fundamentals SG #1 Flashcards by Stephanie Martin

a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant

Critical Thinking

How well did you know this?

Not at all

Perfectly

knowledge based on research or clinical expertise, makes you an informed critical thinker

Evidence-Based Knowledge

How well did you know this?

Not at all

Perfectly

3 levels of critical thinking

basic
complex
commitment

How well did you know this?

Not at all

Perfectly

analytical process for determining a patients health problems

Diagnostic Reasoning

How well did you know this?

Not at all

Perfectly

process of drawing conclusions from related pieces of evidence and previous experience with the evidence

Inference

How well did you know this?

Not at all

Perfectly

you feel certain about accomplishing a task or goal such as performing a procedure or making a diagnostic decision

Confidence

How well did you know this?

Not at all

Perfectly

you learn to consider a wide range of ideas and concepts before forming an opinion or making a judgment

Thinking Independently

How well did you know this?

Not at all

Perfectly

deals with situations justly, bias or prejudice does not enter into a decision

Fairness

How well did you know this?

Not at all

Perfectly

responsible for correctly performing nursing care activities based on standards of practice.

Responsibility & Accountability

How well did you know this?

Not at all

Perfectly

willing to take risks in trying different ways to solve problems. Often leads to advances in patient care

Risk Taking

How well did you know this?

Not at all

Perfectly

misses few details and follows orderly or systematic approach when collecting information, making decisions, or taking action

Discipline

How well did you know this?

Not at all

Perfectly

determined to find effective solutions to patient care problems

Perseverance

How well did you know this?

Not at all

Perfectly

original thinking, finding solutions outside of the standard of care while still keeping standards of practice

Creativity

How well did you know this?

Not at all

Perfectly

question and test their own knowledge and beliefs

Integrity

How well did you know this?

Not at all

Perfectly

admit your limitations in your knowledge and skill

Humilty

How well did you know this?

Not at all

Perfectly

3 ways of developing critical thinking skills

reflective journaling
meeting with colleagues
concept mapping

How well did you know this?

Not at all

Perfectly

2 steps of critical thinking approach to assessment

Collection of information from a primary source (patient) and secondary sources (family members, health professionals, medical record)
The interpretation and validation of data to ensure a complete database

How well did you know this?

Not at all

Perfectly

an approach for obtaining from patients the data are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness

Patient-Centered Interview

How well did you know this?

Not at all

Perfectly

describes human responses to health conditions or life processes that exist in an individual, family, or community

Actual Nursing Diagnosis

How well did you know this?

Not at all

Perfectly

describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community

Risk Nursing Diagnosis

How well did you know this?

Not at all

Perfectly

Describes the essence of a patient’s response to health conditions in as few words as possible

Diagnostic Label

How well did you know this?

Not at all

Perfectly

identified from the patient’s assessment data and is the reason the patient is displaying the nursing diagnosis

Related Factors

How well did you know this?

Not at all

Perfectly

PES format

PROBLEM: nanda-1 label: impaired physical mobility
ETIOLOGY: related factor: incisional pain
SYMPTOMS: defining characteristics:evidence by restricted turning and positioning

How well did you know this?

Not at all

Perfectly

reflects a patients highest possible level of wellness and independence in function

Patient-Centered Goal

How well did you know this?

Not at all

Perfectly

is an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week

Short-term Goal

preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures from specific patients with identified clinical problems

Standing Order

helps to differentiate nursing practice from that of other health care professionals

NIC Interventions

5 processes of the Implementation Process

1. Reassessing the Patient 2. Reviewing and Revising the Existing Nursing Care Plan 3. Organizing Resources and Care Delivery 4. Anticipating and Preventing Complications 5. Implementation Skills

presence and growth of microorganism within a host but without tissue invasion or damage

Colonization

some of these have little to no risk for transmission

Infectious Diseases

disease can be transmitted directly from one person to another

Communicable Disease

pathogens multiply and cause clinical signs and symptoms

Symptomatic

Infectious agents (4)

1. bacteria 2. Viruses 3. Fungi 4. Protozoa

A place where microorganisms survive, multiply, await transfer to a susceptible host

