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Nursing Fundamentals > Unit 3 and 4 > Flashcards

Unit 3 and 4 Flashcards

1
Q

What are the purposes of the systematic approach used by all nurses (besides LPNs)?

A

Gather, critically examine, and analyze data.
Identify client responses.
Design outcomes.
Take appropriate interventions.
Evaluate the effectiveness of interventions.

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2
Q

What is the nursing process?

A 
A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
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3
Q

What is the purpose of the Assessment phase?

A

Gather data

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4
Q

What is the purpose of the Diagnosis phase?

A

Identify PT’s health needs

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5
Q

What is the purpose of the Planning phase?

A

Goal outcomes - What do I want PT to achieve?

Interventions - How to get there

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6
Q

What is the purpose of the Implementation phase?

A

Put into action

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7
Q

What is the purpose of the Evaluation phase?

A

Did our implementations work?

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8
Q

T/F - Per the ANA, assessments are a professional responsible of nurses

A

True

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9
Q

T/F - Legal actions are plausible if assessments are not done well

A

True

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10
Q

Assessment

A

The systematic gathering of information (data) r/t the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community.
Written, comprehensive, gather info.

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11
Q

What are the 5 steps needed to perform a systematic assessment?

A

Step 1 - Data collection
Step 2 - Organize data - spiritual, emotional, mental - Holistically organized
Step 3 - Validate data - is the data correct/accurate?
Step 4 - Clustering/grouping data to identify patterns to analyze data
Step 5 - Record + Report data - Document, report vital into

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12
Q

Critical info must be reported within what time frame? Example of critical info? Reported to who?

A

Within 1 hour, critical lab values, reported to someone who can do something about it

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13
Q

What are the 2 types of data?

A

Subjective

Objective

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14
Q

Subjective data

A

Symptoms from pt, CAN NOT be measured, direct quotes from pt. Include clients feelings, perceptions, and descriptions of health status. ex: “I do not feel good”

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15
Q

Objective data

A

Signs, more reliable, from the source and CAN be measured. These are findings observed and measured during physical examination. Feel, see, hear, and smell through observation or physical examination. ex: BP 120/80

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16
Q

What is an example of both subjective and objective data at once?

A

Pain scale 1-10 is the pt verbally telling you how much they’re in pain, but it is measurable.

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17
Q

What are the two sources of data?

A

Primary, Secondary

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18
Q

What is a primary source of data?

A

From the source itself. From the pt, or health care provider for a confused pt (Alzheimers and HCW saying the pt is confused)

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19
Q

What is a secondary source of data?

A

From someone other than the source. Example: wife of a husband pt, parent to a child pt, confused Alzheimer’s pt

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20
Q

Assessment: Data Collection - Methods of Data Collection? (4 listed in powerpoint)

A

Observation
Interview
History collection
Physical Examination

(Also listed: “Other sources of Data Collection”, no examples given in class)

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21
Q

Data Collection: Observation

A

“hallway observation”; 4 senses - see, hear, smell, touch; general appearance - agitated, calm, alert and oriented, color, age (does chronological age match?), how do they interact?

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22
Q

Data Collection: Interview

A

getting info; establish nurse-patient relationship before asking questions.
Consider age and development (child, teen, middle aged, etc..)
Open ended questions.
No “why” questions - leads to defensive answers.
Listen actively - nod, validate, reflective questions, no interrupting

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23
Q

Data Collection: History collection

A

Gathering - previous diagnosis, past history, maintenance/management? prescription changes

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24
Q

Data Collection: Physical examination

A

Head to toe assessment in systematic manner

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25
Q

What is the goal of data collection?

A

Identify health problems and opportunity for nursing interventions

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26
Q

Are lab values primary or secondary data?

A

Primary

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27
Q

Is a nurses report primary or secondary data?

A

Secondary

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28
Q

How is collected data used?

A

to create care plan for pt

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29
Q

What are the types of assessments? (6 listed in powerpoint)

A 
Initial/Admission
Focused assessment
Comprehensive/Shift
Emergency assessment
Time-Lapsed
Special Needs
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30
Q

What is the purpose of an initial/admission assessment?

A

Establish complete, comprehensive database on pt.
Baseline data.
Are there problems with the pt?
There is a certain amount of time to complete this assessment - get it done sooner than later to establish proper baseline data

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31
Q

What is the purpose of a focused assessment?

