ever 2 hrs
* basics every 15-30min
* reasses for continued use
35
For Non-behavioral restraints do you need a physicians order?
Yes
36
How do you apply a restraint?
* 2 finger breadths
* quick release to **bedframe**
* document
37
What restraint can be a hazard for strangulation?
Vests
38
What are problems that can occur to the patient with restraints?
* dehydration
* strangulation,
* cutting off circulation
* patient coming out of sedation
39
NDNQ
for quality indicators
40
Threats to safe nursing practice
* unfamiliarity
* inadequate time
* poor communication
* underestimating risk
* workflow
41
Why do nurses make errors?
* accessible
* distractions
* work-arounds "shortcuts"
* limited short term memory
* scheduling
42
IOM 6 Aims
1. Safe
2. Timely
3. Effective
4. Efficient
5. Equitable
6. Patient-Centered
43
QSEN
Quality for Safety and Education for Nurses
44
is it possible to have SHEER **without** FRICTION?
NO, but it is possible to have friction without sheer
45
What is cultural awaremess
* an in-depth self-examination of one’s own background, recognizing biases and prejudices and assumptions about other people.
46
Ethnicity
common sense of identity
47
How do you develop cultural humility
self assessment
48
What are barriers in culture?
* langugage
* pre-conceived ideas
* gender
49
What are the 5 stages social identity theory?
* Naive, no social consciousness
* Acceptance
* Resistance
* Re-definition
* Internalize
50
What can you do to make them comfortable?
* smile
* touch
* listen
51
Good Questions to ask?
* What do you think caused your illness?
* Who would you like to be involve
* What have you done to treat your illness?
52
What can you do in difficult ethic situation?
find resources, get ethics committee
53
What is communication?
* encoding/sending
* the message
* sensory channels
* decoding/receiving
* feedback- 2ways
54
Kindness means
* a smile
* eye contact
* active listening
* touch
* generosity
* acknowledge special needs
55
Communication failure affects
* safety
56
Components of Communication
* subject matter
* words
* gestures
* substance of the message
* open to interpretation
57
Principles of Communication
* Verbal/Nonverbal
* Dynamic
* Verbal supports Nonverbal
* Trust
* More than talking/listening
58
Intrapersonal means?
self-talk, inner dialogue
59
What is an example of false hope?
"Everything's going to be okay"
60
What is the sequence for using a cane
1. Put weight on good foot
2. Step out with bad foot
3. Place cane forward
4. Move good foot forward
61
Define Enculturation?
Socialization into one’s primary culture as a child is known
62
Define Assimilation
when an individual gradually adopts and incorporates the characteristics of the dominant culture.
63
What is stereotyping?
unwarranted generalizations about any particular group that prevents further assessment of the individual’s unique characteristics.
64
What are health disparity populations?
a significant increased incidence or prevalence of disease or that have increased morbidity, mortality, or survival rates compared to the health status of the general population
65
How do patients suffer cultural pain?
when health care providers disregard values or cultural beliefs
66
what is feedback
summarizing what the patient said
67
You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do?
Talk with him about his favorite hobbies
68
Simple assertive statements include
* referencing the person you are addressing
* the behavior that is a problem
* its effect
69
If a patient has limited ability to speak or understand English, he or she has legal rights to...
an interpreter
70
What is therapeutic nurse-client relationship?
* **info** about health treatment
* **wellness**
* therapeutic **communication**
71
4 Phases of therapuetic relationship
1. **Pre**-orientation- *biases?*
2. **Orientation**- *smile, what does day look like?*
3. **Working Phase**-*collaborate*
4. **Termination Phase**- *document, tell patient*
72
What is therapeutic communication?
* patient centered
* goal directed
* strengthens relationship
73
Communication strategies
* say "I"
* eye contact
* keep promises
* empathy
* touch
* ask permission
74
Blockers of communication
* false reassurance
* changing the subect
* refer to handout
* close ended questions
* asking "why"?
75
What percent of negative effects occur because of gaps in communication?
* 85%
76
SBAR stands for
* **S**ituation
* **B**ackground
* **A**ssessment
* **R**ecommendation
77
HCAHPS
* Hospital Consumer Assessment of Healthcare Provider Systems
* *feedback from patient*
78
What statement about nonverbal communication is correct?
