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161 Cards in this Set
- Front
- Back
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definition of nursing process
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organized systematic approach to meet healthcare needs of individuals, families, or communities
Decision making approach that enhances critical thinking Organizing framework for professional nursing practice |
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Order of nursing process
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Assessment
Nursing diagnosis plan implementation evaluation |
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NANDA
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north american nursing diagnosis association
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what is the purpose of nanda
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to identify a classification system that identifies nursing functions
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what does nanda provide
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common diagnostic terminology for nurses
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difference between nursing process focus and medical process focus
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nursing process focuses on teaching independence in ADLs
Medical process focuses on teaching how the diseases and trauma are treated |
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difference between nursing process and medical process
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nursing process considers how pt and families are affected by organ or system function (human response)
medical process considers organ and system function |
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explain the difference between NIC and NOC
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NIC (nursing interventions classification) = work backwards from meds
NOC (nursing outcomes classifications) = work backwards from the end result |
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waht is a nursing diagnosis
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a conclusion drawn about data collected from a client
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what are some benefits of nursing diagnoses
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provides a common language
identifies nursing interventions helps staffing issues provides documentation creates a standard for nursing practice |
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describe the process of assessment
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gather info from client/family interviews, chart review, other health care providers, h&p, labs, xrays, progress notes, physician orders, literature reviews
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describe the process of the nursing diagnosis
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gather data, identify the problem, identify nursing diagnosis using nanda guidelines
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two types of nursing diagnoses
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actual diagnosis = PES (problem, etiology, symptoms)
Risk for diagnosis = PE (problem, etiology) |
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describe the planning process
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develop long term and short term goals; establish measurable outcome criteria and a target date for these; decide on nursing interventions to be performed independently, collaboratively or physician initiated
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describe the implementation process
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perform planned nursing interventions (independent, physician initiated, collaborative)
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describe the evaluation process
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upon target dates assess measurable outcome criteria; 3 outcomes = outcome criteria met completely, outcome criteria met partially and client condition changed or wrong diagnosis
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3 mistakes of nursing process
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medical diagnosis
signs and symptoms for "risk for" diagnoses Evaluating the wrong thing |
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how are nanda nursing diagnoses organized
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according to maslow's hierarchy of needs
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why do we perform client teaching
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care for increasing numbers of patients in the community
prevent disease effects clients expect more involvement in their care reduce health care costs improve quality of care help patients achieve optimal wellness and preventing illness |
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list the purposes of client education
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maintenance and promotion of health
restoration of health coping with impaired functioning |
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what is the ultimate goal of patient teaching
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change in behavior
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what must we take into consideration when educating patients
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psychosocial attitudes, anxiety and values
spiritual cultural values desire to actively participate in the educational process |
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what are some expected changes with client education
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knowledge
attitude behavior skills |
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list the 3 domains of learning and define
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cognitive - thinking
affective - expression of feelings and acceptance of attitude, opinions or values psychomotor - require the integration of mental and muscular activity |
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what categories are under cognitive domain
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knowledge
comprehension application analysis synthesis evaluation |
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what categories are under affective domain
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receiving
responding valuing organizing characterizing |
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what categories are under psychomotor domain
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perception
set guided response mechanism complex overt response adaptation origination |
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list the principles of learning
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readiness
attentional set motivation compliance psychosocial adaptation to illness active participation ability to learn learning environment |
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define attentional set
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mental state that allows the learner to focus on and comprehend a learning activity
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define motivation
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force that acts on or within a person that causes the person to act in a certain manner
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define compliance
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adherence to the prescribed course of therapy
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list the ways in which patients adapt to illnell or loss (psychosocial)
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denial or disbelief
anger bargaining resolution acceptance |
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list some inhibitors/motivators to patient learning
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attention span
health care beliefs perceptions & preconceived notions ability to comply desire to learn attitudes, language pain, fatigue, anxiety, etc culture, socioeconomic |
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how do we document patient teaching
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be specific about what was taught and the method used
be specific about behavioral changes |
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what did perioperative nursing used to be called and what did they do
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used to be called operating room nurse; used to just hand instruments to the surgeon basically
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list the ways in which patients are preoperatively prepared
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assessment
preadmission testing preoperative teaching informed consent patient preparation |
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where are 70% of surgeries perfomed
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outpatient basis in doctors' offices or surgicenters
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what is the main job of the preoperative nurse
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identify factors that will increase risk of patient
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if a patient does not understand a surgical procedure what should the nurse do
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get the doctor
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what does obesity increase the risk for in regards to surgery
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risk for delayed wound healing or wound healing problems
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what things should preoperative nurses teach
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TCDB
early mobilization pain management special considerations for ambulatory surgery patient |
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who does the responsibility of obtaining informed consent lie with?