A

Gather ongoing data about specific problems that already has been identified.
Patient w/ pneumonia? Check respiratory/cardiovascular.
Focus on problem area.

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32
Q

What is the purpose of a comprehensive/shift assessment?

A

Establish prioritization and continuous data collection. Do things match for your received hand off report? Establish your baseline data for your shift.

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33
Q

What is the purpose of an emergency assessment?

A

Identify life-threatening conditions.

ER uses this a lot.

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34
Q

What is the purpose of a time-lapsed assessment?

A

Compare patient health status to baseline.

Periodic assessment checks. Used a lot in LTC facilities.

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35
Q

What is the purpose of a special needs assessment?

A

Specific to certain patient populations.
Ex: nutritional/BMI of 15 = low. Need more info from pt, dietary consult/referral.
Function impaired? PT/OT

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36
Q

What is the difference between medical vs. nursing assessments?

A

Medical assessments focus on DISEASE and PATHOLOGY.

Nursing assessments focus on patient RESPONSES to illness. Treating signs/symptoms and patient.

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37
Q

Can nurses delegate an assessment?

A

Only to another nurse. Be aware of scope of practices.

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38
Q

Can nurses delegate vital signs to an LNA?

A

If the patient is stable. If the patient is unstable, vital signs are considered an assessment, so NO.

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39
Q

Why is clustering data important?

A

Allows patterns to be recognized.

Helps to identify nursing diagnosis pertinent to your pt

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40
Q

How can you cluster data?

A

According to a model or framework (ex: body system, Maslow’s basic human needs model, etc).
By body system or need deficit

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41
Q

How should data be reported when assessment findings are critical? Time frame?

A

VERBALLY and immediately, within 1 hour!

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42
Q

Is documentation legally binding?

A

Yes!!! and If you did not document, it did not happen.

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43
Q

When should you document?

A

ASAP, immediately if possible.

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44
Q

What is effective documentation?

A

Consistent, clear, concise, thoughtful, timely, sequential, reflective of nursing practice, universal language. ONLY APPROVED ACRONYMS.
Write legibly and type correctly
Avoid using inferences
Use pt’s own words - Quotes, do not chart anything not relevant.

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45
Q

A good way to chart no new orders from Dr:

A

“Patients vitals _____, Patient symptomatic, No new orders received.

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46
Q

Record only _________, ________, and _________ data.

A

Pertinent, Important, Relevant

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47
Q

What are the formats of documentation? (3 listed in powerpoint)

A

1) Charting by exception - only chart abnormalities from baseline. “respiratory assessment within normal limits.”
2) Problem oriented medical record - problem focused, organizes data around the pt’s problem rather than the sources of information.
3) SOAP - subjective, objective, assessment, plan

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48
Q

SBAR

A

tool of communication.

Situation, background, assessment, recommendation

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49
Q

How is critical thinking used in nursing diagnosis?

A

Using critical thinking skills to identify patterns in the assessment data and draw conclusions about the pt’s health status.
PPT Unit 3 part 2, slide 12

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50
Q

Identifying Nursing Diagnosis

A

Common language for nurses, a clinical judgement.
Provides a basis for selection of nursing interventions so that goals and outcomes can be achieved.
NANDA list of acceptable diagnoses

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51
Q

What is nursing accountability?

A

Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

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52
Q

What are the 3 main types of nursing diagnosis?

A

1) Problem-Focused Nursing Diagnosis
2) Risk Nursing Diagnosis
3) Health Promotion Nursing Diagnosis

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53
Q

Problem-Focused Nursing Diagnosis

A

Actual problem, typically 3 signs/symptoms to prove.
Actual evidence of s/s of diagnosis exist.
Ex: Fluid volume deficit

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54
Q

Risk Nursing Diagnosis

A

Potential/Risk for a problem, maybe 1 sign/symptom.
Database contains risk factors of diagnosis, but no true evidence.
ex: risk for altered skin integrity

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55
Q

Health Promotion Nursing Diagnosis

A

Describes health status, but not a problem. AKA Wellness Diagnosis.
Ex: Readiness for enhance comfort.

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56
Q

What are the 5 steps to Diagnostic reasoning/Clinical judgement?

