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316 Cards in this Set
- Front
- Back
What is the nursing process?
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process for writing and taking care of patients
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What is critical thinking
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active, organized, cognitive process
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What does critical thinking examine?
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thinking of others
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What does critical thinking require?
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good cognitive skills
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What is reflection?
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looking back on similar experience
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What does reflection do in our case?
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connects classroom with clinical
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How do you stay well-informed?
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read the paper, websites, magazines
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How must you think to critical think properly?
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clearly, precisely, accurately
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What reflects clear thinking?
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precise, clear language
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Are thinking and language closely related?
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yes
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What is intuition?
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sensing that something is happening
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What should you always be conscious of?
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what you know and dont know
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What is decision making?
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choosing an option
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What diagnostic reasoning?
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assessing client
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What method of research does nursing use?
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scientific method
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What is the first step of clinical decision making?
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assess the problem
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What is the 2nd step of clinical decision making?
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identify priority
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What is the 3rd step of clinical decision making?
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choose nursing therapy
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What is the 4th step of clinical decision making?
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decide how to combine activities on more than 1 pt.
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What is the 5th step of clinical decision making?
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delegate if able
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What is learning?
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a lifelong process
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What two things are inseperable?
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learning and thinking
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What does learning require you to do?
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be flexible, open to new information
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What are the parts of critical thinking?
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knowledge base, experience, attitudes, confidence, responsibitity, risk taking, disciipline, perseverance, creativity, curiosity, integrity, and humility
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What does ADPIE stand for?
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Assessment, Diagnosis, Plan, Implementation, Evaluation
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What does the nursing process provide for?
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continuous, ongoing care of clients
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What does the nursing process enable the nurse to do?
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identify cts health care needs, determine priorities, est. goals and exp. outcomes, deliver nurs. intervent. eval eff. of care
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What does the nursing process integrate?
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elements of critical care
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What is the nursing process used for?
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identify, dx, and treat human response to health and illness
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How many steps are there in the nursing process?
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5
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How do you establish a data base?
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collect data
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What are the two types of data?
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subjective and objective
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In which step of the nursing process do you collect data?
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assessment
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What is subj data?
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information gathered from client statements
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What does subj data include?
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client feelings and perceptions
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Is subj data verifiable by someone else
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no, except by inference
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What is obj data?
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information that can be observed by others
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What is obj data free of?
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feelings, perceptions, prejudices
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In what step of the nursing process do you do an interview?
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assessment
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What is an interview?
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organized conversation with client to obtain health hx and info about current illness
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What does the interview give you an oppertunity to do?
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intro. yourself and exp. role; est. therapeutic relationship; gain insight about client concerns and worries, determine client goals and expectatison, obtain cues regard. where you need more info
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What does the nursing health hx include?
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biographical information, RSC, HPI, health hx, fam hx, environmental hx, psychosocial and cultural hx, ROS
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In which step do you pay attention to interviewing techniques?
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assessment
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What type of attitude should you have when doing an interview?
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nonjudgmental, interesting and caring
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What should you pay attention to when interviewing?
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environment, client comfort, and comm tech.
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What type of questions should you use?
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open ended
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What type of questions should you avoid?
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why and CEQ
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When performing the phys. exam what do you examine?
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vital signs, obj measurements and all body systems
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What do you observe for in the physcial exam?
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any abnormalitites that may yield info about past, present and future health problems
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What four assessment tech should you use?
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inspection, auscultation, palpation and percussion
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What should you always remember to do when giving an exam?
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explain each step to client
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What should you always protect when doing the phys exam?
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client privacy, dignity and warmth
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In what step do you observe for client behavior?
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assessment
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Should subj and obj data agree? What if they dont
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Yes - further data collection
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What is congruency?
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matching or agreement between two or more things
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What is consistency?
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refers to degree client operates at same level of function throughout assessment and day to day
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What is the obs. of client funct.
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What you see client doing not what they say they can do
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What are some other sources of data for the hx?
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family, friends, sig. others, health care team, lit. review (chart)
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What does validation of assessment data involve?
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comparing data with another source
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What happens when you validate info?
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opens door for gathering more info
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What is the last part of the complete assessment?
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data documentation
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What is the basic rule of data documentation?
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record all observations
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What does data documentation include?
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facts only
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Should you generalize or form judgements to early?
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NO
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What becaomes a nursing dx in the data documentation part?
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conclustions and observatison
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How many steps are there in the assessment phase of the nursing process?
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2
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What is the first step of the assessment process?
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collect and verify data from primary and secondary sources
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What is the second step of the assessment process?