Reservoir

ability to produce disease, to enter and survive in the host and the susceptibility of the host

Virulence

requires oxygen, Staphylococcus aureus

Aerobic

does not require oxygen, Clostridium difficile

Anaerobic

Most pathogens live between what temps ex: Legionella pneumophilia

20-40C (106-109F)

temperature or chemical that destroys bacteria

Bactericidal

Is skin considered a port of exit?

yes

Broad-spectrum antibiotics can lead to what? bc they have eliminated the normal flora as well.

suprainfections

containing RBCs (looks reddish/pink)

Sanguineous

containing WBCs & RBCs (white/reddish)

Purulent

are not as strong as tissue collagen and assumes the form of scar tissue

Granulation

a type of HCAI from a diagnostic or therapeutic procedure such as bronchoscopy

Iatrogenic infections

Part of the patient’s flora becomes altered and an overgrowth results

Endogenous infection

eliminating the infectious organisms and supporting the patients defenses

Acute Care

Process that eliminates many or all microorganisms with the exception of bacterial spore from inanimate objects

Disinfection

Complete elimination of destruction of all microorganisms including spores

Sterilization

energy needed to maintain life-sustaining activities for a specific period of time

Basal Metabolic Rate

polysaccharide that is the structural part of plants that is not broken down by the human digestive enzyme

Fiber

mainly from plant foods

Carbohydrates

o Essential for synthesis of body tissue in growth, maintenance and repair o Collagen, hormones, enzymes, immune cells, DNA, & RNA

Proteins

Fat-Soluble Vitamins? | Water-Soluble Vitamins?

1. A, D, E, K | 2. C, B

inorganic elements essential to the body as catalysts in biochemical reactions

Minerals

- measurement system of the size and makeup of the body

Anthropometry

when the normal red tones of the light skinned patient are absent

Blanching

Nonblanchable Redness of Intact Skin o Discoloration of the skin, warmth, edema, hardness, or pain may also be present

Stage 1 Pressure Ulcer

Partial-thickness Skin Loss or Blister o Present as a shallow open ulcer with a red-pink wound bed without slough. o Or presents as an intact or open/rupture serum-filled or serosanginous filled blister

Stage 2 Pressure Ulcer

Full-thickness Skin Loss (Fat Visible) o Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed o Some slough may be present o It may include some undermining and tunneling

Stage 3 Pressure Ulcer

Full-thickness Tissue Loss (Muscle/Bone Visible) o Full-thickness tissue loss with exposed bone, tendon, or muscle o Slough or eschar (black and brown necrotic tissue) may be present o Often includes undermining and tunneling

Stage 4 Pressure Ulcer

Full-thickness tissue loss in which the actual depth of ulcer is completely obscured by slough

Unstageable/ Unclassified: Full-thickness skin of Tissue Lose- Depth unknown (Pressue Ulcer)

a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear

Suspected Deep- Tissue Injury- Depth uknown

damage to the spinal cord above the sacral region, loss of voluntary control of urination

Reflex Incontinence

bladder is overly full and bladder pressure exceeds sphincter pressure, resulting in involuntary leakage of urine

Overflow Incontinency

increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions

Uremic Syndrome

awakening to void one or more times at night

Nocturia

Excessive Output

Polyuria

- urine output is decreased despite normal intake amounts

Oliguria

coffee, tea, cocoa, cola drings that contain caffeine

Diuresis

leads to the spread of organisms into the kidneys and possibly to bacteremia or urosepsis

Bacteriuria

- involuntary leakage of urine that is sufficient to be a problem

Urinary Incontinence

temporarily or permanently bypasses the bladder and urethra as the exit routes for urine

Urinary Diversion

3 common urine tests

1. Urinalysis 2. Specific gravity 3. urine culture

when the bowel temporary stops peristalsis

Paralytic ileus

results from unrelieved constipation, collection of harden feces wedged in the rectum that a person cannot expel

Impaction

inability to control passage of feces and gas from the anus

Incontinence

temporary or permanent surgical opening in the abdominal wall. The intestine is brought through the abdominal wall to create the stoma

Ostomies