* nurses' verbal communication should be reinforced by nonverbal cues
79
If a child swallos a toxic substance what is the first action to tell parents
call poison control
80
A patient with risk of falls is wondering halls, what do you do?
1. Leave a night light on in the bathroom
2. Provide scheduled toileting during the night shift.
3. Keep the pathway from the bed to the bathroom clear.
81
What is the most important intervention when a patient is having a seizure?
* Clear the area around the child to protect the child from injury.
82
A patient gets out of bed often, is a fall risk, what is the initial nursing intervention?
Place a bed alarm device on the bed
83
At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?
prepare for an influx of patients
84
3 types of documentation
1. source oriented
2. problem oriented
3. electronic computer based
85
What are the basic principles of documentation
* timely
* accurate
* complete
* legible
* easily retrieved
86
What does charting by exception mean?
charting what is outside the norms or parameters
87
What are flow sheets are comprised of?
* vital signs
* intake/output
* pain
88
SOAPIER stands for
Sub Obj Planning Intervention Evaluation **Revision**
89
What is a nursing **admission** assessment comprised of?
* patient history, allergies
* done several times
* ask the patient who should be present
* baseline
90
Kardex or Client Care
* "down & dirty"
* demographic, medical diagnosis, allergies, diet, meds, safety, treatments
91
Occurrence Report is
* unusual or accident
* not a part of patient's health record
92
What are sentinel events
* stuff that shouldnt happen under our care
* wrong site surgery
* patient suicide
* op/post-op
* fall
93
What is elopement
losing a patient
94
What is effective communication for transition in care and handoff reports?
SBAR
95
When do you do hand off?
* shift to shift
* transfers
* breaks
* therapist to therapist
* allow questions
96
Do you take verbal orders only in emergency?
yes
97
What are the steps for verbal/tele order?
* write, read it back
* clarify spelling
* date, time, providers name, your signature
98
Evolve:
Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (POST-OP)
* respiratory rate increases.
* The heart rate also increases because the heart is trying to improve oxygen levels.
* crackling
99
Evolve:
Why do we use stockings after a surgical procedure?
external pressure on the lower extremities and assist in promoting venous return to the heart.
100
Evolve:
What could being on bed rest be a risk for?
falling
101
Evolve:
Coffee ground–like aspirate from the feeding tube are a sign of..
bleeding in the GI tract
102
Evolve:
when patients are immobile and the joint is not exercised through their ROM (range of motion), what can happen?
the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.
103
Evolve:
Immobilized patients are at risk for impaired skin integrity, what are your interventions?
1. An objective assessment scale allows the nurse to assess for pressure ulcer risk over tim
2. Using a device to relieve pressure when patient is seated in chair
3. Teaching patient how to shift weight at regular intervals while sitting in a chair
4. the higher the risk for skin breakdown, the shorter the interval between position changes
104
Evolve:
When we are helping a patient walk, which side do we want to be on?
the weak side
105
Evolve:
What part of the body do you want to be holding when assisting a patient to walk?
His waist, not his arm. Using a gait belt to avoid risk of injury.
106
Name some causes of orthostatic hypotension
1. dehydration
2. medication
3. heart problems
4. thyroid/endocrine
5. nervous system
107
Evolve:
Which action(s) are appropriate for the nurse to implement when a patient experiences orthostatic hypotension?
1. Allow patient to sit down.
2. Take patient’s blood pressure and pulse.
3. If patient begins to faint, allow him to slide against the nurse’s leg to the floor
108
Evolve:
If you can't lift a patient from bed to chair what can you do?
call the lift team for support
109
Evolve:
Which is the correct gait when a patient is ascending stairs on crutches?
* modified three-point gait.
* The unaffected leg is advanced between the crutches to the stairs
110
Evolve:
a patient prescribed bilateral partial weight bearing, which crutch gait is most appropriate for this patient?
The two-point gait requires at least partial weight bearing on each foot
111
Evolve:
What does a 3 point gait require
* that the patient bear all their weight on **one foot**,
* For a patient with one injured foot/leg.
112
Evolve:
Which of the following activities does the nurse delegate to nursing assistive personnel in regard to crutch walking?
1. Notify nurse if patient reports pain before, during, or after exercise
2. Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise
3. Notify nurse of vital sign values.
4. Prepare the patient for exercise by assisting in dressing and putting on shoes.
113
Evolve:
What applies to the proper use of a cane?
1. patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs
2. The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times.
114
Evolve:
What are some critical thinking skills?
* ethics
* analytics
* self confidence
115
Evolve:
The pain scale is an example of which intellectual standard?
consistency
116
Evolve:
What is basic critical thinking?
concrete and based on a set of rules or principles
117
Evolve:
What is unique to the commitment level of critical thinking?
Anticipates when to make choices without others’ assistance.
118
What is the difference between negligence & malpractice?
when the patient is involved
119
Where can you get resources for negligence & malpractice
* standards
* expert opinion
* instiutional policies
* state by state
120
When delegating, who is responsibile for the action?
the person delegator is liable
121
What are the 5 rights in delegation
1. task
2. circumstance
3. person (doesn't have to be a CNA)
4. direction
5. supervision
122
What is the delegation process
1. communicate, expectations
2. monitor
3. evaluate
4. give feedback
123
What can a nurse not delegate, even to another nurse?
* assessment
* evaluation
* nursing judgment
124
What can you delegate?
* Vital signs
* meds
* technical tasks
* procedures
125
What leaves an RN vulnerable?
poor records
126
When you delegate to a CNA, can they refuse?
* Yes
127
Patients Rights
* informed consent
* privacy
* dignity
* to be treated fairely
* safety
128
Informed Consent
* Nurse, witness patient's signature
* down to the doctor's responsibility
129
If the procedure was not done under informed consent, what could it be considered?
battery
130
What does informed consent include?
* risks
* patient bill of rights
* nature of health concern
* description of treatment
131
When does informed consent get overrided?
* emergency
* law presumes they want to be saved
* therapeutic privilege
* when information could harm the pt
132
How to prevent liability
* follow standards/protocols
* delegate appropriately
* keep up on information
* identify fall risk, decubitis
* safe environment
* document well
133
When should you question a physicians orders?
* when client questions
* question and record verbal orders
* avoid miscommunication
134
Causes of negligence?
* **patient falls**
* equipment injuries
* failure to monitor
* failure to communicate
* medication errors
* **medical errors**
135
Intervention errors
* not performing task correctly
* interpret carry out doc's orders
* pursue the physician
136
What are the 6F's
1. asses/monitor
2. changes
3. adequate education
4. standards/policies
5. document
6. failure to act as an advocate
137
What is the purpose of liability precautions
quality improvement
138
Be able to determine negligence vs malpractice
139
Grief?
* physical, psychological, and spiritual responses to loss
140
Mourning
action associated with grief
141
Bereavement
mourning/adjustment following loss
142
What affects grief
* significance of the loss
* amount of support for the bereaved
* developmental stage
* timeliness of death
143
Hubler Ross 5 Stages of Grief
* denial
* anger
* bargaining
* depression
* acceptance
144
What are types of grief
* uncomplicated
* complicated
* chronic/masked/delayed
* disenfranchised- *miscarriage, society doesnt recognize*
* anticipatory- *pre-grief*
145
Define Death
* historical definition
* heart-lung death
* whole-brain
* higher-brain
* uniform determination of death act, *loss of brain stem fucntion*
146
What are the stages of dying (assessment)
1. 1-3mnths prior, *withrawn*, *sleep more, not eating*
2. *1*-2 wks, *vitals change, skin color change*, *apnea, cheyne stokes*, *death rattle*
3. days to hours- *walk, eat, energy, swallowing diff, dehydration*
4. moments to hours- *unconsciousness*
147
What is palliative care
holistic comfort care
148
What is hospice care
* doctor order
* 6 months left to live (guess)
* survive on donation
* help family 1 year after death
* must sign a DNR
149
What does palliative care team look like
* advanced practice nurse
* physician
* chaplain
* case manager
* pharmacist
150
What are legalities in end of life
* advanced directives
* living will
* POA
* DNR
* Assisted Suicide
* Euthanasia
* Autopsy- *unexpected death, dialysis*, *what if family doesnt want it?*
151
What is our assessment for end of life?
