Unit 3 and 4 Flashcards
(147 cards)
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.
2
Q
What is the nursing process?
A
A - Assessment D - Diagnosis P - Planning I - Implementation E - Evaluation
3
Q
What is the purpose of the Assessment phase?
A
Gather data
4
Q
What is the purpose of the Diagnosis phase?
A
Identify PT’s health needs
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
6
Q
What is the purpose of the Implementation phase?
A
Put into action
7
Q
What is the purpose of the Evaluation phase?
A
Did our implementations work?
8
Q
T/F - Per the ANA, assessments are a professional responsible of nurses
A
True
9
Q
T/F - Legal actions are plausible if assessments are not done well
A
True
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.
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
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
13
Q
What are the 2 types of data?
A
Subjective
Objective
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”
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
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.
17
Q
What are the two sources of data?
A
Primary, Secondary
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)
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
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)
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?
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
23
Q
Data Collection: History collection
A
Gathering - previous diagnosis, past history, maintenance/management? prescription changes
24
Q
Data Collection: Physical examination
A
Head to toe assessment in systematic manner
25
What is the goal of data collection?
Identify health problems and opportunity for nursing interventions
26
Are lab values primary or secondary data?
Primary
27
Is a nurses report primary or secondary data?
Secondary
28
How is collected data used?
to create care plan for pt
29
What are the types of assessments? (6 listed in powerpoint)
```
Initial/Admission
Focused assessment
Comprehensive/Shift
Emergency assessment
Time-Lapsed
Special Needs
```
30
What is the purpose of an initial/admission assessment?
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
31
What is the purpose of a focused assessment?
Gather ongoing data about specific problems that already has been identified.
Patient w/ pneumonia? Check respiratory/cardiovascular.
Focus on problem area.
32
What is the purpose of a comprehensive/shift assessment?
Establish prioritization and continuous data collection. Do things match for your received hand off report? Establish your baseline data for your shift.
33
What is the purpose of an emergency assessment?
Identify life-threatening conditions.
| ER uses this a lot.
34
What is the purpose of a time-lapsed assessment?
Compare patient health status to baseline.
| Periodic assessment checks. Used a lot in LTC facilities.
35
What is the purpose of a special needs assessment?
Specific to certain patient populations.
Ex: nutritional/BMI of 15 = low. Need more info from pt, dietary consult/referral.
Function impaired? PT/OT
36
What is the difference between medical vs. nursing assessments?
Medical assessments focus on DISEASE and PATHOLOGY.
| Nursing assessments focus on patient RESPONSES to illness. Treating signs/symptoms and patient.
37
Can nurses delegate an assessment?
Only to another nurse. Be aware of scope of practices.
38
Can nurses delegate vital signs to an LNA?
If the patient is stable. If the patient is unstable, vital signs are considered an assessment, so NO.
39
Why is clustering data important?
Allows patterns to be recognized.
| Helps to identify nursing diagnosis pertinent to your pt
40
How can you cluster data?
According to a model or framework (ex: body system, Maslow's basic human needs model, etc).
By body system or need deficit
41
How should data be reported when assessment findings are critical? Time frame?
VERBALLY and immediately, within 1 hour!
42
Is documentation legally binding?
Yes!!! and If you did not document, it did not happen.
43
When should you document?
ASAP, immediately if possible.
44
What is effective documentation?
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.
45
A good way to chart no new orders from Dr:
"Patients vitals _____, Patient symptomatic, No new orders received.
46
Record only _________, ________, and _________ data.
Pertinent, Important, Relevant
47
What are the formats of documentation? (3 listed in powerpoint)
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
48
SBAR
tool of communication.
| Situation, background, assessment, recommendation
49
How is critical thinking used in nursing diagnosis?
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
50
Identifying Nursing Diagnosis
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
51
What is nursing accountability?
Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
52
What are the 3 main types of nursing diagnosis?