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analyze data as basis for developing nsg dix and plan of care
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What are the types of nursing dx?
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actual, risk, wellness
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What is the second step of the nursing process?
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dx
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What is the nursing dx?
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clinical judgment about individual, family, or community responses to actual and potential health problem or life process
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What does the nursing dx reflect?
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level of client health or response to disease or pathological process
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What is a med. dx?
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id of disease condition based on specific evaluation of physical signs, symptoms, history, diag. tests and procedures
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What does NANDA stand for?
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North American Nursing Diagnosis Association
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What is the actual nursing dx?
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human response to health conditions or life processes that exist in an individual, family or community
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What is a risk nursing diagnosis?
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describes human responses to health conditions or life processes that may develop
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What is wellness nursing dx?
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human responses to levels of wellness
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What does the diagnostic process consist of?
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the decision making steps used to develop and diag. statment
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What is the first step of the diagnostic process
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data validation and clustering dervied from assessment
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What is the 2nd step of the diagnostic process?
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analysis and interpretation of data, id of client needs and formulation of nsg diag.
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What do you look for in data analysis?
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patterns and trends
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What do you compare your data wiht in data analysis?
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normal healthful standards
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What do you judge in data analysis?
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wheter the grouped s/s are normal for this client and whether they are within range of healthful responses
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What does problem id look for?
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characteristics not within healthy norms
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What are defining characteristics?
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clinical criteria that support presence of diag. category
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What are clinical criteria?
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obj and subj s/s or risk factors
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What are related factors?
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etiological or contributing conditions that have influenced client response
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What must the etiology of a nsg dx be?
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within domain or nsg practice and a condition that responds to nsg interventions
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Can nursing interventions chg a med dx?
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NO
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What can nsg interventions be directed at?
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behavior or conditions that you can treat or manage
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What dimensions is the nsg dx derived from?
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physiological, psychological, sociocultural, developmental, spiritual
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What are some sources of diagnostic errors?
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data collection, data clustering, interpretation and statement of nsg diag.
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What type of judgments should you make in the Nsg dx?
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professional not prejudicial
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What type of statements should you avoid in the nsg dx?
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legally inadvisable
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When you identify the problem and etiology what should you avoid?
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circular statement
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How many client problems should you identify in the client statement?
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one
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Which nsg dx is listed first?
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one w/ highest priority
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What is the 3rd step of the nsg process?
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planning
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What is planning?
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category of nsg behavior in which client centered goals est. and interventions designed to achieve goals
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What do high priorities result in?
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harm to client of others
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What are intermediate priorities.
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non-emergent, non life threatening needs
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What are low priorities?
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may no be directly related to specific illness or prognosis but may affect clients future well being.
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What are the 2 purposes of planning?
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provide direction for selection and use of nsg interventions, provide focus for evaluation of the effectiveness of interventions
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What is a client centered goal?
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specific and measurable behavior or response that reflects the clients highest possible level of wellness and independence in function
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Should client centered goals only be set by the nurse?
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No - should be set mutually
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What are the two types of goals?
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short and long term
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What is a short term goal?
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objective behavior or response that is expected to be achieved in a short time, usually less than a weekk
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How long should it take to accomp. a short term goal?
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less than a week
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What is a long term goal?
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objective behavior or response expected to be achieved over a longer period
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how long should it take to accomp a long term goal?
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weeks or months
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What does goal setting est?
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framework for nsg care plan
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What part of the nsg process identifys and coordinates resources to deliver nsg care?
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planning
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What do written nsg care plans do?
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organize info exchanged in change of shift nurses
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what are the seven factors considered when writing goal and expected outcomes?
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client-centered, singular, observable, measurable, time-limited, mutual, and realistic
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What is the time frame for a goal?
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The period of time in which the goal should be met
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How many factors do you consider when selecting a care plan?
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6
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What are the 6 factors you consider when selecting a care plan?
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char. of nsg dx, expected outcomes and goals, nursing knowledge, feasibility of the intervention, acceptability of client, competency of nurse providing care
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What does a nursing care plan include?
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diagnostic statement, goals, expected outcomes, specific nsg activities and interventions
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What does the nursing care plan decrease?
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risk of incomplete, incorrect, inaccurate care
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What are expected outcomes?
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specific, step by step objectives
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what do expected outcomes lead to?
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attainment of goal
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What is the 4th step of the nsg process?
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implementation
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What is implementation?
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initiation of nsg behavior in which actions necessary for achieving goal and expected outcomes of nsg care initiated and completed
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What does implementatin include?