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person performing the procedure
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when is an informed consent not legal
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if patient is confused, sedated, a minor or mentally incompetent
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what is required when a phone consent is given
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must be given to 2 nurses
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how do perioperative nurses prepare surgical sites
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do NOT shave anymore; clip with scissors
preoperative showering |
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when should preoperative antibiotics be given
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within 1 hour of initial cut
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list types of anesthesia
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general
regional and conduction topical and local conscious sedation |
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list stages of general anesthesia
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induction, maintenance, emergence
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what is PACU
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post anesthesia care unit
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how long should initial dressing stay in place after surgery
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24 hours
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what are keys to preventing complications after surgery
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incentive spirometry
early mobilization fluid balance prophylactic medications medical asepsis surgical asepsis |
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how do you prepare for a sterile procedure
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gather sterile items
check expiration dates perform hand hygiene or medical asepsis/aseptic handwash ensure work space is flat, clean, dry, waist level |
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what areas are considered contaminated during sterile procedures
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below the waist; behind you aka never turn your back on your sterile field
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how do properly don sterile gloves
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hand hygiene
grasp 1st glove by edge of cuff-keep thumbs up! slip your fingers under the second glove cuff and pull on fix fingers after both gloves are on keep hands at or above waist level and in sight at all times |
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how do you properly remove gloves
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grasp outside of cuff or palm with other gloved hand
pull glove off turning it inside out keep dirty glove in palm of remaining gloved hand in a ball place fingers of bare hand inside cuff of other glove and peel off inside out wash your hands |
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5 things you must always do when removing sutures and staples
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check doctor's orders
gather correct supplies check expiration dates identify patient check allergy band |
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procedure for removing staples
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cleanse hands; put on gloves
cleanse incision count staples insert staple remover under center of staple and squeeze gently remove staple and place on gauze steri stip bw removal of every other staple as indicated place removed staples in sharps remove gloves; wash hands document |
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list the types of sutures
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individual or interrupted
continuous sutures blanket sutures retention surtures |
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what are retention sutures generally used for
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surgical incision to prevent dehiscence and/or evisceration
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how do you remove interrupted sutures
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grasp the knotted end with forceps
snip suture opposite the knot |
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how do you remove continuous sutures
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snip first suture at end opposite of knot
snip second suture on same side grasp knot and remove first two lines grasp loose end of 3rd line, snip opp end and pull repeat until last suture snip last suture on opposit side of knot trim tail from next to last suture pull knot and remaining sutures out |
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what is the largest organ in the body
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skin
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list functions of the skin
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immune function
protection of internal organs control of body temp provides sensory perception assists in maintenance of fluid and electrolytes communicates feelings (body image) |
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what is a wound
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break in skin with disruption of the normal continuity of structures from a physical means
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what do we use to classify wounds
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status of skin integrity, age
etiology (cause) severity cleanliness descriptive qualities healing intention healing stages color |
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list and describe classes of cleanliness for wounds
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clean = closed, GI, uninfected operative outside of respiratory, genital or urinary tract
Clean-contaminated = operating wounds in resp, gi, genital or uninfected urinary tract Contaminated = open, fresh, accidental, op room break in sterile technique, gi spillage, nonpurulent inflammation Dirty or infected = old wounds with dead tissue, infection, perforated viscera Colonized = wound already has contamination |
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list and describe the classification of wound types
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laceration = tearing of tissue
abrasion = scraping of skin surface contusion = closes wound; bruise puncture = small, deep wound incision = intentional cut into tissue |
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list three healing processes
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primary
secondary third or tertiary |
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describe primary healing process
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clean surgical incision
edges are well approximated minimal tissue loss wound that is sutured or stapled healing occurs by epithelialization |
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describe secondary healing process
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edges are not well approximated
pressure ulcer |
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describe healing by third intention process
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after debridement of large necrotic wound
after management of infection delayed suturing grafts |
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list 3 healing phases
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inflammatory phase
proliferative phase maturation phase |
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describe the inflammatory phase of wound healing
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swelling redness heat pain fever
begins at time of injury usually lasts 3 days WBCs ingest bacteria and prepare tissue for repair |
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describe the proliferative phase of wound healing
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new granulation tissue is generated producing a red, beefy, shiny tissue with a granular appearance
fibroblasts stimulate production of collagen epithelialization with scar formation |
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describe the maturation phase of wound healing
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collagen fibers reorganize, mature and gain tensile strength
process continues until scar tissue has regained 70% of the skin's original strength; can take months to years scar tissue is NEVER as strong as original skin |
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give the characteristics of red wounds
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granulation
new healing tissue very fragile at first |
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characteristics of yellow wounds
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slough
like moist scab necrotic tissue needs to be removed |
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characteristics of black wounds
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eschar
slough dry scab necrotic tissue that needs to be removed |
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characteristics of granulation tissue
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smooth, velvety texture
dark red color bumpy texture results from angiogenesis and collagen deposition |
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characteristics of slough
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creamy white, stringy, loosely adheres to wound
composed of dead tissue or eschar black, fibrinous network of platelets and cells forms scab food for bacteria delays healing needs to be removed |
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list some complications of wound healing
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hemorrhage
infection dehiscence evisceration |
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how do we address dehiscence and evisceration
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cover with sterile gauze saturated in saline and call dr immediately
