Foundations Test #5

Front 1

The planning of nursing care occurs in three phases:

Back 1

Initial: involves the development of a preliminary care plan following the client’s initial assessment and initial selection of nursing diagnoses. This phase can be challenging due to the short length of client stay.

Ongoing: continuous updating of the client's plan of care. As the client condition changes, for better or worse, continual assessments need to be made, and revisions may be necessary.

Discharge planning: involves the important aspects and preparations needed for the client to go home.

Front 2

Goal

Back 2

A broad statement that describes the desired change in a client’s condition or behavior
An aim, intent, or end

Front 3

Expected outcome

Back 3

Measurable criteria to evaluate goal achievement
A specific, measurable change in a client’s status
Provide focus or direction
Determine when a specific, client-centered goal has been met

Front 4

Client-centered goal

Back 4

A specific and measurable behavior or response
Reflect a client’s highest possible level of wellness and independence in function.

Front 5

Short-term goal

Back 5

An objective behavior or response expected within hours to a week

Front 6

Long-term goal

Back 6

An objective behavior or response expected within days, weeks, or months

Front 7

Types of Goals

Back 7

Client-centered: outcomes and goals reflect the client behavior and responses expected as a result of nursing interventions.
Singular Goal: addresses only one behavior or response.
Observable: be able to observe if change teaks place in a client's status.
Measurable: set standards against which to measure the client's response to nursing care.
Time-limited: indicates when you expect the response to occur.
Mutual factors: ensure that the client and nurse agree on the direction and time limits of care.
Realistic: that a client is able to reach.

Front 8

Nurse initiated

Back 8

Independent

Front 9

Physician initiated

Back 9

Dependent

Front 10

Collaborative

Back 10

Interdependent

Front 11

Selection of Interventions-Six factors to include

Back 11

Characteristics of nursing diagnosis
Goals and expected outcomes
Evidence base for interventions
Feasibility of the intervention
Acceptability to the client
Nurse’s competency

Front 12

Nursing Care Plan

Back 12

Enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care

Front 13

Student Care Plan

Back 13

Useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care.

Contains a nursing diagnosis, assessment findings, goals, expected outcomes, nursing interventions with supporting rationales, and evaluative outcome criteria

Front 14

Institutional Care Plan

Back 14

Does not have a scientific rationale.
Allows quick reference to the needs of the client for certain aspects of nursing care

Front 15

Concept Map

Back 15

A visual representation of client problems and interventions that shows their relationship to one another

Front 16

Consulting other healthcare professionals

Back 16

Consultation is a process in which you seek the expertise of a specialist to identify ways to handle problems in client management or the planning and implementation of therapies.

Front 17

Clinical guideline or protocols

Back 17

are documents that guide decisions and interventions for specific health care problems or conditions. They are developed on the basis of current scientific evidence and help nurses, physicians, and other health care providers make decisions about appropriate health care

Front 18

A standing order

Back 18

is a reprinted document containing orders for the conduct of routine therapies, monitoring guidelines and/or diagnostic procedures for specific clients with identified clinical problems.

Front 19

Cognitive skills

Back 19

involve the application of critical thinking. No intervention should be automatic. Nurses need to think and anticipate how to individualize care for their clients

Front 20

Interpersonal skills

Back 20

are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client and family. In Chapter 24 we will further discuss communication

Front 21

Psychomotor skills

Back 21

require the integration of cognitive and motor activities

Front 22

Direct Care

Back 22

ADLs: These instrumental ADLs include the day-to-day activities a person performs. These include shopping, preparing meals, writing checks to pay the bills, taking medications.
Physical Care Techniques are the activities that nurses perform while rendering care. These including turning, positioning, and administering care, as well as performing tasks such as Foley catheter insertion, NG tube insertion, IV insertion, administering IV, IM, or SQ medications.
Lifesaving measures are those activities you perform when a client’s physiological or psychological state is threatened. These activities include CPR, administering emergency medications, and falls prevention.
Counseling involves emotional, intellectual, spiritual, and psychological support to your clients. Box 19-3 presents examples of counseling strategies.
Teaching is a constant part of nursing. Teaching occurs formally and informally and involves clients and their family members. We will further discuss this in Chapter 25: Client Education.
An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. Before performing any skill or task, you need to know the possible adverse effects or reactions that can occur.
Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the client’s health potential, application of prescribed measures, health teaching, and identification of risk factors for illness and/or trauma.

Front 23

Indirect Care

Back 23

Communicating nursing interventions
Written or oral
Delegating, supervising, and evaluating the work of other health care team members

Front 24

Achieving Client Goals

Back 24

Nurses implement care to meet client goals.
At times, multiple interventions may be needed.
Priorities help nurses to anticipate and sequence nursing interventions.

Front 25

The Evaluation Process-Includes five elements:

Back 25

Identify evaluative criteria and standards.
Collect data.
Interpret and summarize findings.
Document findings and clinical judgments.
Terminate, continue, or revise the care plan.