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MANY THINGS
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What are the types of nsg interventions?
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nurse initiated, phys initiated, collaborative init, protocols, standing orders
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What is a protocol?
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written plan specifying procedures to be followed
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What is a standing order?
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document containing orders for specific clients with identified clinical problems
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What skills are needed for implementation?
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cognitive, interpersonal, psychomotor
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Why do you initiate direct care interventions?
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to compensate for adverse reactions to therapy
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what should you always do when providing care?
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use precautionary and preventitive measures
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What are clinical pathways?
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allow staff from all disciplines to participate in plan of care
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what is a consultation?
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process in which a specialists help is sought to identify ways to handle problems
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Why do we need cognitive skills in implementation?
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to have a nsg knowledge base, and identify client needs
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What do we need interpersonal skills in implementation?
|
to develop trust to help communicate with pt
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What do we need psychomotor skills in implementation?
|
incorp. cognitive and interpersonal skills helps to do procedures
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What is the 5th step of the nsg process?
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evaluation
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How many steps are there to objective eval?
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5
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What are the 5 steps to obj eval.
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examine the goal statement, assess ct. for behavior or response, compare est. outcome criteria, judge the degree of beh. or resp., analyze why beh. or resp not achieved
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What does evaluation measure?
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client response to nsg actions and ct progress twoard achieving goals
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How often do you collect data to measure changes in fuctioning, daily living, or in avalability to use resources?
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ongoing basis
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When does evaluation occur?
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each time you have contact with ct
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What is the emphasis in evaluation?
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client outcomes
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What are positive evaluations/
|
when desired results are met then the plan met goal
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What are neg. evaluations
|
undesired results indicatre interventions no effect - need to chg plan
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What are the outcomes of evaluation?
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care plan revision and critical thinking, discontinue care plan, modifying a care plan
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What are the steps in modifying a care plan?
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reassessment, nsg dx, goals and expected outcomes, interventions
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Do you have a goal or outcome for each nsg dx?
|
yes
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Which goals have time frames?
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every goal does
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When is a goal met?
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when ct's resp. matches or exceeds outcome criteria, considered resolved, d/c in care plan
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When is a goal partially met?
|
behavior shows changes but does not meet criteria
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When is a goal not met?
|
no progress
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What do you do when you do not meet a goal?
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modify care plan, identify variables that interfered with goal achievement, reassess and review
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What is the def of evaluation?
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continuous systematic method for analyzing results of nsg care
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What are the 5 rights of meds?
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R. med, R. dose, R. clint, R. route, R. Time
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What is the 6th right at VC?
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R. BD
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When do you check to make sure it is the rt med?
|
before remove from drawer, b4 remove from container, ck b4 throw away packet, ck at bedside
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What is a unit dose?
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single dose package
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What does a unit dose do?
|
minimize med errors
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When does risk of error increase with meds?
|
when in bottle, calculations,
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To check right client what do you do?
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check MAR, check MAR against ID badge, ask ct to identify self, check BD
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Who writes the route of the med?
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prescriber
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What do you make sure when giving paraenternal meds?
|
make SURE med is labeled for parenternal use
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Do you need to know why medications are ordered at specific times?
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YES
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What is a half life
|
amt of time 1/2 med gets out of body
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Should you be sensitive to cts schedule?
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YES
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In regards to meds what does the pt have the right to do?
|
r. to question, refuse, and understand med
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When a pt refuses a med what do you do?
|
call phys (sometimes) mark MAR, find out why
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Do we hurry when giving meds?
|
NO
|
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Do we teach about meds when we give them?
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YES
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Who needs to understand what the medication is for?
|
nurse, family and pt
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What is a generic med?
|
normal drug, off brand
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When do you record a med?
|
after you give!
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|
what is polypharmacy
|
on lots of meds
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What is an example of self-prescribing of meds?
|
saving left overs
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What are the difficulties with meds?
|
polypharm, self prescribe, misuse, noncomplience
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What is the easies and best way to give meds
|
oral
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How much fluid should you follow an oral med with?
|
60 - 100 ml of fluid
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What do you watch for when admin an oral med?
|
aspiration
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What type of effects can topical meds cause?
|
systemic and local effects
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What do you always use when applying topical meds?
|
gloves
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What do you do to prepare for giving topical meds
|
clean skin - no hair
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Where do you spread paste?
|
over entire surface
|
|
Where do you not touch dropper on nasal or eye med?
|
nare or eye
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When do you cleanse the area on a nasal or eye drop
|
if drainage noted
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What does pt do after giving nasal med?