A

Analyze & interpret, Draw conclusions, Verify problems, Prioritize, Record

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57
Q

Acronym for Diagnostic Statement

A

P.E.S.
Problem (nursing diagnosis), Etiology (r/t), Signs and Symptoms (AEB)
r/t = related to
AEB = as evidenced by

Ex: Impaired skin integrity r/t immobility aeb stage III decubitus ulcer, red inflamed skin, purulent

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58
Q

What are the don’t’s of writing a nursing diagnosis? (2 listed in powerpoint)

A

Don’t use Medical Diagnosis (Altered nutritional status r/t CANCER)

Don’t state 2 separate problems in one diagnosis
ex: “anxiety and fear r/t…”
Needs 2 separate diagnoses and 2 r/t’s and possible different therapies.

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59
Q

What are the do’s of writing a nursing diagnosis? (2 listed in powerpoint)

A

Use accepted qualifying terms (altered, decreased, increased, impaired) - in NANDA as well

Refer to NANDA list

60
Q

When does discharge planning start for a patient?

A

Discharge Planning begins when the patient is admitted for treatment.
Starts on admission - example: pt with hip replacement, will need PT consult

61
Q

What are the three planning types?

A

Initial planning, ongoing planning, discharge planning

62
Q

Initial planning

A

Written as soon as possible after initial assessment

Development of the initial comprehensive care

63
Q

Ongoing planning

A

Changes made in the plan as the nurse evaluates the patient’s responses to care

64
Q

Things to know when prioritizing nursing diagnosis

A

Places problems in order of importance - ABC’s if two competing aspects in Maslow’s hierarchy.
Does not mean you must resolve one problem before tending to another.
Determined by the theoretical framework you use.
Consider patient preference (ex: bathe or food first?)

65
Q

ABC’s

A

Airway is structure.

Breathing is the process of taking in air and blowing off CO2. Can they utilize the O2 and CO2 appropriately?

Circulation is how blood, O2, and nutrients move through the body.

66
Q

Prioritizing problems - problem urgency

A

High priority - life threatening.
Medium priority - Not a direct threat to life, but may cause destructive physical or emotional changes.
Low priority - Requires minimal supportive nursing intervention.

67
Q

What are goals/objectives/outcomes?

A

Used to describe what is wanted/an aim/end goal.

Derived from the problem statement of the nursing diagnosis.

68
Q

What is considered a long-term goal?

A

To be achieved over a longer prior of time (weeks, months, or more).
Example: the pt will walk the length of the hallway independently by the end of 2 weeks.

69
Q

What is considered a short-term goal?

A

To be achieved within a few hours of days.

Example: The patient will ambulate down the hall within 2 days.

70
Q

What is a nursing-sensitive outcome?

A

The outcomes that can be influenced by nursing interventions.

71
Q

SMART Goals

A 
S - Specific
M - Measurable
A - Attainable
R - Relevant
T - Time Bound
72
Q

NIC vs. NOC

A 
NIC  = interventions
NOC = outcomes
73
Q

What is NOC?

A

Nursing evidence-based goals that are related to patient outcomes

74
Q

Components of a pt-centered outcomes statement

A

Subject - “patient will”

Action (verb) - measurable. Use Blooms Taxonomy.

Performance Criteria - to the extend to which you expect to see.

Target time.

Special conditions - independently? with a cane? etc.

75
Q

The 5 rights of clinical reasoning

A 
Right cues
Right action
Right patient
Right time
Right reason
76
Q

What stage of the nursing process is the following:

Systematically collect patient data

A

Assessing

77
Q

What stage of the nursing process is the following:

Clearly identify patient strengths and actual and potential problems

A

Diagnosing

78
Q

What stage of the nursing process is the following:
Develop a holistic plan of individualized care that specifies the desires patient goals and related outcomes, and the nursing interventions most likely to assist the patient to meet those expected outcomes

A

Planning

79
Q

What stage of the nursing process is the following:

Execute the care plan

A

Implementing

80
Q

What stage of the nursing process is the following:

Evaluate the effectiveness of the care plan in terms of patient goal achievement

A

Evaluating

81
Q

What does HELP stand for?

A

H - Help - observe the first signs pt may need help. Look for signs of distress (pallor, pain, labored breathing.)
E - Environmental equipment - look for safety hazards; ensure that all equipment is working (IVs, O2, catheter)
L - Look - examine pt thoroughly.
P - people - Who are the people in the room? What are they doing?

