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Flashcards in week five Deck (91)
1

Nursing Diagnosis

Clinical judgement/patient problem about responses to health problems or life processes that nurses are licensed to treat

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Etiology

The probable cause of the problem joined with r/t. can not be medical diagnosis.

3

dx

diagnosis

4

Subjective Data

Things a person tells you about that you cannot observe through your senses; symptoms

5

Objective Data

what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination

6

Interview

meeting between examiner and patient with the goal of gathering a complete health history

7

Physical Health Assessment (Examination)

an evaluation made for the purpose of diagnosis by identifying physical evidence of disease, such as signs and symptoms

8

Assessment

Collecting data, organizing data, validating data, documenting data

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Diagnosis

Analyzing data, identifying health problems, risks, and strengths, formulate diagnostic statements

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Planning

Prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting nursing interventions

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Implementing

Reassess client, determine nurse's need for assistance, implement the nursing interventions, supervise delegated care, document nursing activities

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Evaluating

Collect data related to outcomes, compare data with outcomes, relate nursing actions to client goals/outcomes, draw conclusions about problem status

13

Describe the relationship between critical thinking and the nursing process

Critical thinking is the purposeful, reflective, mental activity using skills in reasoning, analysis and decision making relevant to the discipline of nursing. The nursing process is a systematic approach to the delivery of nursing services.

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Describe the step in assessment: Collect Data

gather information about a patient's health status using information that comes from the patient (primary source, or family, health records, other health professionals (secondary source).

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Describe the step in assessment: Organize Data

Written or electronic format organize the collected patient data systematically

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Describe the step in assessment: Validate Data

Double-checking of gathered data to confirm it is accurate and factual. Not all data requires validation.

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Describe the step in assessment: Document Data

Data are recorded in a factual manner without interpretation by the nurse. Subjective data should be documented in the patient's own words and in quotes.

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Data Collection Methods: Interview

planned communication. Directive: structured for specific information - nurse controls. Non Directive: build rapport, patient controls. The three stages of an interview are the opening, body, and closing.

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Interview Opening

Sets the tone, establishes rapport and states the purpose for the interview

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Interview Body

Communication phase, data collection

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Interview Closing

Nurse or patient end the conversation, important for building trust and continuing rapport

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Data Collection Methods: Physical Assessment

Inspection, palpation, percussion, auscultation

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Inspection

visual examination, purposeful and systematic, must have sufficient lighting

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Palpation

Sense of touch, determine texture, temperature, position, size, distention, mobility of organs, pulsation, presence of pain

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Percussion

Striking or tapping the body surface so that sounds can be heard or vibrations felt

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Auscultation

Listening to sounds produced within the body. Can be direct (with ear alone) or indirect (with a stethoscope)

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Actual Nursing Diagnosis

The problem is present at the time of assessment

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Risk For Nursing Diagnosis

The problem does not currently exist, BUT based on the RN's clinical judgement there are risk factors that indicate that a problem is likely to develop without RN intervention

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Wellness Nursing Diagnosis

Focuses on the patient's desire to maintain or increase current level of health/wellness. "Readiness For"

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dx

Diagnosis

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Substantiating Data

What you actually observe/find in your patient that explains/validates the defining characteristics you have chosen.

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Defining Characteristics

the clinical criteria or assessment findings that support an actual nursing diagnosis

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Risk Factors

factors linked with a disease by association but not yet proved to be cause of an actual disease in the patient.

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Collaborative Problem

Both medical and nursing interventions are needed to prevent and treat the problem. Begin with statement "Potential complication"

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Medical Diagnosis

Problem with the structure or function of an organ or body system requiring diagnosis and treatment by a physician

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NANDA

North American Nursing Diagnosis Association International

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Steps of Diagnostic Phase: Analyzing and Interpreting the Data

compare the data you have collected against what is expected, is the data normal or abnormal, what type of problem does the abnormal data point to, look for gaps or inconsistencies

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Steps of Diagnostic Phase: Clustering the Data

done after assessment, organize data and look for common patterns, review patient responses and symptoms, identify gaps and inconsistencies

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Steps of Diagnostic Phase: Identifying Health Problems, Risks, and Strengths

Joint effort between nurse and patient, determine if problem is a nursing diagnosis, medical diagnosis, or a collaborative problem

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Steps of Diagnostic Phase: Formulating Diagnostic Statements

This is a 2 part statement including a patient problem or diagnostic label from the NANDA list and the etiology or probable cause of that problem joined with r/t. Etiology must be within the domain of nursing practice and not the medical diagnosis.

