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1

Nursing process -steps

Assessment,

diagnosis,

outcome identification,

planning,

implementation,

evaluation

2

(*Perform the nursing actions identified in planning)- nursing process

Use community resources

Provide health teaching and health promotion

Document implementation and any modifications

Coordinate care delivery

Use evidence-based interventions

Implement in a safe and timely manner

Implement

3

Evaluate persons condition and compare actual outcomes with expected outcomes (progress toward outcomes)

Include patient and significant others

Ongoing assessment to revise plan or diagnoses

Communicate/inform results to patient and family

Evaluation

4

Review the clinical record

Health hx

Physical exam

Functional assessment

Cultural/spiritual assessment

Use evidence-based assessment techniques

Assessment

5

Compare clinical Findings of normal and abnormal variation in developmental events

Cluster associated data

Validate data

Confirm accuracy

Look for gaps

Interpret and Identify problem/data

Document the dx

Diagnosis

6

Identify expected outcomes

SMaRT components

Short term and long term goal measurement

Include a timeline

Cultural appropriate

Individualize to person

Realistic and measurable

Outcome identification

7

Establish priorities

Develop outcomes

Set timelines for outcomes

Identify interventions

Integrate evidence-based trends and research

Document plan of care

Planning

8

What are the components of evidence based decision making ?

Is there scientific evidence/research evidence

Patient preferences/values/circumstances

Clinicians experience and judgement

9

SMaRT components ?

Specific

Measurable

Attainable

Relevant

Time bound

10

Closed or open ?? Benefits of it

Tell me how you are feeling?

Open ended questions:

Narrative answers

Feelings and opinions

Develops rapport

11

Closed or open??

Do you have pain?

Benefits?

Closed ended questions

-specific info

-yes or no

-limits rapport, neutral

12

Barriers to communication? Not to use

Providing false assurance or reassurance

Giving unwanted advice

Using authority (your dr knows best)

Avoidance language (they are in a better place)

Distancing (lump in “the breast”)

Adjust language to patient understanding

Leading questions (you don’t smoke do you?)

Interrupting

Don’t use why questions

Nonverbal skills (touch, voice,eye contact, gestures , facial expressions, posture , appearance

13

Reason for facilitation, cues, leads ?

Examples ?

Shows you are listening

Encourages to say more

-nodding head yes

-mmhmm

-eye contact, shift forward

14

Gives the client time to think

Silence

15

Echos clients words to help patient identify feelings

“You have difficulty getting the day started?”

“It’s hard getting up in the morning”

Reflection

16

It must be difficult not being independent

Empathy

17

So you have difficulty lying down if you lie flat and you need pillows?

Clarification

18

Before you said you do not smoke but now you mentioned smoking with your friends?

Confrontation

19

I always take this blanket with me.

So this blanket must be very important to you

Interpretation

20

You cannot eat anything for 12 hours prior to surgery

Explanation

21

Condenses everything discussed allows plants to make corrections if needed

Summary

22

Lack of interest/attention

Door, curtain, computer, temp

Patient can not hear you

Safety- fear

Psychological barriers: Shocked, fear, embarrassed

Language Barrier

Barriers to communication

23

Types of pain

Referred
Phantom
Acute
Chronic
Breakthrough pain

24

Pain that is felt in a location other than where the pain originates

Referred pain

25

Feeling like the limb is still there after amputated due to damaged remaining nerve endings

Phantom pain/ sensation

26

Short term pain which is self limiting

Cause by ?Tissue damage

Less than 6 months

Mild moderate pain- sympathetic ns ?

Severe pain- parasympathetic ns ?

Acute pain

27

Last longer than 6 months

Intermittent or continuous

Does not stop after injury heals

Abnormal processing of pain fibers ?

Chronic pain

28

How to assess pain? Physical changes with pain ?

Posture/behavior

Facial expression

Sounds

Palpation

Vitals (increased BP, Pulse, resp)

Pupil size dilation

Sweating/increased temperature

29

Pain that occurs between doses of pain medication

Breakthrough pain

30

Pain that is acute and starts outside NS

Results in actual or potential damage

Responds to opiated and inflammatories

Nociceptive pain

31

Abnormal processing of pain from injury to nerve fibers or CNS

Chronic

Numbness, tingling,shooting, burning, poorly responsive to pain meds

Neuropathic pain

32

The point at which a person feels pain

Pain threshold

33

Duration or intensity of pain a person will endure before outwardly responding

Pain tolerance

34

What is pain ?

Whatever the patient says it is and whenever they say it is occurring

35

PQRST pain assessment

Precipitating or palliative

Quality or quantity

Region or radiation

Severity scale

Timing

36

What consists of substance abuse assessment ?

Techniques to elicit (get) info from patient?