|
lay supine for 5 min
|
|
What do you give client after administering nasal or eye med?
|
tissue
|
|
When do you hold the lacramal duct
|
if systemic effects with eye drop
|
|
What type of precautions do you use with vaginal and rectal meds?
|
universal
|
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what do you always wear when giving vaginal and rectal meds
|
gloves
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What must you always do before administering vag or rec meds?
|
explain procedure
|
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Can pt do vaginal or rectal meds themselves
|
yes
|
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What does pt do after insertion?
|
lay supine
|
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What is parenternal administration of meds
|
by injection
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What do parenternal meds increase
|
risk of infection
|
|
What are the parts of the syringe?
|
barrel, plunger, handle of plunger, hub, shaft or plunger, needle
|
|
What do you not touch on a syringe?
|
tip or inside of barrel, hub, shaft of plunger, needle
|
|
are needles attached or unattached to syringe?
|
both
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What are the parts of the needle?
|
hub, shaft, bevel,
|
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How do you always point the needle upon insertion?
|
bevel up
|
|
What are ampules?
|
small glass vial
|
|
How do you open an ampule?
|
break it open
|
|
What type of needle do you use to draw up med from an ampule?
|
filter needle
|
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If you have two meds, one from vial and the other from ampule, which do you draw up first?
|
vial, then ampule
|
|
When mixing meds what do you always do between meds
|
change needle
|
|
What must you know before injecting meds
|
the anatomical landmarks
|
|
What do you do before you inject?
|
map out site and cleanse area
|
|
What do you cleanse injection site with?
|
alcohol
|
|
Do you make sure you tell pt before you stick them?
|
yes
|
|
What do you do generally after you give injection?
|
wipe area - unless heparin
|
|
Where do you dispose of needle/syringe?
|
in sharps container
|
|
Where do meds go in SQ injections
|
loose, connective tissue - fat
|
|
Is SQ absorption lower than IV or IM?
|
YES, both
|
|
what must you do when giving multiple SQ inject?
|
rotate sites
|
|
How much can you give SQ?
|
no more than 1 mL
|
|
Where do you get the fastest absorption in SQ?
|
abdomen
|
|
How do you give SQ shot
|
pinch skin, 45-90 degrees
|
|
What injection is faster than SQ but slower than IV
|
IM
|
|
What do you risk when giving IM injection
|
pushing med into blood stream
|
|
what angle do you give IM shot
|
90 degrees
|
|
What is the greatest amt of med you give IM
|
4 mL in one site
|
|
What is crucial in IM shots?
|
landmarks and identifying sites
|
|
What are the IM sites?
|
Ventral Gluteal, Vastus Lateralis, deltoid, dorsal gluteal
|
|
What do you risk when giving a dorsal gluteal shot?
|
puncturing sciatic nerve
|
|
When IM shot is good for small amts
|
deltoid
|
|
What IM shot is good for children and adults
|
vastus lateralis
|
|
What IM shot is safe for all?
|
ventral gluteal
|
|
What is the preferred IM injection site?
|
ventral gluteal
|
|
How do you give a ventrogluteal shot?
|
demo
|
|
How do you give a vastus lateralis IM shot?
|
DEMO
|
|
How do you give a deltoid IM shot?
|
DEMO
|
|
How do you give a dorsal gluteal IM shot
|
DEOM
|
|
What do you always do when giving IM meds
|
z-track
|
|
What does z-track do?
|
seals med in muscle
|
|
When is ID injection used?
|
in skin testing and TB testing
|
|
what angle do you give ID injection?
|
10-15 degree
|
|
What should appear on skin after ID injection
|
small bump
|
|
What have needleless devices done?
|
reduce needle stick injuries
|
|
Will we always have a need to use needles?
|
YES
|
|
What do you do if stuck by contaminated needle?
|
bleed area, tell supervior, blood tests
|
|
What are the SQ sites?
|
back of arm, abdomen, top of leg, subscapular, love handles
|
|
What is the advantage of IV therapy?
|
rapid absorption
|
|
What are IV meds used primarily for?
|
fld replacement, supply electrolytes and nutrients, med admin
|
|
Who usually prescribes IV therapy?
|
DR
|
|
Name a isotonic solution?
|
D5W, NS
|
|
What is the electrolyte content in an isotonic solution?
|
310 mEq/L
|
|
What is the osmolality of isotonic solutions?
|
same as body fluids
|
|
What is the osmolality of a hypotonic solution?
|
less than body fluids
|
|
Name a hypotonic solution
|
1/2 NS
|
|
What is the electrolyte content in an hypotonic solution?
