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50 Cards in this Set

  • Front
  • Back
The planning of nursing care occurs in three phases:
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.
Goal
A broad statement that describes the desired change in a client’s condition or behavior
An aim, intent, or end
Expected outcome
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
Client-centered goal
A specific and measurable behavior or response
Reflect a client’s highest possible level of wellness and independence in function.
Short-term goal
An objective behavior or response expected within hours to a week
Long-term goal
An objective behavior or response expected within days, weeks, or months
Types of Goals
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.
Nurse initiated
Independent
Physician initiated
Dependent
Collaborative
Interdependent
Selection of Interventions-Six factors to include
Characteristics of nursing diagnosis
Goals and expected outcomes
Evidence base for interventions
Feasibility of the intervention
Acceptability to the client
Nurse’s competency
Nursing Care Plan
Enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care
Student Care Plan
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
Institutional Care Plan
Does not have a scientific rationale.
Allows quick reference to the needs of the client for certain aspects of nursing care
Concept Map
A visual representation of client problems and interventions that shows their relationship to one another
Consulting other healthcare professionals
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.
Clinical guideline or protocols
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
A standing order
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.
Cognitive skills
involve the application of critical thinking. No intervention should be automatic. Nurses need to think and anticipate how to individualize care for their clients
Interpersonal skills
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
Psychomotor skills
require the integration of cognitive and motor activities
Direct Care
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.
Indirect Care
Communicating nursing interventions
Written or oral
Delegating, supervising, and evaluating the work of other health care team members
Achieving Client Goals
Nurses implement care to meet client goals.
At times, multiple interventions may be needed.
Priorities help nurses to anticipate and sequence nursing interventions.
The Evaluation Process-Includes five elements:
Identify evaluative criteria and standards.
Collect data.
Interpret and summarize findings.
Document findings and clinical judgments.
Terminate, continue, or revise the care plan.
Quality improvement and performance improvement
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).
A medication
is a substance used in the diagnosis, treatment, cure, relief, or prevention of diseases.
Drugs can have 3 names:
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.
Pharmacokinetics
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
Absorption
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
Each route of administration has a different rate of absorption.
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.
Distribution
After absorption, distribution occurs within the body to tissues, organs, and to specific sites of action.
Distribution depends on:
Circulation
Membrane permeability
Protein binding
The rate and extent of distribution depends on the physical and chemical properties of medication and the physiology of the client.
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.
Metabolism
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.
Medications are excreted through:
Kidney(MAIN ONE)
Liver(Anesthetic gases, alcohol)
Bowel
Lungs
Exocrine glands
Types of Medication Action:
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
Medication interactions
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.
Serum half-life:
Time for serum medication concentration to be halved
Peak:
Time at which a medication reaches its highest effective concentration
Duration:
Time medication takes to produce greatest result
Onset:
Time it takes for a medication to produce a response
Trough:
Minimum blood serum concentration before next scheduled dose
Plateau:
Blood serum concentration is reached and maintained
Prescriber's Role
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.
Standing or Routine:
Administered until the dosage is changed or another medication is prescribed
Single one-time:
Given one time only for a specific reason
Now:
When a medication is needed right away, but not STAT
PRN:
Given when the client requires it
STAT:
Given immediately in an emergency
Prescriptions:
Medication to be taken outside of the hospital