NURS301 day 4 Flashcards
(23 cards)
Foley
an in dwelling catheter
Five steps of nursing process
Assessing—collecting, validating, and
communicating of patient data
Diagnosing—analyzing patient data to identify
patient strengths and problems
Planning—specifying patient outcomes and related
nursing interventions
Implementing—carrying out the plan of care
Evaluating—measuring extent to which patient
achieved outcomes
The Nursing Process is used to:
Identify needs
Establish priorities of care
Maximize strengths
Resolve actual or potential alteration in responses to health and illness
Name the five Characteristics of the Nursing Process
Systematic—part of an ordered sequence of activities
Dynamic—great interaction and overlapping among the five steps
Interpersonal—human being is always at the heart of nursing
Outcome oriented—nurses and patients work together to identify outcomes
Universally applicable—a framework for all nursing activities
Benefits of the Nursing Process to the Patient (3)
- Scientifically based, holistic individualized patient care
- Continuity of care
- Clear, efficient, cost-effective plan of action
Benefits of the Nursing Process to the Nurse (3)
- Opportunity to work collaboratively with other healthcare workers
- Satisfaction of making a difference in lives of patients
- Opportunity to grow professionally
Intake (I’s)
Anything that the patient takes into the body.
Examples: foods they eat, liquids they drink, IV fluid that is being infused
Output (o’s)
Anything that the patients releases from the body.
Examples: urine, stool, emesis (vomit)
Why is it important to monitor the I’s and O’s?
*To keep track of a patient’s fluid balance.
Many diseases and medications can affect fluid balance
*Ensure that patient’s are meeting their caloric needs.
Conditions like wound healing require high amounts of dietary protein.
*Assess elimination status.
Enables the nurse to assess kidney function, GI function, and medication side effects
Clear Liquid Diet
abdominal surgery type patients
full liquid Diet
milk added to fluid like ice cream
Cardiac Diet
salt reduction
Puree diet
Patient cant chew
Renal Diet
min sodium, phosphorous, and potassium, restrict fluid intake, adhere to ordered levels of protein and carbs. Goal of a renal diet is to cut down on waste in blood
Diabetic Diet
no sugar
Mechanical Soft Diet
pt may not have enough energy or teeth to chew all foods. The foods in this diet are easy to eat and do not need a lot of chewing to swallow safely.
Although assisting with meals is commonly delegated to the nursing assistant, what must you be sure to do as the nurse?
It is your responsibility as the nurse to ensure that the patient is eating the appropriate diet and to assess and monitor for any potential complications
Assisting with eating considerations (5)
Ensure that the food is an appropriate temperature, not too hot or cold.
Make sure the patient is positioned correctly to eat
Sitting upright in the bed or chair
Take your time! Make sure the patient has plenty of time to chew and swallow before providing more food.
Alternate solids and liquids.
Provide the appropriate amount of assistance based on patient needs.
What are the goals associated with assisting with Eating?
Patient consumes adequate nutrition: 50-60% of meal tray is target
Avoid Aspiration!!
Patient expresses contentment-patient is full!
Factors Affecting Urinary Elimination (6)
- aging (due to reduced muscle tone)
- Food and fluid intake
- Psychological conditions (nervousness)
- activity and muscle tone
- pathologic conditions (CHF, infections of urinary tract)
- medications
Equipment used to assist with Elimination
bedpans, urinal, indwelling catheters, bedside commode
Factors Affecting Bowel Elimination (4)
Mobility
diet
medications
intestinal diversion ex ostomies
How often must you usually provide perianal care with an indwelling catheter?
every 12 hours and whenever a patient has a bowel movement
*remember to clean in a downward motion, away from the patient’s genitalia