|
less than 250 mEq
|
|
What is the osmolality of a hypertonic solution?
|
greater than body fluids
|
|
What is the electrolyte content of a hypertonic solution?
|
375 mEq or higher
|
|
Name some hypertonice solutions
|
D51/2, D5NS,
|
|
How do hypertonic solutions work?
|
pull fluid out by osmosis
|
|
What can the use of hypertonic solutions lead to?
|
renal failure
|
|
Content of solutions
|
pg 367 - whatever named
|
|
What do you normally add to IV solutions?
|
viamins, KCL, meds
|
|
What color are IV solutions with vitamins
|
yellow
|
|
How do you never give KCL? why?
|
IV push, fatal!!
|
|
Are IV fluids considered meds?
|
YES
|
|
What are the ways meds are givin IV?
|
mixture within large volume of IV fluids, bolus, piggyback
|
|
What is the saftest and easiest way to admin IV meds?
|
large volumes of fluid
|
|
What are the two types of tubing?
|
macro and micro drip
|
|
What is the drop rate for a macro drip
|
10-15 gtts/ml
|
|
What is the drop rate for a micro drop
|
60 gtts / ml
|
|
Why do you sue a macrodrop?
|
goes faster, bigger drops, deliver more
|
|
Why do you use a microdrop?
|
sm. volume more precise
|
|
What is the rate on an IV controlled by?
|
roller clamp, slide clamp
|
|
With what IV med would you need a filter?
|
Mannitol
|
|
Do you have a pump with the use of a roller or slide clamp ?
|
no
|
|
What is the most common IV?
|
over the needle
|
|
What part of the otn stays in the pt
|
cannula
|
|
In what type of IV does the needle stay in
|
winged infusion needle
|
|
What is another name for a winged infustion needle
|
butterfly
|
|
Where do you usually use winged infusion needles
|
scalp vein
|
|
what does PICC stand for?
|
Peripherally inserted central catheter
|
|
What does CVL stand for?
|
central venous line
|
|
Where does a PICC line go?
|
ins site to superior vena cava
|
|
Do you do BP on arm with PICC line?
|
NO
|
|
Where are CVL's normally placed
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sub clavian
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Which is shorter, a PICC or a CVL?
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CVL
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What is an example of a Volume control device?
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burretrol
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Where does a vol. control device go?
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between iv bag and pump
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Why do you not use joints when doing an IV unless you abs. have to
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Impairs mobility - easily occluded
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what do you assess when acessing the availablity of vein
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client condition, client comfort, condition of vein, anticipated duration of infustion, gerontological consider
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What must you make sure of when selecting a needle
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That the vein is large enough for it
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What is a normal site in childern not used in adults
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foot
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do you need an order to start an iv
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yes
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What is the direction you start working to put in an IV and then move to
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Distal to proximal
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Should you take into consideration if pt is left or right handed?
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yes
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Should you use the larges or smallest gage of needle possible with iv
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smallest
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Why do you avoid the back of the hand
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skin and vein fragile
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What makes a vein more likely to roll
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less SQ tissue
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What does an infusion pump do?
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delivers meaured amt of fluid over period of time
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What does an IV controller do?
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delivers fluid with aid of gravity based
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What is the formula for calculating infusion flow rate?
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volume X tubing / min
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What is KVO
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keep vein open
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Do you increase the flow if you are behind
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NO
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when starting an iv, how full do you fill chamber
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1/2 to 3/4 full
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What is an adequate height for an IV solution
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3 ft
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If an IV is hung highter what will it do
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run faster
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What are some factors incluencing iv flow rate
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patency, site
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What is patency?
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if IV is flowing, clear
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What is flow directly proportional to?
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the diameter of the tubing
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Does longer tubing make the flow slower or faster
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slower
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What type of fluid runs faster highly viscous or thin
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thinner
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How often should you change the IV site?
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72 hours
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What must you always be sure to do with the system
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keep it sterile
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What do you always do to the ports before you use them - w
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wipe them down
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What do you check with an IV
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no kinks, air, infusing at correct rate
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When do you change the tubing
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when you change the iv
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What type of dressing do you use on IV site
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transparent
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What do you do when discontinuing an IV
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remove dressing, clamp fluid, use 2x2 gauze, pressure
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What is an infiltration?
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iv fluid enters the sq tissue around site
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What causes an infiltration
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needle dislodged from vein
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What are some symptoms of an infiltration
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swelling, cool, clammy, pallor, pain, decreased or absent flow rate, no blood return
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how do you get blood reture
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raise site above heart
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