41

Health

Many definitions of health. "An experience of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Incorporates a personal perception of well-being as well as can be expressed on a continuum

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Well-Being

Well being is subjective, perception, and personal opinion of health status

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Wellness

A state of well-being, a personal responsibility, a process, daily choices/decision, an ultimate goal, holistic and individual

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Emotional Wellness

recognize your feelings, accept your personal limitations, manage your stress, express your feelings appropriately

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Physical Wellness

maintain adequate nutrition and hydration, achieve proper level of body fat proportion, support fitness of all body systems, avoid excessive use of alcohol or abuse of drugs, including prescribed medications, avoid risky behaviors

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Social Wellness

love and belonging, develop respect and tolerance of other's differences, interact successfully with others within their environment, maintain intimacy with those close to you

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Environmental Wellness

improve your community's standard of living, promote local quality of life, buy locally grown foods and services, support healthy air quality, sustain water resources

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Occupational Wellness

develop a balance for work and personal life, acknowledge your beliefs regarding education, employment, and personal life and seek to understand others beliefs, one's personal beliefs effect their relationships with others

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Spiritual Wellness

human beings believing in a uniting force such as religion, nature, science, or a higher power, belief provides meaning and purpose to life, this belief forms and supports one's morals, values, and ethics

50

Intellectual Wellness

ability to learn, develop thoughts and reasoning for use in developing career, personal and family life, ability to cope with challenges and problem solve, to learn ,retain, and use knowledge

51

What are the components of the health/illness continuum?

pre-mature death, disability, symptoms, signs, neutral point, awareness, education, growth, high-level wellness

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Factors that may affect health status, beliefs, or practices

Internal Dimensions: biologic, psychological, cognitive. External Dimensions: environment, standards of living, family and cultural beliefs, social support networks

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Levels of Prevention: Primary Prevention

Promotion or protection

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Levels of Prevention: Secondary Prevention

Screening/early identification and/or treatment to prevent complications

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Levels of Prevention: Tertiary Prevention

Training, Teaching

56

What is the nurse's role in health promotion?

role model, facilitator, teacher/educator, advocate, coordinator of services, consultant

57

What are the central goals of Healthy People 2020?

Vision: a society in which all people live long healthy lives. Key Components: risk assessments, public health priorities, health preparedness and prevention. Federally funded and high on health continuum.

58

What are the effects of hospitalization/institutional living on clients?

behavioral and emotional changes, self-concept changes, body image changes, lifestyle changes, loss of independence, financial concerns, role changes, increase stress, change in social norm or structure

59

Examples of inpatient settings

hospitals, extended or long term care, retirement community or assisted living, rehabilitation centers, sub-acute centers, hospice houses or centers

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Examples of outpatient setting

ambulatory care centers (clinics), MD/primary care offices, occupational or industrial health clinics, out-patient, urgent care, child or adult day-care, crisis centers/support groups, home care/public health

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Levels of long term care

Skilled Nursing Facility, Assisted Living, Independent living for seniors, residential care facilities (disabilities)

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Skilled Nursing Facility

offers skilled care from a licensed nursing staff until clients are able to move back into the community or into residential care

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Assisted Living

facilities where residents live who need some assistance; they do not usually require skilled care.

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Independent living

allow self-care individuals to rent or purchase an apartment in the facility; provide services such as meals, housekeeping, laundry, transportation, social events, and basic medical care.

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Residential Care Facilities

sheltered environments that do not provide professional healthcare services and thus for which most health insurance programs do not provide coverage. Mainly for people with disabilities

66

What is the role of the community health nurse?

advocate, caregiver, care manager or coordinator, educator

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What services are available in the home setting?

less expensive, familiar surroundings, family involvement, improved client outcomes, enhanced quality of life

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Hospice

a program of medical and emotional care for the terminally ill

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Urgent Care Center

delivery of ambulatory care in a facility dedicated to the delivery of care outside of a hospital emergency department, usually on an unscheduled, walk-in basis. Urgent care centers are primarily used to treat patients who have an injury or illness that requires immediate care but is not serious enough to warrant a visit to an emergency room

70

Crisis Intervention Center

secondary prevention: help people deal with short term stressful sitch requiring immediate therapeutic attention

72

Day Care Center

day care centers provide treatment during the daylight hours with patient being released at night. Child and Adult.

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Home Care

provides nursing, therapy, personal care or housekeeping services in the patient's own home

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Rehabilitation Center

A facility that offers care for patients with ongoing recovery from a disability. This can include medical, psychiatric, or physical therapy.