1) Problem-Focused Nursing Diagnosis
2) Risk Nursing Diagnosis
3) Health Promotion Nursing Diagnosis
53
Problem-Focused Nursing Diagnosis
Actual problem, typically 3 signs/symptoms to prove.
Actual evidence of s/s of diagnosis exist.
Ex: Fluid volume deficit
54
Risk Nursing Diagnosis
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
55
Health Promotion Nursing Diagnosis
Describes health status, but not a problem. AKA Wellness Diagnosis.
Ex: Readiness for enhance comfort.
56
What are the 5 steps to Diagnostic reasoning/Clinical judgement?
Analyze & interpret, Draw conclusions, Verify problems, Prioritize, Record
57
Acronym for Diagnostic Statement
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
58
What are the don't's of writing a nursing diagnosis? (2 listed in powerpoint)
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.
59
What are the do's of writing a nursing diagnosis? (2 listed in powerpoint)
Use accepted qualifying terms (altered, decreased, increased, impaired) - in NANDA as well
Refer to NANDA list
60
When does discharge planning start for a patient?
Discharge Planning begins when the patient is admitted for treatment.
Starts on admission - example: pt with hip replacement, will need PT consult
61
What are the three planning types?
Initial planning, ongoing planning, discharge planning
62
Initial planning
Written as soon as possible after initial assessment
| Development of the initial comprehensive care
63
Ongoing planning
Changes made in the plan as the nurse evaluates the patient's responses to care
64
Things to know when prioritizing nursing diagnosis
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
ABC's
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
Prioritizing problems - problem urgency
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
What are goals/objectives/outcomes?
Used to describe what is wanted/an aim/end goal.
| Derived from the problem statement of the nursing diagnosis.
68
What is considered a long-term goal?
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
What is considered a short-term goal?
To be achieved within a few hours of days.
| Example: The patient will ambulate down the hall within 2 days.
70
What is a nursing-sensitive outcome?
The outcomes that can be influenced by nursing interventions.
71
SMART Goals
```
S - Specific
M - Measurable
A - Attainable
R - Relevant
T - Time Bound
```
72
NIC vs. NOC
```
NIC = interventions
NOC = outcomes
```
73
What is NOC?
Nursing evidence-based goals that are related to patient outcomes
74
Components of a pt-centered outcomes statement
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
The 5 rights of clinical reasoning
```
Right cues
Right action
Right patient
Right time
Right reason
```
76
What stage of the nursing process is the following:
| Systematically collect patient data
Assessing
77
What stage of the nursing process is the following:
| Clearly identify patient strengths and actual and potential problems
Diagnosing
78
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
Planning
79
What stage of the nursing process is the following:
| Execute the care plan
Implementing
80
What stage of the nursing process is the following:
| Evaluate the effectiveness of the care plan in terms of patient goal achievement
Evaluating
81
What does HELP stand for?
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
What is the review of systems and what are the 4 methods used to collect data?
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
Difference between a cue and an inference?
Cue - an indicator that something may be wrong.
| Inference - the judgement you reach about the cue
84
What are the five rights of delegation?
```
Right task
Right circumstance
Right person
Right directions and communication
Right supervision and evaluation
```
85
What are the six rights of medication?
```
Right client
Right medication
Right dose
Right time
Right route
Right documentation
```
86
AC
Before meals
87
PC
After meals
88
PO
By mouth
89
Enteral
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
Parenteral
via a peripheral or central vein
91
Stat
Right away
92
PRN
as needed
93
"q"
every
94
SL
sublingual
95
What is a "now" prescription?
Similar to a stat prescription but it is not as urgent. Administer within 90 minutes.