82
Q

What is the review of systems and what are the 4 methods used to collect data?

A

the examination of all body systems during the nursing physical assessment.

1) inspection - deliberate, purposeful observations in a systematic manner.
2) Palpation - use of the sense of touch to assess the skin temp, turgor, texture, moisture as well as vibrations w/in the body.
3) percussion - act of striking one object against another to produce sound
4) auscultation - act of listening with a stethoscope to sounds produced within the body

83
Q

Difference between a cue and an inference?

A

Cue - an indicator that something may be wrong.

Inference - the judgement you reach about the cue

84
Q

What are the five rights of delegation?

A 
Right task
Right circumstance
Right person
Right directions and communication
Right supervision and evaluation
85
Q

What are the six rights of medication?

A 
Right client
Right medication
Right dose
Right time
Right route
Right documentation
86
Q

AC

A

Before meals

87
Q

PC

A

After meals

88
Q

PO

A

By mouth

89
Q

Enteral

A

involves the esophagus, stomach, and small and large intestines (i.e., the gastrointestinal tract). Methods of administration include oral, sublingual (dissolving the drug under the tongue), and rectal

90
Q

Parenteral

A

via a peripheral or central vein

91
Q

Stat

A

Right away

92
Q

PRN

A

as needed

93
Q

“q”

A

every

94
Q

SL

A

sublingual

95
Q

What is a “now” prescription?

A

Similar to a stat prescription but it is not as urgent. Administer within 90 minutes.

96
Q

Common abbreviations for extended release medications

A 
CD- CONTROLLED DOSE
CR- CONTROLLED RELEASE
CRT- CONTROLLED RELEASE TABLET
LA- LONG ACTING
SA- SUSTAINED ACTION
SR- SUSTAINED RELEASE
TR- TIMED RELEASE
TD- TIME DELAY
XL/XR/ER - EXTENDED RELEASE
97
Q

What are adverse effects to medications?

A

undesired, unintended responses to a medication

98
Q

IM

A

intramuscular

99
Q

IV

A

intravenous

100
Q

IVPB

A

intravenous piggy back

101
Q

KVO

A

keep vein open

102
Q

Asepsis and what is the primary behavior

A

the absence of illness-producing microorganisms. hand hygiene is the primary behavior

103
Q

medical asepsis vs surgical asepsis

A

medical asepsis refers to the use of precise practices to reduce the number, growth, and spread of microorganisms.
surgical asepsis refers to the use of precise practices to eliminate all microorganisms from an object or area to prevent contamination.

104
Q

T/F nitrile gloves are latex

A

false. nitrile gloves are non-latex

105
Q

What should hand washing be accomplished using? (3 options)

A

antimicrobial soap and water
plain soap and water
alcohol based products

106
Q

what are the 3 essential components of handwashing

A

soap
running water
friction

107
Q

When, at a minimum, should health care workers perform hand hygiene?

A

before and after every client contact, and after removing gloves, before eating, after restroom, or when hands are visibly soiled

108
Q

What kind of solution should be used for hand hygiene when caring for clients who are immunocompromised or have infections with multidrug-resistant or extremely virulent microorganisms?

A

antiseptic solution

109
Q

How many seconds washing to remove the transient flora?

A

at least 15 seconds

110
Q

Up to how long washing visibly soiled hands?

A

up to 2 minutes

111
Q

Proper etiquette for turning off faucet

A

dry hands w/ clean paper towel, discard towel, new towel to turn off faucet

112
Q

How many feet minimum from those with a cough?

A

3 feet, or have them wear a mask

113
Q

Prolonged exposure to airborne microorganisms can make ________ items ___-_______

A

Sterile; non-sterile

114
Q

only _________ items can be in a _________ field

A

sterile; sterile

115
Q

Items considered contaminated regarding a sterile field:

A

outer wrappings and 1-inch edges of packaging that contains sterile items.
Objects held below the waist or above the chest.

116
Q

For what precaution should patient be placed in a negative air pressure room?

A

Airborne precautions. ex: TB, varicella (chicken pox), and rubeola (measles)

117
Q

How many air changes per hour for negative pressure room?

A

6-12 air changes per hour

118
Q

What infections are for airborne precautions?

A

TB, varicella (chicken pox), rubeola (measles)

119
Q

What infections are for droplet precautions?