Learn terminology

Tolerance

Dependency vs addiction

Watch for withdrawal symptoms such as nausea, vomiting, anxiety, headache, tremor

???

37

CAGE questionnaire ?

Cut down, annoyed, guilty, eye opener

Questions to determine if your running is uncontrolled

Cut down (should you cut down?)

Are you annoyed of criticism you get about your drinking )

Have you ever felt guilty about your drinking?

Do you drink in the morning ?

38

Alcohol use disorders identification test

AUDIT- questionnaires with ? Such as how often do you have a alcoholic beverage?

Covers 3 domains: alcohol consumption, drinking behavior or dependence , and adverse consequences from alcohol

39

Frequency of use of alcohol, tobacco, rx, for non-medical use, illicit drugs

Quick assessment (substance abuse)

40

Who needs to be assessed for domestic violence ?

When to report??

Everyone

41

What percent of women and men experience rape, physical violence and/or stalking ?

36% women and 29% men

42

Types of violence or abuse

Sexual
Physical
Threats
Emotional
Neglect
Financial

43

How to asses intimate partner abuse IPV

Scores?

Use your own words and be non- judgmental such as “domestic violence is so common I ask all my patient about abuse in the home.”

HITS
H-hurt
I- insult
T-threaten
S-scream

1-5 never to frequent

10 or more indicates IPV

44

When to assess for IPV?

Assess at every visit

Abuse assessment screen

45

S/s of abuse

Frequent UTIs

Chronic pelvic pain

STIs

Anxiety/depression

Back pain

PTSD

Failure to follow up

Frequent healthcare visits

46

S/s of human trafficking

Injury/sign of abuse

Malnourished

Disoriented

Lack of ID

Few personal belongings

Fearful, anxious, submissive

Scared of the law

Can not freely contact friends and family

Avoids eye contact

47

What to do if you see signs of human trafficking?

Must report

Call 911 if unsure

Contact national human trafficking resource center

48

What are the characteristics and risks of human trafficking ?

Victims are usually white/black and US citizens

Risk factor:

Age
Poverty
Unemployed
Gender inequality
Sexual abuse
Mental or health problems

49

The degree of balance between nutritional intake and nutrient requirements

Intake sufficient for basic needs

Nutritional status

Optimal nutrition

50

Two are two primary components of this :

Health history-subjective

Physical examination-objective

Health assessment

51

Too much food energy or excess nutrients to the degree of causing disease or increasing risk of disease, a form of malnutrition (sedentary lifestyle)

Related conditions:

Heart disease
Diabetes 2
Stroke
Gallbladder disease

Overnutrition

52

What fraction of kids are overweight or obese?

What ages?

1/3

Ages 6-19

53

Occurs when nutritional reserves or depleted or when nutrient intake is in adequate to meet day today needs or added metabolic demands
- impaired growth
-lowered resistance to disease
-delayed wound healing

Undernutrition

54

How to asses food intake ? What methods??

24 hour recall

Food diary (most comprehensive)

Food frequency

Typical food intake

Direct observation

55

Difference between 24 hour food recall and food diary ??

Food diary may be more accurate - write down everything consumed for a certain period of time. Write down immediately after eating.

24hour recall- questionnaire to recall everything eaten within the last 24 hours. Can evoke Specific information about dietary intake.

56

Factors what can affect nutritional status?

Problem based hx:
Weight loss, weight gain (when it started, intentionally ?

Difficulty chewing or swallowing
(Types of food you eat)

Loss of appetite/nausea

57

Normal vs for an adult:

Bp:

P:

R:

O2:

T:

Bp:systolic- 90-120
Diastolic- 60-80

P:radial, apical, carotid , brachial 60-100 bpm

3+ is full, bounding
2+ is normal
1+ is weak
0 is absent

R:10-20 count for 30 sec x 2

T:98.6

O2:95-100%

58

How to take-

pulse:

Bp:

30 seconds and times by 2

59

What affects vital signs?

Stress, pain, drinking fluids, temperature, position, wrong cuff size ...

??

60

What can influence a normal body temp ? What is being assessed?

Drinking hot or cold fluids
Exercise
Stress
Age
Gender - mensuration in women
Time of day
Smoking
Chewing gum

61

Characteristics assessed for pulse?

Pulse strength , Rhythm, BPM

62

R-

What does a normal breathing pattern look
Like?

relaxed, regular rhythm, quiet, 12-20 per minute

63

Temperature methods? Accuracy of them? Trouble shooting?

Tympanic ear - accurate
Oral - most convenient and accurate
Temporal- fast and accurate
Rectal -most accurate to core temp
Axillary- arm pit - kids

64

What do the bp numbers mean?

Systolic ?

Diastolic?

Bp is the force of blood pushing against the side of the vessel wall. (The strength charges with the event in the cardiac cycle)

S-the maximum pressure felt in the artery during left ventricular contraction

D-blood pressure flow when heart is relaxed or resting between each contraction

65

What is orthostatic bp?