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what are retention sutures used for
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surgical incisions
prevention of dehiscence after dehiscense to prevent evisceration |
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list the types of wound drainage
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serous
purulent serosanguineous sanguineous |
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describe serous drainage
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clear, watery, no cells; can cause maceration
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describe purulent drainage
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thick, yellow, green, tan or brown
contains WBCs and bacteria |
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describe serosanguineous drainage
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pale red watery mixture of clear and red fluid
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describe sanguineous
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bright red; actual bleeding
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describe signs of infection
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increased exudate
pallor of wound bed delay in healing |
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describe the procedure for obtaining a wound culture
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cleanse first
collect from wound base, not drainage use sterile technique |
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list some factors that would impair wound healing
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nutrition, age, body build, impaired oxygenation, smoking, diabetes, drugs, radiation, wound stress, psychosocial impact
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what is wound healing influenced by
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nutrients available; moisture level; cleanliness; status of skin integrity; comorbidities; treatments; cause; severity of injury
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what things do we look at when we at when assessing a wound
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location
size amount of drainage, color consistency wound base - type of tissue moisture content any tunnels or undermining wound margins surrounding tissue signs of infection? progress toward healing |
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what do we use to clean wounds
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saline
non cytotoxic |
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what are the 4 methods of debridement
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autolytic
enzymatic mechanical sharp |
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what is debridement
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removal of necrotic tissue
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list the purposes of dressings
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protect wound
aid in hemostasis promote healing support or splint the wound protect patient from visualizing wound promote thermal insulation to wound surface provide moisture between wound and dressing remove excess moisture |
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list types of dressings
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gauze, film, hydrocolloids, hydrogels, foam, alginate, combination dressings, medicated dressings
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list the characteristics of good dressings
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will remove excess exudate and not allow wound to dry out
allows gaseous exchange minimizes contamination from outside sources not traumatic to wound when removed |
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what is the nephron composed of
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glomerulus, bowman's capsule, proximal convoluted tubule, loop of Henle, distal tubule and collecting duct
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what is the normal urine output
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1500-1600 mL per 24 hours
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where is the kidney located
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one on each side of vertebral column in the lower back
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how big are the kidneys
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approx 2 inches in length
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what are the functions of the kidney
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filters water, glucose, amino acids, urea, creatinine, and major electrolytes in blood
forms urine in the nephron secretes erythropoieten which stimulates production of RBCs in the bone marrow regulates calcium and phosphate |
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describe the location, size and function of the ureters
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connect kidney to bladder
approx 5 inches in length transport sterile urine to bladder |
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describe the location size and function of the bladder
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in pelvic cavity behind symphysis pubis
size of a fist receptacle for urine |
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describe location size and function of urethra
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inferior aspect of bladder
women = 1.5-2.5 inches men = 8 inches conduit connecting bladder to outside of body |
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what should we assess with urine
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color, clarity, odor, amount
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prerenal disease
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decreased blood flow to and through the kidney
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renal disease
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disease conditions of the kidney
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postrenal disease
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obstruction that occurs below the kidney preventing urine flow through the system
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common alterations in urinary elimination
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urinary tract infection
urinary retention urinary incontinence urinary diversions |
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diabetes is the leading cause of ?
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adult blindness
end stage renal disease non traumatic lower limb amputations risk for cardio deaths 2x to 4x higher risk for stroke 2x to 4x higher |
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list the types of diabetes
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type 1, 2, gestational, IGT
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clinical manifestations of type 1 diabetes
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polydipsia, polyphagia, polyuria
sudden weight loss |
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pathology of type 1 diabetes
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damage to beta cells of pancreas
possible autoimmune response caused by genetic predisposition, viral infections, environmental stimuli, unknown stimuli islet cell autoantibodies are present |
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how do we manage type 1
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intensive therapy
admin of insulin > 3x day self monitoring >/= 4x day dietary intake anticipate exercise conventional therapy requires admin of insulin 1-2x day self monitoring of urine or blood glucose 1x day client education on diet and exercise |
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how does diabetes affect exercise
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you have to plan for it
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what is ketosis
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abnormal accumulation of ketones in the body caused by excessive breakdown of fatty acids
develops in the absence of adequate metabolism of carbs |
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which ethnicities are prone to type 2 diabetes
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native american, african american, hispanic american, asian american, pacific islander
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clinical manifestations of type 2 diabetes
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gradual onset of polyuria
gradual onset of polydipsia easily fatigued frequent infections esp UTI often discovered w/ diagnosis of comorbidity |
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what is the #1 risk factor for type 2 diabetes in children
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obesity
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pathology of type 2 diabetes
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insulin resistance
insulin secretory defect islet cell antibodies |
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risk factors for type 2 diabetes
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obesity
family history ethnicity |
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methods of management for type 2 diabetes
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oral agents
exercise insulin diet |
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what criteria govern the use of insulin for diabetics
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severity of diabetes
comorbidities client |
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how do we manage the risks of diabetes
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attention to skin care
glucose monitoring as ordered or prn prompt treatment w/ meds know clinical manifestations of hyper/hypoglycemia client education |
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what is the number one way to manage diabetes
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control, control, control!!