* knowledge
* history
* coping
* meaning of loss
* depression or grief
* physical assessment
* cutlural/spiritual assess
152
What are NANDA's for end of life
* powerlessness
* hopelessness
* denial, ineffective
* coping, ineffective
* nutrition imbalance
153
What does care entail for dying patient
* physiological
* psychological
* spiritual
* cultural
154
What is a quintessential answer for therapeutic
"tell me more"
155
Patient Self Determination Act
letting patient know their rights to advanced directive
156
Post Mordam Care
* comfort dignitiy cooperation
* who validates death?
* donor?
* autoposy? (*everything stays in)*
* making them presentable
157
What is rigor mortis?
* put in dentures before
* muscles stiffen up
158
Evolve:
The nurse asks a patient, “Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a patient-centered interview?
Collecting Assessment
159
Evolve:
What technique(s) best encourage(s) a patient to tell his or her full story?
1. Active listening
2. Back channeling
3. Use of open-ended questions
160
Evolve:
What is validating?
comparing data with another ?source
161
Evolve:
What is probing?
encourages a full description without trying to control the direction of the patient’s story
162
Evolve:
Is a chest x-ray considered a nursing assessment?
NO
163
Evolve:
A patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient?
1. Lean forward when interacting with the patient
2. Acknowledge the patient’s answers through head nodding
164
Evolve:
What is the related factor or risk?
a condition for which the nurse can implement preventive measures
165
Evolve:
What does a nurse do when reviewing data?
the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data
166
Evolve:
A risk diagnosis does not have defining characteristics, instead what does it have?
Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem
167
Evolve:
**Time Frame** what it is & what it is NOT
* IS:
* when you expect a response to your nursing interventions
* helps to organize nursing priorities
* IS NOT
* which problem is most important
* a nurses work schedule
168
Evolve:
What must an **outcome** have to be a precise measurement?
* quality
* quantitly
* frequency
* length or weight
169
Evolve:
When does implementation begin as the fourth step of the nursing process?
After the plan of care has been developed
170
Evolve:
When interpreting findings you...
compare the patient’s behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation.
171
Evolve:
A goal specifies the expected behavior or response that indicates
Resolution of a nursing diagnosis or maintenance of a healthy state
172
Evolve:
The evaluation of interventions examines two factors:
1. the appropriateness of the interventions selected
2. the correct application of the intervention
173
Evolve:
An evaluative measure determines a
a patients response
174
Evolve:
What criteria would you recommend in choosing a nursing center?
1. clean look like patient's home
2. adequate staffing on all shifts
3. Meals should be high quality with **options** for what to eat and when it is served.
4. active family involvement
175
Evolve:
blurred vision, sensitivity to glare, and gradual loss of vision
cataracts
176
Evolve:
eye condition resulting in a person having difficulty adjusting to near and far vision
presbyopia
177
Evolve:
Who makes the request for organ and tissue donation at the time of death?
Specially educated personnel make requests
178
Evolve:
How do you start the conversation about the goals of care at the end of life?
asking the patient to identify his or her beliefs about the goals of care while the **family member is present**
179
Evolve:
What action honors cultural beliefs at the end of life?
Giving people options in caregiving (i.e. family members)
180
Evolve:
Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient?
Older adults have usually sustained many losses in life, which influence the current loss
181
Evolve:
A nurse stops to help in an emergency at the scene of an accident, injured party files a law suit
The Good Samaritan law holds the health care provider immune from liability as long as he or she functions within the scope of his or her expertise
182
Evolve:
When is a living will invoked?
when the patient has a terminal condition or is in a persistent vegetative state.
183
Evolve:
What can posting medical information about the patient on a message board in the patient’s room cause?
information being accessed by persons who are not involved in the patient’s treatment. Violation of hippa
184
Evolve:
Who are mandated reporters of suspected child abuse
nurses
185
Evolve:
What type of communication is used during the orientation phase of a relationship
unrelated small talk
186
Evolve:
What do you include in a hand off report
1. patient’s name, age, and admitting diagnosis
2. allergies
3. patient pain raiting
187
Evolve:
A patient newly diagnosed with type 2 diabetes says, “My blood sugar was just a little high. I don’t have diabetes.” The nurse responds:
with silence, gives patients time to process their thoughts.
188
What is the purpose of NCLEX
To determine if it's safe for you to begin practice as an entry-level nurse
189
What are topic of the NCLEX
1. Safe care environment
2. Health promotion/maintenance
3. psychosocial
4. physiological
5. nursing process
6. communication, documentation, teaching
190
what organization developed the NCLEX testing system
National Council of State Boards of Nursing
191
What are the 4 recommendations of the IOM?