96
Common abbreviations for extended release medications
```
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
What are adverse effects to medications?
undesired, unintended responses to a medication
98
IM
intramuscular
99
IV
intravenous
100
IVPB
intravenous piggy back
101
KVO
keep vein open
102
Asepsis and what is the primary behavior
the absence of illness-producing microorganisms. hand hygiene is the primary behavior
103
medical asepsis vs surgical asepsis
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
T/F nitrile gloves are latex
false. nitrile gloves are non-latex
105
What should hand washing be accomplished using? (3 options)
antimicrobial soap and water
plain soap and water
alcohol based products
106
what are the 3 essential components of handwashing
soap
running water
friction
107
When, at a minimum, should health care workers perform hand hygiene?
before and after every client contact, and after removing gloves, before eating, after restroom, or when hands are visibly soiled
108
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?
antiseptic solution
109
How many seconds washing to remove the transient flora?
at least 15 seconds
110
Up to how long washing visibly soiled hands?
up to 2 minutes
111
Proper etiquette for turning off faucet
dry hands w/ clean paper towel, discard towel, new towel to turn off faucet
112
How many feet minimum from those with a cough?
3 feet, or have them wear a mask
113
Prolonged exposure to airborne microorganisms can make ________ items ___-_______
Sterile; non-sterile
114
only _________ items can be in a _________ field
sterile; sterile
115
Items considered contaminated regarding a sterile field:
outer wrappings and 1-inch edges of packaging that contains sterile items.
Objects held below the waist or above the chest.
116
For what precaution should patient be placed in a negative air pressure room?
Airborne precautions. ex: TB, varicella (chicken pox), and rubeola (measles)
117
How many air changes per hour for negative pressure room?
6-12 air changes per hour
118
What infections are for airborne precautions?
TB, varicella (chicken pox), rubeola (measles)
119
What infections are for droplet precautions?
rubella, mumps, diphtheria, adenovirus in young children and infants
120
What infections are for contact precautions?
multidrug-resistant organism
121
Extra precautions when dealing with immunosuppressed patient?
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
infection
disease state that results from the presence of pathogens in or on the body
123
pathogens
disease-producing microorganisms
124
what are the components in the cyclic process of an infection?
```
Infectious agent
Reservoir
Portal of exit
Means of transmission
Portals of entry
Susceptible host
```
125
Infectious agent categories (3 listed in book)
Bacteria
Viruses
Fungi
126
Bacteria
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
Virus
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
Fungi
plant-like organisms (molds and yeast). Present in air, soil, water.
can include athlete's foot, ringworm, yeast infection. treated w/ antifungal meds.
129
Stages of an infection
Incubation period
Prodromal stage
Full (acute) stage of illness
Convalescent period
130
An organism's potential to produce disease in a person depends on a variety of factors, including: (4 listed in book)
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
Colonization
When an organism/bacterial invasion resides in a person's body but there are no clinical signs of an infection
132
Reservoir
the natural habitat of the organism. can include other people, animals, soil, food, water, milk, and inanimate objects
133
Portal of exit
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
Means of transmission
direct contact - close proximity
indirect contact - personal contact w/ a vector (such as insect) or inanimate object (called a fomite)
135
Airborne transmission vs droplet transmission
airborne particles are less than 5mcm
| droplet particles are greater than 5mcm
136
Portal of entry
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
Susceptible host
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
Incubation period
interval between pathogens invasion and appearance of symptoms of infection.
organisms growing and multiplying.
length of incubation may vary.
139
Prodromal stage
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
Full stage of illness
infection specific s/s present. length of illness and severity depends on type of infection.
141
Convalescent period
involved recovery from infection.
| s/s disappear, return to healthy state.
142
localized symptoms
symptoms that are limited or occur in only one body area
143
systemic symptoms
symptoms manifested throughout the entire body
144
signs of acute infection
redness, heat, swelling, pain, loss of function
145
Examples of infections requiring contact precautions
MRSA, herpes simplex, C. difficile, wound infections
146
Examples of infections requiring droplet precautions
Influenza, Mycoplasma pneumonia
147
Examples of infections requiring airborne precautions
pulmonary tuberculosis