A change in bp after standing up after laying down.

Person may feel faint or dizzy

66

Types of assessments to screen for pt history?

Comprehensive health hx

Complete total health

Focused or problem- centered database

Primary, secondary, and tertiary prevention

General survey

67

Comprehensive health hx

A detailed examination that typically includes a thorough health history and comprehensive head-to-toe physical exam.

Also includes an examination of social and behavioral influences, health risks and information needs of patients and/or families/caregivers.

68


Complete total health

Complete health hx and a full physical examination

Yields the first diagnosis

69



Focused or problem- centered database

Limited or short term problem. Mainly one problem or one body system

70



Primary, secondary, and tertiary prevention

Primary- prevents health problems (safety glasses, vaccines, exercise)

Secondary- screening, catch problems early

Tertiary- cardiac rehab, support groups

71

General survey - what is it and what things to look for in patient?

A study of the whole person, covering the general health state and any obvious physical characteristics

Age sex, loc, skin color
Posture , body build
Gait, ROM
Facial expression, mood , speech, dress, hygiene

Intro for the physical , objective parameters which apply to the whole person

How the person stands at their name , so they look sick?, make eye contact? Smile, shake hand firmly? Health hx, measurements , vs

**Physical appearance , body structure, mobility, and behavior

72

How and when to use tools/equipment?

Oximeter ?

Thermometers?

Stethoscope ?

Etc.

Have all equipment at easy reach and laid out in an organized fashion

Make sure they care cleaned after using with sanitizer whipe

73

What are the 4 techniques of assessment?

What information will each technique tell you?

1.inspection
2.palpation
3.percussion
4.Auscultation

74

Why to use assessment techniques?

to know your patient and identify their real needs

Forms the basis of the care plan

75

Direct vs indirect percussion?

direct, which uses only one or two fingers, Immediate or Blunt Percussion; Percussing hand directly strikes the body wall (done w/ sinuses)

indirect, which uses the middle/flexor finger. striking a punch-like object with a hammer or percussor. Mediate Percussion; Involves 2 hands

76

Know medical terminology- from packet??

??

77

Know definitions in culture
(From crossword-mod 3)

Snsn

78

What are some cultural competence methods?

Explore patients beliefs , values, and needs to build effective relationships with them.

Understand that each patient is unique

79

Causes/types of illness in culture?

Biomedical illness

Naturalistic illness

Magiocoreligious illness

80

What is a material vs non material cultural characteristic?

Material: dress, tools, art

Non material: verbal, religion, customs, beliefs

81

What are the components of a mental assessment?

ABCT:

Detailed mental status exam

Assess through health hx

Be aware of:

Meds taken
Hx of alcohol or drug use
Stress levels
Sleep disorders

Appearance
Behavior
Cog function
Thought process

82

What are expected age related changes? When it comes to memory/mind?

? Normal aging is associated with a decline in various memory abilities in many cognitive tasks; the phenomenon is known as age-related memory impairment (AMI)

May need more time to learn new material or tasks

83

A condition which is Sudden onset, interrupting the bodies homeostasis

Orientation:

Altered consciousness

Rapid mood swings/emotions

Reversible


Delirium

84

delirium?

What can affect it?

start of delirium is usually rapid — within hours or a few days. Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal

85

This condition has a slow gradual onset (organic)

Orientation:

Consciousness is not altered

Flat, agitated

Incoherent , slow, repetitive

Not reversible

Dementia

86

What can affect dementia :

Can be caused by vascular disease, HIV, Alzheimer’s disease

87

how to Assess ones orientation?

Test attention span

Recent memory

Remote memory (long term)

New learning

88

Components of the mental exam status ?

MMSE (mini-mental state examination

Set of 11 questions that tests orientation to time and place , naming , reading, copying orientation , writing, and following three stage command. Can also test for dementia or mental illness

89

Performing mini-cog? What is it?

A newly developed, reliable , quick and easy available instrument to screen for cognitive impairment in healthy older adults


Takes 3-5 minutes- ask adult to listen carefully to, then repeat the 3 words that you will say. (Short And unrelatedly words) Make sure there are no distractions. Have them do something else and then repeat again later.

90

Disease caused by bacteria, virus, etc

Biomedical illness

91

Illness caused when there is loss of natural balance

Ting/yang
Hot/cold

Naturalistic illnesses

92

Illness caused by supernatural forces

Folk remedies

Magiocoreligious

93

What is normal gait?

Walk is smooth and even

Balance with out assistance

Movement of arm symmetry are present

94

WT and height in 80s and 90s ?

Prominent bony areas

Muscle shrinkage and weight and height decreases- especially in males

Fat loss from face , forearms, abd and hips (even with good nutrition)