75

Define Nursing Diagnosis: Falls, risk for

Increased susceptibility to falling that may cause physical harm

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Risk Factors for Falls, risk for

Age 65 or older, history of falls, lives alone, lower limb prosthesis, use of assistive devices, wheelchair use, less than 2 years of age, bed located near window, lack of automobile-restraints, lack of gate on stairs, lack of window guard, lack of parental supervision, male gender when less than 1 year of age, unattended infant on elevated surface, diminished mental status, cluttered environment, dimly lit room, no antislip material in bath, no antislip material in shower, restraints, throw rugs, unfamiliar room, weather conditions, angiotensin-converting enzyme (ACE) inhibitors, alcohol use, anti-anxiety agents, antihypertensive agents, diuretics, hypnotics, narcotics/opiates, tranquilizers, tricyclic antidepressants, anemias, arthritis, diarrhea, decreased lower extremity strength, difficulty with gait, faintness when extending neck, foot problems, hearing difficulties, impaired balance, impaired physical mobility, incontinence, neoplasms, neuropathy, orthostatic hypotension, post-operative conditions, postprandial blood sugar changes, presence of acute illness proprioceptive deficits, sleepnessless, urgency, vascular disease, visual difficulties

77

Define Nursing Diagnosis: Mobility: Physical, Impaired

A limitation in independent, purposeful physical movement of the body or of one or more extremities

78

Defining characteristics for Mobility: Physical, Impaired

decreased reaction time, difficulty turning, engages in substitutions for movement, exertional dyspnea, gait changes, jerky movements, limited ability to perform gross motor skills, limited ability to perform fine motor skills, limited range of motion, movement-induced tremor, postural instability, slowed movement, uncoordinated movements

79

Define Nursing Diagnosis: Oral mucous membrane, Impaired

Disruption of the lips and/or soft tissues of the oral cavity

80

Defining characteristics for Oral mucous membrane, Impaired

bleeding, cheilitis, coated tongue, desquamation, difficult speech, difficulty eating, difficulty swallowing, diminished taste, edema, enlarged tonsils, fissures, geographic tongue, gingival hyperplasia, gingival pallor, gingival recession, halitosis, hyperemia, macroplasia, mucosal denudation, mucosal pallor, nodules, oral discomfort, oral lesions, oral pain, oral ulcers, papules, pocketing deeper than 4mm, presence pathogens, purulent drainage, red or bluish masses, reports bad taste in mouth, smooth atrophic tongue, spongy patches, stomatitis, vesicles, white, curd-like exudates, white patches/plaques, xerostomia

81

Define Nursing Diagnosis: Self care deficit: bathing

Impaired ability to perform or complete bathing/hygiene activities for self

82

Defining characteristics for Self care deficit: bathing

inability to access bathroom, inability to dry body, inability to get bath supplies, inability to obtain water source, inability to regulate bath water, inability to wash body

83

Define Nursing Diagnosis: Self care deficit: dressing

Impaired ability to perform or complete dressing ad grooming activities for self

84

Defining characteristics for Self care deficit: dressing

inability to choose clothing, inability to put clothing on lower body, inability to maintain appearance at a satisfactory level, inability to pick up clothing, inability to put clothing on upper body, inability to put on shoes, inability to put on socks, inability to remove clothes, inability to remove shoes, inability to remove socks, inability to use assistive devices, inability to use zippers, inability to fasten clothing, impaired ability to obtain clothing, impaired ability to put on necessary items of clothing, impaired ability to put on shoes, impaired ability to put on socks, impaired ability to take off necessary items of clothing, impaired ability to take off shoes, impaired ability to take off socks

85

Define Nursing Diagnosis: Self care deficit: toileting

Impaired ability to perform or complete toileting activities for self.

86

Defining characteristics for Self care deficit: toileting

inability to carry out proper toilet hygiene, inability to flush toilet or commode, inability to get to toilet or commode, inability to manipulate clothing to toileting, inability to rise from toilet or commode, inability to sit on toilet or commode

87

Define Nursing Diagnosis: Skin integrity, Impaired

Altered epidermis and/or dermis

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Defining characteristics for Skin integrity, Impaired

Destruction of skin layers, disruption of skin surface, invasion of body structures

89

Define Nursing Diagnosis: Skin integrity, risk for impaired

At risk for skin being adversely altered

90

Risk factors for Skin integrity, risk for impaired

External: chemical substance, excretions and/or secretions, extremes of age, humidity, hyperthermia, hypothermia, mechanical factors, moisture, physical immobilization, radiation. Internal: alterations in skin turgor, altered circulation, alter metabolic state, altered nutritional state, altered pigmentation, altered sensation, chronic disease, developmental factors, history of pressure ulcers, immunological deficit, medication, psychogenetic immunological factors, skeletal prominence, vascular disease

91

Define Nursing Diagnosis: Tissue Integrity, impaired

Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues

92

Defining characteristics for Tissue integrity, impaired

damaged tissue (cornea, mucous membrane, integumentary or subcutaneous tissue), destroyed tissue