Front 26

Quality improvement and performance improvement

Back 26

are interchangeable terms.
An approach to the continuous study and improvement of the processes involved in providing health care services to meet the needs of clients and others (JCAHO, 2004).

Front 27

A medication

Back 27

is a substance used in the diagnosis, treatment, cure, relief, or prevention of diseases.

Front 28

Drugs can have 3 names:

Back 28

chemical: provides the exact description of medication’s composition

generic: the manufacturer who first develops the drug assigns the name and it is then listed in US Pharmacopeia

trade, also known as brand or proprietary name. This is the name under which a manufacturer markets the medication.

Front 29

Pharmacokinetics

Back 29

The study of how medications:
Enter the body
Are absorbed and distributed into cells, tissues, or organs
Alter physiological functions

absorption, distribution, metabolism, and excretion

Front 30

Absorption

Back 30

The passage of medication molecules into the blood from the site of administration
Factors that influence absorption:
Route of administration
Ability to dissolve
Blood flow to site of administration
Body surface area
Lipid solubility of medication

Front 31

Each route of administration has a different rate of absorption.

Back 31

Topical administration has the slowest rate of absorption. The mucous membrane and respiratory tract have a quick rate of absorption. IV administration has the fastest absorption rate. The oral route takes some time due to the passage of medications through the GI tract.
When the site of administration contains a rich blood supply, the medication will be absorbed quickly.

Front 32

Distribution

Back 32

After absorption, distribution occurs within the body to tissues, organs, and to specific sites of action.
Distribution depends on:
Circulation
Membrane permeability
Protein binding

Front 33

The rate and extent of distribution depends on the physical and chemical properties of medication and the physiology of the client.

Back 33

Once the medication has entered into the bloodstream, it is carried throughout the tissues and organs of the body. The speed of the distribution depends on the vascularity of the various tissues and organs.
In order to be distributed to an organ, a medication has to pass through the organ’s tissues and biological membranes. Some membranes serve as barriers to the passage of medications. For example, the blood-brain area allows fat-soluble medications to pass into the brain and CSF. Both fat-soluble and non–fat-soluble agents often cross the placenta and produce fetal abnormalities such as respiratory depression. Narcotic use can create withdrawal symptoms.
The degree to which medication binds to serum proteins will affect medication distribution. Most medications bind to albumin to some extent.

Front 34

Metabolism

Back 34

Medications are metabolized into a less potent or an inactive form.
Biotransformation occurs under the influence of enzymes that detoxify, degrade, and remove active chemicals.
Most biotransformation occurs in the liver. Biotransformation can also occur in the lungs, kidneys, blood, and intestines.

Front 35

Medications are excreted through:

Back 35

Kidney(MAIN ONE)
Liver(Anesthetic gases, alcohol)
Bowel
Lungs
Exocrine glands

Front 36

Types of Medication Action:

Back 36

Therapeutic effect:
Expected or predictable

Adverse effect:
Severe response to med

Idiosyncratic reaction:
Over- or under-reaction to a medication

Side effect:
Unintended, secondary effect

Toxic effect:
Medication accumulates in the blood stream

Allergic reaction:
Unpredictable response to a medication

Front 37

Medication interactions

Back 37

may occur when one increases or diminishes the way the other medication is absorbed, metabolized, or eliminated.

Alcohol has synergistic effect on antihistamines, antidepressants, barbiturates, and narcotics since alcohol is a CNS depressant. On the other side of the spectrum, a client with HTN may need to take a combination of medications, such as a diuretic and vasodilator, to control high blood pressure through the synergistic effect of the two medications.

Front 38

Serum half-life:

Back 38

Time for serum medication concentration to be halved

Front 39

Peak:

Back 39

Time at which a medication reaches its highest effective concentration

Front 40

Duration:

Back 40

Time medication takes to produce greatest result

Front 41

Onset:

Back 41

Time it takes for a medication to produce a response

Front 42

Trough:

Back 42

Minimum blood serum concentration before next scheduled dose

Front 43

Plateau:

Back 43

Blood serum concentration is reached and maintained

Front 44

Prescriber's Role

Back 44

Prescriber can be physician, nurse practitioner, or physician’s assistant.
Prescribers must document the diagnosis, condition, or need for each medication.
Orders can be written, verbal, or by telephone.

Front 45

Standing or Routine:

Back 45

Administered until the dosage is changed or another medication is prescribed

Front 46

Single one-time:

Back 46

Given one time only for a specific reason

Front 47

Now:

Back 47

When a medication is needed right away, but not STAT

Front 48

PRN:

Back 48

Given when the client requires it

Front 49

STAT:

Back 49

Given immediately in an emergency

Front 50

Prescriptions:

Back 50

Medication to be taken outside of the hospital