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signs of hypoglycemia
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hunger, erratic behavior, confusion, trembling, shaking, cool & clammy skin, pale skin tone
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signs of hyperglycemia
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polyuria, polydipsia, headache, diabetic ketoacidosis
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how should diabetics care for their feet
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have podiatrist trim toenails
monitor temp of bath water wear protective footwear seek treatment for sores |
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what is required to perform accucheck on a patient
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order from physician or assessment by nurse if symptomatic
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how long is a box of strips good for with accucheck monitor
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3 months
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what must be written on the vial of strips for accucheck monitor
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date opened
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what is a central venous access device
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long thin flexible device designed to administer medications, nutrients, blood products and other viscous fluids through the central veins
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what is the most common site for a CVAD
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subclavian vein above right atrium
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what are indications for a CVAD
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multiple IV access sites needed
no accessible peripheral veins or sites receiving total parental nutrition receiving multiple incompatible infusions multiple blood transfusions multiple blood draws hemodialysis central venous pressure monitoring |
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list some of the sites for CVAD
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subclavian vein
internal/external jugular vein femoral vein basilic/cephalic vein (PICC) |
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what happens if the CVAD line goes to far into heart
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dysrhythmias
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3 types of CVAD
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PICC lines
non tunneled tunneled |
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describe the PICC line
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located in basilic or cephalic vein
decreased incidence of infection no phlebotomy or blood pressures in affected arm |
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describe non tunneled CVAD
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acute,short term, <6 weeks
multiple ports available usually in subclavian vein |
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describe tunneled CVAD
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chronic, long term >6 weeks
multiple ports generally in subclavian vein surgically tunneled beneath the skin sutured or stapled in place surgically removed |
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complications of insertion of CVAD
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pneumothorax
bleeding infection |
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possible signs of infection with CVAD
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red site
purulent drainage moisture under dressing inflammation at site elevated temp elevated heart rate decreased blood pressure |
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how often is the CVAD dressing generally changed
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every 7 days
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what do we use to clean CVAD sites
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chlorhexidine 2%
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what technique do we use when changing CVAD dressings
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sterile
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list uses of an enteral tube
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decompression of the stomach through removal of contents using intermittent suction
lavage of stomach compression of stomach or esophagus feeding and med admin |
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types of enteral tubes
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nasogastric
gastrostomy duodenal tube jejunostomy tube |
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describe continuous feeding with enteral tube
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use of pump to deliver nutrition over 12 hours or 24 hours
ordered by physician open or closed tubing systems |
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describe intermittant feeding with enteral tube
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nurse administers using gravity and syringe
aka bolus feeding |
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what position should patient be in for enteral feedings
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fowlers with head of bead at 30-45 degrees to prevent aspiration
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how do we verify placement of enteral tube
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check pH of gastric residual
X-ray is most definitive |
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when should enteral feedings not be given as ordered
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when residual >100mL or double hourly infusion rate
check in 1 hour after holding feeding; notify doctor if not gone down |
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how do we maintain the patency of enteral feedings
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flush with 20 mL of tap water at a minimum of every 4 hours or as needed if blockage occurs
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what do we do with residual from enteral tube
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return to patient to maintain electrolyte balance and digestive secretions
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why does dumping syndrome occur with enteral feedings
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occurs with hyperosmolar solutions-formulas high in electrolytes and carbohydrates
fluids are drawn into the formula from the vascular system through osmosis rapid distention of location in GI tract resulting in cramping and diarrhea |
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how do we prevent the symptoms of dumping syndrome with enteral feedings
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assess patient to rule out other reasons for diarrhea
slow down formula admin administer feeding at room temp consider amount of enteral flushes report dumping syndrome and discuss continuous vs intermittent feedings with dietician/MD |
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what is tpn and when is it used
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total parenteral nutrition or hyperalimentation (HAL)
requires central line access utilized when the gastrointestinal tract cannot be accessed for an extended period of time |
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how do we measure for an NG tube
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from tip of nose to earlobe to xiphoid process
add 6 inches |