A

rubella, mumps, diphtheria, adenovirus in young children and infants

120
Q

What infections are for contact precautions?

A

multidrug-resistant organism

121
Q

Extra precautions when dealing with immunosuppressed patient?

A

ensure health care provider is healthy.
restrict visits from f/f who have colds/contagious illnesses.
avoid collection of standing water in the room (humidifiers).
avoid plants and flowers (soil is a source of bact. and mold)
Follow hospital protocols regarding PPE for neutropenic precautions.

122
Q

infection

A

disease state that results from the presence of pathogens in or on the body

123
Q

pathogens

A

disease-producing microorganisms

124
Q

what are the components in the cyclic process of an infection?

A 
Infectious agent
Reservoir
Portal of exit
Means of transmission
Portals of entry
Susceptible host
125
Q

Infectious agent categories (3 listed in book)

A

Bacteria
Viruses
Fungi

126
Q

Bacteria

A

categorized in multiple ways.
1) Shape: spherical (cocci), rod shaped (bacilli), corkscrew (spirochetes)

2) Gram + or - … gram + holds violet dye due to thick cell wall. gram - loses violet dye with alcohol.

3) need for oxygen.
aerobic - require oxygen to live and grow
anaerobic - can live without oxygen

127
Q

Virus

A

ABX has no effect on viruses.
Viruses cause common cold, Hep B and C, AIDS.
Antiviral meds can help some viruses, when given in prodromal stage, can shorten full stage of illness.

128
Q

Fungi

A

plant-like organisms (molds and yeast). Present in air, soil, water.
can include athlete’s foot, ringworm, yeast infection. treated w/ antifungal meds.

129
Q

Stages of an infection

A

Incubation period
Prodromal stage
Full (acute) stage of illness
Convalescent period

130
Q

An organism’s potential to produce disease in a person depends on a variety of factors, including: (4 listed in book)

A

1) Number of organisms
2) Virulence of the organism/ability to cause disease
3) Competence of the person’s immune system
4) Length and intimacy of the contact b/w person & microorganism

131
Q

Colonization

A

When an organism/bacterial invasion resides in a person’s body but there are no clinical signs of an infection

132
Q

Reservoir

A

the natural habitat of the organism. can include other people, animals, soil, food, water, milk, and inanimate objects

133
Q

Portal of exit

A

the point of escape for the organism from the reservoir
in humans: respiratory, GI, or genitourinary, as well as breaks in the skin. blood and tissue can be a portal of exit as well.

134
Q

Means of transmission

A

direct contact - close proximity

indirect contact - personal contact w/ a vector (such as insect) or inanimate object (called a fomite)

135
Q

Airborne transmission vs droplet transmission

A

airborne particles are less than 5mcm

droplet particles are greater than 5mcm

136
Q

Portal of entry

A

the point at which organisms enter a new host.
Often the same as the exit route from the prior reservoir.
Skin, urinary, respiratory, and GI are common portals of entry.

137
Q

Susceptible host

A

Susceptibility is the degree of resistance the potential host has tot he pathogen. microorganisms survive only in a source that provides shelter and nourishment.

hospital pts are often in a weakened state of health. more susceptible to infection.

138
Q

Incubation period

A

interval between pathogens invasion and appearance of symptoms of infection.
organisms growing and multiplying.
length of incubation may vary.

139
Q

Prodromal stage

A

Most infectious stage. Early s/s present but are often vague and nonspecific such as fatigue/malaise/low-grade fever.
Lasts several hours to several days.

140
Q

Full stage of illness

A

infection specific s/s present. length of illness and severity depends on type of infection.

141
Q

Convalescent period

A

involved recovery from infection.

s/s disappear, return to healthy state.

142
Q

localized symptoms

A

symptoms that are limited or occur in only one body area

143
Q

systemic symptoms

A

symptoms manifested throughout the entire body

144
Q

signs of acute infection

A

redness, heat, swelling, pain, loss of function

145
Q

Examples of infections requiring contact precautions

A

MRSA, herpes simplex, C. difficile, wound infections

146
Q

Examples of infections requiring droplet precautions

A

Influenza, Mycoplasma pneumonia

147
Q

Examples of infections requiring airborne precautions

A

pulmonary tuberculosis

Nursing Fundamentals (3 decks)

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