1. practice to the full extent of their education and
training
2. achieve higher levels of education and training through an improved education system that promotes seamless academic progression
3. full partners, w/ physicians and other health care
professionals, in redesigning health care in the United States.
4. Effective workforce planning and policy making require better data collection and an improved
information infrastructure.
192
What is the reasonable man standard?
a hypothetical person in society who exercises average care, skill, and judgment in conduct and who serves as a comparative standard for determining liability.
193
What are common examples of malpractice
* Doing or Saying Nothing When Action Is Required
* Injuring a Patient With Equipment
* Improper Administration of Medication
194
What is EMTALA
* no patient with an emergency medical condition, unable to pay may be treated differently than patients who are covered by health insurance
* Emergency Medical Treatment and Active Labor Act
195
What is the bill of rights for nursing?
nurse's rights in the workforce
196
What are 4 elements that must exist for malpractice
1. Duty
2. Breach of Duty
3. Causation
4. Harm/Injury
197
What 2 components are mandatroy to report?
1. communicable disease
2. abuse
198
Intentional Torts Relevant to Nursing
* Confidentiality
* False imprisonment
* Assault and battery
* Fraud
* Invasion of privacy
199
This is a term for a published false statement that is damaging to a person's reputation
Libel/Slander
200
What is flexion?
bending
201
What is extension?
the straightening of a part
202
What is abduction?
**away** from midline
203
Pronation is?
inward roll of the foot
204
supination
outward roll of the foot
205
What are the steps for formulating a nursing diagnosis
1. identify problem
2. write diag statement
3. validate
206
What is a diagnostic label?
world/phrase represents a pattern of related cues. Describes the problem or wellness response
207
What does ANA define in standards of Nursing?
ADOPIE
208
What is the Colorado Nurse Practice Act?
evaluating health status thru the collection and asessment of health data
209
What do you do if you make a mistake?
* follow the policy/procedure of the facility
* Never obliterate an entry or use white out
210
It is important for nurses working with patients with a diagnosis of dementia to
adopt a common approach of care because these patients have consistency and sameness in their environment
211
What is delirium?
* An **acute** condition that have altered brain functioning
* Reduction in cerebral functioning
* **sudden** disturbance in consciousness or cognition
212
What is dementia?
A clinical syndrome involving reduced intellectual functions with impairment in memory, language, visiospacial skills and cognition.
* chronic/irreversible
213
What is caregiver burden?
increased morbidity & mortality of caregivers and increased risk of LTC placement
214
What are causes of delirium?
* Fever
* Infection
* Allergic reaction
* Vitamin deficiency
* Drug toxicity
* Malnutrition
* Electrolytes
* hypoxia
* hypoglycemia
215
Types of dementia?
* Alzheimer’s Disease
* Lewy body disease-*hallucination, get worse w/meds*
* Parkinson’s disease
* Subdural hematoma-*bloodclot in brain, stroke*
* Normal pressure hydrocephalus
* Focal brain atrophy syndrome
* Creutzfeldt Jakob disease-*mad cow*
216
What tools can be used to measure dementia?
Blessed Scale and Clock Drawing tests
217
What are nursing interventions for a dementia patient?
* evaluate environmental and placement choices
* Maintain safe environment
* driving and occupational safety
* long term financial and legal planning
218
What would the prudent nurse
* high level
* picks up on subtle changes
219
What is an intervention for delirium
take labs!
220
What is the common cause of delirium for the elderly?
UTI
221
NANDA for delirium
acute confusion, disturbed throught processes, interrupted family processes, risk for infection, acute pain, ineffecting coping,
222
What is a common cause for alzheimers (dementia) of death?
aspirations pneumonia
223
What are the steps for transferring a patient?
1. high fowlers position, dizziness
2. place a gait belt on the patient
3. bring the patient to the edge of the bed and dangle their legs
4. assist the patient to a standing position and transfer to the chair
224
What does a "problem" suggest"
Client Goals
225
What does etiology suggest?
interventions
226
What do cue clusters suggest?
* whether the correct nursing diagnosis has been identified
227
What is focus charting?
Clients Concerns & Strengths
